Eat your way to better gynecological health

A good gynecologist is like a detective. She gathers evidence to diagnose infections. She uncovers the truth behind stages like puberty, pregnancy and perimenopause. Yet many women still feel that their physiology is a mystery. 

What if a clue to that mystery hides in our diet? Similar to the gut, certain foods make the vaginal microbiome thrive. New research suggests that the right diet could alleviate symptoms of the most common gynecological diseases.

Alongside Jen is King’s College London professor and ZOE’s Chief Scientist Sarah Berry. Sarah shines light on the growing evidence of the role of nutrition in offsetting uncomfortable, and sometimes dangerous, symptoms of menopause.

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Transcript

Jonathan Wolf: A good gynecologist is like a detective. She investigates areas that women can't see on their own. She gathers evidence to diagnose infections. She uncovers the truth behind life stages like puberty, pregnancy, and perimenopause. Yet many women can still feel their physiology is a mystery. What if a clue lies in our diet?

Just like in the gut, the vagina has a microbiome, and certain foods help these microbial communities thrive. New research suggests that the right diet could alleviate symptoms of the most common gynecological diseases. 

Dr. Jen Ashton, a board-certified gynecologist and leading expert in women's health, has been researching solutions for decades. As the chief medical correspondent for ABC, she's educated millions of people across America. 

Joining me as a co-host today is Professor Sarah Berry, a professor of nutrition at King's College London and chief scientist at ZOE. 

Jen, thank you for joining us today. 

Dr. Jen Ashton: Thank you for having me. I'm so excited to be here on ZOE.

Jonathan Wolf: Well, we're excited to have you, and we have a tradition that always kicks off these podcasts, which I think you were being warned about earlier, where we have this quickfire round of questions. They come from our listeners, and we have these very strict rules; you can say yes or no, or if you absolutely have to, you can give us a one-sentence answer. Are you willing to give it a go? 

Dr. Jen Ashton: I'm willing and ready. 

Prof. Sarah Berry: Can certain foods reduce the symptoms of gynecological disease? 

Dr. Jen Ashton: Yes. 

Jonathan Wolf: Does the vagina have its own microbiome? 

Dr. Jen Ashton: Yes. 

Prof. Sarah Berry: Can a poor diet increase your risk of infertility? 

Dr. Jen Ashton: Yes.

Jonathan Wolf:  Is weight gain in menopause inevitable? 

Dr. Jen Ashton: Yes. However, it can be modified and strategized.

Prof. Sarah Berry: Can diet help with polycystic ovary syndrome? 

Dr. Jen Ashton: Absolutely yes. 

Jonathan Wolf: We have one final one. You get a whole sentence. What's the biggest misconception about women's health? 

Dr. Jen Ashton: I think the biggest misconception is that women are smaller men and that everything we know about men in medicine and science can be extrapolated to women. And that is not true, just as children are not small adults. 

Prof. Sarah Berry: I think that's fascinating, Jen. Now you're a board-certified gynecologist and a leading expert in women's health and you've been researching solutions for common gynecological problems for decades. 

Now there will be lots of men listening but also women all over the world that have actually never even visited a gynecologist. So can we start with the real basics, which are what is a gynecologist and what are the main health issues that you focus on? 

Dr. Jen Ashton: First of all, the definition of our specialty, obstetrics and gynecology, they're really two different specialties, but they're combined in terms of medical education and training. It is considered a surgical subspecialty. 

I've been trained and have performed thousands of operations on women's gynecologic system, which means ovaries, fallopian tubes, uterus, cervix, vagina, vulva. 

There's also a lot of medicine in gynecology, and so that would be reproductive endocrinology, that would be some types of GYN cancers. Obviously, the way hormones work from a gynecologic standpoint that affects puberty, pregnancy, and menopause, that's within the expertise of a gynecologist. 

Definitely in the United States, it is pretty standard for women to go to their gynecologist as their sole medical provider, whereas obviously in other parts of the world, there are a lot of other healthcare professionals who can do a lot of the same things, but the training is fundamentally different.

Prof. Sarah Berry: And what are the main conditions that you would focus on as a gynecologist? 

Dr. Jen Ashton: What I love about the specialty is, first of all, the age range. We are literally seeing girls and women throughout their entire lifespan. 

We treat anything from painful periods, polycystic ovarian syndrome, pre-menstrual syndrome, perimenopause, and menopause symptoms. Oftentimes we'll manage osteopenia, osteoporosis as women get older. 

It's really the care of the entire woman and I've said many, many times, I believe gynecologists should treat the whole woman, not just a body part. So, at least here in the United States, we tend to think of an OBGYN as just vagina, cervix, uterus, ovaries, fallopian tube, menopause. But in reality, there's usually a woman attached to those body parts, so we're often times seeing a lot of breast issues, even a lot of psychiatric issues as well, skin conditions, you name it.

If it's happening to a woman, a gynecologist is oftentimes the doctor who's seeing it first. 

