The Gut-Hormone Connection In Menopause: Why It Matters and What You Should Know

What if I told you that your symptoms of perimenopause and menopause are made worse or better based on your gut health? So today I'm joined by Cynthia Thurlow. You may know her as one of the most watched TED Talks about intermittent fasting, or as the podcast host of Everyday Wellness. But today we are talking about the menopause gut. And this is an upcoming book by Cynthia Thurlow, but we covered some really amazing information about how the microbiome plays a role in your bone health and things like trauma and ovarian aging and how the ovaries are really the biological clock of the human. And we go way, way deep into what may be causing some of our symptoms that we experience, even weight gain. In perimenopause and menopause and how the gut plays a role. So listen to us today on Menopause Mastery, where I'm joined by my dear friend Cynthia Thurlow. Ah, Cynthia, I am so glad we are talking today about our, our microbes in our gut, our microbiome or our strobilome, and hormones. And we're going to cover, uh, for everybody listening, we're going to cover a bunch of things you probably have never ever heard before. And, um, Cynthia's speaking my language. Her new book that's coming out, The Menopause Gut. We actually connected strongly, I guess, a couple years ago because that was an area of research of mine. My dissertation literally was looking at it in women with IBS, and she has like dove in so deep. So, I'm so excited. So, let's kind of dive in and let's talk a little bit about the interrelationship between women's hormones and their gut, their microbes, and what they really need to know. Like, what are your things from all the research that you did that you think they just missed the boat on?

Yeah, thank you so much, Betty. And, and I feel like I want to take an opportunity to thank you. You've been so gracious. You shared your dissertation with me, which I was able to reference for my book and allowed me to understand things at an even deeper level than I already did. I, I think having a podcast and being able to interview so many experts, I started seeing these connections And even as a clinician, let me back up even further and say, you know, 10 years ago when I left traditional allopathic medicine and I started doing stool testing and all these integrative medicine tests, I was like, what is it about middle-aged women? Like, their microbiome looks so different from a pre-perimenopausal woman's does. And so, in having all these opportunities to connect with these experts, I started putting some pieces together that ultimately became the basis of the the book itself. And what I would say is women are not small men. I think that there's very much a reductionistic methodology applied to men and women that, oh, we're all the same. And what's interesting is the influence of hormones throughout our lifetime. Lisa Mosconi talks about the 3 Ps, and so the influence of hormonal changes in puberty, pregnancy if we choose to become pregnant, and then also perimenopause, the dynamic diversity, inflammation, everything changes dynamically with these alterations in estradiol, progesterone, testosterone, and other hormones. And what I think in many instances is because we can— we know what a heart looks like relatively, we know what a brain looks like, we know what lungs look like, we know what a liver looks like. When people hear gut microbiome, they're like, what is that? It's not even tangible. For the benefit of listeners, helping them understand, there are 40 trillion bacteria, viruses, fungi, and protozoa that comprise the gut microbiome that's situated neatly in our large intestine or our colon. And it's influenced by everyday things, all, you know, where we are in our menstrual cycle until we no longer have a menstrual cycle, what types of foods that we eat, our stress patterns, our diet, all of which dynamically influences. And I would actually argue that our gut microbiome is as unique as we are. So there's very much a bio-individual approach. Some things we have control over, some things we do not. And so, when I started looking at all these stool patterns, I was like, "Why is there so many alterations in keystone bacteria, like the basic bacteria of the microbiome? Why is there so much more inflammation? Why are we seeing alterations in digestive fire, changes to how we process fat, how we, you know, break down carbohydrates, how we process protein? Why are we seeing so many opportunistic infections?" And so, it really does speak to the fact that, as an example, estradiol is a potent immune modulator in the body. So, I think we think about estrogen as bikini medicine. It's responsible for our menstrual cycles, it's responsible for fertility, and then it probably doesn't have a lot of other— it doesn't have any other components in the body. And I would make the argument that all of these hormones that we're talking about have potent effects on nearly every cell or system in the body. And the gut microbiome is no different. There's important communication patterns with our vaginas, our oral microbiome, our ovaries, our bone, our lungs. Literally every organ system in the body is connected to the gut. So, it's really been the last 5 to 10 years that we've started to learn so much more about it and why it's so important. It explains why some women go on hormones and they gain weight. It explains why some women, you know, consume certain diets like ketogenic diets, which were all the rage for a long period of time, but can be very therapeutic, why they work well for some and not others. And also, like, why we're impacted, you know, food and mood. I always remind people that, you know, the bulk of our neurotransmitters, our immune system are all housed there. And so, it's just really important for people to understand that the gut microbiome is more than just a digestive organ. It is actually a unique endocrine organ with signaling molecules that are going all across the body, you know, just kind of like little messengers or mailmen or mailwomen, however you wanna phrase it.

Oh my goodness. Okay. So, you unpacked so much there. We're going to kind of back up and go over each one of those subject areas in detail. But, I want to jump in because I know my listeners and they were listening and all of a sudden they heard weight gain during hormone replacement or in that perimenopause-menopausal journey. And, I've had a lot of conversations about that and obviously had a lot of podcasts just sharing some of the metabolic effects of menopause and the loss of estrogen or the variation of estrogen. But, let's go in specifically about the relationship with the microbiome, because I don't think women realize that there is a lot of interplay there. Mm-hmm.

