The Unique Health Journey Women Face – Dr. Sara Gottfried – HPP 138

SPEAKERS

Keith Kurlander, Dr. Will Van Derveer, Dr. Sara Gottfried

 

Dr. Will Van Derveer  00:13

Thank you for joining us for the higher practice Podcast. I’m Dr. Will Van Derveer with Keith Kurlander. And this is the Podcast where we explore what it takes to achieve optimal mental health.

 

Dr. Will Van Derveer  00:23

For those of you who are unaware, the month of March is Women’s History Month. And Keith and I wanted to kick off celebrating the important contributions of women over the course of history with a rerelease of a podcast episode that was very popular. From back in June of 2020, with our guest and friend, women’s health expert, Sara Gottfried, MD. If you’re not familiar with Sara’s work, here’s what she writes in her bio. She’s a wife, mother or scientist, researcher, speaker, connector, scholar, seeker, Harvard educated physician with 25 years of experience, and author of four. Yes, that’s correct four, New York Times best-selling books. Dr. Gottfried is also the course director of the integrative psychiatry Institute, personalized medicine, training for mental health, which is an advanced program for medical providers who are eager to understand the most cutting-edge tools for resolving the root causes of mental illness. We hope you enjoy this episode as much as Keith and I did.

 

Keith Kurlander  01:50

Hi, Dr. Gottfried. Thanks for being on the show.

 

Dr. Sara Gottfried  01:53

My pleasure. Happy to be here.

 

Keith Kurlander  01:55

Yeah, it’s great to have you. And I’ve been following your work for a really long time. My wife was actually really into your books way before me years ago. And so that’s how I got introduced to you. We’d love to get started with a pretty basic question. We ask a lot of people on the show just about you. And for you, really, I would love to hear a little bit about how you got so interested in women’s health and also, obviously, into more integrative and functional and personalized approaches to medicine. I don’t know if there’s a personal story there or very curious about what got you so interested?

 

Dr. Sara Gottfried  02:37

Well, I think there’s almost always a personal story. And I love Brene Brown’s quote, that stories are data with soul. So I didn’t start out interested in women’s health, I actually started out interested in neurology. So it kind of cracks me up now because I can’t even imagine being a neurologist. But what happened for me was that I grew up with a beloved grandmother, who was diagnosed with Alzheimer’s disease. And when I was growing up in Maryland, she used to pick me up at the bus stop and drive me home to her house. My mother worked full time. And she started to get lost driving home on these very familiar roads. And I could just remember, you know, that look of panic on her face as she couldn’t figure out where to go, which way to turn. And she was trying to remain calm, I think for my benefit, but I could just see how confused and confabulated she was. And maybe what was the most worrisome and all of this was that when she was diagnosed with Alzheimer’s disease, there was absolutely nothing that could be done to help her. And so I spent the next 20 years watching the personality just drain out of my grandmother. And I think that was so devastating and traumatic for me, that it motivated me to go into medicine, because I imagined that we could do better than just what I later came to know often happens in neurology, which is diagnosed and adios. And so I wrote my med school essay about my grandmother and I really intended to go into neurology, but I found that the emphasis, at least when I landed at Harvard Medical School in 1989, the emphasis was on diagnosis. And there were so few solutions. Now unfortunately, that’s changed over the past 30 years. But I just didn’t like that sense of helplessness in terms of trying to guide my patients in a way that could help them reverse disease. So I backed off from this plan to go into neurology and what I found in medical school was that I loved everything. Pretty much everything. I loved psychiatry, I loved internal medicine. I loved, you know, kind of the intellectual parts of those two fields. I even loved radiology, I loved brain scans, I loved ultrasound, and kind of this ability to look beneath the skin at what’s going on at a deeper layer. I loved surgery. And it wasn’t until the end of third year that I did my first rotation in obstetrics and gynecology. And that’s where I felt like it all kind of came together, I had this moment of witnessing my first birth. And that was just a transcendent experience. And I just felt like I had come home. So that’s how I got into women’s health. And, you know, the more I got into women’s health, I also realized, wow, there’s a lot of work to be done. Because at that time, you know, Premarin was the number one prescription for women. It was a prescription, you know, to help with women as they went through the aging process and perimenopause and menopause. And yet, it had never been tested. In a randomized trial. hysterectomy was the number one surgery that was done on women. And I just felt like, Okay, this is a place where I can really make an impact. And not that that’s the most important thing, but it just helped me because I felt like the personal was political, when it comes to women’s self. So I did, you know, the mainstream conventional training in women’s health, as you know, but then even that field me. So that’s, I would say, that was the Epiphany, that led me to go into more of an integrative and functional direction. And that came when I was, it was a series of experiences. But it started with postpartum depression, when I was 32. And I would say, it ended when the epiphany occurred. When I was in my mid 30s, I couldn’t lose the baby weight. I felt so stressed trying to balance work, and family. And I just felt like I didn’t have solutions for mainstream medicine. And I remember the moment of going to my primary care provider. And I think this is true for a lot of us that go into integrative and functional medicine. But I went to my primary care provider, and I, you know, sort of went through my list of woes, including PMS, and this baby weight and feeling so stressed, and also losing my libido. So I just, you know, I had this really hot husband, but I wasn’t attracted to him. And I remember, this physician said to me, Well, here’s the prescription for an antidepressant. Here’s the prescription for a birth control pill. And, to kind of top it all off, he said, you know, this simple math of weight loss, you just need to exercise more and eat less, and even wrote it on a whiteboard in the exam room. And so at first, I felt ashamed. But then I got angry. I think it’s that anger, when it’s directed in a healthy way, that can really start to start a revolution. You know, that kind of righteous anger that if I’m facing this as an OBGYN, being told the wrong thing, you know, not even having a diagnosis of depression and being offered an antidepressant, being given a prescription for a birth control pill, because supposedly, that solves every hormonal problem that a woman has, at least until menopause and maybe past menopause. And then, to be told this wrong thing about the calorie myth. It made me realize, so many millions are facing the same problem. So I left his office and went to the lab. And that was the first time I checked my hormones. And, you know, I found that my cortisol was three times what it should have been, I had insulin resistance, I had no idea. You know, I had, I was in a pre diabetic state. And that was why weight loss was so hard, and probably was related to the inflammation and the mood issues I had. So that was really the pivot for me, where I said, There’s got to be another way. And I’m going to figure this out, like, I’m gonna apply what I know from my medical training and knowledge to my own situation, and then share it forward with my patients. So that’s how I became integrative and functional.

