I get it. Nobody thinks they’re going to have infertility, so they sure aren’t going to save for it. Borrowing money when you really want a baby has become somehow normal and accepted. For whatever reason, most employers, a long time ago, decided that infertility did not need to be a covered benefit. A loan becomes the only option when you need something now and don’t have the money for it.

Egg freezing is a different proposition. Women don’t need egg freezing. They may not even know if they want to have kids. They just want the possibility of maybe having a baby later. Nobody borrows money for a maybe. We learned that the hard way.

I was helping to run one of the largest fertility practices on the West Coast. We recognized that women who wanted to freeze their eggs were different from our regular patients trying to get pregnant. They didn’t have a medical diagnosis. It was a different vibe, so we gave them their own place. A separate service line, right next door to the one for our patients who were treating their infertility. Modern aesthetic, communal space, nurse practitioners running intakes instead of the subspecialists. (We seriously considered a smoothie bar.) It was a good idea.

The ones who came in to actually freeze eggs had one thing in common. Somebody else was paying for the procedure. Usually, it was the employer sponsored benefits.

We tried to get more clients. We threw egg freezing parties to educate women about the benefits of fertility preservation. The parties were popular. Women were interested and they appreciated the fertility education. They would sign up to get their AMH tested but that was it. Almost none of them froze eggs unless they had coverage.

That is why the clinic failed, and it is worth understanding. The demand is for real. Women would like to preserve their options. They just didn’t have ten thousand dollars lying around. The parties fell out of fashion for the same reason the clinic did. We had hung up a special shingle, offered financing, but no one bit. The only people who borrowed money to freeze eggs had a cancer diagnosis. They had urgency. But everyone else could afford to wait.

The price has gone up in most parts of the country. Between the special hormone injections, surgery center to remove the eggs, and a lab staffed by embryologists who have mastered freezing a single cell without destroying it, it’s hard to see how we are going to bring down the cost. Ten to twenty thousand a cycle is a typical spend now, and some women need to do more than one cycle.

So how should we get this paid for? Twenty-five states and DC require some fertility coverage, but the variability is large. Several cover fertility preservation but only for cancer patients, which does nothing for most women in this situation. My own state has tried to pass a mandate for the past three years and it keeps stalling. But here is the bigger issue. Even in states with mandates, people fall through the cracks. Self-funded employers and small business owners are often excluded from mandates, and most don’t voluntarily choose to cover it for their employees.

When employers do cover it, it works well. Fertility coverage turns out to be the benefit their own employees request most. The programs are popular. Women ask for it and appreciate it. It is a way to retain and attract talent. It doesn’t tell women when they should or should not start their family.

The odds of success with egg freezing are really good now. Last year, in a study published in Fertility and Sterility, women who froze their eggs in their mid-thirties had a pregnancy or live birth rate near 75%. It is still not a guarantee, but freezing eggs gives hope and a small amount of control.

Here is what makes egg freezing different from every other fertility expense. You can see it coming. Women know that it’s common to be single and deal with their biological clock in their thirties. A runway gives time to plan, and planning means time to save.

The timing is tricky. Freeze too young and the eggs are great, but they may never be needed. Freeze after thirty-eight and quality and quantity have already started to slide, so more cycles are needed. The sweet spot hugs thirty-five, precisely when women are building their careers and saving for a down payment and retirement.

Most parents know the launch of kids does not end at eighteen, or at twenty-six when they get kicked off the family’s health insurance plan. If you’re the parent, you want to keep being part of your kids’ lives. You’ve probably thought about how you’ll contribute with your money or time. Maybe you’d help with a down payment, or you’d offer to watch the first grandchild one day a week. You have lived with a budget longer than they have. You have almost certainly never thought about saving for your daughter’s egg freezing cycle. Not because you couldn’t. Because nobody has ever laid it out this bluntly. Now that you see it, don’t unsee it. Reorder the priorities and think about how you can help her. Help her when it matters. The house can wait. The eggs won’t.

You and she both can build an egg freezing fund. Put in fifty dollars a month, then a hundred, then two hundred. Make it automatic and increase it when you get a raise or a bonus. You can invest the money you are no longer spending on her health insurance and mobile plan (cut that cord too) and start saving for the possibility of grandkids. Match hers or double it and invest it so it compounds. You may have been used to contributing to a 529 to pay for her education. Paying for your future extended family is a good thing to invest in as well.

If she decides not to freeze, gets pregnant or doesn’t, nothing is lost. The money will find a cause. It can become a wedding fund or an infertility treatment fund, which beats a high interest loan every single time. It can cover the down payment for a condo or house, or a 529 for the grandchild you were hoping for anyway. The money won’t be wasted.

And here’s a marketing idea: I would love to see a bank or an employer offer an egg freezing savings plan. Just like employers that offer these benefits, I bet it would be popular. And if the government ever wanted to be genuinely useful, they could nationalize it like the 529 or the HSA and let the interest grow tax free. Until then, take it on yourself. You’ve spent your life investing in her future.

Tell your friends you started an egg freezing fund for your daughter, and that if she decides to freeze in five years, you plan to celebrate. The cake will be small. She’ll want it after the procedure.

I also have two daughters in their early twenties. If you ask either of them whether they want kids on any given day, you might get “definitely not,” or “maybe,” or “I can’t think about that right now.” I understand that answer. Life is harder for them than it was for us. The environment, lack of entry level jobs, and the cost of living are straining young adults in ways we didn’t face.

When I grew up, I knew I wanted kids even though my family was financially strained (my dad lost his job when I was thirteen, my mom worked part time as a professional recruiter). I still felt like a “normal life” was possible. I planned for a career, marriage, house, and a first kid by my mid thirties. I didn’t doubt it would happen.

But life throws curveballs. Lots of them, and not the ones you anticipate. Being an OB/GYN did not insulate me from infertility myself. I didn’t know my first-born son would have a severe brain injury. He came out after an easy, full-term pregnancy not breathing and developed a resistant seizure disorder, global developmental delay, quadriplegia. He required 24/7 care during his short life. My husband and I navigated lots of things we did not anticipate. We went on to have two typical kids and have found plenty of ways to experience joy. But the fragility of life is real to me, and our good times together are that much sweeter. I deeply appreciate a messy, fun family vacation or a late afternoon neighborhood walk with my husband as the sun dips in the summer sky.

I’m telling you this because I want you to know my background. I don’t think having kids is required, and I know too well it is not a guarantee. Something that feels like it should be a basic human right, the ability to have a child, that should come easily and without stress, can become a monster and take over your life when it doesn’t happen. As a fertility doctor, I sat across from people at their most vulnerable, watching them want something so badly, and being willing to do almost anything to get it.

I’ve watched women cycle through the stages of grief as they deal with infertility: deny and keep trying, negotiate how to afford IVF, suffer from depression and anxiety, try to reach equanimity that a baby may not happen. I saw individuals navigating these stages as I helped them through their journey, and I lived parts of it myself. In the past thirty years, modern medicine and assisted reproductive technologies have made success much more likely, but only for those who can afford it.

This series is about how economics and biology collide in the lives of people in their twenties and thirties. Whether you are thirty and noodling on egg freezing, contemplating when you and your partner will feel financially ready to start trying, or fifty five and quietly wondering if you will ever be a grandparent, I want to lay out some groundwork before opportunities shift.

As parents, a lot of us have had money conversations with our kids: pay bills on time, know the difference between needs and wants, set up an emergency fund, start saving and investing early (because compounding is really what you need to get ahead). These money skills are not intuitive, and schools do not teach them anymore. It’s an ongoing conversation you should continue to have, with more sophistication as your kids enter adulthood. There may even be more time to have these money talks than you anticipated, especially if your kid is living back at home right now trying to figure things out.

Most people haven’t had another conversation. How do you plan when to have kids, and how do you plan to afford it? They’re not going to ask. They’re more interested in their friends and finding a date on Hinge. But that doesn’t mean they don’t need to think about it. It means you need to bring it up. Maybe having that conversation will make the other conversation more possible. The one that starts with when they can plan to have kids, not wonder if it will ever be affordable.

That’s the real argument for this series. Not that you should write a check for egg freezing for your daughter (although you may decide it’s in your best interest as a future grandparent). Or that you should tell your son to avoid sports betting (you should) and get out there and date more. It’s that you have experience with living. Real world budgeting and parenting, and wisdom to share. You know that there will be challenges and hurdles. But you may not know what they are facing, and why it is so different from your reality at twenty five.

I’m going to show you their budgets, and what it would cost to buy more time. I’ll also get into what’s different for parents of sons, because this conversation isn’t just about daughters. If my son were alive today, I’d be having conversations with him too.

Having the tough conversations with your kids is why you became a parent, right?

Imagine a world in the not too distant future where your primary care is provided at home, by Doctor AI. You have a sensor that plugs into your wall or is embedded in your phone that picks up your vitals and transmits them to your personal health dashboard. Wearable devices feed in. You snap a photo of your meal to track your nutrition and protein intake, to be alerted to any vitamin deficiencies. Your at-home scale tracks your fat and muscle mass. Your ring or watch tracks your exercise pattern, whether or not you have a cold coming on, and if your menstrual cycle is due to start.

As you gracefully enter middle age, your annual labs feed into the dashboard. You track things like your LDL and HbA1c and get told when to start a statin or a GLP-1 to live longer and better, avoiding painful things like dying of a heart attack or stroke in your 60s, or getting nerve damage in your hands and feet or kidney failure from diabetes.

Your home health dashboard tracks your menstrual cycles and falling estrogen. It can tell you when you’re in the menopausal transition, and when your bones will start to lose density. You’ll be nudged to start replacing estrogen. If you have a uterus or if your mattress detects that you’re not sleeping as well as you used to, it will have you replace progesterone as well.

Your libido will be measured by your mattress or wearable, and if things are declining, men will be prompted to consider testosterone (women too), along with drugs for erectile dysfunction.

And who will oversee all of this? Doctor AI, at your service.

Now there are lots of reasons you might find this level of technology exciting, or an invasive nightmare. All of your health data in one place, on your phone, where you can actually track it? Or would you prefer no monitoring, and just live life non-digitally?

Imagine the ability to monitor an aging parent in another city, preventing a fall, making sure their AI companion keeps them entertained with a benevolent parasocial relationship so they’re not battling loneliness. That has a certain dystopian appeal.

The hard part isn’t the sensors and the dashboards. It’s how soon we will trust the AI doctor to act on its own.

Of all the things AI does well, it’s pattern recognition. Noticing when things deviate and nudging action is a genuinely good application. Monitoring health patterns longitudinally and delivering preventive care at scale is something we’ve never actually had. Your AI doctor will watch and nudge. And unlike your actual doctor, it won’t be running behind and burned out.

Your AI doctor will know your allergies, conditions, medications, supplements, eating and exercise patterns, and family history. It’s been tracking your health for years. Someday soon it may be prescribing a new medication, starting low, increasing the dose gradually, collecting your feedback on side effects, and monitoring whether it’s working. It may be better than a provider who sees you for the first time after a three-to-six month wait, skims your chart for a minute, spends seven minutes with you, writes a prescription, and tells you to come back in four to six months. Doctor AI may get it right, it may not. But it will likely be better to react and adjust than our current system. This is not as far-fetched as it sounds. An AI prescribing model for medication refills is already being tried in Utah.

AI is moving into healthcare like a runaway train, and much of it is genuinely useful. Tools like Open Evidence show your doctor the latest research while you’re still sitting in the room. It’s exciting and now feels indispensable. AI scribes record visits so your doctor can make eye contact with you for ten minutes instead of staring at a screen. The not so fun billing and endless clicking in the EHR can now happen before and after the visit.

In other parts of the system, pre-authorization has become a battleground. AI vs AI. Your doctor submits a request for a procedure. The insurance AI denies it. Your doctor’s AI scours your records and resubmits an appeal. The insurance AI finds another loophole. Insurance companies operate on profit. They want to keep more of your premiums and pay for less care. Physicians are exhausted by trying to get care they want their patients to have. The patient is losing. I haven’t met one person who thinks this is a good system. Maybe I haven’t met the insurance executives.

