Menopause Part 3: Body Composition, Bone, Brain, & the Fitness Changes (The Data vs the Influencers)

24:06Dr. Austin Baraki:It may make it easier for them to adhere to the dietary changes we're recommending or the exercise habits or just might make their life less unnecessary suffering, which is all great. But again, if they have nothing else at all that I can pin on it, then I'm probably kind of trying to redirect and say, look, we have way more effective options. If we're looking to try something outside of just kind of quote unquote lifestyle alone for weight management, there are far more effective options that I would be way more confident would get you to where you want to be in a shorter time period than menopausal hormone therapy.

24:33Dr. Jordan Feigenbaum:Yeah. Yeah. I mean, this is the same way that I think about GLP ones, for example, right? Is that they're mostly a behavior change sort of instrument or tool in that they help people who use them to do the things that they had likely set out to do multiple times in their life before and have yet to be successful. And so to the extent that menopausal hormonal therapy addresses any of these underlying drivers of the behaviors that happen associated with the perimenopausal transition, whether it's compromised sleep and subsequently that, that effect on appetite or willingness to participate in exercise, things of that nature, then yeah, we would predict a pretty, pretty good response from a weight management standpoint.

25:16Dr. Jordan Feigenbaum:However, if those things aren't really happening and you, you know, you're almost asking a patient for a reason to prescribe hormonal therapy, not exactly, not because you're gatekeeping because it's likely to be safe, but to the extent it's going to benefit them is directly proportional to, are they experiencing symptoms we know are, are, are well treated, well managed by these things versus something else. Um, and so, yeah, if a person had that, it would make, uh, I would predict very good response, but if not, it's like, well, let's use a better tool. Cause we have some of those. If it's purely about the weight change, does that kind of square with what you're saying?

25:48Dr. Jordan Feigenbaum:Totally agree. Yep. Let's talk about a concern that a lot of my patients bring to their clinic visits. Women often come in feeling frustrated because they are eating the same, they're maintaining roughly similar activity levels, but still struggling with their body composition. They feel like something has changed despite their best efforts. Because these changes seem to accelerate around menopause, it's completely natural to want to blame the hormones. But the best evidence that we have shows it's not that simple of a story. When researchers have followed women over long periods of time during the menopausal transition, we actually don't find rapid accelerations in muscle loss during perimenopause, especially in those women who remain physically active.

26:38The weight gain curve is actually steeper before perimenopause begins, which already suggests that those most dramatic hormone shifts that come along with menopause aren't the main culprit here. Now, what menopause does do is shift the location where the fat distribution ends up. So more towards the waistline and the belly as compared to the hips and thighs. And there's lots of theories as to why this happens, but the truth is that we are not 100 % sure yet. The question of metabolism frequently comes up in this conversation. and metabolic rate is actually a target that's been rigorously measured, but declines in metabolic rate that are specific to menopause or hormone status haven't been found.

27:30There are some age related declines that tend to appear at around age 60 on average, but menopause itself doesn't seem to accelerate these changes. So what can MHT do for body composition? Unfortunately, a lot less than we'd hope, at least directly. It doesn't directly increase fat loss or fat redistribution. What it definitely does do, however, is treat symptoms like hot flashes and night sweats. And when this leads to improved sleep, energy, and motivation, improved lifestyle habits tend to follow as well. And these are important downstream effects, even if indirect. On the topic of testosterone, we don't have strong evidence to prescribe it to perimenopausal women for body composition.

28:26There's actually paradoxical data from the one study that would suggest that higher levels of bioavailable testosterone during menopausal timeframe may contribute to central fat accumulation. And so this is not a tool that I reach for in this case. Ultimately, the changes that women in this stage of life experience are real, but they are not inevitable and they are not insurmountable. Treating your symptoms, protecting your sleep, and supporting physical activity often will make the most meaningful difference. All right.

29:04Dr. Jordan Feigenbaum:Well, that's the body composition story. When we come back from the break, I'm going to talk about what happens to cardiometabolic health, specifically cardiovascular disease risk.

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34:32Dr. Jordan Feigenbaum:All right, we're back here on the Barbell Medicine Podcast. And in the first section, We talked about body composition, metabolism, things that happen around the perimenopausal transition. But now I want to talk about this sort of cardiometabolic shift. So body composition is half of the story. The other half is what's happening to a person's cardiovascular health, the lipid panel, blood pressure, insulin sensitivity, all the things that drive cardiovascular disease over the long run. And there's one specific change here that's clearly driven by menopause, which is anchored to the final menstrual period, not just background aging.

35:05Dr. Jordan Feigenbaum:So in 2009, Matthews and colleagues published a study in the Journal of American College of Cardiology where they ran annual lipid panels on just over 1 ,000 women in the SWAN study that we talked about earlier. They used a statistical method that lets the rate of change in low-density lipoprotein, LDL, these are the sort of proteins that carry around cholesterol in your body. And so this statistical method lets you detect the rate of change in LDL at a specific time point. And they set that point at each women's own final menstrual period, which let them separate the slow drift of aging from the sharper change that happens around menopause itself.

35:44Dr. Jordan Feigenbaum:In the two years around the last menstrual period, LDL cholesterol rose by about 5 mg per deciliter per year, and apolipoprotein B, those levels rose by about 3 mg per deciliter per year. If you don't recall what apolipoprotein B or ApoB is, this is the kind of detectable protein that's attached to what we think causes atherogenesis or heart disease primarily. And so just to put this into perspective, if you were unclear, if you were at risk for heart disease based on your standard lipid panel, an apolipoprotein B test would be more instructive because it captures all of your atherogenic load, or at least most of it.

36:24Dr. Jordan Feigenbaum:So in any case, across this perimenopausal window, low-density lipoprotein LDL went up by about 10 points and apolipoprotein B or APOB rose by about 6 points beyond what aging alone would have done. And the rise is concentrated in this sort of tight window right around the final menstrual period. Now, waist circumference, as we mentioned earlier, does tend to increase across this window, but it's too crude of a measurement to separate the visceral fat redistribution from general midlife weight gain. That's why they had to rely on CT data, which is ultimately impractical for most folks. The American Heart Association themselves put it the same way in their scientific statement on midlife women.

37:03Dr. Jordan Feigenbaum:The menopausal transition is a window of accelerated atherogenic lipid changes, but the magnitude is modest. So that's the picture on lipids. Next question is whether the rest of the cardiometabolic profile follows the same pattern or whether something different is going on with insulin sensitivity and metabolic syndrome risk. So in 2008, Janssen again looked at the SWAN data and looked for the rates of metabolic syndrome, the cluster of high waist circumference, worsening lipid panels, high blood pressure, and high blood sugar that often traveled together. Now women in late perimenopause or early postmenopause had about 45 to 60 % higher odds of developing these issues compared to premenopausal women of the same age, those who hadn't gone through their final menstrual period.

37:50Dr. Jordan Feigenbaum:But when the analysis adjusts for the visceral fat redistribution we just covered, most of that effect disappears. The hormonal change kicks the visceral fat redistribution into gear, and the visceral fat is what's actually causing the metabolic problems. I actually think if they would have measured liver fat directly, perhaps that would have been even more predictable, but harder to measure that on some level. In any case, the hormone change is upstream, and the fat is what's doing the damage. uh austin is this something that you talk about with patients when you're kind of you know because you are such a good clinician and so thorough and also very very deeply uh um into sort of cardiometabolic health is this something you bring up as like an add-on at a visit like hey and by the way we don't necessarily directly tie it into like as soon as we have determined that the person

38:41Dr. Austin Baraki:has crossed quote-unquote to the menopausal transition then suddenly we need to do this because we have probably been doing it all along already. The situation where I tend to emphasize kind of the cardiometabolic risk assessment much more and just the overall degree of risk is when menopause is either early, meaning before age 45, or when the person is frankly having premature ovarian insufficiency or premature ovarian failure before 40 because those are much more substantial, you know, long-term cardiovascular risks having it that early. And or if the woman has had prior history of significant obstetric complications.

39:15Dr. Austin Baraki:So that means like they had preeclampsia with one of their pregnancies or certain things like that because all of those factors are things that are generally predictive of much higher longer term cardiovascular risk. And the higher the risk is for the person, that's usually when we treat them more aggressively. By the time we've gotten to quote unquote natural menopausal transition, if they're going through that at about the expected timeframe, we're monitoring all these things anyway and I'm not necessarily rigidly tying them to menopause. There's already enough kind of catastrophizing messaging out there around what menopause does to you.

39:46Dr. Austin Baraki:And it's just I'm looking out for your health and all the things that we need to be thinking about as we transition into the, you know, through midlife is, you know, your general health, your body composition, your physical activity, your bone density, your cardiometabolic function and things like that. So that's generally the way I approach it. I emphasize it much more explicitly when it is a much, much higher risk situation. Otherwise, it's just, I think, a good part of routine primary care.

40:16Dr. Jordan Feigenbaum:yep yep well said all right so that's the deal on insulin sensitivity some lipid changes but what about blood pressure now blood pressure does tend to rise across midlife in women also in men but it similarly tracks aging and body composition more than menopause itself so if you take an otherwise healthy 45 year old if you took everything menopause does to her lipids and blood pressure and run it through a 10-year heart disease risk calculator, it moves her absolute risk of having an unwanted cardiovascular event by about one to three percentage points. That's a real effect over time, especially when it stacks on whatever trajectory she was already on.

