Menopause and the gut with Cynthia Thurlow

Welcome to Living Light Metabolic Coach. In today's interview with Cynthia Thurlow, I have a chance to unpack the menopause gut. As women go through menopause, there are some major changes that take place in their hormones, and there's equally major changes that take place in the gut. And this could be a hidden source of many of the challenges that women might be facing. So if you're somebody who is in perimenopause, menopause, or even postmenopause, this interview is gonna be very enlightening. Cynthia and I talk about some of the emotional shifts that take place and the catalysts that can cause emotional shifts in our bodies and especially in the gut. We talk about what lab testing would be appropriate if you're struggling with some of the symptoms of menopause and what you can actually do about it. We had a great conversation and I know you're gonna find this really powerful and impactful and very actionable for yourself. If you're not going through menopause, I'm sure you know someone who is. So please feel free to share this interview because I feel like every woman needs to hear this. Enjoy my interview with Cynthia Thurlow. Welcome Cynthia. Thank you for being here today.

Thank you, Sachin. I've been looking forward to connecting with you and your community.

Yeah, I'm really excited cuz you've got, and I'm sure you're really excited because you've got a new book out and it's called The Menopause Gut. It's coming out here pretty soon and I'm thrilled to be able to share your knowledge and your expertise with our community and our listeners because not only have you written the book about this, but you yourself have a podcast and you've interviewed hundreds and hundreds of experts from all over the world. And I know that there's probably a p— a little piece of each of them in what you now teach and train, and of course in your book. So, uh, tell us before we dive deep into this topic, you know, what inspired you to write this book and, and do the work that you do?

Yeah, I mean, I think for the last 10 years I've been myopically focused on women in perimenopause and menopause. And so in a in a vain effort to better understand the changes, the experiences, the labs, the symptoms that women experience, I think the podcast has really served as not just a teaching environment for my community, but also myself. And so every guest that comes on, because I believe in being a lifelong learner, always forces me to think about the world a little differently. And so there was definitely a constellation of specific guests over the past 2 years that kind of gave me new insights into the gut microbiome. And so obviously I've been doing a lot of diagnostic testing and working with women at this stage of life. And I recall my editor reached out to me and said, hey, do you think you have another book in you? And I've been saying no all the way along. No, no, no, no, no. And then in 2024, I said, you know, I've got an idea, but I don't know how well it's going to land. And I said, what if we choose to talk about the changes in the gut microbiome vis-à-vis these alterations in neurotransmitters, hormones, etc., and the research around all of that. Because every time I interview a new researcher, I'm like, oh my gosh, I hadn't thought about that. And so this book really is a synthesis of what I have learned clinically over the past 10 years, and then also the research of these incredible individuals that I've had the honor of interviewing, and then also kind of interplaying it with experiences I've had clinically working with patients and then myself. I mean, I really start the book out talking about my romantic trip to Morocco that ended up, you know, landing me in the hospital a few months later. And so it really helped me understand my physiology. How could I end up in the same place as my husband eating the same food, and one of us got sick, very sick, and the other one did not? And so I then kind of view everything differently through that lens of understanding what's changing in the gut microbiome that impacts immune function, our reproductive health, etc., and wanting it to be a useful tool. Like, ultimately, I always say, like, my platform is to educate, inspire, and empower women. And really using this book as an opportunity to educate other clinicians, but also, you know, the lay public and patients as well. Because I always say, this is the book I wish I'd had 12 years ago because it would have saved me a lot of challenging thought processes because 10 years ago, quite transparently, Sachin, no one was talking about perimenopause and menopause. I mean, 8 years ago, I did a TED Talk on perimenopause. And I remember at that time, there were 4, 1, 2, 3, 4 talks on menopause. So, I was green-lighted to do a talk on perimenopause because no one had done that. And I think that really speaks to the time that that we were, you know, 8 years ago, 10 years ago. I think there's this evolution now. There's a desire for women to better understand their physiology, how to support their bodies, how to thrive in middle age and not just survive. Because transparently, a lot of women have been gaslit. And I think this is an opportunity to help them feel empowered and not frightened about what's to come. Or, you know, we can find the reframe and say, what are the things we can celebrate about the aging process instead of looking at it as being a negative thing?

Yeah, that makes a lot of sense because from what I understand, there's no like ICD-9 code for perimenopause or menopause. And so when we go to the doctor, they're trying to put us into a box, right? With this constellation of different symptoms we have, and they just may associate it to the natural aging process, but everyone's experience is a little bit different and some people may have very, you know, minor symptoms or no symptoms at all, which I believe is kind of the, the normal way of going through it.. And then some people completely, you know, is an upheaval to their life and creates some major changes in the way they function and go through the world. I'm curious, like, what was the most shocking thing that you learned in this process? What was the, what's the thing that kind of made you gasp and be like, oh my God, like everyone needs to know this?

I think the research around trauma and stress and how that ages our ovaries. That to me was shocking. And I thought to myself, you know, when I trained in inner city Baltimore, where arguably anyone that lives in the United States knows that Baltimore is like number one for, I mean, a constellation of social issues, including, you know, when I trained it was heroin, now it's fentanyl overdoses, teen pregnancy, syphilis rates. I mean, it's kind of like all of the poor choices of man all incorporated in one city. But it was such a gift to train there because I was exposed to so many things as someone who'd never lived in a city, so many big T trauma things that it left me with an indelible impression. But I think what I was trained around was this big T trauma, the concept around rape and suicide and homicide. And yet little t trauma is, I would argue, is equally insidious and pervasive and corrosive. And how, at least from my generation, so many of us grew up with quite a bit of childhood trauma and how that influences not just our risk for autoimmune conditions, metabolic health, and other things. So I was frankly shocked when I started really digging into the research and really understanding constellations of issues that I saw patients dealing with, because I look at perimenopause and menopause as a litmus test It's a litmus test for how well we take care of ourselves. And when I'm talking about taking care of ourselves, I'm not talking about per se the going to the gym and eating nutrient-dense foods. I'm talking emotional health. I'm talking spiritual health. Because when you have those decline in hormones and neurotransmitters, and in many women it pulls your mask off. Like maybe you've been able to achieve, achieve, achieve, be really successful, and then you get to middle age, and all of a sudden you're like, well, wait a minute, everything that makes sense in my life no longer makes sense. Uh, everything that I believe to be true no longer feels true intrinsically. And so I look at it as an incredible opportunity for growth. And I'm really speaking to that emotional, spiritual growth. And I think it allows women to have newfound clarity because with those changes in hormones, for so many of us, we go from being big people pleasers, which is what allowed me to be extremely successful. As a human being to being someone that is no longer a people pleaser and now actually speaks from a place of continued authenticity, but does things purely based on what's ultimately the right choice, not necessarily like pleasing everyone around me and subjugating my own needs, but now advocating. And so that's a lot of the work that I help women with, is helping them find their voices in a way that is not per se disruptive, depending on who their loved ones are, but I think for many, they feel much more grounded, comfortable, accepting of where they are, and just much more peaceful and happy. And I think that is the differentiator. I think there's a degree of physicality forced upon us as we're aging. Like, you know, the social media can be cruel and the media can be cruel and other humans can just be cruel. And I'm like, if you are centered, grounded, and happy with where you are, it's like there's a lot less focus on the physicality piece. And suddenly people are like, I feel— finally feel like I know myself. I feel so grounded and so peaceful and so happy. But that chronic stress and trauma piece, I was shocked by. When I tell you, like, I literally— I think I had to take a day just to process everything that I was reading because I was so shocked. Uh, and, and quite honestly, not, not enough people are talking about this.

