I am honored to connect with Dr. Stacy Sims today. She is a forward-thinking international exercise physiologist and nutrition scientist on a mission to revolutionize exercise and nutrition performance- particularly for women.
In our conversation, we discuss the exclusion of women from research in the modern science era and how gender differences begin in utero. We look into the importance of tracking our menstrual cycles, the differences between follicular and luteal phases, and problematic ovulatory cycles, exploring the current research on oral contraceptives, the impact of the Women's Health Initiative, and the kind of training that is essential for women in perimenopause and menopause. We also cover the physiologic changes that occur in perimenopause and menopause, and Dr. Sims shares her thoughts on weight loss resistance, SECO, undereating, the importance of protein, and essential supplements for middle-aged women.
I know you will love this invaluable conversation with Dr. Stacy Sims.
IN THIS EPISODE YOU WILL LEARN:
Why are women still excluded from many studies?
How the physiological differences between men and women begin in utero and continue through adulthood
How stress during pregnancy affects the developing fetus
How the muscle morphology of women differs from that of men
Why girls need to learn new ways to move and build strength during puberty
How tracking menstrual cycle phases helps women optimize their training
The potential long-term effects of using oral contraceptives
Why a diverse diet is essential for supporting gut health
Common misconceptions surrounding hormone therapy
Why Dr. Sims recommends creatine for women in perimenopause and menopause
“Women need to make a conscious effort to eat more protein to preserve and build lean mass and prevent body fat gain.”
-Dr. Stacey Sims
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Connect with Dr. Stacy Sims
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 Dr. Stacy Sims. She's a forward-thinking international exercise physiologist and nutrition scientist who aims to revolutionize exercise, nutrition, performance, and especially in women. Today, we spoke about how women have been excluded from research in the modern science era. Differences between genders that starts in utero, why tracking our menstrual cycles is so important, as well as key differences between follicular and luteal phases, and why anovulatory cycles are so problematic. The role of contraception and current research around oral contraceptives, the impact of the Women's Health Initiative, what type of training is critically important for women in perimenopause and menopause that incorporates resistance training, jump training and compound movements? Key physiologic changes in perimenopause and menopause, thoughts around weight loss resistance, CICO and why undereating is problematic, the importance of protein, and lastly key supplements including creatine monohydrate for middle-aged women. This is an invaluable conversation that I know you will love.
[00:01:48] Well, Dr. Sims, I've been really looking forward to this discussion. Thank you so much for carving time out of your busy schedule.
Dr. Stacy Sims: [00:01:54] Yeah, no, it's great.
Cynthia Thurlow: [00:01:56] One of the things that I think is so interesting as a clinician myself, is really understanding at the basis of why women have been excluded from research for such a lengthy period of time. Do you feel like, as a research scientist yourself, is this a byproduct of concerns over women's safety? Or is this more a complication of thinking about women's physiology, dealing and addressing with the menstrual cycle and how much hormonal flux that goes on in a woman's body day to day, week to week, when they're still in their peak fertile years in perimenopause.
Dr. Stacy Sims: [00:02:35] I actually look at it from a historical perspective. If we think back to when we had modernization of medicine and we think about who was in the room, before that it was the women that were the healers primarily and the caretakers, right? But then we see that men started coming to their own saying, “Well, women aren't as smart as us.” Even Darwin said women had smaller brains so I count that against him. [Cynthia chuckles] And just became who was in the room. And women were excluded from being involved in higher education, university, medical settings, that kind of stuff. So when science first came to be modernized, as we see it now, as the hypothesis driven answers through research, who was in the room was men, right. And so when they were designing studies, they were designing studies based on them and based on what they knew from male cadavers, right.
[00:03:29] And so when you start moving it forward, it didn't really enter the conversation or enter the minds of the people who were designing studies that, “Hey, wait, maybe we should be looking at women differently.” Because the isolation of our sex hormones wasn't until the early 1920s, 1930s, for the most part. So as we see from the early 1900s to now, there has been a shift. We have a long way to go, but it's a relatively small period of time when we look at that whole aspect of what is modern medicine and what is science. So I'm happy to see that things are moving forward, but it still was 1990s I think NIH put out mandate saying, we have to include women and you have to have a biological or some other reason why you would not include women. And people still found loopholes. And this is where that conversation, “Oh, women are too difficult to study because they have so many different hormone perturbations, they might have anovulatory cycles. We don't really know how to test for it. It's too burdensome.”
[00:04:27] And the language of recruitment as well. So we look at the language of recruitment and the attrition rate, it's all very masculinized because science comes from that masculine and patriarchal background, because we've been able to unpack all of that. We're seeing a lot of movement forward in the space of looking for women to be involved in female studies, to be involved in sex difference studies, even right down to mouse models, now have to have female mice versus male mice. So there's still, like I said, a long way to go with regards to getting equality and closing that gender data gap. But we have come a long way from that initial who was in the room?
Cynthia Thurlow: [00:05:08] So interesting, because as I was getting prepared for our conversation, I was looking at current statistics, and even though women are now better represented, we still are only 41%, which seemed actually quite high. Only 41% of research that actually goes on in females. And it didn't break it down based on animal models versus human subjects. And so from so many different perspectives, I think as a clinician, drug therapy, we prescribe certain kinds of medications and why I knew over time certain drugs I'd use teeny-tiny doses in my elderly female patients versus my elderly male patients, but yet there was no data to support that. It was just clinical experience that I was drawing upon.
Dr. Stacy Sims: [00:05:53] Yeah. I see that now. I've talked about it before. My husband and I both have had surgeries by the same surgeon, and we get released with the same type of drug and the same dosage. I was like, “Wait a second. He's 180 pounds, [Cynthia chuckles] 6’ something dude and I'm a 130-pound, 5’6” woman.” So there is still that discrepancy.
Cynthia Thurlow: [00:06:15] Yeah, absolutely. And so I would love to kind of unpack some of the physiologic differences between men and women based on the research. I know that what I found really interesting from conversations that you've had, is it actually starts in utero. So when our moms were pregnant with us or we're pregnant with our children, the impact of stress is different on a fetus depending on the gender and how that from a physiologic starting point can impact the way that we evolve differently as men and women.
