Menopause Part 4: Training, Protein, Cortisol, Hormone Therapy, & Bone Density

25:35Jordan Feigenbaum:For conditioning, we'd want people to engage in at least 150 to 300 minutes of moderate intensity cardio or 75 to 150 minutes of vigorous intensity cardio or a combination based on preferences and time availability. the less time you have available to train, the more intensity, the higher intensity your conditioning should be. For resistance training, approximately two days per week or more of lifting weights that challenge all of the major muscle groups of the body, ideally with compound multi-joint movements. They should be relatively heavy relative to the individual's current strength level, but not necessarily maximal.

26:08Jordan Feigenbaum:Somewhere in that 60 to 80 % of a one rep max range for sets of three to 12 reps with a couple repetitions left in the tank. there is a thought to add in some hops and or jumping into a program designed for a perimenopausal woman this is a holdover from the lift more trial that we'll get into later so effectively in that trial they saw an increase in bone mineral density and part of the protocol was that they did jumping pull-ups and landed with straight legs and so the thought is by jumping you introduce this large mechanical stress on the bone and yes at a microscopic level the bone slightly deforms And as a response, you get an increase in bone mineral density.

26:45Jordan Feigenbaum:That's not really evidence-based. It's more vibes-based. I don't think that hops or jumps are bad per se, but if somebody is lifting heavy enough weight, I also don't think that it's necessarily additive. It's just kind of one of those questions that remains open at this time. That said, the menopause fitness market is built on the claim that this woman needs something different, but she doesn't. And in fact, while there's a decent amount of data here, the only a few findings in the research come up as menopause specific, even though they're also not. This comes from the Orsadi 2022 trial where 113 postmenopausal women went through a 16-week lifting program.

27:21Jordan Feigenbaum:And the first signal that popped up here had to do with training frequency. The authors found that twice weekly training had a higher non-response rate than three times per week. And so the recommendation was, well, you got to train at least three times a week. but the nuance here is that it's not the frequency it's not that they were just lifting up three days per week versus two days per week it's that they were doing more volume frequency is a tool to distribute the training volume or more specifically the training load which is not just how much training you're doing it's the nature of the training so for me i looked at this and i was like okay frequency that's not the thing they just did more training which makes sense there's a dose response across basically every adaptation here yeah because i can i can spin this scenario a

28:03Austin Baraki:little bit and ask you, let's take a sample, you know, client that we might be coaching who is, I don't know, anywhere from 25 to 35 years old. And they've been training twice a week and not getting a great training response. What are you most likely to do? Yeah, if they say I have all the time in the world to train, what would be your next most likely intervention, you might be like, yeah, let's add a third day of training. Yeah. And so that kind of illustrates that this is not necessarily a uniquely menopausal consideration. But rather, this is like a fundamental approach to training responsiveness or not, which is much more an individual level phenomenon.

28:35Austin Baraki:I think it's less likely, for example, that you would have, say a woman who is training and doing great and getting fantastic gains training just twice a week leading up to menopause and then suddenly goes through the transition and absent, you know, say the impact of menopausal symptoms, disruption of sleep or anything else, absent any of those things, that suddenly the same twice a week training has like no more effect. And suddenly she's like, I'm not responding. You know, the type of person who is already responding well is likely to keep responding well, assuming that most of the other variables of interest, like your sleep and your nutrition and things like that are in check.

29:09Austin Baraki:But that's also the case across the entire training career.

29:12Jordan Feigenbaum:Yeah, the only the only sort of frequency specific thing I can think of here that would would relate to, let's just call it an untrained or undertrained population is that is fatigue that accumulates during a workout. So had no number of days associated with it. So you had, you know, less 20 exercises, right? And you could do it on one day, you could do it on two days, three days, four days, five days, whatever, split it up, however you want. At some point, it's going to be too much exercise in a given session for somebody to actually, again, acquire or accumulate the same training load, meaning that they're gonna have to lift lighter, they're gonna do less reps.

29:51Jordan Feigenbaum:And so training load is going to go down. And at that point, modifying frequency is probably going to have a big effect. And so I I think for untrained or generally undertrained individuals, that sort of fatigue shows up earlier in a session. And so if you actually meet it or spread the training out over more days, then perhaps the training level will go up. Which again, it's the same relationship, just a kind of like wrinkle and how that's being explained there. All right, so that was the first signal that popped up. And again, not menopause specific, but more just like training for all individuals.

30:21Jordan Feigenbaum:The second one is also not menopause specific, but they did find it. It's insulin sensitivity. for every one unit increase in a test that's called a HOMA-IR, that's an acronym, and it's a measure of insulin resistance, it was associated with a roughly 40 % higher odds of non-response to training. Now, HOMA-IR is a number you can pull from a fasting glucose and insulin test, and it indexes how insulin-resistant someone is. So a healthy and normally insulin-sensitive person sits around one or so. Two is borderline. Three we consider real insulin resistance. So the gap between a one and a three in HOMA-IR on these data in this data set is like a doubled risk of not responding to a real training program.

31:04Jordan Feigenbaum:But this is where that cardiometabolic story from episode two connects directly with training. The pathway that insulin resistance blunts is the same pathway resistance training works through. Insulin resistant muscle has a dampened anabolic response to a given training stimulus. And this is true across populations. It shows up in trials of older adults, in people with type 2 diabetes, in people with obesity. It's not just menopause-specific. Training improves all of these things nonetheless, but to me, this finding in postmenopausal women is one slice of a much larger pattern. So that's the training side.

31:39Jordan Feigenbaum:Nutrition is the other half, and it follows the same pattern. Most of what's being sold as menopause-specific is smoke and mirrors. There's a 2026 review aimed directly at this. A group pulled together 34 strength training studies done specifically in postmenopausal women, about 1 ,500 women, and asked one thing. Once she's already lifting, does adding some specific diet or supplement do anything on top of that? The training itself reliably improved muscle, strength, and bone. It's a sledgehammer. Then they looked at protein in nine of those studies. Above a pretty low floor, eating more protein added nothing to strength or muscle mass.

32:14Jordan Feigenbaum:So that message you've heard that you suddenly need a gram per pound the moment you hit menopause doesn't seem to be supported by evidence. Now, of course, you can. It's not dangerous. And we still want you hitting enough somewhere around 1.2 to 1.6 grams of protein per kilogram body weight per day. But chasing huge protein numbers isn't really necessary. Now, the one dietary change that clearly did do something was a modest calorie deficit, a few hundred calories a day under maintenance. and all that did was help with weight loss, typically fat loss, which is exactly what you'd predict. It has nothing to do with menopause.

32:48Jordan Feigenbaum:Creatine, calcium, vitamin D, ranching amino acids, omega-3s, and the herbal stuff, the evidence that it adds anything on top of the training was thin to non-existent, which is kind of the whole point. The training, again, it's the sledgehammer. It's the most important piece. The nutrition supports it. It doesn't replace it. And almost none of it needs to be menopause-specific. Most of what's being sold as menopause-specific is just marketing hype. There's a lot of talk about protein intake, particularly in this population, from some very popular and loud people saying, you've got to eat a gram per pound of protein per day, suggesting that women in this phase in life need more protein, which is not evidence-based.

33:34Jordan Feigenbaum:And in fact, our recommendation would be if you're going to have a protein target, 1.6 grams of protein per kilogram body weight per day is fine. If you wanted to lower that to 1.2, we'd probably also be okay with that. Because again, increasing protein in the absence of resistance training is going to have a very limited, if any, effect. The best effect, if I was being super charitable to this claim about increasing dietary protein, it's that when people do that, they tend to pick minimally processed or unprocessed sources for this protein, and it can displace other foods that we wouldn't necessarily want the person consuming a lot of.

34:10Jordan Feigenbaum:That said, just the increase in protein, if that's the only thing that changed, the dietary quality didn't change or whatever, you and I would both predict almost no real appreciable change here. But if you wanted a protein target, it is no different in the perimenopausal state, postmenopausal, premenopausal, any other stage in life. All right. So three to four meals per day with roughly 30 grams of protein, you know, whether it's from whey, dairy, eggs, lean meat, fish, soy, legumes, whatever, that's all going to work. But there's no menopausal specific protein intake. And if you want to go higher than that, we don't think that it's risky.

34:44Jordan Feigenbaum:It's just mostly costly. Like it's going to cost you more. and you know to the extent that you love a high protein diet that's great but it doesn't need to be any higher than that unless you really want to and then i have questions on why do you really want to if it's a palate thing or it's because you've been conditioned to believe that it's

34:59Austin Baraki:better totally yeah yeah that reflects my usual recommendations in this conversation you know a lot of folks especially those who are um you know i'm seeing a lot of folks who are using glp1s for you know uh weight management especially in this phase of life that's probably the majority of patients that I see are peri and postmenopausal women in this stage of life who are interested in using GLP-1s. And so pushing to very, very, very high protein intakes can become actually quite a challenge for some folks, depending on their degree of appetite suppression. And so if I can get them over consistently 1.2 grams per kilo per day, I'm actually quite content with that.