Well, thank you for sharing that. And, you know, not an easy topic to unpack. And I think there's, and I'm, I'm here more to learn than to talk. So I just want to share this and plant this seed and maybe we can unpack it. But, you know, when there's big T trauma, it's usually not, not always the case, but it's usually maybe an isolated incident. Right, that we kind of maybe keep replaying or reliving in our heads and in our bodies, of course. And then there's the little t trauma, which can be a death by a thousand cuts. Yes. Right. And, and that often we sweep under the rug and we might not think it's a big deal. And so some people might think, well, I don't— I wasn't, you know, sexually assaulted or I didn't have a tragedy in my life, so I don't have any trauma. But then they've got like a thousand other things that are just eating away at them. And, you know, cortisol is corrosive, as I say, and just surging through their veins constantly throughout the day. And from what I understand, and, and please correct me if I'm wrong or, or, you know, guide me in the right direction here, but really the state of our adrenals is what determines the, the transition that we go through in menopause. So if we're just like burnt out or, or, you know, on fire, so to speak, then that's gonna really determine how we navigate this time of our lives. Is, is that accurate or is that what you found?

No, I think it's absolutely accurate. And for listeners, to give them some sense, like when we're looking at little t trauma, it could be just neglect. It could be maybe you had a parent that had a substance abuse problem, or you grew up with a parent with a personality disorder, or there was verbal abuse but not physical abuse, which again can be the death by a thousand cuts, or bullying. And certainly there are more— there are people that are more sensitive to these things. And I'm an empath, so I absorbed everything I grew up within. But what I find is really interesting is that when you talk about adrenal glands and helping women understand as progesterone is declining, your adrenal glands really become that main quarterback of hormone support. And so, this is why when I say the things that got you to where you are are not going to get you to the next level, it is really understanding that your 20s and your 30s when you don't get enough sleep and maybe your nutrition isn't on key and maybe you're not getting enough exercise and you know, maybe you work in a busy hospital where you're up, you know, you're working shift work, or you work in an environment where it's unpredictable and stressful. Your body weathers that better until you get into this transitional point in your life where the lack of sleep, the lack of stress management, the not dialed-in nutrition, the plus or minus too much exercise or too little can be what helps you unwind. And when I say unwind, I mean that those those adaptive patterns that have allowed you to be successful despite your experiences start to unwind, they then become maladaptive. I'll give you an example. How many of my patients are Orange Theory Fitness, CrossFitters, you know, they're very physically active. They realize as they start getting into their late 30s, early 40s, that all of a sudden they don't recover as well, they don't sleep as well, they can't manage their stress as well. And so those adaptive patterns then become maladaptive. And so, as our physiology is changing, we are best served by adapting. This doesn't mean that we're throwing in the towel and we're accepting. It just means you're adapting to your physiology because you can still work out intensely, but it's shorter little bursts of training. It's, you know, more restorative work. It is more downtime. It is more parasympathetic work. And as, you know, a reformed people pleaser and hardcore type A person that lived on adrenaline for years and years and years, That took a lot to process. And I know many of my patients struggle with that as well, because you're essentially saying, like, everything that got me to where I am is no longer an effective strategy. I don't know how to make sense of what to do next. Like, I'll give you an example. Probably 12 years ago, I was so burned out physically and probably fried emotionally that I didn't go to the gym for a year. All I did was walk outside. That's all I did for an entire year, because every time I would push the exercise, I would get more depleted and more tired. And so it was my body's way of kind of forcing me to recalibrate. And so that's a lot of the work that I do now is helping women understand, like, there's a point to which you push yourself. It's all about hormesis, beneficial stress in the right amount at the right time. But so many of us have been, you know, 180 degrees, you know, going 1,000 miles a minute for years that it feels like you have lost yourself through the process of navigating this menopause, this kind of perimenopausal transition. And so I think for a lot of women, there's a lot of resonance because they're like, that's exactly what I'm experiencing, but no one's actually talked to me about it. They just tell me, do less exercise, eat more carbohydrates because you aren't eating enough carbs, eat more protein, maybe add some fiber in, try to sleep more. And then they're just like, there's too many things to change. How do I even know where to start? And so I always say starting with sleep is, the first thing to focus in on. And I always jokingly say, show me a woman who doesn't sleep well and show me a woman who doesn't manage her stress, because they're so intertwined. And so it really becomes apparent. That's why I use it as— it's the litmus test of life. How we take care of ourselves really shows up in middle age.

Yeah, I think I wrote about this like maybe like 4 or 5 years ago. I'm 48 now. And, you know, when I see some of my friends who I haven't seen in years, and maybe this, the same applies for you, like you can tell who's doing the work and who isn't. And I feel like that gets really amplified in these middle, mid-forties. And as we approach into the fifties, and it's really a blessing for some people if they take it that way, that now their body is communicating to them that, Hey, something needs to change. And a lot of times, you know, less is more. So I mean, more sleep is, is less work, right? You just gotta lay there and hopefully you can fall asleep and sleep through the night. And sometimes people are reluctant to hear that. They don't want to hear that they need to sleep more, or instead of going for this intense exercise session that they just need to go for a walk in the woods. I remember working with a client, a friend of mine, she had worked with us a few years prior and then she started this whole like morning running thing and she would post a picture of her sweaty face after she was done exercising. And really she was going for a run in the morning. And so she would put on her sunglasses, she'd have her hat on, and then she'd put on her AirPods listening to rock music and going for a run in her neighborhood. And so a month later I asked her, hey, like, you know, how's it going? And she's like, this sucks. Like, I'm actually gaining weight. I feel terrible. I feel like I haven't made any progress. And I said, well, let me make a suggestion to you. And are you coachable? And she said yes. And I said, well, let's take off the sunglasses. Let's take out the AirPods. Listen to the sounds of the birds. Get the sun in your eyes. Go for a walk, right? Preferably in nature so that your body feels safe and your nervous system feels safe. Instead of listening to music that's tuned to all the wrong frequencies, you're blocking out the sun's, you know, hormonal signaling system and you're just putting yourself into a state of fight or flight. And when she did that, just that simple change, the weight started coming off naturally. She had way more energy. She was actually sleeping better and all of her cravings disappeared of, you know, sugary and fatty foods that, and then salty foods that, you know, were holding her back. And, and so less, less can be more. And I'm curious as to what your theory is on why people resist those simple changes. That can help them so much?

