Perimenopause Sleep Hormones: Cynthia Thurlow on Why Rest Changes First

25:11So I always say if you haven't gotten in there yet. Statistically, you will. So it really becomes this domino effect, not to mention the fact the vagus nerve is the communication gateway between the brain and the gut. And all of a sudden, you know, women start experiencing more anxiety, more depression, with less estrogen, they're not making as much serotonin. And so suddenly that irritability, that feeling cranky, feeling like you're not yourself. I mean, there's all these alterations in the neurochemistry, neuroanatomy of the gut. And so this direct communication that goes on with our brain is, you know, it can lead to, you know, if you have an inflamed gut, if you've got leaky gut, you've got leaky brain.

25:47I think a lot of people don't realize that the blood brain barrier is designed to protect the brain. But once it's been breached in the gut, the research is certainly suggesting we then get leaky brain. So it means that, you know, you may not understand it at a, at a, the level that you and I are talking about it, but more inflammation, brain fog, I mean, all these symptoms that women experience, sometimes just gets chalked up to one hormone changing. But I'm like, no, it's so complex and so nuanced. There's not one area of the body that is not impacted by the gut microbiome. And it's this full on domino effect that just starts and just it's like it just adds layers after layer after layer.

26:25We see it so common for women in their 40s to get a new diagnosis of IBS and to be told, that's it, there's nothing you can do. Maybe we can give you some motility drugs. Like, you know, maybe you should modify your diet. But what can women be doing if they're starting to notice these gut changes? Yeah, I would say, you know, first and foremost, when someone starts reporting new bloating or they feel like they maybe have a new food intolerance, I'm like, okay, we need to back things up. You know, we really, like, I'm a huge fan of stool testing. I'm a huge fan. It doesn't necessarily have to be food sensitivity testing, but really getting great.

26:58Keep a diary of, you know, if you eat X food and then you notice you have this constellation of symptoms, understanding that could be contributory. The other thing is, as estrogen is changing, so does nitric oxide production. And so the innervation of the gut may change. Women will tell me, I don't feel as hungry. I feel like it takes longer to digest my food. And so whether that's a digestive fire issue, whether it's underlying food sensitivities, whether it's a stool test, I think it starts from a very basic level. Like before we even do testing, are you in a parasympathetic state when you're eating?

27:29How many of us stand up when we're eating? How many people like I used to round on patients with a protein bar? I mean, I think about this now. It makes me cringe. But how many of us are never sitting down to eat a meal because we're eating in the car? We're feeding our kids and standing up. So helping women understand like this kind of top down approach. If your body is in a sympathetic state and you're eating, you're not going to you're not going to break down or assimilate your nutrients. You're not going to be able to detoxify properly. I mean, it really is this, again, the domino effect that we see in so many issues.

28:00But I would say, you know, take five breaths before you eat your food. You know, try to get yourself in a parasympathetic state. Try to sit down and eat. Try to spend, you know, 10 or 15 minutes sitting down. I think many women perceive that to be a luxury. And what's ironic is when I made that pivot from traditional allopathic medicine nine years ago, one of the things I started doing immediately was I was like, I would literally sit and eat my lunch. Like it was a coveted 15 or 20 minutes of my day. And that was something I'd never been able to do. It made a big difference in my digestion. But when I'm working with women, we'll sometimes start there and then kind of work backwards.

28:36Like, tell me about, you know, is it every meal that you have these symptoms or is it just the last meal of the day? Are you eating too close to bedtime? Are you eating too large of a meal too close to bedtime? So it's really getting all the details and then determining like what's the next kind of approach we need to take. But almost always there's some diagnostic testing in there. Is there anything in the literature that's been shown to prevent the loss of microbial diversity as estrogen begins to descend? Well, the research around the microbiome and estrogen is evolving. I mean, there's some postulated like we think HRT, it's not a primary indication yet, but there is a suggestion that transdermal estrogen and as an example may be beneficial long term for helping to support that microbial change.

29:19I think the bigger conversation is, what are you doing before then? Like, you know, it's the antibiotics, it's the chronic stress, it's, you know, exposure to glyphosate. I mean, there's a lot of other things that I think certainly contribute that we can be doing up way before we get to perimenopause and menopause. And I think for so many women, they're not, it's not on their radar. I mean, when I was learning about, you know, the two sentences I got in my nurse practitioner program about menopause, literally, that's about as much as we had. I was like, that's so far off. Like, I don't need to think about that.

29:52Oh, man, I hear that from women who are like 38. And they're like, that's so far from now. And I'm like, as someone in their 40s, it will be here before you know it. Yeah, unfortunately. Yeah. And you better think about it sooner rather than later. So I think it's that, you know, that disconnect from our brains, like, oh, it's so far away. I don't need to worry about it right now. But I think there's a lot we can do before we ever get to perimenopause that can optimize things so that we have an easier transition. But certainly the research is looking like there will ultimately be an indication for estradiol therapy being a primary preventative source of that microbial shift, but we're not there yet.

30:29I think there's so much of the research is focused on like bone, appropriately brain, heart health, but all these other indicators, I think, will eventually come to pass. Yeah. I have seen smaller studies on primary ovarian insufficiency, which is when you lose your period, typically for good. It can come back sometimes before age 45. And I have seen estrogen as an intervention, restoring to some degree, the microbial diversity in the gut. And I'm like, look, if we can do that in a 30 something, and all the studies are looking at is estrogen, then what if we do that? And somebody who has been eating a very diverse diet, who's been doing the food hygiene that you've been talking about, But what impact can we have if women have already been taking the steps towards health every day in their life?

