GLP-1 Weight Loss in Menopause: How HRT Amplifies Results

29:31And I think that when we look at, a lot of times women are told things like eat a vegan diet and then they're like, well, what about my muscle mass? Or they're put on different medications. If we could have something coming in early on that's getting at the root of issues or even is complementary, like that could show a lot of promise in women's health. I feel like I'm beating this drum over and over, but after menopause, the risk of heart disease rises. So we have to keep that in mind when we're considering what we're starting to see in these trials. If you are overweight, specifically having increased visceral adiposity, you are diabetic or you have prediabetes, again, go back to the insulin show.

30:14I'll link to it so you know exactly what labs I'm talking about, what those markers should be. If you have prior heart events, then your clinician may want to consider GLP-1s as part of like a comprehensive plan, right? We still have to do lifestyle, sleep, resistance training. We have to protect our muscle mass. And hormone therapy should be part of that conversation. Now, as I say all of this for people who are definitely GLP-1 skeptics, I want you to know the goal is not just a smaller body. It's a strong body. It's better heart protection, better metabolic control. And as we're seeing the influence of these big trials, this is why many cardiology guidelines are now considering GLP-1s in high-risk patients.

30:57So your clinician may not be aware of these things, and it might be important for you to bring up because you're at risk. And again, just bears repeating, I'm not talking about just anyone. I'm talking about people who have a risk that we can practice some preventative medicine with. And yeah, sometimes that requires a pharmaceutical because it's better than heart surgery when we start looking at the tier of medical interventions, right? We always want nutrition and lifestyle to be our foundation and sometimes we need a drug. But boy, if we can avoid surgery, I definitely want to do that for you.

31:30It's always important to keep in mind as well that prescription medicines have real side effects. So these are prescription in the U.S. There's other countries where you can get them yourselves, but you really want to do this under a practitioner's supervision. Hey, Chicago, class it up with Crocs. You know back to school is coming in fast. So why wait to find your new Fave footwear? Step into a local Crocs store and step into your new look. Try it. Style it. Make it yours. Because the right pair doesn't just show up, it shows off. First day fits, handled. Walk out ready for whatever's next. Visit your nearest croc store today.

32:14Now, some of the most common side effects that people have, especially when the dose rises too fast, nausea, constipation, feeling full, you can't eat enough food in the day. The other thing is that I think we just need to say that, you know, these are not for everyone. There are rare thyroid tumors. If you have a history of pancreatitis, you should talk to your provider because you could be at higher risk. And I just really should just underscore that, like, you need to talk to your provider who knows your history. I know there's some boutique, like, medical clinics out there that are just like, well, prescribe GLP-1s to everyone.

32:53and they're not doing their due diligence because there's a lot of money to be made here. And I don't recommend that, honestly. I really think like there are people who get desperate because their doctor will not prescribe these things. But I think that you, if you're going to see someone new, they need to do a full history, a family history, a personal history, and really understand your risk and be able to answer all of your questions and be there for you when you do have side effects. If you do have side effects, you might not, but someone needs to be there. caring for you. Before we go into how are these typically prescribed and what you should be aware of and what you should be testing for first, I just want to summarize, sum this up, is that these GLB-1s have shown meaningful protection for your heart and your brain.

33:42And if heart health is on your mind, especially if you're menopause, then have a conversation with your clinician. If you are somebody who has a family history, you're at higher risk for these things and you're edging towards menopause, you're already there. Make sure your clinician can talk to you beyond GLP-1s, but also talk to you about hormone replacement therapy because they may work together synergistically and provide you the most benefit. Now, before prescribing anything, whether it's hormone therapy or GLP-1s. You want to have a clear understanding of your metabolic baseline, your hormonal status, your family history, your personal history.

34:26So you want to make sure a provider gets all of that. Lab testing, that's a good idea to have done. Let's go through that. I think it's smart to have a fasting insulin, a hemoglobin A1c, get a full lipid profile, and look at inflammatory markers like C-reactive protein. I also think it's really important for women to understand their body composition. And so that can be an in-body machine. Some clinics have that. And getting a DEXA scan. Just know your bone health because there are people who go on GLP-1s, they don't eat enough, and they start losing their bone. We don't want that, okay? I would rather you have more meat on your bones than lose your bones.

