In this episode of the Everyday Wellness Podcast, host Cynthia Thurlow shares insights from episodes that are invaluable to listeners! Joining Cynthia are Dr. Mariza Snyder (Episode 370), Dr. Suzanne Fenske (Episode 392), Dr. Stacy Sims (Episode 406), and Dr. Mary Claire Haver (Episode 376).
They will cover many essentials related to perimenopause and menopause including recognizing symptoms, strategies to help navigate, and management tools.
Be sure to tune in to strategies and tools to help you take control of your health!
IN THIS EPISODE:
Understanding the hormonal changes during perimenopause and menopause
The concept of perimenopause as a "zone of chaos" due to fluctuating hormone levels
Factors influencing the timing and experience of menopause, including genetics, lifestyle, and medical interventions
Common and lesser-known symptoms of perimenopause and menopause, such as mood swings, sleep disturbances, and cognitive changes
The role of estrogen and progesterone in physical and mental health during this transition
Exercise, particularly resistance training and high-intensity workouts, for managing symptoms and maintaining health
The significance of nutrition, including protein and fiber intake, for overall well-being during menopause
The impact of stress and gut health on hormonal balance and symptom management
The potential benefits and considerations of hormone therapy and testosterone therapy for women
The need for education, awareness, and open dialogue about menopause to empower women and reduce stigma
Connect with Cynthia Thurlow
Follow on Twitter
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Submit your questions to support@cynthiathurlow.com
Connect with Dr. Mariza Snyder
On Instagram
Energized with Dr. Mariza (Podcast)
Dr. Snyder’s books are available on Amazon
Connect with Dr. Suzanne Fenske
On the Tara MD website
On Instagram
Connect with Dr. Stacy Sims
Connect with Dr. Mary Claire Haver
Transcript:
Cynthia Thurlow: [00:00:01] 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.
[00:00:30] Today is an extra special episode completely devoted to essential tips for navigating perimenopause into menopause from top experts including Dr. Mary Claire Haver, Dr. Stacy Sims, Dr. Mariza Snyder, and last but not least, Dr. Suzanne Fenske. I know this will be an invaluable discussion packed with great, actionable information for women in middle age and beyond.
[00:01:00] So, I'd love to start the conversation around some of the terminology that you've utilized about perimenopause. I think for a lot of listeners that have not yet made that transition into menopause, and you coin it properly, you talk about this zone of chaos. Why is perimenopause fraught with chaos?
Dr. Mary Claire Haver: [00:01:20] The best I can explain it is to do some basic endocrinology so people can understand. So, human females are born with all of our eggs, right? We have a finite supply, and menopause really represents when we run out of them. Okay, so in a normal, healthy reproductive cycle, which is probably 85% of women, we have ovulation each month. And the rise and fall of our hormones is dependent on the rise and fall of stimulating hormones coming from the brain. So, let's back it up. The hypothalamus is a big gland in our brain, well, like walnut size and it's constantly sampling our blood supply for estrogen.
And when those estrogen levels naturally get low in the certain times of our cycle, it sends a signal to the pituitary, another gland in our brain, to say, “Hey, make the stimulating hormones so that the ovary can ovulate an egg and we'll get our estrogen levels back up.” Okay, this is a very predictable EKG-like curve each month. So, we know for a certain woman, on day 12, she's going to do this, on day 18, she's going to do that. We're going to have these levels that are very predictable each month. And the brain loves predictability. So, what happens in perimenopause is wherever that is for you, each female reaches a critical threshold of egg supply and also our eggs are aging with us. So, there's also like dysfunction within the egg itself because it's old, for lack of a better explanation.
[00:02:49] So, the same signals that come from the brain don't work as well. We become resistant to those stimulating hormones. So, normal signals get down the ovary, can't quite get the egg out, can't quite get those estrogen levels up. And the hypothalamus gets mad and says, “Hey, where's the estrogen I was looking for?” And the pituitary is like, “I sent a signal” and the hypothalamus says. “send more.” [Cynthia laughs] So, the pituitary ends up getting a bigger burst of this LH and FSH in order to get the ovulation going. And so, we end up with maybe two eggs ovulating that month. And we get much higher estrogen levels typically, than we would have in our normal reproductive years. And then we have this crash of estrogen much lower than we would have in our regular reproductive years.
[00:03:36] And then progesterone in that second half never quite gets up to where it was. So, what used to be this very predictable EKG, like month to month to month to month, suddenly becomes a zone of chaos where we can't predict at any point in the cycle when your estrogen is going to peak, how high it's going to be, how low it's going to dip, and when progesterone is going to come into play. And so, what that looks like in laboratory testing, well, it just depends on the day. And so, it's chaotic. And so, we don't have a great blood test to be able to clearly predict if a woman is perimenopausal. You might catch it, but really, it's talking to the patient, believing her.
[00:04:15] I do a lot of blood work to rule out overlapping symptoms like hypothyroidism and autoimmune disease, inflammation disorders, etc., nutrition disorders. But I'm not doing a lot of hormone tests because I can usually use her symptoms to guide me into her diagnosis.
Cynthia Thurlow: [00:04:33] Some people may not know that our ovaries are as old as we are, but what are some of the more common things that you see that will hasten ovarian aging? Because I think for some people, they may not be cognizant of these.
Dr. Mary Claire Haver: [00:04:45] So, we all have a genetically predetermined shelf life of our ovaries, but we can certainly see that up. So, genetics does play a part. If your mother went through early or premature menopause, you are more likely. It's not 100% correlation. Nothing is in genetics, but genetics plays a very big factor here. Lifestyle is humongous here. Oh, gosh, it just breaks my heart, but when we look at trauma and stress in females. So, one of the greatest studies ever done on this was looking at women who were sexually abused as children, who had children, who were then sexually abused. They happen to look at the age of menopause for these women, and they lost nine years off of the life of their ovaries. Nine years, so we know that stress and trauma play into it.
[00:05:37] We know that exposure to radiation plays into it. We know that nutrition, most likely to some degree, plays into it. We know that smoking, you lose about two years on the ovary. We know that with a hysterectomy, where your ovaries are left behind because we're cutting off a little bit of the blood flow to the ovaries, we lose four years. I did not know this until I started doing a deeper dive outside of the box of what was taught to me. And I cannot believe I did hysterectomies for 20 years without counseling patients that she would go through menopause four years sooner. You have one ovary out, you lose about a year and a half or so.
[00:06:14] And depending on the age of when that happens, you have your tubes tied, you lose about a year and year and a half. Genetics as far as your race, Asian women tend to go through a little bit later, whereas African-American women tend to go through sooner compared to Caucasian patients. So, lots of nuances here in women that age of the ovary, we don't know things that are going to reliably extend the life of the ovary because we don't test for those things, but we do know the things that can hasten your menopause.
Cynthia Thurlow: [00:06:43] Now, you mentioned tubal ligation. So, I think for a lot of women their main focus in terms of having some control over their reproduction. When they're done having the finality of a tubal ligation, what are some of your favorite forms of contraception for women in perimenopause who may be, you know, let's be honest, not every husband is signing up to get a vasectomy.
Dr. Mary Claire Haver: [00:07:07] Vasectomy. Yeah. So, my number one favorite is take it out of her hands and give it to him.
Cynthia Thurlow: [00:07:11] [laughs] Yes, exactly.
Dr. Mary Claire Haver: So, if the patient is having heavy, heavy period and she needs contraception, I love a progesterone-containing IUD because it's going to concentrate progesterone in the lining of the uterus, thin that lining out to where her periods become not a life-disrupting factor. Not enough progesterone escapes that IUD to get into our blood to make a significant impact on our menopause symptoms like sleep and those type of things. But for just contraception and heavy periods, the IUD can be a wonderful form of contraception. I used to be a fan of tubal ligation, especially if she was having a C-section. She knew she was done with childbearing. This is so easy. Just with the caveat, I would now say we're going to lose about a year, year and a half off the shelf life. If you're over, we're going to monitor you a little bit closer as we get to those ages and pay attention to that.
[00:08:06] So, I still really like it because it's nonhormonal. I'm in there anyway doing a surgery. To do a tubal ligation on someone who is otherwise healthy and normal, again, it's a nuanced conversation. If this is what she wants and she's absolutely, I don't care what age she is or how many kids she has, that is her decision. But I'm going to talk about all the options with her and let her make a decision.
