BEYOND THE PRESCRIPTION officially goes on sale next week.

Get your advance copy here:

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Last week, I spotted a large box on my front stoop as I pulled in from work. It was either the dog food I‘d ordered from Amazon or fresh-printed copies of my debut book. When the return address read “Simon & Schuster, New York City,” I thought to myself: the dog is going to be hungry and THIS IS IT!

I called out to my husband and asked him to film this moment. He shot it in one take, no prep. As you can hear, I have lots of instructions for him 😆

Let me know what you think! (Besides needing a box-cutter ✂️)

Last, a huge THANK YOU to this readership. Without you, I wouldn’t have gotten the book deal, I wouldn’t be reaching people far and wide, and I wouldn’t have built a community of supportive, curious, thoughtful people who want to be more okay tomorrow than you are today.

See you next week!

🙏 Lucy

*BEYOND THE PRESCRIPTION* BOOK UPDATE: UPCOMING EVENTS 👉

• August 6 @ 6-7 pm PT | Zibby’s Bookshop | Santa Monica, CA | in conversation with Elise Loehnen | RSVP here!

• August 12 @ 7-8 pm | Politics & Prose | Washington, DC | in conversation with Franklin Foer

• August 15 @ 1-2 pm | Mitchell’s Book Corner | Nantucket, MA | book signing

My book, Beyond the Prescription, comes out on August 11. I wrote it with you in mind. The book is a roadmap for navigating your health in real life without perfectionism, pseudoscience, or shame.

PRE-ORDER HERE

You can order your copy at Amazon, Bookshop.org, or Barnes & Noble.

• August 6 @ 6-7 pm PT | Zibby’s Bookshop | Santa Monica, CA | in conversation with Elise Loehnen | RSVP here!

• August 12 @ 7-8 pm | Politics & Prose | Washington, DC | in conversation with Franklin Foer

• August 15 @ 1-2 pm | Mitchell’s Book Corner | Nantucket, MA | book signing

PRE-ORDER HERE!

📣 Click here to send me your questions for future Q&As! ✍️

The following questions have been lightly edited for length and clarity.

QUESTION #1: FULL-BODY MRIS

Is there any utility to full-body MRIs as a health screening tool? I have seen a lot of health and wellness influencers promote this but haven’t seen any evidence.

—Angelica

Dear Angelica,

Great question. MRIs are wonderful for detecting a wide range of structural problems in the body—for example a herniated disc or an abdominal mass that an X-ray can’t capture. But using them as “kitchen-sink” screening tool for the whole body is not evidence-based, nor is it generally a good idea.

Here’s why:

• Full body MRIs detect many abnormalities that are not clinically significant, leading to unnecessary anxiety, testing, and medical interventions. Just recently a patient of mine underwent a Prenuvo full body MRI that revealed benign findings that (understandably) sent her anxiety into overdrive.

• Insurance doesn’t cover full body MRIs. They are expensive and time-consuming.

• Having a normal full body MRI is not the same thing as being healthy. Full body MRI look at structure, not function. So it cannot detect some of the most common and important medical issues we see—for example diabetes, hypertension, metabolic dysfunction, non-specific inflammation, certain infections, fatigue, insomnia, depression, chronic pain, and cognitive impairment.

• These scans can give people a false sense of security. MRIs provide a snaphot—a point in time—without context—in the same way a photograph of your family can’t possibly characterize the relationships between members or their individual personalities.

The American College of Radiology and other medical organizations do not recommend routine full body MRI for asymptomatic individuals, as the risks tend to outweigh the benefits. Better than any snapshot to assess your health is getting regular check-ups and targeted screening tests based on your age, family history, unique risk factors and symptoms. So, I suggest saving your money!

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QUESTION #2: INSOMNIA

Hi, I struggle with insomnia sometimes due to anxiety and my mind whirring too much. So, I use Xanax for nights that I just cannot relax. But my doc wanted me to switch to Trazodone. Neither medication is great. This is not an everyday problem but it feels harrowing when I get into a weird insomnia phase. Do you have any thoughts on what to do? Thank you for considering my question. You are a blessing and great resource!

—Kathy

Dear Kathy,

As you know, sleep is the glue for our whole health, but getting adequate rest is easier said than done. I commonly hear from patients that they turn to sleep aids like Nyquil, Unisom, or even alcohol to quiet a noisy brain at bedtime. The problem with these stop-gap measures is that they produce a state that is closer to sedation and not actually restorative sleep. They can also be addictive and can cause unpleasant side effects like nighttime eating and fuzzy-headedness upon awakening. The same can be true for prescription sleep aids like Xanax and Ambien. Ambien can also negatively affect cognition over time. I generally prefer Trazodone because it is safer for long-term use compared to Xanax (or its cousins, Clonazepam or Lorazepam) which can be particularly habit-forming. While prescription medications can certainly be appropriate for some patients, it’s important to remember that everything we put in our bodies—prescription or not—carries risk and reward.

The best medicine is optimizing the environmental, behavioral, and psychological “ingredients” for sleep. People tend to sleep best when:

• their bedroom is dark, quiet and cool—and when it’s free of pets or pesky bed partners (i.e. try using earplugs, eyeshades, or noise machines as needed).

• they develop a bedtime routine in order to naturally wind down. Try ditching screens an hour before bedtime and instead writing in a journal, using a meditation app like Calm, Headspace, or Insight Timer; or taking a warm bath and listening to calming music.

• they are managing their stress and anxiety. Sleep comes a lot easier to people who exercise regularly, actively process their worries (i.e., with a therapist, friend, or coach), and ask for support for emotional distress.

Some of these items—like ear plugs—are quick and easy. Others—like setting an electronic curfew—are easier said than done. And others—like reforming a snoring bed partner—may be close to impossible.

So just do the best you can. And remember that this is a process. For example, even if you can only manage a 15-minute window of screen-free time before bed, it’s well worth trying. If you notice it helping just a wee bit, you might try experimenting with it further. You might even delete an over-stimulating app or two and find yourself more refreshed upon awakening.

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QUESTION #3: GLP-1s & HAIR LOSS

I am a Diabetes Nurse Practitioner and have been prescribing GLP1 such as Ozempic, Wegovy, and Zepbound. I have found they cause mild hair loss. What are your thoughts regarding these medications that are now consuming our time with Prior Authorizations and have become almost a request with every patient with or without DM for weight loss.

—Terri

Hello Terri,

I’ll answer this question in two parts. First, yes, these medications can cause hair loss—as can any intervention that causes significant weight loss or shift in metabolism. This is one of the many reasons gradual weight loss is better than sudden weight loss.

The best way to prevent hair loss from rapid weight loss is so go slow with GLP-1s. Be closely monitored by a board-certified physician, not someone you met online one time. Make sure you are getting your labs checked, including vitamin levels and blood counts. And remember you still have to eat while taking a GLP-1. Relative malnutrition causes a stress response that can cause hair loss—among other things—and is not the goal of GLP-1s in the first place.

As for my general thoughts on GLP-1 agonists, they are wonderful tools in the toolkit for patients with obesity, diabetes, metabolic problems, and the downstream effects on the heart, brain, and blood vessels. The applications for these drugs keeps growing. Thankfully the medical establishment is waking up to the fact that obesity is not an intellectual or willpower problem, but rather a chronic disease, and these medicines are terrific when used in conjunction with lifestyle modifications.

That said, they are not a panacea. They can have side effects. They are expensive if not covered by insurance. They require close medical monitoring. As for the prior authorization dance (read: nightmare) with insurance companies, it is extremely burdensome for patients, providers and staff. I could hire an army of assistants to help process these meds alone. As frustrating as it can be to get the drugs in hand, for the right person, and with appropriate medical guidance, they can be a wonderful way to help patients medically and psychologically in tandem.

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QUESTION #4: THE SNORING BED PARTNER

My husband snores but denies it. It is negatively affecting our relationship (at least on my end!) How does one stop/prevent snoring that is negatively impacting a relationship?

—DL

Hi DL,

It sounds like there are two problems: your husband’s snoring and his denial about it. Let’s start with the first. Snoring by a bed partner is one of the more common complaints I hear about in my office. The best way to treat snoring is to address the underlying cause, which can include the following:

• Obesity: Excess body weight, especially around the neck, can put pressure on the airways and lead to snoring.

• Nasal congestion: If the nasal passages are blocked due to a cold, sinus infection, or other nasal issues, airflow can be restricted, contributing to snoring.

• Sleeping position: Sleeping on your back may cause the tongue and soft palate to collapse to the back of the throat, narrowing the airway and causing snoring.

• Alcohol and sedatives: Consuming these before bedtime can relax the muscles in the throat, increasing the likelihood of snoring.

• Smoking: Smoking irritates the membranes of the throat and nose, leading to inflammation and increased snoring.

• Age: As people age, the throat muscles may become weaker, increasing the likelihood of snoring.

• Anatomical factors: Some people may have anatomical features that contribute to snoring, such as a low, thick soft palate, enlarged tonsils or adenoids, or a long uvula.

• Sleep deprivation: Lack of proper sleep can relax throat muscles and contribute to snoring.

• Sleep position and sleep hygiene: Poor sleep hygiene, irregular sleep patterns, or insufficient sleep can contribute to snoring.

• Sleep apnea: In some cases, snoring may be a symptom of obstructive sleep apnea, a serious sleep disorder where breathing repeatedly stops and starts during sleep.

The second issue is more persnickety. Denial is a common response to being told you snore, but that doesn’t mean you aren’t making your bed partner crazy! My best advice is to lead the conversation about your husband’s snoring with empathy and curiosity about his health (this will land better than an accusation). Remind him that sleep disturbances can lead to heart disease, metabolic problems, and even memory issues. Then encourage him to seek medical attention. It’s also important to name how you feel, saying, for example, “I’m worried about you.” Or “I need more rest than I’m getting and I want to help you figure out your snoring issues.” You could always sleep in separate bedrooms (what people call a “sleep divorce”), however, addressing the problem head-on means you’re less likely to miss a significant health issue—and that might help you sleep at night. I hope that helps!

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If it wasn’t SUPER OBVIOUS already, my book, Beyond the Prescription, comes out on August 11!

PRE-ORDER NOW

• August 6 @ 6-7 pm PT | | Santa Monica, CA | in conversation with | RSVP here!

• August 12 @ 7-8 pm | Politics & Prose | Washington, DC | in conversation with Franklin Foer

• August 15 @ 1-2 pm | Mitchell’s Book Corner | Nantucket, MA | book signing

PRE-ORDER HERE!

POP QUIZ ✏️

What would you do if you woke up with out-of-the-blue chest pain?

Would you ignore it? Would you calmly take some deep breaths and think, I can handle this? Would you race toward the internet to Google heart attack symptoms? Or would you call your doctor immediately and do whatever they told you to do?

Over 25 years of patient care, I’ve witnessed a wide array of reactions to the same set of symptoms. Some people call me for every symptom, while others forget to mention the chest pain that signals serious heart disease.

I don’t judge patients for how they react—I have my own sometimes-helpful-and-sometimes-nonsensical response to vulnerability—but I do think it’s useful to reckon with something I call your patient personality.

We all have one. Your patient personality is the version of yourself that shows up in the doctor’s office or when you’re sick or faced with medical unknowns. It’s the set of beliefs and mental shortcuts we bring into the exam room. It is a product of your medical history, your threshold for asking for help, your relationship with certainty, your past experiences with doctors, and many other factors. In my experience, knowing your patient personality—and naming it out loud—can help you get what you need. It can also help you get out of your own way.

What is YOUR patient personality?

• The Optimizer is someone who believes that willpower guarantees outcomes. They have great habits and are disciplined, but they can have a hard time accepting things out of their control. (This was me before I realized health is about much more than being fit. In fact, you can be fit and quite miserable at the same time.)

• The Pleaser is the person we discussed last month, the one who thinks, If I can just get the doctor to like me everything will be fine! This is the person who only comes in for their checkup once they’ve lost weight so as not to disappoint the doctor. It’s also the person who minimizes their symptoms or tells their doctor things they want to hear in order to get the proverbial gold star. (This is me, too, when I recently told my doctor I exercise most days of the week. I don’t. I mean sure, I MOVE MY LIMBS daily, but let’s be honest.)

• The Internet warrior is the patient who loves data and information, who spends hours on the internet researching symptoms and diseases, and who comes in with scientific studies—and often a lot of anxiety about their health. (This WOULD be me if I didn’t have a medical degree.)

• The Outsourcer is someone who respects expertise and defers to medical advice. They are low on the anxiety scale and they often aren’t interested in the “why”—they just want the prescription or pills. They don’t want to think too hard; they’d rather just trust the experts and do what they’re told. (This is not me; sometimes I wish I didn’t need to understand the why and just DID THE THING without questioning it.)

None of these is good or bad. Each is a natural response to being in the patient role. Most people are some kind of Venn diagram of two, like I do. (Remember my neck pain problem? When the Denial Plan wasn’t working, I combed the internet for quick fixes, only to learn from an MRI that my spinal cord was compressed by a bulging disc. It took me a minute to notice my left arm wasn’t working, and only then did I call for help and get the medical care I needed.)

Why does this matter?

Not to shame and blame ourselves but rather to know yourself well enough to identify strengths to play up (e.g., understanding your body and respectfulness toward other people); identify weaknesses to work on (ruminating on symptoms without asking for help); and to communicate these things to your doctor so they can help you best.

For example, if you tend to be a Pleaser, you might say to your doctor, “Hey doc, I tend to minimize symptoms” or “Hey doc, I get worried about being judged by doctors.” Acknowledging your tendencies helps build a rapport and signals to your doctor that you know your biases and you’re working on them. That humility builds trust. It also might generate a reply from your doctor like, “No need to perform for me. I’m here to help the real you.”

