Millions of Women Stopped Taking Hormones Because of a Misread Study | Dr. Sharon Malone

21:42Didn't understand what led to what. And that's why you saw so many young girls who did not understand. Well, imagine that was how that phase of life was even dealt with. And, you know, we've said probably not a good idea. And we've evolved and we make sure that young girls understand the transition so they know how to prepare for it. They're not. It's not something that's alarming. Okay. That's the good news. Then you make it through your what I call premenopausal years, which really starts at puberty and goes for most women until their mid-30s, maybe early 40s. That's premenopause. And your peak reproductive years are somewhere probably in your 20s and early 30s.

22:27Then there's this thing called perimenopause. And if you think about it, it's that same transition, like you have to transition from being pre-pubertal to puberty. when you're perimenopause you're transitioning from your reproductive years to your post-reproductive years and that process is what women have been left in the dark about because you think you just go from one to the other no it's a years-long process and for some women it can take as long as a decade for black women perimenopause starts earlier it lasts longer up to a decade and to not be prepared. And when there's so many symptoms you can have during perimenopause, many of which we associate with menopause, but they start happening much sooner.

23:15Dr. Mark Hyman:And they're misdiagnosed. Right. And you think, oh, I'm depressed or I'm anxious, I can't sleep, or, you know, changes in my libido. All of these things start to happen that really are divorced from what's going on with your period. So you think that, you know, everybody associates menopause with, okay, I'm not going to get my period anymore. Well, what if all the symptoms of menopause can start showing up a decade before? You can see how there was confusion and you get misdiagnosed. If you're depressed, here's an antidepressant. Oh, I'm, you know, I can't sleep. Here's a sleeping pill. We sort of have been picking off women's symptoms one at a time without understanding that it all sort of falls under this rubric.

24:00And women would be, I think, much more tolerant and I think much less distressed if they just understood it's a natural process going from one place to the other. And once you get to menopause, and so we've gone through pre-menopause, now we're in perimenopause, a transition of a years-long transition. And then once you get to menopause, that just means that's the end of your fertile period. No more.

24:27Dr. Mark Hyman:And technically it's defined as a year from your last period. Yeah. And you know what? I don't, that, that definition. That's what I learned. Yeah, it is. That is, that is what I learned as well. But in today's world, that definition is so woefully inadequate because it implies that you're not menopausal until you've gone 365 days. And it's like, no, you were menopausal at whatever moment it started. But that is just the marker by which we divide and say, if you bleed more than a year after your last period and you start, then that is the time that we should investigate that bleeding. But it has no real...

25:05Dr. Mark Hyman:Because it could be uterine cancer or something else. But it has no biological significance, really. You know, it's just how we look at it. But there's so many ways to be menopausal that really don't tie to that at all. Well, a lot of women have IUDs. Guess what? You have an IUD, you haven't had a period in years. How do you know? Women have had ablations. Women have had hysterectomies. An ablation is when they cauterize the interceded. You have heavy bleeding, so you don't keep bleeding. Or you've been on birth control pills. There are a lot of different ways that you can go through that transition, and it has no bearing on what's going on with your menstrual cycle.

25:46So that's where I think we have to change that definition because it really doesn't.

25:50Dr. Mark Hyman:Well, because we also like medicalize a lot of things. So we basically, it changes the natural history of these things. Yeah. And then, and then once you get to menopause and this is just my little, you know, pet peeve, I don't like the term post-menopausal. I don't. Because once you're menopausal, and if we define that as, you know, no longer the end of your fertility, either naturally or otherwise, you're menopausal. Saying that someone is post-menopausal implies that whatever goes on in menopause stops after your symptoms stop. And they don't. Well, let's talk about this. Because I think you're right.

26:31Dr. Mark Hyman:Like, I've seen women, you know, just go through with no symptoms and then fine and everything's great. I've seen women start, you know, like 10 years before and having, you know, all these disruptions and symptoms, hot flashes, vaginal dryness, libido changes, mood changes, sleep issues, and irregular periods, heavy periods, you know, just every kind of symptom you might imagine. And they're often, like you said, very dismissed or they're medicalized and treated as something else, or they're not, I don't think, adequately sort of diagnosed or treated. So can you talk about how this whole process of menopause affects every organ system in the body, not just reproduction, and what the consequences are if it's not handled properly in terms of the long-term risks of disease, in terms of the short-term symptoms that women have to suffer from.

27:16Dr. Mark Hyman:And I personally believe it's criminal to not take care of women in a way that relieves their suffering because we have the tools. We know what to do. And there's so many women walking around with so much suffering from all these hormonal dysfunctions that we know what to do with them. I think that you're right. Women have been, like I said, in terms of neglected, in terms of their symptoms, minimized and dismissed. That's a given. But when you get to this point in life, we have looked at the hormones or lack thereof, or even this transition as being just about reproduction. And it's not, you know, women make estrogen in a cyclical fashion throughout their lives once they, once they finally get their periods.

27:56And that estrogen affects every major organ system in your body, and it starts with your brain, your brain, your skin, your hair, your eyes, your heart, your bones, you know, your vascular system. And we have not really looked at menopause through the wider lens. We've looked at it from a very narrow prism, you know, only as it affects the reproductive system. And oh yeah, by the way, now we know that it affects bones, but we're kind of late to the game in terms of getting to the real effects on what's happening to women's brains. And that goes back to what I was saying earlier, is that people haven't been asking the questions.

28:42We just sort of accept that as, oh, well, it's getting older. And it's not just getting older. It's that change in your reproductive system.

28:51Dr. Mark Hyman:So kind of highlight the major cyst symptoms that women might experience. and then talk about like the consequences of not adequately treating women with the right types of hormone therapy. We're going to get into what that looks like. Well, let's start with the one that everyone knows, hot flashes. You know, hot flashes is the most common. 80 % of women will going through this perimenopause and menopausal transition will have hot flashes. 20 % don't, lucky you. But hot flashes themselves have been treated as jokes. Oh, here's a woman, she's flashing, you know, look at her, you know, and women were embarrassed by hot flashes.

29:33But this is why I say hot flashes are not benign. Because if you have hot flashes and night sweats, well, what does that mean? You can't sleep. You can't sleep. You can't sleep. Guess what's happening to you the next day? You're in a bad mood. Your brain is foggy. We've been residents. We all know what it feels like to not have a night's sleep. You're not in your best frame of mind the next day.

