Estrogen, Alzheimer’s & Osteoporosis: Perimenopause + Menopause Uncovered

Today I want to focus on women's health, specifically transitions that are happening in perimenopause and menopause. I will pull it out to all stages of women's health because I do believe there's a lot of takeaways, but there are a lot of big things that are happening and drawing more attention to this critical stage of changes that I really want to highlight and address. So recently there was a group of OB GYNs, urologists and other physicians that went to the FDA to to have a roundtable that the FDA was hosting to ask them to remove the black box warnings on vaginal estrogen creams and increasing essentially the message around the importance of hormone replacement therapy and decreasing some of the fear mongering that has existed over the years. And I don't even want to say some of the fear mongering, but a lot of the fear mongering that has happened with to clinicians and patients over the years. So essentially, the 2002 Women's Health Initiative suggested that hormone hormone replacement therapy was associated with an increased risk of breast cancer, heart disease, stroke and clots. And that has led to a lot of the concerns around hormone replacement therapy in women. A lot of doctors who will still tell their patients that going on hormone replacement therapy can increase their risk of breast cancer or increase their risk of heart disease. And then there's that black box warning that is not scientifically sound, that is on the vaginal estrogen creams that does not have any research behind it. So these doctors went to the FDA to have advocate for removing that black box warning, but also increasing the awareness around the safety of hormone replacement therapy for many women who don't have contraindications. So the 2002 Women's Health Initiative ended up indicating that there was a association between hormone replacement therapy and an increased risk of breast cancer, heart disease, stroke and blood clots, which sent everyone into high levels of fear. Practitioners stopped recommending hormone replacement therapy. Women stopped asking for hormone because there was a huge concern over the risk of cancer and heart disease. The Women's health initiative, as Dr. Joanne Pinkerton pointed out, ended up being very flawed and it has created a lot of unnecessary harm over the last few decades, which these experts were there to try to clarify. So she had stated that the Women's Health Initiative, among the many flaws, that it included a wide age gap. It included women between the ages of 50 to 79, with the average age of the woman going through the Women's health initiative being 60. And she highlighted that before the age of 60, that they actually see a very small numbers of heart events, blood clots and stroke. And at the same time, women that are under the age of 60 who start hormone replacement therapy have much lower risk of breast cancer, all fractures, all cancer, all cause mortality and diabetes compared to women who are not taking hormone replacement therapy. So the fact that age matters in the time that you start hormone replacement therapy matters, which was something that they were really highlighting within these flaws of the women's health initiative that have created this unnecessary fear and harm over the last two and a half decades. So there was a huge push, of course, it's so important. There's a huge push for decreasing some of the stigma around this, educating more practitioners, because they highlighted the fact that most OB gyns and doctors as a whole receive zero menopause training or education, and that this is a critical aspect of a woman's health that makes up so much of her lifespan. So the physicians did an incredible job advocating for these changes around hormone replacement therapy. I'm going to highlight some of the key lessons and learning opportunities from the FDA panel, but I would really encourage you to watch the entire thing on YouTube. They have it on YouTube that you can watch. And I, in this episode, wanted to pull it full circle to what I do in working with women in the last 10 years who have been so dismissed by different practitioners that they're working with one of the ob gyns had highlighted the fact that women, as they're experiencing perimenopause and menopause and they're dealing with a whole host of different symptoms that can range from anxiety to mood swings to depression to increased risk of cognitive decline, hot flashes, vaginal dryness, increases in so many other symptoms and an increase in a lot of labs, like increases in cholesterol and increases in blood sugar as insulin sensitivity goes down. So there's a lot of changes that are happening. Women are very dismissed across the board. This is an experience that I have had in working with thousands of women over the last 10 years. My dietitians and I see this in many, many of our clients, that they aren't getting the answers. They aren't having a physician who regularly and proactively even tracks their labs and the changes to their labs a six month or a one year time frame. When I say is tracking labs, I mean comprehensively, like looking at super important markers like HSCRP and fasting insulin and a lot of markers that end up being missed. But then there's also not any discussion around the importance of nutrition and