Ep. 212 Pt. 2: A Deep Dive into Hormonal Imbalances and Menopause with Dr. Tabatha Barber

Today I am happy to share the second of my two conversations with Dr. Tabatha Barber. Dr. Barber is a triple board-certified OB-Gyn menopause and functional medicine expert. She is also known as The Gutsy Gynecologist.

Dr. Barber is the kind of healthcare provider we are all looking for! She answers all the questions that women are often afraid to ask. In this episode, she and I dive into menopause. We talk about the myths surrounding GYN care, the issues with the Women’s Health Initiative study, how that has adversely impacted female hormonal health care over the last twenty years, and hormone replacement therapy options versus navigating natural menopause therapies. We compare the impact of hormone replacement therapy on our bone, brain, and heart health with not using it. We discuss tobacco use and endocrine-disrupting chemicals, statistics around skipped cycles, and the predictors for who will navigate the menopause transition with fewer issues. We talk about extreme stress and being underweight, how that can push women into menopause earlier, and the physical changes we can anticipate, including muscle-loss, vasomotor symptoms, and vulvar-vaginal symptoms. We also touch on bladder incontinence, overactive bladders, and prolapses.

I know this episode will be valuable for you, and there will definitely be a third episode with Dr. Barber! I hope you enjoy listening to today’s conversation! Stay tuned for more!

IN THIS EPISODE YOU WILL LEARN:

• Dr. Barber dispels some myths around GYN care and explains the importance of making informed decisions about bio-identical hormone replacement therapy.
• How can menopause impact women’s brain health?
• Some problems with the findings of the Women’s Health Initiative study.
• What happens to their eggs when women go into menopause?
• Women need to realize that aging does not cause heavy periods.
• Intermittent fasting can ease the transition into menopause.
• How can being underweight, smoking, and stress cause women to go into menopause at a younger age?
• The physical changes women can expect with menopause.
• Women need to understand that their sex hormones need high-quality fats. 
• Dr. Barber shares her thoughts on vasomotor symptoms. 
• What causes an overactive bladder?
• Dr. Barber talks about vulvar-vaginal and bladder issues in menopause.

Connect with Cynthia Thurlow

• Follow on Twitter, Instagram & LinkedIn
• Check out Cynthia’s website

Connect with Dr. Tabatha Barber

• On her website
• The Gutsy Gynecologist Show
• On Instagram and TikTok

Books mentioned:

Estrogen Matters by Avrum Bluming and Carol Tavris

The XX Brain by Lisa Mosconi

“Women need to know that hormones are not only safe, but they are healthy, and they keep us from aging.”

– Dr. Tabatha Barber

Transcript

Cynthia: Welcome to Everyday Wellness Podcast. I’m your host, Nurse Practitioner Cynthia Thurlow. This podcast is designed to educate, empower, and inspire you to achieve your health and wellness goals. My goal and intent are to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives.

Today’s episode is my second conversation with Dr. Tabatha Barber, who is a triple board-certified OB-GYN, menopause and functional medicine expert, and she’s also The Gutsy Gynecologist. This time around, we dove deep into menopause, myths surrounding GYN care, the issues surrounding the Women’s Health Initiative study and how that adversely impacted female hormonal healthcare over the past 20 years, options for hormone replacement therapy versus navigating natural menopause therapies, the net impact of hormone replacement therapy or not using it on our bone, brain, and heart health, statistics around skipped cycles, and the predictors for who will navigate into the menopause transition with less issues. The role of tobacco use, endocrine disrupting chemicals, and extreme stress, and being underweight, and how that can push us into menopause a bit earlier. The changes to our bodies to anticipate including muscle loss, vasomotor symptoms, and vulvovaginal symptoms as well. We could have talked for hours, but today’s podcast episode, I know will be incredibly valuable, because we also touched on bladder health, incontinence, overactive bladders, and prolapses. Like I said before, there will definitely be a third episode with Dr. Barber. She is always the kind of female provider we are all looking for and she answers all the questions you are oftentimes afraid to ask. I hope you will enjoy this conversation as much as I did recording it.

Tabatha, it’s so good to connect with you again. I would love to do a little bit of a deep dive into menopause. I refer to it affectionately as puberty in reverse, but let’s dispel some of the myths. What are some of the confusions or terminology that you feel your patients really struggle with around this time in their lives?

Tabatha: Oh, my goodness. This is what I used to hear in the office all of the time. I’m done having babies. I don’t need to see you anymore, right? Huge myth. That is not true at all. You still need to have your ovaries and uterus examined periodically, you need a breast exam, and if you have a good gynecologist, you’re going to talk about your hormone journey and how things shift and change. If you don’t feel your gynecologist is capable of that, then find someone who is well versed in hormone replacement therapy or at least understands the menopausal transition. I always tell women, “You don’t need to be on bioidentical hormone replacement, you don’t need to go into menopause naturally. You need to do what feels right for you and you need to know all of the options, and the risks and benefits, and alternatives.” That is how I’m just so strong about that like, “You should know what you’re signing up for or not.” 

