In this episode of Longevity By Design, Dr. Gil Blander and Ashley Reaver interview Dr. Sara Gottfried. Dr. Gottfried received her MD from Harvard Medical School and completed residency at UCSF, however she is more likely to prescribe a continuous glucose monitor and personalized nutrition plan to her patients than the latest pharmaceutical.
This episode is a must listen for anyone trying to optimize their wellness plan. Dr. Gottfried discusses all the data she tracks, and how that helps her practice precision medicine. This conversation also sheds light on how birth control pills impact women's health, how erectile dysfunction is an early warning sign for atherosclerosis, and gives advice for women seeking hormone replacement therapy.
- Introduction: (0:00–1:00)
- Dr. Gottfried’s motivation for becoming a physician: (1:00–4:30)
- Dr. Gottfried’s fascination with performance and healthspan: (4:30–5:30)
- How do we define “Hormone balance”: (5:30–7:10)
- Is hormone balance more common in men or women? (7:10–9:30)
- Understanding heart disease trends in women: (9:30–12:07
- Why women should track their body composition over time: (12:07–16:23)
- Testosterone is the most abundant hormone in the female body: (16:23–19:19)
- Chronic stress can accelerate testosterone decline in women (19:19–20:20)
- How the birth control pill impacts women: (20:20–26:58)
- Cortisol is one of the most important hormones in the body: (26:58–32:50)
- Dr. Gottfried’s recommendation for lowering cortisol?: (32:50–37:30)
- Insulin and avoiding diabetes: (37:30–38:45)
- Tracking your metrics over time (time-series): (38:45–40:30)
- DEXA scans and tracking body composition: (40:30–42:30)
- Cortisol in professional athletes: (42:30–45:43)
- The female athlete triad: (45:43–49:45)
- Understanding your health goals: (49:45–51:50)
- The importance of sleep: (51:50–59:11)
- Behavioral science: (59:11–1:03:10)
- Keto diets and the mediterranean diet: (1:03:10–1:07:30)
- Hormone replacement therapy: (1:07:30–1:15:35)
- Erectile dysfunction: (1:15:35–1:19:00)
- Dr. Gottfried’s top tip for healthspan: (1:19:00–1:21:33)
About Dr. Sara Gottfried
Dr. Sara Gottfried, MD, is a physician, researcher, educator, mother, and seeker. She graduated from Harvard Medical School and MIT, and completed residency at UCSF—however she is more likely to prescribe a continuous glucose monitor and personalized nutrition plan to her patients than the latest pharmaceutical.
Dr. Gottfried is a global keynote speaker and the author of four New York Times bestselling books about trauma, hormones, and health. Her latest book is called THE AUTOIMMUNE CURE and publishes in March 2024. She is Clinical Assistant Professor in the Department of Integrative Medicine and Nutritional Sciences at Thomas Jefferson University, and Director of Precision Medicine at the Marcus Institute of Integrative Health. Her focus is at the interface of mental and physical health, n-of-1 trial design, personalized molecular profiling, use of wearables, and how to leverage these tools to improve health outcomes.
Defining hormone health with Dr. Gottfried
Hormone balance refers to having the proper ratios and levels of hormones in the body, reflective of your current life stage, for optimal health. When hormones are balanced, the result is being relatively symptom-free, according to Dr. Gottfried.
In contrast, hormone imbalance indicates one or more dysregulated hormones. Imbalances can occur for many reasons, such as disease states, autoimmune disorders, and more. Examples of common conditions caused by a hormone imbalance include polycystic ovarian syndrome (PCOS), hyperthyroidism, and hypothyroidism.
Is hormone imbalance more common in men or women?
Hormone imbalance is more common in women due to greater vulnerability to hormonal dysregulation. Women undergo more periods of dramatic hormonal shifts than men throughout their lives, such as during pregnancy, postpartum, perimenopause, and menopause. In contrast, men experience a more gradual decline in testosterone with age.
The figures below show how a woman's hormones fluctuate during her menstrual cycle and during the menopause transition.
The dramatic hormone shifts associated with menopause raises a woman’s risk for health problems including heart disease, stroke, and osteoporosis. For more information on how menopause impacts women's health, check out this episode with Dr. Jennifer Garrison.
The hormone cortisol helps regulate blood sugar and inflammation in the body
Cortisol is a steroid hormone produced by the adrenal glands that plays several critical regulatory roles in the body. Cortisol helps control blood sugar levels by stimulating gluconeogenesis—the process of breaking down fat and protein to form glucose for energy. It even helps regulate the immune system by reducing inflammation.
