Ep. 362 Optimizing Health: Strategies for Menopause Well-Being with Dr. Suzanne Gilberg-Lenz

I am thrilled to connect with Dr. Suzanne Gilberg-Lenz today.

Dr. Gilberg-Lenz is involved in women’s empowerment and public education, appearing frequently to share her expertise in women’s health and integrative medicine. She received her medical degree from the USC School of Medicine and did her residency training in obstetrics and gynecology at UCLA Cedars Sinai Medical Center. She is the author of The Menopause Bootcamp. 

In our discussion, we dive into paradigm shifts and identity differentiation in middle age, debunking the common misconception that our worth ties into our physical attractiveness or the ability to have children. We talk about ageism and the impact of misogyny on sexual education and healthcare, exploring precursors to disease risk in menopause, pelvic floor advocacy, bone and muscle changes in menopause, and the effects of disordered eating on mental health. We also touch on brain remodeling, the three Ps, and how cycle changes can impact our ability to interact with our environment and affect our relationships. 

I am excited for you to listen to this insightful conversation, which is the first of two discussions with Dr. Gilberg-Lenz.

“There are estrogen receptors in every single tissue in your body, which is why we have such a wide array of symptoms in perimenopause and menopause.”

– Dr. Gilberg-Lenz

IN THIS EPISODE YOU WILL LEARN:

• How women get pressured to conform to societal standards 
• Sexual health education is so important
• Why we need policy changes to address gender-related health disparities
• How our past medical history is essential for predicting our future health outcomes
• The importance of pelvic floor health for women
• The benefits of vaginal estrogen and energy-based devices during menopause 
• Why annual pap smears are essential for sexually active women over 40
• The musculoskeletal changes that occur in menopause
• How disordered eating patterns often get hidden, and how they can worsen with hormonal changes and mood disorders
• How the brain chemistry brain of women gets remodeled with puberty, pregnancy, and menopause

Bio: Dr. Suzanne Gilberg-Lenz

A Diplomat of the American College of Obstetrics and Gynecology, Suzanne Gilberg-Lenz, MD, received her medical degree in 1996 from the USC School of Medicine and completed her residency in obstetrics and gynecology at UCLA/Cedars-Sinai Medical Center. Dr. Gilberg-Lenz is involved in women’s empowerment and public education. She appears frequently as an expert in women’s health and integrative medicine in print, online, and on TV, where she is the Chief Medical Correspondent for the Drew Barrymore Show. She is the author of MENOPAUSE BOOTCAMP: Optimize Your Health, Empower Your Self, and Flourish as You Age (Harper Wave; October 11th) 

Connect with Cynthia Thurlow  

• Follow on Twitter
• Instagram
• LinkedIn
• Check out Cynthia’s website
• Submit your questions to support@cynthiathurlow.com

Connect with Dr. Suzanne Gilberg-Lenz

• On her website
• Dr. Gilberg-Lenz on Instagram
• The Menopause Bootcamp on Instagram
• Learn about Dr. Gilberg-Lenz’s Menopause Bootcamp

Transcript

Cynthia Thurlow: [00:00:02] 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.

[00:00:29] Today, I had the honor of connecting with the delightful Dr. Suzanne Gilberg-Lenz. She received her medical degree from USC School of Medicine and completed her residency in Obstetrics and Gynecology at UCLA Cedars Sinai Medical center. She’s involved in women’s empowerment and public education. She appears frequently as an expert in women’s health and integrative medicine. She is the author of the Menopause Bootcamp. 

Cynthia Thurlow: [00:00:56] Today, we spoke at great length about how we have paradigm shifts and identity differentiations in middle age and how our worth is not tied to our physical attractiveness or ability to bear children. The impact of ageism and misogyny as it relates to sexual education and education of our healthcare professionals. What are some of the precursors to identifying who is at greater risk for disease and menopause? The impact of pelvic floor advocacy, which includes things like incontinence, genitourinary symptoms of menopause, energy devices, chronic UTIs, and STDs, changes to bone and muscle in menopause, the impact of disordered relationships with food and mental health. And lastly, discussions around brain remodeling, the 3 P’s, and how cycle changes can impact our ability to interact in our environment and personal relationships. I know you will love this conversation as much as I did recording it. This is the first of two discussions with Dr Gilberg-Lenz.

[00:02:10] There was something that you wrote in the book that really struck me. It starts in the beginning. You said, “Our worth is not tied to our physical attractiveness or ability to bear children. Despite the messages women receive on social media, in the movies, in books.” Let’s really start the conversation there, because I think for so many women, there’s so much shame around the aging process. There’s certainly a ton of shame just talking about this loss of fertility, which is a natural evolution of aging. It’s not something to be ashamed of. But I feel like this speaks to so many of us. There are so many people who still have a desire to feel as young as they look. 

Dr. Suzanne Gilberg-Lenz: [00:02:52] Mm-hmm.

Cynthia Thurlow: [00:02:52] I think for many people there’s so much tied up into our physical appearance and in many ways, as we navigate into menopause, it’s like having less estrogen makes us be less people pleasers. It allows us to feel more comfortable articulating our opinions and not feeling like we have to subjugate our needs. And so, over the course of your 25 plus years as a clinician, as a woman who has been through many stages throughout her life, how does this show up for your patients as you’re speaking to women about this normal evolution of aging?

Dr. Suzanne Gilberg-Lenz: [00:03:28] Well. I mean, that’s an amazing question I love that you’re leading with that, because I think a lot of times, the more I do this work, Cynthia, the more I sort of see that my role in this community, in this conversation, is this. Sure, I’m a physician, so I understand the science, the practice of medicine, I’m a longtime clinician. I’m seeing people on a daily basis, which I think feeds into my perspective more. Because I will answer your question. I’m getting feedback all the time from people walking through the door and it also helps me to reflect on my own experience. But I really feel that my role in this conversation has been more honestly about the narrative, about the paradigm shift, about the more high-level thinking. 

[00:04:13] My framework is really much bigger and more philosophical or even spiritual, to be perfectly honest, which I think if you read my book, that doesn’t surprise you, because my background is a little bit different. So, I think it’s sort of been an unfolding of my own experience, personally. And I think that the gray hair story that I tell in the book is really. it epitomizes that. It was the message that we get. “Okay, so I colored my hair, sure, for my own personal reasons, but really, why does a person color their hair?” Which, if you want to color your hair, I really. I don’t care what you do. Like, I want you to do what you want to do. But I started coloring my hair because I was quite young, going gray. Now, that right there says a lot. You’re not supposed to be gray when you’re young whatever. It’s hair.

[laughter]

[00:04:57] But it says something and I understand we’re presenting. People are visual. We have become as a society and the culture, a lot more visual than we ever were. Look at all of our communication. This communication, you and I are doing a podcast. It will also be on video somewhere, YouTube, I don’t know, wherever you broadcast it. We are visual beings, and our media of communication is highly visual. So I understand, I’m not here to say that that’s not a thing, but when worth and value gets tied to the visual presentation, and the visual presentation is not just an expression of self, a creative endeavor, whatever it is, it becomes confused and confusing. And I think the messaging, and this isn’t anything new, the messaging for women in general has been, look a certain way, sound a certain way, be a certain way, is very much tied to sexuality. Not being too sexual, not being sexual enough, sexuality, being divorced from reproduction. But actually, the most important thing about you is that you can reproduce, “Oh, but you can’t reproduce. Who are you?” Oh, no, you wanted to reproduce. You didn’t reproduce. You did reproduce. You stopped. It’s overwhelming. And this is like the constant talk that’s underneath every single thing that we are doing. It’s about identity.