Prof. Sarah Berry: Now, I think what you describe is very different to what I thought. I've never heard it described in a way that you do so holistically, which I think is important because everything is connected to everything else in the body.

Jonathan Wolf: I'm already taken away by how complex this is, the way these things are fitting together, right? It's very hard. 

I wanted to switch us over to one of the other questions that came from the quick-fire, because we already mentioned this thing, the vaginal microbiome, and there'll be a lot of listeners saying, what's that? I've never heard of it. What is it? 

Dr. Jen Ashton: So most people now have heard of the term microbiome, and that refers to the vast environment, collection of bacteria or organisms that live in our body all the time. 

The gut microbiome, for example, has more genetic material in it than our actual DNA. So we're actually more bacterial species than we are human species, which I think is kind of interesting to think about. 

Even though the gut microbiome is still relatively in its infancy, meaning like 10 years, 15 years of data, not a hundred years of research. It's now a really exciting time specifically for women's health because we're learning that it's not just about the bacterial species in our GI tract, but there's also bacteria in the vagina, right?

The vagina is an open conduit from the outside world to our peritoneal cavity through the uterus. The uterus is kind of like the intermediary room. And so there are bacteria in the vagina, bacteria in there. There's also fungal species in the vagina oftentimes. Of course, viruses can live in the vagina as well.

But specifically talking about bacteria in the vagina, they exist in a nice, peaceful symbiosis. There's a lot of different species of bacteria in the vagina. And when they are getting along with each other, the woman has no symptoms. 

Prof. Sarah Berry: What about when they're not getting along with each other?

Dr. Jen Ashton: When they're fighting? Then the woman can have symptoms. And what can those symptoms look like and feel like or smell like? 

There can be itching, there can be discharge, excessive amount of discharge. There can be an odor, there can be painful intercourse. And in some cases, potentially even that bacteria can go upwards, can ascend through the cervix, which is kind of the gatekeeper to the uterus and cause an infection in the uterus or beyond. 

Thankfully, that rarely happens. But just in terms of day-to-day existence for the woman, we probably all have friends. I've seen many patients through the course of my nearly 20 years in practice, where it's almost like a binary population. There are women who say I've never in my life had a yeast infection. I've never in my life had any kind of vaginitis or a vaginal infection. 

And then there are women who say I am so prone to vaginal infections, I've had bacterial vaginosis, I've had yeast infections, I get a yeast infection around the time of my period. 

There are a group of women, of course, who fall in between that, who maybe have one or two over the course of their lifetime, it's more common in my clinical experience that it's one or the other. And so the vaginal microbiome now is a really hot area of research, which I think is fantastic and what kind of things can affect it for the negative or for the better. 

Jonathan Wolf: We discuss the gut microbiome often on this podcast. My co-founder, Professor Tim Spector, this is his area of specialization. Sarah spends a lot of time on it as well.

We haven't really talked about the vaginal microbiome at all. Is it playing some sort of beneficial role in the way that we now understand the microbiome does in the gut? Or is it just that because it's open, of course there are some bacteria? Do we know any of these things today? 

Dr. Jen Ashton: I mean, if the gut microbiome is overall big picture in its infancy, the vaginal microbiome is even more. It's a newborn. 

There is some really interesting preliminary data that suggests that what we eat absolutely has an impact on the vaginal microbiome, which is interesting. 

Our behaviors also have an impact on the vaginal microbiome. Semen changes the pH of the vagina. Menstrual blood changes the pH of the vagina. Condoms and certain lubricants change the pH, saliva changes the pH of the vagina. 

So all of these things are constantly affecting the species of bacteria, some of which are doing good work. And so we want to make sure in general that we're learning as much as we can about ways to help it and ways to avoid hurting it.

I don't think there's enough of a body of evidence right now to make broad sweeping statements yet. But there are a lot of researchers doing really interesting work on this, particularly in the area of supplementation and diet and how that can potentially impact the vaginal microbiome and therefore the clinical wellbeing of a woman.

Prof. Sarah Berry: We study, like Jonathan said, loads about how food impacts your gut microbiome. For me that is obviously, it's logical, the food's actually, you've got the debris of the food getting to your gut, so you've got the food for the microbiome and the bugs that are down there to feed on. 

I can't quite understand how food can impact your vaginal microbiome. And I know you've coined this term in nutritional gynecology. Could you just expand a little bit on that? 

Dr. Jen Ashton: Well, first of all, you're thinking about it the right way. And I don't think that anyone, and definitely myself included, yet, can say with the utmost scientific certainty and that something conclusively does X, Y, or Z.

Again, the first step, as you know, as a scientist is observation. And then we start the exploration and experimentation. And because there's a different woman attached to each vagina, it's very difficult to tease out these variables. 

But you ask about an area that I find incredibly fascinating. I started describing it as nutritional gynecology. What does that mean? It means how the area of nutritional science, but practically how we eat, how it affects the gynecologic realm and well-being of a woman. 

If you think about big picture and go back to my answer to Jonathan's first question and your first question of what is gynecology, and we talk about puberty, we talk about pregnancy, we talk about PCOS, we talk about perimenopause. Most of them, by the way, all start with P, I'm not sure why. 