Because I came out of training at a time where hormones were dangerous and scary. We just have this idea that women’s hormones are not safe and it is complete garbage. It’s totally false. Our hormones are very protective. We need to understand that when we go into menopause and our hormone levels go down permanently, they’re now at this nice, low level continuously that we are no longer protected. Our risk of heart disease goes up, our risk of diabetes, our risk of dementia, our risk of bone loss, not to mention the vanity things, our skin changes, our eyesight, our hair, our nails, all of that stuff, our libido. So, women need to know that hormones are not only safe, but they are healthy and they keep us from aging. It’s up to you whether or not you want to do bioidentical hormone replacement therapy, but you’re not being told the truth to make that decision in the first place. That’s where I get fired up and angry. [laughs] 

Cynthia: Not bad. For listeners, I did an amazing podcast with Dr. Avrum Bluming and Carol Tavris earlier this year talking about the book, Estrogen Matters, which I strongly encourage everyone to read and make informed decisions. I really agree with you that I would say, it’s 50-50. 50% of the women, they’re roughly my age-ish or a little older. Many of them are using some type of bioidentical therapy. Then there are others who are choosing not to and there’s no judgement. But I think it’s important that you make an informed decision. Remember, in our last episode, Dr. Tabatha was talking about informed consent. Why it’s so important that you make a decision from a place of knowledge, not out of fear. And yes, we both trained around the same time, because I remember in around 2002, when I was finishing up my medical training saying to my mom, “Oh, my gosh.” The Women’s Health Initiative comes out and it’s like estrogen is bad. Now, we realize it was just really bad data that they extrapolated, and the media perpetuated, and now, you have not just patients who are scared of hormone replacement therapy, but clinicians which just perpetuates the bad information. I think it’s really impacting women on really profound levels. I always say that. “The older I get, the more I think about brain health.” 

There’s a great book by Dr. Lisa Mosconi, The XX Brain. I hope eventually to interview her on the podcast. She’s doing a lot of research right now. But that book really changed my whole perspective on hormone replacement therapy. The more I understood about the physiology of the brain and how all of our sex hormones, not just estrogen, but progesterone and testosterone have signaling areas in the brain that impact our ability to not just metabolize glucose, but have clear cohesive thoughts, and whether or not people recognize this or not, women are largely protected from things like cognitive issues and Alzheimer’s until they go through menopause and why does that happen? Because we lose estradiol signaling. Estrogen is an insulin sensitizing hormone and we really need to think about Alzheimer’s as a type 3 diabetes. We need to understand really at the basis of that is insulin resistance. I think it was interesting. I think it was Bruce Willis recently, sounds like maybe there’s some cognitive deficits going on with him and I actually said to my husband. I probably have no doubt. He’s gone through andropause. Yes, it happens to men, too. It isn’t just women. The number one reason why men develop insulin resistance here in the United States is either from exposure to estrogen mimicking chemicals/insulin resistance and would not at all surprise me if that’s contributing. I don’t know anything about his medical care. I’m just surmising from the outside based on what I’ve read.

Tabatha: Yeah, it’s so important and that’s been more important to me lately. Like you mentioned, once you start transitioning, and you are no longer having regularly cycling hormones, and you’re getting that brain fog, all of a sudden, you realize how important it is to have your brain health when you don’t have it anymore. I commonly see women age 60 to 65 coming to me, they’re five, 10 years out of menopausal range, and they’re like, “I can’t think, I can’t concentrate, I can’t remember anything. I can’t sleep.” They want their hormones back because no one had that discussion with them. It’s really frustrating that the most commonly heard thing is, “Well, if you’re not having hot flashes and night sweats, you don’t need hormones.” That’s the other big myth that’s being perpetuated by conventional medicine. The third one that kills me by gynecologist is, if you don’t have a uterus, you don’t need progesterone. Progesterone is only to protect the uterus from overgrowing its lining and causing uterine cancer. That’s totally false. As you mentioned, there are receptors all over our body in our brain. We metabolize progesterone into a couple of different forms. One is called the alpha pregnanediol and that actually hits our GABA receptors in our brain, and prevents all that anxiety and insomnia that so many women are struggling with during perimenopause and menopause. Our body likes our hormones. The key is they need to be bioidentical. 

You mentioned the study, the WHI that just shifted life for millions of women, so many problems with that study. First of all, they were studying synthetic hormones. Conjugated equine estrogen from horse urine, that’s not what we make. They were studying a synthetic progestin, totally not what we make. They started women, average age of 64 I believe on these hormones, so, they were already over 10 years into menopause, and having heart disease, and diabetes, and dementia, and everything else set in, so many problems. Then there’re two arms to the study. Estrogen only or estrogen and progesterone. The findings of the study weren’t even explained correctly. It was really that the synthetic estrogen was increasing your risk of blood clot and stroke, and adding that synthetic progestin was what increased breast cancer by one out of every thousand women or something. The findings were not of statistical significant value, they were not the hormones that we would recommend, they aren’t given in the way that we recommend to give them. We’ve learned so much since that study almost 20 years ago at this point. What we’ve learned is that hormones are safe. If you are mimicking your own physiology, if you’re monitoring it in the bigger piece like that I want to drive home is that you’re metabolizing them correctly. I can give you bioidenticals, but if you’re not doing other work to have a healthy liver, and a healthy gut, and moving your body, and all of these other things, keeping your blood sugar in control, then you can still have risks with those bioidentical hormones. Because it’s not just about your levels and your amounts. It’s how you’re metabolizing them. I can’t emphasize that enough. So, that’s where testing is really important, and being monitored, and knowing. What is your body doing with these things that you’re putting in them, right?