Oh, why do they resist it? I think that change is hard. And I think if people have found particular strategies, I'll use common examples that I see. If a little bit of exercise is good, more is better. If a little bit of fasting is good, more is better. If a little bit of carbohydrate restriction is good, more is better. And so women have kind of gotten it into their mindset that they have to take everything to the extreme. So I think it's partly human nature, but I also think it's fear. It's fear of the unknown. Like, maybe this might work, but I know if I continue doing this, I'm gonna force that to work. So it's like that ease of forcing an outcome. And we were talking about this before we started recording, that being unattached to outcome is the biggest flex right now. Just accepting that maybe doing something different is the most important thing you could be doing And when women come to me, more often than not, I'm telling them to back off on fasting. I'm telling them to back off on the intense exercise. I'm telling them to eat more protein and more carbs, as an example. I'm encouraging them to connect to nature, just like you were saying. Like, your body starts to crave it. Like, we have a whole, you know, like most families, we have a whole mindset around morning routines, and it involves being outside with our dogs We live in a very hilly part of our state. There's a lot of nature that we see every morning, and that's just part of, like, the process before we even get into work, before we shower, before we even exercise. That's just part of what we do, and I crave it. Like, when I'm traveling, I crave that. So to your point about suggesting to your friend to do less, it is almost anti— and I live in the United States— it's almost anti-American to do less because we're always taught to do And so, I think that it's finding that reframe about middle age is, again, embracing your physiology, but also understanding that sometimes the best thing you can do is to do a lot less, make it less complicated. Like, I think about when I was a new nurse practitioner 1,000 years ago, and I would make these very long lists for my cardiology patients. I would tell them all the things I talked about. And then I can imagine how overwhelming that was for them to leave clinic with a long list of things to do. Whereas now when I talk to patients, I give them 1 or 2 tangible things because less is more. It's also easier to continue making, making small changes if they're achievable, not if you give them a laundry list of 25 things with subcategories. I used to have subcategory A, B, and C. Sachin, I'm not kidding. It was so well-intentioned, but now I cringe thinking about that. Whereas now I'll tell women, I want you to take 4 to 5 deep breaths before you eat a meal. And they're like, you want me just to do that? Yes. That's the first thing I want you to try to go to bed 30 minutes earlier, like something that simple. So less is indeed more. And I think that is the ultimate flex when you, when you have that realization, because so many people, whether it's a trauma response or it is just the way that they've wired their mindset, they're, they, they struggle with making changes. That's number one. And then number 2, they start to doubt themselves. And once that process starts, they get into analysis paralysis. And this is where adaptive patterns from the past become maladaptive patterns of our present and future. And so I think a lot of these women, they just, they really lack, they lack confidence in making those changes, even though we're encouraging them lovingly and explaining why. I always say, if I can understand the why, I can wrap my head around just about anything. But I think for so many of these women, it's just hard. Like, change is hard, and we don't acknowledge that. I think sometimes there are those of us that change almost feels easy, and it's not that it's easy. We just have to find the reframe in our brain of why we're doing something differently. But I think some people need a little bit more, a little bit more time to be able to do that than others. I don't know if that's been your experience clinically as well.

Yeah, you know what? I sometimes will do the same thing that you described yourself doing many years ago. And I, I still find myself as you're saying that, I'm like, oh, that's me. I might be overwhelming people because we want what we have for ourselves. We want it for them. And sometimes I'm like, well, they're paying me, so I should help them achieve that as quickly as possible. But if they're in a state of overwhelm or they're emotionally maladapted, or maybe they've tried a lot of different things and, or maybe they're type A and they just go like, you know, they're gonna push themselves too hard and, and that could potentially backfire. So I'm definitely guilty of that.

Oh, I think we all are well-intentioned. Of course I do. I, I'm guilty of that myself.

So, so, you know, tying this all to the gut, stress and the gut go hand in hand and people may not necessarily understand that connection, but you know, one of the concepts that we talk about and maybe you call it something different, but is autonomic pairing. And when the nervous system is mismatched from the task, then that's where dysfunction takes place. So you talked about taking a few deep breaths before having a meal because eating is a rest and digest activity. But if we're stuck in fight or flight, then we're not even sending blood flow, adequate blood flow to that region to perform its function. And one thing I tell my clients is that don't eat until you salivate first. So it's kind of like going through a car wash, you know, if there's no water running in the car wash, you're gonna destroy your paint. If you just go through it, the brushes are just gonna scratch up the paint. But if there's water and there's soap and lubricants and all that stuff, then you're gonna get a good car wash. And an outward sign that we're ready to eat and in that parasympathetic state is we have saliva production taking place. So it's like, clues us in into the fact that our body is ready. So I'm curious as to what are some of the outward signs that someone might experience, women in particular, because obviously I'm not a woman and I want you to speak from your experience, but what are some of the signs that we're kind of stuck in that fight or flight pattern or that we have this autonomic mismatch taking place?

Yeah. I mean, I love the idea of saliva. I have a, I'll just interject this because I think it's funny. I have a, I have a Bernedoodle puppy. And this Bernedoodle puppy, because he has jowls, as soon as he thinks he's going to eat, I mean, the amount of saliva that drops on the floor. My husband and I were like, oh my gosh. And it just made me think about my dog and how his is so over-exaggerated because he's a dog and not a human. Outward signs of cortisol dysregulation. I mean, I think a great deal about, like, it starts— if we're thinking top down, it's sleep disturbances. It is anxiety and depression. It can be, you know, digestive issues. It can run the gamut from bloating, constipation, diarrhea, depending on your predilection. It can be reflux. It can be feeling like you have food stuck in your esophagus, which a lot of my patients, they would be so— they'd be rushing to eat that they wouldn't even properly chew their food. It can certainly show up as skin manifestations. Like, it can run the gamut from psoriasis, eczema, hives, the whole constellation. If you're still getting a menstrual cycle, it can involve your alterations in your menstrual cycle either being too short, too long, too in between, too heavy. Also, just thinking thoughtfully about— people will describe the sensation of feeling like their food just doesn't sit. It sits too long in the digestive system. And I can physiologically explain why that's happening in middle age. But women that are in a— not in a— they're in that kind of, um, being chased by a saber-toothed tiger, not only are they not going to be in the parasympathetic, but they're not going to be able to secrete enough hydrochloric acid to break down protein. Their digestive enzymes will be inhibited. They probably won't be able to break down and emulsify fat, so they may be fat malabsorbed. And so They may feel like their food is sitting in their digestive system a whole lot longer. You know, again, it goes back to the alterations between constipation and diarrhea depending on the individual, or having a frequency or urgency to have to go to the bathroom immediately after eating. That is not normal. Those are the most common things that I typically see. Obviously, with prolonged stress, you get catabolism of muscle, so you got muscle breakdown. You can lose your hair. You can stop having a menstrual cycle entirely. I think for a lot of individuals, their chronic, you know, lack of parasympathetic can show up in their sleep. So I always say, you know, that sleep piece, it's again, another litmus test that I get. Not recovering from workouts. I mean, it's the domino effect. It can go just on and on and on. But most often people will say weight loss resistance. Abdominal, you know, truncal obesity, so more abdominal accumulation because we have more cortisol receptors there, alterations in digestion, and then just an inability to be able to focus because their prefrontal cortex has been overridden by their amygdala, which is their kind of lizard primitive brain. But that's because your body perceives that you are under threat and duress, and so it doesn't allow you to multitask. Maybe that's not a bad thing. But it also doesn't allow you to— depending on the individual, some people can't manage or regulate their emotions very well. So this is when I use the pandemic as a great example. When people were stressed and they couldn't regulate their emotions, they were sometimes saying and doing things they otherwise would not have been doing. So I always look at behavioral patterns as a good indicator. If someone can't follow directions, um, especially when we have intake forms and it's very clear about what they need to do in order to book an appointment, and, you know, they've skipped over 5 5 things they need to do and they jump to the end because they're just anxious to, to be a patient. So I think it's a constellation, as unique as we are, but for each one of us there's probably a pattern. Like for me, when I'm stressed, I tend to have digestive issues. I tend to, you know, I, I have to put my blinders on and block everything else out. I get very myopic and focused on one thing. But I think for a lot of individuals, they would say it's a constellation of any of those symptoms that they can experience, as unique as they are.

