How Metabolic Health Affects Women's Reproductive Health | Dr. Shawn Baker & Dr. Andrea Salcedo
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And it has to do with the whole thought and the concept of something called bacterial translocation or leaky gut. That is actually when a time that a woman's body is craving a little bit more carbohydrates. And everybody knows this, like the week before a period, people are like, you know, eating more sugar than usual. Well, that's actually biologic. And so that's the whole concept of like fasting, like a girl that like Mindy Peltz talks about.

And there's a lot of truth to that because we don't want to be in these like crazy high ups and downs of carb crashes during that time because it's very dysregulating to like the actual balance of norepinephrine and like serotonin in our brain. And so high insulin levels, high glucose levels really do change our internal thermostat and cause what we call vasomotor symptoms, which is just basically hot flashes. ♪

Hey folks, it's Dr. Sean Baker here. Hey, if you or someone you love is suffering from chronic disease and you're tired of just managing symptoms with potions, pills, and procedures, I want you to check out revero.com. Our team of dedicated professionals is committed to tackling the root cause of your issue and finally getting you healthy. Hurry up though, our spaces are filling up very quickly. Everybody, welcome to Dr. Salceda. She is a gynecologist. She's going to be joining us today to talk about...

I suspect some women's issues, I assume. So anyway, Dr. Celestino, first just tell us a little about who you are.

Yeah, hi. My name is Dr. Andrea Salcedo. I'm a board-certified OBGYN. I work at Loma Linda University Health, which makes everybody laugh because everybody knows about the Seventh Day Adventist and their alignment with more plant-based eating. But they know what I'm doing. They know I'm more of an animal-based person. And I use a lot of metabolic health to

and metabolic medicine really to treat normal gynecologic diseases like endometriosis and uterine fibroids, bleeding, but I also use it kind of within the pregnancy space too. So it's really exciting. I'm a clinical researcher and I am a full scope OBGYN. I do surgery and stuff too. So it's a lot of fun. Thanks for having me.

Yeah, this would be fun to talk about. Yeah, I want to just ask you, what led you down that path in the first place? I mean, not everybody starts out doing metabolic interventions for disease because we're not really taught that, at least I wasn't. So what got you down that path?

Yeah. So, you know, I was just like everybody else, you know, working real hard. And I, you know, finished OBGYN residency back in like 2012. And I was, you know, I had this really fancy job. I was making like a lot of money and working real crazy. And then I wasn't able to get pregnant. And I had already had one son and I was having regular periods, you know, but I

got a year and a half of trying, I wasn't able to get pregnant. And so then all of a sudden, you know, I realized that it's wasn't just diet. I mean, I was eating the typical normal diet that everyone was at that time, you know, it was like,

chicken, no skin, quinoa, all that kind of stuff. And I was having a couple of beers a week with my family. It was just like a normal person. But I couldn't get pregnant. My job was crazy stressful. And so I thought I was doing everything right diet-wise. And so I quit my job. And

And then I got pregnant. And then so I was like, wow, there's something here. Well, then I in that pregnancy, I became a gestational diabetic. And it was really surprising because my one hour glucose tolerance test was 200. And so I didn't even have to do my, you know, three hour confirmatory test. And all my colleagues were laughing at me when because I ended up going back to Loma Linda to work. I trained there.

And they were like, what are you, how come you're diabetic? You're 125 pounds. You know, you're slender. You look great. The only risk factor I had for me, I think I was like 35 or 36 at the time when I had my second son.

And everyone was laughing, couldn't understand it. And so I, you know, they didn't even have me do the diet, you know, teaching that they teach you because they figured I had it all figured out. And everything I thought that was healthy was throwing my sugars off. I was having quinoa and, you know, whole grain things. And my, you know, and I was eating about 30 grams of carbs per meal and my sugars were terrible. And so finally, I was just like, I can't eat any carbs, even plant carbs I couldn't eat.

And, you know, so I was probably nearly, you know, ketogenic. It's really easy to get into ketosis when you're impregnant. And my son came real easily with six and a half pounds. I did great. And I started becoming incredibly frustrated with typical OBGYN care because everything involved birth control pills or, you know, some sort of rubric diet that like didn't make sense. And so I

I started doing a lot of reading and I looked into the nutrition network, which does a lot of education at that and still does. And I started realizing that if we talk about end organ damage with like hyperinsulinemia and diabetes, and we talk about the eyes and diabetic retinopathy and, you know, osteoarthritis for you, right. And, you know,

diabetic kidney, you know, all those things. How come we're not talking about the uterus as an end organ also, right? We call this like end organ disease, right? But the uterus is an end organ too and is a recipient to all of those cardiovascular disease risk factors. So that just became my new research interest. So for the last seven, eight years, I've been doing clinical research on how the uterus is an end organ.

and how it is susceptible to all of these hyperinsulinemic metabolic risk factors. So that's what I do. It's a lot of fun.

I'm a little disconcerted you say I laughed at you when you said you were a gestational diabetic. It doesn't seem like a laughing matter to me. But anyway, so with regard to the uterus, there's a couple of conditions that I'm sure you're very familiar with that I see women ask me all the time, hey, can diet help this? And my response is I've seen it happen, so I think so. Endometriosis, which is basically the uterine lining gets distributed outside the normal locations.

And then, of course, you're in fibroids. So talk to me about how diet might impact those things through what mechanism and what have you seen in your practice?

