Monday, November 19, 2018

What Is a Cystoscopy

A cystoscopy is an interventional procedure that provides an immediate view of the interior of the bladder and/or urethra, the tube that carries urine from the bladder to outside the body. The test is used for diagnosis and treatment of medical conditions that affect these organs. A thin tube (cystoscope) is inserted into the urinary opening, threaded through the urethra, and into the bladder. A small camera attached to the cystoscope relays live video feed to a monitor, which can be viewed by your doctor.

A cystoscopy can be used to investigate symptoms that involve the urethra or the bladder. You may need to have a cystoscopy to determine the cause of concerns such as:

However, this invasive procedure is typically done after an abnormality of the urethra or bladder has been discovered on an X-ray, magnetic resonance imaging (MRI), or a computed tomography (CT) scan, which are non-invasive tests. Cystoscopy provides your doctor with a different view that can help lead to a diagnosis.

Upon visualizing the inside of your urethra and bladder, your doctor may be able to identify structural abnormalities, areas of inflammation, growths, or ulcerations and diagnose a number of conditions on sight, including:

If a diagnosis cannot be made based on appearance alone, your doctor may obtain a sample of abnormal tissue for biopsy during the procedure so that it can be evaluated. (A cystoscope is often equipped with a tool that can quickly this sample.) If you have a biopsy, this does not necessarily mean that you have cancer. Biopsy is used to examine areas of infection, inflammation, and benign growths as well.

If a cystoscopy is being done for therapeutic reasons, it may be to visualize the bladder or urethra to allow for the removal of small growths, bladder stones, or to treat urethral strictures.


A cystoscopy cannot identify every problem involving the bladder or urethra. For example, it often does not find the cause of urinary incontinence or neurogenic bladder. A cystoscopy also is not useful in diagnosing kidney disease.
Risks and Contraindications

In most cases, a cystoscopy is a safe, common procedure without complications. Rare complications can occur, such as an infection or injury. Complications related to general anesthesia are not common and can include respiratory or cardiac problems.
Before the Test

If you are going to have a cystoscopy, your doctor will discuss the procedure with you ahead of time. You may or may not need a biopsy or treatment during your procedure, and that will dictate if you have it done at your doctor's office or elsewhere. Your doctor and medical team will discuss your specific situation with you and explain the plan, as well as what you need to do to prepare. For example, you may be asked to avoid urinating for about half an hour prior to the test so that your doctor can send a urinalysis.


The level of anesthesia that will be used, if it is used at all, will mainly dictate where your procedure is done. This decision depends on how complicated your condition is and the findings of your preliminary tests. Most cystoscopy procedures are performed in your doctor's office with local anesthesia. But if she anticipates that your procedure may take longer than average or may involve painful or extensive removal of tissue or repair of strictures, you will likely need to have your cystoscopy done under general anesthesia in a hospital or surgical center.


You should expect to spend about an hour or so at the doctor's office if you are having a simple procedure done there. If you are having a cystoscopy under general anesthesia, anticipate spending approximately half a day at the hospital or surgical center.

The cystoscopy itself generally takes about 10 to 30 minutes to perform. The time can vary based on the reason you're getting the test done and what is discovered during the procedure. Your medical team can give you a more specific estimate based on your symptoms and preliminary imaging tests.

What to Wear

You will be asked to wear a gown for the procedure, so you can wear anything you want on the day of the test.

Food and Drink

If you are having general anesthesia, you will be asked to abstain from food and drink for about six to eight hours prior to your procedure.

Cost and Health Insurance

As with most tests, your insurance may require a pre-authorization request. The staff at the facility where your cystoscopy will be done will take care of this, but you can check with them and your insurance company ahead of time to confirm. You may need to pay a co-pay, and you can verify the amount with your health insurance carrier in advance.

If you are paying for the procedure completely out of pocket, you should expect to pay several hundred dollars for a simple diagnostic procedure and several thousand dollars for a procedure that includes a biopsy or therapeutic treatment.

