Menopause, Your Microbiome, and the Vicious Cycle Nobody Warned You About

Hi and welcome to How Humans Heal. I'm Dr. Doni Wilson, and today I'm honored to introduce you to Cynthia Thurlow. She's a nurse practitioner and host of Everyday Wellness Podcast, as well as a bestselling author and international speaker. She has a TED Talk with over 15 million views, and her most recent book is out now called Menopause Gut. Thank you so much for joining us today, Cynthia.

Thanks for having me, Doni. It's so nice to be back.

You know, I feel like this book, this Menopause Gut book, is your story. Like, you're actually getting to tell the story of what you've just been going through the past, what, 5 years, 10 years of your life.

Yeah, it's interesting how a trip to Morocco that was designed to be this incredibly romantic holiday is really at the precipice of the realization of how much our microbiome is changing, our immune system is changing in the setting of declining hormones. And it wasn't something that I actually was aware of until after the fact. And I think in many instances, when we're talking about women in this, you know, perimenopause-menopause transition, we talk a lot about heart health and brain health and bone health, all of which are very important. But most people are not aware of the microbiome changes that are literally impacting every body system. And so, That romantic trip turned into a really bad case of food poisoning that then led to a lengthy hospitalization. And I just had no idea how much our immune system takes such a massive hit, especially with a reduction in estrogen. So I humbly sit back and say I was like the N of 1 experiment to really bring to fruition a better understanding of what's changing physiologically in our bodies in middle age.

I'm so glad that you're bringing this to the spotlight because it isn't something that we hear about or we talk about. And, and even as a naturopathic doctor where I'm trained to think of the gut first, healing the gut first, and yet this connection between the hormone changes that happen with perimenopause and menopause and the gut is still not something that's at the forefront of awareness, even for most practitioners, even for naturopathic doctors. So it's really important that you're talking about this and sharing the research because the research does exist to show, right? When you started looking, I know you shared this in the book, you're like, oh my gosh, all this research shows that it's related.

Yeah. And it's, and it's interesting. There was so much research in the book that it's not part of the book itself. It would have added 20 pages to the book. So all of those references for those that are nerdy like me and want to learn more are actually going to be housed on my website. And we did that for a reason. I really wanted the book to be scientifically sound but also accessible. And I was shocked as I started looking at the research, because I really think most of us, especially clinicians, maybe the last 5, 10 years, we've been hearing more and more about it. But when I dove into the research, there was a lot on like the gut-bone axis, the interplay between trauma and adverse childhood events and how that stresses the ovaries vis-à-vis the gut microbiome. And so really, there's nowhere in the body that is not integrated with the gut microbiome. And to give listeners some perspective, because I think most of us know where our brain is, our heart, our lungs, but the gut microbiome seems kind of nebulous and intangible, but it's 40 trillion bacteria, viruses, and fungi that are located in the colon or large intestine, and they interface with every single organ system. And it's really sophisticated. I, I think that is the thing that I was so taken aback by why, you know, we certainly didn't learn this 25 years ago, uh, when I was in my medical training, but It's really this burgeoning field, and we're starting to understand there are more of them in terms of microbes than there are human cells in the body. And so we humbly sit back and we're like, gosh, they're like little communication superhighways between all of these organs, all of these cells, and how important it is to nurture the microbiome, especially in the setting of perimenopause and menopause, when we see alterations in hormones and neurotransmitters and the way we perceive ourselves and maybe even the way that others perceive us. And so I think it becomes a really critical component to this larger conversation. It's more than just replenishing hormones. It's more than that estrogen patch. We really have to think comprehensively about our health.

And it's not just about taking a probiotic either. That's kind of the simple— like, there's so many probiotics out there and so many people are now aware, oh, maybe I should take a probiotic. But that's just like the tip of the iceberg. It's not even touching the— getting anywhere close to what you're talking about in terms of our health.

Yeah. And it's interesting because people will oftentimes ask me— in fact, I think in the last podcast interview I did, they're like, what are your top 3 supplements? And I think they expected me to talk about a probiotic, butyrate, and maybe something else. And most of what I talked about were— there were things that help sleep, they help with muscle, they can help with gut, you know, the gut layer. Gut microbiome layer, but they weren't per se probiotics. And I was like, listen, I want listeners to really focus on nutrient-dense whole foods, getting your probiotic-rich foods. You know, we can talk about postbiotics and prebiotics, and while they're also important, but getting those from nutrient-dense whole foods as a starting point. And then if you have a deficiency, if we do stool testing or we're looking at micronutrient testing and it's evident that you have a true deficiency or you really need something to specifically bolster a particular part of the microbiome, then I think it's absolutely fine. But unfortunately, I think a lot of messaging has been around, just take this probiotic and you don't have to change anything else. And it's not to suggest there aren't some great qual— high-quality probiotics out there, but I think the message needs to be lifestyle first, and then we layer in when we know there's a true deficiency or a true need.

Okay, so I wanna come back to several things you just mentioned. And first of all, I wanna help make sure that those who are listening are really connecting what they might be experiencing, you know, 'cause I'm thinking they might be like, "Wait a minute, you're saying that what's going on in my gut could be related to what's going on with my hormones?" Especially if you're having, even before your period stops happening, right?