29:58Dr. Mark Hyman:No, cranky. And then sleeplessness increases your risk of mood disorders. It increases your risk of hypertension. It increases the risk of maladaptive behaviors. Because when you feel bad, you self-soothe or medicate. That's your relationships. You drink, you overeat, you do all of these things. It also, people who have really severe hot flashes, you know, these are things that increase your risk of cardiovascular disease down the road. Oh, absolutely. Type 2 diabetes, sleeplessness, all of these things go up in women because of the downstream effects of the hot flashes. If you don't sleep, you crave more carbs and sugar.

30:43Dr. Mark Hyman:Exactly. I know that one. I was going to say, we understand that. We get to work in the emergency room like 2 a.m. And the only thing opening is McDonald's. And I would go and get the apple turnovers because I needed some sugar. Because, you know, you get it. Because, you know, when I was a resident, I used to say the same thing. I can only, I can't be hungry and sleepy. It's like one or the other. So you're going to do something. I'm going to drink Coke. I'll drink whatever it is to make myself feel better in the short term, even though it has not good effects later on. But those are the kinds of things that we talk about when we're talking about cardiovascular disease in women and why it goes up.

31:23And the cardiovascular disease risk does not go up for women until after menopause.

31:31Dr. Mark Hyman:before that. That's why we've also lived with this notion that women don't experience heart attacks and cardiovascular disease at the same rate as men. We do. It's just 10 years later because of what is happening with menopause. And so women are having all these symptoms and they get vaginal trinitis, they get libido, they get mood changes, they have sleep issues, and it really impacts their life. And, you know, my experience, you know, treating women more nutritionally with lifestyle is that those modalities are so helpful. Like if women smoke, if they drink, if they don't exercise, if they eat tons of sugar, if they have so much stress, if they're, you know, exposed to a lot of environmental toxins, all these things disrupt hormonal function and balance and they exacerbate symptoms.

32:21Dr. Mark Hyman:So there's a lot of, even aside from just giving a hormone prescription, there's a lot of things that women can do to reset their hormonal balance and feel better. Sometimes that's enough, sometimes it's not. And so if we do all those things, and I've written a lot about that, and I'm sure you talk a lot about that as well, when women need to start thinking about hormone therapy, can you help us kind of frame how they should start thinking about it? Because, you know, my, this is, again, my understanding and looking at the literature is that the hormones that were pushed on women, which is prescription premarin, which is pregnant mare's urine.

33:00Dr. Mark Hyman:That's why they call it premarin, pregnant mare's urine, which is conjugate estrusions, has very different biological effects than bioidentical hormones. It increases inflammation, increases triglycerides, it increases clotting risk more than other forms of hormones that the body actually makes. And the same thing with the synthetic progesterone or progestins, like Provera, which my joke was it makes women depressed and have facial hair and gain weight. So it makes them fat, hairy, and depressed. So I don't like that. And so I found that using a very more nuanced approach to hormones, where it's personalized, where it's often topical, not going through the liver, where it's as low dose as possible to achieve the effect, or it's in the bioidentical forms, often works better.

33:51Dr. Mark Hyman:And there's, you know, FDA approved versions of those. And there are things that I tend to lean on more. And I'd love to hear your perspective on how you think about it. Because there's vaginal estrogens, there's topical estrogens, there's testosterone being used for women. There's so many people having questions about this. I would really love to hear as an expert, how you think about this approach. It's just a one size fits all. Okay, you're penipausal premen, provera, see you later. And if it doesn't work, good luck. And you know, I'm going to take an unpopular position here because I'm going to take the privilege of age because when I started, because, you know, I feel like I have seen every permutation of hormone therapy that there is.

34:29And when I started in 1992, I inherited a practice from two 70-year-old men.

34:36Dr. Mark Hyman:70? 70. Yes, they were prescribing hormones in the 60s. Imagine this. So I'm a brand new resident, you know, and I know what I know. And, you know, you're never more sure of yourself. Oh, yeah. You know everything when you finish residency. I know everything. I'm good now. And I had these women day one who were 80 years old who'd been on hormones since 1969. Yeah. And I was like, and I was appalled because I was like, oh, my God. Then we had just sort of figured out that you can't give estrogen by itself. to women who have a uterus. Remember that the addition of the progestogen was a relatively recent onset.

35:25So that happened like in the 80s. And when I saw these women who had been on primrin for 30 years, I was like, oh my God, they're all going to die.

35:33Dr. Mark Hyman:Well, because just for people listening who don't know, if you give what we call unopposed estrogen, unopposed by progesterone, it increases the risk of uterine cancer. That's exactly right. And guess what? They were all fine. You know, I came in and I would say, oh, my God, I'm the new doctor. And they've been seeing this doctor for 30 years. And I say, well, we've got to add a progestin and, you know, and they were quite reluctant, but I convinced most. But the point is, I've seen women who've been on Primarin for 30 years and they were doing fine and they were great and didn't, you know, and weren't bent over.

36:07So yay for that. And then when we got to, by the time I started, we did have, we had bioidentical estrogens then. It was another name brand. It was Estrace, which was estradiol. And we had Primarin. Primarin had better name recognition. It was a bigger company.

36:27Dr. Mark Hyman:More marketing. Definitely better marketing. And so primarin had been the hormone that we had been using for the longest, since 1942. Okay. So my objections to primarin have little to do with the effectiveness of primarin. It works. It works. For symptoms, but it causes other downstream problems. No, not necessarily, because even the Women's Health Initiative, all of the positive things that we know— Sure, bone health, brain health. All of that comes from Premarin. Yeah, for sure. That was the only medication used in that study. So, you know, I think before we say, oh, you know, Premarin's terrible.

37:10No, it's not. It's estrogen. It works. You know, it has different combinations of estrogen. It's not bioidentical. However, all of the good things that we know about what hormone therapy does really comes from primarin. And we've extrapolated a lot of that data to estradiol. Because remember, there's not another big, large-scale study after that. So that's one.

37:30Dr. Mark Hyman:And that's my beef. I wish that the Women's Health Initiative used bioidentical hormones. I really wish it did. And there are some smaller studies that have. And they actually do so benefit. And I don't disagree because, you know, even then I didn't use Primarin nearly at the rate that my predecessors did simply because, and again, this is personal, has nothing to do with this. I didn't like the fact that it came from pregnant mare's urine. Right. You know, I'm like, well, okay, you can get one from horse's urine or one that's not. Okay, I would choose the one that's not. Yeah, yeah. But that's the, that was my objection.