31:16Well, I think for a lot of women, it's that, well, I know I certainly had this amnesia effect of like, oh, I'm in my mid-40s. Yeah, I might be in perimenopause. But I think for a lot of women, it's not until things get tough that they're like, oh, okay, maybe I need to change what's going on. But I think for a lot of women, because they can't see their microbiome, they don't think about it. Like they can see a, well, hopefully they can't see a bone, but most of us can envision a bone. We can think about our hearts. We can think about our brains, but the microbiome seems kind of intangible. And so for a lot of people, they're like, I don't even know where that is.

31:50What is that? Where is it? What does it mean? Why is it important? And I think unless we're tending to it, we're probably not thinking about it. Eczema is unpredictable, but you can flare less with EpGliss, a once-monthly treatment for moderate to severe eczema. After an initial four-month or longer dosing phase, about four in ten people taking EBCLIS achieved itch relief and clear or almost clear skin at 16 weeks. And most of those people maintained skin that's still more clear at one year with monthly dosing. EBCLIS, LibriKizumab, LBKZ, a 250 milligram per two milliliter injection, is a prescription medicine used to treat adults and children 12 years of age and older who weigh at least 88 pounds or 40 kilograms with moderate to severe eczema.

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32:58How do you recommend women tend to their microbiome? Oh, that's a great question. Well, I mean, it goes back to those basics that I kind of always talk about, like sleep is important and stress management is very important. You didn't start with food. I want everybody to tune into that because most people start with food. But I think a lot of people listening don't make the connection that literally every aspect of what you do in a day, no pressure, impacts your microbiome. Yeah. And I think for a lot of people, it's just it's reassuring to know if they're hearing the same consistent message, sleep, stress, nutrition, exercise, you know, dealing with your stuff.

33:36So if you've got a trauma history like I did, I mean, there's a lot of a lot of things that you can do. But I think that, you know, on a very tangible level, like it doesn't mean that you have pristine sleep every single night, but you should be focusing on high quality sleep, you should be focusing on managing your stress. Because we know that stress, chronic stress has a lot to do with leaky gut, lowering your immunity. I mean, if you have a lot of chronic stress, you are going to lower your sex hormones. I mean, I hate to kind of lump all the sex, the hormones just there, but I think for a lot of people in the hierarchy of needs, your body is going to prioritize survival over having sexual intercourse or bonding.

34:16And so I think for a lot of people, they don't make that connection that, you know, chronic stress can lower their testosterone, can lower, I mean, it has this kind of, again, that domino effect that I like to refer to, that it's never just one thing. I would say the other thing is being conscientious about the quality of your food, being conscientious about the quality of your water. You know, get your water tested. It doesn't necessarily that everyone needs a fancy reverse osmosis system. That may not be what you need. But I think for a lot of people, it's the chronic exposure of pesticides, herbicides, chemicals over time that I think can be more problematic as we get older.

34:49Like I always say the toxin bucket gets filled throughout our lifetime. And it's usually by the time we're in middle age that maybe, you know, maybe it's heavy metals. I mean, there's a lot of things. Maybe it's mold and mycotoxins. You know, there's a lot. Maybe it's a tick borne illness. There's a lot of things that can overflow that bucket. So it's that nuanced approach, but the basics always apply. What is the sign or symptoms that women can be looking for to identify that that toxin bucket is overburdened? Yeah, I mean, I think a lot of a lot of like neurocognitive effects, you know, for many people, they may not realize that the brain fog they're experiencing can be problematic.

35:28They may have, you know, the detoxification piece, you know, there's genetic susceptibility, people that don't detoxify well, maybe they've got MTHFR, maybe they've got CompTI SNPs that are contributing to why, you know, yes, our livers are designed to break down and detoxify things. There's two phases in liver, and then it goes to the gut. if your liver isn't processing things properly. I think about headaches. I think about the neurocognitive stuff. I think about people that will tell me they're not pooping every day. And I know poop is not an exciting topic for most people. But I would say if you're not detoxifying on a daily basis, and yes, our bodies are designed to poop and pee and breathe and sweat, and all those things should happen.

36:08But there's a lot that can contribute to why that's not functioning optimally. And in the gut, you've got the estrobilome. And so it's always this piece of maybe, you know, phase one, phase two are okay, but you get to the estrobilome. And the estrobilome, which is what is designed to package up and get rid, it's like a present, package up the present, get rid of it into your poop. For a lot of people, they don't go to the bathroom every day, or they don't realize that, you know, they have, their estrobilome is not optimized. Maybe they've got high beta-glucuronidase. They're not able to actually break down the estrogen in a way that they can break it down and get rid of it.

36:42And so I think that there's a lot of different things, weight loss resistance, bloating, constipation, diarrhea. I mean, any digestive symptom, skin manifestations for sure. And that's very bio-individual, but I see a lot of like odd symptoms that women will experience. So I think it can be as unique as the individual, but those are the things I see with greater consistency. For women who are listening, their doctor may have told them, it doesn't matter if you poop every day. And we see self-proclaimed hormone experts on social media saying the same thing. It's actually not that important to have a bowel movement every day.