Cynthia Thurlow: [00:08:30] Yeah. I think it's so important because many of us again may not be aware of these limitations to some of these options. Now, one of the most common symptoms that I see in women in perimenopause and so many of my clinical cardiology patients were on antidepressants, antianxiety agents, largely because of this, these fluctuating levels of progesterone. Let's talk a little bit about mental status changes because there's so much interplay between our sex hormones and these neurotransmitters and how this can show up in perimenopause in particular.
Dr. Mary Claire Haver: [00:09:08] So, this is one of the most poorly understood faction, probably one of the most important factions of perimenopause. And couple months ago, I went to a conference in Chicago and we had four sections and Dr. Sharon Malone and I did HRT. It was a whole section on cognition and psychiatric changes. There were two neuroscientists and a couple of menopause specialists. And I just was floored. And they really did a deep dive into the data. So, what we know is that our neurotransmitters, these are the chemicals where the nerves in our brains talk to each other, serotonin, dopamine, GABA, norepinephrine, epinephrine, all of them are really, really affected by the changes in our sex hormones. So, estrogens rise and fall.
[00:09:55] There's one thing about estrogen plummeting that's post menopause, but you go into chaos and perimenopause and the brain hates chaos. And that is leading to the cognition changes and brain fog, sudden increase in brain fog, memory, can't remember your keys and women are quitting their jobs, surgeons are quitting because they're terrified, they're going to hurt a patient. And sleep disruption is huge with progesterone disruption and the mental health changes. So, the data coming out of Australia looking at the mental health changes across the menopause transition, so we double the rate of SSRI use, antidepressants from 10 to 20% across the menopause transition. So, one in five women after menopause will be on an antidepressant. And these are important medications and I use them, but they are being used as a panacea for menopausally related mental health changes.
[00:10:47] And the data is now clear that in a perimenopausal patient, treating her with hormone therapy is more effective and more efficacious than treating her with the traditional antianxiety antidepressant medication. And it is going to be a while before every practitioner who treats the female patient understands this. So, like you're spreading the message. We're all trying to spread the message, those of us who are educated, so that patients can get the greatest benefit because it's more effective than these SSRI.
Cynthia Thurlow: [00:11:15] Yeah. And it's interesting to me just how many women I saw in their late 30s, early 40s that were on multidrug therapy.
Dr. Mary Claire Haver: Yes.
Cynthia Thurlow: [00:11:26] And really what they probably needed was some progesterone to help with sleep, to help with cognition and something else that I see emerging. I'm not on TikTok all the time, but when I am on TikTok, something that I find interesting is seeing younger women. So, let's talk about average age of menopause, 51, 52, premature menopause versus this premature failure-
Dr. Mary Claire Haver: [00:11:49] POI,
Cynthia Thurlow: [00:11:50] -or POI which is the new term. I'm seeing 20- and 30-year-olds that are haven't had a period in years and they're not on contraceptives. So, let's talk about this because it's not benign, it's not a benign entity.
Dr. Mary Claire Haver: [00:12:03] It's not benign at all. And the earlier you are when you lose your ovarian function, as in menopause, regardless of the title, we put on it early, premature, whatever, the more risk you have. The longer your body is forced to live without the benefit of your natural estrogen, the less healthy you're going to be. You accelerate mental health, you accelerate cardiovascular disease, you accelerate insulin resistance, you accelerate obesity, all of it goes up.
[00:12:31] And so these women who are having earlier menopauses and not being counseled appropriately and not being offered appropriate treatment because if you're early, you don't need menopause hormone therapy dosing, you need to be dosed as a premenopausal woman, okay, you don't need to be treated like a 60-year-old, you need to be treated like a 30-year-old and give her back those levels which are higher. And these poor women are being shelved, not diagnosed adequately, not being treated adequately. And it's heartbreaking to me because I know that their lives, their cardiometabolic function is going to be much harder than the age matched person who went through menopause 20 years later, 10 years later, would have had. And I think it's a travesty and I think it's malpractice.
Cynthia Thurlow: [00:13:14] Now, when we talk about some of the changes that are happening in menopause, I think that certainly on this podcast we talk a lot about loss of muscle, sarcopenia, loss of insulin sensitivity. What do you think are some of the lesser-known changes that maybe most women are surprised to hear are occurring behind the scenes or maybe don't show up until little bit later.
Dr. Mary Claire Haver: [00:13:35] So, certainly when we look at cardiometabolic risk these things go up with aging. So, there's that, right? We're all getting older, but when we look at age matched women, because we all go through menopause at different ages, so fortunately, people have looked at this and they take like 50-year-olds because half of us will be menopausal and the other half weren't because the average age is like 51. And they match them for everything other than menopausal status. And they look at insulin resistance, triglycerides, cholesterol levels, diabetes, and hypertension. It is astounding the changes that are happening simply from the loss of hormones.
[00:14:10] So that's what shocks a lot of women when I blow up the Internet, when I talk about cholesterol and what I'm seeing with my patients, vitamin D levels plummeting, multiple reasons for that, but really having to function without a normal, healthy vitamin D level when we look at. And then what's also happening is the loss of bone, which accelerates, happens with aging. We reach our maximum bone density, about 35. It starts trending down and then really plummets across the menopause transition. And as a medical community, we are doing a terrible job at helping women understand the impact of this and diagnosing it early enough to make a real significant impact. And so, palpitations, these poor women are showing up in the ER with night sweats, so they come in sweating. They come in with pounding heart rate. They get in an appropriate workup for menopause.
[laughter]
[00:15:10] And so, they're ruling out all these catastrophic things, which, “Okay, you're in the ER.” That's what they do. But no one, at the end of the day, they're saying, “Okay, you're normal. go home.” But no one is suggesting that all of this constellation of symptoms could be your menopause. And it's not the clinician's fault. It's the fault of the medical system that we're not training all these clinicians, not just OB/GYN like me. Why should it be dumped in my lap? I'm busy doing C-sections and Pap smears in my former life. This should be any clinician who touches a female patient should have a breadth of knowledge about how unique she is and how her health needs change with menopause.
Cynthia Thurlow: [00:15:36] Yeah. And I think it's interesting because even working in cardiology and how many patients had atrial fibrillation? So, I had many, many menopausal patients that had atrial fibrillation. And understanding that interrelationship between estrogen and this propensity for atrial arrhythmia is bothersome. They can cause strokes. They're not nearly as problematic as ventricular arrhythmias. But still, how many patients came in with chronic palpitations and we put monitors on them, and we'd see, a couple premature beats, and we'd say, “Oh, everything's fine. If it's really symptomatic, we'll give you a beta blocker.” And then that created another constellation of symptoms that they then dealt with, which it's with good intent, but you're absolutely right. If we had some awareness, we could at least counsel patients. Maybe it's time to go back and see-- [crosstalk]
Dr. Mary Claire Haver: [00:16:22] Let's do a trial of hormones and see if it gets better.
Cynthia Thurlow: [00:16:24] Exactly. Such a benign way of addressing things. What are your thoughts surrounding body composition changes as we're navigating this transition? Because I think many women, as they're navigating, they'll say, “I'm still doing the same exercise, I've changed how I'm eating, my sleep is dialed in, my stress is dialed in, and yet I seem to have more body fat and less muscle mass.” What is the way that you like to evaluate this? Because I know there are people that will remain nameless across social media that will talk a lot about MRIs. And that's great. If you can afford that, that’s fantastic.
Dr. Mary Claire Haver: [00:16:56] Oh, an MRI for muscle. Yeah. Who can afford that?
Cynthia Thurlow: [00:16:57] Exactly.
Dr. Mary Claire Haver: [00:16:58] I don’t do that.
Cynthia Thurlow: [00:16:59] No, no. I had a guest on recently and he was talking about that. I was like, “Well, that's great.” Most people probably can't afford that. But what are some of the ways that you like to evaluate fat mass to muscle mass?
