104: Intermittent Fasting and Hormones w/ Dr. Felice Gersh

104: Intermittent Fasting and Hormones w/ Dr. Felice Gersh

by Dr. Anna Cabeca September 21, 2019

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Fasting is not only something you do when you’re trying to lose weight; it’s been proven to help regulate your metabolic system during and after menopause. Plus, it’s something that women should be doing throughout their lives in order to maintain healthy bodily functions. Dr. Felice Gersh is with us today to explain how our changing bodies are supported by fasting. 

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Felice is a board-certified gynecologist who has a holistic, well-rounded approach to women’s health. Her integrative insight looks at every aspect of a woman’s body to determine the best course for treatment; so everything is working together to bring your health back into alignment.

In today’s episode, Felice describes what happens when our bodies go through menopause at a metabolic level. It’s not only our estrogen production that changes during this time! And she explains how intermittent fasting can improve your health during these hormonal changes.

In fact, Felice goes on to say that women should be fasting regularly twice a year from their twenties in order to support their metabolic and hormonal health. Her favorite type of fasting diet is a fasting-mimicking one, which almost tricks your body into thinking you’re fasting when you’re really eating food! Fasting and timed eating can also help you get your circadian rhythm back on track at any time of your life.

Next, Felice gives us her medical opinion on how destructive taking birth control pills is to our body and what happens when we control or take away a woman’s natural hormones long-term. She explains why we shouldn’t be taking hormone supplements orally, and how, instead, we should be taking them. And then Felice lets us know how important progesterone is to our bodies at all times.

Are you looking for more hormonal support through menopause? Have you ever tried getting your body into ketosis? Do you take the birth control pill?

In This Episode:

  • What happens to women metabolically when they go through menopause
  • How the different hormones in our body react to going through menopause
  • How intermittent fasting can improve your health, especially through menopause
  • Why you should fast twice a year to help improve your metabolic and hormonal health
  • What happens to your body when you start on a fasting-mimicking diet
  • Who can benefit from a fasting-mimicking diet
  • Why you should avoid taking birth control pills 
  • How timed eating can help you get your circadian rhythm back on track after menopause
  • Why you shouldn’t take estrogen supplements orally
  • How important progesterone is as our bodies go through menopause
  • What happens long-term when we take away women’s natural hormones

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Quotes:

“No matter how hard you exercise or meditate, no matter how many vegetables you eat, eventually every woman, universally, will get into menopause. So we all face this. Every female. We’re all in this together. So we want to make those post-menopausal years really wonderful ones.” (6:25)

“To get the label of food, it actually has to have nutrition in it! And most of the things we eat have no nutritive value. So if you put things in your mouth that have no nutrition, that’s not food! It’s like, you might as well lick the street! Do not put anything in your mouth that’s not food.” (17:44)

“Testosterone levels go down independently. And by age 40, the average woman has only half the testosterone she had at age 20 and boy, that does change everything.” (39:11)

“A period is a vital sign of female health. If you have an abnormal period because you have cramping, it’s heavy, it’s irregular, you have to fix the health of the woman! You don’t try to cover it up with birth control pills.” (51:54)

Links

Order your copy of PCOS: SOS

Find Dr. Felice Gersh Online 

Find Felice Girsh onFacebook |Instagram |Twitter |LinkedIn

 

Transcript

Dr. Gersh:
A period is a vital sign of female health. If you have an abnormal period because you have cramping, it's heavy, it's irregular, you have to fix the health of the woman. You don't try to cover it up with birth control pills and then you're harming these young girls so tremendously. If you look at the site for cervical cancer, it shows you if you're on birth control pills for fewer than five years, it increases your risk of cervical cancer by 20%. If you are on it for fewer than 10 years you're increasing by 60%.

Dr. Anna:
Hello and welcome back to Couch Talk, intimate place for intimate conversation. Today we're really going to get into metabolic health and the menopausal transition, and how fasting can really play an integral role. Now I have with me a guest, Dr. Felice Gersh, who I have known for a while and she is an amazing gynecologist and obstetrician, and really a leader in this space. She's just been sharing so much good information on the Internet and she maintains a very active clinical practice. She is an award-winning physician, a board-certified gynecologist, and obstetrician, also trained in integrative medicine. Her educational background includes an undergraduate degree from Princeton University, a medical degree from the University of Southern California School of Medicine, an OB-GYN training at Kaiser Hospital in LA, training with Dr. Walter Crinnion in environmental medicine.

Dr. Anna:
What a huge, amazing background. She also did a two-year fellowship in integrative medicine at the University of Arizona School of Medicine. She is a pioneer in this space and dedicated her career to women focusing on the aspects of women's health, which are unique and underappreciated, and poorly managed. She has a strong focus on the role of women's unique rhythms and hormones, emphasizing the impact on female health, the female health aspects of nutrition, timed eating, intermittent fasting, fitness, stress management, emotions, sleep, and electromagnetic energy. You can see that we are two peas in a pod. Excited for this discussion and excited for your reception and reaction to it. Here we go. Welcome, Dr. Felice Gersh to Couch Talk. I'm so glad to have you here. One of the most brilliant minds in the world.

Dr. Gersh:
Well, thank you, and it's wonderful to join you here today.

Dr. Anna:
We want to talk about this, and something I talk about with my community a lot is getting keto-green, and part of the lifestyle is the intermittent fasting. I know we're going to hit on that today, but women's health is such a conundrum, especially this menopausal transition. What are you finding that goes against the grain of what we've been taught at our ivy tower institutions?

Dr. Gersh:
Well, what I have found is virtually nothing is being taught properly at those institutions. Menopause is just talked about as, well, you don't have fertility any longer and you don't have a period, end of the story. Women are taught almost, "You should be happy you don't have to deal with your period anymore." It's something to celebrate. Of course, we want to celebrate everything in life, but I have to be honest, there's nothing to really be happy about when you lose your ovarian function. Because of the ovarian function, the making of these incredible hormones, estrogen, and progesterone, and of course testosterone, which it declines even long before the menopause begins. These hormones are not just about reproductive functions. Of course, they are about making babies and sustaining pregnancies and so on. But they're about, the actual health, the life of the woman, the whole body.