Cynthia: Well, and I think it’s really important, because again, we’ve conditioned our patient population that a pill is going to fix everything. Oftentimes, when I’m talking on social media or I’m talking about my personal circumstances of my own journey. I always say that, “If I didn’t have all the other things dialed in, I could have a very different experience.” You have to get the sleep dialed in, you have to get the nutrition dialed in, you have to get the gut health dialed in, you have to do all these things before you band-aid with hormones. The hormones, let me be clear, if you want to take hormones, by no means, it’s the right decision for you. But if you’re not doing all the other work, it’s not going to help you. How many women do you see that say, “Oh, I got put on HRT and I feel better, but then I gained 15 or 20 pounds?” I’m like, “Well, you have to back up the bus.” You can’t eat like you did when you’re 20, you can’t get by with not getting enough sleep.

Especially, in light of the fact that and I’m hoping we’ll touch on some of these things. Some of the physiologic changes that are occurring in our bodies as we make that transition into 12 months without a menstrual period, when you understand the physiology, it explains why sleep becomes more important, it explains why stress management is not just two minutes of meditation once a day and you check the box. It explains why anti-inflammatory nutrition is important and you might not tolerate alcohol anymore. I’m always super open and “I’ve never been a big drinker,” but during the pandemic, I was a social drinker. And so, I wasn’t doing anything socially and I actually said to my husband, “Every time I have a glass of wine or a martini, my sleep is terrible.” One, just one. My sleep is terrible, my REM scores are in the toilet, I have hot flashes, and it just isn’t worth it. If I don’t drink alcohol, I don’t have those symptoms. When I suggest that sometimes to people on social media as the reason why I don’t do it, they’re like, “Oh, I never would have made that connection.” But I think it’s important, each one of us might need something different to have a big impact. 

Now, I’d love for us to start from the beginning. Starting from when we are born, we have so many primordial follicles. By the time we go into puberty, we have 300,000 follicles. By the time we get close to menopause, we have a lot less of those follicles. So, talking about each month ideally, when we’re in peak fertility, we’re having an ovulatory cycle, releasing an egg, hopefully, the healthiest egg of what’s available. So, when we go into menopause, do they become dormant, are they dead? What happens to those eggs?

Tabatha: [laughs] That’s a great question. It’s important for women to realize they are born with the eggs that they’re going to have and potentially use to have a pregnancy and create a human. Whereas men, they make their sperm every 48 to 72 hours throughout their life. It’s completely different. It matters how healthy your mom was when she was pregnant with you because that determines the health of your eggs and your baby. It’s amazing to me. But that piece becomes really important in fertility issues because I do case reviews for Fab Fertile. They help with fertility with high FSH, low AMH. Your FSH is follicle stimulating hormone coming from your brain and it’s telling your ovaries make more estrogen, get ready to ovulate. Sometimes, doctors will measure in FSH level and they will determine your future off of it. They will say, “Oh you can no longer get pregnant. You need donor eggs, IVF, you’re in menopause, you’re done.” I will tell you, I see FSH get reversed all of the time in my Fab Fertile clients that I do case reviews for because it’s a dynamic situation. Hormones are very dynamic. It is not a light switch, it’s not you on and off, it’s not one and done. Say you’re 35 years old, you missed a couple cycles, they draw on FSH, it’s 40, “Oh, you’re in menopause. You’re done. We’ll see you later.” Well, then you have a period six or eight months later and you’re freaking out like, “What’s wrong with me? Do I have cancer? Am I okay?” 

Because it’s not a light switch. It’s dynamic. Things affect and talk to the brain all of the time. Not only are your ovaries talking to your brain, your thyroid is talking to your brain, your adrenal glands are talking to your brain, your pancreas is talking to your brain, your blood sugar, your cortisol, your thyroid, they’re all influencing your sex hormones. It’s really important for women to understand that your body first and foremost wants to survive. It’s going to choose that route first before it starts to procreate. If everything’s dialed in, then your sex hormones can get attention and get balanced. But everything else is a mess, then that’s going to be the last thing to be dealt with. Same thing with your liver. We’ve talked a lot about it on the last episode that we did together. Liver has to metabolize your sex hormones. But it’s going to choose the alcohol toxin that you just ingested first over those sex hormones. Your estrogen will be dealt with later, if ever, because if it keeps dealing with alcohol, and Benadryl, and Ativan, and stuff like that, it’s ever going to get to your estrogens and they’re just going to pile up. I think of it as like, you have to not only take the garbage out of the kitchen and put it on the side of the road, but the garbage truck guy has to come and take it or it will pile up on the side of the street. There’s a lot of different places in your body that you need to be thinking about how is this affecting my hormones. Back to our cycle. We get in there, our brain or ovaries start talking that causes menarche or first period, things continue on. 

