85. Cynthia Thurlow: What Your Doctor Isn't Telling You About Menopause and Metabolic Health

What if the symptoms you've been told to "just deal with" during perimenopause could actually be addressed? In this episode of Extend, I sit down with Cynthia Thurlow, a nurse practitioner who left traditional cardiology to focus on women's health and metabolic medicine. We explore why the medical system has failed women during menopause, the critical biomarkers your doctor probably isn't checking, and how the misinterpretation of one major study has left generations of women suffering unnecessarily. We also discuss why LDL cholesterol might not be the villain it's made out to be and how hormone replacement therapy could be one of the most important interventions for long-term health. Cynthia Thurlow is a nurse practitioner and intermittent fasting expert. She's the author of "Intermittent Fasting Transformation" and hosts the "Everyday Wellness" podcast. She specializes in helping women navigate perimenopause and menopause through lifestyle medicine and bioidentical hormone replacement therapy. We Also Discuss: The Women's Health Initiative Disaster: How One Study Damaged Generations of Women Why Your "Normal" Fasting Glucose of 95 Means You're Already in Trouble ApoB and Lp(a): The Heart Disease Markers Your Doctor Isn't Checking Dutch Testing vs. Blood Work: Which Hormone Tests Actually Matter The $100 Calcium Score That Should Be Routine After 40 Why 60-Year-Olds CAN Start Hormone Replacement Therapy GLP-1 Medications: Beyond Weight Loss to Metabolic Healing The Intermittent Fasting Mistakes That Wreck Women's Hormones Pellet Therapy vs. Patches: The Hormone Delivery Debate Why Statins Are the Most Over-Prescribed Drugs in History Dysautonomia and HRV: The Nervous System Signals You're Missing The Gut-Menopause Connection No One Talks About Thank You for Our Sponsors: Pendulum: Use code DARSHAN or use the link https://pendulumlife.com/discount/DARSHAN to get 20% off IM8: Try IM8 today with a 30-day money back guarantee. You can get 20% off your first order with code DRSHAH at https://im8health.com/discount/DRSHAH. Learn more about Dr. Shah: Website: https://www.drshah.com/ Clinic: https://www.next-health.com/ Instagram: https://www.instagram.com/darshanshahmd/ Learn more about Cynthia Thurlow: Website: https://www.cynthiathurlow.com/ Podcast: https://www.cynthiathurlow.com/podcast Instagram: https://www.instagram.com/cynthia_thurlow_/

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:03Dr. Darshan Shah?

  Welcome to Extend with me, Dr. Darshan Shah, a podcast dedicated to cutting-edge science, research, tools, and protocols designed to help you extend your health span. Having become one of the youngest doctors in the country at the age of 21, and trained and board-certified at the Mayo Clinic, I've accumulated three decades of practice as a board-certified surgeon and longevity expert. Over that time, I've discovered that a mere 20% of health knowledge yields 80% of the results when it comes to your health span. We're living in a new era where we are creating a new healthcare system, no longer focused on disease management, but achieving optimal health and vitality. Join me as I interview world-renowned experts, offering you a step-by-step guide to proactively avoid disease, and most importantly, extend your health span.

• 0:50Dr. Darshan Shah?

  Cynthia, thanks so much for joining me today at Extend.

• 0:53Speaker 01

  Yeah, I've been so looking forward to having this conversation with you in real life.

• 0:57Dr. Darshan Shah?

  I know, this is fantastic. We've been talking about this for a long time, but you're all the way out in Virginia, and we tape in person because I just feel like it's such a better conversation in person, you know?

• 1:07Speaker 01

  You really do. And as someone who's just ventured into the in-person podcasting space for my own podcast, I agree, there's a degree of intimacy and connection that you miss when you're doing it over Zoom or Riverside or any of the other options that we use to make these happen.

• 1:24Dr. Darshan Shah?

  Exactly, and it just goes to show you, like, there is something really real about how physical connection really does create, I think, better health, better longevity, better mental space, all of it.

• 1:36Speaker 01

  Oh, it's also important. And these conversations are important because we have an ability to share the knowledge and the experiences that we have as clinicians and make it accessible for people everywhere.

• 1:47Dr. Darshan Shah?

  Exactly, and this is one of my favorite reasons for having you is because we're both clinicians. We're both seeing a lot of patients all the time. And, you know, I think there is a jump from what people talk about to what really happens, right?

• 2:02Speaker 01

  Well, and I think that there's well-intended messaging that comes out from non-clinicians, as an example. But, you know, you worked in surgery. I was an ER nurse before I worked in cardiology. I have seen the sickest of the sick types of patients. And so it just gives you a breadth of perspective that I might not otherwise have. But I always say that I'm so grateful for those experiences. But I like a lot less stress in my life, like what I used to experience years ago.

• 2:30Dr. Darshan Shah?

  Oh, absolutely. You don't miss seeing 80 patients a day?

• 2:32Speaker 01

  No. No, in fact, I was talking to someone recently about how they used to add on more patients to when we were in clinic. And they would say, you don't need to take lunch, do you?

• 2:43Dr. Darshan Shah?

  That happened to me all the time.

• 2:44Speaker 01

  And I was like, well, yeah, I actually do need to eat. And I do need to empty my bladder. And I do need to drink some water. But you would just say, okay. What I started doing is having, I would say, I'd rather you give me time at lunch to have even 15 minutes of a break and just add them earlier in the morning. So that became, they knew that they could add someone at 7:30 in the morning before I started my usual patients.

• 3:06Dr. Darshan Shah?

  It's so crazy. And you know, like, being in the medical field, it's mind blowing the number of patients that are out there. I mean, it's just way too many people are sick. And it's all, when I was doing surgery, it's like, why does everyone in the world need surgery? This shouldn't be this way, right? And it's just nice to be on the other side of the coin now where I'm trying to prevent people from going to surgery for all sorts of reasons, right?

• 3:34Speaker 01

  Yeah. Well, and it's interesting, because I spent 16 years working in clinical cardiology. And I remember it's probably the last three or four years, I got very interested in lifestyle and very interested in talking to my patients about nutrition. And most of my colleagues were tolerant at best. And they would say, this is our nurse practitioner who likes to talk about food. And then they would refer people to me. And I was like, oh, this is great. But what I found is that so many of us are just so indoctrinated in that traditional allopathic model, that even the patients were like, Cynthia, I'm not gonna, I'm not gonna stop smoking. I'm not gonna change my diet. I'm not gonna start exercising. Just give me the pill. And that to me was so disheartening because I would say to them, if I could get you to eat less often, and if I could get you to eat more protein and knock out a lot of the processed

• 4:19Speaker 01

  food that you're consuming, and if I could get you to stop smoking, you know, maybe you wouldn't have this progressive worsening vascular disease.

• 4:25Dr. Darshan Shah?

  Right.

• 4:25Speaker 01

  Or progressively worsening diabetes.

• 4:28Dr. Darshan Shah?

  Yep.

• 4:28Speaker 01

  And I think in many instances, our patients have just been conditioned to ask for the pill instead of doing the hard, and I know it is hard work.

• 4:36Dr. Darshan Shah?

  Yep.

• 4:36Speaker 01

  The lifestyle piece, which is absolutely essential for health.

• 4:39Dr. Darshan Shah?

  Yeah, you and I in total agreement about that. And what I also tell my patients now is the pharmaceuticals will have maybe one third or even a quarter of the effect that you're looking for. It's really the diet, exercise, lifestyle, stress management, sleep piece that's going to have 80% of the effect or more and make the pharmaceuticals more effective. And my whole goal with patients is to get them off their pharmaceuticals at some point, right? And so that's never going to happen if you don't get the lifestyle piece.

• 5:09Speaker 01

  Correct. Right. And I think for a lot of people, and maybe in their teens, twenties, and thirties, they can get away with eating whatever they want and not exercising and engaging in any type of extraneous illicit experience. But I think as we start navigating perimenopause, andropause, menopause, the game shifts. I mean, I tell everyone that, you know, my one big vice that's left is dark chocolate, but even that is not something that I can do all day, all the time. I mean, those differences in lifestyle make an enormous, enormous impact. And I think for a lot of individuals, they assume that what they see on social media are people that live a lifestyle where they get to engage in whatever they want. And I'm

• 5:52Speaker 01

  the first person to say, everything has to get more dialed in the older that we get. That's the unfortunate truth. And I'm very honest with patients when I just say that it's like we're constantly fine tuning a piece of sculpture. If that's how you want to think about it, it's like we're constantly honing that sculpture. And that's what allows us to continue to have that high quality of life, which I know most of us are looking for.

• 6:13Dr. Darshan Shah?

  Exactly. And you know, you eventually get to a point in this journey of modifying your lifestyle that it actually feels much better and it becomes more inspiring to live with a lifestyle that promotes health versus degradates it all the time. Right? And so I could feel so much better doing the things that I do now versus what I was doing 10 years ago. And I'm more inspired to do these things on a daily basis. You just have to find that moment where you kind of turn the corner into this new lifestyle. You sink into it and then you love it.

• 6:42Speaker 01

  Do you ever look back retrospectively and think about when you were in the heyday of your surgical residency? Or even first practicing as a surgeon? The amount of stress and the lack of sleep and the poor quality food that you ate because that's all you could grab in the hospital. Because the hospital is littered with junk food. I mean, all of the nurses' lounges were littered with junk food. I mean, in Baltimore, it was Krispy Kreme donuts are a big thing.

• 7:07Dr. Darshan Shah?

  Krispy Kreme everywhere. So same in California.

• 7:09Speaker 01

  Yeah.

• 7:10Dr. Darshan Shah?

  Yeah. I look back and I was like, the exact opposite of how you should be living. You're completely stressed out all the time. And it's not just doctors and nurse practitioners that live this way. I think a lot of us live this lifestyle where we wake up in the morning stressed. We did not get a good night of sleep the night before. We eat garbage because we're stressed and we're rushed. And then it just keeps going in this horrible cycle all day until you finally crash at night after a couple of drinks because it's the only thing to get you to unwind. And you get another bad night of sleep and it just keeps going and going in that cycle. I think a lot of people can appreciate that because a lot of people get stuck in that cycle. And you can blame whatever you want. You can blame your career. You can blame family stresses. You can blame.

• 7:53Dr. Darshan Shah?

  There's a lot of reasons that you get into that cycle. But there's a lot of people also living a good, not necessarily a good, but also maybe a a clean lifestyle that don't, that also are in these careers too. So it can be done, right?

• 8:09Speaker 01

  Yeah, and I think a lot of it is choices. And I think sometimes we don't realize that it's it's kind of like a boulder going downhill.

• 8:15Dr. Darshan Shah?

  Yes.

• 8:16Speaker 01

  That it's usually one choice after another that kind of leads to that feeling.

• 8:19Dr. Darshan Shah?

  Right.

• 8:19Speaker 01

  Many people feel powerless. They feel like they're in a position where they can't make a change. They can't course correct. And so in many instances, it's helping empower people to understanding like we can start to change the trajectory of the direction in which we are going. And I think for a lot of us, myself included, it wasn't until I hit the wall of perimenopause that all of a sudden I really started to question everything in my life because I was like, all the things that I used to do that served me very well as a very high functioning, type A, successful individual, no longer serve me. And that word pause is the is the word that I always encourage people to consider irrespective of whether we're male or female, is understanding that it's a time in our lives where we are invited to change.

• 9:04Speaker 01

  We are invited to kind of pause and reflect. And for so many of us, we've been in these positions where we're go, go, go, go, go all the time, that all of a sudden it's like, you want me to stop and think? I've been on autopilot for 10 years, 15 years, 20 years.

• 9:18Dr. Darshan Shah?

  Right. I love that. So pause, menopause, andropause, take some time to stop, reevaluate your choices, your life, and maybe choose a different direction.

• 9:30Speaker 01

  Yeah.

• 9:31Dr. Darshan Shah?

  Right?

• 9:31Speaker 01

  Well, and I think for a lot of people, they they can course correct and and that then leads to exponential gains emotionally, spiritually, physically, et cetera, or they can continue on that same path. And I certainly saw a lot of those people. I mean, it isn't it isn't unique to just healthcare, but those are the examples that I think of of the people who just looked haggard and exhausted and tired all the time.

• 9:54Dr. Darshan Shah?

  Right, right, absolutely. So in your practice, you're doing cardiology for many, many years, and now you're focused on women's health. Integrative health, lifestyle medicine. How did that transition occur?

• 10:07Speaker 01

  You know, life imitates art. So I hit that wall, as I referred to. So, you know, over 10 years ago, I, I could barely get out of bed. I was exhausted. You know, I, I wasn't depressed. Clearly something hormonal was happening, but nothing had prepared me. You know, not my mom, not my GYN, not my girlfriends. Because women in many instances 10 plus years ago weren't talking about the changes that were happening in our bodies. You know, menopause was so many years away. I mean, that's, you know, that's never going to be here. And so I, I think for me, it was started with the overall exhaustion, the feeling like I couldn't keep up with myself. You know, I'd always done pretty intense exercise. And all of a sudden I could barely get through a class. You know, my hair was falling out. I was gaining weight. I was really, really tired. And at the time I had two young kids.

• 10:52Speaker 01

  My husband did a lot of international travel. And for me, I think it was the realization that something wasn't quite right. And it was trying to figure that out for myself. And through me determining what was going on with my own health, that pause definitely encouraged me to think about what was going, what was the next half of my life going to be like? Because if this is what my life was like right now, it was like, this is not sustainable. Absolutely not sustainable. And so, you know, I think I went the traditional allopathic route initially. And that's when my GYN offered me the pill, an IUD, an ablation or hysterectomy. And I said, no, no, no, no.

• 11:29Dr. Darshan Shah?

  Yeah.

• 11:29Speaker 01

  Um, and then I kind of pivoted and, and I started getting more interested in, in the lifestyle piece and started examining like, what's the research really telling us? Because I ultimately always go back to what research has been done, not a lot. What are the things that we know in terms of lifestyle have the greatest net benefits? And so for me, that led me to intermittent fasting. And I always tell people, I came to intermittent fasting like many people do with a desire to lose weight. What kept me there was just how much better I felt. And so that was the beginning of this shift. And then that led itself to, I really started questioning my job. And I remember I went to the practice I worked for and I said, I'm not growing intellectually anymore. And, and my practice was incredibly good to me. I worked at that point, two days a week, two.

• 12:13Speaker 01

  Essentially six hour days because they allowed me to keep reducing my hours to work around my kids' stuff. And they just said, we'll give you anything, anything you want. And I said, it's, it has nothing to do with you all. It's everything to do with me. I'm just not growing anymore. And so I left, you know, nine years ago, without a business plan, without any idea of what I was going to do. I said, I know I'm going to be successful. That was, that was either, you know, arrogance or just complete naivete. And so

• 12:39Dr. Darshan Shah?

  Medication.

• 12:39Speaker 01

  Yes. And so my, my husband, who's an engineer, is very fiscally conservative, thought I'd lost my mind. He's like, is this a midlife crisis? Is this what people talk about? And so the irony is that almost instantaneously, women started coming to me because they felt like I was talking about things that they were experiencing and I was listening in a different way. And so I started with group programs and that kind of morphed into one-on-one programs. And so that just started this other path that was incredibly fulfilling because I was meeting women's needs in a way that they were not being met at that time. And then it morphed into a lot of other wonderful things. But I think the, the biggest impetus

• 13:17Speaker 01

  was my own healthcare hiccup, my own healthcare issue that led to me deciding that I was not willing to walk around feeling like I had brain fog. I was exhausted all the time. My hair was falling out. Very clearly, there were a lot of hormonal imbalances, not the least of which I have thin phenotype PCOS. And so I've always been low in progesterone and that just magnified all these low progesterone symptoms. And so I think for me, my own journey is what allowed me to, to pivot and to then turn into a position where I had a larger platform in which to speak to women and inspire them and their families to live differently. I feel like the, the tide has shifted a great deal in 10 years.

