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Rethinking heart health, one question at a time.
I’m Dr. Sanjay Bhojraj—interventional cardiologist, functional medicine expert, and lifelong student of what really keeps us well. In this podcast, we go beyond prescriptions and procedures to explore the deeper drivers of health, disease, and healing.
From inflammation to intuition, cholesterol to consciousness, I sit down with doctors, researchers, and changemakers who are reshaping how we think about the heart—and the whole human behind it.
Whether you're a fellow clinician, a health seeker, or someone navigating your own transformation, this show will challenge what you thought you knew—and invite you to stay curious.
Sanjay Bhojraj MD (00:01.474)
Hi everybody and welcome to this episode of the Curious Cardiologist podcast. My name is Dr. Sanjay Bhojraj recovering interventional cardiologist, now working in the functional medicine space. And we are here today with Emily Sadri, who's just a fascinating person. We'll get into a lot of her background in training, but trained as a nurse wife and a, or sorry, nurse practitioner and a, I don't know what a nurse wife is, but maybe a nurse midwife is what I meant to say, but a nurse practitioner became a midwife and now
Emily Sadri (00:24.885)
A nurse midwife.
Sanjay Bhojraj MD (00:31.426)
focuses a lot on hormone therapy and metabolic disease and its influence on all of our health. So Emily, thank you so much for being here. It's still there, yeah, it's still there layers deep, but it's almost sometimes you have to deprogram yourself when you've been in the conventional world for so long in this space. So what...
Emily Sadri (00:40.181)
Thank you for having me. And I love that I could say that I'm a recovering midwife as well. Still in me, but you know, there is a recovery. Yeah.
Sanjay Bhojraj MD (00:59.002)
Well, let's just start out. We'll just jump right in. Tell me a little bit about your journey from the conventional medical space where you're practicing before into what's morphed into a pretty awesome practice that you've got right now.
Emily Sadri (01:11.849)
Yeah, thanks. So many years ago, I started my career as a nurse practitioner and nurse midwife. So was delivering babies in a low resource setting in urban Cleveland and really got into midwifery before I even knew that you had to be a nurse. So it's kind of an accident that I even ended up with a more official medical designation of nurse practitioner. And I really felt pretty burned out when I was approaching year five of practice simultaneously while I was in school and in early practice, I had four children.
So, you know, that may have conflict.
Sanjay Bhojraj MD (01:44.462)
Please, please tell me you had somebody else deliver them for you. didn't just midwife yourself through, okay.
Emily Sadri (01:48.157)
Well, actually, well, didn't know I did have midwives. I did have midwives, but I did have home births. Something I just knew was what I wanted and would have been happy to deliver in the hospital if I needed that. But for me, was was the right choice. But I caught babies in the hospital and I just felt this massive disconnect not only in my own health. And it's interesting. One of the things that popped into my head as you were introducing yourself was you may see this as well in your practice that
Sanjay Bhojraj MD (01:53.73)
Okay.
Emily Sadri (02:16.617)
Some of our hardest patients are physicians or nurse practitioners. The people that are working in the system who probably got into it for really altruistic reasons are just so beat down and so disconnected from their own health and so disconnected from the pillars of the things that we know make us most healthy, like good sleep, good fresh food, love and connection.
Sanjay Bhojraj MD (02:38.882)
mean, just not having a nervous system that's fried all the time, right? Like,
Emily Sadri (02:42.121)
Right, all the time, right? And I think more sensitive people are attracted to medicine because we wanna help. And so we're even more susceptible to the sort of lifestyle of it. So I felt myself very much cracking under that. I actually had gestational diabetes in my third and fourth pregnancies, which to me made no sense because for all intents and purposes, I had a very healthy diet. I was active, I wasn't overweight, but metabolic issues branded my family and...
What I found was that the only thing that really helped my morning blood sugar, which was the only marker that was ever really off for me, was meditation and deep relaxation. That it didn't matter how much I restricted carbohydrate grams. In fact, even being at 30 or 40 grams of carbohydrates a day, which is extremely restricted for a pregnant woman, that didn't affect my blood sugar. But doing deep relaxation did.
Sanjay Bhojraj MD (03:34.4)
That's pretty amazing. The whole thesis, if you will, of the podcast, The Curious Cardiologist, is looking at old problems in new ways. Exactly what you're saying is that I'm sure the conventional docs were saying, just don't eat sugar, reduce carbs. That still had no effect. What we need to do is connect the mind and the body and realize that there's something going on. think nowhere is that connection more sacred than
Emily Sadri (03:44.373)
Hmm.
Sanjay Bhojraj MD (04:03.628)
while you're manufacturing a child, right?
Emily Sadri (04:05.985)
100%. Yeah, it was really eye opening to me. it was also, I learned a lot about sort of genetic type and sort of diet tolerance. Some people don't do well with high saturated fat, sort of keto approach. Like that is actually more pro-inflammatory. And I'm one of those people that actually does better from a glucose control perspective when I'm eating more whole grains and vegetables and much leaner proteins. I don't tolerate saturated fat as well from an inflammatory perspective. again, things that just sort of weren't
Sanjay Bhojraj MD (04:16.098)
Mm-hmm. Yeah.
Emily Sadri (04:33.567)
disgust and that made me really curious and made me go, you know, if I'm struggling this hard to be healthy, you know, then I just didn't feel authentic in my work anymore. It didn't feel authentic to me to be helping other women be healthy when I was just constantly sort of lying every day about how I felt. So right before, right after I gave birth to my fourth, I resigned from my position.
before going back from maternity leave. It didn't hurt that it was the middle of COVID and I had three other kids home from school. And it was a time when people made big decisions and that was my big decision.
Sanjay Bhojraj MD (05:11.246)
It was, I mean, I've got triplets as probably our listeners have realized at this point. And I can't imagine four, I would just fold. mean, there's like a, there's a, there's a, well, there's like, I think there's a maximum number of stress humans can have. So I can't even imagine like going through training and practicing as four kids. mean, kudos to you. And I do think you're right. COVID was an interesting time for us, right? Because it made us,
Emily Sadri (05:22.697)
I mean, but yours are the same age. That's that's craziness right there.
Sanjay Bhojraj MD (05:41.102)
you know, a couple of things, realized that we needed to slow down, either we were forced to do it or the pace of our lives just kind of changed. And you're right, it allowed us to make some big decisions. how did that, did you make the right choice in your big decision of leaving?
Emily Sadri (05:44.193)
Hmm.
Emily Sadri (05:57.147)
And the other interesting thing about COVID was that we probably had the same experience. We didn't see patients as much, right? The people that had to be seen every two weeks suddenly could go three or four weeks. All of our medical model of what needed to happen changed. And I just thought that was so interesting. was like, maybe we don't need to stress people out as much. we can, like, what is the...
We learned a lot about less is more during that time. And I was doing a lot of virtual visits during COVID because we switched to primarily telehealth and I was pregnant. So I was sort of first on the list to take patients by telemedicine. And I was like, I really like this. Like I like the fact that I can go to my kitchen and like, you know, eat food that makes me feel good and like be there for my patients. And it doesn't feel like so much stress to drive across town and all these things. So it was an easy leap. That being said,
Sanjay Bhojraj MD (06:32.046)
Me yeah
Emily Sadri (06:51.201)
I, for, for people out there who are providers, I'm sure you have providers listen to your podcast who are thinking about taking the leap. Just my little plug would be like, start before you're ready because I didn't have a plan. I didn't, I'd never had a business before. didn't know how to set up an LLC. Like I didn't know anything, but I really trusted. I think many healers will resonate with this, that if I made the right decision for my body and my health, it would lead me down the right path. And that like the healthier that I became, the better I would become.
and that it would all unfold. And it did. I it really did. I started out by just doing home visits and I would do your pap smear and your breast exam and your blood draw and your home. And then, a weeks later we would meet via Zoom to review your results. And I loved that because it was like midwifery, but for primary care. You know, was really like meeting people where they were.
Sanjay Bhojraj MD (07:38.316)
Yeah. Well, and I like to kind of the hybrid model because when I was doing telehealth visits in cardiology, even the background of the patient, you know, gave me some insight into what their home life was like. I'll never forget. I was on a kind of two visits. Number one, some guy, we're doing a telehealth visit and he had his video off.
And I said, I'm sorry, sir, it helps me to have video on so I can see and whatnot. And he's driving, right? And I'm like, you gotta pull over to the side of the road, right? So I think that kind of speaks to how aggressively people multitask and try to get so many things. And that drives a lot of our sympathetic dominance, as I'm sure we'll talk about. The other one that was absolutely hilarious was I was talking to somebody and I wanna see this kind of white kind of column kind of rising up. But I'm like, wait, is...