37:18I want you to talk a little bit about that because I think we take for granted the things the body does kind of on autopilot, right? Like when we talk about deep breathing and people kind of dismiss that, they're like, it's breathing. I mean, it's breathing. So what? And like, it's pooping, like, right? My body should just do that. So can you talk a little bit more about that and what you typically see with your patients? Yeah. I mean, so I always get a sense of like, do you have a bowel movement every day? And I would say 80 % of the time, it's a no. And so whatever our normal is, is what we assume is normal.

37:51So that's number one. Like maybe you haven't been a daily pooper your entire life, but it's almost always a reflection of, are you hydrated? Are you someone that is, you know, if you're in a stress state, your body doesn't feel safe, you're not going to poop. So if you're someone that gets up in the morning and you immediately like rush to work and then you go to work and you're rushing around all day long. I mean, you may not have allowed your body to be in a relaxed state to go to the bathroom. So that's a secondary issue that can be problematic. Sometimes it's the ultra processed diets. I mean, if you're eating a low residue diet that has like five grams of fiber in it, you may not go to the bathroom regularly.

38:27And so I always argue with the carnivores because they're like, you don't need to poop every day. It's not important. And I'm like, okay. Some of those bros are eating raw chicken, so I would not take any advice from them. Salmonella is real. Yeah, I've had that. It's not fun. And so I think that when I'm looking at what are the optimal ways that our body should function, having a bowel movement every day is not an unreasonable effort. But I think for a lot of people, they kind of get to this point where they're like, I don't want to talk about it. Whatever my normal is normal. But the contributory factors are, are you chronically stressed?

39:03Are you hydrated? And hydration is like so underrated. Like I tell people all the time, I mean, I'm a great example. I'm not properly hydrated today because I've been doing a lot of talking. And also welcome to Vegas. Yes, exactly. And it's like, I would say it's so dry and I'm an East coaster. And so it's like this whole thing. What's your diet like? If you eat no fiber or low to no fiber, which is the standard American diet, And, you know, the recommendations are certainly pushing that 25 to 30 grams a day. What does fiber do? Fiber like feeds the colonocytes. I mean, there's different types of fiber, but ultimately it's feeding these cells in our colon.

39:39But getting back to the poop conversation, when someone's not pooping, I start thinking, what else is going on in their gut? Do they have a latent infection? Is there something that's opportunistic infection that's problematic? Do they not have enough digestive fire? Are they someone that's eaten like a no fat diet because they're paranoid of fat? And so their bile is viscous. And, you know, we know the bile helps break down and emulsify fats. And so if they start reintroducing fats, sometimes they get constipated. And so it's just really looking at the whole picture to decide, like, what's the contributory piece.

40:10But I will be the first person to say not pooping is not normal. And if it's new, it needs to be investigated. Absolutely. So that's something I get very concerned about when doctors are so flippantly dismissive of not pooping every day. One, if it's a change, that could be a sign of ovarian cancer. Like that's very serious to take in a postmenopausal woman. And I mean, perhaps even before them. But the other thing too is that we know neurodegenerative diseases often manifest with motility issues in the gut. The enteric nervous system of the gut is what is affected first. And we just ignore that.

40:48And then we act shocked. Like, we never saw Alzheimer's coming. We didn't see Parkinson's coming. We didn't see this coming. And it's like, yes, you did. She said it to you. But likely, you had 30 plus patients in a day. And you were like, are you going to die? Yes or no? Okay, like, let's keep moving. Because that's the system that doctors have been set in. And I frame it in that way purposely for people listening because they think that we have a really great system of insurance, pharmaceutical company, legislators, and they've all made the doctors and the healthcare practitioners really the villain.

41:25But everybody went to like medical school, to their different programs to help people. And then they got stuck into a paradigm that doesn't match what the intention or even the intended impact is of that provider. Well, and I think there's also this degree of cognitive dissonance. You bring up such a good point about the enteric nervous system. And I think for a lot of people, like I even said in my talk today, I was like, when you look at what's changing in the innervation of the gut, like both progesterone and estradiol have innervation in the gut. And as those alterations and hormones are changing, nitric oxide production goes down, all of a sudden the motility piece becomes problematic.

42:02And patients will say, I feel like if I eat a little bit of food, I feel full. huge red flag for me personally. It's like I start thinking, okay, well, we need to, hopefully it's nothing. Let's like work through this. If you're a clinician listening, this is a red flag, not just for her, for all of us. Yes, exactly. I start thinking like, what else is going on? Like, do they have a latent gastroparesis? I mean, there's a lot of things that can go on, but I think on a lot of different levels, when motility is not working optimally, it's a bigger problem. And I think that as someone who just had a colonoscopy.

42:33Thank you, my parents, because I inherited some crappy genetics. I've been getting colonoscopies since my 30s. Oh, man, I'm coming up on my deadline. Yeah. Well, the worst part's the prep, which is the truth. Yeah, and it's true. Well, in the US, it's actually pretty bad, but other countries are not hitting it as hard as the US is. I have a new gastroenterologist, and he's amazing. I was like, thank you for not making me have to eat a crap diet for an entire week in order to prep. This one's far more laid back. Okay, make your point, but I think we should explain what we're talking about with colonoscopies.