40:53Dr. Jordan Feigenbaum:And in the United States, it generally is not very good. A woman whose LDL was already creeping up before her final menstrual period is much more likely to cross the sort of treatment threshold during this window than a woman who started at quote optimal levels. The clinical implication here isn't that menopause flips her into a high risk category overnight. It's just that the transition is the right moment for a full cardiovascular risk assessment because the lifestyle interventions that address these changes return the most when they started early before the risk accumulates. We think that the risk is proportional to not only how high these risk factors are, but for how long they're elevated for.

41:32Dr. Jordan Feigenbaum:Now, you alluded to a specific case, premature menopause, especially before the age of 40. Well, this is formally recognized as a cardiovascular risk enhancing factor, and it does get treated differently. For natural menopause in the typical 45 to 55 range, the cardiovascular changes are real, as the American Heart Association's scientific statement makes clear, but they're not categorized in the way in risk calculators. So to be clear, natural menopause does affect cardiovascular risk. The reason premature ovarian insufficiency gets categorized separately is that the magnitude and the clinical implications are different.

42:07Dr. Jordan Feigenbaum:And we'll come back to that later in this episode. So Austin, the patient, she's 51. Her final menstrual period was last year and her lipid panel shows that her LDL is 145 versus 125 two years ago. Her apolipoprotein B is elevated. Her menopause coach told her that this is an estrogen crisis and she needs menopausal hormonal therapy to fix her lipids. What does that conversation look like?

42:31Dr. Austin Baraki:Yeah, I think the audience is maybe picking up on a common theme of the menopause coach catastrophizing menopause and saying that the hormones are going to fix everything. This comes up both in lipids, this comes up with bone density, this comes up with a lot of things. And as we've alluded to both between the last episode and already here, there are certain symptoms where we can feel very, very confident that estrogen therapy is very likely to have a substantial impact arguably a bigger impact than any other treatment that we have available the prime examples of that are the vasomotor symptoms right very very likely or or the genitourinary syndrome delivering local vaginal estrogen very very likely to deliver better effects on that particular symptom than anything else that we have available this does not extend to every potential manifestation of the menopausal transition When it comes to, you know, lipid changes, for example, using menopausal hormone therapy for that purpose, less effective than directly addressing that risk factor.

43:28Dr. Austin Baraki:When it comes to bone density, let's say somebody has already established postmenopausal osteoporosis, using estrogen therapy at that stage, less effective than directly treating the osteoporosis. It doesn't mean that the hormone therapy may have no role at all, but I think we need to put these things in their proper context and recognize the magnitude of benefit that is likely to be gained by using them, depending on the situation that we're in. And so this woman, again, just like the one who was concerned about her weight gain earlier, this woman may have some other reasons to use menopausal hormone therapy.

43:58Dr. Austin Baraki:She may have the vasomotor symptoms. She may have some of the other justifications that may make it more strongly justifiable. But just if she has, again, no other symptoms whatsoever, no other concerns whatsoever just a you know modest i would say increase in her blood lipids from you know an ldl cholesterol of 125 to 145 that itself i would not expect to be you know directly and substantially reversed to very low risk levels by you know offering her an estrogen patch for example there are still many other aspects of the conversation i'm going to talk about all the things that we hammered on in our cholesterol article series and podcast series talking about the dietary habits making some smart substitutions the physical activity thinking about insulin resistance family history doing a risk assessment and trying to determine does this need directed medical treatments for the lipids in particular or is there some other secondary cause for example did this woman develop hypothyroidism that's another reason that people's lipids can go up has she had her tsh checked that can also make you feel tired and again this is a good example of why if you are for example a quote-unquote menopause coach and you know default shades to people who identifies that but if that is the extent of your expertise and your tendency is to view everything through the lens of menopause and hormone therapy, you are going to miss a lot of things.

45:13Dr. Austin Baraki:Because again, thyroid dysfunction can look similar. Sleep apnea can look similar. Anemia, iron deficiency can look similar. Chronic infections can look similar. Autoimmune diseases can look similar. You have to have some degree of experience and expertise in recognizing, thinking about differentiating all of these different things so that you don't lead people down the wrong path of cranking up hormone doses is higher and higher and higher. Meanwhile, you're giving them the wrong hormone and they need a thyroid hormone replacement or they needed an iron infusion or they needed something else entirely.

45:43Dr. Jordan Feigenbaum:We, this is not unique to the menopause space though. I mean, you think about the testosterone in the manosphere and such, you know, if everything looks like, you know, testosterone deficiency to you, you know, you're going to miss a lot of stuff. And so the results are predictable. Every man needs these tests and it's all about testosterone and estrogen in or whatever. I'm like, could use a CBC to see if they're anemic.

46:08Dr. Austin Baraki:Yeah. This is why, this is why generalists are good. In fact, that's my hot take. Wow. Wow. Really, really, really killing it.

46:15Dr. Jordan Feigenbaum:All right. So that's the story on cardiometabolic health. Now we get to bone where the clinical picture and the underlying data have been out of sync for longer than just about any other area of women's health. What women have been told to do and what the data say they should do are diametrically opposed. We're going to start out with the SWAN bone sub-study. So this is from that same research group out of UCLA, Greendale. They published another SWAN analysis in 2012, this time on bone, in just under 2 ,000 women followed across their final menstrual period with regular DEXA scans. Yes, this x-ray technology not only tells you body composition indirectly, it also, and perhaps to a more accurate degree, tells you bone mineral density.

46:57Dr. Jordan Feigenbaum:The pattern of bone loss across menopause isn't a straight line. It's slow in the years leading up to the transition. It picks up as a woman enters perimenopause. It peaks in the year or two around the final menstrual period and then slows back down within a few years afterwards. Peak annual loss at the lumbar spine was about 1.8 % per year. At the femoral neck and the leg, about 1 to 1.2%. The cumulative loss across the five-year transmenopause window was about 10.6 % at the lumbar spine and about 9 % at the femoral neck. The distal radius in the arm shows the same pattern, but at a smaller magnitude.

47:38Dr. Jordan Feigenbaum:Now, the problem here is that DEXA misses most of these sort of fragility fractures that women will have. Most fragility fractures in postmenopausal women don't happen to women who have officially crossed the line into osteoporosis on a DEXA scan. They happen to women whose bone density is in the osteopenia range or even in the normal range. The classic study here is from Ceres in 2001 where 82 % of women showing up with fractures had bone density that wouldn't have qualified them for an osteoporosis diagnosis. Their T-score, which is the standardized score DEXA gives you, was better than the cutoff, which is again when people uh report studies on dexa improving bone mineral density you know dexa measured improvement in bone mineral density that's only half of the story you also have to look well did they fall less or more do they have more or less fractures because that's what you really care about the score is nice to have but it's uh you know on some some levels it's just a surrogate number um you want the actual clinical uh the hard clinical outcomes all right so enter the Lift More study from 2018.

48:42Dr. Jordan Feigenbaum:For decades, postmenopausal women with low bone mineral density were told to avoid heavy lifting. There was actually a 1995 recommendation to say, look, if you've got osteoporosis or osteopenia, do not load the spine because it's going to be risk of fracture. And that for generations of women had put them in a bad place. The thought here was that fragile bones plus heavy loading equals vertebral compression fractures. Again, this is from the ACSM, the American College of Sports Medicine. They should have known better, but you know, it is what it is. Now, Belinda Beck's group at Griffith University, I believe it's in Australia, ran the trial in direct opposition to this.

49:17Dr. Jordan Feigenbaum:So this is the Lift More trial. It included 101 postmenopausal women with low bone mass, and they randomized them to either do high intensity progressive resistance training plus impact training, which if you've listened to a few of our podcast episodes before, you'll know that this is from when they were doing jumping pull ups and they landed from those with straight legs. So they either did that or a low intensity home exercise program. The intervention was eight months of supervised training twice a week, about 30 minutes per session. And they did five reps for five sets at 80 to 85 % of the one rep max on barbell exercises like deadlifts, overhead presses, back and back squats, plus the jumping chin ups.

49:57Dr. Jordan Feigenbaum:Now, before any of the lifters at home, you know, cry out, they did five reps at 85 % of

50:03Dr. Austin Baraki:one rep max? No way.

50:05Dr. Jordan Feigenbaum:Maybe it was a training max. These people were also new to exercise so that it is possible they can do that. Let's just say that it was heavy. Okay. Now across 2 ,613 supervised sessions, the published total injury rate was one mild lower back strain that fully resolved. The person didn't miss any sessions. The intervention was safe in a population that the field had spent decades telling to avoid the exercise. Now, Austin, before we get to the results on what having a bone mineral density. Let's take the same patient that you would have seen 10 years ago, maybe even longer. She's 65. She has osteopenia and she's been told for 15 years by her family doctor to avoid heavy lifting and stick to walking and Pilates.