35:32Austin Baraki:And then I'm putting way more emphasis on, are we getting enough muscle stimulus? Are we getting training done? And if they're like, look, I cannot even manage to get my protein intake to that level a i'm assessing like is our dose a bit too high do we need to back off on the dose or like are we over suppressing this person's appetite but if not and they're still like maybe closer to one or 1.1 but they're like training plenty i'm like you're probably still

35:55Jordan Feigenbaum:actually in a really good spot yeah yeah yeah it's just gonna take a lot for me to want to recommend higher and recommending higher than 1.6 is more like an experiment it's like yeah sure the point estimates in the data suggest maybe up to 2.2 grams and like maybe you respond a little bit better but at that point it's incremental it's not like this is going to change your life yeah the second thing that gets thrown around a lot with respect to diet uh is creatine creatine is had a resurgence i think in the 90s and early 2000s creatine was like what is this new thing and then it kind of went away everyone just accepted that creatine is the most well-studied dietary supplement and you know there wasn't a lot of hype around it but now it's back for whatever reason and ironically it's getting like advertised to menopausal women like that It has this unique benefit.

36:40Jordan Feigenbaum:I just saw this on threads and I got into it with this particular individual because they said it has the biggest effects in any population in postmenopausal women. And I was like, citation, like desperately. Show me. I would love to see that.

36:52Austin Baraki:Yeah, yeah, yeah.

36:53Jordan Feigenbaum:There are studies here. So, for example, there's a meta-analysis by Dos Santos. Ten randomized controlled trials and older female participants found small to moderate strength benefits larger in trials that are lasting over 24 weeks. This is the same as we see outside of menopause, a modest effect on strength. No loading phase is needed. You can just do three to five grams of creatine per day. Or if you want to do body weight based dosing, it's 0.03 to 0.05 grams of creatine per kilogram body weight per day. But with the loading phase, this is where most of this bloating claim comes from, particularly in women.

37:31Jordan Feigenbaum:So during these loading phases, people are taking like 20 grams of creatine per day. now interestingly those bloating uh sort of observations came from studies in men so it is interesting that this is kind of translated over to creatine causes bloating in women um existing data shows that creatine does not increase total body water unless somebody's doing a loading phase and so dr baracki because you love uh bean physiology aka renal physiology kidney physiology If total body weight doesn't, total body water doesn't go up, right? And there's not a massive reallocation of where that water is stored in the body.

38:08Jordan Feigenbaum:How is it possible that creatine would cause bloating in an individual?

38:14Austin Baraki:Yeah, it does not strike me as a fluid or a hydration mediated phenomenon. It might be primarily gastrointestinal in some way, but much more likely if the total body water assessment. because you know the body we don't need to get into my like nephrology chalk talk of like the body compartments and the you know extracellular intracellular interstitial fluid compartments and things like that but um overall it is more likely to be some form of a subjective sensation that may be mediated from within the gastrointestinal lumen than it is from like the interstitial tissues or certainly like the extracellular fluid compartment which would be the main one that people would like quote unquote notice you're not likely to notice anything in terms of intracellular fluid compartment which is actually the bigger one between the two

38:56Jordan Feigenbaum:but anyway yeah we don't need to get into that yeah the loading phase does seem to draw a bunch of water into the gut which is why we think people get those those sort of gastrointestinal related symptoms whether it's upset stomach whether it's feeling of being bloated or whatever but not in regular dosing three to five grams per day and people are like well you got to drink more water because it's going to dehydrate you it's like well if total body water doesn't change change right and the amount of water that goes into the muscle cell intracellular water it's a very small imperceptible change then again explain to me how it increases rate of dehydration and in fact when it's actually been studied decreases same symptoms of dehydration or what people classically associate with that which would be cramps for example there's studies in kidney patients on dialysis and there's studies in d1 football players showing decreased instances of cramps with creatine.

39:44Jordan Feigenbaum:In any case, creatine is fine if you want to use it and you're a perimenopausal woman, but not life-changing just like it's not life-changing for anyone else. You don't need a different dose. You don't need a pink one. You don't need a specific brand. We would just advise if you're going to use dietary supplements that they're third-party tested, it should be stamped somewhere on the label so you know that it's not contaminated with something else that could potentially cause some harm. Another two items here related to the diet that are commonly sort of discussed with respect to perimenopausal women, vitamin D.

40:16Jordan Feigenbaum:I don't know that it's uniquely discussed on the internet because it seems like everybody needs vitamin D, but in clinical cases, yeah, vitamin D comes up quite a bit, mainly with respect to bone health. Now, this is controversial. Both of us would admit that. When do people need to be supplementing vitamin D? When should you be testing for vitamin D? So I'll get your take on this quickly. But my thought here is that if somebody has frank vitamin D deficiency, they're below 30 nanomoles per liter below 20, certainly a vitamin D supplement is reasonable to replete, replenish vitamin D. I'm not sure that's going to do much, but I do feel better about buffing the chart in that case.

40:53Jordan Feigenbaum:But if somebody has a range between 30 and 50 or whatever, I'm less certain that it's going to do anything. And in fact, I'd be more curious, why is their vitamin D level low in the first place? Whether that leads me on a chase to suss that out. I don't know. What do you, how do you think about vitamin D in this particular population?

41:09Austin Baraki:Yeah, I think that your lower cutoff of 20 is definitely the threshold that would get more of my attention. I think we have stronger evidence to get people above that level if they are below it. The 30 you'll see also used as a cutoff in a lot of places. I think that the evidence for that cutoff is quite a bit weaker. And certainly, you know, there are some folks out there who are saying like, you need to get it up to like 75 or 90 or something like that. And there's literally like no compelling evidence that that will dramatically improve outcomes for somebody definitely for like who's already vitamin d sufficient excuse me so like going from like 50 to 80 or something like that compared with going from 10 to you know 35 uh the the latter i would be much more in favor of the former i'm much less in favor of or more indifferent to i would say and so you know this population the the main consideration here is is mostly relating to their their bone health and so there are some implications for that because there are well-established direct implications of estrogen withdrawal on bone health at any stage of life.

42:09Austin Baraki:And so that's where this becomes most important. All of the other purported effects of vitamin D, again, I'm open to being convinced if somebody can show a well-done clinical trial of taking people with an issue who are also insufficient, randomizing them, restoring levels, and seeing a clinically meaningful impact on outcomes. that's kind of the thing that you don't see from a lot of people out there who hype up vitamin d a lot or um you know who are involved in this conversation is just like here's the type of evidence that i'm looking for that would like lead me to change my recommendation in other words i'm like pre-registering my uh belief change criteria show me that and then i'm like happy to change that advice but until then i'm like kind of more of a shrug outside of those like true frank deficiency ranges which is at least 20 and then a much softer case for getting over 30.

42:59Jordan Feigenbaum:Yeah yeah the next one is supplemental calcium it does have a possible cardiovascular safety signal and post-menopausal women specifically so if there's anything in this conversation so far that's post-menopausal specific outside of like maybe fear-mongering or sort of the need for some sort of special approach this could be it so far there's a Kim meta-analysis that found a roughly 15 % higher cardiovascular disease risk in post-menopausal women who are taking supplemental calcium with the signal concentrated in coronary heart disease specifically. This is contested and is controversial, but it is, uh, was reported in this meta-analysis.

43:36Jordan Feigenbaum:I don't know how this squares with any of your recommendations regarding supplemental calcium, uh, with respect to like bone mineral density and this kind of vulnerable population. Is this something you take into consideration or how does that, uh, yeah, it's super individualized.

43:50Austin Baraki:I'm taking usually going to be more of a dietary history on somebody to get a sense of like ballpark how much there are there are these tools out there like dietary calcium intake calculators where you can just roughly put in like how many servings of a given set of common food items and it'll spit out an estimate for you of what the habitual daily calcium intake is there are also other situations where calcium you know taking some form of supplemental calcium may be particularly beneficial those are going to be much more individualized related to malabsorptive disease states and things like that so getting a bit beyond our beyond our scope here so ultimately this is just going to end up being a very individualized uh recommendation i don't routinely say that like every person in this particular demographic or above this age range or postmenopausal should be taking a calcium supplement because i don't have good evidence

44:34Jordan Feigenbaum:to support that yeah yeah so that's the uh the the story when it comes to exercise prescription and some sort of dietary nuance it's pretty much the same prescription would give any healthy adult with maybe a handful of specifics that need to be discussed more for postmenopausal women due to what's been said to them previously. Now, one of these specifics deserves further discussion, in my opinion, because it is the mechanism, it's the story that the menopause supplement market leans on the hardest. And this has to do with anabolic resistance. Now, the popular framing here is that menopausal and postmenopausal women have anabolic resistance, that their muscles less responsive to the protein and the exercise stimulus that worked at age 30.

45:14Jordan Feigenbaum:And that is the reason that they need a specialized supplement protocol stack. Like a lot of other of these popular narratives, it's partially true in some cases, but mostly overstated. So this anabolic resistance idea comes from a specific kind of study. Researchers will feed someone a measured dose of protein and then directly measure how much new muscle protein the body builds in response over the next few hours. It's called muscle protein synthesis that they're kind of trying to measure that response. Now in young adults, around 20 grams of high quality protein at a meal maxes out that muscle protein synthesis response.