You know, for people who are in relationships, maybe you can talk a little bit more about how relationships can be impacted, whether it's social relationships or perhaps even equally important or more importantly, personal relationships like marriages or, you know, significant others. Like, how does our relationship with other people change in that when we're in periods of stress like this or transition?

Yeah, I mean, I think sometimes people can still be on their best behavior outside of the house. I think their relationships, their interpersonal, like private relationships can sometimes suffer the most because people let their guard down and they can truly be themselves, or they don't feel like they have to be careful or conscientious with how they choose to speak to their loved ones. I think that it can be corrosive. I think that Sometimes it can be the individuals that they're married to or coupled up with can be a punching bag. I mean, that's certainly something that I experienced as a child with my parents' relationships. And so I think you can see a degree of corrosiveness, toxicity, maybe verbal abuse, hopefully not physical abuse. People may or may not choose to have a physical relationship anymore, so you may see a lack of libido. I mean, that's true, like, extreme stress. When it comes to other interpersonal relationships, maybe outside the house, they may struggle to, you know, again, it's that mood lability. If people are not able to suppress, suppress their amygdala and still use their, their prefrontal cortex, they may not make good decisions. They may get fired from a job, or they may have altercations at work, or they may have road rage, or they might have um, you know, just maladaptive patterns in general. They may just be, you know, coined as difficult or uncooperative or people who can't follow through with directions. Like I mentioned, sometimes we see that on intakes. So I think it very much becomes a trickle-down, but a lot of it has to do with emotional regulation. And so even the most emotionally well-regulated people can have bad days, but people who cannot emotionally regulate in general you're going to see the most severe manifestations of all of these things I just mentioned. These are the people that tend to have a lot of drama. Like, there's no other way to put it. They're tending to be people who, wherever they tend to be, there always tends to be a lot of upheaval. And, and some people thrive on that kind of dynamic. I find that draining. But I say this from personal and professional experience, having family members like this just kind of observing the kind of chronic behavioral patterns. I think another thing, Sachin, that I see with women in particular is if they're chronically stressed, they become chronically busy. So, they can't just come home and relax and sit on the couch, which is probably what they need to do. They're constantly cleaning or they're constantly fidgeting and they're constantly reorganizing things because being idle means they're aware of what's going on. So they need the distraction because they don't want to be reminded of what they're trying to avoid. So it's the whole concept of uncomfortable feelings. That's what I see a lot of. Like, women will explain to me, oh, I don't just sit around. I don't just watch a movie. I don't just go sit outside and observe nature. I don't just, you know, I just don't really— I have trouble relaxing. And so I think that can also be a sign of whether it's a trauma response or again, it's that inability to process those uncomfortable feelings that can be part of chronically overactivated cortisol or sympathetic dominance.

Thank you. How much of that do you think is modeled versus, you know, you talked about how you experienced the punching bag analogy you used. So I'm curious, how much of it do you think is modeled from our mother or mothers in this case for women or even parents? And how much of it do you think is circumstantial in terms of what's going on in their body?

I think there's a nature-nurture aspect, but I think role modeling for children is really insightful. I think it is an unusual child who grows up with a lot of poor emotionally regulated parents that doesn't replicate that in their own home. And I say that from personal experience. I just know that, you know, I have a, I have a group of family members and we're all the same generation, and so we talk openly about some of this emotional regulation and family members and how each one of us has kind of had to navigate having different experiences in our own personal relationships and our own families. But I think most of it is modeled, and it's much easier to model what you grew up in than it is to break that cycle. It's much, much easier because you don't have a, like, a firm kind of sounding board with which to work from. You're just like, okay, I'm, I'm literally walking blindly in a snowstorm. Or I can continue with the patterns that I saw as a child. And what I would invite anyone who's resonating with this conversation to understand is that we may not have control over what happened to us as children. We have tremendous control over what we choose to do with the rest of our lives. And so whether that's in therapy, talk therapy, or other experiences, now there's so many, there's so many somatic therapies, so many options now that people can work through uncomfortable feelings or issues that they had growing up in homes that were not emotionally well-regulated. Because I think that our familial upbringing has a lot to do with our imprinting, but that doesn't have to become our destiny.

I did ayahuasca, it's been about a year now. And what came up for me in the ceremony, because, you know, my father is an amazing father, he's still alive. And there's things that I would change if I could go back in time, but I realize I have an opportunity and that I'm not my father. I can take the attributes that I love about him and really the attributes I want to pass down to the next generation because we have to really see it that way. We're not just raising children, we're raising our grandchildren and great-grandchildren and great-great-grandchildren, all 7 generations down.. And when we do the work to heal ourselves and live in awareness, we can also heal 7 generations back. So what's really cool about working on ourselves is that it has such a huge ripple effect forwards and backwards. So I'm curious, like, what tools you offer your clients or what tools you can offer our audience that can help them become more present? I think that, you know, when we're present to our children, our spouse, or our partners, or even present to ourselves, that's what brings out the best in us. But when we're constantly in fight or flight and our thoughts and mind and body scattered in a million different directions, it's really hard to be in this moment. And I know there is a, right now there's a huge movement towards longevity, which is just this pressure not to die anytime soon, you know, and it takes us away from the present moment, which is where life happens. So what are some tools that people can benefit from or you know, maybe things that you found have worked for you that bring you into this present moment, get your nervous system, you know, into that more parasympathetic state so that you can hold space for yourself and those around you?