Is that an ashtray in front of your computer? Are you actually smoking while you're on a cardiology visit? Come on, dude. At least put the ashtray behind the screen so I can't see the smoke. But I didn't even know that that patient smoked. And I've got a pretty sensitive nose, as probably most health care people do. So even if you had a cigarette two weeks ago, I could smell it. But it gives a lot of insight into it. But I also think that a great part of it was, in a sense, people
Emily Sadri (08:36.575)
while on your cardiology visit.
Emily Sadri (08:46.485)
Hmm.
Sanjay Bhojraj MD (09:01.902)
took a little bit more ownership of their health. I don't know if that makes sense. like people realized, you know what, like, I need to do these things a little bit more. And, I don't just offload everything to the doctor, because I don't know when I'm going to see him or her, whoever my healthcare team person is, maybe I need to take a little bit more control. And we saw that, you know, I mean, I not tons of opinions on the pro or anti vax kind of side, but people were more concerned about what these treatments, how it affected their own health, right. And I think that was kind of a weird way, a good thing. And to your point,
you know, after I left, my health improved so much as well. So for the practitioners, you know, I realized that I was on track, you know, as I approached 50 to have my own heart attack as I was treating everybody else's heart attack, right? So I think that for the practitioners listening, we have to be aware of the toll that our careers take on ourselves, right? So I think that's a hugely important lesson.
Emily Sadri (09:51.893)
Yep. Yeah. I think totally, I think during COVID we saw firsthand that people who were more unhealthy, especially from a metabolic standpoint, were more likely to die from COVID, right? And that was a real reckoning for a lot of people, you know, that there was this threat and there was this, now I'm in my house and I'm kind of face to face with like how I'm feeling and what my risks are. And, you know, for better or worse, that was a wake up call.
Sanjay Bhojraj MD (10:19.416)
Yeah, no, absolutely, absolutely true. Well, why don't we kind of push into kind of what you're doing nowadays? Because I'll tell you, as a cardiologist, and I did my functional medicine training through IFM, and I'm actually going through A4M right now, hormones were something that I would never have wanted to touch with a 10-foot pole, to be honest with you. think that even men, it's much simpler in men than women. You've got testosterone. Essentially, that's it, right? Women, you've got all these.
cycles and things and all these kinds of craziness. But I didn't really appreciate hormone replacement therapy as a cardiovascular therapy, right? Which more and more, I think the literature is starting to support. And I know that's a lot of what you talk about in your practice as well. let's kind of, how did you get, how did that become, how did that evolve through your training as an NP and then as a midwife?
You know, how did you get to hormones and then specifically how did you kind of link that to metabolic disease?
Emily Sadri (11:20.117)
Yeah, I love those questions. So when I was in school in the early 2000s, I was actually had a minor in public health. So I had a lot of epidemiology and my entire epidemiology course was on the WHI study, which some of your listeners will know is the large study that came out in 2002. Yes, exactly. And that was the Holy grail. I mean, we studied what a well-designed study it was. And so we also concomitantly in my clinical training learned that basically hormones were off limits.
Sanjay Bhojraj MD (11:34.523)
It's like the ultimate, ultimate medical facepalm.
Emily Sadri (11:50.145)
SSRIs are the number one treatment intervention for symptoms of menopause. we spent 90 % of the education was learning about birth and delivery and prenatal and postpartum. And then the other 10 % was make sure to give people calcium, treat them if they have high cholesterol, give them baby aspirin and screen them. Like that was really sort of health after 40 in a nutshell. like...
Sanjay Bhojraj MD (12:13.112)
Yeah
Emily Sadri (12:13.729)
And it's crazy. if you take the menopause society exam today that will board certify you as a menopause trained clinician, most of the questions are still on that primary care stuff. It's like, what age do you do this? because we didn't have tools, and so the only thing we could do was say, make sure to screen them well. The wild thing, and this still persists, I think, in both sides, on the conventional side, on the integrative side, is that midlife
women, their health really falls off a cliff. It's different than for men, right? For men, they are more likely to have a heart attack when they're younger, but women far surpass male counterparts after the age of 50 in terms of cardiovascular disease risk, and cardiovascular disease is the number one killer of women. But no one is making the connection that the loss of estrogen dramatically accelerates that risk.
Sanjay Bhojraj MD (13:05.762)
Absolutely, and I think one of the earliest signs of, I guess, perimenopause that cardiologists see all the time is that LDL bump out of nowhere, right? Like in retrospect, I would have so many women, this is before I did my functional training, and you know, their LDL would just jump 30 points, and I'd be like, what are you doing? Are you eating differently? Are you not exercising in much? All these things, and...
Emily Sadri (13:26.923)
Yep, made them feel guilty like every good doctor does.
Sanjay Bhojraj MD (13:28.494)
Yeah, mean, it's, well, it's the, it's the, the doctor doesn't know what's going on, we just blame the patient, right? Like that's just kind of how it is, right? So, so it's like, what are you doing that you're not following my recommendations? But in retrospect, think cardiologists are actually probably frontline in detecting when perimenopause happens. And that's why I think it's so important for us as cardiologists, functional cardiologists, conventional to at least recognize and then refer if you can't do it yourself, right? So, yeah.
Emily Sadri (13:32.577)
Totally. Unforso true.
Mm-hmm.
Emily Sadri (13:53.653)
Yep, yeah, 100%. Yeah, estrogen has a direct impact on the liver and the way that it decides to sort of bring back LDL from circulation in the way that it produces HDL. So it down regulates the production of HDL. Estrogen influences insulin sensitivity. So as we become more insulin resistant, our triglycerides go up, visceral fat deposits as estrogen declines. So it's just this dramatic cascade.
And there is, of course, an independent metabolic sort of aging or inflammation or sort of fall apart, I like to call it, that happens. And I know this because it's really interesting in our practice. We, one of the methodologies of HRT that we do is called like a sort of dynamic or precision HRT, where we sort of mimic the menstrual cycle. And we do this sometimes with women who have premature ovarian insufficiency, who are like 25 or 28 years old, don't have a cycle or amenorrheic.
and ovulatory women with PCOS who are very severe cases, like in their early 20s who have an estradiol level of 20, right? And an FSH through the roof. And we could get into all the reasons why that happens because it's really, it's a bad situation, right? How many women are sort of have hormonal fall apart and young age and all of the root causes of that. And part of what we do while we're trying to work on those root causes and get them healthier is we'll put them on rhythmic hormones to replicate their cycle.
And the fascinating thing is that these women will come in and they'll present like 50 year old, 60 year old women with metabolic issues, right? They have A1C at 5.7, they have, you know, high LDL, they, all the things, they have the whole syndrome. And as soon as you put them on cyclic hormone therapy, everything completely normalizes, like within three to six months. Like it's profound.
Sanjay Bhojraj MD (15:33.102)
you
Sanjay Bhojraj MD (15:39.544)
Wow. Well, it's the body functioning as it's designed, right, to function. And one of the amazing things, and I'm not a women's health person, meaning I don't practice in women's health, but I have a lot of women in my life, my daughters and my wife. And I think back to kind of the nonsense of hormone replacement therapy in terms of like birth control pills and how easy it is for young girls to get
birth control pills for like acne and know, painful periods and seemingly, I don't wanna belittle this, but not kind of more symptomatic or life threatening things. But yet at the same time, when you have women in an older age group, it's like pulling teeth because of the WHI for them to get the therapies that they actually need to reduce their cardiovascular risk, improve cognitive function and improve quality of life, right? So I just, I don't know.
you know, in a formal, like when I was in med school, I think we were talking earlier, I loved OB GYN, I loved delivering babies. My mom told me, don't go into it because guys aren't supposed to do OB GYN. I was like, I'll just be, I'll just take the easy route and be an interventional cardiologist instead. But I never understood the conventional kind of mindset around, and I came out of training right around WHI. So, you know, not as intimately involved with that study as you are probably, certainly, but.
Emily Sadri (16:53.398)
Yeah.
Sanjay Bhojraj MD (17:02.926)
You know, it it didn't make sense. Like, why is it okay when we're younger but not older when we really need it?
Emily Sadri (17:07.851)
Totally. Well, and you could argue easily that the birth control carries more risks than transdermal bioidentical estradiol. The WHI, for those that don't know, was done on premarin, which is a synthetic conjugated equine estrogen. So it's very different molecular structure than human estrogen. It was also taken orally. And it's really important for your audience to understand that oral forms of estrogen, whether synthetic, like birth control, or in premarin, versus, or...
or just being bioidentical like oral estradiol still carry higher risks from a cardiovascular perspective than transdermal estrogen, right? They upregulate clotting cascades. They have to go first pass through the liver. So they, you know, do increase VTE risk. Whereas transdermal estrogen has not been shown in any study to increase VTE risk whatsoever.