45:51Jordan Feigenbaum:In older adults, you need more, somewhere in the 25 to 40 gram range to get the same response. So the per meal requirements for protein appear to shift upwards with age and that gap is what anabolic resistance describes. You just respond less robustly to dietary protein and subsequently to exercise as well. The gap, however, appears to be in those who are inactive, particularly older adults with metabolic disease or people who are immobilized, like on bed rest or are hospitalized for some reason. It is small or absent in older adults who are active, especially if they're lifting weights. Even a short bout of activity effectively eliminates it, like a 10-minute walk.

46:32Jordan Feigenbaum:before a meal, all right? A few weeks of actually exercising, lifting weights in particular, improves it even further. So being active, relatively healthy, and being non-sedentary, do most of the work here. Importantly though, this is not a menopausal finding. The literature on anabolic resistance is largely in older adults of both sexes and mostly clinical populations, people in a hospital. The largest study to date on basal muscle protein synthesis, 215 healthy non-obese adults across a wide variety of ages found no difference between young and old and no difference between men and women in muscle protein synthesis.

47:11Jordan Feigenbaum:They had the same baseline anabolic machinery regardless of age or sex. Now, these people were generally healthy, right? They were not in a hospital. They were not on bed rest, right? So they were somewhat active at least and they didn't have any of this metabolic disease which we think is a big factor here. The Eisenman trial that we walked through earlier showed that postmenopausal women added measurable muscle thickness measured by direct ultrasound after a standard barbell training program, which is not what an anabolically resistant population would look like. and the meta-analytic data on sex differences in training response in older adults find similar relative gains in men and women.

47:46Jordan Feigenbaum:And so the literature where anabolic resistance shows up most clearly is in sedentary older adults, usually those with metabolic disease, and particularly those on bed rest or who are mobilized in a hospital, none of which is a description of healthy, active, post-menopausal women. The menopause fitness market still leans on this, and they've taken this sort of finding in the literature and marketed it. to you. So the prescription, to my mind, is the same. Lift, do enough conditioning, eat enough protein, but you don't need to micromanage it, and manage any of the medical conditions that you may have.

48:18Jordan Feigenbaum:You can skip the leucine pills. Anybody can do that. Skip the HMB. Anybody should do that. And the specialized menopause protein powders and supplements that you're paying a pink tax on anyway. All right, so Austin, a patient walks in with a supplement stack and a question. 48 years old. She's perimenopausal. She's got hot flashes. Her sleep is bad. And she's been listening to a menopause coach. She's on creatine, magnesium, ashwagandha for cortisol, a phytoestrogen blend, collagen marketed as menopause specific protein. She's even taken evening primrose oil in addition to vitamin D and a separate adrenal support blend.

48:54Jordan Feigenbaum:She wants to know whether to add MHT on top because of anabolic resistance and whether her current stack is doing what the coach said it would. how does that conversation go it's like you have been sitting on my shoulder for so many

49:07Austin Baraki:conversations that i have had with patients so uh separate i would say that most often they're not necessarily coming in specifically with concerns about anabolic resistance but rather the nature of their symptoms and lots of other concerns but this backstory of the symptomatic presentation the substantial supplement stack is one that i see actually quite often the first thing is just listening to what their experience is like what have they been through from the beginning what led them to start pursuing you know this coaching and these supplements and what have they felt has been the impact of those things because i think the the wrong way to go about this conversation is just to immediately be like dismissive right off the bat of like everything that they're doing or everything they've done because maybe it's actually very likely that they have a much better rapport with their existing coach compared with you and you have to build that up up front and so getting a sense of the the symptoms the severity the path that led them to each of these supplements and whether they feel like they're they're helping because along the way it's possible that you can validate the things that are helping them which can also go a long way to build some rapport so if they want to take creatine that's fine if they want to take vitamin d that's fine the magnesium also gets a shrug for me some people anecdotally say it helps them with all sorts of things and as long as your you know renal function is okay it's very unlikely to cause harm worst case scenario it can have a little bit of a laxative effect for you.

50:26Austin Baraki:So, you know, go for it. That's all good. The remaining things are where I'm going to probably set up a little bit more pushback, right? So the idea that you need to be on something like for cortisol, explain, you know, the thought process, what we're trying to treat, what the issues are there. The phytoestrogen blend, I'm also not likely to be in favor of because, hey, this person's still having hot flashes and, you know, presumably some night sweats and things like that. And it's like, well, if that's what estrogen helps with and if that was doing its job your symptoms would have dropped precipitously and i can just give you real estrogen and help with those things and the idea that there's a menopause specific protein is you know you know between you and i total nonsense but the way i'm going to discuss that might be a little bit different and then you know so that's kind of how i'm going to go about this conversation and then i would probably frame the conversation about the consideration of use for menopausal hormone therapy not so much directly to quote-unquote treat anabolic resistance because if she is already you know otherwise like pretty healthy and especially if she's very active she is unlikely to have any meaningful anabolic resistance outside of being on you know high dose glucocorticoids or being very sedentary being super inflammatory state from an autoimmune untreated autoimmune condition like those are the kind of things that can contribute to anabolic resistance we know that even among older adults or even middle-aged adults who remain highly physically active they can retain much of the anabolic sensitivity of their younger years.

51:49Austin Baraki:But that doesn't mean to say that this patient might not benefit from menopausal hormone therapy, but it might be that, hey, if we use an effective formulation dose route of menopausal hormone therapy, maybe we mitigate your hot flashes, your night sweats, you sleep better, you recover better, you can train harder, and then you get even better results from your training program, right? And so trying to identify like, what are the primary issues that this person is experiencing? And what options do I have to manage those safely and effectively, rather than trying to like you know treat a much more of a theoretical phenomenon that's unlikely to even be happening with this patient so ultimately listening validating trying to you know encourage or be validating of using the things that are either working or are like fine to take trying to trim away the the things that are unlikely to be helping or may even be harmful and then use a more effective method of menopausal hormone therapy to treat the debilitating symptoms if that's what she's interested in but not so much to say this is how we treat anabolic resistance because the way, if it's framed that way, then you may as well be like, well, why aren't you just going on anabolic steroids?

52:49Austin Baraki:Because that would be a great way to treat anabolic resistance. Yeah.

52:53Jordan Feigenbaum:Should we do a hot take on whether or not you think MHT should be allowed in sport or we'll save that?

52:59Austin Baraki:Yeah, no issues from my standpoint, but yeah, that'd be an interesting question.

53:03Jordan Feigenbaum:Yeah. All right. So that is the story with, oh my God, what were we just talking about? Oh yeah. That is the story with anabolic resistance. Now the next question is what people with the loudest voices and the largest audience in the space are actually saying and where it lines up with the data and where it doesn't. We'll get to that right after the break. This podcast is sponsored by Factor. Between finishing our new book, Signal, work, and training, my schedule right now is not exactly relaxed. And when I get home late, cooking is just not happening. Relying on willpower is a problem that even I run into, but staying prepared with Factor is how I've been solving it.

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57:29Jordan Feigenbaum:Now available in Canada too. That's Q-U-I-N-C-E dot com slash BBM for free shipping and 365 day returns. Quince.com slash BBM. One of the questions we get asked all the time is what books do you recommend for people who are interested in coaching others or who are taking their training very seriously? and it just so happens that a friend of the show, Dr. Eric Helms, along with Andy Morgan and Andrea Valdez, just released the third edition of the Muscle and Strength Pyramid books. Now, if you're not familiar, these cover the full hierarchy of what actually matters for nutrition and training, organized by priority, so you spend your time on the things that actually move the needle, and you get all of the science behind it too.

58:09Jordan Feigenbaum:Over 200 ,000 copies of the book have sold at this point, and for good reason. I read it, and it is excellent. so if you're looking for a great resource to have alongside our book signal and you want to go deeper on programming and nutrition planning this would be a great addition to your library right now you can go to muscle and strength pyramids.com slash bm10 and use code bm10 for 10 off that's muscle and strength pyramids.com slash bm10 code bm10 gets you 10 off at checkout All right, we're back here on the Barbell Medicine Podcast. Now, every generation of women has been told a different wrong thing about exercise.

58:44Jordan Feigenbaum:In the 1890s, the dominant medical advice for middle-class women was the rest cure prescribed for the diagnosis of neurasthenia. Don't exert yourself. Lie in a dark room. Chill out. In the 1960s, women were told not to run long distances that would damage their reproductive organs. The first women's Olympic marathon was 1984. until 1994 the american college of obstetricians and gynecologists told pregnant women to keep their heart rate under 140 beats per minute a recommendation that was based on vibes and was quietly withdrawn for that reason now each one of these was the loud confident cultural message of the decade each was wrong and the women who absorbed each one of them paid for it in lost training years the menopause fitness market is that current installment now to be fair the loudest voices in the space are mostly telling women to lift, to eat protein, train for their bone health, and to stop being afraid of lifting heavy, which is directionally correct.

59:38Jordan Feigenbaum:But the same voices are also overstating effect sizes, claiming a menopausal exceptionalism that the data does not support, demonizing aerobic exercise, and selling proprietary supplements and protocol stacks that the literature doesn't back. We're going to walk through a few specific claims to push back on the claims, not necessarily people, although some shade intended. So claim number one, lift heavy or you're going to lose your bones. The version of this in circulation is often associated with Stacey Sims. And it's that women must lift heavy or they're going to lose their bones. That intensity is below 85 % of your one rep max is essentially useless for bone.