I just want to point out a couple of things. Periods shouldn’t be miserable, they shouldn’t be heavy, they shouldn’t be so painful and horrible that you miss school, you shouldn’t have crazy migraines. Those are blood sugar issues, heavy toxic burden issues, too much cortisol. Those are other issues. That is not your sex hormones. First and foremost, if that’s what you got from this podcast, that’s huge. When you start cycling, you are producing estrogen from that FSH response. LH comes in and says, “All right, everything looks good. Let’s ovulate. Boom.” You release an egg from the ovary, the place where the egg actually was, is now called the corpus luteum on your ovary and that’s what produces progesterone. It used to be common for PCOS to go in and do ovarian drilling. I don’t know if you remember this, but gynecologists or surgeons, we were trained that we would go in laparoscopically and drill a bunch of holes with cautery with electrical burning technique, and burn a bunch of holes in the ovaries. That would fix your PCOS. That was super popular for a while. When really all it is was destroying those follicles that you have left, so, you have less ability to ovulate and less ability to make progesterone. And so, it actually made PCOS 10 times worse because then your androgens were really unbalanced and there was no progesterone to keep it in check. Unfortunately, we try out a lot of things on women. Women are like guinea pigs.

Just know that, if you don’t ovulate, your ovary can’t make that progesterone that you need. You can get a little bit from your adrenal glands and other things from pregnenolone being changed, but that’s really insignificant. It used to be that you would ovulate consistently until about age 45, 48, and then you would be running out of eggs, and so, you wouldn’t ovulate, and you wouldn’t make progesterone, and then your brain would go, “Oh, okay, we’re done doing this. Let’s decrease the amount of estrogen” and then you would slide into menopause. But the past 20 or 30 years, women’s lives have changed so significantly that that’s no longer a smooth, short transition. It’s now a long process. We really need to dial in what’s causing this prolonged perimenopause, so that we can transition smoothly into menopause and then we need to change the conversation of how do you want that to look, do you want it to be natural? Let’s make the most of it or do you want to slow this aging process and suspend yourself in the 48-age range with bioidentical hormones, and what does that look like in a healthy, safe way?

Cynthia: I think it’s really important. When I was prepping for our conversation, there was a statistic I found really interesting. It was saying that if you’re in mid to late perimenopause, two skipped cycles in a row, gives you a 95% chance that you’re within, I thought this is ironic, four years of menopause. I was like, “I would think as you start skipping cycles, you’re getting closer and closer to that.” And then on top of that, it was interesting. It was saying that two years from menopause, 50% of your cycles you have are completely anovulatory. Meaning, you’re not ovulating, you’re bleeding, but you don’t even realize that you’re not ovulating. I think for many women that are in mid to late 40s, excuse me, most of them are not really focused on conceiving a child. They’re not even thinking that way. But it’s surprising to me how many women I speak to who are in this late perimenopausal transition, they’re like, “Oh, I can’t get pregnant.” I’m like, “Well, technically, you probably could.” It would probably be a surprise if it were to occur naturally, but just understanding that when your cycles really start getting, you start skipping more cycles, you’re getting closer to that transition and I think a lot of women don’t understand. They just say, “Oh, well, I got a period once every four or five months. That’s fine with me. I just don’t know when it’s going to come.” Much to our last conversation on the last episode leaning into how do you feel, what’s your libido, what’s your energy to get a sense of where you might be in this long-protractive cycle?

Tabatha: Yeah, definitely. It’s important for women to realize that you can bleed like you mentioned without ovulating. Estrogen is coming in the first half of the month and it’s stimulating that uterine lining that endometrium to grow. Even if you don’t ovulate and produce progesterone, the lining still grew and it’s going to shed eventually. Without progesterone, it’s probably going to shed earlier. It’s really common to see your cycle start to be every two to three weeks as opposed to four weeks. That’s a really common complaint. That’s telling me, you don’t have progesterone there to keep that lining stable and hold on to it for the entire four weeks. It’s being released early or skipping months is when your estrogen wasn’t high enough to stimulate growth periods. So, nothing bled, nothing had to be released. But it’s so common for women to have that symptom cover up. We don’t have that as a gauge and I love having that as a gauge. I am really not a proponent for an ablation or an hormonal IUD, unless, it’s really significantly necessary. These are important conversations to have individually. 

I would love for women to go to their gynecologist, and the gynecologist to say, “Let’s figure out why you’re having heavy periods? Let’s not just cover it up.” I first see that future. It’s got to happen. It really does. But in the meantime, you as a patient have to be your own self advocate and say to the doctor, “Why am I having heavy periods?” If they say it’s because you’re aging, that is a lie. That is not a true statement. Aging does not cause heavy periods. There’s no physiological explanation for that. It’s because of the dysfunction in the other areas that we talked about on the last episode. It’s really important for women to realize. Your perimenopausal transition doesn’t have to be five, 10, 15 years of misery being on this roller coaster. You just have to dial in the other stuff and then we can transition so much smoother. I think intermittent fasting, that was a key for me. That was a game changer without a doubt.

