What Is the Cause of Autoimmune Disorder? The Hidden Triggers Too Many People Ignore | Dr. Sara Szal

Dr. Sara Szal: [00:00:00] 30% of relatively healthy people, people like you and me who are getting their blood drawn have positive anti-nuclear antibodies. But right now, about four out of five people with autoimmune disease are women. 

Dr. Jolene Brighten: You brought up a NA, the anti-nuclear antibody. That's one test. Let's talk about what that is and the top signs of autoimmune disease people should be aware of.

Narrator 1: Dr. Sarah Saal. Gottfried 

Narrator 2: is a groundbreaking physician, Harvard and MIT graduate and New York Times bestselling author who is redefining modern medicine 

Narrator 1: known for her innovative approach. She's more likely to prescribe a continuous glucose monitor or microbiome restoration than the latest pharmaceutical.

Narrator 2: As the Director of Precision Medicine at the Marcus Institute of Integrative Health and a sought after global keynote speaker, 

Narrator 1: Dr. Saal is leading the charge of the intersection of mental and physical health, personalizing care with cutting edge technology. Her latest book, the Autoimmune Cure, continues her mission to revolutionize how we approach [00:01:00] chronic illness and wellness.

Dr. Sara Szal: Toxic stress can be a trigger for developing autoimmune disease. And then this three-legged stool that Alessio Fasano first. Coined as a requirement for developing autoimmune disease. It's number one. 

Dr. Jolene Brighten: We saw a lot of negative things happen during the pandemic. I would love to hear your thoughts about it in terms of you, you know, your feeling on if this was contributing to the rise in autoimmunity.

The problem is, as a researcher, it's welcome back to the Dr. Brighton Show. I'm your host, Dr. Jolene Brighton. I'm board certified in naturopathic endocrinology, a nutrition scientist, a certified sex counselor, and a certified menopause specialist. As always, I'm bringing you the latest, most UpToDate information to help you take charge of your health and take back your hormones.

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Don't forget to subscribe, leave a comment, or share this with a friend because it helps this podcast get out to everyone who needs it. Alright, let's dive in. Dr. Sarah Saul, welcome to the show. Thank you, Dr. Brighton. So happy to be with you. I'm really excited for today's conversation. If anyone's not familiar with you, I often say that I.

Uh, you walked in women's health really [00:03:00] paving the path for hormones so that everybody else could run and we could really expedite the healing, the information, the conversations that we need to have. So, um, everybody, this is the reason why I think we feel we can talk about hormones in the way that we do.

Thanks to you. 

Dr. Sara Szal: Well, it's very generous. I would say that it's, uh, it's women who've really, um, helped to pae the way, and women who are saying, I'm not gonna put up with this anymore. Like, this way that we're treated, the way that we're dismissed, the way that there's not enough education about women's hormones, about perimenopause, menopause.

So I, I appreciate your kind words. I also feel like it's, um, witnessing this massive gender health gap that has been the primary motivator. 

Dr. Jolene Brighten: Yeah. Well, okay. So I wanna talk about autoimmune disease today and hormones and women's health, but you just [00:04:00] mentioned the gender gap in healthcare. What is that?

What should women know about that? The gender health gap is 

Dr. Sara Szal: this really massive rift that we have between men's health and women's health, and the way that, you know, research was not conducted on women for such a long time because they were considered too complex compared to men. Mm-hmm. So whether it's the stress response that was studied in the 1930s, or even the use of hormone therapy on women for 59 years before a randomized trial was done to look at whether it was a good idea, there's this massive research gap, and then it shows up as a massive gender health gap.

So things like the way that drugs used are used in men, how that's been studied very thoroughly. If you look at something like Ambien and then it's assumed to apply to women and it often doesn't. So women tend to have more side [00:05:00] effects. And it just leads to, you know, a, a long list of statistics that show that women get the short end of the stick.

Dr. Jolene Brighten: And when you consider that there is, you know, a significant amount of harm being done in medicine by gaslighting women, ignoring women, and then we also have this gap of information and knowledge of how do pharmaceuticals work on women, or how do you know these interventions affect women differently?

Even looking at something like, how do women experience heart attacks? They're not just the standard, you know, chest pain, arm pain that we think of as men. It can be as simple as looking like upset stomach, like they are having digestive issues. And all of this definitely contributes to. Why so many of us have felt stuck and why so many of us have really had to DIY it ourselves, which, you know, thankfully you write books and we have lots of information available.

You write books, we, we all write [00:06:00] books. Right. Um, the, you know, having this information available so that women can take charge and put it in their hands. And I think, as you were saying at the top of this, that is really been one of the biggest instruments of change in women's health. 

Dr. Sara Szal: It is. And you're, you're speaking to a really important point, which is that there's sexual differences.

So there's differences between those that are assigned female at birth and those that are assigned male at birth. And then there's also gender differences. So when you look at something like a heart attack in a woman, and the atypical symptoms that women have, because coronary arteries are smaller in women.

Um, we tend to have more microvascular disease in the heart compared to men. Um, we, you know, instead of the classic substernal chest pain, like an elephant is sitting on your chest, women have, as you describe, more gastrointestinal symptoms like nausea, jaw pain, um, [00:07:00] a feeling of doom. And then when women seek care, there's then a gender difference, which is socially constructed so that if they see a male physician in the emergency room, their survival is half or even lower compared to if they see a woman in the emergency room.

So there's both the sex differences working against us and then also these gender differences. I. 

Dr. Jolene Brighten: Mm-hmm. I appreciate you parsing that out because I think sometimes all of those things get lumped together and we're not recognizing that they are in fact distinct and they have to be looked at that way and really examined through the lens of what biologically is your body doing and then what is happening because of bias.