Sanjay Bhojraj MD (17:59.67)
And I think there's a lot of confusion and that might be why it's so difficult as a cardiologist for me to want to step into this because the studies are so kind of variable, right? Like not just in terms of dosing, but route. you know, I didn't, honestly, I didn't really understand before I started doing all this of, know, bioidentical, what that really meant versus synthetic and, and, you know, and I mean, the three estrogens and estrogen is a cluster of, of hormones, not just one thing. I mean, it's,
It requires, I think, a lot more specialized knowledge than people realize. And that's why I think when women are concerned, like really reaching out to a hormone specialist or someone who focuses in menopause, think you can never have enough menopause specialists, I think, because it's so complex. But there are so many people, I mean, women that suffer through this.
Emily Sadri (18:45.569)
100 % and
Emily Sadri (18:50.113)
Yeah, and only about 4 % of the eligible population is currently on HRT. Yeah, and there are tens of millions of women who are suffering and who, maybe they know that their symptoms are menopausal, maybe they're just suffering from metabolic fall apart and they don't understand the connection whatsoever. And there's only 7,000 menopause providers out there in the country. So we're grossly underserving that population. We really have a big need to be met. So I really think that
Sanjay Bhojraj MD (19:12.61)
That's it.
Wow.
Emily Sadri (19:19.805)
every provider, including you, who works with women in midlife, should know how to prescribe basic hormone therapy, especially because it's going to change your outcomes. I we see dramatic changes in LDL as soon as we initiate estrogen therapy with people. It's astounding. I see people's A1C decline with no other intervention except for estrogen.
Sanjay Bhojraj MD (19:41.723)
Yeah, cardiologists are like toddlers in that way, is we only care about what we care about, right? So, you know, when you tell your toddler to eat vegetables and they don't want to, but then you say, it, your brother is doing it, you know, whatever, and then they do, right? So I think once we start talking about cardiovascular benefits, you know, cardiologists, our ears perk up and say, okay, what can I do to take better care of our patients? So why don't we talk a little bit about, kind of as you mentioned, so you've seen improvements in LDL, improvements in HDL.
you know, let's kind of run through, let's maybe back up and say, all right, when should I, what should I recognize as a cardiologist or as a primary care doctor or healthcare practitioner, NP, whoever it is, I'm looking at labs, I'm looking at lipid tests, which I think, like I said, for me, it's the canary in the coal mine when we start talking about hormone health. when is, when is it appropriate to get on therapy, meaning bioidentical hormones? When should I refer out? Like, what is that?
maybe run me through that process in your mind.
Emily Sadri (20:41.089)
Yeah, yeah, so I think these are great questions. And I think foundational things to know are that the earlier that we intervene, the better. So that's one thing that we see in the literature. It doesn't mean that people can't be started on HRT after a certain age. I started my mother-in-law on HRT at age 75. She's doing great. So it really takes personal evaluation. And some of that data around not past 10 years, past menopause, still comes from the WHO.
The average age of women in the WHI was 63. So they were mostly more than 10 years post-menopause. They were also a more unhealthy population than... So the average age in the US is about 51. And I don't even love the designation of menopause because so many people will never even be able to know when they haven't had a period for a year because they've had an ablation or a hysterectomy or maybe they're using an IUD. so...
Sanjay Bhojraj MD (21:16.812)
And what is menopause supposed to happen, for those of us who don't know?
Perfect, okay.
Emily Sadri (21:34.665)
it becomes this very sort of this moving target of like, don't really even know how to determine that.
Sanjay Bhojraj MD (21:39.598)
It doesn't show up as a Google Calendar reminder.
Emily Sadri (21:41.921)
No, perimenopause lasts for 10 to 15 years. And most of the problems are happening beginning in perimenopause. And that's when you really need to be looking out. Even before there's any changes to the menstrual cycle, we see in our clinic that the typical first symptoms are mood symptoms. And these often get written off because women in this phase of life are busy. Like me, they're caring for elder.
elderly parents, little children, they're growing their careers. So it's normal that they're exhausted and tired and stressed and maybe their hair is thinning and they have a shorter fuse and maybe their PMS is worse or their sleep is disjointed. But there's a million things to blame that on. And particularly their PCP or OBGYN is not making the connection for them that it could be hormonally driven. The other thing that we see though, is that these women are starting to gain weight, their LDL is going up. women
From the age of 40 on will gain about a pound and a half per year, doing nothing different with their entire lifestyle.
Sanjay Bhojraj MD (22:41.742)
And part of that is probably not just gaining fat, but also losing muscle, I would guess as well, right? So we have to, like whenever we talk about weight, I always kind of focus on rather than weight, body comp, right? So body composition starts to change. Visceral fat, I would assume would increase as well.
Emily Sadri (22:45.985)
100%.
Emily Sadri (22:58.037)
Yep. And this is a red flag. So if someone says like, you know, it's just weird. Like I haven't gained any weight, but like my pants don't fit and my belly, like what is this belly fat? Like that is not to just be written off. That is an increase in visceral fat that is directly related to the loss of estrogen. But it's also the point that I was making earlier is that although estrogen is driving metabolic decline, metabolic decline is also happening independently of estrogen decline. Like when we replace hormones in older women, it doesn't...
100%, you know, 360 make a change, right, in a woman's metabolic status. There is also independent metabolic aging that needs to be addressed, right? We have to be thinking about sort of a pro-metabolic diet, you know, a different sort of everything.
Sanjay Bhojraj MD (23:40.022)
like toxicities and lifestyle and endocrine disruptors and all of those other things.
Emily Sadri (23:44.212)
And also just think the beta cells age in the pancreas. These mechanisms by which we maintain homeostasis are all also aging. There's just cellular aging. So we are just not as efficient at dealing with energy and energy distribution. And so all of those things need to be independently addressed and part of a cohesive whole. Estrogen is one part of it. But I rarely see dramatic changes from a metabolic standpoint with estrogen alone. We can't treat it in a silo.
Sanjay Bhojraj MD (23:47.79)
Mmm, true.
Sanjay Bhojraj MD (23:53.326)
Alright, truth.
Sanjay Bhojraj MD (24:12.3)
Yes. I mean, one of the things that frustrates me so much about hormone replacement in general is, well, number one, that not everyone's getting it that needs it, right? But number two, people are going on hormone replacement therapy without really treating all the underlying issues that are happening, right? Like you need to get your metabolism in balance. You need to get your stress right and your sleep right because if you are stressed out all the time, not sleeping, eating like garbage,
There's, mean, correct me if I'm wrong, but there's not enough surface area of the skin to get transdermal estrogen in there to help because we are, we're putting these hormones that are trying to do their best into a system in a milieu that's already so out of balance that you can never really balance it. And I see that with guys all the time that, in my cardiology practice, I tend to see a lot of men and they always ask me about going on testosterone. And I'm like, dude, yeah, I mean, it'll help, muscle mass and all these things, but.
You know, you're eating like garbage. You're not sleeping. Your lifestyle is so jacked that, yeah. mean, yeah, like these monster, like these energy drinks and all these things. I'm like, unless you get that, the rest of the house in order, right? Hormones are, it's like it's trying to mop up the ocean, right? It's like a drop in the bucket. It's not gonna do much for you.
Emily Sadri (25:13.323)
taking in like 500 milligrams of caffeine. Yeah.
Emily Sadri (25:28.651)
Yep. Yep. Yeah. And you can, you really can age healthily without HRT. I think it is much harder. I think that a really healthy woman in my experience always does better with the addition of HRT. I would say there are some exceptions, like people who have, you know, a lot of MCAS symptoms and, you know, lot of severe mast cell activation can be very hard to onboard to HRT. can be done. It just, you really have to manage both simultaneously. And that's like, you know, you really need an expert to do that.
But you can also have excellently optimized HRT and have a horrible lifestyle. And I think it's only doing you a little bit of favor. So it's really a both and. And our hope in my practice is really give the woman back a little resilience, give her back some of her stamina, because it's going to help her, number one, to sleep better. I mean, also estrogen has an impact on just on our oxygenation and our airway health and the collagen formation.
Sanjay Bhojraj MD (26:06.328)
Yeah.
Sanjay Bhojraj MD (26:22.392)
Well, I mean, many different things. mean, I, course, in the cardiovascular realm, you know, decreasing cardiovascular risk, we're talking about a study I just read today that was looking at a mouse or a rat model and showing that estrogen actually affects the vasomotor tone to specific areas of the brain. So you're talking about personality shifts and things like that. I mean, there's less blood going to certain parts of the brain, depending on where your estrogen is at. So.
