Ep. 264 Peri/Menopause are a Natural Function of Aging: See you later, Ovulator!

I am honored to connect with Esther Blum today! She is the bestselling author of “Cavewomen Don’t Get Fat,” “Eat, Drink, and Be Gorgeous,” and most recently, “See Ya Later, Ovulator!”. Esther currently maintains a busy virtual practice where she helps women balance hormones, lose stubborn body fat, and treat the root cause of health struggles. 

Today we speak about medical gaslighting, how weight gain does not have to be a part of aging, andropause and menopause, and the Women’s Health Initiative. We dive into physical changes and significant symptoms during perimenopause and menopause, the role of the pelvic floor, deciphering what the dreaded “menopot” is, what does not work, and advocacy in terms of testing and hormones. We also address constipation, weight loss resistance, and how our tolerance for alcohol changes as we age, especially when using bioidenticals or hormone replacement therapy. 

“The better your gut health, the better your transition through menopause will be.”

– Esther Blum

IN THIS EPISODE YOU WILL LEARN:

• How women can redefine their experience and continue having an active sex life after menopause.
• How to surrender, lean in, and take the pressure off yourself while going through perimenopause and menopause.
• Why is there so much misinformation and medical gaslighting in our society?
• Why Esther wrote See Ya Later, Ovulator!
• Some common symptoms of perimenopause.
• Risks women may face after a hysterectomy.
• Changes that happen in the vaginal canal and pelvic floor during menopause.
• The significant and profound impact of the decline of sex hormones.
• How to avoid weight gain in menopause.
• What can menopausal women do to prevent fatty liver and digestive problems?
• Lab tests women should be asking their health providers for.
• Why should perimenopausal women avoid alcohol? 
• Some simple ways to address constipation.

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Esther’s Books

Esther’s book, See Ya Later, Ovulator!, by Esther Blum

Cavewomen Don’t Get Fat, by Esther Blum

Eat, Drink, and Be Happy, by Esther Blum

Transcript

Cynthia Thurlow: 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, is 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, I had the honor of connecting with Esther Blum. She’s the best-selling author of Cavewomen Don’t Get Fat, Eat, Drink, and Be Gorgeous. And most recently See ya later, Ovulator! She currently maintains a busy virtual practice where she helps women balance hormones, lose stubborn body fat, and treat the root cause of health struggles.

Today, we spoke at great length about medical gaslighting that weight gain does not need to be a normal function of aging, the role of andropause and menopause, the Women’s Health Initiative, changes to our bodies in perimenopause and menopause as well as significant symptoms, the role of our pelvic floor deciphering what the dreaded menopause is, what doesn’t work, advocacy in terms of testing and hormones, how to address constipation, weight loss resistance, and how our tolerance to alcohol changes as we get older, and especially if we are using bioidenticals or hormone replacement therapy. I hope you will love this conversation as much as I did recording it.

Welcome, Esther. I’ve been really looking forward to this conversation. 

Esther Blum: Thank you. Me too, Cynthia for, like, a long ass time. 

Cynthia Thurlow: Absolutely. 

Esther Blum: Can we curse on this because I do curse a lot.

Cynthia Thurlow: Yeah, I grew up in Jersey so, nothing surprises me. Before we started recording, we were kind of talking about or alluding to a lot of the medical gaslighting that goes on and how many listeners have probably heard things like weight gain is a normal function of aging, which was the thing I heard that completely lit me up and made me angry. But I think on a lot of different levels, there’s been such poor amounts of information shared with women about what to expect in perimenopause and menopause. There are not enough GYNs that are even getting enough training sufficiently about women in the latter stages of their lives or the second half of their lives. That’s how I like to think about it. There’s a first stage and a second stage and you have a statistic in the book that mentions by 2030, 1.2 billion women will be in menopause. 

So, if you’re listening to this podcast, either yourself or someone you love is going to be in menopause. And so, this is a wonderful thing that actually happens for women. I always like to use it as a reframe. All of a sudden, women’s energies are not focused on fertility, contraception, pregnancy, postpartum periods, little itty-bitty children. You and I, definitely, we have collectively lots of teenagers between us. But I think it’s so helpful for women to know that a lot of the traditional perspectives on aging, traditional perspectives on menopause and perimenopause, for that matter, are woefully inadequate. And that’s why I love your work. I think it’s so important for women to find their voice. As we’re losing estrogen, we lose those people pleasing skills or tendencies I should say. I think that your message is one that is very much needed in this space. 

Esther Blum: Yeah. Thank you. I feel like as we lose progesterone, the filter goes away, too, which I love. It’s so funny because I keep hearing people say, “Ah, women are so invisible in this age.” And I was like, “Oh, my God. I’ve never felt louder or more in my power.” I don’t plan on being quiet or any less visible. If other people choose to look away, that’s their priority. I feel like the 50s are so awesome. My mom had hysterectomy when she was 46 or 47, and she was like, “Oh, my God, it was the best.” I literally came home from college and got up in the middle of the night to go to the bathroom. My mom was, like, walking around the house without any clothes on. I was like, “Mom, can you just keep it under wraps?” She and my dad were together for over 55 years before he passed. 

He passed when he was 91 and they were still taking naps together, they were still snuggling and cuddling and were just like two spoons glued together. You can have an active sex life. You can have absolute arousal. You could still have raging orgasms even after menopause. You’re not like some dried up old lady. That’s just not how it has to be at all. We can totally redefine this time in our lives. 

Cynthia Thurlow: I think it’s really important. I had spoken on a recent podcast about the degree of shame women have about aging and the aging process and talking about the changes in our bodies. Unlike when our kids are young and maybe people are postpartum and maybe they’re just sad or they’re exhausted or just the kind of routine things, women in many instances stop talking about what’s happening in their bodies, the anxiety, the depression, the changes in their skin. I mean, all of a sudden, people don’t want to talk about it. It’s like this big elephant in the room. That’s why I think destigmatizing this and generating these conversations is so invaluable. It’s very validating as a woman to know that your peers are experiencing exactly the same thing more than likely. 