Take my patient, a man in his mid 50s, who comes in to see me every year with spreadsheets and data from his various trackers and apps. When we discovered he had heart disease he was distraught, not just because of the test results showing coronary disease, but because he felt like a failure. I explained that his heart was better off because of his diligent exercise routine and careful attention to his diet and reminded him that we cannot control our genetics. And that this wasn’t his fault. For years he still refused to take cholesterol medication—not because he didn’t trust me but because it didn’t fit his self-concept. It was only when I was able to get at his internal narrative of guilt and shame that he agreed to take the medication his heart needs.

Chapter 15 of my book is all about the patient personality. (It’s the most asked-about chapter so far.)

For your pop-quiz pleasure, pasted below is a one-page self-assessment tool to help you identify your patient personality. It’s page 6 of my 11-page Patient Self-Advocacy Starter Pack (which comes free when you pre-order my book here!)

Get your free Patient Personality Quiz here!

So I’ll ask you, what is YOUR patient personality? What are your strengths as a patient? And what are your blind spots? Tell me—I am all ears!

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Beyond the Prescription comes out on August 11! I wrote it with you in mind.

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• Join me at Zibby’s Bookshop in LA on August 6 at 6 pm PT 🥂🎉

• Join me in Times Square in NYC on August 11 at 4:15 pm ET 🥂🎉

• Join me at Politics & Prose in DC on August 12 at 7 pm ET 🥂🎉

• Beyond the Prescription releases on August 11. Pre-order on my website and claim your bonus!

PRE-ORDER BEYOND THE PRESCRIPTION!

📣 Click here to send me your questions for future Q&As! ✍️

The following questions have been lightly edited for length and clarity.

QUESTION #1: DIET COKE

This maybe is a silly question, but am I negating all my efforts to eat clean and avoid processed food by having a daily Diet Coke? I feel so guilty. I try to focus on organic fruits, veggies and meats/fish. I only drink wine on the weekends and I exercise regularly. But I can’t seem to give up my daily diet Coke. I would love your thoughts!

-Julie

Dear Julie,

No, your healthy habits aren’t negated by soda. Would swapping your can of Diet Coke for a glass of water be healthier? Probably yes. The caffeine in Diet Coke can increase stomach acid, interfere with sleep, increase urinary frequency, and dehydrate you. The artificial sweeteners and chemicals in Diet Coke probably aren’t great for you, but there’s also no credible evidence that they cause cancer. It also sounds like Diet Coke provides you great pleasure!

One suggestion is to try a month without it. If your sleep, mood, and sense of calm improved, you might decide to limit it. But if you decide that the benefit of a midday energy boost outweighs the frequent trips to the bathroom, then keep it!

Everything we put into our body has pros and cons. Everything we do carries risk and reward. Health is about mitigating risks while optimizing rewards. Sometimes that means enjoying Diet Coke and tolerating the downsides. Sometimes it means quitting a joyful habit because we took stock of the harms. Meanwhile, nice work with your generally healthy lifestyle, Julie! Nothing—not even Diet Coke—can undo that.

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QUESTION #2: WEIGHT WORRIES WITH ADULT CHILDREN

How do you approach talking to adult children about weight gain? My daughter is smart, a parent of two young children and a busy professional. I understand all this and remember how hard it is to eat healthy when you are so busy. I don't care if my daughter gets thin. I just want her to be healthy. Her weight gain over the past few years really worries me. How can I talk to her, an adult in her late thirties, whom I love but whom I worry is harming herself by not attending to this problem or getting the help she needs? Should I suggest a GLP1?

—Grace

Hello Grace,

It’s normal to worry about our children’s health, even when they are adults. That said, it’s safe to assume your daughter is well aware of the potential harms of obesity and the health benefits of maintaining a healthy weight. She knows. I’m also guessing she’d like to lose weight but has a hard time doing it—like so many people do—and is already feeling the pressure herself. And I promise you she’s well aware of GLP-1s!

My advice? Acknowledge your worry. While it’s well-intended and coming from the right place, your worry is not going to help your daughter get what she needs. She needs to get there herself. Then do your best to soothe your own anxiety. Journal, talk with friends, even see a therapist to work on accepting that you cannot change or “fix” your daughter’s health issues, habits, or personal decisions—and that trying to do so runs the risk of harming your relationship. Let her figure out her health issues on her own timeline and with her own doctor. Instead, focus on loving and supporting her for everything that she is. That is the medicine you can give her.

I hope this helps.

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QUESTION #3: GAS AND BLOATING

What is the best way to deal with gas, bloating, and irregular poops? Is a probiotic any help? Everyone I ask has a different suggestion.

—Lois

Hello Lois,

My patients commonly report exactly the kind of bowel irregularity that you describe. In the US, irritable bowel symptoms account for 25 to 50 percent of all referrals to gastroenterologists. The root cause will be different for each person, so it’s important to talk to your doctor to get to the bottom of the issue (no pun intended.)

I wrote an article about what your gut might be trying to tell you here. In the meantime, here are a few things you might do to help alleviate the symptoms.

• Identify and avoid trigger foods: Certain foods such as beans, onions, broccoli, cabbage, and carbonated drinks can produce more gas in the digestive tract. Many of my patients like using the list of FODMAPs as a guide. (These are foods that commonly irritate the gut.) The gut also tends not to like alcohol, caffeine, and heavy meals. Try keeping a food diary to identify which foods may be causing your symptoms and do your best to avoid them.

• Eat slowly and chew food thoroughly: When you eat too quickly, you swallow air that can lead to gas and bloating. Chewing your food properly can also help break down food more effectively, which can reduce the amount of gas produced.

• Take a walk after meals: Going for a short walk after meals can help stimulate digestion and move gas through the digestive tract.

• Try over-the-counter medications and supplements: Over-the-counter medications such as simethicone (GasX) can help break up gas bubbles and relieve symptoms of bloating and discomfort. Peppermint is lovely for calming the gut.

• Work on stress management: Stress lives in our bodies, and it commonly finds a home in the GI tract. You might consider relaxation techniques (i.e., deep breathing, yoga, or meditation), talking to a friend or loved one, or asking for professional help to help reduce stress and its effect on your whole health.

I don’t put too much stock in probiotics unless I have a particular reason—for example, in a patient who is taking antibiotics for Strep throat. As with anything in medicine, there is no one-size-fits all prescription here. Wishing you luck!

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QUESTION #4: DURATION OF ANTIDEPRESSANT USE

I have used antidepressants for many years to treat my anxiety and mild depression. I asked my psychiatrist recently if this is safe to do over decades (thanks RFK), and her answer was that I can take a smaller dose “if I want to.” Later I was frustrated by the complete lack of answers. Months, years and decades go by and nobody ever seems to question if the antidepressants are still needed. What do you tell your patients?

—Laurel

Hi Laurel,

This is a great question. The short answer: there is no rule here. Anxiety and moods are informed by genetics, brain chemistry, behaviors, relationships, and the robustness of our coping tools. Medications for anxiety and depression are tools in the toolbox, just like exercise or sleep are tools. Some people need lifelong meds, some need meds as a bridge to making a needed habit change.

When prescribed appropriately, medications like Prozac, Lexapro, and Zoloft can help reduce suffering and improve patients’ quality of life. But they are not a panacea. They are not a substitute for appropriate behavioral, chemical, and/or environmental changes that drive or trigger psychological distress.

For example, a patient with depression and alcohol overuse might find their depression lifts with sustained sobriety, and they never need an antidepressant medication. Or they might need an antidepressant to lift mood into order to get sober in the first place. Or they might remain depressed even without alcohol, thus requiring an antidepressant long term.

The question isn’t “How long should this patient be on an antidepressant?” It is, “To what extent are the patient’s symptoms fixed versus dynamic?” (and then how readily is the patient able to make needed lifestyle or habit changes).

Does that help?

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If it wasn’t SUPER OBVIOUS already, my book, Beyond the Prescription, comes out on August 11!

PRE-ORDER NOW

• Join me at Zibby’s Bookshop in LA on August 6 at 6 pm PT 🥂🎉

• Join me at Politics & Prose in DC on August 12 at 7 pm ET 🥂🎉

• Beyond the Prescription releases on August 11. Pre-order on my website and claim your bonus!

PRE-ORDER HERE!

This story is told with permission from my patient.

A patient messaged me last week from an airport gate. She’d just seen a story on CNN about a new blood test for Alzheimer’s—one that can now, apparently, flag the disease years before it starts. She was flying to visit her mother, who has Alzheimer’s, and the timing had rattled her.

“Should I just bite the bullet and get the test?” she asked me.

She’s in her 60s and has no particular memory issues beyond the usual fog of a woman juggling a job, a family, and her mother’s care at once. But the question underneath her question wasn’t really about a lab value. It was: Am I next?

Her question is a good one, and it’s newly urgent. On July 14, a study published in JAMA revealed that a blood marker called p-tau217 can estimate a healthy person’s risk of cognitive decline up to a decade before any symptoms appear. The study showed that in people without cognitive complaints, higher levels of p-tau217 tracked with a significantly higher chance of developing Alzheimer’s down the road. For a disease we’ve long been able to confirm only after it announces itself, this is a giant leap for science. Not long ago, spotting the earliest signs of Alzheimer’s required an expensive brain scan or a spinal tap. Now it can start with a blood draw.

A quick word on basic brain science: Alzheimer’s stems from the abnormal accumulation of two proteins: amyloid and tau. Amyloid lives outside brain cells and builds up silently for decades. Tau lives inside brain cells, and its buildup tracks with the severity of memory loss. Think of amyloid as the match, tau as the bonfire. Strike the match, and the bonfire spreads through the brain, kills cells, and tracks the damage that eventually surfaces as memory loss. P-tau217 is a fragment of tau that starts slipping into the bloodstream early in that process. Which is why a blood draw can now catch (proverbial) smoke before you feel any heat.

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So here’s where I slowed my patient down. Smoke is a warning, not a verdict. A high p-tau217 raises your odds; it doesn’t seal your fate. Plenty of people with elevated levels never develop dementia in their lifetimes, and the test can’t tell you when—if at all—symptoms will come. It’s also only about 85% accurate in everyday practice, which means real people can get frightening results that turn out to be wrong.

And then there’s the even bigger question to ponder: if you got the answer, what would you actually do with it? The unpleasant reality is that that the drugs we have for Alzheimer’s (and we do finally have a couple that modestly slow the disease) are FDA approved only for people who already have symptoms. These drugs also carry real risks, including brain swelling and bleeding, and they require a lot of monitoring. In other words, for someone with no symptoms and a worrying p-tau blood test, there is no approved pharmacologic treatment to alter the course of one’s cognitive health. Whether these drugs help before symptoms begin is still being studied. So a scary number, today, mostly buys you anxiety, not a plan.

Which is why no serious guideline recommends the p-tau test for healthy people yet. Screening for a disease makes sense only when the test is accurate enough and a positive result would change what you’d do. For Alzheimer’s, in someone without symptoms, knowing a p-tau level wouldn’t change what your doctor recommends—at least not yet.

If that sounds discouraging, stay with me, because this is the part I most wanted my patient to hear. You don’t need a p-tau test to alter the course of your brain health. Regardless of your p-tau score, the non-pharmacologic interventions known to protect cognitive health are still in play.

Roughly 45% of dementia risk is tied to factors within your reach. (See my conversation with Harvard neurologist Dr. Jonathan Rosand here.) What’s good for your heart is good for your brain, so the unglamorous work of managing blood pressure, blood sugar, and cholesterol matters more than any lab you could order. Move your body, because exercise has actually been shown to lower p-tau217, the very marker in question. Protect your sleep, which is when the brain clears its own waste. Get your hearing and vision checked, because straining to hear and see hastens decline. Stay socially connected and mentally engaged. Go easy on alcohol. And keep up with your vaccines; the shingles and flu shots are both associated with lower dementia risk, for reasons we’re still untangling.

A word of caution about what a discovery like this tends to summon. Very soon, someone will be selling you a pricey “brain panel” or a supplement that promises to lower your number. Be skeptical. The drug the internet was certain would also rescue our brains—semaglutide, the molecule behind Ozempic—just failed its large Alzheimer’s trial. The real levers are the boring ones, and they’ve been available to you all along.

So what did I tell my patient as she boarded her plane? I told her the truth: the test can’t yet give her what she’s really after, which is reassurance, or a plan she doesn’t already have. What it might hand her instead is a number she can’t unknow, about a future none of us can fully see. I also told her that her fear was pointing her in the right direction—toward her health, toward her mother, toward paying closer attention—even if this blood test wasn’t the tool for the moment.

Knowing your data can be powerful. But your data is only ever half the story, and worshipping a number you can’t yet act on is its own kind of trap.

So here’s the question I’d leave you with, the one I asked her: if a test could tell you your risk years early, would you want to know? And what, if anything, would you do differently if it did?

Have a parent, or a fear, like hers? Tell me in the comments. I’m all ears.

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Beyond the Prescription comes out on August 11! I wrote it with you in mind.

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I spent all day in NYC yesterday doing book-related media events. Stay tuned for fun podcast episodes, to be released during publication week (8/11)!

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📣 Click here to send me your questions for future Q&As! ✍️

The following questions have been lightly edited for length and clarity.

QUESTION #1: NEW CHOLESTEROL PILL

Dr. McBride, I just read about the new cholesterol medication Lipfendra. Is it better than statins? Should I switch from Crestor?

—Dan

Hi Dan,

I’ve been getting a lot of questions like this since Lipfendra hit the headlines this week. Here’s the short answer: Lipfendra isn’t a replacement for statins—yet. Right now it’s designed to work alongside them.

Lipfendra (generic = enlicitide) is the first pill in a class of drugs called PCSK9 inhibitors. Until this week, these drugs required self-administered injections. PCSK9 drugs are impressive at lowering LDL (”bad”) cholesterol—often by 50% or more on top of a statin. But here’s what this week’s headlines miss: lowering a number on a lab report isn’t the same as preventing a heart attack. Statins have decades of data showing they reduce heart attacks, strokes, and deaths. Lipfendra doesn’t have that evidence yet. Those studies are still underway.