Yeah, I mean, isn't weight loss resistance a middle-aged woman's greatest fear, slash, symptom, slash, pain point? Uh, without question. And it's something I've experienced myself. You know, you sit back and think to yourself, everything I used to do no longer works, and why is that the case? So if we're looking specifically at the gut, We know based on the research that, you know, if your gut is not healthy, and by that I mean a balance between beneficial and non-beneficial bacteria, making sure there's not a great deal of dysbiosis or, you know, leaky gut, which can be when the small intestinal lining is breached, which happens pretty readily because it's only one cell layer thick. Right alongside that small intestinal lining is our immune system. And if that gets provoked, it drives inflammation, can lead to underlying food sensitivities, and it goes on and on and on. So, when I think about how the gut microbiome influences our weight, number one, I'm thinking about that loss of insulin sensitivity that accompanies that loss of estradiol that is influenced by short-chain fatty acid production, which I'm sure we'll talk about these potent immune modulatory/signaling molecules in the body. And, when we talk about signaling molecules, it just means it's like the postman or the mailman or the mailwoman, however you want to genderize it, I also think a great deal about extraction of calories. I mean, there is research to suggest that based on the, the composition of the microbiome can influence whether or not you are extracting more calories from the same meal. So if you take 5 women and maybe we don't have a good sense of the health of their microbiomes, the research certainly suggests that if you have more inflammatory species, if you have less keystone bacteria, um, you are more likely to extract more calories from the same types of foods. Even if it's a healthy food, even if it's chicken and broccoli, or, you know, steak and sweet potato, you will extract more calories than someone with a healthier microbiome. And so, those two things along with these alterations in estradiol and progesterone and testosterone can also influence, you know, our food choices. I know people don't like to think about that. It's very much this Goldilocks effect. And, for every woman listening, there's probably a range where their estradiol levels are optimal, versus not. And we know that estradiol plays a large role in appetite regulation. It is not just the bikini medicine. Testosterone plays a large role in body composition. I think many people think of it just as a libido hormone, also important for executive function. And then, you can add in, Betty, all the things that happen with lifestyle when things are not dialed in. As one example, if you're not sleeping well, We have circadian clocks in our gut that influences our food choices. So lifestyle really comes at a forefront and then looping in all these other aspects. But there's probably 10 or 15 things that are impacted in the microbiome vis-à-vis alterations in neurotransmitters and hormones themselves.

Yeah, I want to go back because, you know, we were, we were speaking a little bit on, on cam before we went on camera and talking about kind of, you know, As women, especially Gen X women, I think we mastered the, you know, dietary trends. You know, every couple months there's a new dietary trend. And I know I went on my first diet probably when I was in like junior high. You know what I mean? Like, so we have done this. And I think especially when we look at the midlife woman, you know, 40+, and particularly some of the more recent dietary trends, the hardcore ketogenic diet. The carnivore diet and other things where, you know, well-meaning, reduce insulin dependence, improve insulin sensitivity. But we're also talking at a time where your hormones are changing and the impact to the microbiome can be radical here. And you could create an environment where you've got major dysbiosis. Those bacteria are all out of balance. Let's talk a little bit about that, because I know I saw it clinically and, you know, in my team at Minerva and then in my clinic now I see a lot of it where you can tell these women have done those extreme diets and they may have resulted in weight loss. However, they're now not working anymore because they're in perimenopause and menopause.

Yeah, it's such a good point. And, and for full transparency, in 2019 I spent, uh, 13 days in the hospital and I was full carnivore for 9 months because these 6 weeks of antibiotics, antifungals, a stressful hospitalization, almost dying, my gut was decimated. So I I do think there is a place in the short term if someone is really struggling with irritable bowel disease or an autoimmune condition. I do think that there can be therapeutic value to doing some of these diets short term. But, to your point, long term, you're missing out on whole food groups when you're talking about carnivore, a true full carnivore not having any fiber in their diets, really eschewing carbohydrates in general. I think for many people, whatever has worked for them, they then, it becomes part of their identity. We have this rigid dogmatism, and I say this respectfully because I have many, many friends who have seen huge health effects, beneficial health effects of changing up their diets. You know, ketogenic diets, depending on the individual, might be like a lowest carbohydrate diet, and then they get stuck in this widget of not being able to moderate their fat or their protein intake because they're so low carb. And so, I think when you start limiting entire macronutrients out of your diet, my concern is that you are potentially leading to an inability to create, you know, we touch on short-chain fatty acids, but if you're not adding in some fibrous vegetables or legumes or flax and chia seed, you may be starving off these beneficial components of the microbiome. And I think the short-chain fatty acid, discussion, especially knowing that the reduction in hormones leads to less circulating short-chain fatty acids. So, when I think about the average middle-aged woman, they may be feeling better, but they may not know what's going on beneath the surface. And that's why these conversations are so important because I'm not saying there isn't value to increasing your protein intake. I think we would actually make the argument with the Protein Leverage Hypothesis, this is really important for women but also understanding we don't want to be cutting out entire food groups. I think that there's a big difference between processed carbs versus nutrient-dense whole carbohydrates and strategically implementing them into our diets around physical activity and sleep and everything else. And so, I think for a lot of women, when we start thinking about vegan diets or carnivore diets or keto— really strict ketogenic diets because I also know people that consume keto, but their carbohydrates are really liberalized. And so technically, it's more of a moderate carbohydrate diet, which is fine too. But I think we have to be careful if we are making absolutist statements that are demonizing an entire macronutrient without understanding what the research suggests about how that influences the composition of the microbiome. You may be able to get away with that at 25 or 30, but knowing what I know now about what is happening beneath the surface, as these hormones are declining, I would actually say I would be really reticent to make that recommendation. If you do it for 2 weeks, 4 weeks, 6 weeks because you're trying to get on top of inflammation, you come back from vacation, you've fallen off the wagon, but not a long-term solution to a problem.

