165. Cynthia Thurlow: The Menopause Gut - Why Healing Your Hormones Starts With Healing Your Gut

Welcome to Extend with me, Dr. Darshan Shah, a podcast dedicated to cutting-edge science, research, tools, and protocols designed to help you extend your health span. Having become one of the youngest doctors in the country at the age of 21 and trained in board-certified at the Mayo Clinic, I've accumulated three decades of practice as a board-certified surgeon and longevity expert. Over that time, I've discovered that a mere 20% of health knowledge yields 80% of the results when it comes to your health span. We're living in a new era where we are creating a new healthcare system no longer focused on disease management but achieving optimal health and vitality. Join me as I interview world-renowned experts offering you a step-by-step guide to proactively avoid disease and most importantly, extend your health span. You're eating well, you're exercising, you're doing everything you've always been doing, but somewhere in your 40s, your body stops cooperating, your weight starts to shift, your sleep gets broken, the brain fog settles in, and no one gives you a really good explanation about why. The menopause conversation has come a long way where there's still a missing piece most clinicians aren't talking about, the gut. Specifically, what happens to the microbiome when the hormones shift and how that one change cascades through virtually every system in your body? Cynthia Thurlow is a nurse practitioner. She's a good friend of mine and a host of the Everyday Wellness Podcast. She's authoring a new book called The Menopause Gut. She's been on Extend Before, but this time we go deep on HRT, hormone testing and intermittent fasting for women and how all of that affects your gut. This time, we're going to talk about things that we didn't talk about in our first conversation such as your gut microbiome and the hormone connection. Today, Cynthia walks us through why the gut becomes the body's primary regulator once hormones change, how a specific cluster of gut bacteria controls the way estrogen is metabolized and why inflammation and metabolic dysfunction show up even when you're doing everything right and what it actually takes to restore your gut and midlife. This is the explanation a lot of women have been waiting for. Cynthia, I'm so excited to have you back on the podcast for your second time here. You're one of the smartest people I know. No, you really are. A huge compliment. I love speaking with you. You're so deep in the science of everything and you're just such a great force for the progression of healthcare in the right direction. So many great things and I'm really happy to know you. Thank you. Thank you. Listeners won't appreciate this conversation, but LA traffic plus a couple of kerfuffles this morning. So thank you for being so gracious. Oh, of course. Of course. So I'm really excited because this time we're having you on to talk about an incredible new book, which I think is going to be a game changer called The Metapause Gut. And I would love to know why this book. It's a great question. I think having a podcast myself, I get to interview the best and the brightest researchers and clinicians. And I just felt like in 2024, there was a larger conversation that needed to be had. I was interviewing microbiome researchers and gastroenterologists and longevity experts. And it just really hit me that there's this piece of the kind of perimenopause to menopause conversation, the aging process that we're not focusing in on that I think for a lot of us, not just women, but also men is contributing to the symptoms we experience, how well we feel and how well we are aging. And I think that I pitched the idea of my editor because she had reached out to me and I literally wrote a one page, two paragraphs, and she green-lighted the project immediately. She just said, I think this is really unique. I think you've got a really fresh angle. And I think that this is a very important conversation that is not being had. So I have to credit Lucia Watson for green-lighting the project when I pitched it to her as an idea. And for anyone that's listening, they may not know when you write a book proposal, it's usually 50 to 100 pages. So to go from my first book proposal, which was 100 pages, to one page really demonstrates that this is a really novel and new, fresh idea, one that I think is going to really have an enormous impact on all of us that are practicing, but also the lay public as well. Yeah, I agree. And I think that at every location in Nex Health, we have this thing called the wellness wheel. You've seen it downstairs. And this is metabolic health, inflammation, cardiovascular health, hormone health, gut health, toxin exposure, like all of these different aspects of your health on the wheel that we need to address during your course as being a patient here at Nex Health. And one of the things I do when I train providers sometimes that work for us is I have them draw lines of what's connected to what, right? And usually it's incredible to me that many providers don't connect the gut to really anything else, right? And so a few of the ones that have been listening to the podcast, they'll make a line between gut and brain, right? But this entire connection between hormones and gut health, it's so underappreciated. And that's why I was excited to have you on to really talk about this in the context of what happens as we go through life, right? And so I think this is a conversation that is, even though your book is titled the menopause gut, there's also the manopause gut, I think as well. And this decline in our mid-40s of our hormones, women kind of go off a cliff, men have a gradual decline, but there's definitely a decline there, is very connected to the gut bi-directionally, which means the hormones affect the gut and the gut affects the hormone. So I would love to kind of dive in a little bit deeper with you first on why does our gut seem to change in this time of our life? Like what happens in midlife that changes our gut and what are those changes? Yeah. I want to talk about what the gut microbiome is because it seems incredibly intangible. You know, we know where the heart is, we know where the brain is, hopefully our lungs. The gut microbiome seems a little less tangible. And so it's 40 trillion bacteria, viruses, fungi and protozoa that accompany the large intestine of the colon. And it's heavily imprinted on how we're delivered into the world. So whether we're a C-section or vaginal delivery, whether we are, I almost said, bottle fed, whether we are formula fed or breast fed. And then, you know, there's kind of key times in men and women's lives. Number one is puberty, not surprisingly, that heavily influences the microbiome by virtue of testosterone and estrogen and progesterone. And for women, you know, whether they become pregnant or not. And another big hit is perimenopause for women. Obviously men go through andropause, but as you astutely stated, it is much less dramatic. But perimenopause is where we start to see some significant changes in the microbiome. And for a lot of individuals, because the gut seems so intangible, it's like, oh, it isn't all connected. It's all siloed, like in traditional allopathic medicine. You know, this is the cardiovascular system. This is the gastro-system. This is the pulmonary system. So I think for a lot of individuals, they would be surprised to know that our immune system governs the way that we age. And the immune system and the gut microbiome interface, I mean, 70 to 80 percent of the immune system is housed in the gut. So they're heavily influenced one another. When I think about the things that are influencing us as we're getting older, number one, the most mitochondrial dense organ in a woman's body is our ovaries. It actually sets the pacemaker of aging. Men have the testicles. Most mitochondrial dense organ in men is the testicles. Not surprisingly. Yes, neither did I until I started writing the book. I think so many of us think about the heart and the brain. But not surprisingly, it's what helps create life. So that makes a great deal of sense. I think as we're navigating our middle-aged years, so 35 and up, 40 and up, we start seeing decline in hormones. The hormones in many instances are processed through the digestive system. A lot of people don't realize it's that kind of cumulative net effects over time. As we are getting older, as our immune system is changing in response to changes in hormones, as we are more susceptible to opportunistic