Now I do wanna talk about autoimmune disease. You have a new book, um, that you did a wonderful job outlining autoimmune disease and especially as women, [00:08:00] uh, what we need to understand, and as I was preparing for this interview, I was looking up, I'm like, where are the statistics at now for autoimmune disease?

And according to the Institute of Health, as many as 50 million people in the US have an autoimmune disease, and it is now the third most prevalent disease category only surpassed by cancer and heart disease that we were just talking about specifically for women. How prevalent is autoimmune disease? 

Dr. Sara Szal: It is incredibly prevalent.

So the statistics, when I looked at, uh, what we've got in terms of prevalence, I was amazed that they're old. The data is about 10, 15 years old and there's no national organization in the United States that tracks what's happening in terms of autoimmunity or the progression of autoimmunity to autoimmune disease.

So these statistics of somewhere around 25 to 50 million [00:09:00] people affected in the United States with autoimmune disease are old and probably outdated. So the more recent statistics, including, um, talking to a colleague of ours, mark Hyman, who has a, a lab test that he runs on people and he's had a hundred thousand people sign up to do those lab tests, um, what he's seen is that 30%.

Of relatively healthy people, people like you and me who are getting their blood drawn. 30% have positive anti-nuclear antibodies. Mm-hmm. And it's not just him reporting this anecdotally, the data is showing that there are certain populations that are, uh, that have this uptick in terms of autoimmunity, especially anti-nuclear antibodies, um, where you have an antibody against the nucleus of your cells.

And I'm one of 'em. So this is part of what motivated this, [00:10:00] uh, this book because about seven years ago, I tested positive for anti-nuclear antibodies. Not just a little bit, but a pretty big amount of these antibodies. And, um, we think that the pandemic has also increased the prevalence of autoimmunity.

Mm-hmm. And so when I speak about this difference between autoimmunity or what I think of as pre autoimmune disease and autoimmune disease, there's a spectrum here. And we know that the people that have the, the greatest increase in prevalence are adolescents and also men. So women already have a pretty high prevalence, and we can talk about some of the reasons for that, but right now, about four out of five people with autoimmune disease are women.

Dr. Jolene Brighten: Mm-hmm. That's huge. And why are we seeing an uptick in adolescence? 

Dr. Sara Szal: You know, it's, it's hard to [00:11:00] say exactly what the reason is, in part because we don't have enough research money going into this. Yeah. But, um, I would say it's some of the culprits that you and I talk about a lot, it's. Um, a toxic culture that is really stressful.

We know that toxic stress can be a trigger for developing autoimmune disease, and we can talk a little bit about, you know, what's the three-legged stool, what, what, uh, leads to a diagnosis. And then I would say our food supply, you know, big food, the way that it's. Um, poisoned us in many ways. I think that's a huge factor in terms of our immune system just being pummeled in a way that it wasn't a hundred years ago.

I have a great grandmother who died at 97. She was born in 1900. So it always is helpful for me to, 'cause the math is easy, you know, she's someone, she's someone who had a very different food supply, you know? Mm-hmm. [00:12:00] When she ate an apple, it was like a cute little green apple that was not very big. And food dramatically changed since 1900.

Mm-hmm. And we know that there are certain foods that tend to trigger the immune system, things like gluten and dairy and nightshades. So, um, our food supply has changed. The amount of stress that we manage has dramatically increased. And then this three-legged stool that Alessio Fasano first coined as a requirement for developing autoimmune disease.

It's number one, genetics. Number two, increased intestinal permeability or leaky gut. And then number three, a trigger, and it's the latter two that you can actually do something about. Yeah. But the trigger is interesting, and when you look at trauma as a trigger, which we see in about 80% of people who develop autoimmune disease.

Mm-hmm. Our experience of trauma has increased. [00:13:00] And so that's another potential cause that these triggers have increased. 

Dr. Jolene Brighten: Yeah. It's interesting that you bring up the pandemic because I think people's minds directly go to the virus itself, which certainly we know viral illness can trigger autoimmunity.

And certainly Covid, we were, we were seeing autoimmune disease, new diagnosis, new antibodies coming up. However, the thing that we're not supposed to talk about, it feels like, because, you know, somebody always rushes in to be like, it was all necessary. I mean, history will tell us if it was all necessary. I think it was incredibly traumatic to be isolated as humans, to be shut down, to not be given a playbook.

You know, we didn't have a playbook to the pandemic. None of us knew what the best thing was. We were living in a lot of fear, a lot of shock. People were losing loved ones without being able to be there with them by their side. Not having closure, not having, being able to attend a funeral, not being able to attend weddings, graduation births.

I know birth trauma [00:14:00] really increased during the pandemic, especially for. Black and Hispanic women, we saw a lot of negative things happen during the pandemic, and yet I feel like the only thing that gets focused is, well, there's a virus. That's why there's new autoimmunity. And not the entire society being disrupted.

I mean, small businesses, closed people's livelihood was threatened. Um, I would love to hear your thoughts about it in terms of you, you know, your feeling on if this was contributing to the rise in autoimmunity. 

Dr. Sara Szal: It definitely was. I mean, the problem is as a researcher it's difficult to measure. You know, how do you, how do you measure that?

You know, one of the ways that we track trauma is, uh, looking at adverse childhood experiences and that kind of questionnaire, which is well validated, doesn't apply to the trauma of the pandemic. So I would say. This experience of the pandemic [00:15:00] and sheltering in place and the isolation. We definitely know that isolation and loneliness is a trigger for autoimmune disease.

Mm-hmm. So that is well established. We've got so many concordant studies showing that association. So I definitely believe that that's a factor. It's just something that's relatively difficult to measure. Mm-hmm. And it's a good point because yes, sometimes a trigger for autoimmune disease is a virus.

