PMS, Hormonal Imbalance, and PCOS

Mark Hyman, MD

Full Transcript

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Dr. Mark Hyman
Coming up on this episode, many young women are becoming increasingly aware of the potential harms of birth control, not because their conventional gynecologist is explaining it to them, but through their own personal experience. They're on a journey to educate themselves, and they want a more nuanced personalized approach to hormonal health. Before we jump into today's episode, I'd like to note that while I wish I could help everyone via my personal practice, there's simply not enough time for me to do this at this scale. And that's why I've been busy building several passion projects to help you better understand, well, you. If you're looking for data about your biology, check out function health for real time lab insights.

If you're in need of deepening your knowledge around your health journey, check out my membership community, Hyman Hive. And if you're looking for curated and trusted supplements and health products for your routine, visit my website, supplement store, for a summary of my favorite and tested products. Hi. I'm doctor Mark Hyman, a practicing physician and proponent of systems medicine, a framework to help you understand the why or the root cause of your symptoms. Welcome to The Doctor's Pharmacy.

Every week, I bring on interesting guests to discuss the latest topics in the field of functional medicine and do a deep dive on how these topics pertain to your health. In today's episode, I have some interesting discussions with other experts in the field. So let's just jump right in. PMS is not a normal consequence of being female. If you're one of the many women who do suffer from PMS, you don't have to suffer from PMS every month.

And during mood swings, breast tenderness, fluid retention, migraines, bloating or heavy painful periods. While medications may sometimes be helpful, they can have pretty significant side effects. And the good news is you can balance your hormones without them and without their potential side effects. Many young women are becoming increasingly aware of the potential harms of birth control, not because their conventional gynecologist is explaining it to them, but through their own personal experience. They're on a journey to educate themselves, and they want a more nuanced personalized approach to hormonal health.

So today, we're gonna discuss what you can do to support your menstrual cycle through your diet and a comprehensive functional medicine approach to get rid of PMS for good and feel great all month long. The key to solving this type of problem is getting to the root cause of the symptoms. Now I hear this story all too often, but the good news is that there are simple solutions that don't involve taking medication. We know what causes hormonal imbalances. Sugar, caffeine, alcohol, stress, a lack of exercise, and environmental toxins all contribute to hormonal imbalance and worsening of PMS.

Even changes to your gut microbiome can affect your hormonal health. So what would conventional medicine docs do for PMS? Well, they give you NSAIDs or things like Ibuprofen, birth control. They might give you Sarafem or Prozac, in other words, but they don't get to the root cause of symptoms and they inhibit your natural cycle, your inphrady and rhythm. And the birth control pill often has significant side effects with long term use, including mood and gut issues, dysbiosis, taking the pill depletes folate, vitamin b 2, b 6, b 12, vitamin c and e, magnesium, zinc, selenium, all important, by the way, for fertility.

There's also an association between hormonal birth control and depression. In fact, a nationwide perspective cohort study of over a 1000000 young women in Denmark reported an increased risk for antidepressant use in women prescribed hormonal contraceptives. And the results were published in JAMA Psychiatry, and the risk was highest in the adolescents who were aged 15 to 19 years old. So we don't wanna be giving these teenagers antidepressants and the pill and just medicating the side effects of medication. It's crazy.

So you have to look for what are the real underlying causes of PMS. Well, it's hormonal imbalance, and there are a lot of causes for hormonal imbalance. So it's important to understand what they are and how to deal with them. The main problem is something called estrogen dominance, which means that your estrogen levels are too high and your progesterone levels are too low. Now this may be an absolute increase.

In other words, a very high estrogen, low progesterone, or it may be a relative dominance of estrogen over progesterone. And unfortunately, this is not something well recognized by traditional medicine. And you can measure this. Right? The fluctuations in estrogen in relation to progesterone can cause all sorts of problems, including neurotransmitter signaling and lots more, because estrogen in part regulates serotonin levels in the brain and that can contribute to PMS symptoms, things like mood swings, depression, irritability, and an absolute or relative excess of estrogen in relation to progesterone drives most of the symptoms of PMS and menstrual problems like fluid retention, breast tenderness, migraines, mood swings, heavy bleeding, cramps, all that is really related to this excess estrogen and inadequate progesterone as women get through their later cycles in life.

Poor diet is certainly a big factor. And when you clean up the diet, a lot of hormonal stuff just gets sorted out. And then there's a lot, unfortunately, hormones in conventional meat and dairy products. So I encourage you to eat regenerative, organic products, and particularly dairy might not be your best friend if you're having a lot of female hormone issues. I encourage people to just quit dairy as an experiment to see what happens.

There are also environmental toxins that play a big role in hormonal health. And unfortunately, a lot of these petrochemical toxins are also endocrine disruptors. They act as hormonally active compounds in the body even at low doses. And in fact, there's a word for them. They're called xenoestrogens.

Foreign xeno means foreign and, obviously, estrogen means estrogen. So foreign estrogens, and they come from pesticides, plastics, many personal care products, skincare products. I mean, these petrochemical products act as a toxic foreign estrogen like molecule that drives hormonal imbalances and most female cancers like breast, uterine, ovarian cancer. So toxins are a big factor and you have to reduce your exposures. A lot of nutritional deficiencies also affect hormone function, particularly magnesium, vitamin d, and also iron.

What else should we be doing for PMS or premenstrual syndrome? How do we get you back in balance and so you don't have to suffer and be really struggling your whole life? Because I just I just don't think that it's something that women should accept. It makes me actually quite angry that the conventional medicine system doesn't really take this seriously or just tries to medicate it instead of dealing with it from the root cause. So the first thing is food.

Food is medicine. It it's information. It controls every function of your body and mind, including your hormones. And it connects us to almost everything that matters in our lives. So you have to know that what you put on your fork is the most important thing you do every day for your health.

So the first step to do with your diet is to cut down inflammation because inflammation will mess up your hormones. So first, get rid of the junk. Right? Then get rid rid of the junk and then add in the good stuff. So take out the bad stuff, add in the good stuff.

What's the bad stuff? Well, our current diet is really high in sugar and starch, and that drives insulin resistance, and that leads to belly or visceral fat. And here's something most people don't know. It's not just your ovaries that produce estrogen. Your belly fat is also an estrogen producing factory.

Right? So all those belly fat cells in there aren't just holding up your pants. They're actually spewing out hormones. And there's something called aromatase also that increases estrogen production that's found in fat tissue. So, you know, having more estrogen is not necessarily a good thing, especially when it comes from your visceral fat.