That's such a great question, Sachin. I think that what I can say is, if you had asked me 30 years ago, would I ever be a parent, I would have said no, not because I didn't want to be a parent. I was so fearful of recreating what I grew up in. So when I think about the things that have made a big difference in me evolving into a very different type of parent than what I grew up in, number one, my choice of spouse has a lot to do with that because we were very committed to what type of environment we wanted for our children. But I've been in some form of therapy or somatic therapy, or I mean, for 30 years. And every time I, you know, would get triggered by something, I would go back to whatever therapist I was seeing at that time to say, okay, there's some You know, the onion peel has been peeled back another layer. I've got something I need to work on. But from the time that I found out I was pregnant with Jack, who's now 20, I committed myself that I was not going to recreate what I grew up in. And so I did things very differently. I mean, I worked full-time for a very large cardiology practice. I cut my hours back to very part-time. My husband at the time worked for a very large energy company, did a lot of travel. So, it was me and my boys for a lot of the time. It was just the 3 of us during the week. And so, the things that I did was, this is before there were smartphones. So, I was always very present. I was not distracted by my phone. I know obviously now we don't have that same benefit, but, you know, my kids always knew that they were my primary focus. Like, on the days that I was not working, I was taking them to the park and taking them to activities.. And so I did a lot of things as a mom where I got on the floor and I played with them. And this might seem trite to some people, but this is so different than what I experienced growing up. And then also being their fierce advocates, like protected fierce advocates. And even when I got triggered, because I'm not perfect and I have one child who's easy and the other one is not as easy, I'll just put it to you that way so it doesn't sound pejorative. I was like, if I'm getting triggered, what is this saying about me? What is it that I need to work on? So I was constantly iterating on that. I think it's important to have resources and modeling. Like, although my parents were not my role models, I had other friends with kids that were older than mine that I would seek counsel in, and I would talk to openly, like people I felt comfortable, or I could kind of say, this is what I'm thinking, is this normal? And then, you know, they could provide some degree of validation. I also think for me, it was very important that my kids always knew that they were our biggest priority. Like, people will sometimes say it's your relationship with your spouse, and yes, that is, but beyond that, like, they are our biggest priority. So there were sacrifices that we made on every level to make sure that they got the best education and, you know, whatever they were interested in, we had the money to be able to— for them to pursue it, sometimes at the expense of things that we wanted to do as as a couple or as adults. So I think from my perspective, it's not that I have this one kind of catch-all thing that will be insightful for people. It's the knowledge that I did not want to recreate what I grew up in, the continued efforts and work on myself as a human being. And then getting to a point where I could talk openly with my kids, not giving them details, but I'll give you an example. Last summer, we were in Istanbul, all of us, and we're in this amazing restaurant having— I mean, we loved Istanbul, the food, the people, the sights. It was amazing. And my father, who passed away in 2024, came up in conversation, and my older son looked at me and he said, Mom, just stop. He's like, you didn't have good parents, but you and Dad are nothing like your parents. And like, you're, you know, Liam and I have figured out for ourselves, like, we're so fortunate. He's like, I went off to college and I realized how incredibly fortunate I was. Maybe I didn't realize it at the time. And they were having this conversation just about how they acknowledged how differently they grew up than what they had seen, the behavior they had seen amongst my parents and things they had heard from other individuals. So I think the modeling goes both ways, both good and bad. And so my hope and my intent by sharing all this is to say that even if you grew up in a poorly emotionally regulated house where things were not ideal, that doesn't have to be your own destiny if you're willing to put in the work. And it is work. I mean, I'm certainly not perfect, but I acknowledge now that there are many good things that my parents invested in me that allowed me to be incredibly resilient and incredibly hardworking and valuing my education. And those things are— I take from my parents. But the emotional regulation was something that I acknowledged very early on before I even had the words to explain it. The reason why I was incredibly successful in, you know, high school, college, and beyond had a lot to do with the fact I was emotionally regulated. But that was a choice. So a lot of these things are choices that we make. Maybe we don't have the words to fully understand our behavior, but the acknowledgement that it can have a huge imprinting on, you know, how we navigate our lives moving forward.

Yeah. So important. I think that our parents can be a, a source of inspiration of what to do and, and perhaps sometimes what not to do. And we can honor them for, you know, doing their best. I think everyone is doing the best with the information that they're given, but also the nervous system that they were given. And, you know, it sometimes is hard to know where in the lineage that may have come from or what challenges they had to face.. And I think forgiveness can be a very powerful tool and also recognition of, hey, like everyone's doing their best. And if we can use that experience to then do our best and, and sometimes, you know, the pendulum can swing both ways and it seems like it's swinging in the right direction for you and your family. And I know that the blessing that you're offering both you and your husband to your children of how to do it right, you know, how to, and it's not about being perfect. I get that perfection is, can also be very jarring, especially to somebody who's, who's, I'm, I think I'm a type A personality as well. You know, we can go to extremes, but it's beautiful to recognize that, you know, and sometimes we're kind of dealt the right, we're always dealt the things that we can handle, right? God has a way of giving us the things that we can handle and taking, you know, that lead and turning it into gold. And it's beautiful to see what you've done, you know, with all of that experience. And now you're out here helping, you know, literally millions of people. So kudos to your parents for perhaps doing their best and raising you in such a way that allows you to do the work that you do today.

Thank you. And I agree with you that forgiveness piece is important. It's interesting when And I don't share this to sound sad, but in 2024, my dad and I had had this kind of awakening before he got sick and passed away. And I remember feeling so incredibly grateful because there are a lot of people that stay angry with a loved one or someone in their lives. And I can say with certainty that when my dad passed, all of that had kind of been it was water under the bridge. And what's interesting is when someone is gone and I was the one that was given the responsibility of having to go through papers and to find things for my brother and I. And I was saying to my brother that what people choose to keep towards the latter stages of their lives is insightful. And I walked away with such a profound deep empathy for my dad. The more that I uncovered and understood that I was like, all of us are just doing the best that we can with what we have at that moment. And I think had my dad been born in the 1970s or 1980s, I think he probably would have had the support that he probably needed when he was a young man. But back in the 1940s and '50s, there were not the same resources. And so I have tremendous empathy for individuals who feel misunderstood and, and end up developing maladaptive patterns because they just— they're trying to find a solution to a problem. If you have social anxiety, probably back then you might have developed an alcohol problem or some other type of addiction. And so it allows me to view him with great empathy and also clarity. It's like, I understand this so much better. I wish I'd understood it better when I was younger, but I just didn't have the capacity to do that. But I can look at him now and say, you know, when we say our parents do the very best they can with what they have, you have to view it that way. They don't go out of their way just to be spiteful and mean. I think sometimes people just never learn. It's like they never got the training wheels on the bike. They just expected to ride the bike without the training wheels. And so they didn't have the preparation and the time to be able to invest in the good habits. So they're just winging it through parenting and marriage and all sorts of relationships throughout their adult lifetime.