Sometimes it's the postviral, um, situation in your immune system, in your, um, pine network, your psychology, your immune system, your nervous system in your endocrine system. So I would say the best data that we have is just knowing that loneliness and isolation increase the risk of autoimmune disease. So that's the closest that we can get.

And I would say the more research that we have questionnaires [00:16:00] about how people are doing post pandemic, how are they, they were doing during the pandemic, how that then correlates with autoimmune disease. We don't have those data yet. It's forthcoming, I hope. 

Dr. Jolene Brighten: Hopefully, I'm not sure that we'll ever be able to get really clean data to isolate and say these things in particular.

So I just want anyone who's listening to know that if you feel like that's true for you, odds are it's true for you, and you don't have to wait for a study to validate your experience. And as we were talking about, it can take a long time for us to get research altogether on autoimmunity, but research on women and not all of us have the next 40 years to wait around and be like, I need, I need to be validated about this study before I actually take action.

I move forward with things. You brought up a NA, the anti-nuclear antibody. That's one test. Let's talk about what that is and, and let's also talk about symptoms. The top signs of autoimmune disease people should be aware of. 

Dr. Sara Szal: Sure. And maybe [00:17:00] we could riff on this, because I know you know a lot about this too.

I have multiple autoimmune diseases, so there's that. Right, right. Well, anti-nuclear antibody is one of these measures in the blood that is, uh, where your immune system is attacking the nucleus of your cells. And pretty much all of your cells have a nucleus, with the exception of red blood cells. So it's a very general test.

It doesn't point toward a particular autoimmune disease. There are now more than a hundred autoimmune diseases. There are just a few, when I went through my medical training 30 years ago, but now there's more than a hundred of the classic autoimmune diseases, which are, um, a constellation of symptoms that fit together with attack of a particular usually organ system.

And then positive antibodies. So the most common ones are Hashimoto's thyroiditis. Graves Disease, type one Diabetes, multiple [00:18:00] sclerosis, uh, psoriasis. Those are some of the common classic autoimmune diseases. And then there's also what I call non-class autoimmune diseases where. Your immune system is attacking your own healthy tissue.

Things like endometriosis, adenomyosis, where you are attacking the muscle wall of the uterus, which is something that I've had, and also even irritable bowel syndrome. Mark Pimentel, uh, Cedars has shown that there are some people with irritable bowel syndrome who are making antibodies against their own normal tissue.

Uh, with anti-nuclear antibodies, are you, are you willing to say whether you have positive a NA? Um, 

Dr. Jolene Brighten: I don't have positive a NA and because I've been on a fertility journey, I get it measured every six months. Um, so that, that's one that hasn't come up. I have Hashimoto's, uh, hypothyroidism, so [00:19:00] my immune system decided to attack my thyroid.

I also have psoriasis and so, which is worse following birth for me, which is common for a lot of women, um, where I will get some plaques on my scalp, but mine is really psoriatic. So if whenever people are like gluten-free, just a, a trend, I'm like, I wish. 'cause if I get gluten in the United States. I can't type, I can't move my joints.

They are so inflamed for weeks that I'm like, yeah, I wish, I wish it was, uh, as simple as that. And then I have had antibodies, 21 hydroxylase antibodies. So Addison's super bad. No, but I'm like all out. Immune disease is bad. But that's one that I really harness. Uh, you know, I really like, check my stress on because that's one I've never shown any, um, adrenal issues in terms of frank adrenal dysfunction.

And I have put those antibodies, I've put all my antibodies into remission, but they will pop up from time to time. And then I also just got [00:20:00] diagnosed, uh, very recently, 29 years of periods and finally diagnosed with endometriosis and adenomyosis. So, and as you brought up that I, I'm with you. If it's not autoimmune, if they show that there's another, cause I will be shocked because I feel like this point, we have so much evidence that's pointing to it.

It's one of those things that they teach you in medical school. And I find myself saying to my child all the time, like, stop looking for zebras in a herd of horses. If you've got a herd of horses, odds are, it's a horse. It's not a zebra. 

Dr. Sara Szal: Right? Yeah. It's, uh, I mean there are studies showing antibodies with endometriosis, adeno MAs.

There's less data. I mean, again, this is something that doesn't get sufficient research funding, but I'm with you. I feel like, uh, your body is attacking itself. The immune system is overactivated. Uh, there's a difference in the way T cells respond. Um, you know, one of the key [00:21:00] warriors of the immune system.

So, um, I'm so sorry that you have had these multiple autoimmune conditions and as you are, uh, describing and suggesting I. Women are also more commonly affected by multiple autoimmune diseases. So, um, most of these conditions that we're talking about affect women way more than men. And it's, uh, yeah. The gender gap continues.

Dr. Jolene Brighten: Yeah. Well and it's interesting 'cause when you look at some of the studies, they say by the time somebody gets a doctor to recognize one autoimmune disease, so one diagnosis, they actually have three. Because once you lose tolerance to yourself, once your immune system is confused, um, it doesn't get smarter.

A lot of the time that stays confused. But, you know, as the issue you raised before, and I'll let everybody know, I'll put a link to taking, um, the ACE score, the adverse childhood events. I'll put that in the show [00:22:00] notes. That's something that you and I have talked about before. I check every box except for one, I could do nothing about that.

I can't go back and change my childhood. I wish it was different, but that, that really, I had the genes and that set the course and it's really been a lot of work of going back and healing and working on that aspect of things. So I want everyone to know, like. Yes, you can cut out the foods. Yes, you can.