Yeah. So let's talk about uterine fibroids. That's kind of like a really, you know, interesting thing to talk about because we know that the uterus is made of smooth muscle, right? We learned about this in anatomy class and histology. Well, smooth muscle is also what is made within the vasculature, right? So the arteries and the veins and stuff are also

smooth muscle. Well, since the 1960s, we've learned that the same myocytes, like the same muscle cells that cause atherosclerotic disease are the same ones that cause uterine fibroids. And so that's like really fascinating to me because, you know, I'm, you know, I'm a surgeon, you're a surgeon, we're really good at like, you know, surgical interventions. So if it's like you're bleeding, we got a, we got, you know, we got a solution for that. Right. And a lot of times, like

When women have heavy menstrual periods and related to uterine fibroids, like they really do need that because they're, you know, hemorrhaging, they're needing blood transfusions and stuff. But then we don't really share with women about why those fibroids came to be. We just give a solution and then we kind of move on.

But if we really think about it, a lot of patients and doctors receive the message that, oh, your uterine fibroids are just related to your genes and like, good luck, right? But unfortunately, that's really not the case. That's actually one of the lower risk factors that cause all these problems. And so like on the top of the list are risk factors as hypertension and diabetes and visceral adiposity. Okay, I

And so then when we start looking backwards and tracing it back, those same inflammatory factors that cause atherosclerotic disease are the same ones associated with the inflammation that leads to uterine fibroids. So when I teach my residents about why fibroids come to be, it's basically cardiovascular disease or atherosclerotic disease of the uterus, right? And so if a woman is having these concerns...

You really need to be sharing about their associations and their risk factors that manifest as gynecologic problems. So that's, you know, uterine fibroids. Let me just interject here because when you say uterine fibroids are atherosclerotic disease, I mean, it's not that the feeding vessels are atherosclerotic. It's just the same metabolic milieu that's driving it.

you know, endothelial hypertrophy is driving hypertrophy because the fibroid is an enlarged muscle basically. It's just an enlargement and you end up cutting them out is what you guys often do is you go in there and do myomectomies and

disremove it. Is that a more fair way of thinking that? It's the metabolic component? It's a little bit of both. Yeah, it's a little bit of both. You get some blood flow compromise is what you're saying, perhaps. Absolutely, because those fibroids actually end up becoming necrotic. And so it is like calcifications and hardening of the arteries and stuff that lead to this hypertrophic globular mass of tissue. And

And so, yeah, so it really is atherosclerotic disease of the uterus. It's impaired vasculature, just like what we call pathologic neovascularization. So like a disease process that's causing the blood vessels to form irregularly. So you're absolutely right when you have patients and maybe folks that you're educating about, does this lifestyle help improve that?

you know, it definitely helps prevention. But then unfortunately, there's no study right now that shows that a really good ketogenic or carnivore or low carb diet can make fibroids get smaller. I get that question all the time. But this is such new science and new data that like that is actually not something that's unreasonable to consider. Have you seen that in clinical practice, though, irrespective of study? Because there's always, you know, you always see these clinical anecdotes. Is that something you've seen?

Oh, yeah, I have, you know, and I haven't seen them in like giant ones, like five, six, seven centimeters, but I've seen them in a lot smaller ones, you know, where they just kind of goes away, which is really exciting, because I think there's something here for that. You know, but I've yet to see it for large ones, but it doesn't mean that that's not possible. So the small ones and the intervention, just to be clear, the intervention that you've seen it associated with getting smaller is what?

probably three to five or maybe one to three centimeters. I've seen that and I've seen, um, and mostly I see it with ladies who are on ketogenic diet. I have yet to see it in carnivore diet, but just because that I have not seen it just because I haven't, don't have a lot of women who do are doing carnivore diet. I mean, I work at Loma Linda, everyone's vegetarian, you know? And so, um,

But when I guide them down that process, you know, then it makes a lot of sense. And a lot of women are actually willing to go there. But most of the time when people do carnivore diet, they're actually using it for endometriosis and a lot of the work that I do.

So, I think it's fair to say if you have someone with small uterine fibroids, you would say it's reasonable to try a dietary intervention. These may go away based on what you've seen up to this point. Based on what I've seen anecdotally, that pushes the needle for research, absolutely. Yeah, given that we haven't had the research yet, and hopefully that will soon happen, I'm really hoping, hopeful that we can get some of these done. Now, let's switch gears to talk about endometriosis. This is something that plagues a lot of women. It's miserable. They're just

So tell us what endometriosis is and why do you think it's happening pathologically? And then how might nutrition play a role there?

Yeah, I just love that you're asking about endometriosis. I don't know any, you know, ortho guy that would be asking about this. So this is like really great. But endometriosis is a really tough phenomenon. It is the most difficult gynecologic disease to treat because there is no cure. And so you're right. You alluded to endometriosis as being the lining of the uterus, like escaping the uterus somehow, right? And so there's all kinds of different, uh,

theories about why this happens. But one of the biggest ones is that it has to do with something called retrograde menstruation. So when a woman has their monthly cycle, the blood comes out vaginally, but it also comes out through the fallopian tubes. Okay. So as it's coming out through the fallopian tubes, then it sits in the pelvis, right? And so it'll sit in the space usually between the uterus and the rectum.

And then through normal processes, it'll get absorbed, all that blood and all those tissues get absorbed when the immune system is activated to process it. But here's the really interesting thing, and it's a big area of clinical research of mine, is that we're actually noticing and looking at the patterns of what's going on in the inflammation in the abdomen and the peritoneal cavity.