• 14:00Dr. Darshan Shah?

  Yeah.

• 14:01Speaker 01

  It's very different now than it was even nine years ago. When I, so it was April 1st, 2016 is when I left traditional allopathic medicine.

• 14:09Dr. Darshan Shah?

  Wow.

• 14:09Speaker 01

  And never looked back, never questioned that decision at all.

• 14:13Dr. Darshan Shah?

  That was kind of the time period too, that I made the decision to start changing my career because I had taken a course in functional medicine.

• 14:20Speaker 01

  Yep.

• 14:21Dr. Darshan Shah?

  And I just learned two things that completely changed the trajectory of my own health. And I, same as you, like I incorporate those into my life. I'm like, I have to talk about this to all the men and women out there that have not They don't have this information, you know?

• 14:35Speaker 01

  Well, and it's interesting because I didn't mention, but I did initially a functional nutrition program. And that lit me up. I was like, the power of food. Oh, my God. Food is medicine. And so that got me interested and that then allowed me to feel much more comfortable, confident saying, everything I've been telling patients about food is wrong.

• 14:54Dr. Darshan Shah?

  Yeah.

• 14:55Speaker 01

  Every single thing. I mean, I actually kept one sheet that the Nurse Practitioner Service had created to talk to our patients about food, and it made me cringe.

• 15:05Dr. Darshan Shah?

  Really?

• 15:06Speaker 01

  Because it was focused on avoiding butter and avoiding ghee and consuming plant-based fats. So, you know, Brummel and Brown and all these, you know, canola-based spreads, those are great for you. And, you know, eat your heart-healthy grains and, you know, small amounts of protein and saturated fat is bad. And so when I look at that now, I should probably plaque it, but when I look at that now, it's like, it makes me recognize, number one, how far I've come. And number two, I feel like I will spend the rest of my life ensuring that I'm spreading information that is actually going to be helpful to our health as opposed to detrimental, because, you know, we could have a whole sidebar conversation about

• 15:47Speaker 01

  how, you know, my plate and the food guide pyramid and how it should really be flipped upside down and completely the opposite of what, you know, we've been telling our patients. Yeah. And it's like, I always say know better, do better. That's kind of my prevailing philosophy in life that

• 16:02Dr. Darshan Shah?

  Exactly.

• 16:02Speaker 01

  now I know better and now I do better and I make sure that we talk about the conversations around lifestyle that I wasn't having, you know, 20 years ago with patients.

• 16:12Dr. Darshan Shah?

  Absolutely. And, you know, we were trained in medicine around the same time. And, you know, we were taught all the same things, low saturated fat diets, low protein diets. And, you know, the fruit pyramid had grains at the bottom of the pyramid. And that was what we would tell people, like, you know, heart-healthy grains, right? And, yeah, nothing could be further from the truth now than it's exactly the opposite in my food advice, too. So it sounds like you kind of landed on two of the main topics that I landed on that made a huge difference for me, which was metabolic health and hormonal health. Those are the two places I made personal changes in my own life. That's usually where I start with my patients as well, particularly after 35 and, you know, that whole time period.

• 16:53Dr. Darshan Shah?

  And it sounds like kind of that's where you landed, is the two main categories where you can really create a difference.

• 16:59Speaker 01

  Well, and for me, being in cardiology, I had a bird's eye view of What does a diabetic patient's trajectory of their life look like? What does a patient that is started on a statin at a very young age? Because that's back when, you know, kind of prevailing medical dogma was, you know, we're going to start you on a statin because you have a high LDL. We're going to put you on, you know, this, this drug Tricor because your triglycerides are high. Your HDL is low, but really what you need is to change your diet. You know, let's talk about poor metabolic health. So for me, I was talking about fasting insulin way before they became very much considered to be, you know, this is a, this is something everyone should be asking for. And I kept saying, if we know that we can diagnose someone earlier

• 17:43Speaker 01

  or prevent them from developing diabetes, isn't that really the key? I actually recently a physician said to me, I don't know how to interpret that. I said, well, let me help you because this is going to be life changing for your patients. Um, don't be afraid of looking at a fasting insulin. But I was talking about fasting insulin a long time ago. And so, you know, for me, being in cardiology, metabolic health was always something that was prevailing and important. And then because life imitates art, because I myself was a perimenopausal female, I was like, why aren't we talking about what's happening with our hormones? Like, why is my progesterone so low? Mine was even lower than low. And why am I now, you know, relatively estrogen dominant? And let's not even talk about testosterone.

• 18:25Speaker 01

  But all these sex hormones, not to mention other hormones that are impacting women in particular as they're navigating this perimenopausal transition. Because if we could talk to patients about what to anticipate, then they would, they could start making course corrections along the way as opposed to like where I was, where I hit the wall. Where it was like, I had to make a lot of changes very quickly because I was unwilling to continue living like that. Not everyone is that way, but I'm kind of, I can be, I can sometimes go to extremes. But for me, it was, I had to change so many things all at once because I was unwilling and impatient, frankly, to wait forever for me to feel better. It was like, okay, what are the things that are going to yield the greatest results the fastest?

• 19:09Speaker 01

  And, you know, it's like, I'm always looking at it like, hmm, what's the net positive? Of making a lot of changes really quickly and kind of having to like, you know, go through this process and have it be uncomfortable and arduous, at least upfront, and then it'll be a little bit smoother. And so I, that's just my personality.

• 19:23Dr. Darshan Shah?

  Yeah, yeah.

• 19:24Speaker 01

  I'm like, I will accept that suck it up kind of mentality upfront.

• 19:28Dr. Darshan Shah?

  Right.

• 19:28Speaker 01

  And then, you know, that's usually not how I encourage my patients to make changes. But for me personally, with my personality, that was better for me.

• 19:35Dr. Darshan Shah?

  That was better for you. And some people, they just have to, you know, people come to us. Sometimes they need to make a lot of changes quickly because they've hit a wall, you know? Maybe they're 50 pounds overweight, maybe they are now just got a diagnosis of prediabetes or diabetes, or they come in with severe perimenopause symptoms. Sometimes those patients are willing to make many changes rapidly. What I'm seeing a lot more of now, and I don't know if you are as well, you probably are, is people that are now have their, have their minds wrapped around proactive diagnosis and being more proactive. So you can make, like you said, course corrections early. So you don't end up hitting a wall in the future. And I'm really looking forward to a world where that is the standard, right?

• 20:19Speaker 01

  That would be amazing. And I think for myself, you know, being able to look retrospectively over the last 10 years, I think that the women that are in particular, and that's the population of people that I speak to, but even looking at my friends and their significant others or spouses, men go through andropause too. It's just not nearly as dramatic. And as men kind of sit back and they're looking at their wives kind of humored, like, what are they going through? I want to better understand it. And so I think from many different levels, when we're looking at these changes that are happening in sex hormones, understanding it is normal, but normal doesn't necessarily mean optimal. And how can we navigate these conversations so that people can be both proactive

• 21:01Speaker 01

  and feel supported? And that means having the conversations earlier. That means, you know, when someone's 30, when of course they think they're going to live forever, they're never going to get sick, even talking to my, you know, I have a 19 year old and explaining to him, you know, maybe in 10 years, things will be a little bit different. But just understanding the way that things change physiologically, whether it's, you know, bone and muscle mass, whether it is understanding the The changes of losses of insulin sensitivity that can happen. Just explaining to them about the physiology of their bodies.

• 21:29Dr. Darshan Shah?

  Right.

• 21:30Speaker 01

  So that they have, they can be more anticipatory as opposed to reactive, which is how the traditional allopathic model is kind of designed to be. It's like, oh, it's like whack a mole. Like, oh, you got a symptom, let's hit the symptom with a pill and then we'll move on. And when another symptom develops, you know, and to give context to listeners. As an example, like one of the frontline drugs to treat hypertension or high blood pressure is diuretic therapy, okay? And so we prescribe a lot of diuretics in cardiology. And diuretics are both good and bad, right? They can be very cost effective, they can be very helpful for managing blood pressure, but they can also create other problems. And so certain drugs would then lead to low potassium. And so you'd add, you know, potassium. And then, you know, patients that they were on enough of certain diuretics, they might end up getting gout.

• 22:13Speaker 01

  And so gout is this painful joint condition. And so it's just like, it becomes this domino effect of

• 22:20Dr. Darshan Shah?

  Right.

• 22:20Speaker 01

  You prescribe one drug to treat one issue that then begets another issue, which then begets another issue, and it just becomes this domino effect. And in fact, in cardiology, we used to not laugh, but we were humored sometimes at the amount of drugs our patients were on. Sometimes 25, 30, 50 drugs.

• 22:37Dr. Darshan Shah?

  It's crazy.

• 22:37Speaker 01

  And that was normal.

• 22:39Dr. Darshan Shah?

  Yeah. Yeah, and that's a perfect example, I think, hypertension of how allopathic medicine is structured, right? If someone comes with hypertension, you don't even talk about what the cause is. Like, what's causing this hypertension? Why is your blood pressure high? We know this multifactorial. All of those factors can be addressed and you can reduce your blood pressure significantly. Instead, what we do is give someone a medication, a diuretic makes you basically pee volume out. So now you're dehydrating your body so that you have less volume in your blood vessels. So you don't have to have such a high blood pressure, which is so enigmatic of what every medicine basically does, right? It covers up the symptom without even addressing the problem.

• 23:22Speaker 01

  Yeah.

• 23:22Dr. Darshan Shah?

  Which is, which is the big problem, which is the, the whole challenge here, right? And that's why people just get on 50 medications, one right after the other.

• 23:29Speaker 01

  Well, and it's interesting. So I, you know, my, my father passed away last year, but we would have a lot of conversations. He was put on a statin very, very early. My dad was not an obese individual. He was insulin sensitive, but you know, we just have these genetic susceptibilities. And I would say to him, Dad, I want you to understand the side effects of this drug. And, and by no means if anyone is listening that is taking a statin, I'm, I'm not suggesting that you stop it. But I would talk to him about mechanism of action. He was very smart. And I would explain to him, you know, maybe if we could change some of the things you're doing with your diet, maybe you wouldn't need medication because you're on quite a heavy dose of this statin agent. And you know, ultimately we did see some side effects from the statin. But it was interesting that his prevailing perspective, and he was born in 1942,

• 24:14Speaker 01

  was this is what my doctor told me to do. I'm not questioning it.

• 24:18Dr. Darshan Shah?

  Yeah.

• 24:19Speaker 01

  And, you know, you're my daughter, but like, you know, you're, you're not being objective.

• 24:23Dr. Darshan Shah?

  Right.

• 24:24Speaker 01

  And so I remember saying to some of my brother, I was like, it was amazing to me that generationally I would see certain types of patients that were not willing to question their provider. And I encourage everyone, like, ask questions. If your provider is really good at what they do, they will welcome your questions. As I encourage people to do all the time. But my dad, he was, you know, at that, that kind of tail end of the 1930s into early 40s, not willing to tell his provider that he was not comfortable with that decision choice. And just took the statin, which, you know, again, the, the side effects are many. And he definitely experienced them quite significantly.

• 25:01Dr. Darshan Shah?

  Yeah, see, and I think rightfully so now things are changing. I think, I think people are asking more questions. They can get on ChatGPT and ask ChatGPT a question. So it's great that people are asking more questions, but there's still a significant portion of the population that doesn't really ask the questions. They still do the same thing. They just take whatever the doctor prescribes and they don't even know what it does or how it works. They just take it because my doctor told me so. A lot of times these doctors have only spent 15 minutes with them and they're treating a number with a drug without the entire context at all, because they just don't have the time. They, they just prescribe the drug, you know, and it's a. It's a tragedy, I think. I think that's why statins are the most over prescribed medication in history right now.

• 25:42Speaker 01

  Well, and I personally have been told multiple times many years ago that, oh, you have a high LDL. You should be on a statin. And I knew better. And I would just say, thank you for that information. But no, I don't. You know, and the other thing that I think is important is that when we're having these conversations around medications, and especially about these short visits that providers are kind of beholden to because of the current medical model and insurance reimbursement. There's an interesting story that I always like to share to give everyone some perspective.

• 26:11Dr. Darshan Shah?

  Yes.

• 26:12Speaker 01

  There was a wonderful cardiologist that I work with. He was very good at what he did. And he would comment, he would say, you know, how did you get the patient to tell you all this information? And I would say, well, I listen. And he said, well, you do more than listen. But he's like, here's the thing. You don't ever let the patient have, if they come in with a list of questions, he who holds the list is in control.

• 26:31Dr. Darshan Shah?

  Uh huh.

• 26:32Speaker 01

  And so his job, he'd say, your job, I'm going to give you some advice, your job is to get the list away from the patient. So you control the narrative. And I remember I was so shocked that he said that out loud. And I just said, okay, thank you for that. But it reminded me that there are a lot of providers that feel that way, that they're so pressed for time, that they want to ensure that they get your top question answered, but they are not going to make more time than what they are capable of in that model to answer those questions. But it's a kind of a statement of a lot of what is wrong with the current model, that providers feel that pressured, that they want to have control over every variable to ensure that they can get out of that room as quickly as possible.

• 27:16Dr. Darshan Shah?

  Yeah.

• 27:17Speaker 01

  And I believe, and I endeavor, and I believe this fervently, most providers really love their patients. They love being a provider. They want to deliver high level care. They're just incredibly constrained in the current medical model.

• 27:29Dr. Darshan Shah?

  Yeah, I think most people going to medicine, they wish they could spend an hour with every patient and treat it like a case, right? I remember doing cases in medical school and we would spend three hours discussing one case and that's the way, you know, we learned medicine. But unfortunately, because you get paid $50 a visit by insurance, you have employees to pay, you have the lights to pay for, you have your rent. There's no way you're making all of your bills if you don't see 50 dated patients a day. And so you have to stay within a certain time period. And unfortunately, that's how the whole system is built right now. People can get out of this system now if they invest a little bit more money into their health by finding providers like yourself, but it does take some investment, investment of money, time, resources.

• 28:13Dr. Darshan Shah?

  And yes, you know, I think we have to get out of this mindset that insurance is going to pay for this because if you think about it, you have car insurance, right? Insurance is for disasters. If your car gets into a car accident, you call your insurance and you say, hey, I got into a car accident, will you help pay for this? You don't call your car insurance to do your oil changes, to put gas in your car. It's not meant for that. Insurance is in the health world has become, yes, is there for disasters, but it's also become kind of like a discount card. Like now I can go see that primary care doctor for a $20 copay versus the $500 or $400 I should be paying for two hours of this person's time to really sort through all my health issues. And unfortunately, it's not meant for that.

• 28:58Dr. Darshan Shah?

  That's, this is the system that has been created because people expect their insurance to pay for health care. It's really there to pay for sick care and disasters, not for health care, unfortunately.

• 29:08Speaker 01

  Yeah, and it's interesting, this past year, you know, my, my husband got sick in the fall, and we were talking about this before, and my husband, never having been sick a day in his life, when he started seeing the hospital bills coming in, he looked at me and he said, now I understand why we have insurance. We didn't pay a dollar. And he had hospital bills that were six figures.

• 29:30Dr. Darshan Shah?

  Yeah.