You know, you can take all the supplements, you can do all the therapies, but if you don't look at that trauma and heal your childhood, it is very hard to keep those antibodies in remission and to keep that autoimmune disease from progressing 

Dr. Sara Szal: Well, you and I are similar in that way. I don't have an autoimmune disease that I know of yet, but my anti, anti-nuclear antibodies Right.

Um, my anti-nuclear antibodies went down to negative, the normal level. And it was mostly, I believe, through working with trauma. [00:23:00] Mm-hmm. And as, as you said, you can't do anything about a high A score. My A score is six or seven, depending on who is, um, counseling me about it. But the, the way that it lives on in your body is something that you can work with.

And that is super empowering. You know, the idea that you could, you could choose. Post-traumatic growth and I'm someone who ran around with partial post-traumatic stress disorder, kind of, um, hypervigilance and a lot of the other aspects of PTSD after childhood, and I. Uh, there's a lot that you can do to manage it.

It sounds like you've been on that journey along with me, Jolene. 

Dr. Jolene Brighten: Yeah, I would love to hear some of the things that you have done to management. I actually, and I'm gonna share this with you, I'll put this in the show notes as well. I actually just had somebody recommend this, my end therapy of like [00:24:00] working through your trauma that I'm actually gonna start.

And, uh, it was, um, a therapist I was working with and she's like, you're Mexican. You should be working with this Mayan energy. And I was like, and I've looked into it, there's YouTube videos about it. Um, and you basically are going back and you're, you're just, you're basically trying to bridge the, the past and now and, uh, basically healing that on the energetic lineage because as we know, you know, people will be quick to be like, oh, that's so woo woo.

And yet we know that the trauma can energetically imprint. Ourselves, and we've seen that I think some of the best data has come out of Holocaust survivors and how that trauma has been passed down, which as I say this, people might be like, oh, great, there's so much work to do, but let's talk about, you know, the, the, when we say trauma, what does that actually mean?

Because I think so often people think like the extremes of trauma. 

Dr. Sara Szal: They do [00:25:00] think of the extremes, and a lot of folks don't realize that some of the maybe small t traumas that they've experienced also count. They have this signature that can live on in the body. And so you're right, Rachel Yehuda has done such interesting work looking at a few groups of people.

She started with Vietnam veterans and then she looked at Holocaust survivors in their offspring. And then she also looked at survivors of nine 11, and especially the women who are pregnant during nine 11 during the terrorist bombings. And she's found a number of different things. So yeah, it may not just be your own experience of an overwhelming experience, uh, overwhelming, um, traumatic event.

It could also be that it's in your lineage and it's passed down epigenetically. And that can be passed down, for instance, with the way that your body, uh, signals cortisol. So some of the enzymes that manage the [00:26:00] conversion of cortisol to cortisone, which helps to inactivate cortisol, the main stress hormone, you might've inherited a parent or a grandparent's tendency to not do a good job inactivating cortisol.

So that's an example of an epigenetic change that can occur. And um, yeah, I love hearing about, for instance, the Mayan healing that you're describing. I feel like, um, when I started looking at what, what is the standard of care for someone who's got trauma, whether that's big T trauma, you know, like someone who survived a car crash or nine 11 or the Holocaust, or the small T trauma, you know, maybe a, um, a romantic partner who is, has narcissistic traits.

Or, you know, there's a way that you are sacrificing authenticity to [00:27:00] remain attached in a relationship or, um, difficulties at work. You know, having a boss who's misattuned and um, assumes the wrong thing about you. Either one of those and kind of anything along the spectrum can affect these parts of the body that are vulnerable to it.

And I like to frame that as the pine network that we talked about. Your psychology, your immune system, your nervous system, and your endocrine system. So, um, when it comes to the kind of things that have been helpful, when I first started to look at this and I. Did my first ACE score, which is right around the time that my anti-nuclear antibody was positive.

I was really interested in MDMA assisted therapy 'cause I could see that if the gold standard for people with post-traumatic stress disorder was to go to talk therapy, [00:28:00] sometimes trauma informed, but often not. Yeah. And to be prescribed a selective serotonin reuptake inhibitor. What I saw, Jolene, was that the efficacy of those things, the gold standard was about 30% in terms of the resolution of PTSD 30%.

Whereas MDMA assisted therapy has an efficacy that's more than double that. 

Dr. Jolene Brighten: And what is MDMA? What is that therapy for people who may not be familiar with it? 

Dr. Sara Szal: MDMA is known by its street name, which is X or ecstasy or Molly. It's a, um. I think of it as a sacred medication that's been studied in multiple randomized trials, and it's been shown with two to three treatments together with integration and preparation to help people resolve post-traumatic stress disorder.

It has a way of working with the signature of trauma, especially in the brain mm-hmm. To help resolve some of the, the stuck pathways that can occur. And [00:29:00] importantly what we've learned is that the part of the brain where trauma has its signature is different than the part of the brain that you might access with talk therapy, kind of the understanding part of the brain.

So there's these two different parts of the brain. We think that MDMA when it's given together with therapy, MDMA assisted therapy with a licensed therapist, that it can help to resolve that trauma signature in the brain. So understanding and talk therapy doesn't seem to do it, but this seems to be a lot more efficacious.

Dr. Jolene Brighten: Yeah, it's been interesting now that, uh, there's been a little bit of a less barrier. I feel like there's still stigma, so everybody who's listening be clear. We're not talking about just go do ecstasy on the weekend and you can heal your trauma. This is done with a practitioner, but you know, we've seen things like psilocybin, so, uh, shrooms is what people would call that.

And, uh, even [00:30:00] seeing ketamine therapy, seeing these different therapies now being explored and understanding that by accessing this different part of the brain, as you're saying, people can actually really, it's, it's like, you know, it's almost like turning on the light. And so the shadow is no longer there.