Medicare pays for almost half of all healthcare in America. What this CMS system decides to do, the rest of the insurance industry copies. So even if you are under 65, your care plan is influenced by Medicare. They set the rules and trends for how medicine gets practiced everywhere in the US.

Medicare recommended tightening rules around remote monitoring and proposed physician pay cuts again in 2027. So this utopian dream of getting preventive health care monitoring paid for by your insurance plan is facing hurdles. They might require more physician oversight and less ability to have an outside tech company provide the interpretation for the home health dashboard and get reimbursement. I’m not sure I know any physician who will want to hold the liability for that.

Cutting physician pay and increasing responsibilities is one of many reasons why there is a significant and growing shortage of primary care physicians. At the beginning, when medical students do the math and choose a specialty that will let them pay off $200,000 in debt while also figuring out how to buy a house and start a life, primary care looks pretty unattractive. And at the other end, practicing physicians in their 40s and 50s face burnout from doing work that has nothing to do with patient care: pre-authorization requests, specialty referrals, nurse practitioner oversight, refill requests, patient portal messages, and all of it is unpaid and jammed after hours.

Our health care system was built around caring for patients. That’s why most of us went into medicine. It has since been reconfigured around the money. Insurance companies, private equity, hospital systems, government payors, and prior auth algorithms got in between the doctor and the patient. Each component takes their cut and adds friction to the delivery of care.

Doctors hold the power to prescribe meds and are needed for surgeries and procedures, but they don’t run the systems that run the business of medicine. Most work for some entity. Many are feeling undervalued by the system and replaceable. The doctors contemplating leaving haven’t stopped caring. They are just frustrated and worn out. They are figuring out their exit.

So, we have a gap. Doctor AI will fill it. Here is the thing nobody wants to say out loud: for a lot of people, it might actually be an upgrade. Doctor AI isn’t replacing the doctor who sits down with you for thirty minutes and knows your name. It’s replacing a seven-minute visit after a four-month wait with someone who has never met you, for a problem that has been bothering you for months. That is our current system.

Doctor AI will be “good enough” medicine for the population. Concierge care for the people who can pay for it. Be prepared to take more personal responsibility for your care. The systems are driving the humans out.

Last week the Pentagon added annual testosterone screening to every male service member’s health assessment starting at age 30. The FDA is simultaneously moving to remove the label restriction that limited T therapy to men with confirmed clinical deficiency. Age-related decline in T could become a legitimate reason to prescribe it to many more men.

If you’ve been wondering if you’re not reaching peak performance because you might be a little low on vitamin T, this affects you.

I am a reproductive endocrinologist and have spent twenty years in the field of hormones. Here’s what’s missing that you should know.

Is this a symptom or a lab finding?

The symptom list for low T is fatigue, low motivation, brain fog, reduced libido, mood changes. Lots of things cause these like stress, lack of sleep, poor diet, alcohol. Symptoms or not, if you tell someone you are going to test their T, and oh by the way, it’s less than last year, they will infer that it’s a problem that could be treated.

Testosterone in men generally declines gradually with age, and there is plenty of individual variation. Most men in their sixties are still within normal range. It tends to follow a gentle slope. Yet testosterone prescriptions in the US have more than tripled, with many cases involving men without a true deficiency. And there are gaps. A 2022 study found only one in seven online prescribing companies asked whether men planned to have children. The military program is a visible signal, and the trend is spreading.

What nobody mentions before starting T.

Testosterone is a male contraceptive. Meaning it prevents pregnancy. It’s not being marketed as this because we don’t think men will want to take a daily pill, but if you’re taking it to bulk up, you’re also causing your testicles to shrink and your sperm production to stop.

I have had to tell men to stop their testosterone because it caused azoospermia. Recovery after stopping is variable and can take months, sometimes longer. The longer someone has been on T, the less likely a full recovery. Coming off T after your body has come to rely on it can be brutal. Complete lack of energy. No drive. Men do not feel like themselves and cannot wait to get back on it.

Is anyone going to have that conversation with a 32-year-old who tested on the low end of normal and was told he might benefit from a little extra T? That he might need to continue it for the next fifty years or feel like crap if he discontinues it? Are they going to ask if he is planning to have children anytime in the next decade and tell him what he can expect?

Most men recover sperm production. But sometimes it takes a very, very long time. Not a great thing if his partner is in her thirties. Some take two years. Ten to twenty percent do not recover at all, meaning you might need donor sperm or IVF. Once you start T, it is hard to stop, and getting off it is not pretty.

The hormone crisis that we're still not addressing

Now look at women’s hormones.

Estrogen in women does not gradually decline. It falls off a cliff. Two thirds of circulating estradiol can disappear in the four years before menopause. Men’s testosterone declines over a few decades. Women feel their decline acutely. The message has been, “ride it out,” as if it’s heroic to not treat it.

The symptoms are not vague and not trivial: hot flashes, sleep disruption, brain fog, mood changes including rage, joint and muscle aches, decreased sex drive. Menopausal symptoms are very treatable, and estrogen therapy is the most effective treatment for most of them. It’s not complicated, yet it’s still not the expectation.

I know women who have been completely frustrated because they can’t get their symptoms addressed adequately and it’s affecting their home life and workplace. A Mayo Clinic study puts the US productivity loss from menopause symptoms at $1.8 billion annually. It’s shocking that we are not paying more attention to this as a society.

If you’ve been lying awake at 3am wondering what’s happening to your mind and body, and why you can’t seem to find adequate help, you have a sisterhood who are feeling the same things.

The inequity hiding in plain sight.

Women also have testosterone loss with age, but their starting number is lower than men’s. It’s still enough that some age-related decline in T for women causes symptoms that aren’t adequately treated with E. And there’s still no FDA-approved testosterone product for women in this country. Other countries have made approved formulations available, but not here. So when a woman wants to try it, to see if it helps relieve some of her symptoms, she needs to find a physician who is comfortable prescribing it, and then use a male product at a fraction of the dose, or use a compounded preparation, or use subcutaneous pellets that cannot be adjusted once they are in. Too high from implanted pellets? Sorry. You will have to wait three months till the hormone has run its course. There is no reversing it.

I am all for treating real hormone deficiency. I am for minimizing symptoms and preventing future disease. I am not for treating a lab value with a vague symptom list attached, and I am not for normalizing a medication that can actually cause infertility.

We have turned a gentle decline in male hormones into a national screening ritual with treatments available, while menopause still gets treated like a natural condition to suffer through. In the T versus E debate, we know which hormone is falling faster and causing more problems. We still aren’t acknowledging it and treating it like the problem that it is.

For any man considering testosterone, ask two questions first: what will this do to any future fertility, and how will I feel if I want to stop taking it? If the clinician cannot answer you adequately, find one who can.

For any woman dealing with symptoms, find someone who will help you until you are feeling better.

Nothing here is medical advice. Find a doctor who will listen to you.

If you want more:

North A. Why young men are killing their sperm. Vox. 2026. vox.com/culture/490501

Faubion SS, et al. Menopause symptoms and work outcomes. Mayo Clinic. newsnetwork.mayoclinic.org

But here’s the catch. The years women spend building a career, any career, are also their most fertile. Late twenties to early thirties. Two clocks, one window. Both need attention.

No reason to panic, but I do want to give you a number you probably aren’t aware of. About one in four women physicians who try to get pregnant run into infertility, well above the general population. Nobody’s tracking other fields, but I’d bet women in law, finance, tech, and startups aren’t far behind. And infertility on top of a demanding career is brutal. The kind of added stress that anyone would rather avoid.

Last weekend I sat on a panel for the American Medical Women’s Association, talking about all of this. Three of us traded war stories. We froze eggs when we weren’t sure of our timeline. We did IVF and asked our own colleagues to be our doctors (I tell that personal story over at The Fertility Brief). We worked right up to our induction dates and planned C-sections. We have kids now. But each of us had to navigate career and family building in her own way.

If I can share one thing I’d like women to reconsider, it’s this. Somehow 35 became ingrained as the start of the fertility fall. That was my anchor since high school. I thought build a career, find my person, start a family at 35. Until I learned differently.

Fertility doesn’t fall off a cliff at 35. It starts to slide around 30 and steepens after 35. And we haven’t figured out a good way to slow this down. So, 30 should be the fertility anchor, not 35.

But honestly, maybe kids aren’t on your agenda. A big, full life can include kids or not. A good chunk of Americans don’t want kids and that is just fine. Pursue your happy. Life is short. But if you think you might want them one day, it’s something where having the right facts at the right time can really help.

Smart employers have started to figure this out, because life happens on its own timeline. They cover fertility care and egg freezing, not just as a nice perk but because it’s a real draw for attracting and keeping talented women. Freezing eggs keeps a window cracked open a little longer, but it’s not a guarantee. Same goes for IVF. When fertility benefits expand and more employers and states cover fertility care, I’m all for it. It’s a great thing. But the most powerful move is knowing and taking control of your own reproductive timeline.

A lot competes for time and attention in our twenties and thirties. If having kids might be part of your plan, even if you’re unsure, pin it. Put it on your calendar and give it a minute of thought when you’re 30, not because you need anyone telling you to have children, but because if you do, starting earlier may help you avoid the painful process of infertility. And I cautiously say may, not will, because plenty of people start early and still need help. Infertility isn’t anyone’s fault. It just happens. Starting earlier just buys a little more room. That’s it.

What do you wish someone had told you sooner?

I write here about pulling back the curtain on medicine, culture, nutrition, and health tech.

Women with this condition visit multiple doctors before getting an answer. Many diagnose themselves first. They’ve done the research. They come in frustrated. In a large international survey, about a third waited more than two years, and almost half saw three or more doctors before anyone put the pieces together.

And then it gets worse. PCOS sits between two specialties: medical endocrinology and reproductive endocrinology. Medical specialties tend to have boundaries and PCOS doesn’t fit neatly into any of them. Not trying to get pregnant? A reproductive endocrinologist may not see you. Go to medical endocrinology? They may not know how to manage your menstrual symptoms. You fall between the two, and training is thin on both sides.

Where should it live? Honestly, in the place where chronic conditions live: primary care. A good primary care doctor or general OB/GYN can make the diagnosis, protect the uterine lining, screen for diabetes and cholesterol problems, and check in on mood and eating patterns over years, not just one fertility season. Almost every woman I’ve treated has insulin resistance, even lean women, and most never get screened for it. Then, when they are ready to try for pregnancy or if the metabolic picture gets complicated, that’s when reproductive endocrinology or medical endocrinology can step in.

The new name quietly argues for this too. Polyendocrine metabolic ovarian syndrome says, in the name itself, that this is not a problem to hand off to a specialist. It is a chronic metabolic condition. It belongs in the same room as your blood pressure, your cholesterol, and your annual exam.

I’ve spent twenty years focused on helping women with PCOS. Thousands of patients, researching different types of diets, supplements, and insulin sensitizers. I never liked the name, but it was sticky.

Polycystic Ovary Syndrome. Cysts right in the name. Real cysts are big, painful growths that rupture, but these are tiny, quiet follicles around eggs, the same ones in every ovary, just more of them. Not dangerous and not a problem. The name didn’t describe what was happening. It described what you’d draw if someone asked you to sketch an ovary.

This week, after 14 years and 22,000 survey responses, PCOS was officially renamed PMOS: Polyendocrine Metabolic Ovarian Syndrome. The final name was chosen by just 90 people: 63 physicians, 27 women with PCOS. It was almost called EMOS, Endocrine Metabolic Ovulatory Syndrome, until an international committee of clinicians and patient advocates Googled it and realized EMOS was also a teenage subculture known for black eyeliner, emotional distress, and a general air of doom. The committee pivoted. This was uncharacteristically described in the Lancet paper, possibly because it may have been a better name. Anyways...

Dropping polycystic is genuinely helpful, but polyendocrine? Endocrine is not a word most people use, and polyendocrine even less so. Metabolic is maybe a little more common, but when I ask patients what brought them in, they say: I can’t lose weight no matter what I do, I never know when my period is coming, I’m tired of waxing my upper lip. The new name is clinically accurate, but it may still need a translator.