[00:06:17] When people start shifting their experience on a chemical, biological level, which is what the hormone shifting is doing, they don’t recognize who they are. And I hear this all the time. I can’t tell you how many times this week I had a patient come back after starting hormone therapy and tell me, literally, the opening quote was, “I feel like myself again.” That’s enormous. So, some of this is, as you mentioned, the natural, physiologic, developmental event, which is menopause. It is an expected experience. It’s not a disease. If you spend, let’s say, from 12 to 50, 40 years of your life, which is the majority of your life in reproductive cycles, that’s who you feel like you are. It’s who you are for a lot of your life. It’s not everything you are. So, some of it’s also coming in from inside the house. So when that starts to shift, and my belief personally, is that part of the big issue with perimenopause is that because we identify with our hormonal variations in a predictable way, when it becomes unpredictable, of course it’s uncomfortable, literally, “Who am I?”

[00:07:30] Okay, if we can educate women that this is actually going to be a challenge and we are going to help you get through it, these are the tools in the toolkit. You’re going to reach for this tool this time, that tool the other time. Everybody doesn’t have the same tools. That will make it less difficult. But the messaging is still, but you’re supposed to be that person for that 40-year period forever. But that’s not true. And actually, who you are is evolving in all ways. So, your hormones are evolving. I mean, now we have the really brilliant and extremely impactful brain research work of people like Dr. Lisa Moscone explaining to us that our brain is being remodeled yet again. It’s a renovation. It’s an upgrade for a purpose. You and I were just talking right about renovation. I’m actually renovating a home too, like much like childbirth and pregnancy. Uncomfortable, not fun. Does anybody actually like that process? I mean, I guess if you’re a designer and you’re using someone else’s money and you don’t live there, [Cynthia laughs] it’s probably fun and interesting, but when it’s your place, it’s rough. But then you get the finished product. You did it for a reason. You tore up your kitchen for a reason. 

Cynthia Thurlow: [00:08:33] And I think that’s such a beautiful way of explaining that process of the peak fertile years and then there’s this time in between, and then there’s the menopausal period. And for me, so many other people, nothing prepared me for perimenopause. And I always say very humbly, I went to a big research hospital. I think there was probably a paragraph about menopause and I was like, “Oh, that’s so many years away. I’m not even thinking about that. And you bring up in the book the lack of education even in our healthcare providers. 

Dr. Suzanne Gilberg-Lenz: [00:09:06] Yeah, yeah.

Cynthia Thurlow: [00:09:07] And I think this is so significant because if our healthcare providers aren’t aware, how are they going to prepare their patients? And the other piece that goes along with that, my mom is still of that generation where you don’t talk about menstruation or very little, but sure as heck don’t talk about menopause. I think my mother denied she was in menopause until she was 60. She wouldn’t even talk about it. 

Dr. Suzanne Gilberg-Lenz: [00:09:31] [chuckles] Yeah, yeah. 

Cynthia Thurlow: [00:09:31] And so, I think there’s this contributing factors. You have the clinician piece and the lack of education about it. And then there’s also this shame secrecy generationally that I think just exacerbates. Like, I recall having a conversation with my mom and my mom said, “Oh, I think I was 60.” I was like, “Mom, there’s no way you were 60 when you stopped menstruating.” Like, “I don’t believe that.” If that’s what you’re holding on to. And she said, “Cynthia, you have to understand, my mother didn’t talk about it. I didn’t talk about it. Your generation loves to talk about it. And I think that’s great.” But I think for so many people, finding good information, good resources, opening up those opportunities to start talking way before perimenopause. So, women are better prepared for this–

Dr. Suzanne Gilberg-Lenz: [00:10:19] But this should be part of just sexual health education in general. Like it really– and it’s hard, like, I’ve raised kids, so I understand. And I also have taken care of women of all ages for my entire career. So, I understand that like you said, it feels so far away, but I think at least just bringing it into the curriculum so that there’s like, “Oh, right. I remember reading something about that.’ Like, “This is going to happen. It’s not the end of the world. It’s like the beginning of the next phase.” And I think, going to accomplish that because I think our generation is talking about this so much now. And I will tell you that even since the book was written, since the book was published, it has changed so much. Like, if you would have come in to see me as a 40 something having some complaints now, I’m, like, educated and interested in this. And I would have said to you as a patient three years ago, let’s say, “It sounds like perimenopause.” I would say more than half of my patients would have been offended or shut down around it because it still was this internalized kind of ageism and misogyny that we have. Now the conversation, this is how rapidly this conversation has shifted. I have patients coming in their late 30s and early 40s wanting to get ahead of it. And this is in the space of 18 months. 

Cynthia Thurlow: [00:11:28] That’s incredible. 

Dr. Suzanne Gilberg-Lenz: [00:11:30] So it is really, really rapidly changing. And I think that the difference in the way millennials approach everything [laughs] is going to have an impact also, because they are very much about, like, “I want the research. I want to know; I want to be prepared. I want to hack it.” I’m not saying that Gen X doesn’t do that. Gen X, in my opinion, is responsible for this paradigm shift because we’re just like, “We’re done.” The way this is being done doesn’t work. Doesn’t work for me. It never has worked for me. I know people think that we complain, and that’s fine, I don’t care [Cynthia chuckles] because our complaining has been helpful. We’re trying to help you all. And we have taken the microphone [laughs] and we are speaking about it. So, we’re trying to catch up. And then I have boomers coming in who are really upset. They’re upset that they were denying this opportunity. It’s dawning on them, like, how they were misinformed. I’m really, like, generalizing here. So we’ve got a lot of things to do at once, but the conversation has shifted. These kinds of conversations that we are having amongst ourselves and that people like you who have a big platform, are broadcasting are having enormous, enormous far-reaching impacts that are very, very positive. 

[00:12:38] So, I think what you’ll see now is more inclusion in curriculum because, as you mentioned, we have a big problem. We have a big education gap, not just on the public side, but in the professional side. And look, I have a lot of compassion for my colleagues. Like, there’s only so many things a person can learn and get good at. But not talking about 50% of the population and 30% to 50% of their lives, it’s just it’s not acceptable. So, we’re going to have to find a better way to manage the enormous amount of information we’re trying to fit into a curriculum, create tracks of educational opportunities and experiences for practitioners to get really good at this because we are entering an age where people live longer and there’s a big population that’s over 50. So practically speaking, we have to do it. Here’s the other thing that I really want to point out, and it’s very interesting. So again, there’s all sorts of data about like maybe 15% or so of even OB-GYNs who are specializing in women’s health feel confident coming out of their specialty training dealing with menopause, which is appalling. And it’s very easy to point the finger. And I’m not a fan of pointing the finger. It’s like a fact, I think. I don’t have the stats on this, but the Menopause Society, which was formerly called the North American Menopause Society, has seen a huge uptick in interest and in training. They have a program to certify menopause practitioners, which is outstanding. 

