Women and Cardiometabolic Health: Impact of Chronic Medical Conditions

Women suffer greatly from cardio metabolic illnesses, and they’re often not recognized that these are actually happening within their bodies, that these changes are occurring within their vascular system and within their hearts. So we’re going to explore what very common medical conditions that a very significant percentage of women experience actually link to the cardio metabolic health of women. So what we’re going to cover is this surprising link, surprising for many people, many doctors and patients alike, that these chronic conditions and diseases that women suffer from actually have a very significant impact on their cardio metabolic health status. And we’ll look at what the underlying linking mechanisms are that create this intermesh of chronic conditions and cardiovascular disease in women. And then we’re going to look at lab testing so that you can actually recognize which of your women patients actually carry the highest risk so that you can then take effective strategies to help your women patients to live optimized, healthy lives. And why does this matter? Why do we even care? Because cardiovascular disease is the number one killer of women. It claims more women’s lives than all cancers combined. Look at the statistics. 64% of women who die from sudden cardiac death have no prior symptoms. If you, as their health care provider, don’t acknowledge and recognize those women in your practice who have risks, you will not be able to prevent sometimes catastrophic events. And it turns out that what is commonly the only lab test that’s a pain and sometimes not even that which is a standard lipid panel, will not identify a very significant percentage of your women patients who have very substantial cardiovascular risk because there are so much more that’s going on. We’re going to cover that. And of course, the cost is very substantial in terms of dollars. But in terms of lives and the emotional impact, that’s where it’s really the greatest. So here are some of the conditions that women very commonly experience, these medical disorders that are so not connected to cardiovascular risk among the population, among your patients, they don’t know. They have no idea. And even the health care providers often don’t realize. So the ones that I have in blue are the ones that are going to touch on. But I actually created a slide deck that included all of them. But we’d be here for a good half a day if we really wanted. We’re going to cover all of these conditions. But I wanted to at least put them on the list so that you’ll recognize that every one of these medical conditions that I have listed here have a significant association with cardiovascular risk. And what do they all have in common? What links all of them? The link is inflammation. And so inflammation is the driving force that creates cardiovascular risk among all of these diverse medical conditions. So let’s look at what happens with inflammation. So inflammation is a very key function of our body. If we could not create inflammation, we would die because the least little scratch or cut on our body would allow invaders, bacteria, viruses, parasites, fungus to just get in and take over. So our body has this amazing immune system that’s designed to create an acute inflammatory response when we have a trauma to allow our bodies to heal. The same thing if an invader like a virus gets in, our immune system kicks into high gear to help us to kill off those invaders. But what happens with these conditions is that a chronic inflammatory state exists. And when you have chronic inflammation, the immune cells, those white cells that are designed to kill off invaders, become activated in a chronic fashion, and they release their inflammatory cytokines. They they create chemotaxis, they release their chemokines, the pull in the troops are drawing more inflammatory cells and the different growth factors that actually then can create altered cellular construction. So it actually has like altered structure. So it does modification or modifying the structure of different tissues, including the vascular system. And then you have this chronic inflammatory response which creates free radicals, oxidative stress, which can then cause the lipoproteins, like when you have LDL, which we sometimes people call it, that’s bad cholesterol, HDL, good LDL is bad, but that’s not true, as we’ll see. These are very key elements of health, and these lipoproteins are very key to immune function. But when they get oxidized, when you have LDL, that becomes like rancid. When it becomes oxidized, that’s when it can cause havoc in the vascular system. And as this process continues, then you can have plaque in the artery that becomes destabilized and you have activated platelets that are designed to help you not bleed to death if you have an injury, but in this case are activated inappropriately and can cause clot formation on a plaque that becomes opened or ruptured. And then you can develop all the inflammatory process results in terms of myocardial infarction, stroke, unstable angina. So that’s what we want to get involved with and prevent. So if we look at it, what happens is we have this inflammatory response. Now it turns out that the plaque can become unstable. Now, plaque is pretty much universal. They’ve shown that by age 20, most people have some degree of plaque. And it’s really important for you to know that it’s often the smaller plaques that have the most instability. So there’s a new understanding that if you have lots of small amounts of plaque, they can become unstable and can kill you often at a higher rate than the very large calcified plaques. And we’ll talk more about calcification in plaques as well. So when you have a plaque and plaques don’t kill people, only ruptured plaque kills people. So we want to make sure that we don’t have unstable plaque. But the way that it can become unstable is both from inside and outside the artery. So you can have ruptured plaque from inside when it becomes unstable and inflamed. And you can also have endothelial dysfunction from the outside that can cause rupture from the outside. So you can have unstable plaque both directions. And either way, can actually kill. And some of the ruptured plaque that comes from some of these immune conditions that we’re going to discuss may actually come from endothelial dysfunction and rupture more from the outside than the inside. But we have to be aware of all of them. And once you have unstable plaque and it can have small ruptures every time a plaque rupture doesn’t result in death. But what it does is it actually then creates a more inflammatory state which can cause more accumulation of inflammatory T cells like th1 cells, and they can produce even more pro-inflammatory cytokines and proteolytic enzymes like metalloproteinases which which cause tissue remodeling and can actually alter the muscle of the artery and actually change its configuration and change the actual structure of the artery. And you can actually get thinning of the outside of the of the wall of the plaques that you can even have more rupture down the road. So let’s talk about some of the actual conditions that women often