Nobody learns the full name. Ask anyone with lupus, that’s systemic lupus erythematosus, or MTHFR, that’s methylenetetrahydrofolate reductase deficiency. They learn the shorthand and they own it. PCOS has something rarer than a good acronym: it has a community. Support groups, IG accounts, podcasts, books, hashtags, millions of women who built an identity around four letters. PMOS has to earn all of that. The real test is not whether it shows up in clinical notes. It is whether the woman who has spent ten years saying, “I have PCOS” starts saying “I have PMOS” and feels like it fits.

We finally have something more clinically accurate, and that matters. Maybe now women will be screened for diabetes instead of just being given birth control pills. Insulin resistance runs through nearly everyone with the condition, even in lean women, and raises the risk of diabetes, heart disease, and high cholesterol over time. It needs more attention in clinics and during medical training.

But I keep thinking about the women who filled out those surveys. They wanted a name that didn’t make them feel broken, something they could understand, something that reflected what they were actually experiencing.

We gave them Polyendocrine metabolic ovarian syndrome.

None of the women I have taken care of over the years will likely remember the full name. But PMOS is close enough to PCOS that they may come to know it as just that, and it will probably be PCOS/PMOS for a few years. PCOS will live in the literature forever. Maybe naming it more accurately, for what the condition is actually about, will help health care providers give better care to the women who are dealing with their own set of symptoms every day.

Story in progress.

If you’re interested in reading more: Teede et al., The Lancet, May 12, 2026. Open access at doi.org/10.1016/S0140-6736(26)00717-8

About half of them barely cooked. Nobody had taught them and they hadn’t made it a priority to learn. They grew up in households where parents worked, and family dinners rarely happened between sports and homework. Then first apartments, new cities, an empty fridge and DoorDash an easy tap away. No established cooking infrastructure in their day to day existence. It may have been part of their family culture once, but they hadn’t made it part of their identity...yet.

We eat multiple times a day and yet we don’t stop to ask ourselves why we eat the way we do. What values are underneath our food choices. What story are we living out every time we open the refrigerator, order from an app, or eat in the kitchen looking at our phones.

You have a food identity. You may just not have named it.

First, a quick reality check.

The question “what’s your food identity” is itself a privilege. For over two billion people dealing with food insecurity, eating is about getting enough, not about pleasure or optimizing.

I’m visiting Sardinia, one of the original Blue Zones. People aren’t wealthy here. They are just sharing meals with friends. And walking. A lot. It’s hilly here. If you have the luxury of choosing your food identity, you have more choice than lots of people around the globe. Are you choosing by design, or is your food identity being chosen for you?

It’s a spectrum.

At one end: food as function. Calories, efficiency and optimization. Food to serve your body, your schedule and budget. You can track macros and protein targets or take it even further, a la Bryan Johnson. You might not find food interesting and eat because you know you need to. Or, like many people across the globe, getting two meals a day is basic nourishment.

At the other end: food as experience. Pleasure, connection, culture, novelty. Foodophilia. This end includes the culinary explorer who seeks out restaurants at home or in new cities, the creator who keeps sauerkraut fermenting on the counter, the person who enjoys making a Saturday night multi-course meal for friends.

The interesting question isn’t what happens on a random Tuesday. But where your default sits. Do you make active choices, or did you let yourself be persuaded by bright shiny packages or the temptation of a quick meal you didn’t have to cook?

Questions to discover your food identity.

When you travel, do you seek out the local food culture, or do you find yourself looking for something familiar?

On a random Wednesday night, is dinner something you look forward to, or something to manage?

Do you eat alone, with people, or with your phone most of the time?

Do you feel better when you know exactly what you’re eating? Where it came from and how it was produced?

Can you taste the difference between different olive oils? Do you care?

What did your table look like growing up? Was there abundance or were you worried you wouldn’t get enough? Did you have dinner with family or on your own? Your food story travels forward with you.

Here’s the other thing about food identity: you might identify one way but eat another. You might value slow communal meals but live on protein shakes or eat lunch at your desk. You might consider yourself an adventurous eater but eat comfort foods most of the time because you’re under a lot of stress.

Have you felt guilty about eating certain foods? That’s worth examining too. Food shouldn’t carry moral weight. Does it for you?

Did you choose your identity or did it happen to you?

Some food identities are developed intentionally. You pride yourself on being a skilled home cook. Or someone who eats efficiently and gets back to work. Health is a value underneath some part of your food identity.

Other times your food choices and identity happen by default. What is quick, easy, and in your eyesight. These are usually the less healthy options, ultraprocessed, attractive, engineered to be hard to resist. But if you take the time to think about your food identity, what your priorities are, and how you want to live, you might be more likely to keep your food wardrobe stocked and ready on short notice.

Does what you eat most days match your priorities?

If you have a gap between your behavior and your identity, the fix isn’t willpower. It’s inventory.

UPFs sneak their way in when the pantry is empty, or hunger hormones are surging. The people who eat well most of the time aren’t more disciplined. They just have beans in the cupboard and know how to use them.

Foods that work for the functional eater or the sensualist tend to be the same simple foods that make up diets across the globe. Beans. Lentils. Eggs. Olive oil. Tuna. Oats. Frozen vegetables. Cheap, shelf stable, nutrient dense. Dressed up or down. Your food capsule.

You’ll have plenty of future meals to think about it. Or better yet, discuss with a friend over dinner this weekend.

Tell me what you eat. I’ll tell you what you value. Do you like what that says about you?

We already solved this problem once. Not everybody remembers.

If you’ve ever cleared the junk food out of your house, eaten well for two weeks, then found yourself buying Twizzlers and Doritos because, well...road trip! That’s not weakness. That’s culture. And it’s really hard to fight the culture you’re living in.

We got tens of millions of people to quit one of the most addictive substances ever marketed. Not with education campaigns. By changing the culture, in the form of a door.

The warnings didn’t work as well as the door.

The Surgeon General’s report came out in 1964. Smoking rates barely budged. People understood it and kept smoking. If doctors are smoking, how bad can it be? It’s really hard to do something to benefit your future self if the temptation and pleasure is right here and now.

Information is free and everywhere. Most of the time, you ignore it.

Then, a change. States started banning indoor smoking. You had to leave your friends and go stand outside in the rain. That’s different than a tax. It’s a social cost. When states actually wanted to see fewer people dying from lung cancer and COPD, they changed the laws that changed the culture.

If the government really believes ultraprocessed foods are driving obesity, diabetes, and heart disease, it’s going to have to do more than restrict SNAP benefits.

My mom started smoking at 16. She was still smoking when she got diagnosed with lung cancer. Most smokers quit. Not because of the scary label. Because smoking stopped being something people did and started being something smokers did. We went from more than 4 in 10 adults smoking to around 1 in 10.

The only people who didn’t quit were the ones who couldn’t. My mom felt demoralized and weak when she couldn’t quit. What was once something the cool kids did became what the cool kids didn’t do. I grew up thinking it was gross. Culture moved but she didn’t.

Nudge. Nudge. Shove.

It’s not so easy to get rid of big tobacco.

Welcome new products! Sexy, no smell, fun flavors, and built for a generation that never watched anyone die of emphysema. The same industry that spent fifty years marketing cigarettes figured out how to start over with vaping, a “healthier” product? You can use it in the school bathroom! I worry about my daughters and their friends.

Society moves toward whatever looks normal. The more people try it, the more normal it becomes. The culture reverses course all the time when the story changes.

Can we change the story on ultraprocessed foods?

Ultraprocessed foods are energy dense and shelf stable. You can say they are not as good as real food, but better than nothing when you are short on time or really hungry.

And it’s much harder to tease out the health outcomes related to ultraprocessed foods than smoking. Are they as addictive as tobacco? Can we just eat less of them, or is that not really possible?

The state can do its part by taxing certain unhealthy foods or beverages. They can add a front-of-package warning label so you can see that the protein bar you think is healthy is actually closer to a candy bar. But how do you make chips or soda uncool? Stop advertising on all platforms? It’s not as easy as banning on network TV anymore.

The goal is to make choosing these foods feel the way smoking feels now. Where you think, remember when we used to eat that sh*t? We need that same shift.

Which is exactly why SNAP restrictions won’t work to cause a significant change in our society’s health or habits. They don’t touch the norm. They just shame one group. Not everybody.

Power to the people, actually.

Governments don’t create stigma. They can nudge. Culture determines shame. People decide what’s in and what’s out.

It has to be a groundswell. If it just feels like a nanny state from the government or a few do-gooders preaching a cause, it will come off like the food police and nothing will change.

Changes come from choices most people make every day. Every time you make something from scratch and take it to a cookout instead of a bag of chips, you’re doing the thing that actually worked with tobacco. You’re making a different choice visible. You’re nudging the social norm. Put it on TikTok and you might start a revolution.

I doubt we’ll see a Pringles tax. Nobody’s banning indoor chip eating. We’re not going to get kicked outside if we order fries with that. But that’s exactly how we made progress with cigarettes. A change in rules plus social friction caused the shift and dropped lung cancer way down on the list of how most Americans die.

The damage from ultraprocessed food is invisible until your parent has a stroke. Then, you might wonder if it was preventable.

Or maybe we decide as a society that we’d rather keep eating burgers and chips and just let the pharmaceutical industry run the show. Everyone on their statins and GLP-1s! I’m honestly on the fence about whether we’ll change the culture on this one.

Have you changed what you eat? What influenced you?

That freezer was considered a necessary piece of household equipment that made expensive meat more affordable and accessible year-round on a budget that didn’t have much slack. The family meal was a given. The freezer served it.

That’s not how most households work anymore.

The people I know who still have deep freezers hunt, fish, garden, or shop at Costco. They have a direct relationship to their food, sometimes killing, catching, or harvesting it themselves, other times buying a quarter of a grass-fed cow from a certain rancher, or shopping in bulk because that’s still how they think about feeding a household.

Everyone else has the garage fridge.

Stocked with soda, sports drinks, beer. Nobody sat down and decided they needed this in their life. It just didn’t get hauled away when the new one arrived. And then the options multiplied. Gatorade. Snapple. Energy drinks. Hard seltzer. Multiple flavors of sparkling water. It’s a hospitality station for your family, your friends, your neighbors.

There’s a shift embedded in that. The deep freezer said: I’m running this household with intention. The garage fridge says: I can offer my neighbor a drink when they stop by. One required skill, time, and a relationship with real food. The other requires a few more dollars on the monthly electric bill and keeping it stocked with an enviable variety of brand name beverages.

The companies whose products live in your fridge didn’t get there by accident. Companies worked hard to get your attention. And once you understand the economics of how some foods can support heavy marketing while others cannot, you may start to look at your refrigerator and grocery stores very differently.

How the margin works

Marketing is pretty fascinating when you think about it. It is the art of psychology, using behavioral science to manipulate our purchasing decisions. And it all starts with margin.

Gross margin is the money left after the direct cost of making the goods to be sold, before marketing, before salaries, before anything else. These are gross margins, not profit, not what ends up in anyone’s pocket. But gross margin funds what comes next: the advertising, the shelf placement fees, the influencers. And it’s what determines who gets to take up space inside your head.

Look at the typical gross margin of grocery items and it becomes obvious which foods come out ahead. You pay $6 for something, say a six-pack of soda or a dozen eggs. Did it cost five dollars to get it to the store shelf, or two? If it only cost two dollars to make it, they have plenty of runway to get that product in front of your eyes.

Soda: 55–65%. Energy drinks: 55–70%. Chips: 45–60%. Breakfast cereal: 40–55%. Protein bars: 40–60%.

Now the other side. Chicken thighs: 8–20%. Eggs: 10–25%. Oats: 10–25%. Milk: 10–25%.

So you’ve got some segments of our food system with large amounts of money left to spend on advertising. And when you spend on advertising, you win over consumers and sell more stuff.

Follow the money

Broccoli does not have enough margin for an ad agency. Lentils do not sponsor stadiums. Sardines can’t afford to hire influencers.

A 6-pack of soda is mostly water, sweetener, flavoring, and carbonation. Cheap inputs, room-temperature shipping, months of shelf life, and brand loyalty that no zucchini can compete with. That margin gives companies power to fund the next campaign, which works to deepen the loyalty. The pattern is self-sustaining. Build loyalty, keep customers coming back.