infections, we talk a lot about the small intestine. It's one cell layer thick. It's really important for absorption, but easily damaged by things that we probably do day to day and don't even think about. A round of antibiotics appropriately prescribed. We're exposed to glyphosate in our produce. Just thinking about chronic stress is another big impetus for the impact on small intestinal lining. The thing that I find most interesting, Darshan, is when we're talking about middle-aged women in particular, their rate of autoimmune condition. There's over 100 diagnoses now, including things like long-haul COVID and chronic Lyme, but when you and I were training, there were probably like 20 or 30 that were commonly accepted. For women, there's these unique changes that are happening in the microbiome, susceptibility to autoimmune conditions. We are four to five times more likely to develop autoimmune conditions in middle-age, which is a byproduct of this loss of protective barrier of the small intestine, whether it's food particles or endotoxin or lipopolysaccharides that will reach the small intestinal lining, they will provoke an immune response and get into the bloodstream. A lot of people will say things like, the first sign of perimenopause I didn't realize was, I started getting bloated after I ate and I could not understand why. There's very much this tipping point as we are starting the conversation around, as the gut microbiome is changing, what are some of the first things we will start to see? Some of the most commonly reported symptoms are things like bloating or digestive changes. I think there's a lot of great awareness around bowel changes and how those are things that we need to be talking to our practitioners about. First and foremost, if you're suddenly having a lot of diarrhea, a lot of constipation, a lot of bloating, you have to get that checked out. I think that those things seem so benign that we don't yet fully appreciate. Those can be the first signs that there's things that are starting to change in the microbiome at a microscopic level that will magnify other symptoms. I would say the other thing that I think is interesting and significant that patients will report is we have this wonderful vagus nerve that runs the span from the gut to the brain and as you stated, it's bi-directional so information is transmitted back and forth. But if there's a lot of inflammation, whether it's inflammatory foods that we're eating, whether it's chronic stress, that inflammation transmits to the brain and we can get brain inflammation. We can experience brain fog. A lot of patients will tell me they have more anxiety, more depression, more obsessive compulsive symptoms that can be a sign that there's alterations in not only neurotransmitters, but that brain inflammation can actually exacerbate some of these symptoms that patients will experience. Those are some of the common kind of like what I would consider to be like the domino effect. Those are sometimes the very first symptoms that patients will report that can be a sign that their microbiome is starting to shift, probably not in the direction that they're hoping it will go. Right. And these are all connections that previously when I went to medical school, none of these connections were made. So it was kind of more of a leap to me to make some of these connections. But the more I dive into the science, they're all definitely connected. Specifically, you mentioned the vagus nerve, the connection between your brain and your gut. Right? So one of the things that we were talking about earlier was this concept of accumulated stress over our lifetimes that affects this communication mechanism between our brain and our gut, specifically related to long-term traumas, even just traumas as a child. Right? And could you dive into that a little bit with us and how that works? Yeah. So it's interesting when I was writing the book, this is one particular chapter that really hit me hard because I trained in inner city Baltimore and arguably I saw a lot of big T trauma, rape, murder, suicide that no one will question as traumatizing. But the kind of more nuanced conversation is about little T trauma. We're talking about exposure to addiction, neglect, emotional, physical abuse, bullying, and how that can imprint susceptible people in a way that it will rewire their autonomic nervous system. So their nervous system will be rewired, they are more likely to experience poor metabolic health, more autoimmune conditions, more disorder relationships with food, more likely to perpetuate what they grew up in. And so I always say it's the little T trauma that is corrosive. And in many instances, maybe there's a degree of shame and people don't want to talk about it. And it oftentimes will kind of go undicipered until we get to middle age because in middle age, both men and women are going to see alterations and hormones, changes in neurotransmitters, and those experiences, adverse childhood events. There was a joint venture between the Kaiser Permanente and the CDC and anyone that's listening can go online. You can get access to this very short quiz to give you a sense. The higher the number, the more likely you are to experience these physical and emotional symptoms. But what I think is really interesting is there's this undercurrent where a lot of men and women, they experience these adverse childhood events as children, they suppress it, and they get through their teens, 20s, and 30s, hopefully with adaptive patterns that allow them to move through that. When they get into their 40s, when women get into perimenopause, men get into andropause, suddenly those alterations and hormones, and they're not able to cope as easily. What I think is most interesting is the impact of chronic stress on our reproductive health. We know it can age the ovaries faster. That is something that I had never realized before, and it explains why a lot of my colleagues that are ER medicine, GYNs that are up, delivering babies, surgeons, people that work in very high acuity areas, not just in medicine, but EMS workers, police officers, et cetera, these individuals, when you look at longevity markers, you look at when people are transitioning into menopause. Sometimes it's a whole lot earlier. Average age of menopause in the United States is 51. A lot of these women I'm seeing in their mid to late 40s, and so I think it is a byproduct of chronic stress. And I would say stress is, hermetic stress is a good thing. Beneficial stress in the right amount at the right time, but chronic stress is corrosive. It'll be catabolic, breaks down muscles, makes you more likely to develop leaky gut, lower pressure, immune system function. And so it's the perfect storm. Like I always say that perimenopause is this litmus test of how well we are living our lives. And so it's this perfect storm where all these things are coming together at the right time that really makes those adaptive patterns that people create become much more maladaptive in middle age. And so these are people that will sometimes have more magnified symptoms of the perimenopausal transition. They may explore more metabolic health issues, more autoimmune conditions. As I mentioned, it's this four to five times greater likelihood in middle age. So imagine that just gets magnified. So maybe someone had psoriasis in their 20s, maybe they had alopecia in their 30s, and all of a sudden their 40s come and they've got two or three additional autoimmune conditions, which really is speaking to what is transpiring in the microbiome, in that kind of small intestinal lining that's making them much more susceptible to these kind of opportunistic opportunities. Do you think that many rheumatologists, you know, a lot of people when they get autoimmune disease, they go, the first person to go to see is a rheumatologist. Do you think many rheumatologists are addressing the gut or perimenopause or hormone decline as part of their treatment algorithm? Probably not, unless they're newer trained. Like I think our own contemporaries probably not because they just weren't given those tools. It's really been maybe the last five to 10 years that we're seeing more microbiome research. And I think about pivotal books that have come out over the last few years talking about the role of trauma and being this wound that are making, I think most of us much more aware of how corrosive long-term stress can be. Because I think that, you know, certainly my parents' generation, they didn't talk about any of these things. They didn't acknowledge it. They shuffled it down. It