That said, the data on its cousins, the injectable PCSK9 inhibitors (called Repatha and Praluent) are impressive: they have been shown in large trials to reduce heart attacks and strokes, not just cholesterol numbers. Early data on Leqvio, which is a twice-yearly injection targeting the same pathway, also hint at fewer cardiovascular events, though its definitive trials haven’t finished. So the pathway Lipfendra targets is a proven one; the pill itself just hasn’t earned its stripes yet.

If your cholesterol is well controlled on a statin, there’s no reason to switch. If it’s not, Lipfendra may be worth a conversation with your doctor—as an addition, not a substitute.

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QUESTION #2: POOR AIR QUALITY

Dr. McBride, I keep reading reports about wildfires creating hazardous air quality all over this summer, and I'm wondering what I should actually be doing to protect my health on bad air days. Right now, my weather app says the air outside is "unhealthy." I have mild asthma, and I'm trying to figure out what I'm supposed to do when the air we are supposed to breathe is unhealthy?

—Michelle

Hello Michelle,

Yes, it’s bad out there in various parts of the country right now. The sad truth is that staying indoors is your best bet on days when Air Quality Index, or AQI, is in the “very unhealthy” or “hazardous” range. I suggest checking AirNow.gov for real-time conditions in your area. (It’s more reliable than most weather apps for this specific purpose.)

“Unhealthy” air typically means AQI in the 151–200 range, at which point everyone can start to feel effects, and people with respiratory conditions like asthma are at higher risk. On days like that, the general guidance is to limit outdoor exertion (not necessarily to stay completely indoors) but to avoid anything that has you breathing hard outside, like running, cycling, or yard work.

When indoors, try to keep windows and doors closed and run your air conditioning if you have it, since AC filters and recirculates indoor air rather than pulling smoky air in. An air purifier with a HEPA filter can be well worth the investment (it’s not just a wellness gimmick), particularly for anyone with asthma living in a location where wildfires have (tragically) become part of summer.

For your asthma specifically, make sure your rescue inhaler is accessible and not expired, and if you notice your symptoms worsening on bad air days, e.g., more wheezing, tightness, or you’re reaching for your inhaler more than usual, call your doctor rather than pushing through. Wildfire smoke contains particulate matter that is particularly irritating to airways, and it can trigger flares even in people whose asthma is otherwise well controlled.

Here’s hoping the air clears soon.

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QUESTION #3: SLEEP TRACKING APPS

I’ve been using a sleep app from my smart watch that says I’m only getting 20 minutes of deep sleep per night. I wake up tired most mornings even though I’m in bed for 8 hours. I’m 49 and wondering if I should do a sleep study, or if these apps are just making me anxious about normal sleep.

—Jennifer

Hello Jennifer,

You’re asking exactly the right questions. Consumer sleep apps and wearables are notoriously inaccurate when it comes to measuring sleep stages, especially deep sleep. These devices use movement and sometimes heart rate to estimate sleep phases, but they can’t actually measure the brain waves that define true deep sleep. That requires specialized equipment used in sleep labs. I’ve had patients develop real insomnia from obsessing over their sleep scores!

The more important question is why you’re waking up tired despite eight hours in bed. At 49, hormonal changes from perimenopause could absolutely be disrupting your sleep quality. Other common culprits include sleep apnea, medication side effects, caffeine later in the day, or even stress that doesn’t let your mind truly settle.

A sleep study might be worth considering if you have signs of sleep apnea—like loud snoring, gasping during sleep, or morning headaches. It’s also reasonable if you’ve addressed other factors like cutting caffeine after 2 PM, creating a cooler bedroom environment, and managing evening screen time without improvement.

In general I suggest focusing less on what the app says and more on how your body feels, then discussing this with your doctor. Sometimes the most helpful thing is to step back from the technology and tune into what your body is actually telling you.

I hope that helps!

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QUESTION #4: MOUTH TAPING AND NASAL STRIPS

I keep seeing mouth tape and nasal strips being promoted for better sleep, more energy, and improved athletic performance. I'm a decent sleeper and not an elite athlete, but maybe I’ve been breathing wrong for awhile. What do you think about trying these out?

-Donna

Dear Donna,

The short answer is that there's real science here, even if the marketing has gotten ahead of it. The nose filters, humidifies, and warms air before it reaches the lungs, and nasal breathing produces nitric oxide, which has real cardiovascular and pulmonary benefits. Chronic mouth breathing—especially during sleep—is associated with worse sleep quality, dry mouth, and dental problems. Athletes who’ve focused on nasal breathing during training report improvements in endurance and recovery, and there’s emerging research supporting this.

Nasal strips work by physically widening the nasal passages, which can reduce resistance and make nasal breathing easier, particularly useful if you tend toward congestion at night. They’re low-risk and a reasonable place to start. Mouth tape is a more significant intervention with an earlier-stage evidence base, but for people who are confirmed mouth breathers during sleep, the logic is sound, and some people find it genuinely helpful.

One thing worth knowing before trying either: mouth tape isn’t appropriate for anyone with undiagnosed sleep apnea. If you wake unrefreshed, snore significantly, or feel fatigued during the day, a conversation with your doctor is the right starting point before experimenting on your own. (I cover more on sleep apnea in this episode of my podcast here.)

For a decent sleeper who’s simply curious, nasal strips are an inexpensive place to start.

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This story is told with permission from my patient.

She came in convinced she had Lyme disease. A woman in her mid-60s, she’d spent a few weeks hiking in Maine this spring. She never saw a tick. But in June she started feeling achy in her hips and exhausted for no clear reason. She also had a dull headache that wouldn’t quit. She did what most of us would do: she went online and read up on Lyme disease.

Then she took herself to an urgent care clinic in Maine where they ran basic labs including a Lyme test. Everything came back normal. “Good news,” she was told by a cheerful young doctor. Except it didn’t feel like good news when she felt draggy and not herself.

So she kept looking. A friend recommended a clinic that claimed to specialize in chronic Lyme. There, she got something urgent care hadn’t offered: someone who took her symptoms seriously. She also got a treatment plan—IV antibiotics and oral supplements for $5,000 without good evidence behind any of it. By the time she sat down in my office this month, she wasn’t sure who to believe: the provider who told her nothing was wrong? Or the one who told her he knew exactly what was wrong?

I could tell you the same story about a patient recovering from COVID, or mono, or influenza. (Or any patient with non-specific symptoms and normal labs.) The details change; the limbo doesn’t.

To be clear, the urgent care doctor wasn’t a bad doctor. She just didn’t have time to surface my patient’s whole story. My patient asked, “Do I have Lyme disease?” The labs said no. Visit over. Because answering the question a patient brings in is faster than discovering the question underneath it. Her real question wasn’t “Do I have Lyme?” It was “What could cause fatigue, joint pain, and headaches in a woman my age?” Those are two very different medical encounters.

And the Lyme clinic? It offered the most precious commodity for anyone feeling lost and unwell: someone who listened. That’s why these clinics thrive. Validation is the product; the treatments are the price.

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Here’s what both clinics had in common: they took her question at face value. One answered “no” and stopped looking. The other answered “yes” and stopped looking. A dismissal and a diagnosis-for-sale are twin mistakes, each one ending the search.

Because here’s the ugly truth about lingering post-infectious syndromes: they are usually not one thing. In my experience, what gets labeled “chronic Lyme” or lumped under “long COVID” is often several different problems wearing the same costume—de-conditioning after weeks of illness, insomnia triggered by coughing jags or fitful sleep, depression or anxiety showing up in physical form, an underlying condition such as diabetes or COPD that the infection unmasked. Each of those has a different treatment. None of them is discoverable if curiosity ends at “Your labs are fine” or “It’s chronic Lyme.”

So what happened in my office? I took a detailed history: her migraines, her pre-diabetes, her family history of rheumatoid arthritis, her medications and supplements, her sleep, her stress. I examined her head to toe. And I re-ran her labs, this time casting a wider net, including markers of inflammation and a more detailed Lyme panel.

When she left, I told her the truth: I didn’t know yet what was going on, but I was optimistic we’d figure it out.

Her results came back a few days later. Lyme: negative, again. Everything else normal—except a sky-high sedimentation rate, a nonspecific marker of inflammation. A sedimentation rate that high isn’t a diagnosis; it’s a flare sent up by the body. Finding the source meant going back to her story. So, I called her on the phone and asked more about the headaches. They had started localizing to her right temple. That detail—along with her age, her fatigue, and that inflammatory marker—pointed to temporal arteritis (also called giant cell arteritis or “GCA”), an autoimmune inflammation of the arteries in the head that, left untreated, can threaten vision. I started her on steroids that day, arranged a biopsy to confirm the diagnosis (which it ultimately did), and looped in my rheumatology colleague.

The hip pain turned out to be a separate story: wear and tear from a car accident years ago, unmasked when fatigue knocked her off her regular stretching routine. An X-ray proved it. The pain was related to her new diagnosis, just indirectly—which meant the treatment for hip pain wasn’t treating the GCA; it addressing an old injury that was flaring alongside it.

It’s funny—even after she got fully better on steroids, she still didn’t quite believe me that a tick bite wasn’t behind the whole shebang. And I told her: maybe it was. Maybe a tick bite she never saw set the cascade in motion. Medicine is an art as much as a science. Labs are only half the story. The other half—the timeline, the fears, the life surrounding the symptoms—is data too.

If you’re living in this limbo—if your tests are normal and you still feel terrible—the question isn’t “Who will finally believe me?” It’s: “Who will keep looking alongside me?” That’s a different kind of help, and you’re allowed to ask for it by name.

Have you lived in this limbo—after Lyme, COVID, or anything else? What did it take to be taken seriously? I’m all ears.

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The following questions have been lightly edited for length and clarity.

QUESTION #1: CYCLOSPORA OUTBREAK

Dr. McBride, I just read about a Cyclospora outbreak and I had never heard of it before. How does it spread? Should we stop eating certain kinds of food?! How can we avoid this? (The symptoms sound so unpleasant!)

—Amber

Hello Amber,

I’m getting this question a lot lately! Cyclospora isn’t a household name, but right now case counts are higher than usual and fresh summer produce is at the center of it.

Here’s the deal: Cyclospora is a parasite that gets into the food supply through fecal contamination (I know, yuck), typically on fresh produce. Bagged salad mixes, fresh herbs, raspberries, and snow peas are the usual suspects. You eat it, it sets up shop in your small intestine, and roughly a week later, you feel it. The symptoms are miserable: watery, persistent diarrhea, cramping, fatigue, nausea. What makes Cyclospora particularly annoying is that it tends to seem like it’s getting better before it comes back. That relapsing pattern is actually one of the things that tips clinicians off.

The reassuring part: it’s very treatable once identified, and it’s not the kind of thing that typically lands healthy adults in serious trouble. The catch: Cyclospora requires specific testing to diagnose (it won’t show up on a standard stool culture), so if you’ve had persistent GI symptoms that aren’t resolving, be sure to mention the possibility to your doctor by name rather than assuming they’ll think to test for it.

For now, you don’t need to stop eating produce. Just wash everything thoroughly under running water. (Cooking eliminates the parasite entirely.) And stay alert to GI symptoms that don't resolve.

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QUESTION #2: TOO MUCH PROTEIN?

I have a question - Is it possible to eat too much protein? I’ve started adding peanut butter to my high protein shakes, and I also eat a lot of protein bars but now I’m wondering if you can you overdo it?

—Jake

Hello Jake,

Great question. I get this a lot as people pay more attention to the role of protein in energy, muscle maintenance, metabolism, and overall well-being. The short answer: yes, it is technically possible to eat too much protein. But for most people, the concern isn’t “too much” protein. It’s not enough, especially as we age.

Here’s some context. Most healthy adults need about 0.7 to 1.0 grams of protein per kilogram of body weight per day (that’s about 0.36 to 0.45 grams per pound). For a 150-pound person, that’s somewhere in the range of 55 to 70 grams of protein daily—more if you’re physically active, recovering from illness or surgery, or trying to maintain or build muscle in midlife and beyond.

If you’re adding a shake or a protein bar or two to your day, you’re probably not overdoing it. In fact, you might be landing closer to where your body wants to be—especially if your previous intake was light on protein (which is very common, especially among women).

That said, excessive protein can, over time, stress the kidneys in people with preexisting kidney disease and may crowd out other important nutrients like fiber. So it’s less about the total grams and more about balance—and listening to your body. If you’re suddenly relying on bars and shakes for most meals or feeling bloated, constipated, or sluggish, it might be worth dialing it back and focusing on whole food sources of protein (like fish, eggs, beans, tofu, or lean meat) and pairing them with fiber and healthy fats.

Protein is essential, not just for muscles but for mood, metabolism, immune health, and more. You don’t need to fear it. Just aim for a steady, balanced intake throughout the day and check in with how you feel. That’s usually the best data of all.

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QUESTION #3: URINARY URGENCY

Hi Dr McBride, I am in my late 60’s and when I get the urge to urinate I have to get to the bathroom very quickly or I am unable to hold back very well. Are there exercises that I can do to strengthen my muscles and keep this from happening? Thank you!

-Theresa

Dear Theresa,

Urinary urgency—i.e., the sudden need to get to the bathroom—is one of the most common complaints I hear from women after menopause. And it’s not something you have to accept as part of aging.

In postmenopausal women, urinary urgency typically results from some combination of weak pelvic floor muscles and the absence of estrogen affecting the bladder and surrounding tissues. It can also be from a UTI, so it’s worth ruling that out first with a simple urine test, since infection can mimic urgency without the typical burning symptoms that most people expect.