Dr. Stacy Sims: [00:06:48] Yeah. I remember giving a lecture when I was pregnant with my daughter, and it was all about strength training and exercise when you're pregnant. So when you start looking at the literature and the research to give a lecture, you realize that there really isn't anything there. I was like, “Okay, this is really interesting.” But I want to dig in a little bit more about blood flow and fertility because I want to understand from the very basic cellular level. So when you start looking at what's happening in utero, and you start looking at how stress affects things, like how vascularized the placenta is. So we see that small bits of hypoxia through exercise will increase the blood flow and the vascularization of the placenta, which means better blood flow and better nutrition to the developing fetus.
[00:07:32] When you see the opposite side of high stress rates, where we're having elevated cortisol, poor blood lipid, poor blood sugar control, it becomes a fight for controlling the stress in the mom's body versus the fight for all the stuff that the developing fetus needs. And we see that under high, high levels of stress like that, there's often more miscarriage, and it's more often the male fetus that does not survive. So it comes right down to the stress and stress resilience of the developing cells and how they're expressed. And then that feeds forward to, “Okay, the baby is born. What was the in utero experience? Was there high stress and resilience? And was there exercise, which causes an epigenetic or that surface conversation change within the DNA to improve the stress resilience and the metabolic outcomes of the kid into adulthood?”
[00:08:28] So when I was giving this lecture, I was trying to unpack and explain it all. It's like, “Okay, well, yes, exercise is great.” And the whole idea of keeping your heart rate low and just walking is all because men who started the guidelines were afraid that women were delicate flowers. But when you start looking at more of the modern research, you see that the body is really resilient. And we want to tell women, “You don't want to try to build muscle and build your fitness. You want to maintain what you have. But if you haven't done anything, then you want to build. You want to build your fitness so that you have better metabolic control, so that you have strength, so that you can have a robust pregnancy with a really stress resilient fetus in that development phase.”
Cynthia Thurlow: [00:09:13] Well, I can remember when I was pregnant with both of my boys, I had two singletons that my OB really stressed. I know you like to work out. I don't want you to get your heart rate above 120.
Dr. Stacy Sims: [00:09:24] Oh, my gosh.
Cynthia Thurlow: [00:09:25] And I can remember dutifully wearing my Garmin watch and looking at my chest strap, and 120 wasn't much. It buffered what I did, although I did a lot of walking. I did some light strength training, but I now have a 19-year-old and a 17-year-old and so that's 20 years ago. But realizing now it's actually of benefit for women to remain more physically active throughout their pregnancies. And so my hope and intent is to get people thinking and discussing these topics so that we can all advocate for ourselves. What are some of the differences in terms of lung volume, blood volume, the impact of puberty on our bodies as we're kind of navigating growing up as children into teenagers and young adults? Based on the research, what are the kind of broad stroke physiologic differences between men and women, beyond the obvious?
Dr. Stacy Sims: [00:10:23] So when we looked at things like muscle morphology, which is the muscle fiber types, and have full disclosure, when I'm talking about the sex differences, I'm talking about the biological XX versus XY, because we don't have enough research on other perturbations of our sex hormone. So I have to just go with the literature that's there. So when we're looking at XX versus XY, by the nature of being XX, you have more endurant or oxidative muscle fibers. So we have less glycolytic, less fast twitch. We have better mitochondrial proteins within our muscle for mitochondrial respiration. We're more metabolically flexible because we have more robust mitochondria. We have better oxidative capacities, better anti-inflammatory capacities, we have better ability for transferring lactate.
[00:11:17] So when we do higher intensity exercise, we don't have a lot of glycolytic fibers, so we don't produce a lot of lactate. But when we do, our body's like, “Yeah, we know what to do with this.” So there's really good uptake to the brain, which helps with brain metabolism. When we are looking at structural differences, we know that women have smaller hearts and lungs and less hemoglobin. And that's all by the nature of being XX. When we get to puberty, this is where it's interesting and it's shift because we start to see changes. I guess when kids are between seven and eight years old, we see it on the elementary school playground where we start seeing this more divergence of the boys are off being more rough and tumble, and the girls are like, “Okay, I'm going to do more monkey bars and have more of that motor control type work.” But then we start seeing the divergence of 10, 11,12-year-olds, right?
[00:12:08] And we're seeing more and more girls are not going to monkey bars and they're feeling less confident in their bodies where the boys are still out there rough and tumble and playing and pushing and trying to get more of the soccer fields and that kind of stuff. And no matter what kind of conversations you have, it just happens by human nature. And it has really to do with what's happening with girls’ bodies, because as we start to get that early exposure of our sex hormones before menstrual cycle actually happens, we see that girl center of gravity changes. So it goes from more upper chest down to lower abdomen area. So we have lower center of gravity in the pelvis area. We have a widening of our hips, so that changes the angle of the hip to the knee. We have widening of our shoulder girdle to have more balance. And all of this creates gangly-- and girls tend to grow their periphery faster, so their limbs grow a lot faster than the rest of their body, so do not to have a lot of core strength.
[00:13:08] So this comes more into why now they're not on the monkey bars because they can't do what they did before, and they feel really kind of a bit misstep. And when you're seeing girls playing volleyball or basketball or soccer in their middle school or 6th grade to 9th grade, you don't actually know how old they are because there's so many different changes there and how fast puberty goes for some and how slow it goes for others. It's a very confusing time. For boys however, with that epigenetic exposure of testosterone, they get leaner, they get fitter, they get faster, they get more aggressive, which creates this more divergence and this increase of that discrepancy of trying to keep girls active and in sport versus it's a natural progression for boys to keep doing their sport and activity.
[00:13:57] So when we're bringing it back down to puberty, we're like, “Okay, if we want to keep our girls in sport, yes, there's the conversation of, your body is changing.” We know that you're going to have a menstrual cycle. When it actually comes? That's arbitrary between ages 11 and 14. But what we do want to do is we want to teach you again how to run, how to throw, how to jump, how to land, how to work in this new biomechanical orientation that you have. So one of the first steps that we'd want to do is put that into physical education. All kids will benefit from functional training and learning how to do squats and lunges and jumps and that kind of stuff. But reteaching in this new mechanics is one step closer to getting girl’s confidence back. Because if we get that confidence back, then it holds through all the way through post menopause, right.