Dr. Mary Claire Haver: [00:17:08] So, for visceral fat, it's not perfect, but it's much better than your weight or your BMI is doing some kind of a waist-hip ratio or looking at waist circumference. And that's a really nice way to track your efforts to see if the waist versus your hips is getting smaller. It's a reasonable marker for visceral fat. Again, if you have a diastasis. I mean, there's a million different things you want to do in the morning when you're not bloated, etc. But that is clinically something that is super easy for people to use. I took it a step further in my clinic, and I have an electrical impedance scanner.
[00:17:40] The in-body scan is the brand that I use, and I have the highest grade with the most electrodes on it, and it basically runs a current through your body that bounces off, for lack of a better word, different compartments. So, muscle, fat, water, etc. And it's able to give me a reasonable estimation of visceral fat versus subcutaneous fat and then muscle mass as well. So, when I'm individually counseling patients about what are our risks moving forward quite often my obese patients have wonderful muscle mass. Turns out they've been wearing a weighted vest their whole life. They have to work harder just to go to the bathroom and do things. And so, I'm first of all giving them high five for having wonderful muscle mass.
[00:18:20] And then we direct the conversation around fat loss and what that's going to look like for her. What we know is that women on hormone therapy, we can attenuate their visceral fat accumulation across the menopause transition. With HRT again, you still have to eat the things, you still have to move, you can't get around the whole package of what body composition. But hormone therapy can be a tool in that toolkit that is going to make your efforts easier.
Cynthia Thurlow: [00:18:48] When we think about symptoms around menopause, some of them are obvious, like vasomotor symptoms, mood changes. But some of them are less common. And so, I think a lot about vertigo, tinnitus, dry skin.
Dr. Mary Claire Haver: [00:19:04] Yeah, vertigo, tinnitus, dry skin. They're more when like--, I don't want to get this wrong ever now-- one of the two telemedicine companies and I can't remember which one, did a review of symptoms with their patients or with their people who were inquiring. So, they have thousands of women, thousands and thousands and thousands and said tell us what your symptoms were like. And of course, hot flashes were up there, but they were number five. Okay. Sleep disturbances, mood disturbances, weight gain were the top three. Those were almost universal. 80 to 85%, 90% of women were complaining of the same things. It's just we were only able to blame hot flash and menopause, outside of tuberculosis, women don’t have hot flashes and that's easy to rule out with a skin test.
[00:19:52] But now that we have to broaden the definition of what menopause symptoms look like, we're learning so much more. And so yeah, tinnitus and vertigo blow up the Internet. Women are like, “Wait, what?” I did one the other day on TEDx Talk. Yeah. Because of the estrogen, such a powerful anti-inflammatory, we see this resurgence of atypical asthma, which is probably menopausal asthma, typical for a menopausal woman. [laughs] I mean it's just absolutely-- and she doesn't respond to the typical inhalers. She needs estrogen and probably some anti-inflammatory till the estrogen catches up. But she doesn't respond to atrophy-- or I forget all the names. I don't do medicine anymore. But outside, yeah, I don't do pregnancy and that's when we were treating asthma in pregnancy.
Cynthia Thurlow: [00:20:37] Yeah.
Dr. Mary Claire Haver: [00:20:37] So yeah, every time I turn around, the one that really kills people is frozen shoulders. So, the musculoskeletal syndrome of menopause, that's another one that's in the top five, 80% of us will have it and for 20% of us, it is the most debilitating symptom. And forever it's like, “Oh, get an x-ray, it's not broken.” Okay. “Oh, get an MRI, ta, ta, da.” It's literally loss of the anti-inflammatory effects of estrogen. And now we pulled that blanket out and you are kind of naked and so you're seeing the residual effects of that.
Cynthia Thurlow: [00:21:09] Well, and it's so interesting because I follow Vonda Wright and she'll be a podcast guest in a few weeks. And I had more questions come in around knee pain, shoulder pain, ankle pain, foot pain. I mean, just one thing after another. And people saying, like, “I've been x-rayed, my x-ray, I didn't break the bone. I don't know what else is going on.” And so, if you're listening and you're one of these individuals, it could very well be a manifestation of this low estrogen state that is driving the degree of inflammation you're experiencing. Now, one thing that I find really fascinating is that as women are navigating perimenopause and menopause, there's a profound net change in the gut microbiome. And I know there's been a lot of emerging research around this.
[00:21:51] Let's talk about some of the things that you're seeing with your patients that's relevant to this community because it can explain why we're at greater risk for opportunistic infections.
Dr. Mary Claire Haver: [00:22:01] Sure. So, I think ZOE's done the best work here. The ZOE nutrition study, they actually tracked the gut microbiome through the menopause transition with hundreds of women. And they saw lack of diversity and more overgrowth of the, “bad bacteria” and our nutrition needs change through menopause. We can't deny that. And so again, the 30-plant challenge can be huge here. So, I talk to the patient. What's also changing is the estrobolome, which is how, the gut microbiome is also responsible for some of the ways that we metabolize estrogen. So, it starts in the liver and then it gets excreted into the biliary tract and then out into the poop, but the gut microbiome has its own little factory where it's kind of recirculating estrogen levels a little bit.
[00:22:51] And so the full impact of that, we're not sure, we need more studies. We know there is an impact, especially in perimenopause when our estrogen levels are fluctuating so much. And so, a healthy gut is always best maintained with healthy nutrition, with eating the plants and eating the things. And the more colors, we eat the rainbow and Galveston diet or the more variety of those plants, the better off your gut microbiome is going to be and of course probiotics refeeding the pond. And so, the body always prefers. We get that stuff naturally through food. But if you can't tolerate yogurt or you don't eat kimchi or miso or other things, Chinese pickles that are rich in natural probiotics, it's reasonable that decent studies looking at a probiotic supplement.
Cynthia Thurlow: [00:23:36] Yeah, it's so interesting how it really does start with nutrition. And yet as a culture, we like novelty, we love supplements. And I'm like, okay, there's a place and a time for a lot of these things, but this is really where it becomes very, very important. I want to make sure we at least touch on. There was a study that you talk about in the book that said, “The Journal of Menopause reported that women that used estradiol or estrogen at age 50 could expect to live up to 2 years longer-
Dr. Mary Claire Haver: [00:24:08] Yep.
Cynthia Thurlow: [00:24:09] -and a 20% to 50% decrease in dying from any cause.”
Dr. Mary Claire Haver: [00:24:14] Per year. Yeah. So, the all-cause mortality in a woman is lower significantly on a woman with hormone therapy than without. And that comes out of the Women's Health Initiative data. So, two of the medications were so antiquated we barely use them. Premarin and medroxyprogesterone acetate, both the Premarin only arm and the combined arm show decrease of all-cause mortality year per year. And I think we have better products now we're giving our patients. It's just no one's really studying us right now because of the drama of the WHI everyone's terrified. But when you go back and look at that data, it is clear we're going to live longer. At the end of the day, women are living longer than men and here's what I want to see.
[00:25:03] Women are living longer than men three to four years. Okay fine. But that trade off, is that they're living not just those three to four years, but 20% to 25% of their lives in poorer health than their male counterparts. Okay, so we are much more likely to have a longer protracted course of debilitating disease than our male counterparts. Men live fairly functional, then die quickly. Women have a long slog in general to decline cognition deficits, they end up in long-term care facilities because they can't move and they can't think and they can't take care of themselves. And so, hormone therapy seems to attenuate that significantly.
[00:25:47] And I'd like to see, as more women are getting brave like myself staying on hormone therapy well outside of the 10-year range what that's going to look like for my longevity and my health moving forward.
Cynthia Thurlow: [00:26:01] I think it's really important. I have a family member that was just moved into memory care, has end-stage Alzheimer's, was not on HRT because she kind of fell into that WHI timeframe. And I had a conversation with her on Saturday and yesterday and she said, “I know my brain's not working right. Why is this happening?” And it's heartbreaking. absolutely heartbreaking. And when I looked around the room of individuals that are in this memory care, easily 95% are women.
Dr. Mary Claire Haver: [00:26:31] Yeah.
Cynthia Thurlow: [00:26:32] And all in the same kind of situation and circumstances and she's getting excellent care. But it's something that is so profoundly preventable and that to me is heartbreaking.