lifestyle interventions for mitigating these symptoms and effects. So we have women every single day that come into our ego system through our programs that are experiencing symptoms and they aren't getting answers to their nutrition is very much impacting the underlying chronic inflammation or the insulin sensitivity or other things that are already exacerbated from the changes to their hormones. And this is whether they're on hormone replacement therapy or not. Hormone replacement therapy can be very important if you know you're a great candidate for it, if it's initiated early enough, close enough to menopause that you're not then increasing your risk of things like heart disease. And I am, absolutely. I think that the work that these physicians are doing is so, so important, and I 100% stand behind them. And then I also want to expand the conversation to say, how can we focus more on the role of nutrition in lifestyle as we're. We're going through this transition as well, because it really matters. Okay. So this group of physicians, again, they did an amazing job highlighting many aspects of women's health and how it's underfunded, how it's under discussed, how it's not taken seriously enough, and that it's been too long that women have been suffering. Women have been dying unnecessarily because they're not being given the proper treatments that they need in order to extend their life. Extend their life, meaning, like decreasing their risk of heart disease or even. Dr. Rachel Rubin highlighted the fact that so many women die of UTIs on a yearly basis and complications with UTIs, and the fact that, you know, even something like vaginal estrogen cream, she states, is extremely beneficial for preventing the recurrence of UTIs. She said specifically, like a $13 tube of estrogen can be a lifesaver in many instances, highlighting an experience that her mom actually had when she was in the ICU for six months. And the doctors were just completely unaware of the role that vaginal estrogen creams play. So in thinking about this, I want to start with some of the key areas that were highlighted. One, there was a physician, Dr. Roberta Diaz, who had talked about the fact that 2/3 of Alzheimer's cases are in women and one third are in men. So women are at a disproportionately higher risk of Alzheimer's disease, and the disease starts earlier in women during the menopause transition. So she highlighted the fact that this is not just because women are living longer, it's actually that it's starting earlier, and it's correlated with the menopause transition. So she said that when the brain undergoes a substantial loss in ability to utilize glucose as its primary fuel, that this happens in the menopause transition. And there's a coincident rise in beta amyloid levels in the brain that's at this time. And that taking hormone replacement therapy can actually reduce risk of Alzheimer's disease, Parkinson's disease, ALS and all causes of dementia. So focusing on brain health being one that is directly tied to having hormone support, and I'm going to go a little bit deeper into the nutrition. But another physician, Dr. Vonda Wright, who's an orthopedic surgeon, had highlighted the fact that 80 million women over the age of 40, that 40% of them will develop osteoporosis. The rate for osteoporosis is four times higher in women than in men, and it occurs 10 years earlier in women than it does in men. So she specifically highlights the fact that in the five to seven years surrounding perimenopause that women will lose 15 to 20% of their bone density. And it's at the exact same time that we're losing estrogen. Half of women will have an osteoporotic fracture. 70% of all hip fractures happen in women. And she said verbatim, the minute that you break your hip, a woman has a 30% chance of dying in one year and a 50% chance of never returning to that pre fall function that she was experiencing. I literally cannot get over this, especially because I have been in the field of nutrition as a dietitian. I did not learn this in school. I didn't even learn this in my first many years of practicing as a dietitian, the attention that's needed for bone health. It actually wasn't until a family member of mine recently went through and an entirely preventable osteoporosis diagnosis. Had the awareness been there and had she been recommended a DEXA scan looking at her bone health at least 10 years earlier than it had been recommended. Because waiting until the age of 59 for a DEXA scan to look at your bone health is completely missing the mark. It's like training for the marathon in mile 20. It's like it's much too late. Women are losing 15 to 20%, according to Dr. Vonder Wright, of their bone density. And five to seven years surrounding perimenopause. We also see a decline in bone health postpartum and in breastfeeding. And so if you are going from the postpartum phase, then just like going back to living your life and after breastfeeding and all that. And you're not accounting for the muscle and the bone that you had lost. And then you enter your 40s and you're continuously losing up to 1% of your muscle mass and a significant amount of your bone mass every single year. And then you enter perimenopause, and you're losing 15 to 20% of your bone density in five to seven years. You are at a very high risk of poor bone health, frailty, fractures, and