Dr. Gersh:
Nature made it so that the whole body is one. We've had this problem in our healthcare system where we break the human body into organ systems as if they're all working in isolation. Well, the reproductive system does not work in isolation, it's part of the whole female body. Nature, of course, coordinates it so that a woman who is fertile would also be healthy, right? We don't want an unhealthy woman making babies. She's not going to survive to raise that child and be successful. The whole body's metabolic function, the whole thing is organized by estrogen and other hormones, and estrogen is a key player. We don't want to not recognize the seriousness of what happens in menopause to a woman's body, and that's really not talked about in our medical societies really.

Dr. Gersh:
That's what I want to bring to the forefront is the fact that women take a big metabolic hit when they go through the menopausal transition. We know that it's a process. We talk about menopause like it's a moment in time like you're crossing a finish line, but you're not. It's a process of ovarian aging or ovarian senescence, and it goes on over many years. Of course, it parallels fertility, right? We know that you're not as fertile in your late 30s as you are in your 20s, and that's paralleling the decline in the function of the ovaries. Keeping that in mind, it's a process, and aging is a process. It's not like you've crossed the finish line there either. Recognizing that the impact of the changing hormones, as the ovaries are aging, is something over time... We need to be on it and be aware of this long before the [inaudible 00:05:28] period happens.

Dr. Anna:
Absolutely, and it's not a pause at all, is it? It's named so poorly, right?

Dr. Gersh:
It is. Menos is from the Greek word for moon. That's kind of lovely. I like the recognition that we are lunar creatures, that we are cyclic. The pause sounds like it's just a moment in time. It is a permanent stop. When the ovaries are done, and we don't know what moment that is. No bells go off when the last bit of estrogen comes out of our ovaries. We don't know when that happens. But when that is done, it is really done, and we're entering a whole new chapter of life. It's a very different chapter, and it could be half of our lives. For many women, they live half their lives during the menopausal years. We want to live them wonderfully. We want to have high-quality life, what we call health fad. That's one of my missions, is to help everyone, because no matter how hard you exercise or meditate, no matter how many vegetables you eat, eventually every woman universally will get into menopause. We all face this, every female. We're all in this together, so we want to make those post-menopausal years really wonderful ones.

Dr. Anna:
Yeah, absolutely. Something else that we're not taught is the reversal of menopause. Okay, we have premature ovarian failure, early menopause that was my diagnosis at 38, and it was actually post-traumatic ovarian insufficiency, if I would name it something, right? Understanding that because reversed it and then hit again a time period where it looked like, FSH, LH out the roof, and no periods for months on end, and everything else declining, brain function, memory, weight gain that comes on without doing anything different, right? That metabolic stall, and then getting back out of that with something we both appreciate, intermittent fasting. For me, it's my keto-green way, but incorporating these important lifestyle activities that it's not just about what we eat, to empower our hormonal condition.

Dr. Anna:
A few things that we recognize in the menopause is certainly the decline of hormones, but how that relates to the major hormones, right? Insulin, cortisol, oxytocin, all of those are going down, adiponectin. All of those are going down and that affects our metabolism. Let's talk about some strategies that we can [inaudible 00:07:54] to open up this time frame or recreate the practices in our lives so that we have a vibrant health span like you're saying.

Dr. Gersh:
Right. Yes. As a body, all of our hormones sync or swim together, right? They're all beautifully interrelated, so absolutely we have to look at the whole family of hormones. There's some interesting studies that actually were in primates in terms of prolonging. I love the idea of prolonging our reproductive years. Definitely, when women go through very traumatic times, they may have some, really, hits to their ovaries, and so we can actually help rejuvenate the ovaries. As long as we have some viable eggs, we can help to rejuvenate them and actually expand the lifetime of reproductive life, which is really very important for overall life in general. The longer you have your hormones, the better.

Dr. Gersh:
One of the things they found with primates was that when they put them into a periodic fasting routine where they would fast for a few days, and then they would re-feed them appropriately and they'd have a healthy primate diet, then they would do another round of the periodic fasting. What happened was their lifespan of reproductive functionality increased. Now we don't have human studies, but we have so much in common that... and especially since we know so many benefits in humans that have been proven in terms of reducing inflammation, increasing brain growth factors like brain-derived neurotrophic factor, lowering visceral fat, and reducing liver fat, which we know is such an epidemic. Talk about advanced aging when you have fatty liver, your body is really going downhill.

Dr. Gersh:
We know that periodic fasting in primates can actually extend reproductive longevity. We know in humans it can reduce overall body inflammation, improve brain health, improve immune health, and it's like a reboot to the circadian rhythm and the gut microbiome, all of which are key to overall health. I like to start early. We talk about osteoporosis typically in women who are in their 70s and 80s. You've got to think about bone health when you're young, really young because we build our bone, which is really essential for life itself, when we're in our late teens and into our twenties. Well, we build our metabolic powerhouses, our ovaries, to keep them healthy when we're young, so I'm all about starting very early.

Dr. Gersh:
We have to educate young women, not just women who are approaching menopause, but really early on, to maintain every aspect of their body to be optimized. I do incorporate in my younger women in their 20s if they're open to it, and many are because many women are trying to delay their fertility. They're looking at careers and we have now this giant enterprise of egg freezing of women in their thirties, well, and then they're finding that their eggs are really poor. We want to make sure even if people get into that situation, that they have really wonderful eggs and we want to maintain fertility.

Dr. Gersh:
I start the periodic fasting routine and I use ProLon, The Fasting Mimicking Diet. People can also do water fasting, but I believe that if you do something like that... if you want to do water fasting, you should probably check yourself out with a physician to make sure that you're okay. With ProLon, you don't actually have to go through a doctor. You can do that independently as long as you're healthy. By doing that, you reduce all these inflammation markers, you really improve your overall health. As women go through the real menopausal transition, they need all the help they can get to maintain metabolic wellbeing. There I really step it up. Younger women, I might want to recommend twice a year that they do a minimum of twice a year.

Dr. Anna:
[inaudible 00:11:42] days are you saying 72-hour fast? 24-hour fast?

Dr. Gersh:
Those are five. These are five days, five days, that's all it is. Four days of a water fast, where you only drink water, or five days where you do ProLon, The Fasting Mimicking Diet. They actually created a company out of the research at the Longevity Institute at USC where they developed a diet that... I call it stealth food. It flies under the radar of the detectors in the brain, the nutrients sensors. You actually get to eat food but your body doesn't see it. You get the benefits of fasting and the joy of eating. That's how I can really implement that because it's very hard to get people to stop eating and just drink water. It really is hard because we do love our food so much.