50:47Dr. Jordan Feigenbaum:What would your priors have been? What would you predict the lumbar spine bone mineral density change in eight months of supervised heavy lifting? Yeah.

50:56Dr. Austin Baraki:I mean, I think that there's the traditional perspective on this, that that is something that at best, you might be able to slow the decline a bit, but unlikely to have a substantial effect. And then there's the side of things that we recognize based on our kind of experience working with people who train and seeing just how adaptable people can be. And that might lead us to a little bit more favorable of a prediction. But I think the overall view in the medical community would have been that this is going to have a somewhat modest to even negligible effect, just based on, you know, their level of knowledge and experience of what this sort of thing can do to, you know, somebody's body.

51:35Dr. Jordan Feigenbaum:Yeah.

51:36Dr. Austin Baraki:Yeah. I agree. Uh, perhaps even harmful.

51:38Dr. Jordan Feigenbaum:You would have predicted a higher injury rate and you say, well, that's interesting, but like while you got away with it, it still probably didn't do much.

51:44Dr. Austin Baraki:Yeah. Maybe you predicted the trial would have been halted early because everyone, you know, dissolved under the park. That's right.

51:49Dr. Jordan Feigenbaum:Well, here's what the lift more study found. Lumbar spine bone mineral density rose 2.9 % in the lifting group and it fell 1.2 % in the control group. Femoral neck bone mineral density held steady in the lifting group while controls lost almost 2%. This is in eight months. Again, this is in postmenopausal women with an average age of 65 with bone mineral density well below normal doing deadlifts at 85 % of their one rep max twice a week for eight months and they gained bone while the controls lost bone. So the LiftMore trial established that heavy progressive resistance training is not only safe in individuals with osteopenia and osteoporosis in postmenopausal women, but it also showed that it produces measurable bone mineral density gains in this population as well.

52:36Dr. Jordan Feigenbaum:Still, this trial did not address fractures, and thus you can't really say that, well, heavy lifting prevents fractures. We might predict, due to our biases, that that would happen, but that trial to date has not been done. So the bone mineral density finding is reliable and seems to be rather large, But the fracture sort of inference from there is another leap that we just need to have studied. There's another study that repeated a similar type of setup. This is out of Germany. It's called EFOPs, which stands for Erlingen Fitness and Osteoporosis Prevention Study. I'm certainly butchering the name of that city.

53:11Dr. Jordan Feigenbaum:So sorry to all of our listeners who are near there. This is the longest controlled trial in the space. 16 years of follow-up in early postmenopausal women. They were doing multi-component exercise, which is a fancy way of saying they were doing a bunch of things. This included resistance training. And they compared that to controls who mostly didn't exercise. The results showed preserved lumbar spine bone mineral density in the exercise group and roughly 4.5 % loss in controls. There were no major adverse events attributed to the exercise intervention across 16 years. Now, since Pilates is trending, I want to talk about it.

53:47Dr. Jordan Feigenbaum:In the MedExOP trial, the same group that ran the LiftMore study compared their heavy resistance training program against a Pilates-based program called BuffBones. And this was in 115 postmenopausal women with low bone mass. Across eight months, the heavy lifting group gained 1.9 % in lumbar spine bone mineral density. The Pilates group gained essentially nothing, 0.1%, which is well within the error bars of the test. And in the subgroup of women who are not on bone mineral density medications, so medications you can take to actually increase bone mineral density, Pilates actually lost a bit of lumbar spine bone mineral density.

54:26Dr. Jordan Feigenbaum:And whereas the lifting group gained the same 1.9%, the heavy lifting group also did better on functional measures. So back extensor strength, leg strength, and the five times sit to stand test that we sometimes use to screen for sarcopenia. Both programs were equally well tolerated, but the heavy lifting just worked much better. So I keep coming back to the same thing I've been saying about Pilates for years. It is fine as a physical activity. And if you like it, I love it, but it is not adequate for building bone and muscle and strength. And I think that people who have a pretty balanced view of this would agree.

55:01Dr. Jordan Feigenbaum:It is interesting to me when I get pushback saying that I don't know what Pilates is or Pilates does X, Y, and Z. And to that I say, show me. I'm open to the fact or the idea that Pilates would be sufficient to meet the current muscle strengthening guidelines, resistance training guidelines. But to date, every time that it's been investigated, it has fallen short. Austin, is that kind of your take on Pilates or we can extend it to yoga or Tai Chi or water aerobics? I don't know, what do you think about all that?

55:31Dr. Austin Baraki:I would not classify all of those things in the same bucket. Certainly water aerobics is one that, while again, a great activity for a lot of people, social environment, you know, might feel good in various ways is definitely the one that I would say is the outlier here in terms of like, actually, essentially, no skeletal stimulus is being delivered here. And we need to have some something else as a form of true load bearing. For the others, I don't have extremely strong opinions for what I'll call like the undifferentiated trainee, somebody who has had been insufficiently active and is choosing among their menu of options of how they're going to enter the physical you know space if their way of introduction is going to be pilates and i feel like that might be the way that they get bit by some bug and then we can build from there again going from nothing to doing something is likely to have some measurable benefit but it's unlikely to have very very large effect sizes on some of these things that we care about more that there are probably better ways to achieve the goal so i think there are there's the perspective of use the best tool for the goal outcome but then there's also the more like real world pragmatic approach of like, well, if the person is unwilling or unable to engage with that best tool, is there a slightly less best tool that they might engage with to start out with and kind of build from there?

56:45Dr. Austin Baraki:As far as like specific outcomes, I have honestly outsourced many of my opinions on Pilates to you because you choose to fight those battles more than I do. And so I'll take your word for many of those things. But honestly, like I just had this same conversation this morning with another patient and yesterday who are in these low bone density type situations and so these topics do come up pretty regularly in practice and so that's kind of how I lay it out is and I'm also getting a read on the person in the conversation of kind of like when we've talked about quote-unquote maximizers and minimizers before somebody who's highly motivated to do everything they can to use the best tool for the job okay it's an easy sell to say we need to do some like true you know skeletal load bearing somebody who's much more of a minimizer and I'm like struggling to get them to do much of anything then I might see what entry point can I find to get them at least started.

57:29Dr. Austin Baraki:And then maybe we can build from there as they build some confidence, some self-efficacy, even they might start to enjoy it depending on the setting.

57:35Dr. Jordan Feigenbaum:Yeah, no, I'm with you, especially like this goes back to how we kind of prescribe exercise, generally speaking to people that's undifferentiated people who are kind of new to it. Whatever, whatever turns your crank, I'm here for it. Later though, I am going to try to push you to not only meet the current physical activity guidelines, but to exceed them. And so the main thing first is like, yes, you're making this part of your lifestyle. You're excited. You're having fun. You're bought in. And then I need to kind of push you potentially towards doing something. This is the same way I feel about people who get like bit by the powerlifting bug.

58:09Dr. Jordan Feigenbaum:Like, great. We are aligned for whatever reason. We're all degenerates. We like powerlifting, but now I got to push you to do some conditioning, you know, or the endurance athlete. I'm so impressed by you, but we got to do some lift. Like, so it's not unique to Pilates or yoga or whatever else. The whole point is this is like, I don't think that they should be represented as like, this is enough. But again, that's not unique to Pilates. There's no single exercise modality that is enough. It's not CrossFit. Anyway, we've beaten this horse a few times. All right, well, look, increasing bone mineral density is one thing, but to reduce fractures, we also have to reduce falls.

58:49Dr. Jordan Feigenbaum:Now, there was a Cochran review done in 2019 that pooled 108 trials and over 23 ,000 community-dwelling older adults. exercise reduced the rate of falls by about 23 percent the strongest signals were from programs that combined balance training with progressive resistance training now the balance training is as you like to say heterogeneous people there's not a single protocol which is why none of our programs include the specific balance component and further the majority of our programs what we recommend have that intrinsically baked into it there are freestanding exercises that do challenge your balance.

59:25Dr. Jordan Feigenbaum:And we feel like that adequately addresses this balance component while also building not only bone, but also muscle and muscular strength. So Austin, the patient, she's 64. She's post-menopausal. She had a DEXA scan last year that showed that her T-score was negative 1.4 at the lumbar spine and negative 1.6 at the femoral neck. Her primary care doc told her to avoid heavy lifting. She's asking, hey, should I be deadlifting? Walk me through that conversation,

59:53Dr. Austin Baraki:assuming this actually happens in practice i just had this conversation about three hours ago today and i had another conversation uh of the same uh you know type uh yesterday morning as well with with a few different patients so pretty common near daily uh sort of experience for me um at this point you know these these t scores are not in like terribly alarming uh territory um obviously this is more in the osteopenia range rather than immediately meeting criteria on their own for osteoporosis now if the person had a history of fragility fractures that would automatically upgrade them to that osteoporosis category regarding despite the despite the t scores but the conversation starts out by just getting a sense of you know the person's understanding of their condition and then also what might they be willing to do the they might be coming in with tons of fear and apprehension about dead lifting right off the bat and a lot of times you know in the conversation that i had earlier today i actually don't tend to use the word dead lifting with people who are not already in the lifting space that often.