35:12I would rather see you have more body fat to a point, right? Because too much and in the wrong places, we can have cardiometabolic issues, but it is better to be a little heavier than to lose bone. We know this from mortality studies. You are more likely to be past tense if you lose your bone mass. So get the DEXA. I think it's a good idea for everyone to get a DEXA in their 40s just to know what their baseline is. And that's really what this testing is. Get your baseline because you can celebrate some wins if you have them, but you can also understand if adverse things are happening. We want to get a starting point so you can track whether weight loss is coming primarily from fat or if it's coming from lean tissue, your muscle, if you're having any bone loss, this is super critical for women in midlife.

36:04And then, of course, if you're considering hormone replacement therapy, we want to confirm your menopausal status or where you're at. We can do that a lot from history. We can also check like an FSH, an estradiol to see and confirm like, are you in fact in menopause? But if you haven't had a period in 12 months and you're over 45, you're in menopause. So not having labs is not necessarily a hurdle that you have to overcome if you want to get hormone replacement therapy. I think it's a good idea to have baseline labs and to track labs when you're doing therapy. But as of right now, the guidelines do not say, like you have to have labs first.

36:42So to assess metabolic and hormone status, we want to look at fasting insulin, hemoglobin A1C, a lipid profile, and HSCRP, which is highly sensitive C-reactive protein. When you get your lipid profile, you can get as part of a comp metabolic panel, and then that can also show us liver and kidney function as well. And then body composition, DEXA scan, these are really important to have as baselines. And as I should just say, with the COMP metabolic, looking at the liver and the ALT, AST, and GGT, that can help us understand fatty liver disease in postmenopausal women. That's why I said get it as part of a COMP metabolic panel.

37:23Now, the other thing I think is important is also getting a full thyroid panel. I have an upcoming episode with Dr. Christine Marin where we go through thyroid health in detail and she talks a lot about GLP-1s and thyroid themselves. I also have an episode with McCall McPherson who is also a thyroid specialist using GLP-1s and I will make sure that I have the link for that one. So if you're like a thyroid patient and you're like, say more and I'm afraid of thyroid cancer, girl, I got you. Gonna have it all on the Dr. Brighton show for you. But in terms of thyroid testing. TSH, which your brain says to your thyroid, how does it respond?

38:01That's a free T4. What does your body do with it? That's a free T3. And because the number one cause of hypothyroidism is Hashimoto's thyroiditis in the United States, TPO and thyroglobulin antibodies. Now, when it comes to sex hormones, I did talk about estradiol, but I do want to mention that getting a total and free testosterone along with sex hormone binding globulin and DHA sulfate can also be a really good baseline to have because so often when it comes to women's health, it's all about that estrogen, maybe about the progesterone, and everybody forgets testosterone. It is going to be very hard if somebody puts you on a GLP-1 for you to be building muscle mass if you do not have sufficient testosterone.

38:44So we need to check testosterone as well. We want to be looking at you comprehensively. And if you're going to use a GLP-1 and we're going to say, hey, keep your muscle mass, make sure you work out. We need to make sure that you have your hormone allies to do that as well. I should just also mention that I said like, oh, if you're over 45 and you've lost your period, you're in menopause. If you're under 45 and you've had your ovaries removed, you are also in menopause. So surgical menopause, chemical menopause, these are also confirmation enough. We don't have to do lab testing. But if your doctor does do lab testing, if you caught my perimenopause episode.

39:19I will link to it in the show notes. FSH, that's consistently above 25 with low estradiol. Those ovaries are retired. So that's the brain starting to yell at the ovaries and the ovaries are like, I'm done here. I will not work another day for you. Once those baseline labs are getting established, so sometimes, you know, with a patient, I'll be like, you got your blood drawn? Great. You're starting HRT that day. I'm not going to wait for the lab results. If you're somebody, you're like 52. I'm like, we know, we know you're in menopause and you're a candidate for hormone replacement therapy because we have done our due diligence in working you up.