Esther Blum: Oh, yes. For anyone listening to this, every single woman I talk to is going through this. Also, again, lack of libido, lack of confidence around your body, waking up and just not even recognizing yourself. Like, I was looking at my boobs in the mirror this morning, and I was like, “Wow, I got a biggie and a small tier.” Like, we’re just some months I’m bigger, some months I’m smaller. Hormones are raging and fluctuating.

I think surrendering and leaning in is really helpful and just kind of taking the pressure off yourself, being like, “All right, I’m going into this amusement park. I don’t exactly know all the rides. I may not feel great on all of them, but let me just see how I can find my way through and really optimize the situation,” because even if you have gained weight, even if you have cellulite and wrinkles and hair loss and all the things, it doesn’t have to be permanent at all. This is a transitional time, but it doesn’t have to be the rest of your life at all. 

Cynthia Thurlow: Well, and it’s interesting. It’s been my experience with a lot of different patients that perimenopause is a constant state of flux, that’s when you have wildly escalating amounts of estrogen, sometimes more estrogen dominance at that stage of life than any other time period. Dr. Lara Briden was talking about that when you look at the research and then these lowering amounts of progesterone, and then in menopause, things kind of quiet down for most people, maybe not every single person listening. I still do hear from women who say that, “I’m having terrible hot flashes and I can’t sleep, I’m having drenching sweats, and I just keep getting prescribed antidepressant.” 

The reason why I’m kind of bringing this up is some of the common things that I hear from women as we’re starting this conversation are, “I was prescribed an antidepressant. I was given oral contraceptives. I was given an IUD. Someone suggested I get my uterus ablated. Someone else referred me on to therapy.” Why do you think there’s so much misinformation medical gaslighting that goes on? What has driven that in our society? Do you think it’s a byproduct of how medicine in many ways is predominantly male dominated? I’ll be the first person to say that, you don’t normally on this podcast hear me talk about the patriarchy, but I do think that if men had such substantial shifts in hormones that women go through, that they never would have stood for this. They would have demanded better care for themselves a long time ago. 

Esther Blum: Yes. Although sidebar men go through very big andropause and are also not given the tools and the resources and the offering of nutrient therapy, diet changes, and testosterone, or they’re just put right on pellets, which is a whole another story, but I agree. So, 59% of medical schools, I talk to Shawn Tassone about this all the time. I was like, “What the hell is this bullshit?” He’s like, “Okay, 59% of medical schools have menopause care in the curriculum, but they’re not even obligated to teach it, and they certainly don’t go into detail until residency, if you’re lucky.” 

Okay, so there’re so many parts to this conversation. I’m going to try and dismantle all the pieces. But you come out of medical school, you’re not that confident as a doctor prescribing hormones. The pamphlets in waiting rooms and the handouts that you get from the pharmacy on hormone replacement are still referencing the Women’s Health Initiative study from 1991, which gave women synthetic Premarin, which is derived, it’s estrogen derived from the urine of pregnant horses, which is not exactly physiologically compatible with a woman’s body. They didn’t give any opposing progesterone with it. I always say hormones are like a symphony. They’re not a solo act. 

So, anytime you’re overriding nature and giving them as drugs, synthetic drugs versus now, bioidentical hormone is technically a medication, but it’s plant based, it’s much more physiologically compatible with a woman’s biochemistry, and again, you’re giving it in harmony. Under those circumstances, your risk of heart attack, stroke, and cancer that the Women’s Health Initiative said you were going to get if you went on Premarin. And by the way, they gave these women the hormones 10 years post menopause, not even at the greatest time of intervention, which is right on the cusp, it’s in perimenopause is when I encourage people to start bringing in hormones as per their tests. 

The study designed was so flawed and only in 2018 and 2022 did the North American Menopause Society reverse its position or came out with two position papers saying, “Hey, you know what? We looked at that data. It was a very poorly designed study. Hormones are, in fact, beneficial. They can be used for the long term, at minimum, 10 years.” By the way, I have women in their 70s who I’m treating who have been on hormones for 20 plus years and are like, “I am never going off. I feel awesome.” So, yes, I believe as more and more research comes out, the safety and efficacy will be there. Whether or not medical schools change their tune and the curriculum, that remains to be seen, because Big Pharma is also a part of this. Doctors can generate a lot more income for pharmacological companies, drug companies giving IUDs, giving the pills. No one’s making money off bioidentical hormone therapy. So, there’re so many systemic problems. 

This has happened to me even in my doctor’s office, which is so ironic, I came home and said to my husband, I could have written the conversation that happened in the office today. And it wasn’t my usual GYN. It was a covering physician. I went in with ruptured cysts, which is freaking painful. It was like labor pains. They were like, “Well, you can go on the IUD or the pill or just have a hysterectomy.” I was like, “No, no, and no. What else you got?” They were like, “Oh, yeah, you could take Advil for 10 days a month.” I was like, “No.” My acupuncturist was like, just use some castor oil topically in your pelvic region and I’ve never had a cramp since. 

So, it’s like, women are still being gaslit to this day. That is why I wrote See ya later, Ovulator! because I was like, we can either sit and wait another 100 years before the curriculum changes, or we can just say, “All right, I’m going rogue. I am going to figure this out for myself.” I put in the book like, “Here are all the tests you need to ask for. Here’s all the research studies you can show your doctor on the benefits and safety and efficacy of hormones, and here’s how to advocate for yourself. And good luck to all of you. I’m here for you to try and help you find a physician in your area or tell you what diet to follow and tell you the test to ask for.”

Man, but it’s brutal. The other piece is that hormones are not, no one is telling women that you can get hormones covered under insurance. Like, you can get bioidentical hormone replacement therapy covered under insurance. Like, I can get a bottle of progesterone for a month for $3. It doesn’t have to be prohibitive. So, the testing and if you work with a good functional medicine doctor or GYN or NP or ND, then yes, you may pay upfront, but I guarantee you’re going to save yourself time, heartache, and frustration doing it. 