Cynthia: Well, it’s interesting, because my natural inclination was to dive into, what are some of the things that can impact, how quickly a woman transitions into menopause from that transitional period? I was thinking about meal frequency, and insulin resistance, and how– We know that can exacerbate a lot of the symptoms women experience in perimenopause. But something I thought was interesting is what has been your experience with women? Obviously, I don’t know a lot of people who smoke. During my training, I saw a lot of it because I was in Inner City, Baltimore. But it’s interesting. When I was looking at tobacco use as being a risk factor for going into menopause earlier, what I found interesting and I’m curious to know if this is your experience that smoking in and of itself causes irreversible damage to ovarian follicles and then secondary to that blood flow. So, it would make sense that smokers would probably be at greater risk for going into menopause at an earlier age. Was that your experience with your patients?

Tabatha: Oh, yeah, definitely, without a doubt and causing infertility because our fallopian tubes have these tiny finger-like projections inside of the tubes just like our intestines do. They’re called papillae and they move things along. If your fallopian tubes have stunned or dead fingers, they’re not going to move that egg through there and you’re not going to be able to get a fertilized egg, and so that can be really effective. Luckily, I don’t see a lot of women smoking nowadays. We’re finally getting the message that it really compounds, especially menopause. It just compounds all our hormonal issues. I will tell you the biggest thing that I see for premature menopause is stress. Women, who go, go, go from dusk till dawn, 12, 14, 16-hour days, nonstop, they don’t sleep, they’re sleeping probably four, five hours max, consistently over time, they’re over caffeinated. They are driving this major adrenal cortisol dysfunction pattern and they’re living on all of the stimulants required to keep them going. All the caffeine, the nicotine, the alcohol, all of these things to get them up and then put them down, get them up and put them down. If you do that long enough, your sex hormones will say, “Yes, she does not love us. She does not want us to cycle.” That is what I see consistently women who stopped having periods 43, 45, 47 years old is. That’s their life.

Sometimes, it’s salvageable, if you catch it early enough. That is the time that I rarely see it reversed. I talked about FSH levels going up, and affecting your fertility, and you’re not having periods. If it’s for other reasons, it’s almost always [unintelligible [00:27:05]. If it’s from this chronic adrenal dysfunction, you have to make major life shifts for that to reverse the effects that it’s had on your sex hormones. If you’re listening to this and you’re like, “Man, I can tell that my hormones are off and that’s me living that crazy life.” You’re going to have to make some hard choices. You’re going to have to evaluate your boundaries with work, with life. You’re going to have to really start writing in the calendar, self-care stuff every single day and making some major shifts or you will definitely go into menopause, and then you’re going to have to deal with that.

Cynthia: Yeah. How about women who are underweight?

Tabatha: That’s another issue. We see low BMI or highly athletic women not produce enough estrogen. A little bit of estrogen is actually made in our fat cells. It’s this feedback thing where estrogen is a growth hormone, so, it feeds our fat, and our fat makes more estrogen. You want to find that happy balance that happy medium because if your BMI is too low, then we don’t see enough estrogen and that increases your risk of bone loss, and fractures, and increases your risk of premature menopause. I would say, that’s the woman that I want to focus on high-quality proteins, and healthy fats, and weight training, and really focusing on muscle health and muscle strength. Because muscle keeps your fat in check, muscle burns the fat, but that is going to keep her stable longer. I don’t ever suggest like just try to gain weight and gain more fat. I don’t think that’s healthy. I don’t know. I would love to hear your two cents on that.

Cynthia: Yeah, it’s interesting because I’ve had quite a few women that are– I’m not per se identifying them as anorexic, but they’re very fixated on their weight. I get a lot of these women who want to fast, because they want to maintain their weight and they get very fixated on the scale and the weight. I know from everything that I read is that the lower your fat mass and we’re talking about very thin women. I’m not talking about an average lean woman. We know it can accelerate follicle aging. That was one of the reasons that I was curious to ask had this been your experience as well that I am seeing women 47, 48 going through earlier. I definitely think in 2019, when I lost 15 pounds because I’m not a big person that that pushed me over the edge. I know I was getting closer, but I do think that that contribute. Because I lost so much muscle mass, I had no fat left on me when I left the hospital, and it took a period of time to gain healthy weight back. I remember saying to my GYN, I have a feeling that’s probably what did me in at an earlier age and she said, “Women that have major stress” like they’ve had an illness, or they’ve been hospitalized, or they’ve gone through a bad divorce, or they lost their job, those kinds of things can certainly accelerate that. I think getting back to your saying about the people who are super stressed out whether it’s circumstantial, beyond their control, etc., that can definitely push you over. 