1:00:50Dr. Austin Baraki:I asked like, are you able to pick anything up off the floor? Pickups, as we've talked about before. And so that was how I actually started the conversation earlier today. Can you pick something up that's like maybe a little bit challenging for you, something like that? And she was like, oh yeah, I can totally do that. So that was how I framed that conversation. Now, I don't think that, you know, the way the question was framed should be deadlifting. I don't think everyone has to do this. There are a variety of ways to deliver an axial load through the skeleton, particularly through the axial spine through the through the pelvis through the hips things like that so for the individual that i spoke with earlier today you know i asked if she was able to do essentially chair sit to stance one of my favorite introductory exercises as folks get get older was she able to do them you know unassisted without using her hands was she able to do them while holding a load even in front of her and she was able to do all of these things so then we started talking about you know how we might introduce an even heavier load potentially across the back she had access to a barbell and in the home whether a straight bar or a safety squat ball or whatever something like that and then whether she wanted to do it as a freestanding squat or whether she wanted to do as a box squat as something that's like a little bit more accessible and may have a little bit of less apprehension at the bottom of the movement but can still deliver a challenging stimulus so that was one example and then just picking something up that's heavy off off the ground if her preference had been to start out with maybe more machine-based training and we wanted to do that i would similarly be able to pivot that way and think about things that could you know deliver some sort of axial stimulus through the lower extremities through the hips through the pelvis a little bit harder in that situation to deliver something through the spine when it's not necessarily freestanding but there are some creative things that we've done before so I don't kind of myopically focus on like okay the deadlift is the the cure for this sort of thing it is an option if you're interested and willing to do it and I don't have apprehensions about prescribing them if the patient's interested in doing them based on the t-score minus 1.4 that doesn't really concern me I'm more concerned about is the person training regularly is the dose appropriate um and then do they have comfort in guiding this on their own or that would they benefit from some some additional supervision yeah i think this is

1:02:49Dr. Jordan Feigenbaum:just where our bedside manner just differs you know because i would just send her the video of john paul sigmerson deadlifting 1003 we're at the top of his lockout he says there's no reason to be alive if you can't do deadlift and i think that that's catering to slightly different populations

1:03:06Dr. Austin Baraki:it seems. Yeah, yeah, self-selected population.

1:03:09Dr. Jordan Feigenbaum:All right, so that's the story on metabolism, cardiometabolic health, and bone. Next up is cognition, because this is a big concern that women raise. Brain fog, for example, is the second most common complaint that patients bring up across the menopausal transition, outside of vasomotor symptoms, the hot flashes, and the night sweats. Now, patients often describe it as word-finding difficulties, trouble holding multiple tasks in working memory and the feeling that thoughts arrive more slowly. Across the published literature, roughly half to two-thirds of perimenopausal women report cognitive complaints, depending on the group and the test being used.

1:03:47Dr. Jordan Feigenbaum:The complaint is real, but the harder question is whether the subjective experience maps to objectively measurable declines in cognitive function. So again, we go back to the SWAN study, and they have a cognition sub-study that followed approximately 2 ,300 women in the SWAN cohort with serial neuropsychological testing. This test included verbal episodic memory, processing speed, working memory, and more. During late menopause, women's processing speed dropped a bit more than you'd expect from aging alone. The size of the drop was small to moderate. Memory took a similar hit, but even smaller than that.

1:04:23Dr. Jordan Feigenbaum:Once women got into early postmenopause, their trajectory went back to the normal age-related pace. So the dip during the transition didn't turn into a permanent deficit. Women got back on their sort of regular aging curve once they were through the menopause transition. Now, there's two caveats here. First, this is a population level finding. Individual women have variable trajectories at baseline. Some recover fully, some don't. Second, the SWAN cognition sub-study was observational, and it's not an RCT, right? It's not a randomized controlled trial where we have definitive sort of proof. But one of the major contributors to this sort of cognitive complaint is poor sleep.

1:05:01Dr. Jordan Feigenbaum:Specifically, sleep disturbance is one of the most disabling perimenopausal symptoms and underpins much of what gets described as, quote, brain fog. Now, two things happen to sleep across this sort of perimenopausal transition. First, vasomotor symptoms fragment sleep, particularly in the second half of the night when core body temperature rises and the awakening threshold gets lower. Second, sleep architecture itself shifts in a way that's partially independent of these vasomotor symptoms. Multiple studies have shown reductions in slow wave sleep. This is the deepest, most restorative phase of sleep.

1:05:34Dr. Jordan Feigenbaum:More frequent awakenings also have occurred and longer sleep onset or sleep latency across this perimenopausal transition. Sleep lab data shows modest reductions in sleep efficiency in late peri and early post-menopausal individuals compared to when people are premenopausal. So overall, a meaningful portion of perimenopausal cognitive complaints comes through sleep rather than estrogen acting directly on the brain, which means that the treatment should be directed at sleep, not necessarily the brain. So if you treat the vasomotor symptoms, whether with MHT, so menopausal hormonal therapy in eligible women, or with non-hormonal options, like we covered on our last episode, like fesalinatant or paroxetine or cognitive behavioral therapy for insomnia, you can improve sleep and you indirectly improve daytime cognitive function.

1:06:23Dr. Jordan Feigenbaum:That's an indirect cognitive benefit via sleep, not a direct effect of menopausal hormonal therapy or estrogen on the brain. So Austin, imagine this. A 49-year-old woman comes in with brain fog, night sweats, and broken sleep. She's anxious that her cognition is going. Her menopause coach told her that menopausal hormonal therapy will fix all of it. Walk me through how you talk to this patient.

1:06:46Dr. Austin Baraki:Yeah, right at the outset, I think it's worth recognizing that this is going to be a longer term kind of clinical relationship, meaning I don't think it's reasonable to expect that we're going to just one and done, like nail everything and fix it all in a single visit. And I think from that perspective, there's a couple of ways that you could go about this. My thought would be, you know, to whatever extent the brain fog, quote unquote, may or may not be related to the hormonal changes, I am much more confident that the night sweats and secondary to that, the broken sleep are likely to improve if she's otherwise appropriate to receive hormonal therapy.

1:07:20Dr. Austin Baraki:And so maybe I just kind of pick my battles here and say, look, I'm very confident that we can help the night sweats, the sleep by instituting some menopausal hormone therapy if it's appropriate for you. And then we can see how you do once you're sleeping better. And maybe the brain fog just like lifts at that point. That's one way to go about this. At the same time, though, we do need to be vigilant for other things that could be contributing so that we don't kind of kick the can down the road too far. And a perfect example, literally a visit that I had with a patient a couple hours ago, a different woman earlier today.

1:07:51Dr. Austin Baraki:So you can see how often I'm having these conversations with folks. This is a woman who was, you know, in her mid-40s, had an IUD. So she was not having menstrual periods. So there's not really a sense of, you know, where she's at in her menopausal transition. With that said, she had been experiencing some fatigue and some brain fog. She brought this up. Somebody started her on menopausal hormone therapy. She is not exactly clear on whether it's helping or not. She does not feel confidently that it's helping and i don't really know where she's at in the menopausal sort of transition meanwhile she has obesity she snores she's had witnessed apneas at night she's extremely high risk for having obstructive sleep apnea and so now i'm wondering you know has this been untreated obstructive sleep apnea all the time leading to non-restorative sleep leading to cognitive functions mood changes all the other things that we know go with sleep apnea during the day and the menopausal hormone therapy is treating nothing because it has not led to a meaningful benefit for her and i don't even know whether she's even perimenopausal because she's not having any you know menstrual periods or any other no vasomotor symptoms no hot flashes no night sweats right so what do we end up doing we're pausing the hormonal therapy see how she feels see if she develops any of those perimenopausal or menopausal symptoms and then going to do a sleep study and see if i'm nearly 100 certain she's going to have obstructive sleep apnea that will get treated and then we'll see if we get things kind of on the right track so this happens regularly so to the to the scenario in this question i would be not only very willing to treat the night sweats if that is a predominant symptom and concern that this patient has but also thinking about what are the other things that can lead to this ultimate manifestation that is often described as brain fog for someone do they have any of these other things that the less specific sort of syndromes that we talk about so often the sleep apnea the thyroid the anemia the iron deficiency all these other sorts of things and checking off all those boxes along with this rather than framing it as this is 100 % exclusively estrogen deficiency and getting it back on estrogen is going to immediately take away all these things because it happens all the time, but that doesn't actually end up panning out as well as people would hope.

1:09:48Dr. Austin Baraki:Sometimes it helps, but not always.

1:09:50Dr. Jordan Feigenbaum:The menopause is going to be upset with you for telling big truths here in the menopause space.

1:09:56Dr. Austin Baraki:Go seek care from whoever you'd like. That is okay.

1:09:59Dr. Jordan Feigenbaum:All right, so that's the story on sleep. Let's talk about depression because perimenopause is a sort of vulnerability window for new onset depression and for recurrence in women with prior major depressive disorder history. So a couple of the classic studies here are the Harvard study of moods and cycles and also the Swan mental health study plus some others. They all converge at roughly the same point. There's a two to four fold increase in the odds of new onset major depression in late perimenopause compared to premenopause. This sort of window of vulnerability tracks the hormonal instability of late perimenopause, not really the steady state situation that we see in post-menopause.

