[Robin Berzin] (0:00 - 0:21)
We have been told the wrong message for a long time, which is to grin and bear it, sit around and wait for menopause to appear, and then menopause will happen, and you'll grin and bear through that, and then you'll move on through your life, and that is wrong. What's changing in our biology and midlife? Your female hormones, your oestrogen and your progesterone are beginning to be on the move.

It's like the anti-puberty.

[Angela Foster] (0:21 - 0:31)
For a woman who's doing everything right, is it possible that she could navigate her way through perimenopause and become postmenopause and not have hormones and be optimised?

[Robin Berzin] (0:31 - 0:38)
What I would say based on the new data that we're understanding about menopause and perimenopause and hormone replacement therapy, I am of the belief that...

[Angela Foster] (0:39 - 1:23)
Is there evidence that by staying on menopause hormone therapy, that can lower your risk of dementia? You know, it's a great question. For a woman listening to this, how would she know that she was a really good candidate for menopause hormone therapy and it would improve things for her?

The first thing I always recommend is... Dr. Robin Bazan, you are an internal medicine and functional medicine physician, women's health expert, really pioneering this field. You see thousands of women at Parsley Health.

Many of my listeners are midlife women. They feel like they're doing everything right. They're eating well.

They're exercising. They're trying their best to focus on sleep, but they feel exhausted. What's going on biologically when this happens?

[Robin Berzin] (1:23 - 2:17)
This is such a common experience that women have. And I hear over and over again, the things that I was doing yesterday suddenly stopped working today. And if that is you, you are not crazy.

Nothing is wrong with you. What is happening is that your body is changing, your hormones are changing. And so your response to stress, your response to the foods you're eating, your response to your environment, your response to variations in your sleep that used to not be a big deal.

All of this has new and profound changes in our symptoms and the way that we feel as your hormones begin to shift. And we have been told the wrong message for a long time, which is to grin and bear it, sit around and wait for menopause to appear. And then menopause will happen and you'll grin and bear through that.

And then you'll move on through your life.

[Angela Foster] (2:17 - 3:00)
And that is wrong. How can we best approach it? Because I think the thing that I hear so often is, and this was true for me as I was going through my 40s, is when I was a corporate lawyer in the city, I didn't think about resilience.

I had hormone resilience and I could push through, power on. And then I think it's not until you feel it's gone or it's going that you suddenly think, oh my God, yeah, that worked. Like resilience actually means something to me.

And as you say there, you have less flexibility. You have to pay better attention to sleep and circadian timing and all of these different things. Can you explain for the women listening to this, what's actually going on?

What's changing in our biology and midlife?

[Robin Berzin] (3:01 - 6:08)
So your female hormones, your oestrogen and your progesterone are beginning to be on the move in ways that you haven't experienced since you went through puberty. It's sort of like the anti-puberty. It's going in the opposite direction.

And progesterone starts to move and starts to decline on average over time. Oestrogen is all over the place. Sometimes it's totally normal.

Sometimes it's high, sometimes it's low and it's becoming erratic. And then for many women, up to 80%, your testosterone levels are also starting to wane. Not everyone loses their testosterone, but the majority do.

And so in this time, these hormones serve so many key purposes. Oestrogen is anti-inflammatory. And so it's keeping brain inflammation lower.

It is potentiating your dopamine. So it makes your dopamine in your brain work better. So if you have underlying ADHD or you've been masking ADHD, or even if you just have a high stress, high powered life, the missing oestrogen is going to make it harder for your brain to function.

As inflammation creeps up in your body, you start to gain visceral fat. And that's that fat in your belly, around the middle, around your organs, that like all of a sudden appears in your middle. And you're like, what's going on?

Oestrogen is the foot on the gas of your metabolism. And imagine you're in a car and the foot on your gas is going up and then it's coming off and it's going up and coming off. Like how herky-jerky would your car experience be?

And this process can start as early as 35. In most women, it doesn't start until your 40s. It really depends.

And how healthy you are, by the way, and how inflamed and metabolically healthy you are going into this process actually has a huge influence on how well or not so well it goes. And so one of the lies that we've been told is that this just happens to you and there's absolutely nothing you can do about it. Actually, if you're active, if you have good lean muscle mass, if you've been working on bone density, if you're eating an anti-inflammatory diet, if you're making sure your nutrients are repleted, key nutrients like omega-3s and iron and B vitamins, things that we get depleted in after we have babies, especially I have three kids, I've experienced this myself.

If we replete those nutrients and we kind of build this stronger, healthier, less inflamed body going into perimenopause and menopause, we do have, by and large, a less symptomatic experience. But that said, nothing is going to change the fact that these hormones are going to wane and be all over the place. And depending on your life, your stress level, your environment, your genetics, your microbiome, all different aspects of yourself, your other health risk factors and health conditions going in, those things are going to start interplaying with these changing hormones.

And your period can be regular and normal and you could still have a baby. And you could still be going through all of these symptoms and this era that is perimenopause and menopause.

[Angela Foster] (6:08 - 6:49)
Do you think that for somebody who does all of those things, they focus on everything, exercise well, they've got low inflammation, they're very health conscious with what they're eating, they're sleeping well, they're maybe meditating and managing their stress, do you think it's possible for a woman in that situation? It's kind of hard to imagine a woman that doesn't have any stress because I, like you, have three kids as well. Let's just say midlife is chaotic sometimes.

So I guess for a woman who's doing everything right, is it possible that she could navigate her way through perimenopause and become postmenopause and not have hormones and be optimised in terms of her lab work, her cognitive health, her physical health?

[Robin Berzin] (6:49 - 11:07)
You know, it's a great question and everyone is different, which is why I love practising functional longevity medicine because I get to treat everyone as their own experience and look at them as a whole person and understand the context of their life, their genetics, their biomarkers, their biometrics, and put the pieces together, their mental and emotional health, the pressures they're under, right?