One of cortisol's most vital jobs is managing the body's stress response through its effects on metabolism, blood pressure, and neural activation. When functioning properly, cortisol provides these beneficial impacts. However, chronic stress can cause excessive cortisol release, which may disrupt blood sugar regulation, immune function, and other systems that cortisol helps regulate. Sustained high cortisol is linked to health issues like impaired cognition, depression, and heart disease.
While some cortisol is necessary for optimal health, excessive amounts due to high stress can negatively affect the body. Dr. Gottfried recommends tracking cortisol levels over time to understand your baseline level and how your body responds to stress over time.
Erectile dysfunction is an early warning sign for atherosclerosis
Erectile dysfunction can serve as an important early indicator of developing atherosclerosis. The penile artery closely resembles coronary arteries in structure and function. Thus, plaque buildup and reduced blood flow that impedes erections may signal similar processes occurring in the heart. Dr. Gottfried emphasizes that erectile issues should prompt evaluation for subclinical cardiovascular disease.
Next steps for assessing atherosclerosis should include a coronary artery calcium scan to quantify atherosclerotic plaque. This quick test can provide actionable information about cardiovascular risk. Additionally, she recommends getting an advanced lipid panel, which should test markers like ApoB, LDL, and Lp(a) cholesterol.
Testosterone is the most abundant hormone in the female body
During the conversation with Dr. Gottfried, she emphasizes how vital testosterone is to the female body. In fact, testosterone is the most abundant sex hormone in women. “Although women's testosterone levels are about 10 times lower than men’s, women are exquisitely sensitive to this hormone,” says Dr. Gottfried. Testosterone helps regulate sex drive, muscle mass, strength, and energy levels in women. Moreover, adequate testosterone is necessary for strong, healthy bones.
Signs that testosterone may be low include decreased libido, reduced muscle tone, lack of energy, and hair loss. Dr. Gottfried recommends women track their testosterone levels over time to ensure they stay within the optimal range.
Chronic stress and taking birth control pills increase the risk for low testosterone in women
Two major risk factors for low testosterone in women are chronic stress and use of birth control pills. Dr. Gottfried shares that chronic stress accelerates the decline of testosterone and DHEA in women. Additionally, birth control pills raise levels of sex hormone binding globulin (SHBG), which binds to testosterone and reduces the amount of free, usable testosterone in the body. It’s important to note that some women are more susceptible to this effect than others.
While the topic is commonly debated among practitioners, Dr. Gottfried disagrees with the notion that birth control pills "balance" hormones—rather, they override and suppress the body's natural hormonal rhythms. Rather than using birth control pills as a means to balance hormones, women should work with their healthcare providers to find sustainable solutions to balancing hormone levels.
Risk of cardiometabolic disease differs by sex
Rates of cardiovascular disease can differ drastically between men and women. For example, cardiometabolic diseases are now being seen at increasingly younger ages in women. Dr. Gottfried states that the age group with the highest rate of hospitalization for acute myocardial infarction is women between 35-54 years old. In the same cohort, the incidence of heart attack remained relatively stable among men in this same age bracket. 
Women experience different heart attack symptoms than men
In discussing how disease trends differ between men and women, Dr. Gottfried points out that women experience very different heart attack symptoms than men. The symptoms that women experience aren’t necessarily the classic “elephant sitting on your chest” pains experienced by men—which can lead to inefficient detection. This is in part due to women having smaller coronary arteries and more microvascular cardiac disease compared to men. Rather than sudden severe chest pain, women often experience waxing and waning symptoms including back pain, nausea, and breathing issues. Dr. Gottfried says that recognizing these variances is critical for promptly identifying and treating heart attacks in women.
Tracking your body's data over time helps optimize your wellness plan
A major topic of discussion during this episode with Dr. Gottfried is the importance of tracking your body’s data over time. She encourages getting as many biometrics as possible to precisely understand your state of health. This can include getting your body’s data from fitness trackers worn daily, quarterly blood testing, body scans, and more. She specifies to track your data as a time series—meaning checking health data at regular intervals over an extended period of time. This allows you to detect subtle changes and emerging patterns personalized to your physiology.
“Having a baseline and being able to identify your unique fluctuations and vulnerabilities enables precision interventions to correct imbalances and promote optimal health,” shares Dr. Gottfried.