Like, what should women be looking for to think, "Hey, should I be paying attention to my microbiome at this point?" I would say everyone needs to pay attention because a lot of the constellation of symptoms that women experience in perimenopause are a direct reflection of the health of the microbiome. I'll give you an example. We know that women start experiencing more bloating as they are navigating this, this transitional time. And the bloating can be from a variety of things. It can be the fact that there are alterations in stomach acid, there are changes in digestive enzymes. We know as estrogen is declining, our bile starts to change in response to this. It won't, it won't break down and emulsify fats quite as well. So we start seeing a lot more steatic crit in the stool, which is a fancy way of explaining we start seeing more in our poop, we start seeing more fecal fat. So that's not something that should be there. We start seeing alterations in smooth muscle contractility with reductions in progesterone. We get changes in something called nitric oxide, which is a key vasodilatory signaling molecule, as we see alterations in estrogen. For a lot of women that are experiencing bloating, it can be from any of those things. It can also be just from having a leaky gut. That small intestinal layer is only one cell layer thick. It is easily damaged by ultra-processed foods, chronic stress, toxins like alcohol, chronic antibiotic therapy. And let me be clear, sometimes we need to be on antibiotics. I don't want anyone to feel— if you're taking them, don't stop them. There's generally a good reason, but the chronic overuse and overprescription of antibiotics, all of those things can damage that, that very delicate layer. And when that is breached, and it also did, it also is impacted by a decline in estrogen. Estrogen is like the mortar. So if we think about brick and mortar, those tight junctions, you will leak food particles into your bloodstream that will trigger an immune response. So sometimes foods that are otherwise healthy, like let's use an example, grains or dairy or anything like that triggers an immune response. And women will say, "Oh my gosh, anytime I eat raw milk cheese, or I have some yogurt, or I had some rice, all of a sudden, I have these constellation of symptoms that can involve bloating and can get more dramatic, like even leading to hives because of mast cell degranulation in the setting of higher estrogen levels and histamine response." That happened to me during my last book launch. I developed hives in the midst of an interview, and someone was like, "Are you okay?" And I was like, "No, my hormones are just clearly all over the place." But I think for a lot of women, they don't make the connection that the health of the microbiome alters any of these symptoms. So bloating is not uncommon to be seen. A lot of women get diagnosed with irritable bowel syndrome. They're told, "Oh, the alternating diarrhea and constipation or predominantly one over the other, that's normal. It's just IBS." It can have so many things relevant to these alterations, not just in neurotransmitters, but also in hormones. And then I also think about if you're not properly breaking down your estrogen, you can recirculate it. And so, it's not to oversimplify the estrobolome, but it's this estrogen processing center in the microbiome. There's specific bacteria that are designed to kind of break down into water-soluble compounds through the liver and then in the gut. And if it's not packaged up and pooped out of the body, it can get recirculated, and that can magnify weight loss resistance, joint pain, brain fog, breast tenderness, all these symptoms that we think are just related to declining hormones, but really can be a mirror for the health of the microbiome. And that's why I feel so passionate about sharing this information because I feel like not enough clinicians that I interact with are talking about it. And I think it can explain why some women will say to me, I do a really good job with my sleep and I try to manage my stress and I try to eat mostly nutrient-dense foods and I exercise every day and I'm on HRT, but I still don't feel better. And so I always say like, that can be a reflection of many things, but I do find that there's a component of gut health that is playing a huge role. And so again, it's why the messaging is so important, because if you think you can just slap on an estrogen patch and fix all of your lifestyle-related issues, it won't do that. It is not a magic pill, although it's an important component to the conversation. Every woman listening deserves to have a conversation with a perimenopause, menopause savvy prescriber to determine if that's the right decision for you. But unfortunately, just replenishing hormones doesn't fix all of these things that I'm talking about.

It's such an important point because we are hearing so much more about HRT, and, and thank goodness, we've— women are starting to hear the message that the research that we got over 23 years ago was what— now the researchers came out and said, actually, we were wrong, that hormone replacement therapy isn't causing cancer except for the, the synthetic progestins. So it's like a totally different story. And so women are starting to hear, wow, that hormone replacement therapy is— and it's becoming more trendy, and not just trendy but important. And yet at the same time, it's not a, a one magic fit, like you're saying. Like, you can't just expect that just HRT is going to solve all of your menopausal symptoms. And from what you were just describing, I really see this vicious— that it's a vicious cycle. And you talk about this in the Menopause Gut book, and I talk about this a lot in my books too, where it's like a vicious cycle, right? One thing leads to the next. Next thing you know, you've got, you've got the stress, you've got the hormone changes, you've got the toxin exposure, maybe you needed to be on antibiotics, or maybe you were traveling and you had food poisoning, and then it just becomes this like snowball, right? Like this leads to leaky gut, this leads to a bacterial imbalance, this leads to this, and next thing you know, you've got bloating, weight gain, skin rashes, brain fog, right? It's like, is it like that? Like this snowball?