Dr. Mary Claire Haver: [00:26:44] So, there's a beautiful book written about this. There's two books she wrote. Lisa Mosconi wrote The Menopause Brain and she also wrote The XX Brain. And for anyone who was worried about this, especially if you have a family history, please pick up those books. Because she doesn't just address the role of estrogen in the brain, which is humongous because Alzheimer's is a disease with symptoms in old age that begins in midlife. Now is the time for us to start making these interventions. She talked about nutrition, exercise, and how all of that is going to play into the risk of you developing Alzheimer's with the [unintelligible [00:27:20]. So just incredible data there for those of you listeners that are concerned about this area, I touch on it in The New Menopause. There's a whole book written on this.
Cynthia Thurlow: [00:27:32] Well, I know when I read The XX brain, it was the first time that I felt like a little switch went off in my brain. And I thought, this changes everything. Understanding what's happening physiologically in the brain. Now, before we wrap up today, I know you touched on some of your favorite supplements or equipment. Let's give, like Mary Claire's top five. If someone's listening these are the game changers. These are the things you recommend most frequently to your patients.
Dr. Mary Claire Haver: [00:28:01] So again, full disclosure, I do sell supplements. So, go buy them wherever you feel like you-- But always try to get nutrition [unintelligible [00:28:07]. However, vitamin D, really hard for us to keep our levels up. Okay, 80% of my patients are not just low, I mean deficient in vitamin D probably because the gut, they can't absorb it the guts aren't as healthy. We're protecting our skin against the sun for good reasons. And that's just leading to low vitamin D levels. So, if you're struggling to maintain vitamin D level 60 or above, you want to consider a vitamin D supplement. In the ones I have, I add vitamin K and I add some omega-3 fatty acids because they play well together on vitamin K unintelligible [00:28:42] absorption, one.
[00:28:42] Recommendation number two, get a nutrition tracker, free one. MyFitnessPal, I use chronometer. Get the free one, track what you eat for two or three weeks. Eat healthy and then look to see where your deficiencies are. Are you getting enough FRDA magnesium? Are you getting enough calcium? I don't routinely recommend a calcium supplement. I recommend you getting calcium from food. Calcium supplements have never been shown to decrease your risk of osteoporotic fracture and the cardiologists hate it. They think that it increases the risk of calcification of your atherosclerotic plaques. Also increase your risk of kidney stones. So, get your calcium from food. There's not a good substitute for that. Fiber, great studies on fiber and cognition and they looked at dietary fiber plus a supplement. And this was in 60, 70, 80-year-olds who were in long-term care facilities.
[00:29:29] And so the higher level your fiber up to 30, 35 g for female, the higher your cognition scores. Fiber feeds the gut microbiome. Fiber speeds up transitive of stool through the colon. Fiber decreases the rate at which we absorb sugars into our bloodstream. There's nothing bad I can say about fiber. Most of it should come from food. If you have to supplement, we have supplements out there. Number three magnesium. I love magnesium. I use it for sleep. [laughs] So, I like the magnesium L-threonate for sleep. It has pretty good studies showing it crosses the blood brain barrier. There's lots of great magnesium out there that do get your levels up. We have a hard time nutritionally getting magnesium up.
[00:30:10] You want to try to get it from food because foods that are rich in fiber, foods that are rich in mag, foods that are rich in calcium, they're in a package with a lot of other healthy stuff. So with a spinach leaf, you can hit so many birds with one stone and using food to figure out those nutrients I think is going to be key. Turmeric, I don't recommend for everyone, but if you're struggling with arthritic pain, it does seem to be pretty helpful. And in some patients, they did see decrease in visceral fat, probably from the anti-inflammatory benefits. Not a menopause cure. I don't sell menopause cures. I'm selling ways to support your nutrition which is struggling through the menopause transition. Oh, and collagen--
Cynthia Thurlow: [00:30:55] [laughs] I have to ask. So, for you, as a menopause expert, as someone that is so well respected and really helping to change the narrative, how do you feel when you see predatory advertising for women at this stage of our existence?
Dr. Mary Claire Haver: [00:31:13] It makes me so sad because these people send them to me all the time and you have to go down these rabbit holes and they're promising you miracle cures. “Get your sexy back, you'll feel like you're 25 again.” All of these things and women are so desperate and they've been dismissed and it really, really is predatory for such a vulnerable population who have struggling to get their voices heard and it just kills me. So, I try to take them down as much as I can, but again, it's like whack a mole. You hit one over the head and then 10 more pop up. So, to your listeners, buyer beware. There really isn't great menopause cures out there.
[00:31:53] There are certain supplements that might help your body as it's adjusting to the loss of estrogen, but nothing's going to replace the estrogen in your body. Now, you can be healthy without hormone therapy. It's just harder. And I like to stack the deck in my favor and so, and my patients are coming to me for that same thing. But it's not required for you to live a healthy, happy life. It just may make your life a lot easier.
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Cynthia Thurlow: [00:32:19] The other thing that I wanted to mention is that doses of estrogen in oral contraceptives have tremendous range, anywhere from 20 to 50 mcg. 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 [crosstalk]. I'm like, “That's the pill.” [laughs] That's not actually menopausal hormone replacement therapy. That's actually quite different.
[00:33:21] 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. 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: [00:33:45] Yeah. I did my [unintelligible 00:33:45] 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.
[00:34:26] 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.” “Oh, 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.
[00:35:14] 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. And so, there's 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.
[00:36:05] 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 menopausal hormone therapy for helping with bone at that end of things. 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 on menopausal hormone therapies, when they're 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.”
[00:36:49] 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: [00:37:16] Yeah, I love that you're 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.
[00:37:48] 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, like 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: [00:38:21] 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 hormones flux our brain as well. We also see that there are times where we can recover better and there are times where we don't. And so, we see that our hormones affect everything.
[00:38:57] 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, remember when we're talking about puberty, how everything's all over the show and we need to teach 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.
[00:39:38] So, when we're looking at those factors, we know that estradiol or E2 or 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 in insulin. 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 of the visceral fat, we're starting to see more inflammation and oxidative stress. We're seeing a misstep in our brain metabolism because it's is becoming hypometabolic, meaning that it's not using blood glucose very well.
[00:40:35] 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? So, as we get older, we look and see how important resistance training is. And I don't mean booty bands, I don't mean the five pound dumbbells, [Cynthia laughs] 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.
[00:41:21] 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 used to be responsible for those three things. When we're looking at 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.
[00:42:14] 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 the cereal 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. 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.
[00:43:09] 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. 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 those problems that people are talking about, why they should be going on menopausal hormone therapy for looking for brain health, resistance training, and high intensity work.
[00:44:05] 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. Muscle is 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 crosstalk 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. So, when we're looking at what do perimenopausal women need to do, they need to polarize their training, making resistance training the bedrock.
[00:44:51] 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?”
[00:45:42] 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: [00:46:05] 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 minutes 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: [00:46:30] 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 supersetting, 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. And so, you're hitting major compound movements three times a week, 20 minutes.
Cynthia Thurlow: [00:47:31] Yeah, 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've 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 and 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: [00:48:09] I hate Christmas time when all [Cynthia laughs] 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 4 calories of protein respond differently in the body than 4 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. And 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. We're having issues sleeping.
[00:49:03] All of that is being perceived as stress, which feeds the gut bacteria that creates more obesogenic outcomes. 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 minnow belly, so what do I do?” 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, calories out. I see so many women who are under eating and people are like, “What? 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 five pounds in the past month.”
[00:49:56] It's because you're not eating enough. 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. 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 increase their food in around their training and they were eating according to their circadian rhythm, all their blood markers look 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: [00:51:01] 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.
[00:51:43] 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 five 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. 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.
[00:52:27] 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: [00:53:19] Yeah, absolutely. Protein's 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'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 resistance training to stimulate muscle. We need more protein to build that muscle. The other thing is what we call the protein leverage theory.
[00:54:19] 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.
[00:55:06] So, we need to really put that emphasis on protein. 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 intake.
Cynthia Thurlow: [00:55:55] Yeah, I think people are oftentimes surprised they forget about some of the plant-based sources of protein that they can use complimentary to 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: [00:56:23] 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. And we also can see a benefit for muscle performance. It's only 3 to 5 g, 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.