[00:14:49] So I see that early development and puberty so essential for taxing into let's get some more type 2 fibers working, right. So let's get more lactate production. Let's work on that pure strength development. Let's work on how we are moving through all the planes of motion. Not only is that building confidence for what we're doing for sport, but it just builds confidence for overall movement, which is good because that's what we want, right. We see that people who-- boys and girls that are moving more have better mental health. If you have better mental health, that's more confidence. More confidence is better learning, better learning and all these subsequent outcomes.
Cynthia Thurlow: [00:15:30] I think it's so important because I think back to when I was growing up I think if your parents talked to you about the changes that you were going to experience, you were probably fortunate in the 70s and 80s versus now I think it's probably a bit more proactive. But your points about helping young women and young men understand physiologically what's happening in their bodies so that they can optimize training. And I really think about this. You don't necessarily have to be a full-fledged soccer player, lacrosse player, but just being physically active is so critically important. We're looking at escalating rates of diabetes and metabolic disease in young kids. When I finished my medical training, it was so unusual to see children dealing with type 2 diabetes. That was a lifestyle issue and now you're seeing it in younger individuals.
[00:16:22] Now, when we're talking to young women about menstrual cycle. And I think, again, this goes back to some schools are talking about this proactively, some people are getting information from home. I know you're a proponent of helping young women understand their physiology, their menstrual cycle, and actually training for their cycle. So let's talk a little bit about the phases of the menstrual cycle and how young women can actually optimize their training. And when I say training, you don't necessarily have to be an athlete. You could just be someone who's an avid exerciser or someone who's prioritizing physical movement into their lifestyle. But I don't think we talk enough about menstrual cycles. I think it's sad to admit this, I'm now in menopause, but I think I understand more now than I ever did. And yet I think about it like as a clinician, we do such a poor job in many ways of talking to women about the physiology of their bodies and what it all represents.
Dr. Stacy Sims: [00:17:22] Yeah. I mean child of the 1970s, 1980s so I completely get that right. [Cynthia laughs] I got some information from my sister, others from friends. My daughter doesn't stand a chance having me as a mom. But yeah, it's still a little bit of a taboo thing because I'll go and I'll give talks to high school students and they all still are kind of like, “Oh, you're talking about menstrual cycle.” But when we talk about it's a natural thing, right. And we see that there's a whole socio-cultural construct around it as well as a physiological. So when we talk about the physiological, just the brief outline of day one is the first day of your bleeding around day 12 or 13 is ovulation, which is you'll have a surge of estrogen, and then after ovulation is what we call the high hormone or the luteal phase, when you're building that endometrial lining, so you have an elevation of progesterone that is more of our catabolic hormone.
[00:18:20] So that's what's providing all the building blocks for the endometrial lining. We also see that there's a lot of carbohydrate that gets put into that endometrial lining, so our glycogen storage is affected, so that goes more into that endometrial lining. And then around day 28 to 30, you have an inflammatory response that causes a shedding, which leads you to the next bleed. What happens a lot in those menstrual cycle conversations is that when you're first starting, the first few years are going to be very irregular we know that, right. And no one tells kids that, like you're 12, you start your period. And a lot of girls think in health class, “Oh, it's going to be a bleed phase for five to seven days, and then it's going to be over.” But it's really irregular. They don't know how long the whole cycle is going to be, so they get very confused. Their parents don't know or their mom doesn't know, so they get confused. Then, unfortunately, they'll go to a GP. The GP doesn't have a lot of time. They get told to put on an oral contraceptive pill. So there's a lot of things that go with it where we're like, “Hold on, take a step back.”
[00:19:28] For the first three years of your menstrual cycle, it's going to be irregular. We know there's a lot of anovulatory phases, and so you're going to have short and long, and that's normal. As we get older, as we get into our late teens, early 20s, you should have a regular cycle, which means it's between 21 and 40 days. If you start seeing changes in the bleed pattern or you start seeing changes in the length of the cycle, we need to take a step back, because we know that there's some undue stress that's causing some menstrual cycle irregularities. We also know that there are four to six anovulatory cycles a year in the normal woman, which is increasing a lot from the 1970s, where we'd see maybe two or three.
[00:20:12] There's an environmental influence that's being researched into why we're having more and more of these anovulatory fertility issues. You'll still have a bleed if you have an anovulatory cycle, but the actual bleed pattern is different, so you'll see it shortens. It's not as heavy. When we're talking about how do we train according to menstrual cycle. The first thing that I tell women to do is track their cycle so they can understand what their own patterns are, so then they can see, is there a change in the bleed pattern? Is there a change in the length? Is there a change somewhere along the way when I'm talking about what does my cycle mean to me? Also finding your own pattern of how you feel across your cycle, because women will say, “Oh, yeah, I feel bulletproof the day before my cycle starts or maybe I feel absolute shit, right.” So you know what your own nuances are.
[00:21:05] Then when you lay that over, how your life goes and times where you can train hard, and when you should train easy, you can use your own menstrual cycle to pattern that out. We know from a molecular level that the low hormone phase or that follicular phase from day one up to ovulation, we see there's a change in the immune system where we have more capacity for fighting off virus and bacteria. Our body is more stress resilient, we have a better capacity for recovery. We also have more motivation and aggression, which is a way that we can really feedforward into our training. And then after ovulation, there's a metabolic switch where we have more of that catabolism, because progesterone comes up if you ovulate so that's the key thing. If you ovulate, then you know that you can modify your training to be more aerobic, endurance based, maybe more technique oriented, and really see how you feel. But because we're having more and more anovulatory cycles, we can't really dictate what's happening there. That's why I tell women, “Let's go back to the basics, and I want you to track your own cycle.”
[00:22:17] So when you start seeing your own patterns, that's how you can dial in your training. Because when we're talking about what is training, you want to get the most amount of training stress so that your body can respond to it, adapt and get fitter. So if you wake up and it's day 18 of your cycle, and you're like, “Day 18, I always feel fantastic.” Then you're probably going to prioritize a really good hard work out because you have that advanced notice, you know that you can go hit it hard, you're going to get a high training stress. Your body's going to adapt to that, recover from it, and you're going to get fitter. But say you wake up on day 20 and you're like, “Ugh, I feel awful.” And you know you always feel awful. You're not going to do day 18 workout on day 20. So it's a way of being able to manipulate your training and your life around how your hormones make you feel. And this is a big subjective area of research that people are somewhat bringing in. But a lot of the voices in menstrual cycle research are ignoring because they're like, “Yeah, we don't care, we just want to look at the physiological.” And then there's a group of us are like, “No, no you can't tell a woman to go hard if she's like, physically I feel two, mentally I feel a one.” And you want me to be on a scale at 10, it's not going to happen.