Yeah, no, I agree. I mean, there's the— it's, it's the difference between a therapeutic diet and a maintenance diet. Therapeutic diets are designed for short-term to improve a particular scenario, but if It's when we decide to use those therapeutic things as maintenance that we run into trouble. I wanna backtrack a little bit and just clarify for any of our— my listeners that may not be aware of what a short-chain fatty acid is, but short-chain fatty acids are byproducts of your microbiome and they are made from the consumption of predominantly carbohydrate, fiber, and your polyphenols. And so when you remove vegetables and legumes and all those things, you are starving off what I like to call the cats and dogs of your gut. Right. So all your little, all your little, you know, domesticated animals that you love and, and love you back are getting killed off because they're starving to death. And we have a natural change in our gut, like Cynthia was saying, that we start to see shifts in the production of these because of the loss of hormones. So when you're 40-something plus, you are already fighting a battle here to support those really good microbes, you know. And I think that's just so, so important. So I want to talk a little bit now that we're talking about short-chain fatty acids and talk about how those short-chain fatty acids have an impact on bone health because women do not recognize the risk for osteopenia and osteoporosis. And standard of care today says we don't have to screen somebody until 65 when that train left the building in your late 40s at latest. But many of us didn't even put down bone enough before 30.

Yeah.

Like, and it's huge because we handle it on both sides, the clinic and the telemedicine side. And it's It's so frustrating. So frustrating.

Yeah, and I, I don't think there's enough conversations around bone health. I think that our generation was probably put on oral contraceptives early as teens and young adults. Many of our generation also got Depo-Provera, and I'm sure we can unpack some of the research there because that is quite compelling. It has a black box warning about bone health. But when we think about short-chain fatty acids, they are produced, we consume fiber, and in the large intestine or colon, We produce these, you know, they break down and they create these little short-chain fatty acids. So, fiber is the food for the colonocytes, which then go on to produce short-chain fatty acids. And, to give people a sense, they're so important. Like, there's one in particular called butyrate that actually diffuses across the blood-brain barrier. So, we think about butyrate like, "Oh, grass-fed butter and ghee." Yes, you can get butyrate from that, but not enough to starve off what's happening in the gut. A lot of things are designed not to cross the blood-brain barrier, which is designed to be impermeable, but this is particularly important. Remember I talked about the mailman, we're going from the large intestine to the brain to send information there. But short-chain fatty acids are also important for endogenous GLP-1 regulation along with akromantia. They're important for producing mucus, which protects that one-cell layer thick of the small intestine. So, just to give people some context. But, with regard to bone, Well, we know within the first 5 years of menopause, that's when we lose the bulk of— that's when we really start upregulating this bone breakdown. And, both progesterone and estradiol are designed to— it's like a seesaw, it's all about balancing. Estradiol is bone building, progesterone is bone breakdown, and it's designed to balance each other out. But, what starts to happen and unwind in the setting of less hormones, we get more bone breakdown than we do bone buildup. What we're dealing with, especially in that first 5 years of menopause. But, what's interesting is these short-chain fatty acids actually control osteoclastic activity. So, in the setting of less short-chain fatty acids, less hormones, we're getting an acceleration in this bone breakdown. And, I think a lot of people don't think about that connection between the gut and the, and the bone, but it's actually the gut-bone axis. So, you know, more inflammation in our bodies, worsening insulin sensitivity. Leaky gut is leaky bone. Leaky gut is also leaky brain. And so, I remind people, if you've got an autoimmune condition, you're probably at risk for bone loss. And we really have to think about it in a very systematic manner and not think about it in that traditional siloed allopathic medicine model, which I always say if it's an emergency or an urgency, we do a better job than anybody else. However, for prevention, And chronic disease management, we don't, because we don't think broadly. We think symptom and a pill, and that is kind of the prevailing allopathic model that we're thinking about. But let's back up more and think about how our generation was so heavily influenced, whether you had contraceptive needs or not. If you had heavy cycles, irregular cycles, or you just wanted to have more control over your life, everyone was, most, if not all of my girlfriends were put on oral contraceptives, which, I'm very pro contraceptives. I think it's important for women to have control over when and if they choose to become parents. But I don't think the conversation is ever had with these teenage young women. If you're on oral contraceptives, you're kept in a low estrogen state. Guess what never happens? You're, you're missing out on peak bone and muscle mass. And it's even worse with Depo-Provera, where the research suggests 2 years of Depo-Provera use, you're really building— you're really backing off on bone health. It is reversible. And the studies were done on for a 2-year increment. I was talking to someone today who had been on Depo for 10 years. So we don't yet know. I was like, you're 35 and you need a DEXA scan or a REMS immediately so that we at least know what we're dealing with. But I think in many instances, we're not doing fully informed consent. Women don't realize that these are initiated when they are teens and young adults. We probably need to also have a conversation about bone health. And so what's happening is most of these women, they go on to plus or minus, they have children or don't have children. They lactate, they breastfeed for a couple years 'cause we're encouraged to do that. No one's checking bone health then, and we know that we lose quite a bit of bone while we're breastfeeding, while we're lactating. And then, we're not checking till 65. Sometimes the first time a woman realizes she's osteoporotic is when she has her first fracture. And, I wanna highlight the fact that a hip fracture or even these fragility fractures, wrist fractures, hip fractures, et cetera, they're not benign. They're a sign that this frailty piece has been going on for a protracted period of time. And there's a lot less that we can do at 65, or when we have that first fragility fracture at 57, than we could have done when a woman was younger, and we could have intervened much, much earlier.

