#432: Midlife Wake-Up Call: Why Doing Less Is Important During The Peri- and Menopausal Transition With Cynthia Thurlow

Now we get into hidden drivers behind weight gain, sleep issues, and brain fog, including how estrogen loss affects your gut, your immune system, and your ability to handle stress. Cynthia also shares why high achieving women often struggle the most during this phase and why the old push harder mindset completely backstage. Now this conversation is equal parts science and reality check, and it might completely change how you think about mid.

Her new book is called The Menopause Gut and you'll definitely wanna check it out. Next, we're just gonna thank a couple of the sponsors who make this show possible and then we're What if doing less actually helped your body do more? We're constantly adding things to our routines, more supplements, more workouts, more products, more protocols.

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Cynthia Thurlow, welcome back to the show. It is an absolute pleasure to have you back here today.

tumultuous transition, if you will, next to puberty uh in a woman's life. But what is the cost to women of unaddressed Perimenopause, and maybe not just to them, but to the people around them.

it is perhaps the first time in their adult lives where they get clarity on what is working well for them and not. And so I think for so many women, their strategies and their patterns of behavior that work well as a teenager, twenty and thirty something, suddenly no longer work quite as well and can become incredibly maladaptive. And I'm really speaking to the women that are very high achieving have been incredibly successful in any capacity of their lives.

where they suddenly look in the mirror and they're like, Not only do I not feel like myself, I can't identify with the person I am today. And so I really think about perimenopause as this hormonal chaos period in our in our lives. Very different than puberty. I think puberty we go into we're just kind of stumbling, bumbling forward. Whereas in perimenopause, we've had, you know, thirty plus years of life to be able to reflect on and say, Am I happy with my partner? Am I happy in my job?

Am I happy energetically with where I am at this point in my life? And so I think it's an invitation for us as women to really reflect on what is working for us and what isn't. I know for myself personally that as a for formed people pleaser.

One of the reasons why I was such a successful nurse practitioner working in predominantly a male dominated field of cardiology was that I was incredibly accommodating. And I think for so many women, one thing that they find, they find their voices in middle age.

And they stop looking back. They're just like, I'm only looking forward and this means that I'm gonna be clear about what I like and I don't like. I'm gonna get clarity on my relationships. I'm gonna get clarity on my choice of occupation. And it's why I think in many instances women start making some pretty dramatic changes. And when I say that, it doesn't per se mean that women leave their job or they leave their partner or spouse.

But they get tremendous clarity about what they want and what they don't want. And that can be empowering and also terrifying. I think for so many women, it's perhaps the first time in their lives that they're doing exactly what they want. And I think that that is

you know, perhaps for those of us in our lives that are used to us maybe playing small and being incredibly accommodating and just doing what we're told. All of a sudden we're questioning our relationships with family members and we're questioning our relationships, you know, at work and questioning what we're doing and

trying to figure out what serves us and no longer serves us. So I I look at this time in a woman's life as a great awakening. It's a great opportunity to course correct and, you know, change the narrative for ourselves and that's something that I don't

per se see a lot of people talking about, you know, we we talk a lot about hormone replacement therapy and supplements and peptides and things that are clearly very important, maybe very clear. But all of a sudden it's like, are we really asking women what they want at this time in their lives?

If your hormones are all over the map and kinda running the sho running the show and maybe running you into the ground because you're not sleeping, because you don't feel like yourself, because you're you know, you're moody or whatever the you know, all the things that can come with menopa with perimenopause when, you know, in a world where too many women are still being told by their doctors Oh well, you're in pedromanti pause, you know, strap yourself in and hang on for the ride kind of thing.

That's where I think the greatest disservice maybe is being done to women is by not offering them the support, whether it's a supplement, whether it's lifestyle, whether it's biodential hormones, whether it's conventional whatever, without without acknowledging and giving them that support.

we're now being asked to go we're we're now in a position of going through this transition where the way you describe it it can be so incredibly positive moving forward. But it's kinda like asking a drunk person to make a good decision.

Uh, who is much more alignment with where I wanted to be. And so I want any woman that's listening to this conversation to know you do not have to accept. uh care that is not in alignment with your true values. And if anyone listening decided to take the oral contraceptives or the IED or the ablation of hysterectomy, that's the right choice for you. And that's great. It wasn't for me. And even as a licensed medical provider.

Those were the options I was given. Now, granted, twelve years ago we weren't having these kinds of conversations quite as openly. And I think we've made great strides over the last five to ten years, but I think in many instances there's still women being told. Shut up, take the oral contraceptive. You expect your sleep to be bad. So what if you can't feel like you feel like you're losing your mind? We're gonna put you on an antidepressant, we're gonna treat you with anti anxiety meds.

Uh, and you just have to accept things as they are. And and I I think that that is a really terrible way to reframe middle age and beyond that you just have to accept things as they are with no alternatives and no other options.

But the stress of my job, because the NPs in my practice, it was a very large cardiology practice. We did inpatient, outpatient management. We functioned like residents. We were incredibly autonomous. The stress of my job combined with little kids, combined with a husband who traveled, combined with not enough sleep, combined with being hardcore paleo, so I was really low carbohydrate.