38:04And then also there's cost. Yeah. You know, because Primarin is branded. It always has been and probably always will be. So it's much more expensive than others. And then when it comes to what we know about the Women's Health Initiative, when we look back and we look back now, we have 22, 23 years of data to look over. We found that, OK, it's not the estrogen. Oh, look at that. Estrogen doesn't cause breast cancer. Estrogen doesn't cause a lot of the negative things that we have been ascribing to hormone therapy. We said, well, then if it's not the estrogen, it must be the progestin. It must be that nasty little Provera that was in that pill that the women were taking.

38:49And to that, I would say yes and no. You know, I would say all things being equal, I would take the bioidentical. But what we also have to eliminate is some of the fear moving forward because micronized progesterone is great if it works for you. Some people don't tolerate micronized progesterone. So if you don't, I don't want women to sort of get into this notion or even doctors to feel like progestin's bad. It's so bad. No, it's not. It's, you know, it's a different one. It works for some people. The majority of women should and probably could use bioidenticals. But don't take that off the table because if you do, you're sort of doing the same thing that we did before.

39:33Well, you have a toolkit.

39:34Dr. Mark Hyman:You have a toolkit, right, with a lot of different tools. Yeah, a lot of different tools. A lot of different hormonal applications, variations in the formulations, the types of estrogens. You can use estriol, estradiol, estrone, all these different ones that are available for people. and there's, you know, obviously the synthetic progesterones or progestins and natural bioidentical progestins. But I think that the question is, um, when you're, when you're working with a woman, how do you, how do you start to think about when and what to do? Because when, when you look at the data, they do seem to, there's some new data that seem to have, correct that it's better to start at different times if you want to get certain benefits.

40:13Dr. Mark Hyman:And you know, the, the thing that just maybe we should just unpack is this black box warning that came from the FDA because it's what got people really scared. And I remember because I was practicing really heavily with women that during that time when that study came out and it stopped the study, they literally stopped the study because they were concerned about the harmful effects. So that's a big deal. And overnight, I think 50 million women stopped hormones, which created a catastrophe in the the country. How well I know. Yeah. Right. And so we kind of had a backlash. Now we're kind of coming back to a more coherent way of thinking about it.

40:52Dr. Mark Hyman:And I'd like you to unpack, you know, how you think about prescribing hormones and which hormones and for whom and what the benefits are, because the Women's Health Initiative did show that increased stroke and increased heart attack. And there were some... Did it though? Did it? I mean, that's what they said, right? And I'm going to tell you it didn't really say that. Because the effect sizes were small? The effect sizes were small, and they were as prescribed. Remember, the women entering the Women's Health Initiative, the average age was 63. You could be anywhere from 50 to 79 years of age to be in that study.

41:34They didn't really even say, all right, these are women who've never had hormones before. and now we're going to give some hormones and some not. The criteria for entering and being randomized, you just had to not have taken hormones for three months before entering the study. Do you see what I'm saying? So the population was really murky. They were too old. That's not how we're prescribing today. We prescribe what we do know is that the earlier you start treatment, the more long-term benefit you get.

42:05Dr. Mark Hyman:And is it riskier to start it when you're older? Well, yes. there are some, you get less benefit. And I don't think it takes any leap of faith to understand that the purpose of the Women's Health Initiative was to sort of figure out whether or not the hormones really were the secret sauce in reducing the cardiovascular disease. Because when the nurses study, 50 % decrease in heart disease in the women who took estrogen. Okay. Is it that, or is it something else? And to have women come into the study at 79 years old, I think we can all agree that it doesn't matter what I give you. That horse is out of the barn by then.

42:52And by having too many women who already had established heart disease, well, how are you going to prevent something that you already have?

43:01Dr. Mark Hyman:Yeah. It's like they didn't do angiograms on everybody and see what their hearts look like. Exactly. So when you stratify, even the Women's Health Initiative, when you looked at the younger women who were in the minority, but the younger women did not have an increase in the risk of cardiovascular disease, all of the bad things, the only finding from the Women's Health Initiative that was statistically significant was there was an increase in the risk of blood clots. Yeah, blood clots. But there's a heart attack is a blood clot, right? No, but yeah, but that's separate. This is listed as separate in part because it's DVTs or DFA and thromboses or pulmonary emboli, and that was reported separately.

43:42Dr. Mark Hyman:But estrogen does mechanistically cause an increase in clotting risk. We know that. Yes, yes, it does. However, again, perspective matters. You need to know, to say to someone that it's a 50 % increase or 100 % increase, well, what's the baseline? You know, and what we do know is that for women who start estrogen even oral earlier, when you're 40s or 50s, when you start, that increased risk of blood clotting that we don't have it, we don't see it. It happens when you're older. And so a lot of the findings from the Women's Health Initiative that were negative, even the cardiovascular disease was elevated, but only in the first year and not after that.

44:26Because, again, you're probably giving something to women who already have fairly advanced heart disease. What about the breast cancer risk? Ah, the breast cancer. Because that's what freaks women out. That is the number one reason why women avoid hormones. Oh, cardiovascular risk. I don't care about that. it's the breast cancer. That was the, that was really the nail in the coffin.

44:48Dr. Mark Hyman:Yeah. Cause it did show some increased risk, right? That's what they reported at least. Okay. Let me, let me tell you. I mean, that's what the, that's, that's what the, that's what the public said, understood from the study. Oh, trust me. I've been in this, I've been in the weeds on this for so long. I'm just, I'm just framing it so people know. It's like, I'm not just saying. No, no, no, no, no. That was, that was what they held. That was the headline. That was the press conference. Oh, not only does this, you know, they held a press conference when they stopped the Women's Health Initiative to say, oh, not only does it not help your heart, it increases your risk of blood clots and heart disease and strokes, and it went on and on and on.

45:23Well, that's very scary. And I would challenge anyone to give me another example of when the NIH, the regulators at NIH, held a press conference to announce a study. I mean, that's how big of a deal they thought that was. And I'll also mention that Bernadine Healy was not there at that time. So we're going to give her a pass on that. But here's the breast cancer story. And I will say this. The data is the data. You don't get to change the data because you don't like it. Okay. You can change your interpretation of the data, but it is what it is. But let's take it at face value. What did the Women's Health Initiative say about women who took estrogen, the primarin, and the provera?