All of these things have import and they matter. And so you just, in conventional medicine, we sort of ignore most of that stuff and treat you like a number or a protocol. In functional medicine, I get to treat you like you are and look at all of these different variables and put them together and understand you.

There are some women for whom all of the pieces line up and they can go through menopause and perimenopause. And because of the exercise, the eating right, the mental health practises, the constellation of factors in their environment and their stress levels, and maybe their genetics, they kind of smooth sail through it. And it's not such a thing.

It's the vast minority of folks, but it is some. And yet what I would say based on the new data that we're understanding about menopause and perimenopause and hormone replacement therapy, I am of the belief that we will soon be proactively putting almost, not all, because there are variants, but almost all women on some form of proactive preventive hormone therapy or MHT, menopause hormone therapy, because of the data of how much it lowers the risk of dementia and Alzheimer's, osteoporosis, heart disease, and cancer.

And even if you're somebody who feels good, symptomatically, for whatever reason, you have no vaginal dryness and no brain fog and no hot flashes and no weight gain, et cetera, et cetera, good on you, that's awesome, congratulations, amazing. But that still doesn't mean that the hormones and their impact on your brains, your bone, your metabolism, you're sorry, your brain, your bones, your metabolism, and your metabolic health isn't profound as you age. And as we think about optimising your healthspan and longevity, I'm seeing how hormone therapy is really critical.

You know, my mom is in her early 80s and she was on the old bad form of HRT back in the late 90s and 2000s. And when the Women's Health Initiative study came out in 2002, that was then misinterpreted and popularised in the press as saying that, you know, hormone replacement therapy causes cancer and clotting and all these things. And at that time, they were using a synthetic form of progesterone that turned out to be not great.

They were using oral estrogens and higher dose estrogens and sort of everything about it was not what we do today. Plus the data was looked at incorrectly, plus they were looking at the data in older women starting HRT later, so many issues, right? At the time, my mom's gynaecologist at Johns Hopkins I grew up in Baltimore, looked at the data himself and looked at his experience with his patients who are on hormone therapy and said to my mom, we don't see it.

We're not seeing the breast cancer that's being reported by the media. We're not seeing these issues, especially in someone like you, who's a non-smoker, who exercises, is a healthy weight. And my mom stayed on hormone therapy for over 20 years.

And she is such a healthier 80 something. I won't say no, then she really would have been otherwise. And that plus what we're seeing in the data today, looking at 120 million medical records and seeing the trends.

Now that's observational data. It's not a randomised controlled trial. So it's not perfect data, but it's mass data, which in randomised controlled trials, we usually get 50, 60 people in them.

Sometimes we get a thousand, but usually these RCTs are tiny. And so we have data in 120 million women to show that HRT has incredible benefits for our proactive preventive health. And so I'm interested in it.

And I don't think the data is fully there yet, but I'm interested in it as a proactive measure in almost all women. And I think we'll get there.

[Angela Foster] (11:08 - 11:20)
And when you talk about dementia prevention there, is there evidence that by staying on menopause hormone therapy that can lower your risk of dementia? Yes, absolutely.

[Robin Berzin] (11:20 - 12:57)
So that's what this research looking at over 120 million women, some on HRT, some not, but a huge dataset showed far lower risk of dementia for those on HRT. And we've always known, right, that there's a big oestrogen brain connection. Oestrogen is anti-inflammatory and when that anti-inflammatory force of oestrogen disappears, inflammation goes up all over the body.

It's why we see first autoimmune presentations in perimenopause and menopause. It's why 80% of autoimmune disease is in women, not men, this oestrogen connection. We've known this for decades.

We also know that women have two to three times the likelihood of developing Alzheimer's as men. We understand that this loss of oestrogen is, you know, we understand that oestrogen was protective and its loss is anti-protective. And what happens is these microglia, these immune cells of our brains, which are in charge of regulating the immune system of our brains and kind of keeping the right level of inflammation, right?

You want your body to be able to repair and heal in the brain. That's your immune system doing its good work, but you don't want it on all the time and on overdrive. And oestrogen is one of the factors that tempers these microglia and when they get overactive, that's when we see dementia.

It's now the activity of these microglia is now being understood to be probably the biggest driver behind Alzheimer's and Parkinson's disease, for example.

[Angela Foster] (12:57 - 14:09)
Very interesting. I mean, when you look at that, you know, I have a mom of similar age and actually she sadly does have Alzheimer's. And when you look at that generation, a lot of them, unfortunately, and they were, as you say, right?

Taken off menopause hormone therapy. That's one factor. I think as well, they didn't have the same education around things like resistance training and taking care of their metabolic health.

And one, I mean, one question I have for you, Dr. Berzin is I'm curious when it sounds like for the vast majority of cases, you would prefer to prescribe menopause hormone therapy. I think there'll be women listening to this who think, actually, I'm fine. I feel fine.

But what I found was I actually felt pretty good, but then I almost didn't know just how much better I could feel until I took menopause hormone therapy. And I think that's a difficult thing to explain to someone because there is, as you lose some of these hormones, right? Particularly progesterone, first of all, there's sort of, I felt a little bit of a creep with anxiety and things like that.

But I couldn't quite put my finger on it. You just know that you don't feel quite like yourself anymore. So for a woman listening to this, how would she know that she was a really good candidate for menopause hormone therapy and it would improve things for her?

[Robin Berzin] (14:10 - 22:13)
Dr. Melissa Nugent You know, the first thing I always recommend is active listening to our bodies. I think we all live in our heads and I've described it as though there's like a concrete wall between our heads and our bodies. And a lot of us are living in our heads and not really attuned to what's happening beneath.