I do. Yeah, I do. I do think of it as a domino effect. I think it's a cumulative net effect. And I do think about how by the time women get to middle age, you know, the habits that allowed us to be successful in our teens, 20s, and 30s can sometimes turn out to be maladaptive because as our physiology is changing, it becomes critically important that we adapt. And I know women don't like to hear that, and sometimes I get hate mail because I'll pick on Orange Theory Fitness or CrossFit, and I'm like, listen, I'm not saying not to exercise. What I am saying is, as your physiology is changing, you have to change your lifestyle. And the things that I did at 35 are not the things I do at 54. And I think it's a really important distinction to make. I probably take better care of myself now, but the things that made me an incredibly successful student, young adult nurse, then nurse practitioner, are very different than the things I do now. And I think for a lot of women that have been very high achieving, very goal-oriented, pushing the envelope in every way of their personal and professional lives, It is a little bit of a mind screw when you get into middle age and you're effectively told, "Hey, guess what? Your physiology doesn't match this anymore. Now, you need to sleep more. You need to manage your stress more proactively. You can't eat an ultra-processed diet. You can't be a couch potato. Think about your gut. And oh, by the way, if you had significant either big or little T trauma growing up, that can make your perimenopause journey harder." I think— of perimenopause is a litmus test for how well you take care of yourself. And I always use myself as the example because people think I live this perfect lifestyle. And I can tell you, it took, it's taken a long time to really rein in on a lot of my habits because I am a very type A person. I worked in really intense areas of medicine. I was an ER nurse first in inner city Baltimore, and then I turned into clinical cardiology. So I was managing very acutely sick patients in the ICUs. All across the telemetry floors, and then also did clinic— clinical cardiology. So very sick, very high acuity patients until it wasn't fun anymore. I didn't want that much stress. And so for me, I did a major pivot 10 years ago. But up until that point, I hit the wall of perimenopause. I was not sleeping enough. My exercise was way too intense. I had a super stressful job, not surprisingly, as I've already shared. My kids were young. My husband did a ton of international travel. And so I always say, like, what served me okay in my 30s really became problematic in my early 40s, and I had to radically change what I was doing. And I feel much more at peace now than I probably did when I made all those changes. But I think in many ways, understanding that, um, we really have to view things through the lens of changing physiology, find the reframe. It's not a negative thing. I feel so fortunate and so blessed that I have the platform to be able to help educate women to say, hey, don't do what I did, or at least, you know, make sure you're thinking about these things in your latter 30s. Make sure that if you're in your early 40s, you're probably already there. And I would much rather that women that are younger than us actually benefit from us sharing our stories without shame or secrecy, but just being really honest and heart-centered because I think that every woman deserves to have a smoother transition into menopause. I always say perimenopause is the storm before the calm. Like, if you get it right in perimenopause, you will eventually feel like menopause is not such a big deal. You know, it's all those fluctuating hormones, and then all of a sudden things kind of quiet down. And that is, that is a lot of orchestration and change in your personal and professional life to make that happen.

It's such a good point. And thank you so much for, for doing the work you do to raise awareness and to bring this information to women. I also want to point out how, as a stress expert, how happy I am that you share about stress and trauma and the impact of stress and trauma on gut and menopause health for women to know that too, because it oftentimes isn't connected. That can, you know, that women aren't realizing that their their stress even from early life is having an impact now, and that there's things we can do about it to help ourselves recover from that stress and trauma so that it doesn't have to continue impacting us going forward.

Yeah, and I do think for a lot of— certainly my patients or women that I talk to or friends with— we hold it together pretty well because we've created lots of adaptive strategies to deal with whatever we grew up within. And then we get to perimenopause and all of a sudden, you know, with those changes in estrogen and progesterone and neurotransmitters, it's a lot harder to keep that mask on. And I think that is the opportunity for women to, you know, either deal with feelings that they may be even subjugating. Like I always say, uncomfortable feelings are really at the basis for nearly every addictive, maladaptive behavior that we can imagine. And I say this lovingly as someone who grew up with an addictive parent, and also experienced quite a bit of adverse childhood events. And for anyone that's not familiar with that term, um, there was a joint venture between the CDC and Kaiser Permanente. Anyone that's listening can get online and they— it's, it's a very quick quiz. You can get a quick rapid assessment of whether or not you experienced quite a bit of adverse childhood events. But we know these people are at higher risk for poor metabolic health, disordered relationships with food, more likely to have mental health issues, more likely to have autoimmune conditions. And what I find really interesting is there's even research to suggest that that chronic cortisol exposure, which cortisol is not a bad hormone, but it gets a really bad rap. It can be corrosive. It can age the ovaries. So we know there's a very strong connection between the gut microbiome and ovarian function. So that gut-ovarian axis, our ovaries are the most mitochondrial dense organ in our bodies. They are very sensitive. You know, they're like the canary in the coal mine. So whether it's toxins we're exposed to, chronic stress, tobacco use, anything that disrupts the health of the ovaries has the potential to age you faster. And what I found really interesting was there's certainly research to suggest, I mean, it's still evolving, but if you are dealing with a lot of chronic stress and trauma, that can actually age your ovaries faster. So, you know, we define average age of menopause here in the United States as 51. Premature menopause is before the age of 40, and then early menopause is before 45. So anywhere between 45 and 55 is considered normal. But I don't think 45 is ideal. The longer we go without those hormones, the more likely we are to suffer the sequelae. And so I think very thoughtfully about this, that had I known, you know, 30 years ago what I know now, would I have changed things? And so is it any surprise that a lot of my colleagues that worked in very high acuity areas— ER medicine, obstetrics— where they're up delivering babies all night long, or even, you know, kind of intense areas of medicine that I worked in, a lot of these women are going into menopause in their 40s. And so I just think thoughtfully about the fact that we have not given enough attention to the impact of that autonomic nervous system. So parasympathetic, rest and repose side of the brain, your, your neurologic system gets rewired when you're dealing with chronic stress. And so cortisol, not a bad hormone, but gets a bad rap. You know, if your cortisol goes up, your blood glucose goes up, your insulin goes up. We know that cortisol can be a catabolic hormone. It can break down muscle. It can lower your immune function. It can— so we already know our immune— we use the term immunosenescence, but the immune system ages right along with us. We become more prone to autoimmune conditions. Women are 4 to 5 times more likely to be diagnosed in middle age. We know women make up 80% of the population. with autoimmune conditions, but I think it's quite significant. And at the time that I finished my medical training, I was trying to think back, like, did we maybe know 20 or 30 autoimmune conditions? Now there's over 100 recognized autoimmune conditions. So we have this explosion of autoimmune conditions, not to mention the fact chronic stress weakens that little, that little one-cell layer thick of the small intestine, drives inflammation. Inflammation is at the basis for nearly every chronic disease state that we see. And so I think it's definitely a really powerful conversation around how important it is to proactively address our stress, not to think that doing 5 minutes of meditation once a week is going to do it. You need to have a stress reduction practice, which I know you talk about in your book. And I think for a lot of women, it's like they haven't really gotten serious about it. I certainly didn't, Doni, until I was in perimenopause and I was like, oh my gosh, my body is sending out an SOS. I need to really rein this in. And I think for a lot of women, it becomes this— they feel like they're— they have an adversarial relationship with their body. They're like, I don't understand. Everything that used to be easy is now incredibly hard. Why does it have to be this hard? And so it's really helping us understand our physiology so that ultimately we are able to navigate middle age and beyond with grace and with dignity and also find it enjoyable. Like, there's something to be said for finding your voice in middle age. Like, that word pause is really designed to force us to sit back and think a little bit, or think thoughtfully about the way that we're living our lives.