Cynthia Thurlow: I love that because the Women’s Health Initiative is something that the listeners are definitely familiarized with, because I talk about it with nearly most of our guests that have an appropriate background to be able to speak to that. So, yes, I feel like when I was a baby nurse practitioner, when I was first practicing, I went directly into cardiology, but I was still exposed to women that were taking hormones, and all of a sudden their hormones were removed. So, I was finishing around 2001. That’s really when things really shifted catastrophically for so many women. How many of my patients would cry. They would say, “I felt so much better when I was taking estrogen and progesterone. Now my physician, my NP, and my PA are afraid to prescribe this for me.” I do know that there were many that were still prescribing despite the WHI.

But I think on a lot of different levels, it’s very reassuring to know that more and more healthcare practitioners are speaking up and speaking out against it. I love that NAMS actually came out and reversed their position. For people that are not familiar, it’s North American Menopause Society. It’s a good resource if you’re looking for a practitioner in your area that more than likely will be very well versed in the research and likely will allow for additional opportunities for you to navigate perimenopause and menopause. Now, I think for a lot of different individuals, the concept of perimenopause seems so intangible. 

I think we’re still thinking, we’re so young in our 30s. Yet that’s when these things start to shift, really, menopause is the 10 to 15 years preceding menopause. Average age of menopause in the United States is 51, 52. So, if you’re in your late 30s and this is when I had babies and toddlers, and so I was just so tired all the time. I had no idea, even as a clinician, I had no idea this is what was going on behind the surface. So, for people that are listening that are in late 30s, early 40s, what are some of the common symptoms your patients will start talking to you about or maybe they’ll lean into working with you because they’re trying to figure out what’s going on with their bodies? 

Esther Blum: Well, the first thing most women notice is that their periods, like the PMS time window tends to get longer and longer. So, your luteal phase may still only be two weeks, but instead of maybe two days of PMS or one day, you’re feeling like five days, seven days. For me, it was always like 10 days out. I knew, I was like, “Oh, the storm is coming.” You start to get less restorative sleep, poor quality sleep, more fatigue, more irritability, breast tenderness, more tearfulness. Also, vaginal dryness can start rearing its head at that point, lower libido, brain fog. I always get the dropsies [unintelligible [00:16:33] just– low progesterone affects your vasomotor skills. There’re so many things, some women are spotting, cramping ahead of time, and also the flow changes. You can start to notice that your flow may get much lighter, but for a lot more women, I see much more heavy, intense periods, a lot more clotting. It’s like they feel like they can’t leave the house. That’s also another sign of lowering progesterone and relative estrogen dominance.

Cynthia Thurlow: Yeah, it’s interesting. I used to pray that I would not start my cycle when I was rounding because there was no amount of tampons and pads that could save me. There were more often than not, very sympathetic nurses. Like, I would walk up to the nurse’s station and say, I need supplies stat and they understood. Anyone that’s been a middle-aged woman that’s had those, I affectionately refer to them as crime scene periods, understands that you don’t have the ability to go very long in between needing to use the restroom, change out a tampon and/or a pad as a backup because your menstrual cycles are so heavy. And so, for me, that was the first glimpse into something was shifting pretty significantly. 

I recall and I love sharing this story, I was seeing my GYN, I was telling her it was my yearly exam. I was telling her I’m having really heavy cycles. I happened to start that morning and she went to do a physical exam and the first thing she said was, “Oh my God, you weren’t kidding.” And this is the GYN saying this. I was like, “Did you think I was kidding.” The typical repertoire, how many women listening have been offered oral contraceptives, an IUD, an ablation, or let’s just remove everything because you’re beyond the age that you want to have children, let’s just do a hysterectomy. I said no to all of the above. 

Esther Blum: Yes. A lot of doctors will say, “Well, your life will just be easier,” but they’re not acknowledging the fact. Yes, okay, you won’t have monthly cycles anymore. But they don’t mention the fact that your body is literally going to go into menopause overnight and have great potential for osteoporosis, risk of heart disease down the line, risk of Alzheimer’s down the line. No one is replenishing what needs to be done. I like you, Cynthia, I do hear like, “Well, I’m just going to do it naturally and this is the way God intended.” 

But to me, why not use the science? Why not use the research? If you go look at a memory care unit, it’s almost all women and Alzheimer’s and dementia takes a good 20 years before the symptoms really have taken over your life. Well, what happens 20 years before is menopause. So, I don’t know about you. I really want to make it my mission to empty out memory care units and not have this be inevitable. Like when they say, “Well, family history of dementia and Alzheimer’s,” that doesn’t mean that you can’t override genetics. Genetics are a much smaller puzzle than we think. It’s to me, I’m like, “Let’s work aggressively on this.”

And the other piece that women are not talking about are changes to the vaginal canal and the pelvic floor because when you go into menopause and you’re losing vaginal estrogen, you’re losing estrogen systemically. So, vaginally, the vaginal canal thins out, you lose collagen and elastin, you lose hydration. So, the tissues get papery thin and very painful, like sex can be painful. You get micro cuts in there. That may not be the technical term. Also, you’re much more prone to UTIs and atrophy because the pH has changed. So, vaginal estrogen, I did a post on the importance of vaginal estrogen, I love the work of Dr. Rachel Rubin, every woman past 45 should be on vaginal estrogen. If you’re symptomatic or not because A, it’s incredibly safe. It’s a microdose, it stays localized. The Nurses’ Health Study showed 18 years of research on vaginal estrogen, there’s absolutely no increased rates of cancer from that. Imagine like you can prevent the collapse of your vaginal walls, save yourself from time and years of pelvic floor therapy and uncomfortable UTIs. People say, “Well, I’m not having any symptoms now.” I’m like, “Wait 10 years. You will be and you will be incontinent if you’re older or you could be.” I want to offset that too. 