39:56So we'll go ahead and start the hormone therapy that is right for them. And oftentimes that is doing both estrogen and progesterone, and in some cases, testosterone if warranted. And I have episodes on why I talk about why it needs to be estrogen and progesterone together. I will link to those so you can take a deeper dive on the whys of HRT. And why we're often starting the estrogen progesterone is because that's laying the groundwork for the improved insulin sensitivity. It's helping sleep, mood stability. It's doing all this metabolic intervention, but also helping you rally so you can do the lifestyle, the exercise, the diet, all the stuff you need to be doing to have excellent health.

40:39When it comes to estrogen, as I said, I'm usually using transdermal, topical. That's because we want to decrease the clot risk. And then what I typically do after prescribing is that I will measure estradiol levels usually a couple months later because we might be adjusting doses earlier on. And the reason for that is because we want to make sure that she's reaching therapeutic range. It's not enough just to do symptom control because we know for like cardiometabolic health, many women need to have certain serum levels of estradiol. Some of the research provides to like 60 to 100 picograms per milliliter when you're using transdermal therapy, but optimal ranges can vary by the individual and by the routes that you're taking.

41:25So is it oral? Is it transdermal? Are you using just vaginal estradiol? Like it just depends on your case. So I always want to make that super clear. Like I am a doctor, but I'm not your doctor. So you got me with your doctor because, well, we talk kind of blanket statements about HRT. It is very nuanced for the individual. But I do think it's a really good idea that we are measuring serum estradiol, so blood tests, because we know the research is clear that if it is subtherapeutic levels, even if she's not having hot flashes, we shouldn't be expecting the full metabolic benefit. And that's what we're talking about here, right?

42:03Visceral adiposity, insulin resistance, inflammation. so we got to be checking those levels now that's the hormone piece for a menopausal woman the glp1 piece let's talk about that so if that's considered you know a pertinent therapy based on everything we've talked about so far in this episode right not willy-nilly not just like hey let's just give glp1 to everyone i don't know if that'll be a thing in the future and this won't age well but as of right now no we're not doing that so if glp1 is considered appropriate because there is persistent visceral adiposity. You know, she's doing everything where she's like, I am eating and I am training and my like belly fat that's deep will not budge.

42:47If there's insulin resistance, if there are metabolic comorbidities, like there's already pre-diabetes, type 2 diabetes, fatty liver disease, there's elevated cardiovascular risk that is not improving despite trying everything, doing everything right, then that's when GLP-1s are considered. And then, of course, the standard of like, you're obese, you have a larger body, and your goal is to try to lose weight. So these are the times where adding a GLP-1 receptor agonist would be considered to help with appetite dysregulation, with hyperglycemia, so high blood sugar levels, weight loss resistance.

43:28the things that we see can really impede a postmenopausal woman's body composition, and the things that are putting her at risk for adverse cardiovascular outcomes. So again, if there is visceral adiposity, there's insulin resistance, there's metabolic comorbidities. And let me just say, sometimes we'll try hormone replacement therapy and we're doing lifestyle and it's still not working. And that's when we'll be like, okay, maybe we should consider GLP-1. So I am framing it in this way because I think that sometimes the perspective, especially as I see people online, is that doctors are just like handing it out like candy.

44:06Those people definitely exist. I am not those people. Most of the providers I talk to are not those people. Nobody really wants to start a patient on a drug that isn't clinically indicated because these are not cheap. and also that isn't medically going to shape and change their life for the better. Well, you know, these injections are just these tiny little needles. They're not really that big of a deal. Somebody who's gone through IVF, all the IVF ladies are like, right, right, yeah. It's still an injection. It's still a weekly injection, right? And so we're not being liberal here with how it's being prescribed.