[00:57:15] 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. 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 our cells 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. 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.
[00:58:04] 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. So, those are the three big ones that I talk about for the most part. And then they're 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: [00:58:42] 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: [00:58:58] So, we want to make sure that you're using Creapure. So, this is a German B2B. It is a 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 g. 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're having. Again, look for Creapure, start at a lower dose and work your way up.
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Cynthia Thurlow: [00:59:40] And I thought it would be relevant/timely for listeners that have not yet crossed over into the menopause valley. For so many listeners that are in their mid to late 30s, early 40s and are trying to make sense of a constellation of symptoms. Let's talk about, because it's not pejorative “warning signs of perimenopause.” Because I still think that there's a lack of understanding, there's a lack of education by a lot of healthcare professionals. There are many of us that are doing a great job around this, but many others who don't really prepare their patients and their clients for what is to come. So, in your experience, what are some of the big warning signs that maybe get overlooked or women are gaslit probably the number one being weight loss resistance.
[01:00:30] It's like, “You're 40. Maybe this is just the way things are.” That's certainly what I heard.
Dr. Mariza Snyder: [01:00:34] Oh, yeah. Oh, my goodness. Just infuriating. [Cynthia laughs] Well, let's start with some of it because it's a-- Again, this is a journey. It's a continuum that could last, sorry ladies, 10 plus years. And so, in a lot of ways, it can be gradual. For some, not so much. But because, as you know, natural menopause can happen anywhere between 45 and 55 years old. That means that perimenopause, which is the transitional period to that one defining moment, that one day that you haven't had a period for 12 months. It is a process. It is a journey. And I call it a reckoning in so many ways. [laughs] But that means that some of us can start to experience warning signs or symptoms as early as our mid to late 30s.
[01:01:19] And what I'll normally see in the beginning, often they'll say that your period stops or your period's changing and that's a lot of what the literature indicates, that perimenopause, one of those signs of perimenopause is that you just have irregular periods. And I wish that's all that there was, but I rarely have ever had a woman come to me and say, “I think I'm in perimenopause because my periods are becoming irregular.” No, there's always symptoms that come up right before or many years prior to, even when your menstrual cycle begins to shift and become more irregular. So, those early signs and warning signs, I guess, in terms of peri, are often in relation to the low progesterone. That was definitely, for me, what I noticed out the gate. I'm like, “What is this?”
[01:02:04] And for many of us, that'll often be in that luteal phase, that late luteal phase, that's when we have progesterone. And it's that late luteal phase where our PMS symptoms, what they are but then I find that they get kind of amplified. So, women will notice a lack of stress, resilience, all of a sudden things that they could handle, they're not able to handle as well. They find themselves just a little bit more or maybe a lot more irritated than they used to be, maybe noticing other mood changes, like more anxiety, more depression, more rage called the perimenopausal rage, sleep issues. Yeah, and you start to notice that weight resistance, the bloating that begins to happen towards the end of that second week of the luteal phase.
[01:02:46] So, those will be some of the early warning signs I'll notice for women in perimenopause. And then as time goes on, symptoms begin to really ratchet up. And so, women will start to notice a lack of word recall, a lack of alertness, more fatigue, especially in the middle of the day. They'll begin to notice the weight resistance, as you've mentioned, all of a sudden, even if the scale doesn't move there, the fat has relocated to the belly and not where it used to be. And so, and it's not as easy as it used to be. They may notice themselves less strong in that they're losing muscle mass.
[01:03:22] And then obviously some of the more kind of what I consider to be really overt symptoms, like palpitations and itchy ears, itchy scalp, again, like severe low energy, we start to notice a slew of symptoms as they move into that second phase of perimenopause, the late perimenopause, where estradiol and progesterone are beginning to drop. Estradiol is also wildly fluctuating.
Cynthia Thurlow: [01:03:46] It's really interesting to me because if you look at the way estrogen is distributed over the course of perimenopause, we have some of the most wild fluctuations of our entire lifetime. And it does that for a while. And then toward the latter stage of perimenopause, things kind of drop off a cliff. And what I find so interesting is that most of what I experienced as a woman was magnified times 10. I had those crime scene periods, I had trouble sleeping, I was weight loss resistant. But all those quirky things that-- your dermatologist will just give you a steroid cream for the skin itchiness. And colleague of mine just reached out the other day and said “She has seen five specialists for itchy skin.” And I finally said, “Does anyone talk to you about estrogen?” And she said, “No.” And she said, “I'm going to go ask for a prescription immediately because I'm tired of being itchy inside my ears.” You mentioned the scalp, but she said her entire body is just itchy and she's done everything.
[01:04:44] When we're thinking about strategies for navigating perimenopause into menopause, We've talked a little bit about macros, we've talked about continuous glucose monitors, wearables, things like that. Thinking about fiber, what are your thoughts about what is the most efficacious way to be exercising? So, exercise in and of itself is not what we do to lose weight. So, I think that's one kind of reframe that I think many of us have to kind of wrap our heads around.
[01:05:15] What are some of the things that you do in terms of physical activity that you feel like are the biggest needle movers for you at this stage of your life?
Dr. Mariza Snyder: [01:05:23] I've come from years of exercise burnout. I would say that exercise was probably the Achilles heel that really finally tipped me over for Hashimoto's thyroiditis and so I have recovered from some pretty intense HIIT training classes over the years. But what's important to me, and I think that's important to all of us, is that I want to be able to throw my luggage into the overhead compartment at 5’2, I want to be able to pop up from the floor, I want to be able to pick up my sick 3.5 year old off the floor if he just doesn't have the energy to do it and not even bat an eye. And so, strength is so critical to me.
[01:06:05] And so the thing that I prioritize, three to four times a week is strength training and with progressive overload so that I'm getting stronger over time. But the other thing that I really do feel like it's probably the magic bullets is walking. I walk so much. I walk in the sunshine as much as possible. I walk after dinner, I walk after lunch, I try to walk after breakfast. I would say that I walk probably four to five times a day. Like if I have a 10-minute window between two meetings, I grab shoes and I'm out the door, that is what I'm doing. And I clock somewhere between 12,000 and 15,000 steps a day. And I'm not necessarily doing it for the metabolic aspect.
[01:06:47] More so for me it's clearing my mind, it's a moment to myself, it's recalibrating my stress response system, it's telling my body that I'm safe and it's something that I just get to do for me. And as a mom and an owner of a company no one gets to mess with me. I'm so protective of my time and walking is one of the most beautiful ways that I do that. And again, there's so many beautiful benefits. Like, I've worn a continuous glucose monitor on and off for almost three years now. And I will say that, hands down, if I want to get my blood sugar back into optimal range, which for me is 70 mg/dL to 110 mg/dL, girl, I'm looking for optimal. Okay. The walking is the ticket.
[01:07:27] So, if you wanted to bank on longevity, I think for all women or all people listening, like, that's the way to do it. And when you get to do it with family, you get to connect in that way. It's just a beautiful way to boost that oxytocin and to get kind of calm, that nervous system energy.
Cynthia Thurlow: [01:07:43] Yeah. And I love that you really emphasize you're doing this throughout your day. It's not like you walked for three miles or four miles in the morning that you integrate this throughout your day. And you've seen significant health benefits.
Dr. Mariza Snyder: [01:07:55] Yeah.
Cynthia Thurlow: [01:07:55] The one thing that I've really been disciplined about doing for the past year is wearing a weighted vest.
Dr. Mariza Snyder: I know. I love it. You look good. [laughs]
Cynthia Thurlow: [01:08:02] I only started featuring it on social media, because I kept saying, “I talk about it and I'm not showing people what I'm doing.” And, it was interesting. It was humbling because you put the weighted vest on and it's balanced. I started with 10% of my body weight, and I remember saying to my husband, the first time I wore it, I could go about 15 or 20 minutes. And then I just felt like, “Oh, my gosh, so much more weight on my frame.” Having said that, I think it's so helpful to know that it gets my heart rate up into that solid zone too. For me, I do feel like the one thing I've really noticed is I've been hungrier. So, to me I kind of convey that I'm doing more benefit to my body.