Dr. Gersh:
By doing that in younger people, we know that we're going to help to maintain their weight, we're going to help to prevent fatty liver, we're going to keep their inflammation down. Then as they get older, when they're really going to get that metabolic kit, when their hormones are really going into a steep decline, we can really help to help their metabolic state really stay optimized through those challenging years.

Dr. Anna:
Felice, what does the eating look like? What kind of food is it that's the stealth food.

Dr. Gersh:
It was developed by Professor Valter Longo, who's a director at the Longevity Institute. He's Italian and he loves Mediterranean food, which of course we know has a lot of benefits and a lot of studies on it. He didn't want to do shakes, he wanted to do real food. For breakfast you have a very tasty nut bar. It's primarily fat, right? Because it's helping you to get into a keto state. It's a very, very low protein because it's the protein that really triggers the sensors, what we call mTOR, the sensors that know that you're eating. It has primarily fat and not a lot of calories. For lunch and dinner, you get different soups and then you get what I call a little extra. Different days of the five days you can get kale crackers or a little cocoa crisp, it's like a little brownie, or you get olives because olives are amazing. They're such a healthy food, they're almost pure fat, and they're just filled with polyphenols. It's one of my favorites. You can get, of course, a lot of that from olive oil, but the best source, in my opinion, is to eat the olives. You get olives many of the days.

Dr. Gersh:
That's it. You get a breakfast bar made out of predominantly nuts and then you get a soup for lunch, a soup for dinner, and a little extra something, and on the... you get lots of teas to drink. Very nice teas, you want to stay hydrated. On day two through five, you get an energy drink that has virtually no calories but helps you to stay hydrated. It's really easy. The first time people do it, sometimes on day three when they're really going into ketosis, if they're eating what I call, the SAD diet, the standard American diet, they're eating a lot of processed carbs, and they really are not burning fat very regularly, they're always living on their carbs, they may have trouble converting into burning fat. For a few hours, they may feel really lightheaded, hypoglycemic.

Dr. Gersh:
That's why, for those people, I don't start them right off. I like to do what I call a reset. Basically it's a detox off of garbage food. Right? Junk food. We get them eating lots of vegetables, getting them to do more time-restricted eating, which is another very big thing where you don't do this grazing all day long. You try to get your calories in earlier in the day if you can and have a good breakfast, and I recommend that. We try to get them eating real food and trying not to snack all day long, and then I get them into the fasting with the fasting-mimicking diet. Then they don't go crazy on day three when they have to go into ketosis.

Dr. Gersh:
Once you're in ketosis, people feel great. Their brain is so sharp, they feel smart. I know, I've done it 15 times myself, the ProLon, and on day five I feel like I could beat anyone in chess, and I hardly ever play chess. You just feel super smart and then maybe you get a little less smart, but then it's like you go up to five steps and then maybe go down two. Then you go up... You feel like you're getting smarter and smarter, which is pretty darn good as you're getting older and older.

Dr. Gersh:
They're doing a lot of research now in areas of autoimmunity, and in dementia, and a lot of work in cancer. There's so much of the body that's linked to, of course, how you eat, and how you don't eat, and when you eat. We can impact on the immune system, which we now know really is everything, right? Everything is about the immune system. We can lower inflammation, we can get our T regulatory cells working properly, we can keep our immune cells from going crazy and exploding with inflammatory cytokines. Then we can actually prolong a really great health span. This is my goal for myself and for my patients.

Dr. Gersh:
I know my own experience has been really wonderful with incorporating time-restricted eating and fasting. I virtually never feel really hungry. It's not that I don't ever feel hungry, but I never had that, I'm famished. I'll die if I don't eat, feeling. Ever. That is a wonderful way to live. It's so liberating. You don't feel like you have to eat. You feel like you want to eat, and you can eat when you want to. You don't feel, "I have to stop everything and I just have to eat." It gets rid of those binge eating feelings when you just crave things, those terrible cravings that people feel. It really helps to get your appetite centers appropriately managed the way that nature intended it to be.

Dr. Gersh:
We've changed everything with these crazy foods that we've created. I don't even make the definition of food. I actually had to go to dictionary.com to find out what is food because I'd go to the airports. You and I both travel a lot, so I'm in a lot of the airports and I see all these people eating this stuff and I'm thinking, "I don't think that really qualifies as food." I went to dictionary.com and the answer is, it's not food. To get the label of food, it has to actually has to have nutrition in it, and these things have no nutritive value. If you put stuff in your mouth that has no nutrition, that's not food, it's like you might as well lick the street, right? It's not food. It doesn't qualify. Do not put anything in your mouth that doesn't qualify as food.

Dr. Anna:
I think that's a good visual versus licking the street.

Dr. Gersh:
It's so basic that we have to eat the right foods. We have to eat at the right time, not eat all the time, not eat at night when our pancreas is going to sleep and trying to rest, and we then push it over the limit by trying to make it make more insulin when it's not ready to.

Dr. Anna:
Felice, do you allow coffee? [crosstalk 00:18:27]-

Dr. Gersh:
Not during [crosstalk 00:18:28]-

Dr. Anna:
... alcohol. No.

Dr. Gersh:
Well, not during those five days. I say, "Look, it's five days. The way that you started, you do, I call it a loading dose. You do the ProLon for five days for three months in a row. It's only five days, and the other days you're eating your healthy diet. Whether you're doing all the vegetables, the keto-green, but you're definitely eating food, so it's only five days that you are doing the fasting-mimicking diet. The first day of the fasting-mimicking diet is about 1200 calories and then the next four days are a little under 800, so it's not like a starvation diet, that's the brilliance of it. It's how it's composed. That's why you can't really easily just do this on your own because you'll probably just end up with a low-calorie diet, which has its own benefits, but you're not going to trigger what you get triggered.

Dr. Gersh:
When you do a fasting-mimicking diet, you do all the different things that I mentioned, like you reduce inflammation, you reduce visceral fat, liver fat, and you increase brain growth factors, but you also trigger apoptosis. You take yucky senescent cells, ones that may have what we call misfolded proteins. These are cells that may be on the path to becoming cancer cells. These are not good cells, and the body just loses its proper mechanism to make them self-destruct. Actually, when you do the fasting-mimicking diet, it's like it pushes the explode button and these bad cells kill themselves off, which is a blessing. Many of your organs actually shrink, but you're getting rid of crappy, bad cells.