They can see it for what it is. They can work with it. And, you know, it's so often. You know, we, we see like cognitive behavioral therapy and so often we talk about like referring people to therapy, which is important. But as you were saying, if, if somebody is not trauma informed, sometimes therapy dredges up things that you then are not given the tools to handle, which is what is very different about what you're describing with MDMA.

Dr. Sara Szal: Exactly right. So, MDMA allows you to look at what happened to you without the story or the narrative that you maybe have always attached to it. So it allows you to look at it with fresh eyes and often with less fear. [00:31:00] And when you look at it with less fear, it often allows you to bring in more of a healing approach to it.

So I think it's, it's really important. You know, right now we're in the United States, kind of, um, reassessing whether the FDA will approve MDMA assisted therapy. They want more data and more populations and they wanna look at safety and efficacy. Although I would also add that the safety of some of these medications such as MDMA, ketamine, psilocybin, it's so much safer than alcohol.

Mm-hmm. And yet, um, they're safer than riding a horse. And yet, um, you know, it's a big threat to big pharma here in the United States. So, yes, we're not talking about just a weekend, uh, going to a rave and taking Molly. We're talking about a very structured way of taking it. And I also feel like I should add that I've been a total [00:32:00] square all of my life.

And I never took, I never even smoked weed when I was younger. And it wasn't until I was. In my fifties, and I had this positive anti-nuclear antibody, and I also had conflict with my, uh, family member that it got me to consider taking it myself. And did you find that it was helpful? Well, my anti-nuclear antibodies went into remission.

Um, I did it together with some other things, including an elimination diet. Um, I'm someone, and I'm curious if you had this at all, especially with what you're describing with your ACE score. I feel like in medicine we're selected for, um, people who can cognitively dissociate, who can mm-hmm. You know, kind of forget about whether they have to go to the bathroom or sleep.

Totally. Right. Like, you know, you, you get lauded for working around the clock, 36 hour [00:33:00] shifts. And there's a degree of dissociation that it has to happen Yeah. To be successful in that system. So a big part of this work for me was learning how to not dissociate, how to really be fully embodied. Mm-hmm. And, um, I would say psychedelic assisted medicine has helped me more than anything else with that quality.

Dr. Jolene Brighten: Yeah, no, what you're saying is so true and I think that's where sometimes patients have such a hard time with their practitioner's bedside manner. Is that there you, you sometimes, you know, depending on the situation to be fully present. With someone's pain and then to do it again and again, isn't it, it can be a trauma in itself, but it is, uh, you know, if you don't have the tools for it.

But we're never given the tools and we're told exactly that. Like, forget about who you are. Forget about what your needs are, be solely present for this [00:34:00] individual. And so there is a reinforcement there. And I also think that being present in your body is incredibly uncomfortable because of a myriad of reasons, but certainly more so if you've been impacted by trauma.

Great point. 

Dr. Sara Szal: And it's, um, you know, I wish, I wish we learned more about this particular aspect because you've got your finger on something really important, which is the vicarious trauma of taking care of patients. Especially when you're someone who is, uh. Empathic and, um, sensitive. I'm one of those highly sensitive people and it's, um, I remember, uh, working with a energetic healer in my thirties when I was feeling burned out and I was seeing 40 patients day, and a lot of them had, you know, crises that I was dealing with.

And I was still [00:35:00] taking a, a woman with a ruptured ectopic pregnancy to the operating room to try to save her life or doing emergency cesarean sections. Mm-hmm. And there was a way that. I was so wide open to these experiences of my patients and had difficulty kind of managing how much I would let in while still being empathic and it would lead to burnout.

It would lead to, you know, sort of one experience burnout after another, and then I would, you know, reduce. How much I was working and go on vacation and I would get a little bit better and then I'd be back at the burnout situation another six or 12 months later. So that's another sign I think of, um, the way that you work with trauma.

Is burnout part of your experience? Are you someone who's got, you know, this uh, sort of wide open, energetic system that can be easily affected by others? And I'm not saying you [00:36:00] don't wanna do that, it's more that you wanna be more skillful about the way that you manage the energy flow. How would you advise somebody to avoid that burnout?

Oh, that's such a good question. Well, maybe we could riff here, Jolene, because I know that you've also worked with these things, especially as a woman with multiple autoimmune diseases. I would say first that. One's home, whether you're in a committed partnership or not, must be a sanctuary. Mm-hmm. Must be a sanctuary.

And I didn't have that. So I grew up with parents that were divorced. Um, I made some choices in terms of my marriage that, um, did not provide that ability to completely rest and restore and rejuvenate at home. Mm-hmm. I think that's really essential, especially for women [00:37:00] who've got big lives and wanna, they're on a mission to help others in a big way.

So I think that's one piece. I would say psychedelic assisted medicine helped me clarify authenticity in a way that I was less clear about. And, um, that's part of, I. I mean, this is a whole other conversation, but I would say plant spirits in the way that they can initiate us are very powerful. And then, you know, more on the medical side, I would say tracking my health, tracking on my dashboards, some of the, the levers that I think are so critical.

So for me, for instance, anti-nuclear antibodies, measuring the amount of inflammation in my body, um, being able to track how to, um, how to navigate that and do and of one experiments to see what improves them, [00:38:00] such as, um, M dmma assisted therapy. Um, that's been very helpful. And then I think there's a, this is related to relationship.

There's a level of sovereignty. That I think is critical where you're not looking to others to, um, be validated, but you've got this internal sense of sovereignty and boundaries. Um, and then last I would say is regulation. I mean, the list goes on, but I would say really understanding what it looks like to feel regulated, to have your hormones kind of at your back and supporting you and not working against you.

