The Peter Attia Drive

• #348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.

  View the Show Notes Page for This Episode Become a Member to Receive Exclusive Content Sign Up to Receive Peter’s Weekly Newsletter Rachel Rubin is a board-certified urologist and one of the nation's foremost experts in sexual health. In this episode, she shares her deep expertise on the often-overlooked topic of women’s sexual health, exploring why this area remains so neglected in traditional medicine and highlighting the critical differences in how men and women experience hormonal decline with age. Rachel explains the physiology of the menstrual cycle, the complex hormonal shifts of perimenopause, and the wide-reaching health risks associated with menopause, including osteoporosis, cardiovascular disease, dementia, and recurrent urinary tract infections. She also breaks down the controversy surrounding hormone replacement therapy (HRT), particularly the damaging legacy of the Women’s Health Initiative study, and provides guidance on the safe and personalized use of estrogen, progesterone, and testosterone in women. With particular emphasis on local vaginal hormone therapy—a safe, effective, and underused treatment—Rachel offers insights that have the potential to transform quality of life for countless women. We discuss: Rachel’s training in urology and passion for sexual medicine and women’s health [3:00]; Hormonal changes during ovulation, perimenopause, and menopause: why they occur and how they impact women’s health and quality of life [5:30]; Why women have such varied responses to the sharp drop in progesterone during the luteal phase and after menopause, and the differing responses to progesterone supplementation [14:45]; The physical and cognitive health risks for postmenopausal women who are not on hormone therapy [17:45]; The history of hormone replacement therapy (HRT), and how misinterpretation of the Women’s Health Initiative study led to abandonment of HRT [20:15]; The medical system’s failure to train doctors in hormone therapy after the WHI study and its lasting impact on menopause care [29:30]; The underappreciated role of testosterone in women’s sexual health, and the systemic and regulatory barriers preventing its broader use in female healthcare [35:00]; The bias against HRT—how institutional resistance is preventing meaningful progress in women’s health [46:30]; How the medical system’s neglect of menopause care has opened the door for unregulated and potentially harmful hormone clinics to take advantage of underserved women [53:30]; The HRT playbook for women part 1: progesterone [57:15]; The HRT playbook for women part 2: estradiol [1:05:00]; Oral formulated estrogen for systemic administration: risks and benefits [1:13:15]; Topical and vaginal estrogen delivery options: benefits and limitations, and how to personalize treatment for each patient [1:17:15]; How to navigate hormone lab testing without getting misled [1:24:15]; The wide-ranging symptoms of menopause—joint pain, brain fog, mood issues, and more [1:31:45]; The evolution of medical terminology and the underrecognized importance of local estrogen therapy for urinary and vaginal health in menopausal women [1:37:45]; The benefits of vaginal estrogen (or DHEA) for preventing UTIs, improving sexual health, and more [1:41:00]; The use of DHEA and testosterone in treating hormone-sensitive genital tissues, and an explanation of what often causes women pain [1:50:15]; Is it too late to start HRT after menopause? [1:56:15]; Should women stop hormone therapy after 10 years? [1:58:15]; How to manage hormone therapy in women with BRCA mutations, DCIS (ductal carcinoma in situ), or a history of breast cancer [2:00:00]; How women can identify good menopause care providers and avoid harmful hormone therapy practices, and why menopause medicine is critical for both women and men [2:06:00]; and More. Connect With Peter on Twitter, Instagram, Facebook and YouTube

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• #347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5

  View the Show Notes Page for This Episode Become a Member to Receive Exclusive Content Sign Up to Receive Peter’s Weekly Newsletter In this quarterly podcast summary (QPS) episode, Peter summarizes his biggest takeaways from the last three months of guest interviews on the podcast. Peter shares key insights from his discussions with Jeff English on the journey to healing from trauma; Ashley Mason on improving sleep and CBT-I; Sanjay Mehta on misconceptions around radiation and its use in cancer therapy and treating inflammatory conditions (such as arthritis and tendonitis); Sean Mackey on understanding and treating acute and chronic pain; and Susan Desmond-Hellmann on insights from her extraordinary career that pertain to the use of AI in medicine, understanding cancer, and the development of cancer therapeutics. Additionally, Peter shares any behavioral changes he’s made for himself or his patients as a result of these fascinating discussions. If you’re not a subscriber and are listening on a podcast player, you’ll only be able to hear a preview of the AMA. If you’re a subscriber, you can now listen to this full episode on your private RSS feed or our website at the episode #347 show notes page. If you are not a subscriber, you can learn more about the subscriber benefits here. We discuss: Summary of episode topics [1:45]; Jeff English episode: how trauma shapes behavior and identity, and the value of understanding personal adaptations and working through unresolved emotional wounds [3:45]; Practical behavioral changes and emotional tools Peter has applied since the Jeff English episode [13:00]; Ashley Mason episode: treating insomnia using CBT-I and practical behavioral techniques for improving sleep quality [19:15]; When to seek professional care for sleep issues [30:30]; Sanjay Mehta episode: radiation therapy’s evolution, its underused potential in treating inflammatory conditions, and the cultural misconceptions surrounding radiation exposure [33:45]; Peter’s predictions and insights for the upcoming Formula 1 season [43:15]; Sean Mackey episode: the neuroscience, classifications, and treatment strategies for chronic pain, and the importance of personalized care [57:45]; Susan Desmond-Hellmann episode: how AI is revolutionizing medicine through advancements in drug development, biomarker discovery, and the potential of training models on private clinical data [1:05:45]; More from Susan Desmond-Hellmann: why cancer is so difficult to treat with drugs, the promise of immunotherapy, and the long-term hope for systemic treatments [1:14:00]; and More. Connect With Peter on Twitter, Instagram, Facebook and YouTube