 

Keith Kurlander  09:35

Well, thank you for sharing that. I love the just the last statement you said of shared forward, so powerful, and we’re gonna speak a lot today about women’s mental health specifically, just because you’ve studied it so deeply. And there’s one thing I want to ask you before we get really deep into that conversation. Because you said you had such a powerful I think you said trans transcendental experience with the first childbirth that you attended. And I’m really curious about, assuming you’ve seen a lot of children being born in your time, right? I’m really, really curious about, if you have anything to share just about, after seeing all the births that you’ve seen any, whether it’s a spiritual comment about it, or just some kind of comment from you, since you’ve, you’ve been there for so long. And then you’re also in this integrative world. And just any comments you have there.

 

Dr. Sara Gottfried  10:35

It’s, you know, my first birth was so filled with awe. And I think, when we face these moments of tremendous awe, in many ways, they’re wordless. And so it’s challenging to put it into words, but I’m also a writer. So let me try language appropriately. You know, I think in many ways, when we create the language around an experience, like birth, we have to be careful not to reduce it, not to be overly reductionistic. And so I think there is something just spiritually awesome about watching the birth. I’ve seen all different types of births, because I’ve seen close knit families of all different stripes and types. I went from Boston, Massachusetts, to San Francisco. And my first night on call at San Francisco General Hospital, I was taking care of a woman who was in labor, and she had a substance use disorder. And she was addicted to heroin. And I walked in on her in early labor, and she was injecting heroin into her neck veins. And nothing in medical school had prepared me for that moment. So it is an incredible time in a woman’s life and a family’s life. However, you define that family and I define it very broadly. It’s also a time where I think trauma, and socio economic inequalities come to bear. And, you know, in some ways, talking about birth as a transcendent experience, may make me sound a bit privileged, I think we have to be careful as we talk about it. But for me, there was something about the experience of those first few bursts. That gave me a sense of radical health. And sort of what I would call, really honoring the biology of a female. There’s lots of differences between men and women. And I want to be careful not to be too gender binary here, but one of them is pregnancy. And I think pregnancy and birth and the postpartum period is just a really rich time that can be a very rich time in a woman’s life. And another influence that I think made that first birth, so transcendent, as well as the next 10. And I think I’ve delivered somewhere around 5000 Babies since I was taught obstetrics, initially by midwives. And I think this was a really important part of my education, because I got to witness normal birth. And it was, you know, this was at the birth center at the Brigham and Women’s Hospital in Boston. And I got to see, there’s a model for birth, that’s much less medicalized, much less interventionist. And the range of what’s considered normal is much broader. Now, if you look at a labor curve, kind of that S shaped curve that women are supposed to fall on to, and if they don’t change their cervix and active labor one centimeter every hour, then you got to do something, you got to like, crank up the Pitocin, or like, do something break their bag of water. And I was fortunate to learn, not disease, birth, but the birth of health. So I think that really influenced me. I mean, it certainly color’s the way that I take care of patients now, because we all know that medicine. I think the chair or the chief of Mass General said this, medicine is one of the only industries that doesn’t study its own gold standard of health. And instead, you know, what I learned was the biology of disease. I wasn’t taught about the biology of health, except by the midwives. So I think that experience with midwives was very rich. I imagine you guys might have something to say about the birth experience and the transcendence of birth. It’s also such an interesting time of looking at our addictive pattern around control, because birth often pulls that from you, you know, you go into your birth, maybe with the birth plan, and I want it to be like this, and I’m gonna be in the hot tub, and I’m gonna, you know, I want this, I don’t want this intervention, but I’ll take this one, I want an epidural at this point. And birth often just sort of takes that birth plan and throws it out the window. So I’m talking about a lot of different threads here. Any comments or feedback from you guys?