Prof. Sarah Berry: And they're all influenced by the food that we eat? 

Dr. Jen Ashton: They all have a major role in food, nutrition, and metabolism, right? 

When you think about it. What happens in puberty? You don't menstruate, you don't get your first period until you have a sufficient amount of body fat tissue, which also is a source of estrogen, right?

And so there's weight gain that comes around that time that's important for puberty. That's important for the first period. That happens then. Pregnancy, we don't need to remind people what happened in terms of pregnancy, metabolism, weight and its hormonal interaction. PCOS, that overlap between, in some cases, insulin resistance, weight gain, difficulty losing weight, and increased risk of going on to develop type 2 diabetes. There's a hormonal and metabolic component to that. And so too, perimenopause and menopause. 

So we know that estrogen, for example, estradiol, many even gynecologists may not realize this. Not only does it affect every kind of organ system in the body, but they're in the central nervous system. Estrogen acts as an appetite suppressant.

Interesting. So when a woman goes through perimenopause and menopause, and her estrogen levels start to decline, it's one of the reasons to go back to your rapid-fire question, Jonathan, that perimenopausal or menopausal weight gain is is really inevitable. That doesn't mean we can't over-strategize it.

Estrogen level drops, you get less central nervous system appetite suppression, you get more insulin resistance with less estrogen, and you get an increase in weight gain in adipose tissue and in particular, visceral adipose tissue. 

Prof. Sarah Berry: And I think that's a really important point because I think that it's such a challenging time anyway, perimenopause and menopause.

And if you think, my gosh, what's wrong with me? Why am I failing? Why is my body changing? And I think to be aware, and we see this in our own ZOE data that we have on all of the research we're doing on menopause, that there's three things happening. 

There's the changes in hunger, you're not perceiving hunger in the way that you used to. So we'll often hear women anecdotally say, but I'm eating the same, but I'm feeling more hungry. Yes, that's because we know estrogen affects your hunger signaling. 

We know that estrogen affects your metabolism. So we know, again, from our own research and what else has been published, that the way you metabolize food changes.

And then exactly in the way that you've said it also changes where you distribute the fat and how much fat you lay down and you lay it down in your tummy, which is metabolically worse for you, etc. So it's also about being kind to yourself as well. 

Dr. Jen Ashton: Yep. You nailed it. And there's even more factors.

We were just talking about the microbiome in the gut and the microbiome in the vagina. There's an estrobolome in the gut, which are bacterial, and fungal species that can break down and metabolize estrogen and other hormones. 

Depending on largely your diet, but of course also your genetics and a number of other factors, you can either break down more estrogen and then you're basically, in effect, contributing to low estrogen symptoms. Or you could be eating a diet that positively affects these bacterial species and enables them to either not break down as much of the estrogen you have, or to recirculate it back into your systemic circulation.

So that estrobolome is a newish term that a lot of people who do this kind of research are paying more attention to. And I think that's why, again, it's important to understand that women are different than men in what's going on in their gut, just like in the rest of their body. But women of different ages are also experiencing different metabolic and bacterial behavior that affects the whole organism. 

Jonathan Wolf: I think it's pretty amazing. Could you talk about how diet maybe hits then puberty, for example, and what the difference is, what's the consequence of poor diet on puberty?  

Dr. Jen Ashton: I think, first of all, in the United States, there's a general consensus because there's an acronym for it, SAD, the Standard American Diet, and it's not just sad, it's bad.

It's heavily processed or ultra-processed foods that are typically calorie-dense, nutrient-poor, and actually result in sending signals from the gut to the brain that then send signals back through the rest of our body and drive us to seek these foods that are not healthy, more. 

And they have a direct effect on weight gain and the whole domino effect that follows from that. We know, we're seeing the consequence of this, that in part, childhood conditions of overweight and obesity are leading to girls having their first period at an early age. It's one of the factors, it's not the only factor, of course. 

Jonathan Wolf: So, Jen, you're saying that the food that they're eating is actually causing them to go into puberty earlier than otherwise?

Dr. Jen Ashton: I would say indirectly. I'm sure there are people who would say directly, yes. Again, it's one factor. Their genetics are another factor, exposure to other environmental agents like the Forever Chemicals, which has known to be endocrine disruptors, plays a role. 

But our bodies, when you talk about women and girls, are so finely attuned to fat composition and body weight that it's a big, big factor.

Prof. Sarah Berry: And Jen, given that for adolescents, they have the highest intake of ultra-processed food, this is in the U.K. and the U.S., what is this doing to girls who are going through puberty? What are the harms of this? And what can we do positively for this? 

Dr. Jen Ashton: Well, this is why I love this concept of nutritional gynecology because it really involves one hand talking to the other. One area of science literally hybridizing a base of knowledge and taking things that were traditionally siloed, like just talking about food. And saying, how does this food and this way of eating and the conditions of overweight and obesity affect, in this case, in my field, gynecology?