showed up as, you know, addictive behaviors or maladaptive patterns. And I think that, you know, perhaps it's our generation that's bringing greater awareness to this, bringing a greater lens to it so that it's part of the conversation. Because if you can screen patients earlier, if you know it 30, someone at 30 has an A score of nine, you know that there's a lot that they need to be doing way before they get to middle age. Exactly. And gives us opportunities to intervene because it's all about quality of life matters. You know, we talk about the autonomic nervous system, but we're really speaking to the enteric nervous system that's in the digestive system that, you know, is all responsible for all these sensory nerve innovations. So you may think that because you're not, you don't have poor mood regulation or you're not having explosive personality that somehow you are processing what you're going through and what I find for a lot of patients, it's not until the great awakening of middle age that they suddenly start dealing with uncomfortable feelings, things that they've experienced as children. And there's certainly a lot of things we can do for them. Myself included, I would say like it's a constant iteration, you know, day to day to work on our stuff so that we are thriving and not just surviving in midlife. Yeah. I had Gabby Bernstein on this podcast and she, when she wrote her book, is self-help. And she really addresses this concept of all these little tea traumas that we build up and how they affect our day to day. And how you can use like her techniques and family systems to really kind of unwind some of this on a daily basis. And I think that in combination with seeing a really good therapist, for example, can really help unwind a lot of this. And to your point that, you know, a lot of people don't even realize because you live a lifetime suppressing these things, taking that ACE quiz, the accumulated childhood, what does the ACE stand for again? It's adverse childhood events. Adverse childhood events quiz, right? Exactly. And maybe eye-opening and illuminating for some people. Yeah. Well, and it was funny when I was writing the book, I was talking about my own personal narrative about this and how I've been in some form of therapy since my 20s. But I said, had I not done all this work, I couldn't be having these conversations. But I think it is so vitally important for us to be having these conversations because there are a lot of women who say like, I didn't see someone get raped or murdered. I didn't experience that. So I didn't experience trauma. But yet it's the corrosive subtleties to trauma that can be equally problematic for a lot of individuals. And I think there are people that are maybe missing opportunities to get the help that they need and deserve. There's so many options, so many somatic therapies, talk therapies. I know that there are even some colleagues that are doing work with MDMA to process those feelings and, you know, kind of accelerate the healing process. But there's a lot that people can do. And I think it's vitally important in middle age as those hormones are changing that we find strategies that are going to help us heal as opposed to just, you know, just take that antidepressant but don't actually. And let me be clear, there are people that absolutely benefit from psychiatric medications. I'm not being critical of that. But I think it's really important to say, you know, if there's something that we need to address at a root level, it's going to allow some to accelerate their healing. That's really the very important work that I think so many of us are really focused on. Exactly. And I think, you know, if you get diagnosed with an autoimmune disease, you have to go looking for the root cause, right? A lot of the times that is in your gut or in your hormones, there's a lot of ways that we can at least decrease the dose of these expensive medications and hopefully work hand in hand with the rheumatologists to get you off of them at some point, right? And so I myself had an autoimmune disease and I got myself off of a prescription that I thought I'd be on for life, a biologic actually, and never suffered with it again once I got my gut healed, you know? And so I think it's a really important thing to keep in mind. And I also feel that, like you said, the psychological work that people need to do can be just as impactful as healing your gut in these type of situations. And I think it's, I think they really do go hand in hand. I think you can't have one without the other. If we're talking about healing our guts, if we're really speaking at a deep level, we really do have to take into account that emotional component because for so many people, whether or not they ended up in a career of medicine and part of taking care of others is healing themselves. I think for so many people, they have to understand that it's more than just taking a supplement. It's more than just taking a prescription medication, which you may need all of the above. But for a lot of individuals knowing that you have some control over, you know, the path that you take forward. Right, exactly. So we've talked about seeking therapy or working on your traumas as one way of healing your gut. We've also talked about avoiding kind of like the foods and the antibiotics and the non-shrant inflammatory drugs that are like nuclear bombs to your gut. Let's talk a little bit more about the parasympathetic-sympathetic regulation piece of this through your vagus nerve. How can someone assess where this stands, you know, this balance between the parasympathetic and the sympathetic nervous system, and how can you improve it? Yeah, I think heart rate variability is a really interesting metric for this. I think that for a lot of individuals, they may perceive that they have good balance between the rest and repose side and the sympathetic fight, flight, flea or fawn. They may perceive that they're well-balanced, but that HRV doesn't lie. And I think for a lot of patients, they'll say, oh, sometimes when I travel, if I'm at altitude, I notice my HRV drops. Or if I get an argument with my spouse, or if I'm having a protracted amount of stress, I notice my HRV drops. So it's really speaking to the balance between the autonomic nervous system. So that's a fairly objective way that I think is important. I mean, obviously looking at vital sign metrics can be helpful. Some of my patients, especially when I was in cardiology, they would say, oh, I don't feel stressed and their resting heart rate's 110. I'm like, okay, clearly there's something going on beyond, you know, you're telling me it's just because you're consuming too much caffeine. I'm like, it probably is more than that. I think for a lot of individuals, it is this kind of calculated approach to supporting the vagus nerve. Number one, it's thinking thoughtfully about what are the things that we know are effective at improving heart rate variability. And just to say have less stress is not realistic for most people. So it's more about like, what are the things we know can be helpful? So things like gargling, humming, singing, those things will stimulate the vagus nerve. So before I step on a stage, I'm usually doing some controlled breath work that will help me stimulate my vagus nerve and slow things down. I think that for a lot of people, they automatically jump to gadgets. And yes, gadgets can be fun. And I'm all about, you know, fun and novelty. But I think at a very foundational level, it's taking four to five deep breaths before sitting down to have a meal. Like in my family growing up, we always said grace before we ate. And so allowing your body to understand that you're sitting down, you're getting ready to consume a meal. What maybe people sometimes don't know is that when we talk about digestion, if you're in that fight, flight, flea or fawn stage, your body can't properly secrete hydrochloric acid, digestive enzymes, forget about trying to secrete sufficient amounts of bile to break down in most of my fats. You can't absorb and assimilate. You won't be able to detoxify. So at a very, very basic level, sitting down and having a couple deep breaths or even doing some of that vagal training. I mean, there's things beyond that. There's actually, you know, breath work, legs up a wall, you know, meditation, grounding work. I know sometimes people think it's woo woo. It's finally warm enough that we can actually do that in Virginia. But getting your feet on the earth. I mean, there's actual science behind that connection to nature. You know, I think a lot