So what are the things you should eat and not eat to eliminate PMS symptoms? Right? Eat real food. Right? Real food.

You know what that is. Right? My joke is if God made it, eat it. If man made it, leave it. Did God make an avocado?

Yeah. Did God make Doritos or a Twinkie? No. Right? Just don't eat that.

So also you wanna reduce fast absorbing carbohydrates. Right? Any flour products, sugar, quickly absorbed sugars like flour, instant oats, white rice, potatoes, or not not all potatoes, like the small, fingerling potatoes may be okay, but the big starchy potatoes we all eat are a problem. And they can spike insulin, and that leads to insulin resistance and inflammation, and that can cause PMS, can cause PCOS. It can increase risk for all chronic diseases.

Also, you wanna really limit caffeine or get rid of it entirely for a while to see how it affects your hormones and for sure alcohol. Alcohol, it will screw up your estrogen and make you estrogen toxic ultimately. These really make hormone imbalances worse. Also, I would encourage you to do a full dairy elimination for 8 weeks. It's often a huge factor in PMS and many menstrual and hormonal issues.

Next, I want you to avoid ultra processed foods. Right? Starch, empty carbs, grains, sugar, sugar sweetened beverages, energy drinks, teas, coffee. You know, I mean, think about any any coffee or frozen blended drink from Starbucks Dunkin' Donuts with flavor means tons of added sugar or glucose syrup. And and lots of women drink these, and they start their day with these drinks not realizing it's a sugar bomb, like a vanilla latte, mocha frappuccino, even a matcha, tons of added sugar.

I mean, a grande mocha frappuccino has almost 13 teaspoons of sugar. I mean, you'd never put 13 teaspoons of sugar in your coffee in the morning, but if you're going to Starbucks for your morning fix, you're literally killing yourself. Also, avoid some of these, quote, healthy nut milks or oat milks. They're they're often blended starch, sugar, and water, so be careful. Oat milk really spikes your blood sugar.

Sometimes there's also additional sugar from the flavoring too, like vanilla or chocolate, whatever, hazelnut. Just stay away from all that stuff. Drink black coffee and put a little almond milk in it. Ask for the unsweetened almond or coconut milk, although usually you don't have that. Also, I want you to avoid processed food, packaged food, all kinds of food with quote health claims on the label, you know, plant based, vegan, keto, gluten free, whatever, it doesn't mean it's healthy.

And my rule is that if it has a health claim on the label, I guarantee you it's bad for you. So just don't don't eat. It's a way of of getting food marketers to kinda get you engaged, but it's it's often hiding something bad underneath. You want foods that really balance your blood sugar. You wanna focus on fiber rich, low glycemic, non starchy veggies, low glycemic fruits.

And fiber is really important because it helps balance out your hormones. It helps build a healthy microbiome. It helps prevent the reabsorption of estrogen that can cause estrogen toxicity. So you wanna eat the rainbow. Aim for about 8 to 10 servings of colorful veggies daily, for all their health benefits.

Make sure you you sort of eat every day something from the cruciferous vegetable family. Like, that's the broccoli family. Broccoli, cauliflower, kale, college, cabbage, brussels sprouts, arugula, bok choy. They're all important because they they actually support estrogen detoxification, and they help balance the estrogen and progesterone because they contain amazing phytochemicals such as glucosinolates or indole 3 carbonyl, dionyl methane. All all of these are, you know, big medical words, but they're essentially molecules that are in the broccoli family that help induce the expression of certain enzymes called, CYP 450 enzymes that enhance the the metabolism of estrogen in the right way to produce beneficial estrogen metabolites, including, for example, they call 2 hydroxyestrone, and they reduce the formation of a toxic estrogen metabolite called 16 hydroxyestrone.

This is associated with heavy periods, with breast tenderness, breast cancer, and DNA damage. So so there's different ways your estrogen can be metabolized in your body to the good or bad metabolites. And and the bottom line is if you eat more broccoli, you'll be shifting towards the good metabolites. So that's the take home. Okay.

And but the science is there. It's quite fast. And I and I do measure in my practice the estrogen metabolites, and I can see what's happening with women's metabolites and whether they need more b vitamins or more support food with thione or more, these chemicals from food, these phytochemicals like indole 3 carbinol or dandymethane. You also wanna focus on on, slow absorbing and burning carbs. Sweet potatoes, yams, lentils, some whole grains are fine, like quinoa, non starchy veggies.

Protein, to avoid the blood sugar spikes. Those are really important then. You eat protein first as opposed to starch first. Eat about 4 to 6 ounces of protein per meal, roughly the size of your palm. Make sure you use high quality sources, grass fed meats, pasture rich eggs, poultry.

I recommend Force of Nature. I love it. It I don't have any financial relationship, but they have great regenerative sources of chicken and, meat and bison and venison, all so forth. You you actually need protein, by the way, to make to make hormones. So they're part of the building blocks.

You need good fats to make hormones as well. Make sure your diet is really nutrient dense. You want a lot of bioavailable micronutrients like iron, magnesium, b vitamins, and so forth. Nuts and seeds are great for hormones. I I I allow, a bunch of science on how they regulate hormonal health, but things like flax seeds are my favorite.

Almonds, chia seeds, hemp seeds, pumpkin seeds, sesame seeds, sunflower seeds, All these are rich in fiber. They're full of good fats. They have micronutrients like calcium, magnesium, zinc, iron, b 6, phosphorus, which are all important for a healthy menstrual cycle and hormone balance. Right? Your body is just a big biochemical machine, and you have to put in all the right ingredients to make the right things work.

And what the problem is is most of our diet is depleted. Most of us are nutritionally deficient at some level or other. Most of us are unhealthy microbiomes. Most of us are exposed to toxins. Most of us eat too much sugar.

Most of us drink too much coffee. Most of us drink too much alcohol. Most of us don't exercise enough. No wonder we're having all these problems. Right?

So we really need to get our act together. We wanna reset. And it doesn't take that long. 1 or 2 cycles of doing this for women really helps reset the whole system. One of the cool things you can do is use flaxseeds.

Ground flaxseeds, about 2 to 4 tablespoons. It's great for your hormones. It's great for beneficial compounds that that are helpful in in regulating your hormones like lignans. And, also, it's great for bowel movements. Right?