When you talk about that and you look at puberty, you say, what are the risks or consequences of a girl going into puberty, being overweight, being obese?

Well, based on association and observation, a higher chance of that girl having polycystic ovarian syndrome, or PCOS. A higher chance of that girl, when she gets pregnant, having gestational diabetes, or other complications of pregnancy that are directly related to her weight. And then when that girl becomes a perimenopausal woman, difference in vasomotor symptoms, an earlier menopause, a later menopause, a more severe menopause.

So, we really have to start connecting the dots more with what we're eating, our nutritional status, the impact that has on our health, and all of these reproductive hormonal stages. 

Jonathan Wolf: And so you touched on puberty. I want to move on to the next P, which is pregnancy. 

Dr. Jen Ashton: Well, listen, you're growing a human, right? And there should be no question that the nutritional input and the metabolic factors that go on during pregnancy are important. 

I was fascinated by the nutritional input. And when I went back to Columbia University and got my master's of science in nutrition, I remember the day I sat in a lecture given by a very famous sugar researcher in the United States, with a PhD named Nicola Vina.

And she was talking about the importance of the in-utero environment for the offspring and the generations from that offspring, based on animal data and human data, whereby the glucose concentration of amniotic fluid has a role of genetic imprinting on that fetus. 

Jonathan Wolf: So what does it mean, the glucose level of the fluid?

Dr. Jen Ashton: I'm going to overgeneralize this to make the example very, very clear. You have a pregnant woman who consumes a high-sugar diet; sugar-sweetened beverages, and ultra-processed foods. She takes in a lot of sugar in her diet and beverages, and that from a couple of quick steps results in an amniotic fluid concentration with higher glucose that surrounds the fetus. 

That fetus is exposed to this high glucose blood flow from the mother and the placenta. And that in turn winds up producing a high glucose level amniotic fluid and that's the fetal environment, that's the in-utero environment. 

Because of the mother's diet, the fetus is exposed to this high glucose, and goes through this concept of genetic imprinting, where that fetus then has an increased risk of obesity, type 2 diabetes, metabolic syndrome. 

And so truly, as a woman and a mother, as well as an OB-GYN, when I learned this ten years ago, I thought, Oh, fantastic, another reason that I can feel guilty about what I did or didn't do when I was pregnant. 

We're not talking about blaming, we're not talking about pointing fingers. We're just citing the fact that the in-utero environment has profound metabolic consequences that could affect that fetus way down the road and therefore that fetus's offspring.

Prof. Sarah Berry: Jen, we are spending a lot of time as nutritional scientists looking at this now that we're understanding just how important maternal diet is. And to future generations. And so I think it's important to say as well as sugar, it's everything that the woman does.

Whether it's how stressed you are, that's your physical activity, but it's your entirety of your diet that we now know is incredibly important in shaping the health outcomes for your baby in the future.

Dr. Jen Ashton: Correct. And I think that, again, it's one thing to talk about the science and the biochemistry. It's another thing to talk about the person and the patient and the real human being. Pregnancy is an incredible process and women are incredibly resilient. 

We all know, we really know, intuitively as well as intellectually, what's good fuel for our body and our growing fetus and what isn't. Yes, we have to live with moderation. Yes, we have to be realistic as well as idealistic. But I think that most women will know that having an occasional cookie or a slice of cake or a cupcake is very different than having one every single day, especially when you're growing another human.

You know, what my mother, who was a registered nurse, said to me, both as a mother and as a nurse; control the controllables. So there's so much that's not under our control, but there's a lot that is. 

And so, to the extent that we can control something, which, when you're talking about 40 weeks or 9 months, that's not forever. It's a little easier to do that. 

Jonathan Wolf: Can I ask one quick question before we move off pregnancy? Because you talked a lot about after being pregnant. What's the evidence about diet affecting your ability to get pregnant, because I've heard a lot about that. What does the science say? 

Dr. Jen Ashton: I think that the science there is a little bit more vague. So, there's no evidence that any one food or any one supplement in isolation has any statistically significant impact positively on a woman's fertility. 

But again, as an organism, we know things that are not good for fertility. Which is a lot of inflammation, excessive body weight or hormonal imbalances, and those things obviously can be tied to diet.

What I encourage women and couples who are trying to conceive, is try to eat from the farm, not the factory. Try to minimize your ultra-processed or highly-processed foods. Obviously don't smoke, don't consume alcohol. 

Again, that's not good for your whole body, not just your ovaries or your fallopian tubes. And again, in that way to use Sarah's term, I really do take a holistic view. 

Prof. Sarah Berry: Can we move back to talk about PCOS?

Jen: PCOS, polycystic ovarian syndrome, it's called the most common but least well-understood hormonal condition affecting women. And in the medical literature, it is quoted as affecting 10%, sometimes 15% of women. I believe it could be even higher than that. So it's incredibly common. 