• 29:31Speaker 01

  For two hospitalizations and a big surgery. And so, you know, from that perspective, I a hundred percent agree with you. And what's interesting is we now pay extra to a functional medicine provider, myself. Like I don't treat myself and I don't treat my husband and I don't treat my kids. And they're getting a level of care and attention that is allowing me to feel like I can exhale a little bit. And I think for many, many people, it's understanding that yes, we have insurance for catastrophic events, God forbid. But like the day to day and the, you know, having someone that can spend more time with you and can really look through your medications and, you know, go down a rabbit hole to look at labs from a different perspective, that is the investment that we choose to make. And I always say it's a choice and it's something that we choose

• 30:16Speaker 01

  to make. Like, we aren't people that eat out very often. And I'm like, I'd rather take that money that I would use to eat out every week and use it for, you know, a higher level of care.

• 30:24Dr. Darshan Shah?

  Right.

• 30:25Speaker 01

  And especially for what my husband went through health-wise last year. I was like, I'm so grateful that we have the ability to do this because there were things that got missed along the way that had he been, had he been part of this practice at that time. And my husband's incredibly stubborn. I'd been trying for about six months. And I, as I said to someone, you know, you can only encourage your spouse only so much. And then maybe they had to wait till they had a big hospitalization. Like, okay, I surrender.

• 30:49Dr. Darshan Shah?

  Yeah.

• 30:49Speaker 01

  Now I know that I need this, this level of care. But I think for so many people, we have to shift that mindset around insurance is going to cover everything to understanding that we may need to pay out of pocket for some resources and that ultimately that will allow us to, you know, probably, you know, age in a way that allows us to be in alignment with our values.

• 31:09Dr. Darshan Shah?

  Exactly. And that's my, one of my missions is to kind of uncouple these two systems. You have a sick care system and then the next health, you know, we are their health, the true health system, right? And a lot of people, what they're doing now, and this is what I've done, is I only pay my insurance to cover for disasters. So I have like, you know, disaster care insurance. Everything else I put into my HSA plan and I use it for my own functional medicine physician and some of the other things that I do on the health and wellness journey. And my thesis is the more I can focus on my health and wellness journey, checking my biomarkers every quarter, working with a functional provider, integrative provider, the less I'll have to use this disaster care, right? And the

• 31:52Dr. Darshan Shah?

  longer my health span. And I think the more we get our mind wrapped around creating these two separate journeys, pathways, the, the longer we'll all live, the more health spend we'll have. But also, The less we'll utilize the sick care system, right? And then that will unburden that system, making it less expensive in the long run for us. I think that's the only solution here.

• 32:15Speaker 01

  Well, and it's interesting because I think a lot of people still pay five, six hundred, seven hundred dollars a month for insurance that they themselves are not per se using. And that could be better spent with disaster care coverage. And that I know we max out our flex spending because that's what I use for most of our, most of my medications and things like that, as well as those monthly fees that we're paying for that functional integrative medicine care. And it's interesting because it's starting to shift. But I think for many people, they're still kind of beholden to that, that kind of traditional model of, oh, you know, 30 years ago, yes, you probably could get most of your care in a, in a traditional model because 30 years ago, things were very different.

• 32:58Speaker 01

  Even, I mean, I remember in the 1990s, ER medicine was totally different. Those ER doctors worked up everything before they called in a specialist. And then as I was kind of leaving cardiology, we would get called if a 20 year old came in with chest pain. Totally different emphasis.

• 33:13Dr. Darshan Shah?

  I know, I know. So let's dive into a couple of health topics that I really want to talk to you about. And I wasn't going to talk to you about this, but I think we should anyway. You mentioned statins a couple of times. And so, you know, one of the things you said was my LDL was high and they prescribed me a statin and I said, no way. And I would love to unpack that a little bit because I think a lot of people hear that statement. Your LDL is high, here's a prescription for Crestor, right? And so why is LDL not necessarily an indicator of heart disease?

• 33:42Speaker 01

  Well, I can say that if I were to look at the way that I practiced in 2000 and 2001, when I was a new nurse practitioner, was that we really looked at this very narrow lens with what was driving, you know, this heart disease paradigm. We weren't thinking about insulin resistance. We weren't looking at these other biomarkers. And so we would look very transparently with a LDL is must be this driver of what is leading to plaque progression, whether it's cerebral vascular, cardiovascular, peripheral vascular disease, that is what the primary driver. And so we steadfastly hung On to that model of high LDL equates with cardiovascular disease. Instead of looking at other things like, you know, low HGL being much more predictive with high triglycerides.

• 34:27Speaker 01

  And, you know, it's kind of a vault or saying to patients, your total cholesterol is high, therefore you need a statin. That is, in fact, the way that a lot of people have practiced for a very long period of time. What has started to emerge is this other, you know, heart hypothesis, really looking at what is the primary driver of inflammation oxidative stress. In many instances, it can be insulin resistance. But it's also looking at other types of lipoproteins and other types of lipid particles. Things like apolipoprotein B is being, you know, one, but the really, the torch bearer is really this lipoprotein, so LP little a, which is both genetic. And what's interesting is if you look at a lot of individuals, and if I remember the

• 35:10Speaker 01

  data from my conversation with Tom Dayspring, really looking at, you know, there's subsects of the population walking around not realizing this is this elevated LP little a in and of itself is the driver of inflammation oxidative stress and can lead to this plaque burden and buildup inside the endothelium, inside the lining of our vessels. And so we've, we've kind of starting to pivot away from that kind of heart disease paradigm. But I can tell you without question, because we get questions, thousands of questions every year around this in particular, helping people understand that LDL in and of itself is not the, you know, forebearer of doom. And many people like, you know, there's, there's research coming out about these lean mass hyper responders that, you know, I'm one of them.

• 35:54Speaker 01

  I'm, I'm a lean mass hyper responder. You know, this is kind of a developing paradigm or differing perspective that you can have a relatively healthy lifestyle and still have this elevated LDL. It doesn't equate to having plaque burden. Now, the other side of that is, you know, years ago, we just did stress testing. And if you really were concerned, we might do an angiogram. We might go in and look and do a cardiac cath. But now we're looking at different types of testing, looking at, you know, a CAC, a coronary artery calcification, which that can be helpful for, you know, looking is, is that zero? If it's zero and you have abnormal lipids, that's probably not as big of a deal. Looking at, you know, more non-invasive testing like CIMT, which is looking at your carotids,

• 36:35Speaker 01

  or doing even moving to a CT angio, which for many people can be very helpful. But usually you take that along with symptoms to make a determination. There's even this clearly that now a lot of people are doing testing with. And so, you know, thinking of LDL as the only reason or the only manifestation of this progression of cardiovascular disease is really missing an opportunity to look a little bit more deeply. And so I think most people that are developing vascular disease, there is a genetic component without question. I'm one of these people. My LP little a, when it was first drawn, I nearly fell over. With that being said, there are ways that you can address that without a statin. But also looking at plaque burden, you know, looking at the other diagnostic testing

• 37:17Speaker 01

  to see if you are at risk or if you are someone that really needs to be watched and monitored really carefully. I'm curious for you, when you're working with your patients, are you doing clearly? Are you doing, yeah, you're shaking your head.

• 37:30Dr. Darshan Shah?

  Yeah, shaking my head on everything that you're saying because I think, well, people don't really understand in the last five to eight years, there's been a massive shift in the technology available to us to really treat cardiac disease the way we should be treating it, which is not jumping from LDL to statin. Instead, now we have a lot more clarity into what's actually happening at the vessel level of your heart. We never had this before. That's why people did stress tests, which is a way late indicator. If your heart is not getting enough blood when you're stressed, that's a problem.

• 38:02Speaker 01

  Or if your EKG is.

• 38:04Dr. Darshan Shah?

  Or if your EKG is abnormal, right? We never had this level of clarity until the last few years, I would say, where we can actually do a CT angiogram, which is, has better resolution than a real angiogram. Because now you can see every vessel, every soft plaque, every hard plaque. But the sad thing is for. Two decades, we've had the CAC score available, the calcium score, but insurance never paid for it, which made zero sense to me.

• 38:29Speaker 01

  It's like a hundred dollar test.

• 38:31Dr. Darshan Shah?

  It's a hundred dollar test.

• 38:32Speaker 01

  It's totally frustrating for me is,

• 38:33Dr. Darshan Shah?

  Right.

• 38:34Speaker 01

  You know, let's talk about, you know, resources. This is something that is accessible to most, if not all people. And yet we're still doing what I consider to be in many instances testing that's not nearly as effective or diagnostic or sensitive.

• 38:48Dr. Darshan Shah?

  Yeah. And I think the reason for this is because a lot of medical guidelines are passed down to what works at a population level, right? At a population level, yes, we can get LDL levels on people. That's not too expensive for the nation. That's not too hard for the nation to do. But it is harder to get a CAC score because you have to go into a CAT scanner for 10, 15 minutes, right? That's much less accessible. We're not going to be able to screen the entire population with that because we just don't have those resources. However, I think if you are someone that has some resources, it shouldn't be completely hid from you as though something that you should never even consider, right? And so I think that's something to take into account.

• 39:31Dr. Darshan Shah?

  And LDL scores as well, like I think that we've had these cholesterol panels for decades and only recently have we upgraded to what I consider, we should even just stop looking at LDL. I just look at APB and LP little a now. That's, those are the two indicators that I look at. And what's incredibly surprising to me is 90% of the people I see in my practice here have never had either one of those checked.

• 39:59Speaker 01

  It's unbelievable.

• 39:59Dr. Darshan Shah?

  Even though they're visiting their primary care doctor at age 55 for a yearly visit.

• 40:03Speaker 01

  It's unbelievable. And what's interesting to me is that they're not expensive tests. So if someone's listening and they're like, oh, is this one of these integrative medicine tests? It's going to be expensive. They are very inexpensive. And what's interesting is if your LP little a is normal, you never have to have it tested again.

• 40:19Dr. Darshan Shah?

  Exactly.

• 40:19Speaker 01

  And I think that's what's significant. It's not a, oh, I have to keep monitoring this forever and in perpetuity. Now, what I think is interesting is these conversations are so important because it could save someone's life.

• 40:30Dr. Darshan Shah?

  Right.

• 40:31Speaker 01

  Really and truly, because we know, at least for women, the number one cause of death is heart disease, not breast cancer. And it's important to screen for breast cancer, but number one reason women die, one in three, is because of heart disease. And we should be screening men and women earlier and younger.

• 40:48Dr. Darshan Shah?

  Yeah, completely agree. And I feel that. Unfortunately, women, for some reason, don't get screened for heart disease as much as men do.

• 40:58Speaker 01

  Well, statistically, we present differently. Women generally tend to present later. We're the caretakers. We worry about everyone else and ourselves last. Women typically don't get those typical, I have crushing left chest pain, I have pain down my arm, I'm having jaw pain. I've had women that literally their only symptom has been fatigue. I had one elderly non, she had pain in her left hand. And everyone kept working her up there like, oh, you've got cervical radiculopathy, you've got all these, you have diabetes, it has to be this. And I think that part of the impetus of why I think these conversations are so important, number one, is just to bring greater awareness that not every patient presents the same way.

• 41:41Speaker 01

  But women in particular, we tend to have more small vessel disease, which is the stuff that can't be stented. And so, we just have to understand our physiology is a little bit different. And we know that we are largely protected until we go into menopause. You know, the estrogen is a very important hormone for a lot of different reasons. It's involved in immune function, you know, it's involved in inflammation. And so, helping people understand that, you know, men may have that classic crushing chest pain symptom, and that's usually how my patients presented. Women might be totally different.

• 42:13Dr. Darshan Shah?

  Yeah, that's such an important point, for sure. So, men and women, in your practice, at what age do you generally start checking blood tests like ApoB, LpA?

• 42:23Speaker 01

  North of 40. Without question, because I tell them, listen, if your LpA is low, you never have to check it again. Now, Apolipoprotein B, I think, is certainly one of those that I like to monitor it. And what I find is if I look at a, and I haven't done a study on it, but if I look at my population, watching them as they're traversing perimenopause and menopause, we know, once you hit menopause and that loss of estrogen is catastrophic and drops quite substantially, all of a sudden, your lipid markers may look very different. That is certainly what had happened to me. I would not have believed it if I had not seen it on myself. You know, a significant 20 to 30% higher increase. And not just total cholesterol, LDL, but, you know, looking at my ApoB, looking at my LpA, I was shocked.

• 43:08Dr. Darshan Shah?

  So even your LPA went up with menopause?

• 43:11Speaker 01

  It was already high. It was already high. Let me be clear. It's not like it went from being low to suddenly high. It was already high to begin with and it just got even a scooch worse. Like, I was shocked. It was like, I wouldn't have believed it had it not been on myself.

• 43:24Dr. Darshan Shah?

  And was hormone replacement therapy helpful in reducing your lipid markers?

• 43:29Speaker 01

  Yes, absolutely. And to me, it was like, the more I understood about the role of estrogen, and certainly now, after writing a book that I spent a whole chapter talking about immune function and sex hormones, I'm like, holy cow, now it makes so much more sense. So this is one of many reasons of why I think HRT and bio-identical hormones can be really an important conversation to be had, not just for women, but also for men as well.

• 43:53Dr. Darshan Shah?

  Absolutely, absolutely. And I think, you know, the more conversations I have around this, you just realize more and more how integrated everything really is. We would never talk about hormone replacement therapy in relationship to cardiac risk, right? And now, for me, it's a conversation I have all the time because they are definitely intertwined.

• 44:12Speaker 01

  Well, I think I'm almost embarrassed sometimes when I'm talking to patients and I'm like, oh, the reason why I saw so many elderly women with atrial fibrillation, that's estrogen. Estrogen, low estrogen is driving your propensity, your likelihood of developing atrial fibrillation. And I thought to myself, we were never talking about sex hormones in cardiology, ever. Certainly not in my practice. And this is a very well-regarded, well-respected practice. It's just, we tend to be very siloed in medicine. That we're like, oh, those sex hormones thing, that's a GYN problem. That's not a cardiology problem. They're like, no, we have a systemic estrogen deficiency that is impacting every single system in the body. That, if we would look at things from that lens, that makes a great deal more sense.

• 44:56Dr. Darshan Shah?

  Absolutely. And I think, you know, just even going through medical school and then training by myself, I could see why the cardiologists would not want to talk about hormones. It's just because you stop your hormone education your last year of medical school, you stop talking about it, right? Then you start going into internal medicine, cardiology, and it's hard to remember what you learned 20 years ago about hormones. And then what do you do? Refer? The woman, sometimes to an OB GYN,

• 45:20Speaker 01

  Yep.

• 45:20Dr. Darshan Shah?

  Or the man to an endocrinologist. And they're mostly treating hormonal disease. You know, they're treating thyroid cancers, for example. They're not treating day-to-day hormone deficiencies. And so it completely misses the boat in Western medicine of hormone replacement therapy.

• 45:38Speaker 01

  Well, and it makes me laugh because I have two good friends who are endocrinologists, and all they treat is diabetes and thyroid issues. That is it.

• 45:45Dr. Darshan Shah?

  That's it.

• 45:45Speaker 01

  They're like, every once in a while, we get a unicorn case. We get some really unusual case, but like, that is our bread and butter.

• 45:52Dr. Darshan Shah?

  Right.

• 45:52Speaker 01

  And I'm like, that's great. But I agree with you that I was oftentimes admonished, especially when I was a new nurse practitioner, that I would sometimes, a patient would share something. I'm like, oh, we need to call urology. And they were like, Cynthia, stop talking to the patient about anything that is not cardiac-related. But now realizing it's all cardiac-related. Like, everything begets everything.