44:46It is very much going through an algorithm in our minds of what is this person's risk factors? What things have they already tried? Because I am always about how do we intervene with the things that you don't require from me, like with your nutrition, with your lifestyle, right? With your exercise, getting good sleep. You don't need me for that. I want you not to need me. I want you to take charge of your health and to feel your best. and what you need me for is prescriptions. And so, yeah, my goal is always like, I want you to have that foundation of health. I want you to be as healthy as possible without needing a prescription.

45:23But if a prescription is necessary, I don't want to withhold that from you if I know that it can be beneficial. But I also am not going to force it on you because it's your body and it's your decision. And I don't think any provider should force any prescription on a patient at all. It should be entirely their choice based on having a true informed consent. And we have to be realistic that these medications alone are not going to preserve your lean muscle mass. You're not going to keep your muscle when you're on these if you're not ensuring that you are doing everything to keep your muscle mass.

45:59And so with all that said of me being like, I want you to be able to do as much on your own and take charge of your health, let's talk about what some providers are not saying and we need to talk a lot more about with GLP-1. So number one is you got to eat protein. And generally, we're looking at like 1.2 to 1.6 grams per kilogram of body weight per day. That's going to be spread across meals, okay? And that's to maximize protein synthesis. And sometimes you got to do protein powders. If you've listened to the podcast, you know I'm drinking collagen in my coffee. That's another thing that I will recommend people to use.

46:42That collagen isn't complete amino acids, so you can't just put collagen in everything. You would have to have a complete protein powder. But we have to emphasize protein intake to maintain muscle mass because what will make you feel full? If you heard my perimenopause weight loss episode, I'm like, eat your fiber and your protein and you will stay full longer. Well, what are the first things that start to go when people are on GLP-1s? Protein and fiber, they start to go because someone's getting full too fast. So they just want to eat like a cracker because that's easy and easy to digest. And that I think is a problem.

47:21I think that in my opinion, my clinical opinion, and in my practice, if you're getting a GLP-1, you're getting nutrition specialists to hold your hand through this because you deserve that support and you need to learn what your needs are so you can be successful at home in maintaining your muscle mass. But it's more than just what you eat. Resistance training is non-negotiable. You have to lift weights. Why? Because lifting weights tells the body, we're prioritizing muscle. You better build it because this is hard and we need to get stronger. You have to have that tension, that friction, that like push the body vibe to your training to get it to build muscle.

48:02So it's going to be a minimum of two to three times a week. If you can get up to four, that's going to be even better. But it depends on how you're training. Because if you're working major muscle groups, like let's say Monday, Wednesday, Friday, you're doing full body workout of like chest, back, triceps, biceps, then you're doing legs and glutes, and you're doing that three times a week. Fantastic. But you have to be doing it. So strength training, we've got to combat sarcopenic obesity. Whether on GLPL ones or not, you're going to lose muscle You are going to lose muscle if you don't do something about it, but you can do something about it.

48:35That is the beautiful thing. You absolutely can do something about it. Now, also in that strength training, you got to have balance and mobility moves as well. If you're somebody who has connective tissue issues, you have hypermobility, work with a physical trainer or occupational therapist because you still need mobility, but you may need to do it differently. and we all need to challenge our balance because listen if you're listening to this podcast you better not you better not have a hip fracture uh because it is seriously one of my goals with this podcast is that i'm not blaming you if you do but one of my goals is to make sure that women know you need to build muscle and you need to work on balance because we want to avoid hip fractures and you can also do that so i have um i have balance boards in my house these are actually for my adhd kids because they help them so much.

49:26But then I was like, I should just stand on these while I'm writing my book, working at my computer. The other thing is that I have a vibration plate. I love the vibration plate. Some people say they lose weight with it. I don't know that there's any efficacy to that. So leave me in the comments if you're like, I did lose weight on a vibration plate. I want to hear about it. I use it. It's great for your lymphatic. It's great just to be jostling postural muscles, but I will do balance moves on it. You can also buy a Bosu that's both sides up. It's a half ball. You can stand on that, do balance exercises.

