Why Your Gut Falls Apart in Perimenopause (And How to Fix It)

We eat too much carbohydrate, we eat the wrong types of fats, and we eat too little protein. Women are eating like 40 or 50 grams of protein. This explains why you're standing in your pantry or looking in your freezer at 8 o'clock at night saying, why do I feel like I'm hungry? For a lot of clinicians and women, we're kind of conditioned to understand that the decline in hormones impacts brain health and cardiovascular disease risk and bone health. But what most of us do not understand, because we were never taught it, is that the microbiome is this incredible inflection point in terms of how it interfaces with every single organ system, every single cell. And you better believe those changes in hormones and neurotransmitters dynamically impact the microbiome. For a lot of women, they're oftentimes very surprised to see that their digestion starts to shift and change, not just around their menstrual cycles. We know that progesterone, as an example, is a smooth muscle contractility type hormone, so it helps move food through the digestive system. And estrogen's really important for nitric oxide signaling. So how food moves through our digestive system can be altered quite significantly in perimenopause, just depending on where we are in our cycle, the better we can support our gut microbiome heading into perimenopause and menopause, the less symptoms we're going to experience, the healthier our bones will be, will be lessening our inflammation and probably impacting how well we control our metabolic health as well.

Today on the Being Bridget Show, I'm joined by Cynthia Thurlow, a nurse practitioner and host of the Everyday Wellness Podcast. She's also the author of this incredible book, The Menopause Gut, which I am so appreciative of because everyone thinks of menopause as just when should I start HRT? And that's of course a very important part of the conversation, but without addressing the changes that are happening in the gut through menopause, we're doing a huge disservice for women. So Cynthia, the book is so important. Can you explain in your own words why that is the case?

You know, I, I'll be honest with you. I think life imitates art, Brigid Titgemeier. There was certainly a time when I was neatly tucked away in clinical cardiology. I didn't really think a lot about perimenopause because no one had actually prepared me for it, but it wasn't until I took a trip in 2018, and this is how I kind of start out the book, was that we were in Morocco, it was so romantic, we did all these amazing things, we ate the same food, and one of us got terrible food poisoning and the other did not. And when I reflect back on why I was so susceptible to Giardia and other pathogens, it had a great deal to do with how much my immune system and my gut were changing in the setting of declining hormones and changes in neurotransmitters. And so I think for a lot of clinicians and women, we're kind of conditioned to understand that the decline in hormones impacts brain health and cardiovascular disease risk and bone health. But what most of us do not understand, because we were never taught it, is that the microbiome is this incredible inflection point in terms of how it interfaces with every single organ system, every single cell, and you better believe those changes in hormones and neurotransmitters dynamically impact the microbiome. So when I think about the missing link for most midlife women, it's thinking about the gut as this very, very important inflection point. And one that I think the better we can support our gut microbiome heading into perimenopause and menopause, the less symptoms we're going to experience, the healthier our bones will be, will be lessening our inflammation and probably impacting how well we can control our metabolic health as well.

Mm, I love this so much because really the gut, you know, think about from a functional medicine terminology standpoint, like the gut microbiome is the epicenter of health. And that's even more so the case for women as their hormones are changing. And like you said, no one is really talking about this. So you have women that have gone from childbirth into, you know, possibly multiple rounds of antibiotics, whether it's having like strep B or an infection after birth or whatever the case is, rolling right into breastfeeding and fluctuations in hormones right into perimenopause. Now today, with even less of a gap, you know, as women are having babies older, and no one then explaining, you're going into this phase often with a depleted microbiome, or you've had multiple rounds of antibiotics for other reasons that are then exacerbating all of those symptoms. So can you explain, like, why that's so concerning?

Yeah, you know, I think it's many things. So let's back up and just identify what the microbiome is, because for a lot of people it's not tangible. It's like we know where our heart is, we know where our brain is, we know where our stomach is. So the gut microbiome is 40 trillion bacteria, viruses, fungi, and protozoa that accompany the large intestine or colon. And it's heavily influenced by how we're born. So whether or not we're a vaginal delivery or a C-section, whether we're formula fed or breastfed. And not surprisingly, at puberty, we get tremendous shifts in the microbiome in response to key changes from estrogen, progesterone, testosterone, if we go through pregnancy and then perimenopause. But the things that can impact the microbiome before we ever get to perimenopause are chronic stress and trauma, looking at antibiotics, toxins we're exposed to in our environment, the processed food industry with emulsifiers and additives and things our bodies have never needed to be exposed to before. And not to mention the fact, at least in my generation, my generation, we were put on oral contraceptives to fix every single period problem known to man. Whether it was irregular cycles, heavy cycles, acne, or plus or minus also for contraception, which we know can heavily influence and imprint the microbiome and especially the estrobolome. So as women are, you know, transitioning through all these different stages, we have varying degrees of health of the microbiome. And it may not be until we get to our mid to late 30s or even early 40s that we may experience things like bloating, Digestive changes. For a lot of women, it could be that maybe they never had issues with constipation before, maybe they, maybe they never had diarrhea. This is a time when a lot of women are diagnosed with irritable bowel syndrome, and in fact, it's probably not irritable bowel syndrome, it is probably an underlying food sensitivity. You know, really looking at this blood sugar stability, you know, the blood sugar roller coaster that I know you and I both talk about a great deal with our patients, helping them understand that as we're transitioning perimenopause, we're getting changes in muscle mass, we're losing insulin sensitivity, we don't have the same carbohydrate tolerance that we had before. Note, I'm not saying that we shouldn't consume carbohydrates. It's the quality of the carbohydrates become very important. And so when I'm helping women understand first and foremost what's happening— more inflammatory species, more likely to develop autoimmune conditions due to leaky gut, just more overall inflammation— that can change the way that we feel, and that can change the way that we perceive our world. I think for a lot of women they're oftentimes very surprised to see that their digestion starts to shift and change, not just around their menstrual cycles. We know that progesterone, as an example, is a smooth muscle contractility type hormone, so it helps move food through the digestive system. And estrogen's really important for nitric oxide signaling. So how food moves through di— our digestive system can be altered quite significantly in perimenopause, just depending on where we are in our cycle. And then in this kind of postmenopause age range, so The microbiome interfaces with just about every single organ and, um, cell in the body, but is heavily influenced by environmental, um, food choices and also the choices that we are making day to day. You mentioned antibiotics. Hopefully everyone that's listening is not using antibiotics, um, inappropriately, but when they're appropriately prescribed, they can be life-changing. But unfortunately, in our modern-day medical system, antibiotics are given so easily and so readily. That we're already kind of setting ourselves up for not only changes in the microbiome that can impact us long-term, but also setting us up for leaky gut. And leaky gut in and of itself, which, you know, 10, 15 years ago when I'd mentioned that, my colleagues were like, that's not a real thing. It is a real thing. That small intestinal lining is only one cell layer thick, so it's very easily damaged or broached. Then you layer in the changes in hormones, especially with estrogen, which is a powerful immune modulatory hormone. Makes us much more susceptible to developing things like celiac, Hashimoto's, lupus, rheumatoid as we're getting older.