• 46:10Dr. Darshan Shah?

  Exactly. It's so true.

• 46:16Dr. Darshan Shah?

  Dr. Shah here, and I want to take a quick moment to talk to you about metabolism. So you've probably already heard, unfortunately, 88% of Americans are metabolically unhealthy. And it's not because of what they're eating. It's actually a lot about what's living in your gut. I'm talking about your microbiome. This is the community of bacteria that controls everything from how you process sugar, to your energy levels, to your mood. There's actually one specific strain in your microbiome called Akkermansia muciniphila. That's absolutely critical for metabolic health. This is a bacteria that strengthens your gut lining. It helps you metabolize carbs more efficiently, and it increases GLP-1 production naturally.

• 46:59Dr. Darshan Shah?

  The problem is, almost everybody is completely deficient in it. And until recently, there was no way to get this. But that's why I'm really excited about joining Pendulum. They're the first company in the US to bring live Akkermansia to the market. The company was founded by PhD scientists and doctors with the Mayo Clinic as their first investor. The metabolic daily formula that I take every single day doesn't just contain acromansia, it's formulated with multiple next generation strains. And these all work together to optimize your metabolism from the inside and out. So you can track every macro and calorie if you want. But if your gut microbiome is out of balance, you're going to be fighting an uphill battle.

• 47:40Dr. Darshan Shah?

  Pendulum is going to give you the tools that you need to fix your gut at its source. Try Pendulum today. Head to my link below and use a discount code. You're going to feel the difference a healthy gut microbiome can make.

• 47:58Dr. Darshan Shah?

  So let's talk about menopause. Why do you think for so long, it's kind of a little bit of rhetorical question, but why do you think for so long, women have not talked about menopause?

• 48:07Speaker 01

  Certainly, I think that there is a lot of shame and a lot of grief for women as they're navigating the loss of fertility. I think that's part of it. You know, certainly when I think about my mother's generation, my mother never had a conversation, my mother was a nurse. Never had a conversation. None of my aunts or grandparents ever talked to me about menopause. I think women were expected to suffer in silence. And I feel like I've interviewed enough physicians now on the podcast that have said that to me, that I have to agree that I think there's been this prevailing thought process of you're eventually going to go through this and you're going to just suck it up and white knuckle it. And since the Women's Health Initiative, you don't get hormones because they're going to cause cancer. And so you just suck it up and accept it.

• 48:51Speaker 01

  And so I think that there's both a shared fear of women aging. And that's number one. I think there's, again, a lot of shame and secrecy around the aging process. Because I think even now, even with as progressive as I think we have gotten comparatively to probably our parents' generation, I still think there are women that don't want to admit like, I'm no longer fertile. I no longer get periods. It's like saying that is like the big elephant in the room. And I hope that this destigmatization continues because it is so critically important that women are speaking up and speaking out. Because in many instances, sharing our stories allows other women to talk about their stories and to normalize it. But I think in many ways, it starts when teenagers start menstruating

• 49:35Speaker 01

  or young women start menstruating. It's like fear and shame around period products and tampons and period underwear and contraception. It's like everything that evolves around sexuality is taboo. And I think the only way to move beyond that is to continue having conversations where people can openly discuss their experiences and not in a way where we are suppressing women's experiences.

• 49:59Dr. Darshan Shah?

  Right.

• 50:00Speaker 01

  I think that that is very important. And when I talk to aunts of mine who are obviously now menopausal, they'll say, well, no one talked about it. Like, I was told I was given an antidepressant because I had vasomotor symptoms. I was told that I was becoming diabetic with no one saying, well, you're becoming diabetic partly because you've lost this estrogen signaling. You know, the brain fog, oh, you just need to sleep more. Or here's another antidepressant. So I think in many ways, we have convinced women that their suffering is part of the process instead of saying, okay, what you're experiencing is real and let's figure out a way to make it better.

• 50:38Dr. Darshan Shah?

  Yeah.

• 50:38Speaker 01

  And so I think in many ways, it's multifactorial. I think there's a lot of reasons that have contributed to it, but I'm hopeful that our generation is changing the narrative.

• 50:49Dr. Darshan Shah?

  Right, right. Yeah, it's finally happening, I feel like it, but sadly, it takes a long time for the information to spread. But thank goodness for podcasts because things are spreading a lot more quickly now. And thank you for coming on this one to talk about this.

• 51:02Speaker 01

  Yeah, absolutely. But I think, I mean, and I'll be honest with you, there was a period of time. So in 2019, I was hospitalized for 13 days and I was actually quite sick. I had a ruptured appendix and got septic and got very sick. And you can imagine as a surgeon, how sick a ruptured appendix can be and a slew of complications. And I never had a period again because I lost 15 pounds and I'm not a big person. So that was the end of my, you know, that was the beginning of the end of my fertile years. And so, you know, I think there was probably two years after I was officially in menopause, I didn't want to talk about it.

• 51:35Dr. Darshan Shah?

  Yeah.

• 51:36Speaker 01

  And I kept saying like, why am I not talking? Like, I'm a nurse practitioner, why am I not talking about it? And so I do understand how women can feel a sense of stigma and shame around that aging piece.

• 51:48Dr. Darshan Shah?

  Right.

• 51:49Speaker 01

  Although now I look back and I'm like, that was so silly. Like, why would I even waste emotional energy about talking about something that's going to happen if we live long enough?

• 51:55Dr. Darshan Shah?

  Right.

• 51:56Speaker 01

  And especially because, you know... I didn't expect to go into menopause at forty eight, but it was hastened by this pesky appendix that created so many problems. But with that being said, I think for a lot of people, it is societal conditioning to, you know, kind of de-emphasize your experience, to kind of nullify your experience. And when I say this, I'm not saying that everyone behaves this way, but if I look at it as a broad contextual, like, women aren't supposed to age, like, women are given this kind of a lot of powerful messaging, whether it's the filters on social media, whether it's stuff that we see on TV, or in movies, or print ads, if anyone even still reads magazines, or stuff that we just

• 52:37Speaker 01

  see in general, I think it, I think people can be cruel and can be mean. And it's like, I sometimes will say to my husband, I'm a huge introvert, and I sometimes just love to observe people's behavior. And I'm like, you know, men, in many ways, if I look at comments across social media, men can get away with quite a bit.

• 52:55Dr. Darshan Shah?

  Uh huh.

• 52:56Speaker 01

  But you'll see a woman who's naturally aging, and in many instances, people will make comments about it. And I'm like, this is why women are afraid to talk about these things. And yet, it must be talked about.

• 53:08Dr. Darshan Shah?

  Right.

• 53:08Speaker 01

  It's so important that we talk about it.

• 53:10Dr. Darshan Shah?

  Absolutely. So in your practice, what do you consider the state of the art now for hormone care? Let's just call it hormone care to start with, and then we'll talk about hormone replacement therapy. But how do you start someone on this journey? I assume women are coming to you, maybe they're in their late thirties, or even early forties, and they're saying, you know, I feel like maybe I'm experiencing some of the symptoms of perimenopause. How do you start them on this evaluation and treatment process?

• 53:37Speaker 01

  Yeah, I mean, I would say, you know, symptoms guide everything, really and truly. I mean, you can look at lab work, and I know this can be very controversial, you know, the traditional allopathic model says, what's the point of looking at, you know, sex hormones? There's no need to do that. I'm a, I'm a data person, so I do like to look at labs. And I like to have something objective to say, okay, we just did this salivary cortisol distribution over the, over, you know, twenty-four hour salivary cortisol, looking at data points. And I can see where you're really tired, because, you know, you don't have Have a robust, you don't have a robust, you know, circadian rhythms should follow a typical kind of pattern, you know, it increases one to two hours after weakening and then ebbs and flows throughout the day and is lowest at night ideally. And so I can sometimes back it up and say, well,

• 54:21Speaker 01

  it makes sense why you're exhausted because it's not flatlined like I'm worried they have cushions, but it's, or Addison's rather, it's just, it's flat. It's evident to me that there's something quite significant going on and looking at lab where we can look at trends over time. And I think that can be helpful. So taking a really good history, which I think is the A number one biggest, most important thing you can do, you know, looking at symptoms and, and looking objectively like, talk to me about your sleep because I tell everyone if I can't get you to sleep through the night, that's A number one, the biggest thing that I have to worry about first. You know, really looking at like, what are you eating? And, and I always tell people like, don't tell me what you think I want to see. Like, I actually need to understand what are you eating?

• 55:01Speaker 01

  Because most adults are consuming ultra-processed foods. I think it's 70%. I think Sean Stevenson mentioned that last time he was on the podcast, 70% of us, that's the bulk of our diet is ultra- processed foods, which we know not only does it dysregulate hormones, but also encourages us to eat 500 to 1,000 calories more. And that's just per day. So over time, that's quite a bit. Looking at how they manage their stress and what I find is most 40-year-olds, they're not managing their stress. They think it's five minutes of meditation once a week, helping them understand like, it does need to be a proactive practice, like something we're doing every day. And then the other piece is, you know, really looking at like, what type of exercise are you doing? Because my whole generation, our generation has been conditioned that cardio is king. And

• 55:43Speaker 01

  helping people understand like, that loss of muscle mass as we are navigating our 40s into our 50s is catastrophic for insulin sensitivity. And so helping them kind of re-engineer those lifestyle pieces is a starting point, along with testing. I am a fan of testing. I like to look at a lot of different things, whether it's a NutriVal, looking at micronutrient deficiencies, whether it's looking at a Dutch test to look at estrogen metabolism, whether it is looking at stool testing, which I do on everyone. And I tell everyone, I'm like, before we do any other fancy tests, I want to know what's going on with the gut biomarkers. And then, you know, Looking at other types of serum labs, you know, blood testing labs to see what might be going on. But that is like a very kind of cursory perspective.

• 56:25Speaker 01

  I think that, you know, I would be nowhere without the health coaches on my team because they fill in the conceptual gaps in terms of information and every woman might need support in different ways. But usually people are coming, it's always weight loss resistance. That's, that is the impetus for people trying to figure out what's going on. It may not be the brain fog, it may not be the forgetting the, you know, the word in the middle of a sentence. It may not be that they have no libido, but the weight loss resistance is usually the biggest pain point. Cause they're like, I've done everything that I could imagine to fix this problem. And it's not fixable, like what I used to do no longer works. And so the weight loss resistance piece is usually the biggest question that they have. Like, why am I weight loss resistant? Why is this happening?

• 57:08Speaker 01

  But that's a starting point. Now for you with your male and female population, are you, I, I, and I, I know this question. I know the answer to this question without even asking it, but I would imagine you're doing quite a bit of diagnostic testing. You're offering that to your patients.

• 57:22Dr. Darshan Shah?

  Right. Yeah. And for multiple reasons, not just for menopause or, or andropause. We're, we're doing it because we want a full picture of what's happening. But, you know, totally aligned with you on the testing. I think that it's so critical to have the testing because I think that symptoms are great to follow. And I love, I obviously follow symptoms, especially when it comes to hormone replacement therapy. But I also find that symptoms are very lagging in a lot of disease processes to what's actually going on in the blood works. You can detect things 20, 30 years before they actually manifest themselves. And metabolic disease, obviously we know is a huge culprit there. I'm a big fan of Dutch testing as well. Could you just describe in your own words, the difference between Dutch testing, what it is and blood testing?

• 58:04Speaker 01

  Yeah. So, so I like to use both the urine and the saliva when I do the Dutch. So there's different types of Dutch's and this test can be controversial. There are people that, you know, think it's pseudoscience. I find it valuable because it allows me to look at both urinary and cortisol and saliva metabolites for cortisol and DHEA as a starting point. It allows me to get a snapshot test of. Looking at metabolites for estrogen, looking at how you break it down. You know, there's preferential pathways for estrogen metabolism. It allows me to look at, you know, byproducts of testosterone metabolism. It allows me to look at progesterone, although I don't find that to be a super valuable test for progesterone, and I always tell my patients that upfront.

• 58:47Speaker 01

  It allows me to look at oats, so the organic acid, you know, looking at metabolites for, you know, certain neurotransmitters. It can, you know, I can look at melatonin, and it's a really unique and novel. And I'm a huge believer in that melatonin is, as I know you are, is more than just a sleep hormone. It is a master antioxidant in the body. So it gives me kind of a gestalt of a place to kind of look at, like, what are the things we need to do? As an example, if your estrogen metabolites are not going down a favorable pathway, it's like, okay, is there genetics involved? Are there lifestyle things that we need to do to better support this? It can also allow me to see, you know, if you've got, again, it can be genetics, phase one, phase two, detoxification effects.

• 59:28Speaker 01

  And so, like, I'm someone that has the MTHFR mutation, so I always need phase two detox support, and that always shows up. I mean, it's a pretty consistent thing. So for me, it allows me to personalize and kind of tailor what I'm doing. But the Dutch can be done in different ways. It can be done on men and women. There are, you know, you can do cycle mapping, which I don't do much of, because most of my women are kind of towards the end of their fertile years. But you can look, I think, rather persuasively and objectively at other data points. And for me, the value of doing the Dutch is really getting that, that distribution of cortisol. For me, that's why I really like it, looking at estrogen metabolism in particular, looking at the phase one, phase two, and then making decisions.

• 1:00:11Speaker 01

  Like, for me, many times, the, the information that I receive can actually, like, point me down a direction. Is there a genetic snip that's contributing to why we're seeing very low testosterone in an otherwise, you know, very young woman? And that's been an interesting thing to learn about as a provider. It's like, oh, okay, well, there's definitely some snips that can contribute to this. And so for me, it's, it's a test that I like to offer, but I always explain the limitations, that it's not the same, per se, as looking at. Serum blood for specific markers that to me it's it's one of many detective tools that I can use to decide, okay, what direction do we want to go down now? One thing that I always say is that if you are doing a Dutch with a provider, make sure it's actually someone who's looked at a lot of them because it is quite a complicated test.

• 1:00:56Speaker 01

  And sometimes I actually get referrals from other providers to say, I ran this test on my patient, I have no idea how to interpret it. Would you mind like taking a look at it and giving me some perspective? So it's definitely not an uncomplicated test.

• 1:01:09Dr. Darshan Shah?

  Right, right. It's pretty complex and you need to have some experience reading it for sure. But definitely, obviously, you know, we're all checking blood markers of estrogen, progesterone, testosterone, total testosterone, hormone binding globulins. I think those are all kind of where we start. And then when do you start someone? Or let me ask you before that, is every woman a candidate for hormone replacement therapy?

• 1:01:31Speaker 01

  I think it is every, every individual is worth having a conversation around it. You know, it's informed consent. You know, certainly there are people that are at higher risk for having problems than others. And so it's, it's really sitting down and having a conversation like, you know, I met someone recently who had a history of DVTs and you know, it's like having that conversation. Okay, maybe transdermal estrogen is appropriate for you, but I would never give you oral estrogen and here's why. And so I think there's very few people that it's not appropriate for. Like I use the example of vaginal estrogen should be given to everyone. You know, you and I have seen over the years of working in hospitals, what happens when women don't have enough adequate estrogen and develop urosepsis and in many instances

• 1:02:14Speaker 01

  get very sick, end up in the ICU and in some instances can die and that can be largely preventable. So vaginal estrogen is a yes for most, if not all, and I like to compound it so that they get more than just estrogen. When I think about conversations around transdermal delivery systems for most of these drugs, I think that's makes things less likely to have side effects. It doesn't mean it's impossible not to. When I think about who's appropriate, who's not, it's really sitting down and it's like, what's your personal history? What's your family history? What are the things you're concerned about? What are the symptoms that are really bothersome? Can we help avoid them? I think that, you know, one thing that I found that's been really interesting is that pregnant alone is this memory hormone that I I test on everyone.