And so many aspects of our culture and our society and our training, like tell us to block that out. Block out your fatigue. Have another coffee.

You know, you're hungry, eat the convenience food that spikes your blood sugar and ultimately leads to insulin resistance and hangriness and brain fog. But, you know, just keep going. We have so many messages around that in our work culture, in our societal culture, around motherhood, that it's sort of trained into us.

And then on top of that, we have a medical system that is reactive. So unless you're sort of a mess, you're highly symptomatic, your hot flashes are through the roof, you're miserable. We're like, oh, there's nothing to be done.

If you think about the 10, 15 minute visit you have with your PCP or your GYN, where they order some basic tests and do a very basic exam. And unless there's something really egregious, they sort of send you on your way. And like that message also gets reinforced by our healthcare system, right?

You're fine. And so I recommend, you know, at Parsley, we have it on our website. We have a symptom score.

It's proprietary. We've published it in the medical literature multiple times. We developed it to be able to give patients a way to track whole body symptoms over time.

It's called the Parsley Symptom Index. And it takes two minutes and you do it online and it gives you a score. And it looks at nine body domains from your hormones to your mental health, to your gut health, all of it.

And it allows you to assess. It's designed to be done at most every two weeks. So it's a two-week look back.

Because beyond two weeks ago, do you remember how you feel? I mean, I don't even know how I felt like two days ago. I don't know, two weeks ago, right?

So two-week look back. So you're supposed to do it at most every two weeks. But it allows you to kind of begin to score and understand how am I actually feeling?

And it's a huge wake-up call. We have patients do it before every visit at Parsley. And it's such a wake-up call.

Wow, my brain fog. Wow, I've got this new joint pain. Wow, I'm aching everywhere.

Wow, these headaches are out of control. Wow, I really haven't been sleeping well. Wow, the things that we're kind of burying.

And so I always recommend first do this assessment. Because how you feel may show up in before your period starts to change. Before even vaginal dryness and hot flashes.

Yes, menstrual irregularities, vaginal dryness and hot flashes are the big three that we associate with menopause. But far before that, you could be finding brain fog, inability to focus, sleep disruptions, hair loss, hormonal acne. Like I've been dealing with a huge hormonal acne issue for the past couple of months, which is brand new for me since a very long time ago, which is absolutely a combination of stress.

So I was stressed before, right? Life is stressful, three kids, job, all the things. Stress interacting with what is slightly lower progesterone.

And that slightly lower progesterone is no longer quite tempering, having a little bit of a softening, let's say, on my androgens, my testosterone, which is leading to breakouts around my chin and like the lower part of my face. These are sometimes the early signs, joint stiffness, achiness, changes in libido, changes in energy level, weight gain, even subtle weight gain. These are all ways in which this can show up.

And so the symptom tracking is a really nice way to start to check in on that. And then adding to that, getting proactive blood work. So the old adage, the old sort of, you know, classic medical recommendation is like, oh, don't test your hormones in menopause or perimenopause because they're going to be all over the place.

I'm like, that's literally insane. That's like, let's just fly blind. Who cares if your testosterone is cratered?

We're not going to give you testosterone anyway, so why bother to know? Well, if I'm working with a woman, I want to know where her testosterone is because I have some of my women who their testosterone is freaking fine. I have some patients who are like 70 years old and their natural testosterone is like A-okay.

It must be genetic. I don't know why. I'm freaking jealous.

That is not me, but it's some of us. Okay, cool. You don't need outside testosterone.

Fabulous. Or you probably don't need it. Or if you do, you need very, very little.

That's very different than somebody who does. I also want to see how is your oestrogen and progesterone moving over time? So it is correct.

One random blood test of your sex hormones is pretty useless. But if you get a baseline in your mid-30s, let's say, and then you test at least once a year or ideally twice a year from there, well, now we have a trend line. And now if I'm working with you over time or you have access to your labs over time, you can see how oestrogen was used to be kind of here and now it's kind of here and now it's kind of here.

And you can see how progesterone used to land after ovulation up here. And now it's still here. You're still ovulating, but it's down here and so on.

We can see the trend. And that trend is what tells us that, yes, you are changing. And it will show up in the labs if you do them repeatedly and you track them over time.

And so we track symptoms over time. We track labs over time. And then we treat, right?

And that's the last piece, which is so horribly missing in conventional medicine is this willingness to say, hey, let's be proactive here. You know, I love to prescribe cyclic progesterone. I prescribe it for women who have irregular cycles, PCOS, other causes of irregular cycles or lack of cycles in the fertility journey.

We have helped so many women get pregnant by re-kickstarting their cycles, by addressing some of the reasons that they didn't have cycles in the first place underneath, and then using progesterone topically or vaginally in the second half of the cycle to get their cycles going regularly again, like too many to count. And on top of that, okay, now you're on the other side of the fertility journey as I newly am. My youngest is four.

I have three kids and I toyed with a fourth and I think we're good. But at this point, right, you're on the other side of the fertility journey and your hormones are starting to wane, but you still have your period. So you don't want to take progesterone all the time because that will send things super haywire.

And you may not even be ready for oral progesterone, which if you're not ready for it, it can cause bloating and fluid retention and sometimes sleepiness. Like some people react to it a little bit. Some people feel great, but you might be ready for cyclic progesterone again in the form of a topical cream or a vaginal suppository, which is the best, or sometimes even maybe an oral just in day 14 to 28 or so of your cycle after ovulation.

And that might be just enough to help with the sleep issues and the breakouts and some of the symptoms that you're beginning to have. You might start with just that little bit of progesterone. And so what is that?

It's a willingness to track your symptoms proactively. It's a willingness to track your labs proactively. And then it's a willingness to say, hey, let's get started with just a little bit of hormone replacement therapy in a very personalised way.