So what did I miss? Jolene, 

Dr. Jolene Brighten: let's hear. Yeah. Well, I, I love that last piece of, uh, being regulated but also recognizing dysregulation as it's mounting and it's building. So, and, and this leads into. Certainly identifying if you are neurodivergent, you're going to be more, [00:39:00] more apt towards burnout just because of the sheer volume of information that you process at a much higher rate than the neurotypical individuals.

So I'm speaking to autism than A DHD as well. We know a lot of women have fallen through the, through the cracks, but when we hear dysregulation, that's usually the, the population we think about, and yet dysregulation can happen to any of us. So that's the, you know, the being in your body and going back to that, noticing your breath, noticing the tension that you hold, noticing, you know, and, and giving yourself permission.

The sovereignty you talked about, I think is so key as well. Like if you're in a situation, so for example, you know, a four M, this is a medical conference that happens every year. It's a great conference, but I will only speak there about, you know, I'm like, uh, maybe every four years guys, because. The sound of Vegas, the smell of Vegas, the lights of Vegas, everything about Las Vegas leaves me [00:40:00] dysregulated in my body.

And then there's the performance. As you know, I think sometimes when I. You are a speaker and you do it well. People are just like, you just, it's so natural. It's such a gift to you and you're like, I am like noting what your face is doing in the audience and do my jokes land and our people come and there's just so much going on.

And so all of that is to say from my personal experiences, like, you know, I go in, if I'm walking through the casino, blue light blocking glasses are on. I also do that if I go to Costco, I wear, uh, noise canceling headphones a lot of places or earplugs in my life. Uh, if I wanna be like covert, I have loop earplugs.

Um, but even going into, um, like, uh, restaurants or stores where they think blasting music makes for an ideal experience. All of these little inputs I know add up over the day. And I will say that I have to, if people are like, this is so much work, it, I have a toddler. At home. So getting that space at [00:41:00] home can sometimes be more difficult.

So it's a season of things. So I think there's what you can do preventatively, but there's also noticing how your body's feeling and if you can remove yourself from situations, if you can have a practice. I know you talk about deep breathing practices. I mean, the research definitely supports that. Why don't I let you explain to people you, you have your own practices around deep breathing and using breath to regulate your nervous system.

Dr. Sara Szal: I really feel like those of us who have had adverse childhood experiences, especially before age three, we benefit so hugely from daily practices that help us regulate and reset the nervous system. So I do it every morning. I was outside. By the beach this morning doing deep abdominal breathing for about 30 minutes.

So I find that that is really helpful. I became a certified yoga teacher in my thirties, mostly because [00:42:00] I just, I needed it to function and I needed it as, um, you know, more than a balm, like a, a way, a bellwether, a way to assess my own regulation, although we didn't really call it regulation back then.

Dr. Jolene Brighten: Mm-hmm. 

Dr. Sara Szal: So I practice yoga. I can't always sit. I'm sort of a fidgeter. And I've got, um, a DD, uh, which was diagnosed in perimenopause. Very common. Yep. Um, so yoga is something that still really helps me. But I would also say, you know, I've been practicing yoga for 50 years. I learned it for my great-grandmother, and yet it wasn't enough.

For me to resolve the trauma in my system. So it helps me and it's part of a daily practice. And I'm also a fan of some of the other breathing techniques that I talk about in the book, like holotropic breath [00:43:00] work, which is a good alternative for people who don't wanna try psychedelic medicine. 

Dr. Jolene Brighten: I explain what that is.

The first time I did it, I was like, this is the most magnificent thing I've I've ever done with my breath. But for people who don't know. 

Dr. Sara Szal: So Holotropic breath work was developed by Stan Groff, who was a psychiatrist in still lives in Mill Valley, not far from me. Um, it's a, a way of breathing where you are hyperventilating and it just allows for this physiological change in your body.

The way I think of it when I practice it is that I'm making my own medicine, and it can be psychedelic, it can take you on journeys. It's funny, the first time that I did it was actually at an A four M conference and I'm you, I'm with you. I go to, I go to a four M and it takes me like a week to recover.

Um, just the casinos, the noise and having sensitivity, it's just really tricky. And there was a dome at [00:44:00] the expo maybe five years ago at A four M where, um, I. They were teaching people how to do holotropic breath work. And I went in, it was like day three of being at a four MI had a mild headache. I was dehydrated, I wasn't sleeping well.

And inside of 20 minutes with holotropic breath work, I felt this complete reset. So I'm curious about your experience. Did you, what, what did you find Jolene? 

Dr. Jolene Brighten: So it definitely felt like, you know, as somebody who hasn't, um, experimented enough with drugs to say for certain, um, it is something that, it did feel like that everything that you see, like in the media about what a trip would be like, it felt like that, like this out of body experience.

But I just remember feeling like. When I came to the end of it and really reset and grounded, it was like my soul dropped into my body and I felt so clear and so present [00:45:00] and unbothered by so much stuff for, um, as I say unbothered, I'm like, that's really been like the energy I've been, um, channeling as, you know, being on social media.

I, it can sometimes be, um, a very interesting space of a lot of people projecting trauma that you can't, you're not here to heal them. And I've been channeling unbothered, so as that comes up I'm like, oh, I think it's time to go back and do some of that breathing. It's time, it's time to practice that. Um, and I think that, you know, for people who are like, I don't know about.

Giving up control because Right. Uh, these psychedelic therapies can, you can feel that that loss of control and there can be that fear. This can be a good step towards that and maybe it's enough for you. And that's a beautiful thing that if we can find interventions that, you know, have the least amount of side effects, but you can also do on your own and be practicing in a way and that creates change for you, I think [00:46:00] that's beautiful.