[01:08:41] It's a little bit more hormesis or hormetic stress, but not in a negative way. It's not like I'm not recovering. And I 100% agree with you that I am really cognizant of getting on and off airplanes and lifting my own bag. And I'm sure there's lots of wonderfully chivalrous human beings out there who always graciously offer. And I always say, “Thank you, but no thank you.” I need to do this because one of the things that precedes muscle loss is strength loss.
Dr. Mariza Snyder: [01:09:07] Yeah.
Cynthia Thurlow: [01:09:07] And so that to me is something I want to avoid. The other thing that I have found to beneficial is trying to balance one leg. So, balance work is important. Like my husband will sometimes look at me like, “What are you doing?” I'm like, “I'm putting on my shoe, I'm tying my shoe and I've got one leg bent and I'm doing it to balance.” And I said, “Balance is really important.” As we're getting older, it's not only telling our bodies where we are in terms of proprioception, where we are in time and space, but also shows it me where I need to do more work. [crosstalk]
Dr. Mariza Snyder: [01:09:39] Yeah, I do a lot of unilateral training. Yeah, I'm always testing one side of the body, either one leg or arms. So, I do a lot of unilateral training and gosh, it is so-
Cynthia Thurlow: [01:09:50] Humbling.
Dr. Mariza Snyder: [01:09:50] -humbling. I also brush my teeth with, [crosstalk] I'm left-handed, so I brush my teeth with my right hand. And yeah, it's always, it's all very humbling. I love Zone 2 training as well. I probably do it three times a week. It's not my favorite. I would much rather lift weights and just go for walks. But I'm committed to my cardiovascular health. I do some sprint training too. Not as probably as often as I should, but whatever. And I've been wearing a weighted vest at all. I'm at 10 pounds. That's where I'm at right now and that's working for me.
[01:10:20] And yeah, it is a very humbling experience. But it's such an easy thing to do to add to your walking routine or workout.
Cynthia Thurlow: [01:10:29] Absolutely. And again, 10% of your body weight. So, my husband bought me a 20-pound vest and I put it on and I was like, “Oh, that’s a little heavy.”
Dr. Mariza Snyder: [01:10:36] Yeah. [laughs]
Cynthia Thurlow: [01:10:37] It is little spicy. I'm not ready for that.
[laughter]
In terms of managing stress and addressing sleep, what are some of your favorite ways to support both? Because stress is part of life.
Dr. Mariza Snyder: [01:10:50] Insidious. Yeah.
Cynthia Thurlow: [01:10:51] Right.
Dr. Mariza Snyder: [01:10:52] And part of life.
Cynthia Thurlow: [01:10:53] Yes. It's kind of like I don't know anyone who lives a stress-free lifestyle, but obviously healthy boundaries and finding ways to manage the stress that we do have that sometimes we have no control over.
Dr. Mariza Snyder: [01:11:05] Mm. I would say that if you ask friends of mine, definitely if you ask my husband, I am the boundary queen and because I was boundary list for so long. So, boundaries I think are super Important. But I think boundaries even around how you live your life. And so, I have boundaries around my sleep. I fiercely protect my sleep. Like it's a million-dollar meeting. And unless you are my million-dollar meeting, like you cannot interrupt [Cynthia laughs] Including my husband. I'm like, “Huh ah, like get out.” So, fiercely protecting my sleep. I kick off my sleep routine in the morning. Yeah, I try to be up before my family's up and family, I mean my son, my toddler. And I'm outside in, well, it's sometimes gloomy, I'm on the coast, but I'm outside in the sun or outside for at least 5 to 10 minutes.
[01:11:52] Usually walking, just walking around, just up and down the street. I know I shouldn't go too far. Because my son's going to be looking for me pretty quickly. So that's one of the best ways I know to help to support my sleep. And then in the evening and other thing I do all day is like I said we talked about, I'm moving throughout the day, I am clearing that cortisol, I am making sure my body is good to go. We eat early because I know that our blood sugars benefit and it gives us an opportunity to walk as a family to the ocean. So, we do that. So, I usually have a three-to-four-hour gap before that in bed. And then I kick off my bedtime routine after I get my son to sleep, which is he's in bed by 8 o'clock.
[01:12:29] I kick it off with my supplements. And girl, I take supplements. I have my magnesium. It's Inflammatone by DFH. It's a wonderful kind of systemic enzyme. With me, with Hashi’s, I always want to make sure that I'm just gobbling up anything that's left over that's residual. I take my progesterone in the second half of my cycle. Like I have a little-- And so, when I do my supplements, that kickstarts my hour sleep routine that I am fierce about. And at that point there is no stopping me from getting into my rhythm of sleep, which is reading and journaling low lights, making sure the bed is ready, that I'm cozy. You do all the things you do. And so that I'm in bed about an hour prior to actually going to sleep.
[01:13:10] And I am consistent every single day. So, those are the things I do for sleep. For stress, there are a lot of ways that I manage and support stress. I have no problem admitting that I used to be addicted to stress. I used to think that it was my slight edge. And so, I have, recovered from a lot of being in survival mode, deregulated cortisol levels to the point where they were actually extremely low. And so, I have learned that I have some deeply embedded patterns that I'm still healing and I am very actively on that journey. And so, in order to mitigate my kind of default patterning that likes to come on in all that, she's always just like, “Hey, let's be this way.” And I'm like, “Okay, maybe that doesn't support me.”
[01:13:56] Walking is a way that I mitigate listening to meditations, even walking meditations, because again, that little efficient version of me is always like you could do two things at the same time [Cynthia laughs] and so walking meditations, reading, breathing in, sometimes breathing essential oils, doing breath work. I'm really big into breath work, either by myself or facilitated breath work. I'm in therapy with an internal family system therapist. So, there's lots of hugs and kisses from my son. So, there's just a lot of things that I do every single day to help mitigate what I call some deeper embedded patterns that can kind of drive me back into a survival-based state.
Cynthia Thurlow: [01:14:35] But if you were going to layer in something else for a patient that is otherwise, doing the lifestyle stuff, maybe they are or are not yet on hormone replacement therapy. What are some of your favorite brain supportive supplements?
Dr. Mariza Snyder: [01:14:51] Absolutely. Well, as you know, I had a brain injury last summer to the degree that I couldn't shower, I couldn't drive my car, I couldn't even get my son ready in the morning, which is something I really love to do every morning to get to spend time with him. And there was a dark moment there where I thought, “Oh my gosh, what if I don't recover?” Because oftentimes people with brain injuries, there's a part of them that just isn't there. So, it was a very kind of scary time. But supplementing was so critical for me at that time. So, I just want to speak into kind of my personal journey around that. And I will tell you that perimenopause. Holy moly.
[01:15:31] We talked about one of those, kind of signs or kind of warning signs. I would say that more women come to me with a noticing that their brain has shifted. They have word recall issues, they've alertness issues, they're afraid that they're going to mess up a presentation. They're not able to concentrate the way that they used to. So, I think this is a major issue and that's why the little mini thing around hormone replacement therapy was mentioned. But I'm a big fan obviously of Omega's. I'm a big fan of 5mg of creatine every single day for brain boosting and metabolic support, muscle boosting. I love, I mean, I think vitamin D is so critical, probiotics, digestive enzymes. Again, the microbiome is so tied to your brain. I also love green tea.
[01:16:18] I know it's not a supplement, supplement, but I do matcha every single day. Matcha is beautiful for the microbiome but also amazing for the brain. I love mitochondrial support because at the end of the day one of the hungriest energy-consuming organs of the body is definitely the brain and that's mitochondrial function right there. So, I love acetyl L carnitine. I love, again vitamin D, I love B vitamins I think that are absolutely critical. And then I also love like glutathione, something that's going to really help support antioxidant support. So those are some of my non-negotiable, every single day brain supplements that I love.
[music]
Cynthia Thurlow: [01:16:57] When we're talking about navigating the beginning stages of perimenopause, what are some of the more unusual symptoms that your patients will experience? I think it's not uncommon for women to hear about sleep disturbances and potentially having changes in their menstrual cycles. But for you clinically, as a GYN, what are some of the less known or less common things that we're talking about as a community of women that are navigating these changes?