Cynthia Thurlow: [00:23:40] Well, and I think it really takes into account this bio-individuality. That's why stress tracking your cycle to get a sense. What do you think the increased frequency of anovulatory cycles is attributable to? Because I know you mentioned initially it used to be two to three a year, now we're seeing four to six. That's quite significant when you have individuals that are trying to conceive or considering trying to conceive in the near future, because that could potentially mean two-thirds of the year someone may not be able to actually become pregnant.
Dr. Stacy Sims: Right. So, we see there's a lot of-- well, not a lot. There's rise in femtech where we're seeing some at home tracking kits. So, Proov has just been FDA approved and it is a way of monitoring fertility, specifically looking at the progesterone metabolite. So if we're looking on day 22 to 24, using a urine dipstick test to determine if you've ovulated or not, very, very helpful. We're seeing this increase in anovulatory cycles from high stress because we have a globalization of increased stress and poor mental health as we talked about earlier. The food system, we're seeing increase in ultra-processed and very overly farmed foods that are generally available. And it's really interesting to me as a nutrition scientist to see that across the world there's malnutrition. We have malnutrition with obesity and we have malnutrition from scarcity, but there is a significant amount of malnutrition that is occurring that is contributing to infertility. And it's kind of scary.
Cynthia Thurlow: [00:25:24] It is very scary, especially I have all boys, but starting to think about the ramifications. There's also escalating issues related to male sperm counts being low and dealing with male factor infertility. So these are definitely concerns that everyone should embrace. I feel like we would be remiss if we didn't at least touch on contraception because I'm thinking about the young women that have irregular cycles who are told by their provider, “Hey, we've got a fix for this.” They put them on oral contraceptives for 10, 15, 20 years. What they don't realize is that being kept in that low estradiol state, that low sex hormone state, they're missing out on the peak opportunities to build bone and muscle in their 20s and 30s. I speak from personal experience.
[00:26:10] So I would imagine that when you're talking to your clients or dealing with your research subjects, do you have preferences of how to address contraception? Because I want to respect a woman's right to choose and I am a believer and we have to find the solution that works best for us. What's interesting to me, and I was asking several girlfriends, how many of us were on oral contraceptives in our teens, late teens, 20s and early 30s. How many of us felt terrible? We didn't realize we didn't actually have bad PMS. It was a byproduct of being on these synthetic endocrine disrupting chemicals. So help us kind of understand the net impact of contraception on training and what can we do to optimize if we need to find a good option for contraception, but also being cognizant of what's going on behind the scenes with regard to some of these medications.
Dr. Stacy Sims: [00:27:06] Yeah. Well, I get really frustrated when GP’s will say, “We'll put you on an OC, so you get period.”
Cynthia Thurlow: [00:27:14] Yep.
Dr. Stacy Sims: [00:27:14] Because the withdrawal bleed is [Cynthia laughs] not a period, right. And so many people are like, “Oh yeah, I have a regular cycle. I'm on the oral contraceptive pill.” It's like, “Well, first and foremost, we know that the OC downregulates your natural ovarian function, so it's not representative of your endocrine system, we can't tell if you're over training, we can't tell if you're adapting because your endocrine system is so important.” When I'm talking to my athletes or I'm creating a research study, I want to know not only if they're on an oral contraceptive pill, but what generation of the progestin and how much estradiol, because those all affect people differently and outcomes differently. So I tell people the OC is experimental in its own right because there are so many different formulations and variations.
[00:28:03] And it was just last year that a study was released looking at the amygdala and some of the brain volume of young girls who were put on OC and how it shrunk it and increased the capacity for anxiety and fear and. And for adults who went off it, that was reversible. But they don't know if that is true in younger girls who are still developing. So that's a question that still needs to be answered, right? And we're looking in 2024, we're just getting these answers. So it is a little bit of a misstep because there's so many girls who don't understand. Because they get put on it and they don't understand what are the ramifications. So when I give a talk about this, I'm like, “Look, it's your right to choose, but I want you to know what amount of estradiol is in there, you want to know what progestin is in there, because there are different generations they'll have a different function.
[00:28:56] If you are put on an oral contraceptive pill for irregularity, when you get off, you're still going to have irregularity. If you are within the first three years of your menstrual cycle and you're having irregularity, you should not go on an OC. If you have bad skin, you don't go on an OC. We have really, really good dermatologists and really advanced science to understand and help with skin issues. If you have heavy menstrual bleeding or menorrhagia and you have other issues that might require you to be on it, well, let's take a look. We know that you can use tranexamic acid or you can use passion flower extract for heavy menstrual bleeding. We also see an IUD is really effective for that. IUD is very effective for endometriosis, and you will still have your own natural ovarian function if you're using an IUD.
[00:29:48] If you are some of my tactical athletes who are out in the field and they have to go on mission, they don't know what's going to happen, IUD is where they go, because they won't want to worry about taking the pill the same time every day. IUD, after maybe two to three cycles, almost completely amenorrheic, not from ovarian dysregulation, but from autophagy. So the endometrial lining becomes so thin, the uptake can be through autophagy instead of a bleed. So, I get frustrated with the lack of education that the medical field has because they've been around since the 1960s, well actually earlier than that, right. And then we have the other side of the coin where now people are talking about menopause hormone therapy [chuckles] and comparing those two, and they're completely different. So we see contraceptive formulations are completely different from hormonal therapies for menopause and other low ovarian function. And people don't understand that either because there's that lack of communication and a lack of education.
Cynthia Thurlow: [00:30:54] Yeah. It's so interesting to me because I think that there's this lack of fully informed consent not done for any other reason other than for the most part, for the traditional allopathic medical model, we're looking for a solution to a problem and full stop and that is really what we are focused on versus understanding that a lot of the women that are started on oral contraceptives, as one example, probably have polycystic ovarian syndrome as the number one endocrine disorder, not hypothyroidism, like many people believe. And if you put someone on oral contraceptives who has PCOS, you're not fixing the problem, you're [crosstalk] actually putting a little blanket over it. And I think many, many people don't understand that the withdrawal bleed they get on oral contraceptives is not actual real period bleeding.