experience that have these strong cardiovascular links. Let’s start with thyroid. Hyperthyroidism is not anywhere near as common as hypothyroidism, but it is very, very strongly linked to heart problems, particularly rhythm problems. Atrial fibrillation, tachycardia, palpitations and also hypertension are very linked to hyperthyroidism. And not only not always just overt hyperthyroidism, even subclinical. So I want you to when every patient comes in that has tachycardia or develops unexplained atrial fibrillation or unexplained hypertension, be sure you check their thyroid. Test and look for a low TSH. Even if you have normal thyroid like Free T4 free T3 look normal but you have a very a suppressed TSH think hyperthyroidism and get a TSI, thyroid stimulating immunoglobulin test, to see if they may have auto immune hyperthyroidism. So make sure that’s on your radar because many women come in with palpitations, tachycardia and atrial fibrillation is like an epidemic now. So think hyperthyroidism. Hypothyroidism is incredibly prevalent and 80% of thyroid disorders are related to hypothyroidism. And in fact, somewhere between 4 and 10% have of Americans have overt hypothyroidism and the majority of them are women and subclinical hypothyroidism has been very much in the medical news and there’s been quite a bit of, well, we’ll say, uncertainty as to what the clinical significance is of hypothyroidism. But the bulk of the literature say it is important. The overt signs of hypothyroidism are fatigue and weight gain, cold intolerance, constipation, dry skin, often like brain fog. But you can have very we’ll say not very obvious signs of hypothyroidism, but they can still impact on the cardiovascular system. So don’t just look for the really severe hypothyroid patients to be at risk. Think even the subclinical ones, the ones that have hypothyroidism. But they say they feel fine because look at the profound effects that hypothyroidism has on cardiovascular health, that the thyroid hormone plays a critical role in heart muscle function. So cardiac contractility is related to thyroid levels and in fact in people who are in the intensive care unit, like in a hospital, if they have heart failure and they have low T3, they have a much higher mortality rate. So thyroid is critical to myocardial health and function. So very important there and also involved in the vascular function. So blood pressure is very related to hypothyroidism and arrhythmias. You can actually have A-fib not just from hyperthyroidism, as I mentioned, but also from hypothyroidism. And when you have low thyroid, you will have a reflux of high cholesterol. So any of your patients that you say, I don’t know why you’re high, you have such high cholesterol this, you know, they seem to be doing things right. You know, they’re eating correctly and even exercising and they have very high cholesterol, abnormal cholesterol. Think hypothyroidism even subclinical. Make sure you don’t just test the TSH. Make sure you get a free T4 and a free T3 and don’t just look for the reference range. Make sure they’re in an optimal area of the reference range. You don’t want to be at the bottom of free T3. So if someone is having a lot of cholesterol problems, they’re feeling sluggish and they’re free T3 If the reference range is say 2.2 or 2.0 and they’re .1 above that, so they’re like 2.3 or they’re 2.1, that’s not optimal for that patient if they’re clinically having symptoms. So look at the total clinical picture as well as the lab test. The carotid intima is really important to check. I check in my office. I’m lucky I have vascular scanning and we check the carotid intima media thickness on all of our patients that have any cardiovascular risk. And you can get it through radiology centers. But think about checking that in your patients with hypothyroidism. Make sure you check the triglycerides that’s often elevated. And as I mentioned with the heart, it’s very involved in heart health. Women have a very significant rate of diastolic dysfunction, and a lot of cardiologists actually don’t pay much attention to it. But what that means is that you have a stiffer heart. You have a heart that has less energy and it doesn’t relax well, during the diastolic phase. So definitely, if there’s a question, make sure you get an echocardiogram and you can look at heart rate variability, which is very important for health. And a lot of people are now looking at that. So we definitely want to think of all of the risk factors for the heart health, the vascular system with hypothyroidism. So here is some of the very basic life. Now, I’m not, I can go to town on a lot of these and I, I happen to personally use the Cleveland Heart Lab along with Quest and I get all of their inflammation markers. I would like to mention the inflammation markers because I just wrote inflammation markers because it’s quite a few. So I wanted to just spell them out. What I get on my patients who have low thyroid. And I’m concerned, of course, about their cardiovascular well-being. So I get myeloperoxidase and Lp-PLA2 activity, which is an enzyme that’s involved with the core of plaque. That’s an enzyme which when elevated, suggests that you have instability within the core of the plaque. I get an HSC or a high sensitivity C-reactive protein. I measure micro albumin. That’s a very important test you may not have heard of. So micro albumin is a measurement of protein coming out in the urine, not because they have nephrotic syndrome or serious kidney disease. It’s a vascular issue. It’s a sign of leaky arteries. I’m sure you’ve all heard leaky gut. You can have leaky arteries. Any endothelial lining where the cells can separate some and you can have leakiness. And in the kidney you can leak out some protein that doesn’t get resorbed. And so you have excessive but not not high like you have kidney disease, but you have an elevated amount of protein. That’s why they call it micro albumin. And that’s a sign that your arteries, the endothelium, your arteries are not healthy in your patients. When that is elevated. So that’s a really important test. And then I get ADMA, and that is a measurement indirectly of nitric oxide and of inflammation and oxidized LDL, because as I mentioned, LDL is not evil. In fact, there are studies showing that across the all the LDL levels, it doesn’t correlate with heart attacks and death. But what does correlate with metabolic syndrome is oxidized LDL. And we know that metabolic syndrome is certainly a high risk factor for cardiovascular events. And I also get F2-Isoprostane, which is a measure of lipid peroxides, which is like thinking about like having rancid lipids in your body. So that’s a sign of oxidative stress often related to poor diet. So you can get all of these tests through quest and your representative can go over them in more detail with you. I always look at hormone levels. One of the things that’s really important I talk about this all the time is that estrogen is very related to thyroid function and thyroid receptor function. So make sure you look at for your women, your young women, your reproductive age women check and see what how their hormones are doing. And of course, all the standard things and you want to look to see if they have insulin resistance, pre-diabetes or even overt diabetes, because all of these things are happening even in young women. Let’s move on to autoimmune disease now with the thyroid, you know as well, and I mentioned that I did mention it, but I will it’s in my slide, that you want to check for thyroid antibodies because many thyroid conditions I mentioned for hyperhyroidism to check for the TSI with the hypothyroidism, check for thyroid antibodies anti anti TPO and thyroglobulin antibodies. So moving more into other autoimmune diseases and cardiovascular risk. It’s quite a mosaic of how autoimmune disease occurs in women. 