Perimenopause Symptoms Can Start in Your Late 30s - Dr. Remina Panjwani | TUH #312

Episode Overview

• Host Gary Brecka (a human biologist with a data science background) interviews Dr. Ramina Panjwani—a board-certified Internal Medicine Physician, Air Force veteran, functional medicine practitioner, TEDx speaker ("Regulate Before You Stimulate"), and author of Odd Girl Out and the Doctor Within—on how autonomic nervous system dysregulation drives burnout, hormone imbalances, gut dysfunction, and generational trauma.
• The conversation explores why high performers and biohackers cannot out-supplement or outperform a nervous system stuck in sympathetic "fight or flight," and why layering intense optimization tools onto an unregulated body acts as an additional physiological stressor.
• Brecka and Dr. Panjwani examine the overlooked signs of perimenopause and menopause (which can begin in a woman's late 30s), the limitations of standard blood work compared to comprehensive hormone and metabolic panels, and the history of FDA warnings on hormone replacement therapy.
• The episode connects psychological stress to cellular DNA changes, developmental trauma in 7-year increments, and gut-brain axis disruption via the vagus nerve, offering foundational habits to restore baseline biology.
• Disclosed business ties and sponsors include Dr. Panjwani's private functional medicine brand/practice (having left full-time conventional hospital medicine, though she still picks up hospital shifts to maintain skills) and her book; Brecka's paid VIP community; Brecka's own brand The Ultimate Brew (independently tested, USDA Organic certified coffee tested for molds and heavy metals, available at Sprouts stores starting October 7th at THEULTIMATEBREW.COM); Baja Gold Mineral Sea Salt ($15–$20 bag); and H2Tab molecular hydrogen tablets (DRINKH2TAB.COM, promo code: ULTIMATE10).