Hallmark features are signs of hyperandrogenism. Signs are increased testosterone levels, producing acne, excessive body hair, male pattern baldness, difficulty losing weight or gaining weight, menstrual irregularities, so irregular periods. Those are a lot of the common signs or symptoms, but just to keep it fun and interesting, women can have PCOS and not have any of those signs or symptoms at all.

Prof. Sarah Berry: As a woman listening to this, I think a lot of women will think, well, hold on, I might have one of those symptoms, which doesn't necessarily mean they've got PCOS. Unless you have one of those kind of symptoms and it's bothering you or impacting your life, is it something that if you didn't get it investigated, there would be no long-term harm?

Dr. Jen Ashton: Well, the thing that's interesting about PCOS is that Women and girls with known PCOS have a higher risk of going on to develop type 2 diabetes in their lifetime. So, um, It's certainly not a scenario where we recommend screening every woman or every girl for this. But because of the constellation of symptoms and signs that we talked about, if they're persistent, if they're new, if they're bothersome, absolutely a workup, you know, an investigation should be done to see if that person has it.

And I'll give you a couple of examples. Acne on the back or chest of a woman or girl. An older adolescent or teenager is not common and if it's persistent, it is generally a sign of PCOS. All of us can get a pimple on our face every once in a while. Extreme or even moderate to extreme acne on the back or chest of a woman is generally a sign of an androgen imbalance, so a higher level of testosterone.

And the clue, both from, for a dermatologist as well as a gynecologist will be. When a dermatologist can't really have an impact on acne. I usually say, and most of them would agree, that that's because it's not a skin problem, it's a hormonal problem. And so all dermatologists are very accustomed to hormonal basis for acne.

They see it all the time. And so their radar, their index of suspicion is generally up already. Maybe this isn't a skin problem, maybe this is PCOS. 

Prof. Sarah Berry: I'd love to know about the relationship between diet and PCOS. 

Dr. Jen Ashton: There's been actually a decent amount of this reported in the peer-reviewed medical literature. Not enough, in my opinion, never enough.

But there's been a decent amount of well-constructed studies that, even though many of them are observational, it's still some valuable information that suggests that women with PCOS who lose 5% of their starting body weight, and so most of that is going to be fat tissue.

Fat mass can have a significant impact on their ovarian function, their ability to resume regular ovulation if that's a problem for them and improve their insulin resistance. That's good because it's very, I think, empowering from a behavioral and nutritional standpoint. 

What's not so good is that it's easier said than done. If you talk about a woman who weighs 200 pounds or about 90,85 kilos. You know, 5% is 10 pounds of weight or 5 kilos. That's hard. 

Prof. Sarah Berry: And given how hard it is, is there any dietary changes independent to weight loss or in addition to when women are trying to lose weight?

Dr. Jen Ashton: It's a great question and I think the general approach has been a diet that is certainly lower in added sugar. And I really go by the maximum added sugar of no more than 25 grams a day, which is the World Health Organization recommendation for women. 

You'll hear people say for PCOS, low carb. But remember, our bodies run on carbohydrates. That's what every cell needs to function is glucose. So not all carbs are created equally, right?

So eating an apple is very different than eating a cookie when you're talking about metabolically and hormonally in PCOS for everyone. By the way, I would say that for men as well. Okay. 

So for people with PCOS who are incredibly sensitive to how their body metabolizes carbohydrates, a diet that's higher in lean protein, even plant-based protein, higher in the healthy fats, like the olive oil, the avocado, the nuts, is going to be helpful.

It's not going to be a magic bullet, but it should be the mainstay of how someone with PCOS eats. But guess what? It should be really the mainstay of how we all eat. 

Prof. Sarah Berry: Yeah, I was just thinking that. It's the mainstay of the ZOE diet that we encourage as well with a lot of fiber as well because I think it's really important if anyone's ever going on to a low carbohydrate diet to make sure they're still getting enough fiber. 

Okay, so we've talked about the four P's. So puberty, we've talked about pregnancy, we've talked about perimenopause, and we've talked about PCOS. 

There's another gynecological condition that I hear about a lot, that I know affects about 10% of women, and this is endometriosis. And it's something certainly I don't understand. I know lots of my friends talk about it, that they might have it. It's incredibly underdiagnosed as well. 

Could you just walk us through that quite briefly and how the diet might be able to help? 

Dr. Jen Ashton: Let's talk about, first of all, what endometriosis is. It comes from the term endometrium, which is the inner lining, the type of cells that are inside the uterus.

And in endometriosis, there are a lot of different theories as to why this happens. But in endometriosis, those endometrial cells are dispersed outside the uterine cavity. Basically anywhere else. So they can implant on the sidewalls of your body. They can implant on the bladder, the bowel, the undersurface of the diaphragm. There have been women with endometriotic implants in their lungs. 

It can be an incredibly painful and debilitating condition that is chronic. As you mentioned, Sarah, it is underdiagnosed because typically it's a diagnosis that has to be made surgically most of the time, not all of the time. 

There's some very exciting research, by the way, about ways to test for endometriosis using menstrual blood, which I think may be interesting down the road, some other ways to test for it, but we're not there yet in terms of the gold standard of testing or screening. 