And what we know now is that endometriosis is actually a gut microbiome disorder. And so I feel like, you know, all of these diseases that are really tough to treat are all basically high brain zoonemia and gut microbiome issues. And so when we see how does the gut microbiome play a role? Well, when there's gut dysbiosis, when there is leaky gut, when there is some sort of damage to the protective layer of the lumen of the small intestine,

That causes leakage of inflammatory molecules and bacteria with gravity down to the space between the rectum and the uterus. Okay. So then, then the body has an activation of the immune cells that, and there's like all these different cells, like mast cells and macrophages and all these inflammatory molecules that come.

to try to repair because the intestinal barrier and the peritoneal barrier has been compromised. That like slippery lining in our pelvis has been compromised. And so the body's already active trying to remove those

um debris that shouldn't be there then a woman has her menstrual cycle and so when she has her menstrual cycle those endometrial cells the cells of the menstruation go through the fallopian tubes

and are implanted in different areas because the immune system response that has already been activated creates a new connection between the endometrial cells and the slippery layer of the peritoneal cavity. And so those vasoactive factors, those are like fancy words for basically whenever the immune system is activated, blood vessels are brought to repair those different areas that are compromised.

But if they're already compromised from leaky gut, then you have menstrual cells with blood vessels on them. Then that inflammation allows new connections that make those endometrial cells active in various spots of the peritoneal cavity and the intestines. Then what happens is that those cells, those menstrual cells receive the same endocrine hormone activations, just like the lining of the uterus. And

And then those cells bleed monthly, just like any other cells of the lining of the uterus, but in various spots. And so sometimes it's on the ovaries, sometimes it's on the intestines, and people have crazy bloating and really bad pain when they go number two, especially when they're on their menstrual cycle. And so a huge part of what I do is when I... Okay, so like number one, so that's endometriosis, okay? But

But then patients come and see us gynecologists for treatment, right? And then we give them birth control pills or something that shuts down their cycle, but it like doesn't get to the root cause of the disease. It only stabilizes the lining of the uterus, which is like for some people, that's all they need. But unfortunately, a lot of the prevailing wisdom of how we treat and diagnose endometriosis involves surgery. So then like the gynecologic surgeon puts a camera in to take a look around and oftentimes when

Women are in various stages of healing. And so sometimes it's like the cavity looks perfect and it doesn't look like endometriosis. Or sometimes the surgeon will take pieces and little biopsies and it just shows inflammatory cells. Well, that's because the immune system's already processed that. And very rarely does the pathology actually even show that.

endometriosis cells. Well, then sometimes if you get pathology that doesn't show endometriosis, then patients feel incredibly frustrated because then it's like, well, what is it? Doesn't mean that it's still not endometriosis. It is. It's just maybe part of like, you know, depends on where they are in the spectrum of healing. So if we approach it from a gut microbiome disorder perspective,

and we try to remove all those inflammatory triggers that cause gut dysbiosis, then patients get like a ton better. And so, but it requires work, right? Because a lot of this has to do with like avoidance of carbohydrates, which we know are incredibly addictive, or like removal of certain, you know, dietary problems. Most, really a lot of these triggers tend to be lectins and like the skin on certain like vegetables and fruits and stuff that are really heavy and really

trendy right now. Like everyone's like all into like whole grains and stuff, you know, and lentils and things. But that can cause a ton of bloat and inflammation that like makes endometriosis worse. So, so that's a big part of what I do. And it's really exciting because my practice has a huge, like minimally invasive gynecology practice where a lot of people are going like getting endometriosis cleanouts and stuff. And

And then my colleagues will like send them to me to keep their endometriosis and their leaky gut like really suppressed by using dietary and like lifestyle interventions. So it's a lot of fun.

Yeah. I mean, again, my background is orthopedics, but these days I run into everything. A lot of women, they express particular frustration on endometriosis because just like you said, they put you on birth control pills. Maybe they do a laparoscopy, can't find anything. It's like multiple, multiple procedures. They never get better. And you just feel like you're chasing your tail and it's very frustrating. So it's interesting when you attack the root cause, you have a better chance of...

I fix that. Does that sometimes, because there's a condition, as I'm sure you're familiar, pelvic inflammatory disease, where a lot of women have this chronic, and that may have some shared connections, perhaps. Maybe you can talk a little bit about that one. Yes, it's very true. And I love, I'm glad because not very many folks ask this question about pelvic inflammatory disease. So pelvic inflammatory disease is a

disruption of the healthy bacteria within the vagina, within the lining of the uterus and the fallopian tubes. So, and even in the peritoneal cavity. So a lot of folks historically have believed that those areas were sterile. Okay. That there like, there was no like bacteria in there other than like the vaginal cavity. Excuse me, but that's actually not true. There's all kinds of really healthy bacteria that are there.

that are very helpful with stabilizing and causing like an environment that's hospitable for a pregnancy and for babies.

the allowance of the conceptus to go through the fallopian tube and all this stuff. Well, when you have gut microbiome disorders, usually it's also connected to disorders of the gut dysbiosis or dysbiosis of like the gynecologic organs as well. And so oftentimes we see a lot of young women who have pelvic inflammatory disease, which is basically some sort of polymicrobial or many microbes

of dysregulation in the private area and the gynecologic organs of a woman. And a lot of times doctors erroneously tell women it has to do with STDs and sexual activity and stuff. And that's part of it. But most of the time, about 75 to 80% of the time that women get pelvic inflammatory disease, it's not related to gonorrhea or chlamydia, which everyone's kind of think like assuming, right?

And so when it's those tests are negative, then people are like, well, why did I get that? Well, a lot of times right now, this has to do with trying to be really clean down there in your private area. And so there's like all these crazy products out there that make women feel that they need to be cleaner. So like, you know, shaving products and like, you know, all these like pH balanced soaps and things like that, which is like,

actually detrimental to the genitals of a woman because when a woman goes through her very first period, what happens is that there's like a huge flood of estrogen and it changes the chemistries of the vulva to allow the attraction of a special microbe called lactobacillus. And lactobacillus secretes hydrogen peroxide, okay? And so that's kind of like nature's soap.