• 1:02:58Speaker 01

  And most women are really worried about cognitive decline. And so pregnant alone is not per se something you have to have compounded. There's actually supplements over the counter, just like DHEA. And hopefully, cross my fingers, that won't change anytime soon because it makes it pretty affordable for people. But kind of looking at those different variables to determine what makes the most sense. But I think when we're talking to women in perimenopause and menopause, it is driven by symptoms. It is driven by their goals. It is informed consent so they understand the potential side effects of anything that you're prescribing. And I think most of us are doing that. But the other side of it is helping them understand that interrelationship with, you know, thyroid. How many patients are you having to address thyroid? And, you know, not making people feel like there's something wrong with them if their thyroid suddenly lags.

• 1:03:43Speaker 01

  And and they, whether it's latent Hashimoto's or Graves' disease, helping them understand that part of that complex hormonal replenishment is looking at thyroid, looking at adrenals, making sure that it's not just narrowly focused on sex hormones, but thinking comprehensively, I think is very, very important. But I would say informed consent is the most important thing. And really getting clear, some people are like, I'm not ready to dip my toe in the pond totally. Maybe I just want some compounded progesterone to start. And that's what I'm willing to do. I have a lot of women that are fearful fearful to start estrogen because they think they're going to gain weight. They're fearful to start testosterone because they're fearful that they're going to have, you know, too much androgenic stimulation.

• 1:04:25Speaker 01

  And then just helping them understand that when HRT is dosed appropriately, the side effects should be minimal to none. That is, that is what we all aim for. I think there are certainly practitioners out there that think differently and and want to, you know, they want to go different routes of administration that can, that are more likely to have significant peaks and troughs that can, you know, develop more side effects than when I I tend to be more conservative. And I think that's where my like comfort level lies.

• 1:04:51Dr. Darshan Shah?

  Yeah, no, no, that's fantastic. And, you know, one of the questions we get all the time is I have a history of breast cancer in my family. Am I not a candidate for a replacement therapy? How do you answer that question?

• 1:05:02Speaker 01

  Well, we always go back to the informed consent. I always pull out Avram Blumming and Carol Tavers's book, Why Estrogen Matters, and help them understand like, this is a process in which the information from the WHO was was misinterpreted in many instances and helping them understand that just because you have a family history of breast cancer, there's genetics that we can look at, you know, genetic markers, that's number one. In the absence of you having an increased risk based on genetics, it's, you know, let's take this low and slow and make sure that, you know, we're the nutrition, the lifestyle, detoxification pathways are all optimized so that we're less likely to develop that. It's interesting because I don't know if you've, if you're familiar with Avram's work, but he's an oncologist and he talks about how his wife

• 1:05:46Speaker 01

  and his daughter both had breast cancer. He felt strongly that his wife's circumstance, because she was menopausal, was probably in a low estrogen state, more likely to develop this particular type of breast cancer. So I always remind women that there is research that is coming out that is suggestive that, you know, if estrogen caused breast cancer in most instances, then we would be seeing a lot of younger women with breast cancer. And I'm not suggesting that doesn't happen, but that is less of a, less common. But it's really this low estrogen state that can stimulate this proliferation of malignant cells. And so number one is informed consent. Number two is doing the genetics. Number three is seeing like, what does this patient want to do? And I find in most instances, careful monitoring, you know, whether it's breast cancer,

• 1:06:32Speaker 01

  endometrial cancer, uterine cancer, just, you know, making sure they're getting their annual pap exams, making sure that they're not missing opportunities to screen. And obviously mammography is coming up as being, you know, one of these screening tools that the more information that's coming out is suggesting that there's other modalities to monitor and evaluate breast tissue, like QT imaging as an example.

• 1:06:52Dr. Darshan Shah?

  Right.

• 1:06:52Speaker 01

  I'm not sure if you're familiar with Dr. Jen Simmons's.

• 1:06:55Dr. Darshan Shah?

  I just saw something come through my desk on the new machine. Is that what you're talking about?

• 1:06:59Speaker 01

  Yeah. Yeah. Where she's there examining breast tissue. And she was a breast cancer surgeon for years and years and years. And so I think inviting those conversations to say, you know, there's no perfect screening tool, but, you know, we know that lifestyle plays a huge and enormous role in cancer risk. And so dialing in all the things that we've kind of alluded to can be very helpful.

• 1:07:19Dr. Darshan Shah?

  Yeah, absolutely. On the QT scanner, talk about that a little bit.

• 1:07:25Speaker 01

  So I know just know the basics.

• 1:07:26Dr. Darshan Shah?

  Yeah.

• 1:07:27Speaker 01

  Dr. Simmons has been a guest on the podcast twice. It's ultrasound, but it's actually more sensitive and specific than MRI or mammography. Without all the radiation, I mean, your breasts are actually in like a sound bath. I mean, and it, there's real science behind it. Like I started explaining it out loud, people are like, what? But it's, it's apparently it's supposed to be more diagnostic, less radiation. Because one of the things that Dr. Simmons talks about is that this cumulative radiation of the breast tissue over time can be problematic for potentially injuring tissue. And so, you know, her biggest thing has been, you know, what is something that we can do that is less invasive, more diagnostic? Hopefully we'll be eventually covered by insurance, but you know, a lot of insurers, they wanna, you know, they, they want their way or no way.

• 1:08:12Speaker 01

  But with that being said, like, I understand just the bare bone basics. I don't even understand all the physics involved, but now I'm gonna, I'm gonna endeavor to, to learn more so that I can speak more openly about it.

• 1:08:21Dr. Darshan Shah?

  Yeah, it can be a game changer because it also looks a lot more comfortable as far as a test goes, too.

• 1:08:25Speaker 01

  Yeah, mammography screening is not fun.

• 1:08:27Dr. Darshan Shah?

  Exactly. And, you know, there's, there's, I've always wondered, I did a lot of breast cancer surgery when I did surgery, reconstruction as well, removing tumors and then reconstructing. And I always wondered, like, you know, when you're doing a mammogram and you're putting the breast in between two plates, you're causing a lot of damage and you're concentrating the radiation exposure into that much smaller area to tissue that's being actively damaged. Again, those multiple incels at the same time cause a regenerative response that can't be a good thing over and over again, year after year, especially if you're one of these women that need special views done of a certain area. So I've always been a little bit suspect of mammography and I'm not telling women to stop getting mammograms at all. Keep getting mammograms, the best thing we have right now, combined with maybe an every

• 1:09:12Dr. Darshan Shah?

  other year MRI. However, I'm really excited about new imaging technology because I think it's really needed.

• 1:09:19Speaker 01

  No, absolutely. And I think there are a lot of people who who are scared and worried about breast tissue. And certainly, I personally have three or four girlfriends who were all super healthy, all developed, you know, breast cancer and, you know, went through a lot of surgery, a lot of radiation, chemotherapy, etc. And so I, in no way am I suggesting that screening is not not important. It's, I think we're starting to just learn that there are other options that may be more diagnostic and less likely to cause issues. What's interesting is every time I get a man, and I usually do it every three years because that's, that's what I was comfortable with. And I'm looking at the PSI, you know, the pounds per square inch that are coming down on the breast tissue, and me holding my breath the entire time and just cannot wait for it to be over. But, I mean, it

• 1:10:04Speaker 01

  is painful. And I think for a lot of women, it's one of those things like, much like anything in life. It's like you just kind of look at it, just like getting your teeth clean, going to the GYN. It's like just one of these things you have to do. But I'm excited that there might be technology that's going to help women and be able to do it in a way that's much less painful.

• 1:10:21Dr. Darshan Shah?

  Yeah, absolutely. You mentioned genetic testing. You talk about the BRCA gene test?

• 1:10:25Speaker 01

  Yes.

• 1:10:25Dr. Darshan Shah?

  Okay, great. Any others?

• 1:10:27Speaker 01

  Not for me. I mean, if I have a high index of suspicion, I have colleagues that I'll refer out to when I, when I feel like this is not my area of expertise. If I feel like there's something, if someone has a unique genetic kind of makeup, you know, I use the BRCA screening, but it's interesting to me how many people will say, oh, I've, you know, I've got a lot of uterine cancer in my family, endometrial cancer, colon cancer, colorectal cancer. I'm like, you're someone that I would feel most comfortable that you see someone that is very specialized to get their feedback before we do anything. And again, I think it just hearkens back to, you know, just being, you know, that conservative nature. Like, I'm, I'm like, I'm never going to be the person that's, I'm never going to be the person that's kind of, you know, cavalier about hormones. It's just not my

• 1:11:11Speaker 01

  comfort level. And I'd be the first person to say, as a nurse practitioner, at a time when I became an MP in like, the early 2000s, and there weren't as many of us. And I remember I felt like I had to take the extra due diligence in everything I did because our training is so different. And I remember saying that to a colleague of mine, a physician colleague, and he said, No, I totally agree with you. And so I would say like, I'm like, I'm probably a little more conservative than maybe other people are being. I'll give you an example. So I'm licensed in the state of Virginia. Occasionally, women will come through programs and they're in a group program and we can, we can facilitate a lot of things in a group program, but if they need hormones, referring them to someone in their state. And so now there are a lot of telemedicine options.

• 1:11:50Dr. Darshan Shah?

  I know.

• 1:11:51Speaker 01

  And there've been a couple of hiccups that have made me realize there are certain companies that are not in alignment with the way that I think. And I would have women, I would say to this, I would make a referral. I would say this patient, I think, needs thyroid replacement, maybe some progesterone. They always got put on testosterone. I know it's always injectable and they came back to me, they had acne and their hairs falling. They're so mad and they're like, I know you didn't do this, but what's happening? And I'm like, you know, this is a great example of, you know, route of delivery is important, too high of a dose. And then I'm feeling, you know, it's, it's like, I'm going to always be that reform people pleaser, that immense guilt of like, oh, if you lived in my state, we could have gone a completely different direction. But with that being said, I think anytime we're doing telemedicine, there's a lot of great companies doing great things, but there's also

• 1:12:36Speaker 01

  a few out there that, you know, are, are prescribing much higher doses than what I would feel comfortable with starting a patient at, or just completely negating the need for thyroid replacement when the clearly they need thyroid replacement and are just focusing on like maybe two or three sex hormones. And that's all that they're talking to the patients about, which I think does them a disservice and they're paying a lot for these medications they're getting too.

• 1:12:58Dr. Darshan Shah?

  Yeah, I agree. And I see this over and over again. I mean, this is ubiquitous in men's health especially. You know, you get an online blood test for just a total testosterone level and then they just send you hormones and you don't even talk to anybody. And what you're missing there is the big picture, right? You're missing, what is the metabolic health of this person? What is the inflammation levels of this person? What are the other disease processes going on at the same time? If you're going to an online hormone center or getting your hormones online and they're not looking at all of your biomarkers and they're just focusing on a few, that's a red flag in my opinion.

• 1:13:34Speaker 01

  Yeah, no, and it's interesting because even I was having a conversation with my husband and I said, you know, the main reasons. Why men have low testosterone right now is exposure to mycoplastic. So estrogen mimicking chemicals. Number two is insulin resistance. So if someone's prescribing you testosterone without addressing those two issues, or at least having a conversation around it, that's a huge red flag. And I have to believe that most telemed people are endeavoring to do what's right for the patient. But I do think there are some bad apples and that's on the women's health side as well. Like there's someone that will remain nameless that I interacted with when I first started hormone replacement therapy. And it was clear to me within like two months that this was not a good fit for me.

• 1:14:16Speaker 01

  And this individual is still practicing and you know, I just kind of hold my breath. I'm like, but how many people don't know better?

• 1:14:23Dr. Darshan Shah?

  Right.

• 1:14:23Speaker 01

  Like for me, I knew very quickly something was not right. But even with proper vetting, sometimes you can end up in the hands of someone that's not a good fit for you.

• 1:14:32Dr. Darshan Shah?

  Right. So your preferred route of delivery for women is a transdermal cream.

• 1:14:37Speaker 01

  As a starting point.

• 1:14:38Dr. Darshan Shah?

  For estrogen, testosterone, vaginal transdermal vaginal estrogen. And then progesterone, obviously is a tablet. So that's how you like to start women because you have less complications.

• 1:14:49Speaker 01

  Yeah, I mean, and I'll be honest, I mean, I like an estrogen patch. I think, you know, I'm someone that was using compounded estrogen for like two years. I just wasn't absorbing it well. And so I finally got to a point now I'm on an estrogen patch. I absorb it really well. And so I think for as bio individual as we are, as we navigate middle age, men and women, each one of us might need a slightly augmented regimen. And so I think estrogen is great. I think for some women, they need not just also vaginal estrogen. Some of them need DHEA and/or testosterone because we know that that can be very helpful for the muscular layer and the vaginal walls and not just estrogen is also very important. I find for a lot of people, I have women who are fearful to take estrogen. They're like, I just want the testosterone. I just want the progesterone.

• 1:15:34Speaker 01

  And so it's helping them understand like, what is the research show? What is beneficial? Again, that cognitive function is something that a lot of women get concerned about. And I'm like, I get that. I never want to be a burden to my family. In fact, I jokingly tell my husband, I slap that patch on twice a week. Because I know I'm like doing the right thing and making adjustments as we need to. Progesterone, I think is interesting. Micronized progesterone, you can buy very inexpensively. It is immediate release, not sustained release. I find a lot of women do better with sustained release formulations that help with the sleep piece. Testosterone, not everyone needs testosterone. And I know people are surprised. I think it's about 25% of women in menopause still make plenty of testosterone. I was not one of them. I think testosterone is super important, not just for, people think about

• 1:16:17Speaker 01

  it just solely from the lens of libido, but I always think about testosterone from executive function. It's to get off the couch and get moving. It is, you know, helpful for muscle, which is so precious and hard to build.

• 1:16:30Dr. Darshan Shah?

  Right.

• 1:16:31Speaker 01

  At this stage of life, you know, I'm just not one of those people that wakes up in the morning and I'm instantly buffed. I am going to have to lift heavy for the rest of my life to maintain my muscle mass.

• 1:16:41Dr. Darshan Shah?

  What do you think about pellet therapy for estrogen and/or testosterone for women?

• 1:16:46Speaker 01

  Well, I would say as a whole, I think pellet therapy can provide, obviously provide super therapeutic levels of hormones. Do I have a couple colleagues that I think probably are pretty conservative and do a nice job? Yes, because we've had conversations about that. I think the vast majority of these pellet factories, pellet mills, people might feel good initially and then they don't. And the problem is, once it's inserted underneath the skin, you are left with that for, you know, 90 to 120 days. And so I think that, I think it's controversial. I personally haven't had a patient that's done well on them. I think people that gravitate towards me are very likely individuals that are looking for a more conservative approach. But I understand, I mean, it makes sense. Like, wouldn't it

• 1:17:29Speaker 01

  be great if we just inject a little grain, it's like the size of a grain of rice, underneath the skin and it delivers hormones for three months and we don't have to think about it again? It's incredibly expensive. I think that, um, yeah, I think some women start doing it and then they realize it's incredibly expensive and that's a whole other issue. I had one woman that was in a program that said, I know my testosterone's low. My testosterone is definitely low because I can feel it. Turned out it wasn't her testosterone, it was her cortisol was low. Her testosterone was actually super physiologic and in fact so high, it was like the value I would expect a male, you know, an adult male to be within that range. You know, I've certainly seen a lot of reports of women that are having MIs because their myocardial infarctions, heart

• 1:18:12Speaker 01

  attacks, because their testosterone is super therapeutic. So I, I think that, I think in a very capable conservative hands, maybe pellet therapy. I don't, that's not what I subscribe to. Uh, but, but I do think the vast majority of people are significantly super physiologically dosed. I know that's the point of them anyway, but it, it puts them at a, at a level that, you know, if they have a side effect or a problem, there, there's nothing you can do about it.