Prof. Sarah Berry: So how could someone listen to this at home who has some concerns around this? How would they be able to identify it? 

Dr. Jen Ashton: Pain is the hallmark symptom of endometriosis. It's the most common and it's the most severe. Low pelvic pain that is generally, but not always, cyclic. 

So again, remember these endometrial glands, they're hormonally responsive. So just as the uterus lining sheds with a woman's menstrual cycle and changes in her hormone levels, you can imagine that contraction of the uterus causing menstrual cramps occurring in microscopic areas all over the internal cavity where those endometrial glands are kind of splayed out.

So, it's very painful. Refractory pain or severe pain is a hallmark feature of endometriosis. There's a saying in gynecology that is still, I believe, valid, but it's not 100%, that a teenager, so an adolescent who has been put on non-steroidal anti-inflammatory medication, so that's something like ibuprofen available all over the world, and low dose birth control pills. Those two treatments together, who still has severe pain with her periods have a 50% chance of having endometriosis. 

So, that could be a clue. And I believe for a woman of any age, and even an older woman, 20s, 30s, 40s, if you're on birth control pills for whatever reason and you're taking a drug like ibuprofen for pain and you still have pain, that's a red flag.

Jonathan Wolf: And there are things that you can do about it if you make it to a gynecologist? 

Dr. Jen Ashton: Yes, there are ways to manage it. There's not a cure for it. And it can be very difficult. The treatment should be individualized. And it really, really is important, ideally, if possible, for a woman who thinks she has endometriosis or knows she has endometriosis to go to a gynecologist who really has a tremendous amount of experience in managing it because it's not a one-size-fits-all treatment.

Jonathan Wolf: I mean, one of my takeaways from this is just how complex a lot of these female hormonal-related things are, Jen. Just listening to this, that there's, you know, it's a bit like when you talk about, Sarah, about going through menopause and the way that like every cell in your body is changing with these hormones.

I'd love to switch to actionable advice. And what does a diet look like that supports overall gynecological health? 

Dr. Jen Ashton: I think it looks exactly the same as the diet that supports brain health. And heart health and skin health, head to toe. I think the importance in considering the term of nutritional gynecology is just so that we have an awareness that yes, how we eat affects all of those P's and more, right, as women.

But that doesn't mean that we should eat one thing for our ovaries and another thing for our brain. So what that diet looks like is a diet that has a lot of fiber, has not a lot of added sugar, not a lot of chemicals, that is as much as possible comes from real whole or fresh foods that resemble their form found in nature. And that we minimize again, as much as possible, chemical additives. 

I think in a lot of ways, even though people try to make it very complicated, it's actually not. It's very simple, but that doesn't always mean it's easy. 

Prof. Sarah Berry: I love the fact that you've said that actually what we need to eat for good gynecological health is what we need to eat for good heart health, for good brain health, for our whole body health.

Because I think there's so much misinformation out there. And I also think there's lots of companies that are preying on people's desperation, whether it's fertility, whether it's menopause, whether it's other gynecological areas. 

I think the principles that you've referred to are the principles that good nutrition scientists would promote to everyone. They're the principles that underpin all of what the findings are that we have at ZOE and the advice that we give to our ZOE members. 

So the fiber, the diversity as well is something that we really promote having these diverse, whole-plant, unprocessed foods because we know that they positively impact the microbiome.

And I think this is really interesting that there might also be positively impacting the vaginal microbiome that then might have beneficial effects as well. 

Dr. Jen Ashton: And I think it's how all of these things interact with not only each other but with our organism, our entire body, that's the secret sauce.

They all need to be good. Another way of looking at this a little bit outside of the realm of nutrition, but definitely connected is that the best diet, the best, most pristine, perfect diet is still not enough to negate a bad lifestyle, right? 

So you can eat perfectly, but if you don't sleep enough and if you pollute your body with smoking or vaping or too much alcohol, or in some cases any alcohol or you don't exercise, it doesn't matter how great your diet is. You're not going to be a healthy organism. And I think that's the balance that's really, really important. 

Prof. Sarah Berry: We often talk about the four pillars of health. Diet is one of them. Obviously, we believe it's one of the most important, but also physical activity, stress, so mental health, and sleep being so, so important.

Dr. Jen Ashton: Yeah. So I think that there is emerging data for a variety of gynecologic conditions that high fiber is beneficial, whether you're talking about pregnancy, PCOS, or menopause. I think we can all agree with that, but high fiber is good for literally almost everything, especially the gut microbiome. 

Jonathan Wolf: A lot of the regular listeners to this podcast will also be ZOE members, which means they're part of this personalized nutrition program. Then after you go through this program, you retest again about four or five months later. 

One of the specific things we see is that people who are eating a high diversity of plants, and the number we often talk about is 30 plants a week, that have better microbiomes, and they tend to have a better starting point of their health. And also if they make that change, they have like a better endpoint of their health. 