[00:14:01] I think it’s conservative, whatever, it’s fine. Baseline, it’s really good. It’s very evidence based. There’s been a huge number of people now moving into that, and I don’t have the numbers, but lots more people doing it in the last two years that’s great. We’re putting more providers out there. Here’s the problem. We can have everybody trained in menopause care, and if they’re not getting paid, you’re not going to get access to care. So, you’re going to have a whole bunch of specialty menopause clinics that are super amazing and they’re cash only, or you’re going to have people dying on the vine in an academic setting, or insurance-based system. It’s a big problem. It’s a really, really big problem. And really what we need to do is not just the policy changes that we’re seeing. We’re seeing big push toward funding research into women’s health, but we need to see the payers understand the value of treating 50% of the population for 30 plus percent of their lives. I mean, the fact that I have to say that sentence is ridiculous. It’s just insane. Let’s say you don’t care about people. I’m not saying somebody does or doesn’t. [Cynthia chuckles] Let’s say you only care about money, not just saying that it’s a bad business move, makes no sense business wise. So, this is complex. 

Cynthia Thurlow: [00:15:15] This is absolutely complex. And I reflect back on many conversations that I’ve had on this podcast, and I recall the brilliant Avram Bluming and Carol Tavris [crosstalk] as a guest and Avram said, “Cynthia, if men had to put up with what women have put up with, this never would have occurred.” 

Dr. Suzanne Gilberg-Lenz: [00:15:35] Yeah.

Cynthia Thurlow: [00:15:35] He said, “When we look at the care that women have received, it never would have happened if men had been dealing with this issue as well.” Like, you think about women being called histrionic and you’re having a midlife crisis, and all this terminology and pejorative language that’s utilized to describe the trajectory in many ways of a woman’s lifetime, and I agree with you wholeheartedly nothing makes me more sad. And we get a lot of messages on social media. Women will say, “I went to see a menopause practitioner or practitioner who addresses middle-aged women’s concerns, and the only options they gave me were compounded options.” I’m sure we’ll probably touch on this. 

Dr. Suzanne Gilberg-Lenz: [00:16:14] Yeah. 

Cynthia Thurlow: [00:16:15] And my standard response is, there are lots of great generic, bioidentical options that you can get at your Kroger or your grocery store. And I talk about estrogen, estradiol patches and oral progesterone. And I said if they didn’t at least give you that option or at least ask you, like, “Here are your options.” And if you say, “I’m on, I need to be conscientious about how I spend money.” I don’t want to be spending a couple hundred dollars a month on hormone replacement therapy. And I get concerned when there’s this differentiation of, do you have enough money to afford to see these specialists? Whether it’s functional integrative medicine or are you stuck in a system in many ways where women in perimenopause sometimes are offered therapies that aren’t particularly attractive? 

Dr. Suzanne Gilberg-Lenz: [00:17:07] Mm-hmm.

Cynthia Thurlow: [00:17:08] I think about the woman like I was, you know crime scene periods. I didn’t understand enough at the time to really be able to advocate, other than I was not going back on oral contraceptives, but I was given the options of oral contraceptives and IUD and ablation, or we’ll just do a hysterectomy because you’re done having kids. And I remember just reflecting on, I know quite a bit, and these are the options I’m being given and not understanding even at that time, that women are trying so desperately to get solutions to problems. I don’t think women want to not be aware of what’s happening in their body. I think women want to be their own best advocates. I think in many instances, they just don’t know that they have options beyond what is available in a conventional model. And again, much like you, I don’t like to point fingers. That’s not my place to do so. But I think most women really do endeavor and desire to feel good, to not feel like they are not able to sleep, they can’t manage their stress, they don’t feel like they recognize their bodies anymore because so much has changed. And that’s why these conversations are so very vitally important. 

Dr. Suzanne Gilberg-Lenz: [00:18:14] Yeah. Vitally important is exactly the right term because I think the incredibly difficult path that authors like Avrum Bluming and Carol Tavris have been on because this is a doctor for your listeners who don’t know, who is a retired now cancer doctor, oncologist who has been looking at and producing data on treating breast cancer survivors in menopause for decades. And really, he’s having a huge influence. He’s having a moment finally in his 80s, [chuckles] so one of the things that he has noted, and you probably are aware of the big study that came out earlier this week. It is, when we say vital, we are not exaggerating because our long-term health depends on how we come into perimenopause, get through perimenopause and beyond. And it is not a one size fits all solution. But I think taking things– like not presenting the full menu of options is not good medicine. 

Cynthia Thurlow: [00:19:16] I think that on so many levels, and I can retrospectively say this now, like where I was 10 years ago, in terms of my awareness or lack thereof, because my whole background was in ER medicine and cardiology, I didn’t deal with a lot of menopausal, perimenopausal-related concerns other than patients–

Dr. Suzanne Gilberg-Lenz: [00:19:34] Except you did and you didn’t realize it. 

Cynthia Thurlow: [00:19:36] Right. And I look back now, and I can retrospectively say that’s the wild ride of perimenopause. Gosh, I wish I had known in my late 30s what was coming. I would have been better prepared. But I think that one of the things that I started to find so interesting is there are some prognostic indicators, things that are part of our younger woman history. You talk about how pregnancy is a stress test. I’m using this as one example. We’re not talking enough about this. So, if a woman has had preeclampsia or gestational diabetes or even recurrent pregnancy loss, that can be an indication that you are at greater risk for developing sequelae of, whether it’s coronary artery disease, cardiovascular disease, ultimately developing diabetes. We know that metabolic health is a really big issue right now. 

[00:20:34] When you’re talking to your patients and helping them build awareness around some of this past medical history. Let’s talk about this, because there’s probably women listening that are like, “Oh, I had gestational diabetes. I didn’t have diabetes after I delivered.” But understanding that women, I think it was a 50% greater likelihood of developing diabetes in their lifetime. That is significant. 

Dr. Suzanne Gilberg-Lenz: [00:20:56] Yeah. And it’s similar numbers with preeclampsia, so any hypertensive disorder in pregnancy, you’re at much higher risk for developing any of these metabolic disorders, which, of course, again, I want to just remind everybody, these are the number one killers of humans including women. So, heart disease far and away outstrips cancer deaths. But here’s the thing, instead of it being a scary stat, it’s an opportunity to empower you. I had gestational diabetes during my first pregnancy, I knew all long the irony here is that when I got breast cancer, I was like, “Oh, I can’t have breast cancer. I’m going to get diabetes.”

[laughter] 

Dr. Suzanne Gilberg-Lenz: [00:21:35] That was the way I thought about it. I was in my 40s. I shouldn’t have been getting any of it. But it happened. So really, my mind was like, “Wait, what? I’ve been prepping for diabetes.” [chuckles] 

Cynthia Thurlow: [00:21:46] This was not on the continuum. This is not what I expected. 

Dr. Suzanne Gilberg-Lenz: [00:21:50] This isn’t part of the plan. So I still, by the way, still have high risk for diabetes. But I think if people know that, then they can be preparing themselves, making sure they’re watching those numbers, making sure they’re watching their lifestyle. I mean some things are under our control, some things are not. One of the other, I’m sure you see this all the time. When our patients get into sort of just around that real, like, right at the transition point, all of a sudden, their blood sugar goes up, their cholesterol goes up, their blood pressure may go up, and all the time they’re like a gap. Like, “How can that be? I have literally changed nothing.” I know you haven’t. Your hormones changed. No one’s blaming you. I think the other thing we have to support and encourage our patients to remember a couple of things. Not everything is going to be under your control. You can do everything right and still have some shit go down. And it’s not a shield. Like, your thoughts are not a shield. Your habits are not a shield. They’re going to help you. They’re going to ease the way.

