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Women & Addiction: Substance Use and Misuse

Review of gender differences in substance use addiction and a functional treatment approach

by Sara Gottfried, MD and Bronwyn Storoschuk, ND

From the President of Metagenics Institute, Sara Gottfried, MD: As a gynecologist board certified in the biological issues women face over their lifetime, I’ve thought a lot about what women are up against when it comes to work and life—often there’s tension between the competing priorities of family, raising children, being a partner or spouse, supporting aging parents, making money, and, last on the list, finding time for self-care. It’s no wonder that women are commonly in a state of the sapped superwoman (in scientific parlance: hyperarousal), and that a little something to take the edge off, like a glass of wine, pint of ice cream, dose of cannabis, or even online shopping, seems like the best option. In my experience, that hyperarousal in the setting of stress and pain is the root of addiction.

We’re expected to be perfect at work and perfect at home, and few of us are wise enough to see the conundrum or refuse to buy into it. We go about our way with limited guidance, biding our time until retirement, armed with few good or realistic models for how to integrate it all into a sacred, cohesive whole. Not only do we lack a model of wholeness, but most of us end up on the path of developing cravings and addictions: alcohol, caffeine, affirmation from excessive work, social media, exercise, or opioids. The overwhelm of daily life and cycles of exhaustion—physical, emotional, spiritual—make it challenging to find the homeostasis we need.

Meanwhile, the rates of addiction continue to climb, and women are increasingly using and misusing substances at higher rates compared to previous years. Longevity has declined for the third straight year in the United States, and addiction plus its downstream effects (including overdose) are considered a major contributor. As addiction becomes more common in medical practice, we now need to consider a broader concept of it, rooted in the genome interacting with the environment, particularly as it relates to stress, pain, triggers, mediators, hyperarousal, nutrient gaps, blood sugar dysregulation, and “reward deficiency syndrome.”

Addiction is considered to be a condition in which a person engages in the use of a substance or in a behavior despite detrimental consequences. Given such a broad definition, one may be addicted to classic substances, such as opioids or alcohol, or even “soft” addictions like overeating, overspending, binge watching television, obsessing over a smart phone and/or social media, surfing the internet excessively, pornography, or playing too many video games. The full range of addictions mute consciousness, drain energy, and may rob a person of health.

Over years of clinical practice, we’ve learned that many of our patients fall somewhere on this spectrum of addiction. Addictions are costly both economically and in terms of suffering. While we once may have considered addiction to trigger a quick referral to the psychiatry or mental health folks, the current epidemic and the evolving picture of addiction medicine call us to reconsider our approach. What if addiction is not a mental disorder, but a symptom of gene-environment interactions that we could address and even ameliorate in our practice of personalized lifestyle medicine?

At the root of addiction is the chemical hit of pleasure acting through the reward pathway in the brain. In this article, we will cover substance use and misuse. Specifically, we will address the sex and gender differences in addiction, and the personalized lifestyle medicine approach to recovery. In subsequent articles, we will cover other addictive patterns including “spread” addiction, food addiction, and process addictions.

Patients often don’t realize that their brain dopamine activity may be dysregulated—either too low or too high, but certainly in a state of altered balance—putting them at risk for addictive behavior as their brain bodies seek homeostasis from external sources. Think of dopamine as the that-feels-good, do-it-again-please neurotransmitter. It’s the star of the pleasure-reward system in the brain and the neurotransmitter involved in motivation, sex, satisfaction, and habit formation. Dopamine is central to one’s reactions to behaviors that naturally produce dopamine (such as exercise and meditation) and substances that stimulate dopamine production but may cause harm (alcohol, caffeine, cigarettes, opioids, etc.). When a patient is in hyperarousal, there’s an internal pattern driving a patient to seek outside substances to satisfy the feel-good brain receptors that aren’t, well, feeling good.