the fact that there is not as much attention around the actual risk of death around fractures. I remember hearing Dr. Rachel Rubin say that the risk of death in fractures is just as high as the risk of death in breast cancer. And I still cannot get over that statistic either, because there just is not enough awareness around this being such a preventable condition that women are being diagnosed with every single day. And the role that we have in taking ownership of our health from a nutrition and lifestyle standpoint, of course, hormone replacement therapy, especially when it's being given from a preventative state, which is what she highlighted, the role of giving hormone replacement therapy prior to the osteoporosis. Not that I actually am not even sure of the guidelines for using it once osteoporosis is diagnosed, but I do know many women that have initiated it, even once they've been diagnosed with osteoporosis alongside their physician in a safe way, that have been able to drastically improve their osteoporosis and improve their. Their overall bone health. But this has to be a part of the conversation. And I just think about, you know, osteoporosis has such a large effect on our overall health, and nutrition plays such a large role. I'm going to get into that in a second. But thinking about how much nutrition, not only from a micronutrient standpoint, but adequate amounts of protein, thinking about lowering levels of inflammation, like, the body is one interconnected organism, and so even things like inflammation can be tied to risk of osteoporosis overall. So the other thing that I wanted to highlight is that in some ways, when you think of menopause for so long, I think there was a stigma that it's like, oh, it just happens in really old women. And then you realize that perimenopause can actually start as early as 35 years old and that we will start to experience a shift in hormones or many women. It obviously completely depends on the person. And there's very much a range for which this can take place, with the average being more in the mid-40s. But the average years of perimenopause are four to eight years that a woman will be experiencing these hormonal transitions and experiencing more symptoms. And then the average age of menopause is 51 years old. So Dr. Heather Hirsch had highlighted the fact that many physicians will get an hour of menopause education, which she said was her experience where she had a voluntary lunch and learn where she learned about menopause. And on average, a woman will go to five to seven physicians before they get help with the symptoms that they're experiencing. Now, I know that as a woman, you wanna be thinking about your health based on where you're at in your life stage. But I do wanna highlight the fact that the earlier that you start, the better. Right. It's again, that analogy of if you start training for the marathon on mile 20, you've waited too late. And so really, if you are in your mid-30s, if you have not experienced some of these hormonal shifts yet, if you're in your early 40s, and you still haven't even experienced as many of these hormonal shifts, you're back to a state of hormone balance after having babies. Or maybe you haven't had babies or you've chosen not to have babies. I cannot emphasize enough the importance of supporting your nutrition and lifestyle because it plays such an important role in this entire experience. Of course, being aware and educated on hormone replacement therapy also plays an enormous role, which is why I would highly encourage you to check out that FDA roundtable because it was very enlightening and. But at the same time, we have to be expanding upon the role that nutrition and lifestyle play in our overall hormone balance. So when you think about a functional nutrition approach to hormones, there are many different factors that can impact our overall hormones. We have nutrition, of course, and I'm going to talk about some of the ways from chronic inflammation to insulin sensitivity and those sorts of things. But we also have chronic stress levels. We have sleep deprivation, which directly impacts nutrition. Because sleep deprivation increases your ghrelin levels, it'll decrease your leptin levels, which are your hunger hormones that then cause you to eat more specifically, higher carbohydrate rich foods the next day. Research shows that even just a few nights of sleep deprivation will drastically increase a person's consumption of carbohydrates, more like processed and refined carbohydrates, because of the way that it skews our hormone balance, our hunger hormone balance. And so when that's happening, it makes us susceptible to making choices. That are only going to continue to fuel the underlying hormonal havoc that's happening underneath the surface by increasing inflammation, chronic inflammation, by increasing our insulin resistance. So thinking about the role that sleep plays, in addition to the role that sleep plays in a variety of other factors like insulin sensitivity, but then also thinking about toxic exposure, toxic exposure is another huge one, environmental toxic exposure exposure. So the things that we're exposed to on a day to day basis, they directly impact our overall hormones. They have many of the toxic exposures that we are surrounded by, whether that's the plastics or it's the artificial