So they're they they really balance the hormones and they block the negative effects of some of the excess xenoestrogen. So if you're exposed to environmental toxic estrogens, you can actually reduce your exposure to them by having these flaxseeds. Also, you wanna increase the anti inflammatory fats in your diet, the omega threes, EPA, DHA. And my favorite sources, obviously, are sardines, herring, mackerel, anchovies. You can use small wild caught salmon.

Sometimes there's omega 3 enriched eggs. There's plant based sources like walnuts, chia, and hemp, but, they're not really moving the body into the EPA and DHA. Only about 10 percent is converted. So you wanna get the the also the preformed EPA and DHA from from fish or from supplements. Now if you're a vegetarian or vegan, it's really important to supplement with omega 3 fats.

It really will help your hormonal health. Also increase monounsaturated fats. These are avocados, olive oils, extra virgin olive oil, macadamia nuts, seeds, really important. Saturated fat may not be bad for most people. You just have to watch your cholesterol and see what happens.

But, grass fed butter, ghee, coconut oil, actually saturated fat is the building block for, your hormones. Right? Your hormones are made out of fat. Also, you wanna decrease the inflammatory fats. Right?

Trans fat, hydrogenated fat, margarine, even lovely vegan butters. They're they're actually not recognized as safe to eat anymore by the FDA, but they're still lurking on the grocery store shelves. So be religious about never eating them. Also, you wanna reduce your intake of vegetable oils, these refined, highly processed oils. You know, if they're cold pressed, if they're organic, if they have high oleic levels, they may be okay.

We need some. But the amount we're eating is just a pharmacologic dose. Sunflower, corn oil, canola oil, safflower oil, not so great. Also stay away from processed meats. Stay away from, like, hot dogs.

Stay away from reprocessed cheeses. I mean, it shouldn't be in there anyway, but Kraft Singles, they can't call it cheese because it's not more than 51% cheese. That's just a bunch of chemicals. Obviously, reduce your exposure to pesticides and and hormones and antibiotics that are stored in in in, in some of these foods. And you can use the clean fifteen and dirty dozen guide from the environmental working group to guide you on which are the least contaminated or the most contaminated foods, fruits and vegetables.

So it's not always possible, but try to eat grass fed and organic when possible, filtered your water. I mean, also support your gut. Really important to support your gut. Probiotic rich foods are key, things like sauerkraut, kimchi, miso, natto, which may taste weird, but it's actually really good for you. And prebiotic foods also like asparagus, artichokes, jicama, and Jerusalem artichokes, all great for for your gut health.

Don't eat within 3 hours of bedtime. Don't fast for too long. Actually, it can be problematic for women. And start your day with, a nutrient dense food. Right?

Protein, fat, and fiber. Think protein, fat, and fiber. Not the typical breakfast we have. Cereal, muffins, bagels, you know, sugared coffees, I mean, French toast, pancakes. I mean, the American breakfast is the worst, and you do not wanna start your day with that.

You want protein and fat and fiber for breakfast. So you have eggs, spinach, peppers, olives, maybe some feta cheese from sheep, an omelet with avocado, protein shake. And you also need potentially some supplements. A number of supplements been shown to really help ease PMS symptoms because they improve metabolic health, hormonal metabolism. And here's the superstars.

Magnesium glycinate, 406100 a day. Calcium's sometimes helpful. It's calcium citrate, about 600 a day. Vitamin b 6, really important for estrogen metabolism, 50 to a 100 milligrams a day. And folate, especially a preformed form called methylfolate, about 800 micrograms a day.

Vitamin b 12, in the form of methylcobalamin, about a 1000 micrograms a day. And evening primozole, that works really well. Take, 500 milligram capsules, 1 or 2 twice a day. Take fish oil, omega threes, EPA, DHA, about a 1000 milligrams, 1 or 2 a day. Taurine, also really important for hormone metabolism.

It's an amino acid, about 500 milligrams a day, helps liver detox, and a good multivitamin. All these things work together. And the good news is there's also a lot of herbs and phytochemicals that can really help, including chasteberry. Also, vitex is known as vitex, but chasteberry fruit extract is very good for regulating, menstrual cycles and helping with PMS. Milk thistle, dandelion root also is great.

Certain isoflavones from soy, red clover, kudzu root help improve estrogen detoxification because they boost some of the metabolism enzymes that you need to properly regulate estrogen, and they can be taken as supplements or in the diet.

Dr. Elizabeth Boham
When I see a woman, you know, so often we're dealing with hormone imbalances. They're so prevalent. You know, everything from, as you mentioned, PMS to, you know, to, issues with menopause and perimenopause, to issues with estrogen dominance, right, or over over levels of estrogen, high levels of estrogen in the body which can lead to breast tenderness or more PMS or, cancers like uterine cancer and breast cancer.

Dr. Mark Hyman
And fluid retention and heavy bleeding

Dr. Elizabeth Boham
That too.

Dr. Mark Hyman
And all kinds of nasty symptoms.

Dr. Elizabeth Boham
Yeah. So hormones are

Dr. Mark Hyman
swings and mood issues.

Dr. Heather Huddleston
And So

Dr. Elizabeth Boham
we're really thinking about hormones and hormone balance when anybody comes into the office. So, I mean, that's something I think that that's an area

Dr. Mark Hyman
And it's so common. Right? 75% of women suffer from PMS. How is that normal? That's not a normal state of biology.

Dr. Elizabeth Boham
Right.

Dr. Mark Hyman
It's an abnormal state.

Dr. Elizabeth Boham
Right.

Dr. Mark Hyman
Just because it's so common doesn't mean it's actually optimal. Right?

Dr. Elizabeth Boham
Absolutely. So then we need to ask that question why. Why are the hormones out of balance? And we look at everything

Dr. Heather Huddleston
from how is the body

Dr. Elizabeth Boham
metabolizing the hormones, how is the, microbiome, and how is that influencing it, how is the person dealing with stress, and is that influencing their hormone balance? Yeah. So, you know, you wanna look at look at the whole body when you're trying to figure out what may be out of balance with somebody's hormones.

Dr. Mark Hyman
Even fertility issues. I mean

Dr. Elizabeth Boham
Oh, that's just getting so common. Right?

Dr. Mark Hyman
It's so common. You know? It affects so 1 out of 7 couples. And it's big. And and so when you go to a regular doctor and you have these, you know, symptoms of PMS or heavy bleeding or, you know, menopause, like, what do they do?