Emily Sadri (26:48.031)
Yep. Yeah. And any listener who doesn't know Lisa Moscone's work, she's doing such incredible work in the area of cognition and the role of estrogen. And we're just at the beginning really of that research because there's still a black box warning on all estrogen products that say can cause Alzheimer's, can cause VTE, which is not true of transdermal estrogen methods.
Sanjay Bhojraj MD (27:10.04)
Venus thromboembolism blood clots for those who don't have ETE.
Emily Sadri (27:12.009)
Yes. And so it's really important too, if you're out there trying to advocate for yourself, to be aware that the pharmacy may say, hey, this person shouldn't go on this vaginal estrogen or this estrogen patch because they have a history of a blood clot. We have started people on estrogen who have an active DVT. It is not contraindicated. You can do that. You can start them on transdermal estrogen because it does not go by first pass. It does not increase clotting factors. And it probably is going to make them feel better.
Sanjay Bhojraj MD (27:29.57)
Hmm.
Emily Sadri (27:39.457)
To kind of go back to a few of the positive benefits of estrogen, just for the sort of cardiology nerds. And also, I just want to say a side note that I have said to numerous colleagues and friends of mine that there is not a good medical provider who is not also humble. So I love the way that you describe being curious in your medicine practice and I love the name of the podcast. So I think that's wonderful. But some of the things that estrogen does, right, is it promotes nitric oxide. I mean, we're talking about
Sanjay Bhojraj MD (28:00.803)
Thank you.
Emily Sadri (28:07.295)
nitric oxide in so many realms of integrative medicine and ways to improve nitric oxide production. That's exactly what happens when you use vaginal estrogen, is it increases nitric oxide in the vaginal tissue and improves vascularity, collagen production. It's really quite amazing.
Sanjay Bhojraj MD (28:23.598)
And that becomes important not just for sexual drive and things, but also frequent UTIs and anatomic issues with the loss of moisture in the vaginal mucosa. I these are not just, I mean, hate to call it like a vanity type issue, but it's actual medical things, right? Yeah.
Emily Sadri (28:29.569)
correct.
Emily Sadri (28:41.299)
No, it's not a vanity issue. Yeah. And if looking into Rachel Rubin's work is really important here, she's a urologist who has done a lot of research and published a lot on the cost savings to Medicare that would occur if we put every woman over 50 on vaginal estrogen in terms of complications from UTIs. Because as you know, it's like one of the first things we learned when we're in medical training is the cost of UTIs, especially for women inpatient and what happens because they don't present with UTI symptoms.
present with delirium and it's brushed off and then they get sepsis and then they die. Yep.
Sanjay Bhojraj MD (29:13.228)
or chronic colonization and the vaginal microbiome kind of altering over time. mean, so many things, so many things, yeah.
Emily Sadri (29:17.673)
All of it. Yeah, vaginal estrogen can fix that. Right. So at the very minimum, even if you're a person who doesn't want to do HRT, considering some kind of vaginal estrogen product is a really, really good idea. know, estrogen increases insulin sensitivity. So like at baseline, you know, that also I think just changes the way that people feel because when you're less insulin sensitive, right, you tend to have more food noise than do not feel full after meals. You know, you're more fatigued. Yes.
Sanjay Bhojraj MD (29:44.918)
food coma afterwards. It's a wild ride. I kind of think of Kramer from Seinfeld.
Emily Sadri (29:47.765)
Totally, all of those things. So 100%. Yep. The other thing is there's a lot of good data on how it improves thickening of arteries. So just from a very, very, very basic standpoint, from a physiologic standpoint, the presence of estrogen maintains that tensile nature of blood vessels. And it helps to promote healing. It's anti-inflammatory.
A lot of people think about the reason that we get clots is just because we eat too much saturated fat and we have clots and then they just accumulate in the blood vessel. But it really starts with these sort of micro abrasions. And the ability to heal those without sort of the stiffening of the artery worsens that pathology.
Sanjay Bhojraj MD (30:31.918)
Yeah, no, mean, and when you think about the number of cells in men and women both that have hormone receptors or particularly estrogen, it's almost every cell but the red blood cell. So what does that mean? Estrogen has an effect in every cell but the red blood cell. And I'd say even the red blood cell gets secondary benefits to good estrogen, right, because of vascular health. So it's still implicated in a kind of a cross, you know, a drive-by kind of way, but there's still benefits to estrogen.
Emily Sadri (30:39.752)
Every cell but the red blood cell.
Emily Sadri (30:52.982)
Totally.
Sanjay Bhojraj MD (31:01.834)
One of the things that came up on a podcast before that I was on and I never really thought about it is, do you find that some women brag about not needing hormone replacement therapy? I ended up, called it menopausal machismo because my point was, if there's so much cardiovascular benefit and we really want to be preventative, why are we waiting till somebody has symptoms of menopause to really put them on there? I like what you said is that...
every woman after age, what, 45 or 50, whatever it was that you said should be on there because we're not just treating symptoms with this, right? But as we talk about health span and lifespan and optimization, this is, and I didn't know about the nitric oxide association, which is super interesting to me, but because nitric oxide levels being associated with so many things, cardiovascular health, brain health, organ health, kidney, all these things, should we consider hormone replacement as a
healthspan slash longevity therapy, not just a, my gosh, it gets so hot I have to turn the temperature down to 50 degrees in my house therapy, you know?
Emily Sadri (32:06.901)
Yeah, well, let me ask you a question. Do you think that we should never screen people for thyroid issues and we should only screen people who come in and complain of like low thyroid symptoms? Or do you think that it's important to test a thyroid panel on everyone as part of your annual workout?
Sanjay Bhojraj MD (32:15.48)
mean, yeah, I mean, that,
Sanjay Bhojraj MD (32:22.126)
Yeah, no, I mean, that's exactly the point, right? Is that when you look at population-based statistics, when do we screen, right? We screen when it makes, well, but my point being is that it makes sense to screen when we have a high enough incidence of condition XYZ in a population that goes undiagnosed that it could lead to worse outcomes. I mean, right now there's this huge push to move colonoscopy age to less than 45 years of age. mean, in the once upon a time days when I would, med school, I think it was 60.
Emily Sadri (32:29.803)
Well, there's no guidelines for that. Yeah.
Emily Sadri (32:47.585)
Hmm.
Sanjay Bhojraj MD (32:51.224)
then it became 50 and then it became 45 and now they're thinking of moving down to 40. Nobody feels like I've had friends my age that had colon cancer and they didn't have severe intractable abdominal pain, right? But the incidence and the consequence is so high, right? That they've moved that colonoscopy age and they're thinking of getting it even sooner. So to your point, you yeah, you might not feel bad, but we know that it's, I mean, what percentage of women go through menopause? I would assume anybody.
Emily Sadri (32:58.847)
Yep. It's really rising in younger populations.
Emily Sadri (33:19.265)
100%. Well, I think, yes. So I have completely my whole frame of mind on how to, because in the medical model, none of this makes sense, right? And everything needs to be tested and proven in so many different ways before it becomes practice. I the Menopause Society says it could be considered for prevention in cardiovascular disease, but still should be really just used for symptoms. And there's only five approved intervention like.
Sanjay Bhojraj MD (33:20.352)
Exactly, mean, so you have a potential incidence of 100%. Yeah, I mean, I think what you're saying makes sense.
Emily Sadri (33:45.857)
approved FDA approved, you know, menopause society, FDA approved reasons to use hormone therapy, premature ovarian insufficiency, meaning like menopause before age 40, prevention of osteoporosis or treatment of osteoporosis. However, guidelines don't recommend DEXA scanning until the age of 65, which is far too late, right? And also pass that 10 year critical window, which we know is so important, meaning we can still initiate hormone therapy after 10 years post-menopause, but it should be case by case really evaluated. It's most effective in all the literature when started early.
Right. And my opinion in perimenopause before menopause even occurs. But the other indications are basal motor symptoms. So hot flashes, which not everyone experiences. Although if you do, it's generally an indication that you have more metabolic inflammation, right? It's a concerning thing. So if you have hot flashes, you really do need to be looking at metabolic picture. And when we work up women, we always do a complete workup because menopause is a multi-systemic disease. It's not just, it's not just like about your hormones and about hot flashes.
and genitourinary symptom of syndrome of menopause. But the things that are not on there are mood, energy, libido. Like none of the things that people are actually feeling, right, are indications.
Sanjay Bhojraj MD (34:52.866)
Well, that's I was going say. It's the things that you actually suffer from on a daily basis, right?