And yes, maybe you're not ready for an oestrogen patch and oral progesterone and all the things that come kind of in later perimenopause to menopause, but you are ready for some level of intervention. And I think that's kind of the optimal trinity as it were for women in this phase of life.

[Angela Foster] (22:14 - 23:33)
If you're getting value from this show, the single best thing you can do to help us keep bringing you the highest calibre guests is to subscribe or follow wherever you listen or watch. It takes 10 seconds, but it genuinely makes a difference to the quality of the guests we bring you week after week. I think what I'm hearing from you there is just how bio-individual it is, right?

And I think how each woman needs to be treated separately. Her labs need to be looked at, her symptoms. I love the fact that you have this symptom index.

I mean, it's interesting what you were saying there about the sort of breakouts around the chin. So I went through a real phase of that myself. And I was thinking, oh, the androgens must be really high.

And actually my testosterone turned out to be quite low. And the trio of oestrogen, progesterone and testosterone cleared up my skin. I felt so much better.

And as someone who'd had PCOS when I was younger, what my doctor was saying to me is you probably were used to higher levels of testosterone, which then affects your kind of mood and energy and things. And I think just what I've learned through my own experience in working with women and interviewing people like yourself is just how individual this is. Do you also track other things like with wearable data?

For example, do you look at individual sleep? Do you look at their HRV? What do you see going on with heart rate variability in perimenopause?

Absolutely.

[Robin Berzin] (23:33 - 26:23)
So I'm on WHOOP's medical advisory board. So WHOOP and Aura are sort of like the two big trackers in the world. And I love my WHOOP.

And actually my WHOOP has been super illuminating for me. As I started Parsley 10 years ago, it was in the sort of Fitbit days when tracking was, in my opinion, kind of basic and kind of lame. Like how many times can you see how many steps you took?

Like, I don't know. I just, I didn't find that information terribly useful. I'm a New Yorker, so I walk a lot.

So it was like, great, true, true. And what I expected. But I think that as wearables have gotten so much more sophisticated, what I'm so impressed by in my WHOOP is how much data and insight I get into things that, again, just like we all brush our symptoms aside, sometimes we brush our lifestyle aside.

And I've been blown away by my own. So this is the one I'm terrible at. My own sleep inconsistency is really bad.

I am not good at going to bed at the same time or within the same 30 minutes every night. It is absolutely at this moment in life, my Achilles heel. And I see in the WHOOP how it's impacting and raising my biological age significantly, actually by a year.

And when I dove into the data on sleep consistency, for example, and how it's even more of a driver of ageing than sleep duration, right? Seeing it in your data is a real wake-up call. Because we can all, again, I don't even remember what all the times I went to bed last week.

If I just was asking myself to remember that, I would just like have no clue what time I went to bed last Tuesday. It'd be impossible for me. But the WHOOP shows you that.

And it gives you this real barometer of, oh, maybe this thing I'm doing is not helping me so much. And maybe the reason I'm so tired is not this massive mystery. Heart rate variability, as you bring up, is another one that's heavily bio-individualised and starts to change in perimenopause and menopause.

And it starts to, by and large, go down. It also goes up and down, everyone, at different points in your cycle. So seeing your average HRV over months at a time is also really helpful.

Because if you zero in too much at one point in your cycle, and you're like, my heart rate variability is low, get upset about it, right? It wouldn't be telling you the whole picture. But it does show you how your stress, your cortisol levels, your catecholamines, like epinephrine and norepinephrine, which is that fight or flight side of your nervous system, that tampers down your heart rate variability.

When that's always on, heart rate variability really responds. And then what you see is that in perimenopause and menopause, that heart rate variability is more sensitive than it used to be to those stress hormones and those catecholamines. And so you have to do more stress reduction and more resilience building to bring it back up.

[Angela Foster] (26:24 - 26:29)
What do you see in relation to HRV when women start menopause hormone therapy? Does it have an impact on that?

[Robin Berzin] (26:30 - 26:38)
Yes, absolutely. Absolutely. It makes your HRV more resilient to the stress you're under, period.

It makes your whole body more resilient to the stress you're under.

[Angela Foster] (26:38 - 26:55)
So you don't see, you know how there's sort of an association between HRV dropping in the second half of the menstrual cycle, when women start taking progesterone, do you then see a drop in HRV, particularly if they then move from cyclical to continuous progesterone, for example, is there any impact of that on HRV?

[Robin Berzin] (26:55 - 28:14)
I usually see HRV by and large. Again, I'm not so interested in the HRV in a specific day of the week, as I am sort of understanding it over time. And by and large, HRV improves overall with hormone replacement therapy.

Just like inflammation improves. Yeah, exactly. And just like your ability to, you know, I was talking with a friend the other night and she was talking about how she turned 50 and all of a sudden she gained 20 pounds and was overnight, it was all around her middle and she experienced severe vaginal dryness and she was like, and her joints all ached and she was like, it was overnight.

It was just like crazy. And she talked about going on hormone replacement therapy and seeing how not overnight, but over a matter of months, everything re-regulated itself and got better. And it's not about going on such high doses of hormones that you're necessarily even all the way back up to your height at, you know, 25.

But it's about being on enough that your body gets the anti-inflammatory, pro-dopamine, pro-metabolic, pro-bone building capabilities back that it can resurrect its own ability to do those things on a daily basis.

[Angela Foster] (28:15 - 28:30)
Yeah, for sure. Can we talk about, you've mentioned a couple of times there around dopamine and also ADHD-style symptoms. I know you've done lots of work in this area.

What's happening with our neurotransmitters in that perimenopausal change?

[Robin Berzin] (28:31 - 31:02)
So, you know, oestrogen is your brain's dopamine stabiliser. It makes the dopamine production in your brain a little bit higher. It makes the synapses more sensitive and the receptors more sensitive to dopamine.