46:07All right. they reported there was a 26 % increase in the risk of breast cancer in estrogen and progestin users versus non-users. 26%, that sounds terrible. Who wants that?

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47:36Dr. Mark Hyman:It's involved in hundreds of biochemical reactions in the body, including regulating the nervous system, supporting muscle recovery, and helping your body transition to a restful sleep. Now, what's interesting is that newer research is starting to look at how certain forms of magnesium may support brain health and sleep quality. Now, one randomized clinical study, adults who took a brain-available form of magnesium reported improvements in sleep quality and daytime functioning compared to placebo. Now, magnesium is one of the most common nutrient deficiencies I see, and low levels can contribute to stress, poor sleep, muscle tension, and low energy.

48:12Dr. Mark Hyman:And the challenge is that most magnesium supplements only contain one or two forms, and they're not always well absorbed. And that's why I recommend Magnesium Breakthrough by Bioptimizers. It's a full-spectrum formula that includes seven different forms of magnesium designed to support your brain, your muscles, your stress response, and your sleep. I take it as part of my evening routine. Try it today and go to bioptimizers.com slash hymen and use the code hymen at checkout to save 15 % off your order. That's B-I-O-P-T-I-M-I-Z-E-R-S dot com slash hymen and use the code hymen. But what did that mean in real terms?

48:48That means for women who did not take estrogen and progestin, the natural incidence is about 30 per 10 ,000 women per year will be diagnosed with breast cancer, living long enough to get it. In the estrogen and progestin user group, it went from 30 per 10 ,000 women per year to 38 per 10 ,000 per year with no increase in the risk of dying from your breast cancer, even if you were diagnosed on hormone therapy. So let's make that sound a little better. All right. Eight per 10 ,000 additional cases of breast cancer. That's 26%. That's 26%. Right. With no increased risk of dying from it. And then make it even better.

49:31Less than one in a thousand additional cases of breast cancer in the women who took estrogen and progestin. Now, that doesn't sound nearly as scary as 26%. Correct. But that was never really put into perspective.

49:47Dr. Mark Hyman:I think Mark Twain said there's lies, there's damn lies, and there's statisticians. Exactly. Yeah. And, you know, and there is, and when you put it that way, you say, oh, okay, well, eight in a thousand, but I'm no more likely to die from it, even if I'm taking hormone therapy. And even that statistic itself, and you and I know in a medical study, if you were going to report a finding, to call it a finding, it has to be statistically significant. It was not statistically significant. But that stuck like glue. It's still with us today because doctors and patients still believe that a family history of breast cancer is a reason not to take hormone therapy.

50:31So that's just a worst case scenario. Let's, you know, put it on, blame the old bad Primrin and Provera. Even that did not statistically increase your risk of breast cancer. And that is what has taken a long time for people to really understand those numbers. And because I remember the day that came out, it was 1992, and I had been prescribing for 10 years. Well, 2002, and I had been prescribing for 10 years before that. Yeah, me too. And patients were horrified. Oh, doctor, I can't believe you're trying to kill me with this stuff. And when I read the study, I said, wait a minute, it's not as bad as what they said.

51:12Yeah. And again, remember, applying that data, again, take it as it is, you can't apply the same data from 79-year-olds and 65-year-olds to 45-year-olds. They're not the same.

51:26Dr. Mark Hyman:So let's talk about that because I think that I want to really help women understand our newer thinking and what the newer data is around what to start and when. because it has implications for brain health, for bone health, for heart health, for overall symptom reduction. The black box warning I want to talk about before we dive into all that, that's recent. It's a black box warning for people who don't know what that is. The FDA puts a black box on the drug label that says, if you're taking this, beware because it can cause X, Y, or Z. So the black box warning for hormone therapy was what? Warning, Will Robinson, it will increase your risk.

52:07See, only you and I get that joke.

52:08Dr. Mark Hyman:Lost in space. But it will increase your risk of heart attack, of stroke, of dementia, breast cancer. Now, if you picked up your medication from the pharmacy and it said, wow, my doctor didn't say that to me, even for the patients who had an adequate discussion about it, they would read that warning, go take it home, and not use it. The black box has heart attacks, strokes, cancer, and dementia. Dementia, yeah. That sounds fun. That's pretty discouraging, I would say. And as I said, going back to the original study, it never— Remember I told you the only statistical finding that was significant was blood clots.

52:49Dr. Mark Hyman:Yeah. So how can you say all those things? So my point is that— And that was removed just in 2025. Well, I think it may be just off now because I think, you know, they had to go through all the inventory, the stuff that already had it on there. But now it's off. And it's in the regular package insert. You know, every drug has, you know, risks and side effects that are listed in that long. It's like thin paper that you could fold out. It's like a million words on it. With very, very small print. So it's in that part now. It's not on the box. Yeah. And that's what we're like. it took an active, I don't know, whatever, to get people to realize it's like, no, don't say that because you can't.

53:34That's not science.

53:35Dr. Mark Hyman:Given that's true, let's talk about the plus side here because I don't, I said earlier, I don't think women should have to suffer from hormonal dysregulation and symptoms. We have a lot of understanding about what causes it from a lifestyle perspective, including things that are not really being well addressed in medicine, whether it's the microbiome or environmental toxins, because those do play a role. We know nutrition plays a role, exercise, sleep, stress, all those things, smoking, alcohol, people understand those. But what are we thinking about now as the right way to approach hormone replacement therapy?

54:09Dr. Mark Hyman:When should we start it? How long should it be given? What are the right formulations that work best? What are the options for women out there? I want to sort of dig into all this with you. Okay. Well, this is the - Like kind of where the rubber meets the road. So perimenopause does not have a bright line that signals when it begins. A lot of it depends on, again, lifestyle, it's genetics, it's, you know, personal to you. So someone may be perimenopausal at 35, someone else may be perimenopausal starting that process at 45. And there's no blood test that's going to tell you yes or no, you're in perimenopause.

54:45Perimenopause is a clinical diagnosis. So remember all those symptoms that we said, hot flashes, mood swings, night sweats, sleeplessness, weight gain, all of those things that we associate with menopause can start in perimenopause even while women's periods are relatively regular. And perimenopause actually has three stages itself, early, mid, and late perimenopause. Now, the question is, if I can't diagnose it by blood tests and I can't really use periods as the defining factor of when to start, then how do you decide?