Now, I want to make sure that we at least can touch on some of the changes women can expect. I think women are sometimes surprised to know that muscle mass, as an example, is something that– We start to lose, I think it’s 0.7% of muscle mass each year in our 30s and 40s and this, actually, muscle is this organ of longevity, it impacts our insulin sensitivity, it can be improved with estrogen. Estrogen replacement, obviously, bioidentical. But the concept of sarcopenia, I think for a lot of people, they’ve never heard that term, they don’t know what that means. It’s muscle loss with aging. It’s not a question of if but when, but it’s certainly something for myself that keeps me very vested in making sure I’m having that conversation. I’m sure as a GYN, you probably have women in your practice that were menopausal, but we’re super skinny, but they lost all this muscle mass, so, they just look skinny. They don’t look like they have defined muscles. I remind people that’s not a look you want. Because usually what goes along with that is osteoporosis and sarcopenia. Maybe this is someone who back from the WHI study is now concerned/fearful of hormone replacement therapy. But understanding that our muscle mass can improve with hormone replacement therapy. 

Tabatha: Yeah. I really feel for women [chuckles] who are 50 and over in this country, because they lived through the low fat, no fat era, and the high intense cardio aerobic Jazzercise era. All of those things were really harmful to women. We were trying to tell women like, “You can’t eat any fat, you have to exercise until you can’t even stand up. You have to sweat, sweat, sweat, and deprive, deprive, deprive.” What we’ve learned is that shuts down your sex hormones faster than anything else does. What I’m seeing every day in my practice is those women still trying to recover from that brainwash of cardiology and everybody else in the medical field saying, “Don’t eat fat, exercise more, eat less.” They’re having a lot of mental blockages trying to make this transition. When I explained to them like, “You need to do intermittent fasting with a healthy ketogenic diet,” they’re scared to death. Or, “You need to do weight training instead of five hours of Jazzercise.” They’re like, “I’m going to bulk up and be fat. What are you trying to do to me?” It’s just trying to get rid of all of these lies, and all of these myths that we told them for so long as medical professionals who didn’t understand health and wellness whatsoever. And so, finally, cardiology and all these societies are putting their tail between their legs and saying, “We got it wrong,” but they’re doing it in very quiet way. Media is not helping whatsoever. Women are confused. 

I’m really glad that you wrote this book because it’s important for women to understand that your sex hormones, your testosterone, and your estrogen, your progesterone, they come from a cholesterol backbone. If you aren’t eating healthy fats, you will go into menopause. You will stop making those hormones. What we see is, “As soon as you go into menopause, ah, your cholesterol goes up.” “Well, no duh. You’re not using it to make those hormones anymore.” Everybody panics and says, “You’re going to die from heart disease.” It’s not because your cholesterol went up. We told women take all this calcium when they’re in menopause and then we found out that calcium goes and helps block your arteries. We’ve done a lot of things wrong as a medical institution in this country, and as physicians, and nurse practitioners, and we just need to say, “We made a mistake, and we were actually wrong, and it’s okay.” This is what the science is panning out to show is that the way God created us with this innate intelligence and this ability to not eat for days, and then eat and have a feast and not eat, that is literally how we’re supposed to function. So, we just need to get back to how our bodies were made and honor that innate intelligence in our physiology, in our homeostasis and stop trying to muck it up with these fads and everything else. 

Cynthia: No, I couldn’t agree more with you. I think on a lot of levels that I cringe, because in the early 2000s, we were still perpetuating seed oils and eating lots of complex carbs and so it makes me cringe. But I’m glad that slowly, slowly, slowly, the knowledge is getting out there that healthy fats are important, high-quality fats are important, adequate amounts of protein, the fasting will not hurt you. A couple more things I just want to touch on largely, because these are things that clinically, I wasn’t dealing with when I was working in cardiology. Number one, vasomotor symptoms. The people that are listening they’re like, “What does that mean?” Unless you’ve experienced that, it’s almost as if you’re burning from the inside out. I recall exactly where I was the first mini-hot flash, because they were never severe. But we know 80% of women will experience them and some of its– I think a lot of people like to blame estrogen like, “Oh, it’s because estrogen is falling.” And yes, estrogen is involved in temperature regulation. But it’s so much more than that. It’s interesting, when you look at like you can break it down by demographics, you can break it down by race, 25% of women will experience minimal ones and then there’s another 50% that are kind of in between and then there are people called super flushers. Now, you never want to be one of those. [laughs]. 

Tabatha: [laughs] 

Cynthia: But it’s interesting, when you look at the research, alcohol and caffeine appear to be two risk factors. I would add into that insulin resistance because the worse your insulin resistance or diabetes is, the more likely you are to be in that 25% of super flushers. And thankfully, I can count on two hands how often I’ve had them, but they’re never pleasant, they’re never fun. What are your thoughts about that in terms of when you’re working with a woman and she’s dealing with out-of-control hot flashes, which are not fun?