A package of chicken thighs or a gallon of milk is the opposite in every way. Perishable within days. Refrigerated the entire supply chain. Vulnerable to weather, feed costs, and supply disruption. Priced like the commodity it essentially is. There is no jingle. There is no brand identity. A steak behind the meat counter is not a brand.

So, some of the healthiest foods in the store are also the least profitable to produce and sell. That’s just reality. And it explains why it feels like our grocery stores have been taken over by packaged foods.

And then there’s the psychology. More variety means more decisions. Once you’re standing in front of twelve versions of the same brand of chip, the question stops being whether to buy chips at all. It becomes which one.

My mom’s deep freezer didn’t reflect marketing trends, save for a few freezer pops. It was just a way to make good food last, bought strategically, served at a table where everyone sat down together.

The garage fridge is reflecting something quite different.

You don’t have to opt out of any of it. You just might want to know what you opted into.

Do you have a second fridge or freezer? If so, what’s in it?

Play Short, Win Long is where Angela Thyer, MD pulls back the curtain on food, hormones, technology, and the systems quietly shaping your health.

I just got back from a three-day AI mastermind retreat in La Jolla. Glorious, sunny southern California. If some beautiful soul hadn’t scheduled a group surf lesson and kayaking excursion for each of the days, I’m not sure any of us would have gotten up.

At the airport on the way home, mindlessly scrolling through my phone like you do, I read about a 30-year-old in Florida who lost all his savings to mobile sports betting. It got me thinking. One of my friends at the retreat was building a program that analyzed predictions markets. Following micro-movements throughout the day seemed a bit scary, like he was building what could become a pretty addictive platform. Or was it just be a smart way to make money while you do other things?

And then there’s me. The hours disappear and I’m buried deep in my creative brain, working on my startup and thinking holy shit, I made this? not wanting to stop.

Are these the same things? They seem different. But I wasn’t sure. So I did what I always do. I went looking for the research.

If you’re a maker, you know

There’s the one where something gets made and you surface hours later feeling really alive. And there’s the one where you pick up your phone to take a break and put it down forty minutes later feeling like you wasted a bunch of time.

Same person. Still a screen. Completely different neurochemistry.

Making things, like writing, coding, and making music, can trigger a cascade of five neurochemicals simultaneously: dopamine, norepinephrine, anandamide, endorphins, and serotonin. All at once. Your brain’s own performance-enhancing cocktail. Pretty cool.

Researching this piece, there was one on the list I’d never heard of.

Anandamide is the secret sauce of the flow state. It lets you think laterally, connecting ideas with no obvious relationship and widening your own pattern recognition. It inhibits fear so you take creative risks you normally wouldn’t. You get lost in your thoughts and lose track of time. It’s why you come out of a session with ideas you didn’t go in with and feel like you’re on fire. It comes from the Sanskrit word for bliss, ananda, and that’s pretty much how you feel when it hits.

Serotonin shows up at the end. That’s the afterglow, and it’s still there the next morning. This is eudaimonia. Not pure pleasure. It’s the feeling you get when you feel like you nailed it.

The other brain loops

Sports betting, predictions markets, crypto trading, online gaming- examples of dopamine at its finest, firing during the uncertainty, then crashing when the outcome hits. Win, lose, win, lose. Euphoria, then emptiness, then craving. Too much exposure to these ups and downs, and ordinary things can start to feel flat. Testosterone amplifies the dopamine hit, making the spike feel bigger and the crash more urgent to fix. This is partly why it skews male. It’s neurobiology being engineered by apps.

Have you tried these betting apps? Don’t.

Social media runs on cortisol instead. It’s not about winning, it’s about scanning and searching. Your brain switches into low-grade threat detection without you realizing it. The anxiety baseline creeps up over time until you notice you’re not sleeping well, and you wonder why people aren’t liking what you post. This hits women harder because social media exploits a system women use more, targeting connection-seeking specifically. Looking for belonging in parasocial relationships is pretty much a losing proposition.

How do you feel when you’re online? Or the day after? That’s the tell.

We live in two worlds now.

Here’s what actually made the retreat shine. It wasn’t just the work, although I walked away feeling pretty accomplished. It was making new friends. Walking on the beach. Conversations about who we wanted to be. Trying surfing and laughing at feeling awkward. Riding the swells in kayaks. Connecting over three course dinners.

Real connection brings oxytocin and serotonin through a completely different circuit- the social engagement system, separate from the others. Nature and movement activate endorphins and genuine calm. You can feel your nervous system actually settling, not just temporarily pausing.

Making things on your own is great. It can get you to a flow state. Cherish that. But it can’t give you everything. You need the friend across the table too. Someone you can count on when the going gets rough, and it will. And chasing and seeking? Maybe take a pass sometimes.

Which loop are you in right now? Making, consuming, or connecting?

Your nervous system knows the difference.

Trust it.

You get a notification. Your test results are ready to review in MyChart, so you log on.

It’s 9 PM on a Thursday.

The numbers on your screen, your thyroid test, your AMH, something flagged on your mammogram, look wrong to you, even though you’re not entirely sure what it means. There’s a message: Please make an appointment to discuss your results.

Your healthcare portal delivered the result. Without context or interpretation. Thanks, new technology.

Now more technology steps in. You jump into Google. Start asking questions, following links, reading about how other people dealt with the same result. What did it mean for them? Did it turn out to be nothing? Or something?

These tools are not emotional support the way a friend or a family member would be. They do very little to decrease your anxiety. In fact, they probably amplify it.

An hour later you’re on your third Reddit thread, you’ve self-diagnosed something serious, and you’re reading about someone whose situation sounds exactly like yours except theirs turned out to be terrible.

If you’re lucky enough to have a friend who’s a doctor, you might reach out to them. My doctor friends and I get these calls plenty of times from family and friends, and we’re happy to help out where we can. But it’s not a substitute for seeing your own doctor, who knows your history and can make actual recommendations.

This is not a willpower problem. This is not you being irrational. This is an algorithm doing exactly what it was designed to do. With no interpretation.

The real reason you can’t stop scrolling

Everyone blames dopamine. It’s a clean story. Sounds like science but that’s not actually what’s happening.

It’s not dopamine that keeps you scrolling when you should be winding down. It’s cortisol.

Algorithms are built for engagement. The most reliable driver isn’t reward. It’s stress. Conflict. Threat. Worst-case outcomes. Your brain was wired, over millions of years, to pay attention to danger. The algorithm figured this out. It feeds you content that raises your cortisol, not your mood. Stress keeps you scrolling in a way that satisfaction never could. It didn’t create your fear. It’s feeding it.

Cortisol has a body cost, not just a mental one. Chronic stress disrupts your thyroid, destabilizes blood sugar, and wrecks your sleep. The anxiety keeping you up at night is actively undermining the sleep that would help you think clearly in the morning. One bad night is tolerable. A week of poor sleep and high cortisol floating around can do real damage.

This is why your health spiral at 9 PM feels compulsive. You’re not chasing good news. You’re stuck in a loop of uncertainty, and every new search result introduces slightly more of it. The algorithm isn’t trying to help you. It’s trying to keep you on the page.

What your screening test was actually designed to do

Reddit threads were never meant to explain screening tests.

Here’s the thing about screening tests. They’re built to catch everything that might be a problem. That’s literally the point. Cast a wide net.

But that also means a flag is not a diagnosis. It means something needs a second look.

A mammogram callback is designed into the system. Callback rates are deliberately high because missing a single cancer is worse than bringing more people back for follow-up imaging. A benign cyst found on an ultrasound ordered for something else, an incidental finding on a full-body CT. These often reflect the fact that you were looking everywhere, not that something is wrong.

Studies show patients often see results before their doctor has even reviewed them, arriving to your portal with no personalized message. Or at best, a brief note saying you need a conversation. Well, that sure doesn't decrease anxiety levels.

Sometimes a second test does confirm something. That’s real, and it’s worth saying. But the algorithm doesn’t know that, and it doesn’t care. It knows that fear keeps you engaged, and it will serve you content accordingly.

The finding may or may not be serious. The Google spiral can’t tell you which. Your doctor will.

Use these instead

If you can’t wait (and sometimes you genuinely can’t), there are tools that are better than Google.

You don’t need a subscription or a special setup. Go to perplexity.ai, claude.ai, or chatgpt.com and type your question. These tools have no engagement incentive. They answer your question and stop. No algorithm deciding what to show you next. No feed pulling you deeper. Perplexity is particularly good for this. It pulls from clinical guidelines and peer-reviewed sources and shows you exactly where the answer came from. You can check it yourself.

First, tell it who you are:

“Explain this to me in plain language. I don’t have a medical background.”

Or: “I have a science background. Give me a detailed explanation.”

Then ask your question:

“How do you interpret this result? What factors other than disease could cause it to be abnormal?”

“What are my next steps, and what kind of specialist should I see?”

“What questions should I bring to my doctor about this result?”

That last one is the most important. Use AI to build your question list, not to find your diagnosis.

Before you use these tools, understand one thing. Consumer AI products may or may not protect your privacy the way your doctor’s office does on MyChart. You don’t need to upload your personal records. Just ask the question in plain language. That’s enough.

Box It Up

When you find yourself spending too much time researching a result, catch yourself. Interrupt the process. Write down your questions or dictate them into a voice memo. Then put your thoughts in a mental box and close the lid. That can lower your cortisol and get you back to whatever it is you should be doing.

Even mentally telling yourself “I’ll think about this later,” and meaning it, can break the loop. The worry is still there, but it has a place to go. You can come back to it before your appointment once your subconscious has had time to surface any new questions worth asking your doctor.

If you want more structure: set your phone timer for 15 to 20 minutes, ideally in the afternoon. Search your heart out. Take notes. When the timer goes off, stop.

Postponing worry to a defined window can reduce intrusive thought loops, and the worry often loses some of its urgency by the time you get there.

Box it up. Close the tab. Don’t go back.

Your questions will keep until your appointment. Google will always be there, stealing your time.

What to bring to that appointment

Your doctor wants you to come in prepared for a conversation. Bring the questions you wrote down. If you used one of the AI tools and it helped you understand the terminology, bring that summary too. It saves time and shows you did the right kind of homework.

What your doctor needs is your history, your symptoms, and your questions. Talk about what scares you most. They can tell you what the results mean and give you different options about what to do next. That’s the conversation worth waiting for.

The algorithm was never on your side. Your doctor is. Give them the appointment they need to actually help you.

If you got an abnormal result, what did you do? Are you a googler or have you tried the newer tools?

Leave a comment

This post is for informational purposes and doesn’t constitute medical advice. If you have concerns about a test result, please follow up with your own doctor.

Angela Thyer, MD is a lifestyle medicine physician. Her Substack, The Long Game, covers metabolism, hormones, and the technologies reshaping health.

She’s in her mid-30s. Married, financially stable, settled. Genuinely ambivalent about having kids. Nervous about what pregnancy would do to her body. Worried about what it would cost. Watching her friends start families, aware of her age, and getting the occasional nudge from her mom.

That’s not uncommon. About 1 in 3 women under 35 without kids say they’re unsure if they want to start a family.

If you're past that question entirely, stay with me. This test has something to tell you too.

So she did what seemed like a reasonable thing. She went to her doctor and asked for a fertility test. A simple blood draw that takes five minutes to order and gives you real information about where you stand.

Her doctor told her she didn’t need a test. Just start trying.

I was floored. She was upset. She didn’t want to start trying. She wanted information. Those are not the same thing, and a doctor should know the difference.

AMH isn’t just a test for women actively trying to conceive. It’s a window into your ovarian timeline, useful whether you’re planning for next year, keeping your options open, or just trying to make an informed decision about your own life. AMH measures your egg supply: quantity, not quality. It tells you how much time you have, roughly speaking. Not whether you’re ready to use it. You can get it for all kinds of reasons. Every single one of them is valid.

AMH is your barometer, a personal forecast. Think of it as a prediction market for your cycle length and eventual hormonal demise. A high AMH signals a high egg count, which is common in adolescents and women with PCOS. A low AMH tells a different story. Cycles shorten first, then stretch out, then start getting skipped altogether. Add in some sleep disruptions and hot flashes and you’ve got perimenopause. If your cycles are changing and your AMH is very low, that’s a reliable signal, especially if you’re seeing it in your 30s before you’d expect it.