None of that has been focused on anything to do with gynecology, specifically, as you hear that, are you surprised and how might that link through to someone who's maybe thinking about any of the many conditions that you were talking about today?

Dr. Jen Ashton: I always encourage people all the time, you should do an experiment in self. You should be perpetually and constantly curious about you. In science, we say N of one. Well, you're the one. You're really the only subject that should matter to you. 

So when you add those 30 plants a week and you get a test that says, yes, you have changed your microbiome. Then the real fun starts because then you should be looking at literally everything about yourself. 

As your own little living science experiment and say, What do I notice? Is my skin clearer? Does it look more hydrated? Am I sleeping better? Do I feel more cognitively sharp? More physically energetic? Are my bowel movements better? Is my sex life better? Do I have more vaginal lubrication? Are my periods less painful? 

I mean, just keep going down the list. That's the exciting thing about science. And you don't have to be a scientist to do this. Right? You can use yourself as your own running science experiment.

But what you care about, because you've done incredible science and research and you have the data, is that a ZOE listener can say, Well, I did this and this is what I feel, right? 

And that doesn't mean that if they don't feel anything, that it's not worth doing, by the way. And I want to make that very, very clear because that's a conversation or an example, an analogy that you could make for someone who drinks social alcohol, right? Or moderately and says, well, I did a dry month, which I know is very popular in the U.S. I do several every year. I know it's popular in the U.K. and other parts of the world. And they say, Yeah, I did it. I didn't really feel any difference, but that doesn't mean they didn't do something good for their body by doing it.

So it's just another end point. It's just another thing that I would encourage, and I'm sure you would encourage your listeners to do. It's part of that experiment itself. 

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Prof. Sarah Berry: Yeah. I mean, obviously, as scientists, we want to show that the average response improves. We recognize that we're all hugely variable. This is the whole purpose that underpins what we're doing at ZOE, is understanding what's the best diet? What's the best food for each individual? 

We have, though, been really interested in looking at how this plant diversity beneficially changes the microbiome, but how it has an impact on all of these different things you've described. And what we see is that if you have a more diverse plant-based diet, you're giving yourself loads of different fibers. We need a diversity of different fibers. You're giving yourself a diversity of other chemicals. We know on average each food contains about 72,000 chemicals. We want to have a mix of all of those thousands of chemicals.

And some of these chemicals, like polyphenols, have such a profound impact on our gut microbiome and on our health. And it's only by getting a diversity of different plant-based foods, so up to 30, maybe even beyond that, that you're going to have this really big impact, we think, on your health that we know is partly mediated by the microbiome.

Dr. Jen Ashton: And there's a precedent for that also in the rest of our health and physiology which is in the world of exercise physiology. You talk about the four pillars and I talk about them too. I really believe they are all equally important, believe it or not. Some have much more research and data behind them than others.

But your body is a very smart machine, just like your gut microbiome is very smart and it will get used to anything that it sees too much of, including exercise, which is a good thing. So I love the concept of diversity in what you eat. 

It's no shock to me, it was no shock to me even before I got my master's in nutrition that that's better for our gut microbiome. Just like someone who tells me, I run. Oh, I exercise. I run five miles a day. And I say to them, that's first of all, impressive and great and good for you and it's better than nothing. But understand that your body sees five miles a day as a flat line and you need to challenge it. You need to confuse it. You need to mix it up a little bit. 

Jonathan Wolf: Are there other lifestyle changes other than diet that can really support their gynecological health? 

Dr. Jen Ashton: I actually believe that meditation and stress reduction. Talk about something that hasn't been studied. I think, I believe there is very likely a connection between meditation and stress, overall stress. We're talking about negative stress, not positive stress, and someone's gynecologic health because of the hormonal interaction there. 

The brain sends hormonal signals to the rest of the body, including the ovaries. So it would be absolutely plausible to me that there is a connection there. And so addressing stress from the top down level, I believe can have positive effects. A potentially very positive effect on someone's gynecologic well-being. 

Jonathan Wolf: I think that's so brilliant because I was brought up with this idea that the mind and body are completely separate.

I understand that's partly maybe a bit of a British stiff upper lip, the way I was brought up in these other sort of things, but they had nothing to do with each other. And I think about my grandparents, particularly my grandmother, who I love so much, she'd been through the war and was like, you don't make a fuss, you just keep going. 

And so the idea that these two could be in any way linked is very alien, really, to how I was brought up. But what's interesting is you're talking about it, like, serious doctors and scientists talk about this idea that you could meditate, it might actually change what's going on inside your ovaries. It's sort of mad, and I love it. 

Dr. Jen Ashton: I believe that. I mean, the mind-body connection is real. 

Jonathan Wolf: Jen, I'd like to just quickly try and summarize, please correct me if I got anything wrong. First, you described what you cover, and I was struck by just how many different parts of a woman's health actually are sort of tied back to what you're responsible for.

You talked about this idea that here should be this thing called nutritional gynecology and that really affects your health. And it shouldn't just be this old world of either you're taking medicines or nothing else. 