What to Bring

You should bring your order form (if provided), your health insurance card, a form of personal identification, and payment to cover the co-pay or the cost of the procedure, as applicable. If you will be getting general anesthesia, you should also make sure that you have someone who can drive you home after your procedure.
During the Test

You will meet with the urologist, who is the doctor who will perform your test. You will have other team members involved in your care as well, and these may include a surgical assistant, a nurse, and an anesthesiologist or anesthetist.

You will likely have more people involved in your procedure if you are having it done in an operating room, and fewer people if you are having it done in a doctor's office.


Prior to your test, you will be asked to fill out several forms. These will include an agreement to pay for the test or to authorize your health insurance to pay for it, a patient privacy form, and a consent form stating that you understand the purpose and risks of the procedure.

You will then be asked to undress from the waist down, put on a gown, and empty your bladder. When your medical team is just about ready to perform the test, you will lie down on an exam table and place your feet in stirrups.

Local anesthetics used for a cystoscopy are typically in the form of a gel or other jelly-like substance. If you are to receive this, it will be inserted into the urethra. The doctor will wait a few minutes for the anesthetic to effectively numb the area before inserting the cystoscope.

If your procedure will be done under general anesthesia, you will have an IV placed in your arm or hand, and the anesthetic will be injected. You will also be hooked up to oxygen level and heart rate monitors, which will be checked throughout the procedure.

Throughout the Test

The cystoscope will then be inserted into the urinary opening. It will make its way to your bladder, with your doctor's help, via the urethra. Both may be of interest to your doctor, who will pause at times to view them on the monitor.

Your doctor may use a flexible cystoscope or a rigid cystoscope, which are generally the same size. There are advantages to each. For example, rigid cystoscopes tend to have a better camera and allow your doctor to have more control for removal of a mass or a stone, while flexible cystoscopes tend to produce less discomfort. Your cystoscopy may involve a white or a blue light to visualize the bladder and urethra. Blue light cystoscopy may be better for detecting bladder cancer.

A solution of saline or sterile water will be inserted into your bladder via the cystoscope, once in position. The solution expands the bladder, allowing your doctor to get a more detailed view. You may feel some pressure at this point.

If your doctor finds an abnormal growth, a biopsy may be done during your cystoscopy. While your doctor may have anticipated the need for this in advance, the decision to perform a biopsy may also be made in the moment. It only takes seconds for your doctor to obtain a tissue sample, and you may feel a slight pinch or a cramping sensation during the biopsy.

If you need to have a procedure to remove a mass or a bladder stone or to expand a stricture, it will be performed at this time. This is generally planned in advance.

At the end of the cystoscopy—which generally takes half an hour or less, unless a biopsy or treatment is being performed—your doctor will remove the cystoscope and you should not need any stitches or bandages.


As long as you are feeling fine, you will be discharged once your team verifies that you are able to empty your bladder. You will be directed to a restroom or provided with a bedpan; ask for assistance, if needed.

If you had general anesthesia, it will take an hour or so for you to feel awake. Staff will make sure that you can walk without assistance before allowing you to head home with someone who can drive you.

If a tissue sample was collected, it will be sent to a lab for testing.
After the Test

After the procedure, you may experience a slight burning sensation when you urinate and see a small amount of blood in your urine. You may also feel the need to urinate frequently, even though the amount you produce each time may be low. This is normal and can be expected for up to 24 hours after the procedure.

Managing Side Effects

If you experience significant bleeding, incontinence, urinary retention, or if you see blood clots in your urine, call your doctor promptly. If you develop fevers, chills, or if your urine appears cloudy, you may have a urinary infection, and you should call your doctor.
Interpreting Results

Your test results are based on your doctor's observation of your bladder and urethral anatomy during the test, as well as the biopsy results (if applicable). Your doctor may discuss the results with you during the test itself or immediately afterward, or she may schedule a follow-up appointment later to discuss the results and next steps in detail.


The follow-up plan depends on your results. If you have a urethral stricture, for example, this may need to be repaired with a procedure. If you have an enlarged prostate, this can be treated with medication or surgery. And if you have a benign mass, it may need to be removed if it is causing symptoms. If it is discovered that you have cancer of the bladder, you may need to have chemotherapy, radiation, or surgery, or a combination of these treatments.