Would you want to know if you were 3 years from menopause? Or, if you ever thought about IVF to freeze your eggs or have a baby, would you want to know how many eggs or embryos you could expect to get? Typically, it’s under $100, so it’s a pretty worthwhile thing to test. And unlike FSH, you don’t need to get it on day 3 of your cycle. It’s stable enough to test any time.

There is no blood test for egg quality. The best predictor is actually just your age. Like most things about your body, it's best prior to age 30, then takes a slow and steady decline in your 30s with a pretty global drop after 40.

Here’s something most people don’t know: most women’s fertility window is effectively closed about a decade before menopause. If you have your last baby at 40 and hit menopause at 50, that fits. You can still have regular periods in your 40s while your best eggs are long gone, which can make you think you’re still fertile. But it drops off steeply every year as the quality of those few remaining eggs withers. And if you’re done having kids, know that you can still have a rogue good egg in your 40s and pregnancy can occur, with a higher chance of miscarriage, so contraception still matters.

The best fertility predictor? Age and AMH together. If you’re under 35 with a low AMH, probably okay. After 37 with a low AMH, it may be a struggle. After 40 with a low AMH, IVF is less likely to be successful with your own eggs. This is based on groups of women, not individuals, and of course not everyone follows typical patterns. But this is why an AMH could be really helpful to someone in their 30s who is feeling ambiguous. Maybe it pushes them forward to start trying, or maybe it makes them feel okay with backing off and not entering the fertility chase.

Which brings me back to my friend. She didn’t know about AMH. She only knew vaguely that there was a “fertility test.”

What her doctor heard: fertility concern.

What her doctor missed: a woman trying to understand her own body so she could make her own choices.

Part of this is time. Doctors are rushed, appointments are short, and a question about ovarian reserve from a woman who isn’t trying to conceive doesn’t always land. Part of it is that AMH testing has lived mainly inside fertility clinics. It's not a mainstream test — yet. And ob/gyns may not know the nuances. That needs to change.

So women go looking elsewhere. Dr. Google. Reddit threads. TikTok. Deep conversations with AI. Trying to figure it out without a good navigator. Sometimes going off course. And never quite getting to the heart of what they’re actually trying to answer for themselves.

She didn’t even know you could order an AMH test at home. She didn’t know home semen analysis kits exist. She didn’t know any of this because nobody told her, and the one person in a position to tell her pissed her off.

Women deserve better than that.

Nothing here is medical advice. It's information I wish more women had access to.

Has your doctor ever dismissed a question you had every right to ask? I want to hear about it.

And the foods getting squeezed out? The ones your gut bugs actually need.

So I’ve made you a cheat-sheet. One plate you can picture, two numbers you can remember, and a few facts you can think about at any table.

The Guidelines got weird

The 2025 Dietary Guidelines doubled down on protein and even floated beef tallow as a “healthy” cooking fat while technically keeping saturated fat under 10%. On paper, you can stay under 10%. In real life, there’s basically no way to eat the pattern they suggested and keep saturated fat that low. The science on saturated fat is in question right now. What isn’t really in question: when people swap saturated fats for olive oil, nuts, and seeds, cardiovascular risk goes down. That’s the boring, consistent part that isn’t making headlines.

Fat is bad, then good. Eggs are bad, then good. Sometimes you just have to trust your gut and make your own call. If you want a nudge or some easy "rules," that's what I'm here for. Most people don't read other countries' dietary guidelines. I do.

Other countries do things differently

Canada. In 2019, Canada scrapped the old food groups and released a new guide built around a plate, not a pyramid. Half vegetables and fruit, a quarter whole grains, a quarter protein, with a clear nudge to choose plant-based protein more often. Simple, visual, actually usable. And here’s the part I love: Health Canada explicitly excluded industry-commissioned reports from the evidence base and leaned on systematic reviews instead. Imagine designing nutrition policy without asking, "But how will this feel to the butter lobby?" Canada, I'm sure, doesn't care a whit about our new guidelines.

The UK on salt. One public health program they got exactly right has nothing to do with the guidelines. Starting in 2003, the UK set progressively lower salt targets for food manufacturers and worked with industry to quietly reformulate processed foods. The changes were so gradual that taste buds didn’t notice. Nobody’s Friday-night fish and chips were ruined. Estimates suggest this has been preventing thousands of cardiovascular deaths every year and saving the healthcare system huge amounts of money, on the order of hundreds of pounds saved in healthcare costs for every pound spent on the program. If that were a stock, your financial advisor would tell you to buy and never sell.

What I’d actually tell you in your kitchen

In years of working as a physician, the question I get asked most often about food isn’t “what should I avoid?” It’s, “Can you just tell me what to eat?”

So here it is. I don’t start with macros. I start with a plate.

Half: vegetables.

Greens and cruciferous are a strong start. Spinach, kale, broccoli, cauliflower, Brussels sprouts, cabbage. Roasted, sautéed, raw, whatever you’ll actually eat and actually enjoy. This is not a punishment. This is your new value system and part 1 of your fiber number.

One quarter: protein.

Some combination of beans or lentils, fish, poultry, eggs, dairy, tofu or tempeh, or occasionally beef, pork, or lamb. The source matters less than the habit. Mix and match. Use what fits your budget, your culture, and your taste.

One quarter: whole grain or starchy vegetable.

Brown rice, quinoa, farro, oats, sweet potato, winter squash, corn. Think whole and boring. Maybe tan, orange, or purple. This is part 2 of your fiber number.

Add extra virgin olive oil. Salt it properly while you cook. Under-seasoned food causes unnecessary suffering for our taste buds. What the UK did was reduce salt in processed foods through quiet reformulation, not tell home cooks to stop cooking well. Those are completely different things.

Salting while you cook makes vegetables pop. Adding olive oil gives depth. Both together make it much easier to actually enjoy vegetables.

Eat with people when you can. A shared meal does something for your health that no supplement can replicate. The magic is mostly in the company and the conversation.

Not just for dinner

The same plate design has to work for breakfast and lunch too.

Vegetables at breakfast sound extreme until you reframe it: a scramble with spinach or whatever greens are in the fridge, a hash with sweet potato and peppers, a small salad on the side. You don’t have to become the person eating a full grain bowl at 7 a.m. Just decide vegetables at breakfast are normal and find your version. Or add a piece of whole fruit if that’s easier.

Snacks follow the same idea: no naked carbs. It has to come with protein or fiber or both. If you're grabbing something packaged, the same rule still works. Crackers and cheese. Chips and an apple. The carb doesn't have to be virtuous - it just can't be alone.

The two numbers to remember

There are exactly two numbers I want in your head.

1. Fiber: 25 and 38

• 25 grams per day for women

• 38 grams per day for men

Roughly 9 out of 10 adults are not getting there. Most people are cruising along at about half of what’s recommended.

Fiber is basically a love letter to your gut microbiome. It feeds the bacteria that help with immune function, mood, vitamin production, and keeping inflammation in check. In a huge analysis pulling together more than a hundred studies, people eating the most fiber had significantly lower rates of heart disease, stroke, type 2 diabetes, colorectal cancer, and death from any cause.

Easiest way to raise it? Beans, lentils, whole grains, nuts, seeds, vegetables, fruit. Dried beans and lentils are basically the world’s cheapest, most boring ‘superfood.’ They just don’t have a marketing department.

If you’re going to give it a try, do not start fibermaxxing in a week. Going from 12 grams to 25 overnight is a great way to feel terrible and decide fiber is not your friend. Increase gradually. Give your gut bugs time to catch up.

2. Protein: 25 and 30+

• Roughly 25 grams per meal for women

• 30+ grams per meal for men and for adults over 60

Unlike fiber, most Americans are getting enough protein without trying. But a few groups need to pay closer attention:

• Vegetarians: plant protein is great but a bit less efficient per gram for muscles

• Older adults, whose muscles need more protein “signal” to get the same response

• Adolescents with very restrictive eating patterns

• People undergoing cancer treatment or recovering from major surgery

• People losing weight on GLP‑1 medications, who can easily under‑eat protein and lose muscle with fat

You don’t need to panic about protein. You just need to be intentional if you’re in one of those groups, or you live with someone who is.

A story from the cereal aisle

Recently I was browsing when I noticed a visibly pregnant woman reaching for a box of instant protein oats, toddler in tow. I asked if she’d buy it.

“Absolutely,” she said without hesitating. “I love that stuff. I’ll buy anything with extra protein.”

I was surprised. Then she added: “But my husband wouldn’t want me to. We’d buy those” she pointed to the rolled oats and steel cut oats right next to it “and add our own maple syrup at home.”

I turned the box over. The ingredient doing the heavy lifting: whey protein isolate.

Oats already have protein. They have fiber. They have everything you need for a solid breakfast. The marketing found a gap that didn’t exist and filled it with a processed ingredient, added “protein” to the front of the box, and a premium price tag.

Plain steel cut oats: 5 grams of protein, 5 grams of fiber, nothing added. The protein version: 12 grams of protein, 3 grams of fiber, whey protein isolate. The one thing oats are actually famous for went down.

Her husband was right.

The bottom line

Make plants a priority. Move your body. Occasionally lift something heavier than your laptop. Sleep enough. Eat with people you like when you can.

The food industry needs nutrition to be complicated so you buy more stuff with numbers plastered right on the front of the package. You don’t need them to do it. Figure it out on your own. A plate, two numbers, and most of the work is done. Everything else is a solution to a problem you don't have.

Build a good plate most nights. Hit the two numbers most days. Order the cheese enchiladas on Friday if that’s what you want. The long game has plenty of room for real life.

Steal this (AI edition)

If you’re not sure where to start, steal this. Open any AI tool and type something like:

"Give me three days of meals plus snacks for one person that hit 25 grams of fiber per day and 75–90 grams of protein per day, take under 30 minutes to make, and stays under $25 per day."

Then rework it. Ask for Mediterranean, vegetarian, dairy-free, kid-friendly, budget higher or lower, whatever fits your life. That's advice built for you, not a guideline built for 300 million people.

And if you’ve created a prompt that you like for meal planning, grocery lists, hitting your fiber or protein targets, share it in the comments. I’d love to build a little library together.

Your dinner with friends homework:

Two questions for you:

What’s the worst or most conflicting nutrition advice you’ve heard?

If you’ve played with AI for meal planning, what prompt hit your numbers, fit your budget, or surprised you?

Drop them in the comments. I’ll share the best ones in a future issue.

Leave a comment

And if all you remember from this is:

• The plate: half veg, quarter protein, quarter starch

• Your fiber number: 25 or 38

• Your protein number: 25 or 30

You’re already doing more than most guidelines manage.

Subscribe now

References (for the curious)

1. Health Canada. Canada’s Food Guide. 2019.

2. He FJ, Brinsden H, MacGregor GA. Salt reduction in the United Kingdom: a successful experiment in public health. J Hum Hypertens. 2014;28:345–352.

3. Reynolds A, et al. Carbohydrate quality and human health: a series of systematic reviews and meta-analyses. Lancet. 2019;393(10170):434–445.

4. Bailey RL, et al. Most Americans are not getting enough fiber in our diets. NHANES 2013–2018 analysis. American Society for Nutrition, 2021.

5. Paddon-Jones D, Rasmussen BB. Dietary protein recommendations and the prevention of sarcopenia. Curr Opin Clin Nutr Metab Care. 2009;12(1):86–90.

6. Moore DR, et al. Protein ingestion to stimulate myofibrillar protein synthesis requires greater relative protein intakes in healthy older versus younger men. J Nutr. 2015.

Want the backstory on why those new federal guidelines frustrated me, and the personal health crisis that changed how I eat? That's here.

I keep thinking about her because she’s not alone. So many women aren’t finding what they need with their current doctors. And the reason I’m writing about it today, just after International Women’s Day, is that we need to talk about one part of our health‑care system that doesn’t always work well for women.

It’s doctors. We’re not a monolith. We have different training, different biases, and wildly different relationships with new evidence. The care you get can depend more on which doctor you happen to see than on what the actual science says. That’s a problem. If you’re not getting answers, push. Get a second opinion. You are allowed to find someone who will actually engage with you and your symptoms.