And so a lot of women will talk about, they see like bleach stains in their underwear and stuff when they're in their mature time of their reproductive years. And that's because they have a healthy bacteria called lactobacillus that's secreting hydrogen peroxide that kills off all the germs. And so women actually don't need to use any soap in their private area to be clean because nature is doing it yourself. But when there's like wipes and like,

all these like different products, it actually cleans away all of that good bacteria and allows them more disease causing things to overgrow. And that's a big reason why people get like bladder infections and then also infections within the uterus itself.

Now, the other interesting thing is that let's say a woman isn't even sexually active or even pre-pubertal before her first period. There's a lot of associations, and I did a case report on this where virginal young women were getting pelvic inflammatory disease and like tubal ovarian abscesses. Well, guess what? They were also terribly controlled type 1 diabetics.

or like type 2 diabetics that were really terrible and not in great control. And it has to do with the whole thought and the concept of something called bacterial translocation or leaky gut, okay? And so what happens is a lot of those pathologic bacteria from the intestines leak through and cause inflammation at the fallopian tubes because guess what? The intestines and the fallopian tubes are like right next to each other.

And so what happens is that a lot of those like bacteria translocate into the area of the fallopian tubes and call these big abscesses or pockets of pus. And then patients and doctors are like really confused because they're like, well, this woman, she's 12, like she's not having sex, like what's going on? Well, nine times out of 10, it has to do with hyperinsulinemia and metabolic dysregulation, even in young women. So it's fascinating.

Yeah, fascinating, but also disturbing that that's happening. It sure is. Well, to anybody in general. So when you talk about bacterial translocation, I remember hearing about that stuff years ago in my surgical residency. General surgeons had some perception that was a bad thing. But can we measure that? I mean, because if your assumption is that some of this is microbial dysbiosis, gut dysfunction, increased translocation, hyperpermeability,

There are way, you know, double sugar tests. There's PEG 400. Is that part of your practice or do you just, just look at the end stage effects down the road? Cause it'd be interesting to see the direct correlations. There are a lot of marketed tests that look for, you know, different gut balance, you know, imbalances and stuff. I try to keep it really simple because a lot of those things are like pretty pricey for a lot of my patients and stuff. And so,

you know, I just really, I mean, a very good history of like their inflammatory triggers is really all I need. And so then I'm able to just like help them remove things, you know, and some people like, you know, tests and things like that. And if they feel really called to that, then sure, I can point them to some whatever, you know, gut microbiome tests and stuff. But by and large, you know, if you just have a really great history about what they're exposed to, that's all patients really need.

Now, given that you are in Loma Linda, which, as you pointed out, is a sort of a vegetarian haven, a lot of vegetarian thought and vegan thought comes out of there just because of the religious affiliations that they've had for 150 years or whatever. How difficult is it for you to broach that subject of nutrition and steer people in maybe a less of a carb-heavy, plant-heavy way? Is that a challenge for you there uniquely? Or is it just, are they open to it?

Yeah, you know, I get this question all the time. And it's really funny, because I think in this space of, you know, low carb and, you know, things like, we definitely hear a lot of that, you know, rhetoric or discussion about, you know, leaning one way towards the other and really, yeah.

I really try to think about it like has like how Robert Lustig approaches things as more of like we're more we have more in common than we have like not in common, you know, and so we're talking about whole food. We're talking about avoidance of processed food. And then we talk about physiology. Okay. And so folks really can't like disagree when you talk about PCOS or hyperinsulinemia as it relates to how carbohydrates play a role. And so people,

for me, when I have when I give grand rounds, when I do clinical research, I really just keep it based on the physiology. And so you can't dispute that high insulin levels come from stress and carbohydrates, like you can't, you can't argue with that. And so then with you approach it based on a mechanistic and mechanism of action process, then people kind of leave me alone.

And but I'm really, you know, very much like open with what I'm doing and stuff. And I say, hey, like, you know, this is science. This is not like trying to like, you know, bring like something in vogue or, you know, culturally like, hey, everyone's kind of doing this diet now. It's it's very scientific for me. And so if you approach it in that way, then it's hard to argue with the evidence.

Hey folks, it's Dr. Sean Baker here. Hey, if you or someone you love is suffering from chronic disease and you're tired of just managing symptoms with potions, pills, and procedures, I want you to check out revero.com. Our team of dedicated professionals is committed to tackling the root cause of your issue and finally getting you healthy. Hurry up though, our spaces are filling up very quickly. Now maybe let me back up a second. You said something that I just want to get your thoughts on because you said stress and carbohydrates. I mean, clearly it's

I mean, I think most people are comfortable with carbohydrates causing increased insulin secretion. That's pretty indisputable. Stress, as we know, I mean, there's obviously good stress and bad stress and stress

can be negative. There's, you know, it's physiology. How does stress impact insulin secretion? Is there, is there, is it, does that lead to hyperinsulin amyloid either indirectly? Normally I think of stress as, you know, the, the fight or flight hormones, which would be, which would be the counter, you know, kind of regulatory hormones, glucagon, cortisol, and norepinephrine. And so how does insulin evolve with stress? Yes. So,

There's a lot of different ways that we can go with this, but particularly when we think about womanhood, okay, and the reproductive years. So...