Key Concepts

• Sympathetic Overdrive and High-Performer Burnout: While a morning cortisol spike that tapers off by bedtime is a normal diurnal rhythm, remaining in a sympathetic "fight or flight" state after a stressor passes leads to burnout. Early warning signs ("yellow lights") in high performers include fatigue, disrupted sleep, brain fog, hormone shifts (in both men and women), changes in body composition, low libido, gut sensitivities (inability to eat certain foods), frequent illness, inflammation, and joint pain. Brecka compares Type-A high performers in daily life to conditioned professional triathletes: whereas amateur triathletes who "bonk" during races usually only need a roadside saline IV, conditioned pros push themselves so far into their physiological threshold that when their body shuts down, it is almost a medical emergency.
• Unconventional Backgrounds in Medicine: Defying cultural stereotypes, Dr. Panjwani shares that her working-class South Asian parents did not push her to become a doctor, instead telling her to just get married and have kids; she rebelled by joining the US Air Force to fund and forge her own path into medicine. Alongside her internal medicine training, she advocates for modalities like vibroacoustic therapy (sound healing), binaural beats, hypnotherapy, and shadow work to bypass the analytical mind, while noting that it takes about 21 days to tap into neuroplasticity to rewire a brain or nervous system response (and longer to sustain it).
• Overlooked Perimenopause Symptoms and Hormone Replacement Therapy (HRT): Perimenopause and menopause symptoms can begin in a woman's late 30s and frequently include 3:00 AM wake-ups, brain fog, mood changes (often misdiagnosed and treated with antidepressants), joint/shoulder pain, and a random "belly pooch" regardless of diet or HIIT workouts. Brecka shares that his wife, Sage Workinger, entered menopause in her mid-40s, which took 18 months to recognize because hot flashes came at the very end; her symptoms included brain fog, waking exhaustion, loss of organizational capacity, irritability, unprovoked crying, random itchiness, and frozen shoulder (adhesive capsulitis) where she could not raise her arm above 90 degrees and which an orthopedic surgeon wanted to break under general anesthesia. Just 3 weeks after starting HRT, her libido, energy, focus, mood, and frozen shoulder completely resolved. Brecka notes the FDA recently removed black box warnings from female hormone therapy, citing commentary by Dr. Marty Makary estimating that 50 million women needlessly suffered due to the patently false belief—not supported by what the Women's Health Initiative (WHI) study actually said—that hormone therapy caused or exacerbated breast cancer. Dr. Panjwani notes that for the right women, bioidentical hormones support cardiovascular health, mood, brain function, and memory, though she hedges that women in their 30s do not have to jump straight to bioidentical hormones.
• Comprehensive Hormone and Metabolic Diagnostics: Standard blood panels (CBC, CMP, basic lipid panels, basic LH/FSH/estrogen) are a mere snapshot in time and miss progesterone, pregnenolone, and hormone metabolites. In contrast, the DUTCH test provides a personalized breakdown of hormone pathways, showing different forms of estrogen, how hormones are metabolizing, methylation/detoxification status, progesterone levels, and whether a simple B-vitamin deficiency is impairing hormone metabolism. Similarly, because chronic cortisol causes metabolic derangement (blood sugar dips, "hangry" cravings, insulin resistance), stores belly fat, and pulls from muscle tissue so you cannot build muscle, patients should test fasting insulin and fasting glucose to catch dysfunction early rather than relying solely on HbA1c, which only measures a 3-month average of blood glucose.
• US Healthcare Spending and Generational Trauma: Brecka points out that the United States spends $5 trillion a year on healthcare, yet 42% of prepubescent children have at least 1 chronic disease—a rate not found even in third-world countries lacking clean water and sanitation. Dr. Panjwani explains how chronic physical or psychological stress in a pregnant mother feeds stress hormones into the womb, turning psychological stress into physiological cellular changes that embed into DNA and pass on to the child, wiring their nervous system for survival mode. She adds that humans experience developmental milestones in 7-year increments: caregivers make a massive imprint on how a child responds to triggers during the first 7 years (0–7), while the next increment (7 to 14 years) involves school environments (such as bullying) that further shape complexes. Brecka explicitly notes that "there's no test for" generational trauma in primary care and disclaims his own expertise, stating he has "very limited experience with this in terms of treating it or having any real training in it."
• The Gut-Brain Axis and Evolving Peptide Therapeutics: The central nervous system (brain) and enteric nervous system (gut, which houses trillions of microbes) communicate bidirectionally via the vagus nerve. Chronic stress halts digestion and inflames the gut lining, compromising tight junctions; in the US, the three most common inflammatory food offenders are gluten, dairy, and "sometimes eggs." Regarding emerging therapies, Brecka notes a recent FDA Pharmacy Compounding Advisory Committee (PCAC) meeting recommended allowing the compounding of 6 peptides, moving them from Category 2 (research use only) to Category 1 (human use). Dr. Panjwani hedges on the peptide trend, noting that "more information is being released" and emphasizing that they are helpful "for the right person, looking at, of course, the whole picture" rather than as a standalone magic bullet.