Cynthia Thurlow: I think it’s really important and kind of backing up to the statement about looking at memory care units, seeing the rate and the prevalence of women in those centers and understanding that our brains in our 60s, 70s and beyond are made in our 40s and 50s. This is when you start looking at women who maybe weren’t insulin resistant in their 20s and 30s suddenly with these changes in estrogen and the loss of muscle tissue, they lose this degree of metabolic flexibility. If you’re still eating in your 40s and 50s, like you did in your teens, 20s and 30s, you’re definitely going to set yourself up for some metabolic health issues. 

And I love Dr. Lisa Mosconi’s work. She’s a Cornell researcher. She’s looking at postmortem brains. She’s looking at brain tissue especially in women. We really are starting to fully understand and appreciate why these changes in our brains and our bodies are systemic. It’s not just localized. It’s not just our vagina, it’s not just our skin. It’s not just these exterior structures that we tend to think about as being a reflection of aging. It’s so much more profound than that.

I love that you talked about, you call it the vagician [Esther laughs] in the book talking about vaginal health, because a lot of people are uncomfortable having these conversations. But how many of my patients years ago were on chronic antibiotics because no sooner had they finished a course of antibiotic therapy, they had another urinary tract infection. And in little frail elderly people, they can get septic, like, they can actually get we call it urosepsis but it’s very common to see a urinary tract infection go on to become a systemic infection, and then people are hospitalized with more antibiotics. So, really understanding that helping to maintain the pH of the vaginal microbiome, helping maintain those tissues, as you mentioned as we’re losing estrogen, it changes the pH, the lactobacilli, which are these kind of happy beneficial bacteria in the vaginal, they die off. 

And so, I think for a lot of people understanding that maybe the first step in early perimenopause into later perimenopause and menopause is maybe you’re taking some oral progesterone, maybe you’re using some vaginal estrogen. And I think they’re both so benign. I jokingly say, “Till the day I die, I will take progesterone,” because it has made such a big difference in my sleep, such a substantial difference. But again, such a good point about how if you don’t use it, you lose it. So, if you’re not having sex regularly, your vaginal canal can actually agglutinate. So, Dr. Tabatha Barber talked about this and she was saying, like in some of her elderly patients, she would, very gingerly, put a speculum in and it would just tear because the vaginal canal had actually stuck together because of lack of use and these physiologic changes that had gone on.

I remember years ago, I had a wonderful relationship with my great aunt and my grandmother and my grandmother and my great aunt were widowed in their 70s and of course, being naïve. I was in my 20s. I was like, “Are you going to date?” They looked at me like I was crazy. They were like, “That ship has sailed. There is no chance of that.” And now I kind of understand they were part of that generation that didn’t get hormones, that wasn’t even on the table and yet I think when we’re looking and talking to women, it’s being really honest about you may not see these changes right away, but over time we know the net impact of this loss of sex hormones is significant and profound. 

Now, one of the most common complaints I hear from women, and I’m sure you hear this as well, is cortisol belly or menopot. Let’s talk about why this happens. I know it’s the scourge and frustration of nearly every middle aged or older woman all of a sudden feeling like they used to have some semblance of waste, now their waste is gone and helping them understand the impact of andropause in addition to menopause. 

Esther Blum: Yeah, it’s such a combination of factors. Number one is, I notice that it’s a lot more sedentary of a lifestyle. We’re often at the peak of our careers. We paid our dues for so many years. A lot of women, their kids are out of the house, they’re going back to work. Or if we’ve been in the workforce all along, you’re really seeing careers take off. So, you’re at your desk more. I mean, what it’s like to write books. So, you’re definitely much more sedentary. Even if you’re standing a lot working, you could be standing in one place. So, sedentary, poor sleep with the decline in progesterone, definitely and estrogen, decline in both hormones can dramatically help sleep. Progesterone really is great at helping you fall asleep and estrogen really helps you stay asleep. 

There’s also with the decline in hormones and especially testosterone, you really do lose muscle mass if you’re not optimizing your protein intake and doing strength training and you don’t have to gain weight in menopause. I feel like a lot of women are like, “Oh my God, I’m expecting it. I see my waistline is thickening due to the change in hormones.” But you can actually stay lean and fit and muscular. There are studies done on people in their 90s doing strength training who are able to build muscle, so it is never too late at all, even if you have gained weight, I always say this is transitional. 

When we optimize insulin management and I love having women wear a continuous glucose monitor, so they really see that food is affecting them differently. When I was in my 20s, I was like the candy girl. I knew where every candy place was in New York City. Those bins of malt balls and gummy candies to this day candy is joy for me, but I know that it has to be a treat and cannot be every day. 

But in my 20s, I was also working out an hour and a half four times a week and walking. I was in the hospitals the first five years of my career and living in New York. I mean, I probably had 15,000 steps a day easily and lived in a six-floor walk-up. Like, I was getting my movement in, but I’m not getting my movement in now to that level. So, you really do need to dial in your diet. You can absolutely bring in some intermittent fasting. I know someone who wrote a great book on that actually. Her name is Cynthia Thurlow. [laughs] 

Cynthia Thurlow: Thank you. 

Esther Blum: You can absolutely change your diet, optimize your protein intake, make sure that your carb intake, like I always say, log your food for three days in any tracking app. If your protein is around 120, which is a really nice goal for a lot of women, your carbs should be around 100. You can even go lower carb. If you read my book, Cavewomen Don’t Get Fat, I teach you how to find your carb tolerance by clearing them out for two weeks just getting your carbs and veggies and a little fruit, and then slowly add in cooked starch after that and kind of see where your sugars and your body comp are. 