Dr. Gersh:
Then what happens is, the good cells in the body go through this process called autophagy, which is essentially recycling the cellular components in the lysosome, which I call the cell recycling bin, and it spews out the amino acids, and the lipids, the fatty acids so that it can reconstruct new structures within the cells. It's like a rehab of the cell. You get the cells living longer that are good and actually working better. That's autophagy. Then what happens is, you stimulate stem cells to reproduce the cells that you just killed off, the bad ones. You actually regrow your organs back to normal size, but they're regrowing with brand new healthy cells, and you actually increase your pool of stem cells. People travel all over the world trying to get stem cells, and here you're just rejuvenating your own stem cell supply and you're getting rid of the crappy cells.

Dr. Gersh:
You're rejuvenating your organs and you're rehabbing your healthy cells so that they live longer. In mice, they actually live longer. They have shown that when they do their own little mouse version of the fasting mimicking diet, they live considerably longer. Of course, there is no human data on longevity. How you're going to do that, right? But we have all the markers that show that the same things are happening in humans. It's something that every woman, as she's going through menopause, needs to really know about and then incorporate. There's only a few exceptions of women who would not qualify if you are too frail. You have to have fat to burn, right? If you have such a low body mass that you have virtually no support fat, then you might actually burn your lean muscle. They've shown that when you do it, a normal healthy weight person or an overweight person, as long as your BMI is at least 18, you will actually preserve your lean body mass. You do not burn your muscle.

Dr. Gersh:
We do body compositions in my office and we've shown people losing by doing this process and over time they will lose, say 25 pounds and maybe three pounds are lean body mass and all the rest is just pure fats. What diet? What kind of program can have you burn off your fat and preserve virtually all of your lean body mass is pretty amazing. That's why we watch you, but if you're very thin then this might not be for you then. If you're very old, well there's no data on old people. They haven't done the study. You're on your own if you're much over 65. There are people older that are doing it, but I think once you're into that age group, you should be doing it with a doctor watching what's happening to you because we have no data. If you have cardiac problems, if you have arrhythmias, we don't want to do that. If you've been very ill.

Dr. Gersh:
When you actually are in the middle of a fast, or fasting mimicking diet, your immune system is actually somewhat suppressed. It's important to know that your white count will actually go down, so you do have some reduced immune function, and then, of course, it comes back. You would never do this if you were just getting over the flu, right? You don't do that. You really have to make sure you know what not to do. Don't do it when you're sick or if you've just lost a lot of weight and you're now underweight because you were ill or something of that sort. But they're actually doing some research, but these are under the supervision of doctors, people who have cancer who maybe are very thin because they maybe [inaudible 00:23:27]. But, you have those people and that's not [inaudible 00:23:30] structured. You have to be supervised under those circumstances. But the vast majority of people are excellent candidates.

Dr. Anna:
Yeah. Yeah. I agree with you. Also fasting is a muscle, you have to exercise, right? It continues to be a muscle you have to exercise. Recognize the first time, it's like going to the gym for the first time. It's got to hurt, you're going to be sore, not going to be able to do it as much or as long. It's an exercise and [inaudible 00:23:55]thing that you just have to keep getting into. Felice, I want to talk about something that I've noticed in clients. Women who have had hysterectomies and their ovaries removed experience what we know in gynecology as surgical menopause. I have come across many, numerous, too many to be coincidental, women who had hysterectomies in their to 30s early 40s with their ovaries removed and then hit a second menopause in their 50s, like 52 to 55 with the hot flashes resurging and all of this.

Dr. Anna:
We know that this is not well described in our reproductive endocrinology textbooks. I mean, I haven't read it or heard anyone else talking about this, but I wanted to bounce this off of you because the metabolic stall that's occurring during this time is regulated by something other than our ovarian. It's the feedback to the ovarian, what's triggering it. I wondered if you've seen the same thing and what you thought about it.

Dr. Gersh:
Well, in my practice, most of the patients who usually elsewhere. I mean I would do everything not to take out ovaries unless they were massively diseased, or there was cancer involved or something like that in a younger woman. But the traditional approach is putting them on birth control pills, and birth control pills are non-hormones, and they change everything about how the body works. It really alters our ability to make nitric oxide, it alters our ability to have proper functioning of our immune system. We know that our immune system is really key in terms of regulating our temperature, our regulatory systems and so on because we know when we have neuroinflammation, we will have flashes and hot flashes. That's why you can have hot flashes and not have menopause. You could have malaria, right? You could have some kind of brain infection because when you have inflammation in your brain, it dysregulates your temperature-regulating centers and then you can get night sweats and hot flashes.

Dr. Gersh:
There are a whole variety of things that can happen. One of the things that's very important is having adequate amounts of this gas, this incredible signaling gas called nitric oxide. One of the things that happen as we age and this is related but also independent because everything has some relationship to everything, and that is what they call the aging guts. As our digestive tract ages as we age, it becomes leaky, what we call impaired gut barrier function. There is so much immune system that lines the intestinal tract. When you have this impaired gut barrier, you have the wrong bacteria growing in your GI tract, and we know this is what happens with age. They get what they call a dysbiotic gut and they have abnormal microbial populations in the gut and they make these products called endotoxins or lipopolysaccharides.

Dr. Gersh:
When you have a leaky gut, these toxins that are made in the GI tract can pass through the wall of the gut and then interact with the immune cells that are lining the gut in what we call, the gut-associated lymphoid tissue causing them to explode, because these immune cells can cause inflammatory responses. That's what they're there for. They're there to protect you, but when things go wrong, unfortunately, they create inflammation inappropriately and chronically. These inflammatory products called inflammatory cytokines can actually travel to the brain causing inflammation in the brain and can give you night sweats and hot flashes.

Dr. Gersh:
When this sort of thing happens as people get older, and it seems to be independent of something like you just lost your estrogen, think that your gut is dysbiotic, you have an impaired gut barrier or a leaky gut, and your immune cells are creating inflammatory havoc in your brain. Now we know that things like dementia, Alzheimer's disease is really a response. The amyloid-beta that's produced in the brain of people with Alzheimer's is there to try to heal the brain. It's actually a response to inflammation in the brain. That's why all the pharmaceuticals that have been trying to get rid of the production of the amyloid-beta have failed because that is a response, it's not the cause. You have to think you're getting brain inflammation, when you're getting hot flashes and you don't know why, and you're getting older, you're getting inflammation in your brain. It could be something else, but the number one thing to think about is what's going on in your GI tract, maybe you need to work with a functional medicine doctor or work with a program to try to do whatever you can to get a healthy gut back.