A Word From Verywell

Conditions that affect the bladder or urethra can be very uncomfortable, causing pain, or discomfort with urination, and even in between urinating. Having an interventional procedure may also briefly cause additional discomfort. In general, cystoscopy is well tolerated with few, if any complications. Once diagnosed, medical conditions that involve the bladder or urethra can be effectively treated.

You may be surprised to learn that the composition of our body fluids is quite complex. With respect to body fluids, form follows function. Our body synthesizes these fluids to meet our physical, emotional, and metabolic needs. With that, let's take a closer look at what the following body fluids are made of: sweat, cerebrospinal fluid (CSF), blood, saliva, tears, urine, semen, and breast milk.

Sweating is a means of thermoregulation—a way that we cool ourselves. Sweat evaporates off the surface of our skin and cools our bodies.

Why don't you sweat? Why do you sweat too much? There is variability in how much people sweat. Some people sweat less, and some people sweat more. Factors that can affect how much you sweat include genetics, gender, environment, and fitness level.

Here are some general facts about sweating:

    Men sweat more on average than women.
    People who are out of shape sweat more profusely than people who are at a higher fitness level.
    Hydration status can affect how much sweat you produce.
    Heavier people sweat more than lighter people because they have a greater body mass to cool.

Hyperhidrosis is a medical condition in which a person can sweat excessively, even during rest or when it’s cold. Hyperhidrosis can arise secondary to other conditions, such as hyperthyroidism, heart disease, cancer, and carcinoid syndrome. Hyperhidrosis is an uncomfortable and sometimes embarrassing condition. If you suspect that you have hyperhidrosis, please meet with your physician. There are treatment options available, such as antiperspirants, medications, Botox, and surgery to remove excess sweat glands.

The composition of sweat depends on many factors, including fluid intake, ambient temperature, humidity, and hormonal activity as well as the type of sweat gland (eccrine or apocrine). In general terms, sweat contains the following:

Sweat produced by the eccrine glands, which are more superficial, has a faint smell. However, sweat produced by the deeper and larger apocrine sweat glands located in the armpit (axilla) and groin is smellier because it contains organic material derived from the decomposition of bacteria. The salts in sweat give it a salty taste. The pH of sweat ranges between 4.5 and 7.5.

Interestingly, research suggests that diet can affect sweat composition, too. People who consume more sodium have a higher concentration of sodium in their sweat. Conversely, people who consume less sodium produce sweat that contains less sodium.
Cerebrospinal Fluid

Cerebrospinal fluid (CSF), which bathes the brain and spinal cord, is a clear and colorless fluid, which has numerous functions. First, it provides nutrients to the brain and spinal cord. Second, it eliminates waste products from the central nervous system. And third, it cushions and protects the central nervous system.

CSF is produced by the choroid plexus. The choroid plexus is a network of cells located in the brain ventricles and is rich in blood vessels. A small amount of CSF is derived from the blood-brain barrier. CSF is made up of several vitamins, ions (i.e, salts), and proteins including the following:


Blood is a fluid that circulates through the heart and blood vessels (think arteries and veins). It carries nutrition and oxygen throughout the body. It consists of:

White blood cells, red blood cells, and erythrocytes all originate from the bone marrow.

Plasma is by and large made of water. Total body water is divided into three fluid compartments: (1) plasma; 2) extravascular interstitial fluid, or lymph; and (3) intracellular fluid (fluid inside cells).

Plasma is also made of (1) ions or salts (mostly sodium, chloride, and bicarbonate); (2) organic acids; and (3) proteins. Interestingly, the ionic composition of plasma is similar to that of interstitial fluids like lymph, with plasma having a slightly higher protein content than that of lymph.
Saliva and Other Mucosal Secretions

Saliva is actually a type of mucus. Mucus is the slime that covers mucous membranes and is made of glandular secretions, inorganic salts, leukocytes, and sloughed-off skin (desquamated) cells.

