How Menopause Changes Your Gut Health with a Leading Gastroenterologist

In this episode of unPAUSED, recorded on location at the Aspen Ideas Festival, Dr. Mary Claire Haver sits down with Dr. Trisha Pasricha, neurogastroenterologist at Beth Israel Deaconess Medical Center, assistant professor of medicine at Harvard Medical School, and author of the new book You've Been Pooping All Wrong. Women in perimenopause and menopause who describe bloating, new constipation, or digestion that suddenly feels unfamiliar are often told it's stress or age — Dr. Pasricha explains the real biology, starting with the estrogen receptors inside the gut's own nervous system, and makes the case for treating the gut as a second brain rather than plumbing. She breaks down why IBS affects women about twice as often as men, and why women with gut pain are so often told it's all in their heads — in her words, it's not the stress causing the symptoms, it's the symptoms causing the stress. They cover the less obvious causes of bloating — including pelvic floor dysfunction — accidental bowel leakage after menopause and how it's treated, the link between smartphones in the bathroom and hemorrhoids, what to expect from GLP-1s, and why women treating iron deficiency can often take oral iron every other day to ease constipation. Then it's the serious part: the four colorectal cancer red flags women should stop normalizing, which stool colors need attention, why colonoscopy is the only screening option that prevents colorectal cancer, and why new bloating after menopause should always be evaluated. The practical takeaways include daily fiber targets, the case for psyllium and fermented foods, why ramping up fiber slowly prevents gas and bloating, a realistic approach to cutting ultra-processed foods — and the habit Dr. Pasricha asks of her own patients: look at your stool every day, because knowing what's normal for you is how you notice when something changes. Guest links: Dr. Trisha Pasricha (Website) https://www.trishapasricha.com/ Dr. Trisha Pasricha (BIDMC Gut-Brain Institute) https://research.bidmc.org/gut-brain/people/team-member-1 Dr. Trisha Pasricha (Instagram) https://www.instagram.com/trishapasrichamd/ Dr. Trisha Pasricha (TikTok) https://www.tiktok.com/@drtrishapasricha Gut Checker (Substack) https://gutchecker.substack.com/ Ask a Doctor (Washington Post) https://www.washingtonpost.com/people/trisha-pasricha/ Books: "You've Been Pooping All Wrong: How to Make Your Bowel Movements a Joy," by Dr. Trisha Pasricha https://www.penguinrandomhouse.com/books/776380/youve-been-pooping-all-wrong-by-trisha-pasricha-md-mph/ "The New Perimenopause," by Dr. Mary Claire Haver https://thepauselife.com/pages/the-new-perimenopause-book "The New Menopause," by Dr. Mary Claire Haver https://www.amazon.com/New-Menopause-Navigating-Through-Hormonal/dp/B0CKBZ4K1Z

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

• 0:00Speaker 00

  Your gut is a brain. A lot of these diseases start in the gut years and years before that disease itself manifests. You have identified four colorectal red flags. The obvious ones is bleeding, abdominal pain, change in your bowel habits. And then the last thing is iron deficiency anemia. This is a big one. It's not the stress causing the symptoms. It's the symptoms causing the stress. The key to why IBS is more common in women than in men is that estrogen plays a critical role in pain signaling from your gut. The interesting thing is that we can treat it, though, with pretty good accuracy.

• 0:45Dr. Mary Claire Haver?

  The views and opinions expressed on UnPaused are those of the talent and guests alone and are provided for informational and entertainment purposes only. No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis, or treatment. I've heard this from a thousand women. Her gut has turned on her, bloated by the afternoon, constipated in a way she never used to be, and every doctor has told her the same thing. It's stress. It's your age. It's in your head. For years, I didn't have a better answer. The gut was not in my training. When a woman in perimenopause told me that her digestion was falling apart, I filed

• 1:27Dr. Mary Claire Haver?

  it under stress, the way we file almost everything women bring to us. And then I found today's guest, and she was saying, with the data to back it, that none of this was ever in our heads. Estrogen receptors sit inside the nervous system of your gut. When estrogen drops, your gut slows down and starts feeling pain it used to ignore. This is biological, not psychological. Dr. Trisha Pasricha is a physician scientist at Beth Israel Deaconess Medical Center and an assistant professor of medicine at Harvard Medical School. She writes the Ask a Doctor column for The Washington Post and is the author of the book, You've Been Pooping All Wrong.

• 2:11Dr. Mary Claire Haver?

  As a neurogastroenterologist, she proved the gut is a second brain and documented that medicine dismissed these symptoms in women as hysteria for over 100 years. Today, we take that back. Let's get into it. I'm Dr. Mary Claire Haver, a board-certified obstetrician and gynecologist and certified menopause practitioner. I'm also an adjunct professor of obstetrics and gynecology at the University of Texas Medical Branch. Welcome to UnPaused, the podcast where we cut through the silence and talk about what it really takes for women to thrive in the second half of life.

• 2:49Dr. Mary Claire Haver?

  This episode of UnPaused with me, Dr. Mary Claire Haver, is brought to you by Alloy Health. One of the things no one really prepares you for in your 40s and 50s is how much your skin can change. And it's not simply aging. When estrogen declines during perimenopause and menopause, skin can become thinner, drier, and lose elasticity. For years, I thought the answer was just finding a better cream or stronger retinol. But when hormones are part of the equation, skincare alone may not be enough. That's why I was so interested in the M4 skincare from Alloy, specifically designed for perimenopause and beyond. In a clinical study, 88% of women reported improved elasticity with M4 face cream.

• 3:32Dr. Mary Claire Haver?

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• 4:11Dr. Mary Claire Haver?

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• 4:27Dr. Mary Claire Haver?

  As a physician, I constantly tell women navigating perimenopause and menopause that the traditional scale simply doesn't tell the whole story. Midlife hormonal shifts change how our bodies distribute weight, making total body composition a much more clinically meaningful metric than just a single number after age 40. That's why I recommend looking into the Withings Body Scan 2. It goes far beyond the basic scale by providing medical-grade, six-zone, segmental body composition insights, including muscle mass, visceral fat, bone mass, and vascular age. Tracking bone mass is especially vital as bone density loss accelerates during menopause,

• 5:11Dr. Mary Claire Haver?

  raising the risk for osteoporosis and giving you concrete data to discuss with your doctor. What truly sets the Body Scan 2 apart from standard options is its advanced cardiovascular screening, including a six-lead ECG with AFib detection to give you a complete preventative health picture right at home. It brings the same grounded, data-driven clarity to your health that I strive to bring to my practice every day. Head to withings.com to learn more and use promo code UNPAUSED for 10% off. Consult your physician before starting any new health or fitness regimen.

• 5:51Dr. Mary Claire Haver?

  Dr. Tricia Pasricha, welcome to UnPaused.

• 5:54Speaker 00

  Thank you so much for having me. I'm so happy to be here.

• 5:57Dr. Mary Claire Haver?

  So those of you who are watching this on video, we are in a very unique location behind us. We are at the Aspen Ideas Festival, and she was kind enough to agree, we're both speakers here, to have this podcast opportunity with me. So I'm so happy to have you. I've followed you on social media for probably two-ish years.

• 6:14Speaker 00

  Oh, my gosh.

• 6:15Dr. Mary Claire Haver?

  Love everything you're doing. Your book, can't wait to talk about it and dive in. But let's start talking about gut health. This is one of the most requested topics we have from our listeners and our followers. What is a healthy gut? What does that even mean?

• 6:31Speaker 00

  Yeah. Oh, great question. Gut health is a term that is so fraught in some ways because I think traditionally we've defined gut health as the absence of disease in academia, in medicine. And I think we're learning that gut health is a lot more than just not having a disease at this point in time. And part of that is because we're learning that a lot of the diseases that don't even seem to be related to the gut, like Parkinson's disease, which is what I study, a lot of people think that's so odd, a gastroenterologist studying that. But a lot of these diseases start in the gut years and years before that disease itself manifests, and it's just sort of brewing quietly in the gut. So a healthy gut, to me, and gut health means you are laying the foundation for longevity to prevent the disease from ever occurring in the first place.

• 7:16Speaker 00

  And a lot of that has to do with diet and lifestyle and even things that we don't necessarily connect, again, to the gut, like stress management, for example, like hormones, like all of these exciting things that I know we're going to talk about.

• 7:28Dr. Mary Claire Haver?

  Yeah. I learned zero about this in medical school and absolutely nothing in residency. It's, we share, you know, you're gastroenterology, I'm OB-GYN. Our areas are literally laying on top of each other.

• 7:42Speaker 00

  Totally.

• 7:43Dr. Mary Claire Haver?

  And the anatomy.

• 7:43Speaker 00

  Close neighbors, yeah.

• 7:44Dr. Mary Claire Haver?

  And I learned little to nothing, other than how to not open up accidentally in surgery.

• 7:50Speaker 00

  Yes.

• 7:50Dr. Mary Claire Haver?

  How to avoid the gut and who to call if you did it, you know?

• 7:52Speaker 00

  Right, right, right, right.

• 7:53Dr. Mary Claire Haver?

  And so I was looking at an image of the perineum this morning and like, literally, there's a perineal body we both share in our areas of expertise.

• 8:01Speaker 00

  Yeah, and we don't have this conversation as often as we should, do we?

• 8:04Dr. Mary Claire Haver?

  Okay. So you've said, and your book, talk to me, the title of your book and why you chose it.

• 8:09Speaker 00

  Yeah. Oh, You've Been Pooping All Wrong.

• 8:11Dr. Mary Claire Haver?

  Yeah.

• 8:11Speaker 00

  Yeah. It's a, yeah, it's a conversation starter or a conversation stopper, that title, depending on who you're with. But no, I picked that title because it's the phrase I found myself saying so often, either out loud or just in my mind when I was meeting patients, because we don't talk about, we forget about, like, do OB-GYN doctors talk about GI? We don't, nobody talks about GI, I find. Like, you know, we don't talk about our poop because we're so embarrassed by it. And the last time a lot of people ever talked about it was when they were kids, when they were getting potty trained. And then they go their whole lives, never really getting formal instruction on what the science says the right way to do it is, right? Like, yeah, there's a lot of science that says this is the right or wrong way to do it, but you just don't talk about it because we're so embarrassed by it. So this book title, one, the book is like, everything I wish I could tell my patients

• 8:56Speaker 00

  if I had 10 hours to spend with each person. So it's got everything in there. But it's also like a way of just de-stigmatizing it because a lot of times we skirt around the word. If we can't even say the word, you know, then we're never going to be able to bring ourselves to just have a comfortable conversation about it.

• 9:10Dr. Mary Claire Haver?

  So what about this once a day rule? Is that a thing? Like, that's what I was taught or told, and I don't know if my mom told me that or, you know, we talked about it a little bit in medical school, but like, if you just went once a day, that's all you needed to do and you're good.

• 9:25Speaker 00

  Yeah, everyone thinks that. Everyone thinks you go once a day and you are close to God and you're, that's the end of the conversation. Not true necessarily. And that's like a big misconception. I think the idea about it was not wrong in some ways. Like, there is, your body is physiologically primed to go in the morning. And so I think that's sort of where this myth starts, going once a day.

• 9:44Dr. Mary Claire Haver?

  Why?

• 9:45Speaker 00

  Yeah.

• 9:45Dr. Mary Claire Haver?

  In the morning?

• 9:46Speaker 00

  In the morning, right. So this is something that people don't know. Your gut operates on a circadian rhythm, right? Like, you go to sleep, your colon actually goes into this very quiescent state. That's so different from your other organs. Your heart's going to still be beating. It might slow down. It's still going to Your lungs, they're still exchanging oxygen. Your colon says goodnight. It goes to sleep. And then when it wakes up, you have about an hour to two hours of a window where your colon, when it wakes up, revs with activity. So that's your moment to strike. And then the morning is also when a lot of people, they're drinking their first cup of coffee. It's gonna make them wanna go. What coffee's doing, it's activating this thing called the gastrocolic reflex.

• 10:22Dr. Mary Claire Haver?

  I did learn about that.

• 10:23Speaker 00

  Yes, very important reflex. Sometimes people are like, I just ate. How can it be that I have to poop the stuff I just ate? That's not exactly what it is. When you eat something, we think it's the mechanical stretch receptors in the stomach that are sending the signal up to the brain that sends another signal down to your colon. So you're just emptying what's already down there. You're not like shooting all that food down so quickly. That would take a long time. But you know, coffee does this really well. Decaf coffee actually does it. Warm water, like anything, like a big meal that just sort of stretches your stomach can do it. So a lot of people, again, this is why we come back to it. Once a day is not necessarily the only path to God here. People poop every time they eat. A lot of people, just a big meal will cause that reflex and that's okay. So for me, it's like a little bit less about, did I go once a day?

• 11:06Speaker 00

  It's wonderful when you lean into your body's own physiology, like when your colon is doing some of that work for you. But you know, it's gonna depend a little bit on how much fiber you're eating. If you eat more fiber, you're meeting your fiber goals, you're gonna poop more often and you should embrace that side of you. Like that's an okay thing. If you're somebody who has a lot of stress, you might actually poop a little bit less often, a little bit more, depending on it. You're traveling, your sleep is up, all of these things change it. So I don't really focus on once a day. I really focus on how you feel and whether there's a lot of effort. What I don't want is anyone to strain and I don't want anyone to feel like their social life is interrupted. Like they can't leave the house because they're so worried about that. Those things bother me more than a number.