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• #346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.

  View the Show Notes Page for This Episode Become a Member to Receive Exclusive Content Sign Up to Receive Peter’s Weekly Newsletter Susan Desmond-Hellmann is a physician and scientist whose remarkable career has spanned clinical medicine, oncology, biotech innovation, and global health leadership. In this episode, Susan shares insights from her journey training in internal medicine during the early AIDS crisis, treating HIV-related cancers in Uganda, and developing groundbreaking cancer therapies like Herceptin and Avastin. She reflects on her leadership roles at UCSF and the Bill and Melinda Gates Foundation, offering lessons on guiding large-scale health initiatives, navigating uncertainty, and fostering scientific innovation. The conversation explores the promise of precision medicine, the integration of patient care and policy, and the evolving role of artificial intelligence in transforming diagnostics, drug development, and global access to care. We discuss: Susan’s medical training, the start of the AIDS epidemic, and the transformative experiences that shaped her career [3:00]; Susan’s experience working on the frontlines of the HIV/AIDS crisis in Uganda [12:30]; Susan’s time working in general oncology and her transition to biotech where she helped develop taxol—a top-selling cancer drug [26:30]; Genentech’s origins, and its groundbreaking use of recombinant DNA to develop biologic drugs [33:45]; Susan’s move to Genentech, and her pivotal role in the development and success of Herceptin as a groundbreaking therapy in targeted oncology [44:00]; The rise of antibody-based cancer therapies: the development of Rituxan and Avastin [52:15]; The step-by-step drug development process and the scientific and strategic challenges involved [1:01:30]; The ethical and economic controversy surrounding Avastin’s high cost and limited survival benefit [1:12:30]; Susan’s tenure as chancellor at UCSF: leading during a financially strained period, and her strategic approach to fundraising and institutional development [1:14:45]; What Susan learned as CEO of the Bill and Melinda Gates Foundation: strategic processes and decision-making frameworks [1:26:00]; Susan’s philosophy of leadership and how she sought to build an empowering, values-driven culture at the Gates Foundation [1:35:15]; The erosion of public trust in science during COVID, the communication failures around controversial treatments like ivermectin, and the need for better public health engagement and transparency [1:39:30]; The role of AI in transforming medicine: from drug development to cancer detection and beyond [1:53:00]; and More. Connect With Peter on Twitter, Instagram, Facebook and YouTube

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• #345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.

  View the Show Notes Page for This Episode Become a Member to Receive Exclusive Content Sign Up to Receive Peter’s Weekly Newsletter Sean Mackey is a professor of pain medicine at Stanford University and the director of the Stanford Systems Neuroscience and Pain Lab, where his research explores the neural mechanisms of pain and the development of novel treatments for chronic pain. In this episode, Sean joins Peter for a wide-ranging discussion on the multifaceted nature of pain—as both a sensory and emotional experience—and its evolutionary purpose as a critical survival mechanism. He dives into how pain is transmitted through the nervous system, the different types of pain, and why different individuals perceive pain so differently. Sean shares insights into pain management strategies ranging from medications like NSAIDs and opioids to neuromodulation techniques such as transcutaneous electrical nerve stimulation (TENS). Additionally, this episode explores the interplay between sleep and chronic pain and the psychological and emotional dimensions of pain, and it includes a personal story from Peter about his own experience with pain and how Sean’s expertise helped him more than two decades ago. We discuss: The definition of pain, and how our understanding of pain has evolved from a simplistic body-mind separation to a nuanced biopsychosocial model [2:30]; The biological mechanisms behind how we perceive pain [9:30]; The role of consciousness in the perception of pain, and how nociception functions during unconscious states [14:30]; The four types of pain [22:00]; Using fMRI to identify objective biomarkers of pain in the brain [31:30]; The evolutionary role of pain in human behavior and survival [36:00]; How the brain processes and modulates pain signals, Gate Control Theory, the variability in individuals’ pain perception, and effectiveness of neuromodulation techniques like TENS [41:00]; The brain’s influence on pain: the role of emotion, beliefs, sleep, and individual differences in perception and tolerance [53:45]; Peter’s personal journey with chronic back pain, and how the emotional consequences of pain can be more distressing than the pain itself [1:04:30]; The pharmacology of common pain medications—NSAIDs, COX-2 inhibitors, and acetaminophen [1:09:30]; Muscle relaxants: benefits, drawbacks, and personalized strategies [1:20:30]; The definition of chronic pain [1:29:15]; The role of antidepressants in pain management [1:30:15]; Opioids: their controversial and nuanced role in pain management [1:33:45]; Alternative therapies: acupuncture and cannabis [1:54:15]; Fibromyalgia and chronic pain: clinical features, brain mechanisms, and emerging treatments like low-dose naltrexone [2:01:00]; Possible brain benefits of low-dose naltrexone (LDN) for people with mild cognitive impairment [2:15:00]; Peter’s recovery from severe chronic pain—how he went from immobility and high-dose opioids to full functionality [2:20:15]; Breaking the pain cycle: how physical rehabilitation and psychological recovery work together in chronic pain treatment [2:30:45]; Sean’s struggle with cluster headaches, and the value of knowledge, preparation, and empathy in both managing chronic pain and caring for patients [2:39:15]; and More. Connect With Peter on Twitter, Instagram, Facebook and YouTube