Saliva is clear, alkaline, and somewhat viscous. It’s secreted by the parotid, sublingual, submaxillary, and sublingual glands as well as some smaller mucous glands. The salivary enzyme α-amylase contributes to the digestion of food. Furthermore, saliva moistens and softens food.

In addition to α-amylase, which breaks down starch into the sugar maltose, saliva also contains globulin, serum albumin, mucin, leukoctyes, potassium thiocynatate, and epithelial debris. Additionally, depending on exposure, toxins can also be found in saliva.

The composition of saliva and other types of mucosal secretion varies on the basis of the requirements of the specific anatomical sites that they wet or moisten. Some functions that these fluids help perform include the following:
Saliva and other mucosal secretions share most of the same proteins. These proteins are mixed differently in different mucosal secretions based on their intended function. The only proteins that are specific to saliva are histatins and acidic proline-rich proteins (PRPs).

Histatins possess antibacterial and antifungicidal properties. They also help form the pellicle, or thin skin or film, that lines the mouth. Furthermore, histatins are anti-inflammatory proteins which inhibit the release of histamine by mast cells.

Acidic PRPs in saliva are rich in the amino acids like proline, glycine, and glutamic acid. These proteins may help with calcium and other mineral homeostasis in the mouth. (Calcium is a chief component of teeth and bone.) Acidic PRPs may also neutralize toxic substances found in food. Of note, basic PRPs are found not only in saliva but also in bronchial and nasal secretions and may proffer more general protective functions.

Proteins more generally found in all mucosal secretions contribute to functions common to all mucosal surfaces like lubrication. These proteins fall into two categories:

The first category consists of proteins that are produced by identical genes found in all salivary and mucous glands: lisozyme (enzyme) and sIgA (an antibody with immune function).

The second category consists of proteins that are not identical but rather share genetic and structural similarities, such as mucins, α-amylase (enzyme), kallikreins (enzymes), and cystatins. Mucins give saliva and other types of mucus their viscosity, or thickness.

In a 2011 paper published in Proteome Science, Ali and co-authors identified 55 different types of mucins present in the human airway. Importantly, mucins form large (high-molecular-weight) glycosylated complexes with other proteins like sIgA and albumin. These complexes help protect against dehydration, maintain viscoelasticity, protect cells present on mucosal surfaces, and clear bacteria.

Tears are a special type of mucus. They are produced by the lacrimal glands. Tears produce a protective film that lubricates the eye and flushes it of dust and other irritants. They also oxygenate the eyes and help with the refraction of light through the cornea and onto the lens on its way to the retina.

Tears contain an intricate mixture of salts, water, proteins, lipids, and mucins. There are 1526 different types of proteins in tears. Interestingly, compared with serum and plasma, tears are less complex.

One important protein found in tears is the enzyme lysozyme, which protects the eyes from bacterial infection. Furthermore, secretory Immunoglobulin A (sIgA) is the main immunoglobulin found in tears and works to defend they eye against invading pathogens.

Urine is produced by the kidneys. It is by and large made of water. Additionally, it contains ammonia, cations (sodium, potassium, and so forth) and anions (chloride, bicarbonate, and so forth). Urine also contains traces of heavy metals, such as copper, mercury, nickel, and zinc.

Human semen is a suspension of sperm in nutrient plasma and composed of secretions from the Cowper (bulbourethral) and Littre glands, prostate gland, ampulla and epididymis, and seminal vesicles. The secretions of these different glands are incompletely mixed in whole semen.

The first portion of ejaculate, which makes up about five percent of total volume, comes from the Cowper and Littre glands. The second portion of ejaculate comes from the prostate gland and makes up between 15 percent and 30 percent of the volume. Next, the ampulla and epididymis make minor contributions to the ejaculate. Finally, the seminal vesicles contribute the rest of the ejaculate, and these secretions make up most of the volume of semen.

The prostate contributes the following molecules, proteins, and ions to semen:

The concentration of calcium, magnesium, and zinc in semen vary among individual men.

The seminal vesicles contribute the following:

Although most of the fructose in semen, which is a sugar used as fuel for sperm, is derived from the seminal vesicles, a little bit of fructose is secreted by the ampulla of the ductus deferens. The epididymis contributes L-carnitine and neutral alpha-glucosidase to semen.