Emily Sadri (34:56.597)
Yeah. And so, but it's so confusing, right? Because then women are left with this place where they still are conceptualizing menopause as something to be treated when you feel awful. And that was how we were taught in school was, you know, for less than five years, the lowest effective dose and just to relieve vasomotor symptoms. And so really my whole frame of mind around it was it's this natural process. You know, some people have severe symptoms and it was kind of like, because they, you know, have a bad lifestyle, so they have really bad symptoms. So I guess help them throw them a bone.
SSRIs were the number one treatment line, first treatment line when I was in school, which is just horrific if you ask me. But I think about this in this way. We know that ovarian senescence is always occurring, meaning like cellular death in the ovaries, right? We know that people conceptualize this as like, okay, after 35, it's harder to get pregnant, right? But every year really from the time that you're menstruating, you're losing follicles every year. It's just that there's a huge fall off after 35 that grows exponentially every year.
Sanjay Bhojraj MD (35:48.437)
that you're bored in.
Emily Sadri (35:55.819)
So as your cells are dying and aging rapidly in your ovaries, you're experiencing relative hormone insufficiency. And that hormone insufficiency may show up with slight weight gain. It might show up with peeing in the middle of the night. It might show up with more irritability or increasing PMS. But all of these things look like other things. And all of these things can be accelerated by poor thyroid numbers. It can be accelerated by poor blood sugar. All of the lifestyle stuff matters because it will
accelerate ovarian aging, right? So the more oxidative stress that you have in the body, the faster your ovaries are going to age. for a woman who's between 35 and 40, most of the time, not all of the time, but most of the time, we're especially leaning into all of those other factors that are going to extend ovarian lifespan and improve ovarian hormone secretion, right? But we also really want to see like, what is, what, you know, what are your numbers actually doing? And this is why most physicians and practitioners are like hormones. And they just kind of put their hands up and like back away.
because they will say, people are told this every day in doctors' offices, well, we don't really test hormones because they change so much. Okay, well, so does cortisol. there are many things that change, we, exactly, so does blood sugar. And what do we have? We have continuous glucose monitors, right? It is still important to use your brain, right? Most of the time, women are still cycling relatively every 28 days.
Sanjay Bhojraj MD (37:05.742)
So does blood pressure, so does an EKG, so yeah, I've been like, yeah, yeah.
Emily Sadri (37:19.425)
There are methods, are home hormone kits that are not, the correlation with serum is still sort of questionable, but they can show you the pattern of someone's cycle, the Mira monitor, the Anita monitor. And you can see one of the most important elements of a healthy cycle is that a couple of days before ovulation, say in a 28 day cycle, it may be on day 12, your estradiol will peak to the highest level of the whole cycle, peaks once. And then again, in the medullodial phase, but not quite as high as right before ovulation. But for many women in perimenopause,
that amplitude leading up to ovulation is really crappy. And so then they end up kind of the FSH in the brain is like it knows that it didn't hit that point. And so it's secreting extra FSH and then you get kind of a bigger peak in the luteal phase. So you might test someone's hormones on day 21, seven days before their cycle and their estrogen is like 200 or 175 and you go, she's perfect. Her progesterone is eight, which isn't great, but it's there. She ovulated. You're fine. There's nothing wrong with you. Meanwhile, she has poor sleep.
increasing anxiety, increased LDL because she still has estrogen deficiency syndrome. It's just not showing up on day 21.
Sanjay Bhojraj MD (38:26.818)
because it's taking so much of the stimulating hormone. Yeah, it's, I mean, it's, yeah. And it's, it's.
Emily Sadri (38:29.705)
Yes, because she's got so much that she's got this sort of relative estrogen dominance in the second half of the cycle, but she's not getting the amplitude in the first half. So she's having these low estrogen sequelae in the body and no one's catching it.
Sanjay Bhojraj MD (38:42.136)
So is it similar, I guess? And I'd have to go back to my endocrinology textbooks to kind of look at this. But I probably won't. But that's more of a Sanjay brain issue than a textbook issue. But when we talk about blood sugar, Checking a hemoglobin A1c, a blood sugar, is only half of the story because you have to look at insulin level as well. I call it the grandma problem. As my grandma was getting older, she was losing her hearing. So we'd have to yell in her ear really loud for her brain to be able to perceive.
Emily Sadri (38:46.73)
It probably won't help.
Just, just...
Emily Sadri (38:55.606)
Mm-hmm.
Sanjay Bhojraj MD (39:11.682)
what we were saying, now unfortunately it turned out to be earwax, we got our ears cleaned, it was okay, and that went on for years. mean, it's like all my family are doctors, it's like the embarrassment of our family. But the point being is that nobody would say that she had normal hearing because the auditory cue had to be so much louder in volume. So is that similarly kind of what you're talking about here is that the hormone level to get the same, the stimulating hormone level to get the same estrogen level effect goes up precipitously, and so that's a sign like
Emily Sadri (39:24.641)
Mm.
Emily Sadri (39:39.945)
Yeah, but you may not see it in FSH. Like you may not catch an FSH that's really high. Again, because everything's fluctuating all the time. So it's really like when you're evaluating hormones in perimenopause in particular, you, in my opinion, in order to really get the best picture, you need two things. You need comprehensive labs. So this is where like the functional medicine is so helpful. And I think the combination of like precision hormones and functional medicine is great because you're looking at things like vitamin D, which tends to drop in perimenopause. You're looking at LDL, you're looking at APO.
Sanjay Bhojraj MD (39:42.774)
Okay.
Emily Sadri (40:08.437)
you know, be and all of these things that are going to start to shift and change. You're looking at CRP. You're looking at
Sanjay Bhojraj MD (40:13.518)
Well, why don't we just run through, yeah, what are the labs? So if we have listeners out there and they're saying, you know what, I'm in perimenopause, and now we have ways that they can go direct to consumer and get labs, like, you know, there's all these new things. So what are the essential, not the, would be nice if we had it, but the essential blood tests that you think someone who thinks they're in perimenopause should ask their doctor for or to seek out on their own?
Emily Sadri (40:35.807)
Yeah, it's a great question. So I think from a basic micronutrient perspective, B12 and folate are super important. B12 is often low, especially if you're protein deficient or if you've been a vegetarian. Iron and ferritin for sure, vitamin D. Maybe some other Bs, but I would say those are the essential ones. You could do an omega-3 to 6 ratio if you're really getting fancy, just because we want to think about what, is there other pro-inflammatory stuff going on? Exactly.
Sanjay Bhojraj MD (41:02.414)
What is the metabolic milieu kind of a deal? Yeah.
Emily Sadri (41:04.981)
Yeah, and then from your cholesterol panel, but I also like to have like ApoB and I think it's a, depending on the person, of course there's like consent here, but like, I think it's interesting to know your sort of ApoE type and if you carry the genetics for that. Just because we're also focusing so much on protein for women in midlife that we wanna be smart about what type of protein we're recommending and with saturated fats.
Sanjay Bhojraj MD (41:26.286)
Well, and as you're talking about before how keto works for some and not for others, that's really an ApoE-mediated phenomena, right? So if you have the ApoE4 allele, which I think Chris Helmsworth was the celebrity that found out that he had the pre-Alzheimer's gene he found out on like live TV or something. that's, I always talk, one size does not fit all when it comes to diet. We do have these kind of nutrigenomics and all the things. All right, so anyway, we got, so ApoE, HSCRP.
Emily Sadri (41:31.039)
Yep. 100%.
Emily Sadri (41:40.03)
Is he?
Emily Sadri (41:50.697)
Yep, HSCRP, for sure. Homocysteine, so we'd like that to be below eight or nine at the bare minimum, which kind of tells us a little bit about B12 sufficiency and inflammation. Also, of course, a CBC and a CMP. We also just have been running amylase and lipase Paste on everyone because so many people are either on GLP-1s or thinking about GLP-1s, and we just kind of want to know what's going on with the pancreas. Fasting insulin.
obviously your A1C, fasting glucose, which will be a part of your CMP, of course. And then we're looking at, usually doing day 21 serum lab. So we're looking at progesterone, estradiol, estrone, which will often favor in perimenopause and menopause because estrone is converted from estradiol, especially in the presence of inflammation, metabolic inflammation, but it's also the primary estrogen secreted by adipose tissue. So if you're having more fat distribution, exactly.
Sanjay Bhojraj MD (42:44.654)
If you have a lot of peripheral aromatization and things like that, got you.