80% of autoimmune diseases occur in women. And you can see it’s it’s a mix of many different things and under toxic chemicals, I would also like to include toxins that can be biological toxins as well. For example, mold and mold has been much more in the news lately. So think of mold as a source of creating autoimmune disease. It’s dramatically damaging to the immune system. So if we look at cardiovascular health and autoimmune disease, it, for women, it’s really sad. It occurs in women often in their most productive stages of life. Of course, it also happens in postmenopausal women as well. But many young reproductive age women are suffering with autoimmune diseases and there’s really been an explosion of autoimmune disease. But the problem is, in addition to many other problems, is that we need to gain a better understanding of the relationship of these autoimmune disease with cardiovascular mortality and morbidity in order to improve all the long term outcomes for these women. And that’s what I want to share with you, to make sure that this is high on your radar, that women with autoimmune diseases have a very significant risk of cardiovascular dysfunction. And in fact it is such a serious issue that risk the interlinking between cardiovascular risk and mortality morbidity in women with autoimmune diseases that there was a study and this is what their conclusion was. So I’m going to just read this little sentence. Developing new tools for predicting cardiovascular events which incorporate autoimmune inflammatory disease activity biomarkers could help reduce the incidence of these events because how terrible is it for young women to have heart attacks and strokes because they have inflammation related to their autoimmune disease and no one is monitoring them? That’s one of the reasons why in every woman patient of mine who and I happen to be a women’s health specialist, so that’s why I’m talking about all women. But in all of my women patients with autoimmune disease, I get every one of those inflammatory markers that I just mentioned to you. HSCRP, high sensitivity c reactive protein is a surrogate marker for inflammatory cytokines like interleukin 6 and tumor necrosis factor alpha. So it’s a surrogate marker for it. And so if you have a high a chronically high HSCRP, that is a very ominous risk factor. And by high in autoimmune disease, it’s often over 10. I’ve seen numbers over 50. So when we look at these autoimmune diseases which are often involve the joints, so they call them rheumatic diseases, they all involve inflammation or back to inflammation, Heart disease and vascular dysfunction is all about inflammation. When you have ruptured plaque, it’s inflammation and these autoimmune diseases are all involving inflammation with inflammatory cytokines that are damaging structures, often joints. But many other structures like the skin, the eyes, lung, kidneys, the heart, the whole vascular system can be involved with autoimmune disease. Of course, autoimmune disease can be directly involved in the vascular system such as an arteritis, a vasculitis. So we must think of all these rheumatic diseases, autoimmune diseases, as involving the cardiovascular system along with all of their other obvious problems that they involve. If we focus a little bit on rheumatoid arthritis, which is the most common of the rheumatic diseases and has been well-studied in its relationship to heart disease. So we know that it is very, very severe in terms of the risk factors for cardiovascular disease in women who have especially severe rheumatoid arthritis. They will have high levels of these inflammatory markers and the sad thing is that women with rheumatoid arthritis often have no primary screening or any any observation for their cardiovascular risk. It’s really shocking. In fact, in just 55%, did they even have their lipids measured? And the saddest thing is that when rheumatologists are in charge of their care, they’re even less likely to have cardiac screenings of any sort. So you if you were if you were listening and you happen to be a rheumatologist, get on the ball here. And if you’re a primary care physician, if you’re a gynecologist, if you’re a family doctor, or if you’re an internist, please and all of your patients with rheumatoid arthritis think cardiovascular risk. Angina is often undiagnosed or misdiagnosed in women with rheumatoid arthritis. They just assume when they’re having chest pain, it’s related to some kind of, you know, musculoskeletal issue. And it’s really their heart. So please be on high alert in this group. So look at some of the risks here. They have women with rheumatoid arthritis, two times the incidence of coronary artery disease. The risk is the same as in people with diabetes and everyone with diabetes is being screened. But why not women with rheumatoid arthritis? And at diagnosis, it’s unbelievable. But three times they’re three times more likely to have already had an MI than the control population. They’re significantly at risk for venous thromboembolism. They have double the risk for heart failure, and they’re often managed less aggressively. They have poorer outcomes and they often have diastolic dysfunction due to systemic inflammation. Why is this happening? Because diastolic dysfunction is a sign of energy deficiency in the heart and systemic inflammation. These inflammatory cytokines, they poison the mitochondria. So the mitochondria no longer work properly. And so the heart is basically in an energy deficient state, even though, you know, there’s not even one there’s not been a heart attack or a vascular event. The heart muscle itself is energy deficient and they often will have though peripheral vascular disease. And so this really is just pleased to have this high on your radar. So in terms of their lipid profile, and this is what is considered paradoxical, but when you understand that everything in the body is there for a purpose, LDL is not evil, LDL is really involved in immune function. And it turns out that in women with rheumatoid arthritis, they often have suppression of their total cholesterol and their LDL when they have higher levels of inflammation. So it’s a paradoxical relationship because we’re all trained to think high cholesterol is high risk for cardiovascular disease. But in women with rheumatoid arthritis, they’ll often have lower levels of lipids and they actually have more severe systemic inflammation and an increase risk of cardiovascular events because inflammation can alter the lipoproteins, structure and function. And so just be on high alert. You can’t just get a lipid profile, a cholesterol panel