Oh my gosh, I am just so obsessed with everything that you just said and like summarizing that into a few minutes of like the most powerful information for women to be able to connect how all of this is interconnected and how much it can then present as so many different conditions, and then also symptoms like you talked about— the constipation, the mood swings, the anxiety, the depression, the joint pain, the bloating, the like feeling like all of a sudden you're not tolerating certain foods that you used to tolerate before, the insomnia, the fatigue. You know, I think that so often when we think about the gut, that of course the first symptoms that you're going to see are GI symptoms, but I remember learning so long ago that the second most common symptoms that happen for someone that has celiac disease or other gut issues is actually in the brain. And that's where I feel like it's so often missed, that connection, because you think that the fatigue or the brain fog or whatever the symptoms are that are happening neurologically aren't connected to the gut. So can you explain how those are connected?

Well, there's a very important nerve called the vagus nerve, and it's the longest nerve in the body. It innervates from the brainstem all the way through the digestive system. And actually, the bulk of information from the vagus nerve goes from the gut to the brain. So when you talk about neurologic symptoms that people are experiencing, more often than not, it is inflammation that is derived from the gut through the afferent receptors are going up to the brain. And so I think a lot of patients are surprised to know that, you know, those gut feelings, you know, people will actually say, I feel like my gut is telling me something.

It is.

That's a powerful connection to make. But the vagus nerve is very important for a number of reasons. Number one, it's a relay communication system between the gut and the brain, gut-brain axis. But also one of the key regulators of putting us into the parasympathetic, the rest and repose side of our bodies. In our modern-day lifestyles that are incredibly busy and harried, our body can't differentiate being chased by a rabid animal from the traffic that we're dealing with, the stress of, you know, getting from home to try to meet our children on the bus, to getting food on the table, to getting kids to activities, just the demands of day-to-day life. The vagus nerve is a really important way of reminding us that we need to slow down. So things like gargling, humming, singing can be very, very potent for stimulating that nerve and slowing things down. Breathwork, meditation. I think for a lot of people, they never make that connection. The other thing that's really interesting is the bulk of our neurotransmitters are produced in the gut. So a lot of these powerful drugs, like when I was a nurse practitioner student years and years ago, selective serotonin reuptake inhibitors, or SSRIs, were still fairly new. So Prozac, Paxil, Zoloft, um, and they act in brain, but the bulk of the neurotransmitters, in particular serotonin, 90 to 95% of it's made in the gut. So the health of the gut reflects not just our mood, but also impacts these inflammatory inflection points. And so I think for a lot of individuals, they're surprised to know that the foods we eat, the, the amount of stress we're experiencing, all that information for our bodies can be really, really powerful. But the vagus nerve is probably one of the most underappreciated aspects of supporting midlife health in particular. And the And that's one of the things that I think is really important for people to understand, that there's this communication superhighway that is constantly relaying information back and forth between the gut and the brain, although most of it originates from the gut up.

And then when we talk about leaky gut, which I'm so happy that you referenced in the way that you did, because I had just put together something where, you know, in 1980, I think there was a few hundred research papers on increased intestinal permeability, otherwise known as leaky gut. And now we have tens of thousands of research studies. So exactly what you said, that for so long, so many doctors argued that leaky gut is not a real thing. It in fact absolutely is, and it impacts women as they're going through menopause more than any other time of life. And in addition to having leaky gut, it also increases your risk of having a leaky brain. So can you explain what leaky gut is, and then the connection between autoimmune disease and other things that, you know, some women who are waking up with so many of these different symptoms that have never experienced this before, in addition to then the connection to the brain?

Yeah, it's such an important point. So small intestinal lining is one cell layer thick. So as you can well imagine, the things that we consume, either with food, chronic stress, can all heavily influence this. So as estrogen is declining, I always say think about it as a brick and mortar mechanism. This one cell layer thick, the estrogen is the mortar, and estrogen is declining. We are more likely to see openings in these tight junctions so we can leak food particles into the bloodstream. We can leak endotoxin, lipopolysaccharides, or in my case, when I was in Morocco and when I got so deathly ill, all these inflammatory substances which trigger our immune system, which can drive a lot of the symptoms. This is when patients will say to me, I never had a problem with gluten, I never had a problem with dairy, never had a problem with grains, or insert whatever food substance it is. But suddenly I eat an otherwise healthy food, my heart starts to pound, I sweat, I don't know what's happening. And so it's helping them understand that if you have a breach in that small intestinal lining, that leaky gut, that can drive inflammation, drive this inflammatory response, and trigger an immune response. What's interesting is our blood-brain barrier is supposed to be impermeable. That's designed to protect the brain. But more often than not, if you have a leaky gut, you've also got a leaky brain. So this supposedly impermeable blood-brain barrier can be breached, and you can also drive inflammation. So remember what I said earlier, this vagus nerve, how critically important it is for relaying information in the brain. If your gut's inflamed, your brain is probably gonna be inflamed also. And for a lot of patients, this can show up as mood disorders. So whether it is obsessive tendencies, anxiety, depression, preoccupation with certain thoughts or feelings, um, brain fog, fatigue, struggling with word finding. I think so many people just assume, oh, it's a hormone piece. That could be what's contributing, but it could also be underlying inflammation. And it's not acute inflammation, it's usually chronic inflammation that we're really speaking to. But when I think about the things that can worsen leaky gut. It's the chronic stress piece. How many women in midlife are in the sandwich generation? You've got aging parents, you have children that are probably getting a little older, you probably have more responsibilities at work. It can be the perfect storm of this sandwich generation that so many of us are in. Layer on top of that, I always say that I think perimenopause is a litmus test for so many things. A lot of women have experienced a lot of stress and trauma as they're in their younger years. There's a great, uh, study that was done, Adverse Childhood Events Scoring. Anyone that's listening can get online and look at it. It was a joint venture between Kaiser Permanente and the CDC. Fairly short quiz. But I think when we think about trauma— and I trained in inner city Baltimore, I trained at a very big research institution, and we saw a lot of rape, murder, suicide. No one will question what that's like to experience. However, what's equally corrosive are things like neglect, abuse, addiction that children can experience, and that can show up in midlife because the compensatory mechanisms that many of us create to be able to be successful in society can start to backfire in the setting of less hormones, less neurotransmitters. And so what I see with a lot of my patients is they develop leaky gut, they've got this inflamed brain, and then the compensatory mechanisms that they have used to be incredibly successful start to fall to the side, and they really have a lot of feelings that— the uncomfortable feelings they have to deal with. So there are many things that can worsen leaky gut, not the least of which, um, the food piece, chronic stress and trauma, but also understanding you layer in the hormone piece. As hormones are declining, it is probably going to worsen the leaky gut piece. And women are 4 to 5 times more likely to develop autoimmune conditions in midlife. When I finished my medical training, there were probably 40 to 50 recognized autoimmune conditions. Now, depending on which resource you're looking at, it could 80 to 100, including things like long-haul COVID and chronic Lyme. So we're really understanding that the autoimmune piece is not going away. And for a lot of women, by the time I see them, they have 1, 2, 3, 4 autoimmune conditions that they're dealing with. And it has a lot to do with the leaky gut aspects that are probably in many instances not being addressed. They're being negated by a lot of providers. And then once they're acknowledged, it's really kind of what are the things we can do to replenish the gut, to be able to heal and seal the gut, and be able to move the patient forward with less symptoms.