Dr. Elizabeth Boham
So often they'll say, okay. I'm gonna put you on birth control pills. Oh,

Dr. Mark Hyman
yeah.

Dr. Elizabeth Boham
Right? Right? Like, if with with PMS and or regular cycles or perimenopause, that is the common response. You know? Let's just start some birth control pills, and that's gonna even everything out.

Dr. Mark Hyman
Is that safe?

Dr. Elizabeth Boham
I don't know. I mean, it's a good question. Right? I mean, there's there are side effects to birth control pills. You know?

We see we see we see stroke and blood clots with some women with birth control pills.

Dr. Mark Hyman
It's infections, affects the microbiome.

Dr. Elizabeth Boham
Absolutely. There's some there's some women where, we know that the longer you've been on birth control pills or if you're on them more than 10 years or if you're, you know, your risk for breast cancer goes up. So there is an association with long term use of birth control pills.

Dr. Mark Hyman
Cancer or just breast cancer?

Dr. Elizabeth Boham
Just breast cancer. Yeah. Yeah.

Dr. Heather Huddleston
Well,

Dr. Mark Hyman
that is interesting. So you take the pill for a long time and your risk of breast cancer goes up.

Dr. Elizabeth Boham
Yeah. For women, when they're on the birth control pill or if they've been on it a long time, they have a slightly higher risk. And, you know, so that's something we gotta pay attention to. Not everybody handles the hormones in the birth control pills the same.

Dr. Mark Hyman
So not not everybody is being prescribed birth control for birth control. They're using some medical therapy for hormone imbalances when there's a very different way of treating it Absolutely. That works better where either women feel better and their hormones get imbalanced without nasty side effects of stroke and cancer.

Dr. Elizabeth Boham
Right. Right. I mean, you really wanna ask Migraines

Dr. Mark Hyman
and who knows what else.

Dr. Elizabeth Boham
Right. Migraines too. Absolutely. So you wanna ask, well, why is there that imbalance in the hormones and and what may be out of balance for that woman? You know, I think perimenopause is such an interesting time where we get a lot of women who come in to the office at that time because they're just feeling so crummy.

Right? Perimenopause is the timeframe between when your between when your cycles are normal and you can easily get more you could get pregnant and menopause. So perimenopause are those years, you know, you know, it's can be they can be like 10, 13 years of perimenopause and it can occur anytime you can go into menopause anytime between 4555. That's typical. And that perimenopause can be 10 6 to 10 to 13 years beforehand Yeah.

Before you actually go into menopause is considered perimenopause.

Dr. Mark Hyman
What is that?

Dr. Elizabeth Boham
Depends on the gut or

Dr. Heather Huddleston
Yeah.

Dr. Elizabeth Boham
I mean, there's there's just the the the hormones are not as regular and consistent. Right? So what happens a lot in perimenopause is during those years, women will have what are called anovulatory cycles. So so they don't ovulate every time they have a monthly cycle. Right.

Right. And so those anovulatory cycles, meaning no ovulation that month, results in less progesterone being produced in the body.

Dr. Mark Hyman
Because when you ovulate, that's when you make progesterone. And if you're sort of weaning down your years of reproductive life, you don't necessarily make progesterone. You don't ovulate

Dr. Elizabeth Boham
every cycle.

Dr. Mark Hyman
And then you get these high levels of estrogen and that causes a lot of these symptoms of slots and heavy bleeding and bad PMS and mood issues and sleep issues and migraines and all this stuff that women suffer from. It is so unnecessary.

Dr. Elizabeth Boham
Right. You think of it as, you know, when you're having regular cycles with ovulation, you have estrogen and progesterone and they sort of balance each other out. And then when you're in those perimenopausal years, you're gonna have so many women will have cycles where they don't have that progesterone spike. Yeah. So it feels like their body feels like it's higher in estrogen because they don't have that progesterone to balance it off.

And so you feel like you have high estrogen, and and like you mentioned, you get more breast tenderness or more clotting or heavier bleeding, and and the low progesterone makes us often feel crummy. Yeah. So you can be more irritable. You can just, you know Cranky. Cranky.

Hardest time sleeping because progesterone really is a calming hormone. It helps us helps women, helps people sleep better. Yeah. So when it's low, many times you don't sleep as well. You'll have

Dr. Mark Hyman
Mhmm.

Dr. Elizabeth Boham
Irregular sleep patterns where you've never had that before. Yeah. And, and and, you just feel more irritable and cranky and and and it's no fun.

Dr. Mark Hyman
Out of balance. Yeah. Yeah.

Dr. Elizabeth Boham
Out of balance.

Dr. Mark Hyman
And and, you know, it's, it's important to sort of understand that we know a lot about what causes these imbalances.

Dr. Heather Huddleston
Mhmm. And

Dr. Mark Hyman
we know a lot about how to fix them, except your traditional doctor is just not doing it.

Dr. Elizabeth Boham
Yeah. Yeah.

Dr. Mark Hyman
So what are the things that we know create hormone imbalance that make things worse for women? And and by the way, you know, just to sort of a little aside, you know, it's not just sex hormones that get out of balance. And when you when you see this sort of period of life around perimenopause, there's like 4 different hormones that are all interacting that all kind of get screwed up. 1 is insulin and blood sugar Yep. Because you're, you know, you're off in the sandwich generation.

You have kids and your parents are getting older and you're trying to have a career and it's like it's a lot going on at that time for women often. Yep. And then they have, estrogen imbalances and progesterone. They have adrenal imbalances because their adrenal glands are their stress response, and they're highly stressed in that time of life. So their adrenals interact with the sex hormones and screw that up.

And then, of course, you got thyroid thrown in there in a lot of cases. So you got thyroid, adrenal, sex hormones, insulin, and so it's like a big mishmash of hormone chaos. Yep. And actually you can fix it.

Dr. Elizabeth Boham
Absolutely. And I'm so

Dr. Mark Hyman
glad like, so easy to fix with functional medicine.

Dr. Elizabeth Boham
Yeah. Yeah. And I'm so glad you brought that up because all of our hormones are interrelated. They're all playing off each other. They're all influencing each other.

And so that's important to really understand because because that's how we can really help women feel better. Yeah. So when you really focus on the adrenal glands, for example, so you have you have 2 adrenal glands typically. They sit up on top of your kidneys and those glands produce cortisol and they produce DHEA and they a bunch of other

Dr. Heather Huddleston
things. Hormones.