Yeah. And I think for a lot of people who are perhaps our parents' age, it was not really discussed, right? Yeah. It was like kind of swept under the rug and the tools weren't available to them. And, you know, maybe socially it wasn't acceptable to discuss these things and it's like, suck it up, buttercup, is the attitude that a lot of people had to deal with. And, you know, they're, we're all carrying a lot of weight, right? And it's great to, it's great that you had that, that closure, which I think is so, so important because in a, the, the reason is like, I, I think where this conversation is, is really beneficial is because people who are kind of in the middle ages like us are dealing with raising our children, right? Yes. And they're becoming, you know, young adults. And then we're also dealing with parents that might be aging and you're right there in the middle of it all. So it's a lot to process when your body's going through these changes and shifts. And I think a lot of healing and repair can take place if we can heal those relationships. And again, that could go both ways, right? It could be repairing our relationships with our children because maybe we didn't have the tools. I certainly didn't have the tools when my son was born. Fortunately, we had a lot of support, but I didn't have the tools I have now. So I could go back in time. Like, I'm so excited for him to have kids and be a grandparent so that I could, like, do it right, you know, from, from the perspective that I have now. But until then, like, it's, it's important, I think, for all of us, even if you take nothing away from this conversation, to just repair the relationships that you have. And forgiveness is one of those things that can be the most potent medicine for us because it can deal with the big T or the, you know, thousand little T's that we're dealing with along the way. And carrying that in our backpack, so to speak, can be very exhausting, especially when our body's going through all these changes. And our gut's going through all these changes and, and it can, it can be something that it doesn't show up on lab testing, right? Like it's not like you can go to your doctor and say, hey, like run the blood work for big T and little t on me. It's something that we have to, to emotionally process. And, you know, there's different tools. I mean, I know breathwork can be a tool for that. Counseling can be a tool for that. Sometimes our traumas are hard to put into words. So that's where cathartic and somatic interventions can be very powerful. And then for some people, if they still can't get to it, then even plant medicines can be great because it turns off a part of our brain called the default mode network. So it kind of gets us out of our heads and allows us to write a whole new story. I was talking to a friend earlier today who's really trying to find his footing. He had a heart attack in his mid-40s, and it was just like a wake-up call for him. And he's just a wonderful, amazing human being. And he's like, man, what do I do with my life now? And he's trying to find himself again. And he's like, he doesn't feel like he has any value to add because he feels like a failure with his health and, you know, his career and other things in his life. And I'm like, bro, like the most success, the most successful people that I know, so to speak, like, and success means different things to different people, but the people that look up to have gone through some of the biggest hardships and they developed a set of skills and tools as a result of those hardships. And now they're the, you know, the leaders who are teaching other people and giving other people the tools and strategies. And value isn't just in telling people what to do. Sometimes value is in telling people what not to do.

So, yeah, it's interesting because I think one thing I've noticed with a lot of middle-aged women is they, they may not be willing to sit down and do the breathwork. They may not be willing to make all these changes. But when I can talk to them about vagal nerve training, and, you know, if you're like me, I love to track data. So, you know, I have an Oura Ring and I can track my HRV and it generally lets me know if I'm headed in the right direction. But something as simple as gargling or singing or humming, or, you know, now there are gadgets that can help you with this. And I find like For some people, they need the gadget to get them really engaged. But vagal nerve training, I think, in many ways, is a missing link for a lot of these women. And whether it's with a gadget or without, knowing that there's simple ways that can stimulate that vagus nerve. And for listeners, longest cranial nerve in our bodies innervates from the back of the brain all the way through our digestive system. So, when we talk about the gut-brain axis, we're really talking about this vagus nerve, the wandering nerve. But there's lots of ways we can stimulate it. And when I was having a conversation the other day with a colleague, I was saying, "Oh, I remember back when I was an ER nurse in inner city Baltimore, occasionally, people had their vagus nerve severed during surgery accidentally." And at the time, I didn't fully appreciate why that was catastrophic. But now, as we're having this conversation and understanding in the context of middle-aged women that are trying to find better stress reduction modalities, sometimes something as simple as just humming can make a big difference. And, you know, depending on how loud you are, some of these things you can do quietly to yourself, or you can do them in your car. But I think that when we're talking about creating simple, sustainable strategies that are not overwhelming, I can talk a lot about box breathing as something people can do, and that's usually what I do before I step on stage. But in lieu of that, there are other equally supportive strategies. I know these are things that you very likely talk about with some frequency, but I look at that as low-lying fruit. This is something that most of us can do that's not complicated, doesn't necessarily involve a device, and can definitely help with that parasympathetic-sympathetic balance. Help is the word. It's like, what are the things we can do throughout the day that can be helpful? Or even hugging your pet or hugging your loved one and how oxytocin reduces cortisol too. So all these things that are, you know, small, simple things that we can do that can be helpful.

So let's, um, let's switch gears a little bit and talk about the gut, um, more specifically. So, uh, in your research and in writing this book, what are, what are some of the changes that are taking place in the gut as women go through menopause?

Yeah, so when we're talking about the gut microbiome, we're talking about 40 trillion with a T viruses, bacteria, fungi, and protozoa that accompany inside the large intestine or colon. And so with these changes in hormones in particular, we change— see changes in diversity. So the types of species that are growing are kind of slant towards inflammatory dysbiotic organisms. We are more likely to have leaky gut because as estrogen declines— estrogen's kind of like the brick and mortars of the of the small intestine, estrogen acts as the mortar. So as we have less estrogen, we're more likely to have leaky gut. Leaky gut will generally lead to autoimmune conditions. I think there's over 100 now. We get a reduction in short-chain fatty acids. And I always say this is kind of a big— short-chain fatty acids seem like they're not particularly important, but they're signaling molecules in the brain. They drive— driving down inflammation. They're involved in endogenous GLP-1 regulation. So these drugs are really popular right now, what our body makes, GLP-1. One in particular crosses the blood-brain barrier, and this is why fiber becomes more important, because fiber is what ferments in the colon that leads to more short-chain fatty acids. I mentioned autoimmune conditions. There's now over 100. When I, when I went through my medical training, there were probably 25 or 30 that were recognized. There's over now 100 autoimmune diagnoses, and women are 4 to 5 times more likely to be diagnosed. That's just a stepping stone of some of the more common things, more inflammation, more insulin resistance. All of these things kind of are related to these alterations in not only hormones, but also neurotransmitters. Less progesterone means more anxiety, depression. Less serotonin related to less estrogen can also be impactful for irritability. Like women will say, "I'm so irritable and I don't know why." Most of the neurotransmitters are made in the gut too. So if your gut microbiome is not healthy to start with, heading into perimenopause, you're going to get magnification of all of these symptoms. And remember what I said earlier, we have the vagus nerve that runs between the gut and the brain. So if we're having a lot of inflammation, a lot of cytokines that are released, that will inflame the brain. So we talk about leaky gut, we talk about leaky brain. The gut-brain axis is supposed to be impermeable, but in some instances, when we develop a leaky gut, we'll also have that leaky brain. So we can deal with more inflammation, mood disorders, and other types of things that just worsen the symptoms that women experience at this stage of life.

So is there a way to quantify that? Is it going off symptoms, or is it lab testing, stool testing analysis that you do to, to help people? Because sometimes people like to see it, right? They like to see the— they like, they want the validation that something is imbalanced or can be corrected and fixed.