I studied reproductive endocrinology partly because of a mentor named Leon Speroff, a physician who spent his career as a true believer in women’s health and hormones. He wrote the textbook in my field. Literally. And then in 2002, one study came out and seemed to erase all of it: the Women’s Health Initiative. You’ve probably heard of it. What you may not know is what it did to the field, the damage it did to women, and how long that damage has lasted. Some of it may still be lingering in your doctor’s head right now.

Can We Talk About the Numbers for a Second?

Cardiovascular disease (heart disease and stroke) kills more than 1 in 4 women, yet only about 4% of NIH cardiac research funding focuses specifically on women. Women spend more on health care, use it more, and make most of the health decisions for their families. And we are still, in 2026 facing the obstacles to receiving the best health care.

The conditions that hit women hardest are chronically underfunded compared to the suffering they cause. I’m talking about endometriosis, PCOS, autoimmune disorders, and cardiovascular disease. It’s not that women’s health gets nothing. It’s that the gap between how much disease there is and the investment in research is embarrassing. My own professional society, the American Society for Reproductive Medicine, launched a grant cycle to rescue reproductive health research that lost federal funding. Those are the words we’re using now. Rescue health research.

When you zoom in on specific conditions, the gap between what women live with and the care they receive is even clearer.

Sources: University of York 2024; Dokras et al. J Clin Endocrinol Metab 2017; MGH Center for Women’s Mental Health 2015; Santen et al. JAMA Health Forum 2024.

Endometriosis: Not Just Bad Periods

You want to know how long it takes the average woman with endometriosis to get a diagnosis? About six to seven years. Yes, like the meme. Except it’s one in ten women with symptoms that affect her everyday quality of life- painful periods, painful sex, and infertility. And frequently feeling dismissed by the health care community, given only options like OCPs or ibuprofen when there are other more effective treatments available.

One woman, age 21, asked me for a hysterectomy because the pain was so bad. Having future kids didn’t matter compared to the pain she was living with.

Sources: University of York 2024 (diagnostic delay for endometriosis); scoping review of endometriosis diagnosis delays.

PCOS: The Disorder That Falls Between Specialties

PCOS takes over two years on average to diagnose, and nearly half of women with PCOS see three or more doctors before anyone figures it out. I spent years researching it. The metabolic side — insulin resistance, what actually moves the needle — is where most of the action is. But because it lives in the gap between endocrinology and gynecology, many ob/gyns didn’t see enough examples in training. Most often, they reach for the pill. That treats the irregular cycles. But it doesn’t touch the underlying metabolic dysfunction, and not every woman wants that anyway.

What makes it harder is that not every woman looks like a textbook case. I’ve seen women completely overlooked because they didn’t fit the picture. When they finally get a diagnosis and learn there are real options for improving insulin sensitivity, the relief is palpable. They’re not broken. They were just unseen.

And here’s what gets me: once you actually understand PCOS, it can be one of the most treatable conditions, especially when it comes to fertility. Years of confusion. Turns out it’s fixable, if you can find the right provider.

Source: Dokras et al., J Clin Endocrinol Metab 2017 (PCOS diagnosis experience and delays).

Perimenopause or Anxiety?

Perimenopause can start before age 40 for some women and still be going on past 60 for others. Up to 80% of women have hot flashes and night sweats during the menopause transition, along with other symptoms like brain fog, palpitations, joint pain, and sleep disruption. Yet perimenopause is still being called anxiety or depression in many offices.

That’s not totally wrong. Lack of sleep and brain fog can cause anxiety too, especially for women who are used to high performance. But if you just treat the symptoms without treating the root cause, that’s not good medicine.

The reason symptoms are so wide-ranging is that we have estrogen receptors everywhere including our brain, heart, bones, and gut. Low estrogen levels cause real symptoms. You do not have to wait until your period has been gone a full year before you take charge. That’s an outdated threshold that costs women years of unnecessary suffering.

Source: MGH Center for Women’s Mental Health 2015; NAMS 2022 Position Statement.

The Study That Broke Everything

Back to the story. I want to tell you what 2002 felt like from inside the field.

Leon Speroff had spent his career making the case for estrogen therapy. He’d trained physicians, written the textbook, seen the clinical evidence pile up. Then the Women’s Health Initiative published its results and the whole thing collapsed overnight. Doctors stopped prescribing. Women already on hormone replacement therapy were called in and told to stop that day. Prescriptions fell off a cliff.

Overnight, hormone therapy went from “protective” to “dangerous” in the headlines. The nuance was that the study mostly involved women who were, on average, 63 and more than a decade past menopause. It was never designed to answer whether a 51‑year‑old going through menopause right now should take hormones.

Hormone therapy use among postmenopausal women dropped from nearly 27% in 1999 to under 5% by 2020.

Source: Santen et al., JAMA Health Forum 2024.

It has started climbing back up in recent years, but we are nowhere near where we were before a single study scared an entire generation of women and their doctors away from an effective treatment.

And here’s the part that doesn’t get told enough: Speroff said it was wrong. He stood up and said the risks were overstated, the population was wrong, the media had run with a misreading of the data. He was one of the most respected reproductive endocrinologists in the country. But it didn’t matter. The social narrative had taken hold.

Robert Langer, a lead investigator on the WHI study itself, later said the results caused 'substantial and ongoing harm' to women who should have been treated. An analysis estimated that between 18,000 and 91,000 American women died prematurely in the following decade, not from hormones, but from avoiding them. The researchers' best estimate was around 50,000.

Source: WHI original JAMA 2002; Sarrel et al., Am J Public Health 2013

The Science Corrected Itself. Practice Hasn’t.

In 2022, the North American Menopause Society finally said out loud what many of us had believed for years: for most healthy women who start hormone therapy within ten years of menopause, the benefits outweigh the risks - the opposite of what the headlines said in 2002.

Like most messaging, the correction never travels as fast or as far as the original scare. Millions of women paid the price with osteoporosis, sarcopenia, hot flashes, and heart disease. We are still cleaning that up. My friend is still navigating the shadow of a headline because why? Her doctor is choosing which information to believe? Doesn’t every woman deserve the option to consider whether hormones are right for her?

Ok, now you may be shocked here. It takes about 17 years for research findings to become routine care. Seventeen years. And that’s the average. Some shorter, some longer. It’s actually called “implementation science.” And it’s not hard to understand. Doctors absorb an insane amount of information in their training. Then, they are working hard seeing patients every day. And the amount of articles coming out every week just continues to increase. There is no way a human can keep up with it all. For women’s health, where research historically excluded women and entrenched beliefs die hard, the lag runs long.

The “timing hypothesis” for HRT is the idea that starting hormones earlier in the menopausal transition is protective rather than harmful has taken nearly two decades to work its way back into mainstream guidelines. Leon Speroff knew it in the 1990s. He said it out loud in 2006. The data confirmed it in 2021. Some doctors still haven’t gotten there.

Sources: NAMS 2022 Position Statement; WHI re‑analyses; implementation‑science estimates.

Oh, and You Can’t Even Get the Patches Right Now

Here’s a crazy fact: there’s a nationwide shortage of estrogen patches. Generic patches. We’ve been running out.

The transdermal patch is the preferred delivery method because it bypasses the liver, avoids the clotting risk of oral estrogen, and keeps levels steady. For women with cardiovascular risk factors or migraines, it’s often the safest option. And it’s not on the shelves.

Why? Hormone therapy prescriptions went up as more women finally got access to good information. Then the FDA removed the black box warning on HRT in November, the right call and years overdue, and more women started asking for them. Meanwhile, only a handful of companies make estrogen patches for the entire US market. When one has a production hiccup, there’s nothing to absorb the impact.

For women who’ve been taking HRT, being forced off the patch isn’t a minor inconvenience. It means hot flashes, night sweats, insomnia, and brain fog come roaring back which no one wants.

And here’s the part that gets me: everyone knew removing that warning would bring more women in. That was the whole point. Nobody geared up for the increased demand. So now women are calling four pharmacies, getting switched to a different brand mid‑cycle, or just going without. Going without means symptoms come roaring back.

My friend might finally find a doctor willing to prescribe. She just might not be able to fill it.

So, Happy International Women’s Day?

I mean it sincerely, and I mean the question mark too. We can celebrate what the last century delivered: the right to vote, to work, to own property, to run a company. Those are real.

But keep acknowledging and fighting for women who are still spending years undiagnosed. Still being turned away for treatments with solid evidence. Still searching for a doctor who will just have the conversation. Some of them finally found that doctor, got the prescription, and can’t get the medication.

I started FertiHealth because I got tired of watching the gap between what the evidence supports and what women actually receive. I trained under a physician who knew the science was right, watched the world decide it wasn’t, and spent two decades waiting for medicine to catch up to what he already knew. I’m done waiting.

If your doctor dismisses your symptoms of painful periods or irregular cycles, find another one. If you’re perimenopausal and being told it’s anxiety, push back.

Have you ever had to change doctors just to get your symptoms taken seriously?

I’d love to hear your story—hit reply or leave a comment with what helped, what didn’t, and what you wish you’d heard sooner.

And if someone in your life is in the thick of endometriosis, PCOS, or perimenopause right now, consider forwarding this to her.

Angela Thyer, MD is the founder of FertiHealth and co‑author of Getting to Baby: A Food‑First Fertility Plan. The Long Game covers evidence‑based health for women who are done being told to just wait and see.

I take a patient history—What supplements are you taking? Prenatal vitamins. CoQ10. Fertility blend. Vitamin C. Fish oil. Vitamin D. DHEA. Inositol.

“What else should I take?”

Here’s what I don’t say out loud: Nothing. Probably less.

What I do say: “Let’s see what’s in the fertility blend.”

I'm going to show you how I uncovered supplements doing harm, hiding in plain sight in a recently published study.

The supplement industry has built a billion-dollar empire on a simple pitch: antioxidants are good for fertility, so let’s sell lots of antioxidants.

Antioxidants do matter for reproductive health. Oxidative stress can impair egg quality when your body produces more damaging molecules than it can handle. Antioxidants repair oxidative stress, to a point. But too many antioxidants can be harmful.

In 2025, a study analyzing data from 2,685 American women over seven years supported what I’ve been saying for years: the real benefit of antioxidants comes from fruits and vegetables. See what you think.

What the Heck is CDAI?

Researchers came up with something called the Composite Dietary Antioxidant Index (CDAI)—basically, how much of six key antioxidants women were getting: vitamins A, C, and E, plus zinc, selenium, and carotenoids.

Using NHANES data, one of the most robust nutrition datasets we have, they found that women with the highest antioxidant intake had the lowest rates of fertility problems. The relationship held even after accounting for age, weight, education, income, smoking, alcohol, diabetes, and every other factor they could think of.

Imagine lining up 100 women based on their total antioxidant intake, from lowest to highest. The top 25 women had roughly half as many fertility problems compared to the bottom 25.

Sounds like a win for antioxidants, right?

Except when you look at the actual intake levels, the story gets complicated. The relationship wasn’t a straight line—it was a V-shaped curve.

Too little of certain antioxidants increased infertility risk. But so did too much of certain vitamins. And here’s the kicker: it’s nearly impossible to reach “too much” from food alone. You can’t eat that many carrots.

So how do women end up in that danger zone? Supplements.

The V-Shaped Curve

If you get your antioxidants from food, great! You’re in the green zone, and women in this study showed a lower risk of infertility. But if you get your antioxidants from supplements, you could shoot right into the red zone and increase your risk of infertility!

Let me show you what this actually looks like (I interpreted the graph in the paper for you).

Vitamin A:

See that orange dot? That’s a standard prenatal vitamin (770 mcg). It’s in the green zone, the lowest risk of infertility.

Now look at the right side of the graph — that red zone starting around 1,750 mcg. That’s where “fertility blends” live. At 3,000+ mcg of vitamin A, you’re in pro-oxidant territory. Your supplements aren’t fighting oxidative stress—they’re causing it.

The study found a V-shaped relationship. Translation: too little vitamin A increases fertility problems. But so does too much. And “too much” is shockingly easy to hit when you’re taking multiple supplements.