Mm-hmm. No longer was an a l really intense exercise, was no longer in alignment with my physiology. And so I felt incredibly lost in space. Like, where am I going? I don't know who to talk to. You know, I stumbled into a functional medicine practice, thank God. Um, I had a great nurse midwife. Um, shout out to Courtney that lives in Northern Virginia. Uh and and I think that was the beginning, but

There were so many other women who felt exactly like I did, which is why when I left traditional allopathic medicine ten years ago, April first will be exactly ten years, so it's hard to wrap around that. Yeah, exactly. That's a big milestone. Um, no one was talking about these things. And I I think that

I I think in many ways there's been a groundswell of women. Like Gen X is just not sitting down or shutting up. We're just speaking up and out and hoping that this helps younger generations and helps women advocate for themselves because it is not acceptable. You know, the the kind of patriarchal medical system, the way that it is created. And I'm paraphrasing from other guests I've had on my podcast who've said as medical providers themselves, especially male physicians,

No man would put up with what women have put up with. Full stop. So

mid to late thirties into the menopausal transition and typifies the experiences that we have. It's just not just a physiological shift, it is a psychological shift, it is a spiritual shift.

And so middle pause was really born out of my desire to shorten. Very menopause and menopause'cause I felt like I kept saying that over and over and over again in the book. And so I'm like, middle pause, this makes sense. It's short it's short and sweet. And so That that's literally how it came about, just to shorten the phrase, because I would literally just start writing perislash menopause because I was saying it over and over and over again.

But let's talk because, you know, as you had said earlier, your doctor said to you, and yeah, guess what? You're gonna be packing on some weight, which frankly is more insight than a lot of women get. Most women just wake up one morning, look down and go, Where did this all go?

Yeah. This is not me. Right. That's part of the not recognizing yourself. So can we kind of enlighten women or listeners? Because maybe men are listening to this too, to try and understand what the heck is happening with their with their partners. uh what's really happening here on a hormonal, metabolic and immunological level.

As we see these declines in hormones and changes in neurotransmitters, it impacts every single system of the body. It is not just bikini medicine. It is not just about fertility. It is not just about, you know, your breasts drooping or your skin drooping. It really is helping women understand that as estrogen declines in particular.

It has catastrophic effects on the body. That's why we see higher rates of bone health issues, osteoporosis, uh cardiovascular disease, changes in cognition, changes in body composition. But what's interesting to me is I know more about the immune system now than I ever did before. I don't know if that's good or bad. I had to map things out on a whiteboard because it can get very complicated.

But one of the markers of the aging process is something called immunosines, which is really speaking to aging of the immune system that happens right along with us. And one of the big kind of shifts in the immune system is this decline in estrogen. So yes, in perimenopause you get twenty to thirty percent higher levels of estrogen depending on where you are in your cycle, depending on the cycle

And as estrogen is declining, all of a sudden we're starting to see this domino effect in the immune system. So we see at a very basic level more inflammation. So the term inflammation which a lot of people hate, but is a great way of expressing the aping of the immune system drives inflammation. As estrogen is declining at a very basic level, um, the immune system is designed to protect us. So when we talk about digestion, just is just one example.

The small intestinal lining, which is where we get most of the absorption, assimilation of nutrients across that small intestinal lining. Estrogen acts like if we have a brick and mortar system to describe these tight junctions, estrogen acts as the mortar in between the bricks. So as estrogen's declining, we get more leaky gut.

When we have leaky gut, food particles leak into the bloodstream and trigger an immune response. So already women will start seeing more bloating, more digestive issues as a direct impact of this increase in leaky gut.

Leaky gut is important because with leaky gut we get linked to autoimmune conditions. And a thousand years ago when I finished my training, there were probably twenty or thirty recognized autoimmune conditions. Now there are over a hundred. Things like long haul COVID, chronic Lyme. Once you have one autoimmune condition, you're more likely to have others. And women are four to five times more likely to experience autoimmune conditions in perimenopause and menopause. That is significant and and

Something that's really worth mentioning. That's why I see so much Hashimoto, celiac, um, lupus, rheumatoid arthritis, psoriasis, etc.

But that provocation of the immune system, our immune system becomes a little cranky. We start to see some other symptoms that will come up, you know, there are T helper cells. And we start to become a little bit T helper one dominant, which really represents this immunity, this kind of inflammatory process, the autoimmunity. What's interesting if you look at the research, I don't say this to be controversial, because as soon as you say the word vaccine, people get kind of like Flammox.