1:00:14Jordan Feigenbaum:And that the period of perimenopause is a closing window after which bone is lost. Okay. This one, I actually half agree with, so let me give it its due. Bone responds to loading. You load it heavier, you get a bigger response. That's real, and perimenopause does kick off a stretch where you lose bone faster. Also real. And for years, women got told to keep it light, go easy, protect yourself, which honestly just left them weaker and with less bone than if somebody handed them a real weight training program. So when this crowd says lift heavy for your bones, they're pointed the right way for the first time in a long time.

1:00:47Jordan Feigenbaum:Now where it falls apart is how hard the claim gets. It usually turns into two things, that anything under about 85 % of your max, anything light, does basically nothing for bone. I can think of another fitness organization that says the same thing but for strength. And that there's a window. If you didn't catch it, you blew it, you're done. And neither of those is true. Here's the part that trips people up. If you just look at all of the bone studies lumped together, the results are kind of meh. And the lift-heavy people love to point at that. But the reason that they're meh is because most of these studies never loaded anybody hard.

1:01:20Jordan Feigenbaum:It's machines, bands, little pink dumbbells. So you're really just measuring what easy training does to bone, which is, yeah, not much. But heavy doesn't necessarily mean grinding out max one rep efforts that, you know, maybe scare some people away from going to the gym in the first place. When you actually pull the studies where women lifted heavy, the results on bone show up somewhere around 65 to 85 % of your max a couple days a week. Now, that's legit lifting. It's not bands. It's not bodyweight stuff, but it's also not necessarily the one rep max or max effort stuff that is being sold in the space.

1:01:53Jordan Feigenbaum:Bone responds across a large range, just like strength, just like muscular hypertrophy, just like cardiorespiratory fitness when it comes to conditioning. Basically, it just has to be heavy enough. So lift and lift like you mean it, yes. But the idea that there's one tiny window and that you're locked out for life if you miss it, nah, you're basically never locked out. which again is the whole point of this episode. It's never too late. So genuinely moderate loading, 65 to 85 % of one rep max works. Heavy loading above that works maybe a little bit more, but the bone responds across the range once it's heavy enough.

1:02:28Jordan Feigenbaum:Austin, any thoughts on the loading specifics and maybe where that goes awry here?

1:02:33Austin Baraki:Yeah, I think it's useful to recognize that the, much like we've talked about with muscle and strength adaptations before, that the range of loads that can lead to meaningful responses is wider than was previously thought, that's fundamentally a good thing, right? For a lot of reasons, because it makes this type of training more accessible to more people. Because otherwise, you're telling people the only way is to lift 90 % of one rep max or heavier, right? And some people are gonna be mortified to do something like that, especially if they've already been diagnosed with some issue related to bone mass, depending on how it's been explained or delivered to them.

1:03:07Austin Baraki:They're gonna be like, there's no way, I'm gonna risk a fracture, just by which is up to be clear not accurate but that's a lot of common fears that are around loading especially in the context of bony related issues be it osteoarthritis or osteoporosis or osteopenia or any of these things so really we're just like broadening the range of effective options that we can use with patients and it might be that you start out with somebody who is willing to start out at say like 60 ish percent and maybe they get bitten by the bug and over time they want to progress up to those higher levels that's great that's a win right and i don't even think that Stacey Sims would disagree with that idea, but she might say that, hey, the 60 % is like worthless and it's not until you get up to those higher levels that it's effective, which again, we would kind of take some issue with.

1:03:49Austin Baraki:So I think that broadening the set of available options that can deliver efficacy here is fundamentally a good thing. That's the first thing I would say. The second is I have historically kind of pushed back against a like super, super myopic focus on the BMD bone mineral density measurement. So like just the T score alone. I've had these conversations with so many patients over the years who get very fixated on the T-score and its trajectory, not even accounting for like error bars in measurement from test to test, but also recognizing that, you know, you cannot feel your bone density. Having a T-score of a given value does not impact your day-to-day life or your quality of life outside of your risk of fracture, right?

1:04:35Austin Baraki:That's the main thing that we care about here. And so viewing bone density, bone health, osteopenia, osteoporosis purely through the lens of a T-score is again, super myopic. And I try to broaden the perspective here and to say the number one, the most common reason why we start to see not just fractures, but major osteoporotic fractures, and then the really bad outcomes that people have heard about. Because a lot of people have heard like, oh yeah, the super high mortality risk in the one year after a hip fracture and then at that, it's like those people most often are like pretty frail often multi-morbid a lot of medical conditions historically quite sedentary and it was because they fell overwhelmingly it's because they fell and so there's a lot of productive training and activity that we can do that is not necessarily 90 percent of your one rep max that can go a long way to mitigate your risk of falling and make you more robust in general even some like just general athletic activities maybe some power some speed some bounding, some agility, something like that.

1:05:31Austin Baraki:All of the things that go to mitigate your fall risk, I'm like hugely in favor of. And then also the loading as a supportive role. And fortunately, again, the loading ranges that are useful, much broader than you might traditionally think. And then if it's appropriately progressed over time, you're good. All right.

1:05:47Jordan Feigenbaum:I'm going to give you would you rather, and we're not going to belabor this point because we do have more to go. Okay. Would you rather? If a person who does almost exclusively machine-based training, right and their bone mineral density improved by eight percent right versus a person who does almost exclusively free weight freestanding barbell training but their bone mineral density only improved by four percent mainly due to like loading restrictions we'll say right uh if we assume that the free weight person doing free weights has like better coordination kinesthetic awareness perhaps less of a fall risk and that does turn to play out which uh which uh scenario are you picking?

1:06:26Jordan Feigenbaum:Yeah, I think under that assumption, I'm picking the latter.

1:06:29Austin Baraki:Yeah, that is an assumption though.

1:06:30Jordan Feigenbaum:But yeah, that is my kind of thing when people are like, what do you pick freeways versus, you know, machines? Like, why would you do that? I'm like, I do think there's something with the coordination and, you know, ability to prevent falls or something there. I can't prove it to you, right? To the extent that's been investigated, it's been it's insufficient, but that's kind of my vibes based thing. So even people who are kind of averse to training, um particularly heavily or unable to do so for for whatever reason under like heavy uh barbell training heavy free weight training i do still want them to do some free weight movements whether it's just bodyweight squats lunges a step up something like that for like a coordination game to the extent that that's that's the thing we can train does that make sense yeah yeah totally

1:07:08Austin Baraki:and and similarly i would take somebody with a bit lower bone density uh maybe even in the osteopenia range but who is like super agile and athletic over somebody who you know who has a maybe even a slightly better bone density, but like doesn't do anything meaningfully like athletic or active or something.

1:07:22Jordan Feigenbaum:Rocky from Hail Mary. Okay. Yeah, right. All right. The next claim here is that cortisol is wrecking your training and stalling your fat loss. Now, this is the claim with the most legs in a menopause fitness market, uh, or the menopause as it were, uh, shows up in a few different flavors. Cardio raises your cortisol. That's why your weight's not moving. Fasting and dieting also raise your cortisol, which is why your weight's not moving. And your cortisol is high because perimenopause and adrenal stress. And until you fix the cortisol, nothing else will work. And the way to fix it is a boutique panel and a supplement protocol.

1:07:56Jordan Feigenbaum:Of course, uh, Stacy Sims pushes the cardio framing. Can't do zone two cortisol and such. Uh, you can't do too much high intensity stuff also because of cortisol and such. Mindy Pels built an audience around cycle synced fasting, uh, and Sarah Gottfried and the broader functional medicine and corner cells, adrenal resets, and cortisol rhythm panels. The list goes on. Now, all of these claims rest on the same confusion between two states of the cortisol system. The first one is a sort of transient elevation in response to exercise, calorie restriction, or psychological stress that lasts minutes to hours, then returns to baseline.

1:08:30Jordan Feigenbaum:The second is chronic hypercortisolism, Cushing's syndrome, or Cushing's disease. That's a real disease that can have severe impacts on of body across every system that we care about. Data has been clear on this for a long time. We did a full episode on hypercortisolism earlier this year. It's linked in the show notes below. Now, mechanistically, we should say that estrogen, estradiol, does modestly blunt the HPA's reactivity. That is the sort of stress axis that does release cortisol. Loss of ovarian estradiol allows slightly larger stress-induced cortisol excursions in some women, particularly those with severe vasomotor symptoms and restricted sleep.

1:09:09Jordan Feigenbaum:While this is real, this effect is relatively small and not anywhere close to pathological hypercortisolism or Cushing's. Now on exercise, in exercise, cortisol goes up as a part of the sympathetic nervous system's fight or flight response. Its main role is to increase energy availability during exercise, right? Liberate your stored energy so you can use them. You need it. If you didn't have that, you'd be up a creek. In 2021, Dode and Montero did a meta-analysis looking at how high-intensity interval training affected cortisol across roughly 1 ,055 participants, including women. The pattern was the same across all of them.

1:09:49Jordan Feigenbaum:Cortisol does rise sharply when people do high-intensity interval training, but modestly during the session. Again, to create the energy you need to do the exercise. Two to three hours after the session, cortisol drops below where it started. by the next morning, it's back to baseline. The session is a temporary spike and a temporary dip on either side of an unchanged baseline. The day over day total exposure to cortisol doesn't go up. And the comparison that matters here is the comparison to Cushing's syndrome, which is what chronic pathological cortisol elevation actually looks like. Healthy adults run a resting cortisol level around 350 nanomoles per liter.