Pelvic floor physical therapy can make a real difference here, and it goes beyond Kegel exercises (many people don’t perform Kegels correctly or consistently.) A PT who specializes in pelvic floor rehabilitation can give you a targeted program. There are also bladder training techniques that a pelvic floor PT can walk you through, which help retrain the bladder to tolerate longer intervals between bathroom trips.

Vaginal estrogen is also critical. Discuss it with your doctor. It’s delivered locally and is considered safe for most women. It helps restore tissue integrity in the bladder and pelvic floor in ways that can meaningfully reduce urgency over time. (You can listen to my conversation with Dr. Lauren Streicher where we discuss the vaginal estrogen here.) I hope this helps point you in the right direction toward finding relief soon!

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QUESTION #4: BEST EXERCISE HACKS

I know I’m supposed to do some form of aerobic exercise every week … my doctor tells me all the time but I don’t feel like I have the time or motivation to do so. What are some easy & accessible ways to exercise? I need a jump start or a miracle maybe .. thanks in advance.

-Adriana

Hello Adriana,

Patients often ask me, What’s the best kind of exercise to do? The answer: it’s the one you will do. Usually that means you enjoy it, it fits your budget and schedule, and it’s social. In an ideal world, people would get 150 minutes of exercise per week, with a combination of strength training, cardiovascular exercise and stretching. However this can be difficult for mere mortals. I get it.

For busy people, it can feel overwhelming to get started when you aren’t in a regular habit of exercising. However, I will remind you that even a 5-minute walk around the block is better than nothing. Just taking the stairs instead of the elevator counts as valuable movement in your day.

Also, know that changing habits takes about three weeks to take hold. So, if you decide to start exercising, I wouldn’t give up if you hit the snooze button two mornings in a row. Try again, and give yourself a break if you don’t follow through on every promise to yourself.

If you’re in a rut of non-activity and you want to get started on exercise, my best advice is to start by tricking yourself into exercising. Take the stairs, shimmy while you vacuum, walk whenever you can. And if you already enjoy walking, try wearing a weighted vest in order to “supercharge” your cardio and add upper body strength. Voila!

Does anyone have other exercise hacks to share with Adriana? Fire away!

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My book, Beyond the Prescription, comes out on August 11! I wrote it with you in mind.

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Dr. Lucy McBride sits down with Dr. Amy Comander, Harvard breast oncologist and author of Paving Your Path Through Breast Cancer and Beyond, to cut through the fear and misinformation around breast cancer. They cover who is at risk, what the screening guidelines mean in practice, what lifestyle factors move the needle, and how to make sense of the HRT and breast cancer conversation.

Risk: Genetics, Bad Luck, and Everything In Between

• Only 5–10% of breast cancers in the U.S. are due to identifiable inherited gene mutations—BRCA1 and BRCA2 account for roughly half of those

• Another 10–15% involve familial patterns without a single identifiable gene; the remaining majority are sporadic, meaning they occur without an inherited cause we can currently explain

• Having breast cancer in your family doesn’t mean you have a genetic mutation—given that one in eight women will develop breast cancer in her lifetime, sometimes it just means you have women in your family

• A strong pattern—grandmother, mother, and sister all with breast cancer—is a signal worth discussing with a doctor; a single relative is not necessarily a reason for genetic testing

Screening: Mammograms, Dense Breasts, and MRI

• Annual screening with mammography starting at 40 is recommended for average-risk women, with the end point determined by a shared conversation with a doctor

• Dense breast tissue makes mammograms harder to read—finding a tumor in extremely dense tissue is like finding a snowman in a snowstorm; about 10% of women have extremely dense tissue and most should add an annual breast MRI staggered six months from their mammogram

• Heterogeneously dense tissue is common—up to 40% of women under 50—but not everyone with it needs an MRI; the decision depends on other risk factors and should incorporate a validated risk model like the Tyrer-Cuzick calculator

• Breast MRI catches more cancers but also generates more false positives; the downstream anxiety and biopsies are costs that belong in the conversation about pros and cons of MRI as a screening modality

Lifestyle and Prevention

• Alcohol is the most consistent and modifiable lifestyle risk factor for breast cancer—even one drink per day carries a small but real increased risk, and the relationship is dose-dependent

• Maintaining a healthy weight and engaging in regular physical activity reduce risk, partly by reducing circulating estrogen in post-menopausal women and by improving metabolic health overall

• Soy is not a risk factor for breast cancer—this is a persistent myth; soy foods are a good source of plant-based protein and the evidence is clear that they are safe

• Risk factors divide into fixed (age, sex, genetics) and modifiable (alcohol, weight, exercise, metabolic health); the goal is to lean into what can be changed without catastrophizing what cannot

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HRT and Breast Cancer: Separating Fear from Evidence

• The fear around HRT and breast cancer stems largely from the 2002 Women’s Health Initiative study, which used synthetic progestins—not the bioidentical hormones most commonly prescribed today

• In the WHI, women who took estrogen alone—those who had undergone hysterectomy—actually had a reduced risk of breast cancer, a finding that was not widely reported

• The overall increased risk from combined hormone therapy is small, and causation has not been established; a family history of breast cancer is not an automatic disqualification from HRT

• HRT is a tool in the toolkit, not a solution for everyone—the right answer depends on individual risk factors, symptom burden, and what risks a woman is willing to tolerate on both sides of the decision

Vaginal Estrogen and Breast Cancer Survivors

• Vaginal estrogen is considered safe for virtually all women, including most breast cancer survivors, because systemic absorption is minimal

• It is distinct from systemic HRT and should not be lumped in with it—women who have had breast cancer and are suffering from genitourinary symptoms should know this option exists

• For women on systemic HRT who also use vaginal estrogen, the two can be used together; the patch is not a substitute for vaginal estrogen because the tissue itself needs local treatment

• Oncologists are increasingly getting educated on menopause management—the divide between oncology and women’s health is closing, and patients benefit when their cancer doctor and primary care doctor are working from the same playbook

Survivorship: Thriving Beyond a Diagnosis

• Too many women feel defined by their diagnosis, or guilty that they somehow caused it—neither is warranted, and neither serves the goal of getting better

• Breast cancer is not one disease; genomic tools like the Oncotype DX and ProSigna help determine whether chemotherapy is even necessary, sparing many women from treatment that won’t help them

• The pillars of thriving after breast cancer mirror the pillars of health generally—sleep, movement, stress management, social connection, and a sense of purpose

• Patients have more agency than they often believe: where genetics and diagnosis are fixed, how a woman shows up for her body, her relationships, and her care is not

Upshot

One in eight women will develop breast cancer in their lifetime. Most cases are not due to an inherited genetic mutation. Screening saves lives. HRT is not the villain it was made out to be. And breast cancer patients have more agency than they often think.

If you enjoyed this episode, check out my other conversations on women’s health:

• Hormone Therapy, Hot Flashes & Sexual Health with Dr. Lauren Streicher

• Menopause, HRT, & Genitourinary health with Dr. Rachel Rubin

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My book, Beyond the Prescription, comes out on August 11! I wrote it with you in mind.

PRE-ORDER HERE!

• Join me at Zibby’s Bookshop in LA on August 6 at 6 pm PT 🥂🎉

• Join me at Politics & Prose in DC on August 12 at 7 pm ET 🥂🎉

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The following questions have been lightly edited for length and clarity.

QUESTION #1: MOSQUITOS & WEST NILE VIRUS

With summer, I'm seeing more mosquitoes than ever and starting to worry about mosquito-borne illnesses. I know West Nile virus gets mentioned every year, but I don't really understand how serious the risk actually is or who is most vulnerable. What should I be doing to protect myself?

—Aubrey

Hello Aubrey,

I’m glad you asked. West Nile season is off to one of its worst starts in years, and it’s good to think about prevention rather than just swatting and hoping for the best.

The good news is that most cases of West Nile are asymptomatic or mild. Serious illness is less common, nonetheless it’s important to know what to look for. Symptoms like fever, headache, body aches, weakness or numbness in an extremity, or rash—particularly when occurring days after a known bite—warrant a call to your doctor. Note that serious illness tends to occur in adults over 60 or those with underlying health conditions but can affect anyone.

Since there’s no vaccine for West Nile, prevention is key. On mosquito repellents: EPA-registered options containing DEET, picaridin, or oil of lemon eucalyptus are the most effective and are safe for adults and children. Apply to exposed skin and clothing before heading out, and reapply if you’re outside for extended periods.

Because mosquitoes are most active at dawn and dusk, shift outdoor activities to midday if possible to reduce exposure. Lightweight long sleeves and pants during those peak hours help more than most people realize. And around your home, eliminating standing water is one of the most impactful things you can do. Birdbaths, clogged gutters, planters, buckets, even bottle caps collect enough water to become breeding grounds.

I hope you can enjoy being outside this summer—just bring the bug spray!

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QUESTION #2: FATIGUE DESPITE NORMAL LABS

Hello, Dr. McBride. I recently went through a series of blood work to help determine what’s causing my fatigue, the muscle cramping in my legs and feet, and how I’m doing in general. Everything was “normal”. But then I started to wonder, whose “normal”? Men’s “normal” or women’s “normal”? I’m happy things look good, but I was also hoping for more insight into what might be causing these symptoms in an active, healthy-eating, good-sleeping GenX woman. And I refuse to continue hearing this is “normal” and “part of aging” for “women.” We can do better than that. Thanks!

—Chris

Hello Chris,

Your frustration is completely valid, and the question you’re asking—whose normal? —is legit. The short answer: most reference ranges used in standard lab work were historically derived from studies that skewed heavily male. Women’s hormonal fluctuations, body composition, and physiology differ enough from men’s that a number landing “within range” doesn’t always mean it’s optimal for you specifically.

On your symptoms: fatigue and muscle cramping in an otherwise healthy, active woman have a differential diagnosis worth working through rather than dismissing. A few things that frequently get missed (or at least underweighted) include magnesium deficiency, which rarely shows up on standard panels because serum magnesium doesn’t reflect intracellular stores well; iron deficiency without anemia, where ferritin can be low enough to cause symptoms even when hemoglobin is normal; vitamin D insufficiency; thyroid function at the lower end of “normal” that still affects how you feel; and perimenopause or early menopause-related hormonal shifts that don’t always trigger obvious symptoms but can drive exactly what you’re describing.

The “ask” worth making at your next appointment: don’t just request labs, request context. What is my ferritin, not just whether I’m anemic. What is my free T3, not just my TSH. What is my vitamin D level in actual numbers. And if your symptoms persist despite normal results, a referral to a specialist who works with women’s health and hormonal issues is entirely reasonable to push for.

You’re right that we can do better. And asking these questions is exactly how that happens.

PS. Asking better questions and gaining confidence to advocate for yourself is something I cover in-depth in my forthcoming book, Beyond the Prescription! You can pre-order it here.

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QUESTION #3: ALCOHOL CRAVINGS & GLP-1S

I am hearing that people lose their taste for alcohol on Ozempic (and similar medications for weight loss). I would be interested in it for that reason but I don’t know if the side effects are worth it- plus the cost.

-Monica

Dear Monica,

Yes, people who take Ozempic and other GLP-1 medications commonly report reduced cravings for alcohol. Interestingly, they also may find themselves less inclined to engage in other compulsive behaviors (e.g., skin picking, compulsive shopping, etc).

Why is that? These drugs not only reduce appetite and tell the pancreas to produce more insulin, they also act on the brain’s pleasure center, such that people who typically over-indulge in food get less of a dopamine rush in response to eating. They are less interested in food because the reward circuitry in the brain has changed. It makes intuitive sense, then, that the compulsion to drink alcohol is dampened when less dopamine is released when consuming it (or even when thinking about it!) (You can read more about how Ozempic works in my article here.)

You might ask: Could Ozempic be a solution for addiction? It’s too early to tell. The early observational data on Ozempic’s ability to reduce impulsivity and cravings around various habits is promising. Eli Lilly will study the use of GLP-1s to treat alcohol, nicotine and drug abuse.

What do I think? Given that addiction is a complex bio-psycho-social phenomenon, it’s unlikely that medication alone will be universally helpful. In other words, the brain’s dopamine and pleasure circuitry is only one piece of a more complex problem. That said, if addressing the neurobiology of addiction with a drug helps millions of people who suffer from substance use disorders (without doing more harm than good), I welcome it.

I am closely following the Ozempic data and will keep you posted. Now I will ask you—what are your thoughts about this drug and the fanfare around it? Drop me a note in the comments below!

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QUESTION #4: ELEVATED LIVER ENZYMES

Dr. McBride, Three of my last four blood labs in the past three years have come back with mildly elevated ALT (in the 40s-50s). I’m a 39-year-old woman in good health, have never abused alcohol, and all other labs are normal. We’ve ruled out hepatitis and now my doctor is recommending a liver ultrasound, but I’m also wondering—are there any lifestyle changes (other than reducing alcohol) that can help reduce stress on the liver? Thanks!

-Elise

Hello Elise,

Your doctor is right to recommend a liver ultrasound for a persistently elevated ALT. It’s the next step to rule out metabolic-associated steatohepatitis (aka “fatty liver” disease), which is now the most common cause of mildly elevated liver enzymes in otherwise healthy adults. You don’t have to drink heavily, or at all, to develop it.

Assuming that’s what you are dealing with, there’s a lot you can do on the lifestyle front. The liver is super sensitive to metabolic health and dietary inputs. Think of your liver as the garbage disposal for almost everything you consume, so the most impactful changes center on reducing what the liver has to process—like fructose and added sugars. Reducing these are a good place to start because the liver metabolizes fructose directly; excess intake drives fat accumulation in the liver even in lean, active people. Ultra-processed foods have a similar effect. A diet that emphasizes whole foods, fiber, lean protein, and healthy fats supports liver health more reliably than any supplement can.

Exercise matters, too, independent of body weight. Regular aerobic activity and strength training reduce liver fat even when the scale doesn’t move, which is an under-appreciated finding. If you’re already active, you’re already on the right track.