43:06Yeah, yeah. So what's interesting is I was having a conversation with my GI doc before my colonoscopy, and I said, oh, you know, it's interesting. Today, literally as I was complaining about my prep, there's a young country music star who died of colorectal cancer, diagnosed at 38, died at 45. And I was like, I'm just going to shut up because I'm grateful that I get to have a colonoscopy to make sure I don't have a precancerous polyp. But I think for a lot of people, they fear these screening modalities. And I'm like, listen, colonoscopies are both curative and diagnostic. So hopefully you only have to do it once every 10 years.

43:40I have to do them every five. But I think that when I say the worst part is the prep, it's because they give you medication that forces you to evacuate the contents of your digestive system. And it's not pleasant or fun. But then you go and you have a very nice nap and then it's over with. Yeah. And you're hanging out at your house for a while as you prep for this. So it is something that like, don't go to your kid's soccer game or prep for colonoscopy. No, no, you're home. It's like you start at 7 p.m. and you get up at 3 a.m. for the second dose and then it's done and over with. Yeah. Well, for people who are afraid of that, I think that is something that's really common or you've had a traumatic experience.

44:18I think this happens a lot in gynecology. Somebody clamped your cervix with the speculum or the doctor did not ask consent and communicate well and just, you know, shoved a speculum inside of you. Like it's these kinds of things that I think we don't talk enough about that women have experienced trauma. So they want to avoid the doctor or they have fear or they're not getting an informed consent or they think the known is going to be scarier than the unknown. So what would you say to women listening about colonoscopies, about getting screening exams? Yeah, I would say that, you know, if you are worried or stressed or concerned, I would have a conversation with your provider first and foremost, because more often than not, they'll probably walk you through the entire process.

45:05Like, this is what you're going to do. You know, they give you a long list of instructions, but they're going to tell you like the day before you drink bone broth or you just have clear liquids. And then you're going to take two doses of this medication. You're going to spend some time in your bathroom. You're going to come in the following morning. You're going to get, you know, they're going to give you wonderful propofol. You'll forget everything. And then it's over with. But I think that, you know, the greater concern is, and I feel like this is more problematic now than ever because I shared my entire experience on social media and the questions I were getting were phenomenal.

45:35People were like, oh, what's the rate of perforation? Like, first of all, like, you know, that so I smart people. I love that. Sent me down a rabbit hole. And actually, when I read it was such a small, it was such a small. So first, let me back up. In the hands of a qualified gastroenterologist, it's a slim to none experience, but you have to be properly screened. Like we don't do colonoscopies on 80 year old women. We try to avoid doing it on frail people. We try to avoid doing it on people who are actively sick for the purposes of we don't want to go into something that's already inflamed or problematic.

46:10And I think that's why the screening piece is so important. Like screening before you ever have a procedure in the hands of a board certified, fully qualified, experienced gastroenterologist. And that's the only people that should be doing this. The incidence should be like 0.05 percent. I mean, it's very, very small. It's less than an IUD. Correct. Yeah. And so I think that putting that to rest, and I did a whole podcast on it because I got so many questions, and the amount of people that were like, oh, I've been putting it off because I just didn't want to deal with it. And I was like, it's kind of like whether we're getting our teeth cleaned or getting a pelvic exam or any other screening modality.

46:46It's like sometimes we just have to be open and honest with our providers about what our concerns are, discuss the risks and benefits, and then make a decision from there. And to me, a colonoscopy is such a low-risk procedure in an otherwise healthy patient that, you know, we're seeing more and more colorectal cancer in younger and younger patients. Like people in their 30s, people in their 40s. There's a lot of speculation for why that's happening, but it's not a reason not to get screened. I think that's the bigger message is I acknowledge that maybe because I've worked in medicine that I probably have a different perspective.

47:20I'm more of a, you know, it's just one of these things I have to do. But I acknowledge, you know, as you astutely stated, someone has a bad experience with any type of medical procedure or person. It can make it more challenging to go back and have a second procedure or have a second conversation. And this is when I would say, if you've had a bad experience with a provider, see someone else, get a second opinion, and then be very open and honest. Like, I have friends who are trauma-informed providers, and so they know how to approach patients that have had a bad situation. and I think that that's important.

47:57You have to have that open conversation whether it's like dental fear or GYN, you know, exam fear or a colonoscopy or a mammography or whatever it is that you're having done. I think the more honest and open you can be with that provider, the more that they can work with you to explain what's going to happen and also take a little bit of extra time so that you're more comfortable. Good sleep is everything. That's why Oli's Science Bag Support is made with a blend of melatonin, and L-theanine for both kiddos and grownups. So when your mind won't switch off, you've got something that can help. Erasing thoughts and restless nights won't stand a chance.

48:34Find Oli Sleep Solutions for the whole family at oli.com. That's O-L-L-Y.com. I want to shift the conversation into weight. So a lot of women will say, eating the same, same workout routine, change nothing. everything about my body is changing. What's going on there? Oh, yeah. Hello, perimenopause and menopause. And goodbye estrogen. Yeah, exactly. So, I mean, it starts, well, I mean, there's so many things that contribute. I would say, number one, this loss of muscle mass. So sarcopenia is muscle loss with aging. It's not a question of if, but when. So by the time we're 40, we're losing, you know, I think it's 8 % per decade.