1:10:27Jordan Feigenbaum:Now this does vary during the day, but that's just an average sort of resting level. A high intensity interval training session might push that to around 600 or 700 for an hour or two before it falls back. Cushing's patients live above 900 continuously and never come back down. A temporary doubling of the baseline within normal range is not the disease state that wrecks muscle and bone and metabolism like Cushing's is. And again, this is high intensity interval training specifically, the modality that the menopause fitness market often tells women to limit because of cortisol. Don't do the group classes, it's high intensity.

1:10:59Jordan Feigenbaum:Don't do sprints, it's high intensity. Your cortisol, it's going to go crazy. And that transfers over to the diet claim. The diet, dieting cortisol claim is the same problem. A calorie deficit raises cortisol, which raises hunger, installs fat loss. So you have to eat more to lose weight, which is in violation of thermodynamics and has never been shown in the literature to actually occur. The CALERIE trial, that's an acronym, C-A-L-E-R-I-E, is the strongest human randomized controlled trial we have addressing this. It's 220 adults, 30 % were men, 70 % were women. They were on a calorie deficit for two years.

1:11:37Jordan Feigenbaum:Yes, they lost a substantial amount of weight, okay? But there were no significant between group differences in cortisol at 24 months. It's not like, well, men were able to tolerate this and women weren't. The cortisol was fine, was fine. Now, that is different than severe energy deficiency, what we've called low energy availability. That's roughly like 30 kilocalories or calories per kilogram fat-free mass or relative energy deficiency in sport, which is even maybe a further complication of that. That's not what we're talking about. If the claim is that by going on a calorie deficit, most women are getting into low energy availability or REDS, I could be convinced to say that a calorie deficit is generally bad for cortisol.

1:12:19Jordan Feigenbaum:But Austin, have you seen any signal that that's the case? Are women with LEA, low energy availability, or REDS just turning up at clinics all over the world because they've gone on a calorie deficit?

1:12:31Austin Baraki:generally they have a wide set of signs and symptoms from the low energy availability that are generally not attributable to the direct impact or are not mediated by impacts on cortisol in particular and so in other words when there is suspicion for that type of a condition or that type of physiologic state the first thing we're doing is not in fact measuring say either 24-hour urine cortisols or doing dexamethasone suppression tests or something like that because those are the types of things that we do to evaluate for clinical cortisol excess. The extreme, as you said, is Cushing's. There's a milder version that's becoming more and more well recognized now called max or mild autonomous cortisol secretion.

1:13:10Austin Baraki:But what does it look like when somebody has like a mild amount of excess pathologic cortisol? Yeah, they tend to have high blood pressure, they tend to have a bit of insulin resistance, maybe some pre diabetes, diabetes, things like that. And so that's something where you can do the test, do a dexamethasone suppression test, and they won't fully suppress to the degree that they should. And then you can go on and work it up from there. Maybe you find an adrenal adenoma or something like that and you address it. But the idea that, you know, for example, I'll see a patient whose blood pressure is like 108 over 60.

1:13:39Austin Baraki:And we're talking about like chronic cortisol excess. And it's like, you ain't got that. Not really physiologically possible. It's not what I say in that encounter, but that's not really how that works. There are, you know, certain signs that are quite sensitive for the likelihood of clinically significant or pathologic cortisol excess. And that's an example of one, right? And so not really the main focus here. I think it's just, it's nice and convenient to have a tidy narrative, a single like biological thing that you can point to and like demonize. And then you can contrast it like cortisol, enemy, do these things to make it go down.

1:14:13Austin Baraki:Estrogen, friend, everyone on earth should be on estrogen. And it's like this nice, neat, tidy narrative, or especially if you have a supplement that you can offer to like knock cortisol down or a phytoestrogen supplement to bump up estrogen. It's a convenient sort of story that seems internally self-consistent. But as soon as it is tested a little bit more rigorously against like real human data in the real world, it tends to fall apart because you can go to that very study that you described. And it's like, if it were true that the chronic calorie deficit would induce, you know, pathological high, you know, cortisol levels and all the downstream consequences.

1:14:44Austin Baraki:Let me propose a clinical trial to you. Let's take some people and put them on a substantial calorie deficit for two years and watch. and this will be validated by their weight trajectory across that period of time because that's how that would happen. What would you predict based on your understanding of this physiology is going to happen to cortisol at the end of the study? And their prediction would be, well, clearly people on a calorie deficit, they're gonna have really high cortisol. Okay, well, here's the evidence. Now, what do we do with that information? What does that do to the confidence in your hypothesis?

1:15:10Austin Baraki:And if then suddenly the goalposts shift, then you're not really dealing with an honest broker and the conversation is probably not worth having.

1:15:16Jordan Feigenbaum:Yeah, I always wonder, you know, if the claim that going on a calorie deficit it increases cortisol to the level that compromises weight loss, right? That's if that's the crux of the claim, right? And then somehow it spins off to, well, the risk is really low energy availability where cortisol is going high. And I'm like, yeah, yeah. But the reason why we know that they're in low energy availability is because they lost all this weight. That's part of what's causing the symptoms also, okay? It's not like they're just low on calories, but then subsequently like persisting at a particularly body weight, which has never been shown.

1:15:49Jordan Feigenbaum:Never been shown. And this is the last thing I'm going to say about this, is this cortisol belly sort of narrative, that the midline fat redistribution women seen across the menopausal transition is somehow due to cortisol. Now, that can happen. Post-menopausal women do tend to carry more fat in the trunk than pre-menopausal women, even when total fat mass is the same. The mechanism is the loss of estrogen changing where the fat gets deposited, particularly when combined with muscle loss and if the energy balance is off, meaning that people are consuming more calories than they burn. This is uncontested.

1:16:22Jordan Feigenbaum:But if you call it cortisol belly, it names the wrong target, it's estrogen, and points at the wrong intervention. It's not lowering your cortisol by avoiding exercise or avoiding dietary changes that would ultimately get your energy balance back in the right place. It's just the opposite, in fact. It's a grift. And I don't know what else to say about it other than it's wrong and the people who are saying it are also wrong and it makes me upset. do you have any charitable take here because i don't yeah i'm able to say my most charitable

1:16:48Austin Baraki:take is if you are trying to attach like the biological word cortisol for a more generalized phenomenon of like you can call it like stress belly okay if you're trying to like use those words interchangeably in the sense that you have chronic stress you have you're stressed about this like you know life change transition you have poor sleep that's impacting things the poor sleep impacts your appetite you end up inadvertently having a higher appetite during the day calorie excess you have poor sleep you have lower energy you exercise less like there are a whole host of downstream consequences and you know we know that like chronic unmitigrated uh you know stress is not great for people's health in general and i think it's a dramatic oversimplification to like linearize that through specifically just like cortisol signaling right because if it were that simple all we would need to do is just put you on like some dose of a you know a glucocorticoid antagonist or a cortisol like blocking drug, which those do exist.

1:17:43Austin Baraki:They have almost no clinical utility in the majority of cases, but then it would be as simple as that just block the cortisol. And then it goes, and then it goes down and then you're fixed. But that's really not what's involved here. So if nobody's doubting that there can be like a whole host of midlife stressors relating to your, you know, your, maybe your job and your family and your sleep and all sorts of other things that are impacted and how that impacts your day-to-day activities and appetite and intake and activity and things like that, but not just as simple as a single blood biomarker.

1:18:10Jordan Feigenbaum:Yeah. Yeah, I mean, you think about that phase of life, right? A woman in her late 40s, for example, she potentially has children that, you know, some responsibilities there, perhaps aging parents, responsibilities there, job responsibilities there. Like all of this is the perfect storm for activity to go down, for your dietary pattern to go a certain way, sleep to be, you know, compromised, all sorts of stuff. Now, this isn't a blame game. It's not a point of finger. It's just that the behavioral changes are sort of predictable here. And then the sequelae to that are also predictable. And so, again, blaming cortisol and solving for cortisol does not fix any of those things.

1:18:52Jordan Feigenbaum:And so it's just a misappropriation of sort of effort, resources, and so on and so forth, which is why I get so heated about it. My cortisol is probably through the freaking roof right now. I need a cortisol block.

1:19:02Austin Baraki:Yeah, it's really tough. I mean, I can think of two conversations I've had in the past week with women in this demographic who were absolutely I think it's an understatement even to say that they were at their just absolute wits end. One of them actually broke down on the call, like in tears while talking because of how terrible she was feeling and unable to like meet her day to day like needs because of how impaired her sleep was. And if I had said, oh, it's probably just your cortisol, you know, we just need to like take this cortisol supplement. That would have been a terrible response in many, many ways, but much more so validating like the overall experience and how overwhelming it can be.

1:19:36Austin Baraki:And knowing both, I mean, not that we have been through that particular biological phenomenon, but also knowing what it feels like to be super strung out and underslept from going through like, you know, residency did that to me for quite a while, substantial stretches. And then just like augmenting, imagining what it's like to augment what I experienced in that stage with all the other demands that was on this person. And it's a much bigger and more complex problem in trying to find the levers that are actually worth attacking compared with making an oversimplified narrative like that.