 

Dr. Will Van Derveer  15:20

Well, I can certainly relate to the contrast between medicalized birth from my obstetrics rotation in third year, in the 90s. At Vanderbilt, I didn’t know that birth could happen without a lot of tears from the baby. And so when I was in my early 30s, and my wife said, I want to have a home birth, it scared the crap out of me. And, you know, I needed to be, had to be worked with to imagine the possibility of birth as a healthy, natural process that didn’t need to be so medicalized. And we were fortunate that our birth plan actually unfolded in the way that we wanted it to, and stayed at home and stayed in the water. And when my daughter would come out, you know, and I caught her a little over 18 years ago, and she just looked around without any distress. I was scared. I didn’t know what was going on.

 

Dr. Sara Gottfried  16:25

Yeah. Like this reaction was so novel. Yeah.

 

Dr. Will Van Derveer  16:30

Yeah. And so I, for me, it’s kind of a theme reflected back from what you’re sharing of, you know, going through the very heavy technical medical training model, and then having a personal experience. And I’ve had some of the other ones too, but that kind of leads you personally to question whether, you know, the oral contraceptive pill and the antidepressant and the, you know, valgus caloric recommendation has anything to do with what we should actually be doing. And then, like you said, you know, expanding that out and paying that forward, into, you know, I think as a practitioner, I feel a little bit hypocritical, if I’m not offering to my patients, what some of the options are, that I would choose for my own health?

 

Dr. Sara Gottfried  17:26

Absolutely. beautifully put. Thank you. Well, it’s good to know that you had a home birth with your daughter, because, in many ways. That’s what we’re meant to do. I think this idea that other people deliver babies is completely wrong. I think it’s ideally that family unit, with you catching your baby, your wife delivering your baby, you catching your baby, that’s just such a powerful psychic experience, I think for coming into the world. And, you know, Will you and I, I think Keith too, we’ve talked about sort of this through line of trauma, and how common traumas, I think for so many babies, it starts with birth, it starts with this very medicalized birth. And I’m not saying that we shouldn’t have that because, you know, look at the maternal mortality rate right now, there’s certainly places where we need to intervene, you know, there’s higher rates of chronic disease for women who are pregnant now. And many of those women aren’t necessarily candidates for a midwife delivery. And yet, we also know from the study of genetics and epigenetics, that there are these soul wounds that can be passed on from generation to generation. So I’m so happy to hear that you had such an A traumatic birth for your daughter. I just think that’s an incredible way to start her life.

 

Dr. Will Van Derveer  19:00

Yeah, I think it was healing for me because the pictures of me as a newborn are lacerations and bruises all over my head from the forceps and you know the medicalization of that experience.

 

Dr. Sara Gottfried  19:15

Yeah, me too. I was a forceps, baby. I remember reading once that forceps babies have higher IQs. And I just thought, huh, that’s kind of a horrible way to improve your IQ. But my mother, you know, was anesthetized. I was basically yanked out with forceps. It sounds like you probably were to, and my father was like, often in a waiting room. And that was 1967 and a pretty progressive state. So we have a lot of collective trauma around birth.

 

Dr. Will Van Derveer  19:50

Yeah. And I also want to echo your sentiments about you know, thank goodness for the medical backup, in case things do go off the rails.

 

Keith Kurlander  19:59

We had an amazing experience with our daughter. And it was very intense and challenging. It was in a medical setting with a nurse midwife, which was, I mean, a wonderful nurse midwife who just held such a great space for the process. And there were a couple really big things that came out of it. For me, I mean, meeting my daughter was, it’s sort of hard to put words on that, like you said, A, some kind of transmission, I don’t really know how to describe it. But the other thing that came out of it for me that I kind of assumed would come out of it, but not to the degree that it did was, I had already thought of myself as a progressive man who valued women and had respect for women. But after watching my wife, the way she met the birthing experience, my not my respect for her, my respect for women, it’s sort of like was like a quantum leap in in that sort of whatever that internal gender divide is, it was just sort of a quantum leap of just like, you know, being like, I would not be able to do what she just did. Not in the way she met that, and just respecting women and a whole new way of the way that women are bearing children. And the process that goes through that, from pregnancy onward through postpartum and just the epic rite of passage that women go through, I just had no idea. Until I was watching, it really changed me.

 

Dr. Sara Gottfried  21:33

That’s beautifully put, I appreciate that, that concept of transmission, when you hold your daughter, I think that’s, it’s so powerful. And it also speaks to your humility, that you were able to kind of enlarge to receive her and what she knows what she knew, then, and it’s your right. I mean, there’s something just so extraordinary about the biological imperatives of women. And I’m not saying you know, women have to have childbirth as part of this process of being deeply female. But I think when you experience it the way that you’ve described in the way that I was able to witness in my third year rotation in medical school, it just provides this level of respect and understanding that I think is unparalleled. So I really appreciate that. And I love hearing your stories. Thank you for sharing them.

 

Keith Kurlander  22:28

Yeah. Well, this is probably a great transition, which is we talked about going through this talk and try to just get a little taste of what a woman goes through in her lifespan, and the unique biology they’re facing. And maybe a great starting point is, we start with the mother. And maybe we can start, let’s say with postpartum and what’s happening there in the biology of that woman, and why we see so many mental health challenges that women face there. And then maybe after that, we can then go more to the little girl growing up over time. Does that sound like a good plan?