Emily Sadri (42:49.121)
I try not to live or die by estrone because some people just tend to make more estrone. Even people who have had mold exposure in the distant past, but now look really good, still might favor estrone. It's really interesting. I don't know how that remodeling happens, but it's just still interesting to look at progesterone, FSH, and LH. And then we really want to see a full thyroid panel. So TSH, total T4 and T3, and free T3 and T4, reverse T3, which will often be
really high in the presence of metabolic inflammation or just someone who's extremely stressed and can kind of give us this pseudo low thyroid picture. But we especially want to optimize T3 because it helps you to respond better to progesterone therapy if your T3 is above 3 3.2. And we see that it has a huge impact on LDL.
Sanjay Bhojraj MD (43:39.47)
So do you mean that hormones work together? Is that what you're saying? It's not just one and done.
Emily Sadri (43:41.673)
It's crazy. It's like, it's like, it's this weird symphony. It's crazy. It really is the like the, and everything is this feedback loop, right? So like, you pull one lever and you see this and you know, a lot of this stuff I've just learned literally like working with hundreds of patients, like, and we sit with them for so long, right? We have hour long visits and we do so many labs. So you just learn and you find these associations, these things that are happening.
We also really like, we don't always check this, but I do appreciate LabCorp has a whole blood histamine, which I think is such an interesting measure. So somebody like, totally. It's a really interesting place because I think in the last few years post COVID, there's so many people that have mast cell activation and don't even realize it. And a predominant way that it shows up is anxiety, know, fast heart rate. Like these women are going to the ER with thinking that they're having an anxiety attack or a heart issue.
Sanjay Bhojraj MD (44:14.99)
Interesting. Particularly now as we talk about mast cells and MCAS and all these things. Yeah.
Emily Sadri (44:37.683)
even get put on beta blockers, and they have mast cell activation. And they tend to be really challenging to onboard to hormones. And it just takes like a very delicate hand. And oftentimes we want to really modulate the MCAS before we onboard estrogen, because estrogen can be, even though it's an immunomodulator that's very powerful, the interesting thing about hormones is that like timing and dose matter a lot. So like for some people, especially in perimenopause,
a low dose static approach like you would see with a patch or even a transdermal cream method. If it's given low dose static all the time same dose, it can actually make people feel worse because it sort of reverse suppresses your own FSH, especially the continuous methods like patch where there's no break. And so it shuts down your HPO axis and can actually kind of bring you to a lower, almost like a bio identical birth control state is what I find. So I tend to like creams that have breaks between them.
for women in perimenopause because it kind of allows their own FSH to still participate in the process. But I got off track a little bit. But the full thyroid panel and definitely Hashimoto's antibodies, those are really important to check because yeah, and antithiroglobulin because so many women have new onset Hashimoto's post pregnancy, big hormonal shift and during perimenopause, big hormonal shift, right? When you lose estrogen, you lose that immunomodulation. And so whatever was sort of dampening autoimmune activity,
Sanjay Bhojraj MD (45:37.07)
Yeah. Well, no, but.
There you go. So what do you like, the anti-TPO or? Yeah.
Emily Sadri (46:00.745)
that goes away. And so someone may be feeling all these symptoms of perimenopause. And yes, there's some hormonal peace going on, but really they have raging Hashimoto's and we need to take a Hashimoto's approach with them concomitantly to onboarding with hormones. And this is the part that like, I love all the attention that perimenopause and menopause are getting. I think it's wonderful. And I think that people are so eager to find like the one trick, the one thing that's going to fix things.
And we have a very sick population of people. We know that 60 to 80 % of people are metabolically unwell going into perimenopause. And so they have a lot of things that need to be addressed. Just pouring hormones on it is not going to solve the problem.
Sanjay Bhojraj MD (46:38.408)
And that was the point from before, right? Is you have to get as much as you can, everything else in balance. You you're talking about the sick of nature of hormones and how you get worse outcomes with kind of this chronic tonic deployment. And it made me think of actually of all things left ventricular assistive ice patients. So in the cardiac universe, we have these fake hearts called left ventricular assistive ice made famous on Grey's Anatomy Season 1. One of them was one of the...
interns was dating the heart guy and they cut his line, his drive line so that he could get a heart transplant. My wife told me about that and I was like, I was in cardiology fellowship at the time I think and I'm like, my God, this is such nonsense. Anyway, that's an aside. You can't watch that, right? But it's like lawyers can't watch law and order probably and all the things, Except the pit is really good, but that's a whole other podcast. And what we saw is there's two.
Emily Sadri (47:18.719)
You can't watch that show if you're in medicine, it's so painful.
Yeah, our suits.
Sanjay Bhojraj MD (47:30.446)
two versions of these pumps. There's a continuous flow pump. So it kind of took over your hearts, but it was a continuous flow through. You didn't have a pulse or anything like that. And then there were these pulsatile. You didn't have a pulse because it was just a continuous flow, right? And most of these people have EF ejection fractions of like five or 10. They're on a heart transplant list. So they're just kind of getting continuous flow through. And then some of them, some of the LBADs had pulsatile flow. So it mimicked.
Emily Sadri (47:39.777)
and didn't have a pulse at all.
wait. Right.
Emily Sadri (47:50.187)
Right?
Sanjay Bhojraj MD (47:58.466)
kind of a heartbeat so you could feel a pulse. And people who didn't, who had the continuous flow, meaning they did not have the pulse tile, actually had worse brain outcomes and worse outcomes in general. So there's something about, you know, as I'm the curious guy, right? Like there's something about these rhythms of life and these cycles of life that are so important. And, and, you know, probably a lot of people don't realize that men actually have hormonal cycles as well. They're just on a much shorter timeframe, right? Like when we look at testosterone, it's a 24 hour timeframe, or you look at circadian rhythms. And that's why
Emily Sadri (48:06.785)
Wow.
Emily Sadri (48:11.52)
Yeah.
Emily Sadri (48:21.675)
Yep.
Sanjay Bhojraj MD (48:28.392)
I think as you get older, even something as simple as daylight savings that pushes your rhythms back an hour or two, you just feel it so much more because your body has, in a sense, as you mentioned, cellular aging, probably lost a lot of that cellular resilience to be able to just shift, right? And why third shift workers have such a hard time? Night shift people in the healthcare universe and otherwise are like pilots or people in the airline industry, flight attendants are going from time to, it's just bonkers. Super.
Emily Sadri (48:42.091)
Yep.
Emily Sadri (48:48.565)
dramatically higher increased risk of chronic disease.
Emily Sadri (48:55.073)
Yeah, mean, the most basic simple things are the most helpful. you know, we do live in rhythm and the hormonal cycle itself is this infradian rhythm, right? And it is really important and we don't have enough data yet, but we are starting to experiment with like, if we reproduce that infradian rhythm and we keep the cycle going in that sort of same way that it functions naturally, like, do people have better outcomes versus a static approach even into menopause once like the cycle has stopped? What if you continue the cycle?
But if you keep someone menstruating so that you get that peak of estrogen, does that have different outcomes? And I think it's going to be really interesting to see that research come through.
Sanjay Bhojraj MD (49:34.38)
I mean, you know, I'm married, I'm a girl dad, and like women just fascinate me. Like how does that just, how do you exist? I know it's like the dumbest thing, but like I feel so guilty. I mean, I feel so guilty as a guy because I'm like, man, my life is pretty easy, right? Like, mean, like seeing.
Emily Sadri (49:44.565)
We are here to see the world through many different lenses.
Sanjay Bhojraj MD (49:54.678)
I mean, I never had a first period, but I had three of them through my daughters and explaining what was gonna happen. And then they're like, this is gonna happen every month. And it was the gravity of telling my then what, nine or 10 or 11, don't remember, year old daughter, yeah, it's gonna happen every month. I'm like, what the actual F? You have to do this that many times? And I mean, it's just, I don't know. Shout out to the XX chromosome people out there. mean, it's something.
Emily Sadri (49:58.111)
Yeah.
Emily Sadri (50:13.002)
Yeah.
Emily Sadri (50:16.981)
Well, I think that we really...
We are definitely a cool species. But I think that we miss an opportunity to really educate girls from a young age of what you gain from being a cycling creature, how your perspective and your outlook changes under the influence of different brain chemistry, essentially, right? That in your progesterone time, you're more introspective. That's a good time to of wrap things up. And I mean, it's really fascinating. could go down a deep dive on Instagram of like,
people who sync their life with their cycle and their activities and their business structure. I just think it's fascinating and it's stuff we withhold from people. They don't know about that.
Sanjay Bhojraj MD (50:58.446)
And is it so much withholding or just research hasn't really been done? I mean, think there's a lot of, when you look at the healthcare dollars and cardiovascular is a huge offender in this, but up until a few years ago, most studies were like 80 % men. And yeah, I mean, so.