So it kind of takes the dopamine you have, which is your executive function, your focus, your sort of executive control, and it potentiates it. It makes it better. It's not the only reason it's there, for sure, but it potentiates it.

And so as oestrogen declines in perimenopause, and especially as we get into later perimenopause and then menopause, you know, 43% of ADHD diagnoses in women are happening between 41 and 50. That's not an accident. And, you know, in part, and I wrote about this in one of my newsletters recently, because I have been through my own adult midlife and 44 ADHD diagnosis, which really came alongside of my son, one of my children's diagnoses, and understanding his brain became a really big mirror for understanding my own.

And I really looked at how, you know, when I grew up in the 80s and 90s, ADHD wasn't well-recognised. And when it was, it was sort of an issue of like hyperactive boys, right, who couldn't sit still in the classroom. And that was kind of it.

I actually went to all girls school from age five to 18. So this was just not like on the radar screen. And for a lot of women, younger women, anxiety, depression, difficulty focussing, you know, get sort of named, but they don't get the diagnosis of ADHD.

And girls are better by and large, not all, but better at learning coping mechanisms. They learn to sit still. They learn to get really good at masking it and probably having the level of oestrogen they get in puberty helps them with that.

And then they get into perimenopause menopause and oestrogen starts to wane a little bit, even a little bit. And that ability to mask the ADHD gets lessened. And it starts to show up as anxiety and it starts to show up as brain fog and difficulty focussing and a sense of feeling revved all the time.

And that is leading to now with more awareness and more education, more ADHD diagnoses in women in midlife. And I just think that it's fascinating to understand this brain, oestrogen, dopamine connection and how women learn and do work with that differently than men. And I think it's a huge wake-up call for a lot of people.

[Angela Foster] (31:03 - 33:13)
Yeah, I think so. I think it's when, as you say, right? A lot of women notice the difference.

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Oh no, I haven't seen it.

[Robin Berzin] (33:13 - 33:14)
I'll check it out.

[Angela Foster] (33:14 - 34:03)
It's absolutely hilarious. This lady has gone, I think she went from last year from literally just a few followers to in the millions because she was like, we simply do not care. And it's this Do Not Care Club for perimenopausal and postmenopausal women.

And it's kind of like, we don't care that we put the washing machine, the laundry on three times and still didn't empty it or that we didn't have the energy to empty the dishwasher. A lot of that I've understood as well comes from low testosterone. That gives you a really good kick in energy a lot for women.

But what would you say, how can they optimise some of these neurotransmitters? Is it about being very focused on good circadian rhythm, like getting early morning sunlight, dimming the lights at night, being regular, as you said, about their sleep timing? What are the best ways to kind of manage some of these things?

[Robin Berzin] (34:03 - 39:16)
So there's a few ways that can really help and it can help by the way if you have ADHD or some variant of ADHD or you don't. So this is relevant to everyone. But number one is cardio.

Cardio is actually one of the best ways that we can increase energy, focus and mood in folks who have ADHD. So when I did ADHD research at NYU School of Medicine back before I went to medical school is one of my first jobs. And I'm a co-author on a book chapter called Diagnosing ADHD in Adults, which I co-authored when I was like in my early 20s and I had this job at NYU and I look back and it's strange and sort of eerie almost that I participated in this research.

It was like the first publication I had to my name in the medical literature. This is again, before I even went to medical school it was a long time ago. And what we saw then is we were looking at these drug trials for ADHD meds, which was what was being run at NYU.

Universities are often sites for these medication and pharmaceutical trials. We also saw the impact of exercise on ADHD. And so cardio, you know, your zone two that your whoop is encouraging you to do more of and encouraging me to do more of is not only improving your metabolic flexibility, your ability to balance your blood sugar and use both fat and sugar for fuel.

It's also boosting some of these neurotransmitters and allowing you to have better day-to-day mood motivation and focus. Then on top of that, that's kind of the shorter term boost. And then yoga, interestingly, is what kind of rewires things.

So it actually has been shown to increase control over impulsivity, reduce hyperactivity and improve over time the symptoms of ADHD. And looking back, I think it's now again, kind of uncanny, no accident that I had always been kind of in high school, college, like I wasn't an athlete. I wasn't one of those people who was good at sports involving throwing balls and putting them in nets, like just wasn't going to be my thing.

But I was a good runner and I was always active and I was always sort of doing cardio. I ran a marathon. I was running all the time.

I would do long stints on the Stairmaster or the treadmill. Like that was sort of my method of modulation. That was my exercise.

And in my kind of first years after college in New York, I discovered yoga somewhat haphazardly. And it was this massive shift for me. It was the first time I felt like I was in my body.

It was the first time I felt like I was present. It was the first time I felt like I wasn't sort of in this just motorised treadmill running on repeat in every area of my life. And it really changed my life.

And looking back, I think what it was was that I discovered yoga always something that I thought growing up was kind of weird and didn't fit into what I thought of as sports culture. It was really a modulator for my ADHD. And by the way, my ADHD is my superpower.

It's why I'm an entrepreneur. It's why I founded three companies. It's why I'm creative.

Like it gives me so many good things. But I also feel really lucky that early in life, I discovered things like yoga to enable me to sort of modify my ADHD in a healthy way. So cardio and yoga, the other things that can help, there are some supplements that can help.

And it's not some of the supplements that just try to boost dopamine temporarily because those honestly don't work very well. It's things like omega-3s, which modestly, but taken over time, have been shown to improve focus and ADHD symptoms. It's taking magnesium.

I recommend 200 to 400 magnesium milligrammes of magnesium glycinate a day, especially at bedtime. It helps with sleep quality. It helps with anxiety and has been shown to help with ADHD symptoms.