Dr. Anna:
I think definitely it's multifactorial, right? Like you said, it's all-

Dr. Gersh:
[crosstalk 00:28:31]. Yeah.

Dr. Anna:
... interrelated. The other thing with the decreasing levels of adiponectin, if that's also associated with the insulin resistance, which will also cause hot flashes as well. Thinking about these interesting things, we've really related it... Okay, if you've had your ovaries removed, then [inaudible 00:28:48] menopause once you're done, right? Then these menopausal symptoms, for them to come again at this menopause age-appropriate time. It's another part of our circadian clock.

Dr. Gersh:
Well, that's a good point is that estrogen and other hormones, estrogen is... The key [inaudible 00:29:06] not the only hormone, there are many factors. Everything is more complex than whatever we think.

Dr. Anna:
It's why I love talking with you, Felice. You can go in all these directions with me.

Dr. Gersh:
It is. It's the most interesting thing. There's nothing more interesting than trying to... it's like the detective novel, how to figure out how the body is working and what people are experiencing when they're having various symptoms. Definitely, when you have circadian dysfunction, you're going to have potential temperature dysregulation. Of course, you're going to potentially have mood problems and sleep problems because all this goes together. As we age, the master clock in the brain, the word that we use is drift, it doesn't stay on the beat. It's the conductor of the orchestra. The conductor is a little drunk, so it's not leading the orchestra, which is all the organs in the body, to stay on the beat.

Dr. Gersh:
What can we do? Well, one thing is, we can give hormones, but no matter what we do with hormones in menopause, we can't recreate the ovaries. They have to understand that we don't have the ability, the ovaries are not putting out hormones in one blob in the morning, another blob at night, nor is it putting it out exactly the same all day long. If you had a patch, it's not doing that. It has ultradian pulses. It's putting out pulsatile estrogen more in the morning, less in the different times of the day. We can't replicate that. We don't have an estrogen pump. Even that wouldn't be the same, but that would be closer. We don't have that ability. No matter what we do, we can do better, but we can't make our ovaries come back to life, although there are people working on ovarian stem cells. Maybe the next generation will be able to get a new set of ovaries, but I don't think that's in the works for me.

Dr. Gersh:
What can I do and what can other people at my point of life do? Well, we can do what I call the backdoor way into getting our circadian rhythm back on track, and that's through using the peripheral clocks, getting them online. We have main peripheral clocks in the gut and in the liver, but all the organ systems, those are the key metabolic ones. If we do timed eating, so we eat at the right time and we eat at the same time every day, we actually get the clocks of the microbiome to be synced, and then they sync the liver clocks, and then we can actually get our body to work as one whole on the right beat again, through proper timed eating. Implementing fasting also helps, like I said, to get the circadian rhythm back on track. It's like a reboot, a reset.

Dr. Gersh:
Even though our master clock may be drifting a bit and there's nothing we can do to completely repair it, we can do things to help it like a bright light in the morning. That is how the master clock knows it's morning, you see a bright light. That's why people who are blind and they have no sense of light at all, they're in big trouble, right? Because even a little bit of light coming into the eye can help set that clock. For people who live in dark areas, very northern, getting a lightbox can be tremendous. They've used them for depression, and it's all linked because our mood is linked to our circadian rhythm.

Dr. Gersh:
By getting bright light in the morning, seeing the sunlight around noon, watching the sunset is incredible. The colors of the sunset, they help to lower our cortisol output and raise our melatonin. There's magic in the sunset and the sunrise if you get up, or else you can get a sunrise lightbox, so you don't have to actually get up at five in the morning if you don't want to. But these are things that can help set our clocks so that even as we age, even as we go through menopause, we can have metabolic homeostasis. We can keep pretty close to optimal health. We're never going to be 25 when we're 55, but we can do a lot more than what the average doctor and the average person is doing to stay optimized, a lot more than what a lot of people realize.

Dr. Anna:
I agree. I agree. Having been at that stage twice in my life where I was close to ovarian failure, ovarian insufficiency, being able to just boot myself right back out of it, right? It took intermittent fasting, it took getting keto-green. It took resetting their circadian rhythm, getting sunrise, sunset, and establishing a gratitude practice. I mean, those were foundational and again, syncing the body up so it's working as a team just like any good community should. Now let's talk hormones, one of my favorite topics. How do you recommend using hormones? Bioidentical, estrogen, progesterone, testosterone, DHEA, and incorporating that into the lives of women.

Dr. Gersh:
Whenever you use estrogen, please make sure it's not orally, okay? That's very important, not to take an oral form of estrogen. I keep thinking it's going to go by the wayside. It's not going to be out there, but the pharmaceutical world is coming up with new combinations like conjugated estrogen is making a return using serum estrogen. There are these products out there. Beware, do not take an oral estrogen because it gets metabolized through the liver into estrone, which is not the form of estrogen that the brain likes. The form of estrogen that the brain loves is called estradiol. You definitely don't want to just pour estrone in your brain. That's not beneficial. Do not take oral estrogen, also increases dramatically your chances of getting a blood clot, and we don't want it.

Dr. Gersh:
That's where [inaudible 00:34:25] women's health initiatives use Premarin and Prempro, and that increased blood clots significantly. That's why they had so much bad press about hormones because they were using oral forms of estrogen. Then, of course, they combined it with a progestin, which is a manmade word for a chemical endocrine disruptor for progesterone. It's not real progesterone. It's like the evil twin. Do not use that stuff. You only want to use bioidentical. I am of the school that you want to use the highest dose that's comfortable for the woman, and I do monitor levels.

Dr. Gersh:
This is another very important subject, how do you even monitor? I've really transformed into looking at, and I use salivary a lot more. It used to be not ready for prime time, but it is now. High-quality lab testing using salivary samples really helps you to know better what your level is in your tissues, because when you absorb it through the skin... say you're giving it through the skin, which is how I used it a lot, then you can't really know exactly what the level is from the serum, which is the gold standard if your ovaries are making the hormones, but not if you're taking it in through your skin.