and think, Oh, this looks good, it’s low, please don’t do that. These women have high risk and this low, the low levels of LDL and HDL are really very frightening because they have higher risk. And please get all the different tests and all the inflammatory markers so that you have a better picture of what their true situation is and their true risk. So what happens and just to summarize this, this slide, when there’s certain genes that are associated with higher risk for rheumatoid arthritis and cardiovascular disease and and these HLA tests can be obtained so you can order this to see if this gene is present. And what it does is it actually can have an impact on T-cells. And so when you have abnormally functioning inflammatory t cells within the plaque, they can cause more destabilization as well. So just be aware that there is also a genetic link and that these the people with these genes actually have a higher selection for these more inflammatory T cells. So here are some of what I call my basic autoimmune labs. So you first want to check rheumatoid factor. Don’t forget CCP and you want to get an ANA with the whole cascade because you want to look for any signs of lupus and Shogruns disease and scleroderma, all those things you want to check for everything and you want to check for the B12, the folate homocysteine. So you can see, you want to make sure they don’t have gout. By the way, uric acid when it’s elevated is actually a marker for cardiovascular risk. So uric acid is actually something that should be on your radar. We’re not talking about gout today, but gout is associated with higher cardiovascular risk and events. So I want to get an advanced lipid profile. So I want to include my ApoA1 and ApoB. So ApoA1 is also what’s called reverse cholesterol, and that’s the cholesterol that goes out with the particles and picks up. It’s actually the the carrier protein that picks up cholesterol around the body, carries it back to the liver for recycling or disposal. And ApoB is the particle that carries cholesterol that’s made in the liver and distributed through the body. And I also like to check some of the genetic markers like ApoE, which is associated often called when people have before, they often call that the Alzheimer’s gene. But that’s really a misnomer because they should really just call it the risk gene epigenetic marker, because it is also associated with higher cardiovascular risk. It’s really a problem of detoxification. People with the ApoE4 are not as good at detoxifying and so they tend to bioaccumulate more toxins which can increase things like Parkinson’s disease, Alzheimer’s disease and cardiovascular disease. I didn’t mention TMAO but I’ll mention it here. It’s the first gut marker for cardiovascular risk. So when you have an abnormal gut microbiome which is prevalent in women with autoimmune disease, they typically have disbiotic gut microbiota. Microbiota. Their gut microbes are not right. And then when you eat certain forms of animal protein, you actually make a toxic product called TMA, and the liver turns it into TMAO. So that is both a toxin and a marker for cardiovascular risk. And I would urge you to talk to your rep to learn more about it if you’re not familiar with TMAO, It’s really a fascinating topic, and it’s the first test that definitively links gut microbiome dysbiosis with cardiovascular risk and women with autoimmune disease, almost 100% of a disbiotic gut microbiome. And of course, all the inflammatory markers that I mentioned, I would check and check for the Omega 3 status. That’s very important because so many people have very low omega 3, and that’s very, very key to reducing inflammation, inflammation and CoQ10 as well. I always measure that because that’s so important for mitochondrial function. And so you want to make sure that that’s part of the mitochondrial cocktail is to give people I give Ubiqionol because it’s more absorbable than CoQ10, because we want to make sure our heart muscle has energy production at a proper rate. So let’s move on now to osteoarthritis and cardiovascular disease risk. Osteoarthritis is very, very prevalent in women, and most people don’t think of it as having any relationship to cardiovascular disease. But it’s very, very strong, in fact. And when they looked at that in this particular study that was looking at over 40,000 women with osteoarthritis, actually not all were women, but almost 72% of the study subjects were women. The average age was 66. And what they found in this group with osteoarthritis, that they had substantially increased odds of developing heart disease, angina, congestive heart failure and myocardial infarction. So how many of you have patients with osteoarthritis? I’m sure you all do think cardiovascular risk. So here are the labs that I get. I get others as well. But this, you know, I just want to put down to the foundational ones. I always want to rule out rheumatoid arthritis and people can have both. There’s no law that says you can’t have osteoarthritis and have rheumatoid arthritis. Now, osteoarthritis tends to occur more in post menopausal women and actually rheumatoid arthritis increases in incidence after menopause as well. And both of these conditions are more prevalent in the menopause because of loss of estrogen. So I just want to mention, because my favorite hormone is estrogen, that estrogen helps maintain all musculoskeletal structures, including the cartilage, the bone, all tendons and, of course, muscle. So it’s think when you lose, when you have any estrogen deficient state, you’re more likely to have musculoskeletal problems, including osteoarthritis. We now know that osteoarthritis is actually heavily, heavily involved with bone. People always think of it as involved with just cartilage. But actually now we know that it’s very, very much more complex and bone is actually a key function of osteoarthritis. And we’ll talk more about the implications of bone health and and cardiovascular disease in a moment. So here’s a list I mentioned here I put in ferritin. So I actually test ferritin all the time. I just didn’t put on all the list but ferritin when it’s high is a sign of cardiovascular risk. And ferritin is a carrier protein for iron made in the liver. And when you have liver inflammation, which is so common now, like fatty liver, and I do screen a lot of my patients for fatty liver with an ultrasound of the liver because there’s no other there’s no lab tests for fatty liver. But a high ferritin level would be a clue that they may have a fatty liver, as of course, along with elevated liver enzymes so liberally get liver ultrasounds in all of your patients who have elevated ferritin and also elevated inflammatory markers. So here all the labs that I would get, I would always want to rule out autoimmune disease because remember, lupus can happen at any age and can also involve the joints. So we don’t want to assume something is osteoarthritis. We want to rule out that it’s an autoimmune condition or that it’s coinhabiting the same body. So let’s go on to osteoporosis. So most people don’t recognize the risk and relationship of osteoporosis and cardiovascular disease. But it’s extremely high. So in here’s just up there have been several studies and