The top metrics Dr. Gottfried recommends tracking over time include:
- Sleep data (Oura ring or other wearable)
- Fasting insulin (blood test)
- Fasting glucose (blood test)
- HbA1c (blood test)
- Cortisol (blood test or saliva test)
- Cognitive abilities (processing test, memory test)
- Body composition, specifically body fat percentage and lean body mass (DEXA scan or InBody scan)
Body fat is a marker of vitality in reproductive age women
Adequate body fat is critical for hormone production and overall vitality in women of reproductive age. Women ages 20-39 should aim to maintain 21-32% body fat. This can be assessed using body scans, including DEXA and InBody.
Body fat provides the cholesterol needed to synthesize key hormones like estrogens, progesterone, testosterone, and cortisol. Extremely low body fat, often seen in female athletes, can profoundly suppress sex hormone synthesis and disrupt menstrual cycles. The female athlete triad—which includes amenorrhea (loss of menstrual cycle), bone loss, and low estrogen—can occurs when body fat drops below 12-18%.
Excess body fat is also harmful to health, as it is linked to infertility, metabolic dysfunction, and inflammation. Tracking body composition over time and tracking menstrual period cycles can help determine the ideal body fat percentage for an individual woman.
Dr. Gottfried on sleep—"Sleep is as close to a panacea as we have"
Sleep is critical for health, recovery, and hormone balance. During sleep, the brain's glymphatic system effectively "cleanses" neural tissue of toxins, debris and free radicals that accumulate during wakefulness. Skipping sleep prevents this restorative process, allowing waste products to build up. Cortisol and other catabolic hormones involved in stress responses are also modulated during sleep. “Just one night of poor sleep can elevate next-day cortisol, insulin resistance, carbohydrate cravings, and suboptimal decision-making,” says Dr. Gottfried. Ultimately, sleep provides an opportunity for the body to regenerate, detoxify, and recalibrate hormone levels.
Dr. Gottfried shares that sleep is "as close to a panacea as we have." Optimizing sleep duration and quality should be a pillar of any healthy lifestyle. Adults require 7-9 hours of quality sleep per night to allow full brain detoxification, tissue repair, and realignment of circadian rhythms.
Dr. Gottfried's advice on Hormone Replacement Therapy (HRT) for women during the menopause transition
Dr. Gottfried recommends hormone replacement therapy (HRT) for some women as they navigate the changes associated with menopause. For those seeking out HRT, Dr. Gottfried’s first piece of advice is to get a comprehensive hormone panel including markers like estradiol and progesterone to assess where your levels currently stand. She explains that understanding how the menopause transition is impacting your hormone levels and knowing where your levels are is the first step in assessing if hormone replacement therapy is right for you.
Dr. Gottfried’s next piece of advice is to closely track your perimenopause symptoms. There are over 100 symptoms associated with perimenopause and each woman has a different experience—she advises sticking to 5-8 symptoms and tracking them over time. Examples include measuring cognitive function—including processing speed and memory—sex drive, and muscle mass.
Dr. Gottfried also clarifies that not everyone is a candidate for hormone replacement therapy. For example, individuals with a personal or family history of blood clots or breast cancer may not be candidates for HRT.
How is HRT administered?
For those pursuing HRT, Dr. Gottfried says the best option for estradiol—the primary form of estrogen in the body—is a topical solution. She says there are many FDA-approved versions of topical estradiol, including a patch, gel, or cream.
For progesterone, Dr. Gottfried says oral progesterone is the most appropriate for women. Oral progesterone has been shown to protect or prevent women from an increased risk of endometrial cancer.
When should HRT be initiated?
While not conducted ideally, the Women's Health Initiative remains the largest randomized controlled trial investigating HRT. Based on this data, experts recommend initiating hormone therapy within 10 years of menopause onset. For example, a woman who undergoes menopause at age 51 would consider continuing HRT until age 61. Beyond the 10 year mark, the decision to extend therapy should involve discussions every 6-12 months with a knowledgeable clinician weighing the latest evidence.
Dr. Gottfried says hormone therapy would ideally begin in perimenopause to maximize benefits, particularly for brain health. Some data suggests the window of opportunity for neurological effects may be only five years from menopause. She specifies that this approach should be developed in partnership with a clinician well-versed in the nuances of hormone therapy.
Top tip for healthspan
Dr. Gottfried’s top tip for healthspan is to optimize muscle health. “Muscle is the organ of healthspan,” she states in her closing remarks. “Love your muscle, track your muscle, measure your skeletal muscle, measure your lean body mass—and do it as early as possible.”
Similar Longevity By Design episodes we think you would love:
- Dr. Jennifer Garrison—Women's Health and Longevity Part 1
- Dr. Jennifer Garrison—Women's Health and Longevity Part 2
- Dr. Jennifer Lovejoy—How Hormone Balance and Optimal Metabolism Promote Healthy Aging