One more thing to review with your doctor: certain medications and supplements, including acetaminophen used regularly, some herbal supplements, and even high-dose vitamins, can quietly elevate ALT over time. A full inventory of everything you’re taking is critical.

That imaging will give you and your doctor a clearer picture of what’s actually going on. In the meantime, the lifestyle factors above support liver health across the board, whatever the result turns out to be. I hope that helps!

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My book, Beyond the Prescription, comes out on August 11! I wrote it with you in mind.

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A reader wrote me last week. She hit the nail on the head.

I find the U.S. healthcare system frustrating. When I see my “primary care” doctor—for a problem, or an annual physical—it feels like we’re just going through the motions. My few chronic conditions never get better; if anything, they get worse as I age. What’s worse, with a science background, is that I never understand whether we’re ruling anything out, or what’s cause and effect. Is the diagnosis simply that my condition can’t be cured, so I take medication forever? If so, what are the side effects—and if we’re only managing symptoms, what are the other options?

I’ve started having new symptoms: joint stiffness, aches and pains. I’d like to understand what’s wrong—and understand it in the context of the other conditions I’ve been carrying. I feel like I need a new approach, or a new doctor. I wonder if any of the longevity practitioners offer a more holistic approach. Am I crazy, or does this not exist—is it only for billionaires? Can you recommend a way to start?

I’ll be honest: when I read this message, my first thought was that you’ll all think I made her up! Because she’s put her finger on exactly the problem so many people are facing: medicine that’s become transactional and impersonal. Studies have found that doctors tend to interrupt patients in the first 11 seconds. This is not the fault of doctors; there just isn’t time.

There’s no time to ask the questions you deserve to ask. Is this test meant to rule something out, or are you ordering it because you’re worried? Is this medication something I need long term, or is it short-term only? And to weave in your lifestyle, your medications, your goals, your lab work—who you are as a person. That kind of care shouldn’t be a luxury.

So, dear reader, THANK YOU for the layup, because you’ve captured what so many people are experiencing (and the reason I wrote my book).

Here’s what I wrote back to her

You probably don’t need a longevity expert. (The word “longevity” gets thrown around a lot these days.) And you may not even need a new doctor. What you need is someone board-certified in internal medicine or primary care who has enough time to consider your health as an ecosystem.

You are more than a set of body parts. You are more than a set of lab tests. You’re a living, breathing, whole human being. Yes you have lab data; you also have biographic data that needs to be surfaced. You have nutritional inputs. You have a skeleton that carries you through life. You have mental health, emotional health, biases, and personal goals. Healthcare shouldn’t treat you like a transaction; it should help you connect the dots between your habits and your lab results, your genetics and your risk for disease, your life stressors and your everyday experience of being alive. It should arm you with the tools, the information, and the guidance to live the way you want to live.

Healthcare should be a series of conversations, not a stack of prescriptions.

So yes, you may need a new doctor. But what you’re really after is to understand where you have control and where you have to cede it. You want to know what’s fixed, what’s dynamic, and where you have agency over your health.

Take your new aches and pains. I can’t diagnose you from here (that’s a conversation for you and your doctor), but it might be arthritis: something you could manage for a while with an anti-inflammatory or physical therapy, and that might one day mean a joint replacement. It might be muscle imbalances, certain groups that need strengthening, others that need loosening, again with physical therapy. You might decide a joint replacement isn’t something you want at any cost, which points toward more conservative, ongoing management.

The point isn’t which of those is right for you. It’s knowing what levers you have. Maybe you want less stiffness. Maybe you want more mobility. Maybe you want to be as aggressive as possible and have surgery, if it’s on the menu. Maybe you’d rather avoid surgery at all costs and accept that you’ll need medication long term.

Those are your questions to bring into the room. And the ones you’re already asking are exactly right.

So maybe the real question isn’t whether you need a new doctor. It’s whether anyone has ever helped you ask the right questions.

If this reader’s letter sounds familiar, here’s something to take with you. I’ve pulled one page from my Four-Quadrant guide—a set of questions to bring to any appointment, whether it’s primary care, a specialist, or the ER—grouped by the four parts of your health that usually get treated in isolation. Print it, screenshot it, keep it in your bag. Because health isn’t about having all the answers. It’s about asking better questions—to yourself, and to the people responsible for your care.

That’s two pages. (You can download them here.) The full Four-Quadrant Self-Reflection & Action Guide is my gift to everyone who pre-orders the book. →

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Beyond the Prescription comes out on August 11! I wrote it with you in mind.

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The following questions have been lightly edited for length and clarity.

QUESTION #1: INSULIN LEVELS IN NON-DIABETICS

Dr McBride, I’m having some anxiety around all the info (from doctors on-line) that people should have their insulin levels checked, not just A1c and glucose. (For example, may cause heart related diseases). I’d love to see a future post on this. Both of these and my weight are “normal” for me and my PCP isn’t interested.

—Laurie

Hello Laurie,

It’s normal to think, What am I missing? when an online doctor says that a normal A1c and glucose—the traditional measures for diabetes and pre-diabetes—can mask a problem that only your insulin level would reveal.

The fear-mongering is so unhelpful!

Here’s what gets lost: Sure, fasting insulin often can can flag insulin resistance earlier than glucose or A1c. But insulin levels aren’t well standardized, “normal” ranges vary from lab to lab, and in someone like you—normal weight, normal glucose, normal A1c, no symptoms—an elevated number rarely changes the plan. Regardless of your insulin level, when you have a normal A1C and glucose, the plan is to move your body, build muscle, protect your sleep, manage stress, eat mostly whole foods. A spot insulin level doesn’t get you anything you can’t already act on.

So, rather than asking your PCP to order this test, you might try a different question: “Given my whole picture, what would actually move the needle on my metabolic health?” That is more likely to result in a conversation about what to do, not just what not to do.

Does that help?

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QUESTION #2: VAGINAL ESTROGEN AFTER 65

I am not happy. I'm 72 and my primary care clinic won't prescribe HRT to women over 65 or more than 10 years past menopause. Full stop. I’ve listened to you and Rachel Rubin talk about the safety and benefits of vaginal estrogen so I asked the nurse - she hinted that a compounding pharmacy might be an option. Why is this so hard for women?

—Barb

Hello Barb,

This burns me up!! Your frustration is completely justified and all too common. A blanket “no HRT after 65” policy is not evidence-based. It’s liability management dressed up as clinical guidance, and it is failing women like you every day.

Here’s what the evidence actually says: vaginal or topical estrogen, which acts locally with minimal systemic absorption, carries near-zero risk and has myriad benefits for postmenopausal benefits (specifically it reduces the risk for urinary tract infections, vaginal dryness, painful intercourse, urinary symptoms like frequency and burning, and pelvic floor dysfunction).

The risk of estrogen (topical and systemic) has been overblown, ever since the misreading of the 2002 Women’s Health Initiative study. This was a very well done study that enrolled women who were, in many cases, years out from menopause and had pre-existing cardiovascular risk. The problem is that the study’s conclusions about breast cancer and cardiovascular risk were wildly overstated. They have since been substantially revised. The Menopause Society now states clearly that there is no fixed age cutoff for hormone therapy. Vaginal estrogen is safe for everyone. Decisions about whether or not to take systemic hormone therapy should be individualized based on symptoms, medical history, and risk profile.

(You can read my full thoughts on the ten year window and age restrictions for HRT here. And here’s a recent conversation with menopause expert Lauren Streicher MD related to this topic as well.)

Vaginal estrogen is widely available at traditional pharmacies with a prescription. I prefer the vaginal estrogen cream over the suppository. The key is to apply it using your finger, not the applicator (toss it out!), to make sure the estrogen is absorbed into your tissue (around the labia, urethra, and in the vagina) to protect what can become very fragile tissue without hormonal support.

More importantly, none of this should happen without a physician who specializes in menopause medicine in your corner, ideally someone who can prescribe appropriately and monitor your progress over time. The providers exist and increasingly, they may be accessible via telehealth if your local options are limited.

You deserve better!! I hope you find it.

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QUESTION #3: DIETARY CALCIUM & OXALATE

Can you discuss how oxalates and phytates interfere with calcium absorption, how much is problematic, and tips to improve calcium absorption?

I’ve been taking 500 mg. of calcium per day (thinking I was getting the rest from my diet). My last two lab reports came back low in Calcium. I was following (too closely, I think) my endocrinologist’s advice to eat Calcium rich foods like almonds and kale. I have only recently discovered these bind to calcium. Because I take Levothyroxine, I avoided Calcium intake in the morning and took my Calcium supplement with dinner. Thinking I was upping my Calcium intake, I was eating lots of almonds, uncooked kale in salads, chia seeds in yogurt and soups, etc.

-CD

Dear CD,

Great questions. Let’s break them down.

First about oxalates: Oxalates (in spinach, almonds, chia, beet greens) and phytates (in nuts, seeds, whole grains, legumes) bind calcium in your gut and form compounds you can’t absorb, so some of the calcium in “calcium-rich” foods is effectively locked up. There’s no clean cutoff for “how much oxalate is too much.” For most people eating a varied diet, the effect is modest; it matters most when a high-oxalate food is your main calcium source. And here’s a fun fact: kale is actually LOW in oxalates, and calcium from kale is very well absorbed, often better than dairy products. Spinach is the oxalate offender, not kale.

But here’s the bigger point: a low calcium level on blood work usually isn’t a story about dietary calcium intake. Your body holds blood calcium in a tight range, borrowing from bone if it has to. When that number runs low, the usual culprits are vitamin D, magnesium, your parathyroid, or your albumin level (which changes how calcium reads on the test). In other words, almonds and kale rarely bump blood calcium levels.

So, the better questions for your next doc visit: Has my vitamin D been checked? My magnesium? Is this a corrected or ionized calcium? (And separating your calcium from your Levothyroxine, by the way, is exactly right—calcium blocks its absorption.)

That’s the heart of Beyond the Prescription, learning what to ask, and whom. I hope this helps!

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QUESTION #4: BRAIN FOG VERSUS DEMENTIA

Hi Dr. M. I feel like I’m forgetting things all the time. I’m not that old, just 51, but I forget names more, lose my train of thought mid-sentence, and walk into rooms not remembering why. I’m worried about early dementia. Also I have not had a menstrual period in 8 months and have hot flashes at night, and sweats. How do you know if memory problems are normal aging or something more serious? (I know I need to see my doc!) -Stephanie

-Stephanie

Hello Stephanie,

At 51, the symptoms you’re describing, while frustrating, are incredibly common and probably not early dementia. What you’re experiencing sounds much more like menopause or perimenopause brain fog, which is real, frustrating, and usually temporary.

Here’s what’s likely happening: fluctuating estrogen levels during perimenopause directly affect brain function, particularly areas involved in memory, attention, and verbal fluency. Estrogen helps with neurotransmitter production and supports neural connections, so when levels drop and surge unpredictably, your brain doesn’t function as smoothly. Add in disrupted sleep from night sweats or insomnia (also common in menopause and perimenopause), chronic stress, managing multiple responsibilities, and possibly some underlying anxiety about these symptoms, and you’ve got a perfect storm for feeling mentally “foggy.”

True dementia looks different. It’s progressive—meaning it steadily worsens over time rather than fluctuating day to day. It interferes with your ability to function independently—forgetting how to do familiar tasks, getting lost in familiar places, struggling to follow conversations or manage finances. It often involves personality changes or poor judgment that others notice before you do. The fact that you’re aware of and worried about your forgetfulness is actually reassuring—people with true dementia often don’t recognize their cognitive decline.

Independent of hormonal fluctuations, consider other treatable causes of inattention and forgetfulness: Sleep deprivation (regardless of its cause) can wreak havoc on memory and concentration. Are you taking any medications that affect cognition, like antihistamines, sleep aids, or certain antidepressants? Is your thyroid function normal? Are you dealing with significant stress or anxiety? All of these can mimic or worsen cognitive symptoms.

As you say, it’s important to talk with your doctor about your symptoms and get a basic workup—thyroid, B12, vitamin D, iron levels, a metabolic panel. If menopause or perimenopause seems likely, hormone therapy might help—and you would probably know it was helping over the course of a few weeks.

Cheers to a healthy brain!

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My book, Beyond the Prescription, comes out on August 11! I wrote it with you in mind.

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• Another review just in:

  “Beyond the Prescription is a welcome antidote to a healthcare landscape split between futuristic technology and natural remedies. Dr. McBride makes the case — convincingly and warmly — that 21st-century medicine works best when rigorous evidence meets personalized, relationship-centered care.”

  —Adam Cifu, MD, Professor of Medicine at the University of Chicago, and cofounder and editor of Sensible Medicine

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What Risks Can You Live With?

A patient with pre-diabetes recently asked me, “Can I start taking a GLP-1 medication?”

She had read about the side effects—the nausea, the muscle loss, the “Ozempic face.” The way she asked the question sounded like she was asking whether or not she was allowed to take this medication. Like she wanted my permission.

So here’s what I told her: let’s start by reframing your question. Not because the risks of GLP-1s aren’t real. But because the question carries two assumptions—that my job is to grant permission or withhold it, and that one choice is safe and the other risky.

But that’s not how this works.

There is a risk to the “Yes” There is also a risk to the “No.” Neither answer removes risk. Each just hands her a different list of them

So the real question—the one that’s actually answerable—isn’t “Can I?” It’s “Which of these risks can I live with?”

I wrote about risk and risk management for Maria Shriver’s Sunday Paper this week. It was a reaction to the NYT’s recent article about all the women who have been told “NO” to hormone therapy—that the door is closed to them—when so often what they were really handed wasn’t a contraindication but the absence of a conversation. I talk about a patient of mine with a clotting disorder, the kind of woman who usually gets a fast, firm “absolutely not,” for whom I ended up prescribing HRT:

“I didn’t do that because I decided her risk was acceptable. I did it because her risk was never mine to accept or refuse. It was hers to weigh.”