A woman's body, for better or for worse, right? Whether or not we agree with this or not, ladies, I hope I don't get any anger about this. But like women's bodies are made to have babies. Okay. And so that's like how like the physiology is created. That being said, your primordial brain is constantly struggling.

surveilling what's going on in a woman's environment in order to keep her from having a baby at a time that's not appropriate. Okay. So you're right. There are some people that talk about negative stress and the way of like rises and like,

catecholamines and things like that. And yes, those things do cause increases in insulin. And every once in a while, that's pretty healthy and normal, right? So, you know, we call it either like hormetic stress or eustress, anything that is like

helpful and useful to the body. But when women are under chronic stress, a lot of that will raise insulin levels. And then that actually, through a series of processes, will increase the amount of testosterone that is being produced by the ovary that will decrease the amount of something called sex hormone binding globulin by the liver,

And then that increases concentrations of estrogen and testosterone that are sensed by the hypothalamus or the brain to actually prevent ovulation. Okay. And so if you're preventing ovulation, your body is sensing that it is under a stress that is not suitable for conception. And if you think about it, a woman's, um, a woman's, um,

The conception period is like one of the most challenging times of a woman's life. It's there's the biologic investment is huge. It's easily three years of a major commitment. It's like one year of being pregnant and then two years of like active child rearing and like breastfeeding. Okay. And so it's a huge biologic investment for women. So a woman's body is constantly sensing pregnancy.

what's going on in the environment. And so whether your rational brain, your prefrontal cortex is going to admit it or not, if your body is under any kind of stressor, it's going to raise insulin levels that will prevent ovulation over the long term. We know this. Women know this. I mean, we have a lot of friends and people who are like, oh, yeah, I

I had like a death in the family and, um, and I missed my period, you know, and people like, oh yeah, that's happened to me too. You know, or like, oh, young women who are maybe in school and they're like, oh, it was finals week and I missed my period. Yeah. That has to do with hyperinsulinemia during a very short amount of time that blocks menstruation. But, you know, we know that carbohydrates do that too. And then even like in ancestral, um, and what we call, um, like when we think about anthropologic patterns of, uh,

of how women ate the, you know, summertime and then the fall time was when there was a lot of carbohydrates and like harvesting and stuff. And so, and there was increases in weight that were settling on women's bodies because in the wintertime where there wasn't that much food, there was a fast, right? And so you have to be able to handle that fast in nutrition. And so there's all kinds of really interesting evolutionary biology that's related to how high insulin levels

play a role in women. And yes, you're right.

trauma is one of the things that causes high catecholamines, okay? And then when the trauma response, the fight or flight response is when really what women were used to back in several hundred years ago when like the bear was trying to like get us or something and we would either fight or flight, right? Well, when you have high catecholamines, you get a flood of glucose in order for your muscles to fight or flight.

But if you can't, right, because like you're, you know, stuck at like, you know, in modern day traumas, right? So, you know, maybe a car accident or like sexual abuse or assault or someone is holding you down. And if you can't discharge that trauma, then those catecholamines are constantly with you until you can finally discharge that trauma. And so that causes high glucose levels.

And then as a result, people have hyperinsulinemia to keep normal glycemia and for a woman to have normal functioning in the modern process. That's called post-traumatic stress. And so we see that a lot with patients who have a lot of different gynecologic diseases, particularly highly associated with endometriosis. So.

Let me ask a couple other common conditions that a lot of women have been interested in. One is PCOS, polycystic ovarian syndrome, which I think pretty has a clear connection to hyperinsulinemia. And then maybe talk about PMDD, premenstrual dysphoric disorder, which a lot of young women, you know, just have miserable times when they get their period. So maybe you can walk us through those and see if these same sort of things hold true in those situations as well.

Yeah, it seems pretty correlated. And a lot of it, I mean, PMDD is like such a different animal, you know, and it

It is pretty normal for a woman to, before her menstrual cycle, to feel a little bit dysregulated, tired, fatigued, maybe a little bit irritable for a few days before her menstrual cycle. And it's really kind of like just nature's way of telling women to slow down because something is going to happen, okay?

And that is actually when a time that a woman's body is craving a little bit more carbohydrates and everybody knows this, like the week before a period, people are like kind of, you know, eating more sugar than usual. Well, that's actually biologic because that's actually during the time physiologically that the A

egg is present and there and ready to receive some sort of fertilization and then if it does receive fertilization we need to have robust hormone control and secretion during that time and not be under a time of what we call hormesis or fasting like during that time because women are preparing whether they realize it or not for a possible pregnancy so that's where like the um

biologic adaptation of cravings come from like right before the period. The problem is in modern culture, we have like way too much access to carbohydrates and processed food. And that causes a lot of like these carb crashes and inflammatory feelings that women have right before their menstrual cycle. And so we see a lot of improvement when we put people on magnesium and calcium during their menstrual

luteal phase, which is like the phase right before your menstrual cycle. And so really, what is that? Well, if we're supplementing with that, that really has to do with eating meat and having whole foods. And so, and the avoidance of like a lot of carbohydrates. And so if we just have a small amount during the menstrual cycle, or right before the menstrual cycle, it's actually really healthy to do that. And so that's the whole concept of like fasting, like a girl that like Mindy Putz talks about.

And there's a lot of truth to that because we don't want to be in these like crazy high ups and downs of carb crashes during that time because it's very dysregulating to like the actual balance of norepinephrine and like serotonin in our brain that helps keep things really nice and steady. So then when it's even more accentuated and really big fluxes of hormone changes, then that is...

is what we see in PMDD or premenstrual dysphoric disorder, where people are really sleepy, really like they can't get out of bed, they're very moody, all these changes that we see a lot of times in like depression and anxiety that we're seeing now with like Chris Palmer's work, they do really well with like ketogenic diet and being in ketosis. So

When people have PMDD, I really try to screen for like, what are their environmental exposures that are leading to that? A lot of times women are struggling with carbohydrate addiction or, you know, with processed food addiction. So I don't know if you see that too.