about oxytocin and, you know, it's this very important hormone that I think we think about in the context of reproduction, but I think about it about how oxytocin can lower cortisol. And for a lot of people that hugging a loved one, connecting, hugging your pet, having an orgasm, just doing things that bring you joy can lower oxytocin and lower cortisol, which can also have a positive effect on your vagus nerve. So I think for a lot of people, there's a lot of different things, but I always remind them like I want you to do something that you can do consistently. There's a lot of fun gadgets that are out there right now. I've been tooling around with one in particular that I think for me personally, I've seen the most benefits from. But I think what's it called? Pulsetto. Oh, pulsetto. Yeah, I got one. Pulsetto has been my, I was shocked to be able to. I aim to be the founder here on the podcast, yes. Yeah. I was front, transparently, because I get gifted a lot of things. I try a lot of different things. And that was something that I was able to track my HRV to see like what's my improvement. And it was, I can watch it kind of objectively. Is it going down? Is it going up? Where are we going? What do you wear it on your ankle, your wrist? Around my neck. The neck, sorry. Yeah. Yeah. So the pulsetto, that to me, I just found. Fascinating. Yeah. And that to me is incredibly calming. I do it at the end of my day. But the point is, don't jump to the gadget. Right. You know, start with the very foundational things that you can do without any gadgets or having to spend any money whatsoever. Because I think sometimes in the health and wellness space, we get so far ahead of ourselves. We're like, oh, I must have the gadget. Well, the gadgets are fun, but we still need to be able to do the basic things because that's what we can do day to day. Like I'll say to patients, do something you like and do it consistently. Right. And you have five minutes of meditation on Thursday afternoon. No. Like you genuinely need to find ways throughout your day that you can de-stress yourself because it is that vitally important. Yes. I totally agree. A couple of things that I found really beneficial is avoiding alcohol specifically, you know, within the last four or five hours before going to bed. I think most people drink alcohol like right before they go to bed and that's destroying your HRV. I also think having the cell phone distanced from you every night before you go to bed also gives you the same distance, obviously, when you wake up in the morning, getting that away from you. And then I found sauna to be really helpful as well. So it's a great checklist of items you can do to start improving your HRV, but I agree with you, tracking is critical. This episode is brought to you by Momentus. So as a doctor, one of the questions everyone always asks me is what supplements should I really be taking? And honestly, before you even pick what's the right supplements for your body, you always need to think about whether you can trust the brand that you're buying or not. Here's what most people don't really take into consideration. The supplement industry is barely regulated. 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Because I'm not aware right now if there's a filter for microplastics. I think that's a great concern right now is that that's a bigger issue with endocrine mimicking chemicals. Well versus most of the same filter, microplastics, yep, for sure. So that can be very helpful. I think starting with that is a good starting point. You know, the Clean 15 and the Dirty Dozen, you know, environmental working group every year puts out, these are the things that are really worth purchasing organic. Obviously things you can't peel. So I always think about berries. We're heading into summer fruit season when people are really enjoying those in season produce. And you know, saving a little bit of money. Like you don't need to have an organic banana, at least from what I've been able to read. Absolutely. You know, you peel off the outside cover and it's not an issue. I think it's also like just being mindful of what you're exposed to in your environment. You know, when we built, we have a house that we built in Virginia and we had a company come in and talk about how do we, like limit the amount of exposure to EMF radiation, etc. We've control over some of those things. And so we don't per se have a smart house. We have a house where, you know, we have grounding mats. We have a lot of things that were done specifically to limit. We're dialing, you know, you know, I have ethernet in my house, which sometimes people laugh about it. But I think it's just getting conscientious about the things we're exposed to day to day, you know, thinking about the quality of the clothing that you're wearing. You know, there's a lot of athletic wear companies out there that are great. And it, you know, the fabric moves very easily and it wicks moisture away. But getting conscientious about brands that perhaps have a commitment to having a lack of like PFOS exposure, like I'm thinking of a couple in particular, but just being conscientious, not wearing your shoes in the house. That is something that my parents did growing up. And I thought that was odd. And then I realized my parents were actually brilliant because we dragged so many things into our homes. So true. So I think it's just thinking thoughtfully about products we use on our bodies, whether it's deodorant, we don't need antiperspirant. I know people are convinced that they do. You don't, you actually do want to sweat the quality of the toothpaste we use, even like body lotion, just really getting granular and conscientious. Thinking thoughtfully about ultra process foods. And I realized like I do a lot of travel and yes, sometimes I'm stuck in airports where I'm left with no options, but I will carry things with me. But just being conscientious, if you choose to eat something that has a box, a label or a bag, eating with limited ingredients, like I will carry beef jerky with me, but I get clean beef jerky or have a slice of cheese in an airport or a hardball leg, like just being very, very simple. But I think it's those cumulative exposures of things. Obviously, I think a lot about hormones, when we're talking about hormone replacement therapy or replenishment therapy, really trying to be supportive of bioidentical options that our bodies can actually recognize as opposed to synthetics. Also being just cognizant of cologne or fragrances. I think about Glade plugins, starting to call them out. But just the cumulative effects of things we're exposed to, getting conscientious about the quality of the furniture you have in your house. Now, I'm not saying to do everything all at once. I'm just saying, if you're thinking of where you are in the hierarchy of making changes, sometimes something as simple as changing your toothpaste and filtering your water can have a lot of improvement on what you're exposed to over time. Not to mention, I've actually mentioned alcohol. And I always tell people, alcohol is a toxin as much as we don't like to believe that it is. Definitely one of these things we just want to be examining our relationship and just being mindful. Yeah, exactly. And I think, like you mentioned cumulative quite a few times. And I think it's, our gut is made to handle a certain amount of toxic exposure. That's what our microbiome helps us do, keep the toxins out. We have our enterocytes that are usually very good at this. But when they get overwhelmed day after day after day with exposure, they just can't keep up. And that's what leads to the toxins kind of breaking through that gut barrier and our immune system then having to deal with it on a constant and consistent basis, leading to inflammation, which then becomes chronic inflammation, which then leads to all of the disease processes. It's just like giving your body a break every once in a while. Right? Absolutely. Every once in a while, just give it a break. People talk about detoxes and cleanses. The only reason they work, there's no magic ingredient, just because you gave your body a break from the ultra process foods, from all the stuff that you're putting in your body that it can't deal with. Right? Yeah. And I think it's really interesting that I feel like middle ages, when this shows up for men and women, it's the cumulative net of facts. It's like the buckets getting filled throughout our lifetime. And then suddenly in the setting of decreasing hormones or alterations in neurotransmitters, all of a sudden we become