49:17But people say, oh, that's not a big deal. It is a big deal because most of us aren't, you know, we're not building muscle in our 20s and 30s. So you get to 40 and all of a sudden you're like, I'm behind the eight ball in terms of looking at that. And muscle is more than just body composition. It is a glucose reservoir. It's important for insulin sensitivity. The more muscle mass you have, the more insulin sensitive you are. And I think for a lot of people, they don't make that connection. And so I say, you're losing insulin sensitivity and you add to that, you're less physically active. You add to that, you're not sleeping through the night.

49:47You add to that you're chronically stressed. You add to that because you're chronically stressed and your sleep is terrible, you don't make good food choices. You're eating ultra processed diet, which is, you know, 70 % of Americans, that's the bulk of their diet. And so we know you eat an additional 500 to 1000 calories a day. Then you layer in, you know, losing insulin sensitivity, loss of muscle mass, all these other things. And then you get alterations in your, well, they're not just sex hormones, but you get alterations in estradiol in particular, alterations in testosterone for most people.

50:19And I do find that testosterone, people aren't always making the connection that testosterone has a lot to do with body composition. And so these alterations in these specific hormones tacked on with all these things that are changing. And as you edge closer to menopause, you're more likely to put on not subcutaneous fat, it's visceral fat. And the other ironic and terrible thing that also happens is that, you know, estradiol is the predominant form of estrogen, but then our body is looking for a solution for less estrogen. And what does it do? It creates estrone-rich fat tissue. So it's a weaker form of estrogen.

50:51So when women say, I've got more body fat and I'm not happy about it, I'm like, well, your body's looking for a solution to a problem. I would also tack on is, as our estradiol is going down and our FSH is going up, so follicular simulating hormone, that protein leverage hypothesis becomes more critically important. And what that means is if you're not eating enough protein, your body is going to be looking for other sources of calories. And it's not looking for, you know, at nine o 'clock at night, when you're standing in your pantry, you're going to, you're going to grab the chips or the nuts, which nuts aren't intrinsically bad, but they're easy to overeat.

51:25Or you're going to grab the ice cream or, you know, a block of cheese. And this is where I start seeing women, like maybe they didn't need enough calories during the day, certainly not enough protein. They're not satiated and their body is looking for more food. And that's an easy thing to kind of pick is to say, you know, you have alterations in your appetite. So there's not this dampening, you know, leptin and ghrelin start getting a little bit dysregulated. And so it's fascinating to me. I think it's never just one thing. Then you could loop in like gut health issues. I mean, there's a lot that can drive that food sensitivities that people don't want to acknowledge that can make them inflamed.

52:01I think there's a lot to the conversation, but it's, I always say it's like multifactorial that there's so much that's contributory. Yeah. Well, let's talk about the nuance of testosterone and body composition because you're right. I don't think enough people make the connection. And I also think that testosterone hormone therapy can be done wrong and contribute to more problems as well. I was talking about this today that I'm seeing a lot of people that are on super physiologic testosterone levels and it's when women start looking androgenized. So they start having, you know, their jawline changes, their voice changes.

52:35A lot of the changes can be permanent. It may not just be the aesthetics piece. So I think about testosterone is everyone associates it just with libido, but so much of it has to do with like building and maintaining muscle, that executive function piece. And so when I have women that start saying to me, like, I just feel like my body composition has changed significantly. I'm like, all right, timeout. We really have to have this conversation. Like, and if you're chronically stressed, that will definitely deplete these hormones. And so testosterone is interesting because, again, it goes back to everyone thinks about it as the association between sex and libido.

53:08It's a lot more than that. But it is definitely this body composition piece, muscle mass, lean, you know, having less body fat, all a byproduct of testosterone. I was just, we're at a hormone conference. Well, it's not a hormone conference, longevity conference. So that's a hormone conference to me if you want to live long. and so I've seen lots of our colleagues this weekend and we're all talking about testing our hormones and I'm I had to have an emergency knee surgery randomly cartilage fell off my kneecap but I'm like immediately like is this related to my hormones I'm gonna get these tested and I think okay you're about to be 45 your progesterone's not gonna look so good maybe your estrogen might be starting to like when get this done progesterone's optimal I'm like okay Good job this month.

53:59Let's see what next month's, right? Estrogen's fine. And my testosterone is low, which I was like, I'm not even really filling this. But I just turned in my book manuscript. And I'm like, this is not a testament to what stress does to your body. And I ended up being like, I'm going to give myself a little bump of DHEA in the meantime. time and the like boundaries, the assertiveness, like all of the, even my husband was like, and this is my wife. And I'm like, I didn't even notice like how I had like kind of softened and slightly contracted. I wasn't noticing necessarily like, oh, like, you know, like I'm losing all this muscle or anything because it wasn't that significant and for that long of a period of time.

54:44But that is certainly another symptom of testosterone we don't talk about is the psychological symptoms. Oh, yeah, the executive function. Yeah, how we actually start operating in our body and just tiniest little bit of DHEA topically. And I'm like, okay, yeah, got my groove back. I have to work on the stress. That's not going to outdo the stress. But I think it's important for women to hear that because often we frame things as like perimenopause typically is going to start progesterone. And we're talking all about estrogen, but we don't talk about that testosterone piece. So for women right now, we've given some examples of like low testosterone.