1:20:03Jordan Feigenbaum:Yep. Yep. Briefly, I just wanted to say that adrenal fatigue, this adrenal fatigue framing, it's the same sort of claim here. But it is not a recognized clinical diagnosis. The Endocrine Society's patient statement is explicit that no scientific proof exists to support that your adrenal glands that produce cortisol are fatigued, subsequently running out of cortisol. That would be a huge problem. Categani and Cater in 2016 reviewed 58 studies on adrenal fatigue and concluded that the construct does not exist. The symptom complex it claims to describe maps onto depression, sleeping-related disorders, hypothyroidism, anemia, and perimenopause itself.

1:20:42Jordan Feigenbaum:itself the actionable consequence of the misdiagnosis is usually a stack of supplements and adaptogens expensive testing and the reframing of the normal perimenopausal symptoms as adrenal dysfunction that doesn't mean that not any of the symptoms that people experience during perimenopause need to be you know kind of hand waved away or not managed but the whole point is if you call it a thing that it's not then you're going to address it likely in an incorrect way and that's what happens here the endocrine society to that point also warns that adrenal supplements taken without need can suppress endogenous HPA functions of cortisol release and produce iatrogenic adrenal insufficiency.

1:21:19Jordan Feigenbaum:Low cortisol that can persist for months or longer after the supplements stop. In many ways, low cortisol is more risky than high cortisol, so getting the diagnosis right is important and the wrong treatment can cause real harm. Now, Austin, I want you to consider a patient in her mid-40s. I think you've seen this before. She's anxious about her cortisol because a coach or a podcast told her it was the reason why her midsection hasn't budged. She's been avoiding cardio, avoiding fasted training, avoiding caffeine in the afternoon, taking ashwagandha at night, and she's considering a Dutch panel that her functional medicine doctor offered.

1:21:55Jordan Feigenbaum:None of it has changed her body composition to date, but what does the visit actually look like? How does that conversation go?

1:22:01Austin Baraki:This is a long conversation. definitely definitely a lot of listening a lot of validating of the experience to date but finding kind of what i'll call like entry points to gently start to push back against some of the stories that she's been told because if they were all true if those stories were all true then the things that she's been trying so far should have worked right and so that might be my initial entry point is like if really those were all the keys to this then maybe we would have expected and maybe to see if that leads the person to be open to considering alternative approaches to the issue I don't recommend essentially anything that she was doing except maybe avoiding caffeine in the afternoon if she finds that it's disruptive to her sleep.

1:22:39Austin Baraki:But avoiding conditioning, avoiding fasting training, using ashwagandha, Dutch testing, not something that I recommend for anyone. It's not a clinically validated or clinically useful test and don't recommend it. And so then I'm getting a sense. I'm trying to take like an inventory of what are the actual symptoms that this person is experiencing. Is it just the weight management? And I don't say just to minimize it, but meaning is it a weight management challenge? in isolation or are there other associated signs symptoms things that are bothering this this woman that we ought to address are there you know symptoms of persistent fatigue excessive daytime sleepiness um you know other issues that she is experiencing in terms of appetite control cravings things like that because that might impact my chosen treatment modalities so there might be some testing that's indicated maybe this person would benefit from a sleep study maybe this person has iron deficiency that's underdiagnosed maybe if they have a set of you know suggestive symptoms of the menopausal transition, maybe they would benefit from some form of hormone therapy among many other things.

1:23:36Austin Baraki:And so I can offer potentially trading a variety of these ineffective things that she is putting a lot of time and attention into doing perfectly or avoiding with no clear benefit with, hey, what if we took a pause on those things and just try the things that I'm suggesting for like a couple months? Because I would be much more confident that the treatments or the testing that I would have to offer would be much higher yield in a much shorter timeframe compared with if she's been doing all of these things for a long time and not making progress. And then the, it becomes self-evident of like, yeah, maybe we're on a more of a correct track now compared with what we've been doing so far.

1:24:11Jordan Feigenbaum:Yeah. Yeah. That makes sense. Um, so overall, you know, cortisol is a real hormone is real, uh, and Frank disease states involved in it exists, but outside of those measuring cortisol routinely and healthy women is not useful and micromanaging it is not productive. The fragility framing around it can produce some real costs, particularly supplement dependency, avoidance of the modalities that women actually need, conditioning, exercise, sleep, for example, skepticism toward evidence-based interventions like MHT. The cortisol story to me is just a distraction from the stuff that actually works.

1:24:43All right.

1:24:44Jordan Feigenbaum:Next claim is that every symptom that a person is experiencing during menopause is hormonal and HRT fixes all of it. The dominant version of this claim is associated with Mary Claire Haver, whose audience and book are organized around the idea that most midlife complaints in women are downstream of declining estrogen and that hormone therapy is the under-prescribed answer to most of them. Part of this is right and important, as we discussed in previous segments of this podcast series. Part of it is also overstated. As far as where the case is solid, MHT or menopausal hormonal therapy is effective and can do a lot of good for vasomotor symptoms, genitourinary issues, for reducing fracture risk, and so on, as we covered in our previous episodes in our menopause series.

1:25:25Jordan Feigenbaum:Many women who would clearly benefit from it are not being offered it. The louder voices in this corner have done useful work bringing the conversation to the forefront. But the claim that estrogen loss makes muscle building impossible without HRT is wrong. We talked about the 2021 DAM randomized controlled trial, postmenopausal women who had a transdermal estradiol patch versus placebo, both of them doing 12 weeks of resistance training. the placebo group gained almost 4 % of muscle cross-sectional area in their quadriceps, whereas the group getting the estradiol patch made 8%. Estrogen made the training response bigger, but the training worked either way.

1:26:03Jordan Feigenbaum:It's the same thing that we see in men who have legitimate testosterone deficiency. Interestingly, our book on testosterone does not say that it's like a panacea for everything. Perhaps we would sell more copies if that were the case. There was also a Driesing meta-analysis that pulled 23 studies and roughly 9 ,000 women and found that the average strength advantage for menopausal hormonal therapy, MHT, was 5%. While this is also real, it's also modest. And downstream of training, you're gonna have to do the training regardless. There's other claims regarding exercise being a panacea. And look, we're the Barbell Medicine Podcast.

1:26:38Jordan Feigenbaum:We've been streaming about exercise for over a decade now. But saying that exercise treats hot flashes is also overstated. The North American Menopause Society 2023 non-hormone therapy position does not recommend exercise as primary treatment for vasomotor symptoms. And a 2022 systematic review found that exercise reduced hot flash severity slightly, but did not change how often they happen. Doesn't mean you shouldn't exercise if you're having hot flashes, but that it's a singular treatment for hot flashes, probably not the move here. And since it always comes up, we need to talk about testosterone supplementation in women.

1:27:12Jordan Feigenbaum:Yeah, taking exogenous testosterone. Now, the big meta-analysis here pulled 36 trials, over 8 ,000 women, and found no real benefit on body composition, on muscle, or on bone. A 2026 review lands in the exact same spot. The only thing that testosterone is actually approved for is a condition called hypoactive sexual desire disorder. It's basically just low sexual desire. Now, for muscle, bone, cognition, et cetera, the evidence is not really that clear, and it probably shouldn't be driving prescriptions for testosterone, though they have increased over the last decade or so. Now, where you do see a body composition effect from testosterone, it's dose-dependent and pretty inconsistent.

1:27:50Jordan Feigenbaum:You only really get it by pushing testosterone levels above the normal female range, the same relationship we see in men. Now, at that point, you're not really treating anything specific. You're taking PED levels of anabolic steroids, which can come with the risk of side effects to match. All right, before we get into another clinical case for Dr. Baraki, one last claim. Menopause requires a fundamentally different programming paradigm. This is the sort of meta claim underneath all of the others. It powers the entire menopause-specific coaching certification market. The premise is that perimenopausal women need a proprietary protocol, a coach trained in female physiology, and a stack of products to make the training work.

1:28:31Jordan Feigenbaum:I'm being a little bit hyperbolic, but to what it seems like from the outside. the biological case for specific programming for special programming usually rests on three points one accelerated visceral fat accumulation across the menopausal transition two accelerated loss of fat-free mass specifically muscle and then three reduced muscle protein synthesis uh sensitivity right so anabolic resistance the swan cohort data quantified the first two fat gain roughly doubles across the menopausal transition, about a kilogram and a half over three and a half years. And muscle loss averages around two-tenths of a kilo over that same period of time.

1:29:09Jordan Feigenbaum:That's 200 grams of muscle in three and a half years. It's real, for sure, but it's mostly confined to this transition and it's relatively small. All right, so Austin, this whole space is probably also a problem in your office because patients are arriving, having spent time and money on protocols and products downstream of the claims we just walked through. But what does the conversation look like when the patient is already invested in one or more of these protocols?

1:29:34Austin Baraki:I want to know what they're looking for for me first and foremost. Like why did they come and want to talk to me or do they have specific concerns that they were hoping I can help with? You know, there are likely to be things about what they're doing that I would be happy to, you know, cheerlead, to be in support of, to say this is exactly what I would be suggesting or doing. there are probably also a fair amount of things that they might be doing that i think are unlikely to be helpful but may not be harmful in which case they've already paid for it i'm like kind of up to you and then there may be a small hopefully small subset of things where it's like now this is actually actively a bad idea or this is like risky or harmful and those i would be happy to be you know explicit um although you know deliver it in a way that hopefully i have built the rapport that they can they can hear what i have to say about it so really it's just a matter of getting a sense of like, you know, what have they already committed to?