50:01You can do like one-legged deadlifts. There are just so many things you can do to challenge your balance. So we want to put pressure on the bones and pressure on the muscles to make your body have to prioritize them in building them. I would definitely recommend working with a personal trainer if you don't train regularly or you're totally new to it. I feel like personal trainers are getting a really bad reputation on the internet because we're seeing so many men. Tell me why it's always a man with a shirtless profile picture who like comes in and is just like, oh really Dr. Brayton? Yeah, you said doctor there, didn't you?

50:41And they're telling me hormones have absolutely nothing to do with women's metabolic health. And women are like, I hate personal trainers. They're absolute garbage and the worst. There are fantastic personal trainers out there, physical therapists, registered dieticians, certified nutrition specialists. There are fantastic people out there who totally get that your hormones are part of the equation, and they will say, work with a provider who can help you with your hormones. And then they're part of this collaborative team, and we love them. So if you have a great personal trainer that you know is great with hormone health, drop them in the comments for everybody.

51:16I don't expect your personal trainer to manage your hormone health. That's outside their scope. But I do expect your personal trainer to understand that when you're like, my hormones are off and I don't feel great, that they're like, let's try to train you in a way that's working with your individual physiology. So yes, I know that there's some really awful personal trainers out there. And I hear it all the time from women who are like, these guys on the internet are the worst. But I'm telling you that male or female, there are great personal trainers out there. And so don't lose hope. And I'll link to some.

51:48I'll link to some. I'll link to a YouTube series too that I also like to use for strength training. I'll put all that in the show notes because I think that will help some of you get started. Please do not underestimate sleep optimization when it comes to metabolic health either. We know that poor sleep can increase your cortisol, increase your appetite, blunt both metabolic and hormonal benefits that you're working so hard to create. And if you're struggling with sleep, I did a two-part episode series on how to get better sleep. I'm going to link to that for you. I've talked about sleep a lot on this podcast, but just know that most of us are going to struggle with inflammation, with our metabolic health, if we're not getting good sleep.

52:29And that's a reason why I also like using progesterone when we're doing HRT. So I've been talking a lot. Let me just like do a quick recap. For those of you taking notes, you can check me. Did I get it all? Okay. So protein, 1.2 to 1.6 grams per kilogram per day to keep your muscle mass. Resistance training, two to three times a week, add mobility and make sure that we have a balanced component. Sleep optimization, help improve appetite, help your cortisol levels, help your metabolic health. So we want to have those things in place. A big question I get is about the dosing of GLP-1. So let's just say that like the starting dose of your GLP-1 will depend on which one you're actually using.

53:19And then typically there's an increase that'll happen like around a month, but there doesn't have to be. You may stay on just the starting dose and be just fine. You may increase three months later. So while there are these guidelines, your symptoms and your experience should really guide that. And then you should be being followed up on like every three to six months. There should definitely be follow-ups on your metabolic labs, on your in-body analysis, your DEXA scans. So we didn't want to just run them one time. We want to make sure that we're following up. Sometimes it's going to be six months later, depending on what things look like.

54:00Sometimes it'll be a year later. It just depends on the labs, the results, what's going on with your health. And then equally important is how you feel. So are you feeling stronger? Are you feeling weaker? Are you sleeping better? Are you not sleeping at all? Do you have more energy? Your brain's working better? Are you finding that there's brain fog and you need afternoon naps every day? Track these things. They're super important because the goal isn't just a number on the scale. The goal is actually metabolic resilience. I know you care how you look, and that's fine. I'm not saying you shouldn't, but I, as a provider, care way more about how your metabolic panel looks, about how you are preserving your muscle mass and your bone, how your quality of life is.

54:45um you know i think it's really it's great when women are feeling comfortable in their bodies they're fitting into their clothes like and they have positive self-esteem because of how their body looks but i want you to know that the number on the scale and the pant size and the dress size that you wear is the least interesting thing about you it is very very important that we are tracking the things that truly matter for health as well. So thin at any cost, that works at our detriment. So just as a recap, GLP-1s can have tremendous benefits when used correctly in menopause and maybe even perimenopause.