That’s the whole thing, really. Your tolerance for risk is yours. It was never mine to assume.

FULL PIECE HERE

Take my patient with pre-diabetes. We discussed the potential risks of taking a GLP-1, such as constipation, heartburn, muscle loss, fatigue. We also discussed how we would mitigate these risks, for example by adding more fiber, dietary protein, and strength exercises, and following up with me for lab work and dosing adjustments.

We also discussed the risks of not starting a GLP-1 medication and of pre-diabetes itself—such as heart disease, weight gain, the progression to frank diabetes. We discussed how to mitigate these risks with dietary changes, exercise, medications like metformin, and using a continuous glucose monitor for added insight on how her body reacts to fueling it.

My point is that risk is everywhere. It sits on both sides of every medical decision. The question isn’t how to escape it. It’s which side of the decision you’re better off living on.

This is the spine of nearly everything I believe about taking care of people. There are no solutions in health, only trade-offs that reflect what matters to you. My job was never to decide which risks you should accept. It’s to hand you the data, the real trade-offs, and the tools to mitigate both sides.

So the next time someone hands you a flat “No,” I hope you’ll ask a better question—to yourself and to the people responsible for your care.

Not “Can I?”

But: “What are the risks on each side—and which one can I live with?”

Weighing risks and benefits and making decisions like this thoughtfully is a topic I cover in my forthcoming book, Beyond the Prescription! It comes out on August 11, and I hope you’ll read it. I wrote it with you in mind ❤️

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The following questions have been lightly edited for length and clarity.

QUESTION #1: OPTIMIZING FOR LONGEVITY

Hi! I feel like the longevity conversation is everywhere, and there are new recommendations to live a longer, better life coming out everyday. But honestly, most of these suggestions don't feel feasible for the average person (like me.) I'm 59 and I’ve always thought that staying active, eating a decent diet, and keeping up with my regular doctor appointments was enough. But now I’m wondering if I’m being naive or complacent. Thoughts?

—Rick

Hello Rick,

It sounds like you’re being sensible, not complacent! The longevity-slash-optimization movement has turned aging into a daily battle—something that requires constant vigilance, intervention and monitoring. But the (boring) truth is this: the basics you’re already doing—staying active, eating well, limiting alcohol, maintaining social connections, getting good sleep, not smoking, and seeing your doctor for regular checkups—are still the foundation of healthy aging and backed by the strongest medical evidence.

These aren’t trendy, but they work. The more elaborate protocols—extensive supplement regimens, continuous biomarker tracking, cold plunges, restrictive diets—might offer marginal benefits for some people, but they’re not necessary for most of us to age well.

That doesn’t mean there’s nothing to learn from the longevity-focused messengers. Heck, my entire job is to help people live longer! The emphasis on strength training, metabolic health and inflammation has real merit. And being proactive about health is always good. But there’s a difference between thoughtful health optimization and turning your life into a full-time science experiment.

The question to ask yourself is: what feels sustainable and aligned with how you actually want to live? If tracking metrics and following protocols fits your lifestyle and holds you accountable to your goals, great. But if it would add stress, cost, and rigidity to your life without clear benefit, then sticking with your current approach makes more sense. You can always add targeted interventions if specific issues come up—for example checking testosterone, hemoglobin, vitamin D, iron, thyroid and B12 levels for fatigue, or adding more protein if you’re losing muscle mass—without overhauling everything. Ideally you could have a medical guide who centers medical evidence and YOU in the same conversation!

The upshot: don’t let anyone make you feel like basic healthy habits aren’t enough.

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QUESTION #2: GLUTEAL CRAMPING FROM STATINS

Hi Dr. McBride, I have high cholesterol and high Lp*a*. I’m on a statin but have been getting a lot cramping after workouts. What other options do I have besides statins which would be covered by insurance? Should I get tested for the gene that can cause muscle aches from statins?

-Sally

Hi Sally,

Gluteal cramping after workouts is a potential side effect from your statin, but before you assume this is the issue, I suggest confirming with a simple blood test (CK, or creatine kinase), because it also could be from a structural/skeletal problem such as piriformis muscle strain, lumbar disc disease, sciatica, or gluteal tendinopathy.

Given your elevated Lp(a), it’s important to be aggressive about your LDL cholesterol level. The goal isn’t to back off cholesterol-lowering treatments, it’s to find a version of it you can tolerate.

Also know that not all statins are created equal: some people do better simply switching to a different statin or adjusting the dose, since muscle symptoms vary surprisingly from one statin to another. If you can’t tolerate statins, Ezetimibe (aka “Zetia”) is a reasonable next step if that doesn’t work. It’s an oral, non-statin medication, lowers LDL by roughly 15 to 20 percent, rarely causes muscle issues, and is typically well covered by insurance. Bempedoic acid is a newer oral option, often used for people who don’t tolerate statins well. PCSK9 inhibitors (aka “Repatha” and its cousins) are the most powerful tool in this category, cutting LDL by 50 to 60 percent, though they’re injectable and insurance usually wants to see that you’ve tried other options first.

One thing worth knowing about your Lp(a): statins don’t reduce this number much, so think of it as a separate piece of the puzzle. There’s nothing FDA-approved yet that targets Lp(a) directly, though there’s promising research underway, which means your best lever right now is staying on top of everything else that’s modifiable.

To your question about “pharmacogenetic” or PGx testing, this is a way of analyzing your DNA to determine how effectively your body processes cholesterol-lowering medication. Sounds sexy, right? In clinical practice, though, it’s rarely necessary. If your doctor is tuned in to your story and side effect profile, testing like this is just an expensive way of documenting what patients already know from experience. That said, genetic testing can help doctors and patients feel more comfortable selecting the appropriate statin and dosage to maximize effectiveness while avoiding muscle pain and other adverse side effects. It’s reasonable to ask your doctor about getting tested for a gene called SLCO1B1 which is linked to statin-related muscle symptoms if you’ve cycled through a couple of statins already. Labcorp can test you for this with a doctor’s order.

Upshot: I suggest keeping it simple and consider the CK muscle test first. It’ll tell you a lot about where to go from here. I wish you the best!

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QUESTION #3: BIRTH CONTROL PILLS AFTER 40

Hi Dr. McBride, I’m 35 and have been using a combined oral birth control pill continuously for the past five years to stop my period. My gynecologist told me when I turn 40 I can no longer use the pill because the estrogen puts me at a higher risk of clot/stroke and suggested switching to an IUD. My periods are can’t-leave-the-house debilitating, so I’m concerned with switching because I don’t know for sure the IUD will work the same as the pill. Can you tell me what the literature says about the estrogen risks my doctor mentioned?

-Kristin

Hi Kristin,

Thank you for sharing this, and I completely understand the anxiety around switching something that’s been working so well for you for so long. Your doctor’s guidance isn’t wrong, however the picture is a bit more nuanced than a hard cutoff at 40.

The concern is specifically about combined oral contraceptives, which contain estrogen taken orally. Oral estrogen passes through the liver, which increases clotting factor production and raises the risk of venous thromboembolism and stroke. That risk is low in healthy young women but rises with age, and the combination of advancing age, the pill’s estrogen, and any additional risk factors—smoking, migraines with aura, obesity, family history of clots—is what providers are weighing when they recommend stopping by 40 or shortly after. It’s not that age 40 is some absolute biological cliff; it’s that the risk-benefit calculation shifts with age.

On the IUD question: a hormonal IUD, such as Mirena or Liletta, delivers progestin locally to the uterus with minimal systemic absorption and no estrogen at all, which is why it doesn’t carry the same clot risk. The tradeoff is that it works differently. The pill suppresses ovulation and creates a predictable, lighter, often absent withdrawal bleed through its hormonal regulation. A hormonal IUD often reduces periods significantly, and many women stop bleeding entirely after several months, but the timeline and degree of improvement vary more by individual than with the pill, and some women take 6 to 12 months to see the full effect.

Given how debilitating your periods are, this transition deserves a sturdy plan rather than an abrupt switch. I’d talk with your gynecologist now about a transition strategy, like overlapping the two methods briefly (completely fine!) or trying the IUD before you’re forced to stop the pill rather than after.

You have years before this decision is urgent. I hope this gives you some peace of mind!

PS. Weighing risks and benefits and making decisions like this thoughtfully with your providers is a topic I cover in my forthcoming book, Beyond the Prescription!

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QUESTION #4: SLEEP SUPPLEMENTS

I'm 79 and have been experimenting with magnesium and melatonin to help with sleep. Both seem to be working, but I've noticed some grogginess during the day. Are there risks to relying on supplements like these long-term, especially at my age?

-Helen

Hello Helen,

Magnesium and melatonin are generally safe choices for sleep.

On melatonin: it’s a hormone your body produces naturally, and production tends to decline with age, so supplementation can genuinely help. But more isn’t necessarily better. Higher doses don’t always work better and can increase the odds of next-day grogginess, which may be what you’re noticing.

On magnesium: it’s safe for most people, though higher doses can cause digestive upset and, less commonly, affect how other minerals are processed by the kidneys. This matters a bit more as we age, when kidney function naturally declines somewhat. (I have a breakdown of the many types of magnesium supplements and their effects here.)

The bigger picture: both supplements are reasonable for most people in the short to medium term, but they’re worth periodic check-ins rather than indefinite, unsupervised use, especially if doses keep creeping up. If you find yourself needing more and more to get the same effect, be sure to mention it to your doctor.

You're clearly paying close attention to your body, and that's the best tool you have here!

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My book, Beyond the Prescription, comes out on August 11! I wrote it with you in mind.

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Not through ads or algorithms.

To me, there’s nothing more compelling that a friend saying, I loved this book or This book really helped me. I hope my book, Beyond the Prescription, finds its readers this way, too.

That’s why I’m asking for your help.

I’m putting together a merry band of readers to carry this book into the world when it publishes on August 11. I’m calling them BTP Ambassadors—the Launch Team. I’d love you in it.

Who’s running it? My 24-year-old son, Henry. Watching him take this on has been one of the unexpected joys of the whole process. (Thanks, Hen!)

Here’s how to join the Launch Team

STEP ONE — Pre-order at least one copy, from wherever you like to buy books:

• Amazon

• Bookshop.org

• Barnes & Noble

• Books-A-Million

• or your favorite indie bookstore

STEP TWO — Fill out this quick form, and you’ll receive:

• A 6-month upgrade to Founding Member here on Substack

• Access to the BTP Ambassador / Launch Team group chat

• An exclusive advance digital copy of Beyond the Prescription

• Bonus content, including my Four-Quadrant Self-Reflection & Action Guide

Over the summer, I’ll ask you to do a few small things—tell a friend, ask your local bookstore to stock the book, share a graphic during launch week, and leave an honest review once the book is out. Nothing heavy, and nothing that takes more than a few minutes.

You’ll be added to the group chat within 72 hours. It’ll be quiet at first—we’ll officially kick things off at the end of June for a 30-day sprint to pub date. 🏃🏽‍♂️

The thread running through everything I write is that so much of health—and frankly, so much of life—comes down to taking action where you have it. This is one of those places. Every honest conversation about health, every copy that ends up in the right hands is how a book finds the people it was written for.

Thank you for being here, new readers and longtime ones alike. It means more than you know.

❤️ Lucy

Questions? Drop me a line below.

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Beyond the Prescription, comes out on August 11!

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• A recent review!

  Dr. Lucy McBride combines wisdom and empathy in ways that are all too rare in medicine. Beyond the Prescription is the practical, never preachy book that thoughtful patients—and their doctors—have been waiting for. Highly recommended.

  —Robert Wachter, MD, Chair of Medicine at UCSF

• That’s a WRAP, after 26 hours in the studio recording the audiobook! 😅

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The Trouble With Being a ‘Good Patient’

Have you ever felt the urge to reassure your doctor that you’re fine? To dazzle them with your good habits, or convince them that nothing serious is going on?

It happens in my office all the time.

A patient in her 70s recently came to see me after her second trip to the ER for a serious fall. “I’m just a little clumsy,” she told me with a wink. “You don’t need to worry about me.” And if I’m honest, the urge to be reassured is real. What doctor doesn’t enjoy feeling unburdened by concern or impressed by a patient’s fortitude?

Another patient told me last year that she’d quit drinking largely because she wanted me to be proud of her. I was proud of her. But I immediately felt uneasy that she’d handed me a piece of her self-esteem to hold.

So I started wondering: why does it feel so good, for so many patients, to please the doctor? Why do I, when put in the patient role, round up when asked the number of days per week I exercise—and round down the number of drinks I consume? What’s in it for patients? Is it to shield doctors from concern? Is it to avoid hard conversations or risk being lectured? What’s the big deal about racking up a few brownie points with someone responsible for your care?

It turns out, quite a lot.

Most obviously, people-pleasing is often an unconscious way to hide vulnerability. My patient who kept falling didn’t need a pat on the head. She needed an adjustment to her blood pressure medication, a reminder to get rid of the throw rugs at home, and a referral to physical therapy for her balance. When I asked her about the impulse to tell me she was okay, she admitted this: “I suppose if you’re not worried, I don’t have to worry either.” She was using my reaction as a bellwether for her own—a concern that was very much present, just buried under her fears about aging and losing her independence.

It can also mean outsourcing your intuition. My patient who quit drinking had spent years ignoring (or perhaps not noticing) how her drinking made her feel, using my imagined approval as her benchmark instead. So, when we met, I made sure she saw the evidence for herself: her liver enzymes and inflammation markers had normalized, her blood pressure had settled. And I asked her to tune in to her sleep, her mood, her relationships, her energy. Moving the benchmark from my reaction back into her own body, she later told me, is what helped her stay sober.