fragrances in dishwashing detergent and in dry cleaning materials, and in even laundry materials. All these things that we're exposed to, that we're inhaling, that we're ingesting, that are endocrine disrupting chemicals, they mimic our own hormones and they wreak havoc on the body. So underlying toxic exposure, environmental toxic exposure as a whole impacts our hormones. And a lot of traditional practitioners will say that, you know, it doesn't matter that our bodies are equipped to be able to handle environmental toxins by being able to pee them out. If you have kidneys, then you're able to excrete anything that you're exposed to externally. But that could not be further from the truth. The research is showing that we have a higher environmental toxic burden than we've ever had had before. And the body's capacity to actually handle that is not equipped. We're not equipped to be able to handle the increased load that we're exposed to environmentally from a variety of different factors, which we'll get into more in the show, of course. But I just want to highlight the role that minimizing our toxin exposures plays on our overall hormone health. And then in addition to nutrition, getting adequate fiber, getting adequate protein to support bone health and to support muscle health, in addition to a number of other factors. So there was one 2023 systemic review, Meta analysis and meta regression, and interestingly enough, they found that nutritional interventions are promising tools for women who are going through perimenopause and menopause for their mood and anxiety symptoms, finding that nutrition interventions helped to reduce those anxiety symptoms and improve overall mental health as a whole. Another 2023 paper on the importance of nutrition and in menopause and perimenopause had shown that during the menopause transition, risk of chronic diseases like type 2 diabetes, cancer, heart disease and Alzheimer's disease increase, and that this is associated with the decrease in estrogen levels, which therefore means that Dietary interventions, the food choices that we're making, the foods that you're putting onto your plate for each of your meals, that this needs to be an integral part of a treatment plan, that nutritional interventions are an essential element of preventing the chronic diseases that increase as your hormones are changing. And then they also highlighted the role of central obesity in menopause, because as a woman goes through menopause, the way that they store fat actually changes. So they found that central obesity, meaning storing more visceral fat around your waistline, that it actually increases five times, it's five times higher in women that have gone through menopause than women prior to going through menopause. There was epidemiological studies that had found that central obesity, high levels of cholesterol and other lipid markers, glucose intolerance, and hypertension, that they are all the most common risk factors for cardiovascular disease in menopausal women, and that the incidence of metabolic syndrome is two to three times higher in postmenopausal women than in women prior to menopause. So they also highlighted the fact that strict adherence to a nutrition intervention reduced the risk of cardiovascular disease by 14 to 28%. Now, I don't love the idea of strict adherence because in our programs we really find that the all or nothing approach of feeling like you have to be so strict can actually end up working against you, where it creates a level of self sabotage and a level of let me just eat anything under the sun and then I'll go back to trying that diet again in a few months when I'm mentally prepared to do so. So we want to think about nutrition not from like a strict adherence standpoint, but in a way of how can we create the most consistency and sustainability for you in these lifestyle changes and in a way that works best for your body. The metabolic changes that are happening during the perimenopause transition also increase that level of insulin resistance because there's an impairment of insulin secretion and insulin sensitivity, which also increases your risk of type 2 diabetes. When we think about nutrition interventions, just thinking about increasing fiber intake alone can have a ton of positive benefits. So when we think about increasing fiber, this of course can decrease risk of type 2 diabetes. It can help you feel more satiated, it can help with weight management, it can help with decreasing risk of heart disease, lowering cholesterol levels. The list truly goes on and on. But I wanted to focus on the role that fiber, and even fiber sources that are prebiotics that fuel our beneficial microbes and help those microbes exert anti inflammatory effects through the production of something called butyrate, which is a short chain fatty acid. They have shown that this actually ends up decreasing the risk of many of these issues that happen in menopause. They found that the bacteria in the microbiome, because women as they're going through menopause, in these hormonal changes, they actually create a change in your diversity in the microbiome. This has been well established in some of the Zoe Research. And Dr. Rachel Rubin also highlighted that in her FDA hearing she had stated the fact that this is one of the reasons that women are at a higher risk of UTIs, but also