incredibly symptomatic. And to your point about the fact that a lot of people will say, oh, I have this program in a box and I did that and I feel so much better. And it's really that you've just given your body time away from inflammatory foods or you're drinking more water. I mean, things that we should be doing intrinsically more often anyway. But I think middle age is where these things, I would say it's the litmus test of how well we're taking care of ourselves. And I think sometimes people are surprised. Like we kind of bumble and fumble through life. And then we hit middle age and we're like, oh, wait a minute, I'm actually old enough that I have to really be conscientious about what's in my personal care products, my food, and my environment. And the answer is yes, absolutely. Because the differentiator for a lot of patients is that they're suddenly being aware. They're just bringing awareness to the quality of their food, bringing aware of the types of clothing they're wearing. It doesn't mean you change everything all at once. It just means I'm going to be more thoughtful and intentional with the choices I'm making because I know it does have a large impact on how I'm going to live for the next 40, 50 years. Right. Right. Can we go back to hormones? Because I think my audience would love to hear how do your hormones affect your gut? Like what's the mechanism there? Because traditionally, like those two are just not connected. Right. So let's talk about that and the whole concept of the astrobalome as well. Yes, the wonderful astroblome. So this is essentially an estrogen processing center in the microbiome. It's really important because there's two phases of detoxification in our liver, and then the third phase is really going to the gut. So can our body break down these estrogen metabolites into water-soluble compounds? There's a wonderful enzyme called beta-glucuronidase. It's helping us cleave up and package up the excess estrogen. And then effectively, I'm going to oversimplify things. We want to get rid of it, so we're going to poop it out of the body. But what can happen due to a variety of reasons? It can be an exogenous exposure to estrogen mimicking chemicals. It can be due to not an optimal gut microbiome constituency heading into this kind of perimenopausal timeframe. We can actually not properly break down that estrogen, and it can be recirculated in the body. So a lot of the symptoms that women are experiencing, the weight loss, resistance, breast tenderness, brain fog, digestive issues, can be a direct reflection of not being able to properly detoxify and break down these compounds. Instead, they get recirculated, which magnifies all these symptoms. Now, the liver is the heavy hitter for detoxification in the body. It really is an important organ, as are our kidneys and our lungs and our skin. All these things are designed to help our body detoxify without having to take a program in a box. Let me be really clear. But cumulatively, over time, we're thinking about the microbiome and how it's imprinted. Someone that's eating a standard American diet that maybe took 20 years of oral contraceptive therapy, someone that drinks successively, maybe they're sedentary, they're not metabolically healthy, is going to have a microbiome that is not going to be able to properly break down and assimilate these hormones as we're trying to break them down, ensure that they go to the places where they're supposed to go. What if I'm really interesting when we talk about the digestive system, it's helping people understand that at a very small level, these hormones, as they're declining, they impact motility in the gut. So as progesterone is a smooth muscle relaxant, so as it's declining, we may feel things don't move quite as effectively. I always get patients that'll say, do I have gastroparesis? I'm probably highly unlikely. Estrogen helps with nitric oxide signaling. So really important for movement through the digestive system. Estrogen is important for the small intestinal lining. So think about estrogen, you can think about it as a coffee filter, or you can think about it as a brick and mortar system. That's how I like to think about it. Estrogen is the mortar. So as estrogen's declining, more leaky gut, more inflammation, more provoked immune response. But the astrobalome is this really key concept around the microbiome itself. And so this is why the health of the microbiome is intricately interwoven with the astrobalome, and whether or not it's functioning in an optimal way, or we are recirculating unintendedly to recirculate the estrogen's magnifying symptoms. And for a lot of women, it shows up in those pesky symptoms that we don't like to experience in middle age. I mean, men can also experience some projected symptoms, but again, they don't have the, I would say like our hormones are much more dramatic. As they're declining, there's a lot more symptoms. Then it tends to be a little more subtle. So the astrobalome are specific bacteria in the microbiome that are responsible for essentially breaking down estrogen molecules and packaging them up for elimination. But if you don't adequately package them up for elimination, those metabolites of the estrogen can cause all the symptoms that women experience during perimenopause. So the reason I mentioned this is you and I both use a Dutch test for our patients. And so you don't really get clarity around this unless you're measuring for these urinary metabolites of estrogens. And so that can be really helpful if you are perimenopausal or even menopausal and or even a man in menopause to see what metabolites are being created by your body to see why the symptoms are developing. Yeah, it's interesting. And I'll just tell a personal story. Like there was the first time I started hormone replacement therapy. I was on injectable forms of HRT. And we did a Dutch. And I remember I knew my detox pathways were optimal before. And all of a sudden it was pushing down a non favorable pathway. You know, you'd alluded to there's three on the Dutch that we kind of look at. And I remember thinking, okay, this is a huge red flag because I haven't had this issue before. And this is where I think, you know, the Dutch test can be incredibly insightful for, you know, fine tuning the work that you're doing. So obviously that was not the right HRT formulation for me. But I think for a lot of individuals, it can be a good litmus test of, you know, am I breaking down my estrogen metabolites properly down the right route versus some of the ones that have the potential to be a little more pathogenic. Yeah, exactly. So for all the listeners, you know, if you're going through hormone replacement therapy at some point, maybe asking for a Dutch test if they're experiencing symptoms or even if you're not, I still think it's very useful. So what does someone do if they feel they diagnose either their astralbalomas off or maybe they don't even have a Dutch test to do, but they're still experiencing symptoms. How does a woman get their astralbalome to become healthy again? What are you saying? Other than all the things we already talked about, are there probiotics? Are there other things that you can do to reinvigorate your gut microbiome to do this portion of this job correctly? Yeah, I mean, I think it's, if I know that they're phase one or phase two is of issue, there are specific targeted supplements like dim can be helpful for phase one, phase two, we might be looking at calcium to glucorate, getting specific about sulforaphane, you know, broccoli sprouts, you know, being conscientious about cruciferous vegetables, bitter greens. You know, for me, I will come at it from a nutrition perspective because I think it is so valuable. Obviously, good hydration, good detoxification protocols like sauna, dry brushing, I think those things are very helpful. I think for a lot of individuals, if I'm looking at microbiome testing and I think that it's evident that they need a specific targeted probiotic, I think that can be very helpful. Obviously, acrimoncia is one that we have both talked about quite a bit. You know, just being mindful, spore-based probiotics can also be very helpful, but it's really looking at the full picture of, you know, what are you doing for lifestyle, for sleep, stress management, nutrition? Are you eating too frequently? You know, maybe you need to be eating less often. Maybe you're not doing a full intermittent fasting protocol, but maybe you're doing a degree of digestive rest, physical activity, dealing with your stuff. You know, we know you aren't going