Dr. Suzanne Fenske: [01:17:29] Yeah, I mean, I think that people have become a lot more, it's kind of a humorous topic to talk about hot flashes and night sweats and the brain fog. Less humorous and less talked about are some-- there's some very strange symptoms. There's change in body odor, which when I say it to women, they're like, “Oh my gosh, that explains it. Yes, I stink now.” [Cynthia laughs] I personally had this strange itchy palm, one that persisted and of course it kind of falls into the dry itchy skin, the neurological sensations that go on and change during perimenopause and menopause. But even myself, took me a while to kind of link the two together, that this is one of my perimenopause symptoms. But I think that the mental health is still just not really talked about.
[01:18:13] It's just kind of this assumption that we as women kind of gaslight ourselves with it and say that, “This is a difficult time.” Like you were saying, earlier on, before we started recording that empty nesting, I'm about to empty nest. And that explains it or my career, this that kind of explains the changes that I've had in mental health. But I think that's one of the symptoms that really needs to be brought to the forefront and really openly discussed are the mental health changes. Because it's not just anxiety and depression, which in and of itself are enough, but even just complete lack of desire to do all the things you normally would want to do in life. There's just sort of this apathy that is very common that comes to perimenopause.
[01:18:58] That's a really important symptom for women to be aware of that it's not just hot flashes, night sweats, brain fog, and sleep disturbances, but it is, these sort of out-there symptoms, irritable sensations, heart palpitations. I can't tell you how many women have gone and seen cardiologists during this time because they're having heart palpitations and so fearful that they're having cardiac changes now and the mental health changes because I think that if we even just spoke about it amongst ourselves and brought it more to the forefront, there would be less shame associated with it now.
Cynthia Thurlow: [01:19:31] I couldn't agree more. And I think in many ways that the degree of anxiety that I hear women expressing, especially in early to mid-perimenopause when they're in that luteal phase and they have less progesterone and they're wondering why they're waking up anxious, they're struggling to get through their day. And I think on a lot of levels that this lack of awareness and lack of information that's available to women, I've had women tell me they thought they were losing their minds, but in essence it was this loss of estrogen or it was this relative estrogen dominance, given the fact that progesterone and estradiol are designed to balance one another out. But as we're navigating these changes that can be so important. And you mentioned the apathy, anhedonia, just not having a desire to do things.
[01:20:21] We don't talk enough about testosterone, although I feel like, in many ways, the pellet industry and I don't mean to kind of focus on this, but I'm going to talk about it. I feel like I meet a lot of women who will come to me and they'll say, “Well, I was seeing this provider and I felt great when I first got a testosterone pellet. And then, they felt like they were constantly chasing that feeling. Like they initially felt good, and then they were constantly chasing that feeling. And I always like to explain to patients, understanding what's going on upstream is it chronic stress that you're dealing with? You're not dealing with the stress and that's going to deplete sex hormones further.
[01:20:58] But I think in a lot of ways, we're starting to talk more about the need to be aware of how important testosterone is for women, that motivation hormone. I think everyone thinks about it in terms of libido, and yes, that's important, but being able to build and maintain muscle, just thinking about the executive functioning that goes along with testosterone as well and how that plays in with mood disorders. And it's interesting. I just interviewed Dr. Felice Gersh I think for the fourth time. And this time she talked a lot about the loss of estrogen in and of itself in the heart will drive arrhythmias like atrial fibrillation.
[01:21:36] And I know my community has heard me talk about this before, but I think about how many patients I took care of over 16 years in cardiology, what they probably needed more than anything was some estrogen replacement therapy that probably would have improved their paroxysmal, which is atrial fibrillation that comes and goes or their persistent atrial fibrillation. And so, the heart palpitations, lots and lots of workups that for many women yield nothing significant, but what they're experiencing is real. And so, I love that you touched on that. And something that I thought was interesting is that estrogen plays a role in serotonin and dopamine signaling. So, it's not just the estrogen and the progesterone, it's that the neurotransmitters are also impacted.
[01:22:20] So, when you're working with women in your practice and you're helping them understand the interrelationship between the natural evolution of the aging process, but also things like gut health, because if your gut isn't healthy, that can further exacerbate these changes with not only depression, but also estrogen metabolism.
Dr. Suzanne Fenske: [01:22:41] Absolutely. And phase three of estrogen metabolism takes place in the gut. So beta-glucuronidases, which is an enzyme that basically when you're metabolizing estrogen and removing it, phase one and phase two occur in the liver, but phase three takes place in the gut. So, when we do some testing that we do kind of in the integrated modality, we're able to look at phase one and phase two estrogen metabolism. But phase three we're not able to unless you do a gut microbiome sort of analysis. And it's so important because you not just in sort of the, even outside of perimenopause and other hormonal abnormalities. This is an important facet to look at. Even when you're talking about something like endometriosis, which is often a disease of estrogen inflammation.
[01:23:22] And even if you're managing the estrogen but you're not evaluating the gut, that symptoms that occur with endometriosis then with beta-glucuronidase elevation, estrogens being recirculated into the system.
Cynthia Thurlow: [01:23:36] When you are working with your patients, what are some of the low-lying fruit, the kind of easy little things that they can do right away that may perhaps get them stimulated to start releasing some weight and again, helping everyone understand the way that you successfully lose body fat and not as much muscles. It has to be low and slow. It has to be gradual. Anyone that's telling you're going to lose 10 pounds immediately, that's not sustainable. We want is for you to be at a healthy weight, addressing the weight loss resistance to find out what could be an easy reason for why this is occurring and try to work beyond that and help you navigate perimenopause and menopause successfully.
Dr. Suzanne Fenske: [01:24:21] I start off with protein. I do, that's what I do nowadays. I start off with protein. I feel like it just makes it easier. It becomes less, “What am I doing wrong?” And it becomes more, “Oh, you know what, I actually am not consuming enough protein.” The benefits on the flipside, right between us that we know is that it's going to increase satiety. So, naturally you're going to snack less, you're going to feel more full if you consume the protein that you should be for your macronutrient goals. So, the first thing that I always start off with every single woman in perimenopause and menopause is talk about their protein goal based on their ideal body weight, as well as I tend to use 0.8 to 1 g of protein per ideal body weight.
[01:25:01] That the range that I generally use as my macronutrient goal. And I think that the two things that I'll focus on is fiber goal and protein goal and make it very simple and start there. It's amazing how much that changes everything else. Automatically, the carbohydrates that you're taking in are going to decrease because you now have this goal of what fiber you're going to consume. And if you need to have fiber goals, then you're going to consume more vegetables to meet those fiber goals because that slice of bread is not going to meet that fiber goal. If you're consuming enough protein, you have less of that hunger after you eat. Right?
[01:25:35] So, so if you have a higher carbohydrate meal, then an hour later you have that, drop in that reactive hypoglycemia, you're hungry again. If you're focusing on protein, you don't have that reactive hypoglycemia. So, you don't have that. So, I always start off really easy with women because everyone's trying hard, right? Everyone comes in my office. It's very rare that someone comes into the office saying that I'm eating two bags of chips every single day and I don't understand where I gained this weight, right. Most of the women that I see are doing the things, but it's just not working for them anymore. So, when you put it back into perspective of protein and fiber, those are the two things that I always start off with as goals.
Cynthia Thurlow: [01:26:14] Yeah, I think that's such a reasonable and kind of feasible first step. How does chronic stress play into the weight loss resistance piece? Especially, we're four years after the pandemic. But I always say everyone has had more stress, not less over the last several years but how does chronic stress exacerbate this issue?
Dr. Suzanne Fenske: [01:26:34] We have symptoms, right. So, if you say to me that I have so much sugar cravings, okay. That there is actually a sign that your cortisol is elevated if with chronic stress and oftentimes, this is why I do like to do a Dutch test if I can, is especially in the perimenopausal time period, is you see the adrenal component. So, you see those, cortisol spikes that are happening at night. That reverse pattern where instead of having that morning rise in cortisol and then slowly goes down into the evening, oftentimes when I do the Dutch test, I will actually see very low cortisol during the course of the day. And a woman will say, I have extreme fatigue during the day, I want to take a nap in the afternoon. And then all of a sudden wired, but tired at night.