Quotes

• At 0:00:50 - "You cannot outperform a dysregulated nervous system that's always in fight or flight." - Dr. Panjwani establishing the core thesis of the episode regarding high performance and nervous system health.
• At 0:04:51 - "So we get to the point where if we're overstimulating, if you're overdoing, it's still a stressor on your body." - Dr. Panjwani explaining why intense routines and biohacking protocols can backfire when layered onto a stressed physiology.
• At 0:06:54 - "When you're a high performer, you're going to show up differently, burnout's going to show up differently. It's little subtle signs that eventually you're going to pay the bill for." - Dr. Panjwani describing how Type-A individuals mask early warning signs of physiological breakdown.
• At 0:08:16 - "Because they were so conditioned that they would push themselves so far into that physiologic threshold that by the time their body shut down, it was almost a medical emergency." - Gary Brecka comparing elite triathletes who collapse in races to conditioned high performers in daily life.
• At 0:09:41 - "Start five minutes and that's going to be your peak in those simple moments. Start with breathing in bed, start simple. Regulating that breath is with you everywhere and that's going to tap into your vagus nerve and set off your nervous system and balance that sympathetic, parasympathetic response." - Dr. Panjwani detailing how a morning pause rewires the autonomic nervous system for the day.
• At 0:14:37 - "Dr. Marty Makary, when he was still the chairman of the FDA, said they estimated 50 million women needlessly suffered because they thought that hormone therapy led to breast cancer or exacerbated their chances of getting breast cancer, which turned out to be patently false." - Gary Brecka discussing the removal of FDA black box warnings on female hormone replacement therapy and misconceptions around the Women's Health Initiative study.
• At 0:19:18 - "The DUTCH panel gives you everything personalized to your body, like the breakdown of the pathway, if you're having the good form of estrogen, right? It's not just one form of estrogen." - Dr. Panjwani contrasting comprehensive hormone metabolite testing with standard blood panels.
• At 0:26:45 - "You look at the data on just healthcare in general, we spend $5 trillion a year on healthcare, but 42% of our prepubescent children have one chronic disease." - Gary Brecka highlighting the disconnect between US medical expenditures and pediatric chronic illness rates.
• At 0:33:42 - "If you're constantly stressed, whatever it is, if you're constantly stressed, even if it was a physical or psychological, it turns into physiological and that gets into your biology. And what that means is it has a cellular change. The cellular change gets into your DNA and it's passed on." - Dr. Panjwani explaining the biological mechanism behind generational trauma.
• At 0:56:34 - "You can't out-supplement a dysregulated, off-balance biology." - Dr. Panjwani emphasizing that foundational nervous system regulation and food diversity must precede supplementation.

Takeaways

• Practice the 5-to-10-Minute Morning Regulation Window: Avoid blue light and phones immediately upon waking, and spend your first 5 to 10 minutes in bed doing breathwork, meditation, journaling, or prayer to tap into the vagus nerve and balance your nervous system for the day. During acute stress, give yourself a 30-second pause to let your nervous system balance, or use structured breathwork like Box Breathing, the Physiological Sigh (credited to Andrew Huberman), or 4-7-8 Breathing (4-second inhale, 7-second hold, 8-second sigh/exhale) to regulate Heart-Brain Coherence, which can be tracked scientifically via Heart Rate Variability (HRV).
• Prepare for Hormonal Shifts in Your 30s with Protein and Training: Dr. Panjwani advises women in their 30s to prepare for perimenopause before jumping straight to bioidentical hormones by doing resistance training and eating 30 grams of protein per meal.
• Request Comprehensive Hormone, Metabolic, and Gut Panels: Instead of relying solely on standard blood snapshots or a 3-month HbA1c average, ask your practitioner for a DUTCH test to evaluate hormone pathways, methylation, progesterone, and B-vitamin status; test both fasting insulin and fasting glucose to catch early metabolic dysfunction; and utilize advanced stool testing such as GI Effects (Dr. Panjwani's current favorite), GI-MAP, or Gut Zoomer to identify gut dysbiosis.
• Prioritize Whole-Food Microbiome Diversity Over Blanket Probiotics: Because you cannot out-supplement a dysregulated biology, reserve probiotic supplements for targeted goals (such as rebuilding bacteria post-antibiotics) and focus on reducing common US inflammatory offenders (gluten, dairy, and sometimes eggs) while eating diverse whole foods: kefir, kimchi, yogurt, sauerkraut, berries, sourdough, lentils, and beans (which provide fiber for colorectal cancer prevention).
• Choose Nature and Rucking Over High-Tech Stressors: Avoid piling extra biohacking stressors onto an already exhausted body; instead, consider low-tech outdoor movement like Brecka's routine of walking a 3.5-mile loop for 1 hour and 15 minutes wearing a weighted vest at 10,000 to 10,500 feet elevation in Colorado, which he states makes him feel better than his hyperbaric chamber, red light bed, cold plunge, or sauna.
• Evaluate Trace Mineral and Molecular Hydrogen Protocols: In his sponsor segments, Brecka recommends taking 1/4 teaspoon of Baja Gold Sea Salt in water first thing in the morning to provide essential trace minerals (noting a $15 or $20 bag lasts 5 years), and suggests H2Tab tablets to deliver 12 parts per million (ppm) of molecular hydrogen for less than $1 a day, citing over 1,300 published studies showing benefits for oxidative stress, energy, recovery, and brain function.