• 11:44Dr. Mary Claire Haver?

  You know, my area of focus is health after reproduction ends for women.

• 11:49Speaker 00

  Yeah.

• 11:49Dr. Mary Claire Haver?

  And there's a lot of hormone changes going on there naturally. So what should a woman in this transition kind of expect? How are things gonna change for her? And when is it a problem? When should she seek attention?

• 12:02Speaker 00

  Yeah, people's bowel habits are gonna change. And we've studied this and you know, as you know, we need a lot more research than we have. The research that we do have tells us that there are gonna be changes for pre-menopausal women in the menopausal transition and then post-menopause. And you know, one of the biggest conditions in GI that I treat is irritable bowel syndrome. That affects about 1 in 10, maybe even 15% of Americans. So it's a huge condition.

• 12:26Dr. Mary Claire Haver?

  Is it more common in women?

• 12:28Speaker 00

  Yes, like almost a two to one ratio more common in women.

• 12:31Dr. Mary Claire Haver?

  And what is irritable bowel for our listeners? How do you define it?

• 12:34Speaker 00

  Irritable bowel syndrome, the underlying unifying theme is pain, discomfort related to your bowel habits. It can be diarrhea. There is a group of people who have more loose stools, but they have a lot of pain associated with that. It can also be constipation. It's a little bit of a nebulous catchall term, which is why there's been a lot of misunderstanding about what IBS is. But it's one of those things that is very common in younger women and it tends to get a little bit better. The pain part of it, it's actually related to estrogen levels. Gets a little bit better as we age. But that doesn't mean that the bowel habits don't change. Sometimes people, as we age, we all tend to become a little bit more constipated. For some women, and this is pretty common, we start to develop fecal incontinence.

• 13:18Speaker 00

  That becomes significantly more common as we age. That is one of those things that we don't wanna talk about. But that's, that's common in post-menopause.

• 13:24Dr. Mary Claire Haver?

  I mean, really for our listeners, what is fecal incontinence?

• 13:26Speaker 00

  Yeah. You know, people prefer the term accidental bowel leakage, but basically it's like when you poop your pants, right? Like it happens in post-menopausal women. It happens to about, to people about one to two times per month. That's the average for women. So it's huge. And so, I mean, just think, first of all, like I love, I love talking about this topic. One, because I've seen how much it can really hurt somebody's social life and they're so embarrassed about it. So I really think it's important to normalize these conversations. If you think, wait a minute, the average for a post-menopausal woman is like one or two times a month, that means it's happening to all of us, right? And so like you shouldn't feel so isolated and so embarrassed and especially so mortified to even talk to your doctor about it. You know, it's one of those things that we can actually treat, but we do such a poor job in medicine, I think,

• 14:10Speaker 00

  of reaching women and getting them to open up and tell us about it. And obviously people don't necessarily wanna bring it. They'll talk about diarrhea. They'll talk about constipation sometimes. But they're really, it takes a lot to be able to say, you know what, every now and then I wake up in the morning and there's a stain there. I don't know how that happened. Or I coughed and you know, I couldn't control it. That's important to talk about because we treat it differently and there is treatment out there.

• 14:32Dr. Mary Claire Haver?

  So is this related to pelvic floor childbirth? You know, I did learn that in residency. We had a, you know, section in uro-gynecology where we learned about the damage the pelvic floor undergoes when we push eight, nine, 10, seven-pound babies out of our perineum and it stretches and tears and rips things that used to hold all of that in.

• 14:52Speaker 00

  Yeah.

• 14:53Dr. Mary Claire Haver?

  But does this happen outside of just childbirth?

• 14:55Speaker 00

  Yes. And actually, this is something that a lot of people, I think, get confused about because we call some of the issues that we deal with in GI, really in this area, pelvic floor dysnuria. And a lot of times people are like, oh, you know, like I had some pelvic floor dysfunction related to the urinary symptoms. This is different. A lot of this is related to the anal sphincter. And right after childbirth, fecal incontinence, accidental bowel leakage is pretty common.

• 15:19Dr. Mary Claire Haver?

  Yeah. I tell patients to expect it. Some agree.

• 15:22Speaker 00

  Totally, yeah. And, and often that, that period where it's happening, it gets better over time. The problem is that then there's this like second wave that occurs later in life for women. And, and there is, there does seem to be a link to whether you've had a traumatic, in any form, injury from birth. Like maybe there was like a small tear that reached the anus, maybe it was using forceps, something like this. That does seem to increase your risk, but not always. Like there are a lot of, you can get this even without. Some of it is age-related and related to the sphincters. The sphincters, if there's, if they become a little weaker, and that can happen from neurological disease, it can happen from diabetes, it can happen from anal intercourse. If the sphincters are a little bit weaker, then you're at higher risk of fecal incontinence.

• 16:03Speaker 00

  And so the interesting thing is that we can treat it though, like with pretty good accuracy. We can treat it either by saying, what's causing that increased push? Is there some increased diarrhea? Is there looser stools that we need to stop and address? We can do that. Or do we need to do something to kind of increase the integrity of the sphincter? We have dedicated pelvic floor physical therapy with this technique called biofeedback you might have heard of. That's the technique that's been shown to be really effective in not only pelvic floor dysfunction, but also in fecal incontinence. And it can really help people. The other thing that really helps fecal incontinence is taking fiber. Specifically, psyllium husk has been really nicely studied and the nurses helped study from Harvard.

• 16:44Speaker 00

  They looked at psyllium husk and fiber intake and that seems to decrease theirs because we think it's, you know, the fiber, not only can it bulk up the stool, but we think that when those microbes in your gut process and ferment it, it can actually heighten the sensitivity of the receptors close to the sphincter. That actually helps say, wait a minute, we recognize that there's some incoming tidal wave. Let's, let's close the dam. And it does.

• 17:05Dr. Mary Claire Haver?

  Wow. Yeah. Let's talk about bloating.

• 17:08Speaker 00

  Yes, huge, huge topic.

• 17:10Dr. Mary Claire Haver?

  That is one of the top concerns that women go through the transition and they are struggling. I've changed nothing in my diet.

• 17:18Speaker 00

  Yeah.

• 17:18Dr. Mary Claire Haver?

  I've changed nothing in my exercise. I've changed no new stressors in my life. The only thing we can pinpoint is she's going through the menopause transition.

• 17:26Speaker 00

  Yeah.

• 17:26Dr. Mary Claire Haver?

  And now she's dealing with bloating and cannot understand, first of all, what is bloating?

• 17:31Speaker 00

  Yeah, million dollar question. Bloating is, you know what? It's one of the most difficult symptoms to treat, even within GI. I think it's difficult and it's misunderstood. And I think part of the reason is that, you know, we need to do more research on it. But what we know is three things. One, bloating can be related to your diet. And like you said, a lot of people haven't changed their diet. So, so usually by the time someone's seeing me, we sort of know it's probably not necessarily diet related. But for someone who, you know, is thinking about one of those things, it's, it's things like cruciferous vegetables, beans. These things can increase bloating for anyone. The second thing is, well, is it actually a subtle change in my bowel habits that I may or may not have even perceived? That's actually the second most common cause of bloating.

• 18:13Speaker 00

  And surprisingly, pelvic floor dysfunction, which does happen more and more with age, very common in women, is a cause of bloating. It's an underappreciated cause of bloating. And, and the way I describe it to patients is, well, think about your body like a box. Think about your abdominal cavity like a box. Okay, so all bloating is, is something that is causing the front of that box to push out. And sometimes the problem is there's something from within pushing out. Sometimes the problem is that the bottom of the box is or is not moving appropriately. Sometimes it's the top of the box, the diaphragm, that muscle. So actually, one of the treatments for bloating that I think is like the third and least appreciated is something called abdominofrenic dysnuria. That's a big word.

• 18:55Speaker 00

  But what this is referring to is the frenic nerve in the diaphragm. And the idea that there's actually nothing new, it's not gas, it's not necessarily stool. There's nothing pushing that box outwards. It's simply that the abdominal wall muscles and the diaphragm are not coordinating. So the box is just flattening out. It's pushing out on its own. And the problem is in the abdominal wall. Now, this hits for a lot of women because this is something that our muscles in general get a little bit weaker. We need to retrain them. And people do really well with something called abdominofrenic biofeedback. Yeah, it's the same kind of thing where you put sort of electrodes on your stomach through a physical therapist and they kind of work to retrain those muscles.

• 19:37Speaker 00

  And diaphragmatic breathing, like the kind that opera singers do, can actually also help with bloating. So this is like the third, I think, most underappreciated cause of bloating. But it is something that we see all the time in my field. So if you feel like you've tried everything, you've tried everything with changing your diet up, make sure you've investigated, really, are my bowel habits changed or not changed? Because sometimes that pelvic floor dysnuria is subtle and it's hard to appreciate that that's the cause. But if you've done that, you've looked into it, think about abdominofrenic dysnuria. Think about the fact that it actually, it actually could just be my abdominal wall and I need to strengthen and change those muscles.

• 20:12Dr. Mary Claire Haver?

  On social media, where we both have homes, second homes, I see a lot of blame for bloating going towards shifts in estrogen. Is there any truth there and shifts in the gut microbiome?

• 20:24Speaker 00

  I don't think we have the data to say yet that, I mean, I think there's a lot of blame. It's, it's, it's easy to oversimplify.

• 20:34Dr. Mary Claire Haver?

  Okay.

• 20:35Speaker 00

  The microbiome. And I think we see this in every disease field where we say, well, you know, the reason you're at higher risk is the microbiome of X disease and, um, you know, eat this food, it's going to change your microbiome. Now, that is not to say that the microbiome is not necessarily related, like all of it is related. Um, but it's too soon for us to say, okay, we know the exact mechanism we've pinpointed. I mean, it's only within the last five years that we've even really pinpointed the role that estrogen plays in IBS. I mean, all of this data is so emerging, which obviously bloating is a big part of that. So it's too soon to say, like, oh yeah, here's the one thing you need to do to fix your microbiome that's going to fix your bloating. Bloating is hard to treat, but it's often a multifactorial approach that we take and we can make a difference there.

• 21:15Dr. Mary Claire Haver?

  So walk our listeners through where estrogen and gut health kind of intersect, like microbiome, the estrabulin, is that even a thing?

• 21:26Speaker 00

  It's so cool.

• 21:26Dr. Mary Claire Haver?

  First time I read it, I was like, did someone make this up? But it's everywhere now. So like, why does our gut change across the menopause transition?

• 21:36Speaker 00

  Yeah.

• 21:37Dr. Mary Claire Haver?

  In relation to your female hormones?

• 21:39Speaker 00

  Yes. Well, this is, I think, really cool. And I think, again, there's been a lot of misinformation about this, simply because it's still an emerging field. But here's what we know. First of all, our gut microbiome, as you know, it's like shaped probably most profoundly early in life in this first couple of years, like how we're born, when we transition from being breastfed or formula fed to solid food. But we're now learning that there is this other shift that happens in our younger adult years around the time of puberty. And that's when we start to see that the microbiome starts to differ between young boys and young women, right then and there. And then as we grow older, it continues to change. And we have a number of studies that show that between pre-menopausal women and post-menopausal women, there are changes in the microbiome. We know that.

• 22:21Dr. Mary Claire Haver?

  They lose diversity?

• 22:23Speaker 00

  Yes.

• 22:24Dr. Mary Claire Haver?

  Right?

• 22:24Speaker 00

  Yes. Diversity, I'm glad you brought that up because diversity of the microbiome.

• 22:28Dr. Mary Claire Haver?

  How many? Yeah.

• 22:29Speaker 00

  Yeah. Alpha and beta diversity. These are so important when we're thinking about the microbiome because you don't just want a microbiome that has like two or three really healthy bacteria. You want a diversity of bacteria in there. And that's because different bacteria, one, serve different roles. They do lots of different things, but they also ferment different kinds of fiber. Everyone thinks fiber is the same thing. Like, there's lots of different kinds of fibers. Some bacteria ferment some better than others. But related to estrogen, what we've learned about the estrabulin, which is a really cool area of science, is that, you know, when your body, so to speak, this is simplifying it, but when your body's sort of done with the estrogen that it has produced, you can conjugate it, meaning your liver puts this molecular sort of tag onto it. And then that says, okay, great, it's ready to be excreted in your poop. It'll enter your intestine and it'll exit. What we've found now is that some

• 23:14Speaker 00

  of the bacteria that are living in your colon have a way of de-conjugating that estrogen, meaning it like takes that little molecular tag off so it can get reabsorbed and it comes back. Now, how cool is that? Because in a way, it's like, wait, okay, we're recycling some of that estrogen. Maybe this is a good thing. Um, and in some cases, it probably is. And what we don't know yet is in whom do we see these bacteria that have that capability to modulate estrogen? Why, for some people, is it higher? Is it lower? Is it necessarily tied to menopause? Is it not? And what role does this play overall in our health? We don't quite know those answers yet. What we do know is that some bacteria not only can de-conjugate, meaning they can give you back some of that estrogen, but some have receptors themselves

• 23:57Speaker 00

  for estrogen. And so they are using that estrogen themselves. And then that has other functions and changes right there in the gut lining that, but that ultimately help other parts of your body. So it's an emerging field. I think, again, it's like one of those areas that it's very exciting. We are all, can't wait to study this a little more, but it's a little bit too soon, unfortunately, for us to be able to say like, we have the cure or the way to change a lot of what's happening right here in day. But I think like in 10, 20 years, we're going to get there. I know that feels like a long time, but I'm actually very optimistic about this.