[00:22:50] And know that none of these diagnoses or changes to your health are an indictment. It’s a thing that’s happening. We’re going to reach into the toolkit again and recalibrate the program for you. It’s a very different mindset than the sort of prescription pill. “Okay, bye. You’re done.” And that includes for the patients coming in or the person coming in, going through something, expecting, like, “I’m going to lay on hands, I’m going to write them a script, and it’s got, have a great life. Bye.” No, sorry. You’re going to have to participate. We’re going to have to stay in touch. Things are going to change. This might work now. Maybe that doesn’t work in three months. Maybe it doesn’t work in three years. Your genitourinary syndrome and menopause is going to be a thing for the rest of your life. Every single week, they’re like, “Okay, so I do this for how long, [Cynthia laughs] vaginal estrogen. I’m like, “forever, forever.” Just like, you have to try to work on your sleep and you’re eating and your exercise forever. [laughs] 

Cynthia Thurlow: [00:23:46] Yes, yes. And I think that setting those expectations upfront and a lot of questions came in around the pelvic floor. And so, I’m glad we’re proactively talking about this. And for full disclosure, I recall when I was done breastfeeding my first son, my wonderful GYN looked at me and said, “Oh, you’re going to be one of those women that’s going to need vaginal estrogen when the time comes,” and I looked at it and I was like, “Huh?” And she said, “You’re going to be one of those women.” She said, “While you were breastfeeding, you were depleting all these estrogen stores in your body and you are absolutely going to be one of those people. And it’s true. If I miss one day of my vaginal estrogen, I can definitely tell a difference. So, let’s talk about the pelvic floor.- 

Dr. Suzanne Gilberg-Lenz: [00:24:30] Yeah.

Cynthia Thurlow: [00:24:31] -What is the function of the pelvic floor for most other westernized countries after they have babies? We were referred to pelvic floor specialists. So, women are aware of their pelvic floor, whereas I think a lot of women don’t even think about it until maybe they urinate on themselves or they do jumping jacks and they start having problems. And that’s probably why Depend’s has become this multi-billion-dollar industry.

Dr. Suzanne Gilberg-Lenz: [00:24:55] Right. And it gets normalized. Well, you’re just getting older, so just invest in more pads. 

Cynthia Thurlow: [00:25:00] Yes. Like, I think about my grandmother’s generation, both my grandmothers were nurses. And when my grandmother had retired, she said to me, “Oh, I had five vaginal deliveries. I have a rectocele, I have a cystocele.” When I looked at her, I said, “But she could have had that fixed.” And she said, “My generation doesn’t talk about it. We don’t complain. We just suffer in silence.” 

Dr. Suzanne Gilberg-Lenz: [00:25:22] Well, there’s a lot of data on that actually. So that generation for sure, it was a little more exaggerated, but there’s tons of data on, and it’s similar to the chronic pelvic pain, endometriosis, sexual function, all of these things that are like taboo subjects. There can be a six-to-eight-year lag between the patient starting to experience issues that are disruptive and anything getting done about it. Part of the issue is that patients often come into an encounter with their practitioner, expecting the practitioner to bring it up to them. That often doesn’t happen unless that practitioner happens to specialize in that or like just be really into it. And for a number of reasons, again, some of its training, a lot of it’s time. If you only have five minutes to do everything, you’re not going to bring things up that are going to take a long time to talk about. And this is an area where advocacy is really important. So, thank goodness we’re in an era when we’re talking about these things out loud. I think it’s okay to expect things, but if you don’t ask you shall not receive. 

[00:26:16] So make a list of your concerns. Your doctor, by the way, may not have time to do all of that at your annual visit, and you need to accept that as reality because she is trying to see the next patient, and also, she’s only getting paid so much. This is the reality of life. So call and say, “Look, I have a list of things I’d like to have a conversation. How can we do that?” Your doctor will make an appointment for that. We’re thrilled. So you come in prepared, you take the reins, you ask the questions. Having said that, what is the pelvic floor? And I mean, again, I really like for us to be able to move forward in our healthcare journey preventing issues. So thanks for bringing that up, because you’re right. And there’s a big conversation about this too. We have a lot. Even in the time that I’ve been in practice, Cynthia, the amount of referral sources that I have in pelvic floor physical health, I’m in Los Angeles, but in general I had, like, two people I could refer to who really were expert when I started, and I must have 20. And now we also have online platforms, like Origin. It’s really, really incredible. 

[00:27:17] So the pelvic floor, I always do this. The pelvic floor is just a sling of muscles that is literally holding up your entire body. So, it’s the bottom of your body, it’s coming through the urethra, the vagina and the rectum pass through these muscles. It’s not one muscle, it’s a bundle. They attach to the bony, what we call the bony pelvis. So, the pelvic floor muscles are a basket woven together, secured in the pelvic bones, and then coming into the middle, and like any other muscle, you need to be aware of them. You need to learn how to strengthen them. You need to learn how to relax them so that all those body functions work. Obviously, during a pregnancy, even if you don’t have a vaginal birth, the amount of pressure on those muscles is really, really big, and so it stretches those muscles out. And so again, if you don’t strengthen them, they’re not holding up the pelvic organs, the uterus, the bladder, the rectum into their correct positions and functioning can be disturbed. And that’s why you’ll get things like incontinence. And people don’t want to talk about this either. But people can have fecal incontinence. People have air in the vagina, they can have sexual dysfunction, all sorts of issues. And I think the thing with bladder leakage in general is that it’s not just, again, that it’s like, “Oh, ha-ha, that’s terrible or it’s gross or it’s funny.” 

[00:28:37] But urinary tract infections are going to increase for a number of reasons as we age. Loss of vaginal estrogen, loss of integrity of the tissue, increased pH, which changes the microbiome, which changes your susceptibility. The tissue plus the microbiome are going to change and increase your susceptibility to infections and inflammation and tissue damage and discomfort. Now, you add in the functional changes related to the musculature and where the organs are placed, and you definitely are increased risk for getting bladder infections, which are very, very serious the older we get. As we get older and we lose mobility, we’re not just losing urine, but we’re going to have damage to the skin in the area. We’re going to increase our risk for getting infections going up into the kidneys, sepsis, hospitalization. This is like a serious medical issue. And it can be treated with generic estradiol, which is so inexpensive. And my colleague Rachel Rubin, the urologist and sexual medicine doctor, she’s a fellow who did a quick study recently showing that a billion dollars a year would be saved to the medical system if we just treated women with vaginal estrogen, which let me just say, is safe for everybody. It’s not absorbed into your body; it’s not going to manage the other symptoms of perimenopause or menopause. It’s not going to treat your hot flashes or your brain fog or any of those other things, but it will treat the local tissue, both the genital and the urinary, which is why we now call this genitourinary syndrome of menopause. We don’t like to call it vaginal atrophy anymore. Names are names whatever. 

Cynthia Thurlow: [00:30:19] Or the senile vagina. That’s my favorite. 