there’s a lot of data on this that low bone mineral density is highly associated with an increased risk of cardiovascular death. So on all of your patients, you should get a DEXA scan certainly by age 65, if they have osteoporosis, Think cardiovascular risk. Do not forget this because this is so overlooked. So as I mentioned, low bone mineral density is this has been shown, this is proven, this is not controversial, is related to increased cardiovascular mortality and morbidity. And here’s a really an interesting story that the calcification of bone is related to the calcification of arteries and plaque. It’s not have you ever like got like what the heck is going on? Why is why is calcium going in? Well, it turns out that there’s similar cells. The osteoclasts, but it’s sort of a reverse. But it’s a reverse relationship. When the osteoclasts in the bone are eating up the cells, now osteoclasts are modified macrophages, osteoclasts are a form of immune cells are like modified macrophages, and they eat a bone. And so when you have a dysregulated immune system and you have inflammation, I want to make sure you know that osteoporosis is not just about aging, it’s an active inflammatory process. The osteoclasts are inflammatory cells and they eat up the bone and they have a similar type of situation sort of in the reverse that causes the laying down of calcium when you have an inflammatory state in arteries. But it’s actually an interesting link to the different mechanisms. So often when people have low bone, they have a lot of calcium deposits in their arteries. Isn’t that amazing? And a strange finding. So when you have osteoporosis, there’s high levels of inflammation. Osteoporosis is an inflammatory process and we have this amazing system in the bone, that’s the OPG/Rank/RANKL triad and it’s dysregulated. And when you have an inflammatory state and so and you can read more about it I just don’t have time in this in this webinar to go into into great detail. But bone is not boring. I’ve heard people say bone is boring, Bone is fascinating. The other thing I want to mention about bone is that bone is an endocrine organ. It makes and ends. It makes a hormone called osteocalcin, which is key to regulating glucose homeostasis, glucose metabolism, glucose transport is related to this very important bone and bone hormone, which is called osteocalcin. It also helps with cognition and brain function. So do not underestimate the powerful nature of bone as an endocrine organ as well. So in order to have both a healthy set of bones and a healthy heart, you need adequate amounts of hormones. Vitamin K, vitamin D, Vitamin D is involved in everything. It’s very key to bone health and heart health, cardiovascular health. It turns out when you have oxidized lipids, you’re more likely when you have this inflammatory state to have osteoporosis and cardiovascular risks. And they’re linked. I didn’t mention homocysteine, but I want to mention it now. I ordered that test very commonly. It is very, very linked to both cardiovascular disease and to osteoporosis. And when you have high levels, it actually has a very strong impact on vascular health, lipid oxidation, bone mineralization, so you can homocysteine actually links bone health and heart health and nitric oxide, which you can’t measure in nitric oxide, but you can measure a ADMA, which is a surrogate marker for nitric oxide. And when you have nitric oxide, that’s inappropriate and you have an inflammatory state and you don’t have enough of the good type of nitric oxide and you get to the reactive nitric oxide, then you end up having preferential bone. Stromal cells turn into smooth muscle cells instead of turning into osteoblasts. So here are some of the labs that I get when I have a patient with osteoporosis. I always get parathyroid hormone because you want to make sure that they don’t have an excess production of parathyroid hormone. And I want to get all my inflammatory markers, advanced lipids, homocysteine, as I mentioned. I also want to check for autoimmune in a young woman who has a fracture, an unexplained fracture, or she doesn’t have significant trauma, but she breaks a bone. I think celiac disease or gluten autoimmunity could have that malabsorption. So if you have malabsorption of calcium and protein, you’re not going to build strong bones. And a lot of people with celiac disease and gluten autoimmunity, they also do not make vitamin K properly. Remember, vitamin K2 is made by the gut microbiota. So if you have an abnormal gut microbiome, you’re not going to make proper vitamin K, to which I already mentioned. Vitamin K, K1and 2 are both critically involved in bone health and in heart health. So if we look here at one of the a different condition, which is one of my niches, one of my specialties is polycystic ovary syndrome, the most common endocrine disorder of women, and it involves every organ in the female body. It’s not just about having irregular cycles and having facial hair and acne, although it is about those things and infertility, it’s the most common cause of infertility in women. But in this in this particular webinar, I want to focus on that it is a major risk factor for cardiovascular and metabolic problems. So if we do an overview, you can see it involves every organ system. You have dysregulation of the production of estrogen and progesterone. And it starts with the fact that the estrogen is not actually produced properly and the receptors for estrogen are not produced properly due to probably genetic predisposition and exposure to endocrine disruptors. And most research is with BPA. And this is also a long conversation. But the takeaway for today is that women with PCOS have a lot of systemic chronic inflammation, insulin resistance, high rates of fatty liver, increased stores of adipose tissue, which are producing reduced amounts of the, what we might say, the metabolically active kinds like adiponectin, which increase fat burning. They stimulate amp kinase and fat burning. And women with PCOS have low levels of adiponectin and they have high levels of inflammation. And this has been shown over and over again that women with PCOS are systemically inflamed. Insulin resistant and and metabolically unhealthy and have high rates of hypertension and cardiovascular disease. So here in this slide, you can see the many cardiovascular effects of PCOS and you can see that this is overwhelming for a young woman. This is a young woman’s condition. So in all your women who have PCOS and think PCOS, PCOS is often not even diagnosed in women who have it because people are not thinking of it. So women who have irregular cycles, they have evidence of hyperandrogenism with hirsutism, alopecia, acne and that you can get an ultrasound and see that they have lots and lots of little cysts on their ovaries because they’re not ovulating properly. They are at significant risk for cardiovascular disease and of course pregnancy complications as well. Endometriosis is not a rare condition. 