We touched briefly on the vaginal microbiome as one of these examples of going beyond just thinking about medicine. And I think my main takeaway is that if we think that the gut microbiome is still quite early in its understanding, we really, really don't understand very much about the vaginal microbiome. 

But interestingly, you said your patients tend to be in these two groups; ones where somehow it's all living in this very happy symbiosis and they say, I never have any problems. And another group that's saying, I'm just constantly having infections of various different types.

And I'm really struck by the analogy with what you tend to see with the gut, with people who are having gut problems, all these different issues. And what we know is often if you can, over time, shift your food, you can really fix it. So I think that's really interesting. 

I'd love to come back to that on a whole podcast at some point, Sarah, we should definitely do that. 

You then talked about diet affecting the four Ps; perimenopause, puberty, pregnancy, and PCOS. And that basically it can have a big impact across all of these areas. 

You said something that really shocked me, which is that because of the way that the food we eat is changing, actually girls are going into puberty earlier than they did before. So there's like this real direct impact of like this very high level of ultra-processed food that we're eating on something like so measurable like that, which is a bit terrifying. 

You talked about the diet you've had for years before you get pregnant can really have an impact on the baby and it's a lot of pressure around this but still there's something to be aware of. Whereas whether or not has a big impact on fertility, the science is not as strong as maybe some people have been saying. So to be wary, it sounded like some of the claims about diet for infertility.

PCOS, which I'd heard of, but didn't really have any idea what it was, is affecting one in 10 women with a lot of really serious sounding conditions. And you said if you're able to lose 5% of your weight, it can have a big positive impact, but that's really hard. So the reality is probably think about improving your diet. It's probably the best thing you can do, but this isn't going to solve everything. 

We touched on endometriosis, which does not begin with a P, but apparently is another 1 in 10 and with I think a similar message and again a message that this stuff is complicated and that you need to get to a gynecologist to deal with this.

And then coming through at the end to what is the diet? I think the thing that you said that I thought was brilliant is the best gynecological diet is the same as the best brain health diet, is the same as the best heart health diet. It's basically like this really healthy diet for you. 

It's about whole foods. It's about not having the ultra-processed foods that are surrounding us. And then you said something which I haven't heard someone say before, which is, think about yourself as an ongoing science experiment, right? 

There's all this science about everybody else, but you are unique. At ZOE, we believe in that a lot. We see this huge variation. So test yourself, try getting the 30 plants a week that you know has this effect. And actually, you may well be able to feel it. And in fact, you mentioned a whole bunch of potential ways that you might be able to measure that as a woman that I would not have thought of. So other ways that you might be able to see this change. 

And then finally, you said something I definitely wasn't expecting, you say, Jen, after this very serious scientific and medical take all the way through, is when I asked about what else you could do to support your gynecological health, I thought you were going to talk about like sleep or exercise, and you went to meditation. You said the mind-body link is real, and you really believe that that can make a difference. 

Dr. Jen Ashton: Yeah. That was a perfect summary, Jonathan. Gosh, we've covered a lot of great stuff. 

I think the words that stick in my mind in terms of premise and underlying conceptual background, behind everything we've talked about is holistic. Not in the sense that I'm swinging a crystal over anyone's head or body, but that we're connecting the dots between organ systems in the organism and in the environment. That, to me, is what holistic means from a nutritional and medical standpoint, gynecologic standpoint. 

And the other concept that was the 800-pound gorilla in the room, if you will, is inflammation. Because all of the things we talked about, all of the conditions, as well as all of the remedies or approaches, if you will, are either there with an inflammatory component, or because of inflammation, or reduce or prevent inflammation.

And meditation is part of that. Meditation is part of the triage kit to lower systemic and cellular inflammation. There's science to support that and it's behavioral. 

Jonathan Wolf: Jen, thank you so much. Really appreciate it. I hope we can have you come back again in the future. 

Dr. Jen Ashton: Thank you guys for having me. 

Prof. Sarah Berry: Thank you.

Jonathan Wolf: Now, if you listen to the show regularly, you already believe that changing how you eat can transform your health, but you can only do so much with general advice from a weekly podcast. 

If you want to feel much better now and be on the path to live many more healthy years, you need something more, and that's why more than 100,000 members trust ZOE each day to help them make the smartest food choices.

Combining our world-leading science with your ZOE test results, ZOE is your daily companion to better health for life. So how does it work? ZOE membership starts with at-home testing to understand your unique body. Then ZOE's app is your health coach using weekly check-ins and daily guidance to help you shift your food choices to steadily improve your health.

I rely on ZOE's advice every day and truly it has transformed how I feel. Will you give ZOE a try? The first step is easy, take our free quiz to find out what ZOE membership could do for you. Simply go to zoe.com/podcast, where as a podcast listener, you'll get 10% off. As always, I'm your host, Jonathan Wolf.

ZOE Science and Nutrition is produced by Julie Pinero, Sam Durham, and Richard Willan. The ZOE Science and Nutrition podcast is not medical advice. If you have any medical concerns, please consult your doctor. See you next time.