In fact, people with ADHD are lower in magnesium. People who are chronically stressed pee out magnesium faster. And so if you feel like you're chronically stressed, you could probably benefit from some extra magnesium.

Not magnesium in the sense that you are deficient and we're correcting a deficiency. You know, the sort of conventional medicine world is like, well, people aren't deficient. They shouldn't take this.

And that's like, okay, it's not going to show up as a deficiency, like you've been out at sea eating nothing for like months or something, but it is going to show up as suboptimal. And in that suboptimability, in being suboptimal, by using it therapeutically, i.e. using magnesium therapeutically, it can really improve things like sleep, anxiety, and so forth. And then, as you said, this is the one I'm obviously bad at.

It's probably my ADHD at work, but sleep consistency, sleep quality. And another one is avoiding alcohol. So alcohol is schooled into all of us culturally as a coping mechanism.

And alcohol is a huge hit to our dopamine. And so reducing or eliminating alcohol really, really, really helps people who have ADHD. It also really, really helps women at all stages of perimenopause and menopause.

[Angela Foster] (39:17 - 40:16)
I've definitely seen a massive difference since I gave up alcohol almost four years ago. And yeah, as someone who has had a background of clinical depression, it's probably that in combination with exercise are the two biggest mood stabilisers that have allowed me to become, you know, off all bipolar medicine and stay medication free. I would say it was that combination that was the most powerful.

What surprised me there was when you were talking about the exercise, I get it, like yoga definitely brings you into your body. And I think I could do with more of that is when you're talking about zone two, when we think of dopamine, I suppose a lot of us would just jump to that high intensity work, right? Or for me, for example, I find that weight training provides a lot of order in my mind.

I don't know whether it's just counting the reps and physically going through it and also causing a little bit of pain. But certainly in the morning, I feel like my brain is so much more ordered across the day. But from what you're saying, it sounds like I need to spend more time than I do in zone two as well.

[Robin Berzin] (40:17 - 43:15)
I think it all helps. I think it all helps. You know, weight training has been shown to really improve long-term cognitive function.

Why? Because it's improving your metabolic health. And we know that Alzheimer's has been called type three diabetes, right?

When your blood sugar is high and you're insulin insensitive, these things lead to inflammation in the brain, which ultimately is leading to some of these dementia type related diseases. And we know that increasing blood flow to the brain is good for long-term cognitive health, right? And reduces vascular dementia.

So weight training is helping long run and it's probably helping short run too by helping you regulate blood sugar and reducing inflammation. I certainly learn this or see this from my self weight training, which has become a much bigger focus of mine in recent time. And I've also seen how my consistent yoga practise over the years, it is my therapy.

It is my steadiness. And I was on an antidepressant in college for a little while. And I credit the fact that I haven't been on those medications in my adult life to being lucky enough to discover yoga and discover exercise as a way to modulate my mental health, eating a certain way to modulate brain inflammation in my mental health really early in life, like in my early 20s.

I feel so lucky to have discovered that. And by the way, that's not to say that those things are enough for everyone. And it's not to say that those drugs are bad and they're great.

I prescribe those drugs all the time. And antidepressants, anti-anxiety medications, these classes of medications, they can be a lifeline for people. They can be the thing that is pulling you literally from drowning in the river out onto shore.

And they're also not enough. They don't make you happy. They don't fix your life.

They don't change your relationships. They don't skill build. They just don't.

And so I always tell my patients, let's absolutely use this medication. It's important. It's going to help us get you out of the river where you're nearly drowning and gasping for air and onto shore.

And that value is everything. And we also have to use the exercise. And we also have to use the meditation, which has been shown to rewire your brain and reduce your cortisol levels and improve resilience.

And we also have to use the supplements and the food and the mindfulness-based rest reduction and all the practises, because those are the things that are going to help you not just be on shore, but stand up and walk and live your life in a different way. And so it's that sort of multi-perspective conversation that I feel like is missing in conventional medicine that I feel so lucky to be able to have in our conversations with patients in the functional medicine space, because we have more time, because it is more personalised. And because I think we're being intellectually honest with our patients, which is that the drugs are just not enough.

They are amazing.

[Angela Foster] (43:15 - 45:13)
And they're not enough. I love the way you frame that. I think it's just such a rare thing, actually, even in a functional medicine doctor, to see the conversation on both, right?

Is that we can use drug therapy to get us to a certain point, and then we can also use all these other practises and functional medicine to help. Because certainly for me, I don't think I would have come through it without that bipolar medication. As you say, it took me out of the river onto the shore, and it allowed me to see, it changed my brain a little bit.

You know, when you think of like playing tennis and the ball comes over the back of the net, and as you're bringing your racket back, there is time, there's a little bit of space between stimulus and response, right? That happens in the brain. And for me, it allowed me to appreciate that time, which I think yoga also does.

Doing zone two training does this, right? And it gave me an appreciation to come back into my body to understand my thoughts, to be more mindful and present. So it allowed me to do the work that was then necessary for the recovery.

And I just think it's such a powerful message that you're sharing, because I think so many women do need this medication at some point in their lives, but they feel like they shouldn't be on it. And we give ourselves these series of should or shouldn'ts, right? Which we shouldn't really have, because actually, if it's helping you, and it's maybe even facilitating you doing some more of this work, then it's a benefit.

So thank you, because I think I just, I really value you opening both sides for people. You are a high performer yourself, Dr. Berzin. So I think for some people when they're listening to this, they might be thinking, oh my goodness, I've got to do all these different things.

This feels like a full-time job, right? I've got to go to bed at a regular time. I've got to meditate, do yoga, do some strength training.

All these things eat a healthy diet. But actually what I've found in high performance, which is the area I work in, is these things that actually contribute to you being a high performer over the longer term, because they make it sustainable. What would you say to someone listening to this?