 

Dr. Sara Gottfried  23:07

Yeah, that’s great. I like that you’re starting the lifecycle with the mother just giving birth, because I think that’s an unusual way, we tend to go sort of chronologically, so I like this. Well, I mentioned earlier that I had postpartum depression. And I’ve had two births. So I have two daughters. They’re both teenagers. And I had postpartum depression with my first daughter, and I didn’t with my second daughter. What we know is that one of the sex differences between men and women, is that there are these times of extreme hormonal flux for women. Now, men go through hormonal flex to, but not quite as jagged or as extreme as I would say women do. So you know, there’s certainly at puberty, women are increasing their estrogen and their oxytocin. Young boys, young young men are increasing their testosterone and those have different organizational effects. And then in pregnancy, what we know is that a different form of estrogen predominates. So instead of estradiol, E2, which is what we make through our reproductive years, we make estriol which is not quite as potent as estradiol. But what happens in pregnancy is that you have about a threefold increase in the total amount of estrogen and an attendant increase in progesterone, a lot of it is produced by the placenta. And what happens for a lot of women, when they go from kind of the sky high hormones to delivering this baby and delivering the placenta, which is producing all these hormones, they can crash. So your hormones go from quite high down to almost nothing. And there are some women who navigate that quite well. I think the women who are prepared for it, who have a lot of support and have the freedom and flexibility to really focus on, you know, cocooning with their baby and with their family, those women often do better. But some of us maybe related to gene environment interactions don’t fare so well. And I sometimes joke that this is a preview of coming attractions in perimenopause that would happen for you postpartum. And I’ll share a quick vignette, which is, I’m an OBGYN and I remember breastfeeding my daughter, my milk had just come in. So I was like three days postpartum. And I was just sweating like crazy. So I’m breastfeeding my daughter, I’m sitting in bed, it’s the middle of the night. And I’m so hot, you know, it’s like 68 degrees in our room. I’m so hot. And I’m sweating profusely. And I’m looking around, I’m just like, What is going on? Why? What is happening? And then I was like, oh, duh, I’m having a hot flash. Like I’m having night sweats. Like, I would have to change my nightgown every night, I’m having hot flashes, night sweats, like the classic vasomotor symptoms. And like I didn’t put it together, because I was in a pre menopausal state. So when you’re breastfeeding, and you’re breastfeeding exclusively, and you do that for some period of time, you’re in a pre menopausal menopausal state. It’s reversible, hopefully. But what we know is that it’s a very vulnerable time for women, for a few reasons. There’s some micronutrient deficiencies that can make it very hard. There’s these hormonal changes that we’re talking about. There’s, you know, kind of this dramatic change in one’s psychic structure where you’re welcoming this baby into your life. And you may or may not be prepared for that. You know, what I see, I have a lot of women who come to me and have mood changes. And I think the challenge at that point is to investigate it to look at, you know, what are the hormonal drivers? The other thing that’s kind of happening in the narrative is that when a woman gets pregnant, and her egg is fertilized with sperm, about half the DNA of that fetus is not hers. And so there’s this dramatic change that happens in terms of immune adaptation. And then that changes postpartum. And what it leads to is higher rates of Hashimoto’s thyroiditis, autoimmune thyroiditis, it’s just a time of tremendous flux. So I remember going to my doctor and talking about, you know, I’m sleep deprived, I’m crying all the time. I don’t want to eat. I had all these symptoms. And at that time, my doctor just kind of patted me on the back and said, you know, you’re just a new mom, it’s just how it is, you know, you need to nap when the baby naps, I got so sick of hearing that. I think often nobody bothers to look at hormone levels, or to look at micronutrient levels or to understand, you know, okay, this amount of sleep you’re getting is just not possible or sustainable. So how can we troubleshoot a better solution? So I think it’s important that we not dismiss women who are having mood issues when they’re postpartum. It’s not just depression, I think one of the things I see more of is postpartum anxiety, as well as anxiety during pregnancy. I think there’s an increased prevalence of that.

 

Dr. Will Van Derveer  28:34

I’m feeling a lot of gratitude for your stand for looking for the root causes of these challenges that people face, you know, rather than kind of the medical model of just, you know, medicating the symptom with a molecule that doesn’t exist in the human body.

 

Dr. Sara Gottfried  28:51

That’s right. Yeah, you know, I’ll share a quick story. I think I’m allowed to share parts of this. So I have to be careful with privacy here. But I have a relative who just gave birth during the COVID 19 pandemic. And her baby was 27 weeks at the time of delivery. And so the hospital was completely flipped out about the neonatal intensive care unit and the possibility of COVID-19 getting in the NICU, which makes a ton of sense. But what it meant was that she was basically not allowed to leave the NICU. So she stayed in the NICU for about five, six weeks, with a three year old daughter at home with her husband. And it was just so devastating for her. And instead of trying to troubleshoot solutions to solve this, you know, I was like, well, we can get you an aura ring. We can check your temperature every day. Like we can look at your respiratory rate, we can do your oxygen saturation for 24 hours and you know, that should allow you to leave and then come back. And instead of coming up with solutions, kind of Behavioral solutions allowing her to leave for 24 hours or 48 hours. They offered her an antidepressant. And so I think that’s, that speaks to the point that you’re making, you know, often we have this situational adjustment, that a pill is not necessarily going to help.