Dr. Elizabeth Boham
Yeah. So cortisol is one of your stress hormones. So when you're under a lot of stress, if you're under chronic stress, for example, I mean, you you know, your body's gonna be producing a lot of cortisol all the time. And so what can happen what can happen is then the body is spending all this time making cortisol to handle that that chronic stress you're under. You're dealing with your your kids and then your parents as you talked about.

You know, you're you're working all the time at your job. You're not you're not giving your body enough time to rest. You're not getting enough sleep. You might not be eating right. You know, you might be just running from one thing to the other.

You may not be taking the time to do your meditation or your exercise. Right? You're just not doing that self care, which is so important for your adrenal glands. And when that's when that's happening, then then your body's spending all this time producing cortisol that it can't do as good a job at producing progesterone. Yeah.

Right? Right.

Dr. Mark Hyman
And

Dr. Elizabeth Boham
so then you have

Dr. Mark Hyman
It's like a chicken wired thing. It's all connected. It's not like they're all separate.

Dr. Elizabeth Boham
Right. And so then you have more of those signs of low progesterone, which we talked about before, which is irregular sleep, irritability, you know, more crankiness, more pms, right? So, so it's really important that we step back and say, okay, how can we support your adrenal glands? And and that's really a lot of of self care, you know, by saying, okay. I need to give my tie myself time to rest.

I need to give myself enough time to sleep.

Dr. Mark Hyman
Meditate maybe.

Dr. Elizabeth Boham
Meditate. Exactly. I gotta get my meditation in. Right? And, and I think that makes a big difference.

It can really help, with with balancing the hormones. We know, right, that even simple meditation 15 minutes twice a day can cut back on can significantly cut in half the amount of hot flashes a woman has. But during those perimenopause we haven't even talked about hot flashes

Dr. Mark Hyman
yet. Right? Well, I mean, let's talk about the things that screw up your hormones. Right? Yeah.

So sugar Yes. That causes in some resistance, that causes more estrogen to be made and all the imbalances. Right?

Dr. Elizabeth Boham
Right. We were talking about how when you when you get more insulin resistance, you gain more weight around the belly. Yeah. Right? And we know that when we gain more weight around the belly, we that we have more of that aromatase enzyme, which makes more estrogen and, again, throws us out of balance.

Dr. Mark Hyman
And what about alcohol?

Dr. Elizabeth Boham
Yeah. Alcohol alcohol really is a concern because the because the way alcohol you know, there's multiple ways that alcohol can impact risk of of breast cancer, for example, but it also seems to result in a higher level of free estrogen in the body. Yeah. And so, you know and it we know it disrupts sleep.

Dr. Mark Hyman
It is a Right? Liver toxin.

Dr. Elizabeth Boham
Yeah.

Dr. Mark Hyman
And it it literally impes the body's ability to metabolize estrogen. Yep. And I've seen studies that were shocking to me where people were on hormone replacement and drinking and their liver just can't handle it and the estrogen levels spike and their risk goes up. So we have, you know, enormous link there. Even, like, I I remember a study I read years ago, which was if a woman had a glass of wine a day, it increases her risk of breast cancer by 40%.

Dr. Elizabeth Boham
Yeah. You know, unfortunately, there's a linear relationship between alcohol and breast cancer risk. So for every drink a woman drinks per day, like, every time she increases the amount of she drinks per day, her risk of breast cancer goes up even further. So, you know, what's considered moderation for women is 5 or less drinks a week with a drink being, you know, 5 ounces of wine or, you know, a One ounce of hard liquor.

Dr. Mark Hyman
Yeah. It's not very much.

Dr. Elizabeth Boham
No. It's not very and that's up for a whole week. But what's interesting is you're right. There has been even studies showing that even even one drink a day is linked with an increased risk of breast cancer. And and maybe because it it is impairing well, part partly because it's impairing our liver and our ability to detoxify, and it's shifting estrogen levels, and it also depletes the body of b vitamins.

So there's so many so many impacts that alcohol has there.

Dr. Mark Hyman
Yeah. And even even the microbiome plays a role in your hormone balance. Right?

Dr. Elizabeth Boham
Right. Absolutely.

Dr. Mark Hyman
So

Dr. Elizabeth Boham
Right. That's something we're always measuring. Right? We're looking at how the body is metabolizing hormones and, and and we're looking at the microbiome. And I think that that's important when we're dealing with a woman in perimenopause.

Like, sometimes they're they just don't even understand why am I feeling this way. You know, why am I all of a sudden more irritable? Why am I having a harder time with my periods? You know, why are they heavier? Why can't I sleep?

Why am I getting hot flashes now? Right? And so sometimes just educating them is a great first place to start. And a lot of times women just feel better when they start to understand, okay, this is this is gonna you know, my hormones are shifting, and then what can I do to support them?

Dr. Mark Hyman
Yeah.

Dr. Elizabeth Boham
And and we were talking about how great meditation is. Right?

Dr. Mark Hyman
Because it's

Dr. Elizabeth Boham
oh, yeah.

Dr. Mark Hyman
Yeah. And then the things, you know, we see typically the women who have the worst problems have the worst diet, the most stress, they drink too much, they don't exercise, they don't they have lots of stress, they don't meditate. It's not rocket science why hormones get get screwed up.

Dr. Elizabeth Boham
Right.

Dr. Mark Hyman
And and we know how to intervene using, very specific diagnostic tests that we do at the UltraJuana Center to actually help map out what's happening with the hormones. We can look at estrogen metabolism. We can see how to really be sophisticated manipulating those hormones so that actually they are better. We can fix the gut and the microbiome. We can look for environmental toxins, which act like estrogens in the body and get rid of those or heavy metals.

And we can actually have an impact through using various foods to help, whether it's flaxseeds or other broccoli family, help estrogen metabolism, certain soy products that are you know, whole food soy products are good. And and then we can kind of, get people's hormones to kinda work better. We may wanna even use nutrients. You were talking about sulforaphane, which is a powerful broccoli chemical that you can take. And there's a whole cocktail of things we use to help estrogen metabolism.

Dr. Elizabeth Boham
Wait. We should probably talk about soy a little bit because, honestly, this is probably the most common question I get Yeah. Because people are so confused Yes. About soy. Tell us doctor Balam.

What is the deal? Good as we eat soy or not eat soy. So so soy, right, soy foods are in they have these things called phytoestrogens in them, and this is what got everybody nervous. Right? So they have these they have these these components, these phytonutrients, these components in them that can actually impact the estrogen receptor.