• 24:29Dr. Mary Claire Haver?

  I've been doing this for 30. Yeah. So I'm, I, I think that's, you know, reasonable.

• 24:33Speaker 00

  Now, what, the other thing we've learned about estrogen, which is really important in my field, and I think the data is much more firm about, is that the role that estrogen plays in pain signaling. No, I think we don't, yeah, right. We think about hormone. We know that estrogen in the gut, it tends actually to slow down motility. So people who take, for example, hormone replacement therapy, post-menopausal women, they actually find sometimes that their gut, their stomach slows down. It empties a little bit more slowly. We know that it can, um, cause a little bit more constipation. So sometimes that's why we think, well, maybe younger women often have a little bit more constipation. But then, as we get older, there's other factors that lead to that, even as the estrogen levels drop. But what we've learned now, which I think is sort of the key to why IBS is more

• 25:14Speaker 00

  common in women than in men, is that estrogen plays a critical role in pain signaling from your gut. So without estrogen, you actually don't perceive and process pain as strongly, right? Like, when it comes to pain, men and women are not equal. We have never been equal. Numerous studies have shown that women experience more severe pain. We need more analgesics. We don't have the same bodies. Estrogen is part of that story. So estrogen, and this was a big set of studies that have come out over the last five years, estrogen in the gut stimulates some of the cells that produce serotonin, all right there in the lining, that then send signals up to the sensory nerves of the gut, to the brain, saying, we

• 25:55Speaker 00

  are in pain. And in mice, if you take out the ovaries, suddenly, they don't perceive pain from the gut as much. And if you inject estrogen back in, then suddenly, they do perceive that pain coming from their gut. And we think that that's why a lot of younger women have IBS. As women get a little older, a lot of times, that discomfort and pain part of it gets a little better, even though maybe their bowel habits aren't, there's different changes there.

• 26:23Dr. Mary Claire Haver?

  But the way they perceive it.

• 26:24Speaker 00

  But the way they perceive gets better. And some of that can be, we think, linked to this loss of estrogen with life.

• 26:29Dr. Mary Claire Haver?

  And would estrogen replacement, have we looked at that?

• 26:33Speaker 00

  Yeah, we've looked at it.

• 26:34Dr. Mary Claire Haver?

  And I know there's, what our listeners are starting to learn, as I'm learning, is there's a big difference between endogenous estrogen.

• 26:40Speaker 00

  Of course.

• 26:41Dr. Mary Claire Haver?

  And hormone replacement therapy.

• 26:42Speaker 00

  Yeah.

• 26:42Dr. Mary Claire Haver?

  Right. We can't expect them to do the same jobs. Not all estrogens that we, you know, pharmaceuticals are equal.

• 26:49Speaker 00

  Yeah. And are they all reaching the parts?

• 26:51Dr. Mary Claire Haver?

  Yeah, they all reaching the parts.

• 26:53Speaker 00

  I would say it's too, it's early. I think we hypothesize that hormone replacement therapy, delivered in certain ways, could change that. At this point, though, I want to just be like very clear, that wouldn't be the like concern about, oh, am I going to somehow increase my risk of discomfort or IBS? That wouldn't be a reason to not do hormone replacement therapy.

• 27:12Dr. Mary Claire Haver?

  I'm not seeing it clinically, but again, this is my in of one, you know, with a few thousand patients.

• 27:17Speaker 00

  To give you like a sense of how complicated this landscape is, there was a study, a recent one that came out from California, that basically said that, yeah, like IBS does seem to get better in some ways. The prevalence goes down with age. And yet, the women, the post-menopausal women who have IBS, their symptom severity is greater than the younger women. Like, why would that be? If I'm telling you, estrogen seems to modulate pain signaling, estrogen is going down with age, shouldn't their symptoms get better? And this is why the landscape is so complicated. But we think, actually, this is a hypothesis, that even though estrogen signaling from the gut has now gotten better with age, meaning you're sending less pain signals up to the brain, estrogen signaling within the brain has changed in a way that

• 27:59Speaker 00

  may override that. Because pain, obviously, it starts in the gut, but it ends in the brain.

• 28:04Dr. Mary Claire Haver?

  Well, we, we know we upregulate our receptors because they're scrambling, looking for estrogen. Or like, if we have more receptors, then we're more likely to grab any random estradiol molecule floating by.

• 28:13Speaker 00

  Exactly.

• 28:13Dr. Mary Claire Haver?

  And that's Lisa Moscone's work, you know, looking at the brain receptors.

• 28:17Speaker 00

  And so, you know, I think that's sort of the whole thing about the gut-brain connection is you might be able to identify one part of that pathway where you're like, here's the change. This is what's, what's different. But what you don't necessarily always see in the beginning is how this is having upstream changes in the other part of that, like in the brain, is it changing? It's changes to the brain somehow impacting the gut in a way that you didn't see coming.

• 28:40Dr. Mary Claire Haver?

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• 29:21Dr. Mary Claire Haver?

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• 30:03Dr. Mary Claire Haver?

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• 30:44Dr. Mary Claire Haver?

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• 31:23Dr. Mary Claire Haver?

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• 31:42Dr. Mary Claire Haver?

  Topic of constipation, a lot of women, and I was taught to do this well by my mother.

• 31:46Speaker 00

  Yeah.

• 31:46Dr. Mary Claire Haver?

  Is reach for a laxative.

• 31:48Speaker 00

  Yeah.

• 31:48Dr. Mary Claire Haver?

  And or reach for a suppository. Or when should we use this? Is this necessary? Is there ever a good way, a bad way?

• 31:56Speaker 00

  Yeah, well, I have two thoughts about laxatives in general. Like, one, you should use them if you need them and your doctor has told you to try them. Right? And I think there's like a big barrier to using them in some sense. Like, sometimes people are embarrassed, ashamed to use them. And I sometimes tell people, like, there are a lot of people who have slow gut motility and just need a little something from time to time, and that's completely okay. Like, we don't shame people with diabetes for taking insulin. Why would we do that? The same is, you know, people need laxatives sometimes to go. That's okay.

• 32:26Speaker 00

  There's also been a misconception that laxatives, certain types of laxatives, can somehow damage the nerves in your gut. You can develop a dependence on them. That data hasn't actually really borne out. But on the flip side, I actually tend, if somebody's taking a laxative every single day or multiple laxatives every single day, I tend to hit the pause button and say, wait, what are we missing here? Like, is there, one, is there maybe a different type of medication I can help you with that will simplify all of this and maybe act on a different receptor so that you're not putting yourself through 20 different things and constantly playing catch up? Or, two, what am I missing? You know, like, are you taking laxatives because we're missing the underlying cause of your symptoms? And what would that be? And have we done the right tests yet? So sometimes, you know, while there's no shame in taking laxatives when you need them

• 33:10Speaker 00

  and they are good tools to have, I don't want someone to just kind of go years and years of taking them without ever just checking in with their doctor, even a specialist like a gastroenterologist, to make sure that you're on the most optimal regimen or that we're not missing something.

• 33:24Dr. Mary Claire Haver?

  So let's talk about the perineum real quick.

• 33:26Speaker 00

  Shall we?

• 33:27Dr. Mary Claire Haver?

  So the perineum, for those of you who don't know what it is, and we will fly in an image on video, is, I think of it, everything, the skin area-ish.

• 33:37Speaker 00

  Yeah.

• 33:37Dr. Mary Claire Haver?

  From the pubic bone to the tailbone. And our areas connect, but I'm literally taught nothing about the perianal tissue. So the tissue around the anus, we kind of stop at the perineal body, which is that little bit of tissue between the bottom of the vagina and the top of the

• 33:51Speaker 00

  Yeah.

• 33:51Dr. Mary Claire Haver?

  The top of the anus.

• 33:52Speaker 00

  Yeah, which is where I stopped looking.

• 33:53Dr. Mary Claire Haver?

  Yeah.

• 33:53Speaker 00

  Yeah.

• 33:54Dr. Mary Claire Haver?

  So, yeah, exactly. I'm like, that's not my area.

• 33:55Speaker 00

  Yeah.

• 33:56Dr. Mary Claire Haver?

  Doesn't look right, but, you know.

• 33:59Dr. Mary Claire Haver?

  But they're the same tissue and driven by the same thing. So when we go through menopause and we have this GSM, General Urinary Syndrome of Menopause, I think we're missing, so the perianal area actually gets thinner.

• 34:11Speaker 00

  Totally.

• 34:11Dr. Mary Claire Haver?

  With everything else.

• 34:13Speaker 00

  Yeah.

• 34:13Dr. Mary Claire Haver?

  So talk about that.

• 34:14Speaker 00

  Talking about this. Yeah, so I think, you know, as we age, just like the front part is getting thinner and more delicate and weaker, first of all, even to begin with, I think we don't give this area enough credit. It is delicate back there. And I think we, like, treat it, it's rough and tough, it's dealing with poop. It's actually something I think we should be like a lot more gentle with than we are.

• 34:32Dr. Mary Claire Haver?

  Well, how should we be caring for it?

• 34:33Speaker 00

  Well, thank you for asking. Well, you know, okay, a couple of things. One, I think about this a lot as a gastroenterologist, like, more than more people think about this, but I think we need to be a lot more careful with, like, how we wipe. You know? And so, like, a lot of people, I know, I have really strong opinions about this, but I am team bidet. I'm team bidet all the way.

• 34:53Dr. Mary Claire Haver?

  Why?

• 34:53Speaker 00

  Okay. Okay, thank you.

• 34:55Dr. Mary Claire Haver?

  What is a bidet? Most Americans don't even know what that is.

• 34:57Speaker 00

  I know, I know.

• 34:58Dr. Mary Claire Haver?

  Unless they go to Europe or Japan.

• 35:00Speaker 00

  I spend so much time on social media debunking bidets. First of all, bidets are for external use only. This is like a big myth. But all bidets are a little nozzle. It can be an attachment that, like, you just, like, buy at the Home Depot, it attaches to your toilet seat, or it can be like a whole fancy toilet. You replace the whole seat, it's heated, it blow dries the area. So it can go as fancy or as, like, low-tech as you want. But all it is, is like a little water spray. And to be clear, it is like a gentle, like, stream. It's not like this hose.

• 35:29Dr. Mary Claire Haver?

  It's not a jet.

• 35:30Speaker 00

  Yeah, it's not a jet. It's like very gentle. But the reason I love this so much is because that area gets weaker and more delicate with time. And more and more of my patients start to get hemorrhoids if they get older. They get fissures. If you're somebody who's prepping for your colonoscopy, you will thank yourself for having gotten a bidet. Toilet paper is rough, it's abrasive, especially if you're somebody who is dealing with incontinence, you're dealing with diarrhea, you are continually causing micro-trauma to that area every time you're up. So if you're gonna be on, like, team toilet paper, you're, like, not ready for that transition. At least use two plies is like my, like

• 36:07Dr. Mary Claire Haver?

  Okay. It's like, what kind of toilet paper should we buy? Is one better than another?

• 36:10Speaker 00

  I mean, I judge people who use one ply. I'm gonna be so honest. I like worry about you, but I use two ply or use wet wipes. Don't throw your wet wipes in the toilet. They are not flushable. Even if it says flushable, they are not flushable.

• 36:22Dr. Mary Claire Haver?

  I read not all wet wipes are the same. Some have an alcohol base and that can be irritating.

• 36:27Speaker 00

  I try to, exactly. Like, I try to use ones that are, like, just clean, like, as much as possible. But then eventually you get to the point where you're like, why am I even doing this? I should just get a bidet, right? Like, you'll just feel a lot cleaner. So I like it. I actually, like, got really hooked on to them during the pandemic. I think that's the first time a lot of Americans, you remember the great toilet paper shortage of 2020, of course, as one does, they got hooked on bidets. But it's something that I recommend to my patients who have Parkinson's disease. I started recommending this all the time because if you have any balance issues, whether you have Parkinson's or not, reaching back there, this is like hard to talk about for a lot of people, but that's a big struggle sometimes. And just getting the bidet will change your life. Like, you don't have to deal with this anymore. And like, when I was postpartum and everything's, like, sore and puffy, I was like, thank God for a bidet.