to be able to detoxify if you're chronically stressed. And so just getting granular about how much information do we have and based on symptoms and a really solid history, those are things that I will usually kind of start with. And if you notice, I'm not talking about going to extreme measures. We're just being very subtle with layers of nutrition, layers of lifestyle that can be very, very effective. Exactly. So, you know, some of the things that I a fan of is also like you mentioned acrimoncia. So, pendulum has a really good product with that. So, I found that to be very helpful, not just for like weight loss, but also for just reinvigorating the gut lining and getting people's microbiome back in order. Fiber, for example. It's just a massive issue in most people's diet now. It's fiber. A friend of mine, Dr. Kern Rajan, who you interviewed, he came out with one called Loam, which I love. It's been a six different forms of fiber. It's incredible. Six forms of fiber in one little packet that I just take twice a day, actually. You know, I think all these things can be helpful when you're trying to get your gut back into a place of health. You could see inflammation being reduced, but then I think it's also important to maintain this over time because, you know, we all have stressful lives. We all travel a lot. We all go out to restaurants. It's hard to maintain this. And I find that, you know, that fragility point almost where you can like go off a cliff and your gut again is in a bad state. It's easy to get to after just like even two or three days of travel for me. And so, I just try to maintain, you know, the fiber supplementation, the probiotics, and try to be as healthy as I can with all my habits. Big fan of also Vegas nerve regulatory activities like breath work as well when you're traveling to be all very important. And I think travel, like to me, is the ultimate indicator of how well you are in control of these practices, right? Because if everything goes to hell after three or four days of traveling, you're just not doing it right or enough, right? No, I so agree with you. And I love that you brought up fiber. I mean, I jokingly call it the new F word because it is so controversial. Sometimes I'm having conversations and saying, I think the differentiator of a healthy microbiome is really this fiber piece. And I think if you think about the standard American diet is so devoid of fiber, you know, why are we seeing so many changes in, you know, irritable bowel syndrome and inflammatory bowel disease and escalating rates of colorectal cancer. And I think a lot of it has to do with, I mean, there's a variety of things, but I think the devoid diets of fiber are a huge piece. I think for a lot of women, they'll say to me, well, I don't tolerate fiber. And I always say, well, that in and of itself could be a sign that there's a problem that we need to deal with. But, you know, it's like slowly kind of increasing your fiber intake. If you're currently, this is where I think tracking is helpful. So if you're taking, if you're consuming 10 grams a day max, maybe you go to 12, then moved to 15. And I think it's very bio individual, like what might work for you may not be enough for me and vice versa. And so I think that we just want to be very mindful in terms of the missing macro, I always call it the missing macronutrient because we've convinced people that carbohydrates are all bad. So saying again, like it's, you know, that protein piece, I think no one's going to question that, but also this fiber piece is a missing link for a lot of patients. Absolutely. I think, you know, the minute you add fiber to someone's diet, it can be a game changer for people. And to highlight your point, like when someone says that can't tolerate fiber, it's like humans were meant to tolerate fibers. That's a huge problem if you can't tolerate fiber. We've got to fix your gut. Well, more often than not, it speaks to, I mean, I think about, you know, I spent a long, a lengthy hospitalization in 2019. I don't think I tolerated fiber for 18 months. And I knew why, but, you know, I'm happy to report that that has changed over time. And if you look at the research on, you know, how one round of antibiotics can impact the microbiome, it's quite significant. When I was writing the book, it was 18 to 24 months. I think our friend Karen actually presented a paper talking about eight years. So you start to understand like the microbiome is dynamic in response to all of these lifestyle inputs and why it's so important to just be consistently, you know, upping the fiber and take the fermented foods because it's clear from the research and certainly from protocols I've run with patients that they do much, much better long term. Right. Right. Absolutely. You know, I want to go back to one other thing that you said, which is hormone replacement therapy. You are on hormone replacement therapy. And after you did your Dutch test, you found out you needed maybe change it up a little bit. Right. So I would love for you to just kind of talk about, you know, who should be on hormone replacement therapy? What woman should be on hormone replacement therapy? And when? And talk about kind of like the modifications you have to make based on your symptoms and also the Dutch test. I know there's a lot there, but I would love for you to go down down that. Well, I think every woman deserves to have a conversation about hormone replacement therapy. So that's a full stop. Right. I think that you absolutely want to work with someone who is savvy, meaning that they are well-intentioned, well-educated, they're not fear mongering. Right. And they're explaining both the benefits and the potential issues that could come from your unique history. Right. I think that it's clear that starting earlier has more benefits than waiting. You know, when I, you know, I'm 54 and I can tell you 10 years ago, it was like, oh, you wait until right before menopause and then that's when you start it. But clearly there are women suffering in their 30s and early 40s and no one should be suffering. You know, the suffering is optional. And so I think initiating, you know, oral micronized progesterone or compounded progesterone, starting that in a woman's late 30s, early 40s, if she's symptomatic and then adding an estrogen and testosterone when they're appropriate for that patient is a total game changer. I think that we don't yet have a clinical indication for estrogen therapy and progesterone therapy for microbiome support or even testosterone. But I think that will come. You know, the research is certainly looking like it's that important. If we look at microbiomes of a pre-perimenopausal woman and post-menopausal woman using HRT and those menopausal females provides restoration of the microbiome or at least looks, it starts to resemble a younger woman. And we're not talking about aesthetics. We're talking about just at a deep cellular level. I think on a lot of different levels when we're talking about HRT, it's helping women understand there's a variety of options. You know, there's some people that want to do transdermal estrogen. Some people want to do oral estradiol. Others want to do the peanut oil, micronized progesterone, and that works just fine. Others want sustained release. Testosterone is another kind of nebulous topic because it's not yet an FDA formulated option for women, but we can get around that. And I think that these conversations are so vitally important because they're so involved with quality of life metrics long-term. And long-term, chronic disease prevention, prevention of Alzheimer's disease, bone loss, muscle loss, all of it, right? And cardiovascular disease. I had another guest on here. We were talking a lot about cardiovascular disease in women and how it is very microvascular in nature. And estrogen can really prevent cardiovascular disease in heart attacks on women. And women get a false sense of security when they get like a coronary calcium score, for example, that comes back clear. But then they still have microvascular disease that this scan will not pick up on, right? And so I think it's important to highlight that estrogen can still prevent heart attacks in women because whether or not you have an indication based on a calcium scan or high cholesterol even. Well, and it's interesting because the the CAC only shows heart plaque. And what we get concerned about is soft plaque and we know women tend to have... A lot more soft plaque. Right. We have a lot more soft plaque and we tend to have more microvessel disease. And we know, I already