Yeah, you know, I always say that, you know, estrogen is kind of the foreman for bone, you know, and so it tells the construction crew to show up, and the demolition crew to come in and clean up stuff, but to not show up and get overtime. And And, you know, I have my own experience of that. I, you know, was diagnosed with colitis and then eventually celiac. And at the time, I was a powerlifter when my sort of acceleration of disease state, you know, got me to the doctor, right? And, you know, that's what kind of prompted me to go into this arena by asking if I could change my diet. So, it sort of brought me into the healthcare arena. But I remember at the time, I was like, "I'm gonna go get a DEXA," because I wanted to have my baseline because I was— this is what I read about, this is what I spent my time in. I was in the middle of a master's program. And I go to get it. As a powerlifter, and I'm talking heavy, Cynthia. I was like, they called me the Ant. I was so strong. Wow. And I had osteopenia in my left femur already.

Wow. How old were you?

35.

Wow.

And so, and the truth is, I thought it was all absorption. I have a hard time absorbing minerals. Like, I have to take extra iron. You know, it's just, that's part of the autoimmune history. But, you know, looking back on it now, I had also been on the pill religiously to control my contraceptives since I was like 18, 17, 18 years old, you know. And so, you know, we just don't— we don't do informed consent as a whole, right? We just don't in medicine. And people that say that they do, I'm like, really? Really? You know, I had to write informed consent for studies. I guarantee you, you do not, because that's going to be a 15 to 20 minute conversation.

Yeah. Well, and it's interesting because I think I had responsibly prescribing providers all those years. And even in my nurse practitioner training, we never talked about this.

No.

Never talked about this. And even, you know, I have my traditional allopathic friends generally who are very tolerant of some of my opinions. They were like, this degree of cognitive dissonance that bone and contraceptive decisions do not have long-term consequences. And I said, listen, if you put a 38-year-old on contraceptives and that's the first time they've been on it, they've had the benefit of cycling hormones all those years. That is very different than a 14, 15, 16-year-old. And the way that Depo was marketed when I was training in inner city Baltimore was that this is a set it and forget it, uh, contraceptive, completely appropriate for people who don't want to remember or can't remember to take their contraceptives. And so how many women in the '90s, 2000s, 2010s were put on Depo with never a conversation, even though it has a black box warning, never a conversation about the long-term potential impact on bone health, which again, the studies show, like, within 2— with that 2-year timeframe can be reversible. But most of these women are not staying on it for 2 years. They're like, if it works, if it ain't broke, don't fix it. You know, that, that expression goes. And I think for how many of us that were on oral contraceptives, whether we needed it for contraception or we just wanted to have— we wanted to have some control over our cycle. And I put control in air quotes, wanted control over our cycle as opposed to the other way around. And so I think that there's this missing opportunity that I think is still probably not happening. I mean, the good providers out there, I know you're doing it, but most people do not have more than 10 or 15 minutes to spend with their patients. And it's more like What fits your budget? What does your insurance plan participate in? And what works for you? I think that's probably, and young people don't wanna be like putting in a contraceptive diaphragm or a sponge or anything like that. They want a set it and forget it. I get it. I totally get it. They want spontaneity and all these other things. And so, I remember what it was once like to be a young adult. And so, I just think these conversations are so important 'cause there's probably someone listening who has a daughter or a loved one that's in that age group, and that conversation has probably not been had. And we don't screen often enough. And DEXAs are dirt cheap. I mean, they are so inexpensive that there's no reason why women aren't having them done. Just like we think about all these other screening modalities like Pap smears and mammograms, depending on who you talk to, all these other screening modalities that are designed to, you know, give us a sense of where we fall as an outlier. And, you know, the other piece about the DEXA that I find fascinating is You know, sometimes people get kerfuffled over— they're comparing your bone to a 25-year-old's bone. Like, at 50, your bone's going to be a little different. But, by the same token, if you are, you know, if you already are a little osteopenic, is that your genetics?