Emily Sadri (51:03.969)
Emily Sadri (51:15.965)
for sure. I we only started doing research on women in the last, very last part of the 20th century. So there's that. But I also think that we in medicine, we're really averse to woo. And so if anything gets too qualitative and kind of too like, I don't have bench science to back this up. And it's like how you feel. It's like, we don't, we just don't want to go there. I mean, it's why I like a lot of childbirth research, like, you know, just hasn't been, it's like this, but this is just the obvious stuff. You know, it's just the
Sanjay Bhojraj MD (51:44.48)
It just seems, it seems too soft or too weird or like metaphysical and.
Emily Sadri (51:47.337)
100%. Yeah, and you know how Socratic and how like, you know, dogmatic medicine is it's like if you don't have you know how it is. It's like, I know. So it's like, you know, you show up to rounds and like you say something that's like,
Sanjay Bhojraj MD (51:54.286)
Emily, you're talking to a cardiologist. I got pimped on clinical trials on a deal. In the IBIS-2 trial from 1973, what were the results in the things? like, 1973? That was like 1,000 years ago. And one of the things that I learned, maybe probably more in the functional mindset than the conventional is lack of evidence doesn't mean lack of efficacy. And also, one of the truest things ever is population-based statistics don't.
Emily Sadri (52:01.931)
Totally. Yes.
Emily Sadri (52:08.043)
Totally.
Emily Sadri (52:17.537)
100%, yeah.
Sanjay Bhojraj MD (52:23.502)
always don't affect an individual, meaning like in the clinical trials of cardiovascular drugs, know, an 11.7 versus a 9.2 % event rate or whatever it is. You don't have a 9.2 % heart attack. It's binary. have a heart attack or don't. And so I think part of the rigidity, mean, you know, that as being kind of curious all my life, but part of the rigidity that always just frustrated me was exactly what you're saying. It's an all or none phenomenon when even the literature.
doesn't show that anything is an all or none phenomenon. There's never in my read of literature been a study that had a 100 % event rate in a placebo group and a 0 % event rate in the study group, right? So we have to individualize therapies, right? I mean, just in the same way that now when you look at chemotherapy, it's being much more individualized. They take a biopsy of the tumor and look at molecular markers and...
Emily Sadri (53:01.981)
No. Yep.
Emily Sadri (53:16.639)
Yeah, the genomics.
Sanjay Bhojraj MD (53:19.554)
the genomics of all these things, right? Like nobody would ever say, well, let's just go back to the old days where you kill off every cell and hopefully you get more bad cells and good cells. mean, we are moving towards this much more precision model. And I think, you know, we think of this as highfalutin, but it is so frontline when it comes to menopause therapy, you know.
Emily Sadri (53:28.863)
Yeah, precision.
Emily Sadri (53:36.065)
Yeah, yeah, really, I think the most relieving part of functional medicine to me, even though I've left a lot of the functional medicine behind, I didn't really get to this part of my story, but you know, when I first started practicing functional medicine, it was like, geez, all these women in their 40s and 50s are only getting like 10 % better on an elimination diet. Like their husbands will do the elimination diet and lose 30 pounds and these women are like, nothing's happening.
but like that's not what I was taught in IFM. I was taught it was like the gold standard. Like you put everybody on this diet and like they're supposed to get 100 % better, but like their autoimmune markers are getting worse because they're just stressed and they've lost stress resilience. But so that aside, like that aside, I do think that that's like the pitfall of functional medicine right now is that it's still so focused on a male-centric model and it's missing this piece. But the benefit of it was that it really allowed me to have the permission to do these N of 1 studies on people.
Because I already had familiarity with very intimate care coming from birth and having home births myself and training in that space where we had hour long visits. And I understood that knowing that person, knowing what made them tick, what made them feel fear, what made them feel safe, that that could impact an outcome. watching how when one person would storm in the room and make a woman feel fear, how this cascade of events would unfold because her nervous system was dysregulated in labor.
Interestingly, to wrap up our estrogen benefits, estrogen is a massive regulator for the vagus nerve. So when we lose estrogen, we lose vagal tone, meaning that we cannot bounce back to parasympathetic as easily. So the way that this shows up is like a woman in perimenopause, you know, her, I have a four-year-old, her four-year-old like knocks a glass on the floor and it shatters, right? So of course, like you're going to have some amount of upregulation from that, but usually you clean up the glass, you throw it away.
you're fine. A woman who's lost her vehicle tone, like Doug can't shake the feeling of anxiety for hours. Even though she knows cognitively that it's like not upsetting. It's that like physiologic feeling that she can't regulate back to a parasympathetic state. And that's something that I feel like women get gaslit about a lot is like, if they're complaining that they're kind of always feeling like they're in this out regulated state, even functional medicine people will be like, you know.
Emily Sadri (55:51.029)
What are you doing? How much are you meditating? Like, are you doing your yoga? Are you doing your walks? Your grounding and all that stuff is helpful. But so many women, as soon as you apply some kind of transdermal estrogen therapy, it's like the sky opens up. It's like, they're just like, whoa, right? Because they can regulate their vagus nerve and they can also make, you know, serotonin, norepinephrine, epinephrine, dopamine, like all of these things. The precursor for that is estrogen.
Sanjay Bhojraj MD (55:55.181)
Yeah.
Sanjay Bhojraj MD (56:08.866)
Yeah.
Sanjay Bhojraj MD (56:16.792)
Wow, I mean.
So fascinating, all these different effects. I would never have thought that. And as a husband, I'm trying to figure out a way to politely suggest maybe we should look at nesha. Sometimes when my wife freaks out at me, I don't know if that's the political right thing to say or not here. Are you back?
Emily Sadri (56:35.165)
The next time we're in California, we'll have a couple's dinner and I'm sure we'll get there in the conversation.
Sanjay Bhojraj MD (56:40.494)
I mean, it's, I mean, it's when, mean, again, I don't know how women exist or like you guys are like separate creatures on different planes than we are. I mean, even just having a baby, bringing something for the medical metaphysical world into the physical, your portals into different dimensions and all these different things. I mean, it's just the spirituality of feminists, of the feminine is just mind blowing to me. And guys, all we have to do is show up and show up, right? Lift heavy things. I mean, that's the extent to which I contribute to the existence. I give one cell.
Emily Sadri (56:56.225)
and
Emily Sadri (57:08.859)
But we need that masculine energy too, you know.
Sanjay Bhojraj MD (57:11.2)
I guess, yeah, the yin and the yang, but super interesting. I mean, I feel like as with all my conversations on the Curious Cardiologist podcast, and I mean this in the best possible way, I didn't realize how stupid I was until we had this conversation, right? But that's the important part of being curious is really kind of looking at things that you thought you knew through a completely different lens. And man, now I have to go back and look at all these women that I treat and not just because I'm a cardiologist, but probably because I'm
Emily Sadri (57:13.621)
Mm-hmm.
Emily Sadri (57:23.989)
Emily Sadri (57:28.169)
Mm-hmm.
Sanjay Bhojraj MD (57:40.268)
one of the few people maybe in tune to what's going on, right? A lot of people are just out of touch with these sorts of things and really getting women the proper therapy that they need. So Emily, thank you for opening my eyes to this. It's like the most obvious thing that is so not obvious in medicine, right? Is that, you know what? Estrogen matters. Maybe that's a t-shirt we need to make. Estrogen matters or, is it really?
Emily Sadri (57:58.539)
Yeah.
Emily Sadri (58:01.985)
That's a book actually by Avram Blooming. It's a fabulous book written by a physician whose wife had breast cancer and it really made him question the sort of blanket advice that you can't have estrogen after breast cancer. It's actually one of the most well-written books about estrogen in general and all the benefits. So I highly recommend that you read it and any of your providers read it.
Sanjay Bhojraj MD (58:20.802)
Well, there are no new ideas under the sun that was already taken. let me take a look. I'll take a read of that book because as a cardiologist, I can tell you in four years of cardiovascular research and training, estrogen was maybe mentioned zero times. And it wasn't, mean, like we were talking about, maybe it was early periods or late periods or something, but certainly not.
Emily Sadri (58:25.044)
Yeah
Emily Sadri (58:37.811)
Yeah, and probably just as a risk factor for VTE if it was mentioned at all.
Emily Sadri (58:46.369)
Yeah, but listen.
Sanjay Bhojraj MD (58:48.47)
Certainly not at a molecular level that we're talking about here.
Emily Sadri (58:51.617)
The research is fascinating because we know that women who menstruate later and go through menopause earlier have a higher risk of dying from a cardiovascular incident, right? Because the collective protection, yep, and even like the more pregnancies that you've had, the more protection you get because you get these giant boluses of estrogen exposure, right? Estrogen in the thousands, the levels in the thousands. It's just fascinating. And from a breast cancer perspective too, if you have a pregnancy before age 20, I think it is, or maybe 18, you've almost a 0 % risk of getting breast cancer.