many other things is because of the changes in the microbiome and the decrease in relative abundance within many of those healthy strains of bacteria that are helping to work in our favor. So the bacteria with beta glucuronidase activity can actually increase the level of biologically active estrogen in the body. Stating that can help to slow down the development of estrogen deficiency and reduce the symptoms accompanying menopause. So this is really profound, the connection between nutrition and the gut microbiome and then your hormone levels as you're going through really any transition, whether that's, you know, trying to increase your fertility outcomes or postpartum recovery. Our gut microbiome is the epicenter of our health and it is also very closely tied to our hormone health. So that is one factor that I do think is worth mentioning is that when women come in to work with us and you know, we have different nutrition programs, some of which we're running individual lab testing on clients and then others where they're following the being collective framework and protocol to really utilize a lot of these nutrition strategies to help to balance hormones and gut health. But when we're running tests, a lot of my dietitians and I will reflect on the fact that women come in and they say, I want to balance my hormones, that's my number one goal. My hormones are out of whack. And sometimes it is hormones, but other times it's thyroid issues or it's microbiome imbalances that are leading to other downstream effects, or it's chronic underlying inflammation. And so sometimes it's hard to just make the assumption like, oh, it's my hormones. Although that is the natural thing that of course you would jump to because of, especially when you're going through perimenopause and menopause. My point in bringing this up is that it is a very holistic approach that we wanna take of Course, addressing hormones is so important. Of course, taking hormone replacement therapy is so important. But we have to look more holistically at all of these overall pillars that impact our health and decrease risk of not only these diseases, but these symptoms and create health. Right. There's a big difference between even treating disease, preventing disease, and then actually creating health. Creating health means continuing to implement the choices and the habits that are going to move you towards the healthiest, strongest, most confident state so that you're able to age very well. There was a quote from one of the doctors, Dr. Kelly Capperson, the urologist that was there, who said something along the lines of, imagine women over the age of 50, like an entire population of women over the age of 50 who are cognitively feeling sharp and confident and having the energy and having stable moods and feeling strong and having strong bones. And imagine that as a generation of women and what that leads to as far as, like, how it impacts lives and how it impacts businesses and the economy and future generations of women to show them what's possible. So my point in saying this is, of course, hormones play such an important role, but we have to be thinking holistically. Okay? So then when it comes to bone health, thinking about the role that nutrition plays, which we will talk much more in depth about in future shows, but thinking about lifestyle changes that are necessary for improving bone health and reducing risk of osteoporosis, because nutrition plays an enormous role, one maintaining adequate levels of nutrients, thinking not just about macronutrients, because protein plays a huge role and supporting overall bone health and muscle health, but then also thinking about micronutrients like vitamin D and calcium and magnesium and other nutrients that play a big role in our overall bone health. A lot of women are at risk of nutrient deficiencies. This is another very common underlying risk factor that you'll go to your regular doctor and ask about and probably be dismissed saying, oh, no, there's no need to worry about nutrient deficiencies. As long as you're able to eat generally healthy, then you're not at risk. And I can tell you that that is just simply not true. I have run thousands of nutrient deficiency tests. My team of dietitians run thousands of nutrient deficiency tests. And it is very rare to see a person with zero nutrient deficiencies. So thinking about that, regular exercise is included in the guidelines. The combination of cardiovascular training and resistance training, smoking cessation, and then also alcohol consumption, significantly limiting alcohol consumption can also play an enormous role. And the other thing that this research study that I'm highlighting in particular had said is that osteoporosis prevention begins in childhood and adolescence when the peak bone mass is formed. And so of course, we're not able to go back to being a child or being an adolescent, which again, highlights the fact that the sooner you start, the better. But change is possible regardless of the age that you're starting at. Both of those things can be true. So thinking about micronutrients, thinking about overall micronutrients as a whole being extremely important, not just for bone health, but for brain health and mood and so many other things, like looking at B vitamins, vitamin C, vitamin D, calcium, they all play a huge role. Omega 3 