Tabatha: I couldn’t agree more. The women that come to me with those complaints are the ones that hate their job, and they don’t want to confront their boss, and they’re absolutely miserable, or they’re going through a divorce, or they haven’t spoken to their spouse in a week, and they’re on the verge of divorce. That is the kind of stuff that drives hot flashes, I promise you. Sometimes, I also see, especially in younger women, hot flashes coming from gut dysbiosis. Too much Strep overgrowth in your gut or it can harbor up in your tonsils, any of those things. Night sweats are a big one. Estrogen always gets the blame. What I saw for 20 years is, a woman would come in with hot flashes, and it was either me or a colleague would give them estrogen, they would gain weight, and they would feel better temporarily, and then it would be bad again. We’d be chasing this estrogen dosing. “Oh, you don’t need estrogen. Oh, you do. Oh, you don’t. Oh. You do.”

Cynthia: [laughs] 

Tabatha: That wasn’t what was going on. Their blood sugar was dropping in the middle of the night to wake them up and make them sweaty because they were drinking one or two drinks of wine every night. They were metabolizing all this sugar, they were eating snacks in the evening, were still trying to recover from the ADA telling us to eat every two hours to maintain our blood sugar. Another lie. That’s just not how our bodies were created. God did not put grocery stores on every corner of our world for us to eat every two hours to maintain our blood sugar. Hot flashes, night sweats, mood swings. Estrogen imbalance definitely affects this and worsens it, but it’s not the primary driver. It’s blood sugar, insulin, and cortisol almost every time, and then parasites, and gut infections the other times. What I say to women is, “Don’t drink alcohol for a couple of weeks. Just see what happens.” If you can’t do that for two weeks, that’s a bigger problem. You should be able to just not drink alcohol for a couple of weeks to do a little experiment on yourself and see if you sleep better. Don’t eat for at least three hours before you go to bed. You got to get that blood sugar stabilized and it’s not by eating more. It’s by giving your body a rest from eating. That’s key. 

I used to get a lot of complaints when I had my practice of women having to pee during the night. “Oh, I got to get up and pee, I got to get up and pee.” They thought, “My bladder is failing.” We’d put them on medications for urgency and overactive bladder, which are a nightmare in of themselves and have all kinds of problems. It’s not your bladder. It’s your blood sugar, it’s your cortisol dysfunction. I promise you. Don’t be quick to jump on those overactive bladder medications because that constipate you, which irritates your bladder that makes your gut dysbiosis worse. That medication makes you super thirsty because it dries out your body, then you end up drinking more, and that can make you want to pee. I swear all these medications that we give women to fix their problems just cause five new problems. It’s super frustrating. It’s not only frustrating for the patients, but for me as a provider, because they’re looking, they’re like, “Why don’t I feel better? And now, why do I have this problem, and this problem, and this problem?” So, stop medicating everything.

Cynthia: Well, and it’s interesting because I never share these things in an effort to make healthcare professionals not sound professional at all.

Tabatha: Right. Exactly.

Cynthia: However, it used to be a running joke that you would put someone on a blood pressure medicine like hydrochlorothiazide, which is a diuretic, you would have an increased renal loss of potassium, so then you have to put them on either potassium-sparing agent or potassium replacement, and then the diuretic, this one in particular would provoke gout. It was literally the domino effect. You put them on one drug and end up on five more. What Dr. Tabatha is really emphasizing is, we need to do the work, so that we don’t have to be on all these medications and understanding there’s a root cause. Now, ironically enough, one thing I wanted to touch on before we end our conversation and I could just talk to you for hours, so, we’ll have to have you back for another episode. 

Tabatha: [laughs] I know.

Cynthia: Vulvovaginal issues in menopause are a huge issue. I would imagine most if not all women are very uncomfortable having these conversations. And so, for anyone who’s listening, 15% of women will develop these early on, but by the age of 60, it’s almost 75% of women. So, it’s not a question of if but when, and it’s a direct reflection of the loss of estrogen in the vaginal microbiome, just like you’re mentioning the gut microbiome, the mouth microbiome, the vaginal microbiome. Disruptions there have a profound impact. It changes the pH level of the vagina, which contributes to all these problems. Let’s at least talk about this, because this is what I would consider to be probably the most taboo subject for women to talk about. They may be able to talk about the hot flashes and the weight gain, but talking about their vaginas is something that they’re deeply uncomfortable. I’m hoping we can have a discussion and get some good information out there, so, women can better advocate for themselves.

Tabatha: Oh, my gosh, yes. If they’re brave enough to ask about it or if they’re gynecologists actually ask about it, they don’t usually have the best solutions. I would say in my bag of tricks as a gynecologist, I would give you vaginal estrogen and tell you good luck. That’s all I thought about or had for you. As a functional medicine provider, I’m thinking about the vaginal microbiome and the fact that your pH balance shifts so much once your estrogen level declines permanently. Vaginal symptoms are one of the first ones to come on with chronically low estrogen. All of a sudden, things are dry, and irritated, and it doesn’t feel good. It’s not just with intercourse. Intercourse can be very painful. But that tissue in the vagina, the skin actually thins out. You lose this glycogen mucus producing layer that supports lactobacillus. It can almost be as thin as tissue paper. So, imagine how easy tissue paper tears. That’s what happens to the vagina with intercourse or even just physical activity. Because the vagina is a potential space. It’s a tunnel with the cervix at the end of the tunnel connected to your uterus. But those walls are usually closed up against each other. When you put something in, you separate those walls. If those walls are constantly touching each other, you can actually get agglutination. That skin will grow together. When you try to pry it open, it tears, and it bleeds, and it feels horrible. 