Yes, so important, especially because, like you said, once you have one autoimmune disease, your risk of having more goes up that much more and is going to make, you know, the entire, like, hormone shift, um, that much harder to experience. For a woman who's eating ultra-processed foods, or maybe is eating, like, pretty healthy, but not necessarily in a way that's like nutrient-dense and blood sugar regulated and really dialed in, who's overachieving and running off of stress hormones and still like over-consuming caffeine, maybe not moving their body, not prioritizing a regular sleep-wake cycle. How much does that impact, in your clinical experience, um, a woman's experience going through menopause?

Oh, it's going to make it a thousand times worse. And I say this lovingly because so many of us— and I always say like a lot of my patients are the super high achieving, super successful women, and what worked well for them for many years, the intensity of their exercise, maybe their fasting, maybe they did carbohydrate restriction. I find that most of them are undernourishing their bodies chronically and habitually, under-eating protein, not eating the right types of carbohydrates, too much caffeine, too much alcohol. They're probably consuming a lot of protein bars because a lot of women, they're busy on the go and they're trying to like fill in the nutrient gaps. They're like, but Cynthia, the protein bar was 30 grams of protein. I'm like, yes, but yes, but let's read the label. And I'm not talking about once in a while, it's like the chronic habitual, they're counting their macros and they're like, oh, I had to hit a certain amount of protein. And I'm like, but it's not quality protein to your point about nutrient density. Yeah. So I, I think it's understanding that we have to align our physiology and our lifestyle, full stop. So that means you are picking strength training over chronic cardio. That means that you are prioritizing protein with every single meal to stabilize your blood sugar. You're eating the right types of carbohydrates. And that's— I always say, like, I have a 3-to-1 value with vegetables and fruit because my patients would love to eat 3 pieces of fruit and maybe 1 vegetable. I'm like, no, it's the opposite. 3 veggies, non-starchy veggies, and a piece of fruit. Thinking thoughtfully about your relationship with alcohol. And I find that we have a really significant mommy drinking culture. And for a lot of women that come to me that are frustrated because they're weight loss resistant, their blood sugar is not properly stabilized, they're doing a lot of the right things. I'm like, let's look at the alcohol piece because some women consume alcohol to fall asleep, not realizing that's eroding their sleep and dysregulating their blood sugar and also driving inflammation and some degree of weight loss resistance. So looking at that, the lack of hydration, because I know when I was rounding in the hospital, I didn't want to have to pee off frequently. I understand that now. Like, I laugh when my patients used to tell me that and I'm like, but I don't understand, like, you're at home, why can't you just go? Well, it's inconvenient. But the hydration piece for a lot of people, sleep, you know, I had patients telling me, I'll sleep when I'm dead. I don't need to sleep more. And I was like, you actually need sleep more now than you ever did. You need 7 to 8 hours of high-quality sleep. You need to find some way to de-stress your body. And it's not 5 minutes of meditation on a Tuesday. You really genuinely need to find ways to stimulate that vagus nerve to slow your body down, because we do a really good job as women We're the caretakers of everyone. And suddenly in midlife, as those hormones are changing, we start to find our voices. And for a lot of women, it might be the first time in their adult lives that they've actually really stood up for themselves and said, no, I don't want to do that. And then everyone in their family is like, whoa, what's going on? This— I can't believe this is happening. So I think that perimenopause is a litmus test. It's an opportunity for us to start doing what our bodies genuinely need us to do. And the women that are overfasting, over-restricting food, over-exercising, and probably not sleeping enough are the ones that are going to have the worst clinical outcomes and are going to struggle with the most symptoms. I know that women don't like to hear that, but I'm telling you, 10 years ago, I mean, that's one of the reasons why I wrote the book, The Menopause Gut. This is the book I needed because I was doing everything wrong. I had a super stressful job. Husband traveled a lot. I was probably overexercising. I was too low carb for my body. That's when paleo was really, really big. And so it was like, oh, I'm going to go as low carb as possible. Well, if you're a really active person, that can sometimes really backfire. So I think for a lot of individuals, we have to first acknowledge that as our physiology changes, we have to change our lifestyle. They have to match up. And for a lot of individuals, what you did in your 20s and 30s no longer works in your 40s, 50s, and beyond. And that's a pretty powerful realization and sometimes can be a little bit painful at the time.

But it's so— I mean, I think that people are starting to say, or it's like, oh well, you can't get away with what you did in your 20s. And it's like, yeah, but it's so true. It's like so incredibly true.

Yeah. I mean, I'm right now, I have two adult sons and a husband, all super athletic, and they sometimes are humored at how disciplined I am. And I'm like, guys, but you don't understand. I don't— I don't— the things that I choose to do I don't view it as discipline. I just look at it, this is what I have to do to make sure that my body feels good. So you guys can eat all the ice cream and the pizza and do all the fun, you know, fun foods. You can have that beer or whatever else. But I'm like, if I do those things, I don't feel good at all. So for me, I'm like, I am totally happy abstaining from a lot of these things that I used to be able to do in my 20s and 30s, but, you know, no longer serve me at this stage of life. And I don't look at it as a lack. I look at it as a choice. And it's like finding that reframe. And I'm sure you probably see this with your own patients. We have to find the reframe because if you view it from a glass half empty, of course you're never going to be happy. You really have to look at it as this is a choice I am making for my health because this is what my body— this is what allows my body to feel good and to feel like I can sleep and exercise and do all the things.