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No. And it's unfortunate because I know, you know, I've interviewed some integrative gastroenterologists on the podcast. Obviously they're doing that type of testing, but kind of conventional stool testing and allopathic medicine is looking at a stool guaiac to see if you have blood in your stool, which is important. Or you come back with traveler's diarrhea and they might do some ova and parasites testing. And that's pretty much the extent of like stool testing, at least from a very basic level. And so I think it is really this integrative functional approach where we're looking at, you know, looking at patterns of keystone bacteria, looking at dysbiotic organisms, looking at, you know, how is your digestive capacity working? Is your hydrochloric acid sufficient? Are you making enough digestive enzymes? Are you, Are your immune markers suggestive of an acute or a chronic infection? I mean, there's so many variables that we can look at. And I think in many instances, you know, a lot of things that I talk about in the book, like short-chain fatty acid production, there's even tests that can look at, um, short-chain fatty acid production vis-à-vis the stool, which I think is really interesting. Now, I'll be totally transparent and tell you I get a lot of questions about microbiome testing in general. And I've asked the microbiome experts, like the people that are actually doing the research, and they've said more than once, like, we don't think there's per se, like a conventional test right now that is giving great information. Like, it's not to suggest it's not coming, but most direct-to-consumer testing, um, is probably not there yet, uh, because I get asked all the time, like, yeah, it's like, what would you recommend? And I'm like, well, I like the test that you actually have to order through a licensed medical provider's office because then you are also getting appropriately counseled and you go through the test and you can explain recommendations and also why it's important to do certain recommendations. So I think for a lot of individuals, it's, it's evolving. I think for many people, they're frustrated that traditional allopathic medicine doesn't cover all these tests. Like, I know my husband, as a great example, we have a functional integrative practitioner in our area, and that's who we all see. And sometimes he gets frustrated because he's like, well, every test costs, you know, $300 to $400. And I'm like, yeah, but I think there's a it's reasonable to be judicious with testing, meaning I don't ask any of my patients to do what I wouldn't expect of myself. And so, you know, we're doing stool testing at least once a year. I think it's helpful. We're not doing it habitually or chronically, but I do have people who end up in programs that have had very expensive testing ordered for them. The practitioner doesn't per se do a particularly great job evaluating and, and providing guidance and recommendations. And so I think one of my tips that I would say, I'm gonna give this is unsolicited by you, but I'm gonna say this. If someone is recommending a test, I would ask them like, how many of these tests have you looked at? Like there's a, a dried urine and saliva test that I used to use more often than I do now. I still think it's a good test. I just think I've gotten more judicious. But like if a Dutch hormone test costs you $400 to $500 and the person who's interpreting it has only looked at 10, You know, is that going to really be a valuable test? No. I think you need to work with someone that's looked at hundreds of them because I think that then yields more insightful information. And so I don't say this to throw anyone under the bus. It's just more of a recommendation. If your provider is selecting this test, you want to make sure that they've actually been working with it for a while. I know that when I took— I took a Dutch testing course and it was like the binder was— and it tells you how long ago it was. Was like 4 inches thick. And, you know, in the very beginning, I would still have meetings with the physicians. I would say, I'm gonna review the test with you, I have questions. And I would do that, and I didn't charge my patients for that time. I was like, this is me filling in the conceptual gaps until I felt really comfortable. But I think a lot of other people don't do those kinds of things, and it ends up being a very expensive test to run. And if you don't have someone that knows how to properly interpret it, then it ends up being a waste, I think, personally.