I've seen a lot of women state that when they use a low-carb ketogenic carnivore approach that they often have much better menstrual cycles. It's not as much of a problem for them. PCOS, I don't know. I mean, I think most people now, at least in the low-carb space, have heard that PCOS definitely seems to be, at least in some part, associated with hyperinsulinemia and fixing that often fixes the PCOS. I've seen women where

They've got the ultrasounds. They're the cysts. They go on a carnivore ketogenic diet. Six months later, the cysts are gone. So is that something you would comment on? Yeah, I see that all the time. And so this is like the big frustration with the diagnosis of PCOS that, you know, you have to have three, two of the three criteria to meet like this official diagnosis, which really is irregular periods,

hair where you don't want it, and tiny, tiny cysts on the ovaries that don't require surgery. Now, the thing about PCOS, it's a syndrome. It's a metabolic syndrome. And so it really just depends on where you are in that syndrome and how those symptoms and signs are going to manifest. So sometimes patients go and see their doctor and they're like, oh, you don't have PCOS because you don't have cysts. Or, oh, you don't have PCOS because your testosterone is not high enough. But

If you've got physical manifestations and you have irregular periods, or maybe like that month, like you did have a better month of stress and diet, then maybe your periods are regular that those couple of months. And so even the organizational bodies that like create these diagnostic criterias fight over the diagnosis really is, but it really is just kind of like a syndrome that comes and goes. And you're right, it has to do with hyperinsulinemia because then that blocks the ovulatory patterns

And so the tiny, tiny cysts on the ovary are basically the body trying to get ready for ovulation, but it just never happens because those normal fluctuations of estrogen, testosterone that lead to ovulation don't trigger because of the high levels of their constant and they don't allow for the triggering of something called GnRH.

that leads to the LH surge and the ovulation. So those tiny, tiny cysts have to do with the body trying to get ready to ovulate, but those triggers never happen. And so, yeah. And then the other thing too is like folks oftentimes feel a little bit discouraged that, oh, like I have cystic acne or I have hair where I don't want it and things. And, but my testosterone levels are normal, but that's, testosterone is not the only hormone. It's like androstenedione. There's all these other hormones that we can test to look at that,

And testosterone is only just like one piece of the puzzle. So it really just depends on someone's clinical signs and symptoms, but it's very powerfully controlled by insulin.

Let me switch gears. I know you said conscious gynecologist, but at some point you did obstetrics and maybe you still do. But pregnancy, and you mentioned you had your baby was sick, so definitely not macrosomic. And for people who don't know, diabetic moms have big babies a lot of times. These are these 12 pounders that come out, which is kind of crazy. But what are your thoughts on nutrition during pregnancy and specifically pregnancy?

with gestational diabetes, is it safe to do a low-carb, ketogenic, or carnivore diet in pregnancy? Or do you care to come? I know that's kind of a little controversial. What are your thoughts? Oh, yeah. I don't mind, you know, because really it's just like all of this stuff comes from like evolution of thought and what we're trying to do. And so I know some people feel scared about it, but let's just talk about the physiology, okay? Because like we can't dispute physiology. So this is, I still do a ton of obstetrics and I

I think the most fun thing to talk about is the concept of nausea, vomiting, and pregnancy, right? So this is really cool. So the whole nausea, vomiting, and pregnancy, morning sickness that happens in the first trimester, well, that's actually a biologic adaptation. And so let's think about the evolution behind this. So

When we think about nausea, vomiting, and pregnancy, there's a huge aversion to really want to eat a whole lot of things in that first trimester. Like, you know, women don't really want to eat any meat, which can be hard for like carnivore women, right? And they feel oftentimes a little bit frustrated. So here's the reason why. So when, there's two reasons. When we were cavemen, okay, when we would harvest and like sacrifice an animal, we would eat nose to tail, right?

And so then we would cook this meat like over a roast, an open flame, right? And so then what would happen to the meat? Well, the meat would get like pieces of char, right? And so charred meat, all right, is a source of carcinogen. And so like, when do you not want to introduce a carcinogen? Well, in that first trimester, when the organs are like rapidly forming and the DNA is like rapidly replicating,

And so that's like the first thing is that there's very clear medical anthropology literature that shows that one of the big reasons why people have aversions is because you don't want to introduce anything roasted into someone's diet during that time. Well, that's the same reason why a lot of women have aversions to coffee also. And they're like, oh, I mean, for me, for sure. Like I love coffee. And then but in my first trimester, I couldn't drink it. I was like really frustrated. Like why is like my favorite thing to do? Like what's going on?

Well, that has a big part of it is because your body's trying to avoid roasted things. Then the other piece of that is that the concept of and the advent of refrigeration. Okay, we've only had like refrigerators for about 70 years. Okay. Before then, meat was a huge source of food poisoning. Okay. And so when do you also not want to get sick and introduce, you know, pathogenic bacteria in that first trimester. And so a woman also was

like over thousands of years, evolved to avoid all of these things that could potentially cause problems with the development

of the fetus in the first trimester, which is the most important trimester because that's when organogenesis is happening. Then here's the other cool thing is that when does the pancreas form in a fetus between the 12th and the 14th week? That means that before then, there is no insulin for the fetus, okay? It relies entirely on normal glycemia from the mother, okay? And so if you don't,

So that aversion to food and particularly starches that like come in plants, okay, particularly like legumes is a real aversion because your body doesn't want to have high glucose levels that get sent over to the baby. And when it gets sent over to the baby, that decreases the amount of ketones that are being produced at the placenta, okay, at the budding placenta. And we need those ketones

for brain development of the fetus, okay, particularly in the first trimester. And so all of those aversions to food and stuff is actually like a real thing. It's actually a biologic adaptation that your body's doing to protect the brain development of the fetus. And so when patients feel frustrated, they can't eat very well in the first trimester, I say it's okay. Just make sure you get your electrolytes in that you're doing magnesium or some sort of electrolyte water.