• 37:12Speaker 00

  Like, you don't have to, like, that's what they teach women to use, right? Is these, like, peri bottles. It's kind of like that, right? It's just a little gentle stream of water that cleans things up without, like, any trauma. So I think everybody deserves a bidet and should try it out. And before you knock it, try it once. The ones in Europe are usually these, like, big standalone, separate plumbing devices. That's actually not what we usually have in America. We usually have something that integrates into the toilet seat. So it's not, you don't have to, like, redo your whole, it's not a huge bathroom renovation.

• 37:38Dr. Mary Claire Haver?

  But I like the discussion about the peri bottle. I didn't even think of that. We all went home with them from the hospital.

• 37:43Speaker 00

  Totally.

• 37:43Dr. Mary Claire Haver?

  You know?

• 37:44Speaker 00

  Yeah, and that's all it is.

• 37:44Dr. Mary Claire Haver?

  And I was like, what do I do with this?

• 37:46Speaker 00

  I know, like, the dynamics of this is so awkward, right? You're like, where does this go? With a bidet, you sit there, you press a button. You're not, like, crouching, you're not moving, you're not like, where do I point this? It goes in the right spot.

• 37:56Dr. Mary Claire Haver?

  But I think for cost, I think that's a great place to start. And before you can get a plumber in or buy the attachments is a peri bottle.

• 38:02Speaker 00

  Yes.

• 38:02Dr. Mary Claire Haver?

  Which just basically is a plastic bottle with a squeezy thing on top, and it just shoots a gentle

• 38:08Speaker 00

  Very gentle stream.

• 38:09Dr. Mary Claire Haver?

  Yeah.

• 38:09Speaker 00

  Yeah.

• 38:09Dr. Mary Claire Haver?

  Of water to the area to help keep things clean. I think we can start there.

• 38:13Speaker 00

  Totally.

• 38:14Dr. Mary Claire Haver?

  Okay, let's go back to hemorrhoids.

• 38:16Speaker 00

  Yeah.

• 38:17Dr. Mary Claire Haver?

  My first introduction to them was having a baby.

• 38:20Speaker 00

  Yep.

• 38:21Dr. Mary Claire Haver?

  And I pushed for, hmm, five hours, something ridiculous. I was determined to have this baby.

• 38:27Speaker 00

  Yes.

• 38:28Dr. Mary Claire Haver?

  And of course, I had a shoulder distortion, a fourth degree tear, all the things. So I had a C-section with my next baby and it was all great. But, um, man.

• 38:36Speaker 00

  Yep.

• 38:37Dr. Mary Claire Haver?

  And that is the gift that just keeps giving.

• 38:39Speaker 00

  Yeah, once they show up, they do keep coming back.

• 38:42Dr. Mary Claire Haver?

  So what is a hemorrhoid?

• 38:43Speaker 00

  Yeah, okay. First of all, we all have hemorrhoids. Hemorrhoids are just these cushions of veins that we actually all have, whether you notice them or not. We all have them. So picture an anal sphincter, stick with me. Okay?

• 38:56Dr. Mary Claire Haver?

  We will fly one in for the video.

• 38:57Speaker 00

  Right, amazing. All right, so the anal sphincter, it's like, just like a little bit more than like a centimeter or two long, but there's like an internal portion, which you can't see from the outside, and then there's the external portion. There's actually two different types of hemorrhoids. There's hemorrhoids that live on the inside, you can't see them, you could feel them with a finger, or you could look at them if you use an colonoscope or something. And then there's the external ones, which you can always feel. Right in the middle of the sphincter, how we perceive pain and sensation changes, it's called the dentate line, it's this anatomical line. So everything inside of that line, the internal sphincters, on the internal side of it, we don't actually see or perceive necessarily as painful. We perceive the external ones as uncomfortable, as itchy, as painful.

• 39:40Speaker 00

  And they can sometimes fill up with a blood clot and thrombosis, and those are acutely

• 39:44Dr. Mary Claire Haver?

  Very painful.

• 39:45Speaker 00

  Yeah, no fun. But a lot of us have these internal ones that we actually don't even know that we have until they bleed like stink one day and we're looking in the toilet bowl and we panic. There, this is very common after childhood, but they're also just common with age and probably the most underappreciated cause of them is straining, just in general, straining, sitting on a toilet. The longer you sit there without pelvic floor support on your smartphone, the higher risk you are of having hemorrhoids. This is what my lab studied a couple of years ago. And smartphone users, they are at a higher likelihood of having hemorrhoids than non-smartphone users in the bathroom.

• 40:21Dr. Mary Claire Haver?

  So don't take your phone in the bathroom. How long should it take to poop?

• 40:26Speaker 00

  I would say, you know, the formal party line is five minutes. I would say like in an ideal world, you're in and out in a minute. And that would be like that. The dream is you have reached a state where you have just like optimized your body's response. Like you know, when your colon is contracting, you feel that urge. That urge to go is your colon contracting. It'll do that a couple of times during the day, sometimes predictably, like in the morning. We talked about it'll do it in the morning. It'll do it when you have a meal. It'll do it if you drink coffee. You lean into that and you go and you've already primed your system so well because you're eating a high fiber diet. You know, like you have like optimized your circadian rhythm. And so you, so in an ideal world, less than a minute. That's what I aim for. But officially, five minutes is the limit. We'll give you that. But the more you're sitting there during those five minutes, it depends on what you're doing.

• 41:11Speaker 00

  Like if you are straining your eyeballs out, I'm worried about you. And I think we need to figure out why you're straining because one, it tells, it tells you that, you know, one, you're putting yourself at slightly higher risk of hemorrhoids. Like the more you strain and do that, that's part of it. But then it makes me wonder, what are we missing, right? About your constipation? If you, if you tell me, you know, I, I feel like I'm eating a lot of fiber. I'm exercising, like I drink all the water, all of this stuff, but I get to the bathroom and it just doesn't come out. I'm straining and straining. I'm, I feel like I go, but I haven't completely evacuated. That clues me in that maybe we need to think about the pelvic floor. Maybe we've missed the fact that the problem is not that your colon is necessarily moving so slowly or that you're not getting the kind of nutrients you need in your food.

• 41:55Speaker 00

  It's that you have pelvic floor dysfunction and this is underappreciated. But if somebody tells me I strained for 15 minutes and I've tried all these laxatives, nothing seems to work, I start thinking about, actually, the problem could be your pelvic floor.

• 42:06Dr. Mary Claire Haver?

  Wow. For a woman on a GLP-1.

• 42:09Speaker 00

  Yes.

• 42:09Dr. Mary Claire Haver?

  So many of our patients are now.

• 42:11Speaker 00

  Yeah.

• 42:11Dr. Mary Claire Haver?

  How does this change things? So like some of my patients will have diarrhea, some will have constipation. I'm always walking them through, because we do prescribe to the appropriate patients in our clinic and our patients are doing really well.

• 42:21Speaker 00

  Yeah.

• 42:22Dr. Mary Claire Haver?

  But you know, what should a woman who's on a GLP-1, considering a GLP-1, know about what could change about her bowel?

• 42:28Speaker 00

  Yeah. It's funny, I have a lot of, we, we prescribe a lot of these in GI too. And I have a lot of patients who are like, oh, my doctor said I needed to run it by my gastroenterologist first because, you know, like I know it can cause a lot of problems. And, and I really try to reframe that. In GI, we love GLP-1s, mainly because we know it has a lot of benefits. It's associated with a low risk of colorectal cancer. My lab found breast cancer, yeah, like 13 different cancers, right? Like it, I mean, and mainly because I think, we think that it has more anti-inflammatory properties that we haven't quite unraveled that are not necessarily directly related to the hormonal changes. But, um, so I, I think it's a wonderful medicine and I want people from a GI perspective. I always tell my patients, there are going to be GI side effects. We should anticipate them.

• 43:12Speaker 00

  We should plan on them and be aggressive, but let's not let that be the thing that keeps you from getting this medicine that's going to help you in so many ways. And, and honestly, for some people, I, for example, I have a lot of patients who have irritable bowel syndrome. They have more diarrhea. It goes away when they go on their GLP-1 because it actually can slow things down. So here's what we know it does in the gut. We know it slows down the stomach. And when you have this condition where your stomach is slowed, we, we can sometimes call that gastroparesis. It can cause gastroparesis. We know it can slow down the colon. So for a lot of people, it causes constipation. But then there's this other group that it paradoxically seems to cause a little bit of diarrhea too. Usually though, knowing that most people, one, the GI side effects, they're most common during that ramping up phase. Like if you're kind of finding the right dose and you're going up to the highest dose you can tolerate, that's when the GI side effects are most common.

• 43:58Speaker 00

  For most people, they peak, the GI issues peak within the first one or two weeks and then they, they come down.

• 44:04Dr. Mary Claire Haver?

  Okay.

• 44:04Speaker 00

  Most people don't experience severe, severe constipation. Most people experience some constipation.

• 44:09Dr. Mary Claire Haver?

  Is there a difference between the GI side effects on the semaglutide versus the terzepatide?

• 44:15Speaker 00

  They have tried to look at that and I think it's, the head to head data is not clear that there's like one good winner. And I think it's so individualized to the person. So it's like sort of, I think it's going to be hard to know. Sometimes we do find though, that switching one, for, for whatever reason, people do better on them.

• 44:30Dr. Mary Claire Haver?

  Okay.

• 44:31Speaker 00

  But usually I would say, if you're not already doing this, let's just go ahead and preemptively start you on a fiber supplement. Like let's just start something and see how you do during those first two weeks. And if you're like, wait a minute, I've gone overboard, like I, you know, there's, I have diarrhea, like that almost never happens, but great. But most of the time people are like, wow, I've become regular for the first time in my life. And that's a great thing. So, and even there's, you know, sometimes when your stomach slows down, it can cause a little nausea. We can treat that nausea. Like I like to give everybody a fighting chance on their GLP-1s. And then, you know, like the wonderful thing is that those side effects tend to be mild to moderate and they tend to go away.

• 45:05Dr. Mary Claire Haver?

  Great. Let's talk about symptoms that women should really stop normalizing.

• 45:09Speaker 00

  Oh, my God. Favorite topic.

• 45:11Dr. Mary Claire Haver?

  You have identified four colorectal red flags.

• 45:15Speaker 00

  Yes.

• 45:16Dr. Mary Claire Haver?

  So walk us through them.

• 45:17Speaker 00

  Okay. So these are the red flags that have been studied. And if you have three out of four or four out of four in the studies, and this was for early onset colorectal cancer, but you had a sixfold higher risk of having colorectal cancer. And some of them are obvious, some are really not. So like the, I think the obvious ones is bleeding. If you see bleeding, that's never normal. But, and, and you'd be surprised, a lot of people are like, kind of normalize it. Like they kind of say like, oh, it's just my hemorrhoids. Yes. And probably like cause one, two, and three of bleeding from your bum is hemorrhoids. But make sure you've had a doctor lay eyes on it. Because you don't know, like I said, there are internal hemorrhoids you can't see. Sometimes you think you have a hemorrhoid because you feel a bump there. It's just a skin tag.

• 46:01Speaker 00

  It might be the like remnant of an old friend, an old hemorrhoid from two years ago. It's no longer a problem. So just make sure somebody's laid eyes on that. Abdominal pain. And this is one that we normalize, right? Like women normalize, not for our own choosing, but it gets normalized for us, pain in some ways. And I never want to normalize pain. I never want to normalize suffering. You know, and sometimes I think.

• 46:25Dr. Mary Claire Haver?

  We do that to women.

• 46:26Speaker 00

  Don't we? Don't we all the time? I, I think some of the problem is, I think we don't talk enough about what is normal and not normal. Like, for example, there are some people who go their whole lives and they're like, yeah, I feel pain every time I eat. So does my mom though. You know, and like everyone, like we all, we just have stomach problems in our family. And like, I think that means the whole family has a problem. Like I don't think that means that this is normal and this is okay. You know, or they'll be like, well, I get a lot of pain on my period, but so does my sister. Like it's horrible. We can't go to school sometimes. That's not normal. It's, it's like just, the whole family has a problem, you know?

• 47:00Dr. Mary Claire Haver?

  We talk a lot on this podcast about the difference between normal, which medically really just means common.

• 47:05Speaker 00

  Yeah.

• 47:06Dr. Mary Claire Haver?

  You know, under a normal curve, you know, when we look at statistics, but it doesn't mean there's not a pathology there or something that's fixable.

• 47:13Speaker 00

  Totally.

• 47:13Dr. Mary Claire Haver?

  So, you know, the pain issue, you should never hurt. Your gut should never really hurt.

• 47:19Speaker 00

  I, I exactly.

• 47:20Dr. Mary Claire Haver?

  And we see your period should never be painful.

• 47:22Speaker 00

  Yeah.

• 47:22Dr. Mary Claire Haver?

  You know, that's treatable. That needs an investigation.

• 47:25Speaker 00

  You don't have to fight through the anything. And there's some people who are, I think this is actually a reason people don't come to their doctors. They're like, I, this should be a 10 out of 10 level. Like this should be a real big problem for me to seek medical help for it. And we're talking about abdominal pain. And that's not how I view abdominal pain, especially when we're talking about colorectal cancer. Any amount of pain that is causing you discomfort, that's new. That's weird. That's off for you. It doesn't have to be the kind of pain that sends you to the emergency room. It just has to be different for you. It has to be weird for you. It has to be bothering you. It doesn't have to be something that you're like, oh, but my, you know, my husband with this kind of pain, he wouldn't go to the, first of all, he would. Second of all, like you shouldn't normalize. So, so pain, and, and when we're talking about like the kinds of pain that colorectal cancer causes, it is often not like this, like life changing, like I have a kidney stone level of pain.