Dr. Stacy Sims: [00:31:42] Right.
Cynthia Thurlow: [00:31:42] The other thing that I wanted to mention is that doses of estrogen in oral contraceptives have tremendous range, anywhere from 20 mg to 50 mg. What I found interesting as I was preparing for this, is that progestins, which is that synthetic form of progesterone, first and second generations, like Depo-Provera, Mirena IUD, tend to be more androgenic. I know you know this, I'm just kind of including this into the conversation, tend to be more androgenic. And so it's interesting when we're looking at contraception as just one piece of the puzzle, there's so much more to it than we actually give credit for. And nothing is more frustrating to me as a clinician and middle-aged woman, is to have a patient say to me, “Hey, I finally got put on HRT.” And I'm like, “Great, what are you taking?” And then they’re [crosstalk] like, “That's the pill.” [chuckles] That's not actually menopausal hormone replacement therapy. That's actually quite different.
[00:32:42] And I'm sure you probably find that to be baffling as well, that you're like, “They're not synonymous, they're quite different.” [crosstalk] Different dosage, different purposes. Are you sometimes surprised when you either see people talking about this or there's this lack of information? Because patients don't realize, they're assuming that they're getting what they're asking for and then they find out after the fact, “Oh, no, that's actually a contraceptive.”
Dr. Stacy Sims: [00:33:07] Yeah. [audio cut] at Stanford and was working with Marcia Stefanick, who was the PI for the Women's Health Initiative. So I've been into that data and it didn't dawn on me that the people who are outside of that data didn't realize that whole study was designed to look at late postmenopausal women who were 10 or more years post menopause to see if then taking hormones would help with some of these risk factors that came up with menopause. So when all the scaremongering came out about menopause hormone therapy, no one identified the fact that it was a late population that should never have been put on hormone therapy anyway.
[00:33:49] So now we have the pendulum swinging the other way, where now we're hearing the rhetoric that everyone needs to be on menopause hormone therapy for brain health, for cardiovascular health, for bone health, to prevent body composition change. And none of that's true. So I get very frustrated when people are like, “Oh, I'm going to have to be on menopause hormone therapy for my bones.” I'm like, “Oh, wait a second, you are 41 and you have the opportunity to do some jump training, some resistance training, build your bones, get some good health factors in there, you don't have to go on menopause hormone therapy.” Well, I need to because I need to also look after my brain. Like, there is no evidence to show that going on menopause hormone therapy helps with cognition or dementia. We know that exercise does. We see high-intensity resistance training, high-intensity exercise, both of those types of exercise significantly help attenuate cognitive decline.
[00:34:48] And so like I said, the whole pendulum shifting, right? And again, it's lack of education, because everyone is looking at that pharmaceutical fix. Let's just take a pill and make it easy. So when we're looking at oral contraceptive pill, that's a blanket like you were saying. And one of the scary things when you mentioned the Depo is if you're on the Depo for more than a year, then you can kind of say goodbye to your bone mineral density because we see that it significantly drops your bone mineral density. It just attenuates the responses for building bone. And the longer you're on it, the worse it becomes. On the other side of things, for women who have a diagnosis for osteopenia or osteoporosis, going on menopause hormone therapy because it's transdermal estradiol can help. So there is treatment effect of using menopause hormone therapy for helping with bone at that end of things.
[00:35:48] So you do have to understand what the two different ends of the spectrum are and why you want to use it. Instead of listening to everybody saying, “All teenage girls should be on oral contraceptive pills.” I'll get shot for saying that. But yeah, that's how I feel now menopause hormone therapy is. When there's like all women who are in their mid-40s and onwards need to be on menopause hormone therapy, it's like, “No, no, no, no.” We have to unpack each individual and see what the needs are so that we can say, “Yes, you are a candidate for this, or no, you're not or let's try all these other things first.” Because both OCs and contraception, for things other than contraception can have a time and a place depending on health needs. Same with menopause hormone therapy. But there are lots of other interventions in between that we can try because those are just tools in the toolbox.
Cynthia Thurlow: [00:36:39] Yeah, I love that that you're kind of bringing up that point because I think that lifestyle as medicine needs to be at the forefront because to your point, if I put a patient on HRT, and technically it's appropriate because they're menopausal and they're having symptoms, but we haven't addressed the sleep, the stress management, the training. And let me be clear, I think most women are still training like they would at 18 at 50, and they're wondering why it's no longer working. So let's take a couple minutes just to kind of talk about the different types of training that are beneficial for women in perimenopause and menopause, which is a different focus than an 18, 19, 20-year-old athlete or someone who can as the parent of a child who plays college level lacrosse, what his body can handle right now is very different than where he will be in 30 years and that's okay. So let's talk about training needs for women in middle age.
Dr. Stacy Sims: [00:37:43] Yeah. So I like to tell women that our hormones are really good because they affect every system of the body and help us adapt to stress. Because the idea of having a menstrual cycle, you have ebbs and flows, and we see there are changes in the brain across the menstrual cycle, which is why we see changes in our cognition ability, our aggression, our motivation, depression, anxiety, because our hormones flux our brain as well. We also see that there are times where we can recover better, and there are times we don't. So we see that our hormones affect everything. So when we start to get to perimenopause, and we're having more and more anovulatory cycles, so we're not having as much progesterone. We're having changes in our ratio of estrogen, progesterone, changes in our estrogen receptors or progesterone receptors. Everything's all over the show so we have to think.
[00:38:37] Remember when we're talking about puberty, how everything's all over the show, [Cynthia chuckles] and we need to reteach our girls how to run and land and jump and all those things. When we get to this end of things, kind of the same thing. We have to look at training as a way to mitigate the changes that are happening. And we have to look for an external stress that is going to create an adaptive response, the way estrogen, progesterone used to. When we're looking at those factors, we know that estradiol or E2, our powerful estrogen, as reproductive women, is responsible for things like the satellite cell stimulation for lean mass development, also for bone turnover and bone density, also for metabolic control, our blood glucose and our uptake and insulin.