10% of women have endometriosis and very few doctors realize that it has a strong cardiovascular risk relationship. So endometriosis is where the endometrial tissue is growing outside of the uterus in the pelvis, typically on the ovaries, as I mentioned, it affects 10% of women of reproductive age, affects their fertility and chronic pain is very common, very serious. So what has been found is that women with endometriosis actually have chronic systemic inflammation as well as local pelvic inflammation. They have found that there’s decreased levels of antioxidants in the peritoneal fluid and also in the peripheral blood increase markers of oxidative stress, increased inflammatory factors in the peritoneal fluid and the peripheral blood. So be aware that endometriosis is also systemic inflammation and these women have higher risk of cardiovascular events. This is so overlooked. How about uterine fibroids? Did you know that there’s a link there as well? So this has been shown that there is clearly an association between uterine fibroids and obesity, hypertension, lipid abnormalities, abnormal carotid intima media thickness. So please, if you have a woman with fibroids, think that they are also metabolically unhealthy and have cardiovascular risk. In this particular study, they looked at all of these associations. They found there was definitely an association. But in terms of elevated risk, what they really found was that the there was remarkably higher risk for hypertension in women with fibroids. Nearly three and a half times the incidence of hypertension as in controls. So women with fibroids think hypertension. And you know what that means for cardiovascular well-being. And not only that, what they found is that there was asymptomatic organ damage in women with fibroid. So organ damage with the lungs and kidneys and such. And this was predominantly in the reproductive years. So look at that. Look in this graph. It’s unbelievable that women with fibroids have systemic issues that these are commonly overlooked. And of course, when you have renal problems, you know, that always links to cardiovascular as well. But just I don’t want to not be balanced. There was this one study among many others that in this particular study that they felt it was more of an association in subclinical with subclinical cardiovascular disease. But in terms of overt cardiovascular disease, there certainly is a definite relationship. And I would, based on the prevalence of the data and I reviewed all the literature out there, I would conclusively say that if you have a patient with fibroids, you better think cardiovascular risk and hypertension in particular. So here are all the different labs that I get for all of these women that I mentioned, all these different reproductive problems. And I wanted to throw in heavy metals here. I actually do test heavy metals, think heavy metals often. There’s a strong link between arsenic. Lead. Lead is very related to hypertension and so and mercury, you know, they even had this study that showed chelating diabetics with plaque that they actually had lower cardiovascular events when they now I’m not an expert on doing chelation I’m sure you are not either but be aware heavy metals are linked to cardiovascular disease and events. So I actually throw in heavy metals in virtually all my patients that I’m concerned about having cardiovascular risk. So and then in women with PCOS, you of course want to check all of your androgens, your DHA sulfate, your testosterone. And I didn’t mention pregnenolone, but pregnenolone should be actually on your radar, a very low level of pregnenolone. And that’s often called the mother hormone. It’s a steroid hormone. And all other steroid hormones come from pregnenolone. But it’s also a neuro steroid. It actually works in the brain to make you smarter and more alert and feeling better. It’s also made by the adrenal gland. And when you have chronic stress. And so how many of our women patients are chronically stressed, you can have low pregnenolone. Low pregnenolone is associated with cardiovascular risk. So in your patients who have a lot of stress, you know, are you concerned about them throw in a pregnenolone. You might be surprised at how much you learn about what’s going on in their bodies. And Adiponectin, I mentioned that that’s an ad of a kind in women with PCOS. It is too low, so be on alert for Adiponectin Now. Vaginitis is who thinks that vaginitis and cardiovascular risk are related? Well, guess what? Vaginitis is associated with higher BMIs and recurrent women who have recurrent vulvovaginitis are often obese and there is some relationship. So this is just in the beginning stages. Unfortunately, vaginal health in women is a very under studied condition. But think women who have recurrent vaginal infections may also have increased risk for cardiovascular disease. So at least let it be on your radar. So here are the tests that I get for chronic vaginitis. Don’t just think trichomonas and Candida and gardnerella think of those, but don’t stop there. We now know that there are we can actually now test using PCR polymerase chain reaction so we don’t have to use cultures anymore. We can test for DNA from mycoplasma, urea plasma. These are major infectious agents that can cause chronic infection that are going untreated and unrecognized because it won’t show up in a standard culture. And we also look at the different strains of lactobacillus. We now know that lactobacillus, Iners is associated with a worse prognosis for vaginitis. So once again, this is an area that needs lots more research, but it’s just beginning. And we should just have this on our radar. You know, women with a check for HPV and then look at all your lipids and inflammatory markers in women with chronic vaginitis. Think that there can be and may be a relationship with cardiovascular risk. So what are we going to do? You know, we can’t just define risk. We have to then do something about it. So we can only change certain things. We can’t change age, gender, race and age and so on. So what we can change is what we eat, when we eat, how we sleep, stress, physical activity, hormones and so on. So I always start with laboratory testing in terms of evaluation, and I’ve talked about that quite a bit in terms of what we do to try to help our patients over here. Once again, these are foundational ones. Please make sure you think cardiovascular risk in all of your women patients who have all these different medical conditions and then to help them, please get them on a regular exercise routine. In my office, we actually do fitness assessment, body compositions, but even if you can’t do all of that, you can work with a gym, you can find a local personal trainer that you can trust, help your patients to move. It actually has been shown to improve gut microbiome, improve cardiovascular health. Exercise actually reversed impaired microvascular nitric oxide function in sedentary adults. You can’t do better than exercise for your patients. Diet, of course, that’s the foundation of health. There’s a lot of research on the Mediterranean diet, vegan diet. I always start with a vegan diet because I don’t want to incur higher rates of TMAO. Women who have a bad gut microbiome can’t properly process animal protein, and then I can move into more of a modified Mediterranean diet and make sure that your patients eat a lot of probiotic foods, fermented foods, and don’t think carbohydrates are evil when they’re