Dr. Suzanne Gilberg-Lenz: [00:30:21] Well, it’s kind of like geriatric pregnancy. [Cynthia laughs] It’s like the geriatric pregnancy of midlife, senile vagina. I don’t even know what to say about that. It’s so silly.

Cynthia Thurlow: [00:30:31] Well, it’s one of those things you hear and it just makes you chuckle. You’re like, “Okay, let’s add insult to injury. Thank you very much.” 

Dr. Suzanne Gilberg-Lenz: [00:30:37] Exactly. Literally, literally. [laughs]  

Cynthia Thurlow: [00:30:40] Yes.

Dr. Suzanne Gilberg-Lenz: [00:30:41] Yeah. But this stuff is safe for everybody. You could have cancer, you could have a stroke, and you can use vaginal estrogen. I don’t think we can say this loud enough. Whatever your stance on naturally moving into phases of life, whatever your philosophy, please reconsider when it comes to vaginal estrogen.

Cynthia Thurlow: [00:31:00] Yeah. 

Dr. Suzanne Gilberg-Lenz: [00:31:01] I just don’t think there’s a human who has a vagina who shouldn’t be on it.

Cynthia Thurlow: [00:31:05] No, no. I mean, I don’t joke when I say that they’d have to pry it out of my cold dead hands. It is a nonnegotiable. But for me, ER nurse in inner city Baltimore, cardiology NP, how many of my patients were on chronic low-grade antibiotics because they had chronic UTIs? And I literally think now I cannot believe that these women, that we did not know enough to say, “Hey, by the way, you could do away with all this.” But how many patients I saw that were uroseptic, meaning they started with a UTI that evolved into sepsis, which means they had a systemic blood infection, many of whom were very sick in the ICU-

Dr. Suzanne Gilberg-Lenz: [00:31:48] Yeah, they could die from that. 

Cynthia Thurlow: [00:31:49] -powerful medications. To me, I think this is such an important message to make sure women understand that vaginal estrogen is not contraindicated. It’s interesting, I think the statistic in the book you mentioned was 70% of women and 93.3% experience vaginal dryness. So, for everyone who’s listening, eventually you will experience this. What I thought was interesting and I got a lot of questions around this was, “What are your thoughts on if you’re not using vaginal estrogen or you’re using vaginal estrogen concurrently with some of these devices. Everyone likes these devices, vFit some of these other ones. 

Dr. Suzanne Gilberg-Lenz: [00:32:25] Yeah, right.

Cynthia Thurlow: [00:32:25] What has been your experience? Are they helpful? Do you find that concurrently that they’re helpful to utilize?” And I say this, these are things that– these are personal devices. This is not, per se a laser that you go somewhere, and they are, I think the MonaLisas one of the ones that seems to be popularized the most by these centers. And when I say center, sometimes you see it’s at like a Medispa and not necessarily in a physician’s office or a license professional.

Dr. Suzanne Gilberg-Lenz: [00:32:52] As long as you brought that up let me say something about that. [Cynthia laughs] I think the energy-based devices are fantastic. MonaLisa is actually, as it turns out, really not the best for the vaginal dryness or the urinary symptoms. I mean, there’s interesting data on it for other things. The data is not compelling in any way, shape, or form, that it actually helps with long term or short term with vaginal dryness, but the principle that you would cause microdamage and then the body will heal, bring collagen, elastin back to the area, help regenerate the lining, specifically of the vaginal canal, which also has an impact on the urinary system just next door makes sense. And I think actually the radiofrequency devices and the radiofrequency devices with microneedling which penetrate a little deeper. Just so you guys know, it’s 3 mm where as opposed to like 300 microns. So I mean, for the non-science people, I think people know that 3 mm is pretty superficial, but they’re more powerful. And my experience clinically is that they do work really, really well. 

[00:33:52] Now, those have to be done by a medical professional. And you may see medical professionals out there who are not trained in this part of the body. I think if you’re going to go to an aesthetics place or dermatologist’s office or a retired ER doc, anesthesia, they love to start getting into hormones for some reason. That’s a no for me. If the person doesn’t have really, really a lot of experience with that part of the body. So basically, urology or gynecology or sexual medicine, I don’t think you should be seeing them. Now these are cash procedures. The handheld devices at home, “Eh, they’re okay.” The thing is the energy level that can be deployed in a non-medical device, like a medical device that has to be used by a practitioner. It’s just not that. I don’t think it’s that good. And there are like, there are the ones, the trainers, I think, I’m not going to names, but there are the ones that you can do at home that like train your pelvic floor contractions. And I think if you have mild discomfort or mild changes, they might be helpful. I’m not here to endorse or not endorse. 

[00:34:51] I know that the medical grade ones that we use, the Emsella chair, the VTone, which is part of InMode’s device, because we’re medical office and they are FDA-approved devices, we can use a much higher level of energy and they’re much safer and they are pretty effective and there’s pretty decent clinical data to support it. My experience has been that the people who use these in conjunction with other modalities. So, if you’re doing something that’s an energy-based device to work the muscles, but you haven’t done any pelvic floor physical therapy, it’s kind of like going to the gym, getting the most expensive trainer for that first month they offer it and then never going back. It’ll work temporarily, and then you won’t. You have to keep working those muscles. So, I think knowing the pelvic floor and how to use it with a physical therapist is far more effective. And then I think when you layer in vaginal estrogen, vaginal hormones, it works even better. I find that they have a synergistic impact that’s very positive. So that’s my clinical experience. There’s not a lot of data on some of these things but–

Cynthia Thurlow: [00:35:50] Yeah. No, I appreciate that because we got quite a few questions about devices, and my kind of sensitive body parts require an expert. That is kind of my prevailing thought process, that I have a colleague that has done many different modalities for vaginal rejuvenation. And when she was explaining to me that one of these modalities, which we won’t name that she had tremendous pain and was very uncomfortable, and I thought to myself, “Oh, gosh, I mean, that to add insult to injury, literally insult to injury.” Thoughts on and this is for individuals maybe, that are on a second marriage or maybe they’ve gone through a divorce. I think we would be remiss if we didn’t talk about women in middle age being at risk for, now, they call it STIs, used to be STDs. Increasing rates of things like chlamydia and HIV when you’re talking to your patients about how to protect themselves. So, they’re probably like, “Oh, I’ve got a free pass. I don’t have to worry about pregnancy, but now I do have to actually be conscientious about–“

Dr. Suzanne Gilberg-Lenz: [00:36:50] I’m so glad you brought this up, because there was a recent study that came out showing that STIs are on the rise in people over 50. And so I am 58 and I’m in a relationship, but I have been single, like, unmarried for a while. So I mean, I’m probably a little bit more adept at this or like that’s part of my brain space. But, yeah, like, this idea that you are free and clear is nonsense, [chuckles] and I think you got it again. But this is also just basic training about body integrity and respect for ourselves and clear communication around sexuality and normalizing these things. And I’ll tell you the other thing it plays into, which is something that I was talking about with my team this morning because I got yet another message asking, like, “Hey, my new doctor told me that because I’m over 50, I only have to have a Pap every five years. But that kind of freaks me out.” And I was like, “I think you need–” Actually, she was told by the practitioner that their insurance wouldn’t pay for a Pap. And I was like, “That sounds like bullshit, [Cynthia laughs] and you should ask your insurance carrier what they pay for.” 