Could be.

Or, is this a byproduct over lack of stress on your bones over time, plus or minus your use of contraceptive choices? Over the years. And I just think that conversation isn't being had often enough.

No, you're absolutely right. Well, and so many women in our age group, you know, didn't necessarily strength train in those very key years.

No. No, it was the land of—

of cardio, right? Like, "Oh, I did cardio." I'm like, "Well, you ran off bone and muscle." Yeah. And so, you know, so in this age group, we are kind of behind the 8-ball, you know. But if there's younger women that, you know, read your book, they have the opportunity to really get in front of it and sort of stave it off. And I think the I think that's an important part too because a huge percentage of my listeners and, you know, our patients at Minerva and our clinic are women in my age group. So, I'm 56. I'm quite a bit older than you and then beyond that. And, I think the other thing is we can do a lot to improve bone, but it's better to get in front of it and keep it rather than try and restore it, right?

Yeah. No, I agree. I mean, I had a— I think they did a screening at one of the hospitals I worked at when I was in my 30s. And, you know, they were screening wrists. And so, I was like, "Oh, sure, I'll do this." And, I came away, they're like, "You're osteopenic." And, I was like, "What?" And, this is before I had kids. And so, I remember taking that directly to my GYN who was smart and said, "Let's get a DEXA." And, she said, "Sure enough, you're osteopenic. Why?" The question is why? Because you're not, you know, the things that we know impact, I'm not celiac, I'm not anorexic, I'm not someone that was ever restrictive with my eating, although, Sometimes intermittent fasting can be coined in that, although it was many years before I was intermittent fasting. But, the point is I knew at 30-ish that there are extra things I needed to be doing. And so, I think for a lot of women, they would probably make different choices if they knew in their 30s or even their early 40s so that they don't have that fragility fall at 57 or 60. And then, they're like, "Oh, wait a minute, no one ever told me." And then, you add in the post-WHI stuff where so many people, not necessarily from our generation, but a generation ahead of us, might have not actually, you know, started or even thought about HRT.

Yeah, absolutely. No, I completely agree. I completely agree. So, now that we're on this sort of aging conversation, I want to talk a little bit about ovarian aging and how the ovaries are kind of— you, I think, coined the term, the pacemaker of a woman's body, and particularly around like trauma. And, what do we know about that and its relationship with the gut? Because, You know, we always kind of thought of these are, you know, bikini medicine, throwaway organs. Oh, it's okay. You can take out the uterus and the ovaries when you're done with them. And we're starting to see that they really are this sort of biological early indicator clock of aging.

Yeah. No, it's interesting. It— I'll admit this. I thought for a long time that the most mitochondrial dense organ in the body was the heart, because, of course, I'm myopic. I was all about cardiology. And so when I found out the ovaries are the most mitochondrial dense organ in our bodies, it makes sense that they set the pacemaker of aging. And we know based on research, the things that accelerate the aging of the ovaries, some of these are not surprising, right? Like smoking, alcohol use. And the other thing that I found surprising was trauma. So we look at adverse childhood events, and there's a, a joint venture from Kaiser Permanente and, um, the CDC And anyone that's listening can go online. You can get access to this, uh, this quiz, which is pretty quick. And when I trained in inner city Baltimore in the '90s, when we talked about trauma, we were talking about suicide, rape, murder. I mean, these are big things. We weren't talking about the subtleties to little t trauma. So abuse, neglect, substance abuse in the home as a child. And so as you kind of go through those, and you start looking at the research on how this influences the autonomic nervous system, how this regulates how we perceive stress. So, these kids, if your score is high enough, mine is 9, which is quite high, you go through life at a disadvantage in terms of autoimmune conditions, disordered relationships with food, poor metabolic health, and earlier ovarian aging. And so, I think about this, as quite significant because, you know, for many, many years, how many of us were like, oh, I didn't experience abuse as a kid. I didn't, or, you know, I didn't have big T trauma. And that was always like most of us, you know, working in an inner city, we're like, oh, this is real trauma. Not realizing that many of us had and how that influences not only our responsiveness because our cortisol tends to be a little higher, we tend to be, even if I always use the analogy of the duck swimming across a pond. The duck looks very calm at the surface, right? But underneath is paddling furiously to get itself across. That's how most of these women are is that, you know, you learn to subjugate, dissociate. You know, it's, if you think about sympathetic nervous system, it's fight, flight, flee, or fawn. And that's how many people go on to kind of deal with stress, day-to-day stress, big stress, little stress. And so, unknowingly, many of these women don't realize that that can then lead to an earlier menopause. And I've talked to enough GYNs and ER physicians that are women, a lot of them, I'm not saying all of them, probably it's a little bit genetics, a little bit of the stress piece. You're delivering babies in the middle of the night or dealing with emergencies or urgencies in the middle of the night. That's pretty stressful. These women are going into menopause at 43, 44. 45, 47, 48. Your listeners know average age in the United States is 51, but 40s is a big difference. That's a longer period of time without those hormones. And so, we just understand that this dysregulation of the autonomic nervous system, that pine network, the psychoimmunology neurogenic effects, endocrine regulatory system is just off. It doesn't mean it can't be well, can't be addressed. I don't ever want to say it's fixed. I mean, we are who we are. But for a lot of women, they're surprised to know that how we grow up definitely influences. And there was a study that Mary Claire Haver talks about where if a woman was sexually abused, goes on to have children who are sexually abused, she will go into menopause 8 years earlier than her other counterparts. And I think that's significant because it really speaks to stress is not per se benign if it's chronic. You know, acute stress, you know, we're both having this conversation. I'm sure if you measured our cortisol, it's probably up because we're alert, we're engaged, and we're excited because we're having this conversation. But it's the chronic, unrelenting stress that really does impact the health of our bodies and directly influences the microbiome vis-à-vis, you know, alterations in that small intestinal, you know, permeability. How many women listening have more than one autoimmune condition? I started with one. I have four that are all in remission, but I recall having a conversation last year with my integrative med doc, who we both know, Aaron Hartman. And he was like, I don't want you to ever develop a fourth or fifth because we know what that represents. And so for many, many people that have grown up with a lot of stress and trauma, it doesn't mean you can't get beyond it. It doesn't mean that there aren't things to help you process it. But you have to be extra diligent about the health of your gut. And I think so many of us think of the gut as it's just a processing center. You know, I eat food, it goes in one end, it comes out another. And that's as much as people think about, you know, the process of the GI tract. But it's so much more sophisticated than that. And I think a lot of people don't make those connections that, you know, toxins, you know, and it, we could probably also make the argument that endocrine mimicking chemicals are probably contributing to ovarian senescence. And so, I think there's a lot there that for many people seems a little bit intangible when you start saying like how you grow up influences wiring of your autonomic nervous system, which can then contribute to when you go into menopause.