[00:39:25] We see that progesterone is helpful for things like bone mineral density and our bone uptake. We also see that it is responsible for a lot of our vagal tone. So when we're looking at what's happening in perimenopause and we're starting to see a loss in strength and power, we're starting to see more visceral fat, we're starting to see more inflammation and oxidative stress. We're seeing a misstep in our brain metabolism because it's becoming hypometabolic, meaning that it's not using blood glucose very well. We want to take a pause and say, “Okay, what kinds of external stresses can we put on the body to change all of us for the better?” So we see that heavy resistance training is really essential across the board. First step, and this comes from someone who is a long-term endurance athlete. Like, “I did 20 marathons before I was 20. I've done Ironman, I was on the crew team.” So all that stuff, right?
[00:40:20] So as we get older, we look and see how important resistance training is. And I don't mean booty bands, [Cynthia laughs] I don't mean the 5-pound dumbbells. I mean, like, lifting heavy loads, because when we lift heavy loads, we have a nervous response. The brain is stimulating muscle contraction in the fact that we have to lift this heavy load. So now we have faster nerve conduction, which creates more acetylcholine, which is our neurotransmitter, that's responsible for how fast nerve conduction happens. We see that there's a signal for our two muscle binding proteins, myosin and actin, to actually bond and hold together more tightly. And we also see that there is a stimulation for developing lean mass from the nerve, saying, “Hey, wait, we have to be able to have the ability to lift this load because it's going to happen again.” So that's our adaptive response to our external stress, where estrogen needs to be responsible for those three things.
[00:41:20] When we're looking at our metabolic control, we need to do high-intensity exercise. So we're looking at intensities that are 80% or more, preferably sprint interval training, which is 30 seconds or less as hard as you can possibly go, because now we're looking at creating some epigenetic changes. So we're looking at increasing the skeletal muscle ability to open up and allow carbohydrate to come in without using insulin. We're seeing more myokines, which are little signals that get released from the skeletal muscle during this high-intensity exercise that then tells the liver, “You know what, this esterified fat that's circulating, we don't want it to be stored as visceral fat. We want it to be converted into usable free fatty acid for the muscle and the mitochondria.” So then we're reducing that visceral fat storage and gain.
[00:42:16] We're also producing lactate at those high-intensity exercises. When we're producing lactate, we're improving brain metabolism. Why it's so important is one, if you remember at the beginning, I was saying that women are born with less glycolytic fibers than men, so we have to work on our lactate production. Lactate is not a negative byproduct of exercise. It is a preferred fuel for the brain and the heart. So the more lactate we produce, the more we're providing fuel for the brain, so that we have more neurons that are able to talk to each other. We're having better nutrition for that connectivity and we're also increasing the amount of brain neurotrophic factor that's being produced, which improves brain volume.
[00:43:02] So when we're talking about using exercise and different modes and different intensities to improve overall responses as our hormones drop, we also see that these different modes and intensities also address these problems that people are talking about why they should be going on menopause hormone therapy for looking for brain health, resistance training and high-intensity work. Those are the two key things for having faculties around you when you're 100 years old. We also see that strength training improves the amount of muscle that you have, muscles very metabolically active. It helps increase our body's ability to control blood glucose and our metabolic responses. We also see that high-intensity and resistance training, again, helps with the cross talk of the skeletal muscle to the liver and fat storage to say, “We don't need it.” And the other thing about resistance training and high-intensity work, like plyometrics, jump training, is it's all signaling for developing bone and maintaining bone density.
[00:44:07] So when we're looking at what do perimenopausal women need to do? They need to polarize their training, making resistance training the bedrock. And then you pepper it with high-intensity work, that 150 minutes of moderate intensity activity that all the guidelines put out, that's fine if you don't move at all, like, work up to that. But for someone who's already moving and someone who's already living a fitness lifestyle, not appropriate at all, it puts people in moderate intensity that doesn't do anything, doesn't challenge the body enough to create that adaptive stress, but it does create more of a cortisol response. And when we have elevations in cortisol, then we don't get the positive outcomes that we want from exercise. And I see it all the time, because when we're like, “I don't understand, I'm exercising, but I'm not getting any change. I'm getting tired, I'm getting slow, I'm putting on belly fat. I can't sleep very well. What's going on?” It's like, “Let's polarize the training.” Let's pull it all the way back and think about quality over quantity and putting a lot of push-pull motion from load in there to really strengthen the muscle, create these responses and improve our bone strength. And when we start doing that, we see really good positive outcomes over the course of 12 to 16 weeks.
Cynthia Thurlow: [00:45:27] Now, when we're talking specifically about strength training, do you feel that there's a minimum necessary amount of time per training session? Like, do you need at least 30 minutes or can you do two 60-minute sessions per week? What's the frequency with which you recommend? And again, this is like a high-level recommendation. Everyone's their own bio-individual, what are your typical recommendations or suggestions?
Dr. Stacy Sims: [00:45:53] The further you are in menopause, the more frequent doses of activity that you need. So if you're 10 years or more post menopause, then smaller duration but more frequently across the week is what we see is very effective. When you're in peri and early post menopause, we say three times a week resistance training, and it can be maybe 20 minutes. So we're going in and maybe on Monday you're doing a squat focus. So you're doing some heavy squats and some single leg lunges and then you call it. You're not super setting, you're not spending all this extra time doing our triceps, our biceps, all that kind of stuff? No, we're not after that, we're doing compound movements. Wednesday might be push-pull, where you're doing bench overhead stuff, you're doing bent over row, anything that's upper body push-pull. And then Thursday or Friday, you're going in and you're doing all your posterior chain, right. And so you're hitting major compound movements three times a week, 20 minutes [crosstalk]
Cynthia Thurlow: [00:46:53] These are doable. And that's why I was trying to get you to define that because I think many people here, three to four times a week, and they're like, “Oh, my God, I'm going to be in the gym for 3 or 4 hours. And that's not what you're saying-- [crosstalk] that actually most people benefit. When we're talking about bone mineral density, multidirectional stress, jump training, where do things like weighted vests or belted, you see somebody wear a weighted belt, where do those factor? And do you have a preference for those? Is that part of your suggestions or recommendations?
Dr. Stacy Sims: [00:47:28] No. I look at weighted vests and I get frustrated because I see a lot of injuries that come with them because it's changing center of gravity and center of mass for women, which alters biomechanics. So I see a lot of women who are walking up our big hill with weighted vests, right? And so they're like, “Oh, yeah, I'm putting more resistance on to create a harder workout.” It's like, “Well, you're changing your biomechanics and you're putting yourself in moderate intensity because you can't do a 20-minute up the stairs and hold that intensity where we need you to. Weighted belt that moves the center of gravity back down, but it's still kind of the same thing. I do say if you're going to be doing some sprint training, maybe you warm up with a weighted belt so that when you take it off you can go faster.