Um, something that's really helpful to understand is I think many people understand there's this uh genitourinary syndrome of menopause. Super sexy. It's not a question of if but when. We will all develop it. And as estrogen is declining in the vagina, it impacts the healthy lactobacilli. So these very important beneficial species that are there when the pH changes in the absence of estrogen being there or decline in estrogen, it drives a lot of the symptoms women experience. So painful sex

chronic urinary tract infections, more pelvic floor issues. And I think for a lot or getting up at night to pee, also very common to see in the setting of loss of estrogen. So estrogen acts as a help helpful for the barrier. Also helpful for supporting the microbiome constituency, not just in the vina vagina, but also in the gut microbiome and elsewhere. And so I think a lot of people are surprised to know.

that estrogen and the immune system go together. And I'm gonna give you a terrible analogy like peanut butter and jelly. I know maybe not something that everyone loves, but I think about it in that regard, that they are so intertwined that it's helpful to understand that

As your estrogen is declining in mid to late perimenopause, you're going to see more opportunistic infections. And that includes in the gut as well. And so Sometimes people will say, you know, I start off the book talking about this romantic trip to Morocco and how I got sick, deathly sick, and my husband didn't.

And so I didn't know at that time that this loss of estrogen was driving a lot of these changes in the immune system. So the I mean, the immune system and estrogen really are integral to together. And there's a lot more to the conversation, but that is probably one of those like more tangible ways that people can understand this is what starts to happen. Estrogen's important for a lot of things that go on in the body. It's important for nitric oxide signaling. So even in the gut.

Patients will tell me, I feel like my food just doesn't digest as well, helping them understand that as progesterone declines, it impacts. smooth muscle contractility and as estrogen declines, we have less nitric oxide. So a lot of people think about that in terms of endothelial function, which is still very important, but also really important for innervation in the gut. So yes, you're not

You're not imagining things, your digestive capacity will shift, your ability to break down healthy fats because estrogen uh interacts with bile. So being able to break down and emulsify fats will also change. And you know, the domino effect goes on and on and on. So, you know, I think these are probably lesser known things about estrogen. I think so much of us think about, yes, it's important for bone function. It helps, you know, bone build up and

Estr, you know, progesterone helps with b osteoclastic activity and it's meant to balance each other out. Um, but that is like one of the lesser known, and I say this because I've now spoken on m seventy plus podcasts, you know, in getting the word out about this book. And almost always when I talk about the digestive aspect

of the immune system, vis-a-vis, estrogen loss. People are like, oh my God, I just think about it as bone. I think about it as heart. I think about it as brain. And I'm like, guys, it's so much more than that. There's no cell in the body that is not impacted by estrogen loss.

progesterone loss and testosterone loss in most women. Not every woman still has to require hormone replacement therapy for testosterone, but most, if not all, the rest of us do for both estradiol and progesterone. And I think it's important because

You know, unfortunately, there's this prevailing thought process in the health and wellness space that you just slap on an estrogen patch and everything's magically fixed. And I'm here to tell you it is a much larger, more nuanced conversation than that.

There are a lot of people that will say, If you have a leaky gut, you have a leaky brain. Um, which would have a link again, which also would link the loss of estrogen to this brain fog and this lack of cognitive ability that women report to the point where in you know, in extreme situations you have women who actually believe that they're somehow going through early onset dementia or something.

when really there's you have this double whammy of the loss of estrogen, possible excess m kind of like neuroinflammation because the immune system is all Cranky because of things getting in that shouldn't get in, you know, these highly medical terms.

your brain's also inflamed. And I think inflammation is really at the basis for nearly all disease states, especially chronic disease states. And I think for a lot of women You know, there's a could be a million reasons why they're more inflamed on this continuum of inflammatory processes, but it's not at all surprising to know that

you know, these organ systems don't exist in vacuums. You know, that was kind of how I was trained was that, you know, this is your neurology bucket and this is your cardiology bucket and here's your renal bucket. And yet we now know that there's complex interplay between all of these organ systems. and the gut and the brain and that if you are Chronically stressed. and not able to properly regulate your autonomic nervous system.

that is going to make navigating this transition in your life ten times harder. I mean, I say this as a card carrying type A intense person, not surprisingly, former adrenaline junkie.

that it made my perimenopause transition until I was able to master things made it a whole lot harder. And it's it's kind of this and I don't know if you see this with your clients but or the community that you interact with, but The women who are the most able to uh detail oriented, um conscientious, thoughtful, um I don't want to use the word obsessive because I wouldn't describe myself as that, but just like an intense person.

It is hard that when you get into this transitional period that all of a sudden I'm going to say to you, do less. Not do more. Don't do more fasting. Don't do more exercise. Don't do more caloric restriction. That is completely contrary to what we have been taught and told. And and that's one of those backwards things that can be very hard for women to wrap their head around like, wait a minute.

In the past, if I calorically restricted and exercised more and just did more, more, more, more, more, it worked. And all of a sudden you realize your body's like, no, it's actually have to do the exact opposite. in order to master this middle age piece and do so in a way where you feel good.

And you have to choose what's really important and prioritize the most important stuff. And and that m nobody wants to make those choices. Nobody wants to cut anything out.

So on the metabolic side though, let's let's maybe touch on that a little bit because you did a great job on the immune system, which interestingly enough is going to affect metabolism because inflammation is a is a pain point to metabolic balance. Um, but this the metabolic transition that happens that your doctor alluded to, but many women don't even get a notice on that one. Yeah. Um, let's let's maybe which also affect the brain and the gut.