Sanjay Bhojraj MD (58:59.468)
because their time of exposure to estrogen is shorter.
Emily Sadri (59:21.269)
So like, there is something about those peak levels of estrogen that upregulates stem cell production that are massively anti-inflammatory that probably set up the milieu for cardiovascular metabolic health and inflammation like from a very early point, right? It's really fascinating.
Sanjay Bhojraj MD (59:37.262)
I mean, from an anthropologic level, maybe if you have tons of kids, nature needs to make sure that you're around to raise them as a woman, right? And it's just, my gosh, we can think of so many different things. my gosh, Emily, gosh, I feel like I need to have you on. We need to do like a master class or a summit in this and just like eight hours, 10 hours.
Emily Sadri (59:42.976)
Yeah.
I love that.
Probably it's fascinating.
Emily Sadri (59:52.958)
Yeah, no, for sure. should, well, we should also talk, I think for your, for your people, like we should talk about, you know, real doses and stuff. And like, how do you actually, what's the most basic, easy way to start? I have a great osteopath who said to me like, I'm just realizing the connection between musculoskeletal issues and, and, and menopause. I'm going to start putting women on birth control. And I was like, we can do better than that. We can do better. I will teach you.
Sanjay Bhojraj MD (01:00:00.999)
there you go.
Sanjay Bhojraj MD (01:00:12.59)
Well, for whatever reason in my brain, and correct me if wrong, I have like 0.25 to 0.5 transdermal of estrogen and 100 oral progesterone. Is that a good place to start?
Emily Sadri (01:00:21.929)
So to be honest with you, I never start any woman on less than 0.05 milligrams of estradiol from a patch perspective. I just think it's like a pretty useless dose and works for almost no one. Yeah, so that would be if you are like just trying to do the easiest thing for a menopausal woman who's not cycling.
Sanjay Bhojraj MD (01:00:27.681)
Okay.
Sanjay Bhojraj MD (01:00:37.646)
If you're a cardiologist not trying not to kill somebody practicing outside of your scope.
Emily Sadri (01:00:40.641)
You will not kill anybody. Like it's one of the hardest things to kill someone with is transdermal estrogen. But you could do 0.05 and 100 milligrams of progesterone. Super easy from any pharmacy. And that's like a very basic and you're gonna do some good with that.
Sanjay Bhojraj MD (01:00:55.554)
Yeah. And then vaginal versus like oral for estrogen.
Emily Sadri (01:01:00.331)
So vaginal is a, if you're doing, you know, a traditional commercial dosing, everyone needs vaginal as well. So you can do, you know, an esterase cream, like a commercial, you know, product, you can get compounded formulas if people are sensitive. Some people will just be sensitive to esterase, but vaginal estrogen doesn't, breast cancer, like people who have active breast cancer can take vaginal estrogen, right? Does not local exactly, does not affect systemic circulation. But then on top of that, you would also need.
Sanjay Bhojraj MD (01:01:07.084)
Okay.
Sanjay Bhojraj MD (01:01:21.742)
So it's more of a local phenomenon, not as much systemic. All right. All right.
Emily Sadri (01:01:29.377)
your systemic estrogen. I really tried to get people, if we're doing a static low dose, non-complicated, non-precision approach to at least a serum estradiol of about 80. That seems to be suggestive of protection from osteoporosis. And I feel like if we're 100, if we're doing that, then we're probably protecting other organ systems. Again, we don't have enough data to support it. But most importantly, you're going to start to see the changes in their health. But there are other more advanced regimens that can work for people who are
Sanjay Bhojraj MD (01:01:31.106)
Okay.
Emily Sadri (01:01:59.265)
who are in really severe places. yeah, I mean, that's very basic.
Sanjay Bhojraj MD (01:02:01.506)
mean, as you're talking, Emily, I'm like, you've forgotten more about hormones than I'll ever know. So how do people find you? I've got, you my listeners, like I want to send my wife over. I mean, my daughters, I want to send them over. Like, I mean, any woman I know I want to send over to you. So how do people find you?
Emily Sadri (01:02:15.585)
Thank you. Yeah, so you can find me on Instagram, EmilySadri underscore NP. You can also follow my clinical practice. My telehealth practice is called Aurelia Women, Aurelia Health, or our Instagram is at Aurelia Women's Health. And we serve 12 states, which we'll list in the show notes. And you can go to aureliahealth.com. You can work with us. Our programs are seven months long and then people can remain outpatient forever. We like to call ourselves primary hormone care providers because you really do need that.
Whole picture, primary hormone care, I think from perimenopause and beyond, but you can also just come and get a big panel of labs and a one hour consult with us if you want a second opinion or you're curious where you are in perimenopause. Is it related to your lipids? Is it related to your inflammation? We can decode all of that for you.
Sanjay Bhojraj MD (01:03:01.114)
All right, well, I end the podcast always with three rapid fire questions that oftentimes are the most interesting questions I ask in the podcast. So number one, where's your favorite place on earth? Somewhere that you've been where you're like, I could live here forever.
Emily Sadri (01:03:14.049)
Well, we love the Southwest coast of Michigan.
Sanjay Bhojraj MD (01:03:18.69)
Southwest goes, okay, but like Benton Harbor kind of over there.
Emily Sadri (01:03:21.249)
a little bit further south than that, but we just sort of accidentally started going there for vacation and when we moved to the Midwest and we love it. I would say like that my favorite place that I've ever been to would be the Isle of Skye in Scotland. I don't know if I could live there though, because it's quite isolated. I'm very social.
Sanjay Bhojraj MD (01:03:23.616)
Okay.
Sanjay Bhojraj MD (01:03:32.949)
Okay.
I think it's weird because I actually grew up in Northwest Indiana, so that little corridor is like right next to us of that Southwest Michigan corner. Number two, what's your favorite food, healthy or unhealthy? It doesn't have to be kale and locally sourced carrots. Like I had someone say Chicago deep dish pizza, I'm a Chicago guy, I get it. Yeah.
Emily Sadri (01:03:40.437)
Yeah, really close.
Emily Sadri (01:03:50.817)
My favorite comfort food is the siete corn chips. Not the cassava ones, but the corn chips.
Sanjay Bhojraj MD (01:04:01.314)
just actual corn chips.
Emily Sadri (01:04:02.985)
like see, then by CTA, like the healthy ones, but they're like the company CTA, which you know, like is a, you know, healthier kind of good oils and all that stuff. But those corn chips, I would take over any treat any day. They're my favorite thing ever. I just love them. Yes.
Sanjay Bhojraj MD (01:04:06.082)
The company, the company.
Sanjay Bhojraj MD (01:04:10.21)
Yeah. Yeah, yeah.
Sanjay Bhojraj MD (01:04:17.4)
just all the time. As we say with my dog, high value treats. He's got his high value treats, so that's Emily's high value treat. And then finally, what keeps you curious? What do you love to learn about? What is a book or a series of subject that you could read forever?
Emily Sadri (01:04:30.305)
I think that actually the book that got me into this to begin with was The Red Tent by Anita DeMont. It's all about sort of birthing in biblical times and you know how women would go off to the red tent when they were menstruating and I just I'm always so fascinated in the position of the matriarch, the role of the woman. I think why I still love what I do today is because when you make women stronger you affect families, communities, like everyone benefits when women are healthy and strong and so just like
That sort of brand of feminism is fascinating to me.
Sanjay Bhojraj MD (01:05:02.21)
Love it, absolutely love it. Thank you, Emily, so much for being here. Like I said, I love at the end of these podcasts where I'm just like head scratching. I'm like, boy, I had like none of this in my brain yet. So, but that's the power of the podcast and the episodes and the guests that we have like you that just opened up my eyes to new things and our listeners get to learn things in a new way. So thank you so much for being here with me today.
Emily Sadri (01:05:24.213)
Thank you so much for having me. It really was a real pleasure.
Sanjay Bhojraj MD (01:05:27.406)
And thank you guys for taking the time to listen to this episode of the Curious Cardiologist podcast where we're always looking to look at old problems in new ways and today was a great example. If you like what you heard, please make sure to subscribe to the podcast. We're releasing episodes twice a month and increasing from there and bringing more fascination to your life. And if you resonated with something that we talked about or you said, Sanjay, what you said, that made absolutely no sense. You're an idiot.
Leave a comment, let me know. I scan the comments, I love interacting with you guys, the audience, and if you have suggestions as to something that you want me to explore, I'll be happy to take that as well. So thank you guys for being here. Emily, again, thank you for being here, and we'll catch you on the next episode of the Curious Cardiologist Podcast. Bye everybody.