55:21Maybe they're afraid to start testosterone. Maybe their doctor is telling them there's no reason to test testosterone. It's not FDA approved. Yeah. Yeah. That's a whole nother. Marty, if you're listening, can we get it together already? So, okay. What is the first steps? If somebody's coming into you low testosterone, what are the first steps you take them? Yeah. I mean, I, If we suspect it's stress mediated, it's like you have to address the stress. So it's like the elephant in the room, like I can give you testosterone, but it's ultimately it's just a bandaid unless we're also addressing this as well.

55:55And you don't want cortisol to get your friends. No, no. You don't want that. So I think that's part of the conversation. And I think a lot of women are very interested in transdermal application of testosterone, very interested, very open to it. But unfortunately, right now our options are like androgel at one tenth of a dose or we're compounding drugs. And there's nothing wrong with compounding it. It's just you can get it exactly what you want. And it's not in an alcohol base, which doesn't – the application process is weird. And I speak from personal experience because I've now tried both.

56:27I'm like, okay, what do I like better? I think the compounded version is just so much easier. But I think for a lot of women what I find interesting is not every woman in menopause needs testosterone. they assume they do. There are certainly some women who still make enough testosterone, which I think is awesome. I'm not one of them. But the other question is, you know, what are the signs of too much testosterone? And I think for a lot of women, that's the fear. And I'm like, you're not going to get too high of testosterone levels if you are using transdermal. It's the super physiologic dosing that we certainly see in this space sometimes that kind of takes my breath away.

57:03And that's usually injectable, whether it's subcutaneous or intramuscular. That's a different, that's not what we're talking about. Yeah. And women typically just don't feel as well doing the injections. I mean, they get a peak in a trough. Exactly that. They have that, oh, okay, like this little bit, we went a little too far. It's very Goldilocks, right? You're like not ever really hitting that center point and like chill in there for a minute. It's like too much, too little, too much. And unless you're like, I mean, there are ways that, you know, sometimes it'll be dosed where you're doing more injections, but who wants to do more injections during the week?

57:40Like that's not a good time. In terms of testing, providers will tell women, we test your total testosterone. That's enough. You're totally fine. Like it looks good. Why is that not always true? Well, because that's not what's bioavailable. That's why I think testing free testosterone is so helpful. And it's interesting because to me, I like to see both to have a sense of, you know, what exactly is going on, much to the same point that, you know, when I'm looking at, you know, other types of hormones, like thyroid hormones, it's not just checking a TSH, I want to look at a, you know, comprehensively what's going on.

58:12And I think for a lot of women, understanding that free testosterone is what our body has, that they can actually utilize. It's what's bioavailable. And that's an important distinction. Like, it's almost like if you look at, this is a terrible analogy, but I'm going to use it, T4 versus T3. So T4 is the inactive form of thyroid hormone and T3 is the active form. It's important to have a sense of both so that you can determine like what might be going on. Is it a conversion problem? What could be contributing to this? So I would say if you're lucky enough to get your testosterone tested, please ask your provider to ask for both.

58:47It is very helpful. We've been talking about weight loss. There's a lot of proponents of intermittent fasting for women, telling them that's the golden ticket for weight loss. What are your thoughts on intermittent fasting? I think that it's one of many strategies. I don't think it's the perfect strategy for everyone. And I would be the first person to say, like, even though this is something I'm known for, I have gotten very nuanced on this topic. Meaning, if you are under the age of 35 versus perimenopause versus menopause, there's a right and a wrong way to do things. If you're someone that's 35 and under and you're very lean and very athletic, please don't intermittent fast.

59:25If you have PCOS and you're obese and you're under 35 and you want to get pregnant, that may be helpful. That may be beneficial to have some degree of, you know, timing in your day in which you don't eat. You're not, you're not under eating. That's not definitely what, that's not what we want the message to be, but it's entirely dependent on where you are in your cycle. Same thing with women in perimenopause, but we add in the, are you sleeping? Are you managing your stress? Are you able to eat enough food? Because this OMAD, one meal a day has gotten very popular. And I'm very outspoken against it because I'm like, listen, if you come back from vacation and you did nothing but eat for five days and you want to just have one meal and call it a day, that is very different than chronically under eating, which we know can be profoundly detrimental.

1:00:10I think that it always goes back to women in perimenopause and menopause, are you metabolically healthy? Are you still menstruating? And then tweaking these things. But I think intermittent fasting in many ways, like most trending topics, has become the panacea for everything. And I think some women do it and they feel good. And some women do it and they feel awful. Their sleep goes south. They have tons of cravings. They overeat in their feeding window. It triggers eating disorder behaviors. I mean, it is as individual as we are as women. And so it really has to be an honest conversation. Do I intermittent fast?

1:00:49Occasionally, I don't do it like I used to do. And it's because I'm so focused on building muscle. And so I think for every person, it's what are your goals? If you are someone that needs to lose 30 or 40 pounds, it might be a good strategy to use. But make sure that you're doing it around your follicular phase when estrogen predominates in your cycle. And you're not doing it at two weeks at the end of your cycle when progesterone predominates. I think that's kind of the prevailing theme. And what's interesting is I find a lot of menopausal women can do really well with fasting if used appropriately because they don't have as much hormonal fluctuation day to day and week to week like younger women do.

1:01:24And I think that I owe it to your community to say that it's one of many strategies. It's not the only strategy that can help with weight loss. I definitely agree. And it's very much, I think is, you know, a theme that we've kind of gone through in this podcast, which is like honoring what's true for you and listening to yourself and also understanding that you might be intermittent fasting, things are going well, you have a stressful season of your life, it's no longer working for you and you have to give yourself permission to adapt. And our entire species is here because of our ability to adapt.