[00:38:01] But there are protocols out there that have these extended periods of time or stopping getting Paps after a certain age, which is insane to me because it makes the assumption, again, that somehow you go through menopause, your vagina dries up, you don’t use it again, you never had sex. You don’t have– or you’re in a monogamous relationship, or you never had HPV, or all of these assumptions are built in, which is so weird and not evidence based. So here we have this study, “Oh, guess what? Older people are having sex.” Shocking. Not okay, so we have to stop that. I think what people need to know is this, if you don’t want to get a Pap every year, Do I want to get a Pap every year? No, I’m not. It’s not my favorite thing. Is it the worst thing? No. Also, we all do things. I don’t want to do my laundry either, but I do it. [Cynthia laughs] I get it. But also, we’re grown up, so don’t use that as an excuse to not see the physician or the practitioner that you’re seeing. You should be seeing them especially at this age. We just talked about all these things that are going on that are changing, our bodies are changing, we don’t necessarily have great education around what’s happening. 

[00:39:02] So you should be seeing somebody every single year who understands that part of your body and your life. If you don’t want to do a Pap and it makes sense that you don’t have the risk factors, fine. But I think if you’re sexually active, you should be having a Pap every year. I think the other thing that people don’t understand is they don’t know the difference between a Pap and sexually transmitted infection testing. And did they do an exam? “They put something in my vagina.” Did I have testing? Make sure you understand the differences between what is happening and if you ever had HPV, even if it was you had a procedure that treated it, you are definitely at risk for recurrence as you get older. And I see it a lot in this age group, and I’m not sure if it’s that the instability in our immune system around perimenopause, the increase in inflammation that we see in general, metabolic changes. I don’t know exactly what it is, but I definitely see an uptick in recurrence in HPV. And also, we’re an age group that didn’t get HPV vaccines, most likely, so people need to be on top of that. I’m so glad you brought that up. Also again, not a judgment. Just be safe. Use condoms, get tested. You’re entering into– and make sure you’re having that conversation if you’re in a non-monogamous situation, if you’re dating, if you’re in ethical non-monogamy, like, just be on top of it, you know, just facts.

Cynthia Thurlow: [00:40:17] Yeah. No, and that’s without judgment. I think that, because I was an ER nurse in my past life, and it’s amazing, even in cardiology, how much patients, because I was the NP, they would feel like they could tell me anything, they would deal with the crotchety cardiologists, and I love the cardiologist I worked with. So, I’m just saying that more to be flippant. But they would say, I used to call it the handle on the door comment,- 

Dr. Suzanne Gilberg-Lenz: [00:40:40] Oh, my God. Always, always.

Cynthia Thurlow: [00:40:42] -leaving. And then they would decide to ask me that one question, and I would have that poker face. I was like, “Yes, I’d be happy to talk about X, Y, or Z.” And then I’d walk out of the room, and I’m like, “They probably were working up the courage that entire time to ask me that one question that took five minutes to explain and provide resources and referrals and all these other things that maybe they had been wanting to ask for months, and they finally had the courage to ask it.” So don’t be embarrassed, ashamed, or afraid. There is nothing we have not heard, absolutely nothing. And I speak from personal experience. I would love to talk a little bit about other changes in the body that we’re kind of navigating as we’re making that transition. So, I think most of us that have made that transition know, our skin takes a hit, our hair takes a hit. But I think bone and muscle are particularly important. I think that we’re definitely part of a generation. I was on low dose oral contraceptives for a long time, didn’t know that peak bone and muscle mass building ages I had very low estrogen. So, let’s talk a little bit about some of the changes that you see in your patient population regarding bone and muscle, which we could argue muscle is really important, far more important than we ever learned in school, because this is the site where we lose insulin sensitivity first. And so, if you’re not lifting weights or strength training, you should be. But let’s talk a little bit around this because I think it’s important and then also dovetail into a topic that I find really interesting is how many people are dealing with frozen joints. 

Dr. Suzanne Gilberg-Lenz: [00:42:15] Oh, yeah, well, but they’re related. So here’s the thing, when we talk about estrogen, I think people identify this as, like, a female hormone, a reproductive hormone. And of course, we have these names. But there are estrogen receptors in essentially every single tissue in your body, which is why in perimenopause and menopause, in that transition, specifically, we have such a wide array of symptoms because estrogen levels are fluctuating and then declining. So that includes the brain, the heart, the blood vessels, the muscle, the bone. We have very robust data and robust recommendations specifically on prevention of osteoporosis in using hormone therapy. Honestly, estrogen and weightbearing are the two most powerful things that you can do to reduce your risk for osteoporosis. Osteoporosis, again, is, I don’t think osteoporotic fractures, specifically hip fractures in older adults, men and women, increase mortality. The mortality rate, I think, within the first year or two after a hip fracture is like two-fold normal. It’s really, really, really serious. 

[00:43:25] So again, not to scare people, but these are things we can do something about. And this is where protein intake and weightbearing– vitamin D, which you really need as cofactor for bringing in minerals to help maintain bone, you’re not going to build bone anymore. You’re just going to prevent loss. And then again, I think when we’re weight training and we’re being active, so active recovery, stretching, walking, really, really important to maintain your balance because you want to prevent the fall. If you don’t have flexibility and strength, you’re more likely to get knocked over, have the — I mean, how many people have you heard about? Like, I hear about this all the time with my patients. They’re walking the dog. The dog runs into something, goes off leash, they trip, they break something all the time in older women it’s really terrible. And again, this is not their fault, but, like, we have to be cognizant of what we can be doing to protect ourselves. So, you really said it, the muscle is the most metabolically active tissue we have. And one of the things that happens as we age and as our hormones start to change is that a lot of times the number won’t change, that fat distribution changes. 

[00:44:33] So, again, we have a natural consequence of aging as sarcopenia, it’s loss of muscle. So, you have to really be actively working to build more muscle and help to redistribute and get into the inflammatory, the visceral fat loss. Nobody likes how this feels or looks, and I get it. And probably the first thing that people lead with, honestly, at this point now, when they come in to see me, is the weight gain, and I really get it. I’m living the dream right there with them. It’s not like weight gain. It’s this middle section thing, which is not only uncomfortable, but it’s potentially dangerous. So, the way we’re living really has to be addressing those things. I have a wonderful colleague and friend, Vonda Wright, who, if you’re not following, she’s just an incredible orthopedic surgeon who focuses on midlife. And she has coined a term called “The musculoskeletal syndrome of menopause.” Because it’s real. It’s a real thing. But again, there are things that we can do that are reality based, that are doable. We can make lifestyle adjustments. And again, hormone therapy is another area where we can have a lot of impact. 