The urge to people-please in the doctor’s office can corrupt the very information doctors depend on. The patient who tells me she’s been taking her medication every day when she hasn’t isn’t lying, exactly; she just can’t bear to disappoint me. But that small fiction sends me down the wrong path: I assume the drug isn’t working, so I might raise the medication dose or add another drug, and now we’re chasing a problem that was never there. The most useful thing you can hand your doctor is the truth, as unflattering as it may be.

Here’s the part that surprises people: pleasing can get you more medicine, not less. The patient who doesn’t really want the test, the referral, or the third follow-up—but says yes anyway, because declining feels rude—ends up more poked, prodded, and prescribed than their body ever needed. Agreeableness has a cost, and sometimes you pay it in procedures.

The dynamic runs both ways. Doctors are busy, and we’re human, too. A cheerful, unconcerned 2 o’clock patient can be a welcome reprieve from the complicated case waiting at 2:30. But that relief can also keep us from digging deeper, letting our wish for an easy visit quietly override our obligation to be thorough.

Of course, we doctors carry our own biases. If I start to think of you as more capable, less sick, or better equipped to handle illness or difficult news than the facts suggest, I risk co-writing that story with you—even subtly adding pressure to the very tendency that got us there. Imagine if I’d decided to motivate my newly sober patient with something like, “Keep making me proud!” Would she have come back to me when she relapsed a year later? Or would she have disappeared, ashamed, exactly when she needed help most?

None of this means deference is bad. Doctors love agreeable patients! We welcome kindness. The instinct that makes someone a “good patient”—conscientious, respectful, willing to follow through—is often the same instinct that builds a real relationship with a doctor. The problem isn’t kindness itself. It’s when kindness becomes performance, and when performance buries the truth.

In my book, I call this patient personality the “Pleaser”—one of a handful of patient personalities I’ve come to recognize over 25 years of practice. We all bring a version of ourselves into the exam room. The Pleaser brings the one who wants to be liked. (PS. You can pre-order Beyond The Prescription where I dig into all the patient personality types here!)

So here’s the question I’d leave you with, the one worth sitting with before your next appointment: when you walk into your doctor’s office, which version of you shows up? And is it the version that’s actually going to get you what you need?

Drop your comments below. I’m all ears!

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The following questions have been lightly edited for length and clarity.

QUESTION #1: DOES EVERYTHING CAUSE CANCER?

Dear Dr. McBride, It seems like every week we hear about a new product category that causes cancer or has some correlation to it. No black plastic, no non-stick, no aluminum antiperspirant, only all natural makeup and skincare, and on and on and on. How can we know which swaps are really worth making, and which are fueled by someone selling something?

—Shira

Hello Shira,

I hear you. Making sense of medical headlines can be exhausting, and sorting signal from noise is a challenge—even for doctors!

As someone who fields questions about fear-based headlines all the time, I can tell you that the words “correlation” or “association” do a lot of heavy lifting in most of these headlines. An observational study showing that people who use product X have higher rates of deadly disease Y tells us almost nothing about cause and effect. It doesn’t account for what else those people eat, do, or are exposed to, and the association may be coincidental, confounded, or vanishingly small in absolute terms.

The question worth asking isn’t Is there a link between X and Y? but How strong is the evidence that X causes Y, how large is the effect, and does the causal relationship hold up across multiple well-designed studies?

By that standard, tobacco, alcohol, processed meat, excessive UV exposure, and radon all have strong, replicated links to cancer. PFAS chemicals found in certain non-stick cookware, food packaging, and water supplies have a substantial and growing body of evidence behind them. But most of the weekly headlines about diet sodas, black plastic, aluminum in deodorant, your favorite moisturizer, etc do not clear that bar.

The upshot: it’s reasonable to choose products with fewer synthetic chemicals where it’s easy and affordable, but the swaps that matter most for cancer risk are almost never the ones being sold to you (e.g., not smoking, limiting alcohol, maintaining a healthy weight, getting screened appropriately). I hope that gives you a useful filter for the next headline.

PS. Weighing risks and benefits and sorting through medical information is covered in my forthcoming book, Beyond the Prescription—preorder here!

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QUESTION #2: JOINT STIFFNESS AND MENOPAUSE

Hi Doc - when I turned 50 last year, I feel like a switch flipped. I am suddenly so stiff and achy, mostly when I get up after sitting or laying down. Overnight, I have terrible hip pain that I don’t have during the day. I’m a pretty active person, and I usually sleep on my side with a pillow between my knees. I should add I’m a cisgender woman who has been on menopause hormone therapy for a year. Can you tell me why this stiffness issue came on so suddenly and what I should do about it (stretching more seems obvious, right? Anything else?)

-Aimee

Hi Aimee,

Joint pain and menopause are indeed related. How so? Estrogen plays an important role in maintaining joint and tendon health. The decline in estrogen levels during menopause can cause tissues that were previously supple and well-lubricated to become stiffer and prone to irritation. The fact that you’re active, on HRT, and still experiencing this suggests either that your estrogen dose may need to be adjusted (ie. increased), and/or that you’re dealing with a structural issue at the same time.

Note that a condition called gluteal tendinopathy (aka irritation of the tendons that attach the glute muscles to the outer hip) is extremely common in postmenopausal women, often causes exactly the kind of pain you’re describing at night, and is frequently missed. It’s not arthritis and it’s not a structural problem with the joint itself; it’s a tendon issue that responds well to targeted physical therapy, specifically exercises that strengthen the glutes and improve hip stability. Sleeping on your side, even with a pillow between your knees, can actually aggravate it.

If that’s what you’re dealing with, stretching alone won’t fix it and can actually make things worse. Strengthening is the intervention with the best evidence. A physical therapist who works with women in midlife can assess your hip mechanics specifically and give you a targeted program.

Most importantly: be sure to mention hip pain to your HRT prescriber. Joint symptoms are one of the less-discussed effects of the hormonal transition, and it’s important you are getting enough estrogen to protect them.

PS. We cover a ton of topics around menopause in my conversation with Dr. Mary Claire Haver here!

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QUESTION #3: EGGS & CHOLESTEROL

Dr. McBride, I have high cholesterol and have been advised to cut back on cholesterol in things I eat. Can you set me straight - are eggs good for you or not?

-Rachel

Hi Rachel,

Ah! This is a great question I get a lot. The relationship between eggs and cholesterol is a topic of ongoing debate. The short story: egg yolks are high in cholesterol, however, recent research suggests that dietary cholesterol doesn’t have as big an impact on blood cholesterol levels for most people as previously thought. Research has shown that eggs can raise both LDL (”bad”) cholesterol and HDL (”good”) cholesterol, but the effect on LDL is usually less significant than the effect on HDL. Importantly, the ratio of LDL to HDL (which is more important for heart health) may not worsen with moderate egg consumption.

In 2015, the Dietary Guidelines Advisory Committee released a report that removed the previous restriction on dietary cholesterol, suggesting that cholesterol from foods like eggs may have a minimal effect on blood cholesterol levels for most people. This was supported by evidence from several studies showing that saturated fats, not dietary cholesterol, are the main culprits in raising blood cholesterol.

Of course, there are always exceptions. Some people—often referred to as “hyper-responders”—may experience a significant increase in blood cholesterol when they consume cholesterol-rich foods like eggs.

Bonus points for egg-lovers: eating more eggs could reduce your risk of developing Alzheimer’s disease by nearly 50%. For women, eggs may mitigate changes in cognitive function due to old age. This is what a pair of new studies suggest. In one study, a higher egg intake was associated with less of a decline in verbal fluency among women only during a 4-year period (sorry, men!), with those consuming 5 or more eggs per week experiencing the greatest benefit. In the other study, eating 2 or more eggs per week was associated with a 47% reduction in Alzheimer’s disease risk over a nearly 7-year follow-up period.

Clearly more studies are needed to confirm the causal relationship between egg consumption and brain health but personally I can’t wait for breakfast. 🍳

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QUESTION #4: FULL BODY MRI’S

Hi Dr McBride! My Dad was recently diagnosed with kidney cancer which we were told he likely has had for a decade or more due to the slow growing nature of the tumor. This has me considering paying out of pocket for a full body MRI every few years as a preventative measure. What are your thoughts on companies like Prenuvo and why are we not offering preventative MRIs more broadly when the technology is available and it could save lives and millions in treatment by catching something like this years earlier?

-Layla

Hello Layla,

I’m so sorry about your father’s diagnosis. That kind of news has a way of making us look at our own health very differently.

The appeal of full-body MRIs is intuitive: more information feels like more protection, right? But the evidence doesn’t bear that out, and this is worth understanding before spending several thousand dollars. Up to 40 percent of people who get these scans will have findings that require follow-up testing. Fewer than 1 percent will have findings that actually change their health outcomes. The problem isn’t the technology itself. MRIs are powerful and precise for specific diagnostic purposes. The problem is that a scan of the whole body finds everything: benign cysts, normal anatomical variations, incidental findings that look alarming but aren’t, and things that genuinely need attention but that the scan can’t reliably distinguish from the noise. The cascade of anxiety, follow-up testing, and sometimes unnecessary procedures that follows is real and not trivial.

Your father’s situation is also worth examining closely. His cancer was likely discovered for a specific reason—a symptom, a scan ordered for something else, or a clinical concern. That’s a different context from a healthy, asymptomatic person paying out of pocket for a full-body sweep.

The better investment is a physician who knows your family history, assesses your individual risk factors, and orders targeted screening based on what actually makes sense for you. That’s less satisfying than a whole-body image, but it’s what the evidence supports. I feel for you, though, because the tension between wanting certainty and what medicine can actually provide is one of the central challenges patients face today.

Wishing your father and your whole family all the best as you navigate this.

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My book, Beyond the Prescription, comes out on August 11! I wrote it with you in mind.

PRE-ORDER NOW

BOOK UPDATE 👉

• Come celebrate with me in DC! During publication week, I’ll be in conversation with my friend Franklin Foer on August 12 at 7 pm at Politics & Prose.

• Just in! My first official review! "[A] smart debut guide to making informed health decisions... Patients will feel empowered." —Publisher’s Weekly

PRE-ORDER BEYOND THE PRESCRIPTION

A patient in her sixties told me recently that she’d been losing words. She couldn’t summon the word “colander,” so she called it a sieve. Her daughter’s college friend’s name escaped her for half a day, then surfaced out of nowhere while she was brushing her teeth that night. She hadn’t mentioned any of it to anyone. When I asked why, she said, “I guess I feel like there’s not much I can do.”

I hear this all the time. For some reason, the brain is the one organ patients seem to view as fixed, as something that happens to them, rather than because of them. My patients will gladly swallow fiber tablets to improve their gut health and ditch red meat to optimize their cholesterol scores, but somehow people seem to assign their brain to fate.

But the truth is you have more agency over your brain health than you may think! Two things have me thinking about this, and I want to share both with you.

YOUR BRAIN HAS A SCORE

Last week I sat down with Dr. Jonathan Rosand—a neurologist at Harvard and Massachusetts General—in a live conversation hosted by . Dr. Rosand is the mind behind something called the Brain Care Score, and I’d love to point you to it.

It's Your Turn w/ Allison Aubrey

Your Brain Has a Health Score. Here's How to Find Yours.

It’s Your Turn Live is a weekly video series featuring conversations I’m having with people who’ve changed how I think about what’s possible in midlife. The topics cover health, work, identity, relationships, and finding joy and momentum. This week we start with the brain…

Listen now

2 months ago · 10 likes · 2 comments · Allison Aubrey, Dr. Lucy McBride, and J Rosand

Most of us have no real idea what “take care of your brain” means. Patients are accustomed to hearing advice from doctors to “Eat well.” “Get more sleep.” “Cut back on the booze.” But these can feel vague enough not to action. The cool thing is that the Brain Care Score turns the abstract into twelve specific, modifiable things—and a number, from zero to twenty-one, that you can actually move.

Some of them you’d expect: blood pressure, blood sugar, cholesterol, weight. Some you’d recognize from any conversation about a healthy life: how you eat, how you move, how you sleep, how much you drink, whether you smoke. And then three that rarely make it onto a medical checklist at all—your stress, your relationships, and whether your life feels like it has meaning.

Check out that list again! There’s almost nothing on it you can’t influence.

What’s particularly powerful is that the same score that predicts your risk of stroke and dementia also predicts your risk of depression. Raise it, and all three risks fall. That points to the fact that brain health, mental health, and heart health aren’t three separate projects. They’re one system, and it’s largely in your hands.

You can check your own score in about a minute here, and watch or listen to my conversation with Dr. Rosand here: Your Brain Has a Health Score.

YOUR BRAIN AND YOUR HEART ARE PART OF THE SAME SYSTEM

I wrote a guest post this week for physician and chef over at Brain Health Kitchen, on what the new cholesterol guidelines mean for your brain. It turns out your heart and your brain are fed by the same plumbing system.

Brain Health Kitchen

The New Cholesterol Guidelines Are Here

Hello, everyone. Almost three years ago I wrote to you that cholesterol guidelines were woefully outdated. The standard lipid panel doesn’t check for the newer, more accurate biomarkers. It provides a false sense of security when HDL (aka the “good cholesterol”) is high. It doesn’t screen people early enough in life. And—this has been my biggest beef—it…

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2 months ago · 55 likes · 10 comments · Annie Fenn, MD and Dr. Lucy McBride

In it, I describe a patient whose LDL cholesterol had climbed. On paper, it looked like her statin had quit working. But when I asked what was going on in her life, the real story came out: her mother, who has Alzheimer’s, had moved in after a bad fall. Diane had dropped her morning walks, swapped dinners for takeout, and was pouring a little more wine each night to take the edge off. Her cholesterol wasn’t rising because her medication failed. It was rising because her life had changed.

And here’s the part that’s stayed with me: every one of those changes was quietly raising Diane’s own risk of the very disease she was caring for in her mother.

Her labs weren’t the problem to fix. They were a signal, pointing back to a life under strain.