Substance Use Disorder: The Statistics

  • Approximately 48.5 million people in the US report use of illicit drugs or misuse of prescription drugs each year.1 This includes use of marijuana, cocaine, heroin, hallucinogens, inhalants, and methamphetamines and the misuse of prescription drugs.1
  • Excessive alcohol use is responsible for an estimated 88,000 deaths each year in the US.2 Among this population there are clear gender differences in rates of alcohol use disorder, with men having significantly higher rates of use, misuse, and dependence.3
  • While a difference between the sexes still exists, in recent years epidemiological studies have found that the gap is closing, as more women are using and misusing substances.3-5 For example, in the early 1980s men were 5 times more likely to have alcohol use disorder than women, whereas recent reports show men are now only 3 times more likely.6,7
  • Women are more likely to experience chronic pain,8-10 and are more commonly prescribed long-acting opioid analgesics.8,11 Opioid prescriptions are associated with a greater risk of all-cause mortality (hazard ratio 1.64), including death from causes other than overdose.12 Women experience higher rates of migraine, as well as neck and low back pain. Additionally, women tend to be overprescribed opioids after both vaginal and cesarean birth, leading to an increased risk of chronic opioid use during the postpartum period.13 Women with opioid misuse report stronger pain and withdrawal symptoms.14
  • Overdose: among women aged 30-64 years, the death rate from overdose increased 260% from 1999 to 2017, which included overdose from antidepressants, benzodiazepines, cocaine, heroin, and synthetic opioids.15

Studies on substance use and misuse have involved almost exclusively males, and thus, data on female-specific substance use and misuse is limited.16 The increased prevalence of female substance use has brought attention to various sex differences in the epidemiology of addiction-related disorders, neurobiology of substances of use and misuse, etiologic considerations, and psychiatric comorbidity.17

  • Women usually begin using substances later than men do, are strongly influenced by their partners to use, report different reasons for maintaining the use of a substance, and enter treatment earlier in the course of their illness.16
  • Women also appear more vulnerable than men during the transition periods of drug use that are characteristic of drug addiction and relapse and appear to be more sensitive to the rewarding effects of substances compared to males.16
  • Additionally, women tend to experience more side effects and more fatal drug reactions to psychotropic substances.16 This information becomes especially relevant in determining an appropriate treatment approach for this population, as previous strategies have been male-dominated.3



Hormonal variations

Ovarian steroid hormones, estrogen and progesterone, have significant cognitive activity and may influence the behavioral effects of many substances.3,16 This effect is seen throughout a woman’s menstrual cycle. The follicular phase of the menstrual cycle, when estrogen levels are elevated and progesterone remains low, is associated with the strongest responsiveness to stimulant drugs.18 In animal studies examining reward and drug cravings, estrogen administration was found to increase operant behavior, whereas removal of the ovaries diminished the behavior.16 A study done with cocaine use in humans showed that women in the luteal phase, or second half of their cycle, experienced less of a high compared to women in their follicular phase and men.18

Stress response

Chronic perceived stress plays an important role in increasing drug use and relapse.19 Susceptibility to drug use and misuse, dependence, and relapse in women may be impacted by the sex differences in the adaptations to the stress response systems.19 Substance use can cause a blunted stress response, by way of reduced adrenocorticotropic hormone (ACTH) and cortisol, particularly seen in substance-dependent women and not men.20 This dysregulation in the hypothalamic-pituitary-adrenocortical (HPA) axis may help explain why women have poorer relapse-related outcomes, as this alteration causes an increased sensitivity and response to substances during initial periods of withdrawal.20,21

Neurotransmitters & brain morphology

Significant differences in brain morphology are seen between men and women in areas of the brain responsible for craving, addiction, and relapse.16 Also, there is a difference between the sexes in the expression and function of brain receptors activated by different addictive drugs.16 Women have a higher concentration of dopamine receptors in the frontal cortex, and the density and distribution of opioid receptors varies between the sexes as well.22,23 Furthermore, estrogen plays a critical role on mood, mental state, and memory through its interaction with neurotransmitters in the brain, including dopamine and serotonin, and this may suggest that sex hormones can impact behaviors to dopaminergic drugs.24

Pharmacodynamics & pharmacokinetics

Most psychoactive substances are lipophilic and thus fat-soluble.16 Sex differences in regard to drugs of use and misuse may be in part due to differences in muscle and fat distribution between men and women, of course with women carrying more body fat.16 Body composition, volume of distribution, level of gastric and hepatic alcohol dehydrogenase, gastric absorption, capacity of the microsomal ethanol-oxidizing system, and putative hormonal effects on achieved blood alcohol levels are all key features underlying gender differences in alcohol addiction and dependence.25


