Why Doctors Can't Fix Women in 2026

Dr. Sarah explains that current FDA-approved formulations (patches, pills, creams) were designed for 55-year-old women to get through menopause with minimal relief, not for longevity or optimal health. They deliver tiny doses that don't achieve physiological levels. Patches and creams have only 30% absorption; pills are degraded by the liver into toxic metabolites. Vaginal delivery overcomes these limitations. She emphasizes that women need all three hormones (estrogen, progesterone, testosterone) and that giving only one, like a little progesterone, suppresses FSH but leaves the woman feeling terrible because she's not getting everything her ovaries would make. The goal is to suppress FSH with a full replacement, then optimize further with diet and supplements. Dave Asprey notes that in his concierge practice, women on patches or creams often have low hormone levels on labs, and switching to effective delivery transforms them—like watering a wilted plant.

Dr. Sarah explains that 90% of women starting HRT have fibrocystic breast disease, and iodine is the only way to properly metabolize estrogen in breast and uterine tissue—not the liver. She criticizes the fear-mongering around iodine and Hashimoto's, arguing that the temporary worsening of symptoms is due to halide detox, not true thyroid damage. Dave Asprey adds that he was cautious about iodine due to regulatory concerns but includes a moderate dose in his Minerals 101. He describes the old-school skin test: apply a drop of Lugol's iodine to the inner arm; if it disappears in less than 24 hours, you're deficient. Once levels are replete, the stain persists and you may get a runny nose if you take more. He prefers 5-10% Lugol's, calling the 2% on Amazon 'stupid.' Both agree that avoiding iodine because of Hashimoto's is a mistake; you need it everywhere in the body.

Dr. Sarah states that women are overdoing fiber, and that lowering fiber can raise estrogen levels. She notes that switching from a plant-based to an animal-based diet raises estrogen. Dave Asprey adds that women need more nourishment than men and become stressed more quickly when nutrients are lacking; fiber exacerbates this by absorbing nutrients. He distinguishes soluble from insoluble fiber, saying soluble is generally better. He also mentions that collagen is an 'animal fiber' that gut bacteria can turn into butyrate, referencing his Bulletproof Diet research. Both agree that the modern obsession with fiber for regularity is misguided; estrogen is needed for gallbladder function and bowel movements, so constipation in aging women may be due to low estrogen, not lack of fiber.

Dr. Sarah explains that some women have a fast COMT gene, causing them to burn through dopamine, testosterone, and estrogen quickly. This can be seen on labs as lower levels. Increasing protein intake can slow this pathway, helping them feel more focused, calm, and allowing their hormone levels to last longer. Dave Asprey adds that women often don't eat enough protein, starving themselves to lose weight, which lowers dopamine and libido. He jokes that there's nothing sexier than a woman eating a ribeye, and that men appreciate a woman who eats heartily. Both agree that diet alone cannot fix hormone deficiencies but is a powerful adjunct.

Dr. Sarah mentions that testosterone cream used vaginally is sometimes called 'scream cream' because of its potent effects. She says it's fine for occasional use but not daily due to microbiome disruption. Dave Asprey enthusiastically recommends it for date night, saying it will cause 'blood flow like you've never seen before and your toes will curl.' They both frame it as a fun, optimizing tool rather than a primary treatment.

Dave Asprey explains that oxalates are plant protective compounds. The body can handle about 200 mg/day, but a typical superfood diet can exceed 1,000 mg. He notes that 70% of kidney stones are oxalate-based. Dr. Sarah shares her personal experience with matcha-induced kidney stones. Dave adds that collagen and glycine can convert to oxalate via the glyoxylate pathway, so excessive collagen supplementation can also cause stones. He recommends white rice and white flour over whole grains because they are much lower in oxalates. He also mentions that oxalates accumulate in ovaries and uterus, potentially affecting fertility, especially in vegans. The low-oxalate challenge he did helped many people resolve chronic pain and UTIs.

Dr. Sarah explains that traditional hormone labs are problematic because reference ranges for optimal levels don't exist (only five papers worldwide on optimal progesterone ranges). Additionally, levels fluctuate widely depending on time of day and cycle phase. FSH offers a more stable indicator of overall ovarian function. She notes that even a small tick upward in FSH can signal early decline. When HRT is given, FSH should be suppressed; if only one hormone (e.g., progesterone) is given, FSH may drop but the woman still feels bad because she's missing other hormones. The goal is full replacement to suppress FSH and resolve symptoms.