The new cholesterol guidelines themselves are good news: screening starts earlier, there’s a once-in-a-lifetime test for a powerful genetic risk factor called Lp(a), and better tools for estimating your lifetime risk rather than just the next ten years. But a guideline can tell you what your numbers should be. It can’t tell you why yours are moving, or what to do about the life behind them.

You can read the whole piece here: The New Cholesterol Guidelines and Your Brain. Annie kindly took down the paywall for you till the end of the week. (Thanks, Annie!)

So—what can you actually do for your brain?

More than you’ve been told. You can know your numbers and move them. You can treat a rising lab value as a question, not a verdict. And you can tend to the parts of brain health no scorecard fully captures: the stress you’re carrying, the people around you, whether your days feel like they mean something.

Remember the patient I opened with, the one losing words who figured there was nothing to be done? This is exactly what I told her: the belief that you’re powerless is the one thing worth letting go of. We started looking together. That’s almost always where it begins.

So much of health—and frankly, so much of life—comes down to taking action where you have it, and making peace with what you don’t. Your brain is far more within your reach than anyone led you to believe.

Welcome to the many new readers who’ve found their way here—there are 40,000 of you now, and I’m so glad you’re here!

Lucy

My book, Beyond the Prescription, comes out on August 11! I wrote it with you in mind.

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The following questions have been lightly edited for length and clarity.

QUESTION #1: GLP-1S TO LOSE A FEW POUNDS

I’m wondering if you’re getting questions about what I’ll call GLP-1 Lite — meaning someone like me who wants to lose 10 to 15 pounds. I go back-and-forth between 1. hey, a little GLP-1 and I could lose this excess weight and 2. what the heck who cares I’m buying my jeans in a bigger size, concentrating on eating healthfully (including drinking less or even not at all!), and trying even harder to get more exercise, including weight lifting. What are your thoughts?? P.S. All that said, I do worry a lot about the GLP-1 side effects, including nausea, not to mention muscle loss.

—Debbie

Hello Debbie,

I really appreciate the framing here—and your honesty! As you might imagine, I get this question a LOT.

Here’s my honest take: for someone without metabolic issues—e.g., diabetes, pre-diabetes, high blood pressure, high cholesterol—GLP-1 medications offer less of a benefit than they do people who do have those problems. So what your weighing (no pun intended) is the psychological benefit of losing weight versus the potential for real side effects, real costs, and a real need for medical supervision while on the drug.

As for side effects, nausea is common, particularly in the early weeks. The muscle loss concern is legit and requires active countermeasures (adequate protein and resistance training) to mitigate. The other issue is that the weight sometimes returns when the medication is stopped, which raises the question of whether this becomes a long-term commitment for a goal that is, by your own description, somewhat negotiable.

What you’re already doing—eating better, drinking less, lifting weights—is also, not coincidentally, exactly what the research supports for long-term metabolic health.

That said, if the 10 to 15 pounds is genuinely affecting your quality of life, or if you’ve been fighting the same weight for years without traction despite real effort, a GLP-1 might be great for you. GLP-1s aren’t only for people with obesity; they work on the neurobiological drivers of eating behavior in ways that go beyond simple appetite suppression, and some people find that genuinely freeing regardless of how much weight they have to lose. (Ashley Koff and I covered some aspects of this topic in our conversation here.)

The upshot: Instead of asking your doctor, “Can I take a GLP-1,” reframe your question to get the answer you want—and ask, instead, “What are the risks and benefits of GLP-1s for my specific situation?” I hope this helps!

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QUESTION #2: TICK BITES & LYME

Dr. McBride, the ticks are out of control this year! There are so many in my area, and just the other day I found one crawling on me (so gross), and it’s making me nervous. What should I be doing when I find a tick on me, and what symptoms should I be watching for afterward?

-Hannah

Hi Hannah,

It’s tick season, and these little buggers can transmit a variety of infections beyond Lyme, including anaplasmosis, babesiosis, and Rocky Mountain Spotted Fever, so let’s run through some key things to know.

My top advice is to keep your eyes open for ticks. Finding a tick early, that is, before it gets embedded into your skin, is key. Transmission of most tick-borne illnesses requires the tick to be embedded for a meaningful period of time, so regular checking and prompt removal dramatically reduce your risk. Do a thorough once-over after spending time outdoors. Check your scalp, behind the ears, underarms, behind the knees, and groin. Ticks are small and favor warm, hidden spots.

For prevention: DEET-based repellent on skin and clothing, light-colored clothing that makes ticks easier to spot, and that daily check are your best tools.

If you do find one attached, remove it promptly with fine-tipped tweezers. Grab it as close to the skin as possible and pull straight up without twisting. Save it in a sealed bag with the date noted. Having the tick gives your doctor something to work with if symptoms develop. If you think the tick has been embedded less than 48 hours, your doctor may want to prescribe a preventative dose of doxycycline (200 mg, once). But timing is everything.

Here are the symptoms to look for after a tick bite: fever, fatigue, body aches, headache, or any rash near the bite site in the weeks that follow. Most tick-borne illnesses respond well to treatment when caught early, which is exactly why checking yourself regularly is the most important thing you can do.

Here’s my deeper dive on preventing Lyme disease—let me know if that helps.

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QUESTION #3: MAGNESIUM SUPPLEMENTS

I see various forms of magnesium in the supermarket and pharmacy. I hear it is recommended for some of the issues I deal with - like muscle spasms, joint pain, sleep and digestion. My gynecologist recommended Magnesium L-threonate, but would another form be better? Like glycinate, oxide, citrate etc. Can you break down which versions do what?

-Lee

Hi Lee,

Yes! I don’t put too much stock in any one supplement, however, as part of a holistic health plan, magnesium can help with various issues like the ones you describe. Magnesium comes in several forms. Here’s a breakdown of some common types and their specific uses:

Magnesium Glycinate (or Bisglycinate): This is my personal fave. It is known for its high absorption and bioavailability and can help relieve muscle cramps and spasms, anxiety, and sleeplessness. It’s also less likely to cause diarrhea compared to other forms of mag.

Magnesium Citrate: This form of magnesium is highly bioavailable (which means it can provide a quick increase in magnesium levels). It is good for digestive health and can help relieve constipation. Fun fact: in high doses, magnesium citrate is used as part of a colonoscopy prep.

Magnesium Malate: This is often recommended for conditions like chronic pain and fibromyalgia. It’s believed to help with energy production in the cells, however, the mechanism of action isn’t fully known.

Magnesium Oxide: This form is commonly used as a supplement but has lower bioavailability. It’s often used for to help treat heartburn, indigestion and constipation.

Magnesium Sulfate: Also known as Epsom salts (another personal favorite), it’s used in baths for muscle relaxation and to reduce inflammation.

Magnesium Taurate: This form is often recommended for cardiovascular health due to its combination with taurine, an amino acid beneficial for heart function. It can support heart health, may help regulate blood pressure, and has a calming effect on the nervous system.

Magnesium L-Threonate: I sometimes recommend this form for cognitive health and overall brain function. It has been shown to cross the blood-brain barrier effectively, potentially aiding in memory and learning.

Talk to your doc before you start any magnesium supplement. Each form of magnesium has its unique advantages, so the best one for you depends on your specific health needs and how your body responds to each form.

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QUESTION #4: SEED OILS AND BUTTERS

Hey Doc, I eat sunflower seed butter pretty much daily, because my body is a bit sensitive to peanuts (I tend to get headaches and just feel physically unwell after eating them). I also like the taste of seed butter better than, say, almond butter. I’ve been seeing a lot out there about avoiding seed oils, and I’m wondering if it might be a bad idea to eat seed butter every day for similar reasons. What do you think?

-Amy

Hello Amy,

The seed oil debate is one of the noisier corners of nutrition social media right now, and it’s worth separating what’s real from what’s being amplified well beyond the evidence.

Here’s the actual concern: seed oils like sunflower, soybean, and corn oil are high in omega-6 fatty acids, specifically linoleic acid. The hypothesis (and it is only a hypothesis right now) is that excessive omega-6 intake promotes inflammation, particularly when the ratio of omega-6 to omega-3 in the diet is heavily skewed toward omega-6, which it is for most people eating a Western diet. That part is biologically plausible and worth paying attention to at the level of overall dietary patterns.

What doesn’t follow from that is that sunflower seed butter eaten daily is harming you. Whole food sources of fat—seeds, nuts, nut butters—come packaged with fiber, protein, vitamins, and minerals that change how the body processes them compared to refined oils used in industrial food production. The seed oil concern is primarily about highly processed, heavily heated oils showing up throughout the food supply, not about someone eating a tablespoon of seed butter with their breakfast.

Sunflower seed butter is also a reasonable source of vitamin E, magnesium, and healthy fats. The fact that your body tolerates it better than peanuts, and that you actually enjoy it, are not small things nutritionally.

If you want to be thoughtful about the omega-6 to omega-3 ratio, the more meaningful lever is making sure you’re getting enough omega-3s through fatty fish, walnuts, flaxseed, or a quality supplement, not eliminating a whole food you’re already eating and enjoying. I hope this gives you some peace of mind!

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I was in LA last weekend, celebrating my wedding anniversary (26 years!). Cortisol, the infamous stress hormone, was on the brain.

First, my husband had been taking high-dose steroids for a persistent migraine headache. Momentarily forgetting this, I asked him at dinner, “Is it me, or are you talking super fast—and a little loud, too?” (26 years of marriage is really a union of honesty and bluntness.)

“Love, remember I’m taking 60 mg of Prednisone! I could run a 4-minute mile on this stuff!”

Oh right.

It’s funny how administering an oral equivalent of cortisol—the same stress hormone that can leave you wired, revved, and unable to sleep—can also quiet inflammatory processes like migraines and poison ivy and asthma flare-ups.

Then, watching the roller coaster dip and soar on the Santa Monica pier, I felt my palms sweat and my heart gallop. Even though I wasn’t ON the rickety ride myself, my own adrenaline (cortisol’s fast-acting cousin) kicked in—the same primitive reflex those teenagers in line were paying for: the thrill, the simulation of danger.

Before we talk about whether cortisol is good or bad, let’s get the biology straight. Cortisol is a hormone produced in the adrenal glands. It releases into the bloodstream on a circadian rhythm and spikes during periods of physical or emotional stress. It’s a built-in survival mechanism. (Unlike adrenaline, which spikes in seconds on a roller coaster or in a burning building, cortisol works on a slower clock.) There are rare conditions in which the adrenal glands make far too much cortisol (Cushing’s syndrome) or far too little (Addison’s disease); both are real, both are testable, and neither is what most of my patients are dealing with.

For people with normal adrenal function, cortisol isn’t a problem, it’s a signal. Its presence is our best friend when we’re in danger. But when it’s being made in excess, we can feel unwell and our bodily systems can go on the fritz. The body isn’t the problem; it’s doing exactly what it’s hard-wired to do. It’s also inviting us to take stock of what’s going on in our lives.

So why is the internet ablaze with headlines suggesting that cortisol is bad for you? Why do wellness influencers claim that excess cortisol—made by our own bodies—is responsible for everything from weight gain and diabetes to depression and fatigue? Why are there supplements promising to “balance” your adrenals, protocols to lower your cortisol, and mushroom blends to calm your nervous system?

It’s not that cortisol is newly discovered. I think it’s that modern life has made us wired and tired and unsure of what’s wrong with our bodies. Most people don’t know who to trust or what questions to ask.

Last week, a patient in her mid-40s came in to see me for her annual physical. After we reviewed her labs and decided she was squarely in perimenopause, she lowered her voice and asked me the question she came in to ask: “Do you think it’s my cortisol?”

She wasn’t wrong. But the cortisol question is the right instinct dressed up as the wrong question. I get it. She had been combing the internet for answers like we all do. The right question is one only she can ask herself (and the one your doctor likely doesn’t have time to): What physical, emotional, or situational stress am I under—and what, realistically, can I do about it?

That question deserves an answer. And it cannot be answered by a supplement or a protocol. It can be answered, instead, by an honest conversation (with yourself or with your doctor) about your sleep, your alcohol intake (not what you tell your friends it is), your relationships, your hormonal status, your everyday coping kit, what you eat when no one is watching, and what you would change about your life if you gave yourself permission and you weren’t afraid.

The things that actually lower cortisol are not exotic. They are sleep, movement, protein, sunlight, human connection, healthy boundaries, and, for some women, hormone therapy, or an SSRI, or an honest hour with a therapist. They are unglamorous, they are hard to implement, and most of them are free. (Which is why I’ll never make a quick buck off of selling you products!)

So when my patient asks me, “Do you think it’s my cortisol?”—I tell her yes. I tell her she’s right to be paying attention. And then I tell her that the most powerful thing she can do is to insist—of me, and anyone responsible for her care—that the conversation she came in for is the conversation we have.

Which brings me back to my husband and the Santa Monica pier. My husband’s migraine resolved on our trip. He stopped taking Prednisone and returned to his normal 10/10 energy (from a speed-talking 15/10). The roller coaster came to a halt, the screaming subsided. Kids tumbled onto the platform, laughing and releasing adrenaline into the salty air.

Not everyone has an instant off-switch. So whatever is keeping you wired and tired (and depositing weight around your middle) doesn’t taper, because your life doesn’t either.

The upshot: Cortisol isn’t itself the problem. It’s a call to action, to ask yourself the hard questions about what’s going on inside you.

Those questions are exactly what I wrote my book to help you find. Because health isn’t about having all the answers. It’s about asking better questions—of yourself and of the people responsible for your care.

Whats’s YOUR current cortisol level? (e.g., low? simmering? on fire?)

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My book, Beyond the Prescription, comes out on August 11! I wrote it with you in mind.

PRE-ORDER NOW

Please hit the ❤️ or 🔄 button so more people can discover this post! Even better, please share it with friends and loved ones! 🙏

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