• 1:18:38Dr. Darshan Shah?

  Yeah, cause they're already, yeah. You know, we have all the options at our clinic and what normally happens, men do pretty well on pellet therapy. Women, we always start with creams first and patches. And then if we're kind of like at a real stable dose, then we mimic that dose in the pellet.

• 1:18:56Speaker 01

  That's what I'm saying. So like in,

• 1:18:57Dr. Darshan Shah?

  Super conservative.

• 1:18:58Speaker 01

  In the hands of a conservative provider, probably great, but I think a lot of people shoot really high.

• 1:19:03Dr. Darshan Shah?

  Yeah, that's the problem. And we don't like to make anyone super, super physiologic. It's just not, it doesn't lead to anything good in the long term.

• 1:19:11Speaker 01

  No, I actually have a colleague that was given to, was given a male dose accidentally.

• 1:19:16Dr. Darshan Shah?

  Oh no.

• 1:19:16Speaker 01

  And she had every side effect you can imagine. Her voice changed, she had clitoral megaly, obviously very litigious situation because that was like a grievous error. Like not only did you get a, you got a male dose of a pellet.

• 1:19:29Dr. Darshan Shah?

  That's really hard to do because you have to put in a lot of pellets to make a, get a male dose. So it was someone that obviously did not know what they were doing.

• 1:19:36Speaker 01

  No, no. So that's why I was saying like, I, I think there are definitely, there are definitely providers out there that do a great job. And it sounds like you're, you know, very judicious and conservative and that, that is different. And so I never want to say like, absolutely, positively no. It's just, this is My comfort level and I'll leave the pellets for the conservative, judicious, careful, conscientious providers to do.

• 1:19:56Dr. Darshan Shah?

  Right. And it does take, especially for women, it takes some time to figure out the right dosing. And it's so much easier to do with cream and patches.

• 1:20:05Speaker 01

  Yeah.

• 1:20:06Dr. Darshan Shah?

  Yeah.

• 1:20:06Speaker 01

  And it's interesting to me, you know, and my team this morning were sending me questions that were being asked. We had a post on testosterone and so everyone wants to know, what's the therapeutic range? What are you shooting for? And so I was like, they'll answer this at a later date. Cause I was like, my team could spend the whole day responding to that. I think part of the interest around testosterone is twofold. Number one, I think women are curious because right now there's no FDA approved form of it, which is criminal. And number two, I think that there's a lot of, there's a lack of consensus right now about what is therapeutic for women. And so I think that, you know, whether you go based on symptoms, whether you go based on ranges, you know, I think it depends on the provider, what the answer might be.

• 1:20:51Speaker 01

  But I think more often than not, like a patient's symptoms should really guide therapy as opposed to getting very rigid. Like, oh, if it's more, if you're free tea, if you're, excuse me, if your free testosterone is outside this reference range, then there's something wrong.

• 1:21:04Dr. Darshan Shah?

  Yeah. Yeah. I agree with you. We always go based on symptoms more than anything.

• 1:21:13Dr. Darshan Shah?

  Hi, Dr. Shaw here. I want to take a minute to talk to you about cellular health. So in my clinics, I've actually seen 30 year old people with cells that look like they're pushing retirement. And I've also seen 60 year olds with cells that look like they're 40 years old. So what's the difference? It's really about how fast their telomeres are breaking down. Your cells you see are like phones and they have limited cell phone battery. Poor sleep, stress, processed foods, all of these things can drain that battery way faster than it should. So this is the reason why I partnered with IM8. IM8 powers that cellular battery. It's not just another multivitamin. It's a comprehensive 92 ingredient formula designed specifically for cellular health and longevity.

• 1:21:57Dr. Darshan Shah?

  I'm talking 900 milligrams of vitamin C. That's like 20 oranges worth of DNA protection. The clinical dose of CoQ10 that you need to power your cellular engine. You also get zinc, selenium, vitamin E, alpha lipoic acid. All of these work synergistically for cellular repair and protecting your telomeres. So instead of taking a handful of pills every day and all these supplements, IM8 actually gives you everything that you need in one scientifically formulated system. And this isn't just a theory anymore. IM8 had partnered with Oxford University, the International Space Station, San Francisco Research Institute, and they've done studies and they've gotten this NSF certified to truly power your health.

• 1:22:40Dr. Darshan Shah?

  Most people are aging twice as fast as they should, unfortunately. You don't have to be one of them. Try IM8. I actually have a discount secured for you if you go to drshah.com/IM8 or go to im8health.com/discount/drsah and you can get 20% off with my discount code, DrShah. You can also find the link below.

• 1:23:05Dr. Darshan Shah?

  You know, you mentioned the Women's Health Initiative a couple of times. And I was in medical school when the Women's Health Initiative came out. And we, you know, we were obviously taught that hormones cause cancer. Do not give them. And so now we know that that was a misinterpretation of the results. There was also a lot of reasons behind that misinterpretation, et cetera. And that, you know, you can read a lot about that in the book you talked about earlier. But, you know, what's happened is we have Two generations of women now that have missed out on hormone replacement therapy, and sadly, it's still happening. There's going to be a third generation, I feel. And we often get women in our clinic that are in their 50s and 60s that start asking

• 1:23:47Dr. Darshan Shah?

  after they've heard this podcast, or maybe your podcast, they say like, can I, am I a candidate for hormone replacement therapy? What's your opinion on that?

• 1:23:54Speaker 01

  Oh, I think it's very bio individual. And again, it's the shared consent. It's, you know, what's your history? What's your family history? What's your lifestyle like? What are your goals? You know, I think Kelly Caspersen, she's a urologist, but she talks about vaginal estrogen for everyone at any time. And so I think if someone's just looking for genital urinary support, maybe it's, it's just vaginal estrogen and that could be prescribed very inexpensively. I think when you're looking at women that are 10 years out, it's really doing a really good cardiovascular risk evaluation. And by that, I mean, all the tests that we kind of alluded to, both diagnostic and serum lab testing, and then sitting down and having a conversation and saying, you know, we may need to clean these couple of things up first

• 1:24:36Speaker 01

  before we consider progesterone. I don't really worry about, I think estrogen is, is the one hormone that I think a lot of people get concerned about. Even transdermal estrogen is not going to give you super physiologic doses of estrogen. I think if someone was talking about oral estrogen therapy, that might invite like, you know, let's do a hematologic, you know, let's make sure you don't hypercoagulable, you know, especially if someone said to you, like, I threw a clot when I was pregnant. I threw a clot when I was on birth control. Then I'm like, okay, huge red flag. Okay, we need to like, really evaluate this very carefully. I think the answer is never no.

• 1:25:09Dr. Darshan Shah?

  Right.

• 1:25:10Speaker 01

  I think that it's all about informed consent and it's making sure everything's documented. You had the conversation, you understand, like, you know, you're 10 years into menopause and is the potentiality there that you could break off a piece of plaque in an artery if we start some estrogen? I think if you're conservative, my, my statistical The statistical likelihood is probably slim to none.

• 1:25:31Dr. Darshan Shah?

  Right.

• 1:25:32Speaker 01

  But the benefits are so instrumental, are so substantial.

• 1:25:35Dr. Darshan Shah?

  Right.

• 1:25:35Speaker 01

  I really think a lot about my mom's generation and it makes me sad because how many of my aunts were taken off of HRT in the early 2000s? And, you know, in many instances, and they talk very openly, they're like, please talk about us, please educate your community, please share the things we've experienced between the neurocognitive issues, the osteoarthritis pain, you know, the chronic fatigue, I mean, all those things that they experienced, and these are, these are healthy women that are active and doing a lot of the right things. And so, you know, from my perspective, the Women's Health Initiative will go down as like one of the greatest debacles, you know, because of the impetus, because you have a whole generation, generations of clinicians fearful to prescribe hormones, generations

• 1:26:20Speaker 01

  fearful to take hormones, and then, you know, we're trying to, trying to bring things back around to explain about the limitations of the study and how they use people that were not healthy to begin with, that were 10 years into menopause and former smokers, obese, hypertensive, you know, it's like, that's not the population to use for the study.

• 1:26:36Dr. Darshan Shah?

  Right.

• 1:26:36Speaker 01

  So I think in many ways, like, we're circling ourselves back to, you know, a bit of science and talking to patients about informed consent. You'll hear me say that over and over and over again, but irrespective, even when I worked in cardiology, it was all about like informed consent, like here's, here's the pros, cons, here's, let's make a shared decision. What are you comfortable doing? What are you not comfortable doing?

• 1:26:57Dr. Darshan Shah?

  Yep. I came from surgery and is all about the consent form, so I know exactly what you're talking about.

• 1:27:02Speaker 01

  Oh, I, it's like in my sleep for the rest of my life, it's like, you know, that you think you get called in the middle of the night, like, you didn't get the patient to sign the consent form.

• 1:27:09Dr. Darshan Shah?

  Exactly.

• 1:27:10Speaker 01

  You never want to be that clinician.

• 1:27:11Dr. Darshan Shah?

  Exactly, exactly. Yeah, I ask that question because I think it's important because I think a lot of times I talk to women about hormone replacement therapy in their 60s or In late 50s and they say, well, my doctor said it's too late for me. I've been in menopause for 10 years. I can't do it anymore.

• 1:27:27Speaker 01

  Doesn't that break your heart?

• 1:27:28Dr. Darshan Shah?

  It does. And I say, that's not true. Let's do a full risk assessment. Let's look at your metabolic health. Let's look at your cardiac health and your neurocognitive. And I can guarantee you're going to feel better most times, you know? And so I think for any women that are listening to this, even if you're in that age group, it can still be a viable option for you.

• 1:27:47Speaker 01

  And we've found providers all over the United States for women that are in programs. I mean, I'm not exaggerating when I tell you, like, I don't even worry about it anymore. I just say, I know, we're going to refer you to XYZ. And I even interviewed a guest recently who said, I was, after we were done recording, I mentioned my mom is 79 and how she started HRT and then was taken off. He goes, I think you just need to go visit her and slap a couple patches on her. And I just looked at him. I was like, seriously? He goes, yeah. He's like, just slap a couple patches on her. And I was like, okay. But I thought it was so funny. He's just like, go slap a couple patches on her. She'll be fine.

• 1:28:20Dr. Darshan Shah?

  Like, at the end of the day, that's what your knees is.

• 1:28:21Speaker 01

  Right, exactly. Exactly. But I was just like, okay.

• 1:28:24Dr. Darshan Shah?

  So funny. So let me move on to metabolic health. So this is a rhetorical question, of course. Do you think that we should start thinking about metabolic health once we get diagnosed with diabetes? Or should we be looking at things earlier?

• 1:28:38Speaker 01

  Well, I remember in 2002, I was talking to a postdoc from Australia. He was an MD PhD. This is in 2002. And he said, Cynthia, I don't know what's wrong with you all in the United States. You guys wait until people get diabetes.

• 1:28:51Dr. Darshan Shah?

  Yeah.

• 1:28:51Speaker 01

  So I can assure you that I am so proactive about helping patients avoid ever developing pre-diabetes or diabetes, because I think that if you look at the research on what diabetes does to our risk factors for just about everything, atherosclerotic cardiovascular disease, stroke risk, cancer risk, et cetera, you should avoid diabetes like your life depends on it, because it does. So I'm-

• 1:29:17Dr. Darshan Shah?

  And just on that real quick, it's not like a switch is turned on all of a sudden when you get diagnosed with diabetes, now your risk factors start going up.

• 1:29:24Speaker 01

  It's been that way.

• 1:29:24Dr. Darshan Shah?

  The entire time you're developing diabetes, you're increasing your risk of everything else.

• 1:29:28Speaker 01

  Yeah.

• 1:29:28Dr. Darshan Shah?

  Sorry to interrupt you, but I think it's important to mention.

• 1:29:30Speaker 01

  No, no, no. And here's the thing, like, if you wait until your fasting glucose is 95, 98, 102 to intervene. You're already there.

• 1:29:40Dr. Darshan Shah?

  Right.

• 1:29:41Speaker 01

  Like, I think it was Robert Lustig that said on my podcast, when your fasting glucose is between 90 to 99, you are at 30% greater likelihood of developing diabetes. So that's not normal. And what do we do? I actually get chills thinking about it. What do we do? We wait till our patients have full-blown diabetes before we intervene. So fasting insulin is important. Uric acid is important. You know, A1C, do I put a lot of credence in that? I think it'd be valuable, but that, to me, is certainly not as important. It's HDL to triglyceride ratio, super important. Your waist to hip ratio, super important. You know, what a lot of people fail to recognize is there's many different things that start to happen as your fasting insulin is worsening. And, you know, it could be something like your blood pressure starts to fluctuate a bit.

• 1:30:25Speaker 01

  It could be that you're getting more frequent urinary tract infections. I mean, there's so many things that we just don't think about as a whole constellation. And then just forget about navigating perimenopause. I mean, that you're losing insulin sensitivity just like you're losing muscle mass. And all these things coming together are like the perfect toxic brew for developing diabetes if you don't work against it. So I'm a huge proponent of glucometers. I'm a huge proponent of continuous glucose monitors. I am very proactive. I have one woman that was unwilling to go on medication, and we tried everything. I mean, when I tell you everything, berberine, myoinositol, I mean, we tried everything. We even got her on metformin. She didn't tolerate that.

• 1:31:07Speaker 01

  Finally, I was like, I think we have to talk about a GLP-1. And it took her a month. And then she was finally ready. And now, finally, finally. Like, I'm starting to see fasting blood sugars in the 80s. But, I mean, it was like, you know, for like two years, she was not willing to accept. I was like, you are declaring yourself. You are there. It is time to get proactive. And on the GLP-1, she tolerates it beautifully. She's on a very low dose of tirzepatide. It's unbelievable. I think these drugs are changing the game, changing the conversation for not just inflammation, but metabolic health in a way that is unlike anything else I've seen in my lifetime.

• 1:31:47Dr. Darshan Shah?

  Exactly. And I completely agree with you. I think there's been so much media around Ozempic and celebrities taking it. And now they're shaming around Ozempic and the side effects. It's mind-blowing to me what's happened to the discourse around these medications. And everyone should know the side effects happen when you use them incorrectly.

• 1:32:07Speaker 01

  Correct.

• 1:32:09Dr. Darshan Shah?

  That's when the side effects happen, right? If you go to a provider that's judicious, conservative and is looking at your biomarkers and following the dosing guidelines and not increasing you too rapidly, the chance of you getting side effects is almost zero from these things.

• 1:32:22Speaker 01

  No, I agree.

• 1:32:23Dr. Darshan Shah?

  And some of the side effects that people talk about, oh, nausea and, you know, constipation, those aren't side effects, those are effects. Those are gonna happen, you're gonna get through them. But when you look at GLP-1 specifically for metabolic health, there's nothing better out there, in my opinion, right now. The SGLT2s maybe are gonna help even more. These are a new class of medications that help control your blood glucose levels and your metabolic health. But GLP-1s are definitely, for me, a mainstay now in people that are struggling with their metabolic health. And we could talk about weight loss separately and completely differently, but I think metabolic health, 90% of Americans right now have some degree of metabolic health issues and

• 1:33:05Dr. Darshan Shah?

  has to be addressed because it is the root cause of almost every other problem out there.