Well, and I see too often people will come into my practice and they will have, say, done a, a stool test, and then there were never any recommendations. And so you, you're right, you want to be working with a practitioner who's been doing this. Like, I mean, I, I know, I mean, I've been helping patients with their microbiome using like a PCR analysis for probably like 10 years since it's ever been available, and it's And so you want someone who's had that level of experience and done it on themselves, and then that they're going to meet with you and go over it and be like, what does this mean? And what are you going to do? And, and when we see an imbalance in the microbiome, to know that it's— to me, I'm going to use herbal antimicrobials whenever possible. Right. Like there's— I just want people to know that it's because sometimes people will say, is it too far gone? Like, Is my microbiome too far gone and you can't get it back again? And I say to them, listen, I've helped really severe cases get their microbiome back on track. It's so exciting. Yeah, like it's possible to win your microbiome back and reestablish it.

Well, and I think the other thing is, to your point, like the microbiome is incredibly malleable. So even if you've been a couch potato eating ultra-processed foods, the microbiome is incredibly malleable, meaning, you know, if next week you decided to start walking after meals and you started to eat less processed food, like, your microbiome will adapt. Now, is it harder when you have an absence of hormones? Absolutely. But it doesn't mean it's impossible. And that's again why, you know, when people ask me, like, what are the top 3 things you would recommend someone do to support the microbiome, I always say I major in the majors. Like, I'm not throwing a supplement woman at you, I'm talking about sleep and stress. And transparently, show me a woman who doesn't manage her stress and show me the same woman who doesn't sleep well and nutrition. Yep. And exercise. And so, I will tell people, those are still foundational elements. They are the first 4 interventions that I talk about in the book because it is so important. And the research supports that. It is not just conjecture. It is not just anecdotal. It is actually what the research supports. And so I think it really speaks to the fact that, you know, when we're looking at, you know, these online presences and people are talking about testing, I'm like, yes, it is all helpful. However, you really have to have a firm foundation because when you're talking about restoration or improvement, like I talk about in the book, I spent 13 days in the hospital, had 6 weeks of antibiotics and 6 weeks of antifungals. I mean, I went home with a PICC line. I was so sick. I was getting IV antibiotics and antifungals. Because I was that sick. And so, you know, for almost a year I had chronic diarrhea. My gut microbiome had totally been decimated. The antibiotics saved my life. Let me be really clear, this is a case for, you know, what's the greater good, and it was saving my life. But I always tell people, you know, one round of antibiotics can, you know, impact your microbiome anywhere from 18 to 24 months. And there was a study that came out recently that suggested it could be as long as 8 years. So I tell everyone it is a long game. It is not a quick fix. There are definitely interventions that we know you can see improvements pretty quickly. But I think for a lot of women, they tell me, "I'm sleeping and I'm managing my stress," and I can look at their microbiome testing or even any of their testing, and I'm like, "Well, your body perceives you're being chased by a wild animal." Like, even if I believe you, I believe you when you tell me that you're prioritizing self-care and you're putting yourself to bed and you're managing your stress, but you may have to do more. Like, you may have to, like I always say, you know, the first intervention is not an Oura Ring or a Whoop band. But when someone is consistently showing me HRV data that is suggestive that their body is chronically stressed, their HRV is in the 20s, and that's where it hovers, I'm like, okay, well, what this tells me already is your body is in chronically stressed state, even if you don't perceive that it is. And so there's a lot that you need to be doing to help offset that so that you can get yourself back to a better quality of life. Because I think a lot of women don't realize we have the potential to spend half of our lifetime in menopause. And I think many people think of it as, oh, it's just the when we get older stage. And I'm like, well, I mean, you could spend half your— if you're— if you go to menopause in your 40s, I mean, you could be in menopause for half your life. And so I, I say that just to kind of reacquaint women to don't think of it as an afterthought, like don't think of it as I don't have to work hard because I'm only going to be in menopause for 20 years. Well, statistically, you're probably going to be there for 30+ years or longer. And, you know, certainly women outlive men, but we know we typically have that marginal decade. Like, men don't live as long, but women end up having this marginal decade. And I don't think anyone listening wants to have a marginal decade. I think all of us want to be thinking about what are the things we can do in middle age that will ensure that we are thriving throughout the rest of our lives.

I love that you're— first of all, I love that you're talking about the foundational tools and that you talk about them in The Menopause Gut. So people right away in the book, they— you're helping them build that healthy foundation and that you're talking about this mindset shift that in— because so often we're thinking of, oh, you know, like, I know when I was in my 20s and 30s, I never thought I would be in menopause. You know, you just don't think about it.

Oh no, that's like a million years away. Yeah, exactly. I was the same, totally the same.

But now that we're here, we're like, wait a minute, this— we've got the rest of our lives and we have so much opportunity to prevent health issues because solving the gut microbiome also helps prevent dementia, heart disease, cancer, kidney issues, right? It's like all the things are prevented by healing your gut. So we might as well start now. And if you don't mind, Cynthia, I would love, you know, I like to specialize in helping women with their vaginal health. And so I've been reading the research that's connecting the gut microbiome to the vaginal microbiome. And we also know that in— with menopause, perimenopause, and menopause, estrogen drops in the vagina. And what happens then is that as the estrogen drops in the vagina, the healthy vaginal microbiome goes down, and women become more susceptible to vaginal infections let alone bladder infections. And this is not getting enough attention either. And it's related to their gut health.