One of the things that starts at 40 is that we start losing muscle mass. This is called sarcopenia. And I tell people all the time, the loss of muscle mass combined with changes in estrogen levels is catastrophic. Why? Because estrogen is an insulin sensitizing hormone. This is such an important point to understand that you can be doing exactly what you did at 35 and at 40 and 45 you can start gaining weight.

It's because of a combined net effect of loss of muscle mass, unless you're working against that. It is understanding that with this loss of insulin sensitivity, all of a sudden what you ate before is not going to impact you the same way. So women will say, I notice I don't tolerate carbohydrates quite as well. So we know that I think it's gotten out there that we need more protein as we're getting older. We need more protein for muscle protein synthesis, for leucine threshold.

I don't necessarily think all the women understand that qual the quality of our carbohydrates becomes critically important. And we have to understand that there's a timing for carbohydrates, you know, typically I will say earlier in the day, not, you know, nine o'clock at night.

But those processed carbs are not gonna agree with you. So the cookies, the candies, the breads, the pasta all of a sudden is not going to be as hormonally advantageous. You can't quite buffer it. And so when I talk about this loss of insulin sensitivity, it's going to impact whether or not you can build muscle. It's going to impact whether or not you're able to effectively utilize either stored carbohydrates or stored fat for fuel.

It's going to impact brain health because we recognize now that dementia and a lot of neurocognitive disorders are a byproduct of a loss of insulin sensitivity in the brain. It's going to impact um body composition because we know that typically what happens in the menopausal transition is that we put less subcutane the pesky fat that we all complain about that we don't love. You know, the stuff that's on the back of our arms, our hips, our thighs.

That is subcutaneous fat. That is very different than visceral fat. Visceral fat is what is deposited around our our main or major organs and tends to be very inflammatory. It actually secretes cytokines and other inflammatory substances that can further drive more inflammation, more inflammation, irritate that immune system. And so when I'm thinking about metabolic health, I always use the word catastrophic so that people take it seriously.

And this will continue to unwind unless you're actively working against it. So this is why we talk about macros and we talk about meal timing and we talk about, you know, leveraging, maintaining and building muscle. And, you know, there are lots of things that, you know, tips and tricks that I'm sure you probably talk about with your community with great regularity. But I think for a lot of women, they don't understand that you can be doing exactly what you used to do.

Yeah. That high intensity interval training, Orange Theory Fitness, CrossFit, doing marathons. I get hate mail when I say this, but I'm like, listen, when I say do less, it is because you will become less stress resilient. And your body cannot weather the stress that you were able to get away with in your twenties and thirties. It does not mean you are incapable. It just means your physiology is changing. And so instead of doing

Six days a week of Orange Theory Fitness with no recovery, you're probably gonna do two or three days of strength training, do some zone two, get out and walk in the sunshine. That is me better served for your body composition and your physiology.

The other thing that I would say is this is why I'm a huge proponent of lifestyle measures that impact metabolic health, sleep, managing your stress, those macros that I've talked about, exercise, especially strength training. And why I'm a huge proponent of hormone replacement therapy and certainly the research that is coming out talking about women in menopause that are on HRT plus a GLP one.

And I'm not a proponent of saying to people you have to have a BMI of thirty or twenty seven with a comorbidity to qualify. I think that personalized dosing, dare I say the word microdosing. is going to be a way of the future because there is not one patient I have that does not have an autoimmune condition or an inflammatory issue. that being on a small personalized dose of a GLP one is not allowing them to maintain their body composition meaning more

Uh lean mass, less fat fat-free mass, really important. You know, that's why the scale, I used to say the scale is a liar, but that's why body composition is so important at this stage of life. Yeah. So metabolic health for everyone listening. is something all of us need to be concerned about. It's one of many reasons why I take

HRT, it is why I lean into that lifestyle, why I talk to my patients about it, and why I'm also a proponent of leveraging personalized dosing. Notice I'm saying the word personalized doses.

we can't just limit their use based on, you know, whether or not someone has a comorbidity plus their overweight or a beef. I think that we have applicability to a larger population that I think is incredibly exciting.

saying it's it's it's in the details, people. Like if they're used properly, they literally can offset some of the most insidious parts of of this journey for women and to your point, whether it's a microdose or just a smaller dose, in and even if it's in someone who's obese, it's your lowest effective dose that's going to give you the result. that that you're looking for. And whether that's just reducing inflammation or improving insulin sensitivity or whatever the case.