And so for, you know, a bunch of years ago, oncologists used to say, oh, no. It can impact the estrogen receptor. I don't want you to soy. But what we know actually is that they they bind to the estrogen receptor preventing your own estrogen from binding to the estrogen receptor. And as a result, you have a lower estrogen like impact in the body.

Yeah. So multiple studies have shown that that soy is actually associated with a lower rate of breast cancer and and a lower rate additional stress.

Dr. Mark Hyman
A good point. Like tofu, tempeh Yes. Natto, miso, soy sauce.

Dr. Elizabeth Boham
Mame. Right?

Dr. Mark Hyman
Right. Those are whole soy products that are not industrial food. And most soy we're eating today is industrial

Dr. Elizabeth Boham
soy Yes.

Dr. Mark Hyman
Turned in all kinds of weird ingredients like soy burgers and Yeah. And soy hot dogs and texturized vegetable protein that gets inserted in all kinds of protein bars, and isolated soy protein which very different than regular whole soy and maybe linked to cancer in animal studies. So I think it's important people to realize that you know it's it's, you know food is a modulator and it usually helps the body do what it does rather than interfere with it. And so sometimes it's true like you eat too much broccoli or whatever raw broccoli gonna affect your thyroid but the the the phytoestrogens in soy actually help to act more like a thermos. They keep things balanced.

Right?

Dr. Heather Huddleston
Mhmm.

Dr. Mark Hyman
And and I think, you know, recommending those whole soy foods is great and I think that's a really easy thing to do. Flaxseeds also really help. Brown flaxseeds in the gut. Yep. The crock broccoli family vegetables, simple dietary things and getting more fiber to help the the probiotics in the gut, getting rid of all the starch, the sugar, the processed food, all those ingredients, alcohol.

There's really simple things you can do.

Dr. Elizabeth Boham
Yeah. Like balancing your blood sugar balancing your blood sugar by making sure that every meal has a good source of healthy fat, has a good source of fiber, and has a good source of protein. Right? So that prevents the spikes in blood sugar and the spikes in insulin. Right?

So you you make sure your meals are balanced like that, then you won't get those ups and downs in your in your energy. And so you just feel better. And that helps with that helps with all you know, preventing those that high insulin, which

Dr. Mark Hyman
then gonna be binging on carbs and sugar to get your energy up and all that.

Dr. Elizabeth Boham
Right. Right. Right. So then that helps with the balance of all the hormones as you were mentioning earlier. Yeah.

And, and so, you know, when a woman is going through perimenopause, you know, the first place we look at is, okay, what are these personalized lifestyle factors? What can we really focus on with them? I mean, there might be times where we, at the Ultra Wellness Center, may use some hormones to help with their Progesterone. Yeah.

Dr. Mark Hyman
Yeah.

Dr. Elizabeth Boham
To help with their sleep if necessary. But many times just a woman understanding what's going on and then making some shifts in their lifestyle can make a huge impact and make them feel better.

Dr. Mark Hyman
What are the causes of of PCOS?

Dr. Heather Huddleston
Well, it's I mean, I think it's a little bit of a $1,000,000 question. There's a lot of research trying to answer that question. It's also a very heterogeneous disorder, so I don't know if there's one thing that causes it for everybody.

Dr. Mark Hyman
Yeah.

Dr. Heather Huddleston
But I think we do know that a major underlying factor is the hyperandrogenism that is you know, that there's elevated androgens starting at puberty, and that that may then sort of underlie a lot of the phenomena that comes across with women. So one of the things we know is that there's an increase in visceral adiposity, or sort of

Dr. Mark Hyman
Belly fat.

Dr. Heather Huddleston
Belly fat that happens that we know is more common in general with men. But this is what happened when you have elevated androgens in a woman, especially starting at puberty. They lay down fat in that area, and that in women causes a lot of inflammation, that then can really be a setup for insulin resistance. So there may be sort of a pathway where you see hyperandrogenism then in many people also leading to the insulin resistance. Then you start to get into a little bit of a vicious cycle because the insulin resistance in and of itself causes some weight gain, but it also can drive androgen production from the ovaries.

So starting at puberty, a lot of these people get into a little bit of a vicious cycle. It's very hard, if not impossible,

Dr. Mark Hyman
to get out. What starts the high levels of androgens or the male hormones, testosterone and others?

Dr. Heather Huddleston
So it's a debated issue. I think that there's one component maybe that there's just an if you look at some of the enzymes in the ovary and in the adrenal gland, there's just sort of an overactivity of those enzymes in the ovary and in the adrenal glands. So there's some thought that it's just an intrinsic overproduction of androgens. There's also, at least in some patients, we think just a get from the get go, they have an increased LH secretion from their pituitary. This is a hormone that drives androgen production from the ovary, and so they may be set up by that, even sort of in utero to have increased LH secretion.

So we don't really know, but we know that at puberty, immediately, these girls will often start to have much higher androgen levels than their peers, and then that sort of lays the groundwork to for a sequence of events to happen.

Dr. Mark Hyman
Yeah. You know, one of the things that's, sort of read a lot about is the role of, endocrine disruptors in in in our health. And endocrine disruptors are environmental chemicals. Years ago, I read a book called, our stolen future by Theo Colburn. It was kinda like the silent spring of its time where she mapped out the ways in which environmental chemicals affect all kinds of reproductive functions.

And, whether it's a speed of sex, determining sex, or determining risk of cancers or infertility in animals and human models. How how do you think environmental toxins play a role in the uptake of of what seems like this is increasing phenomena of of endocrine disorders in women?

Dr. Heather Huddleston
I think it's hard to know how much they are positive in terms of PCOS. I think it's it's possible. I certainly think it's definitely possible that they may exacerbate certain elements of it by, you know, by interfering with hormonal function. But, you know, PCOS has been around for a long time as far as we can tell. It seems to be present at a pretty standard or set prevalence across many different countries and so and parts of the world, which somewhat argues against it being truly environmental.

Now I do think that certain environmental, endocrine disruptors or, just societal patterns, especially diet, can definitely exacerbate the way PCOS gets manifest. So if you look at PCOS patients in Europe, especially 10 or 20 years ago, or in China, they tended to be much more lean than patients in the United States, and have much less sort of inflammation and insulin resistance. And so there's certainly if you have a PCOS phenotype and you put it in an environment where there is calorie excess or limited physical activity, you are gonna see potentially, at least in some patients, an exacerbation of the symptoms. But I don't know that you I don't know that in my view and from what I understand about this this syndrome, I don't think it's necessarily caused by our lifestyle.