Mood disorders

Anxiety, depression, and panic disorders are all more common in women than in men.26 These mood disorders can encourage use of mood-altering substances, explaining the high degree of comorbidity between substance use disorder (SUD) and psychiatric disorders.16 In a large 12-month study, the prevalence of mood and anxiety disorders among women with substance-use disorders was 29.7% and 26.2%, respectively.27

Eating disorders

Eating disorders are about 2 to 3 times more common in women than in men, and 90% of the cases of anorexia nervosa and bulimia nervosa are found in women.3,28 It has been found that eating disorders and substance use disorder co-occur in up to 40% of women.29 Furthermore, women worry twice as much about weight gain caused by smoking cessation compared to men, causing women to relapse 3 times more often than their counterparts.30

Posttraumatic stress disorder

Many people report alcohol or drug use in response to symptoms of posttraumatic stress disorder (PTSD)3. The Australian National Survey of Mental Health and Well-Being found that 34.4% of respondents with PTSD had a cooccurring substance-use disorder, with at least 1 substance.31 Conversely, PTSD is up to 5 times higher in individuals with an existing substance-use disorder.32 Of women seeing treatment for substance use disorder, it was found that between 55 to 99% of this population of women also report experiencing physical and/or sexual trauma and display symptoms consistent with PTSD.33



Cigarette smoking is the leading cause of preventable disease, disability, and death in the United States.34 Nearly 40 million US adults still smoke cigarettes, and about 4.7 million youth use at least one tobacco product, including e-cigarettes.34 At the current time, men are more likely to be cigarette smokers than women, with 15.8% of smokers being men and 12.2% being women.35 Unfortunately, women have more negative health outcomes associated with smoking than men do. Compared to male smokers, women have twice the risk of heart attack, faster lung deterioration, increased risk of chronic obstructive pulmonary disease and lung cancer, earlier onset of menopause, increased menstrual flow, infertility, and increased risk of miscarriage.3

Women are also more likely to develop dependence on nicotine and consistently show shorter and less frequent periods of abstinence compared to men.36 Many reasons for this vulnerability to nicotine and failure to abstain from smoking have been suggested. Some of the factors include fear of weight gain as previously discussed, need for social support, higher rates of depression, greater withdrawal symptoms, and the impact of the menstrual cycle.37 Interestingly, sex hormones are associated with a women’s success at quitting.3 It has been found that women who attempt to quit during the follicular phase of their cycle are more successful than the women who try to quit during their luteal phase.38 However, it is also known that estrogen speeds up the metabolism of nicotine, fueling a greater dependence.39 This is important to note in women on oral contraceptives, as birth control pills accelerate metabolism of nicotine, which may affect their smoking behaviors.39

Lastly, women who smoke tend to have an increased sensitivity to the nonpharmacological stimuli associated with cigarette use, like the smell of a cigarette or people associated with smoking, versus the nicotine itself.3 This should be a key consideration when developing gender-specific treatment plans.


Historically, men have consumed and misused alcohol at much higher rates than women, but the current gender differences in alcoholism are quite small.4 Women, especially in the younger cohorts, are abusing alcohol more often than in the past, and there is no longer a difference between the sexes in terms of age of initiation.4 However, the motivation for alcohol use still differs between men and women. Women are more likely than men to consume alcohol in response to stress and negative emotions, whereas men are more likely to consume alcohol to enhance positive emotions or to fit in with a group.3 Because of this, women with alcohol-use disorders are significantly more likely to have a comorbid mental health disorder.29 Women are also more vulnerable to alcoholism, as they display significantly shorter time intervals between the initiation of alcohol use and the onset of alcohol addiction and treatment entry, although women are less likely to seek treatment for alcoholism.3,40

There are many differences between men and women that may influence the development of alcohol use disorder, like the rate of absorption and metabolism.16 Overall, women consume less alcohol than men and are less likely to binge drink or drink on a daily basis.16 But women are also more sensitive to the physiological effects of alcohol compared to men, they achieve higher blood alcohol concentrations, report feeling more intoxicated, develop brain damage more easily, and show higher vulnerability to alcohol dependence.41 In addition to this, women also experience a more rapid progression to many of the long-term consequences of alcoholism, including cirrhosis, alcohol-induced cardiomyopathy, and peripheral neuropathy.16

There is inconclusive evidence whether the menstrual cycle and female sex hormones have a role to play in the subjective, behavioral, or physiological effect of alcohol.16