1:10:41Dr. Jordan Feigenbaum:But the nuance about timing matters. A 47-year-old presenting with new anxiety, irritability, and or broken sleep deserves a differential that certainly includes perimenopausal depression. The clinical pattern of an SSRI prescription with no further workup, though, misses a potentially big part of the picture. ssris and other treatments for depression can work for these perimenopausal mood symptoms so does mht in symptomatic women so does the combination the right answer depends on the patient and their symptom profile so new onset depression itself produces subjective cognitive complaints and measurable executive function decreases a patient describing brain fog plus new low mood plus sleep fragmentation has three different issues that need a comprehensive workup like Dr.

1:11:28Dr. Jordan Feigenbaum:Baraki alluded to. The other concern that comes up in this window is dementia. And that is a bit of a different question to my mind. Dementia in postmenopausal women is dominated by aging, vascular risk factors, education status, cardiorespiratory fitness, sleep quality, depression, and hearing loss. Now, the Lancet Commission on Dementia Prevention identifies 12 modifiable risk factors. Menopause isn't on that list. Now, that may be something that changes, but to date has not been on there. The wrinkle here is that premature ovarian insufficiency, so that happens under the age of 40, particularly when it's surgically induced, is recognized as a modest risk factor for cognitive decline and dementia.

1:12:10Dr. Jordan Feigenbaum:It's one of the indications for systemic estrogen replacement until the average age of natural menopause, but that's a different population than the typical premenopausal woman.

1:12:18Dr. Austin Baraki:And one of the really important things about premature ovarian insufficiency that you mentioned, when it's happening at that age below 40, you do not put those patients on menopausal hormone therapy. you put them on high dose because you are trying to give them the same high level of hormonal exposure that they would have had until that age of natural menopause and then at that age if you want to transition them to lower dose menopausal hormone therapy that would be perfectly appropriate it would be a mistake to take somebody who's you know either medically naturally or surgically induced menopause at age 38 and put them on menopausal hormone therapy that would be an error and under treating them yeah but i think the broader question here that women want answered

1:12:55Dr. Jordan Feigenbaum:is whether menopausal hormonal therapy started around their actual menopause transition will protect their brain. Now, there are three major trials here that anchor that conversation. The first one is WIMS, the Women's Health Initiative Memory Study. This was published in the early 2000s. About 4 ,500 women aged 65 and older were randomized to one of three groups. One group got Premarin, that's an estrogen, and Provera, that's a progesterone. So they got both together. The second group got Premarin alone, and a third group got a placebo. In the combined estrogen plus progesterone arm, the risk of developing probable dementia was roughly double that of placebo.

1:13:33Dr. Jordan Feigenbaum:Now that sounds alarming, but when you translate that into absolute numbers, it works out to about an extra 23 cases of dementia per 10 ,000 women per year. It's real, but not necessarily the catastrophe that the doubled risk suggests. And here's where the study design kind of matters the most. The women in the WIMS study were 65 and older. The trial did not test the question that patients in their late 40s and early 50s really want answered, whether starting MHT closer to menopause does something different. The second study here is called KEEPS-COG, the cognitive arm of the Kronos Early Estrogen Prevention Study.

1:14:09Dr. Jordan Feigenbaum:This was published in 2015. This one did look at the younger window. Almost 700 women aged 42 to 58 within three years of their final menstrual period were randomized to get Premarin. Again, that's estrogen. transdermal estrogen or a placebo for four years the primary cognitive input was null no difference neither mht had not neither of the mht regimens had a significant effect on cognitive function in this younger population mood which was a secondary endpoint did show some benefit in the premarin arm that's an oral estrogen but the implication here is that whatever mht does for symptomatic women in this age range, when it does anything, comes through mood and sleep, not from a direct effect on the brain.

1:14:54Dr. Jordan Feigenbaum:And the third trial is the ELITE trial, which stands for Early vs Late Intervention Trial with Estradiol. This was published in 2016. ELITE was designed to test the timing hypothesis directly. Over 600 women were randomized to one of two groups, women within six years of menopause, the early start group, and women 10 or more years out from menopause, the late start group. Both groups got either oral estradiol or placebo with vaginal progesterone added for women who still had their uterus. The primary outcome was actually carotid artery thickness, a marker of cardiovascular disease, not cognition, but cognition was tracked as a secondary outcome and there was no clinically significant effect in either the early start or the late start group.

1:15:35Dr. Jordan Feigenbaum:Taken together, what these three trials tell us is pretty straightforward. In younger women starting MHT closer to menopause, neither benefit nor harm to cognition was detected. The trials weren't powered to rule out smaller effects, so we can't definitively say that MHT does nothing, but we can say it doesn't really prevent dementia, at least not with a robust signal that many in the space are maybe claiming. So Austin, imagine this, the patient's 49, she's perimenopausal, she has new word-finding difficulties and trouble with her working memory. She's got broken sleep with night sweats and some new irritability.

1:16:10Dr. Jordan Feigenbaum:She's afraid she's developing early dementia. Her menopause coach told her this is hormonal and systemic menopausal hormonal therapy, MHT, will fix it. How does that conversation go?

1:16:20Dr. Austin Baraki:Well, I got to be honest that the way you initiated that question, my hospital medicine brain jumped in and said a 49-year-old with new word finding difficulty and I'm calling a code stroke on this patient. So I got to rewind and get back to the outpatient clinic and that this is probably a more chronic sort of presentation that this patient has. So similar to our prior conversations where, you know, the night sweats again being the most specific symptom that I can potentially modify and treat. And there may be some additional downstream benefits of that on sleep quality, on, you know, how she functions during the day.

1:16:52Dr. Austin Baraki:I think that contextualizing this based on the data that you have described so far, I kind of want to summarize my thoughts and general take on this whole area of cognition and the dementia prevention angle. So the first study that you pointed out was able to show us that among late starters of hormonal therapy, so in the older demographic who are already 65 and older, initiating hormone therapy at that age does not prevent the development of dementia. I think that we can say that with reasonable confidence. you're right that there's remained the caveat of starting earlier the second study started earlier and did not find a substantial benefit over the four-year follow-up period and i think that that caveat is worth noting right so you know dementia is a very chronic uh sort of condition and so is that the same as saying that it wouldn't have any detectable impact over a 20-year time frame that that remains possible but the interesting thing here is if you look at the conversation in like the menopause space, they will say with a great deal of confidence that hormonal therapy when started early has a massive effect on lowering the risk of cognitive deterioration in that way.

1:18:05Dr. Austin Baraki:I would love for that to be the case, yet we do not have strong evidence supporting that at this particular time. So again, while I remain open to these possibilities, at this point, we don't have the direct evidence to really show us that that is likely to have such a huge impact. And to kind of compare this to one of the conversations we had last time, this stands in stark contrast to several other, as you pointed out, like modifiable risk factors for dementia that don't get nearly the attention that this does. So there's all this attention and emphasis on hormone therapy for dementia prevention, which lacks a great deal of evidence.

1:18:38Dr. Austin Baraki:While we're not seeing all of this around, you know, the same degree of emphasis on cardiometabolic health improvements for vascular risk factors, on alcohol reduction, on, you know, hearing loss, as you mentioned. There's even evidence on like the shingles vaccine has direct evidence on lowering the risk of dementia. And there is not this. If you were primarily concerned with a certain degree of benefit on lowering the risk of dementia, there would be many other things that you should be emphasizing at least as much, if not more, based on the magnitude of evidence that we have available.

1:19:07Dr. Jordan Feigenbaum:But that's not where it's at. Could you imagine a Stacey Sims podcast that was like, you should get your shingles vaccine?

1:19:14Dr. Austin Baraki:I think that would be the end of her popularity in that way.

1:19:19Dr. Jordan Feigenbaum:Every post. Yeah, right.

1:19:20Dr. Austin Baraki:Yeah, so it's really interesting because if purely we're looking on just like comparative effect sizes, I would love for there to be evidence showing it. I'd be happy to recommend it for that purpose. I don't have that right now. And so I'm happy to treat for very well-established indications. I'm even happy to, again, color outside the lines and treat a little bit for off-label indications as long as it's safe with a plan for monitoring and to say, hey, is this helping? Great, is it not helping? Okay, maybe we bail on this plan. Maybe we try something different. So that's usually the way I would go about it.

1:19:48Dr. Austin Baraki:But if somebody has no other concerns, no other complaints, and they just have word finding difficulty, oh my gosh, the differential diagnosis. Like, again, I'm thinking of like this person could literally have a brain mass leading to word finding difficulty. And if it's like, oh, you just need estrogen, it's like, maybe not the right move. When I think about the whole scope of differential diagnosis for, you know, new onset neurological dysfunction, that could be a mystery case of itself. And I could go down a much longer list than, oh, this is likely a perimenopausal manifestation. Yeah, yeah.

1:20:16Dr. Jordan Feigenbaum:If all you have is a hammer, everything looks like a nail. Exactly. Need some more tools. Yeah.