Dr. Gersh:
I like to understand, and try to mimic as best I can, nature. I will never outsmart nature. I'm not that smart. I can't do that [inaudible 00:35:41]. I try to keep levels, what I call physiologic. That would be like, what is an optimal level for a young woman? A typical optimal level. That's where I want to go. I don't want to go with the lowest possible dose. Why would I want that? That'd be like, I want somebody to eat the lowest possible amount of broccoli. No, I want the optimal amount of broccoli. I don't want the lowest amount of estrogen, I want the optimal. That would be, if I'm going to give a static dose, which is what I use most of the time, it's going to be at a high level in the follicular phase. It's the time of the menstrual cycle before ovulation.

Dr. Gersh:
If you're looking for a level you want it to be about what a woman who is, say 25, who's not on birth control pills, having her own natural hormones, what her level would be when she's like around day nine or 10 of her menstrual cycle in the follicular phase. That is not the lowest dose. The thing about it, it's really important to know, you're giving estrogen transdermally. Our bodies did not evolve to get hormones through our skin. That's a really concocted thing that we've come up with. Women absorb very differently. You really have to monitor and see what any woman is doing. When they did the studies with the estrogen patch, they found if you got 10 women, you put the same dose patch on, you got totally 10 different levels. You have to know that it's very unique, individualized for the woman. The most absorbable place to put it is probably around the opening of the vagina where you have epithelial tissue that's much thinner, it's more like the mucous membrane.

Dr. Anna:
More vascular.

Dr. Gersh:
Much more vascular, much thinner. It doesn't have the keratin layer that acts as a barrier, right? We have that on purpose. We can absorb it into our skin, but that wasn't really nature's intention that we would absorb everything through our skin, it's supposed to be a barrier, right? We have keratin it helps to block absorption. Then we try to absorb things through it, like medications. You absorb better if you have trouble absorbing through your skin, that's where you have to see what your levels are, then you can apply usually a more concentrated amount, it's not as much of a volume, around the opening of the vagina, say the inner labia minora tissue or right into the opening of the vagina itself, and then you'll have much greater absorption. I've experimented a little bit and I've found dramatically different levels in a woman based on where you apply it. These are things that you really have to think about. If you put your hormone on your thigh versus behind your knee, or on your lower arm, around the opening of the vagina, you can have very different levels. They're also going to last different amounts of time, they'll be metabolized at different rates.

Dr. Gersh:
You have to work with a hormone expert. That's how I really feel because this isn't something that's one size fits all world. It just isn't. But I love having the full monopoly of hormones back. We don't want to just focus on one. I agree that we want to, [inaudible 00:38:43] the mainstay. We want to definitely look at progesterone. Even if you don't have a uterus, progesterone is not just about maintaining the uterine lining in terms of presenting, countering the effects of estrogen. Like every hormone, it's multitasking. Every hormone has a variety of functions. Progesterone receptors are all over the body and particularly in the brain, it's very neuro-protective. It's calming. It helps to make GABA. We definitely do not want to give up our progesterone.

Dr. Gersh:
Testosterone goes down independently, and by age 40 the average woman has only half the testosterone level that she had at age 20, and boy that does change everything. DHEA, I know that you work with it all the time, and I'm a very big advocate of DHEA. It's a wonderful anabolic androgen, and it helps maintain our brain, our bones, our muscles, our entire musculoskeletal system, our connective tissue, which is so key to being functional. It gives that boost in the brain, it makes people feel better and that generally is amazing. It helps [inaudible 00:39:48] tissue, so it's definitely on my radar and I use it a lot. These are, I call them, the foundational hormones every woman should know about and talk about with her physician.

Dr. Anna:
Yeah. I want to emphasize a couple of points. The importance of progesterone with or without a uterus, right? With or without a uterus, the protective effects of progesterone. With that, one of the things where I noticed in my client practice when I started using progesterone in women who had had hysterectomies and their ovaries removed, they would come back and say, "Dr. Anna, I feel like a fog has lifted." Over and over and over again. Early in my career recognizing that, because then I was using it for sleep or for whatever else I was using it for mood, for depression, for all these good things. Then just to hear that over and over again, "I feel like a cloud has lifted."

Dr. Anna:
I have found that what's fascinating to me is that the decrease in our brain's ability to utilize glucose for fuel, the rapid decline that happens in our mid-30s to early 40s and mid-40s mimics the drop in progesterone that we experience during that time as well. It's fascinating to me. We talk about the estrogen window for neuroprotection, but the progesterone window I think is even more profound for neuroprotection during this period of neurologic vulnerability from age, mid to late 30s through the 50s.

Dr. Gersh:
The brain is so precious and women have almost three times the incidence of Alzheimer's as do males. Yes, we are vulnerable. One of the things that have really not really registered is how important it is to have healthy hormones through your whole reproductive life. Reproduction is not what everybody wants all the time. I understand everyone doesn't want to run out and have 12 babies. But unfortunately or fortunately, depending on how you look at it, our hormones are linked to our brain, our bones, everything, right? It's linked to all of our body functions. Women spend so much of their younger reproductive life trying to get rid of their fertility, which translates into getting rid of their hormones.

Dr. Gersh:
We really have to rethink what's been happening. Using chemicals to get rid of women's hormones so that they're not fertile, so that they don't have babies they don't want, and what that really means longterm. Because you're talking about what happens naturally as women age. Well, we're advancing that aging process when we take away women's natural hormones and their beautiful rhythms when they're in really the peak years of their growth and development. We just really need to rethink giving women all of these chemicals and by that, it's like birth control pills-

Dr. Anna:
[crosstalk 00:42:36] pills. Exactly.

Dr. Gersh:
[crosstalk 00:42:37] chemicals and the implanted things, which I won't name, that really alter the way hormones are produced. The IUDs that have the [inaudible 00:42:46], which is at least half of women, it stops them from ovulating. It changes their rhythms, their hormones. It's changing the microbiomes of the vagina, the uterus. We know everything has a microbiome. They've even found women who have ovarian cancer have an altered microbiome of their ovary, and we don't know. There's nobody who's looking at a lot of these things. Now that we understand how important it is as we age, to try and do everything to have optimal hormones, optimal metabolic function, what are we doing to our young women in their teens and in their twenties when we're... It's like a wake-up call to all of us, "What are we doing?" We have to wake up about what we're putting in our food, and in our pharmaceuticals, and how we live our lives, what we eat, when we eat, and through every stage of life. Because we know what happens in our young years affects us in our older years.