Dr. Sarah mentions that men do need progesterone and often love it. She finds it converts to testosterone in men, so it can raise testosterone levels. For men who over-convert to DHT or have swings from twice-weekly injections, progesterone can provide stability and allow a lower testosterone dose. Dave Asprey recalls an old functional medicine doctor who recommended progesterone for everything, even rubbing it on a sore neck. He suggests men try progesterone before bed if they can't sleep. Dr. Sarah notes that oral progesterone's metabolites (like allopregnanolone) are sedating, which is why it helps sleep. For men, a small oral dose is sufficient because they don't need the massive amounts women require.

Dr. Sarah explains that the egg does not seek the sperm; women's libido is receptive, open, and tied to connection, bonding, and safety. Estradiol receptors flood the limbic system and estradiol behaves like MDMA, creating a receptive nature. Progesterone and estradiol are foundational to women's libido, yet they receive no credit. Testosterone can cause unwanted effects like constant arousal (one patient felt like masturbating all day) and hair loss. She prefers to give enough vaginal progesterone so the body converts it to testosterone, achieving levels of 30–50 ng/dL naturally. Only if libido is still insufficient does she consider adding a testosterone cream, but warns about hair shedding. This shifts the paradigm from 'testosterone is the libido hormone' to a balanced, female-specific model.

Dr. Sarah points out that women in their 20s can have hormone levels of a 90-year-old. The period is meaningless as a marker; what matters is ovarian function. Environmental toxins (pesticides, phthalates, parabens) bind to estradiol receptors, and birth control suppresses natural hormone production. If a 25-year-old has eliminated environmental chemicals and still has symptoms, bioidentical hormones should be considered because the risk of not being on hormones is greater than being on them. She notes that autoimmunity (Hashimoto's, lupus) and food sensitivities in young women are often hormonal in origin, not just gut issues. Waiting until hot flashes means you've waited a decade too long.

Dr. Sarah explains that fiber lowers estrogen levels, and women are overdoing it—no more than 30 grams a day. Soluble fiber is less problematic because gut bacteria metabolize it, but insoluble fiber acts like sawdust, absorbing nutrients and hormones. She notes that 90% of people have SIBO, and starting HRT can worsen bloating because the hormones feed the bacteria. Dave Asprey adds that soluble fiber can be beneficial for bacterial diversity, but insoluble fiber is the culprit. He also mentions that collagen acts as an animal fiber that gut bacteria can ferment into butyrate. The key is to prioritize protein and fat over fibrous plants, especially for hormone-dysregulated women.

Dr. Sarah says wild yam cream is 'complete bullshit.' The enzyme needed to convert diosgenin to progesterone is not present in humans. Even if it were, the skin is a barrier designed to keep things out; large hormone molecules cannot penetrate effectively (only about 30% absorption for topical hormones). Dave Asprey adds that it takes nine steps in a chemistry lab to turn yams into progesterone, and no one is a chemistry lab. He jokes that vegans might believe it, but it only makes you feel superior and empties your checking account.

Dr. Sarah states that 90% of women starting HRT have fibrocystic breast disease, and iodine is necessary for the breasts and uterus to metabolize estrogen. Iodine deficiency is rampant because it's not in the diet, and bromide and fluoride from the environment bind to iodine receptors. When starting iodine, these toxins are displaced, causing temporary symptoms like flushing, headaches, and fatigue, which are misinterpreted as thyroid worsening. She recommends at least 2,000 mcg/day to treat fibrocystic breast disease, then tapering to once or twice a week after pain resolves. Dave Asprey adds that he was cautious about iodine due to regulatory concerns but includes a moderate dose in his Minerals 101. He also describes the old-school test of applying Lugol's iodine to the skin: if it disappears quickly, you're deficient. He warns that too much iodine can cause watery sinuses and disrupt the gut microbiome, but it's hard to overdose.

Dave Asprey explains that oxalates are razor-sharp crystals that cause micro-damage, leading to chronic UTIs (not from bacteria but from glass shards slicing the urethra), interstitial cystitis, joint pain, and kidney stones. He notes that 70% of kidney stones are oxalate-based. Dr. Sarah shares that she developed kidney stones from daily matcha tea and collagen, and they stopped when she quit. Dave adds that collagen and glycine can convert to oxalate via the glyoxylate pathway, so excessive collagen supplementation can also cause stones. He recommends limiting high-oxalate foods, increasing citric acid (lemon juice) to dissolve crystals, and being cautious with collagen doses. He also mentions that whole grains are high in oxalates, while white flour is low. For fertility, oxalates can deposit in ovaries and uterus, especially in vegans.