The vagina is a highly acidic environment. However, semen has a high buffering capacity, which allows it to maintain a near-neutral pH and penetrate cervical mucus, which also has a neutral pH. It’s unclear exactly why semen has such a high buffering capacity. Experts hypothesize that HCO3/CO2 (bicarbonate/carbon dioxide), protein, and low–molecular weight components, such as citrate, inorganic phosphate, and pyruvate, all contribute to buffering capacity.

The osmolarity of semen is pretty high due to high concentrations of sugars (fructose) and ionic salts (magnesium, potassium, sodium, and so forth).

The rheological properties of semen are quite distinct. On ejaculation, semen first coagulates into a gelatinous material. Coagulation factors are secreted by seminal vesicles. This gelatinous material is then converted to a liquid after liquefying factors from the prostate take effect.

In addition to providing energy for sperm, fructose also helps form protein complexes in sperm. Furthermore, over time, fructose breaks down by a process called fructolysis and produces lactic acid. Older semen is higher in lactic acid.

The volume of ejaculate is highly variable and depends on whether it is presented after masturbation or during coitus. Interestingly, even condom use can affect semen volume. Some researchers estimate that the average semen volume is 3.4 mL.
Breast Milk

Breast milk comprises all the nutrition that a newborn baby needs. It is a complex fluid that’s rich in fat, proteins, carbohydrates, fatty acids, amino acids, minerals, vitamins, and trace elements. It also contains various bioactive components, such as hormones, antimicrobial factors, digestive enzymes, trophic factors, and growth modulators.
A Word From Verywell

Understanding what body fluids are made of and simulation of these body fluids can have therapeutic and diagnostic applications. For instance, in the field of preventive medicine, there is interest in analyzing tears for biomarkers to diagnose dry eye disease, glaucoma, retinopathies, cancer, multiple sclerosis, and more.
re you interested in optimizing your health? Are you overwhelmed by the amount of information and guidance out there? In his new book, How to Be Well, Dr. Frank Lipman organizes your health into six essential pillars. A leader in integrative and functional medicine and member of the mbg Collective, Dr. Lipman wants you to know these facts about carbohydrate intolerance.

Carbohydrate tolerance is a gray area. The amount of carbohydrates that works for one person's metabolism doesn't always serve another's. In the past decade, I've seen a growing number of patients who for years have limited sugary foods and swapped out refined carbohydrates for whole grain products, sweet potatoes, and fresh fruit. Yet they are overweight or have surges of fatigue, foggy-headedness, or cravings. Sometimes they don’t carry any extra pounds but have worryingly high levels of blood sugar. It’s not unusual for these issues to come on late in life; their response to a diet they used to do well on has suddenly shifted.

Why this happens is a topic of robust debate in nutritional circles. It’s likely a combination of factors: a genetic predisposition combined with a sedentary, stressful, and sleep-deprived lifestyle; decades of processed foods and medications that have altered the microbiome; or even (unfortunately) overconsuming the healthy-seeming multigrain breads, bananas, and beans, which all turn to sugar in the blood. All this can lower your personal "set point" for tolerating carbohydrates so that your blood sugars don’t fall back to normal within two hours of eating as they should. Instead, they stay elevated, going beyond what the cells can handle, and eventually this triggers a chain of effects that lead to insulin resistance, the precursor to high blood pressure, heart disease, diabetes, obesity, possibly Alzheimer’s disease, and even some cancers. The 2017 National Diabetes Statistics report found that an estimated 50 percent of Americans have either diabetes or pre-diabetes and that many are unaware of this fact.

Taking your blood sugar seriously is nothing to sneeze at. When carb intolerance is at play, your body is telling you to get stricter with your intake. To follow a low-carb diet, nix all sugars and reduce complex carbs dramatically, replacing them with plenty of nonstarchy vegetables and generous amounts of fat. In addition, take sleep seriously, work on repairing the gut, and increase the amount of movement you do. The low-carb diet, along with these other fundamental improvements, can often help restore order where there was previously metabolic chaos. To catalyze real metabolic change in cases of significant weight gain or diabetes, it may be warranted to take the low-carb approach to its ultimate extreme: the ketogenic protocol.