But also, when you do have starch, cooked starch, like a sweet potato or legumes or quinoa, have it at night. That’s with your dinner. That’s when you’re the most insulin sensitive. So, if you do high protein in the morning and at lunch, you’re going to have really great sustained energy all day. Your cravings are going to fall to the wayside. And then you have carbs at night to help bump up your insulin a little bit and tamp down your cortisol at night, the fourth piece is, when sleep falls by the wayside it becomes this vicious cycle. The high cortisol can keep you awake and then your insulin sensitivity is disrupted and you can gain a lot of weight. 

The other antidote to that is walking and rest based exercise. Walking and strength training two to three times a week, lifting as heavy as you can without injury and walking really lowers cortisol. This may not be the time to ramp up your high intensity cardio and a lot of people say, “But I have a peloton.” I’m like, “Just do the strength classes and go outside and walk.” You may want to just step back from the spin or do gentle rides if you really love to bike, just like those alone can do wonders for your physique. 

Cynthia Thurlow: Yeah, and I think it’s really helpful for women to hear this from multiple different clinicians and experts that have been on that the days of doing and I’m sorry, I’m going to. pick on Orangetheory Fitness. How many of my patients want to do that six days a week and they wonder why they’re weight loss resistant, because they’re over exercising, over fasting. Yes, I’m going to start talking about this more and more on the podcast and their over restriction of food.

And I think that– Certainly I’m not perfect, I think I did that in my early 40s. I didn’t understand that’s what I was doing. I was just exercising as intensely as I had been for a long period of time. But some of these things we have to back off. It’s more about being kinder to ourselves. We’re a little less stress resilient. That’s necessarily a bad thing. I like Zone 2 training, I love strength training, I do a lot of walking. I’m in a very hilly part of Central Virginia. And so, it’s great. I get outside in about 2 miles in the morning with the dogs unless it’s raining. I do like to remind women that really thinking strategically about your sleep when you wake up in the morning. So, getting that sunlight exposure on your retinas, it’s interesting. 

When I was at an event with Ben Greenfield a few years ago, he was talking about how he saves all his carbs for nighttime. I was like, “Okay, I want to hear all about this, tell me all about this because I generally will say to my female patients, we know we’re more insulin sensitive earlier in the day, so eat those carbs earlier.” But he was saying to me for him personally it really helps his sleep. 

I think a degree of experimentation and what Esther is not saying. Esther is not saying go have a plate of pasta. She’s probably referring to like if you’re going to have sweet potato or root vegetables or anything that’s aligned with that. And it’s not even copious amounts. There’s probably a measure like a certain amount. Is there a sweet spot for you when you’re working with your clients, like half a cup, a third a cup, depending on who they are. Is there a magic portion size? 

Esther Blum: Yeah, I mean, at least a cup at dinner. If they’re watching their carbs during the day, the average client I see it ends up being a cup of fruit in the morning and then a big salad. A cup of fruit with protein, obviously. So that could be in a shake, it could be cottage cheese, it could be smoked salmon and eggs and fruit, and they can have salad greens if they want with that. and then lunch is cooked or raw veggies and protein. Dinner I usually like a cup of like it could be a potato, a sweet potato. White rice, I actually have no problem with, as long as you’re pairing it with protein and high fiber vegetables and beans and legumes, you really will notice a big difference in your sleep. 

Believe me, I’ve tried so many low-carb diets. My carbs now are not crazy at all. But I’ve tried like really low and I noticed the first thing to go was my sleep and the second was mood. I was so irritable. You raise a really good point, Cynthia, which is– The other thing I want to say is most women I see are eating between 900 and 1250 calories a day. It’s hard to even meet your RDA, and the RDAs are low for nutrients. It’s hard to even meet your RDAs on 1250. And so, what we do is we diet them up. I have a strength coach who is part of my practice and a nutrition coach as well. We really do a lot of mindset work and slowly ramp them up on carbs.

What happens is that your T4 starts converting to T3, which is the active form of thyroid hormone. So, you’re actually upregulating your metabolism. Your body’s no longer in a fight or flight state. Your body is actually saying, “Ah, you’re feeding me now. I have energy. I can work out more effectively.” But at the same time, I’m actually going to build some lean muscle which will really support metabolism long term and offset the risk of fractures, falls and dementia and sensitize you to insulin again.

I try to get people to exercise more, eat more, and that I really try and get women at least up to 1500 to 1800 calories. If they’re very active and I do have clients who are very physically active, then we really can play. I don’t restrict their carbs so much. Sometimes those clients will have a couple of tablespoons of honey with some salt on it after a workout or honey on a rice cake or white rice with maple syrup. It really depends on how insulin sensitive you are and what your goals are. But carbs are antagonistic to cortisol. So, finding your sweet spot is key, making sure calorically you’re not deprived too long. It’s okay to cut calories for about two to three weeks, but after that you’ve got to really find other ways to optimize your metabolism because it will shut down.

Cynthia Thurlow: It’s interesting because one of the things I hear from women with these changes in estrogen in particular, they’re not as hungry. They’re not as hungry and they’ll say, “Oh, I opened up my feeding window and I had a big meal and then I wasn’t hungry for dinner.” I always tell them your body cannot sustain itself on 1000 calories a day. I don’t per se focus on calories. I was like calories do matter to an extent, however, I think it’s important for people to understand that a lot of women north of 40, when I look at their food recalls, they’re really not eating a lot of food. I don’t think it’s that they’re purposely trying to be restrictive. They’re not as hungry. Could that be the loss of muscle mass? certainly. Could it be that they’ve trained their body just to get by on survival mode?

So, really understanding, like I say to my husband, I definitely had a shift in my hunger levels in my early 40s, probably right around the time that I hit that perimenopause wall. And I said, but I always make sure I get a second good size bolus of protein even if I’m not starving, I’m not stuffing myself, but I remind myself it’s important for me to hit that 100 grams of protein threshold every day. If you’re not currently there that’s what you want to work towards. What are some of the changes that are going on physiologically in terms of how we manage and mitigate digesting our fat and our likelihood of the more commonality of finding women that will develop leaky gut as they’re getting older? Why is that happening? 