• 48:10Speaker 00

  It is subtle. It can just be like discomfort. Why is this there? So, so pain is, is a big one. Change in your bowel habits. That's a.

• 48:19Dr. Mary Claire Haver?

  What does that even mean?

• 48:20Speaker 00

  Biggest one. Yeah. This is any change in normal pattern for you. For some people, and we've had, we've seen a number of kind of big cases of celebrities who've had colorectal cancer now over the years. Sometimes the only change they talk about has been something was just off. Like my stool was looser, for example. And like, I thought maybe it was the coffee I was drinking and then it turns out like it wasn't. You have to get in the habit of knowing what is normal for you. And so that means looking, right? And that means like looking every single day and knowing, okay, this is what my day to day looks like. And now this is what it looks like when I travel. This is what it looks like when I'm a little stressed. This is what it looks like when I start exercising. You have to know all of these different things and these patterns in your life so that when something changes and you're like, wait a minute, my diet hasn't changed.

• 49:05Speaker 00

  I'm still, my exercise routine is exactly the same. Why is this a little different? Just run it by your doctor. I, I tend to say have a low threshold to just put it on your doctor's radar. Send them a message. It's like the easiest thing. If you don't want to, if you can't get an appointment, just say like, hey, I saw a little bit of blood in my stool. There's no doctor who's going to see that message and be like, okay.

• 49:23Dr. Mary Claire Haver?

  You're fine.

• 49:23Speaker 00

  Sounds good. Call me like in a couple of months, I'll see you in six. Every doctor's going to be like, tell me more. You know, so just run these things by. And then the last thing is iron deficiency anemia. And this is a big one. Especially for women. Iron deficiency anemia, officially you need a blood test to make that diagnosis, but you start to feel it often because you feel fatigued, you lose energy. And what's happening is that your body is losing iron. So you're not producing the red blood cells in the healthy, robust manner that you'd like to. And for women, a very common cause, pre-menopausal is

• 49:55Dr. Mary Claire Haver?

  Menarasha.

• 49:56Speaker 00

  Yeah, yeah, yeah. And oftentimes, if you have someone who has heavy periods, they'll say, or even if you don't have any heavy periods.

• 50:01Dr. Mary Claire Haver?

  Yeah, women will be, they'll just assume it's her periods. And I tend to do that without thinking GI.

• 50:07Speaker 00

  Yes.

• 50:07Dr. Mary Claire Haver?

  So.

• 50:08Speaker 00

  It's common. And again, the most common cause of this is not colorectal cancer. But because it's a kind of cancer that we often miss or we catch late, we can't keep brushing things aside without being more confident. And so if you're somebody who's been told, okay, I have iron deficiency anemia, but I've been told by my doctor it's my period, but I don't really have heavy periods. Or like, you know, I'm on like birth control, like this is odd. If it doesn't feel right to you, or you're taking iron pills, you're doing this, but your levels are not normalizing, that tells me we need to look elsewhere. And what could be happening is that you're losing microscopic, just small amounts of blood somewhere else. And/or you're not absorbing iron correctly.

• 50:53Speaker 00

  And maybe that's a problem. We have celiac disease. Like, there's other causes in the GI tract that can lead to this. So we need to investigate those.

• 51:00Dr. Mary Claire Haver?

  Now, along the same lines, talk to me about ferritin. Are you checking that with your patients?

• 51:05Speaker 00

  We do. GI checks like the full iron panel.

• 51:08Dr. Mary Claire Haver?

  Clinic, yeah.

• 51:09Speaker 00

  Yeah, we do. And obviously ferritin is a number that can change depending on, you may have other diseases. If you have other kinds of things that might cause inflammation in your body, it can be falsely elevated. But we check a whole iron panel, which is just, you know, for anyone listening, it's like different measures of the different forms of iron that can take place in your blood. It can give us clues about the cause. But if you, the cause is that you're losing iron, you know, by the guidelines, by the American Gastroenterological Association guidelines, men or women, if you have iron deficiency anemia and we don't have a good answer for it, you have to get a colonoscopy. You have to get an upper endoscopy, actually. Because I mentioned there's causes from H. pylori, is a bacteria that lives there that can cause celiac disease. You have to get both to make sure.

• 51:51Speaker 00

  And I think we usually say, this is like our like last resort. Like, let's make sure we like, you know, like try for years to fix their problems with their periods. Let's not wait years before we look at like this other very common cause.

• 52:05Dr. Mary Claire Haver?

  Yeah. Talk to me about color. Like, what is normal stool look like? And I've seen you discuss the color of your stool.

• 52:15Speaker 00

  Yeah.

• 52:15Dr. Mary Claire Haver?

  What does all of that mean?

• 52:16Speaker 00

  Yeah. Any shade of brown is normal.

• 52:19Dr. Mary Claire Haver?

  Okay.

• 52:20Speaker 00

  Okay. That part won't surprise anyone, I hope.

• 52:21Dr. Mary Claire Haver?

  All right, green?

• 52:22Speaker 00

  Yeah. But, right, I get all these questions that are like, oh, I had like a weird green poop yesterday. Should I panic? And first of all, I'll just say, like, context really matters here. So if you have a green poop and it's watery and you feel sick to your stomach and you have diarrhea, yeah, I'm worried about you. I'll tell you like, let's get you some testing. Let's see what's going on. But if you have like one green poop, you otherwise kind of feel okay. I give people a pass a lot of times for weird colors. And that's simply because a lot of what we eat can show up in our poop. Like, people are taking these greens powders these days. That will give you a nice green poop from time to time. People, if you drink red wine, the anthocyanins in the wine, so we know this from berries, that can show up as a purple poop the next day.

• 53:06Speaker 00

  It can show up as a purple poop three days later, depending on how quickly your own body moves. And you may not be saying, you might be like, well, last night I didn't have anything. Could be, think about like, you gotta dig deep. Like, what did you have two nights ago? What did you have three nights ago? So I usually give a pass to anything that, you know, you otherwise feel okay if it's in like the greens category, once. If it's like a pattern, I will say, let's have a look, let's get this tested. I never give people a pass for red. Red, maroon, black, tarry stool, I'm telling you to go to the emergency room. Yeah. And maybe the only time I'll say, okay, okay, okay, is if you were like, I had the biggest beet salad of my life last night. Then I might like hold my own horses on it.

• 53:50Speaker 00

  But otherwise, you have to make sure, again, that we're not missing something else. White poop, like clay, tan, beige colored poop, that's weird. That's abnormal. That's a, so poop, remember, brown comes from bilirubin. We're producing that on our own. If we take that out, your poop is actually going to be this whitish pale color. So if you see that, it tells us that there's a blockade somewhere, that the bilirubin is not making it into your gut. That can be a stone. It could be a cancer. Like, we have to check that out. That's an emergency. So I don't give a pass to that. I worry about black poop. I worry about red stool. And other than that, it's, you can often attribute the problem to something that you've eaten.

• 54:34Dr. Mary Claire Haver?

  So a huge percentage of women will go through a phase of heavy menstrual bleeding to do with perimenopause because of the hormone fluctuations. You know, they go through a workup, they end, they end up getting put on iron, oral iron to help, you know, build, so they don't become anemic or fixing an anemia. Iron does a lot to our gut, too. Can you walk through some of the things to think about, walk about? You know, my patients are complaining of GI distress, constipation.

• 55:00Speaker 00

  Yeah.

• 55:00Dr. Mary Claire Haver?

  It does change the color of their stool.

• 55:02Speaker 00

  Yeah.

• 55:02Dr. Mary Claire Haver?

  What should someone know when they're starting iron?

• 55:04Speaker 00

  Yes. One, you should know, it will change the color of your stool for a lot of people. It'll turn it black. And sometimes this can be a really difficult conundrum in GI because we often put people on iron because we think they're having a GI bleed. And then they start having blood stool and then we don't know, is this the iron or is this the GI bleed? If you're just starting it and we're not worried about GI bleeding, just know, you might see black. It can also slow down your gut. Like, so a lot of people get constipated when they have it, when they start taking iron. And you know what I usually tell people, because they've looked into how iron gets absorbed? Oftentimes, people are taking like a pill once a day, like one, you know, one iron pill every day. You can actually take it every other day.

• 55:42Dr. Mary Claire Haver?

  I just saw that study. That just came out, right?

• 55:45Speaker 00

  Yeah, you can take it every day.

• 55:45Dr. Mary Claire Haver?

  So listen, ladies, you don't have to take it every day.

• 55:48Speaker 00

  Yeah.

• 55:48Dr. Mary Claire Haver?

  You can skip a day.

• 55:49Speaker 00

  Skip that day. Take a day off. That'll actually help with the GI problems. And your body's going to actually absorb very similar amounts. It's not like you actually get more bang for your buck necessarily by taking it once a day.

• 56:00Dr. Mary Claire Haver?

  Okay. Are there certain forms that you, what do you recommend to your patients? Like, go take iron, bye.

• 56:04Speaker 00

  Yeah, it depends. Like, so there's some people, like, so there's pill forms and there's also even like IV forms.

• 56:09Dr. Mary Claire Haver?

  Yeah, we'll talk about that. Do the pills first.

• 56:11Speaker 00

  Yeah, I mean, I usually recommend like Ferris gluconate. I don't necessarily have like a specific one that I, I think has been clearly shown to be better for the gut. As long as, find the one that you'll actually take.

• 56:23Dr. Mary Claire Haver?

  Yeah.

• 56:24Speaker 00

  So I usually tell people to, you know, to take it every other day. That's more my recommendation, yeah.

• 56:28Dr. Mary Claire Haver?

  That's great advice. Okay, talk to me about IV iron.

• 56:31Speaker 00

  Yeah.

• 56:32Dr. Mary Claire Haver?

  I've actually, I had really low ferritin and through menarasha.

• 56:36Speaker 00

  Yeah, oh, my gosh.

• 56:37Dr. Mary Claire Haver?

  And through perimenopause and went and had an iron transfusion and it was life changing. And I remember, we would not recommend that unless we were pre-op in them for surgery and they had chronic, you know, low iron, we were going to get their fibroids out or whatever. Iron transfusion for pre-op, a couple of weeks before to help them build up. Some of the pregnant patients who just, you know, we have a lot of pica and a lot of nutritional issues in pregnancy. And IV iron was miraculous for these women, but I think it's so underutilized. Do you?

• 57:07Speaker 00

  Yeah, I think it's, I mean, I think, one, people feel amazing.

• 57:09Dr. Mary Claire Haver?

  Amazing.

• 57:10Speaker 00

  Right? Like, it's very quickly. Yeah. And we have, we use it in GI often, probably not as much as we should. Mainly because there is like this, like, you know, it is like this logistical hurdle. You have to deal with setting up an infusion center. Like, you have to come in, you have to sit down for, you know,

• 57:26Dr. Mary Claire Haver?

  Two to three hours, yeah.

• 57:27Speaker 00

  Yeah. All right, so it's, it's not as easy as popping a pill, for sure. However, I've seen cases where we do it because just the constitution is so bad and people are like, I'm over this, I can't, I like, I just can't do this. They prefer the infusion. Great. I've seen cases where we sometimes have causes of GI bleeding that are like small blood vessel abnormalities that just trickle a little bit over time and we go in, we can't quite catch them. They just take iron from time to time to like catch up and that's okay. And we do it with an infusion. So there are a lot of like good reasons to get the infusion. It is underutilized. It's very safe. You know, like, when I was in med school, you probably remember this, there was like some data where like, well, there's some slight increased risk of bacterial infections with iron infusions. And I think that data is not as strong as we once thought it was.

• 58:11Speaker 00

  It's certainly not a reason to withhold this from anybody who needs it.

• 58:15Dr. Mary Claire Haver?

  I just want our listeners to understand, they can ask for it. You know, especially if they're not tolerating oral iron. It's life changing for some of our patients.

• 58:23Speaker 00

  And every, I mean, every GI center has like a way of getting this set up.

• 58:26Dr. Mary Claire Haver?

  We just went, well, through the academic institution I was with, we just went to the infusion center. So it was me and all the chemo patients that day.

• 58:32Speaker 00

  Yeah, exactly. The leery.

• 58:34Dr. Mary Claire Haver?

  Yeah.

• 58:36Dr. Mary Claire Haver?

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• 59:17Dr. Mary Claire Haver?

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• 1:00:01Dr. Mary Claire Haver?

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• 1:02:54Dr. Mary Claire Haver?

  code UNPAUSED20. That's bareminerals.com to get 20% off your first order. Bareminerals.com. Okay, early onset colorectal cancer. I see it a lot on social media, I see it a lot in the news. What's going on?

• 1:03:14Speaker 00

  Yeah, this is the, I mean, this is one of the biggest.

• 1:03:17Dr. Mary Claire Haver?