Yeah, it's interesting. So, genitourinary syndrome of menopause, which I did not name, that whole mouthful, that can occur after lactating. I mean, there can be other times. Sometimes women develop these symptoms when they're on oral contraceptives because their hormones are kept really low. But what's interesting is, as estradiol declines, it impacts the healthy lactobacilli of the vaginal microbiome. And so, what can happen is, you get alterations in pH, you are more likely to, to experience waking up at night to pee, you are more likely to experience pelvic floor issues, you are more likely to have chronic urinary tract infections. If you're sexually active and maybe you're single, you may be more susceptible to STDs. Well, we used to call them STDs, now they're STIs, sexually transmitted infections, including HPV, HPV, and even HIV, which I was shocked when I read that. But the point of why I think this is so significant is that the restoration of the vaginal microbiome is deeply interconnected to the health of the gut microbiome. And so I remind women that we know that, you know, transdermal estradiol, if we look at the— I almost said the oral microbiome— we look at the gut microbiome before perimenopause, in menopause, or in postmenopause, the women in postmenopause and pre-perimenopause, their microbiomes can resemble one another with the addition of transdermal estrogen and progesterone therapy. And so, I really think that part of the restoration of the vaginal microbiome really has to be starting hormones earlier. It's also speaking specifically to vaginal estradiol plus or minus DHEA and testosterone, which can improve the quality of the muscular layer of the vagina. I think a lot of people forget this. And so, you know, it's, it's not a question of if, but when. We will ultimately all develop genitourinary syndrome of menopause. I think it's almost like 90%. But what's interesting is we know just plain vaginal estrogen can reduce urinary tract infections by 70%. Not to mention the fact how many little old ladies did I see in the hospital who became uroseptic, which means they had a urinary tract infection. This can also happen to men, but more common in women. And it gets systemic, so it gets into their bloodstream. They can be very sick. Sometimes they can even die depending on their immune status and how healthy they are overall. And I'm like, you don't want to see Grandma in the ICU because she had a uroseptic infection. I mean, that's terrible. So I think that we know it can be preventative for UTIs. It can also be important for pelvic floor health. I think many women just take for granted they have vaginal prolapse, rectal prolapse, Uterine prolapse. I mean, you can have all three, you can have one at a time, just depending on, you know, your own physiology and your anatomy. Pushing babies out through the vaginal canal can certainly contribute to that. Plenty of people that have had C-sections can also experience that. And so I think it really speaks to— we think of the digestive system as one big tube, but it starts in the mouth and it ends in, you know, the colon and the rectum. But the vaginal microbiome is such close proximity. And I would make the argument that the oral microbiome is equally important. People think it's not a big deal, they're getting cavities, that they have a lot of plaque, um, that they're dealing with periodontal disease. I mean, that is like a mini ecosystem for the entire body. And so I always go back humbly and say, listen, you know, whether it's probiotic toothpaste, whether it's tongue scraping, I mean, there's so many things you can do about the oral microbiome. Obviously, um, I used to be one of those people when I was in the hospital. I didn't drink coffee or tea. I chewed gum because I We go into a patient's room and you smell a lot of horrible things in a hospital. And I accepted that, but I would chew gum because that would be a distraction for me. And when I kind of left traditional allopathic medicine 10 years ago, I stopped chewing gum very often. And I had a guest on the podcast and she was talking about how gum in and of itself alters the pH, changes the microbiome. And I was like, oh my God. And then we're swallowing the, the gum, not the gum itself, but swallowing our saliva as we're doing that. And I was like, I wonder how many people if it's not, if it's not, you know, crappy toothpaste or chewing gum, anything that's altering the oral microbiome or even mouthwash. And we know nitric oxide production goes down as estrogen declines. And I know that's a whole other tangential conversation. But from my perspective, there's just a lot of interconnectedness in the body that when I was training, we had everything very siloed, like this is the genitourinary system and this is the circulatory system and this is the digestive system and they don't really interface with one another. And now we realize like how foolish we were that they all— it's all interconnected. It's all, you know, it's all communicating with one another all the time. So if you have one system that's not functioning well, it probably is making it harder for other systems to not function as well.

Absolutely. It is. It is so important to realize that. And, and it's true. It's this illusion in, in the way the medical system is set up, that you go to the dentist for your mouth and you go to the gynecologist for the vagina, and then you're like, wait a minute. And so you might be experiencing issues in different locations, but they're actually interrelated. And to be able to see that just, first of all, is mind-blowing, but then it opens up the possibilities because then that's when we as practitioners of functional medicine or integrative medicine, we get to see, wow, that means that if we help heal your gut, we can have this wide influence over your whole health. And so we end up seeing transformations where women's whole health gets better. It just gives me goosebumps talking about it. But maybe you can share— I mean, your case is already an amazing example of you healing from what you went through. But do you have— what other cases do you like to share of what happens when we actually get to address these things?