Yeah, absolutely. And I think, you know, you hit on a point that so many people overlook. And I would say, you know, particularly Gen X kids, we were raised by parents that were like, You know, we did, you know, your family and your parents do the best they can with the skills that they have, regardless of what level of T-trauma you have. But we got to understand that just one generation before that, marriage was a business contract, right? So the idea of love and relationship and connection was very limited. But we don't have to have those big, big traumas to have trauma. And I think a lot of people are like, you know, if I wasn't, if there wasn't murder, rape, all those things, then I don't have it. You know, but the reality is you can. And, it's interesting that you say that because my mom just recently passed away after spending a lot of time in an assisted living. So, it was, you know, it's one of those things that it was a blessing to some degree because her quality of life was terrible, but it doesn't change how much it hurts for me. And, it was interesting because I got blood work right in the middle of it, you know, and my antithyroglobulin antibody came back and it hasn't been elevated except for when I did it during COVID because I was, of course, like, "I have COVID. Let's go see what happens." and, you know, because it was in remission, it pops up when something's happening. And at the time, I felt fine, right? There was nothing really, but I was like, just the stress of that made that antibody show up in a way that it hadn't in, you know, 5 years, but even a decade prior to that. And so I think it's just so important for women to understand, you know, and then you have, did you have tubes tied? Did you have a hysterectomy, but they left your ovaries? Like, Cynthia, I had my tubes tied. I had no ovaries at all visible on a full-body MRI. My uterus is there. They're gone. My body reabsorbed them.

Wow.

When? We don't know, right? Because I had, I had a, I had an ablation because after my tubal, I had all kinds of perimenopausal symptoms. Then I had an ablation because I was having a period every 21 days. So I had to kind of use blood work to watch for it. But when I got my Prenuvo, they're like, hey, when did you have your ovaries taken out? And I'm like, yeah, like, I didn't.

Your body resorbed. That's fascinating.

So that's, that's something that a lot of people don't recognize either is when you have a tubal, which is a permanent, you know, or pretty close to permanent control of fertility, the change in blood supply, innervation, and other things can result in a reabsorption and also an earlier menopause. I mean, because I went through menopause at about 48.

Yeah. I mean, I think my hospitalization in 2019 shoved me— I mean, it was like I never got another cycle, but I lost 15 pounds in the hospital, and I wasn't someone that had 15 pounds to lose. And so, you know, I think that was such a shock to my system. And my GYN said, "Oh, yeah, I see women in their 40s going early when they go through a divorce, when they lose a job, when someone in their family gets sick, or they themselves go through a big illness." And she said, "Yeah, you had a big stress test." You know, it was just like you got shut— your fertility was like, "Nope, we're just going to shove you off the cliff." And so, I think for a lot of women, they're oftentimes surprised. I mean, I have girlfriends that are like 53, 54, and they're like, "I'm not in menopause yet." I was like, "You have dysfunctional uterine bleeding. You are no longer ovulating." I fervently believe that. It is highly unlikely at 53, 54, you're still ovulating. I mean, you would have to be a magical unicorn. But, what you're having is dysfunctional uterine bleeding, and they almost always get upset because they're like, "No, no." And, I'm like, "Statistically, it's probably dysfunctional uterine bleeding." And, again, I've spoken to enough GYNs that have, you know, said the same thing. And so, I was like, it's a big— I think for a lot of women, we probably don't talk about this enough. I wasn't hung up on the loss of fertility. I think it was just more of a, "I'm old enough to go into menopause?" I remember it was kind of like a, "What just happened? Did that just happen?" And, it took me like a whole year to be able to say it out loud. And, it wasn't because I have any shame about aging, it was just such a shock. I don't know if you experienced that too. You were like, wait a minute, how did that happen?