[01:27:16] So exhausted all day, but then can't go to sleep at night. And I think that if you don't take care of this aspect of things as well, then weight loss goals is just one aspect, but weight loss goals will not be met. It's very, very, very hard. The other thing that we see right during this time is obviously insulin resistance rise, and as estrogen declines, insulin resistance rises. So, I will focus a lot when I look at a whole picture of a woman who comes in perimenopause at looking at the cortisol values. And again, if you are someone who financially can put those resources into doing a Dutch test, for example, then provider who's aware to ask the questions that are you finding that you're craving this or you're craving sugar? Are you finding that it's very hard to get up and go in the morning if a woman's saying at night, I'm so tired, but my mind's going a mile a minute. These are all your signs of what your cortisol pattern is doing.
Cynthia Thurlow: [01:28:12] We know that the influence of sleep quality is so important, not just for brain health, but for overall health. Talk to us about alcohol. What is your position on alcohol for women at this stage of life? And I talk about this lovingly and my community knows that is one thing I don't do because it just for me disrupts my sleep so much. But I'm sure for you when you're talking to your patients. A lot of women consume alcohol to fall asleep, not knowing that it's undermining their sleep quality.
Dr. Suzanne Fenske: [01:28:42] Mm-hmm. But those same women are going to say that two hours later they wake up in the middle of the night wide awake. So, they're able to fall asleep because of the alcohol, but they're not able to stay asleep because of alcohol. In general, I live my life very kind of moderation. I'm going to say to a woman that if you're going to consume alcohol because you're going out with friends and you want to have a drink, just know that you're probably going to pay the price and there are better ways to consume it. Most women will notice, unfortunately, that wine is really not your friend during this time and period of your life.
[01:29:13] And a better way to do is going to be that if you want to consume alcohol, doing sort of the clear spirits and mixing it with seltzer honestly is the way to go because at least you're hydrating during the course of it too and you're having less of that effect. So, choosing the right alcohol and the amount and then yes, the not popular thing is that you do have to limit alcohol consumption and be aware that you're going to pay the price if you do consume alcohol.
Cynthia Thurlow: [01:29:37] Yeah, it's one of those things that I think for me it was. I've never been a big drinker, but I just recall in my early 40s, it took a while for me to realize like what is it that I just did that now ensured that, I look at my metrics on my Oura, I'm like my deep sleep bottomed out, my HRV is terrible, my heart rate variability clearly is an issue, my pulse rate wasn't where it normally is. And so, for a lot of people listening, understanding, like what we're saying is if you choose to drink, do so responsibly. You mentioned the clear alcohol and I always say clear spirits are going to better. But make sure you're hydrating around that. Make sure you've had food because you don't make good decisions around alcohol consumption.
[01:30:19] If you're drinking on an empty stomach have a meal around it will help buffer some of the effects. What are your thoughts on nutrient deficiencies vis a vis? Looking at adrenal health as it pertains to this challenging life? We know that we become less stress resilient. We know that our adrenals kind of step in to be this emergency backup system as our ovaries are making less progesterone. What do you like to focus on in terms of adrenal health to support women at this stage?
Dr. Suzanne Fenske: [01:30:48] So, I do love to use, but I do use adaptogens. So, I will use adaptogen selectively for women during this time too. Because I think that there's a lot of lifestyle things that I always will teach women during this to employ, but it's helpful to have those aids during that time too. But what's really important with every single woman that comes in, I kind of have these set pillars that I go through. And one of the pillars is stress management. And this means what are you doing on a day-to-day basis to manage your stress and what are you doing in the moment? And I think that's one of the reasons why women during perimenopause and menopause kind of turned to alcohol as much, because it's known, right, if you have a drink, you're going to feel more relaxed.
[01:31:30] And it's an immediate thing. And it's a lack of sort of-- even in our society, focusing in on, day in, day out, stress management skills. And what are we doing to make that better? So, it's as simple as-- And there's things that don't jive with people. Journaling may not be something that jives with you. It's funny when I ask women, “What do you do for stress management?” Everyone thinks that I'm looking it's kind of like pleasing the teacher, right. [Cynthia laughs] So, everyone [laughs] assumes I'm looking for the answer meditation. And meditation does not have to be everybody's stress management modality, but even something as simple as breathwork.
[01:32:05] So I teach every single woman who comes into my office, whatever age you're at, whatever stage you're at, of breathwork and whether it's box breathing, whether it's 4-7-8, I teach them usually those two ones and then whatever kind of jives with them. And say you have a homework assignment. Every morning you're going to do a certain set of breathwork exercises. And every night you're going to do a set of certain breathwork exercises. And then during the course of the day, when you're at work, when you're running around with the kids, when you're having a moment, you're going to take a moment, you're going to go to the restroom and you're going to do a set of your breathwork exercises again.
[01:32:40] And I myself do this during the course of my day, I'm seeing patients and if I feel like I'm getting a bit stressed out, I'm not performing the way that I want to. My head just feels very cluttered. I will go to the restroom because no one bothers you there. And yeah, and do. No one knows what I'm doing in there. Do three rounds of a box breathing or a 4-7-8 and come back into it. So, I do use adaptogens, but I also teach stress management skills, which are very important.
Cynthia Thurlow: [01:33:08] What are your thoughts around testosterone? Are you finding for women that's kind of the missing link in terms of HRT management and kind of improving the trajectory of perimenopause into menopause.
Dr. Suzanne Fenske: [01:33:20] Yeah, I mean, in general I am a big advocate of testosterone. I don't believe every single woman needs it. And I think that it is important actually to do laboratory values and assess where your physiological range is. So, I don't do pellet therapy because of the super physiological ranges. And perhaps things will get better in the future. And this is not, to say anything negative about that's what you choose to do. But as a practitioner, I've seen so many women come to me with these 500 on their testosterone, which is male level.
[01:33:54] 300 and above is male level. Whether someone is slightly super physiological or slightly above the normal physiological range for testosterone, that would feel right for them, that's fine as long as they don't have the negative side effects with it. But these levels that go into the hundreds and hundreds are just dangerous in my opinion. But very often, I think it is the missing thing. Very often. And again, like you said, women will focus on libido as being the missing piece of the puzzle, that it's improved often when they start hormone replacement therapy. Even estrogen alone is going to improve it to some aspect, but still not to the point. And what I will see is vigor, vitality, energy, ability to put on muscle and maintain their muscle as well as libido.
[01:34:39] I mean, cognition too, are all really helped with the addition of testosterone if the values are low on blood work. And in that way, I'll follow it. And women will often feel significantly better with testosterone being that missing piece for them.
Cynthia Thurlow: [01:34:55] Yeah, I'm so glad that it's something that more and more clinicians are talking about because I feel like in many ways, for many, many years, there just wasn't enough emphasis and for the benefit of listeners to understand the side effects of having supraphysiologic testosterone in women can have the potential, and I want to emphasize potential to be catastrophic. I was speaking to Dr. Pam Smith and she's one of these antiaging experts and she said, “I cannot tell you how many women I've seen who've had young women, late 30s, early 40s that are getting pellet therapy. And in some instances, they're so super physiologic they're actually having cardiac events.” Some of these women were having myocardial infarctions or heart attacks. And so, it can be a heart manifestation.
[01:35:43] But I've seen women with voice changes that don't go away, clitoromegaly so they'll get an enlarged clitoris. What are some of the other changes? Have you seen many of the like extreme manifestations of having that super physiologic testosterone level?
Dr. Suzanne Fenske: [01:35:56] Yeah, I mean I've seen rage and life-altering rage. Women will come in saying that they have no control over their emotion and they have rage, acne, hair loss. And women are already battling hair loss during perimenopause, which is another common symptom of perimenopause and menopause is hair loss. And high level, super physiological levels of testosterone cause hair loss as well. And then yes, compounded by the fact I had a woman come in and again, when I did her blood work, she had these super physiological ranges, had been doing pellet therapy, but she had terrible, terrible, terrible acne as well as hair growth on her body. In places that you don't want hair growth to be.
[01:36:35] So, testosterone, everything in life, right, all medications and all things have risks and benefits and just being informed and knowledgeable about them, but testosterone in physiological ranges is super beneficial to the body.
Cynthia Thurlow: [01:36:50] If you love this podcast episode, please leave a rating in review, subscribe and tell a friend.
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