There is another, more accurate way to learn your personal carb set point. Use a glucose monitor to measure the impact of a range of carbohydrate-rich foods on your blood sugar. Twice after eating, at the one-hour and two-hour marks, you can get snapshots of how your body metabolizes starches like grains, beans, and potatoes. If this level of detective work speaks to you, try the protocol outlined in Robb Wolf’s book Wired to Eat. His program of dietary change, basic blood work, and a seven-day carb test can help you zero in on your set point and your level of insulin resistance.

We all know that exercise is supposed to be good for us, but only about 20 percent of people move regularly. Those of us who exercise may be drawn into popular workout trends, like CrossFit or hopping on the elliptical for 60 minutes, but in my research, I've learned that overly aggressive high-intensity interval training (HIIT) or chronic cardio may not be the smartest way to look and feel our best.
Overexercising releases two key hormones.

Overexercising releases two key hormones: CRH and cortisol, both related to the stress response. CRH increases the permeability (or leakiness) of the intestinal wall as well as the permeability of the lungs, skin, and blood-brain barrier. Cortisol levels rise with rigorous exercise, such as running, which may cause too much wear and tear and accelerate aging. High cortisol also alters tight junctions between cells such that small harmful substances may pass through the barrier. Additionally, high cortisol reduces gut motility, blocks digestion, blunts blood flow to the gut, and lessens mucus production, an important immune function. For people with dysregulation of the control system for CRH and cortisol, the hypothalamic-pituitary-adrenal axis, you may need to back off your workouts in order to fully heal, as part of a comprehensive functional medicine protocol. Even elite athletes get help from several workarounds, such as by supplementing with probiotics, omega-3s, and vitamin C; however, moderation may be your best bet.
Sometimes weight loss is counterintuitive.

Personally, I love to run. But at age 35, I discovered that my serum cortisol was three times what it should be in the morning. Intense exercise raises cortisol even further, which was causing several downstream problems for me: weight gain, short telomeres, blood sugar problems, knee pain, leaky gut, fatigue, and I was stuck in a pattern of revving my body too much with my workouts. When I backed down on running mileage each week and added more adaptive exercise like yoga, Pilates, gyrotonics, and barre class, my HPA healed and I got a better response to exercise. I lost weight. My joints were happier. My telomeres were better.
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How much exercise is too much?

On the flip side, inactivity and sitting too much are not good for you either. In particular, sitting too much increases your risk of diabetes and heart disease, plus it makes your hip flexors tight, which can contribute to low back pain and stiffness. Just like Icarus's mandate not to fly too high or too low, there's a middle ground that provides the greatest longevity benefits. When you don't exercise enough, it can harm your immune system, reduce your stress resilience, and dysregulate your circadian rhythm. When you exercise too much—too long, too intensely, too frequently, and without sufficient recovery—you may cause problems to your stress-response system, leading to immune problems, injury, and a leaky gut.

In summary, like many things when it comes to health, exercise has a U-shaped association, meaning that moderate amounts are optimal but low or high levels can be harmful. The general recommendation I subscribe to is to exercise 20 to 30 minutes per day four times per week.

What kind of exercise is ideal? I call it targeted exercise—burst training and adaptive workouts, like Pilates, barre, or yoga. These will stabilize cortisol levels, help with weight loss, and keep your muscles toned.

Here are my basic tenets for optimal exercise:
1. Move less but more often.

Aim for bursts of movement that fold into your natural rhythm. Do a one-minute burst of enthusiastic dancing after you wake up. Invest in a stand-up or treadmill desk, and use it daily (I've walked more than 2,000 miles on mine while writing my newest book, Younger). Practice heel lifts while you chat on the phone or stand in line at the grocery store. Perform 12 push-ups after going to the bathroom. The point is to incorporate moments of movement rather than only forced discipline that's devoid of pleasure. Start small by adding one to five minutes of new movement to your routine each day during this week.
2. Burst-train.