Although many states have legalized either medical or recreational use of marijuana, marijuana continues to be the most commonly used illicit drug in the US.3 Men use marijuana much more often than women, with only 0.7% of women using marijuana daily.42 Initiation of cannabis use is associated with a prior history of tobacco smoking, alcohol consumption, antisocial behavior, intention to use drugs, drug use among friends, and time spent in bars; the latter 3 associations shown to be stronger in females than males.43 Additionally, attending state schools, low academic performance, and living in a single-parent family also independently correlate with marijuana use among girls.43 Again, research suggests that women develop marijuana-use disorders and seek treatment much more rapidly than men do.40

There has been no identified influence of the menstrual cycle on cannabis dependence, but marijuana smoking is known to reduce serum levels of luteinizing hormone (LH), which may impact a woman’s reproductive health and ability to conceive.44 Much more research on cannabis and its impact on women’s health is needed, especially as it becomes more accessible with legalization.


Although rates of stimulant use are similar among adult men and women, adolescent females are more likely to use cocaine at an earlier age and with a greater frequency compared to adolescent males.16 Interestingly, women report shorter periods of abstinence between cocaine use than men, they experience more nervousness after cocaine use, and they have stronger cravings in response to nonpharmacological cocaine cues.16 Relative to cocaine use, amphetamines have shown to induce a faster progression from first use to treatment entry.16

The response to stimulants that women experience may be strongly influenced by the menstrual cycle and hormonal fluctuations3 As previously stated, high estrogen levels with low progesterone levels, as seen in the follicular phase of a woman’s cycle, show reinforcing effects of stimulants for women.18 During the follicular phase, women report a greater high and increased heart rate following administration of cocaine.18 Interestingly, administration of exogenous progesterone during the follicular phase attenuates the positive subjective responses to cocaine.45 It is clear that estrogen and progesterone levels account for some of the sex differences among stimulant users.

Unfortunately, an increase in methamphetamine has been observed in pregnant women and it has been stated that methamphetamine is the primary substance use disorder for which pregnant women seek care.46 Among pregnant women admitted to federally funded substance use disorder treatment centers in 1994, 8% were admitted for methamphetamine dependence, and by 2006 that number increased to 24%.46


More than 191 million opioid prescriptions were dispensed to American patients in 2017, and the number of deaths due to an overdose of opioids, either prescription or illegal, grew by 6 times from 1999 to 2017.47,48 The data is mixed, but overall the rates of nonmedical use of prescription opioids is fairly even between the sexes.49 It is apparent that women are more likely to obtain opioids from family, friends, or acquaintances or have their own prescriptions, while men are more likely to obtain opioids from dealers.50 It has also been shown that women who are addicted to opioids have an earlier onset of opioid use, report being more influenced by social pressure and by sexual partner encouragement, and have an overall greater level of psychiatric distress compared to their male counterparts.51,52

When it comes to heroin, compared to men, women use smaller amounts, use heroin for shorter periods of time, and are less likely to inject heroin.53 Notably, unlike men, the initial injection of heroin by women is strongly influenced by a spouse or partner.49 It has been reported that 51% of the female heroin users were first injected by their male sexual partner, whereas 90% of men were injected the first time by a friend.49

As discussed, there are sex-specific differences in opioid receptors in the brain, which have shown to result in a slower onset and offset of morphine among women compared to men and the need for a higher dose in women to achieve similar effects as men.54 However, due to smaller body size, difference in absorption, metabolism, and elimination of medications, the therapeutic window for women may be narrower, and this may contribute to greater levels of dependency and withdrawal symptoms in women.54

A large review of long-term opioid use in women revealed other sex-specific risks. The findings suggested women using opioids have greater endocrine disruption, infertility, neonatal health risks, higher anxiety and depression, greater cardiac health concerns, and a greater potential for overdose.55 These patterns of use in women and sex-specific health risks indicate that greater attention to prescription drug use and chronic pain treatment among women is required.