Dr. Mark Hyman
And and and and the nutritional part, what what role does that play? Because, I you know, I've had many patients with infertility who when we address the starch and sugar in their diet and treat the insulin resistance, they get better. And, I mean, I had a very close relative who had, you know, obesity and and pretty severe PCOS and her autism and acne. And, we drastically changed her diet, and she was able to get pregnant and have a baby. So can you talk about the nutritional aspects of PCOS and how how that plays a role and where it doesn't play a role?

Dr. Heather Huddleston
Yeah. I mean, I think for sure there's evidence that in some people with PCOS, especially if there's evidence of insulin resistance or if there's evidence of glucose intolerance, you know, that they're they're clearly have entered a a phase where they're not processing glucose well. That if you act to correct that through diet and through exercise and you reduce the degree of insulin resistance, you reduce the degree of adiposity, that in some of those patients, they will ovulate more regularly. They will have more successful, more healthy pregnancies. So that is certainly something that I think I always talk to my patients about when I see them if I think that there's a window for that.

There are patients, however, it's you know, especially when you look at some of the lean PCOS patients or patients from the point of adolescence have never had regular cycles, you know, I think it's a lot to say, oh, just change your diet and you're gonna start ovulating. I don't think that's always the case. So I think every patient's a little different, and you need to really look at it. The what I usually look at though is I wanna say, how are we gonna get you as healthy as possible for pregnancy? And maybe that will help you get pregnant, maybe it won't, but I wanna get you as healthy as you can for pregnancy and get, you know, your insulin resistance as much as possible under control.

Dr. Mark Hyman
Yeah. How about the microbiome? Because, you know, this is sort of the ear of the microbiome. And before, you know, nobody ever thought that the gut played a role in hormones or endocrine health or infertility. But now it's clear that it's sort of got its finger and every everywhere.

And, and and, you know, we see studies, for example, on breast cancer. Women who take antibiotics have high risk of breast cancer. We know that the microbiome plays a big role in hormone metabolism. So can you talk about what you're learning about that and how that plays a role and how you approach that?

Dr. Heather Huddleston
Well, I think that there's there's definitely some really interesting research going on around microbiome and PCOS, and there's this, like, idea that there may be a more sort of inflammatory microbiome that leads to more inflammation in the body. And we know that many patients with PCOS just have high rates of inflammation that is detectable and if you look at sort of blood markers or just even with the insulin resistance. So this is in many ways an inflammatory disorder. And so there is research going into, like, how much of that might be driven by the microbiome. And, you know, that's a little outside my scope and maybe more your scope exactly how that may be the case.

But I think it's definitely a really interesting area for us to try to understand more, you know, and how much that may be sort of setting people up to have PCOS sort of evolve at adolescence and really to exacerbate the metabolic phenotype.

Dr. Mark Hyman
Yeah. Well, you said so super interesting about the inflammation because inflammation, independent of its source, seems to be a trigger for all kinds of things. Obviously, chronic disease in many ways, but for these hormonal disorders. So can you talk and maybe unpack about, a little bit more about the link between inflammation and endocrine disorders and in particular PCOS?

Dr. Heather Huddleston
Well, I think for sure we know the in inflammation may have some direct effect on ovarian dysfunction. So there are some studies showing that if you treat inflammation, you can improve sort of ovulation to some degree in the ovary. So there may be a direct effect of inflammation on the ovary. There's also a path where inflammation does drive up insulin resistance, and that's through sort of TNF alpha and other cytokines that are thought to interfere with insulin action. And we know that insulin resistance really drives androgen production from the ovary, at least in patients with PCOS.

So there's definitely a metabolic sort of driver of the hyperandrogenism and hormonal dysfunction and anovulatory sort of status, that we do see. And then we also know that that inflammation in and of itself has really important downstream consequences, not only in terms of cardiovascular disease, but there's more and more of a thought around depression and cognition that may be impacted by inflammation. So I do think it's really an important piece of this disorder that we wanna try to get a handle on and try to treat.

Dr. Mark Hyman
It's so important and there's so many causes of inflammation. It can be environmental toxins. It can be the microbiome. It can be inflammatory foods. I mean, there's so many factors that we know that are driving, inflammation in our society that are just getting worse and worse.

And so it might be not one thing. It may be so many different things. So can you talk about the difference between the patients you see with PCOS who would be the typical ones we've learned about in medical school? They're overweight. They have acne, hair loss on their head, facial hair, irregular periods, infertility versus the ones who are thin and, you know, exercise and don't seem to have any weight issues.

Can you kinda is there a different subtype? Are these the same kinda condition? How are they different?

Dr. Heather Huddleston
I mean, I I think that they're they're probably subtypes. So, I mean, I think that this is a PCOS is, I think, a very heterogeneous disorder. It's really just a syndrome. Right? It's a collection of things that kinda go together and sort of have somewhat of a shared pathophysiology.

But it's not like you know, if you think about something like hypothyroidism, which is very much you know, it's like your thyroid gland isn't functioning. You're gonna have this. You fix this. It, you know, translates. PCOS is is messier.

And so yeah. So the the the patient there is a lean phenotype. We call it lean PCOS, and it's often quite different than the obese PCOS. Some of the things that may be similar is the lack of ovulation, the need for help with fertility care. So that may be a constant.

The other thing that may be a constant is trouble with elevated androgens, so hair growth on the face, acne, that can still manifest in lean PCOS. But, you know, lean PCOS patients are are lucky in that they're often not quite as much struggling with some of the metabolic features. Although, if in studies where they measure insulin resistance very closely and very carefully in research settings in even lean PCOS, they are more insulin resistant than lean non PCOS. So there is still an insulin resistance piece there, but it's sort of either genetically not as sort of exacerbated or maybe that that person has just a very healthy lifestyle, and they're able to keep a lot of it at bay.

Dr. Mark Hyman
And what, you know, one of the one of the consequences for people if they have P2S? What should they be aware of? What should they know about in terms of their own health and long term risks?