Yeah, no, I mean, my perimenopause was definitely unpleasant, but, you know, I was like, what? That is really young. Like, what is the deal, you know? And I didn't want to associate myself with kind of the branding of a menopausal woman, you know. I think we're all out here trying to change that idea. So, I agree, you know, and I think, you know, I think there's also— and I would say in the functional medicine community, we haven't got a handle on this either— is, you know, there's the idea of estrogen dominance and not enough estrogen. And obviously, the microbiome plays a significant role in that. But I think we're also late to the game of introducing estrogen at the right time because there was this kind of prevailing dogma that if you were having a cycle, you had enough estrogen. I'm like, but you could be having a cycle for years and not ovulate.

Yeah.

You have just enough to have abnormal uterine bleeding, you know. And, and so therefore, we don't address it early enough. To stave off some of the bone loss and other things that we see. And then we wait, you know.

And so I think about how many women suffer, Betty. They really suffer. Like, I, I'm thin phenotype PCOS. I didn't know that until I tried to get pregnant. So in my late 30s, early 40s, my luteal phase was miserable. But I don't even think I had the language because our generation was like, suck it up. Like, don't complain. And I had my second child at 36. I was, and I had a 2-year-old, so I was tired. I just assumed it's because I was, you know, a little bit older than most of my friends having kids. And so I just recall being so, I was so, and I'd never had like mood disorders, but I was so either anxious or like my mood felt labile around my cycle and my, my sleep was terrible. And how much better things would have been if I had known to say, hey, I need some progesterone. You know, in cardiology, we don't talk about these hormones, but I recall like the language, and I remember seeing my allopathic GYN around that time, and I recall the conversation because my period had started that day, and I remember saying to her, my period's very heavy. And so, she did an internal exam and she's like, oh my God, your period is so heavy. And she's like, here, I can fix it, oral contraceptives, or we're going to give you a progestin IUD, or we're going to ablate your uterus, or we're just going to— you're done having kids. "Let's just take out your uterus." And, I was like, "No, no, no, and no." And, that was like I never looked back. I started seeing a midwife who, you know, we did different things. But, how many women don't know there are other options? And certainly, why are we not starting oral micronized progesterone or even compounded sustained-release progesterone for a week or two out of the cycle? How many women's lives would be benefit by that? Even just being able to sleep. I mean, I can deal with anything if I'm sleeping well. If I'm not sleeping well, I can't deal with anything. Well, I can, but not as well. Yeah.

I'm going to be crunchy in that moment.

No.

Yeah, I agree. I think there's just so much. And, you know, the big challenge kind of why I do what I do is we just don't have adequate research. And so, instead of pushing for research to happen independent of the pharmaceutical bodies and other things, you know, a lot of people throw up their hands and go, "Well, we don't have double-blind placebo-controlled trials, so therefore, we just don't do. And I'm like, "Okay. Your hormones don't become magically bad for you at 50." That defies logic, but I think we just have a lot of room there for improvement. And I'm hoping that, you know, it's probably even millennial women. Sorry, we're kind of all in this boat. But I'm hoping the Gen Y, I think that we'll have some real data that we can just avoid some of these pitfalls of midlife. Before they ever get here.

Yeah. And, to your point about estradiol, I mean, gosh, slap an estrogen patch on that woman in their mid-40s. Most of them would benefit from it. I mean, I think—

Well, I was terrified of it.

Yeah.

Because I was estrogen dominant. You know, I'm going to air quote that. You know, yeah, I have a booty, and I have— yes, I was at one point, which also means I have a ton of receptors for it.

Yeah. And, here's what's interesting is, I think many people don't think about the downward effects of less progesterone, less GABA, less estradiol, less serotonin, less melatonin. So, those neurotransmitters, I think, are so important. And, just the declining mitochondrial health, which makes it even harder for your body. So, if we're waiting to start hormones on women when they've already got significant mitochondrial decline, it's going to make it that much harder for those hormones to do their job. We think about— use progesterone as the example. There's all these women that tell me, "I'm progesterone sensitive or intolerant or I have an allergy." And I'm like, "More than likely is you have such significant mitochondrial decline instead of getting upregulation in GABA, you're getting upregulation in glutamate, which is an excitatory neurotransmitter plus or minus depending on what your estradiol is doing. Are you getting a histamine response, mast cell degranulation?" And that's why— so, it's interesting. I think we have a very reductionistic perspective on hormones are good or bad, they're effective or not, and there's so much nuance to this. Really speaking about that mitochondrial decline, if we start hormones before you're in menopause, you're probably going to respond better.