Here’s the Math Women Don’t Know They’re Doing:

• Prenatal: 770 mcg vitamin A

• “Fertility blends”: 1,500-3,000 mcg vitamin A

• Total daily intake: 2,270-3,770 mcg

You just stacked your vitamins right past the optimal zone and landed in the danger zone.

Vitamin C: “Immune Boosting” Risks

Vitamin C tells a slightly different story. See that orange dot at 85 mg? Standard prenatal vitamin C is fine.

But that red zone on the right side—starting around 330 mg—that’s where vitamin C supplements live. The 500 mg tablets. The 1,000 mg “immune support” formulas.

You might think vitamin C is good in the winter, good to shorten a cold. And it’s harmless because vitamin C is water-soluble, so you just “pee it out.”

Except your eggs and ovaries may be seeing that high level. And at high doses, vitamin C may stop being helpful and start its association with higher infertility.

Women with intake levels in that range can only realistically come from supplements. They may be paying money and unknowingly increasing their infertility risk.

Why Food Doesn’t Do This

Notice those green shaded areas on both graphs? That’s typical intake from whole foods.

• Vitamin A from food: 400-1,400 mcg (sweet potatoes, carrots, dark leafy greens)

• Vitamin C from food: 60-250 mg (bell peppers, citrus, strawberries)

It’s nearly impossible to reach toxic levels from food alone. Your body converts beta-carotene from sweet potatoes into vitamin A only when you need it. A sweet potato gives you exactly what you need. A 5,000 IU supplement dumps it all in at once whether you need it or not.

What Actually Works: A Day of Eating for Fertility

Forget the seven bottles of supplements. Here’s what the data says actually works:

Notice something? You’re hitting all six antioxidant categories multiple times throughout the day from different foods. That’s the “composite” part—it’s synergy, the combined effect from varied sources, not megadoses of single nutrients from a bottle.

No stacking. No guessing. Just food.

The Supplement Industry Doesn’t Want You to Know This

Here’s the truth: the optimal zone for fertility is the zone you can reach with food alone. Realize that the supplement industry makes money when you buy from them. When they say,

“Boost your fertility!” “Optimize egg quality!” “Support reproductive health!”

This is marketing language designed to make you believe more equals better. Supplements aren’t supposed to make claims. They aren’t allowed to. They can say antioxidants support fertility, but then it’s up to you to dig deeper to understand what that means.

What I Actually Tell Women

When a woman TTC asks what to do, here’s my advice:

1. Take a basic prenatal with folic acid. That’s it. Check the vitamin A content—if it’s over 1,000 mcg, find a different brand.

2. Stop the fertility blends. Immediately. You’re paying $60/month and may be harming your chances.

3. Ditch the standalone high-dose supplements. No 1,000 mg vitamin C tablets. No 10,000 IU vitamin A. No megadoses of anything.

4. Eat actual food. LOTS, every day! Colorful vegetables. Nuts. Seeds. Berries. Salmon. Whole grains. Legumes. The boring, unsexy stuff that actually works.

5. Stop stacking vitamins. One prenatal. Take others only if you have a diagnosed deficiency (like vitamin D or B12) or can’t get them from food (like omega-3s if you don’t eat fish). Get your doctor’s advice for everything else.

The Long Game Starts with Your Next Meal

This study confirms what I’ve seen in practice: vegetables and fruits are the most boring, least profitable, best thing you can do for your fertility.

The women with the best fertility in this study weren’t taking high dose supplements. They were eating vegetables and taking a prenatal vitamin.

So yeah, I tell my patients to stop stacking supplements. Because the science, again, shows that when it comes to antioxidants and fertility, more isn’t better.

More is just more.

You just became one of the few who know the truth about fertility supplements. Many women may still be chasing false hope and wondering why supplements aren’t making the difference.

Did anything in this article surprise you? Does it make you think about what you may not know? Are you currently taking supplements? Let me know in the comments and I’ll tell you what I think. (I’m guilty of buying supplements too!) Let’s break it open and talk about it.

If you know anyone TTC, share this post so they can stop wasting money and start eating their way to better fertility.

Want to dive deeper into evidence-based fertility nutrition? Check out the book I wrote with Judy Simon, a registered dietitian, Getting to Baby: A Food-First Fertility Plan to Increase Your Odds and Shorten Your Time to Pregnancy for comprehensive guidance on optimizing your preconception health through the 90-day window—no gimmicks, no pseudoscience, just research-backed strategies that work.

Reference: Luo H. et al, (2025) Association between dietary antioxidant intakes and female infertility: evidence from the national health and nutrition examination survey 2013-2020, Gynecological Endocrinology, 41:1, 2590871.

Disclaimer: This article is educational—think of it as what I’d tell a friend over coffee, not medical advice. Always talk to your healthcare provider before making changes to your supplement routine, especially if you’re trying to get pregnant.

A few weeks ago, I told you about the protein problem: how our muscles get harder to build as we age, and that most of us aren’t eating nearly enough protein. This change in muscle metabolism starts in your 30s and accelerates after menopause. But here’s the uncomfortable truth I had to face: more protein alone won’t save you.

(Missed Part 1 on the protein problem? Catch up here:)

I spent years believing my cardio habit was keeping me healthy. The spin classes, the elliptical, the long walks with podcasts. I loved them. Me time. They were good for my heart and my head. But they weren’t doing what I thought they were doing for my muscles and bones.

Why cardio isn’t enough

After menopause, bones and muscles need a very specific signal to stay strong: mechanical loading. The kind that comes from lifting heavy things. Your skeleton is constantly remodeling itself, but it only adds density where it senses stress. A spinning bike and walking doesn’t stress your hip bones. A squat does.

The research is unambiguous: bone responds to high-load, low-rep training, not the light weights and endless repetitions women are often steered toward. Postmenopausal women who trained with challenging resistance showed real improvements in bone density at the spine and hip over time. Those doing gentler work? Not so much.

Here’s how different types of exercise stack up:

Low-impact cardio (walking, elliptical, spin bike) → Little direct effect on hip/spine

Light weights, high reps (3 lb dumbbells) → Small or inconsistent changes

Moderate-intensity resistance (8-12 reps, challenging weight, 2-3x/week) → Significant gains at spine and hip

High-intensity resistance (heavier sets of 5-8 reps, 2-3x/week) → Largest improvements in bone density

Should you skip the cardio entirely? No, it’s still good for your heart. It’s great to get outdoors. And you can be social, a la pickleball, my new passion.

Can I learn to love something new?

I know what you may be thinking. I don’t like going to the weight room.

I had a similar aversion. For years, cardio was my comfort zone. I knew how to show up, put on my headphones, and zone out on the elliptical. Add in temptation bundling (where you save a treat to bundle with a chore), hello…every episode of Breaking Bad! How can I stream Netflix when I have to move around the gym and do different exercises? I’m not getting my fix!

So how can you learn to love something new?

Find the dopamine. Your brain rewards you for things that feel good. With cardio, the reward is obvious: the endorphin rush, the sweat, the indulgence in plugging in and tuning out. Lifting doesn’t give you that same hit - at least not at first. The trick is learning to notice different rewards.

For me, it started with the numbers. I used to struggle to lift 15 lb dumbbells in a chest press. Now I can lift 25s. I can even do regular pushups now. That progression is surprisingly addictive once you start tracking it. Then there’s the functional stuff: bags feel lighter, and the cardio is actually easier (my endurance is better). Your brain starts associating the gym with increased capability.

And here’s something else: other women my age are already in on this. I started noticing them in the weight room. Unspoken solidarity. I go with a friend sometimes. That social proof matters more than you’d think. It shifts lifting from “weird thing I’m trying” to “thing people like me do.”

The key is to stop comparing lifting to cardio. They’re different. For me, cardio was about sweat and escape or getting in the zone. Lifting is about presence and power.

And I’ve taken up pickleball for my new cardio, which feels like pure joy as I blend learning something new with some friendly competition and hanging with friends.

If you’re a newbie, start with a plan

Most gyms have personal trainers you can hire for a few sessions. This is a good idea to make sure you get your form right. Or you can watch videos on YouTube, use AI to build your own program for free, or find an app. The key is to make it easy. Here’s a prompt you can try and modify:

“Design a beginner strength training program for a __-year-old focused on building muscle and bone density. 2 full-body sessions per week, under 45 minutes each—and I don’t want to be too sore! Use the 6 core compound movements (squat, hip hinge, vertical push/pull, horizontal push/pull). Show me options for gym machines, dumbbells, and resistance bands. Include 3 sets of 8-10 reps per exercise, a 10-minute dynamic warmup, and a 5-minute cooldown. Provide a weekly schedule table, exercise descriptions with form cues, and weight progression guidelines.”

Notice how the prompt includes timeline, progression, time limits, and specific deliverables, not just “give me a lifting plan.” The more specific you are about what you want and what constraints matter to you, the better the output.

Paste that into ChatGPT, Perplexity, Claude, or your favorite AI and tweak it as you go.

Remove the friction. Pack your gym bag the night before. Schedule sessions like you would any other appointment for yourself. And here’s what really worked for me: I tied lifting to something I enjoy. After my session, I go to my favorite grocery store and pick up something good for lunch. It’s a little reward that makes the whole thing feel like a treat, not a chore. My husband rides his bike to the gym — he doesn’t love lifting (yet), but he does love the ride. Find your version.

Fish versus chicken

Ok, we are circling back to this question. Both are solid protein sources. But fatty fish gives you something chicken can’t: omega-3 fatty acids. A serving of wild salmon delivers about 1,500 milligrams of EPA and DHA. Chicken breast? Maybe 30 milligrams. Not even close.

Why does this matter? Women who eat fatty fish 1-2 times per week have significantly lower rates of heart disease and stroke. There’s also intriguing evidence linking higher fish intake to lower dementia risk. Your heart and brain both run on these fats.

I’m not saying ditch the chicken. But if you can swap in salmon, sardines, or mackerel two or three times a week, there may be extra benefits. Canned fish counts and can live in your pantry when you need a quick hit.

Do protein powders help?

Here’s the honest answer: protein powder without exercise does almost nothing for muscle. Supplementation in inactive people shows no significant benefit. But when it’s combined with strength training? Sure.

I use a scoop of whey protein powder on days when I want the extra boost, usually after lifting. One serving, not three. The goal is to fill gaps, not replace real food. Look for something third-party tested (NSF Certified for Sport) with a short ingredient list.

A few more things worth knowing

Creatine. This supplement is having a moment, and the research backs it up for women in midlife. When combined with resistance training, about 3-5 grams of creatine monohydrate per day may lead to significantly larger gains in lean tissue and strength compared with training alone. A large position stand from the International Society of Sports Nutrition concluded that creatine is one of the most effective and most studied supplements for exercise performance, with a strong overall safety profile in healthy people. It’s even being studied at higher doses to reduce cognitive decline. I started taking creatine a few days a week. I should probably take it every day. It’s cheap, safe, and boring in the best way, but always run supplements by your own doctor first.

Timing. Protein and carbohydrate a couple of hours before your workout helps fuel your session. And there is data that women probably do better exercising in a fed state (rather than fasted). Protein after supports muscle protein synthesis and remodeling. But total daily intake matters more than the exact minute you eat. Don’t stress about it.

Tracking your body. If you want to know where you stand (and you’re not pregnant), you could think about getting a DEXA scan. It can measure your bone density, muscle mass and visceral fat. These are becoming more commercially available, and you can check it every few years to make sure your routine is keeping you where you want to be. But it does expose you to a low dose of radiation, so you should ask your doctor what they think. I personally like tracking but lots of people don’t.

The playbook, simplified

Protein — 25-35g per meal → Maximizes muscle protein synthesis

Lifting — 2-3x per week, challenging weights → Builds bone and muscle

Fatty fish — 2-3x per week → Supports brain and heart health

Creatine — 3-5g daily (optional) → Boosts strength gains with training

Just some things to consider if you’re willing to do things differently than you did at 30. That’s the new game. And honestly? It’s more fun than I expected.

I’m curious — what’s the one thing you’d have to change to make this work for you?

Drop it in the comments. I want to know what’s getting in the way, what’s already clicking, or what you want to learn about.

And if this landed for you, send it to a friend who’s still married to the elliptical. She might be ready to hear it.

Angela

This information is for educational purposes only and is not medical advice. Please consult your physician before starting any new exercise or nutrition program.