 

Dr. Will Van Derveer  30:17

Right. Great example. Yeah, yeah. And it’s sort of your exam. Thank you for sharing that vignette. Because it brings up for me this bigger theme that I think we see a lot is the medicalization of emotion of grief, the refusal to actually feel those feelings in this case, estrangement from a three year old at home, right? And the impact on that child to have the mom gone for five or six weeks, for example.

 

Dr. Sara Gottfried  30:46

Yeah. And the three year old has no idea. Right? It’s happening and capacity. Yeah. The three year olds are not good at FaceTime, or zoom. Yeah, it was really challenging. And women need support. Families need support to make it through a crisis. You’re right. medicalization of emotion, I think is really a powerful way to describe it. So should we talk about puberty?

 

Dr. Will Van Derveer  31:13

Yeah. Let’s talk about puberty.

 

Keith Kurlander  31:15

Thinking about puberty.

 

Dr. Sara Gottfried  31:19

So I know you have an 18 year old will, how old is your kid Keith?

 

Keith Kurlander  31:23

She’s turning two in August.

 

Dr. Sara Gottfried  31:26

Okay. So your way?

 

Keith Kurlander  31:30

Although sometimes I think she is in puberty.

 

Dr. Sara Gottfried  31:34

Yeah, well, it’s, you know, I still feel like I’m in the throes of coping and adjusting to puberty. And I think in many ways with parenting, that there’s so much richness that comes from a young woman going through the experience of puberty, it’s an interesting mirror, it’s an interesting portal to kind of look at your relationship as a parent. But what’s happening hormonally is what I mentioned before, you know, dramatic increase in estradiol, the primary reproductive hormone, and also oxytocin. So what does that mean? It means that estrogen has 400 Plus jobs in the body. And certainly, it’s, it’s one of the drivers of growing the breasts and growing the hips, but it also has this other role in really caring about your appearance, and caring about, you know, starting to become sexually attracted to others, and really caring about your peer group in a way that maybe you didn’t as much before. And so there is a lot of emphasis on appearance. And I think that can go in a really positive direction. But it also has, there’s some vulnerability there. We know that puberty is when a lot of young women start to have body dissatisfaction. And, you know, can feel like the images they’re seeing on social media or I don’t know if anyone reads magazines anymore. But you know, sort of these images that we see of supermodels who are at a totally unattainable size in terms of their breasts and their hips and their thigh gap. And I think, unfortunately, a lot of young women going through puberty will internalize these images and start to compare themselves in a way that’s unfavorable. And so that’s where I think there’s a tremendous opportunity for us as parents to try to normalize health. Now, this is a really, fairly complicated topic. And I, I’m not necessarily an expert at it, other than kind of understanding the hormonal drivers and also experiencing two daughters going through it. But I’m curious, well, you’ve had some experience with puberty. And with the teenage years, what’s been your experience of this time with your daughter?

 

Dr. Will Van Derveer  33:48

Well, I would say that now we’re coming out the other side of the roller coaster. I think things were really intense around 12 and 13, and 14, and she definitely feels like we’re on the downslope at this point. But one of the things that was so hard for me as a father was the social media piece, and just the very intense environment of comparison. And like you said, the peer group, and it feels to me that Snapchat and Instagram, particularly Snapchat, just kind of adds gasoline on the fire, this vulnerable place that you were speaking about?

 

Dr. Sara Gottfried  34:28

It definitely does. And it’s, you know, I think it’s tricky to be able to document the effects of social media and smartphones, but we know that there’s a significant increase in the prevalence of anxiety among teenagers at night. I believe that’s higher among young women, but I actually don’t know those data. And I think this speaks to it in a few different ways. I think, you know, with watching my two daughters and how they navigated this process, I think one was I’m more into social media than the other. I believe that, you know, there was a period of time where I was letting her experiment with social media probably more than I should have, and it was affecting her sleep. And she was just on SNAP way too much at the time, she wasn’t present for conversations. And, she had a lot of anxiety. So on the one hand, I think social media can be used as a force of good in terms of spreading awareness. You know, I think of, for instance, anxiety campaigns that I’ve seen on social media, in terms of destigmatizing it and raising awareness and having people share their story of what anxiety feels like. On the other hand, you know, we still have to be shepherds, as parents, and my daughter didn’t like it when I started to lock her phone away at night. But I felt like it was really necessary to safeguard her health. I think another important piece is disordered eating, which I think rises out of many of these same issues. And I’m curious about your experiences with disordered eating. You know, that’s certainly when I started to have problems with what I now think of as food addiction, and eating for emotional reasons. Eating when I was happy, eating when I was sad, restricting food, binging on food, purging, with both making myself on it, and also exercising. And so I’m really sensitive with young women about body image. How do you help them create a sense of wholeness? Because I think what really comes through in puberty is this emphasis externally to be perfect. And that’s not you know, that doesn’t work for anyone, we’re not meant to be perfect. We’re meant to be whole. So I think being able to model this sense of wholeness is really important. And another thing I’ve learned as a parent is that sometimes your kid is suffering more than you realize. And I think especially as clinicians, it’s important to get outside help, you know, let’s try an integrative approach. Let’s go to yoga every other day, and see if that can solve your problems. Yes, there’s a time and a place for that. And I think, you know, modeling really healthy food, we certainly know that. In adolescence, that’s the key time to be getting all the servings of fruits and vegetables that you need: regular exercise, restorative sleep, all those components of integrative medicine. But sometimes there’s also a place for pharmaceuticals, where to do it alongside with the integrative approach. So any thoughts or comments about that in terms of your experiences?