Yeah.

There was a woman the other day that I have a free group on Facebook and she was saying, "I've been on estradiol now for 6 months and I thought the brain fog was going to get better." And I'm like, "Well, the problem is they didn't address the mitochondria first." And if you don't address that, then yes, the estrogen patch is not going to be as it's not like throwing out a life preserver and then you're no longer drowning. You're probably feeling like, "I'm just about to the life preserver, but I still don't feel like I'm not drowning." I mean, that is part of the conversation that I think is perhaps not even in the integrative medicine space is necessarily always being had. Mitochondrial dysfunction is driving a lot of what we experience. And, if you don't address the mitochondria, either repairing them or upregulating mitophagy. Sorry, I'm getting in the weeds, but if we're not addressing that, it's going to make it even harder for those hormones to do their job and to get you feeling more like yourself.

Yeah, that's not a good marketing message. Sorry. Yeah, it's—

but I'll tell you, last week on the podcast, I had two physicians, and a big prevailing theme from that conversation, Betty, was We're not talking about the mitochondria enough. And so, I think I share this not to scare anyone, but part of what drives aging is dysfunctional mitochondria. So, it's like we have to be thinking of ways that we can address this in a proactive manner. And, you know, everything will work better. Like, your body will just work more effectively. Like, I know when I got serious about that, my hormones work better. My nourishment and replenishment hormones worked better.

Yeah. No, you're absolutely right. And, we could go down that rabbit hole for a couple hours, but it is true. It's a marketing message to sell hormones now, but real appropriate, well-thought-out, individualized hormone replacement is not just giving hormones because you have symptoms. It's actually looking at the function of the body and doing a deeper dive and understanding how they are being processed, what's the impact, and what's your mitochondrial function, and what's your microbiome, which brings me to why everybody needs to buy your book. And I think they need to do both. So I consume— I consume an extraordinary amount of content. It's just I'm a squirrel, you know, that's got to run and jump and do everything all day. And I would recommend that they do both. Get it on audio, listen to it in your car so you can absorb it that way, because that's one way of processing. And then buy the book so you can highlight, circle, you know, fold the pages, put Post-it notes on it because it's so chock-full, not only of the things that we just talked about, but actually how to fix it. You know, so I intentionally didn't ask Cynthia how to fix it because I want you to get her book because it is methodical and how to deal with it.

Thank you. No, I appreciate that. I mean, I think this book was truly a labor of love. And truly, when I say that, because in the midst of And like, let's get real. I know that, and I'm sorry that you lost your mom. I lost my dad and my stepmother in 2024. And in the midst of all of that, right before I like signed my new book deal. And so I had to write in the midst of all of that. And so when I tell you all the things I talk about that help reduce stress for me were things I had to do while I was writing, because it was, you know, I felt like I was pushing it. I felt like Sisyphus, like trying to push this boulder uphill the entire process. But once I got to the top, I was like, phew. But I think this is a really valuable resource, and it dovetails so nicely into the existing perimenopause and menopause work that's out there. But it's unique, and it's really— it's like my love letter to middle-aged women. It's what I wish I had had. I would have better understood my body. And, you know, I'll be the first person to say, I got a meme the other day from a colleague who was talking about the new F-word is fiber. And I said, you know, it's a nuanced discussion. Everything about hormones and our bodies is a nuanced discussion. And anyone that kind of sells you with a one-size-fits-all, they don't understand the nuance to the conversation. And so, I think that we and I spent a lot of time making sure people felt heard. And it's like, listen, there's no one-size-fits-all for fiber. There's no one-size-fits-all. There are prevailing themes, But, there's no one-size-fits-all for hormones or neurotransmitter support or lifestyle. And so, we tried to be really, really methodical with things that are totally free all the way up to bright shiny objects that, let's be honest, we love bright shiny objects. But, foundationally, there's a lot that we have to consistently do before those things can even be remotely effective.

No, it's absolutely true. It's absolutely true. So, everybody listening today, or any day, any day, I want you to go out, get The Menopause Gut from your favorite bookseller. I'm gonna have a link below because if they buy through this link, they get some bennies, right?

You got some presale bonuses, which are really for like that presale individuals. And let me be clear, people create these bonuses and generally they're not valuable. Like we actually polled my community and asked them like, what would be helpful for you? Yeah, it's not another pantry guide. It's not bonus recipes, although there are amazing recipes in the book, but it's stuff that will actually be helpful that are adjuncts to the book itself.

Yeah. So, definitely use the link in the show notes to order the book and then get your presale benefits. And, like I said, I think you're going to want to do both the Audible and the actual book book. You need to just— that way you get the data and you get it embedded in your brain. And, Cynthia, I want to thank you so much for coming on Menopause Mastery.

Thanks, my friend. Thanks for having me. It's been an honor.

Absolutely. Absolutely. Thank you, everybody, for watching on YouTube and listening, and I will be back with you next week. Don't forget to subscribe so you don't miss any wisdom.