Cynthia Thurlow: [00:48:13] I like that. See that seems completely reasonable. Let's just touch on bone health. I know we talked around it, the impact of osteopenia, which is not technically a real diagnosis, but for women that maybe they were on oral contraceptives for a period of time, they missed out on those peak bone and muscle mass building times in their 20s and 30s, that they get a diagnosis of osteopenia. I'm assuming the jump training or that degree of multidirectional stress is going to be of benefit. Where do you feel like, you know introducing HRT kind of fits into that? I'm presuming it's after we've already done all these lifestyle measures. If we're still dealing with some degree of osteopenia or even osteoporosis, that might be the time to introduce the estrogen.
Dr. Stacy Sims: [00:49:04] Yeah. So osteopenia, that low normal or lower than normal bone. We see if you're doing proper resistance training and maybe some impact, not jumping how we all learn with soft knee landing, but actually absorbing the impact into our bones. So you're not jumping high, you're just landing hard. You do that for 12 weeks and we see an improvement in bone. If we're very consistent, consistency matters. We're talking about osteoporosis that takes longer. I have seen women who have been very diligent and consistent in their heavy resistance training four times a week with some plyometric work, after two months of that kind of stuff, phasing in, and then over the course of six to nine months, they get into normal bone mineral density range. So it's possible, but it takes hard work and consistency.
[00:49:58] And if you're someone who's like, “I'm not that consistent, and hit or miss on how hard I work.” Then you might want to think about using some menopause hormone therapy as that transient as you are building that bone and then think about getting off it. Once you've put in those implementations of lifestyle, it's the same thing like with the Ozempic conversation, where people can use it as a tool to help them get weighed off, but they have to put in the work. They have to put in the work, and then they can get off the drug and maintain that work. So it is that tool to improve the outcome, to get to a better starting point. But that starting point doesn't mean that you rely on the drug and then start something. It gives you that buffer of while you're implementing change, you are garnering benefit to a point where once you have all of those lifestyle changes in play and you're really consistent and you're working well, then you can get off the medication and continue.
Cynthia Thurlow: [00:50:59] Now that's very helpful. And for most middle-aged women, one of the greatest pain points is weight loss resistance. And I find for many individuals, they grown up in this diet culture where we count our calories and we exercise to offset what we've eaten. What are your thoughts on CICO? So calories in, calories out, I probably know the answer to this, but I always like to ask this question of guests because I really want listeners to be reaffirmed in understanding that calories are just one of many things that impact our weight. And I think there's too much emphasis and focus on it.
Dr. Stacy Sims: [00:51:37] I hate Christmas time when all the magazines come out and say, “If you have four cookies and you have to run on the treadmill for 30 minutes.” It's like, “No, you cannot out exercise a bad diet.” And it's not about calories in, calories out, because four calories of protein respond differently in the body than four calories of carbohydrate. We see a lot of the weight loss resistance in middle-aged women occurring from gut microbiome issues because we see a significant decrease in the diversity of the gut microbiome when we start losing our sex hormones, when we're losing that diversity. Unfortunately, we're having an overgrowth of the bacteria that responds to stress because our bodies are under a lot of stress with this hormone perturbation, we're seeing an increase in our baseline cortisol or having issues sleeping. All of that is being perceived as stress, which feeds the gut bacteria that creates more obesogenic outcomes.
[00:52:38] And we see that really happening about the three to four years before menopause actually hits. And this is where a lot of women are like, “I'm putting on meno belly so what do I do?” It's like, but we also have to talk about increasing the amount of really good fibrous fruit and veg, because that really does help with that gut microbiome diversity, which increases our ability to change our body composition, but also because we've all grown up in the 70s and 80s in the diet culture and the calories in and calories out. I see so many women who are under eating and people are like, “What do you mean I can't lose weight? I keep putting weight on. I don't understand. I'm training harder and I've cut my calories, but I put on 5 pounds in the past month.” It's because you're not eating enough, right? You cannot change body composition if you're not eating enough. And we hear, “Oh well, your metabolism slows down when you hit menopause.” It's like, “No, it doesn't slow down.” What happens is we stop moving as much because we're so tired from all the changes that are going on.
[00:53:43] But if you're moving on a regular basis, then you also need to fuel for it. I just got through going through a cohort of 10 women who were varying ages from mid-30s to their mid-50s, and they all had the same profile of undereating, even though they were active because they were all following the FitSpo information of calories in, calories out. I need to restrict, I need to do this, I need to do that. And once they increased their food in around their training and they were eating according to their circadian rhythm, all their blood markers looked better, all their body composition changed, and it's like, “Look, food is really important, but it's the quality of the food that we're having.”
Cynthia Thurlow: [00:54:29] Yeah, it's so important. And knowing that you're touching on the gut microbiome, the changes in diversity, this is the area of focus of my next book, so it's completely timely. And I echo everything that you’re saying as someone that for many, many years used intermittent fasting as a strategy to manage the changes that were occurring in perimenopause. I still eat within a 12-hour window. I just don’t intermittent fast. And to be completely fair and transparent, and I’ve said this on the podcast over the last several months, multiple times, in order to put on muscle, which is what I need to do at this stage of my life, I have to eat three meals a day and I have to eat enough protein with each meal. And what I found interesting and I'm going to say this for the first time publicly on the podcast. my goal has been to put on 5 pounds of muscle. And I can tell you that eating three meals a day, when I've gone eating two meals a day for like eight years, I have not put on weight. And I think a great deal of it has to do with the fact I probably unknowingly was undereating and putting on some muscle is allowing me to have a bit more latitude.
[00:55:40] So I kind of enter this as a cautionary tale because I feel like many, many women, to your point, they undereat, they don’t realize they’re over restricting, they don’t realize they’re over fasting, because it just has become their norm. They’re not hungry for another meal.
Dr. Stacy Sims: [00:55:54] Right.