And, you know, honestly, like, you know, be cheap, just get a glass of water and add some lemon and salt and like a quarter teaspoon of salt. And a lot of people do really well and they drink that all day. I mean, that's actually what we're giving patients when they come to the hospital and they're dehydrated. We give them saline, which is basically sodium chloride and potassium. And so then they feel like a million bucks. And so I tell women, it's okay to be using just a lot of electrolytes and eating a little bit during that first trimester because your body needs to have low glucose levels.

in order to have really great organogenesis. And so then that's the first trimester. And then as the body evolves into the second and then later third trimester, actually become hyperinsulinemic or, and they also become insulin resistant. The reason is, is because the baby is requiring tons and tons of glucose for formation. And so, and all of those metabolic processes that happen. So your body really does need to have

a slightly higher level of glucose so that that gets streamlined over to the baby. And it's also its own processes too.

And so then we need also higher glucose levels when it comes to breastfeeding, right? And so this is not like an overnight process. This happens over weeks and months through the pregnancy. The problem is, is that during pregnancy and modern pregnancies, we just have so much access to carbohydrates, particularly glucose and sucrose, that like it floods the system. And so remember,

This is glucose and sucrose, but fructose is really important because fructose is not controlled by insulin. It's only broken down by the liver. And so if ladies tend to eat a lot of fruit during pregnancy, and I really try to discourage that because insulin doesn't control fructose and only your liver is the only place that breaks it down. And so if you have too much fructose, then you're going to start to get a lot

liver inflammation that leads to worsening hyperinsulinemia and visceral adiposity and stuff. And then also the widening of the abdomen of the fetus, and that has to do with liver inflammation as well. And so, yeah, so it's very interesting. So to answer your question, I do really try to

encourage a low carbohydrate diet for pregnant women. If they feel better on carnivore or keto, like I think that's just fine. But I really don't try to encourage it too much in the first trimester just because of that biologic adaptation. They're just going to want to avoid it anyway. And oftentimes they feel frustrated that they can't maintain that lifestyle during the first trimester. And it's okay. But later as they go through the pregnancy, if they feel like that's all they can tolerate and they do well, that's great. And they should continue that.

The big thing is, is that there were studies back in the 70s, 80s and 90s that showed that women who were in ketosis had babies that were higher chances of like all these neurologic problems and stuff. But the thing is, is that that was a different population because those were women that were in type 1 diabetes or really out of control type 2 diabetes. And so when they had

high ketone levels. They weren't always in ketoacidosis, but those high ketone levels were associated with neurologic abnormalities in the neonate or the newborn. But

That's not like you're it's like throwing the baby out with the bathwater. It has that also has to do with like hyperinsulinemic, like inflammation and liver inflammation that were also highly associated with that population, not with a lot of the more modern folks who are doing low carb and ketogenic diets as we see them today outside of the setting of diabetes. That's not in great control.

Interesting. Yeah, so kind of an apples to oranges comparison with that respect. And it's still, I mean, it's amazing that there still are physicians and clinicians that still confuse, you know, diabetic ketoacidosis with nutritional ketosis, which are metabolically very, very different animals. Very different, yeah.

So I'm trying to think, you know, I remember when I was in medical school, one of the surgical residents was complaining, he said medical school would be three years instead of four, four years if it wasn't for the female reproductive system. So a lot of stuff going on here, but let's, let's maybe let's just advance a little bit. And I don't know how much you get into this stuff, but menopause is a lot of my audience, a lot of pre Perry and men, postmenopausal women. They're always like lamenting the fact that it's harder for them to lose weight and all

All the symptoms that go with menopause. How does, if you have any expertise on this, how does nutrition metabolism impact that aspect of their life?

Yeah, I do. It's a big part of what I do as well. And I feel like this is fine. We're going from like early reproductive years all the way to late reproductive years. And it's very applicable. So what happens in perimenopause and in menopause is the decline of the functioning ovary in terms of release of estrogen. Okay. And so when there is a decrease in estrogen, what happens is that the estrogen receptors

that are normally within like our hips and thighs and stuff that bring a lot of like curve to a woman start to decline. And when those decline, there is a restructuring of those receptors from our hips and thighs to our abdomen. Okay. And so the fat, the adiposity tends to go from your hips and thighs to your abdomen. That's why like little grandmas like don't have like curves anymore. Yeah.

because a lot of the times they go into their abdomen. And so this like abdominal adiposity or fat that women describe during peribonopause is very hyperinsulinemic. And it causes a lot of high glucose levels and stuff that can also make it more difficult and challenging to maintain our thermostat. And so it's a big source of the reasons why a lot of women have

hot flashes. And so the more visceral adiposity and more metabolically unhealthy women are, they tend to get more hot flashes because of that, because it's really tightly regulated within the hypothalamus of our thermostat centers. And so high insulin levels, high glucose levels really do change our internal thermostat and cause what we call vasomotor symptoms, which is just basically hot flashes. And so it all has to do with how our body, as we're declining our estrogen levels, will

we'll restructure that fat from our hips and thighs to our abdomen, which is more hyperinsulinemic as a whole. And so that's why for many years when we did the Women's Health Initiative back in 2002, really the goal of that study was to address cardiovascular disease risk factors. But the problem is, is that we used synthetic hormones. Dr.