So when you talk about even just like how you have to be more diligent than your husband or your boys because of some of these hormonal changes, Let's talk about the estrobolome and how this impacts all of that.

Yeah, so the estrobolome is an estrogen, estrogen processing center of the microbiome. There's specific types of bacteria that are designed to help you break down, package up, and poop out the excess estrogen. Now, I'm oversimplifying it, but there's very much a Goldilocks effect. We want a certain amount of estrogen to be recirculated so we have it available for us. But the bulk of the estrogen, we're really looking, you know, whether it's what we're exposed to endogenously, or exogenously, meaning our body makes a certain amount of estrogen on its own. That's endogenous. The exogenous estrogens that we're exposed to are in estrogen-mimicking chemicals. That's why for a lot of my midlife patients, I'm talking about, well, like, what's in your personal care products? What's in your environment? What's in your food? They all add up. Like, the, the toxin exposure bucket really starts to overflow in midlife. And for a lot of women, this might be the first time they've considered, like, what deodorant am I using? What, you know, toothpaste am I using? But the estrobolome is designed to be a set of bacteria that help us package up the estrogen. And so we have two phases of detoxification in the liver, and the third phase is in the gut. There's an enzyme called beta-glucuronidase that's supposed to help with lock and key to break down the estrogen. Fun fact, estrogen is also important for bile acid synthesis. So if women say to me, oh my gosh, if I eat a fatty steak or if I did a piece of duck, or if I have a piece of salmon, I just don't feel like I break down my protein quite as well. It's because your body needs a little bit more assistance when you're consuming a fatty food, especially those saturated fats. So I'm not sure if you see that with your patients, but, you know, bile acid synthesis— bile is what allows us to break down and emulsify fat. And so for a lot of women, they'll notice that they'll get, you know, they may have— and this is, you know, nurses love to talk about poop, but Um, I'll sometimes ask my patients, you know, do you notice that you have shiny, kind of greasy-looking stools that kind of float at the top of the toilet? And they say, oh my gosh, I had no idea what that was. Well, it could be a sign that you have some degree of fecal fat malabsorption, which can be a sign that your bile is not working as effectively in the setting of less estrogen. So the estrobilum is a very important part of the microbiome. It is heavily influenced by things we are exposed to our entire lifetime. In fact, as I mentioned earlier, my generation was prescribed oral contraceptives to fix every single menstrual irregularity you can imagine. It also impacts the quality of the microbiome. So I think a lot— many people in my generation, probably myself included, probably our, our estrobolones were not optimal in the setting of synthetic hormones. So the synthetic estrogen, the synthetic progestins, which are not body-identical progesterone, But again, chronic stress can impact it. If you're chronically stressed, think about cortisol as a very important survival hormone. But cortisol, when it's elevated over time, is catabolic. It breaks down muscle, lowers our immune system function, contributes to that leaky gut piece, can also contribute to the health of the estrobolome. So I always remind women, you know, cortisol doesn't exist in a vacuum in our bodies. So our body is constantly always trying to find balance. A little bit of stress is good. That's hormetic stress. Too much stress over time can be problematic even for the estrobolome.

I love, I love hearing you say that. So the— because it's like all, it all just hits so much with everything that I believe so much. So when it comes to this toxin bucket, it seems as though as women are getting older, their toxin bucket is getting smaller. So it's the amount— it's like you could be exposed to the same things that you always have been, but it's that your bucket gets smaller, which is why then the toxins start to overflow faster that lead to more of those symptoms that then impact your hormones directly. So what you're saying— because I think that sometimes when we talk about the estrobolome, which is the set of bacteria that break down estrogen, and then women are being told that their estrogen is declining, it's a little bit confusing. Can you explain the nuance there?

Yeah, so the estrobolome is, is still there even in the setting of late perimenopause and menopause. But it's helpful for people to understand that we still need effective ways for our body to detoxify. And let me back up further and say our bodies detoxify every day through our poop, through our urine, through breathing, through sweating. And then two other very important sites of detoxification are the liver and the kidneys. And so for a lot of women, they'll say to me, well, well, help me understand how late perimenopause, menopause, why is it so important to how I detoxify estrogen? We still have to break it down if we're exposed to it, but whether or not it is a byproduct of genetics, like there are SNPs like MTHFR, which I have. There's two phases of detoxification in the liver, and my MTHFR impacts my phase 2. So what is broken down into water-soluble compounds, trying to get it out of the body. This is where nutrition plays a large role. Those cruciferous vegetables, so ferophane, broccoli sprouts become really, really important. But this is where I also like diagnostic testing, which I'm sure you're probably using in your practice as well. Like really looking at is someone's detoxification pathways optimal. Now there's a genetic component, there's a lifestyle component. Irrespective of what life stage you are in, it is important to understand, is your body able to properly regulate breaking down these estrogen metabolites? The other thing is a lot of women think it's normal to not poop on a daily basis. And I'm saying there are women I meet that are going to the bathroom 2 to 3 times a week. I'm like, what do you think happens when you don't properly detoxify and eliminate things that your body need— doesn't need, they can get recirculated. So breast tenderness, weight loss resistance, brain fog, rashes, skin manifestations can all be a sign that maybe things are not working as effectively. So yes, you can be exposed to exogenous estrogens in these estrogen-mimicking chemicals, which can dock at the same receptor site as estrogen and be 1,000 times more potent. That can also explain why people experience these symptoms. Now, it doesn't mean that we have to be paranoid. It just means we want to be conscientious about what we come in contact with because that can negatively impact not only symptoms but how effectively our body detoxifies. And I think the health and wellness industry does a stellar job marketing pills, potions, and powders to support detoxification. But I would say like the most important things you can be doing is like sweating, drinking water, making sure you have a bowel movement every day, utilizing targeted supplements if we know your detoxification pathways. Like when I'm looking at a particular test and seeing that maybe phase 1 is not working effectively, we can look at things like DIM or phase 2 calcium D-glucarate or some of these other supplements. But when and only when we can see documentation that we really think that this is problematic. You know, for a lot of people, consuming things like fiber can be very, very beneficial for supporting not only the estrobolone, but effectively binding up excess estrogen and getting rid of it in the body.

Because these estrogens can be carcinogenic, which then becomes more problematic.

Yeah.