Cynthia Thurlow: [00:55:55] And so I think this is a really, really, really important point to make that we can course correct, we can change things, we don't have to do the same thing. And to your point about having women in their 30s, 40s, and 50s that started eating more food and they're able to change body composition, I think that speaks volumes. So I'm so appreciative that you shared that. One thing that I would love touch on is to talk about protein, because I think many women undereat protein habitually, chronically. And as we get older, we need more protein, not less. Can we speak to this because I think this is such an important point to reaffirm and reestablish so that women understand, like when we talk about nourishing your body not undereating, we really want you to eat the protein because we need more to stimulate muscle protein synthesis at this stage of life.
Dr. Stacy Sims: [00:56:47] Yeah, absolutely. I mean, protein is really interesting. And I always start the protein conversations with, I want people to realize that the recommended daily allowance of protein is based on the least amount to consume per day to prevent malnutrition. We also see that the recommended daily allowance for women is based on older sedentary men who were assumed to have the same body composition as women who are in their 20s and we know that that's not true, different quality of muscle, and old nitrogen studies that don't work. So when we're looking now at protein and what's happening, especially in perimenopause. One, we're becoming less anabolically sensitive to resistance training and protein intake. So we need more, we need more resistance training to stimulate muscle, we need more protein to build that muscle.
[00:57:45] The other thing is what we call the protein leverage theory. So what we're seeing is this loss of lean mass, which is creating a need for more protein. But instead of eating more protein, women are craving more carbohydrate because it's a stress on the body where we're losing this lean mass, we're in a catabolic state. So we need to make a conscious effort to eat more protein in order to preserve and to build lean mass and to prevent that body fat gain. For women who are trying to lose weight as well in that slight calorie restriction, not full calorie restriction to slight. If you have a higher amount of protein intake, then you're preserving and building lean mass and facilitating body fat loss. Whereas if you don't have a high protein intake and you're trying to restrict calories, the first thing that goes is lean mass. So we need to really put that emphasis on protein.
[00:58:37] And in our generation, we haven't had that conversation around protein. It's all about carbs and fat. That's what we've heard from the 70s to now. And now it's protein coming into play and people are like, “Oh, I don't know, how do I eat that much protein?” It's like, “It's not really that much.” If you're thinking that palm size is about 25 g and we're thinking 1 g per pound as a minimum, it's not really that much protein. And you can get it from all sources. You can get it from combination of edamame and seeds and nuts and eggs and yogurt and fish and meat and just a whole bunch of different things and it doesn't take much. If you're having lots of variety of fruit and veg and grains and lean meat and dairy, then you're going to exceed your protein and intake.
Cynthia Thurlow: [00:59:23] Yeah. I think people are oftentimes surprised they forget about some of the plant-based sources of protein that they can use complementary to kind of buffer their protein intake. Now, I'd love to end the conversation talking about supplements. I know that we have some shared supplements that we enjoy. When you're talking to your female subjects or talking on podcasts or publicly, what are some of your favorites that you think for women in perimenopause and menopause can be most beneficial?
Dr. Stacy Sims: [00:59:52] Creatine for one. So good nod of the head there. Yeah, creatine is the good one for all of us. So important because one for women who are eating less and/or following vegetarian, vegan-type diet don't get enough creatine anyway. And we also have less stores than men. We also see that creatine is so important for the fast energetics of our body. So we're talking about gut health, heart health, but in particular brain and brain metabolism. So we really want to push creatine for health. We also can see a benefit for muscle performance. It's only 3 g to 5 g, it’s not a lot. And when we start seeing women who start using creatine, not only do they mentally feel better, they're also seeing better muscle performance. It takes about three weeks to fully saturate though. So it's not something that you just take a one off before training. It's something that you actually want to take on a daily basis.
[01:00:49] The second one that's really important is omega-3 fatty acids, especially in perimenopause for cellular integrity or having more oxidative stress. We need to really protect ourselves. And so omega-3 fatty acids, super important. And the third one I often talk about is vitamin D, because we see such a precedence of low vitamin D intake and low vitamin D levels. We have a lot of the slip slap slop in the sun, right? So we have a hat and sunscreen and a shirt, so we aren't getting that sun exposure. We're also looking at a lot of time inside and the ultra-processed foods aren't doing any good. So we're looking-- if you need to supplement, then a vitamin D3, but also thinking about how mushrooms are your friends, because mushrooms are really good sources of vitamin D.
[01:01:44] So those are the three big ones that I talk about for the most part. And then there are the individuals, like, if you're having sleep issues, you might think about L-theanine. If you're having stress issues, you might look at other adaptogens. And if you're having iron issues, then maybe we look at what kind of carbonyl iron and how to use that. But for the most part most women should really be paying attention to creatine, omega-3s, and vitamin D
Cynthia Thurlow: [01:02:10] I love that. And for women, if they’re listening and say that creatine prompts bloating, it makes them feel like they’ve retained a great deal of water. I know quality is certainly important. And what do you typically say around those kinds of concerns?
Dr. Stacy Sims: [01:02:26] So we want to make sure that you’re using Creapure. So this is a German B2B, so business to business company that is all about how pure that creatine is. So you don’t have any acid leftover, which is from the cheaper versions that can cause some of the side effects. And start small, start with 1.5 g and work your way up to 5. Know that there will be some water retention because creatine pulls water into the muscle cell, but it shouldn't be an overt bloat. If it's an overt bloat, then look at the type of creatine monohydrate you are having. Again, look for Creapure, start at a lower dose and work your way up.
Cynthia Thurlow: [01:03:04] I love that. Thank you so much for your time today. Can you let listeners know how to connect with you, how to find you on social media, how to pick up your books? Your latest book, which I have right in front of me is next level. It's a great resource.
Dr. Stacy Sims: [01:03:16] No, thanks. For all the things that we're doing it's our website, drstacysims.com. It has all the blogs, you can sign up for, the newsletter, it has the courses we're doing, all the books that are coming out, the research that I'm doing. But if you're like, “I don't want to go there. I just want to be on social media.” Sweet. That's good too. [laughter] You can find us on Instagram, @drstacysims, and for those who still use Facebook, we're there and we're also on TikTok. Try to post really good, translatable and transparent science at least four to five times a week. We do some Insta lives and that kind of stuff, but it's just really trying to educate women and men part of the conversation too. Yeah. So that's where you can find me.
Cynthia Thurlow: [01:04:00] Thank you again.
Dr. Stacy Sims: [01:04:01] Thanks for having me.
Cynthia Thurlow: [01:04:04] If you love this podcast episode, please leave a rating in review, subscribe and tell a friend.
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