1:30:24Austin Baraki:What are the things that are good? What are the things that are neutral? What are the things that are bad? And then what do they want from me? Do they want my advice? Do they just want, you know, a hype man? Do they, are they really looking to be like, look, which of these is actually worth my time and money? It's like, okay, let's dissect this. I'm ready to go on that conversation. So really just meeting the person where they're at and trying to get a sense of how I can best help them on that particular day. Yeah.

1:30:44Jordan Feigenbaum:Yeah. That is some excellent sort of clinical experience being related here. So if you're in training uh maybe go back re-listen to that excellent so that covers the broader market sort of um again i don't want to just grat just call it a pink tax on menopause specific training but it does seem like that it's mostly women on women crime and i'm getting sick of seeing it so now we get into the one place that the literature has tightened most over the past five years and where the case for taking training seriously in this particular time of life is best made, bone density. One of the strongest cases for training in this population is to preserve bone health.

1:31:24Jordan Feigenbaum:Heavy loading works, it's safe, and the prior generation of clinical practice that told these women to avoid it was wrong. Belinda Beck's group out of Australia ran the Liftmore trials, published in the Journal of Bone and Mineral Research in 2018. 101 postmenopausal women, mean age was 65, all with T-scores below negative one at the lumbar spine or the femoral neck. Now T-score is bone mineral density expressed as a standard deviation relative to a young adult reference. Negative one is the threshold for osteopenia. Negative two and a half is osteoporosis. Many of these women had been told for years to avoid heavy lifting because of their bone mineral density.

1:32:02Jordan Feigenbaum:And in fact, when I posted this recapitulation of the study on our Facebook group, it's got over a million views now. So our first maybe viral post, people are saying you can't have women with osteopenia or osteoporosis lift heavy because of a fracture risk. So the study, perhaps if they actually read the post or the study I linked, could have avoided that. But then I would have gotten viral. I don't know what to do. The intervention was supervised, high intensity resistance training and impact training. So twice a week, 30 minutes per session for eight months. They did five sets of five repetitions above 85 % of the one rep max on the deadlift, back squat, and overhead press.

1:32:39Jordan Feigenbaum:Plus they did jumping chin-ups with drop landings for the impact piece. They were just jumping down with straight legs. The control was a home-based low-intensity program with bands and body weight. The lumbar spine bone density changed by 2.9%. It went up in the group lifting the heavyweights. It went down 1.2 % in the control group. The femoral neck bone density was up by 0.3 % in the group lifting heavyweights versus minus 1.9 % in the group training at home. Both differences were statistically significant. Compliance was 92%. and it was only one minor adverse. It was a back spasm. A couple of caveats here.

1:33:20Jordan Feigenbaum:One, were they lifting 85 % of their actual one rep max? I assume they tested their one rep max on day one, which also interestingly in this population, you imagine a bunch of women in their, you know, 60s and 70s maxing out on deadlifts and having never trained before. Hell yeah. Well, that's what I'm saying. I'm cool with it, but like how many other people would be like, yeah, it's probably fine. Like I know that it's going to be fine or likely to be fine. So my thought is that they had a one rep max on day one And then, you know, every time they lifted after that, it wasn't really 85 % other than one rep max because it actually got stronger.

1:33:50Jordan Feigenbaum:The intervention was supervised and progressed by a research team and group of experts. So not everyone has access to that. So there's some, you know, something going on there. It was also only eight months, not a lifetime. I still am waiting for like a lifetime study. That would be nice. To your point earlier, bone density is a surrogate endpoint, not a fracture outcome. So that's important to note. Now, the Med-X OP follow-up trial compared high-intensity resistance training against Pilates and confirmed that high-intensity resistance training was again superior at the lumbar spine and did not worsen pelvic floor disability scores in women with osteopenia.

1:34:25Jordan Feigenbaum:More replications needed, but the heavy loading is too dangerous for osteoporosis era should be over. The mechanism is reasonably well understood. Bone is a living tissue. It's constantly being broken down, rebuilt, remodeled. The signal that tips that balance towards formation of new bone is mechanical strain, specifically the magnitude of that strain, the rate of the strain, and how unfamiliar the strain pattern is to the bone. So what we think is under heavy loading, the bone deforms in a microscopic level and that sort of sends a signal to remodel, grow stronger, be more robust. Walking imposes a low magnitude of strain.

1:34:57Jordan Feigenbaum:At a low rate, the bone barely notices it. A heavy deadlift or leg press or similar imposes much higher magnitude of strain through the spine and hip and is relatively novel. We walk everywhere. We don't deadlift everywhere. Present company, obviously excluded. A jumping chin up with a drop landing imposes a similarly high rate of strain. The rate dependent piece of walking or Pilates apparently cannot produce. The two combined is what doing the work here in the Lift More trial and building bone in this window requires a specific kind of stimulus. Walking won't get you there. Yoga won't get you there.

1:35:31Jordan Feigenbaum:Pilates won't get you there. Supplements won't get you there. You have to load the bone in a way it's not used to being loaded. Now, Austin, the part of the Lift More trial that people miss out on is who was in the trial. These were women, average age of 65 with osteopenia, half of whom would have been told by their doctor for a decade to avoid lifting heavy. What does your conversation with that patient look like? Really assessing what their beliefs, their expectations, where they're

1:35:55Austin Baraki:kind of starting from in this conversation and and where they those things came from because as i've talked about before in the world of osteoporosis historically the way that this diagnosis is delivered and explained to people much like when we talk about osteoarthritis being a quote-unquote wear and tear problem and that has certain built-in kind of implications for people in terms of like well then you tell them to exercise and like isn't that more wear and tear and it's like well it's more complicated than that it's like okay maybe you should have bypassed that explanation up front osteoporosis when it is delivered with a narrative of oh it means that you have brittle bones or fragile bones or weak bones and so then you say so go load it and people like wait and then you're like well it's more complicated than that and it's like okay well maybe your explanation was bad and so this is where i keep coming back to the point that you made of bone being living tissue right i think that people don't intuitively understand that unless they have specifically you know been taught it that it is uh continuously recycling adapting either to the presence of load and stimulus or it's adapting to unloading the lack of loading by atrophying not unlike our muscles muscle and bone trajectory tend to go along with one another across the lifespan in most people so for a lot of people who have osteoporosis a fair number of them will also be you know heading towards a future of sarcopenia as well if they're not already there and fortunately mechanical loading can ameliorate both of these problems when it is appropriately and sufficiently dosed because all of these things are living tissues so when we dose them appropriately with loading give it to the supporting environment of nutrition and sleep then everyone who is alive and maintains a regular and perfusing rhythm can adapt to uh to this type of loading so that's the way the conversation goes is like assessing what are they most worried about are those fears justified that you know valid and it's not to say that oh well that's not real the first day you should go in and you know go for your uh all out you know bone on bone quote unquote uh five rep max or one rep max or something like that but if you have that type of apprehension totally fine to start lighter but then emphasizing the role of progression being necessary right just doing i would prefer not to have the same conversation a year from now and find out that you went from like the the light band to like the medium band and i'd rather find out that you went from maybe a moderate intensity load to a much higher load because you have in fact adapted and gotten stronger indicative of your response to the

1:38:09Jordan Feigenbaum:training program yeah yeah i i just can't tell how much of this narrative you know women don't don't lift heavy like like it's just been passed on from for hundreds of years if not even longer than that in fact some of this uh research i've been doing for the lift for your life uh book whatever just historically one notable group um from history actually like advocated that women should train any guesses what that that group is the spartans the spartans i was that was like my actual only yeah yeah so spartans yeah otherwise it was like women shouldn't train or whatever but the spartan sparta they said well look in order for us to produce strong stock sure yeah women need to be strong too and so they would train publicly which is interesting uh and then you know in in america it wasn't until bernard mcfadden um who was he basically published the periodical called physical culture he was the only one advocating for women to train in the 1890s, but everybody else was like, don't do it.

1:39:07Jordan Feigenbaum:Rest the rest, you know, treatment. Anyway, one of the other reasons that heavy loading was historically avoided in this population is partly about fracture risk, which the Liftmore trial addressed. There are no fractures there, but it's also partly about the pelvic floor. And the concern was that heavy lifting could cause or worsen sort of pelvic floor dysfunction, urinary incontinence, or pelvic organ prolapse. The trial data here is pretty reassuring however a study from 2024 took 47 strength trained women and had them do four sets of four reps at 75 to 85 percent of one rep max on a back squat and deadlift in a randomized crossover against a comparator group who rested just rest there were no differences in pelvic floor resting pressure pelvic floor contraction strength or pelvic floor endurance after the heavy lifting compared with the rest so they would have served as their own control so it's like look is it better at rest or is it worse when you're lifting a separate trial by one of the The same authors randomized inactive, overweight, and obese women to 12 weeks of strength training versus inactive control, so they didn't do anything, and found no difference in the new onset of urinary incontinence between the groups.