[00:45:39] So, for people who can’t or don’t want to use estrogen, I’m not telling them they have to. I think they need to reassess whether or not it really is realistic or not realistic for them. I think the answer might have changed in the last couple years, and they may not be aware, but if that’s not your thing that’s okay. This is where lifestyle really, really, really shines. I think the other thing too, is that I had this patient yesterday overtraining, actually is going to not benefit you. You’re going to have more cortisol release. You’re going to have more stress. You’re actually not going to build– You don’t have time for the muscle to rest and recover. And you also have injury, so you have more injuries. So you have sort of, like, all these different things conspiring against you. You have less flexibility. Your collagen and elastin are diminished because of loss of estrogen. If you’re stressed and fatigued and you’re not sleeping, you’re probably not, like, on point as well. You’re not paying as much attention. You’re tired, so you’re more== And plus, you have wear and tear. Like, I’ve been a lifelong fitness person. I have 58 years of wear and tear on this body, whether or not I’m using hormones, whether or not I’m doing yoga, whether or not I’m weightlifting, and I’m doing all of those things. So, I’m just more susceptible to an injury. I have to be careful about that. That’s why you see all these wiffle ball injuries, “How could a wiffle ball hurt you?” But it could. [Cynthia laughs] 

[00:46:54] So here’s the thing, frozen shoulder has been shown now to be more likely as we get into perimenopause and menopause. And here’s the interesting thing. There’s no data to support treating frozen shoulder with estrogen, but we also, we do have some good studies indicating that women who are on hormone therapy have, like, a 50% less chance of getting frozen shoulder. And frozen shoulder is just horrendous. Like anybody who’s literally the joint in the shoulder. So, you’re getting inflammation in the capsule. And again, it’s probably related to a combination of factors, but all this inflammation, decrease estrogen, increase wear and tear. And it is not only that you can’t bring it all the way up. People a lot of times notice like it hurts when they brush their teeth, they can’t take their bra off. That’s like the classic, “I can’t get my bra off” and you can’t sleep because it’s so painful. Look, massage, physical therapy, this is where a lot of the, like, complementary modalities are great. I think hormones, if you’re not on them, I wouldn’t be against starting hormones. I can’t, obviously, I just told you, I can’t say that’s an evidence-based decision, but it’s something to consider. And don’t freak out, because it is going to get better. But can it take up to two years? 

Cynthia Thurlow: [00:48:06] It’s so interesting because I got several questions about frozen shoulders. It’s not something I personally have experienced, but I certainly have seen hundreds and hundreds of women that just suddenly they didn’t even have an injury. They’re just like, all of a sudden, they have–

Dr. Suzanne Gilberg-Lenz: [00:48:19] No, it’s not related to that.

Cynthia Thurlow: [00:48:20] Right. And it’s this reduction in range of motion. You touched on something that I think is really important without realizing this is the direction I wanted the conversation to go in. I start to see a lot of women that have I call it the triad, but it’s a group of women that are overexercising, under nourishing their bodies or we could make the argument over restricting food. And then I have kind of fallen into the bucket of intermittent fasting, which I know that, whether we do 12 hours of digestive rest or people– they tend to go overboard with all of that. And you mentioned you had some patients that were doing a lot of overtraining. I think, in many ways, disordered relationships with food can really get magnified at this stage of life- 

Dr. Suzanne Gilberg-Lenz: [00:49:04] Oh, yeah.

Cynthia Thurlow: [00:49:05] -to a point where, I’m starting to see this emerging pattern that is coming up over and over and over again. And I think it gets magnified by people utilizing strategies that worked for them before that no longer worked. And with all the physiologic changes that are happening in menopause or even in perimenopause, how do you address this with your patients? Because I find this is hard, because this is not just a physical issue. It’s oftentimes emotional. There’s a lot of deep-seated behavioral patterns that are at play here. 

Dr. Suzanne Gilberg-Lenz: [00:49:36] Yeah. I mean, this is something that over the years I really learned, and I identified this pattern pretty early on, and now I think the research has bared it out. So, first of all, we know that mental health issues really peak around this time. Anxiety and panic can come out of the blue, and it’s related to hormone changes. People who we know for a fact at this point that mood disorders are on the rise in this group of women. Now, if you have a history of mood disorders, if you have a history of PMDD, premenstrual dysphoric disorder, severe PMS, peripartum mood disorder, so mood disorders related to the pregnancy or postpartum, you’re at much higher risk for having this flare. Again, if you have long term depression or anxiety, it’s probably going to change, potentially get worse. Those people come in and they are kind of a little more aware. They’re like, “Okay, this makes sense.” The thing is that restricted eating disordered eating or eating disorders are often hidden. And of course, everything we just talked about, your mood is changing, your body is changing, it’s going to trigger everything. And I’ve had patients who have long time well managed or they’re in recovery from disordered eating, and exactly what you said, “They’re doing everything right, they’re doing everything the same, and it doesn’t work the same way, and their body is changing, and it is very, very triggering.” I think it’s really important for– This is where I think it’s important for the practitioner to be sensitive to this and identify it and just ask about the history.

[00:51:03] And I’ll tell you, I have had patients who are mad about it because all they want to know is how I’m going to fix their body. Having dealt a lot with addiction, I recognize it and I don’t take it personally, but when an addict is in their addiction, they don’t like you when you’re not supporting their addiction. And I am not here to be liked, I’m here to help you and do the right thing. I will say that I think I have enough experience in a gentle, loving way that I can handle that. And I think a lot of people all of a sudden see things differently. And hopefully we can help them get help. But this is such an important area to understand. And I think a lot of people are out there. Again, this gets back to what we started the conversation with, when your identity is built around the way you present and the way you look, and the way you think other people are looking at you, and other people’s gaze, it’s really, really painful, challenging and difficult to have that move outside of your control. And we know that eating disorders are like any addiction. They are about control and trying to control something in your life. It’s really, really powerful stuff. I’m so glad you brought it up. It’s really, really hard for people. 

[00:52:14] And I think if anybody listening, if any of this resonates with them, I want them to know that there is help that they can get, whether that is getting into therapy, whether that is working with a dietitian who understands eating disorders and doesn’t support or promote your eating disorder. There are a lot of people, we have a lot of colleagues, Cynthia, out here, and I’m going to give them grace, who don’t realize that they are promoting a lot of disordered eating, a lot of disordered body image, a lot of disordered self-image. I think sometimes I watch influencers and I’m like, “Oh, my God, she needs help.” [laughs] 

Cynthia Thurlow: [00:52:46] Yes.

Dr. Suzanne Gilberg-Lenz: [00:52:46] Like, I’m watching her and act out online, and I’m like, “Oh, my God, I wish I could reach out and be like, do you know about OA?” Like, there are 12-step programs that are free, there are apps that are free. Like, there’s so much help to be had. And even bringing it up, I had a patient say to me yesterday, who is new, and I was so grateful. She was telling me what was going on. We were getting to know each other. She was telling me her issues, and she said, “And I need you to know I had a very severe eating disorder that was treated as a young person. It’s something that I’ve struggled with my whole life.” And I said to her, “Thank you so much for letting me know, because now I know this particular thing is going to be a trigger for you.” This is a person who had a lot of treatment and self-awareness. So, I don’t know that we have a lot of data on this, but it all goes together for me. 

Cynthia Thurlow: [00:53:31] It’s interesting because a 100 years ago, when I was in my training, my psych rotation was at an eating disorder unit. And that left the most indelible impression on me on so many levels. And I’m so conscientious, thoughtful in the ways that I talk about these things because to me, there’s no pejorative measures on my part. It’s just, “How can I help you?” And that may be that you don’t work with me, you might work with someone else.

Dr. Suzanne Gilberg-Lenz: [00:54:00] Right.