I'm curious how you, how you approach that. Yeah, I mean, you can certainly look at labs. Obviously, if you're still getting a menstrual cycle and we're looking at hormones, we know estradiol is a day 3 hormone. We know that if we're looking at progesterone, we're looking at days 19 through 21, um, ideally. We're looking at other things like fasting insulin, fasting glucose, A1C. They can be drawn at any time. That's looking at metabolic health, uric acid, triglycerides, HDL, kind of looking at other inflammatory substances. I think about apolipoprotein B or ApoB and Lp(a). Anyone that knows anything about my background, I spent 16 years in clinical cardiology, so I'm always myopically focused on heart health. And those are two lab markers that everyone listening needs to have. Irrespective of gender. I start to think about as a proxy to growth hormone, which we know declines with age, we can look at IGF-1. I also think a great deal about, you know, just regular electrolytes, looking at red blood cell magnesium, looking at sodium and potassium, looking at kidney function, looking at hemoglobin and hematocrit, ferritin, which many people inappropriately don't address. Ferritin is an iron storage hormone. Or excuse me, iron storage lab. And so we want that greater than 60, at least here in the United States. I don't know if it's concurrent, same system in the— in Canada. But then looking kind of across the board, I'm looking at, you know, stool testing. I do think there's value in looking at stool testing. You know, for me personally, I'm looking to see, do you have certain keystone bacteria? Is there a lot of dysbiosis? Do you have appropriate amounts of digestive fire? So is your digestive enzymes appropriate. Do you have steatocrit, which means you're not able to break down fecal fat? Looking at inflammatory markers like calprotectin, you know, hopefully you don't have a parasite or worms, but we occasionally see those. Sometimes Candida can show up on stool testing, although that's not my favorite test. And those are kind of baseline things that we're looking at. We can look at 24-hour saliva patterns to really get a sense. I think you could draw a serum cortisol, but that just gives you what the cortisol was at the exact moment that blood was drawn versus we can get a 24-hour saliva distribution, which I think is much more helpful. It tells us, you know, what is your saliva in the morning, an hour after awakening, mid-afternoon, evening, and it should follow a pretty predictable pattern. Sometimes it doesn't, and that gives us insightful information. I think that's a good starting point. I mean, obviously there's a lot of other tests that we can do. There's food sensitivity testing, which, you know, I'll be totally transparent, I anecdotally see great value in it. But if you look at the research, it's all kind of segmented towards looking at allergy testing, which is different. And I see a lot of food sensitivities in middle age, which is probably a byproduct of leaky gut, alterations in sex hormones. So in particular, we'll see a lot of estrogen dominance in the setting of lower progesterone, which can be provoked and can potentially lead to, like, if someone's eating a lot of high histamine foods, which are intrinsically healthy, right? It can provoke a degree of mast cell degranulation, which is a part of the immune system that will release these kind of histamine that can then lead to nasal congestion and abdominal cramping and sometimes skin manifestations. Like, could just be a rash or hives, but obviously can be concerning and scary because it can happen quite quickly and can sometimes be mistaken for an allergy when in fact it's a sensitivity. And then we go, you know, from there we can look at other types of testing. You'll get oats testing, you'll look at organic acid testing. It's interesting, I used to do quite a bit of the Dutch, and I do use it on occasion but less frequently because a lot of what's on that test I can get from other modalities. But on the Dutch test, you can look at estrogen detoxification patterns, which I think can be helpful, especially if women are contemplating or are trying to make decisions about hormone replacement therapy, not because I get the values of how high their estrogen levels are in their body, but it gives me an idea of how it's broken down in the body. Um, and that's a starting point. But I really like stool testing. I like to look at saliva-based testing and do so strategically, and then serum labs just based on what we're looking at. But getting a baseline assessment of how healthy is this person, because here in the United States we do a terrible job managing insulin resistance, and even diabetes. And so, that fasting insulin can oftentimes be the very first biomarker that would dysregulate, sometimes 5 to 10 years before glucose looks dysregulated. And we know that women are at greater risk for poor metabolic health as they're navigating life with less hormones. So, important to get a sense of where that is, you know, upfront, and then we can, you know, kind of dial back in from there. But that's kind of an oversight of things that I think are important to look at. Obviously, vitamin D, can be very helpful depending if we're looking at, you know, vitamin B12, folate, etc. Obviously thyroid plays a huge role in middle age, and so most people are getting a TSH, a free T3 and T4, antibodies, maybe a reverse T3, although I don't— well, it's not that I don't place a lot of value. Oftentimes the reason why the reverse T3 can be elevated is because of the hormone changes, the insulin resistance, etc. And so until that's been fixed test, I don't know if I necessarily see a lot of value because that sometimes can add to someone's anxiety. But that's a good starting place for labs.

Okay. Very thorough. I love it. Now, I know you mentioned you use an Oura Ring. So, aside for the benefits of tracking your sleep, what are some of the numbers you might look at on the Oura Ring that you feel are relevant to this?

Yeah, I mean, I think obviously heart rate variability is, is a big one and, and helping women understand like you have a baseline and we can see improvements, but If your baseline is 50, I don't expect you to get to 150. Like, some of that is genetic, some of that is— there are age-adjusted improvements, but it gives women an idea. Like, if I wake up in the morning and I didn't sleep well and my HRV is normally 50 and it's 20, it's like, okay, clearly there's an imbalance between the sympathetic parasympathetic nervous system. Same thing with heart rate variability, especially with travel, altitude, hydration status can also impact Heart rate variability. To me, I see quite a bit of women that have dysautonomia, which is a separate kind of superimposed issue where their autonomic nervous system just doesn't work as appropriately. They'll say, oh, my heart rate's really low, my blood pressure's low, that's all good. And I'm like, yes, but always in the context of what else could be going on. Um, the severe manifestation of dysautonomia is POTS. Um, and I saw quite a bit of it working in cardiology, sometimes with patients who actually had to go on medication because their blood pressure was so dangerously low and they were very symptomatic. But, I think those are the two parameters looking at those two and then deep sleep metrics and REM sleep and being really clear that the Oura Ring is not infallible. Sometimes people are like, "Oh, my God, I only got an hour and 28 minutes of deep sleep. That's terrible." I'm like, "No, in the context of the greater good, that is probably fine." Obviously, when I'm on vacation, when I'm not at home and I'm on vacation and totally relaxed like the last time we were in Belize or Costa Rica, I had 2.5 hours of deep sleep. I was like, "This is amazing." So, clearly, you know, there's something about being on vacation that influences deep sleep metrics. But those are the things that I have patients— I always say, like, we want to be thinking big picture and not get myopically focused on, you know, the day-to-day unless you really— unless you're seeing patterns that are shifting. I think a lot of women get beholden to, you know, "My HRV must be 50, otherwise, I'm doing terribly." I'm like, "Well, it's always the context." is what's your baseline. Like, if my HRV is in the 20s, I'm either sick or I'm at altitude and I'm traveling. Like, that's, that's how I typically will know. But if I'm in the 50s and 60s, for me, that is actually quite good. And I think, you know, when people see online, like, someone's HRV is 150, I'm like, that's great. That's probably a much younger person. There is an age-adjusted variable. There's also some genetics that are thrown in, because I've looked at the research to better understand, you know, what explains why some of my patients are in the 90s and they're doing great. And then I have some that are in the teens. I'm like, okay, we have work we need to do because your body clearly doesn't perceive that it's safe because it's so low. Um, but I mean, that's a good starting point, whether it's with the Oura Ring or the Whoop band. Um, if I can get my patients to remember to charge it, that's always the big thing. Oh, I forgot to charge it.