1:20:25Brain fog is an extremely common concern, and unfortunately, one of the most dismissed. Subjective cognitive concerns do correlate with objective cognitive testing. Also correlates with things like mood, anxiety, and vasomotor symptoms like hot flashes and night sweats. Now, does MHT help? We think so, but probably in an indirect way. The thought is that estrogen may help protect the brain, but only if it started soon after menopause when we believe that the brain is still responsive to it. This has been termed the timing hypothesis. By waiting years or decades, that window of benefit may have closed.

1:21:12The WIMS trial tested MHT in women with an average age of 71 and found no cognitive benefit. Was it too late, we wonder? So researchers designed additional studies to answer this question. The ELITE trial compared early versus late initiators of hormone therapy and found no differences in cognitive outcomes when they followed them after two and a half and five years. The KEEPS trial, who enrolled women aged 42 to 58, similarly found no clear cognitive benefit. Even post-hoc analysis of the WHI showed a similar finding. So what we're left with is a bit of a mixed bag, including a growing list of underwhelming clinical trial results.

1:22:06Now what we can confidently offer is effective treatment for vasomotor symptoms like hot flashes and night sweats. When those resolve, sleep improves and cognitive symptoms tend to follow. There's also evidence that vasomotor symptoms affect cognition through pathways other than through sleep disruption alone. So cognitive improvement may be a secondary benefit, but it isn't something that we can confidently promise as a primary outcome. Lastly, it's important to consider all of the other conditions that can impact cognition and not only focus on menopause just because that's the stage that a woman may be in her life.

1:22:54conditions like anemia, thyroid disorders, sleep apnea, or evidence to prescribe, just to name a few examples.

1:23:04Dr. Jordan Feigenbaum:All right, well, we've covered body composition, covered lipids, bone, and now the brain. Each of those is something that women are told to worry about, and each has a real but bounded menopause-specific signal. But none of them are what's actually going to kill a post-menopausal woman, or even the biggest predictor of how the next 30 years will go. Let's talk about what does. using the u.s national center for health statistics data on causes of death in women aged 45 to 64 cancer is the leading single cause in women aged 65 to 74 cancer remains the leading cause with heart disease at close second from 75 onward heart disease is number one stroke lower respiratory disease alzheimer's disease diabetes and accidents round out the top causes osteoporosis isn't on the top five list at any age.

1:23:51Dr. Jordan Feigenbaum:The UK data is similar, but with one difference. Dementia and Alzheimer's disease became the most common cause of death in UK women in 2011. It's held that position since. Part of that is coding, just medical coding. But part is real. Whether deaths in advanced dementia get coded to dementia or downstream condition like pneumonia is variable and depends on the provider. Still, osteoporosis as an underlying cause of death is below 1 % in every age sort of group. Hip fracture-related deaths are predominantly coded to circulatory or respiratory complications most often. So let's talk about the largest modifiable predictors of all-cause mortality, and that comes down to fitness.

1:24:30Dr. Jordan Feigenbaum:Fitness is the combination of a few different physical capacities, and two of them carry most of the mortality signal. The first is cardiorespiratory fitness, sometimes called aerobic fitness or CRF. That's the body's ability to deliver oxygen to working muscles during a sustained or prolonged effort. That's the thing you're testing when you run, bike, or take like a graded exercise test. The second is muscular fitness, which itself is split into strength, the maximum amount of force that you can produce, and power, the ability to produce force quickly. Both components carry independent mortality signals in the data, and the size of those signals is rather large.

1:25:08Dr. Jordan Feigenbaum:So let's start out by talking about cardiorespiratory fitness. So we go back to a study we've talked about a few times on this podcast by Manceger and colleagues out of the Cleveland Clinic, they published a large retrospective cohort in JAMA in 2018, over 100 ,000 patients undergoing treadmill exercise testing at the Cleveland Clinic from 1991 to 2014. Now, these individuals were followed for an average of eight years. And if you compare those with the top level of fitness compared to those with the bottom level of fitness, the people in the top group had roughly 80 % lower all-cause mortality.

1:25:43Dr. Jordan Feigenbaum:That's the headline number. But two important things to note before we sort of run with this 80 % number. First, this is observational data. The people in the study were patients referred for clinical exercise testing at the Cleveland Clinic, not a general sample of adults. So there's some selection bias there. Second, the 80 % figure comes from comparing the very top of the fitness distribution to the very bottom. The effect between adjacent groups is much smaller. So a better comparison, perhaps, comes from a 2009 meta-analysis by Kodama, which pooled 33 studies and over 100 ,000 people. Fitness in that analysis was measured in METs or metabolic equivalents, which is just a standardized way to express how hard an activity is, more specifically how much energy it uses while you're doing it.

1:26:26Dr. Jordan Feigenbaum:One MET is the energy that you burn at rest. Walking at a normal pace is about three METs and it costs you three times as much energy. Jogging is around seven, costs you seven times as much energy as sitting at rest. So a MET is a unit that is sometimes used in fitness to be descriptive. How much energy is being used? How hard is it? For every one met increase in somebody's measured fitness, all cause mortality dropped by about 13%. So the lever here for cardiorespiratory fitness is real and it's meaningful at any starting point, but the 80 % stat kind of overstates it. Even with those caveats, the fitness lever exceeds traditional cardiovascular risk factors in the same Cleveland Clinic cohort, including established coronary artery disease, mainly because low fitness has this predictive power in the short term, whereas established coronary artery disease is more of a long term risk factor.

1:27:17Dr. Jordan Feigenbaum:In older adults, the death rate in the lowest fitness group was about four times the death rate in the highest fitness group with most of the benefits landing as you move from the lowest level of fitness to the second lowest. So basically doing anything to get you out of that lowest group is going to have the biggest benefit. That's the story on cardiorespiratory fitness. But when it comes to muscular strength and muscular power, resistance training adds a partially independent signal. The first studies from MAMA22 in 2022 in the British Journal of Sports Medicine, they pulled 16 studies together on resistance training and mortality.

1:27:51Dr. Jordan Feigenbaum:People who did regular resistance training had about a 15 % lower all-cause mortality rate than people who didn't. Cardiovascular mortality looked similar. When resistance training was combined with aerobic training, the reduction was about 40%. The two interventions are partially additive. Then there's a question of what to actually measure on the muscle side, because strength and power are two different things. Strength is how much force you can produce maximally, also sometimes called low-velocity strength. And power is how fast or how quickly you can produce that force, also sometimes called high-velocity strength.

1:28:25Dr. Jordan Feigenbaum:A 2025 paper from the Clinimex cohort in Brazil compared the two head-to-head as mortality predictors. in about 3 ,900 adults aged 46 to 75 who were followed for a median of about 11 years when comparing the lowest group on relative muscle power to the highest. The people in the lowest group had a roughly six-fold higher risk of dying during the follow-up. And grip strength, the standard measure of muscle strength in this kind of study, was a much weaker predictor in the same people. So power, the ability to produce force quickly, looks like the more useful power measurement for mortality purposes, not raw strength.

1:29:02Dr. Jordan Feigenbaum:now if you haven't read this study i thought it was pretty ingenious how they actually tested muscle power it wasn't just how fast they could do hand grip strength that would be kind of a goofy way i think to to compare these things it was pulling up on like a weight stack just like imagine like you're starting a lawnmower but with both arms and you have to rip a weight stack up to do so that's how they did it i was like oh this is like a high pull like a you know it's just like a sumo deadlift high pull or something like that yeah pretty interesting so uh no hate comms towards grip strength. Well, maybe some hate comms because grip strength still carries a useful signal.

1:29:36Dr. Jordan Feigenbaum:And what you've probably heard about is, particularly if you listen to Atiyah's podcast, he belabored this point. The pure study, about 140 ,000 adults across 17 countries found that for every five kilogram decrease in grip strength, there was a 17 % higher all-cause mortality. Now, you laid this out very eloquently before grip strength is this sort of integrated high quality readout of not just total muscle mass but how well it functions the neuromuscular function and how everything is integrated together in order to work in a coordinated manner which is why it predicts mortality so reliably in untrained populations kind of reflects the work of everything involved in that sort of system from brain to your fingertips but it's also why the test isn't so good itself.

1:30:24Dr. Jordan Feigenbaum:When you train the grip directly, you can increase grip strength, but it has no correlation to improved mortality. And similarly, there's a strong genetic component to grip strength, as well as a strong mass component to grip strength. So how bigger people generally carry more lean body mass, whether that's an individual with obesity or an individual without. And so there's a sort of paradox here where just, you know, absolute grip strength numbers can be misleading, which is why we're not big fans of like grip strength testing. I don't think that you've ever handed a patient a grip strength dynamometer.

1:30:57Dr. Austin Baraki:No, zero times. I've subjectively assessed grip strength, but that's again, more often when I'm doing a stroke evaluation, and I'm trying to see if their one arm is weaker than the other acutely, but even that is not ideal.

1:31:08Dr. Jordan Feigenbaum:Yeah, we did a whole episode on this. So if you want the deeper dive, check that out. It's linked in the description below. So to my mind, the biggest modifiable lever against the leading causes of death in postmenopausal women is fitness, both the aerobic side and the muscular side. Cardiorespiratory fitness and muscle power each carry independent mortality signals, and the two are additive and in some ways synergistic when you do both. The largest absolute benefit on the aerobic side comes from moving out of the bottom of the fitness distribution, so low levels of cardiorespiratory fitness, to the second lowest level.