Prescription drugs

In addition to opioids, many other prescription drugs have a high misuse potential, like benzodiazepines and antidepressants.15 Middle-aged women, between 30-64 years old, have seen the greatest increase in deaths related to drug overdose from various drugs, including both antidepressants and benzodiazepines.15 Other reports have highlighted the overall increase in overdose deaths and emergency department visits related to drug use, especially among women aged 45-64 years.56

Prescription medications are typically more accessible to women, as women seek care more often than men, leading to greater ingestion of medications and, therefore, a higher rate of adverse effects.54 It has been speculated that women who misuse prescription drugs also perceive these drugs to be safer and less stigmatized compared to illicit drugs.57 Much attention has been given to women of childbearing age about the risks and benefits of certain medications; however, it is clear than more attention much be given to middle-aged women who appear more vulnerable to misusing these substances.15 The unique biopsychosocial needs of women must be addressed when treating women for conditions like sleep disorders, anxiety, mood disorders, and pain.


Women are at highest risk of developing a substance use disorder during their reproductive years, from age 18-44 years.58 In 2012, a national survey done in the US found that 5.9% of pregnant women use illicit drugs, 8.5% drink alcohol, and 15.9% smoke cigarettes, resulting in over 380,000 offspring exposed to illicit substances, over 550,000 exposed to alcohol, and over one million exposed to tobacco in utero.59 Nicotine is the most commonly used substance in pregnancy, followed by alcohol, marijuana, and cocaine.60 However, from 2000 to 2009, there has been a five-fold increase in opioid use during pregnancy.61

The negative effects of smoking and alcohol use disorder in pregnancy are well-established, although the evidence for low-to-moderate alcohol use in pregnancy is inconclusive.62 Cannabis use in pregnancy has been linked to several adverse effects, including preterm labor, low birthweight, small-for-gestational age babies, and admission to the neonatal intensive care unit.62 Interestingly, prenatal cannabis use has also been linked with adverse consequences for the growth of fetal and adolescent brains, reduced attention and executive functioning skills, poorer academic achievement, and more behavioral problems in children.62 These effects are more pronounced in heavy cannabis users.62 Cocaine use during pregnancy has been associated with premature rupture of membranes, placental abruption, preterm birth, low birthweight, and small-for-gestational-age infants.63 Lastly, opioid exposure during pregnancy has significant adverse effects and is a significant public health concern.64 Opioid misuse in pregnancy can have serious adverse maternal and neonatal outcomes, including preterm labor, greater risk of low birthweight, stillbirth, neonatal abstinence syndrome, and maternal mortality.64

The negative consequences of substance use in pregnancy are typically compounded by the high frequency of coexisting substance use and psychiatric comorbidities.62 Furthermore, women with substance use disorders are more likely to experience inadequate prenatal care, poor nutrition, chronic medical problems, poverty, and domestic violence.65


Biopsychosocial model of addiction

The way substance use and misuse are viewed in medicine has dramatically changed over recent years.66 There is no known single factor that can explain why some individuals can use substances without progressing to addictive behaviors while others misuse or become dependent on substances.67 Instead, evidence suggests that biological, genetic, personality, psychological, cognitive, social, cultural, and environmental factors interact to produce addiction. Thus, we have moved away from the reductionist medical model of disease and instead, given favor to the biopsychosocial model, which addresses the factors contributing to substance use disorder.67 It is generally accepted that all of these factors must be taken into consideration in prevention and treatment efforts.67

In the operating system of personalized lifestyle medicine, we start with the basics of Functional Medicine to address obstacles to health. Specifically, we determine what deficiencies need to be filled, such as depletion of B vitamins from high perceived stress, other micronutrient insufficiencies due to gut issues, and what excesses need to be addressed. We look at the seven systems of the body with the goal of restoring homeostasis, from the stress response system to the reward pathways to insulin signaling.

The most successful addiction treatment programs incorporate strategies to enhance coping, reduce cravings, manage triggers, and prevent relapse.67 Historically, there has been an overemphasis on anti-addiction medications as the primary intervention, when pharmacotherapy is just one of many treatment options and is often not considered an essential part of recovery.67,68 The Substance Abuse and Mental Health Services Administration (SAMHSA) announced a new working definition of recovery from substance use disorders in 2011. It recognized that there are many different pathways to recovery, but there are 4 major cornerstones that assist in recovery, including health, home, purpose, and community.69 To elaborate, this addresses managing one’s disease(s), having access to a stable and safe place to live, finding purpose through meaningful daily activities, and having relationships and support networks in place.69 Thus, addressing addictive behaviors involves a multifaceted, individualized approach that may be best served through Functional Medicine.