Esther Blum: Yeah, well, so let’s just address your fat question first and then we’ll go to the leaky gut. So, yeah, about 32% of menopausal women develop nonalcoholic fatty liver disease and they’re not digesting and breaking down their fat. And why is this? It’s due to insulin resistance that we get. So, managing your insulin is really, really important. And then in terms of changes to the gut wall, we have a microbiome, which is the trillions of healthy bacteria in our gut that regulate everything from gene expression to mood to digestive fire. Field of gastroenterology to me is they haven’t even touched, like all that is possible to know about it. But we also have a subset of that called the estrobolome and that helps our gut metabolize and detox estrogen in particular.

Estrogen can be detoxed in the liver, where it’s turned from a fat-soluble compound to a water-soluble compound, and then it goes through the gut, where it can either be reabsorbed and recycled, or it can be excreted through your stool, through your bowel movements. So, when your estrogen and your progesterone drop, it does change the integrity of the gut wall, it changes the estrobolome, and it impacts your ability to produce digestive fire. I also see a lot of, I would say 85% of my practice has H. pylori. I run the GI map and that causes all of this downstream dysregulation in producing hydrochloric acid, getting bacterial overgrowth, parasites. and pathogens. I see so much Giardia and E. coli as a result of H. pylori. I see a lot of Candida, I see methane-producing bacteria, methanogens, thank you.

For those of you listening who are like, “I am lost right now. My eyes are rolling back in my head.” I will say restoring digestive fire is very helpful. Killing off pathogens is helpful. Digestive enzymes like hydrochloric acid and bile acids, they act as a firewall. They do keep out, they prevent bacterial overgrowth. So, if you can work with a practitioner, I always say if you can get your hormones and your gut and your detox pathways checked, that is the ultimate, that’s the gold standard of healthcare and hormone optimization because let’s say you do have a fatty liver and your methylation is poor, you’re really not moving estrogen through your liver well, you’re not moving it through your gut, you got a lot of systemic inflammation, where do you start? 

Well, believe it or not if somebody has that many symptoms, we really work on diet, cleaning up the fatty liver first, and we also work on healing up the gut. I have seen more women resolve their hot flashes and menopausal symptoms from just fixing the gut than I have from just a straight hormone protocol alone. So, gut health, it’s imperative that those pieces are dialed in first. Like I always say, “The better your gut health, the better your transition through menopause will be.” Getting rid of chronic stealth infections can be so helpful because the other thing people don’t realize is we make our neurotransmitters in the gut wall in the small intestine.

So, if you have an inflamed gut, you’re going to have an inflamed brain. You could be depressed, you can be anxious, which you can also be with the decline in progesterone and estrogen, changes in cognitive function with low testosterone, you can have brain fog. So, just helping fix the gut clears up brain fog, gives you better energy, helps you make serotonin and dopamine so that alone is like pure gold and helps with sleep and inflammation. And then you can absolutely work on hormones supporting your detox pathways in your liver. 

So, it is a long game. None of this is an overnight fix. There’re all the pieces. Hormone alone won’t do it, diet alone won’t do it. exercise alone won’t do it. A lot of women say, “But I’m going to do yoga every day and that’s how I’m going to manage menopause.” I’m like, “No amount of yoga is going to have neuroprotective effects that hormones, diet and lifting will.” It’s just you’ve got to do all of it. I still am a huge believer of yoga. I love Pilates. I love so many forms of movement. There’s no one wrong way. But just make sure all the other pieces are dialed in to support you. So, it’s never one thing. We have high maintenance bodies now, ladies, so get used to it. 

Cynthia Thurlow: I think for so many individuals, they’re going from perimenopause and menopause, they get put on hormones and the foundational work has not been done. The sleep, the stress management. You mentioned gut health. I think about adrenopause. I think about thyroid health. I mean all these things that have to be addressed first in order to have great success. You’re right, you don’t go from 0 to 60. It’s a marathon. That’s really how you have to get the mindset in the reframe that this is not something that’s going to be fixed magically with one pill or one supplement or one test. 

Speaking of tests, I know you’ve mentioned the DUTCH and the GI MAP, which I’m a huge proponent of and use in my practice. If you were going to recommend five tests, like five tests that you want to look for that your provider is able to offer you, and especially if it’s a DUTCH, you need your provider to have looked at hundreds of these because it is probably one of the most nuanced, complicated tests I’ve ever worked with. And so, I tell people all the time, “You don’t want to go to the person who’s only looked at five because it really does take looking at hundreds and hundreds and hundreds that you see the patterns.” What would be like your five favorite tests or you think are the five most important tests women should be asking for with their healthcare provider? 

Esther Blum: Yeah, I mean, the DUTCH Complete and the GI-MAP with Zonulin, that’s going to look at your leaky gut, and the DUTCH Complete will look at your downstream. Let’s [unintelligible [00:42:41] come through each one-

Cynthia Thurlow: Sure, okay, yeah.

Esther Blum: -or just kind of give you the recommendations for you. Okay. Well, so the DUTCH Complete looks at your production of hormones, looks at how they move through your liver, all the downstream metabolites, and kind of the end product of your detoxification. But it also looks at your cortisol curve and your HPA axis. And that gives a window not only into your stress and sleep and blood sugar management, but also your thyroid function. If you’re on thyroid meds, we can kind of see how well they’re working, especially if your cortisol really peters out mid-afternoon.

And then I also like the Complete because it has an organic acids test, so I can check for nutrient deficiencies, check your melatonin production, see if you’re making your antioxidants the way you should. So, it’s a very nuanced test. It’s challenging to interpret each and every time. The GI-MAP with Zonulin, again, lets me check for parasites, pathogens, H. pylori, whether or not you’re digesting well, looks at the brush border enzymes in your GI tract. Tells me if you have a leaky gut. There’s an enzyme called beta-glucuronidase that can really– nice because the GI-MAP and the DUTCH speak to each other. If I look at the DUTCH and someone has poor methylation, usually I’ll say, “All right, let’s kind of compare that to the GI-MAP.” 