  How early is early?

• 1:03:18Speaker 00

  Yeah.

• 1:03:19Dr. Mary Claire Haver?

  And are we not screening appropriately?

• 1:03:21Speaker 00

  We are not. You know, early is defined, depending on the studies, either before the age of 50 or before the age of 45, right? We just changed the guidelines in the last couple of years. So now, for someone of average risk, start screening at age 45.

• 1:03:35Dr. Mary Claire Haver?

  If you have a family.

• 1:03:36Speaker 00

  Screening meaning a colonoscopy?

• 1:03:37Dr. Mary Claire Haver?

  Colonoscopy, yeah.

• 1:03:38Speaker 00

  Or? Or you can get a stool kit, or there's also these blood tests that just came online. And the thing that I like, I would like die on this pill to just, if anyone could just listen to nothing else from this podcast, it would be this, which is that the reason colonoscopies are so important is not because they're a good screening tool, it's because colonoscopies prevent the cancer. So, you know, sometimes, yeah, we, we say like, yeah, there's all these different options to screen for colon cancer. There are, there's only one option to prevent colon cancer, and that's the colonoscopy. And the colonoscopy, the thing about what we're doing, we're going in there to look for polyps. Polyps are precancerous tumors.

• 1:04:22Speaker 00

  They're small growths, 5% to 10% of them, if we do nothing about them, we know will become a cancer. It's not everyone, but it's 5% to 10%. We go in there in the colonoscopy, it's a polyp lump. That's the point. We're looking for them, we see them, we take them right out. Like, will we see a cancer if it's there? Yes, for sure. You'll check the box that you got your screening. But most importantly, we're going to take out those one or two tiny polyps that we saw, so you don't get the cancer later on in life. That's the major, and that's why the colonoscopies have been shown to dramatically reduce the risk of mortality of death from colon cancer later in life, which is not what we can say about these other tests.

• 1:04:58Dr. Mary Claire Haver?

  What percentage of people are getting the screening necessary?

• 1:05:00Speaker 00

  Ah, so you asked, are we doing a good job screening? That's still a no. You know, it's, so unfortunately, you know, it's, it's only, and the data changes, it's getting a little better every year, but it's somewhere in the like 60s to 70% range of the percent of people who are up to date with their colon cancer screening. So one, no, we're not doing a great job doing the screening. I think there's a lot of misinformation about colonoscopies, or, or fear, apprehension, right? Everyone's like, the prep, the prep is the worst thing. Let me be clear. Colonoscopy, the prep that your grandfather had, the prep that your dad had, it's very different now, right? Like, you don't have to drink this four liters of chocolate liquid, which I've tried, it's not the best.

• 1:05:36Dr. Mary Claire Haver?

  I've done both. Like, my first colonoscopy was with the gallon, and then the second was just shoot the.

• 1:05:42Speaker 00

  Shoot the pills. Like, there's pills, there's even like a smaller volume.

• 1:05:45Dr. Mary Claire Haver?

  It was a small volume prep.

• 1:05:46Speaker 00

  Yeah. I'm not going to say it's delightful, the end result's the same, but remember, you want to be cleaned up. The point is to clean yourself out so we can find the tiny polyps. So that part doesn't change, but it's not miserable. And like, I tell people, like, there are lots of ways to make the prep taste just fine. Like, shoot it back with a straw, warm it up and put some ramen, like a ramen packet in there. Like, you can get through that prep, and you are buying yourself 10 years of time for the average risk. You don't have to do this again, and you're giving your spouse, your family, the peace of mind that you've checked and prevented cancer.

• 1:06:16Dr. Mary Claire Haver?

  And when should anyone have an upper GI?

• 1:06:19Speaker 00

  Yeah, the upper GI, it depends. Like, there's some people who.

• 1:06:22Dr. Mary Claire Haver?

  So that's a scope going from the, from mouth throat into the stomach?

• 1:06:25Speaker 00

  Yeah, we call it an upper endoscopy, an EGD, which stands for esophago-gastroduodenoscopy, which nobody can say, so that's why we say upper GI or EGD. It depends. Like, if you have a family history of gastric cancer, stomach cancer.

• 1:06:38Dr. Mary Claire Haver?

  Yeah, I had it.

• 1:06:39Speaker 00

  Yeah, we want, we want to take a look.

• 1:06:40Dr. Mary Claire Haver?

  Bring me both. So my brother died of esophageal, and my, lots of colon on my aunts and uncles, and so I, I was like, do both.

• 1:06:51Speaker 00

  Yeah, and once you do both.

• 1:06:52Dr. Mary Claire Haver?

  And I woke up and they're like, you're good. And I just like, what that did for my chronic quarters, all elevations. I mean, I think I lowered my risk of cancer just by knowing I'm okay.

• 1:07:03Speaker 00

  Peace of mind, yeah. And, and I'm bet from your perspective, it was no different. Like, you were asleep. You might as well get it done.

• 1:07:08Dr. Mary Claire Haver?

  I woke up, I'm like, we done?

• 1:07:10Speaker 00

  Yeah, yes. In fact, that's what, I think there's so much fear about, like, is it going to hurt? Is it not? And most of the time, I would say like, this is so common, that patients wake up from their colonoscopy, and they're like, when are we getting started? And I'm like, congrats, we finished. It's already over. So, you know, so you should get, there are certain conditions where you should get the upper endoscopy, like if you have something called Barrett's esophagus, which is, can sometimes lead to cancer, you'll be getting regularly screened. If you have iron deficiency anemia, I come back to that. That's a reason to get the upper endoscopy, because we're going to look for, like, is there something that's causing your?

• 1:07:39Dr. Mary Claire Haver?

  Gastritis.

• 1:07:40Speaker 00

  Yeah, gastritis, something to be inflamed that we need to look for. But overall, they're easy tests for what they do for you, for what the, the years of life they could give you back. If you, if you can't get a colonoscopy, though, for any reason, we should absolutely get you tested. Some test is better than no test. And so in that scenario, a stool kit, where you, you poop in a box, you mail it right back, and you get the results within a week or two that says, you know, here's, yes, we detected something concerning or not, that's easy to do, anyone can get it.

• 1:08:10Dr. Mary Claire Haver?

  And what is the blood test you talked about?

• 1:08:11Speaker 00

  The blood test just came online. There were some big studies in the New England Journal of Medicine within the last like couple of years. It basically showed there is a blood test we can do that's very, it's pretty good at saying yes or no, you, we see cancer or no cancer. It's, it's not that good at saying yes or no.

• 1:08:26Dr. Mary Claire Haver?

  It's not preventative.

• 1:08:27Speaker 00

  Yeah, it doesn't detect those early growths. I mean, that's the whole problem with the stool kit, too, is that it's okay, it's not great at detecting those early things. But there are a group of people who don't have a stable house or address that we could send a box to, who are not that well-connected at the healthcare system. So if we catch them, you know, when they're coming in for another reason, like, I would love to do this test. But what I'm describing is a pretty specific scenario. I don't think of the blood test as a shortcut for anyone. Like, this is the quick thing, let me do this.

• 1:08:55Dr. Mary Claire Haver?

  I'm sure our listeners are like, I want that blood test.

• 1:08:57Speaker 00

  Yeah, who wouldn't, right? It saves time, it's just a blood test. You might, you know, you could, it'll be quick, but what are you taking a shortcut on? You know, like, take a step back and think about that. Like, is this the area where I want to take the shortcut? No. I want you, if you're able to, to do the thing that's going to give you years of your life back potentially, and that's, that is the colonoscopy.

• 1:09:14Dr. Mary Claire Haver?

  Okay, I love that.

• 1:09:15Speaker 00

  Yeah.

• 1:09:16Dr. Mary Claire Haver?

  Let's go back to irritable bowel.

• 1:09:17Speaker 00

  Yes.

• 1:09:18Dr. Mary Claire Haver?

  And why does it have a woman's name on it? You know, like.

• 1:09:21Speaker 00

  I know.

• 1:09:22Dr. Mary Claire Haver?

  Like, if I went into AI and had, show me a picture of a woman with irritable bowel, I mean, it would be a shit show.

• 1:09:28Speaker 00

  Yeah, literally.

• 1:09:29Dr. Mary Claire Haver?

  You know?

• 1:09:31Speaker 00

  I hate the name. I don't know. I don't, you know, the like, the term irritable bowel, like just the word for this.

• 1:09:36Dr. Mary Claire Haver?

  I was diagnosed with it in medical school. I ended up having chronic active gastritis.

• 1:09:40Speaker 00

  Are you serious?

• 1:09:42Speaker 00

  Yeah. It's a, it, it's confusing because irritable bowel syndrome is this catchall term for which we don't have a test, meaning by definition, to become diagnosed with irritable bowel syndrome, all your tests have to be normal. And this has led to this big misunderstanding in medicine and for, for people alike, which is that, well, if all your tests are normal, then everything is normal. Then there's nothing wrong with it.

• 1:10:06Dr. Mary Claire Haver?

  Then it's psychological.

• 1:10:07Speaker 00

  That's the logical.

• 1:10:07Dr. Mary Claire Haver?

  We were taught there's a huge psychological component.

• 1:10:09Speaker 00

  Yes.

• 1:10:10Dr. Mary Claire Haver?

  Biology, it was psychology.

• 1:10:12Speaker 00

  Okay. Let me just like put it to you this way. Okay. So this is my specialty. I'm a neurogastroenterologist. So this is like, all I study is like how the gut and the brain are connected. And there is a big psychological component to IBS. Okay. There's like a higher rate of anxiety and depression in IBS. But tell me one chronic medical condition that causes pain, where there's not a higher rate of depression, anxiety, rheumatoid arthritis, right? And in irritable bowel syndrome, we've done all of these studies, which are good studies, accurate, valid, that show that people get better with cognitive behavioral therapy. They get better when they go on antidepressants. So do patients with inflammatory bowel disease. So do patients with rheumatoid arthritis. Like, all of these conditions cause this cycle, this vicious cycle of pain to go back and forth. Because imagine, you have

• 1:10:56Speaker 00

  IBS. Now, what we know to be true, there's a lot of different causes of it. But one, one molecular pathway that's abnormal in IBS is that the sensory nerves in your colon, the trigger or the threshold at which they are triggered is lower. When you have IBS, those nerves that are sending pain signals up to your brain, they're being triggered at the drop of a hat. If you have a normal amount of gas, which we all have, we have gas passing through our gut the whole time, that's going to cause those, those nerves to send a pain signal up to the brain. And it's not happening to your friend who doesn't have IBS. But that's not something you see with the naked eye. You look at these two women, they look exactly. You look at this man and this woman, they would otherwise

• 1:11:36Speaker 00

  look the same. But imagine you're living your whole day, your whole life, multiple times a minute, multiple times an hour, you're perceiving pain coming from your gut. Of course, you are going to become hypervigilant. Of course, you're going to become anxious about, can I eat this? Is this, should I go out with my friends? Is this going to cause pain? Of course, you're worrying about it all the time because you're suffering, you're feeling something. But then you meet your doctor, who's like, okay, you're really anxious. I sense you're a little stressed. Why don't we work on that? And what they're missing is that it's not the stress causing the symptoms, it's the symptoms causing the stress.

• 1:12:14Dr. Mary Claire Haver?

  Yes. Yeah. Okay. You teach that about 80% of vagus nerve traffic runs from the gut to the brain.

• 1:12:24Speaker 00

  Yes.

• 1:12:24Dr. Mary Claire Haver?

  What is that? Explain that to our poor little lay population who didn't go to medical school.

• 1:12:30Speaker 00

  Well, even for people who went to medical school, something, something that I bet nobody learned is that your gut is a brain. Like, this is the first thing that people need to know and understand.

• 1:12:41Dr. Mary Claire Haver?

  What?

• 1:12:41Speaker 00

  I know. Right. Your gut's not just plumbing. And that's how I learned about it in medical school, is that your gut is involved in digestion and it moves food from point A to point B.

• 1:12:49Dr. Mary Claire Haver?

  You suck out the nutrients and you just scoop out the rest.

• 1:12:51Speaker 00

  Yes. It's just like this, this passageway and all the other organs are doing the real work for your body. But actually, your gut, some people would say, I would say, it's the original brain. Like, if you go back in time, evolutionarily speaking, there were many organisms, jellyfish, for example. Do you see a brain in their heads? No. You can like look through their little translucent heads. There's no central nervous system, yet they're alive. Yet they're making decisions. They're deciding, should I eat this? Where should I swim? How are they doing that? It's because they have a brain in their gut. And that brain in their gut, we have today. It's called the enteric nervous system. It has like about 500 million nerve cells. That's more than the nerve cells in your whole spinal

• 1:13:32Speaker 00

  cord. And evolutionarily, we have this very close connection between the gut, the brain in our gut, and the brain in our heads that's unique. We don't have a brain in our hearts. Not to hate on the cardiologists, but we don't have a brain in our lungs, the pulmonologists, but we have that in our guts. And there's a couple of ways that these two systems communicate with each other. One is they can kind of communicate through hormone signaling and through the bloodstream. But you have this very rugged fence around your brain and your head called the blood-brain barrier. So a lot of the signals from the gut can't reach the brain that way. They have to go through something called the vagus nerve. So the vagus nerve is this large cranial nerve, meaning it starts up in your head, and it

• 1:14:12Speaker 00

  does actually extend down to almost every organ inside your body, but most strongly to your gut. And I think the thing that we didn't realize for the last, like honestly, century that we've been studying the gut-brain connection, we've known about this since the 1800s, is that most of the signaling is going from the gut to your brain. We think that it's the brain calling all the shots. And that we used to think, yeah, it's stress that causes our stomachs to feel unwell. Because we live that every day. Like, if I'm, if I'm nervous to have a chat with you on this podcast, maybe I'd feel butterflies in my stomach, or maybe I'd suddenly have to go to the bathroom. We feel that all the time.