• 1:33:10Speaker 01

  Well, what I find really interesting, and I have a family member that is taking a GLP-1 right now, and he said to me, "I didn't realize how much food noise I had." Because I had said, "Don't be surprised if you feel like the pantry is no longer beckoning to you at night." And that has been their greatest gift and blessing. And so it upsets me enormously when we see people with very large platforms speaking up about GLP-1s as if we are offering people poison.

• 1:33:38Dr. Darshan Shah?

  Right.

• 1:33:39Speaker 01

  When I'm like, first of all, if 90% of us are not metabolically healthy, it is a public health crisis. We need public health crisis interventions. And so, you know, from my perspective, the shaming, the blaming, the, you know, the social media people that like troll to try to like, "What celebrity looks like they lost a bunch of weight?" I'm like, "Just be happy for that person." Just like, you know, to me, I feel like we're, it's almost like Sisyphus. It's like we're trying to like push this boulder uphill and we're forgetting ultimately, what are we supposed to be doing as healthcare providers? First, do no harm. And so to me, if we are dealing with a crisis, a metabolic health crisis, the most important

• 1:34:21Speaker 01

  thing we can be doing is having these conversations and allowing patients to feel empowered to ask for a medication that we know may change their life in a really positive way.

• 1:34:32Dr. Darshan Shah?

  And I agree. I think GLP-1s, if used responsibly, will unburden our healthcare system to trillions of dollars of savings if we just get our heads wrapped around using these, first of all, responsibly. Secondly, using them as an opportunity to change people's relationship with food. And I think that's where, just like with, you know, Crestor and the statins, instead of just flinging them at people with zero advice on what to do with lifestyle, you must pair yourself, I think, with some provider, whether it be a health coach, a nutritionist. I give every patient on a GLP-1, a continuous glucose

• 1:35:14Dr. Darshan Shah?

  monitor, a nutritionist consult. I think those two go hand in hand. You can change your relationship with food, which will eventually lead to maybe you don't need the GLP-1 anymore, but let's at least get your metabolic health under control, right?

• 1:35:25Speaker 01

  No, I think it's important. I mean, the one thing I do caution people about, and I think this information is clearly getting out there to the masses. Number one, you've got enough protein. So even if you're eating less, you've got to eat your protein. Number two, you have to strength train, because the concern is that when we're losing fat mass, we're also losing muscle mass. And we all know that that can be catastrophic if we're not actively working against it. And so I think that's the other piece that none of the people are talking about, because we've conditioned our patients. You take a pill, a potion, a powder, we're going to lose weight, and then we don't have to do anything about it. It's like, let me just do this. And we're here to say, these drugs are powerful, they're important, but we also have to ensure we've got, you know, shared patient understanding

• 1:36:07Speaker 01

  that it is equally critically important that they are lifting the weights, and yes, lifting weights, and we are eating enough protein. And that might not be like every day, you may not hit your goal, but like, over time, over the course of a week, very important.

• 1:36:21Dr. Darshan Shah?

  Yeah. I think while you're on, and you shift your focus to a protein-first diet. And it makes a huge difference. And we also give all of our patients on GLP-1s a bioimpotence scale because we want them to track their skeletal muscle mass over time. And I could tell you, almost universally, we have patients maintain their muscle mass when they're on the GLP-1s because we're so emphatic about it, right?

• 1:36:41Speaker 01

  Yeah, I think the scale is really smart because then people have an objective measure at home of like what they can look at.

• 1:36:48Dr. Darshan Shah?

  Exactly. And, you know, we could argue all day about the accuracy of these bioimpotence scales, but what I can tell you is that if you do it the same time every day, which I prefer first thing in the morning before you get in the shower or after shower, you can track the trend line, which is more important than the actual number. If you're trending downward, you know, you need to increase muscle protein, increase sessions at the gym, you know, and you can head in the right direction. So that's how we how we manage it.

• 1:37:14Speaker 01

  No, I think that's smart. And what's interesting is, you know, there's like BOD Pod, there's all these, you know, options, but like not everyone has access to that in their areas. That's number one. Number two, that might be prohibitively expensive. And so I think the other piece of, you know, in this, being in this functional integrative medicine space is like trying to find what works for most so that it can be accessible, attainable, et cetera.

• 1:37:37Dr. Darshan Shah?

  Right. And these scales are on Amazon for $20. I mean, that's very accessible, I think, for most people. And it's not to measure your weight, just to be clear, it's to measure your skeletal muscle mass or your fat mass and see which direction each one of those are trending. What's the biomarker that you use for getting people's current status of their metabolic health? What is, what is the first biomarker that changes in that sphere?

• 1:38:01Speaker 01

  You know, I think fasting insulin, because I've seen people that have had a fasting insulin of 20, where I'm like, whoa, yeah, I know why you're not losing weight. You know, with intermittent fasting and strength training and whether plus or minus a GLP-1 changes in their diet. I mean, you could see a 50% drop in a relatively, you know, within a 90 day period of time. I do like the CGMs and glucometers because it allows them to have like, you know, should I have eaten 60 grams of carbohydrate with my dinner because I now know what it does to my blood glucose and my excursions? I think that can also be valuable, but I would say. Fasting insulin is a starting point because I can see an improvement pretty consistently. Whereas if they've been insulin resistant and teetering on that for years, it may take a long time.

• 1:38:45Speaker 01

  That's where they get discouraged. They're like, why is my fasting glucose so high? I'm like, well, those cells have been, you know, it's like, you know, you're knocking on a door and it's like muffled. Trying to explain like, you know, it's taken a while for those cells to get resensitized. So, you know, over time, I think that fasting glucose can sometimes be a source of frustration for patients. But I just explain, it's like, it's just the messaging has been muffled and your cells are starting to get resensitized to this important hormone.

• 1:39:12Dr. Darshan Shah?

  Yeah, I agree. And a lot of times, you know, we measure full blood panels on all of our patients like you do. And their fasting glucose is normal with the fasting insulin, like you said, is 20. And that's to me, a warning sign that we're headed in that direction. So it's incredible to me, almost no one, when they come in with their blood reports from their traditional primary care, has a fasting insulin level.

• 1:39:33Speaker 01

  No, they don't. And I mean, I've had physicians, physicians tell me, like, I don't know how to interpret this. I was like, let me help you because this is really straightforward and easy. It is not normal, like you don't look at the normal range from the lab. Like number one, number two, this is where you want it to be optimal. And I was like, draw them quarterly, but if you have patients that are prediabetic, it is criminal. Like I, I think it is criminal not to be drawing them because they're inexpensive, super inexpensive. And the patient then has another objective measure. I tend to attract women that like data too, so it's, it's not surprising that they're like data. I'm like, okay, where we were six months ago, where are we now? You know, how can we kind of look at this, you know, looking at, you know, like as an example,

• 1:40:15Speaker 01

  before we even have conversations around medical treatment intervention for lipids. We're looking at like the cholesterol balance test through Boston Heart. I'm like, are you a hyper absorber? Are you a hyper, I'm a hyper absorber, so it makes a lot of sense. It's like, okay, why don't I do well when I eat fatty foods or like fatty meat? I'm like, oh, it's because I'm a hyper absorber, way more than the average person. But hypersynthesizers, then talking about like, what's appropriate medical therapy? Like maybe you need some Zetia, which is right at the lumen of the small. Intestine. I'm like, that's a super easy drug. It's inexpensive. It was so expensive years ago. I remember calling my Zetia reps. I'm like, you need to drop off more samples because my patients, it's too expensive.

• 1:40:54Dr. Darshan Shah?

  It's so inexpensive now and it's

• 1:40:55Speaker 01

  Dirt cheap.

• 1:40:56Dr. Darshan Shah?

  I find so many people can just take that and their, their ApoB goes down to acceptable range, you know?

• 1:41:03Speaker 01

  I am, I am on Zetia and it was amazing. And it was funny, my practitioner, when we looked, did my labs initially, he was like, oh, because initially he had prescribed me an old cholesterol drug that didn't work well call for me. It just, I could take one out of six. I mean, it was like a joke. I'm taking a whiff of it. He goes, oh my God, you're totally a hyper absorber. I was like, that's why I tell you like, I'm not making this up. But like my ApoB dropped like 60 on Zetia.

• 1:41:29Dr. Darshan Shah?

  I think it's important for the audience to know what we're talking about here. Some people absorb a lot more cholesterol and your liver has a hard time metabolizing all the cholesterol. So it does actually end up in your bloodstream. The way we know that is with this special test called sterol testing. It's available on a blood panel called Boston Heart Diagnostics. So I'm a big believer of everyone that gets put on statins should also have a sterol test done because you might be able to at least reduce the dose of, of any other medications. If you're on Zetia, which is a medication to prevent the absorption of cholesterol. So it's an extremely important point.

• 1:42:04Speaker 01

  Well, and thank you for that. And, and what's interesting is I have several patients who their, their primary was saying, you need to be on a stat, you need to be on a stat. And we ran this test, you know, with their permission. I shared the results with their provider and I explained, you know, this is a test I think all of us should be running before we even have a conversation about a statin. I'm not talking about a diabetic who's had a heart attack. I'm talking about other people. But in the context of that conversation and this provider said, oh my God, I didn't know this existed. I'm now going to be ordering these. So I jokingly said to my Boston heart rep, well, kudos to you because you're going to get more business from this person who has a very large practice, but just explaining like this is another tool in the toolbox. And I, I think it also reaffirms like how many of my patients who are hyper absorbers have the same propensity of,

• 1:42:47Speaker 01

  I can't tolerate fatty meats. If I eat a lot of like fatty, I feel sick. And so the hyper synthesizers, obviously a statin would be indicated, but there are other ways to address that as well. So I think that it's another valuable test that we can offer to patients to get more clarity about what they, in their own bio individual, what their needs are.

• 1:43:07Dr. Darshan Shah?

  Right. And I agree. On the topic of metabolic health, you've talked a lot about intermittent fasting, and I would love to just get your most current perspective around it. There's been a lot of chatter around some people that should not be fasting. A lot of chatter around women and how it affects their hormones. Could you tell us kind of your current thought process around intermittent fasting?

• 1:43:26Speaker 01

  Yeah, I'm glad that you asked me. So obviously, I wrote a book that was published in 2022 called The Intermittent Fasting Transformation. So I spend a lot of time talking about this. I can always say like, it's always, this is the sign of someone who has evolved as a human being, because I still think fasting is a very valuable strategy. I find that most women fast too much, too long, too intensely. And so I think it's always in the context of if you're sleeping well, you're not over exercising, you're not over restricting your diet. Could intermittent fasting be a part of your lifestyle? If you're still menstruating around your cycle, yes. If you're in menopause, yes, it can be. Do I think that I'm a fan of women that are not sleeping, that are going through divorce, they just got laid off, they're going through a big move?

• 1:44:11Speaker 01

  There's some extraneous stress, or they just had a terrible tragic diagnosis of a loved one. There's extra stress going on in their lives, they're not sleeping well. They do chronic, high level cardio, and they never give themselves a rest day. And I see plenty of these women in programs. You know, they don't feed themselves. You know, there's a lot of women that hide their eating disorders in intermittent fasting. So those are definitely the people that I would say 12 hours of digestive rest, every adult can benefit from. And that's kind of the direction a lot of my messaging has gone in. It's, yes, I still believe in the value of intermittent fasting, especially for metabolically unhealthy individuals. But I think that there's an extreme pattern that I see. I always say it's the over fasting, over exercising, over restriction of food people that I call it the triad.

• 1:44:55Speaker 01

  I'm like, these are the people that will crash and burn in perimenopause and menopause, because their body is just under an assault of too much hormetic stress. So we talk about cold therapy, heat therapy, exercise. Hormesis is a beneficial stress in the right amount at the right time. And for a lot of people, they go to extremes. And so it's helping people like realize like, what is the right? Right relationship with meal timing for you as an individual at this point in your life. It might be that six months from now, you can go back to fasting a couple of days a week. But I just find a lot of women use it as it's like this. It's like this, um, I describe it as this ability to embrace a healthy habit and just take it to an extreme where it's no longer beneficial.

• 1:45:39Speaker 01

  It becomes detrimental. And so it's the nuance of fasting that I think is important. I think fasting in many instances, you know, this novel fasting, there are a lot of exercise physiologists that are coming out against women having fasted workouts. You know, my, my N of one experiment was last year when my dad got sick and died. I decided I was like reintegrating myself and getting serious about weight training. Cause one of the things that contributed to my dad's death was sarcopenia, frailty falls. Fell and got a subdural, two subdural hematomas. And, um, I decided I was going to hire a trainer who nicely kicks my butt twice a week. And so it's with this understanding of if I'm intermittent fasting, then I'm having trouble building muscle.

• 1:46:21Speaker 01

  For me personally, so I need to back off on the fasting. I'm still doing twelve hours of digestive rest and I don't exercise fasted ever.

• 1:46:29Dr. Darshan Shah?

  There you go.

• 1:46:30Speaker 01

  And that has been interesting. And so when I had Stacy Sims on the podcast, she was like, I'm so proud of you because you know, your platform is built on this concept and you're, and I'm like, I still believe in it, but I'm just telling you like, I transparently, my perspective is evolving as I'm trying to build muscle. And it'll probably take me an entire year to put on five pounds of muscle. And that's with HRT and the protein and the exercise. And so I think it can be the right strategy at a certain time in your life. It doesn't mean there's anything inherently wrong with it, but I find a lot of women don't do it right.

• 1:47:01Dr. Darshan Shah?

  Yeah, I, I agree with you. I think that, um, the women that do do it, in my opinion, are the ones that are having the over cardio, the over training, the over food restriction. And then they, they, they're adding fasting to that. And it's, those are the only women really doing it for the most part. And it's like, you're the, you're not, if I were you, I would, the first thing I would stop doing is the fasting and then back off the cardio, right? And then let's Even get you into a hermetic level where you're actually thriving and gaining muscle instead. What I do find it's helpful is for men and women that have some visceral fat that they need to lose, that are very sedentary all day long, that have metabolic health issues, a high fasting insulin level,

• 1:47:47Dr. Darshan Shah?

  that don't have a regular gym routine. And so you can almost tell who should be fasting and who probably should avoid fasting. But unfortunately, it's the opposite and who actually does it sometimes. And so my conversation around fasting is always like, let's look at everything else first, and then let's see if that could be a tool that we use as part of the overall program with appropriate monitoring as well. I did find fasting to be almost universally helpful in peoples who have some level of metabolic health issue and they couldn't get their continuous glucose monitor curves to not be so erratic all day long. And when they started fasting, their curves smoothed out quite dramatically, actually.

• 1:48:28Dr. Darshan Shah?

  So it's a good tool if you're struggling with your continuous glucose monitor and getting a stable glucose curve, I think, too.