unprocessed, whole whole grains actually grow your microbiome and polyphenol rich foods, lots of vegetables. I emphasize for my cardiovascular patients, 9 to 12 cups of vegetables and fruit a day. And fruit does not give you diabetes. Nobody got diabetes because they ate an extra apple. It’s chemicals, toxins, sedentary lifestyles, that type of thing, eating processed food. That’s where they get diabetes and of course, hormone imbalances. So we have eating. We want to eat a big breakfast. We want to stop snacking, eat dinner early, try to fast for 13 hours from dinner to breakfast and consider for your patients who need to lose weight, intermittent fasting where they eat less than 500 calories a day for maybe two days a week, or periodic fasting or fasting mimicking diet, which can also reduce inflammation and cardiovascular risk. So by keeping inflammation in control, by recognizing all of these medical conditions that women have very commonly that are associated with cardiovascular disease and fly under the radar of so many doctors by having them get proper exercise, love in their life, eating sometimes, not eating, getting all the proper laboratory tests so you can fully assess what is going on in these women and their cardiovascular status. By doing all of those things, you can help to optimize the health of every one of your women patients, whether they do or don’t have any of these many chronic medical conditions. And I thank you for your kind attention. What a great presentation. Dr. Gersh. Really appreciated it. Now it is time for questions and Harley our operator is there. He’s going to review the instructions for questions. Thank you for the participants over the phone. If you would like to ask a question, you may press star followed by the number one. Please silence your phone and record your name slowly and clearly when prompted. Your name is needed to introduce your question. To cancel your request, you may press star followed by the number two. Once again, it’s star 1 if you would like to ask a question and it star 2 to cancel your question. One moment speakers, as we wait for any questions to queue up. Thank you. Thank you. While we’re waiting to see if there’s any live questions, we do have some coming in through the chat. Dr. Gersh, the first one is there’s an awful lot of information in in your presentation about inflammation and have you read anything about ginger and turmeric reducing inflammation in the body. What is your professional opinion? Oh, absolutely. I mean, I could talk for several hours about inflammation and herbal treatments as well. So curcumin is really one of my mainstays. I use an absorbable form. If you use straight turmeric or curcumin, you have to combine it with black pepper and fat because otherwise it won’t be absorbed. But there are nutraceutical companies that make absorbable forms of curcumin and absolutely people with inflammation should definitely take curcumin. It’s it’s amazing and there’s a lot of published data on it. Ginger as well is very, very anti-inflammatory. I love whole ginger. I recommend ginger tea all the time. I don’t think you need to take Ginger too often as a supplement because it’s a wonderful food so you can get fresh ginger, you can make what’s called a decoction where you take fresh ginger, like scrape it into small pieces and then steep it in hot, hot water and then drink it on and off all day long. It’s wonderful. So absolutely ginger and curcumin are my mainstays. I’m so glad somebody brought that up. Thank you so much. Another question about how often do you assess cardiovascular disease in patients, thyroid disease or with RA? All the time. I mean, so I’m very, very attuned to cardiovascular risk. So in my office, I actually have like I mentioned, I have a a vascular ultrasound tech who comes in with the state of the art equipment and does I do echocardiogram in my office that a read by are board certified cardiologist, I do carotid intime media thickness. I do all of these advanced tests for inflammation and cardiovascular status. So I am I am doing it all the time. I think that’s like the whole takeaway is please have this on your radar and you start doing these things too. Another question Is garlic effective in reducing high blood pressure? So I garlic is also a very good tool. Garlic is very anti-microbial. So when you if you eat well, if you’re going to do garlic, this is what you do. Not everybody can tolerate this. You take two cloves of raw garlic and you press them or chop them into very tiny pieces and you have to eat two raw cloves of garlic every day. Now, that actually helps to improve the gut microbiome. And we now know that the gut microbiome is linked to everything. So you what you what you want to do is lower the production of inflammatory cytokines that come from the gut associated lymphoid tissue that surrounds the gut. So you want to have a healthy gut microbiome by getting a healthier gut microbiome, and you can help to reduce what we call impaired gut barrier function or leaky gut. Then you reduce the production of inflammatory cytokines. So by reducing the overall state of inflammation in the body, you will lower hypertension. So indirectly, yes, garlic is very beneficial by helping the gut. So the way that garlic works is through the gut. So much of what we do actually works through the gut. So if you can tolerate garlic, not everybody can eat raw garlic, but if you can make it part of your regular dietary routine and mention it to all your patients. Thank you so much. Amazing. I’m going to check with the operators to see if there’s any live questions. Harley, Is there? Are there any live questions? Still no questions, ma’am but once again, to ask a question, please press star and then one. You will be prompted to record your name. To cancel your question, star and then 2. One moment again for any questions that may queue up. Thank you. Okay. We have another one coming in from the chat from Carol and she’s asking, should everyone with increased cardiovascular risk be on a statin because it stabilizes the endothelium? Is that correct? So. Well, that would be the word. So there is interestingly, like you mentioned, some data that statins can help with the the plaque or the arterial lining health, it’s actually not about cholesterol, isn’t that amazing? It’s not about cholesterol. When you have high cholesterol, that is a sign of low thyroid inflammation. So it’s like not the underlying problem. It’s it’s a reflection of an underlying problem. Although now we know from talking that even a low cholesterol can be a sign of an underlying problem. So and that can be actually a cardiovascular risk. So, yes, statins may be able to help, but it’s actually not my first line and I not that so this is my personal opinion. I’m not always online with what is sometimes called standard of care because there’s bad data on statins in women as well. So when you look at the data, what we call a number needed to treat like how many women for primary prevention. So these are not women who’ve already had a heart attack or a stroke. So women who are just at risk. So how many women do you have to treat with a statin to prevent one event? It’s well over a hundred. So and then this association, particularly