Dr. Anna:
Yup. Allowing the body's intelligence to heal itself because I know interfering, like you said, "Mother nature always wins," is what I like to say. The transition that happens in menarche, when we start our periods, that is critically important, right? We know there's a rewiring that happens to our brains and our metabolism during that time period. The same with the menopausal transition. We cannot just snuff it out. We have to honor this menopausal transition for the rewiring and then boost up the bottom, right? Because we're artificially living. We're not living in nature and able to get the nature's rhythms into us, how we were designed, so we've got to boost up nature. I'm big on that with the progesterone. Progesterone and DHEA first. That's where I start. I created Julva which has DHEA in it and other amazing ingredients for that. Vulva, that repair of the vulva vaginal areas and [inaudible 00:44:36], and all, just the good things that you mentioned DHEA can do for us.

Dr. Anna:
I typically will start there and then add estrogen and testosterone depending on what's going on or where they're at. But there's that ebb and flow. I recommend holidays periodically too from our vitamins, from our meds. During that fasting time period, often we can take a drug holiday too. I feel that that's an important resetting, recleansing of our receptor sites. I wanted to get your feedback on that too because that's been a practice pattern that I've initiated to up-level for my own health.

Dr. Gersh:
Well, I think that the reality is that... I'm actually part of a group that's raising money and we're going to be starting a study, is to look at trying to, and this has been around, this idea, for quite a long time, the idea of giving hormones in menopausal women to actually mimic a menstrual cycle. Because like you said, it's like a holiday of the menstrual cycle. You do not have the same amount of progesterone every day. You do not have the same amount of estrogen every day. That is not physiologic. Nature never intended us to have what's in a birth control pill or to have menopausal hormones the way we're giving them where we get... If somebody uses a patch or even if it's compounded from a compounding pharmacy, it's usually the same dose every day.

Dr. Gersh:
Now that's not how nature ever intended estrogen to be used or progesterone. Progesterone is not there every day. It's gone then it comes back for two weeks, and then it's gone, then it comes back for two weeks. I think that, for the receptors to go through this ebb and flow, they open, they close, they're upregulated, they're down-regulated. This translates into tumor suppressor genes. They've shown that when estrogen spikes in the mid-portion of the menstrual cycle, which just precedes ovulation, that huge spike of estrogen up-regulates p53 which is a tumor suppressor gene, which actually helps you to prevent getting breast cancer and uterine cancer. Nature took care of all these things.

Dr. Anna:
Progesterone upregulates p53.

Dr. Gersh:
I was just going to say the same thing. Progesterone does the same thing when it has its peak in the luteal phase. Nature intended us to have these ebbs and flows, these up and down-regulation and so on of receptors, and genes and so on. We're not smart enough to try to micromanage this. We're doing the best we can. The more we get closer to nature, to what nature gave us, the way nature programmed our genes, and the way our receptors are designed to work, the better off we'll be. If we're going to try to trick nature into thinking we're young when we're getting old, right? Because isn't that what we really doing when we're giving hormone therapy in menopausal women. We're trying to say, "The heck with your nature. I'm not going to do what you're asking me to do. I'm going to keep hormones going in my body because I know what they do, and I don't want the consequences." We, of course, do all the other things because hormones don't work in isolation from all our lifestyle choices.

Dr. Gersh:
We have to put it together, the giant package. We have to do it all. When we want to put in the hormones, the best thing is if we can mimic nature more closely. But we have to get more research, so that's why we're starting research studies. A lot of people are talking about doing little holidays, taking days off, and so on. We don't really have data on that, but it intuitively makes sense because we know that hormones are never constant in our bodies. They always have an ebb and flow, so doing some sort of a break makes sense even if we don't have the science yet, in terms of the studies, but we have the science in terms of what really happens in the human body.

Dr. Anna:
Exactly. I think that's really interesting. I want to just end with some of the damaging effects of birth control pills because you've brought it up a couple of times, and I know that's probably a new concept to many of my audience. Let's talk about it because it's devastating.

Dr. Gersh:
It's really shocking when you do a deep dive into birth control pills and what they do. I went on PubMed and I researched a lot of the literature. If you go back into the 1990s and even the 1980s, there's a whole bunch of studies that are published showing the negative impact on the cardiovascular system, the metabolic systems of the body from birth control pills. Then it's like it disappeared. I don't know if everybody got paid off. I don't know what happened, but the research seemed to just disappear, and very little. There's some, I found one study, a small study, that showed that birth control pills completely dysregulate the circadian rhythm. Duh, that would be logical. There are several studies that show that birth control pills almost immediately give you a leaky gut. They give you gut dysbiosis, they increase autoimmune diseases, particularly Hashimoto's thyroiditis and lupus, and Crohn's disease. There's research out of Harvard that has shown that going on birth control pills will clearly exacerbate Crohn's disease. There are other data suggesting that it increases the risk of getting it in the first place.

Dr. Gersh:
We know that it's very bad for T regulatory cells because we do cease the production of nitric oxide, which I mentioned as a very key signaling agent. It's what we call a redox signaling, it works with reduction, oxidation reactions. It's an antioxidant and you need it. Birth control pills suppress our production of it and it helps... nitric oxide helps regulate what are called T regulatory cells, which are very important for having a sense of self, for our immune system to recognize itself so that it knows what's the enemy and what is a friend. We get our immune system getting dysregulated and it doesn't know who to kill and it starts attacking our cells. Birth control pills disrupt that system that keeps us on track to know who we should be attacking with our immune system.

Dr. Gersh:
Of course, it dramatically increases blood clotting. It alters the whole inflammatory system of the body so that you increase COX-2, which is an enzyme that gets activated when you have inflammation. There's just... Even though a lot of the research seemed to dry up, we have enough to show, without a doubt, that birth control pills are harmful. You can go to the cancer.gov website. That's the cancer site that's sponsored by, guess who, US government, .gov. If you go to their site, it will show you very, very plainly that birth control pills increase the risk of cervical cancer.

Dr. Gersh:
We have this crazy, I call it the crazy maker. We're giving all these children, these little girls, a vaccine so that they will hopefully reduce their chance of dying from cervical cancer. We don't actually have any proof that it does reduce deaths from cervical cancer, but that's the goal. I understand that is the goal that you're going to reduce cervical cancer deaths. At the same time, we're giving those little girls, a couple of years later, we're giving them by the carloads now the droves. We're giving them birth control pills. I see girls coming into my practice who were put on by other doctors. 13, 14, 15 years old, they're being put on birth control pills because their nutrient status is so bad, as soon as they start having periods, their periods are abnormal.