55:28They're not at this time considered right for everyone. We are looking at very specific metabolic markers. We are looking at not just your weight, but your body composition as well. When we are considering GLP-1s, we want to be considering your personal history, your family history, what is going on in your life right now. Are you going to be able to eat that protein and do strength training? Because like I said before, being smaller at any cost, Well, no one's telling you how big that cost is. GLP-1s may have benefits for cardiovascular disease, for metabolic disease. We do know they may have tremendous benefits for brain health.

56:16That's like to be determined. But we do know cardiovascular health and metabolic health, they have a tremendous benefit. And if you're in menopause, the weight loss part seems to be very positively impacted by using estrogen hormone therapy. I would also argue that estrogen hormone therapy, progesterone, testosterone, when indicated, is going to have a synergistic effect with these GLP-1s. And looking at that full picture is super important. But I always want to remind you, you can't out-supplement and you can't out-medicate a lot of conditions without also focusing on nutrition and lifestyle.

56:59And that is where you hold a lot of the power. So focusing on what you're eating, I will link to a perimenopause weight loss plan for you that is drbrighton.com slash plan. And this is a structured way of eating. It's not super restrictive. I'm not telling you how many calories to take in, and I'm not telling you how many servings you can or can't have. I'm giving you an anti-inflammatory diet that's focused on nutrient density, helping you get your protein, helping you get your fiber, making sure that you get the right types of fat coming into your diet. And it also talks through the exercise that you can be doing to help support your cardiometabolic health.

57:40I want you to be empowered with that and not feel like you are a failure if you need a medication or that you're stuck with only medications, okay? Like, I want you to always have options. And I want to remind you that you are not a failure if you leverage a tool that's available. So GLP-1s are a tool. Hormone therapy is a tool. These are tools that we can leverage, that we can utilize, that can help us. And I also want to remind you, you don't have to share your medical history with anyone. I know people are super judgmental where they're like, listen, I'm a naturopathic doctor. People expect that I should never take a medication or use a medication.

58:25And believe me, I get some hate when people find out I take a thyroid medication. Why do I get hate? Because people think that natural is the gold standard of everything. think we should just be able to do everything naturally. Unfortunately, my immune system murdered a good portion of my thyroid before we ever figured out I had autoimmune disease, and that really sucked. So I don't have the tissue available to make that. And I get to be grateful that I have this medication that allows me to have enough energy that protects my heart, that protects my brain, and makes it so I can show up as a mom with my kids every day.

59:03I think we have to start reframing things. Like I said, I only want to use the medication if it's absolutely necessary. I'm a big fan of putting the power in your hands and giving you all the tools and helping you heal yourself. But if your body is unable to make it to the goal that you've defined, that we have defined, and you need a medication, that doesn't mean that you're a failure. And when we prescribe medications, we always want to consider how can this patient come off of this as well? Is that going to be possible? With GLP-1s, people say you're going to be on it for life. The weight is just going to come back.

59:43You know who the weight comes back for? The weight comes back for people who were not given support. They didn't meet with a personal trainer. They didn't get a registered dietation to help them. They didn't get the support to help them learn how to live in a way that supports their body best. And that's where I think we see a failing. And myself and many of the other people you've heard on this podcast, we don't see people have to stay on GLP ones for life. We see people be able to transition off successfully. And is that going to be true for you? It's just going to depend. So I hope this episode was helpful for you.

1:00:22Please leave me a comment. Leave me a review. I always love hearing from you. And I hope that you're not too upset that I talked about GLP-1s because I know there's a lot of anti-GLP-1 people out there. But I hope that this nuance helped you. And if you want to see more of the studies, those will be linked in the show notes at drbrayton.com. And until next time, take care of your hormones so they can take care of you. Class is now in session. and the UPS Store is here to help you ace arriving on campus. Our certified packing experts can pack everything you need, from desktops to decor. Plus, when you pack and ship with us, you get our exclusive pack and ship guarantee.

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