mentioned like estrogen and nitric oxide, which is an endothelial function. You start to understand this is why that timing hypothesis came out and was postulated that starting earlier is really more advantageous because if we wait for a woman to be in an estrogen deprived state for 10 plus years, you're really talking about someone who's going to need a really good assessment of cardiovascular disease risk. Because starting in someone who has quite a bit of soft plaque can be problematic. And that's where I think clearly and looking at AI assisted CT angio is really beneficial for women. I know that is in the context of our conversation. No, but it's true though. Just to interject that, that I think it's a really important, like just having a negative and negative CAC does not per se give you a clear for you're not at risk. And we know that the protective effects of estrogen as they're declining, more endothelial dysfunction, more small vessel disease, I think for a lot of women, they just, it's just brewing beneath the surface and we don't present the same way as men. We don't get the classic symptoms. Can't tell you how many patients I took care of in cardiology that they simply, they were just tired. And that was their anginal equivalent as opposed to the man having crushing chest pain and shortness of breath, you know, for a lot of women, they present so differently. Just fatigue, right? Exactly. And they often get, go to the ER and they're kind of gasoline told you, you're just dressed to home, you have reflux. Yeah, exactly. You're just anxiety. You know, I've been having almost all of my male and female patients buy is a new blood pressure cuff called the connect. Have you seen this thing? I've heard of it. Yeah. So it measures not just blood pressure, but also small vessel pliability. And, you know, the vessels get stiff in women when they have lack of estrogen and that is pliable. And it gives you a good measurement of that. So it's a, it's a really great, I mean, they don't pay me to say this, but it's a really great device. And I think all my patients buy this as well, just because I think we have to go beyond just blood pressure and look at what's happening at our micro vasculature as well. Well, and I think it's important because it's not part of the common conversations that being, yeah, we look at those vital signs like blood pressure, pulse, pulse oximetry, temperature. And then sometimes we're not thinking beyond that. And that's like the next level of kind of that integrative approach is thinking like, what's another layer of this conversation that's so important and vital for people to have access to? Yes, exactly. They're called vital signs because, you know, these are the things that we measure that were like, if these were off, you're like about to die. You're really sick. Yeah. You're really sick. But things like HRV and small vessel measurements, like these are not things that are normally measured in any doctor's office. And we really need to add those to the conversation. Grip strength, for example, the grip denominator, I think those are all metrics that people can get at home on themselves. And if they understood what they meant, they can track and find potentially, potential problems a lot sooner and address them. Well, and I'm always getting pinging my husband. I'm like, all right, let's see who can do a longer dead hang. He still beats me, but that's okay. I love it. You know, the other topic I wanted to go back to real quick was birth control pills. And so this is something that I'm going to ask a lot. Should I stop my birth control? What are your thoughts on this? Are we talking about middle age or just in general? In general, should adolescents start birth control? What's the best form of it? And then in middle age, what should we do? I think that this is a very nuanced conversation. Number one, we want our younger people to have access to reliable contraception, full stop. I think, however, the other part of that conversation is when we look at the research on things like depoprovera, which is oftentimes given to young teens and adults for pregnancy prevention or we're looking at oral contraceptives, we need to have fully informed consent. We know that depoprovera, as an example, has a black box warning because of bone loss. I think about oral contraceptives in teens and young adults, and I'm like, they are not yet at full bone building and muscle mass capacity. And so I think generationally, if we're keeping young women on oral contraceptives for 10, 20 years, we need to be talking about you're going to be kept in a low estrogen state. So that impacts you may not lay down really strong bone. I mean, we can argue that really strong bone gets started in that six to 12 age range, but I just think about it from the perspective as I was looking at bone health research, where people really susceptible. And I think about, you know, we need reliable contraception, but we need to be having the conversation, say maybe this isn't the best long term solution. Maybe this is the best solution from, you know, high school into college years. And then we reassess, we do know that synthetic hormones have quite a bit of a net impact on the microbiome, not in a positive way. They're considered to be endocrine mimicking chemicals. And so that wouldn't be my first choice long term. But again, we need reliable contraception with our young people. I think about, you know, IUDs, you know, there's copper IUDs that are reliable and well tolerated and most women, those are things I think about because I think most younger people don't want the complication of the rhythm method or, you know, looking at cervical mucus. Like they're just not, they need the set it and forget it option. Absolutely. But that's what I would think about if I had daughters. I would be saying like, let's think about this on a short term basis. Let's be really clear and intentional about what are the other, you know, other options that are available. And I think a lot about the copper IUDs. The copper IUDs are probably the best way to go if you can do that. Yeah. I think that's reasonable. And then, you know, a lot of women stay on oral contraceptives because their doctor tell them to help control their, you know, their menstrual volume or their symptoms. How do you feel about that? I think that's a very personal decision. I know that that was something that was afforded to me in my like late 30s, early 40s. And it was a no, no, no, and no when they gave me this slew of, it was like a, you know, here's, here are all your options. But it's very bio individual. If someone's suffering, if someone's incredibly anemic, they're getting iron transfusions, they're miserable, then, you know, maybe a short curse of oral contraceptives are going to be helpful. But it's not per se fixing the problem, you know, maybe that they're better served with oral micronized progesterone. It may be better served that, you know, do they have latent endometriosis? What could be contributing to this beyond just a relative imbalance between progesterone and estrogen? And I think for a lot of women, it's sitting down and having those kind of deeper conversations. If someone says, I'm suffering and I want an ablation or I want the IUD or just take out my uterus, then we have to respect that that's a decision that they're making. And I don't, I think sometimes people feel very judged if they choose to take oral contraceptives, and I don't want that to be, I want the prevailing philosophy to be, let's talk about your options and let's decide for you what fits best. I don't think they should be demonized, but I know that I have a friend that I can think of who was on oral contraceptives throughout perimenopause, because she said I was so miserable and I didn't want to have a surgical option. And so I just stayed on it till I was 51 and then I transitioned to HRT. And she said that allowed me to have a better quality of life. And I said, I respect that. Right, absolutely. I do think though that the endometrioblation procedure is relatively safe and just a few minutes long now, right? And can be done really easily. And I think it's not an option that's talked about enough with women because people just don't know what it is, unfortunately. Right. They're like, you're going to burn the inside of my uterus? Exactly. That's terrifying. Right. But it could be really safe. It can alleviate the symptoms. It can treat the anemia. A lot of this can be solved in just one quick procedure. Yes. Just find a really good surgeon that knows how to do it correctly