And doing all the things. The diet, the exercise, the lifting. And so I'm with you and I'm so thrilled you brought it up because it It d I find it a little exhausting. The negative narrative on the GLPs, the judgment, the the the negativity It could we just stop being so dramatic all the time and just get down to brass tacks? Yeah. You know, like just

Yes, fifty-six, I had to think for a second. And I look at my twenty year old and eighteen year old and I'm like, there's no comparison. Like they're just biologically at an advantage at the stage of life that they're in. And I think that there's no room for shame and blame. I think that I I think it is far more important that we are using everything that is available to be able to help patients. And to your point about

side effects from GLP ones. Okay, so there's let's be clear, there are definitely I call them pill mills or weight loss clinics that are out there that are run by Some responsibly and some irresponsibly. But if your provider is not concurrently saying to you

You must strengthen two or three days a week and you must eat adequate amounts of protein. If they're not including that in the conversation, then they should not be prescribing it. Because unfortunately, even as a healthcare professional myself, I have been at events where I've had formerly obese

colleagues say to me, I will never stop this drug and I'll be damned, I don't care if I've lost muscle mass. It's the first time in my adult life I don't have food noise. That is powerful. I even have colleagues who are mentioning to me that they have patients who've said, Oh my gosh, I just realized I don't have any desire to drink alcohol.

Oh, I used to recreationally use XYZ drug. I no longer have a desire to do that. So when I say that I think that there is applicability, especially for the at least the second and third generation um drugs like trzepatide. I think that it's really exciting. And so I'm all for things that allow people to have freedom and they allow for people to have autonomy over not just body composition but metabolic health and all the benefits that I think for a lot of individuals.

Maybe they didn't realize at the time they're like, Oh, I shifted body composition a little bit but oh no, there's so many more benefits that yeah I was even unaware of. Like the food noise piece is huge for so many patients. There's been You know, you and I have lived long enough that we've seen so many diet fads that have come and gone, you know, volume metrics and you know, all these, you know, gimmicks to try to trickle. Yes.

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availability of hyperpalatable foods that are the processed foods. So just to be clear, in a perfect world, if you're living in a world where you're only eating whole foods and you're living outside and you're doing all the things You may not be one of those people that needs this, but if you're living in the big city and you're living the c crazy lifestyle and you haven't got the best eating habits and you're doing the hyperpalatable thing and the whole nine yards.

these medications come in and really start to even out the playing field. So moving on from that, I wanna th you know, the book is called Menopause Gut. Let's talk about the gut as a good organ. Let's let's speak to Let's kinda dive in there because we kinda got a little way late on the on the GLP one topic. But I think it's it's such an interesting

topic because it's so top of mind with so many people right now. But let's get into the the this real the connection and you mentioned it earlier about estrogen affecting the microbiome, the loss of estrogen affecting the microbiome. But let's Let's kind of reiterate and and dive into a little bit more for the audience this whole connection between the onset of perimenopause and this transition.

And the gut at a systems level. And and you know, because it's gonna speak to the vagus nerve again and all that kinda. Yeah.

part of the large intestine or colon. So it's really a kind of like the bottom part of our digestive system. And the thing that I found fascinating while I was writing the book is that the gut microbiome interfaces with every single organ system in the body.

Like there's a gut ovarian access, there's a gut bone access, there's a gut brain access, et cetera, et cetera. And what I found really interesting was that there's a lot of things we have control over. If we live long enough, we will eventually go from perimenopause and menopause. And the loss of progesterone and estrogen impacts diversity. So I just talked about those different types of microbes that are in the gut.

Um, we get a decline in the diversity. So that can drive inflammation. We start seeing more leaky gut, as I mentioned. We also see changes in something called short chain fatty acids. And I promise these are relevant. They're very important signaling molecules in our bodies. And they do things like create mucus that lines the digestive system. They uh help reduce inflammation. They're responsible for endogenous GLP one regulation along with some keystone bacteria.

And some of these, including butyrate, can actually cross the blood brain barrier. So really, really important signaling molecules. But as estrogen declines, so do these important signaling molecules. So there's a lot that changes in the microbiome. As we're kind of navigating this perimenopause to menopause transition, but I remind people there's also an aspect of the microbiome called the estrobole.

Or as a as a host said the other day, it was a guy, he said the estrobilomi, which every time I say that now it makes me chuckle. Yes, it just cracked me up. First time this gentleman had ever said it, but it's an estrogen processing center of the gut. It is impacted by the quality of foods we eat. It's impacted by chronic stress.

it is impacted by the types of medications that we take. And so we ultimately want to think of detoxification. The bulk of estrogen detoxification, hormonal detoxification occurs in our liver. So the liver is the main site. It breaks it down into water soluble compounds, it goes to the gut.

The gut is where it's supposed to be packaged up like a present and we poop it out. That's what should happen. However, if we have a a very inflammatory lifestyle, we've had a lot of antibiotics, we've used a lot of synthetic hormones. et cetera, et cetera, it can get recirculated. So the estrogen that our body's trying to break down and get rid of gets recirculated. This is significant for women because it can magnify all of those symptoms.

the brain fog, the joint pain, the skin issues, it can drive a lot of inflammatory changes, weight loss resistance, breast health issues. And I think it's important for people to know that You know, yes, you can replace hormones and yes, that's very important, but if your gut is not optimized, you're going to still have symptoms. I will oftentimes tell women

Well, women are having a lot of vasomotor symptoms, a lot of hot flashes, a lot of night sweats. I'm like, it it's more than just replacing hormones. It's really looking at what is going on in the microbiome because there's a key enzyme called beta-glucaronidase. And if it's working properly, it is helping to break down the estrogen and get rid of it. But when we measure beta glucaronidase in stool,