If you're not— if you're not— if you're not able to actually excrete them. And I think that to your point, it's like the wellness industry often talks about detox support through supplements and powders. But the other thing is that it's like just decreasing the amount that's coming in, right? In addition to supporting your actual detoxification system, it's like limiting how often you're eating out. Out at restaurants and takeout and other things that are exposing you, the different, you know, your laundry detergent, your dishwashing detergent, all of those kinds of things that can just decrease the overall burden that your body's under to decrease the need for detox. Not that detoxification support becomes unimportant, but it helps your body process it a little bit more, um, sustainably. Yeah.

And I think for a lot of women, it's— it could be as simple as like, what deodorant do you What body lotion are you using? What toothpaste do you use? Like, getting really granular about the things you come in contact with most consistently. Like, I know for myself, and this, this makes me laugh, I actually shudder when I think about this, but probably 14 years ago I cleaned up my deodorant. And at that time I was using a deodorant antiperspirant, and it was like I was using a product that was prescription-grade because, you know, all of us believed that was better. And I shudder thinking that I was using an antiperspirant, but I thought it was important not for my underarms to sweat. And I remember I went through this period of like an armpit detox, effectively. And afterwards, I was like, "Why would I not want my armpits to sweat?" Like, I just don't even understand that. I mean, I wasn't someone that had a problem with too much sweating, but we had been conditioned to believe that we did not want to sweat. Like, "Oh, you don't want to have perspiration stains. You don't want to have wetness underneath your armpit." And you're like, "What?" like you're blocking one of your body's ways of effectively sweating, which means you're blocking one of the like more minor ways that our body detoxifies. And to your point about, you know, laundry detergent, I mean, think about how many people are using pods, you know, the pods they put in their laundry that are plastics that literally they're coating their laundry in plastic or even their dishwasher, the dishwasher pods. They're coating our dishes, our silverware, our cups with plastics. So those kinds of things add up over time. I mean, if you did it in the past, let it go. But I'm just saying moving forward, just be thoughtful of ways that you can limit exposure to toxicants and plastics because they are so ubiquitous. Like I had a patient tell me the other day, Cynthia, that's all fine and good, but like it's ubiquitous, it's everywhere. And I said, that doesn't mean that small changes don't add up over time. Like I think that's a really important distinction to make. If we think that it's not important, we're really not understanding that we live in a very, a very, a world that is designed for convenience. And at the expense of that convenience is the understanding that a lot of things are disposable. They can be thrown away. And if they're designed to be disposable and thrown away, they're designed to be like even the fast fashion. I know that wasn't the question, but someone was talking about what fast fashion is. And so whether you see a blogger on Instagram, you like the way they dress, and then they're pushing you to buying like stuff from Shein and Target and H&M. And like, these are like— it's like disposable fashion is also contributing to the toxic things that we're exposed to on a day-to-day basis. So I just mentioned that just to, you know, think about it from a bigger perspective. You don't have to change everything all at once, but maybe change 2 or 3 things that don't seem quite so overwhelming and then go from there.

Mm-hmm. Yes, that's a really important distinction. In your book, you say the gut microbiome's diversity is ever more important as we transition into menopause. The number one priority is how to make our gut as diverse and rich as possible so it can maximize its effort in all areas of our body, including inflammation, improving our immune system, supporting healthy blood sugar, and so much more. Talk to us about a diverse gut microbiome and why— what happens to menopause and why it's so important?

Yeah, so I started off the conversation kind of talking about these 3 Ps: puberty, pregnancy, perimenopause, or 3 big inflection points for the microbiome. But we know it's also influenced by these changes in hormones, right? So as our hormones are declining, we're getting more inflammatory, dysbiotic, non-beneficial bacteria. So the things that can be helpful are like the quality of your sleep, managing your stress. And I don't say that to be trite. It's like, that's what's based on research, the quality of our food. So polyphenol-rich fruits and vegetables. So when you think about brightly pigmented fruits and vegetables, that's important signaling information is polyphenols. So I always say like when you're picking extra virgin olive oil, if you've ever done extra virgin olive oil testing, you know, that kind of bitter, pungent olive oil is actually full of polyphenols. These are important signaling molecules for, um, helping to reduce, uh, helping to improve diversity, but also kind of reducing inflammation in the microbiome itself. The types of exercise we choose to do— this is why a lot of my endurance athlete patients suddenly start realizing like they don't recover the way that they once did. It can be— you can actually develop a transient leaky gut just related to physical activity intensity. So So understanding it's the right amount of intensity at the right time and not, you know, these long-haul 24-hour marathons or the ultramarathons or the Ironwoman or Ironman athletes that, you know, so many people manage pretty well in their 20s and 30s. When I think about other things that are really beneficial, it's looking thoughtfully at fiber. I affectionately call it the new F-word because depending on who I'm speaking to, obviously in the setting of a registered dietitian, I know you are a fan of fiber. But for a lot of people, they've been scared off of fiber. They've been told that fiber is not relevant, it's not important. I can tell you one thing about the research on the microbiome. Fiber becomes very important as hormones are declining because when we eat fiber, fiber goes through our digestive system, goes to large intestine where it's fermented into short-chain fatty acids. These do a lot of things. They lower, um, inflammation. They impact endogenous GLP-1 secretion. So We make our own GLP-1. It doesn't last quite as long as the synthetic versions that a lot of patients are using very successfully to lose weight. Short-chain fatty acids, some of them can cross the blood-brain barrier, some of them can stabilize bone health. So we know that bone health becomes problematic in the setting of less hormones. They can actually stabilize bone breakdown. But these short-chain fatty acids become really, really important when we're looking kind of longitudinally at how things are changing in the microbiome itself. And I would actually make the argument that the patients of mine that are doing the best in midlife are really thinking thoughtfully about nutrition. Now, it may not be sexy, but we don't have to overcomplicate nutrition. I think for a lot of individuals, it's understanding that when you're thinking about what you're putting on your plate, when we're thinking about diversity of plants on our plate over the course of a week, 30 plant varieties a week, which can incorporate some of that fiber, But something as simple as— my husband calls it, I'm married to an engineer, the salad bucket. But we'll make a salad that we'll add to, you know, throughout the week. I mean, it doesn't last the entire week, but, you know, we'll be adding different herbs, whether it's nuts or seeds, adding different vegetables, maybe some fruit. But getting diversity into your diet is going to be really important, not just for the fiber piece, not just for the polyphenols, but thinking about it as fertilizer for the diversity of those beneficial bacteria. Because as the hormones are declining, that starts to change. It's so, so common when I'm looking at microbiome testing or even stool testing. There are consistent patterns. I didn't understand it 10 years ago. I do now. I do understand it so much better now. But there are consistent patterns that you start to see in the setting of declining hormones.