Yeah, you know, we used blinded case studies. So for any of my patients, if they think that I wrote about them in the book, I did not pick any one person. It was, it was taking several people together and making sure the name was changed so that everyone's anonymity was protected. But I talk a lot about women who, you know, whether it's they were treated for chronic Lyme, the county that I lived in for many, many years is endemic for Lyme. It's like the number one case in our entire state of Virginia. And how many women were on chronic Lyme, you know, antibiotic therapy appropriately so And working with a Lyme literate doctor, uh, or practitioner and having to like, what do we do to help restore the microbiome after they're done with antibiotics? And so specific protocols that I kind of put together intuitively at the time, I didn't even realize why, but it makes sense now. But specific interventions for those that have been on appropriately dosed antibiotic therapy, obviously I have used a lot of these, um, you know, people that had just terrible chronic diarrhea and had you know, had been seriously worked up. And let me be really clear, anyone that I'm working with, if there are any red flags that come up, they're always referred back to kind of conventional medicine to make sure there's nothing that's being missed. But someone who had dealt with, I don't know, 10+ years of chronic diarrhea, had been told it was just IBS. And I said, well, if you look at the research on IBS, a lot of IBS is literally food sensitivity issues. And so we did a very targeted elimination diet. Added more fiber into her diet slowly because fiber sometimes, especially for people that have been avoiding it, um, and we talked about, you know, FODMAP foods because she was convinced that was what was making things worse. It actually wasn't. But what was interesting is with a targeted elimination, with introductions of fiber, with a lot of digestive fire support— so when I say just digestive fire, we're talking about hydrochloric acid, digestive enzymes, TUDCA, which is one of my favorite supplements. And then getting very clear and granular about once we have stabilized the micro— stabilized your symptoms, then we dig a little deeper. It's like peeling back an onion. We're like, okay, now we look a little more deeply. And so, you know, did we need to be conscientious about keystone bacteria? Did we have dysbiotic organisms that we needed to address? Did we have issues with like chronic inflammation that, you know, we've ruled out more serious things? And I think this woman in particular that I'm thinking of had been scoped both an endoscopy and colonoscopy. Ascobee to make sure there wasn't something latent. Thankfully not. But we got her back to a point where she no longer had diarrhea. And this is a huge quality of life thing for people. I think this is one thing that I think many people forget is that if you have chronic diarrhea, that is as bad as chronic constipation for a lot of people. But like, they don't want to leave their houses, they don't want to go to social events, they don't want to attend their kids' sports event, they don't want to, you know, go anywhere where they're not in close proximity to a bathroom. So for her to be freed to be able to engage in her personal life, I think was probably her biggest shine. But then, you know, also transparently, I've had some crazy things that have happened. I had plenty of people when I lived in Northern Virginia that travel the world and, you know, you would pick up just weird pathogens and you're like, wow, well, now we need to technically, technically now we do need to— this is clinically indicated, like you do now need to see infectious disease. You do actually now need maybe one one dose of antibiotics, like for Giardia, um, things like that, where they get brisk improvement in symptomatology. And then we make sure nothing else is going on. But I mean, it runs the gamut. For most of these people, it was like quality of life things that had changed. As you change and improve the gut microbiome, suddenly they're sleeping better, they're managing their stress better. And I know we didn't talk about the vagus nerve, but it's a superhighway between the gut and the brain. So if the gut is inflamed, the brain will be inflamed. If you have leaky gut, you very likely have leaky brain. It also means that, you know, for a lot of these people, that maybe it isn't that they have low hormones that's driving their mood disorders, their anxiety, depression. Maybe it's a direct reflection of the health of the microbiome. And so people that had significant mental health issues that felt tremendous improvement, that as we were working through protocols, they were getting tremendous improvement in their symptoms. And that's not to suggest— there are definitely women that would benefit from antidepressant therapy, anti-anxiety meds, plus HRT, plus gut health-related check-ins. But I think for every person, it's very much this n of 1. You know, what I found for many women was perimenopause seemed to magnify a lot of the mood disorders, and then as they transition into menopause, many of them, that would kind of quiet down. I think anyone that has bad PMS or PMDD, they're going to be people that I'm going to be watching more closely for worsening mood issues as they're navigating a decline or alterations in hormones. And again, sometimes it improves when, you know, they, they get to a point where their hormones are no longer fluctuating as much as they once had been.

Absolutely. And it's so important to— there's another connection, right? The more we heal the gut, the more it can help with mood and mood changes, and let alone focus and sleep, like you're saying. Thank you so much for sharing, well, everything we've been talking about. So insightful and so much, even you can imagine in your book, even more than what you've been able to tell us in this, in this amount of time. So I want to make sure everybody knows about and goes to get the Menopause Gut book, because to me it's, it's essential learning for any woman who's either preparing for menopause or going through menopause, or even if you're It was interesting, Cynthia, because I was talking to my mom who's in her 80s, and she's like, why is everyone talking about menopause? And she's like, I'm in my 80s, it doesn't matter to me anymore. And I'm like, you're in menopause, right?

Right. Well, and that's the big thing is that I'd say if you're north of 35, this is a book for you to read. And the other thing is, you know, we have presale bonuses, like bonuses you actually want. No one wants another pantry guide. No one wants more recipes. And so we were very thoughtfully put these together. And so we'll actually extend the presale bonuses to the week after publication. So we'll extend them into May because the people that have picked them up, we've gotten such great feedback. We really tried to poll my community to see what would you find to be valuable. And so, you know, for your listeners that purchase either presale or within that first week, they can certainly get access to the bonuses as well.