1:40:12Jordan Feigenbaum:Again, reassuring that starting a resistance training program, even if it's heavy, does not increase the risk of urinary incontinence. Cross-sectional studies in women who lift heavy do find high rates of pelvic floor symptoms, 30 to 40 percent in some samples. But those numbers get cited as evidence that lifting causes the problem, but this is an error. Pelvic floor symptoms are common in women, generally speaking, especially after childbirth, and the rates in lifters tend to track the rates in match groups of non-lifters. The thing is, the women who aren't lifting weights, they have no real reason to have any sort of incontinence, meaning that there's nothing causing that issue to pop up in their day-to-day life.

1:40:51Jordan Feigenbaum:As far as treating women with established symptoms of stressed urinary incontinence, pelvic floor muscle training does have some good evidence here. There's a 2018 Cochran review of 31 trials and over 1 ,800 women that found that women with stressed urinary incontinence were roughly eight times more likely to report a cure with this sort of pelvic floor muscle training versus not. A study in 2024 in CrossFit women with stressed urinary incontinence, 16 weeks of home-based pelvic floor muscle training produced symptom improvement in 64 % of the intervention group versus 8 % of the control group.

1:41:26Jordan Feigenbaum:Overall, this means that if a woman is lifting heavy and she's leaking, consider referral to pelvic floor PT. Transient leaking or heaviness during a set is not necessarily a reason to stop lifting. It's probably not going to make anything worse. But if you do have additional concerns, referral to an OBGYN would be reasonable to evaluate the patient for something that is concerning.

1:41:45Austin Baraki:Yeah, this is an interesting take. I do not claim to be an expert in you know the these pelvic floor pathologies my wife is a gynecologist and you know sees a lot of these folks regularly and does you know slings and all sorts of other procedures to help in those contexts and the case that you made is kind of interesting that it is very common in the general population which does certainly seem to be true most of the patients that she operates on are not uh you know coming seeking surgery or their mid-urethral sling procedure because of they're lifting. Most of them are middle-aged and older women who are noticing symptoms or pelvic organ prolapse that they are predisposed to for other reasons, as you mentioned, things like childbirth.

1:42:23Austin Baraki:I was trying to think of like, what are some analogous cases in my world that I could think of? And one that came to mind is if I bet if you looked at like, what is the incidence of stable angina, like chest pain among adults who are bedridden? It's like none, none of them have it because they are not exerting themselves enough to manifest the symptom yet once you start to exert yourself you're much more likely to if you have underlying atherosclerotic you know coronary disease to exhibit symptoms of angina and so this is a the underlying problem is super super common right um you know a lot of people have coronary artery disease yet the people who are going to manifest with chest pain with exertion are those who are exerting themselves and then the conclusion would be well you don't exert yourself otherwise you're going to get yourself chest pain just lay in bed when it's like well all these people laying in bed they got it too it's just not being unmasked or realized kind of an interesting way to think about the problem yeah yeah upon doing

1:43:17Jordan Feigenbaum:some digging i i'm moderately confident that that is the case until better data comes along and says look people you took this large swath of people started lifting uh and versus didn't and there's a huge difference in in sui rate stress urinary incontinence right that would have to also yeah

1:43:36Austin Baraki:Yeah, you would also, as much as that question is one that's important to answer, it probably should still not be the only outcome that you look at, right? Because you could say, well, yeah, maybe there's this difference in stress urinary incontinence. But then, for example, obviously it would be a difficult study to do. But like across the lifespan, what's the difference in osteoporotic fracture risk? That carries a risk of mortality. Whereas, you know, some pelvic floor symptoms, not necessarily lethal, unpleasant, you know, very, you know, debilitating in their own way to quality of life. but there might be some just fundamental risk benefit trade-offs that some people are maybe

1:44:08Jordan Feigenbaum:more willing to make than others here yeah yeah if the if the sort of main declarative symptom has no reason to show up you can miss a lot and i think that's what we see here yeah all right austin anything you want to add for the woman who's listening to this podcast who's somewhere in this window who's not started exercising yet and is feeling some combination of overwhelmed and maybe even a little behind?

1:44:31Austin Baraki:I think the case, the most optimistic case that we can make is one that we've been making for a long time. It's never too late to start. Again, you are alive. That means that you can adapt. We just have to find the right entry point, the right dose, something that you can do, that you're willing to do. And if you feel overwhelmed doing it on your own, that's what we've been doing for a long time here. And so we would claim some degree of expertise in being able to guide people through this journey. So if you need help, feel free to reach out. Not only in the exercise front, can you know handle the menopause therapy hormonal therapy conversations all sorts of other things but seek out some trusted guidance if you need it but yeah get started and with with proper dosing and progression you can do a lot of good for your health and improve a lot of these outcomes over

1:45:13Jordan Feigenbaum:the long term let me close the loop by knocking out the three fears that seem to keep women out of the gym fear one i've got osteopenia or osteoporosis or just low bone mass isn't lifting heavy gonna break me? The answer to this is no, quite the opposite. The Lift More trial took 101 women with an average age of 65, and every one of them had low bone density. A lot of them were told for years to avoid exactly this kind of training, and they had these subjects doing heavy deadlifts, squats, and presses. Their bone mineral density went up. Compliance was high at 92%, and the only injury in the whole study was one back spasm.

1:45:51Jordan Feigenbaum:Progressively loaded heavy lifting was apparently safe and effective in the exact population that many people say that it's dangerous for. Fear two, I don't have the time. Now, time limitations are certainly real, but the good news is you probably need less exercise than you think to see a big return. Two lifting sessions a week that are 30 to 45 minutes long, plus a little cardio covers most of the benefit. And the less time you have for cardio, the more you have to lean on intensity. Now, the menopause influencers would say that this is a bad idea because of cortisol, which is 100 % false based on the available evidence.

1:46:25Jordan Feigenbaum:Fear three, I leak when I lift, so I should stop. This is also not true. When researchers compared heavy lifting against just resting, the lifting didn't make pelvic floor strength or function any worse. Leaking or stress urinary incontinence is relatively common in women whether they lift or not. If it's happening to you, the move is a referral to a pelvic floor physical therapist, which has some pretty good evidence behind it. It's not quitting the thing that's protecting your bones and your future independence. And since we just spent an hour telling you who not to trust, let me give you the other side, how to actually pick a coach or clinician in this space.

1:47:01Jordan Feigenbaum:Some green flags. They'll ask you what you can do today and build from there using your preferences, resources, and so on, instead of handing you a pre-made program on day one. They'll talk about adding load over months, not about some magic exercise or magic supplement. They're comfortable saying, I don't know, or the evidence here is confusing or weak. and they treat training, sleep, and your actual medical care as the main event with everything else as optional. Some red flags? Well, they'll sell you a proprietary trademarked program that supposedly only works for menopausal women. They'll sell you a supplement stack sold right alongside the coaching.

1:47:37Jordan Feigenbaum:A menopause-specific certification is often worn as the main qualification, which honestly, if anything, just tells me that they bought into the exact marketing we spent this whole episode taking apart. Now, this isn't meant to throw shade at people seeking additional knowledge, we should be clear, there aren't really any menopause-specific considerations for exercise. The same level of individualization is useful for all folks, regardless of menopause status. And anybody promising that one thing, one hormone, one powder, fixes everything, probably shouldn't be trusted. Real help is individualized.

1:48:09Jordan Feigenbaum:It's a little boring and honest about what it can't do. But let's bring it back to the woman we've been talking about since episode one. The one who walked into her doctor's office tired and unsure, the one standing in the dumbbell rack holding the five pounders because everything she'd read told her that she's fragile now, that her body's broken, that she's missed her window. That's not true. The training that works for her is built upon the same principles that works for anybody. Her bones will respond. Her muscles will respond. Her body has remained adaptive. And the things that actually end lives at this stage, the heart disease, the fall, the fracture, all of it changes in her favor the moment she starts loading her body and starts doing her cardio.

1:48:47Jordan Feigenbaum:It's not perfect. and it doesn't happen overnight, but she will adapt nonetheless. And she doesn't need a pink supplement any more than she needs pink dumbbells, and she doesn't need a proprietary protocol or coach with a certificate to get going either. Dr. Maria Fiat-Aron proved this with women in their 90s back in 1990. 4 ,000 women in a 2026 meta-analysis proved it again, and the answer hasn't changed. It's not going to. It's never too late. You're not too far gone, and the best time to start is today. I'm Dr. Jordan Feigenbaum. That's Dr. Austin Baraki. This has been the Barbell Medicine Podcast, where we bring modern medicine and strength and conditioning and strength and conditioning to modern medicine.

1:49:23Jordan Feigenbaum:Please leave us a five-star rating and a review. It really helps drive traffic to our podcast so we can keep bringing you all the latest nuance in health and fitness. If this has helped you, send it to the woman in your life or to her clinician.

1:49:49Jordan Feigenbaum:something we hear a lot from people who run our programs is that they finish one and then they immediately want to start the next one or that their goals or preferences shifted part way and they want to switch to something different which is actually how training should work it should adapt to you as things change now the problem is buying programs one at a time every time that happens well that can be hard on the wallet so we built barbell medicine premium one subscription and you get the entire program library in our app, all the strength, hypertrophy, conditioning, rehab, general fitness, beginner programs, and everything in between.

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