Usually, people with poor methylation often have a high beta-glucuronidase and things just aren’t moving as well as they should and getting cleared out and detox. So, again, it helps me formulate a plan of attack. It gives me a very specific roadmap of diet, supplements, lifestyle, and the best thing is people can’t argue with you when you’ve got the numbers in front and they’re like, “Well, I only drink three times a week.” I’m like, “But look at your bacterial overgrowth. Like, you’re exploding with funky gut bugs that you’re never going to heal if you don’t stop drinking. So, can we give a pause on alcohol? We’ll also fix a lot of your hormones with the DUTCH test and really support them.” And then it gives people a reason. 

If you just say, “Everyone should stop drinking in perimenopause,” no one is going to listen to you, not even me. Because I’m like the rest of you. I love alcohol. I really don’t drink it much. I’m very judicious, but because I know if I do, I’m going to screw up my gut, I’m going screw up my hormones. It took me a long time to feel really good, so I don’t want to lose that. Or if someone’s drinking a lot of caffeine and you’re like, “Look at your cortisol at 3 in the morning, what it’s doing.” You have to decide, are you going to, can you clean out coffee. I would say just give yourself a 30-day challenge, see how your sleep improves, see how your mood and irritability improves. It’s much easier to do that when you have hard tests and numbers to look at. 

And then, of course, I love fasting insulin and glucose A1c is helpful, vitamin D, and I do love inflammatory markers too. I too worked in cardiology units, so you’re officially my soul sister now. [Cynthia laughs] I love cardiology, so I always look at lipoprotein(a) and apolipoprotein B, and your homocysteine and your triglycerides and really see, like, “Hey, are you kind of heading down the fatty liver, heart attack risk route or can that be prevented?” So, I do much longer tests as well, but if you want to stick to the basics, it’s a GI-MAP, DUTCH, and really looking at your insulin and your blood sugar, that’s always like a great, great, great starting place. 

Cynthia Thurlow: Yeah, I couldn’t agree more. It’s interesting, I can get most of my patients’ labs drawn, but for whatever reason a fasting insulin spins so many traditionally trained providers, they don’t know what to do with it. I’m like, “Listen, it’s like a $12 test. It is not an expensive test. It’s not a functional medicine test.” Everyone listening should have a fasting insulin drawn a couple of times a year. It gives you a sense of whether or not you are on course or if you need to course correct. 

Now, I would be remiss if I didn’t address the one question I was asked multiple times when I mentioned to listeners that we’re connecting. How do you address constipation? I think a lot of women assume this is normal. Women will say, what does constipation mean to you because what we may think of constipation may be very different. I had a woman tell me recently, “I thought it was normal to poop twice a week,” her entire adult life that’s how infrequently she went. How do you like to address obviously, you’re doing testing and you’re doing a really thorough history, but what are some of your common ways you like to address constipation? 

Esther Blum: Yeah, well again, replenishing a lot of people I see just have low bacteria, low beneficial bacteria in the microbiome across the board. So, a third of the weight of your stool is actually dead bacteria that you’re sloughing off in the inside of your intestinal tract. How is that for disgusting, okay. But very healthy and normal. So, really replenishing levels of healthy bacteria, making sure you have enough digestive fire, hydrochloric acid is really important, especially above the age of 30. like, your production of digestive enzymes decline. 

Chewing your food is actually really important. Digestion begins in the mouth, not in the stomach. Your stomach doesn’t have teeth, but your mouth does. Hydration, adding electrolytes, I love for people to drink celery juice. It really heals constipation. I get a lot of flak for it. I’m just telling you, there’s not much science on it. The medical medium started a whole trend on it, but it really does flush the liver and gallbladder. First thing in the morning empty stomach, I think it’s just so hydrating too or water with lemon is really, really beneficial too. 

And then, of course, fiber like most people are getting 5 grams of fiber a day. I like people to get a minimum of 20 grams of fiber. Yes, you can take a fiber powder if you want to or pills, but just eat some fresh fruit and vegetables at every meal. Two cups of veggies at every meal would be really, really nice. And then movement, walking, doing twists and yoga really also helps. It’s like a gentle massage. For more severe cases of constipation, because I have had people with torturous colons and really severe cases. Then you’ve got to get into serious toilet hygiene.

Get a squatty potty or some kind of step stool that’s going to elevate your feet and help position you to help bowel movements pass easily. If you have a weak pelvic floor, you’re going to also want to strengthen that because that can also be a very overlooked piece of constipation. Sitting on the toilet the same time every day, like, guys are so good at this, and women were like, “I just want to drop and run. Let me poop as quickly as possible. I don’t want to stay and breathe and relax and read.” But you kind of have to put yourself on the toilet the same time every day for at least 10 minutes even if nothing happens, you do need to train your nervous system and this can take up to a year to do. 

Nutritionally, certainly like magnesium at night. I love magnesium glycinate. It’s really easily absorbed, high-dose vitamin C at least 3 grams a day, 400 milligrams of mag glycinate twice a day. That is very helpful. But for some people, I’ve had them use peptides like a BPC-157. And again, that’s really costly, so I really try and last resort it. Also, you can do like if you look online, you can go to YouTube, you can do a massage lying on your back that starts from your ascending colon, which is kind of like putting my fingers on it.

It’s like inward from your right hip bone about what 4, 5 inches and then you go straight up and across your abs below your belly button, all the way across and down your left side 3, 4 inches from your left hip. Many, many different things, but often it’s flour products. Flour and water make paste. Flour products is very constipating. Getting on a whole foods diet, hydrating, usually most people, I mean, that alone is phenomenal at getting people to poop every day. It’s really very easily treatable. 