In the morning or before 1 p.m. two to three times per week, do an exercise where you focus on fast-twitch muscle bursts. Cave men and women tended to exercise in bursts: a quick run to the river to fetch water and carry a bucket back to the tribe, a jog with a sick infant to a neighbor's dwelling for help. Our bodies perform well with burst training and then recover at a moderate intensity for one to three minutes. Protocols vary; use one that makes the most sense for you. Burst training can be applied to cardio exercise (e.g., intermittently sprinting on a trail alternating with a jog) or weight lifting (lifting a weight, such as with a biceps curl, as many times as you can with good form for one minute, followed bya one minute of rest). Other examples:

    Walking three minutes fast (approximately 6 or 7 on an exertion scale from 1 to 10, or the green zone of 70 to 80 percent of your maximal exertion), then alternating with three minutes at a normal pace.
    Chi running with sprint intervals or regular running with 30-second sprints.
    High-intensity interval training (HIIT) with weights or cardio (stationary bike, elliptical, treadmill), alternating two to three minutes at a moderate pace with one to two minutes at your maximal pace.

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3. After burst training, get a recovery drink.

It increases muscle mass and keeps the mTOR gene turned off. This is only for people who perform burst training (at least four to five bursts per session) or vigorous training of at least 30 minutes' duration. What's proven to work is a combination of macronutrients high in protein and carbohydrates, even in older folks. But drink it within 45 minutes of your workout; immediately after your workout is ideal. Avoid sugar. The best formula is somewhere between 10 to 40 grams protein (I suggest 20 grams for the average woman), 7 grams or more of carbohydrate (I suggest 10 to 20 grams for women), and up to 3 grams of fat.
4. Get enough sleep!

For optimal weight loss and energy levels, I recommend getting to sleep by 10 p.m. and sleeping seven to eight and a half hours. If you're not getting enough sleep, try to aim for a nap if you're feeling tired. This is so important for your body to produce enough growth hormone and repair itself after a workout. Sleep cleanses toxins and rejuvenates our cells in profound ways.
5. Schedule and take sufficient time for recovery.

Exercise affects your hormones, and adequate recovery keeps your hormone profile in balance so that your adrenals don't get fried and take your sex hormones and thyroid down with them. It's about galvanizing the full arsenal of repair mechanisms in your body: stitching together microtears in your muscles, ironing out the fascia when it gets jangled, reinvigorating mitochondria so you're brimming with energy rather than feeling worn down or burned out. The official definition of recovery is your ability to repair tissues damaged during exercise, rebuild muscles, provide functional restoration of the body such that you prevent injury, rejuvenate emotionally and psychologically, and feel prepared to meet or exceed performance the next time.

Previously, I'd chronically limit my recovery, and I wonder if the same is true for you. If you exercise five days per week, then at its simplest, recovery means 24 hours between bouts of exercise and two rest days. If you exercise four days per week, you take three rest days. For me, my weekends are my harder exercise days, and Mondays and Fridays are my rest days.

Recovery allows you to heal from oxidative stress, which you may or may not feel as fatigue and muscle soreness. But recovery runs deeper; in a larger sense, it's about paying attention to the messages of your cells, your inner voice, and not letting ego run the show. My ego tells me to overexercise and under-recover, which is a recipe for injury, spasm, and weak mitochondria. Don't let that happen to you. Recovery is also about tuning into the messages your body is sending you—the ache in your left sacroiliac joint or the twinge in your right knee. Ironically, I taught myself to ignore those signals during medical residency when self-care came last, but I've been learning to hear and feel those sacred messages from my body in my recovery.

Even if you haven't been exercising consistently, you still have the chance to get on track. Choose an exercise that you enjoy and break a sweat four times this week. As we know, exercise combats stress, helps us sleep better, and raises endorphins. It's good for your sleep, weight, stress, genes, and mind. Even walking counts! Ideally, start to notice your heart rate at rest and while exercising, and after paying close attention to your body, weight, and mood, you'll sort out the perfect route toward feeling and looking your best.

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