1:02:00Each of us had an adoptable ancestor. And yet we've reached this place where there's such rigidity in our society. And we're, you know, there's the A type personality for sure. But then there's also like the wellness personality who's like, orthorexia. Yeah. And this is the thing I have to do. And this is the best way. And even in the face of data, which is their own data saying otherwise, they don't really give themselves permission to say, hmm, this worked. That was great. Thank you. And now I have to adapt in all of this. Yeah. I mean, it's interesting. I've spoken very openly. Like last June, my dad died and my dad and I were very similar body habitus wise.

1:02:38And I kept saying to myself, you know, after, you know, what contributed to his death. And I share this so that people understand my dad was very frail. When people are frail, they lead to falls and whether they get a head bleed or they break a hip, it's a poor prognostic indicator. And so my dad developed multiple head bleeds. And based on his wishes, we let him pass in hospice. And I remember saying to my brother, I was like, if I don't get myself together, because I've always been like a leaner, thinner woman, I was like, I'm going to be just like dad. And I don't want to be just like dad. I don't want that to be my future.

1:03:13And so I got very serious about weight training. And what came out of that was getting really serious about three meals a day. And so I share this that people understand And it's okay if maybe you've been fasting up until this point to course correct. Because if you're not focused on building muscle in middle age, you're going to be one of those statistics. And I don't want that for anyone. Let's talk about that. Someone right now listening that's like, well, sometimes I work out. I'm inconsistent. What is really an ideal strategy for fighting frailty when it comes to exercise and nutrition? Yeah, I would say number one, it's strength training at least two to three days a week.

1:03:50And if you don't know how to strength train, that's okay. Start with bodyweight exercise and work with a qualified trainer who works with middle-aged people so that they know how to safely progress your activity. Number two, it is protein. Please eat some protein. And that means tracking your macros. So for transparency, track your macros for a week. What I find is most women, when I ask them to do that, they're consuming 40 to 60 grams of protein a day. That is not enough to starve off muscle loss. And so it really becomes this, I want everyone to work towards 100 grams of protein a day. And that could be divided over three meals.

1:04:26That could be dieted over two. Today's the day I'm gonna get two meals in and not three. And so it's helping them understand like this is certainly something you can work towards. But that frailty piece, what people don't understand is the reason why we want you to maintain and build muscle is that frailty leads to a loss of independence. I don't ever wanna be in a nursing home. I want to be as independent and strong as long as I can be. And so I, because of taking care of patients for over 25 years, I saw 50-year-olds who couldn't get off a bedside toilet in the hospital. I saw 55-year-olds that would fall and break a hip.

1:05:03And so I think that it's not just a disease or an issue with 70, 80, 90-year-olds. This starts in our 40s and 50s. So it really needs to be something that we prioritize. eyes. And I want to give everyone permission to be so annoyed with having to eat protein in the day. Because it's something that like, I think we have to sometimes talk about the reality of it. But I don't know about you. But there are some days where I'm like, okay, I got to mix protein powder in with my Greek yogurt so that I can like hit this because I need to get my protein. And I'll have moments where I'm like, this is so annoying.

1:05:37And I'm like, no, but it's good for you. I'm like, no no no permission to be like oh this is so annoying and i'm gonna do it anyways yeah i'm gonna do it anyways and i think that it's okay to be uncomfortable and it is okay to challenge yourself with having to do hard things like going to the gym because there are a lot of really rude people out there who like to make fun of women for body weight exercises for having your five pound pink weights everyone has to start somewhere and also if you like pink then rock your pink weights. Who cares if it makes you happy and it gets you in the gym, do it.

1:06:09But we there's such this arrogance about the fitness industry sometimes that I think it becomes obstructive. And so women are like, no, I hear the message. I have to lift heavy. You can't start with heavy. I'm sorry. You're going from couch to to like weights. You cannot start with heavy. And it may be starting with two to three pound weights. And then you're going to progressively increase. And And you should be proud of yourself for even picking that up. You know, I grew up on, I didn't grow up actually. I went to college on the central coast of California. Jack LaLanne, I don't know if you know him.

1:06:45Yep, I remember him. Big fitness guy. He had a whole morning show and he literally was teaching people to lift cans of like produce, right? Like cans of peas. As a workout, I worked in a gym. I was a group fitness manager and saw the women coming in who were doing Jack LaLanne's lifting cans of vegetables who then eventually felt, oh, I can go into the gym. And empowered them. And I think about that. I'm like, that was 20 years ago. And I'm like, that was amazing. We have to continue to bridge that gap and to say like, where you're starting from is a perfect place to start today rather than saying, well, it's not good enough if you're not dead lifting 180.

1:07:27Like, what about this person? you just have to honor where you're at and then set the goals and go for it. In terms of goals for perimenopause, what would you challenge listeners to do in terms of their microbiome, or perhaps it's their hormone health? What is the key message that you would want women to walk away with? I would say I think it's really important. After being so enmeshed in the research, everyone needs more fiber. And so whether it's 30 plant varieties over a week, whether it's getting really granular about eating more fiber-dense foods, whether it's trying something new every week, the research is clear about the role of fiber in the microbiome and how important it is for the colonocytes, for short-chain fatty acid production, and understanding that as you are making this transition, that microbiome takes a big hit.