Cynthia Thurlow: [00:54:00] But ultimately, I’ve met people who are in recovery from disordered relationships with food. I’ve met people who are still struggling even at the stage of life that we are in. And that can’t be easy to spend an entire lifetime having those internal dialogues that are both very punishing and also make it very hard to have a normal relationship. And I’ll say normal lesson that might be look a little bit differently for each one of us. There’s a reframe that you mentioned in the book that I thought was beautiful and wanted to mention it. “Letting our bodies go to letting our bodies be.” So, finding some sense of peace in this stage in our life. And the pivot is talking about the changes that we have about our own behavior as we are navigating middle age. And how interesting estradiol is, this predominant form of estrogen influencing behavior. The people pleasing that, gosh, sometimes I can’t keep my opinion to myself, and it embarrasses my teenagers and doesn’t embarrass my husband. But I’ll sometimes say I can’t not provide this feedback in a constructive, thoughtful way. How does this menopausal transition impact our people pleasing skills? And how do we differentiate that from toxic positivity, which is also equally a problem that I’m starting to see? It almost makes me want to vomit. 

Dr. Suzanne Gilberg-Lenz: [00:55:25] [laughs] There’s definitely been a backlash against that one. I think we’re just starting to really unpack that in terms of the brain chemistry, the brain remodeling. It’s shocking, but people probably don’t understand that as much as we know about the human brain, we really know very little about the female human brain. We’re just starting to look at the amount of research into the differences in the way our brains work under the influence of the specific ratios of hormones that we have, is just starting to be looked at. We don’t know. One of the interesting theories and one of the areas of research that, like I mentioned, Dr. Lisa Mosconi has been devoting herself to, and by the way she came to it, she talks about how she came to it, the back door. She was a dementia and Alzheimer’s researcher. And then she started saying, “Well, wait, women are so much more likely to get dementia, Alzheimer’s dementia. Why? What’s different?” And there was nothing, basically. I’m paraphrasing and so that’s how she wound up becoming a women’s brain researcher. She was a dementia and Alzheimer’s researcher. I mean, she still is. 

[00:56:32] So, one of the things that she has looked at is that at each time of our life, that we have a big, huge hormonal shifts. So puberty, pregnancy, for those who have become pregnant, and then menopause, perimenopause, and menopause, there’s actually a focused remodeling of a specific area of our brain. And the interesting thing is that in the perimenopause, menopause time, it’s the hippocampus, which is where– And I’m not a brain researcher, but it’s sort of the seat of memory. So, when you think about people having memory issues, cognition issues, focus issues in perimenopause, that’s for real. And it is because of both fluctuating and then declining estrogen levels. But the fact is that what we don’t understand and what we’re trying to understand now is what happens going forward, because there may be some evolutionary benefit to that. If you look at the changes in the brain structure at puberty, frontal lobes, executive functioning, figuring out how to be an adult, how to be responsible, how to take care of yourself, how to survive that pregnancy, the amygdala, which is really about emotions and bonding, and you have to be super empathetic, because you literally have to put the life of this little human in front of your own to keep this progeny alive and keep the species going. 

[00:57:46] Hippocampus now remodeling once again, memory, wisdom, caring, leadership. So, there are reasons for these changes. And I think that it isn’t just that estradiol and people– I think you’re not wrong. I will tell you that I have had the same experience personally, and I think that some of it is also like, again, I’m hearkening back to that large chunk of our time where we are in the reproductive age, and look, there’s societal and cultural pressures and other things that are feeding into it, but there is a hormonal influence. And we know research, like, the first half of the cycle when estrogen is dominant, people are more focused, they’re more able to work hard, they’re more articulate. Second half of the cycle after ovulation, before you get a period or get pregnant, progesterone dominates, and that’s more of a time of softening. People are a little bit more emotional, they’re fatigued, they’re tired, they’re resting more, they’re protecting. They’re cocooning just in case. 

[00:58:40] People don’t have to like this biology, but it is biology. It’s physiology. When you get into the peri– I have a slide that I use when I give my talks. When you get into perimenopause, it’s like crazy town. There’s no predictability. The reason you feel crazy is because it is crazy. Who knows today testosterone’s here and estrogen’s there and progesterone’s there. And let me just say something about testosterone that is actually the predominant hormone in females. We don’t have more testosterone than men, but we have more testosterone than estrogen when we’re younger. And we can come back and talk about testosterone another time. But that is the next way of really understanding our testosterone loss and what that does to us in terms of brain, muscle, bone. My personal experience has been once I got into a steady state, I was like, “Wait, this is how dudes are?” “What? [chuckles] Are you kidding? How did I get everything done that I was getting done with this fluctuation?” Now I’m like, smooth sailing, stuff doesn’t bother me as much. I’m just like, “Whatever, not my circus, not my monkeys.” 

Cynthia Thurlow: [00:59:38] [chuckles] Well, and that’s a huge shift to get to the point where you are much less influenced by these tremendous and sometimes profound hormonal fluctuations. I never had really bad PMS. I was never someone that dealt with that. But I recall and the throes of perimenopause, that feeling like that was the only time in my life that I thought to myself, “I understand why people make major life decisions at this stage in their life because their brain, and as you mentioned, the remodeling that’s going on, things that used to make sense no longer make sense, things that you used to like to do, you no longer like to do, and giving ourselves grace in the process.” And understanding it’s not a forever timeframe,-

Dr. Suzanne Gilberg-Lenz: [01:00:18] Exactly.

Cynthia Thurlow: [01:00:19] -as you mentioned, just like pregnancy is not forever and I loved being pregnant, so that’s probably not a good example.

Dr. Suzanne Gilberg-Lenz: [01:00:24] But some people don’t.

Cynthia Thurlow: [01:00:24] Yes, but perimenopause for me was not, it was the wild ride, for sure. 

Dr. Suzanne Gilberg-Lenz: [01:00:30] Yeah. Yeah. 

Cynthia Thurlow: [01:00:32] Well, I have so loved this conversation, and I could easily talk to you for hours. Please let listeners know how to connect with you on social media, how to get access to your wonderful book, Menopause Bootcamp, and how to learn more about your work. 

Dr. Suzanne Gilberg-Lenz: [01:00:45] Well, the best thing to do is, I’m most active on Instagram, but my website has all of my social links. So that’s thedrsuzanne.com and there’s all sorts of information. I’m on Instagram @askdrsuzanne and also the @menopausebootcamp, which is the name of the book. The other thing that we didn’t talk about is that, I have created a certification program so that others can run their own bootcamps. Because my book, Menopause Bootcamp, came out of my experience of running bootcamps for people, to educate them, to empower them, to help them understand what the toolkit can and should involve. It’s not for practitioners. It’s not a how to treat menopause. It’s how to be a person in menopause. And so, for people who are interested in that space, following along with me will help them understand what I’m doing. They can check things out on my website. But I invite you to participate, I love hearing what people have to say, and I’ve learned so much by meeting so many people online, and hearing their own stories, their own journeys. 

Cynthia Thurlow: [01:01:46] Well, it’s such an amazing time to be a woman in perimenopause and menopause because there is so much emphasis, there is so much information, there are so many people doing really great work. So, thank you for your contributions. And I had just learned about your program and I think that’s fantastic as well. Thank you so much for your time today. 

Dr. Suzanne Gilberg-Lenz: [01:02:04] Thanks for having me. What a great conversation. Thanks for what you do. 

Cynthia Thurlow: [01:02:07] Thank you.

[01:02:09] If you love this podcast episode, please leave a rating and review, subscribe and tell a friend.