I remember a few years ago when like the protein craze was really like hitting the ground and just being like, you guys, we are missing so— it's so much more than the protein. It's the fiber, it's the polyphenols, and the interaction that they have with these short-chain fatty acids. You can't just eat a high-protein, extremely, extremely low-carbohydrate diet and think that by cutting out the polyphenols that you're getting from the bell peppers and, and so many of these different colorful foods that you're actually helping in the long run, especially for women as their microbiome is changing. It's like one of the fastest ways to further deplete your gut microbiome.

Absolutely. And I've interviewed recently a gut microbiome researcher, and she said, Cynthia, I was just looking at a paper talking about in the setting of a low-carb or no-carbohydrate diet, what happens in terms of fermentation. She said, so these very high-protein diets, a lot of people are getting to a point where it's actually— they're fermenting and rancidifying their— or putrefying, rather, the protein at the expense of there being no carbohydrates, that the body is trying desperately to ferment something. To support short-chain fatty acid production. And so I found that fascinating. I don't think that we are designed as human beings to exclude an entire macronutrient. So when patients tell me, I don't tolerate fiber, I always say, listen, I've been there, and we can talk about that. Um, but when someone doesn't tolerate fiber, it is very likely a reflection of the health of the microbiome. Because even for myself, in 2019, I spent 13 days in the hospital I spent 6 weeks getting antibiotics and antifungals. I almost died. And I tell everyone, I'm like, listen, I'm so grateful that I didn't die because I wouldn't be here to have this conversation. But most importantly, I came back from a 9-month stint of carnivore because that was the only thing that I could tolerate, to slowly adding back in more fiber. It has taken— I mean, this was now 7 years ago— it took a solid 5 years to feel like I could tolerate ate a good amount of fiber, and now I ate quite a bit of fiber, but it has taken time. And for anyone that's listening that says, I don't tolerate fiber, it might be the quantity, it might be the quality, it might be the type. And so there's lots of different forms of fiber, um, things that I'm sure Brigid talks about on the podcast quite a bit. But it's almost always a sign of the microbiome being really depleted, because if you don't have the right microorganisms to be able to break that fiber down and ferment it, it's not surprising that you're getting gas, bloating, digestive distress as a reflection of the microbiome not being in an optimal state. And there are absolutely things you can do. I mean, I certainly came back from 9 months of full carnivore. I didn't want to be full carnivore. It was literally the only thing I could tolerate. If I ate anything with fiber, it worsened all the symptoms I experienced.

And I think that that's usually like— I always say that when you can't tolerate fiber, maybe it is that you've increased it too quickly, or you haven't had enough water while you're increasing it, or other instance, like you mentioned, but that it's also a sign that you— that there's a gut microbiome imbalance that's happening underneath the surface. It's like a side effect. So it's, it's not actually like the problem, it's a side effect of the problem that's happening underneath the surface that needs to be addressed so that then you can go back to integrating more fiber-rich foods instead of thinking like, oh, I just can't eat beans for the rest of my life because they give me gas or constipation.

Yeah, yeah. And I, I actually, I was telling someone the other day that like one of my favorite things to recommend to patients is a tablespoon of fresh ground flax and a tablespoon of chia seeds as both a little bit of plant-based protein but also some fiber. And it tends to be very gentle. But I had a patient tell me, you don't understand, I did exactly what you told me and then I was totally bloated. I said, well, then reduce the quantity. Like, instead of a tablespoon, do a teaspoon of each and like slowly build your way up because you want to get to a point, just like we build up our muscles, we want to be thinking about, um, you know, building up our fiber intake. You know, I, I ask every single gastroenterologist that I've interviewed on the podcast Why do you think we're seeing more and more escalating rates of colorectal cancer in younger patients? And almost all of them have considered that, yeah, it could be toxins, it could be environmental, but it also could be the lack of fiber in the standard American diet. Like, could that be contributing? They're all like asking the right questions. But from my perspective, I think that most diets are so devoid of protein— excuse me, so devoid of fiber. Could that be contributing? I'm not sure. I think it's very bioindividual. Like, when I see people saying everyone needs 25 to 30 grams, I'm like, I'm like, no, my patients tolerate that much. And then I've got other patients that tolerate 50 grams a day and they're doing great. So I think it is very bioindividual, but more often than not, people are either consuming too much, not the right amount, or their gut microbiome really needs to be healed before we can start pushing the envelope with regard to quantities of fiber.

Is there a fiber supplement that you recommend that is more tolerable for the women that you work with that they can start start with?

Yeah, I would say, I mean, keeping it really simple. So maybe just psyllium. Um, I mean, really, really simple, because I, I mean, there's lots of prebiotic products that I think are great, but I find that if, if we're really dealing with someone who's really struggling with advancing fiber in their diet, I'm saying let's just start really low and slow. Like, let's add a little bit of fiber to a protein shake and let's see how you do, and we'll be super conservative. I have some patients who do well with things like inulin and others don't. Like, I actually have to be careful with inulin. The irony being, on my microbiome testing recently, it showed that I need more inulin. And I was like, well, it's not surprising. I probably need to, you know, support the species that, that need that particular type of fiber. But I think for everyone, psyllium, not too much, you know, starting with a teaspoon, see how they do. We're not talking about Grandma's Metamucil. That's not what I'm talking about. But I think that's a good kind of starting point, you know, apple pectin. So sometimes I'll have patients like actually cook an apple so that it's soft, and sometimes that can be helpful. But in terms of supplementation, I keep it pretty simple.

Even in your book, I feel like you did a great job of outlining in The Menopause Gut different supplements for supporting different areas that are like not extremely crazy supplements, but ones that could really move the needle for women.

Yeah, I mean, I definitely wanted to when I was writing the book and my editor really wanted me to include supplements to just keep it simple, like what was evidence-based, what was pretty simplistic, because I think unfortunately we're in a time and an age where I will have patients literally say to me, I would rather— I would much rather take the supplement than change my diet. I'm like, I understand.

Everyone, everyone would rather do that.