• 1:48:34Speaker 01

  Yeah, I think that's a good observation. I mean, I found fasting and walking after meals, you know, because you have those gluten four transporters that'll help kind of scavenge up the glucose. So those two things for my sedentary people that are like, I'm, don't ask me to go to the gym every day. Don't ask me to do that. I'm not gonna, I'm not gonna weight train. I'm like, okay, let's just start fasting. Like, let's just start there. You have a compressed feeding window. And that can be magical because that can then lead to someone saying, okay, now I'm ready to do more because I'm seeing results. And, you know, they can be very results oriented. They're like, I've lost 20 pounds. I feel so much better. Now I'm willing to do the five other things you asked me to do. And so visceral fat is important to kind of distinguish from the kind of pesky fat

• 1:49:16Speaker 01

  that women in particular don't love. Visceral fat is what's around our, our major organs and is the pathogenic, tends to be very inflammatory fat that we want to avoid as much as possible. So when grandpa says to you that he has to drop, you know, he's, he's lost an inseam in his pants because, you know, he keeps putting his belt down lower and lower and lower. That's a sign that, you know, there might be some visceral fat issues. But it's interesting, like, observationally, when I travel, I sometimes will see people, and I'm like, I don't even think some people are even aware, like, no one's having the conversation to say, hey, visceral fat is toxic. Visceral fat is the stuff we want to avoid, like, our life depends on it. And so, you know, if you think someone having a beer belly is cute, or someone that has a body habitus of like Santa, it's, it's helping people understand, like, or women

• 1:50:01Speaker 01

  that are very apple shaped, and I see a lot of menopausal women that'll come in and be very apple shaped, and they'll say, oh, I've got a really skinny butt and legs, and I've just got a lot of fat around my abdomen. I'm like, okay, that is, that's important, and we need to talk about why that's so important.

• 1:50:15Dr. Darshan Shah?

  Right, exactly. I think, I notice a lot when I travel, too. I sometimes look around the room, and 75% of the room, they have overall, over fat visceral adiposity, and it's just, it's just so prevalent. And if there's one thing you want to focus on to work on first, I would say, is also your waist-to-hip ratio.

• 1:50:35Speaker 01

  Yes.

• 1:50:36Dr. Darshan Shah?

  Start measuring, start doing all the things. We'll do another episode on visceral fat reduction. But it's all the things, right? It's getting your glucose curve under control, looking at your hormones, reducing inflammation, and all, it all contributes to loss of visceral fat. But that's one of the first things we need to do, I think, as a population, too, is lower the amount of visceral fat we have overall.

• 1:50:56Speaker 01

  Well, and I think about, like, other, like, easy things when we're talking about this, is like, cold exposure. It doesn't, you don't have to necessarily be in a cryotherapy chamber, but, you know, 30 seconds at the end of your shower, getting some cold exposure, I mean, that can be very, very helpful for stimulating this brown fat thermogenesis. And so, for a lot of people, it's helping them understand that there's a lot we can do without, like, any fancy testing, like, things that people can do from home, because all, all patients sometimes say, like, my budget doesn't allow for X, Y, and Z. I'm like, okay, then we're going to re-engineer something that will mimic that at home. And so, sometimes those 30 to 60 seconds of cold showers can be helpful for stimulating that shivering response. We had a couple, like, household repairs where we had our hot water turned off for

• 1:51:41Speaker 01

  these things that we were doing with this exterior build, and I had more More than, more than I care to admit, several days of like cold showers. And so I kept saying to my husband, he was like, I'll just wait till the hot water comes on. I was like, oh no, I've got stuff I need to do. So I was like, this is a lot of hormesis, but it's like, this is perfect. It's like, I don't need to do cryotherapy today.

• 1:52:00Dr. Darshan Shah?

  Right, exactly. The cold shower works really well.

• 1:52:03Speaker 01

  It's very effective.

• 1:52:04Dr. Darshan Shah?

  One day someone will do a study, but obviously, you know, it would have to be Kohler or some shower manufacturer saying this is just as good as a cold plunge.

• 1:52:12Speaker 01

  Exactly.

• 1:52:13Dr. Darshan Shah?

  I wanted to touch on based on one last thing with you. I know we've been talking for a while, but you and I had a very interesting conversation about the come, about the concept of dysautonomia. And you know, you're a big follower of your HRV. And I would love for you to just talk to the audience about what is dysautonomia? Why is HRV such an important biomarker? I also think HRV is a biomarker and needs to be brought to the front of our conversation now. The more and more I learn about it, it's just so important. So take it from there.

• 1:52:43Speaker 01

  Yeah, no. So dysautonomia is this imbalance in our autonomic nervous system. And this can happen for a variety of reasons. I suspect, you know, I have multiple autoimmune conditions that are in remission, but that is probably one of the primary drivers. And I was sharing with you that I've always craved salt, but I never really understood why. So I'm someone that is very proactive about electrolytes. So you can imagine 16 years in cardiology. I mean, I am an electrolyte goddess. Like I know how to replete electrolytes in anyone.

• 1:53:11Dr. Darshan Shah?

  Absolutely.

• 1:53:12Speaker 01

  And so I was always very proactive about salting my food and electrolytes. And so I know there are things that will trigger a reduction in my heart rate variability, which is this balance between the autonomic nervous system, parasympathetic and sympathetic nervous system. You know, sympathetic is, you know, fight, flight, or flee, or fawn. And then parasympathetic is rest and repose. That's the easiest way to explain it. And so most of us are sympathetic dominant. We don't have enough parasympathetic stimulation. I know where my heart rate variability is when my autonomic nervous system is better regulated. And so for me, we were walking through Next Health and I was saying, oh, when I did H-Bot, so hyperbaric, my HRV just flew up.

• 1:53:54Speaker 01

  I mean, it was like 20 to 30 points higher than where it normally is. I know there are also things that will impact my HRV quite significantly beyond just being sick, which thankfully doesn't happen very often, but travel, especially jet lag will tank my HRV. Or the other thing that I found is really Impactful is being at elevation. So when I'm in Denver, my heart rate's like, heart rate variability is in the twenties and maybe even the fifteens. Like, I laugh about it, at least now I know. But heart rate variability is another way to objectively measure how stressed your body perceives that you are. And so for me, it is something that I'm always kind of checking in with because it is my objective, like, tell-all. Like, I'm the only person that looks at it,

• 1:54:36Speaker 01

  but it's my way of saying, I need to do a better job of taking care of me. So I just finished writing a book, and I can tell you my HRV was low for about six to eight weeks as we were trying to get it finished and brought in on time. But I think HRV is something that you can monitor through technology. So for a lot of people, your Oura ring, which is what I have on, or a Whoop band. I'm sure there's other technologies that are kind of budding that are out there. In fact, there was an influencer on social media that was trying out a bunch of different companies' rings to find out which one worked best. But this is what works well for me. But dysautonomia can show up in different ways. And for some people, it can be blood pressure-related. They can have issues with hypotension, which is, I've always had a low blood pressure, but I didn't really understand why. You know, there's specific ways that you can test for it.

• 1:55:20Speaker 01

  But for some people, they have extremes of dysautonomia. Like, there are a lot of people that I'm reading in the literature and hearing from colleagues post-vaccination are seeing a lot of dysautonomia that's significant and profound. Like, some people are debilitated by dysautonomia. We saw quite a bit of it in cardiology. We would oftentimes do tilt-table testing. But now there are dysautonomia centers that usually people will get referred to that are doing, you know, kind of cutting-edge vagal tone, things that are very beneficial. But what it has taught me personally is anything that's stimulating my vagus nerve, anything that's, you know, the vagus nerve is the longest nerve in the body, but things, you know, humming, gargling, singing.

• 1:56:02Speaker 01

  Things that bring me joy are all very important for getting me out of the sympathetic. And, you know, a lot of things that I do in my daily life that kind of help keep my autonomic nervous system. So like the right types of exercise, getting on a PMF mat, being married to someone that is very calming to my nervous system, not, not being in a house that's very stressful. Like I grew up in a house where there was a lot of yelling and screaming and physical violence. And so for me, being in an environment that's very different than that is very important. And then honoring boundaries. I would say to anyone that is, you know, addressing or dealing with dysautonomia, boundaries and having boundaries and being very clear about, you know, where your line in the proverbial line in the sand is. So when I travel, I don't,

• 1:56:46Speaker 01

  I don't overload my schedule. I'm very particular and conscientious about who I spend time with, who I spot, who I talk to, you know, the people that I, I choose to, to interact with, because I think that's also part of it. But dysautonomia is a spectrum. Mine is very mild. There are people with very debilitating dysautonomia. So I don't want to make it sound like my dysautonomia is representative, representative of what everyone experiences. But for me personally, these are the things I've figured out work really well for me. And that salt and electrolytes are huge. They're like enormous for me.

• 1:57:19Dr. Darshan Shah?

  Yeah. Yeah. I think it's an important topic for people to do more research into. Maybe we'll have you back one of these days and we'll do a deep dive into dysautonomia as well. But I found HRV to be a very helpful biomarker, and especially the better and better these rings get at tracking it. And once again, it's all about trend lines, right? I mean, you look at the trend and if you're seeing month over month, things are not headed in the right direction, it's time to make some changes. And so I had a meditation back into my life. I took a break for a couple of years on meditation, but my meditative activity now has brought my HRV back into a zone that I'm used to. And then when I had the vaccine, it totally dropped my HRV and I did a lot of different things to get,

• 1:58:01Dr. Darshan Shah?

  get it back up. It took me two years, but these are all, this is very, you know, forefront in my mind because I struggled for a long time. It's been going up and down. For a long time, and there are things that you can do. You mentioned humming, singing, breathwork, meditation.

• 1:58:17Speaker 01

  Holotropic breathing.

• 1:58:18Dr. Darshan Shah?

  Holotropic breathing.

• 1:58:19Speaker 01

  I only interject this because my own provider was like on my case for like six months. I want you to look into this. I want you to do it. Here are some resources. And I did it for the first time in September and I was so amazed as the, on the effect on my HRV for days. I was like, this 15 minute exercise. I was like, how is this possible? So I went to him and I said, I actually did it. And he said, I'm glad because you've been so resistant. I said, well, I do, you know, I'm human. But things like that can be so instrumental. So you can find what works best for you. I don't feel like I have to do it all the time, but I do find that breathwork is for me, very important. The things sometimes you avoid doing because you don't want to do it are the things you need to be doing.

• 1:59:03Speaker 01

  So I just remind myself, like, just like yoga, like I get out of habit of doing yoga and then I realize I need to do yoga more. And then I start doing yoga and I'm like, I feel better. So I think for each one of us, we have things we secretly avoid doing that we actually need to be doing.

• 1:59:16Dr. Darshan Shah?

  Exactly. All of us have those. Wow. What a great conversation. We touched on so much. I love it. You're like a wealth of information. So I can't wait for your next book to come out because I want to have you back to talk about that. Could you just give us a little preview?

• 1:59:29Speaker 01

  Yeah. So I'm getting back to my roots. My first book, obviously, is about women and fasting, but this book is, the working title right now is the menopause gut, but it's because there is so much that goes on in the gut microbiome in perimenopause and menopause that impacts bone health, immune function. It's not just about sex hormones, but it is so significant and profound. And my story that kind of starts the book off, I'll just share that that story now makes so much sense to me as to why I got so sick and led to that 13 day hospitalization. So it's going to be a book that will fit and dovetail nicely into the perimenopause books and menopause books that are out right now. And it's looking at things from a very different perspective. I mean, the changes that go

• 2:00:12Speaker 01

  on in the gut have a systemic effect, not just on mood, on sexual health. It impacts everything. And I go in and talk in depth about signaling. Molecules and do it in a way that's super accessible. And I talk a lot about hormone replacement therapy and the value of that. Because as an example, like estrogen and immunity are like peanut butter and jelly. Terrible analogy considering there's a lot of peanut butter allergies. But they go together like lock and key. And with that loss of estrogen, our gut microbiome is just much more susceptible to opportunistic infections, leaky gut, food sensitivities. There's just a lot that suddenly I was like, oh, this makes a lot of sense. So I think it'll be a really important book that will fit in nicely with the rest

• 2:00:53Speaker 01

  of the perimenopause and menopause books that are already out and that are coming out in the near future.

• 2:00:59Dr. Darshan Shah?

  Yeah, no, I think having more resources around perimenopause is definitely needed because no one's been writing about this for years. And now we do see some more, more authors like yourself and, you know, Mindy Bells, who's a friend of ours and my friend Vonda Wright. Do you know Vonda?

• 2:01:17Speaker 01

  I love Vonda. We were just texting this morning.

• 2:01:19Dr. Darshan Shah?

  Oh, that's awesome. We should send her a picture of us, but she's writing a book on.

• 2:01:23Speaker 01

  Broken.

• 2:01:24Dr. Darshan Shah?

  Yep, exactly. And so that's going to be a great book also. So I think it's, I think every woman should have a library of these four or five books. They understand what's going to happen over the next five, 10, 15 years once you start the journey. And there are things you can do. It doesn't have to be as bad as it's been for our mothers and grandmothers, right?

• 2:01:43Speaker 01

  Absolutely. And what's interesting is when I interviewed Vonda for the first time, I was telling her about the chapter I was writing, which at that time was on the gut bone axis. And she was so excited. She was like, I'm so glad you're writing this. And she's like, I'm writing a whole book about a lot of these topics. But, you know, there is so much relevancy to the things that we're just not exposed to. And so it makes it accessible, like it's written for the lay public, but I'm, I'm confident clinicians will find it to be an invaluable resource as well.

• 2:02:11Dr. Darshan Shah?

  Yeah, no, that's what I love about you in particular and Vonda and people that actually see patients writing books because I think we talk to patients every single day and we figured out the best way to make this information accessible to the regular person and how you can incorporate it into your life with the nuances of everyone is different, right? And so you have to give people different options. You have to help people find out where they are in the spectrum of the options that are available and what's going to work for their biology. And we have these conversations every single day, so we know how to do that. And so this book is going to be an incredibly valuable resource to women that are looking to navigate menopause. And specifically, like you said, it's a topic that most people don't talk about, gut health and how that relates to menopause.

• 2:02:53Speaker 01

  Yeah, it really does impact everyone. And that's the one thing that, you know, I, when I was pitching my idea to my editor, I was saying, I have this really great idea because I'm interviewing all these experts. And I'm like, there's a hole in the literature. And I have been doing stool testing for nine years, looking specifically. And I'm like, this now all makes so much sense. So, thank you for that. I look forward to coming back.

• 2:03:13Dr. Darshan Shah?

  Thank you for that. How can people find you?

• 2:03:15Speaker 01

  Yep. So probably easiest to go to my website. So it's www.cynthiaThurlow.com. Get access to my podcast called Everyday Wellness. You've been a wonderful guest on there. And I'm active, I always tell people, I'm active on Instagram. My team is on TikTok. We do have a free Facebook group that's called the Midlife Pause, backslash my name on Facebook, totally free. There are men and women in there. There are men trying to better understand their significant others and spouses. And that is a free Facebook group. And you can post questions in there that my team and I, I actually answer questions in that group myself. Yeah, that's probably the easiest way to find me. We're slowly growing on YouTube. But that's where we put the full versions of the podcast out. So people, if they want to watch the video and the audio, they can see it there as well.

• 2:03:57Dr. Darshan Shah?

  Yeah, we do the same thing. This was incredible. Thank you so much. I really appreciate you coming and can't wait for more conversations.

• 2:04:05Speaker 01

  Absolutely. Thank you.

• 2:04:09Dr. Darshan Shah?

  Thank you so much for listening to the podcast today. Please remember to subscribe if you liked this episode and give us a good review and share a link with your friends. It really helps to support all of our efforts. I also want to remind you that the information shared on this podcast is for educational purposes only and is not intended to replace professional medical advice, diagnosis, or treatment. Please consult with your healthcare provider or physician before making any decisions or taking any action based on what you hear today, especially if you have any underlying health conditions or on any medications. Your doctor knows your personal health situation the best and it's always important to seek their guidance.