1:31:40Dr. Jordan Feigenbaum:So going from sedentary to even modestly active is where most of the gain is. On the muscle side, the data points towards not only being able to produce a lot of force, which is strength, but also being able to do so quickly, which is power. Now, the training that builds both of those things is not unique to menopause. It's just engaging in progressive resistance training, plus doing some conditioning. Now, the menopause content space, the menopause influencer space, often has the priorities reversed. Heavy resistance training only, often with conditioning work framed as cortisol elevating that you should avoid it.

1:32:13Dr. Jordan Feigenbaum:But the actual data is quite clear here. You should do both because the two together carry the largest combined mortality benefit of any modifiable intervention available. So Austin, the patient, she's 58. She's postmenopausal. She has been insufficiently active for the last 20 years. She's otherwise healthy. She has read enough to know that she should exercise like most people, but she's overwhelmed by conflicting advice. What does that conversation look like?

1:32:37Dr. Austin Baraki:yeah gosh i feel like i just need to you know get patients permission to start recording my business every day because i just had another conversation like this uh you know uh earlier today so it is interesting uh to recognize that she has read enough to know that she should exercise because she has that background information she's coming in i'm already staging her in like the kind of stages of change behavior behavior change sort of model she's coming in already, you know, curious, interested, asking questions. That already gets my foot further in the door than it might with many other patients who are either, they might be aware that it's good for you, but otherwise uninterested.

1:33:14Dr. Austin Baraki:She is at least interested, yet she feels overwhelmed. And so that's where having some professional guidance, some reassurance, helping her kind of dismiss with things that aren't worth being worried about, getting her maybe off of TikTok or social media, algorithmic media that is going to, you know, exacerbate this problem and giving her a set of like really, really quite basic, straightforward advice that can start to take her out of that like bottom quartile into the next one up in a relatively short timeframe, not that difficult to do. And so my first question is going to be whether she has any prior experience with physical activity in general, any sports experience, any group class fitness things, does she have any kind of social circle, anybody else that does this or anyone else who'd be willing to do it with her to see what levers can I pull to improve, you know, initiation and then adherence to this over time.

1:34:01Dr. Austin Baraki:Getting a sense of what her knowledge base is now and kind of tying that into what she might be willing to do. So some form of, you know, aerobic conditioning, whether starting out with walking and progressing to, you know, jog walks or progressing to stationary biking or some form of, you know, aerobic fitness based on her current abilities, her limitations, if she has any like orthopedic or otherwise considerations that we need to think about. And what is she willing to do? What does she have access to doing? And then finding a way to set the volume and the intensity of that aerobic activity.

1:34:31Dr. Austin Baraki:The intensity we tend to set most often in folks like this with something as simple as a talk test. We want to get you to a point where you can, you know, talk but not sing and maybe speak in a couple word sentences but not be able to sing fluently. If you can, you know, be able to belt out a whole verse of a song, it's still probably a bit too easy. That's a reasonable way to do it. If that doesn't resonate, then maybe introducing them to just a subjective effort scale and pushing them to the right degree of effort. That would be the way we do that. And then starting out with a very low volume, maybe two sessions a week, something like that at a moderate amount of duration, say 15 minutes, 20 minutes, and then working that up with our current physical activity guidelines in mind with a defined timeline of how long it should ideally take us to get there.

1:35:12Dr. Austin Baraki:That would be the way on the aerobic side of things. As far as strength training goes, I'll go back to my traditional sit to stance as the place where I start, assess what is the person's current level of muscular strength and power by having them try to stand up again as quickly as they can, because that can introduce a little bit of velocity to it, and then see can they do that loaded, especially if they can stand up already without the use of their hands. And then from there, that can be my launching point to explore what forms of loaded resistance training is this person able and willing to do?

1:35:39Dr. Austin Baraki:Are they going to have access and be interested in going to a gym? Is this going to be a home-based program? If so, what sort of loads do they have available to them, and how can those be progressed over time? If ultimately all I can negotiate is basically for somebody to do some loaded sit-to-stands and some pickups at home twice a week that can be loaded to a level that's again, kind of hard. I'm okay with that as a starting point. And then again, a couple of sessions a week of moderate intensity aerobic activity to where they can talk, but not sing. I'm also okay with that as a starting point.

1:36:06Dr. Austin Baraki:That will be life-changing for this person. And then we can kind of progress it over time based on their abilities, based on the interests, based on their motivation, things like that.

1:36:14Dr. Jordan Feigenbaum:Yeah, yeah. I think when people hear that, they're like, that doesn't sound like much, especially if you're listening to this and you're a coach or you've been training for a long time. And so you think about your own current, like training load or whatever. You're like, that doesn't sound like much. And yeah, that's the point. This person has not been, you know, gradually doing this for decade upon decade, which is unfortunate, but you know, while the best time would have been to start 20 years ago, the second best time is to start today. I think the disconnect is though, when you start talking about optimal, right?

1:36:45Dr. Jordan Feigenbaum:And you're like, well, look, if we're trying to optimize all of the potential outcomes from exercise, the amount of exercise that we would really want to get you to work up to is probably more than you can do. Not because like you're a bad person or there's some sort of moral hangup. It's like, dude, you don't have enough time. You mean you're not a professional athlete? You can't dedicate your life just to being in awesome shape? Unfortunately, that is the case for most people, you know?

1:37:10Dr. Austin Baraki:And that's where the algorithmic media can really become a problem because people either see like amazing feats, which may be natural, may be chemically enhanced, or the messaging on it is really centered around optimizing and optimizer culture and maximizing, which is fine for somebody who really has the time, resources, and motivation to do that, but that's not most folks. And so that can be overwhelming and why people can end up feeling like they have conflicting messaging and why women are worried about, oh, if I exercise too hard, it's going to give me cortisol, belly, and other nonsense like this, which is just not a thing.

1:37:42Dr. Jordan Feigenbaum:No, I have no concern about somebody training to the point where cortisol becomes the dominant hormone and now we've suddenly induced exercise-related Cushing's, for example. Not a thing, yeah. Not a thing, not a thing. Yeah. All right, well, look, there's one more thing worth covering before we wrap up. Now, most of what gets marketed to midlife women as a menopause crisis is better explained by 20 years of declining physical activity. Now, when researchers put accelerometers on people instead of asking them how active they were, less than 5 % of U.S. adults over the age of 40 hit the recommended 150 minutes per week of moderate to vigorous activity.

1:38:22Dr. Jordan Feigenbaum:For women specifically, those aged 40 to 49, only 3.4 % hit this level of conditioning each week. For those 50 to 59, it's about 2.7%. Sedentary time averaged more than seven hours per day. Now, when you compare this to the 42 % of women who self-report that they are doing this much conditioning, you see where part of the problem lies. This is not unique to women. Men do the same thing. Now consider that only about 15 % of women self-report that they're lifting weights. How big of a problem do you think that is? So this lack of exercise has predictable consequences. In the 2005 Baltimore Longitudinal Study of Aging, 375 women were followed with serial measurements of their VO2 max over a meeting of eight years.

1:39:04Dr. Jordan Feigenbaum:VO2 max is just a way to measure your cardiorespiratory fitness. So they found that aerobic capacity does not decline in a straight line. Rather, the rate gets faster each decade after 30. In your 40s, women lose about 8 % to 10 % of their aerobic capacity per decade. In your 50s, that climbs to 10 % to 14%. The menopause-specific piece is worth about 1 % per decade, whereas most of the drop is aging plus the activity decline that we just talked about. for lean mass in 2000 jansen measured whole body muscle mass using mri which is very very accurate in 468 women skeletal muscle mass holds relatively steady until about age 50 then declines about 0.7 percent per year after that strength declines about three times faster the piece that the swan data can attribute to menopause itself is about 200 grams of lean mass loss across the transition Now, compare lifelong trained postmenopausal women against women of the same age who haven't been exercising.

1:40:03Dr. Jordan Feigenbaum:The catch is this kind of comparison comes from selected populations, master's athletes and people enrolled in long-term studies of exercise. So certainly some survivor bias and selection bias. Lifelong exercisers tend to be healthier to begin with, more consistent with their exercise habits and more likely to stick around for follow-up. So while these comparisons tell us what's biologically possible, they don't tell us what an average, insufficiently active woman starting fresh at age 55 is able to achieve. Now, with that caveat in mind, let's talk about aerobic capacity. For aerobic capacity, the Pollock studies followed master's endurance running women over 20 years.

1:40:40Dr. Jordan Feigenbaum:Trained women in their 60s had VO2 max levels of 45 to 55 versus age-matched sedentary controls at levels of 22 to 28. That's roughly a two-fold difference. and the trained 60-year-olds in the sample had aerobic capacities that would put them in the fit range for women decades younger, right? If you look at the average VO2 max for women in their 30s, it's not even that high, it's lower, okay? For bone, that EFOPS study we talked about earlier, at 16 years showed that lumbar spine bone mineral density dropped 4.5 % in controls versus 1.2 % in the exercise group over 16 years. It's not a gain, but a meaningful preservation over 16 years, and oh, by the way, their resistance training component was not very intense.