I'm like, you know, unless it's like digestive fire, like you don't have enough hydrochloric acid, you need digestive enzymes, you need a little tadka. Like if you need digestive support, yes, you absolutely need digestive support. But most of the other things, patients are like, oh, I don't want to eat more protein, can I just take more creatine? And I'm like, I love creatine, but, you know, I think you genuinely need, you know, like the micronutrients, like the trace minerals, like the things that we sometimes forget about. Out, um, like as an example, I just had lab work done and my functional med doc said, I'm shocked your vitamin D levels are as low as they are. And I said, well, I mean, I take vitamin D. He's like, double your vitamin D and try to get a little bit of sun. And I was like, okay. But I think for somebody else, we just forget that sometimes when we do these elimination diets— like I've been gluten-free for years— I'm sometimes low in B vitamins because that's a lot of times where, you know, gluten can be fortified with B vitamins. And So sometimes we have to, you know, be conscientious about where we're supplementing, but I tend to be a little more conservative and just say, let's not supplement unless we absolutely must.

Yes, yes, yes. And being able to test your nutrient levels in order to really see outside of the basics like magnesium and omega-3s and other supplements that are, that are listed in the book.

Absolutely.

Okay. I, I love all of this. Also the 30+ plants per week for the diversity of the microbiome. I mean, so much of— I didn't actually realize how much our so many of our, like, core beliefs and recommendations overlap. There's rarely guests that I'm like, I literally agree with everything on such a deep level of what you've said. So, um, so much of the work that you're doing with the connection between the nutrition and then the gut changes are so important. And when it comes to nutrition, what would you say are, like, the key things that you recommend staying away from and Why?

I would probably, and I know this is not popular to say, alcohol, largely because so many of my patients are weight loss resistant and I'm like, this is low-lying fruit. Like, we have to real— and it doesn't mean if you're listening, like, it's your birthday, it's your anniversary, it's a celebration, but like the day-to-day alcohol intake is number one. Number one, it's not doing your inflammation in your body any benefits. That's number 2. The way that alcohol is metabolized in the body, it's hugely problematic, and there's just too many detrimental effects. I mean, the research is pretty clear about alcohol consumption. And I'll apologize, when I was neatly tucked away in cardiology, I used to tell my patients to have 4 to 6 ounces of red wine every night. And I would say, know better, do better. So I'll apologize for that. Number 2, I would say that It's, you know, we're in a fast food culture.

I get it.

It's the protein bars, the chronic protein shakes in lieu of eating like a real meal. I'm not talking about the day where like your schedule's upside down and you're traveling, but just in general, like I would much rather you put together like some hard-boiled eggs, a handful of nuts, some cut up bell peppers, like make a, you know, I always travel with beef jerky. That's like my protein bar. But I would say like put together something that you can eat fairly quickly that's nutritious. Nutritious. If you tolerate cheese, have a couple cheese sticks. I mean, you can put together 30 or 40 grams of protein pretty readily. Canned tuna fish, I don't care, canned salmon, whatever it is. Um, I would say the other thing that I think is, is a problem is that we tend to, um, chronically and habitually undereat protein. So we are generally, as a society, we eat too much carbohydrate, we eat the wrong types of fats, and we eat too little protein. And I just think for women, especially women that tell me they're never satiated irritated, they're having blood sugar instability, they're not, they're not feeling like their body composition is heading in the direction they want to go in. It is almost always chronic protein underconsumption. And it's like when I look at a food diary, and I don't like patients to do this forever, but even if I just get a week or 3 or 4 days, women are eating like 40 or 50 grams of protein. I'm like, okay, well, first of all, you're not going to be able to maintain muscle mass. You're going to lose it. And sarcopenia is not a question of if, but when.. But this explains in many instances why you're standing in your pantry or looking in your freezer at 8:00 at night saying, why do I feel like I'm hungry? And it's because of this protein leverage hypothesis that if you don't consume enough protein over the course of your day, your body is looking for additional calories to make that up with. So I think that underconsumption of protein is a huge problem. I can say that without reservation, that that is a chronic habitual problem. And once I get women eating enough protein, they'll say, oh, I'm full. Like, I don't even think about eating more food. Like, those, those stretch receptors in their stomach have been stimulated, so their brain then realizes that they're actually full. So I think that's another probably under— it's not sexy, right? It's not a sexy answer, but I think that it contributes to a lot of the problems that we see, or certainly that I see.

And then another one, um, you said in your book about how you focus so much on an anti-inflammatory diet, which about consuming foods that are less likely to drive inflammation while you're also focused on increasing foods that are gonna help to offset that inflammatory response like we just talked about. And you listed gluten as actually the first one on that list. Can you explain why?

Yeah, you know, not everyone has celiac, but I see a lot of patients that have non-celiac gluten hypersensitivity. And it's what is done to gluten in the United States. It's this dwarf wheat hybridization that is designed so that grains don't spoil, right? Gluten doesn't spoil, doesn't spoil. The protein is the gluten, is the protein. But the point of what I'm— or gliadin is the protein. The point of why I'm sharing this is that this hybridization, dwarf wheat, tends to be exposed to glyphosate, tends to be exposed to a lot of things, can be very inflammatory. I think for a lot of people, because it proliferate— proliferates, it's ubiquitous, it's everywhere. We've got gluten everywhere, we've got dairy everywhere, and I just find for a lot of women it is contributing to inflammation because it's in the processed foods. Like bread is fun, right? I was just in Europe and I ate some bread when I was there, and it was fun to eat it there because I don't react to it the same way as I do here. But when I'm home, I'm like, it's empty calories. It's not satiating. Yes, these are fun foods, whether it's, you know, cake or pasta or bread or any of these other things, but they're not generally nutrient-dense foods. They generally tend to be nutrient-devoid. They're stripped of a lot of the kind of intrinsic value of the food itself. And the number one most inflammatory food that I see in most of my patients, if it's not dairy, it's gluten. So when we pull it outta their diets, they have less joint pain, they have less inflammation. They'll tell me they feel like they feel less bloated. In many instances, they start losing weight and they fill that void with nutrient-dense whole foods. You know, I went gluten-free 14 years ago and I recall when I did it, I didn't think I ate a lot of gluten. Gluten, but it must have had so much inflammation that I was, you know, trying to fill my day up with more nutrient-dense foods. And I was like, oh my gosh, I was actually eating more food, but I was then more satiated. So I think for a lot of patients— no, not everyone is celiac, although I see a lot of celiac diagnosed in women in their 40s and 50s— but plenty of people have non-celiac gluten hypersensitivity. And certainly when we're looking at panels and looking at inflammation markers I've seen tremendous strides be made in women in midlife by excluding diet, excluding gluten from their diets because they're forced to eat real nutrient-dense food. Like they're taking the place of like, patients are, what am I supposed to have for a tortilla? Well, there's so many gluten-free options now, but maybe you're having a lettuce wrap, maybe you're having a naked burger. There's so many variations that you get away with. And I feel like women tend to be more satiated their blood sugar is much more stabilized, and in many instances they're losing weight just by excluding gluten, which I think is fantastic.