Dr. Sara Szal: It's a great portal. It's a great way to get started with some of these healing modalities. And even Michael Pollan, um, with his work with psychedelic assisted therapy, he couldn't take MDMA because he is got a heart condition. So he used holotropic breath work as a way of accessing these healing states of consciousness.

And that's what we're talking about. We're talking about, you know, what's the best way for you to access a healing state of consciousness? It doesn't have to involve taking a medication. 

Dr. Jolene Brighten: Mm-hmm. And so people are clear. You, you've talked a bit about cortisol. What happens to the body? What happens to our hormones when we're in that trauma, that space of trauma?

I've 

Dr. Sara Szal: been setting this feels like for decades, because apparently I still need to learn like the details of this. Um, so what we know is that when you experience a threat. [00:47:00] And that threat could be a physical threat, it could be an emotional threat, it could be the tone of your partner when you experience the threat.

Usually, um, adrenaline epinephrine rise in the bloodstream, so they get released from the adrenal glands and then cortisol is close on. Its heals. But really what we're designed to do is to have a stress response like this rise in cortisol and to resolve it within 90 seconds. Mm-hmm. At the most 90 minutes.

We're not designed to have these stressors that come up multiple times in a day and to have these elevated cortisol levels. So I'm someone, when I first started testing my cortisol levels in my thirties. I'm someone who had really high cortisol levels until I started to manage it and navigate it and find through NF one experiments what worked best for [00:48:00] me.

But the, the issue with cortisol, and I wanna hear a little bit about your own story with cortisol. The issue with cortisol is you want it to be in that Goldilocks position where it's not too high and it's not too low, and. My issue was high cortisol. You know, someone who's just got a kind of, um, high level of perceived threat.

Most of the time I've been able to bring it back to those Goldilocks position. But you can also burn out over time and it can lead to high cortisol for a period of time, like with 21 hydroxylase antibodies, and then you develop low cortisol or even a combination of low and high within the same day. So that's, that's part of the story with cortisol.

And it's not one of those hormones that's in isolation. It affects so many other hormones. It affects your estrogen, progesterone balance in your testosterone. And it can be associated with depression. It can even be a suicide marker. [00:49:00] Mm-hmm. So what about you Jolene? What's your experience with cortisol?

Dr. Jolene Brighten: You know, it really took my son developing pandas for me to get. The reset that I needed. So people, if you don't, are not aware what that, uh, what that is. Pan is his pediatric autoimmune neuropsychiatric disorder associated with strep. He got a strep infection. It triggered an autoimmune attack on his brain.

He had lots of informa, uh, inflammation and overnight he went from, so my husband and I were talking about how, um, at six months he said his first word and how he, by the time he was 18 months, he could speak in sentences. And, um, that's, that's not normal for a child to, so you guys know that's very, very early.

That's how verbal he was. But when he got pandas, he no longer could speak. He would just cackle and make the most out of this world noises. Anyhow, there was, and I could talk forever about that. I had been testing over and over via [00:50:00] saliva, be it Dutch tests, like EE every six months, checking my cortisol levels and sometimes I would bring them back into normal, but often, more often than not, they were the high normal in the morning.

Like I was waking up in a panic, like that's what it looked like, like my, I was in full fight or flight. I also have the genes so I don't clear it as well. The Warrior genes, um, once upon a time in a different it d you know, a different time, I, I would be a warrior and that would be fantastic. I would be able to go to the battle and I'd be the person like three days fighting nonstop, but.

I, I'm a modern human now, so that doesn't serve me as much. I want people to understand that these once upon a time served us. Now we have this bit of a mismatch, but it was once my son got sick and I realized how much it was breaking me down and how rapidly as I continued to try to run three clinics.

And this happened right before my book Beyond the Pill came out and just everything that was going on. And I realized that really I was given an opportunity here to [00:51:00] change my life altogether and I could choose life, or I could choose the burnout, the breakdown, what was inevitably coming. And I shifted everything and I decided that, you know, I was like, you know, the pinnacle of success in terms of what we're told.

As you know, doctors, like you're running three successful clinics, you have this full patient load, like you are so successful. And yet I was like, I am not showing up for myself anymore and I'm not entirely happy. Operating in this way. And so it presented an opportunity and I had to shift because, you know, number one priority is my child.

I brought him into this world and I needed to help him heal. But it was through all of that, I really rearranged my life, my perspective. I got serious about rituals and practice, and in all of that I finally. What has it been now almost six years. And I've had a normal cortisol, I could almost cry because if you're somebody who's ever operated under high cortisol, and, and especially as a doctor of like here, I was helping [00:52:00] everybody get their cortisol in check, but like I felt like internally this shame of like, why can't it work for me way nothing is working for me.

And it was because I was in such misalignment with who I was supposed to be in this world and how I was supposed to operate in my entire life. So I will say that for the last six years, like, well, I'd say more like five, like when we got out of that acute response with pandas, that things have shifted and that makes a tremendous impact, as you were saying.

Having easier periods, less PMS. I think I was blessed this to happen in my thirties because if it happened in the perimenopause, like peak of perimenopause, I would've probably lost my mind. Like I would've, you know, it would be so much harder because already progesterone is no longer your bestie, she's just leaving you.

Um, but you know, something else that you brought up was the mood aspect of things and how it impacts depression. And you brought up SSRIs earlier, so [00:53:00] I'm sure people are curious about the impact of the hormones, the trauma on their mood when they're being faced with, like all you can do is an SSRI.

Dr. Sara Szal: That's right. I mean, you and I have a mission. About supporting others and helping them through the dark times of things like depression, PMS, um, and the difficulty gaslighting dismissal that they might experience with conventional medicine. And so when I went to my doctor in my thirties and I had PMS and I had one baby, and I couldn't lose the baby weight and I had a lot of belly fat and I just felt stressed all the time.