Oh, thank you so much. That's so amazing. And I can't wait for everyone to have this information and to get those bonuses. Just as a— even if anyone could say, like, what would be even one tip you might have for people who are like, hey, you know, there's so— it's such a big topic and there's so much you can do to heal your gut and it's going to take time. But I'm curious, like, what you might say if people were like a surprising nutritional tip that you're like, you know, because they— people think, oh, should I have more fermented foods? Should I— what if you were to pick one thing for people to focus on as just a starting tip as they read your book? What would—

Yeah, such a great question. I would say number one, like, track your macros. So, because it— that is through awareness we can figure out, are you eating enough protein? Are you eating enough fiber? And here's the thing, if you look at the research, it'll tell you 25 to 30 grams a day. Not everyone tolerates that. I have some patients that can do 50. I have some patients who are eating a standard American diet, maybe when they first see me, but not now. Maybe they're having 5 to 10 grams a day. So It's with awareness that you can then start making some improvements. So if you're having 10 grams of fiber a day, maybe we put you to 12. And so that's like a micro— excuse me, a micro change that can have a big impact over time. Because as those hormones are declining, there's a lot of things that change in the microbiome. Because fiber is something that is fermented in the colon and has a lot of really important properties— anti-inflammatory, endogenous GLP-1 regulation, helps with the biggest lining, one, um, short-chain fatty acid can actually diffuse across the blood-brain barrier, and that's butyrate. And so really kind of cool thing. So I would say biggest nutritional lever you can pull is being aware of how much protein you're consuming, and then secondary to that, figuring out your fiber intake and slowly increasing it, because you can't go from 10 grams to 30. Your microbes cannot acclimate that quickly. They're very smart, Um, but they need a little bit of tincture of time, and that's where I think going from 10 to 12, 12 to 15, etc., etc., can have a large net impact.

And I find that it's like each individual's body has a preferred type of fiber. Do you see that too? Like, you kind of have to play with it a little and see which fiber is best for your body.

Yeah, I mean, people sometimes will ask, like, soluble versus insoluble versus resistant starch, and I'm like, just Eat more fiber. Like, I think if we get so riddled in confusion around soy, I'm like, have some beans. Like, that will give you soluble and insoluble fiber. Don't stress about it too much. Just eat more. And so I, I think that one of my biggest tips that I generally recommend when people say I don't tolerate a lot of fiber, I'm like, a tablespoon of fresh ground chia flax and fresh ground chia seeds in a smoothie. It's a good amount of plant-based protein, which I don't normally say that, but I think it's a reasonable amount of plant-based protein. And it's also going to give you kind of a gentle fiber as opposed to you try to eat 2 cups of Brussels sprouts. Sometimes that will really bloat people and make them feel like they— I was telling someone on another podcast, artichokes are one of my favorite things to eat, but we jokingly call them fartichokes. Sometimes fiber will ferment and it makes us gassy. And that's not totally unexpected.

Yeah, it's like, how do you find that perfect amount where you get just enough to feed the bacteria? But if you start getting extra bloating or farting or gas, then you know you overfed them.

Or it might just be too much too quickly. So I always say, like, that doesn't mean that you failed, it just means that's valuable information. And maybe next time you eat half the amount and then slowly kind of build up. Because what happens is sometimes when people have not been able to tolerate a lot of fibrous foods they just totally cut them out of their diet, which can kill off beneficial keystone bacteria. And yet, if you don't give your body fiber, it will ferment protein, and that's bad. Like, putrefaction is not what we're aiming for. Um, I just had a really interesting conversation with a microbiome researcher, and she was saying at the very tail end of the conversation, what happens in a lot of these carnivore diets, although they can be therapeutic short-term, let me be very clear about that, But if you're doing that for, you know, a year, 2 years, 3 years plus, what can happen is you end up starving off healthy keystone bacteria. And if you have no fiber in your diet, your body will actually try to ferment the protein. And as you can imagine, putrefaction is not a good thing.

Right, right. Oh my gosh, that's so such good tips. And, and I know you have so many more tips in your book, in your bonuses, and, and in the programs that you offer through your clinic as well.

Thank you. Yeah, I'm really excited. I feel like this book is a true labor of love, a love letter to women. It's the book I wish I had, you know, 10+ years ago. It would have saved me a lot of headaches and a lot of, you know, when I say the word suffering, I mean suffering in the sense of trying to figure out what's going on with your body, not suffering at a significant level, but just the frustration that I think many women experience.

And that's a beautiful reason to write a book so you can share that wisdom and so we can all learn from each other and, and feel better through our lives and improving. That's the thing, right? We want to improve our health and our longevity overall.

Absolutely.

Thank you again so much for being here today, Cynthia. It's such a joy to get to connect with you again. And I'm so happy for you with this Menopause Gut book. Congratulations from all of us here at How Humans Heal.

Thank you, Doni. Always a pleasure to connect with you.

And thanks everyone for listening in. Be sure to look for the links down below to find more information and to reach out to Cynthia Thurlow. And if you are new to How Humans Heal, then I welcome you to subscribe and join me so you don't miss the next episode. I'll see you all soon. Thanks for listening to How Humans Heal. If you liked this episode, leave a rating and a review. And for more resources, visit drdoni.com.