Cynthia Thurlow: Yeah, and I love that. Nearly everything you’re talking about are common sense things. Maybe someone wasn’t familiarized with vitamin C, but a lot of these other products, how they can help with bowel tolerance and get things moving. I want to end our conversation today talking about something you mentioned in your book, which when I read it, I was like, “Wow.” We’re talking about in the context of women who were dealing with weight loss resistance, understanding the impact of alcohol. You mentioned if you drink and take HRT, you will raise your levels of circulating estrogen for four to six hours after each cocktail.

So how many of us go out and it’s party, it’s celebration, you have two or three cocktails and you wonder why you feel terrible the next day. It’s a multiplicity of things. But this in particular, for me, I actually don’t drink because it was the only thing that gave me hot flashes, which is why I don’t drink. I’m a reasonable human being, but I find for a lot of women in perimenopause and menopause, their relationship with alcohol needs to change maybe a little less. Maybe they’re having organic wine, maybe they’re having clear spirits as opposed to darker spirits. Explain this for us because when I read this, I was like, “Oh, my gosh this makes so much sense.” So, alcohol consumption and HRT leads to elevated circulating estrogen for hours afterwards.

Esther Blum: Yeah, I know and believe me, ladies, I feel, like, you’re talking to a girl who wrote a book called Eat Drink and be Gorgeous, with an entire chapter dedicated to hangover recovery. So, like, I am the OG party girl. Yes, on my birthday and our anniversary, I do have a good martini. I just love it. But what happens is this. Our detox pathway slows down, our bile production slows down and bile really is great at capturing. It’s like a magnet for toxins and it really helps bind and pull them out. And alcohol is a toxin. We forget that it’s actually poison we put in our system. So, your liver has the job. Let’s say you go out, you have two cocktails, you have a nice dinner, you get home, you go to bed midnight, you finish drinking at midnight. It’s going to take your body hours to start detoxing. 

So, around 3 in the morning, your body is going to be like, “All right, I think it’s time for this to get out of my system. Let’s just move this shit along.” So, it says, “All right, I can either spend my time detoxing estrogen, which I normally will do, my liver will do that as I rest or I can detox alcohol. So, I’m going to detox alcohol because it’s actually a poison and estrogen is not.” Alcohol gets priority in the pecking order of detoxification. And so, your estrogen is just waiting. It’s like, “Yeah, I can’t go through the liver yet. No, there’s like a long line of alcohol moving through first. It has to sit and wait its turn and then it can move through. Alcohol also disrupts REM sleep, so you don’t get as good of a night’s rest, feel sluggish. You’re definitely still detoxing the next day, especially if you went to bed later than usual and alcohol also lowers your inhibition. So, that’s when you’re going to want the candy or the dessert. 

I always say choose alcohol or a dessert. Do not have both especially if you’re trying to not disrupt your weight loss goals. Like, alcohol is not a fat, it’s not a sugar. So, carbs have 4 calories per gram and fat has 9 calories a gram, alcohol 7. And it’s not a fat, but it’s metabolized as one in your liver. So, if you’re going to drink do the least amount of harm. A, always have food in your stomach, not on an empty stomach, but B, use that as your carb for the dinner, your starch. So, you can have steak and asparagus and a glass of red wine, and you shouldn’t be too puffed up the next day. But alcohol can also take about four days to really puff up. That Saturday night cocktail really doesn’t show up. The full bloat doesn’t go into effect until about Tuesday, and then by the time you get the bloat off on Saturday, you’re having the next glass of wine. So, it does derail fat loss goals. 

If you’re someone who wants to maintain your weight, okay, and your gut is in decent shape, you could probably get away with a drink a week. But if you’re someone who’s really trying to lose fat and optimize your insulin and also feel good on your HRT, then, yeah, you’re going to want to really re-examine your relationship. So, people say, “All right, well, what am I going to do at parties because it’s so weird if I’m just saying they’re not drinking.” 

So, A, as long as you have a drink in your hand, to me, that’s like just a prop. It’s a social engagement prop. Number two, there are all sorts of amazing alcohol-free alternatives that are also sugar free. There’s one I love called Rock Grace. It comes in a wine bottle. It’s rose water infused with some ashwagandha and it has charged crystals. It’s been infused with charged crystals. You can find many alcohol-free cocktails. Mocktails, I should say. You can bring your own, just do the old seltzer with lime. 

Instead of thinking, “I can’t drink, just think I don’t drink.” It’s okay. It’s okay to unzip and shed that layer and detach from it. If you’re using it to unwind as your stress, bring in adaptogenic herbs. There’re so many amazing tinctures on the market you can look up. There’s Wile Women, W-I-L-E, and they have one called Un-Anger and Un-Worry. Those tinctures, put them in your water at night to kind of unwind from the day. Or my favorite, which I’ve done for years now, is meditation.

Some people love meditation in the morning. I love it at night because it totally relaxes your nervous system, helps you with your stress management, helps you just exhale, inhale the gratitude, exhale the bullshit. Just clear your mind for the day, and it puts you in a better place. You’ll be more grounded. I’m definitely more creative and productive with less alcohol in my system. And you’ll be a lot more stable. Like, your moods will be stable. You won’t be so irritable. So, all those things help. 

Cynthia Thurlow: Thank you, No, those are some great suggestions. Esther, let listeners know how to grab your book, which I loved. See ya later, Ovulator! Very tongue in cheek. Love it. 

Esther Blum: Yes, absolutely. You can grab See ya later, Ovulator! on my website @estherblum.com. It’s on Amazon. Follow me @gorgeousesther. You can get my free Happy Hormone Cocktail, which is a nice, simple ebook @estherblum.com/cocktail. You’ll get on my mailing list and get weekly love letters from me all about going into depth on a lot of the subjects we talked about today, because to me, knowledge is power, and we’re all in this community together, and we don’t have to go through this alone at all. 

Cynthia Thurlow: Absolutely not. It’s been such a pleasure connecting with you. And as I said, thank you for the work that you’re doing to help educate women and inspire them to take control of their lives and not be a passive conduit to middle age. 

Esther Blum: Right back at ya.

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