 

Dr. Will Van Derveer  37:39

Well, what you’re talking about reminds me of another really interesting area that you’ve spoken about in the past. I’d love to hear more about the relationship between trauma and female hormones and how trauma can impact the balance of female hormones. I’d love to hear more about that.

 

Dr. Sara Gottfried  37:57

Well, I’m fascinated by this. I was looking at some of the statistics on mental health issues in women before this call. And I had to kind of laugh at myself, because in some ways, I think this separation between physical health and mental health is a false dichotomy. And we know that from what we’ve learned about the immune system, the way that we process the outside world through the immune system, the nervous system and microbiome, the gut brain axis, we know that there’s so much crosstalk between physical and mental health. And so when it comes to trauma, you know, we know that PTSD is about twice as common for women versus men, men certainly suffer from it, but they tend to suffer in a different way. And with women, what I saw was that the lifetime risk, the lifetime risk for a man of post traumatic stress disorder is about five to 6%. And it’s about 10 to 12% of women. And I read that and I thought, that seems way too low. At least from what I’ve seen over the past 25 years, I think it’s much more common in my patients. And I think our ability to diagnose it maybe needs to be revised. And so how does this show up in terms of hormones? Well, we certainly know that trauma can impact the control system for at least sex hormones and probably beyond sex hormones. So what I’m talking about here, of course, is what’s known as the hypothalamic pituitary adrenal axis. I like to think of it a little more broadly as the hypothalamic pituitary adrenal thyroid, good natural gut axis, because I think all of these are interrelated and interdependent. So trauma affects all of them. You know, we know that. For instance, trauma and high cortisol levels are associated with increased intestinal permeability. We know that women with low cortisol have a flat diurnal pattern that’s associated with a greater risk of both post traumatic stress disorder and also fiber I Ultra. And the way that I think of those folks, of course, and I’ve heard you talk about this well, quite a bit, is that those are folks who’ve already gone through several stages of physiologic response to the trauma that they’ve experienced. And they’re on, you know, kind of the burned out phase, the flat phase, and I don’t use the term adrenal fatigue, I think it can be helpful, but I think of it more as HPA TGG dysregulation. So that’s the main thing that I see. And I’ve seen a lot of different patterns, not just low cortisol, I think in some ways, it’s kind of like that, under diagnosis, that potential under diagnosis, I was talking about this rate of lifetime risk of 10 to 12%. And women, I think it’s higher than that. And I think there’s a lot of women who have unprocessed trauma, who are in you know, kind of that earlier snapshot of HPA or HPA TGG dysregulation. So I think it kind of starts with cortisol, I joke that cortisol is like a bully, when it’s not navigated. Well, I had someone call it Michael cortisol, Leone, after the godfather. And I think that’s kind of a funny way to think of it. You know, you’re designed to make cortisol at all costs, you’ll make cortisol, if you’re a highly stressed person, like I was, in my mid 30s, when I was producing three times what I should have, you’ll make cortisol at the expense of your other hormones. So your thyroid won’t work as well, you are more likely to have estrogen dominance, because you won’t make as much progesterone, the right side of the tree that makes androgens like DHEA, and testosterone that tends to be more depleted if you’re making more cortisol. So those are some of the downstream hormonal effects. Is that what you had in mind? Anything you want to add to that?

 

Dr. Will Van Derveer  41:47

Well, I was thinking about that kind of progesterone steal phenomenon that you’re talking about, I think is kind of driving the raw materials for all kinds of different downstream hormones into the cortisol production pathway. And I was wondering if I haven’t, because I’m not a gynecologist, and I, you know, I don’t focus on women’s hormones, per se. It’s something that I have enough knowledge to recognize and refer to in my practice, but I’m wondering if you know if someone with a fair amount of trauma load in their system has trouble with their cycles and their levels? Maybe partly because of this progesterone steel thing that you’re talking about? Do you see when people have successful trauma resolution that their hormones can come into better balance?

 