And there's such a close connection between gluten and leaky gut. Like, I feel that even though there may not always be the strongest amount of quote-unquote evidence— there is evidence, of course, with— as we were kind of starting to talk about before we even pressed play on this, this episode— is that some doctors will argue like there's not enough research behind gluten-free. But when you have enough experience of working with thousands and thousands of women in this stage of life who are all of a sudden like removing gluten and then having exponential changes in their health, it's like, okay, maybe it's— you know, some people will argue that it's because then you lower your FODMAP exposure and that's why then it creates beneficial outcomes, etc. But there is something so particular about gluten that that's— once you work with enough women, it's like, absolutely, this is causing inflammation for maybe not everyone, but the majority of women that can benefit from this approach.

Well, and I feel like the people that get so triggered by eliminating gluten are probably exactly the people that need to eliminate gluten. Like, I, I have a family member who, uh, calls it weird food. He is adamantly opposed to anything gluten-free, but he doesn't realize when he comes to my house, everything is gluten-free. If there's a birthday cake or there's a celebration gluten, and I'll say to him afterwards, does that taste like weird food? And he's like, no. He's like, this isn't gluten-free. I was like, yeah, it is. I was like, it's okay to do that every once in a while. It's not going to hurt you. But people that get very triggered by the idea of eliminating gluten are probably exactly the ones that should. That's my feeling.

That's—

that's— I, I found that to be the case. Like, the people who fight me the most about even temporarily going dairy-free or gluten-free are generally the ones who need to do it the most.

Mhm. Yeah, I, I completely agree. And then you mentioned the stress piece, and I think that especially in this phase of life that you talked about addressing trauma and, and other things that women can do, but why is it so much deeper than just needing to like start meditating? It's like an— it's a different way of approaching your life, slowing down, getting more, you know, aware explain how you think of this and how you present it in the book.

Yeah, I mean, I think there, there's, there's multiple layers to this. So as progesterone is declining, we're getting changes in the inflection points on GABA. So GABA is our main inhibitory neurotransmitter. And so women will say, I feel more anxious, I feel more depressed. And it could be situational around where they are in their cycle if they're in perimenopause. But they start to get a sense that they need to have better mechanisms for managing stress. On the other side of this, estrogen— estrogen is important for serotonin and dopamine signaling, and so women become more irritable. I mean, there's just a lot of changes that are going on hormonally with neurotransmitters that speak to the fact that that vagus nerve stimulation becomes so much more important. Now listen, before I step on stage, I will hum, I will do breathwork. That's stuff that I can do that probably most people don't realize I'm even doing. But I think we have to have a much more targeted methodology. Like I would say to patients, listen, find a couple of things you like to do and do them often. If it's connection to nature, if it's grounding work, if it's breathwork, if it's meditation, if it's, you know, restorative yoga, if it's doing the gargling, the simming, the singing and humming, all of which stimulate that vagus nerve, you have to find things that you like doing and you just incorporate them into your lifestyle. Like I say to people all the time, during the pandemic, we still lived in Washington, D.C. And like the only thing my husband and I felt like we had control over was how often we walked our dogs. So we would walk our dogs miles and miles and miles, but we were outside in the sunlight every single morning unless it was raining. And it just— nature became part of how we connected, how we started our morning without sunglasses. And so that is for me a non-negotiable. If I don't start my day outside in nature walking my dogs, my day doesn't start right. And so for everyone listening, you will find things that appeal to you and don't feel burdensome that you can be doing on a daily basis. But your physiology is changing. You are not as able to manage the stress levels that you did when you're younger. It doesn't mean there's anything wrong with you. It's just your physiology is no longer matching your lifestyle. And so I would say, like, I start with the physiologic changes that are occurring. And then, you know, as you're losing estrogen, the other side of it is it's not just the neurotransmitters, it's that you care a lot less about being a people pleaser. So it could very well be that you say to your significant other, your spouse, or your kids, I need time for myself. I'm gonna go upstairs and, you know, do stretching exercises, do legs up a wall, and listen to a meditation app on my phone. I just wanna be by myself. And that is okay. But we have to find ways that we can stimulate that vagus nerve and things that make us feel good. I mean, I used to live a lifestyle where I was outta the house by 4:30 in the morning. I was at the gym. I came home, showered, got my kids to school, then I started rounding on patients in the hospital, and it was like such a stressful, jolting, jump-out-of-bed morning. And it was like that all day long until I went to bed. And I think about that now, and I can't think of a less pleasant way to live my life. So I think for a lot of us, midlife allows us an opportunity to pause and reflect on what is working or not working for us.

Mm, so, so good. Cynthia, thank you so much for sharing your expertise with I am a huge fan of The Menopause Gut, so everyone should get their copy. You're coming into the Being Collective membership in a week from when this comes out, so we're super excited to do a Q&A with you and allow our women in our community to dive deeper, which is gonna be so amazing. I just actually shared it on Facebook with our group because, um, I shared it on whatever day you agreed, cuz I was like, I don't have any, we don't have any time to create these assets yet. And like Danielle's gonna do that, but I'm just so excited that I have to share this because I, I love everything that, that you share and how knowledgeable you are as a practitioner. And then outside of that, can you share how everyone can find you and benefit from your work outside of the book?

Yeah, thank you so much for having me, Brigid. This has been great. Um, probably easiest to start with my website, www.cynthiathurlow.com. You can get access to social media. I tell everyone Substack is probably my favorite new platform because I really get to speak the way I wish I could across social media, but you just don't have the time, um, or, you know, your space constraint on Instagram or wherever you're dropping content. Obviously, the book is The Menopause Gut. I have a podcast called Everyday Wellness. It is probably one of my favorite things I do within my business. And I just announced— I have not taken new patients in the past 2 years, but I just announced that I'm partnering with a colleague of mine and I'm going to start seeing patients again in person. This fall. And I was laughing with my team yesterday because we put that out on social media and we sent an email out and we just got overwhelmed with people like, oh my God, I'll fly into Virginia, which is where I live. And so I said, I think this is an affirmative, like we're heading in the right direction. So we will be seeing a limited amount of patients in person. And I say me, I will be seeing a limited amount of patients in person starting in the fall again.

Amazing. I love that. I love that. Okay. So many good resources. Be sure to check out Cynthia's work. Thank you so much, Cynthia Thurlow, for being part of the Being Brigid Show. Thank you for tuning in, and I'll see you next time.

Thanks so much.