in women, now recognize that almost all the data on statins comes from studies on men. Almost all the data on everything comes from studies on men. Unless it’s a unique female problem, which is a problem. And the NIH is finally starting to take some action on this. But almost all the cardiovascular studies involving statins are with men. Women and men are incredibly different. We have very different immune systems. I mean, I cannot emphasize how different we are with our immune systems and our cardiovascular state, our women’s hearts are much more prone to diastolic dysfunction than men. And diastolic dysfunction is so overlooked and it’s so important. So statins in women increase the risk of diabetes. And who needs that? That’s a cardiovascular risk. Statins actually lower CO Q10 production and co Q10 is critical for mitochondrial function. So we need our mitochondria, we need that they, they put all kinds of warnings and made it almost impossible to get the highest dose of simvastatin, the 80 milligrams dose because it was causing heart failure. And I already went to all this stuff that women can get heart failure even without having attacks or strokes because of energy deficiency in their hearts, because the mitochondria aren’t working properly. So we I do not use statins as a fruit for primary prevention in women. I prefer to do everything else. All these different things that you can do, eating tons of polyphenols, helping, you know, antioxidants, trying to get the inflammation down, working with the circadian rhythm, looking at environmental toxins, looking at stress. So there’s so much that we can do to reverse cardiovascular and endothelial dysfunction. And a lot of this work, you know, was was done and published before over like over 30 years ago with Dean Ornish’s studies showing that eating tons of vegetables and working on with exercise and meditation, you can have arterial health restored. You can actually reverse arterial damage. So I prefer to go a more natural route than statins because I think that there’s a lot of negatives with statins and particularly with women. Thank you so much. I know we are at after the top of the hour, just two more quick follow ups. He got some response to your garlic suggestion. Does it have to be raw? Yes. I’m so sorry. It has to be raw to make this. Now, you can eat garlic and you’ll get other health benefits. But in terms of its anti-microbial effects, if you want to try to impact the gut microbiome, sorry, it has to be raw. Okay. I think I hear some some feedback from the audience on that one. Co Q10 supplements do you recommend them? If so, how much? So yes, I do. And I measure CoQ10. You want it for hypertension, you want a level over two. So it’s that’s, you know, a substantial amount of CoQ10 So I use Ubiquinol because it’s much more to a CoQ10 is not a very absorbable supplement. So I use Ubiquinol and I don’t use this one dose, you know, for everybody, but probably about 100 milligrams a day of good quality, Ubiquinol will suffice for most people. They’ve done Ubiquinol or CoQ10 in thousands of incredible doses in people with Parkinson’s, because Parkinson’s is very much about mitochondrial dysfunction and lack of energy production. So it’s you can’t overdose and die from CoQ10, but it’s expensive. So I usually recommend about 100, sometimes 200, depending on the situation. Thank you so much. Just a couple more questions before we hang up, if you can hang with us, Dr. Gersh. Uh huh. When one check on any live questions waiting, we certainly have them coming in through the chat now. Operator Any calls? Yes, we have one question in queue and it’s from Lynn. Lynn your line is open. You may proceed with your question. Hi, Dr. Gersh, just wanted to touch base with you. You talked a lot about hypo and hyperthyroidism. I’ve heard endocrinologists say they like their TSH between one and two. Do you have any comfort zones, what you like to see? I would agree a TSH optimal is between one and two, so I’m totally on board with that. We now know that, for example, in pregnant women, we definitely want the TSH to be never more than about a 2, 2.5 would be at the outside. Different organizations have have different, you know, goals. But yes, I agree between one and two would be optimal. Okay. Thank you. Thank you. Are no further questions over the phone. You may proceed. Well, thank you. We are almost 10 minutes after the top of the hour and we want to be cognizant of your time. Dr. Gersh, just one last question about aspirin. Do you recommend that? Do you recommend a daily aspirin? So there’s been so much controversy on aspirin. And now for primary prevention, it is not routinely recommended. What’s interesting, though, is that I’m still on the fence actually myself, because there’s been some data that there’s a type of lipid lipid mediators are really gaining more attention. We’ve always thought about, you know, amino acids and proteins and and hormones. But now we know that there are these very key lipid mediators in one form are called resolvants. And these help prevent inflammation actually help you to transform from an inflammatory state to a healing state, these resolvants, these lipid mediators. And it turns out that resolvants come from Omega 3. We know everyone should be on omega 3. So omega 3 by itself, that’s not a resolvant. And though it has its own benefits, but it’s not a resolvant but low dose aspirin can actually convert omega 3 into resolvant, so, you know, we just don’t have the data. That’s the sad thing. You know, for these young women who have these cardiovascular risk diseases that I want, I ran through a whole bunch of them. We don’t have the data on giving high dose omega 3 with low dose aspirin to help trigger the production of resolvants to help reduce their inflammatory states. So I’m optimistic that that actually there may be a role for that. But, you know, in terms of the conventional recommendation now, it’s like flipped and they’re saying don’t use aspirin if you don’t have any previous cardiovascular event. But I think I would say the door is not closed on aspirin. I think that aspirin is very different then NSAIDs. Aspirin has a different mechanism than, for example, you know, ibuprofen and naproxen and so on. It’s really quite different. It comes from willow bark, which is a natural plant which has some amazing healing and anti-inflammatory properties. So I would say I’m on the fence and I would use it cautiously. But if you have the patient, you might want to consider high dose, low dose aspirin like no more than 81 milligrams, maybe even like every other day along with maybe four milligrams, rather four grams of of omega three. And maybe consider that in your patients who have a tremendous amount of inflammation from such things as juvenile rheumatoid arthritis, lupus and so on. And just sort of looking at it short term. But this is not standard of care. You know, this is my own opinion, so I want to make that clear. But I think that the door is open for getting some other benefits from using aspirin with omega three. I think that may be there may be a future for that. But, you know, definitely take it cautiously. And the standard of care is not to use it routinely for primary prevention.