If it's high, we generally are thinking that there's an issue related to the estrobilome and possibly detoxification pathways in the body. And no, detoxification is not talking about a program in a box. It is actually The fact that we breathe, we sweat, we poop, we pee. all in an effort to help rid our body of things that we don't need anymore. And so I think this is sometimes a forgotten kind of thought process around aging and immunosinescence and changes in hormones that

the estrobilome and the microbiome become really, really important because the one thing that I I've already mentioned is that we're constantly sending and relaying information all over the body. So as you can imagine if you're not able to properly break down and detoxify, you're gonna be sending inflammatory signals to the brain. So when women talk about brain fog and fatigue and mood disorders and things like that, I'm already thinking like what is going on at a micro level?

in the microbiome that's not allowing you to properly clear and assimilate some of these nutrients and byproducts and actually properly eliminate things from the body that should be there. And this is why as as unglamorous as it is, it's important to talk about the need to poop. It is not glamorous or exciting. Um I was interviewing an expert and I said, you know, how do you define constipation as a gastroenterologist? And she said, Well really it's

I let the patients kind of define, does this bother me? Like, does it bother me that I don't poop every day? And I said, Well, that would bother me. I generally tell my patients you should go at least once a day, preferably twice a day. But I would acknowledge I've had patients that tell me they poop twice a week and they think that's normal.

You wanna be asking, Are you dehydrated? Are you chronically stressed? Like I have people that tell me they they are I well, I jokingly call it the non public pooper. It's the person that as soon as they leave their house, they go on vacation, they can't go to the bathroom. And I'm like All the more reason for you to de-stress because you should be able to go to the bathroom on vacation. It should not be this like arduous issue.

There was quite a bit of endotoxin that I ingested and that was what drove a lot of the, you know, vomiting and diarrhea and just feeling poorly. But when you get this translocation, you're actually getting leaky gut and the endotoxin, which is generally caused from gram negative bacteria, it leaks into the bloodstream and provokes a lot of inflammatory cytokines. So it can provoke brain inflammation, it can provoke

Just inflammation, like you can get uh achy joints, you can have uh brain fog. I mean, those weren't the things that I experienced, but it just magnifies the effects of the bacteria that you ingest. So when you ingest Um, a foodborne illness bacteria, and you're vomiting and having diarrhea, your body is trying to get rid of what does not belong, as unpleasant as it is.

But at a very cellular level, when you leak endotoxin into your bloodstream, that is what provokes all these other side effects. And so If anyone listening has ever had really bad food poisoning like I've had, um, I can assure you that every achy body part, every single inflammatory thing, not feeling like you can't think straight.

Um, those are all a byproduct of your body trying to process and get rid of these inflammatory endotoxins. So interleukin six will go up, sometimes tumor necrosis factor. things that can be very noxious to our neurologic system, they can be noxious to um our cells and can become, you know, problematic. So I I think on a very kind of macro level, it's helping people understand that bacterial translocation is a byproduct usually of a provocation of the immune system.

Sometimes vis-a-vis the ingestion of a parasitic friend, like I ingested geordia. And that's probably.

get through those transitions a little easier if we didn't forget instant if we didn't assume that our bodies suddenly turned on us. It's uh I think this is a defensive mechanism. This is a I gotta keep you alive, dude, and it's gonna feel ugly, but this is what has to happen right now.

food poisoning, foodborne illnesses in middle age, your body doesn't weather it quite as well as it did when you were younger. So it just reaffirms why, you know, when you're traveling you have to be careful and conscientious, which we were, but one of us got food poisoning and the other one didn't.

Um, I know we talked about how the microbiome helps in detoxifying estrogen metabolites and hopefully moving them out, allowing assuming you have your doors of elimination open, as they used to say back in nutrition school. Um but How d what is the impact of estrogen on that microbial diversity, which again, we lose it. Which is part of the problem with aging.

Diversity. We're talking about beneficial bacteria, viruses, fungi. Think about it as a you plant a garden, you have fruits and vegetables that you want. And as your hormones are declining, in particular estrogen, you start seeing a decline and maybe you don't have as much tomatoes that time and Maybe you have less corn that's growing. Maybe the peas don't grow quite as much. So you have like a decline in beneficial bacteria. And what can chemically happen is you will have

um more inflammatory species. So I've talked a lot about how inflammation plays this role throughout the microbiome and this decline in hormones. So I always use the term dysbiotic. So non-beneficial bacteria that can grow up in between the fruits and vegetables that you do want.

And one of the things that's really interesting is if you look at the research, the things that impact diversity are the same things that we've same things we've been talking about throughout this conversation, chronic stress. Antibiotics, um, you know, ultra-processed foods, emulsifiers, additives, artificial sugars can damage the microbiome. And so

It really goes without saying that, you know, diversity changes through three kind of key times in a woman's life. Number one is puberty. And let me precede that by saying de depending on whether or not you're a vaginal delivery or a C section, breast fed or formula fed. It imprints the microbiome. Then we go through puberty. Not surprisingly, young men and young women, their diversity changes in response to these hormones.