• 1:14:47Dr. Mary Claire Haver?

  I had it last night. I mean, for the big idea.

• 1:14:49Speaker 00

  Yes.

• 1:14:50Dr. Mary Claire Haver?

  Because it was such a different audience for me.

• 1:14:52Speaker 00

  Yeah.

• 1:14:52Dr. Mary Claire Haver?

  And I was sitting there like, massive gut pain. And I, like, the doctor in me is like, you're just anxious, you're nervous. And the other part of me, are you okay? Are you gonna be okay?

• 1:15:02Speaker 00

  We're in the bathroom.

• 1:15:02Dr. Mary Claire Haver?

  Yeah.

• 1:15:03Speaker 00

  Yeah.

• 1:15:03Dr. Mary Claire Haver?

  Yeah. I ended up being okay. But literally.

• 1:15:06Speaker 00

  It went away as soon as the speech was over.

• 1:15:07Dr. Mary Claire Haver?

  Pretty much.

• 1:15:08Speaker 00

  It went away. Yeah. And that's, I think, how we've thought about the gut-brain connection for so long, is like, these are all the ways that your stress, your anxiety can cause these changes, because we feel that. But within the last 10, 20 years, we've found, wait a minute, most of the signaling is going in the other direction. It's from your gut upwards. And that's really, that's what opened up our field of neurogi, is where we realized, wait a minute, this whole brain in our gut, it's producing neurotransmitters, just like the brain in our head. It's, my specialty is dopamine. I study dopamine signaling in the gut, which is how I ended up tying into Parkinson's. But it's producing those same neurotransmitters. It too can be the cause of anxiety and depression. And I think all of the changes that are happening in the gut happen kind of below our conscious

• 1:15:50Speaker 00

  perception most of the day. So we don't appreciate how much of that signaling, because our brains simply cannot process all of that information consciously. But we are processing it subconsciously. That's called interoception. And so we're processing all the signals, and they're having a massive impact on our mood and on our health. But we just don't necessarily see it with our eyes and our ears.

• 1:16:10Dr. Mary Claire Haver?

  All right. Let's get to some, let's talk about fiber and gut health.

• 1:16:14Speaker 00

  Oh, yeah.

• 1:16:15Dr. Mary Claire Haver?

  Let's talk about like, how do, how do we do this? Okay. So we know all the science and we know it's all connected and we know, you know, but, but what does it take to keep your gut healthy? If I'm gonna, you know, how much fiber do we need?

• 1:16:26Speaker 00

  Yeah.

• 1:16:27Dr. Mary Claire Haver?

  Depends on what goal we're going for.

• 1:16:29Speaker 00

  Right.

• 1:16:30Dr. Mary Claire Haver?

  So let's start there. Everyone needs to eat more fiber. We all nod and say, yes.

• 1:16:34Speaker 00

  Yeah, yeah, yeah.

• 1:16:35Dr. Mary Claire Haver?

  And the last statistics I read, the average woman is getting 10 to 12 grams of fiber per day.

• 1:16:41Speaker 00

  Accurate.

• 1:16:42Dr. Mary Claire Haver?

  In her diet. Is that enough?

• 1:16:44Speaker 00

  Not at all.

• 1:16:44Dr. Mary Claire Haver?

  Why not?

• 1:16:45Speaker 00

  Right. It's not at all. It's like, that's like half the amount of fiber you need. So, okay, let's just talk about what fiber is and what fiber does, right? People, I think, often don't understand this about fiber. We don't eat fiber for ourselves. We don't possess the enzymes to break down fiber. Fiber is not for you. Fiber's for your microbes. And every day, I ask myself, what have I fed those microbes today? Right? Because the microbes which live in the, in our microbiome, we have now understood, it's just, it blows my mind, you know, like how much we've learned in the last 20 years. But there is no organ in our body, there is no disease that cannot be linked ultimately in some way to what your microbes in your gut are doing. And so we have to treat them right. Fiber is their

• 1:17:28Speaker 00

  food, right? And again, fiber is not just one thing. It's not like, you know, you just take like one fiber supplement for the day, you eat whatever you want, and that's done. Your gut and those bacteria want a diversity of plant-based fibers, because some, and they've done these studies, if you eat just like one type, then some, some bacteria who thrive on another kind of fiber, they're going to die off because they're not getting fed. And so you want to have one, you want to meet your fiber goals for women. That is 25 grams if you're under 50. It's 21 if you're over 50. So if you're having just 10 grams a day, that's not enough.

• 1:18:02Dr. Mary Claire Haver?

  Mm-hmm.

• 1:18:02Speaker 00

  We need a lot more. But you also then, that's like, that's, well, honestly, that's like one, two, and three is meet your fiber goals. But for me, the second level is eat a diversity of plant-based fibers, right? And so it's not just eating the same old thing every single day, breakfast, lunch, dinner. But it's trying to bring in lots of different sources. And then three, the third principle that I try to live by for my own gut is try to eat more probiotic foods, right? And this has kind of become a hot topic in the last year or two. People are really getting into eating more fermented foods, like kimchi and sauerkraut. Start somewhere, like, for a lot of times, people are like, whoa, this is, this is really intense. I'm not, not ready to eat kimchi, which I love, by the way.

• 1:18:38Dr. Mary Claire Haver?

  I love, yeah.

• 1:18:38Speaker 00

  I put that like, it's so good with a little like chili flake. I love it. But I started by just eating Greek yogurt. Like, you can just eat Greek yogurt with live culture. So fermented foods, there's two things that can happen. One, fermented foods, the fermentation process changes the nature of the food itself. So sourdough bread, for example, is a kind of fermented food. And that's, that's great. That'll do a certain amount for your gut bacteria. But then some fermented foods also have the live cultures in them, which means they're bringing other types of bacteria into your body that that maybe are not already there or maybe that like need a little bit of a boost. That's where things like the Greek yogurt come in. Kimchi tends to have a lot of this, sauerkraut. The more of those that you incorporate into your diet, the better your bacteria are. So there was this big

• 1:19:21Speaker 00

  study from Stanford. It was a randomized control trial a couple of years ago. And basically, they found that they looked at people who were eating a high fiber diet. Wonderful. We love that. And then a second group that they randomized to eating as many fermented foods as they could. And these are Americans. Okay. It's just like you and me who are like maybe not so like used to doing this. The people who ate the fermented foods, not only did they see this like bloom in diversity in their gut microbiome, after like eight to 10 weeks, but they also saw 19 different inflammatory proteins in their blood went down.

• 1:19:51Dr. Mary Claire Haver?

  Went down.

• 1:19:52Speaker 00

  Yeah.

• 1:19:52Dr. Mary Claire Haver?

  Where do supplements, so fiber, let's talk about fiber.

• 1:19:55Speaker 00

  Yes.

• 1:19:55Dr. Mary Claire Haver?

  And talk about probiotics. Cause you said probiotic foods. And I think that was a very careful choice.

• 1:20:00Speaker 00

  Yes, yes, yes.

• 1:20:01Dr. Mary Claire Haver?

  Does supplementation have any role here?

• 1:20:04Speaker 00

  So personally, I supplement with fiber. I take psyllium husk like every day that I can. And psyllium, you know, is has probably one of the oldest and best studied fibers. It's a soluble fiber and that soluble fiber is what makes it really special. The cardiologist got wind of the psyllium before the gastroenterologist did. And so what they learned is that because it's soluble, it forms this gel.

• 1:20:26Dr. Mary Claire Haver?

  The gel.

• 1:20:26Speaker 00

  Have to drink it with water. Remember this, right? Because the whole point of it is that you want it to form this gel. It needs water to do that. You don't want it to have just like a little bit of water and then just form this like thick compound. You want it to be like a nice, easy flowing gel. So just drink it with like an eight glass, eight ounce glass of water. When it does that, first it traps bile salts, which are these digestive salts that are inside your gut. That forces your liver to produce more because they've been trapped. So it lowers your cholesterol to do that. Great. We in GI have then found that that gel, if you have loose stool, it can bind those loose pieces together and help you have more solid stool. If you have really rock solid hard stool, that gel softens it out. So it's a shapeshifter. That's why sometimes people

• 1:21:09Speaker 00

  are like, wait, I have diarrhea. I have fecal incontinence. You're telling me to eat more fiber. That's just going to make me go more. That's going to worsen the problem. Not if it's psyllium, not if it's soluble fiber, that actually, you know, it can go in any direction. It really works for you. So I take that every day. That doesn't mean that I don't think and believe that the best way to get fiber is through your diet. And again, because psyllium is one type of fiber, I try to do that, but I'm also a realist. I know who I am. And I know that every day I don't quite meet those goals. I do probably most days, but not all. So this makes sure that even like definitely on days that I don't meet my goals, I have. And then on the days that I'm meeting them, I just get like an A plus on my report card and I'm very happy. Probiotic supplements are way more murky.

• 1:21:52Speaker 00

  The data is not as solid as it has been for psyllium. I think this comes as a surprise because probiotic supplements are often marketed as like, well, here's the one that gastroenterologists recommend everywhere. Right? And, and the truth is the American Gastroenterological Association doesn't actually recommend probiotics for most conditions. There are some where the data is a little bit stronger, like in certain types of conditions and inflammatory bowel disease, we might. But the randomized control trial data tends to be all over the place. So I don't recommend that off the bat. I do recommend probiotic foods, just because we know that data is a little bit stronger and can bolster the gut. If you found a probiotic supplement that works for you and you're like, this changed my life, I never, and I never rip it from anyone's hands by any means. But in my clinic, and this is my experience, more often people have come in saying like, I've tried everything.

• 1:22:37Speaker 00

  I've tried all these supplements. It's not working. What do I do? And then I say, okay, let's just, let's go back and look at diet. Let's, let's go back to the basics.

• 1:22:42Dr. Mary Claire Haver?

  Let's go back to fiber for a second. Is there, you know, a lot of people complain, they're like, I need fiber and they double their fiber overnight.

• 1:22:49Speaker 00

  Oh my gosh, right.

• 1:22:50Dr. Mary Claire Haver?

  That, that, then they come complaining. I always warn.

• 1:22:53Speaker 00

  Yeah.

• 1:22:54Dr. Mary Claire Haver?

  Cause we do recommend some fiber supplementation if they can't meet their diet, but like to ease into it because the gut needs a minute. And because the bloating and the gas, talk about that.

• 1:23:05Speaker 00

  Yeah. It's so funny with like, you've seen fiber maxing, trending on social media. The number of people who have come to my clinic who have been like, I fiber maxed, I lived to regret it. Like the next, you know, like several days had explosive diarrhea. That'll happen, right? But in it, I think, and I love fiber maxing, like hashtag fiber maxing. I'm so glad that's trending, but I don't want people to have such a bad experience because they went from zero to a hundred that they're like, I'm never going to do this fiber thing again. That's just not how you're supposed to fiber max, right? It's like you said, you have to ramp up slowly because if you've been living with a microbiome that is not used to fiber, you can't suddenly be like, whoa, like over in the system. If you're going to cause gas, you're going to cause bloating, you may well cause diarrhea. But not if you start low and go slow. So that's what I tell everybody ramping up their

• 1:23:50Speaker 00

  fiber. Like we are all woefully under the, the goals, but that doesn't mean you should turn it over. And we see this like every January 1st, you know, like people like really try hard. So for example, if you're taking psyllium husk, like you might, a teaspoon has four or five grams of it. I might say just start taking half a teaspoon for a week, for two weeks. See how you feel. Like let that settle, let your body acclimate, then go up to another half teaspoon, right? And, and ultimately you might want to get to a dose of two teaspoons per day, but start way, way lower than that. And even with dietary changes, which is ultimately the goal, you know, don't change all three meals of the day in one go. Like make one good, sustainable swap that you actually like. Stick with that for a few days, stick with it for a week, try that out, like.

• 1:24:33Dr. Mary Claire Haver?

  And then.

• 1:24:34Speaker 00

  Yeah. And then ramp up. Yes.

• 1:24:35Dr. Mary Claire Haver?

  So outside of probiotics and fiber, what, what else would you recommend for a gut healthy?

• 1:24:40Speaker 00

  Yeah. I mean, the biggest thing in 2026 is ultra-processed foods, right? And so ultra-processed foods do two things.

• 1:24:46Dr. Mary Claire Haver?

  It's more than like adding things, what should we take out?