And so because we use synthetic hormones in that study, and because synthetic hormones really are different, they hit our estrogen receptors with more affinity, with like more stickiness, and they cause exaggerated effects. And that's what caused all of the concerns of the Women's Health Initiative, like breast cancer and stroke and all these things. But it didn't apply to true bioidentical things like estradiol and progesterone.

And so really the modern advice now is that the earlier you can start hormone replacement therapy, if you're having symptoms of menopause, the better for your cardiovascular health as long as you're using bioidentical hormones. And so that actually is the standard of care. So that's not like going to see like, you know, some strange doctor out there. That's actually like what the Menopause Society and the American College of OBGYNs like actually recommends.

And so, so when patients come and see me, I always start them on bioidentical hormone therapy to help with that. And that reduces that transition of like more metabolic dysregulation as women go through menopause because menopause, when menopause happens, the risk for cardiovascular disease equals that of a man right after menopause. And so,

estrogen is very protective before then. And so the earlier folks can start that, the better for your cardiovascular disease health. Yeah, I mean, it's interesting that women develop more of an android

Because guys are known for the classic deer belly, and then you see the post-partum women start to develop that same thing, and then their cardiovascular risk sort of makes men. So neither of them should be walking around with a big belly. I think it's unhealthy for both of us. That's right. So how, I mean, obviously, I don't want to put words in your mouth, but I'm going to suggest that you recommend diet, nutrition, exercise for someone who's in that situation. How do we fix it?

Yeah, don't you just feel like it's a broken record? It's like the same answer all the time, right? It's like, you know, ketogenic diet, low carb diet, bring that insulin level down, you know, because that's exactly the difficulties that women experience during that time is weight gain. They're like really frustrated, like what I was eating before the exercise I was doing before is not working during this time, you have to be even more strict about your diet, even at that time, because it not only helps like with the hot flashes and stuff, but also the metabolic stuff. And so

So absolutely, you know, ketogenic carnivore diet is really, really important during that phase. Yeah, I want to, you just mentioned, you know, carnivore. And again, this is, you know, I'm just shocked now. I mean, that there are so many physicians now sort of embracing or at least not outright discouraging that and seeing that there is benefit because I see it all the time. Where do you see it to be applicable in your patient population? What are the, what are the, are the best use case scenarios for something like that?

Yeah, pretty much everywhere, everything. You know, I think being carnivore is really great and healthy and it brings a lot of mental clarity. The only place that I feel like, you know, folks don't have to be that strict and should lean more towards low carb or ketogenic diet is like during the luteal phase, which is like that week right after ovulation and before your period.

And so a lot of times women come to me and know in me in this space and know that I'm a very big proponent of these kinds of diets. But they say, oh, my menstrual cycle is starting. I'm starting to have a lot of spotting like before my period or like I just feel exhausted during that week before. And it has to do with the whole carbohydrate thing I was telling about was your body's preparing for conceptus and really discharging lots of hormones from the ovaries and the ovulation.

it requires a certain amount of carbohydrates so that women don't feel that they're under so much hormetic stress or stress of like from like the whole repair that comes with carnivore because it's a good stress that happens right but in women they just have to fast or you know use carbohydrates sparingly during that week before or after ovulation so that your body doesn't feel so stressed out and

And there will be more available hormones that are happening during that week. And then you won't have the withdrawal bleed of that spotting before a menstrual cycle. So that's really the only time that I tell folks that they should kind of be a little bit more liberal with their carbohydrate intake.

And by liberal, I mean like about 30 grams of carbohydrates per meal, not like less than 30, because then we tend to see a little bit more of this like withdrawal bleed. But outside of that, you know, people do really well. So.

Yeah, it's Shane. Thanks. Thanks for that. Because a lot of women ask me about that. And it's certainly not my specialty. I mean, I spent a little time doing OB in my training, but you know, it wasn't my thing. So, well, thank you very much for doing this. And so maybe let's take the last couple of minutes to share.

I mean, you're over there in Loma Linda as far as you practice, but I know you have a social media presence. I assume that's YouTube there. Where do people find more about what you're talking about?

Yeah, thanks. So, you know, people can come and see me, you know, at Loma Linda, definitely. That's my typical academic practice. But I also have a telehealth practice where I see patients from Florida and California in a telehealth capacity. And consciousgynecology.com is the way that folks can get into that practice. And so, yeah.

And then I do a fair amount of, you know, speaking, I'm going to be at the World Nutrition Summit this year. You know, I work with low carb USA all the time. And of course, I have a YouTube channel to call conscious gynecologist. And it's a lot of fun. You know, but I, you know, I think like social media is really important, but I'm really trying to move the needle with clinical research, you know, to try to get this to be more integrated into our practices and our guidelines and stuff. So I,

I do clinical research. I have a paper coming out at the end of August that looks at hyperinsulinemia with abnormal uterine bleeding. It's the first paper of its kind. And so that's really exciting. And but yeah, you know, I mean, there's all kinds of ways, you know, to get a hold of me. And, you know, I'm on Instagram and all that, you know, I don't know how we manage all this stuff. You can do what we do. But those are ways that people can find me.

Well, when your paper does get published, let me know and then I'll share it so we can get a lot of time on that. Oh, thank you. Well, thank you so much for doing this. It's been wonderful. I enjoyed chatting with you. It's been a great way to start the week. Yeah, super great. Thanks so much.