55:22Dr. Mark Hyman:History, history, history. The patient will tell you when she's perimenopausal. If you're having any combination of those symptoms and they are bothersome to you, then that is the time you start treatment. And we do have fairly robust data that says, even from the Women's Health Initiative and some other studies, that say to get the maximum benefit, the earlier you start in this process, the more long-term benefit you're going to get. But how we choose to treat those symptoms during perimenopause, well, again, it will depend. It depends on what your other symptoms are. Maybe you have bleeding issues.

56:06Maybe someone else has more sleep issues. In that case, maybe I'll start with progesterone. So that is where this is the art of how to prescribe. There is no one way to do it. You know the basic components. There's estrogen and there's a progestogen. But the mix depends on what your symptoms are, how old you are, and what we're trying to fix. Maybe you're 37 years old and you're having these things and you need birth control. Well, that's a case where we might use a birth control pill because it has estrogen and progestin in it. But that's why I said it depends. But remember, I want women to understand that it's a clinical diagnosis.

56:47If you are feeling that way, a lot of women will go to the doctor, get a blood test, and be asked the question, when was your last period? And you'll say last month. And they'll go, oh, well, it's not perimenopause. Come back 365 days after you haven't had a period.

57:02Dr. Mark Hyman:Because we're not really trained well in medical school and in residency. Even OBGs, by inside, I don't think really have the right understanding of it. A lot of what I learned about this was really through not just what I learned in residency. We were taught more about it in OBGYN, but it also is trial and error process. The experience of saying, oh, well, that didn't work. Well, let's try this. But knowing that you have the full complement of estrogens and progestins. Okay. Well, let's bifurcate this into symptoms and disease prevention. because on the other side of menopause is heart disease, breast cancer, osteoporosis, and dementia because women experience that at a far higher rate.

57:50Dr. Mark Hyman:So I want to bifurcate it just for making people understand a little bit. How do we really understand this perimenopausal period? Because when I've been treating women, I find that the lab test, you're right, can be all over the place. One day they look like they are, one day they're not. But I do often see this this interesting phenomena that I want you to talk about, which is this sort of reduction in the progesterone in the second phase of the menstrual cycle. We call this the luteal phase. So we see higher levels of estrogen and we see lower levels of progesterone. Then you get this imbalance.

58:28Dr. Mark Hyman:And when you have high levels of estrogen, it causes more body fat. It causes more heavy bleeding. And when you have, for example, if you're overweight, if you're eating sugar, it causes a lot of estrogen in the body. I've seen this over and over. And so you get this sort of imbalance and that causes a lot of these heavy bleeding symptoms and really heavy cycles and things that we often see. So I would love you to sort of talk about that phenomenon or if you think it's not a thing, because I think it's a thing. No, I think that you're right. What's happening is not that - Because we're having an ambulatory cycles.

59:04Right. If you're looking at cycles, you're saying that the reason why when you're in perimenopause that the estrogen levels will sometimes overshoot is because normally it's limited by the amount of estrogen you make is limited by ovulation. So since so many of perimenopausal cycles are anovulatory, which means they get started, but you don't ovulate. That's also why your fertility is not good. But you'll have too much estrogen in the first half of the cycle. And the progesterone that happens in the second half of the cycle only happens after you ovulate.

59:39Dr. Mark Hyman:That's right. That's what I'm getting at. So when you don't ovulate, your estrogen keeps going, and then now you don't have that. That's why having someone who understands that says, well, if this person, maybe giving them additional estrogen at this point is not helpful, maybe we need to supplement with progesterone. And lab tests can help because you can see if you do it in day 18 to 23 in that luteal phase of the second half of the cycle, you see, oh, God, their estrogen is really high, but their progesterone is kind of low for where it should be. Right. But you know what? This is what I would say.

1:00:09An experienced doctor doesn't even need lab work. I can tell by your history, if you come in and you say, God, my periods are going on for two weeks and I'm heavy bleeding. Okay.

1:00:18Dr. Mark Hyman:Or they're longer. Right. Whatever the blood test shows me, ultimately what I'm going to do is I'm going to treat the patient and her symptoms. Right. I'm not going to alter it based upon what her blood results were. You know you can figure that out. Yeah. So that's why I said it depends on what symptoms you're trying to treat. If you've got hot flashes and sleeplessness, the one thing that I will say, estrogen is the secret sauce because it will, estrogen is the most effective treatment for that symptomatic pause. Vaginal dryness, you know, irritation, the mood swings, that's the estrogen that is most effective.

1:01:00So it's a matter of playing with that and saying, okay, if someone only has one thing to give you and they're going to prescribe the same thing if you're perimenopausal and the same thing if you're menopausal and the same thing 20 years down the road, that sort of lets you know that they haven't really, what should I say? They haven't had experience with all of the things and you just need to know what you need at that particular point.

1:01:27Dr. Mark Hyman:Right. This is such an important point. It's personalized, it's customized, it changes at different periods of that transition. That's really helpful for women to understand. You need to work with someone who really understands the nuance of how to understand your symptoms and what you're doing, what's going on, and how to properly address that and what the right combo is of different hormones. And I'd love to sort of hear your perspective on whether people should be using it orally, topically, if it makes a difference, if it should be bioidentical, not bioidentical, how much that matters, how much we know about it.

1:01:56Okay, so let's start from this place that I think more than, certainly more than 50 years ago, most clinicians are going to start with the bioidentical. You're going to use a bioidentical estradiol, not one of the synthetic ones, okay? That being what it is. And I even hate the term synthetic. They're all synthetic. It's just a matter of.

1:02:18Dr. Mark Hyman:It just means. It's just the same molecule as your body mates. Exactly. It's like bioidentical. As opposed to pregnant, marriage, urine. Yeah, let's not use synthetic. So you're going to start there. Yeah. Okay, so once you say, okay, estradiol, it can come in as a pill, a patch, a spray, a gel, or even a vaginal ring. There's a vaginal ring you can put in, I think, leave it in for three months and change it. Those are your options. Those are just modes of delivery. There are certain people that a transdermal may be preferable. If I were giving hormone therapy to someone who's a smoker, I would say, yes, let's do a transdermal because we don't need the extra first pass in the liver effect.

1:03:06If I have someone who is not particularly compliant or they don't like to take pills or whatever, then I'll say, yeah, put a patch on once or twice a week. We'll do a patch. but again don't take oral off the table because the overwhelming majority of women who take oral do just fine and even though the the blood clot risk is higher it's higher of a very small number you know what increases your risk of blood clotting the most of anything you'll ever do? Pregnancy.