• 1:24:48Speaker 00

  Yeah. Yeah. And, and I always focus on the adding, right? Cause I think diet is, you know, as a gastroenterologist, diet is the, one of the hardest things about our lifestyle to change. And it's, it's sometimes I think does people more benefit to say, why don't we add in an extra serving of vegetables at dinner than take away the thing that you love? I would rather have you do something where you're adding in something healthy than you take away something you love. And then you're like, oh, I hate this. I'm going to quit after two weeks. That's really hard. But, you know, sometimes like ultra-processed foods, I don't think any of us can get rid of them a hundred percent every day of our lives. That's the like unfortunate, sad world we live in. But I do think that there are small changes that you can make. Now, remember ultra-processed foods, they're doing two things for you that we don't want. One is what are they bringing into the table?

• 1:25:31Speaker 00

  They're bringing in these chemicals and emulsifiers, which we have studied in GI. Some of these emulsifiers, one, they decrease the mucus barrier in the colon. That's your gut. You know, we've talked about a lot of the things your gut does. One of the big things it does is it protects you from the outside world.

• 1:25:48Dr. Mary Claire Haver?

  It's a barrier. Right. It keeps the bad stuff from getting across.

• 1:25:51Speaker 00

  Yes. You want that to be really fortified. Those chemicals break it down and they also change the bacteria and they can cause inflammation, local inflammation. And so one, they're bringing in new things that your gut doesn't like and doesn't thrive with. And it's not a surprise that irritable bowel symptoms are correlated closely in these studies to how much ultra-processed foods you're eating. But then, you know, sort of by definition, in somebody who is the average American who were eating about 60% of our diet from ultra-processed foods, it means that we're not getting fiber, right? Because the ultra-processed foods tend to not have fiber. They tend to not have protein. They tend to have lots and lots of sugar, lots and lots of salt. You're actually, your microbes don't really love that much salt either. And that's a big problem with ultra-processed foods. So anywhere that you can cut those

• 1:26:33Speaker 00

  down, and again, don't go from zero to a hundred because you can't sustain that. Like fine, for me, I was reaching for chips and crackers as a snack, like from the vending machine in my clinic. And I would eat those for snacks. And then finally, when I made this swap, I was like, you know what? I'm just going to buy a bulk thing of cashews. I'm going to keep that in my office and that's all I'm going to eat. Like then it became easy because it was the only option. I happen to love cashews, but just like find that one thing for you that is actually sustainable. You're going to, you know, stick with it and then build on that. Like make one more sustainable swap every couple of weeks.

• 1:27:02Dr. Mary Claire Haver?

  I ask all the academics who we interview, if I gave you a billion dollars for a study.

• 1:27:08Speaker 00

  Oh my gosh.

• 1:27:10Dr. Mary Claire Haver?

  And I want you to focus on women because that's our audience.

• 1:27:12Speaker 00

  Yeah.

• 1:27:13Dr. Mary Claire Haver?

  What would you do? What would you study?

• 1:27:16Speaker 00

  I would try to study more irritable, on irritable bowel syndrome to start. And I would try to understand how we interrupt pain signaling in irritable bowel syndrome. We have made some progress. We haven't made enough. In, in my field, you know, GI is 80% men.

• 1:27:36Dr. Mary Claire Haver?

  But meaning the people doing the.

• 1:27:38Speaker 00

  Doing the work. Yeah.

• 1:27:39Dr. Mary Claire Haver?

  Doing the work.

• 1:27:39Speaker 00

  And they're great men. My dad's a gastroenterologist. He, you know, he's wonderful. And there are a lot of really great men, but most of the GI, common GI conditions like IBS, they're mostly women, you know? And, and I think to do the work, like you need, you, we, we need to just think a little bit more about the conditions that are affecting women. Women need to go into this a little bit. You know, we need to encourage more women to enter this field. And I think not enough people are studying pain signaling because that's only one slice of GI, right? We have colorectal cancer to contend with. We have reflux to contend. We have like so much. Pain signaling disproportionately affects women.

• 1:28:15Dr. Mary Claire Haver?

  Yeah.

• 1:28:16Speaker 00

  And that's the thing that I would want to study. We, and the reason is that if we can study and we can nail down the mechanisms, then we can develop the right drugs for it. Right now, we don't have good drugs that treat pain in, in irritable bowel syndrome. We have some and we do, and we have a lot of drugs that treat the constipation, that treat diarrhea, but the pain we don't treat well. Or we have these sledgehammers. And I think it's because we haven't quite narrowed down the mechanisms and done the research. So anyway, that's a long answer, but that's.

• 1:28:44Dr. Mary Claire Haver?

  No, no, I love it. I love it.

• 1:28:45Speaker 00

  Yeah.

• 1:28:46Dr. Mary Claire Haver?

  Cause women spend 20% of their lives in poorer health. So if I had a male twin, if we had twins.

• 1:28:51Speaker 00

  Yeah.

• 1:28:51Dr. Mary Claire Haver?

  A twin brother, you know, we would expect to spend 20% of our lives in poorer health than they were. And half of that is in the last decade of life where we're seeing, you know, much higher nursing home, you know, we lose our independence earlier than in general. But back that up, the other is in reproductive years, pain, PCO, PMOS, endometriosis, like, you know, things that autoimmune disease that are understudied.

• 1:29:16Speaker 00

  Yeah.

• 1:29:17Dr. Mary Claire Haver?

  And you, you feel like gut is a big part of that.

• 1:29:19Speaker 00

  Totally. Yeah. I mean, this is like the like bluntest way to put it, but like think about the economic cost, like to how many days of work we miss because of our, whether it's endometriosis or more gynecological pain. But, but GI symptoms cause people to miss work, right? Like especially with my IBS patients, people like, I just, I have to stay home today because I'm going to go to work and I'm going to be in the bathroom all day. And that takes a big toll. Like it changes your career advancement. It changes what field you even decide to go into.

• 1:29:47Dr. Mary Claire Haver?

  Right.

• 1:29:47Speaker 00

  And so your whole trajectory changes. And then like on top of the economic cost, then like it's the personal cost, you're suffering. That's not something we want to pass on to the next generation.

• 1:29:56Dr. Mary Claire Haver?

  Let's talk about some do's and don'ts.

• 1:29:58Speaker 00

  Okay.

• 1:29:58Dr. Mary Claire Haver?

  I want to, as we wrap this up, I want our listeners to leave a checklist they can actually use. So in your words, give me your top three do's for gut health.

• 1:30:06Speaker 00

  Number one is talk to your doctor about it. One out of three.

• 1:30:10Dr. Mary Claire Haver?

  Which, which doctor? Who?

• 1:30:11Speaker 00

  Yeah, any doctor that will listen. But first of all, it'll be, it'll probably would start with your primary care doctor. But I also think that if you feel like you're, you're not moving, like the wheels are just turning, you're not getting anywhere, ask for a referral for a gastroenterologist. But I do think, you know, like one out of three people don't bring up their bowel complaints to their doctor because they're so embarrassed by them. So like the one, like one rule I would tell people is don't be embarrassed. Like, anyone who comes into my clinic, I often see them like, you know, like hemming and hawing for the first five minutes. And I often just say, like, whatever you want to say, you're going to be the seventh person who's told me that same thing today. Like, just get it off your t- don't feel embarrassed in front of a gastroenterologist. Like, we went into this field for a reason,

• 1:30:53Speaker 00

  you know, like, nobody forced us to do this. Like, we're here for you. So just, so tell us, right? That's the one thing. Two, I would say, this is especially important for women with IBS or otherwise, but if you have a doctor who doesn't believe your symptoms, you know, it's not your job to make them believe. It is your job to find another doctor. But so many, and this is not to, again, like, put the blame on women, but I think we feel that we have to make our doctors believe our pain. You know, like, we have to, like, a doctor should just, you tell them you're in pain, that should be the end of that conversation. Like, that's how I think about pain. I'm not like, hey, but you look okay. You, you're not crying, you're not screaming. Hey, you're texting, you can't be in that much pain.

• 1:31:38Speaker 00

  That's not how I think about it. You tell me it's 10 out of 10, that's what we're working with, and that's how I will treat you. So your job is not to make them believe, your job is to find a different doctor, if that's the case. And then I guess the last thing is, you know, we didn't catch on this already, but I, I feel it's worth saying. If you have new bloating in your post-menopausal, don't brush that off ever. Get that checked out. Make sure we're not missing something serious, like ovarian cancer.

• 1:32:02Dr. Mary Claire Haver?

  Yeah.

• 1:32:02Speaker 00

  The reason is that ovarian cancer, as you know, it, we often see it sometimes.

• 1:32:06Dr. Mary Claire Haver?

  We are terrible at picking it up early. We have no screening for it.

• 1:32:10Speaker 00

  Right.

• 1:32:10Dr. Mary Claire Haver?

  And it's usually heavily advanced by the time it's diagnosed. And it started, the symptoms started years before, usually with gastrointestinal symptoms.

• 1:32:19Speaker 00

  Yes. And it's vague.

• 1:32:21Dr. Mary Claire Haver?

  Because like, our, our ovaries, our uterus, our gut are not like in little walls. They are slipping and sliding all over each other all day long.

• 1:32:30Speaker 00

  Yeah.

• 1:32:31Dr. Mary Claire Haver?

  So, including the bladder.

• 1:32:32Speaker 00

  It's like just a red flag for me. Not because I diagnose ovarian cancer every day, but if there's a post-menopausal woman who says, I have new bloating, I wake up with bloating, that pattern really bothers me, I never let that go. I always double check.

• 1:32:44Dr. Mary Claire Haver?

  Okay. Now, let's flip that over. What are your three top don'ts that people are kind of doing regularly and really shouldn't be for gut health?

• 1:32:52Speaker 00

  Well, I think one is ultra-processed food. We're eating more, like, we know ultra-processed foods. I think we've known for a long time, they're, they're not ideal for our heart health, they're not ideal for our metabolic health. I don't think most people, like, understand how much they are immediately damaging the lining of the gut. Like, the, the damage starts right then and there. So for your gut health, ultra-processed foods are a problem. And of course, they are linked. In fact, you know, we talked about early onset colorectal cancer. There is a huge body of literature that links ultra-processed food now to colorectal cancer. So, so that's like the one, as much as you can, that's a big don't. Don't wait for symptoms to become a crisis. Like, I think that's something I find myself telling men and women

• 1:33:32Speaker 00

  all the time is, a little bit of blood bothers me. It doesn't have to fill up the bowl. Like, any amount of discomfort bothers me. I want to hear about it. It doesn't have to be something that sends you to the ED. So just, so don't wait for it to be a crisis. And then, last don't, don't put off your colon cancer screening.

• 1:33:54Dr. Mary Claire Haver?

  Yeah.

• 1:33:54Speaker 00

  You know, we put it off because it's inconvenient, because we're like, this is going to be really, you know, bothersome. I wrote this story for the New York Times a couple of years ago about the prep for colonoscopies. And I was like, trying to sort of explain how there are a lot of ways to make it easier. And one of the comments really stood out to me, and I'm going to paraphrase, but the, it was, it was from a woman who wrote in, and she was like, you know, like, a lot of the comments were like, ah, the prep is so awful, like, they, you know, like, I, it was so, I didn't want to do it. And one of the comments said, you know, every one of these excuses was an excuse that my parent made. They, they put off doing the colonoscopy, and they died last year from colon cancer, and I regret every day that they didn't do it sooner. And I, that comment, like, just

• 1:34:39Speaker 00

  lives in my brain. Because it's like, think about, you're doing it for someone else. You're doing it for your family, for the people that love you, and you're doing it for yourself. And it's, it's not as bad as, as you think it is. Once it's over, you're going to be so glad you didn't.

• 1:34:52Dr. Mary Claire Haver?

  What's the one takeaway message you want for our listeners?

• 1:34:56Speaker 00

  Well, okay, I, I say, this is my soapbox, but I want people to start thinking about their gut as a brain and not as plumbing. And the reason that that's, like, you don't have to dive into the science right there with me, you know, on, on every molecule. But if you, if you just think about that as conceptually, it will change how you view your body. Because you'll stop just treating your gut as a trash can. And you'll say, wait a minute, my gut is as precious as the brain in my head? Like, if you were going to go for a bike ride, you'd wear a helmet, right? Like, you treat that brain in your head, like the most important organ in, in your body. Well, so is your gut. And if you think about it that way, you respect it that way, it will totally change what you do to it.

• 1:35:35Dr. Mary Claire Haver?

  Do you think of our poop as a vital sign?

• 1:35:38Speaker 00

  Yeah, totally. I mean, I look every day. I ask my patients to look every day. Because you learn so much about a person just by looking. And not just looking, but, but being attuned to subtle changes.

• 1:35:49Dr. Mary Claire Haver?

  Thank you so much for coming on UnPaused. We've covered so much. Where can our listeners find you?

• 1:35:55Speaker 00

  Well, they, they can read my column in the Washington Post, or they can find me on social media at TrishaPasrichaMD.

• 1:36:01Dr. Mary Claire Haver?

  Okay. Thank you so much.

• 1:36:03Speaker 00

  Thank you.