Sandi Krakowski

90% of the women we help are under 90. It’s so ridiculous!

You can’t lose weight on hormones if your metabolic health is compromised. It’s gonna take something like Tirzepatide or MOTS-c along with exercise, regular labs monitoring inflammatory markers, higher testosterone and no alcohol. Sleep is critically important. Hormones help a lot, but not in place of the rest.

When a woman has a baseline estrogen of 350, she’s in menopause, but she still storing a lot of estrogen in her fat… That level of estrogen is very different than a woman who had less than a 10 estrogen, her ovaries no longer work, and you give her exogenous estradiol to a level of 400. Both will get very different outcomes! The woman who’s carrying the excess body fat, anything you give her, she’s gonna store and you’re gonna have estrogen dominant symptoms, breakthrough bleeding, swelling, and more. Because it’s metabolic! The woman who came on with less than 10 and you take her level to 300 or 400 with exogenous estrogen, and she has a body fat above 30%, you still have to watch her because she’s gonna start storing it. But if her body fat is below 26%, she actually burns through it rather quickly. Baseline levels and giving hormones to a level for a woman who had none produce very different outcomes. Skinny women with no muscle and bodyfat above 30% are in a dangerous position, just like an obese woman. 

**hEDS symptoms** (hypermobile EDS — the most common type, about 90% of EDS cases):

- Joints that bend too far, dislocate or partially slip (subluxations) easily
- Chronic joint and muscle pain, frequent sprains
- Soft, mildly stretchy skin and easy bruising
- Slow wound healing, hernias
- Flat feet, scoliosis, TMJ problems
- Chronic fatigue and poor proprioception (clumsiness)
- GI trouble — reflux, IBS-like symptoms, gastroparesis
- Heavy menstrual bleeding, pelvic organ prolapse
- Frequent fellow travelers: POTS/dysautonomia and MCAS

**Do women get it more?** Yes — diagnosed cases run roughly 9–10:1 female to male, about 90% women in large clinic cohorts. Part of that is likely real (estrogen increases ligament laxity, so symptoms hit harder around puberty, pregnancy, and perimenopause), and part may be underdiagnosis in men — though researchers also note men may genuinely be less affected, since women report a higher symptom burden.

EDS, MCAS, migraines, bloating, achey joints, neck hurting and more can all be because your BHRT is not providing stable levels.

Think of it as a roller coaster problem, if you’re absorbing properly or your levels don’t stay put. Injections for example should not see peaks and troughs. More frequent injections fixes this.

EDS- The cells that build and maintain collagen have estrogen receptors. When estradiol surges, collagen synthesis drops and ligaments get laxer; when it crashes, tissues tighten back up. In someone whose collagen is already faulty, that constant loosening-and-tightening means joints slip more, more micro-injuries, more subluxations and pain flares.

MCAS- Mast cells also carry estrogen receptors, and estradiol can directly trigger them to dump histamine and other mediators. So each hormonal swing can set off flushing, gut symptoms, hives, or a full flare — then the crash doesn’t calm things neatly, it just sets up the next surge.

Stable levels give tissues and mast cells one consistent signal to adapt to. Peaks and troughs create repeated activation-withdrawal cycles, so symptoms flare on the swings themselves.