1:41:23Dr. Jordan Feigenbaum:For strength, a 2024 longitudinal analysis of competitive powerlifters showed something even more striking. The general population loses about 1 % of their strength per year after middle age. But in this study, women over 59 who kept training and competing gained 2.5 to 5 % per year. That's the opposite direction of what's supposed to happen. So a trained 60-year-old looks more like an untrained woman 15 years her junior across the measurements that matter. She isn't reversing aging as father time is undefeated and the biology that takes muscle and aerobic capacity away over time keeps doing what it does.

1:41:57Dr. Jordan Feigenbaum:But a meaningful amount of what gets lost between age 30 and 60 is recoverable and the data shows how much. So Austin, the woman listening to this is probably somewhere in this window. Maybe she's 48 and she's just starting to notice changes. Maybe she's 58 and she hasn't been exercising for 20 years. Maybe she's 65 with a DEXA scan showing osteopenia and a primary care doc who told her not to lift heavy. Pull the threads together. What is the actual plan for any of them?

1:42:22Dr. Austin Baraki:Yeah, not a fan of the advice from the primary care. So I think that initially seeking out some better guidance and expertise in this space would be worthwhile. Whether the person has symptoms that are concerning to them, and I don't even qualify them as perimenopausal symptoms because I'm going to say that they're going to be a wide variety of potentially specific and non-specific symptoms like seek out some you know qualified expertise and guidance to help you work through it in a comprehensive way i think that that's been one of the two consistent themes throughout this episode is that there are symptoms that you may experience some are more suggestive of the perimenopausal menopausal transition that can be very effectively treated with say things like menopausal hormone therapy or non-hormonal options there are also other symptoms that are maybe less suggestive and that those deserve their own you know broad evaluation to make sure that nothing is being missed that can be treated more effectively in an alternative way that's the first i think key theme is seeking competent expertise to explore the full breadth of these things that you may be experiencing the other is this most powerful lever that you have pointed out and hammered on in the latter segment of this episode the most powerful lever being fitness in general which we break down into our cardiorespiratory component which the prescription of which does not need to be terribly complex it's more a question of sufficient volume where you're meeting certain targets on the on the talk test is fantastic and then the strength training component which can involve some both general strength or low velocity strength can involve if you like some power training can be something fun can be something explosive if you like can involve something like pickleball if you if you love that something that a lot of folks are picking up these days that has numerous benefits both physical social outside lots of other things and so i think that leaning into these two aspects is a great strategy for improving your midlife and later life health targeting the biological components through medical evaluation and treatment when needed psychosocial factors you know as well as protecting your longevity your physical function your muscles and your bones by meeting these kind of physical activity guidelines that we've been hammering on for you know as you said better part of two decades at this point they have not changed that much over that period of time it's more the uptake that we need to keep working on improving.

1:44:38Dr. Austin Baraki:So strength training likely to be safe for the person in this demographic who's listening. Cardiorespiratory activity, there's likely to be some modality that we can find. And then to the extent you're experiencing debilitating, frustrating symptoms, if you're making progress or not making progress with your clinician, again, seeking out other opinions, specifically with expertise in this space can be worthwhile for you.

1:44:56Dr. Jordan Feigenbaum:Yeah. Yeah. Well said. And I think, you know, it's a recurring theme. When we talk about exercise and dietary pattern change. There are very few situations that actually require, I don't want to say necessarily specialized knowledge, but a specialized approach. It's mostly the same. And when you talk about individualizing it to the person, meeting them where they're at, highlighting their preferences, their resources, what do they want to do? What's their motivation, this, that, and the other? That's universal. And so I hesitate to kind of come up with like a menopause-specific program unless it were to sort of be taken up better, right?

1:45:37Dr. Jordan Feigenbaum:If it is branded as such, and I'm very clear that, look, while this is not specific to menopause, I roped you in and now you're gonna get some real training. That's probably to the extent I could do it and feel good about myself and sleep at night. But I, you know, so I do have to, you know, to say that one of my recurring issues when investigating various topics in this space is that there is not only just so much misinformation, but it's almost like siloed in a way where it's like, no, no, you need this specific fund of knowledge and this specific person. I'm like, that does not seem to be well supported by evidence.

1:46:13Dr. Jordan Feigenbaum:If there was, then, you know, look, let's develop a new medical specialty, you know, which I know it has been discussed, but I think that's mostly because OBGYNs are kind of, there's a broad base of things that they have to address. And so, yeah, that might change. But anyway, Austin, is there anything you want to add for the woman listening to this who's somewhere in this window?

1:46:33Dr. Austin Baraki:I think this is probably, you know, to the extent that you are interested in detailed information on this, these episodes can potentially be quite dense, might need some multiple listens. If you are in need of additional opinions or expertise, again, we are available and happy to help by way of consultations. Either the other Dr. Baraki or myself, we do this every day with folks. So yeah, happy to help.

1:46:56Dr. Jordan Feigenbaum:a few things to take away from today first body composition the menopause transition adds about one and a half kilograms of fat and takes about 200 grams of lean mass over a time period of about three to four years that is real and the menopause specific piece is where the fat goes visceral fat goes up and fat that doesn't get stored as subcutaneous or under the skin ends up in places it shouldn't be which we call ectopic fat first is the liver then the visceral compartment that's around the organs inside your abdomen and then in the muscle potentially. The other 8 to 13 kilograms though that's associated with midlife weight gain, that's mostly aging and habits that predate the transition and outlast it.

1:47:37Second, hearty and metabolic.

1:47:39Dr. Jordan Feigenbaum:LDL and apolipoprotein B or APOB rise in a narrow window around the final menstrual period and that part is really menopause. The rest of the picture though, blood pressure, insulin resistance, metabolic syndrome risk, well that tracks with the visceral fat redistribution and aging more than the hormonal change. The hormones are upstream, the fat is what's doing the damage, and exercise can play a big role here. Third is bone. The biggest deposit window or opportunity window to build bone mass is in the teenage years through the late 20s, when peak bone mass is laid down. After 30, it's mostly about preservation.

1:48:16Dr. Jordan Feigenbaum:Bone loss accelerates sharply around the final menstrual period, with most women losing about 10 % of lumbar spine bone mineral density across this window. The bone that you build by 30 is kind of what you have to draw down from. Now for women with low bone mass, when they hit menopause, resistance training is still the standard recommendation. You got to do it. The 2018 Liftmore study established that heavy training is safe and effective in postmenopausal women with low bone mass. But for women with established osteoporosis with prior fragility fractures, pharmacotherapy enters the picture. There are many different medications that can be helpful, including MHT, especially as an option for younger postmenopausal women, especially those with vasomotor symptoms.

1:48:57Fourth, cognition.

1:48:59Dr. Jordan Feigenbaum:Brain fog is real in this phase, but it's mostly recoverable. It generally is the result of poor sleep, mood changes, and vasomotor symptoms, especially those that keep people up at night or disrupt sleep, more than estrogen alone acting directly on the brain. Menopausal hormonal therapy does not prevent dementia based on any evidence that we have, but treating the sleep and particularly hot flashes that disrupt sleep can help cognition indirectly. The fifth takeaway is about mortality. Cardiorespiratory fitness and muscle power are the two biggest modifiable mortality levers that we have and they stack.

1:49:32Dr. Jordan Feigenbaum:The menopause content space mostly has this backwards, heavy lifting only with conditioning treated like it'll spike your cortisol and ruin you. The data says to do both And the biggest single gain is going from doing nothing to doing something. And finally, menopausal hormonal therapy or MHT. It is certainly the right answer for hot flashes, for the genitourinary symptoms, and for some bone protection in eligible women. But it's not really the answer for body composition, cardiovascular disease prevention, cognition, or mortality. now next week we get into the actual prescription what the training and nutrition and other lifestyle changes actually look like for a woman who's in this window how they should start how they should progress and what to do when life gets in the way i'm dr jordan feigenbaum that's dr austin baracki and dr lorraine baracki this has been the barbell medicine podcast thanks for listening

1:50:32Dr. Jordan Feigenbaum:Austin and I wrote a book and it's called Signal What Testosterone Levels Are Telling You About Your Health. And it is available for pre-order right now with copies shipping in June. Here's why we wrote it. The testosterone conversation right now is a mess. About a quarter of testosterone prescriptions in the United States are started without any lab work. And over half of men who meet criteria for low testosterone see their levels normalized on their own without any treatment. And at the same time, nearly 40 % of men who are 40 and older who have low testosterone, only about 1 in 10 of them are actually getting treatment.

1:51:02Dr. Jordan Feigenbaum:So some men are getting medicated for problems that they don't have, while other men who would genuinely benefit from treatment or at least an evaluation, well, they're not getting it. And everyone is trying to make decisions about testosterone, whether it's lifestyle, medication, or otherwise, without a clear framework for what testosterone even does. Signal is the book that we wrote to sort all of that out. It covers the physiology of testosterone from the ground up, how levels trend across the lifespan, and what has been driving them down at the population level over the last 50 years with a surprising increase in the last decade.

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