Dr. Sara Gottfried  42:35

That’s a great question. It’s almost like a before and after question. And I don’t know that I’m trying to like go through my memory banks to see if I’ve got some good cases to demonstrate that. It’s a little tricky, because, you know, there’s a lot of different reasons for women not having enough progesterone, and where I thought you were going with this. So I’ll just take a quick tangent. So progesterone, I think of as nature’s benzodiazepine, works a lot better than benzo. So but it’s what helps us calm down. It’s what helps us soothe ourselves. And you know, the very thing that you need, when you experience trauma, which is soothing, and support and like a wise adult human to say to you, I love you, I’m here for you, I understand that what you’re experiencing is so horrible. And I want to help you know, the very thing that you need, you’re not getting, because what tends to happen is we have this sympathetic nervous system response. And we are making a ton of cortisol and epinephrine, and then we’re not making things like progesterone. And I even think that you could map that to later. Because one of the progesterone metabolites is allopregnanolone. And there’s studies happening right now looking at the female brain, and women who have Alzheimer’s disease, giving them compounded allopregnanolone, to see if it helps them with their mild cognitive impairment or with Alzheimer’s disease. So I think, you know, it’s so unfortunate that the very thing you need, you’re not getting. But to go back to your question about, you know, do you see resolution, the place that maybe fits the best, as a partial answer to your question is with the patients that I’ve had with polycystic ovary syndrome, and as you know, this is something that affects somewhere between about 10 and 30% of women at all ages, not just reproductive years, but post menopause too. And it’s associated with much greater cardiovascular events. And in the reproductive years, it’s associated with oligomenorrhea, so you have a period that’s every 35 days or less frequent, and it’s often but not always associated with insulin resistance. So it’s more common in women who are obese, but you can get it also when you’re lean. And when Other things we see are very low progesterone levels. So you’re not ovulating, and tend to be very high androgen levels that can be associated with acne and hirsutism. But what I’ve seen, you know, my experience with patients with PCOS is that they often have not just this particular dysregulation of how their ovaries are regulated by their brain via the HPA and how that’s talking to the gonads. But there’s also an issue with the stress response. And so that part hasn’t been teased out as well. I don’t believe, you know, mainstream researchers of PCOS. But when I see women with PCOS who process their trauma, I often see that, you know, dietary changes, bringing in nutraceuticals that help them with being more insulin sensitive, it’s often more effective, and they can start cycling regularly on their own. So I’ve certainly seen that, but I would say that’s a little bit of a mixed answer to your excellent question. Thank you.

 

Keith Kurlander  46:06

So I’m really curious about your take on what the endocrine system and hormones in general tell us like if you were coming in as you know, if we separate systems for a moment, cardiovascular system, and we could sort of tell stories, narratives about people and and looking at these systems individually? Why are hormones so important? Why is the endocrine system so important? And what kind of story can I tell about a person?

 

Dr. Sara Gottfried  46:33

Okay, this is such a juicy question, I have about 10 different directions I want to go. Well, let’s go back to the point that we made earlier, that the way that we interact with the outside world is through the immune system, the nervous system and the microbiome. And as I think about that, I think, Well, where do I put the endocrine system, like, that’s kind of my mission in life is to work with the endocrine system, and I left it out of that equation. And I think in some ways, maybe it’s the neuro endocrine system, maybe I’ll put it there. So why is it so important? You know, I think if we take an ancestral perspective, which is always kind of a convenient way to start, I would say the endocrine system was primarily designed to get you out of trouble, like if you had a predator chasing you, so that you could, you know, crank up your epinephrine and your cortisol and you could run or you could fight or, you know, find some way to solve the crisis. And then it was also designed to help us with fertility. And of course, we evolved to have the priority that our fight flight freeze was more important than fertility. I would also say this is now my opinion, I think that we were designed to go into a state of alarm pretty infrequently. You know, I wasn’t on the savanna. So I can’t really say how often that’s supposed to be. But my sense is, like, once a quarter would be about right. And not every day, and certainly not as frequently, as many of us feel stressed and our patients feel stressed. So how do we create meaning out of the endocrine system, I think it’s in part, it’s, it’s this way of dealing with the outside world. And the more that we can have the perception of being able to work with it and navigate it with almost what I would call like a witness consciousness, so that there’s a little buffer between, you know, the email I got at seven o’clock today, that totally triggered me, the more that we can kind of create that buffer and have tools to, okay, my cortisol is high in the morning, but I have all these tools to bring it back down. I think that’s one of our sort of life objectives. And being very careful here not to use the word control, but to have a sense of mastery. So not so much that your endocrine system is controlling you. But that there’s kind of this, this way of meeting it in the middle. And, Keith, you were saying something about how your wife met the birth process, which I really loved. Because what I hear as a subtext is the sense of empowerment, and also your deep reverence for how she went through that process. And I would say, that’s exactly what I’m talking about with the endocrine system. Like it’s a way of meeting the world with a sense of mastery with a sense of options with a sense of, you know, I’m not completely driven 100% by biology here. I have some ability to navigate this. So I don’t know if that answers your question. That’s one train of thought. Any comments about?

 

Keith Kurlander  49:55

I mean, I think it definitely was a great answer to the question and it was obviously a very somewhat of a fill Asafa Chol medical philosophical question. And it was a great answer. And we have a handful of minutes left. And obviously we didn’t get through the life cycle, which I imagined we wouldn’t, because there’s just so many, we could spend hours with you, obviously. But I think a good place to go with the last kind of question here is about women’s empowerment, because you’re speaking to that in the endocrine system. And what would you say just for women in general about how to get more empowered in their health? And, you know, where do they start? Should they be going into their doctor and saying, Hey, let’s talk about hormones? Or should they be doing things with their diet? Or just what would you say in the beginning of just helping women get more empowered in relationship to their own body?