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• #344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies

  View the Show Notes Page for This Episode Become a Member to Receive Exclusive Content Sign Up to Receive Peter’s Weekly Newsletter In this “Ask Me Anything” (AMA) episode, Peter dives deep into nicotine—a topic increasingly debated both scientifically and publicly. He clarifies the critical differences between nicotine and tobacco, highlighting why nicotine alone isn't primarily responsible for smoking's severe health consequences. Peter examines the specific risks associated with nicotine use, including addiction, sleep disruption, cardiovascular concerns, and effects on mood and anxiety. He evaluates various nicotine delivery methods, from traditional cigarettes to gums, pouches, and synthetic alternatives, ranking them according to their relative safety. Additionally, Peter explores nicotine's potential positive and negative impacts on physical performance, cognitive function, fertility, and its interactions with other stimulants like caffeine. Finally, he provides practical guidance for minimizing risks with nicotine use and offers thoughtful strategies for smoking cessation and effective nicotine replacement therapies. If you’re not a subscriber and are listening on a podcast player, you’ll only be able to hear a preview of the AMA. If you’re a subscriber, you can now listen to this full episode on your private RSS feed or our website at the AMA #70 show notes page. If you are not a subscriber, you can learn more about the subscriber benefits here. We discuss: Revisiting the previous AMA on microplastics: low-effort, high-impact changes to significantly reduce microplastic exposure [1:45]; Overview of episode topics related to nicotine [3:30]; The current landscape of nicotine research [4:45]; Addressing the common misconception that nicotine itself is the primary cause of tobacco-related health risks [6:45]; Peter’s Marlboro-branded apparel is a nostalgic tribute to the Formula One era and not a sign of support for smoking [10:00]; The limitations of current research on the health risks of nicotine itself [12:15]; The most common side effects of nicotine [18:15]; The impact of nicotine on sleep [21:30]; Nicotine and mood: how nicotine can have both anxiety-inducing and calming effects based on genetics and dosage [25:00]; The addictive properties of nicotine: factors influencing addiction risk, and why certain people may struggle more than others [29:15]; The various nicotine products and nicotine delivery methods available: effects, absorption rates, and potential risks [33:45]; The relative risks of various nicotine products: how differences in nicotine concentration, absorption rates, and presence of contaminants impact their safety [37:00]; Potential cognitive benefits of nicotine: short-term benefits and impact of chronic use [44:45]; How nicotine exposure during adolescence can negatively impact brain development [47:45]; Nicotine's potential to prevent or slow neurodegenerative diseases [50:45]; Nicotine’s impact on memory, learning, and attention [52:45]; The interaction between nicotine and other stimulants, particularly caffeine [55:15]; Nicotine's potential impact on physical performance [57:15]; The potential effects of nicotine on fertility, and the challenges of distinguishing the impact of nicotine itself from the effects of smoking [58:30]; Considerations for people curious about using nicotine for its cognitive benefits [1:01:30]; How to think about nicotine: weighing cognitive claims, addiction risks, and personal tolerance [1:03:15]; The prevalence of smoking, the health risks it poses, and the substantial long-term benefits of quitting [1:05:45]; Effective strategies for smoking cessation, including the use of nicotine replacement therapies [1:09:00]; The reasons behind weight gain after quitting smoking, the role of nicotine in appetite suppression, and strategies to manage weight [1:15:30]; and More. Connect With Peter on Twitter, Instagram, Facebook and YouTube

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