Pregnancy is another big P and then last is perimenopause. The irony being by the time we get to menopause, the microbiome constituents can look very similar to men's again, but it doesn't it's not advantageous for us. So it goes back to saying that estrogen plays an a critically important role, progesterone to a lesser extent.

And, you know, I would argue that there is some immune function um benefits of testosterone, but I think for a lot of individuals, it's helping them understand that until our hormones start to decline and falter, there's a lot in the microbiome that is optimal.

And then it starts to decline in response to estrogen declining. And and we know estrogen kind of comes that really comes at the tail end of perimenopause. Now if you're taking hormone replacement therapy, the thought process is that that will

lessen the likelihood of the impact of some of those. We don't yet have ranges like we do with bone. Like we know for bone protection, we want your estradiol levels to be anywhere from sixty to a hundred picograms per ml. I know the US related, um numbers, I'm not sure if they're the same uh in Canada, but I think for a lot of individuals, I think this is the direction that research will be going that we'll eventually get to a point where we'll say

to confer protection for um, you know, leaky gut, bacterial translocation, all these other things. We'll wanna maintain an estradiol level of sixty picograms per ml. Now that could change, but

Uh I think that's the direction that I see Richard going in. And I've certainly I I ask all of the I ask all the microbiome experts, like, do you think it's coming?'Cause certainly the research that I've seen sounds very encouraging. And they said, Yes, of course. There'll be lots of benefits beyond just bone, brain, and heart health that is where I think most of the research dollars have been planted.

You know, with this where's this belly fat coming from? Is it the insulin resistance, the cord the elevated cortisol, the lack of sleep? Is there something else? I mean, we've you've already d distinguished the visceral fat which we don't see, which is much more harmful.

But the most vexing fat really, let's face it, is the pooch. Nobody wants the pooch. And especially if you went through most of your life without a pooch or minimal pooch and now all of a sudden you've got this big pooch and you're like, What the heck? And that it and and probably it's the pooch that gets a lot of women into the doctor complaining.

I think it declines in estrogen. I think it's changes in insulin sensitivity. I think it's a loss of muscle mass. I think it is the lack of carb sensitivity. And a lot of women are still eating far too much carbohydrate for their physiology. And by that I mean what is a rough estimate. I would say if you are insulin sensitive, you can probably handle about thirty grams of carbohydrate. What do I see women eating? Fifty, hundred, and then they do that regularly, not just around workouts or

recovery and so I I think that that is a problem. I think the lack of sleep, because I remind women that sleep and the microbiome health are intricately interwoven, it's also interwoven in insulin sensitivity and glucose disposal. And so that's another one. But the chronic stress piece plus trauma. When I have a woman that we have looked at everything, I mean, we've done the gut testing, we've looked at you know, we've looked at inflammatory markers, we've done all the work. I always go back to

What was your childhood like? You know, when we talk about adverse childhood events, which was a joint venture between the CDC and Kaiser Permanente here in the United States, anyone that's listening can get online and get access to a very short quiz. I have an A score of nine. That is significant. And so I remind people that in my medical training, I trained in inner city, Baltimore, uh, we talked a lot about big T trauma, rape, murder, suicide. There's no question that's traumatizing, right?

And trauma is a wound, but equally corrosive and bothersome is little T trauma. You know, that's neglect, addiction, abuse. bullying and for each one of us it might look a little bit different. And so I think for a lot of women, they hold it together in their teens, twenties and thirties. They've created patterns to be able to deal with their stuff, because we all have stuff. None of us are perfect.

Uh and the wheels fall off the bus and perimenopause, meaning For so many of these women, I talked about the litmus test for taking care of yourself. for a lot of women in the setting of a decline in hormones, changes in neurotransmitters, all of a sudden they can't cope quite as w quite as well. And so this is a a a reawakening for women.

Whether it is getting somatic somatic therapy, whether it's dealing with a trauma specialist, whether it's doing talk therapy, whether it's doing Reiki work, whether it's cleaning up your toxic family slash spouse or significant other or job for a lot of people that is the missing link. I think for far too many women. I think now we're having conversations around this. It was the thing, quite honestly Nat, that when I was writing the book, I kind of sat back and was like, whoa. Like

Yeah. When you start looking at the research and something that I didn't mention that I think is significant The gut ovarian access plays a role in when you go into menopause. Guess what ages your ovaries? Lots of things. Um toxins, smoking, chronic stress.

If you look at the research on people that experienced stress like sexual abuse and things like that, go on to have families where their children are sexually abused. There's one research article, women will go into menopause eight years earlier. So I think when I'm talking to women and they tell me they went into menopause at forty five, forty seven, forty-eight, way before the the average here in the US, which is fifty one.