Dr. Heather Huddleston
I mean, it's, I think, a very multifaceted disorder. There's generally sort of 5 or 6 things that I go through with patients with PCOS. So the first is menstrual cycle control. So it's important for people to have somewhat regular menstrual cycles or to have at least some sort of progesterone in their system to prevent overgrowth of the lining. There's the management of their skin or cutaneous findings with PCOS, so how can they manage their hair growth?

There's fertility concerns. There's metabolic concerns, especially things like future diabetes, future cardiovascular disease. And then there's a lot of mental health disorders that we see in PCOS. So there's a high rate of depression. Yep.

And,

Dr. Mark Hyman
Do you think it's a cause or a consequence of it?

Dr. Heather Huddleston
I mean, it's something I've been really interested in researching. One of the things we've shown in some of our work has been a very strong correlation between insulin resistance actually and depression, and, even when you control for body weight, and even when you control for androgens, even when you control for hirsutism. So, you know, I do think at least in some of these patients that insulin resistance in and of itself may be contributing to depression. That's something we see in the diabetes literature as well.

Dr. Mark Hyman
That's a frightening idea because when you look at the metabolic health of America, I think the new a new data came out from Tufts that, 93.2% of Americans are metabolically unhealthy, meaning they have some degree of insulin resistance. And we also see this sort of epidemic of mental health disorders and depression. And I don't think people realize that, you know, sugar and starch and processed foods is driving not only weight issues, but also mental health issues.

Dr. Heather Huddleston
Yeah. I think it's, to me, one of the more profound connections and profound concerns. And I think it's unfortunate because it in some ways, that depression can often make it harder to address the diet and the exercise. You know, if you're feeling depressed, it's you're not in the most ideal state to sort of make those important lifestyle changes. So I think it's important that we take into consideration what's happening in terms of a mental health, milieu for patients with PCOS and take that into account when we kinda talk to them about treatment because that's an important component, I think, that needs to be addressed if we want them to make those important lifestyle changes.

Dr. Mark Hyman
For sure. So what so when you see someone with this this problem, what what's your general therapeutic approach? What how do you treat these patients? What are the ways that we sort of can help them have regular cycles or their acne, their hair growth, their hair loss? And, you know, I think you mentioned something really important, which is that, you want them to have progesterone, which is sort of the antidote to this overbuild up of estrogens that happens in these patients.

And they don't ovulate every cycle, so they don't make progesterone, which is what you do when you ovulate. So, can you talk about what what are the kind of therapeutic approaches and how do we potentially use progesterone or other therapies like that?

Dr. Heather Huddleston
I mean so I think in terms of therapeutic approaches with PCOS, it's always hard because I think it, to some degree, depends on what is their goal. Like, what are they trying to achieve? You know, are they trying to get pregnant at this moment or not? But in terms of the menstrual let's say it's someone who's, like, 22, and she's coming in because she's only having 3 periods a year. And when she does, that's very heavy bleeding.

I wanna address that because we know that when people go many, many, many cycles without ovulating, it means they don't get progesterone. And that means that estrogen is gonna cause over time buildup of the uterine lining, which can lead to very heavy menstrual cycles, but it also is a risk factor for endometrial cancer over time. So it is important that patients with PCOS get some sort of progesterone exposure, and that can be in the form of oral contraceptives. It can be in the form of bioidentical progesterone being taken cyclically. They can be in the form of an IUD that releases progesterone.

I mean, so there's a lot of ways to do it. But if I have a patient who's having 3 cycles a year or something like that, that's an important conversation that I'm gonna have. It's like, look. We need to figure out some way for you to have progesterone because it's not healthy for your uterus to not have that progesterone over time.

Dr. Mark Hyman
So that that's helpful. And then what else do you do to help with their, so besides bidenticalprogesterone, what other kind of therapies support these patients?

Dr. Heather Huddleston
In terms of their

Dr. Mark Hyman
other The symptoms or yeah. How do how do you deal with, you know, hair loss or how do you deal with acne or how do you deal with the the the irregular cycles? What hormonal therapies are used

Dr. Heather Huddleston
besides progesterone? Yeah. So I think the irregular cycles would be addressed through some form of progesterone. But the hair loss or hair growth or acne, those skin findings, are not are most are best addressed, quite honestly, by being on something like a birth control pill because the and you're going to suppress the sort of stimulation of the ovary that's driving up the androgens, and you're also going to increase sex hormone binding globulin, which is a protein from the liver that really soaks up that extra androgen. So that's honestly the best way to get benefit in terms of the especially hirsutism and acne.

And then sometimes we'll even use medications that will block estrogen action like spironolactone. Now I do have patients who don't wanna go on those medications and, you know, feel like that's not fixing the underlying problem, and it's just patching it or they don't wanna be on the pill for any reason. So that tool is not always, you know, the ideal tool for our patients, but it is certainly one one that I would discuss.

Dr. Mark Hyman
And and, what role do you see as diet? Is it a is it a strong lever for changing these patients' reproductive health and their cycles and their symptoms? I mean, if you basically put people on a low starchugar sort of diet that treats the insulin resistance, do you see big changes in their clinical picture?

Dr. Heather Huddleston
I think in some, for sure. And I think, you know, there haven't been great studies on this. There's been a few. I do think that if patients are able to maintain a very low carb diet, sort of a ketogenic diet, they will be able to really manage their insulin resistance, and that really takes away one of the sort of drivers or triggers or things that's really exacerbating their sort of phenotype or their symptoms. So if you are able to get the patient to sort of embrace that approach, I do think that you will see that often patients will see benefits.

I think it's something that has to be monitored. I don't think all patients will suddenly start having regular cycles, and their hair growth isn't gonna suddenly go away. But some patients may have more cycles. Some pay per patients may be able to conceive that way on their own, without fertility treatment, but others will not. So I I think it's something that I try to discuss as an option, but I think I shy away from saying, like, here's a way to fix this.

Because I think in, you know, honestly, it doesn't fix it for some patients, and Mhmm. That's really frustrating if they feel like they're sort of somehow failing.

Dr. Mark Hyman
Well, that sort of speaks to how little we know. Right? Because in some patients, it works. In some patients, it doesn't. You don't really know which one's which.

Right? And it's it's really about personalizing care.

Dr. Heather Huddleston
Yeah. So I I think it's I think it's a challenge, and I do think it's 1 I mean, PCOS is definitely a disorder that just takes a lot of personalization because it's such a diverse heterogeneous disorder, the concerns and the goals are often very diverse. So I think no patient and no treatment plan, quite honestly, is exactly the same.

Dr. Mark Hyman
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