References

1. Optimal resistance training parameters for improving bone mineral density in postmenopausal women: a systematic review and meta-analysis (Zhao et al., Journal of Orthopaedic Surgery and Research, 2025)

2. Creatine monohydrate supplementation for older adults and clinical populations (Candow, et al., J Int Soc Sports Nutr, 2025)

My daughter and me at the gym this month

Everything I learned about fitness in my 20s turned out to be wrong for my 50s. And I’m a doctor.

I used to be a cardio queen. Orangetheory, Zumba, spin classes. I loved them all. I’d hit the elliptical or rowing machine once or twice a week, or walk briskly around Greenlake, listening to Feel Better Live More or Zoe podcasts. I was doing everything right. Or so I thought.

But as my body got older, I noticed changes. Numbers on the scale creeping up. More fat around the middle. Higher cholesterol for the first time. Hiking a little slower with my husband and kids. Feeling middle-aged frumpy.

Here’s what I knew as a reproductive endocrinologist: we reach peak bone density somewhere between 18 and 30, then hold relatively steady until the menopausal transition, when bone loss speeds up to 2-3% per year for several years before slowing down again.

Without intervention, bone density can enter the osteoporosis zone by your mid-60s. The menopause transition (ages 45-55) is when the decline begins.

Muscle strength follows a similar pattern. A gradual decline of less than 1% per year in midlife, then 2-4% per year after menopause. By 70, if you haven’t been fighting back, you’re seriously depleted. The drop in estrogen as our ovaries wind down is partly to blame. But aging itself plays a role too. Two mechanisms are working against us. And understanding them has changed how I eat and move.

Your muscles are speaking a different language now

When you’re young, your muscles are eager listeners. A little protein, a little movement, and they respond. Building, repairing, staying strong. But somewhere around 50, muscles start requiring a louder signal. It’s called “anabolic resistance,” which is a fancy way of saying your body now needs more protein to do the same job it used to do with less.

How much more? A younger woman can trigger muscle building with about 15-20 grams of protein at a meal. After 50, you need 25-30 grams to get the same response. That’s the difference between yogurt for breakfast and yogurt plus two eggs. Sounds small, but multiply it across every meal, every day, every year, and you start to understand why so many women feel like they’re slowly losing ground.

And then we have estrogen, a silent partner in muscle and bone metabolism. It’s working for you in your 20s, 30s, and 40s. When it drops off, protein doesn’t get incorporated into muscle as efficiently and you don’t remodel your bones as well. You lose muscle and bone faster, precisely when building it gets harder.

And men aren’t exempt either. Testosterone declines about 1-2% per year after 30. No dramatic cliff like estrogen, but a slow fade that affects muscle the same way. The golf swing, the Sunday bike ride? Great for mobility and cardio. Not enough for muscle and bone. You need resistance training too, and your protein targets are usually higher, based on body weight.

The good news? You CAN stave off this decline. You can replace the estrogen. (With progesterone too if you have a uterus). You can up your protein to deal with anabolic resistance. And you can get serious about resistance training. When the rules change, we change.

So how much protein do you actually need?

The old recommendation of 0.8 grams per kilogram of body weight was set to prevent deficiency, and most Americans hit that easily. But preventing deficiency isn’t the same as optimizing for strength and longevity.

For women over 50, most experts now recommend 1.0-1.2 g/kg as a minimum. Of course, nobody thinks in kilograms. So, I did the math for you. Half a gram per pound gets you close to the 1.0 g/kg target.

Take your weight, divide by two, and that’s your new minimum. Want to do better? Use 0.6 or even 0.7 grams per pound if you’re strength training (wink wink), over 65, or recovering from surgery.

If those numbers feel daunting, I get it. You may not even know how many grams of protein you’re eating. But maybe you should. As anabolic resistance increases, so does the dose of protein and strength training required to maintain the muscle you have.

Timing matters too

Here’s the thing: your muscles can only use so much protein at once. Spreading intake across three meals, about 25-35 grams each, seems to work better than the dinner-heavy approach most of us grew up with.

It starts with rethinking breakfast. One egg has about 7 grams of protein, so even two or three eggs isn’t quite enough. Add Greek yogurt, nuts, or legumes to get into the 25-30 range.

My new power breakfast: red lentils (just salt, garlic powder, and a little EVOO) over cottage cheese with a handful of whatever leafy greens are in my fridge. Half a cup of lentils and three-quarters cup of cottage cheese gets me to 30 grams.

That lovely mixed green salad at lunch? Make sure it has a serious protein boost. Tuna, salmon, chickpeas, eggs. Make it hearty. Then keep the momentum going at dinner.

This week, try tracking your protein for a day or two. Not to obsess, just to see where you actually land. Most women I talk to are surprised by how far short they fall, especially at breakfast.

But protein alone won’t save you

Here’s the thing: you can eat all the protein in the world, but without the right stimulus, your muscles will still fade. For most of my life, I’ve been all about the cardio. I still love it. But I’ve learned to love strength training too. And I’ll tell you how. Because now, I’m playing the long game.

Next time: the kind of training that actually builds bone and muscle, how to use AI to design your own lifting program, and simple ways to make the gym something you look forward to. Plus, fish vs. chicken, creatine, and the playbook I wish someone had given me at 45.

Stay tuned.

Angela

Beef, butter, and full-fat dairy now sit proudly at the top. Protein is “prioritized.” The message is clear: America has a protein problem, and steak is the solution.

As someone who spent the first three decades where beef was in the center of the plate, I have some opinions.

A Brief History: Me and Meat

I grew up in Columbus, Ohio, home of Wendy’s “old fashioned hamburgers.” As a kid, I remember field trips to COSI and then hopping across the street to the original Wendy’s for a chocolatey Frosty, burger, and fries. My first paid job at age 16 entailed mastering the drive thru, flipping smash burgers, and sampling all the flavors of ice cream after work at GD Ritzy’s, a throwback diner with crispy-edged patties and shoestring fries. Saturdays meant OSU football and lots of parties and snacks. Every spring and summer holiday was a get-together with burgers and dogs on the grill. In my twenties, I moved to Cincinnati and added Skyline Chili cheese coneys and Graeter’s black raspberry chocolate chip to the rotation. Beef wasn’t just food; it was culture. Ohio is where fast food is perfected.

Then I moved. Oregon, North Carolina, Texas. In Texas, I learned what real barbecue was. Brisket so good it could make you religious. Tex-Mex tacos that ruined all other tacos forever. My husband had been vegetarian since college (for environmental reasons), but I couldn’t get on board. When I tried the dishes he ordered in restaurants, sure, I often thought they were better than mine, but I knew better. I needed my protein.

The Part Where My Body Stopped Cooperating

Then, in San Antonio, during my first pregnancy, I developed inflammatory GI issues that just...never went away. Years of symptoms. Medications. Yearly colonoscopies. I tried everything I was supposed to try. Keto. Paleo. Intermittent Fasting. “Clean eating.” All the things that are out there.

Nothing worked.

It was depressing and humbling. I’m a doctor. I counsel patients on health for a living. Why couldn’t I fix myself?

The Plot Twist No One Saw Coming (Least of All Me)

Summer 2020. COVID had cancelled our dream food trip through Parma and Bologna. (Still bitter.) I was already bought into culinary medicine, world cuisines, and lots of veggies, but still animal protein heavy. With nowhere to go and nothing to do, I decided to finally study for my lifestyle medicine boards.

And that’s when things got interesting.

I started reading the research I’d somehow missed in medical school. Studies on plant-forward eating patterns. Data on how food affects metabolism, blood vessels, cancer risk, skin, gut health. Paper after paper showing that the eating patterns most associated with longevity and disease prevention weren’t high-protein carnivore dreams. They were plants. Lots of plants. With protein, yes, but mostly from beans, lentils, nuts, fish.

I started shifting my own eating. Tentatively at first. I knew how to cook tofu and black beans, but I didn’t know how to make plants the main event every day without boring myself to death. So I enrolled in a plant-based culinary program and learned to actually cook this way and make it appealing to my harshest food critic: me.

And then, quietly, without fanfare, my symptoms went away.

No more meds. No more colonoscopies. Just... regular, soft, uneventful poop. (You’re welcome for that detail.)

I love the smell of chicken or beef grilling. But I don’t miss my GI symptoms. These days, I’m plant-forward. About 80-90% of my energy comes from plants. I’ll eat chicken or meat occasionally, and my gut handles it just fine. My body made me a believer.

So About Those New Guidelines

Here’s the thing about the new Dietary Guidelines: they’re not entirely wrong. Prioritizing whole foods over processed junk? Great. Cutting added sugars? Overdue. Telling people to eat real food instead of things that come in crinkly packages? Yes, please.

But the protein obsession? That’s where my opinion differs.

The guidelines emphasize animal protein first (meat, then poultry, then eggs) with plant proteins listed last, almost as an afterthought. This despite the fact that the scientific advisory committee recommended a plant-forward pattern. Their report was... let’s just say, deprioritized.

Here’s what makes this frustrating: the NIH-AARP study (Huang et al., 2020), over 400,000 people followed for 16 years, found that replacing just 3% of energy from animal protein with plant protein was associated with a 10% lower risk of death and an 11-12% lower risk of cardiovascular mortality. That’s not a small effect. And it held up across subgroups.

And then there’s cholesterol. A 2023 meta-analysis in the European Heart Journal (Koch et al.) pooled 30 randomized controlled trials and found that people following vegetarian or vegan diets had LDL cholesterol levels about 10% lower than omnivores, along with a 14% drop in apolipoprotein B, another marker of cardiovascular risk.

But Wait, It’s Complicated (Of Course It Is)

Before you dump all your bone broth for aquafaba, let me be clear: I’m not saying animal protein is bad for your health.

Plant-forward eating has real tradeoffs. Vegetarians and vegans do show higher rates of bone fractures in some studies and falls and fractures decrease quality of life. No one wants to be frail. These are real concerns, especially for women as we age.

So how can you get the benefits from plants without the risks? What will make your body feel and function at its best?

The Part Nobody Wants to Hear

Here’s what the new guidelines conveniently don’t mention: protein doesn’t build muscle just by showing up in your stomach. It needs to be met with strength training, the actual tearing down and rebuilding of muscle fibers, to do its job. Without that, extra protein is just extra energy. And extra energy from any source gets stored as fat.

When someone tells you to “prioritize protein” without mentioning that you also need to lift heavy things regularly, they’re giving you half the story. And half-stories are how we end up confused, frustrated, and blaming ourselves when the advice doesn’t work.

Building new muscle through progressive overload is what gives you the metabolic boost. The protein is just the raw material. You need both.

What This Newsletter Is Actually About

I’m a physician and lifestyle medicine specialist. I spent years thinking about hormones, fertility, and metabolism before realizing that most of the advice we give women is incomplete at best and counterproductive at worst.

Pregnancy, it turns out, is a stress test. If you develop gestational diabetes at 35, you’re more likely to have type 2 diabetes at 45. Pre-eclampsia predicts heart disease decades later. The conditions we treat as pregnancy complications are actually previews of coming attractions.

Which means the choices you make in your 20s and 30s, and during the decades after, matter more than almost anyone tells you.

I started this newsletter because I got tired of the disconnect. Women prepare for pregnancy with gummies and IVF while the things that can have a real impact, food, exercise, metabolic health, get left to wellness influencers.

I’m frustrated by friends hearing from their doctors that they shouldn’t need hormones after menopause, while others get prescribed plenty of hormones, but no one mentions the higher protein intake and strength training we need in the second half of life.

I’m dismayed that so many doctors dismiss lifestyle as not worth their time. Western medicine teaches us to treat diseases with drugs, not food.

This newsletter is for people who want more. The evidence behind diets, exercise, and trending supplements. A better playbook. Lifestyle strategies that work at every stage. Honesty about what we know and strategies worth trying. No wellness perfectionism.

I look at my body as an experiment. I try things, see how I feel, adapt. You can too.

Because here’s what the new inverted food pyramid won’t tell you: it’s not about any single macronutrient. It’s about building a body that can handle whatever comes next. Personalize it. Take what you want from it and leave the rest behind.

That’s the long game. And I’m here to help you play it.