He offered, which you might imagine, he suggested I take a selective serotonin reuptake inhibitor. He's just a birth control pill. 'cause it sounded like I was hormonal. Mm-hmm. And, and he told me to exercise more and eat [00:54:00] less. And so it was at that point that I left his office and I marched over to the lab and I scienced myself and found that my cortisol was three times what it should be.

So I feel like. What's important to know about cortisol is that it's really a dictator in the body. There's not a democracy with these hormones. There are certain hormones that are more important than others, and cortisol, if you don't have cortisol, you can die. So you have to have sufficient cortisol, and that means that it's involved, it's got its tentacles in so many different functions in the body, including your mood, including the way that you signal some of the brain chemicals like, um, serotonin and oxytocin, uh, norepinephrine, pregnenolone, and.

When people have mood issues, I think a hormone [00:55:00] panel is essential. And if you've got a clinician who's not willing to order a hormone panel that includes cortisol and DHEA and estradiol and progesterone, then you might wanna find a new clinician who's willing to order them. So, um, I think it's important to realize that, uh, hormones are often at the root of mood disturbance.

And it's not as simple as let's just throw a pharmaceutical at it. So we wanna look at, okay, what are the root causes and then how do we address those first with lifestyle redesign, maybe with some supplements and only if lifesaving or, you know, really essential use a pharmaceutical. And I'm not saying I'm not non-pharmaceutical, it's there's time and a place for them.

It's just that I think we hand them out way too readily. 

Dr. Jolene Brighten: Uh, why is it so controversial for doctors to test women's hormones? [00:56:00] 

Dr. Sara Szal: It's such a good question. So I, you know, here's what I was taught. So I went through an obstetrics and gynecology residency, and I remember there were sort of two different camps.

There was the camp of, here's basic gynecology, we're gonna teach you women's health. And if a woman asks you to check their hormones, then you don't do it. You tell them it's a waste of time. That hormones fluctuate too much. And then we would go work in the infertility clinic. Women, you know, with women with polycystic ovary syndrome, women with, um, unexplained infertility.

And we would check every hormone. We would check day three, estradiol and FSH, we would look at progesterone, did ovulate. We would look at cortisol and thyroid. And um, so there was a double standard. And I think some of that is set up because [00:57:00] we put a lot of value on women's reproductive health. Mm-hmm. We put more value on reproductive health than we do a woman's wellbeing.

Dr. Jolene Brighten: Mm-hmm. 

Dr. Sara Szal: And then it gets promulgated and the training that we go through. So I would say. Patriarchy is the cause and also just, uh, the way that we're so biased toward fertility, but I imagine, yeah, you've thought about this a lot too, Jolene, so what do you think is at the root? 

Dr. Jolene Brighten: I absolutely agree, and sometimes it feels like all we are reduced too is our baby making capacity.

And once you are no longer in that window of being reproductively viable of somebody who could produce offspring medicine is perhaps even faster than society to discard your value and to discard your, and, and what I mean by value is your wellbeing. When you look at, I, I was shocked there's, um, a new documentary coming out and to see all [00:58:00] of these medical doctors saying, oh, I got no training in perimenopause or menopause, and I, my jaw just dropped because I.

I was taught about these things. I was taught how to prescribe hormones. I, I'm like, shout out to Dr. Windstar. I think in part because she was in perimenopause teaching our gynecology. And, um, I was taught about all of this. And so it, for me, hearing that it was such an aha moment of we've been, I think, so often.

Very vocal about how doctors don't get enough nutrition education, but I think what we have to pipe up more about is that they don't get enough education on women's health outside of, is it disease or can it make a baby? And it really, it is so sad to me how, because we, you know, um, Dr. Who'd said like, we should have never named him sex hormones.

It was like the biggest disservice because it was with naming 'em, that, that made them all about [00:59:00] reproduction and nothing to do with heart health, brain health, I mean, every other way that it impacts us. So I think it's absolutely true. There's the lack of education. There is the, you know, dismissal that if it's, if it won't impede your ability to make a baby, then it really doesn't matter.

And I think that's why we see, looking at the research, I. That women are spending the last, you know, 20% of their life in the worst health of their entire life. And so that is part of why we do what we do, because that narrative really needs to change. And we spend so little time on this planet that it is, for me, it's, there's no time to waste.

We cannot spend it feeling unwell. 

Dr. Sara Szal: That's right. And, you know, this is where we wanna galvanize women to not put up with us anymore. So those days are over the days that, you know, when I was taught that, [01:00:00] uh, menopause was ovarian failure mm-hmm. It was where your ovaries stopped working and, um. Really there was less attention paid to women.

There was a way that women disappeared after their ovaries started to sputter and then fail. And I don't like that language. We don't have to put up with it anymore. Mm-hmm. So we can demand that there's more education for clinicians. We can demand that the clinicians that we see are willing to have conversations about this and have a growth mindset and are willing to learn.

Or you move on to another clinician, like find someone who values the experiences that you're having, who is willing to test your hormones and is willing to collaborate with you to help you feel your best and function at your best. 

Dr. Jolene Brighten: Absolutely. And on that note, I think that's a beautiful place for us to end our conversation.

Although I could talk to you as you know, and [01:01:00] anybody who's listening probably has caught on. We could talk forever. That's true. But I really do appreciate you taking the time to speak with me today, to share your insights. With everybody listening, we will link to your book, your social media, all the things in the show notes.

But I just want to truly thank you for all that you have done. Not just here, but just in all of your work, the lifetime of you. Thank you, Jolene. It's such a pleasure to to be with 

 

Dr. Sara Szal: you and to collaborate with you. I just love hanging with you.