Dr. Gersh:
A period is a vital sign of female health. If you have an abnormal period because you have cramping, it's heavy, it's irregular, you have to fix the health of the woman. You don't try to cover it up with birth control pills, and then you're harming these young girls so tremendously. If you look at the site for cervical cancer, it shows you if you're on birth control pills for fewer than five years, it increases your risk of cervical cancer by 20%. If you are on it for fewer than 10 years, you're increasing by 60% and 10 or more years, which is so common for young women to be on birth control pills for way beyond 10 years, you're actually, at least, doubling the risk of cervical cancer. How crazy is this? We're giving all these girls and nobody's yelling [crosstalk 00:52:38]-

Dr. Anna:
And breast cancer too, right? [inaudible 00:52:40] 16 years old-

Dr. Gersh:
Yes. You'll see it on the same site that it increases the risk of breast cancer. It's not quite as spelled out as it is for cervical cancer. But absolutely, there is no question that it increases autoimmune disease, it increases depression, and even suicide in young girls has been reported.

Dr. Anna:
[inaudible 00:53:00] multifactorial [inaudible 00:53:01]. It's undeniable that [crosstalk 00:53:05]-

Dr. Gersh:
Well, you don't have hormones, so it increases. You don't have hormones. We know, like you said, all these hormones have receptors in the brain. Well, you're not having hormones, these are... By the way, you could go to the toxicology website of the US government and it will list every ingredient that's in birth control pills as endocrine disruptors.

Dr. Anna:
Absolutely. Absolutely.

Dr. Gersh:
Government is what I'm saying, okay? I am mainstream. I'm exactly in line with the US government [inaudible 00:53:30]-

Dr. Anna:
Yeah, exactly. It's a huge, huge issue and it's definitely a conflict because some of you need birth control, right? But, let's say with the whole birth control thing and cervical cancer, there's birth control, then lack of use of condoms and that increases your exposure to HPV and everything else. There's that multifactorial, and that's adjuvant, right? That's an adjuvant exposure which will increase, also potentially, autoimmune issues. Now, I'm theorizing way out here.

Dr. Gersh:
Oh no, I'm with you on that. The vagina is another interface. It's another barrier. Any barrier that's breached can increase autoimmunity. That includes the sinuses, the lungs, the gut, and also the vagina. Absolutely.

Dr. Anna:
Thank you. Thank you. Thank you. It is a huge issue and we're going to need to do an episode just on this. I'm telling you.

Dr. Gersh:
Oh yeah, we could talk about tampons for hours. I'm telling you there's a lot of issues there and the menstrual cups. I mean, I sound like I'm anti-women, but I'm pro-women. We have to be honest. No woman would take her little teenage daughter and go to the doctor and say, "My daughter has really bad periods and she might become sexually active. Would you please give her some cyanide?" No one would say that because they don't see birth control pills the way I see them, I see them as a slow poison. They don't respect hormones, they don't understand hormones, and these are gynecologists. They don't understand what these hormones do in the body. They just think they're about reproduction and it gets back to the very beginning. When we lose our reproductive capabilities with menopause, we are losing a lot more. We need to be aware of that, and then we need to support all our body systems and we need to start from the get-go, from before the birth of course, I mean, to preconceptual planning.

Dr. Anna:
Generational, right? Would you say? Generational planning.

Dr. Gersh:
Absolutely.

Dr. Anna:
Yeah. Oh my gosh. All right. Tell our listeners, please, how to get ahold of you.

Dr. Gersh:
Well, I have a real brick and mortar practice, so I see patients all day long every day. My office is in Irvine, California. I do see patients from all over the world, and all over the country. They come and we work it out that they can come and get care here and then we can deal with it remotely and also [inaudible 00:55:41] work with their own doctors locally if necessary.

Dr. Gersh:
I also have my book, my first book that's out, PCLS SOS, and that's all about a natural way to restore rhythms and hormones and happiness in women with polycystic ovary syndrome. Much of that advice actually translates to every generation and every age, because it's all about circadian rhythm and nutrition and so forth.

Dr. Gersh:
I have an Instagram which I'm actually going to start doing something with it very so please come and look for my Instagram. It's dr.felicegersh. I'm posting more on Facebook, it's easy to find me.

Dr. Anna:
And your next book coming out too.

Dr. Gersh:
I have a new book coming out on fertility. It's The Fertility Fast Track. That will be coming out and it's going to be a workbook. A 12-week step-by-step program to help you improve your fertility, which as we said, it's all about health and we want to have healthy women having healthy babies.

Dr. Anna:
Yes, yes, yes, yes, yes, and naturally as possible. Thank you, Dr. Felice Gersh. Thank you to our listeners. It has been a blessing to have all of you with us today, and Felice always an amazing time to talk. I look forward to, we are going to be getting together shortly next month and-

Dr. Gersh:
I know.

Dr. Anna:
... [crosstalk 00:56:57] time together. Again, I want to thank you so much for being here and being with our audience.

Dr. Gersh:
Thank you.

Dr. Anna:
You're very welcome. All right, so for my audience, check out Dr. Felice Gersh in Irvine, California. Visit her personally, visit her virtually through her online space as well as her book. I mean you've just... you've heard a glimpse, right? A snapshot of the amount of value she brings from looking at the science, discerning, and being a huge advocate for women. We are par to par on this, so I endorse her work tremendously and open the discussion. I want all of you to share this messaging, share it in your podcast, share it in your social media, share it with your friends, relay it to your family. Start this conversation because we, right, empowered women, empower women and men too.

Dr. Anna:
The men that are listening, [inaudible 00:57:52] it's so vital to understand this information and at any time, doesn't matter how long we've been or if we've had 20 years of birth control or whatever, we can empower our bodies post this, and fasting certainly is a big part of it, my keto-green way. Read the resources that we've put here for you and in the links that follow, and share this message. Share this with your friends, share this with the community, certainly share it with your family. I want to thank you all for listening to Couch Talk and I will see you next week.

Dr. Anna Cabeca
Dr. Anna Cabeca

Dr. Anna is a Triple Board Certified OB/GYN, Anti-Aging Medicine expert, and author of the best selling book, The Hormone Fix.

Dr. Anna helps women heal the 9 most dreadful symptoms of menopause with natural, safe solutions. Follow her for content on hormonal imbalances, vaginal dryness, menopause (and more) that are medically backed, and created to empower women — not just treat them.