I used to do exams on women all the time. That’s all I did all day long. If you’re not having intercourse regularly, putting that speculum in is miserable because I’m finally separating those walls that have not been separated and that have been deficient in estrogen for a long time. The same thing happens when you go to have intercourse for the first time in a long, long time. It’s miserable. You really do have to support the microbiome, the bacteria that live in the vagina and that starts with having healthy microbiome in your gut. And probably, being on systemic estrogen, or some local vaginal estrogen, or you can use the precursors. You could use DHEA. That’s another one. Some women will even do progesterone and testosterone vulvovaginally. There’re all kinds of benefits there. 

You need to find a practitioner who prescribes these creams regularly because they’re not a standard prescription. They have to be made at a compounding pharmacy. You have to have a prescriber who understands how to dose that properly and right for those prescriptions. There is relief. I always get the comment, “Well, if God wanted us to have all of that, he would have made menopause later. ”Well, the average age of women was 49 just a 100 years ago. We didn’t live half of our life in the menopausal state. This is all new to us and we need to figure out how to manage that and have a good quality of life. We deserve to have amazing sex, and be intimate with our partners, and enjoy this time of our life. Because we’re finally not worried about getting pregnant anymore and all of these things. We deserve that. You do need to find somebody who can help you navigate that because you don’t have to be miserable. 

The other piece of it I see is your bladder. Not having that estrogen at reproductive levels anymore gets rid of the mucosal barrier inside the bladder that protects it from bacteria getting in and causing issues. The bladder is more susceptible to infections once you’re in menopause. It’s really common for women to get two, three, four bladder infections a year. Not only are they miserable, but then you’re prescribed an antibiotic to kill that infection, which also kills all of the beneficial bacteria in your gut, which disrupts your metabolism of the little bit of hormones that you do have and everything else. It’s just the snowball effect. When I get to that time where I need estrogen, I’m probably going to go on estrogen. Right now, I’ll tell you, I’m on progesterone, but I see so many benefits to bioidentical estrogen in just preventing the disease processes that set in with low estrogen. You really should consider it as long as you’re doing it with a practitioner who knows what they’re doing and who is well versed in all of this. But there are solutions. 

The other piece of it is, things can start to fall. You and I had this discussion in your private Facebook group. Our collagen, not only starts to be depleted in our cheeks and in our arms, and things start to jiggle and sag, the same thing happens in our pelvis, in our vagina. We lose the volume in our vulva, in our labia, in our lips, we start to lose the collagen support that keeps our uterus up and things fall. That can interfere with intercourse, that can cause accidents, urine or even feces. There’re all kinds of things that go on. Back to the beginning of our discussion, it’s really important for you to have a good women’s health practitioner in your corner when you’re done having babies and you’re going into the second phase of your life because you need them more than ever actually.

Cynthia: I could not agree more and I’m so very grateful that you joined me for a second episode recording. Please let my listeners know how to connect with you, how to find your great podcast, how to reach out to you because the one thing I know is, Dr. Tabatha is licensed in many states. So, she may be licensed in your state.

Tabatha: [laughs] Yes, I think I’m up to 29 or 30. I don’t know. I lost count. But you can go to my website at drtabatha.com, D-R-T-A-B-A-T-H-A. It’s all A’s, no I’s. You can sign up to potentially work with me if you feel you need a one-on-one practitioner who can prescribe for you. If you just need support in other ways or you want more information, you can listen or watch ‘The Gutsy Gynecologist’ show on YouTube and podcasts wherever they’re at. Then follow me on Instagram, and TikTok, and all those cool places @thegutsygynecologist. You just need to keep gathering more information and figure out what works for you because we’re all individuals. But I would say the big overlying arch theme is, you can’t balance your hormones with just hormones. That’s number one. The gut affects so much of your hormones. You need to get back to eating the way God created you to be with some fasting super important. And then the piece that we need to come on again. We need to have another episode, because we didn’t even talk about how women don’t love themselves, and that whole mindset piece, and how we self-sabotage. We have all these old recordings playing and all the lies that have been told to us. We need to break all of that cycle. That’s a whole another episode. But start there, do the work, we’re here for you. Let us know what else you want us to talk about, because Cynthia and I could talk all day. [laughs] 

Cynthia: No, in all seriousness, for anyone who’s listening to the second episode with Tabatha, I covered maybe 25% of what I have on my notes. 

Tabatha: [laughs] 

Cynthia: So, we’ll definitely have to have you back. Thank you again.

Tabatha: My pleasure.

Cynthia: If you love this podcast episode, please leave a rating, and review, subscribe, and tell a friend.

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