Gender-specific treatment

Most addiction treatment models have been studied and designed for men, based on male norms.70 However, as this article has demonstrated, there are sex differences in the epidemiology of addiction, neurobiology of substances of use and misuse, and etiologic considerations, and so treatment should be tailored to address these variations.17 Unfortunately, research is this area is limited.

Although women are less likely to enter treatment for substance use disorder compared to men, women are more likely to complete treatment programs and appear more responsive to psychosocial and behavioral treatments.3,16 Treatment programs that promote positive life choices and increased socialization and self-esteem are particularly effective in this population.16 However, in order for these programs to succeed, they must be tailored for women’s specific needs, including childcare assistance, pregnancy, parenting, domestic violence, sexual trauma and victimization, psychiatric comorbidity, housing, income support, and social services.70 Additionally, having a partner who uses or misuses alcohol or drugs is more strongly related to relapse for women than for men, and thus, interventions need to be designed specifically to address these issues.71

All comorbid conditions that commonly affect women, including anxiety, mood disorders, eating disorders, PTSD, and any other health concerns that may impair recovery, must be addressed and treated using evidence-based strategies.3 An individualized approach is foundational and will likely be complex and multidisciplinary.3 Cognitive behavioral therapy, motivational interviewing, pharmacotherapy, and nutritional counseling can be used to address substance use and misuse as well as many of the comorbid conditions.3

Sex differences also exist in the efficacy of pharmacotherapy. For example, in smoking cessation, nicotine replacement therapy (NRT) is significantly more effective for men than women, and bupropion may be a more appropriate option for women, as it will also address comorbid depression.72 Multiple pharmacological agents may need to be initiated before a successful option is found.3 It is also important for interventions to teach women how to cope with nonpharmacological cues of drug use, as women have stronger cravings in response to cues than men do.16 In addition, women who are trying to abstain from drug use may be more likely to succeed if the initial abstinence is scheduled to occur during the luteal phase of their menstrual cycle, when the drug effects are less potent due to higher progesterone levels.18


Substance use disorders affect men and women differently, and it is important that treatment outcomes reflect these variances. The motivation to use a substance, the patterns of use, the rapid progression of disease course, and treatment-seeking behaviors are affected by gender differences in biologic, psychological, cultural, and socioeconomic factors.3,67 Understanding the multifactorial biological mechanisms that predict the vulnerability and sensitivity to substances will allow women to receive more appropriate and specific treatment, with a greater opportunity for recovery from addiction.3 We believe the best recovery results from a personalized and collaborative lifestyle medicine approach.

To learn more about the root causes that contribute to addiction, including stress, pain, hyperarousal, nutrient gaps, and disruption of the gut-brain axis, please attend one of our upcoming seminar series, offered in person and via livestream. Learn more here:


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Sara Gottfried, MD is a board-certified gynecologist and physician scientist. She graduated from Harvard Medical School and the Massachusetts Institute of Technology and completed residency at the University of California at San Francisco. Over the past two decades, Dr. Gottfried has seen more than 25,000 patients and specializes in identifying the underlying cause of her patients’ conditions to achieve true and lasting health transformations, not just symptom management.

Dr. Gottfried is the President of Metagenics Institute, which is dedicated to transforming healthcare by educating, inspiring, and mobilizing practitioners and patients to learn about and adopt personalized lifestyle medicine. Dr. Gottfried is a global keynote speaker who practices evidence-based integrative, precision, and Functional Medicine. She recently published a new book, Brain Body Diet and has also authored three New York Times bestselling books: The Hormone Cure, The Hormone Reset Diet, and Younger.

Bronwyn Storoschuk, ND is a board-certified naturopathic doctor trained at the Canadian College of Naturopathic Medicine. Prior to attaining her ND, Dr. Storoschuk completed her Bachelor of Science (Honours) in Kinesiology at Queen’s University in Kingston, Ontario. She currently works in private practice in Toronto, Ontario. One of her practices is located within an integrative fertility clinic where she provides naturopathic care to individuals undergoing assisted reproductive technology (ART). Dr. Storoschuk integrates evidence-based medicine with the understanding of the body’s natural physiology and innate healing wisdom. She is passionate about empowering women to take control of their hormonal health and has a clinical focus in hormone balance, reproductive health, and fertility.


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