1:03:41Dr. Mark Hyman:Oh, yeah. Pregnancy, oral contraceptives, the amount of hormone that you take in hormone therapy after menopause pales in comparison to those two things. My daughter's about 26 weeks pregnant now, and she called me the other night, and she's like, Dad, I have chest pain, shortness of breath. I'm like, oh, she's an orthopedic surgery resident. I'm like, oh, my God. She's like, maybe I have a PE or pulmonary embolism. Thank God, she just had heartburn yeah and but see she knows to at least be alerted to that possibility right you know so that's why i said oral versus transdermal and there are other things there are other non-medical considerations and you know and i think they're legitimate let's talk about sex okay sure because i think this is a big thing libida goes down vaginal trinus goes up It's a big thing.

1:04:32Dr. Mark Hyman:And you read a lot about it now. We're talking about estrogen. We're talking about progesterone. Let's talk about testosterone and what your view is on that, how to use it, if it should be used, when it should be used. Because I personally have found it extremely helpful for women. And it has also another side benefits. It increases bone health and other things. So can you talk about your perspective on testosterone for women? Okay. It's just one of those things that's out there in the ether right now. I will, because I'm a little bit outside the general conversation on that, too, in terms of what I think about testosterone.

1:05:07But let me say this. When you're talking about libido issues, the first thing you should always address are the woman's menopausal symptoms. Because if you're hot, sweaty, sleepless, you've got vaginal dryness, and every time you have sex, you have a urinary tract infection, guess what you don't want to do? Have sex. There you go. So fix that first.

1:05:31Dr. Mark Hyman:So vaginal drugs are super easy to fix. Even if you don't want to take oral, you can do vaginal estrogen. There's pills that you can stick in there. There's rings. There's creams. Yeah. Yeah. So everybody. So once we. And by the way, by the way, that doesn't really get systemically absorbed that much. So people are worried about breast cancer. No systemic absorption from the amount of estrogen that's in vaginal estrogen. It's minuscule. So it works where you put it. So it will work in the vagina, near the urethrin, because the urinary system is close, right there next door. So it'll fix both of those.

1:06:05But you don't have to worry about overdosing. You don't have to worry about, oh, my goodness, I've had breast cancer. I can't use vaginal estrogen.

1:06:12Dr. Mark Hyman:And you need to use a progesterone or progesterone? No, no. You don't. Because there's no systemic absorption, unless you are taking systemic estrogen, you don't need to take a progesterone. Okay, so that being said. I know that. I just want everybody else to know. So let's get to that. So now I have a patient and I have addressed all of her symptoms. She's sleeping well. She's high. No dryness. And she says, libido still in the toilet. That would be an instance where some point in the future, then I would say, well, let's give it a try. Let's try some testosterone. And again, what I want everybody to understand is the testosterone conversation is not new either.

1:06:57Testosterone, we had it compounded, but that's been around forever. This was, you know, I was prescribing testosterone for women with low libido back in the 90s. So this isn't like, oh, we just discovered testosterone. But here's what I have found. And again, this is the experience part of it. When you are treating libido, it works really well for some women and not so much for others. Testosterone, yeah. Testosterone.

1:07:25Dr. Mark Hyman:And how do you, I mean, the problem is for men, there's a lot of FDA-approved formulations that you can use that are pumps, that are patches, that are, you know, injections. It's all sorts of stuff. For women, it's kind of not, it just, it's not available. And you have to kind of, it's the Wild West out there. Right. It's been in front of the FDA a couple of times to get a female-approved version of testosterone. And it's the same testosterone. It's just that a women's dose is a tenth of what the men's is. So it's difficult sometimes to take the male version and get a tenth of a pump. So you're compounding pharmacies.

1:08:07That's a case where sometimes we're generally speaking, I don't love compounded. But if you can't get it.

1:08:15Dr. Mark Hyman:Yeah, yeah. I've used compounded. And I've had even topically, like I've had clitoral testosterone drops and they work really well. Yeah. You know, and I would argue with no one who says I've tried testosterone and it works really great. And I'm saying yes, then of course. But again, that's the phase in process. I would never start all three at once, even if decreased libido was one of your symptoms that you presented with. because we fix one thing. And we all know that libido with women is much more complicated. It's not a plumbing issue necessarily. It's a lot of things that go into it. People say women's greatest sex organ is between their ears.

1:08:52Dr. Mark Hyman:Exactly, exactly. The other thing I want to just touch on briefly is we're in the world of Ozempic and peptides. And there's actually an FDA-approved peptide for women's arousal disorder, right, by Lisi. By Lisi. Never used it. Never prescribed it. Never prescribed it. Because you don't think it works or because you don't know about it much? You know what? No, it was, you know, when I was practicing, we had two options. We had Addy and we had Vileci. And it's the same sort of situation. I'm one of those people that I'm like, show me, okay? And, you know, I have prescribed Addy to a couple of patients.

1:09:32Vileci, when you, this was, now remember, this was pre -

1:09:36Dr. Mark Hyman:That's a pill. I mean, Vileci is an injection. Everyday pill. Yeah, and by least it's an injection. So this is pre-Ozempic. Mm-hmm, mm-hmm. Most people were not sold on that idea. And you could, it's on an as-needed basis, but every time you have to say, well, 30 minutes before you're going to have sex, go take this shot. And women are like, no, thank you. So it was less, you know, that's why I've had this experience. It does work, though. It does work. And I, you know what, and I. It works for men, too, actually. It works for men, too. And that's great if it does. But like I said, I was never able to convince someone that that was a good option.

1:10:08By the way, I've tried it, and I'm telling you it works.

1:10:11Dr. Mark Hyman:But I don't know how it works for women because I'm not a woman, right? I will take your word for it. I've never used it. But I think that the libido issue for women, again, is something that's been sorely unaddressed. I think we can all agree that men's libido and their ability to perform has been an outsized conversation. And we've not really paid attention to women's libido with the same level of importance and the same level of distress that it causes. No, it is. And we should. Yeah. And we should. We should do better. So we've talked about all the vasomotor symptoms, the irregular bleeding symptoms, the sleep symptoms, all those can be addressed with combinations of various estrogen, progesterone, topical, oral, vaginal.