I'm always thinking, what happened in your youth? Did you have a really stressful job? Like I do I have met clinicians, GYNs, people who are up delivering babies in the middle of the night, ER doctors were working in really high acuity jobs.

um that that will age the ovaries. And so we we don't think enough about the impact of the ovaries. It's the most mitochondrial dense organ in a woman's body. And so I think we need to be really proactive about starting the conversations earlier because I do think, I do firmly believe that that trauma piece is the missing link for a lot of women and understanding how chronic stress

impacts the microbiome, how it impacts that gut ovarian access, how it impacts the brain. Um, I think for a lot of women, that is the missing link. Not just for the gut, but for the the

Um, and now there's this whole rebuild, right? Um so if the gut is the central organ, where do we really start on rebuilding it in y and and actually another question would be, do you think that if women started rebuilding their gut or taking care of their gut earlier

Could it make this change? Because in case somebody's listening to this and, you know, just had it on the card not realizing it was maybe targeting older people. If you're listening to this and you're in your twenties and your thirties Is there should you be you know, if you take better care of your gut now, will could it potentially make that transition easier?

And then if we didn't listen to this in our twenties and thirties and we're already in the middle of the storm, what can we do to really help? Because I think one of the things we one of the macros we didn't talk about was fiber and a lot of people will say Fiber will be the next macro that everybody becomes obsessed with, which frankly I wish we would stop getting obsessed with one thing and start talking about all the things. But anyway.

what, you know, the gut, the the colon will ferment, and then from there your body makes short chain fatty acid. So even more important in the decline of hormones, I think from a very macro level, I always say major in the majors. Sleep, stress, nutrition, exercise, before just about anything else. Because if you can major and and the research is solid, like I spent a chapter on each one of those areas. Everything I've talked about, there's a full chapter on.

I talked about the research on the gut microbiome and sleep quality, why it's important to get at least seven to eight hours a night, why it's important. I hope I've made the argument even talking about the trauma piece. Stress is insidious and most women who are not sleeping, it's because they do not manage their stress. Full stop. Um, nutrition, protein and fiber become really important.

Exercise, right amount. It's the Goldilocks effect. So when we talk about right amount of exercise, right amount of hormetic stress at the right time, it means if you do not sleep, do not go out and try to do high intensity herbal training. Like let's be smart.

I think there are far too many women who don't check in with themselves and then they still are like, Well, today's the day I'm supposed to do really my personal best on high intensity interval training. No, today's the day you go walk outside in the sunshine and do a recovery day.

So at a very kind of macro level, major in the majors, don't get caught up in buying the next gadget, which I love gadgets. I know you love gadgets, but I'm like, don't get caught up in that until you've mastered the basics. Because if you dial those in, you're gonna have much greater success when you start layering in all these other aspects of what I think are critically important for uh perimenopause and menopause gut microbiome effects.

So don't get caught in the bright shiny objects. Focus on the majors, get those dialed in, and then you get to have fun and play.

Before you even think about adding a fiber supplement, please try to get it from some beans, some legume. Right, exactly. Or like my my kind of my ninja is a fresh ground tablespoon of flax. And and chia seeds. For whatever reason, my patients tolerate that really easily. I do it every day. It just bumps up your fiber intake.

You get a little bit of plant based protein, um, and it's very well tolerated versus people say to me, Oh, I've got to have my psyllium husk. I'm like, before you even do that, like just try to get it from food, please, because the bloating that patients describe to me is generally because they've gone up too quickly, too fast, and so they have to back off. In fact, we have like all these resources that we created um as benefits of um people to buy the book.

And one of the things we were I was laughing about with my team, I was like, You cannot tell people to increase their fiber by ten to fifteen grams a day, they'll be mad at us. I said it needs to start slowly. So find out where you are and increase it by two to three grams until you tolerate that and then go up. Um

Do I think that I got everything right in perimenopause? Absolutely not. But when I talk about it, I always say, don't do what I did. These are the lessons I had to learn. And like quite frankly, I am so much happier. Like ten years later, oh my God, I am so much happier. So I think that we have to reframe it in a positive light because you may spend not just a third, but half of your lifetime if you go into like I was forty eight.

So I was fairly young, like I might live half my lifetime in menopause. I don't want to reframe it as a terrible time in my life. If anything, I'm like I found my voice. I'm like I don't put up with anything anymore.

Thriving for each one of us might look a little different. I think that I fully embrace my introvertedness, which I know people are always surprised to hear. Like I am, I like quiet. My husband and I both like quiet. We have a quiet house. We live in a very hilly part of our state where it's quiet and beautiful. And I I've just been able to di identify that what works for you, Nat, or someone else is totally great.

might not work for me and I just embrace my own sense of weirdness. So part of thriving is embracing my unique attributes and not apologizing for them.

Um the midlife pause backslash my name. It's a free community for men and women. There's no drama in that group. I personally answer questions as does my lead clinician, my other advanced practice nurse that's on my team a couple days a week. Um and my podcast is Everyday Wellness, and I'm excited to say that we're gonna grab Nat and have Nat on later this year to talk all about.

All the things that she's so knowledgeable about that we were talking about in the pre-chat that I need to share with my community that are super cool. So thank you again for having me.