fatty acids, which is not always, you know, addressed. It's not always tested. We test Omega 3 fatty acid levels routinely in my Food is Health. And it is astonishing to see the blood levels of omega 3s being as low as they are extremely consistently. There's, I think, just this assumption that if you eat some fish that you can have healthy levels of omega 3s or if you sprinkle some chia seeds into your yogurt bowl, that you'll, you can get healthy levels of omega 3s in your diet. And that could not be further from the case. Not only are chia seeds inadequate for our actual total omega 3 intake, because we do need a combination of fish and plant based sources, but unless you're supplementing with something like algae, we need to address omega 3 levels much more proactively than we currently do. Okay. And then fermentation of polysaccharides and undigested proteins by some microbial strains, they generate short chain fatty acids, which I already started to talk about. Specifically, I mentioned butyrate, but there are three total short chain fatty acids. Acetate, propionate and butyrate are the three that our body produces that possibly have benefits to metabolic pathways. Now, this is something that I have been looking at for more than five years in my graduate class. We actually have students, our graduate students and medical students and dietitian students present on various nutrition topics. And one that we've had students presenting on for the last many years are the role of short chain fatty acids and the effect that they have on our overall metabolic health. So looking at the new studies that are suggesting that supplementation with probiotics or prebiotics or fiber can help with improving cardiometabolic factors, risk factors that occur in postmenopausal women. So again, I'm not stating that everyone needs to go on a probiotic. I'm not stating that everyone needs to be on a prebiotic. I think that it's definitely, there's an individual component to it, but working with practitioners that are taking all these things into account, I cannot recommend enough. And that's another thing that I do want to highlight. For as much as these doctors advocated for the importance of menopausal training, especially for ob GYN residents, it just seems like an absolute no brainer. The fact that menopause has been pushed out essentially of a lot of the training which one of the physicians highlighted, the fact that there used to be 120 hours of residency work that was decreased to 80 hours. And so you can't cut out teaching a person how to, teaching a future ob GYN how to deliver a baby and other things. So aspects of menopause care, especially since physicians were so concerned that hormone replacement therapy was causing cancer, were just kind of like pushed out of the equation. So the importance of having physicians and a physician that you're working with that has the awareness of these sorts of things, but also expanding your health care team beyond just your doctor, because we've put such an enormous load and weight on the doctor to know everything about anything. And if you're truly taking a holistic approach, working with practitioners like functional medicine dietitians, I believe creates enormous power in supporting your overall health and thinking more holistically, thinking broader than what your doctor would traditionally be recommending. So with that, and looking at a note that I had taken, Dr. Marty Makary had said, for too long women's health issues have been sidelined, downplayed and underfunded and under appreciated. I think that's probably the perfect way to end this is to say that there's a lot of opportunity. And I think it starts with you understanding that you don't have to tolerate not being given the answers and being dismissed for the ways that you feel. That is where so much of it starts. There's of course a lot of issues that need to be solved for there's a lot of changes that need to happen across the board. But it is very encouraging to see more of these conversations that are happening with groups of OBGYNs that are on social media or that are educating future residents and doctors, changing the narrative around women's health, which I am so on board with. So if you have benefited from this episode, I would love for you to share it with a family member or friend, any of the women in your life that you feel like, oh, we really need to be factoring this in and thinking about this, whether it's on a proactive level or it's on a I'm in the thick of it level and I don't understand why I don't feel the way that I feel like I deserve feel. Or you're even on the other side where you've gone through menopause but you're looking for other ways that you can optimize your health and maybe if your doctor decides that, you know, it's too late for you to start something like hormone replacement replacement therapy, really factoring in the role that nutrition and lifestyle can play in optimizing your overall health and decreasing a lot of the symptoms that many women experience. Thank you for being here with the show. Being new, it means a lot if you could leave a rating and a review, subscribe to the YouTube show and again share it with a friend or family member that you feel could really benefit. It helps us spread the mission to help more women use food as medicine to support their overall health.