1:10:58Dr. Mark Hyman:Let's talk about the importance of understanding the timing of starting hormone therapy for disease prevention, particularly dementia. and let's also talk about osteoporosis because you know people don't realize this but you know if you have a hip fracture and women get more than men because they're less testosterone lower bone density it's a 50 percent mortality of a year i mean if you get it's like cancer like you get a hip fracture you're likely to be dead in a year 50 percent of the time i i think that when we start talking about things um like the long-term benefits i think that we have fairly decent data on the cardiovascular benefit of hormone therapy.

1:11:41You know, that it decreases the risk of cardiovascular disease. And that's not, you know, we have a lot of different, not just observational studies, but we even have things with, there's the Danish osteoporosis study that started around the same time as the Women's Health Initiative. And when the Women's health initiatives shut down, they shut down. Just go, oh, well, no need in finishing that. But by the time it shut down, it had 10 years of data and it was with bioidentical.

1:12:11Dr. Mark Hyman:Yeah, right. So yay on that. And that showed? It showed a decrease in the risk. They had even 16 years out, they showed that the women who were on hormone therapy had a decreased risk of cardiovascular disease. So I think that that We've got fairly good data on cardiovascular disease. We've always had data on osteoporosis. That was one of the indications for hormone therapy. If you're at risk for osteoporosis, yes, take it. Now, let's go to the dementia part of this. What we do know about dementia, I'll tell you what I know and I'll tell you what I think. Right now, in the current indications for hormone therapy, FDA approved, hormone therapy is approved for women who have a premature or early menopause, however you get to that place.

1:13:09And some women naturally have an early menopause, and early, I mean, before age 45. Premature, if you're menopausal, before age 40. Well, how does that happen? Naturally, sometimes you've had your ovaries out. Sometimes you've had chemo or radiation, things that sort of shut down prematurely. Right. Estrogen therapy and hormone replacement therapy is indicated for those women because what happens if you have an early menopause or premature menopause? You're at increased risk for cardiovascular disease, dementia, and osteoporosis. So the recommendation is not can you, but you probably should. And it would be considered a major misstep if someone takes your ovaries out and you're 38 years old and they do not give you hormone therapy.

1:14:03So that we know. So let's go back to the dementia issue because there seems to be a lot of controversy about it. Yeah. Do you know how long it would take to do a study to, even if you did a randomized double-prime? 30 years.

1:14:19Dr. Mark Hyman:We'd all be dead. Okay. So sometimes you have to go with the data you have. Yeah. And we infer all the time in medicine. We don't, there are very few things that we have. Like I have gold standard, absolute proof that this is the case. And I don't think it's a great leap of faith to say, well, if it prevents dementia and osteoporosis and heart disease if you're 42, why would it not if you're 46? Yeah. You know, you have to look at it from that point, from that perspective. I think that we have some really interesting ways of looking at this now, which I think is going to help give us some data before we are all dead and gone.

1:15:06And that is now we have Dr. Lisa Moscone, who is looking at, she's imaging women's brains. And she has been able to demonstrate that your brain looks different in premenopause, perimenopause, and postmenopause. She and I think it's Dr. Rebecca Brenton are the two neuroscientists that have really delved into this to say, we can do this. We can follow one person through perimenopause, menopause, and menopause and image that same brain. so I don't have to wait 30 years to get that data. And so there is now concrete evidence that estrogen plays an important role in how women's brains function and what the structure of their brain looks like.

1:15:55Dr. Mark Hyman:Yeah, but clearly brain fog and all that gets better with hormones. We know that. That's symptomatically true. So, you know, I think that, you know, if you were, but, but, it gets back, and I'll get to this, the same thing that I was saying before in that it matters when you take it. That's right. You can't prevent or slow down osteoporosis when you're 72. And that's why timing matters. And we've got a lot of the stuff that we talk about hormone therapy. The sooner you start it, the more benefit you get. There's no benefit in waiting five years down the road before you start. Yeah, I mean, you really talk a lot about proactive medicine.

1:16:29Dr. Mark Hyman:And I mean, I think the guidelines for a DEXA scan is like when you're 60, which is insane to me. Totally. I mean, you should do when you're 40. which is a bone density scan and i think you know even even now we're having ways of tracking brain health through brain imaging i i co-founded a company called function health and we can do quantitative brain imaging we can do all kinds of biomarkers that tell you what your brain health is what what i'm curious about is if in this i think at this point it's a conjecture opinion because the question is still out there is why are women so disproportionately affected by alzheimer's and could it be because of this sudden drop in estrogen after, after menopause?

1:17:10Dr. Mark Hyman:And, and does the data show that women who take hormones and have taken them starting early? Because if you start when you're 60, it doesn't seem to do anything. So you got to start like early when you're right. And when you're menopausal, right. That's, that's kind of the take home message. Don't wait. I think that is definitely the take home message because, you know, Now, one of the things that the central question is, why do, you know, why are two-thirds of the people with Alzheimer's in this country women? That's right. Why are black women two times more likely to be diagnosed with dementia than white women?

1:17:50Why is that? That's where you've got to start. And if you look at just the basic things, you say, well, what happens to women in that same time period? and that is the and it has something to do with menopause probably something to do with estrogen and that's what really what we're trying to pin down on that because that's really the big difference between how men age versus how women age a lot of things start to us because when we get to menopause our estrogen levels fall off the table

1:18:20Dr. Mark Hyman:gone it's not a slow gradual decline no it's gone it's gone it's never coming back Right. So there is - But by the way, but just so people understand, even after menopause, women still make estrogen and progesterone. It's not that it goes away. We don't make progesterone. It's not zero. But we don't make estradiol. We make estrone. Estrone, right. But that is something that's metabolized in peripheral fat. Yeah. So if you're a very thin, lean person, you probably don't have a lot of estrone. Correct. And then, yeah, skinny old ladies are the ones who get the fractures. And it's much weaker. Yeah.

1:18:55It's a much weaker estrogen than estradiol. Yeah, fair enough. So, you know, there's that. But what I was saying, getting back to this brain health part of it, is that I'm willing to make the inference. Maybe I'm right, maybe I'm wrong. It will not be the first nor the last time in medicine that we've made decisions.

1:19:20Dr. Mark Hyman:On incomplete data. On incomplete data. You know, sometimes we do. And I hope and I pray that I'm right, but at a minimum, I don't think you're doing harm. Yeah. At a minimum. And I would just add that, you know, we now have, which we never had, you know, when you and I were starting training, tools and diagnostics to really track cardiovascular risk and breast cancer risk and things that matter. So if people are concerned about heart disease risk or breast cancer risk with hormone replacement therapy, we now have deep diagnostics for cardiovascular risk that we do at Functional Health. For example, we look at ApoB, lipoprotein A, lipid fractionation, CRP.