1:08:23So get accustomed to a, it doesn't start that you go from 10 grams of fiber to 30. I'm not suggesting that, but just be more conscientious. It doesn't mean you add a supplement. I mean, it might be that you add a tablespoon of flax and chia seeds every day to your yogurt or your protein shake, where you just find creative ways to start integrating more of these items into your diet, which is greater awareness. Not to make it complicated. This is not designed to be complicated. It's just building awareness about the importance of fiber. What are the red flags like for you personally that were like, okay, I got a 180 this train or things are going to be much worse?

1:09:01I think starting with I was doing really intense like CrossFit like exercise at 530 in the morning, three or four days a week. And so I would get up before I would drive to the gym, I would do my work at, I would rush home, get the kids ready, shower, get them to school, and then I would go to work. And so I was never getting enough recovery. I was never getting enough rest. And I'd been able to get away with that in my 20s and 30s. And all of a sudden, it was no longer serving me. And then you add in super stressful job where we functioned like residents. And so we had a lot of responsibility.

1:09:34We're managing very medically complex patients, sometimes flying them out of the hospital to another hospital for care. And then I would add and not enough sleep. Like I think I, in many instances, my kids were at an age where I would get them to bed at seven or eight and then I would have an hour or two to get stuff done instead of going to bed. And so I really had to learn like, you need to put yourself to bed. Yeah, okay, so what you described is absolutely so common and we're told you need to exercise. Where are you gonna fit that in? You're gonna sleep less. Oh, you've gotta do all your chores at the end of the day.

1:10:05Where are you gonna fit that in? Like you're gonna sleep less. How are you feeling? and how do patients in your practice feel when it's that aha moment of, okay, I need to make a change? I mean, I think for most people, it's challenging because you recognize you need to make the change, but you're like, how do I do this? Like, how do I redo everything that I'm already, you know, my situation, my rituals, my, you know, I was never a lack of motivation for me. So I was like, how do I rewrite everything that I'm doing? So I started working out from home. I started, you know, adjusting my carbohydrate intake.

1:10:41I started putting myself to bed early. I was willing to make those changes. I find the most challenging patients are the very, very type A's who've been able to white knuckle it their entire life. And all of a sudden you're telling them the aspects of your personality that have allowed you to be incredibly successful. You have to pretend like that isn't part of your personality in order to start making these shifts. So in some of my patients who are C-level executives or physicians, I mean, people that are very demanding jobs, it's saying, OK, what we need to do is we need to find someone to help you with meal prep.

1:11:15We need to help find, like, can a trainer come to your house so that it makes it easier? Or can you do workouts from home? Finding ways so that as they were identifying barriers to making changes, I was like, OK, then we need a solution. It doesn't necessarily always have to be something that costs additionally, but finding solutions so that they can move forward without feeling like they're penalized. I mean, I've had some women say that to me, like, I just feel like I'm penalized. Like, suddenly, everything that's allowed me to get to where I am and be very successful in life no longer serves me.

1:11:46Like, what do I do? And so I think for a lot of women, it's this recalibration. It's this reframing of this time in their lives. And I think once there's a degree of acceptance and that reframe is accepted, all of a sudden it doesn't seem so arduous. But if they fight it, if they're unwilling to make changes, then that's a completely different situation. And I would love to say that no one ever has that problem. But there are clearly women that really struggle with having to make all these lifestyle changes. Tell the listeners how your book can help them take those steps every day towards health and maintain the independence that you've spoken to on this episode.

1:12:25Yeah, I would say that, you know, the book kind of walks you through the science, not in an inaccessible way. That was one like really core theme of the book. So walks you through ovarian aging. We were talking about longevity, walks you through the immune system, walks you through all these key components that we've talked about, and then gets you into the actionable portion of the book. I mean, I spent a lot of time talking about all of these things I've talked about, sleep and stress and nutrition. We get into supplements. We get into hormone replacement therapy and why that's important. There's lots of resources.

1:12:56But the thing is that it's accessible. Like I read, I mean, probably like you do as a podcaster, I read a lot of books in a year. And this was really designed to be helpful for not just clinicians but also women and their loved ones so that they feel empowered and not scared. because sometimes the message, sometimes from a podcast might feel scary or overwhelming. And I'm like, listen, we are starting small and working towards big things. And the really cool thing about the microbiome is really small shifts have a great deal to do with the malleability of the microbiome. Like it is very fixable.

1:13:30It is very fixable in terms of not just lifestyle, but also the nutrition piece, the supplements, the hormone replacement therapy. And I unpack the WHI in that book because I think it's important to give people context. And then lots of resources, things that they can look into and learn more about. Yeah. And I would encourage listeners, if you have a practitioner in your life that you feel isn't listened to, isn't getting it, this is a great book. You can give it to them. You can leave it in their waiting room because as we've seen, when enough women get vocal, change is created in healthcare.

1:14:07And this book is certainly a tool for you to get educated, get empowered. But you can also use it to help your provider help more women. So thank you so much for coming on the show. Thank you so much. It's worked out perfectly. Your call has been forwarded to voicemail. Hi, this is Zoe Deutsch. And Nick Robinson. Our brand new movie, Voicemails for Isabel, is all about those little moments that feel like the universe is looking out. Feeling homesick, then your sister calls. Hearing that perfect song exactly when you need it.

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