What does your own routine look like in terms of daily and weekly that helps you run three businesses and also have three children?

[Robin Berzin] (45:13 - 51:24)
The only reason I can do what I do, be a mom to three kids, be a good partner to my husband, be social and have friends whom I deeply care about, have a strong relationship with my parents. All of those things at the end of the day are what it's all about. And then adding into that, I feel super blessed to be able to do something I love, to know what I'm passionate about, and to be able to do work in that field and to start companies and also to write and to speak with you on this conversation and all of it, right?

And the only reason I can do any of that is because for me, health is a practise and I'm living that practise every single day. Health is not this thing I achieve somewhere off in the distance and then I check it and I say, cool, I did it, gold star for me, I am healthy, the end, I'm done now. It doesn't work like that.

Health is a practise. And for me, the things that are the non-negotiables in my practise are as follows. Number one, I meditate every single day.

I developed a really strong meditation practise in my early 20s and everyone for a sort of high strung, overachieving nerd who had some level of ADHD to meditate, let me tell you, was like really freaking hard. Like when I first started to meditate, and this was after I kind of got into yoga, but the meditation thing just made no sense to me. And I was like, I'm sorry, I don't get this, this is annoying.

I would sit down to meditate and a few minutes later, I would actually find myself standing up like in the room. Like I would just like, suddenly I would be standing up and I would be like, wait. It was really hard for me, but I had the fortunate experience of doing a 10-day silent meditation retreat called a Vipassana, which I literally forced myself into the summer after my first year of med school.

So at this point, I'm in my mid 20s. And I really learned to meditate there. It was the hardest thing to date that I've ever done in my life.

It was harder than med school, but it was a massive rewiring of the brain. It was a massive sort of training ground to learn to meditate. And for me, the power of just 15 minutes, I call it my espresso meditation.

So I have a double espresso and I'm definitely caffeine dependent everyone, but I don't have caffeine after 9 a.m. I only have caffeine before 9 a.m. I get up, it's like 6.30. I make my double espresso. It's a beautiful ritual for me. I sit and some people have espresso martinis.

I have an espresso meditation and I meditate for 15 minutes. And I have a number of different meditation modalities, but it doesn't matter which one I use. Ultimately, what happens is that I'm more focused that day.

I'm more regulated. I'm calmer. I feel better.

The day goes better. And it is a proactive wiring of my brain to be able to cope with and face life. And the days that I don't do it, I feel it.

So that's number one. Number two is that I live the medicine I preach when it comes to how I eat. So I eat a low sugar, strong amounts of protein.

I'm not getting 150 grammes of protein a day people, but if I get 70 to 80, it's a really good day. And so as protein focused, high fibre, so getting at least 30 grammes of fibre a day does wonders for your hormones, for your digestion, for your blood sugar, for your metabolism, for your brain health, getting lots of vegetables, eating whole real foods, getting less than 25 grammes or so of sugar a day, whether added or naturally occurring. And for me, I'm gluten-free and dairy-free mainly because those foods cause acne and eczema and breakouts for me.

And vanity is a great motivator. But with gluten in particular, I definitely feel if I eat it a lot, I get kind of angry and irritable and brain foggy. It's just an inflammatory food for me, even though I don't have celiac disease, so I'm sensitive to it.

So I eliminate those things and get a healthy amount of fish oil and omega-3s and eating that way, even when I'm travelling. So I travel a lot for work. That means before I go to the airport the night before or that morning, if I have time, I buzz into the grocery store and I bring a bunch of healthy snacks and a healthy meal and I travel with my own food.

When I land for the crazy conference, I go to this big health care conference in Vegas every year. There's no more at odds place to go to a health care conference, by the way, than Las Vegas. And it's like, what?

And I get there and I take an Uber to the grocery store and I buy a bunch of nuts and seeds and cut up vegetables and sparkling waters and glass and a bunch of things and I bring them to my hotel room. And that way, I'm just eating healthier and have food on hand so I can stay within the eating programme that keeps me calm, that keeps me focused, that keeps me sleeping, that keeps me feeling good. And I can't speak enough to that because our society rewards convenience culture, the sugar, the bar.

Oh, I'm at the airport. I'll eat this thing I wouldn't eat. Oh, I'm at the hotel.

I'll eat this thing I wouldn't eat. And I do that sometimes. I'll have a slice of pizza.

I have a glass of wine on the weekends. I don't drink a lot of alcohol, but I do drink some in a very moderate amount, about once a week. That works for me, doesn't work for everyone.

And so I have permission around these things. I'm not sort of strangling myself in the name of perfection, but I am really on it when it comes to eating the way that I know I can feel good. And in that, I have the good sleep, I have the energy and I have kind of the wherewithal, like the resilience to do everything that I do.

And so those are two of the things that are non-negotiables for me. That I, again, it's not perfect ever anyone, but if I'm there 80, 90% of the time, that is the difference between me kind of being able to function and me being bloated, foggy, hangry and basically having to break down.

[Angela Foster] (51:25 - 51:39)
And how have you juggled it with children? Do you have certain kind of rules of work when you stop working that you won't look at things? Do you kind of ban work in the evenings or do you find you have to go on?

Or do you preserve weekends? How do you approach that? So it's difficult for many of us.

[Robin Berzin] (51:39 - 53:20)
No, I've had to have a lot more boundaries around it. And it's so funny how it changes, like one baby when it's just you and your partner and you've got one baby and you can kind of trade off. I remember I would like work on the weekends and have plenty of time and space for my baby and do all these things.

And then they get older and they sort of need you more in different ways. And then they also start staying up later and like no longer they sleep at 630. And you're like, what just happened to my kids?

I'm dying. Like that transition for me was harder than having a kid. All of a sudden their bedtime is 830 and not 630.