1:19:57Dr. Mark Hyman:We look at metabolic health in a deep way, insulin. These things are really important because aside from all the hormone issues, these are the things that drive cardiovascular disease. And then the same thing with breast cancer. Now we have tools that, you know, whether it's mammograms or breast MRIs or even new liquid biopsy tests, There's more tests emerging that are, you know, proteomic testing for cancer and other, you know, DNA kind of fragment testing that's available through liquid biopsy. So all this is iterating really fast. So I think, you know, it's important for women to sort of track it, not just go, oh, it's fine, but to track their health over time and to see longitude that's happening.

1:20:33Dr. Mark Hyman:And even I think when they get their GYN exam to get a uterine ultrasound and make sure the uterus is okay and everything's okay. because these things like uterine cancer and even ovarian cancer now with some of these liquid biopsies and other tests, we can start to track these things. So I think given the kind of constellation of advanced diagnostics that are here now and that are coming soon, it gives me a lot more, I would say, peace of mind to kind of even move forward with the set of incomplete data that we have. We can't wait to, you know, to give people the information. But, you know, what you and I agree on most is the idea of prevention.

1:21:15You know, I think that, you know, I wrote a book called Grown Woman Talk. It's not just about menopause, but it's about all the things that affect women and men. And at the end of every chapter, I'll give a list of things that these are things you do. I talk about cardiovascular disease. I talk about cancer. I talk about, you know, breast cancer and the chronic stresses and hypertension and diabetes. At the end of each chapter, it's almost the same thing. Don't smoke, limit your alcohol, exercise, eat a healthy diet, and get a good night's sleep. Duh, whether you are, it doesn't matter what you're trying to prevent, breast cancer, colon cancer, dementia, the same basic things go into that you know because that's just the recipe for healthy living yeah and quality living we hope um as we age and it's not like you're gonna take hormone therapy

1:22:07Dr. Mark Hyman:and everything's gonna be mine you can live a crappy lifestyle you gotta do it all right it's both and you know that's not gonna you know and you can have all the the the great you know molecular genetic testing in the world and something else will still come up and bite you so you got to just be able to say you know there is a limit to what we can predict and i i use my mother as an example my mother grew up in rural alabama she grew up on a farm okay i don't think my mother ever ate a non-organic thing in her life in her life that's right that's right my My father grew vegetables. That's right.

1:22:48You know, that's how we ate growing up. My mother died of colon cancer. But my mother died of colon cancer not because of something she did that was wrong. It was she died of colon cancer because colonoscopies weren't a thing. Right, right. You know, in today's world, yes. So we have to take the two together. We take the technology and the science and the knowledge that we've acquired with healthy living. Because I don't want people to think that you don't have complete control over anything as far as your health. You can minimize your risk. You can never eliminate it.

1:23:28Dr. Mark Hyman:Well, this is such a great conversation, Sharon. I appreciate all your dedication over the years. People can learn more about your work. You have a podcast, Second Opinion, right? Second Opinion. And that can be wherever podcasts are found. And your advisor, she's been advised to Ally Health. So just tell us a little bit about what that is. Because I think as women are listening and men are listening who are in relationships with women, they're like, well, what do I do and where do I go? And yeah, the average doctor may not be able to kind of have the nuances here. You know, there are now online platforms and tools that are much more sophisticated, understand these things.

1:24:05Dr. Mark Hyman:And you're an advisor to one of them called Ally Health. Can you just share a little bit about that? And at Alloy, I've been with them for five and a half years now. So I was there from the very beginning. And when I stopped clinical practice, I, you know, I'd accumulated all this, you know, I've got not just the medical background, but I've got the experience of having done this for a while. And what I realized is that you can educate women all you want, but if they don't have access, then what difference does it make? You can't find a doctor. You can't find someone that will prescribe for you or that even knows what to do.

1:24:40And that's why it was important. When I joined Alloy, I was able to take my expertise, train the doctors that work for us, many of whom are, you know, they're all board certified. And then now they are menopause trained. So we can leverage the expertise of a few over hundreds of patients, not just the one-on-one that you're going to be able to see in the course of a day. And menopause and perimenopause treatment lends itself well to dealing in the digital health platform. And that's how a lot of care is going to be delivered in the future. And so, you know, I think that people should feel confident that this is not an inferior version of what you're going to get in a doctor's office.

1:25:30In many cases.

1:25:31Dr. Mark Hyman:It's the superior version. It's the better option. Yeah, yeah. Yeah, well, thank you for doing that work. And thank you for your dedication to this field and writing your books. And where can they find more about you beside your podcast? Do you have a website? Yes, I have a website. And it's easy, drsharonmalone.com. And your social media is? smalonemd on Instagram and threads. Amazing, wonderful. Well, thanks for your work. And thanks for being a voice out there for reason and coherence in a very complicated, confusing space. We need more of you. Well, thank you for having me. If you love this podcast, please share it with someone else you think would also enjoy it You can find me on all social media channels at dr.

1:26:10Dr. Mark Hyman:Mark Hyman. Please reach out I'd love to hear your comments and questions Don't forget to rate review and subscribe to the dr. Hyman show wherever you get your podcasts And don't forget to check out my youtube channel at dr. Mark Hyman for video versions of this podcast and more Thank you so much again for tuning in. We'll see you next time on the dr. Hyman show This podcast is separate from my clinical practice at the ultra wellness center my work at Cleveland Clinic and Function Health, where I am Chief Medical Officer. This podcast represents my opinions and my guests' opinions. Neither myself nor the podcast endorses the views or statements of my guests.

1:26:41Dr. Mark Hyman:This podcast is for educational purposes only and is not a substitute for professional care by a doctor or other qualified medical professional. This podcast is provided with the understanding that it does not constitute medical or other professional advice or services. If you're looking for help in your journey, please seek out a qualified medical practitioner. And if you're looking for a functional medicine practitioner, visit my clinic, the Ultra Wellness Center at ultrawellnesscenter.com and request to become a patient. It's important to have someone in your corner who is a trained, licensed healthcare practitioner and can help you make changes, especially when it comes to your health.

1:27:15Dr. Mark Hyman:This podcast is free as part of my mission to bring practical ways of improving health to the public. So I'd like to express gratitude to sponsors that made today's podcast possible. Thanks so much again for listening.