and it could be really helpful, right? Yeah. And get you off of this chronic low estrogen state of taking oral contraceptives. Well, and I think the big thing is how many people from our generation were put on oral contraceptives as teenagers and young adults and stayed on until they decided to have children. So I think about the long-term effects on bone. I think about the long-term effects on the microbiome. Absolutely. I mean, those are the greater, bigger conversations that I now consider with colleagues when we're talking about this. They're like, wow, like our generation really was just put on it just for, you know, you had a crazy period or you needed reliable contraception or you wanted to have a set it and forget it. It's like, I understand that. But, you know, are we now looking at a generation of people that are at higher risk for autoimmune conditions that are going to be heading into the perimenopause and menopause transition at greater risk for some of the sequelae? Because a low estrogen state is not advantageous for your brain, for your heart, for your bones, your microbiome. It really isn't long-term. Yeah, I think we're going to quickly realize that all the things that happen in our generation, you know, putting people on birth control all the way up to menopause and then at menopause, denying them hormone replacement therapy, we just completely flipped how we were supposed to be doing it. Right? Exactly. And so it's just, I feel really sad for like, you know, like my mom, for example, she's six inches shorter than she was when I first met her. It's a massive compression of all of her joint bones and, you know, every joint replaced. And it's just one of those things you just got to really think like, we were not doing things the right way for so long. No. Now we, we have the technology now to do this correctly. And I think the gut needs to be a huge part of the conversation because it goes hand in hand, right? If you treat your hormones, your gut gets better. If you treat your gut, your hormones get better. Yeah. And I think it's a part of this larger conversation that most people are not having because they're not connecting those dots. Right. And, you know, I think about how there are so many women that they'll say, you know, I started on HRT and I don't feel better. And so I think it's, it's this other side of the conversation that says HRT is certainly very important. Peptides are important. Lifestyle is important. But if we're not looking at the gut microbiome, that could be the missing link for why someone is not feeling optimal or they're, frankly, their labs still look terrible. Right. Exactly. So for the women that are listening to this podcast and they're perimenopausal or menopausal, they know their gut is off. What should be the first two or three things that they do beyond the lifestyle interventions that we talked about? Yeah. I mean, I think it's, it's working with a practitioner that's going to be able to take that really diligent, detailed history, can then offer to you testing modalities. You know, I think, you know, kind of the low high low kind of low lying fruit that we're talking about. It's starting with stuff like, you know, making sure your digestion is optimized, you know, at a very basic level. Do you need hydrochloric acid? You know, I would say digestive fire. Do you need digestive enzymes? Do you need TUDCA? Do you need, you know, fat, biliary support? Those things get people feeling better, you know, taking those couple four to five deep breaths before you sit down for a meal. These are low lying fruit things, making sure you're sleeping because we know the research certainly demonstrates if you're not sleeping well, you know, you have circadian clocks in your digestive system, that makes it worse. I would say also, you know, just trying to manage your stress better. I know it's easier said than done, but those very basic things, you know, this is before I were even talking about investing and, you know, a lot of diagnostic testing or before we're even getting into more complicated conversations around HRT or peptides, like the basics, I would say major in the majors, like getting really granular about these very basic principles that are going to be a big differentiator from you and someone else who's perhaps not ready to do the work or to invest the time or the effort. Yeah, that's such great advice. And on the peptide conversation, are they a part of your gut healing protocol? And if so, which ones are you liking? I mean, I like BPC 157, you know, I like it orally compounded. I like that, you know, I was a fan of thymus and alpha one until it was harder to get access to it. I think that can be very helpful, especially because our immune system is aging right along with us. And that's when I start starting more provoked inflammatory issues. I know we didn't even touch on all the nebulous region of what's happening with the immune system as it's aging. Obviously, GLP ones, we know that they are changing the microbiome at a very kind of microscopic level, I think, especially for reducing inflammation, for improving insulin sensitivity. So for metabolic health, lowering our risk for autoimmune conditions, I mean, at personalized dosing, I know our traditional allopathic peers don't like this word micro dosing, but seeing the results with patients who have chronic auto immune conditions, seeing that that's improving, I think that, you know, the conversations are just ebbing and flowing around this. But I think peptides are here to stay. Obviously, I'm not using the more experimental things. I think that that's just not my comfort level. I would say I will leave that to the peptide physician research experts that are doing cutting edge work. But I think it's certainly very encouraging and exciting. I love it. Other than what we talked about today, what else will people learn from the menopause cut? Oh, my gosh, we talk about, you know, we talk about what the microbiome is, how it changes, how our ovarian aging happens. I call it ovarian senescence. We talk about the immune system. I make it really interesting, lots of analogies. I talk a lot about bone health. The bone and gut microbiome is really fascinating. So if you have leaky bones, you'd probably have a leaky gut. And then I dive into all the protocols and things that we use, you know, starting with sleep and stress and nutrition, exercise. We spent a lot of time talking about hormones and supplements, but making it really accessible. We go from like the very basic stuff that I was mentioning all the way up to more intensive things. And obviously, you know, the nutrition piece is important protein and fiber. If they're not part of your day to day, then your microbiome is probably suffering as a side effect. But it's meant to be an encouraging, uplifting, helpful resource for clinicians and lay public as well. But I can't wait for it to come out in three weeks. Three weeks from today. So by the time this airs, hopefully we'll be able to share a link with people, right? To go ahead and purchase it. Awesome. I love it. Where can people learn more from you, Cynthia? Yeah, my website. So www.CynthiaTherlowe.com. I'm active across social media. I'm aggressively growing sub-stack because I feel like that's a fun place to really connect and share, you know, interesting information. Obviously, Instagram is probably where I spend the most time. I have a podcast called Everyday Wellness, which you've been a wonderful guest on. And there's exciting things coming post-book launch in terms of courses and programs where people want to learn more and dive more into their personalized approach to look at gut health. I love it. I love it. So much incredible information from you. As always, thank you so much for joining me on Extend. And I look forward to the next time to have you on. Thanks for having me. Thank you so much for listening to the podcast today. Please remember to subscribe if you like this episode and give us a good review and share a link with your friends. It really helps to support all of our efforts. I also want to remind you that the information shared on this podcast is for educational purposes only and is not intended to replace professional medical advice, diagnosis, or treatment. Please consult with your healthcare provider or physician before making any decisions or taking any action based on what you hear today, especially if you have any underlying health conditions or on any medications. Your doctor knows your personal health situation the best and is always important to seek their guidance.