I'm like, oh, wow. Then I had to do more and everything was sort of blown up. So yeah, I go home at 530 or six.

And if I'm in the office, some days I work from home, which is such a luxury. I am not working. It's blocked down on my calendar for my job.

Like 630 to 830 is blocked down on my calendar every single night as family time. I don't work on Saturdays ever. That's family day.

We cook and eat dinner as a family at least four to five nights a week. Like let's face it, I'm busy. I have a social life.

Sometimes I'm out, sometimes we don't. But we eat together as a family and cook or have a meal as a family far more often than we don't is what I would say. And setting those boundaries has meant like it's a lot harder to get stuff done on the weekends and the evenings.

After the kids go to bed now, I'm exhausted. I can kind of do some life admin, but I'm useless when it comes to doing anything meaningfully productive for work. And that's the trade-off.

And I wouldn't trade it for anything.

[Angela Foster] (53:20 - 53:52)
Yeah, I do. And I think you know though as well, I think it actually, you have with that recovery, you have better focus the next day. I think that almost isn't it?

Time can no longer expand to the task given when you have three children. Yeah, and the transition to teenagers was what really got me because I'm such an early riser at sort of five and that's when I'll go work out. And now they stay up right until half 10, 11.

I'm like, oh no, this is encroaching on my sleep time. So yeah, it's a moving target, isn't it? With kids, it's always changing.

[Robin Berzin] (53:53 - 55:22)
It's always changing. And I'm always reminded though that humans are so wildly adaptable too. And so I sort of give myself credit for that.

And yes, my favourite time to go to any exercise or a workout class historically was 6 p.m. I'm a morning thinker. I do my best work in the mornings. I wanted to like get up, go, go to work, go to study, do whatever I'm gonna do in the morning.

And then by the end of the day, I basically like run out of dopamine. And that's when I would wanna sort of either pick it up with exercise or do yoga or sort of move into a different mode. And with my kids, that is impossible.

That is a time that I cannot do any form of exercise because it's family time or if I'm not with family, it's social travel time. And so I think that having had to accept that was honestly really hard for me. And for a while it led to, well, I just don't work out because how could I eat into my working mornings with a workout?

And now I do that twice a week at 9 a.m. I have a Pilates class and I have a training session with weights. And I start my day at 10 and because I have to be up with... My kids are little.

And so I've gotta be up and do the whole morning thing and the school drop off and everything. And so it does mean kind of shifting my day later, shifting my focus time later. But I've been capable of more than I thought I was, which is a good feeling too.

[Angela Foster] (55:22 - 55:56)
It's amazing. I think it's all the things, right? That you live and breathe everything that you're sharing here.

Thank you so much for this. This has been super helpful. I would definitely encourage people listening to this to go back and listen again because there's so much in here in terms of just practical tips as much as anything else that you can start doing.

I know you have a fantastic newsletter, which is one of the ways that people can stay up to date with everything you're doing. Parsley Health also is the only medicine practise, I think, that operates across all 50 states in the US. It's pretty incredible.

Please share. How can people connect with you and learn more about everything you're doing?

[Robin Berzin] (55:57 - 57:35)
So my website, robinbersonmd, just my name, robinbersonmd.com, sign up for my newsletter. It's called Offscript. And I dive into all of these topics and I give really actionable tips.

I wrote it the way that I would wanna read a newsletter, which is I have no time. I wanna skim and I wanna be able to get really actionable insights that I can just use in my day-to-day life. So that's my newsletter.

Please say hello to me there or robinbersonmd on all the socials. And then Parsley Health, as you said, thank you for that. It's the only national functional and longevity medicine clinic.

It's the only one that's a network and takes insurance. It's the only evidence-based, truly high quality doctor-led functional and longevity clinic where we not only help you optimise your health and health span and help you optimise your hormones and prescribe HRT and things like GLP-1s and sort of look at all of those things. But we also, at the same exact time, treat the underlying symptoms and conditions that you have.

So we work on a lot of fertility. We work on a lot of menopause and perimenopause, autoimmune, gut health issues, metabolism and heart health, mental health. We've talked a lot about mental health today and the intersection between physical health and mental health, which is so powerful.

And if you're somebody who needs diagnosis or you need help with any of these things and you want a more personalised, kind of proactive personalised approach, we talked earlier about how in conventional medicine, it's hard to get that. Functional medicine is where it's at for that. So check out parsleyhealth.com and find us.

[Angela Foster] (57:36 - 57:41)
Amazing. Thank you so much. We will link to all of that in the show notes.

Thanks again for coming out. Thank you for having me.

Most women doing everything right in perimenopause still feel exhausted, foggy, and frustrated by belly fat that won't shift. This is not a willpower problem. It is an estrogen problem, and most women are being told to wait when they should be acting now.
In this episode, I sit down with Dr. Robin Berzin, founder of Parsley Health, to explore why belly fat accumulates around the middle as estrogen shifts, why 43% of ADHD diagnoses in women hit between 41 and 50, and why estrogen loss drives brain fog and dopamine decline that most doctors are missing. Dr. Berzin also makes the case for starting hormone therapy early and shares what data from 120 million women tells us about HRT, dementia risk, and long-term protection for your brain, bones, and heart.

WHAT YOU’LL LEARN
• Why brain fog gets worse in perimenopause
• The link between estrogen, dopamine, and focus after 40
• Why so many women are being diagnosed with ADHD in their 40s
• The early signs of perimenopause 
• How HRT reduce the risk of dementia and Alzheimer's in women
• How low progesterone affects your sleep, skin, and mood
• How to track perimenopause symptoms and labs over time
• How magnesium helps with ADHD, anxiety, and sleep in perimenopause
• How zone two cardio and yoga improve focus and brain function after 40