 

Dr. Sara Gottfried  50:46

Well, I love that question, too. I think it starts with knowledge. In many ways, you know, just like there’s not a one size fits all, when it comes to anxiety, or depression, or PCOS or hot flashes and night sweats. There’s not a one size fits all, when it comes to empowerment, I think many of us have different tasks at hand. And what I find is that my personal tasks with empowerment tend to keep coming up until I work with them in a way that’s skillful. So, yes, I do think that there’s, I don’t know that everyone needs to get a hormone panel, I would certainly, you know, be in favor of that. Because I think, especially for women before the age of 40, or 45, it can be very helpful to know, what’s your base case, you know, especially at a time where you feel fantastic. And that’s not when you typically want to get a blood draw. You know, if I know what a patient’s TSH was, when she was feeling fantastic at age 32, or 28, it’s much easier for me to manage her thyroid going forward. And if I understand kind of the estrogen progesterone Tango that she had, when she was in her 20s, and 30s, it can be easier to prescribe bioidentical hormones later. So I do think part of empowerment is testing. But I would put it a little broader, I would say, this is more about becoming a scholar of your own health. Because no one’s going to do that for you. I mean, even if you have a very collaborative clinician that you’re working with, that goes a long way. But they’re, you know, what we know from healthcare studies is that about 1% of your time is spent with clinicians or with the healthcare system 99% of the time, you’re running around making choices about the food that you eat, and whether you’re gonna exercise today what the exercise is going to be, and how do you talk to your beloved, and, you know, all those 1000s of choices we make each day. So I would say, empowerment starts with knowledge, and identifying any knowledge gaps that you have, which I was taught to do. And what I hope I don’t teach to my daughters is that you outsource your health to your clinician. And we all know how that’s worked out. Like, we know, we know the punch line. And so I really want to encourage people to not do that. And I think that’s true for hormones. It’s true for health. We were saying earlier, you know that medicine is the only industry that doesn’t study health as a gold standard, I think we need to do that. And my background is also in bioengineering. And I think that, what I hope we’re heading toward is what I think of as, you know, kind of deep medicine, precision medicine, integrative functional medicine, what I hope we’re heading toward, is to really be able to quantify health for each individual. And for some folks, that’s going to be a pretty dense data cloud, like nerds like me, for other folks that maybe, you know, a 10 point panel that they get once a year of different labs, not just hormones, but other things too, like hemoglobin, A13? And, you know, where are you with your fasting glucose and what’s happening with your lipids, things like that, I would also say what I’ve become increasingly interested in is befriending your brain, like really knowing your brain and your mind better. And I think we’re at this really interesting place in history, where we’re able to do that more than ever before. So I would say empowerment is all of those things. And it also needs to be defined by the individual. And I’m happy to coach and help with that. But I don’t want to. I want to be careful not to project my values when it comes to empowerment onto another person. I think we all have to come to that sense of empowerment and how we define it ourselves.

 

Keith Kurlander  54:45

Thank you. That was a great answer. I’m curious about as we wrap up any books of yours, you want to point people toward right now or ways they can connect with you and learn from you and what you would like to say there?

 

Dr. Sara Gottfried  54:59

Sure Here, while I’m on social media, that makes part of my policing of my daughters more difficult, I have to walk the talk, I’m on social media, you know, restricted hours each day. My website is Sara Gottfried md.com, I would say that’s the mothership. That’s kind of where I post blogs, and we have social media streams. I love Instagram, for some of those positive reasons that we talked about, I think it can be a force of good and for raising awareness. I also kind of see it as a lab. So out of all the different social media handles that I have, I would say Instagram is where I’m the most active. And then in terms of books, I mean, the book I started with was the hormone cure. And that came from just really witnessing the seven most common hormone imbalances that I saw in my patients, like, what were the conversations that I was having over and over? What were the pieces that I needed to personalize? And it all started with cortisol. So I think the hormone cure is a great place to start. My last book, Brain Body diet is more about the female brain, and how it connects to these different systems of the body, such as the gut, such as your skin, your adipose stats, kind of the way that you control body fat, the role of toxins, and I have a documentary there on the website for the book that might be interesting to folks on anxiety. And so that website is Brain Body diet.com. Brain Body diet.com. Great,

 

Keith Kurlander  56:35

great. And we are now asking this question to everyone to end it. And the question is, if you had a billboard that every human being would see in their lifetime, and you can put kind of a paragraph on there, well, what would you say to people?

 

Dr. Sara Gottfried  56:51

Oh, a paragraph? Let’s see. Yeah. Well, if you know what I like, I could kind of see a SoulCycle. Billboard, because I think words are so powerful. And I think it would be from this conversation, it would be a friend, your brain, you know, something about becoming a scholar of your brain and mind and your health. I also, you know, I think marketing is really important. So I’m really glad that you asked this question about the billboard, because I consider marketing to be the most sacred duty that I have. And it’s something that I do with every single patient that I see. And I mean, marketing with tremendous integrity. There’s a quote that I’m going to paraphrase from BJ Fogg, who’s a Stanford professor. And he said something like, a good doctor figures out what people need, and then convinces them that they want it. And so I would say that billboards need to convince people of something that they desperately need. And I would say we need more of a focus on the brain in the mind and how to make it better.

 

Keith Kurlander  57:59

Right. Well, Sara, thank you so much for being on the show. Such a pleasure.

 

Dr. Sara Gottfried  58:05

So much fun to be with you guys. Thank you for all the work you’re doing in the world.

 

Dr. Will Van Derveer  58:13

We look forward to connecting with you again on the next episode of the hire practice podcast, where we explore what it takes to achieve optimal mental health.