Occasionally you do need to check your app just to see where your battery life is. Yeah, that's great. You know, sleep is, is definitely a challenge for people in the middle ages. And as women are going through these hormonal shifts, hot flashes and things like that might be disrupting their sleep or they might be tossing and turning. What guidance or tips or suggestions can you offer for somebody who might be struggling with sleep quality?

Yeah, I mean, it's starting off with sleep hygiene, like just like when our kids were babies and, you know, there was a whole ritual that we did with them to to tell them and reconvince them it's time to get ready for bed. We have to do the same. You can't go from, like, tonight I'm teaching and I'm gonna be underneath the lights with blue blockers on until probably 8. I have to have some type of a ritual before I even think about going to bed. So, whether it's getting off electronics, dimming the lights, wearing blue blockers, making sure you exercise that day, being really conscientious about not eating 2 to 3 hours before bedtime. When women are having a lot of hot flashes at night, I start thinking about, is it blood sugar regulation? Because we know that women that experience sustained and persistent hot flashes are more likely to have heart disease problems and poor metabolic health. So, we do take those seriously. I start to think about what's going on with their blood sugar. So, is it something that we want to wear a continuous glucose monitor so we have a sense of what's going on? Are they eating too close to bedtime? Are they drinking alcohol? Are they stressed and they don't have a stress adaptation piece to their nighttime routine? I don't care if someone puts legs up a wall and hums while they're doing it, doing something to try to get themselves out of fight or flight and more relaxed. Maybe they take a hot bath, maybe they— maybe not right now because it's really warm where we are. Maybe they're taking a cooler shower at night, finding ways to decompress their bodies so that they're not instantly just trying to shove themselves off to bed, reading a physical book. I mean, I still read physical books, but I acknowledge that's now becoming not the norm. People are listening to audiobooks, they're reading on a Kindle, or they're watching something on an iPad. And so, I always say you want to go old school when it comes to bedtime. I think when we think about supplementation, I think this can be beneficial, things like myoinositol, adaptogenic herbs like relora or rhodiola or ashwagandha, I also think about— this is where HRT can be helpful— progesterone, depending on where you are in the perimenopause-menopause journey, is usually step one. Maybe you take it the week or two prior to your menstrual cycle starting. At some point, you probably will also need some estrogen because progesterone does a really nice job with helping induce sleep, upregulating not only allopregnenolone but GABA. Estrogen, estradiol can be helpful for staying asleep. So really looking at all pieces of the puzzle because It's part lifestyle, it is part supplement regimen, I think, personally, and then some HRT where appropriate. You know, we can also talk about melatonin. We know that melatonin, just like every other hormone, starts to decline with age, and it's not just a sleep hormone, it's a master antioxidant. So I'm not afraid of giving patients a milligram or two of melatonin. I think that can be helpful. Um, do I think super physiologic dosing, like there There was a guest I had a few years ago, it was very interesting talking about melatonin, but he was talking about 100 milligrams of per rectal melatonin. And I was like, "I don't think that's a sustainable strategy." But if you need a melatonin boost or an antioxidant boost, maybe that's not such a bad idea. But I think it has to really be kind of a targeted approach. The other thing that I would add to sleep rituals, chamomile tea, some people like drinking something warm. Uncaffeinated tea. Obviously, don't, you know, don't have an espresso before you go to bed unless you're a fast metabolizer. I happen to be one of those. Like, I rarely get jittery from caffeine, but I do have some patients that will tell me they can have like a coffee at 7 o'clock at night and still sleep really well. But I think more often than not, poor sleep is really related to poor stress management. So they go hand in hand. And as I said in the beginning, Show me a woman who doesn't sleep and I'll show you someone who doesn't manage her stress. Obviously, sometimes it's situational. And I think that whether someone's going through a divorce or a bad breakup or has a job loss or a move or someone in their family is sick or maybe even themselves, it's like you have to sometimes buffer with more. And this is where I think titration of supplements and even HRT can be helpful to help people over those little rough spots.

Amazing tips and suggestions. Thank you. There's a pearl I wanted to add, and you probably know this, but for our listeners, when we move our eyes left to right, like we're reading, it actually creates a parasympathetic response because you'd be gazing, scanning your environment, sightseeing almost. Whereas if you're scrolling up and down, that would be like running, right? You're looking straight ahead of you. You're looking up and down. And that creates a cortisol response. So when we're scrolling on our phones, our eyes are tracking vertically versus horizontally. So I love the suggestion of reading an old school book because it just, without us even realizing it, it's creating that response in us.

And I tell you, I, when I make suggestions like that, people will say, I read half a page and I was sleepy. I'm like, great.

That's exactly what we want.

Yeah.

Amazing. Well, Cynthia, you've been very generous with your knowledge and, and time today. I wanna just, you know, maybe have you talk about the book, maybe tell us a little bit more about what people can expect, where can they get it, and, and yeah, tell us more.

Yeah, thank you so much, Sachin. So The Menopause Gut is really speaking to the changes that happen in the gut microbiome in perimenopause and menopause. So it is a book for women that even before they get into perimenopause to better understand their physiology, it talks about the gut and what the gut microbiome is. It kind of evolves into talking about how our ovaries set the pacemaker of aging in our bodies. It's the most mitochondrial dense organ in our bodies, not surprisingly, and how the interplay between the gut and the ovaries really sets the pacemaker of aging for us. We move on and talk about bones. We talk about the immune system, and then we weave in all the things that you can do proactively, really starting with lifestyle. Spent a whole chapter talking about sleep and stress, and not surprisingly, nutrition and exercise, all the research on how these impact the gut microbiome positively and negatively. I spent quite a bit of time talking about hormone replacement therapy, if that's appropriate for you, and what the research demonstrates. Thankfully, most of the Women's Health Initiative has now been debunked. We did get some important insights into that, but it changed practice patterns for a long time. And then I weave in supplements, and then we have a lot of, um, great recipes that were designed to be gut-friendly. So lots of fermented foods, fiber, which is— I always say is the new F word. So protein and fiber really become really important. It really is a love letter to women because it's embodying, you know, 25 years of clinical experience, all the things that I've learned, and really talks about the science. Like, there's so much research in the book that actually it would have added 20 pages to the book, so those will be housed on my website. You can go directly to my website itself at www.cynthiatherlow.com. There's a big banner at the top. You can click on that. It'll take you to any of your retailers. And presales are really important for the book. It not only tells retailers, but also the publisher and publishing industry that this book is wanted and needed. And there's a lot of wonderful presale bonuses. I know people sometimes say that, and it turns out to be something you don't need or want. But we actually polled my community to find out what resources they wanted. And so it's a nice accompaniment to the book, and they'll be available up until publication week, which is April 28th. And I'm active across social media. I have a podcast that I love called Everyday Wellness. It's my favorite thing I do in my business, getting— being able to interview the best and the brightest in the health and wellness space. And eventually our, our, our calendars are going to align and we'll, we'll get you on, Sachin. And then I'm active across social. I would say right now I'm most active probably on Instagram, and I have a love and affiliation for Substack. It's allowing me to connect with, you know, followers in a very unique way because it's a much more personalized approach. You know, the podcast is for everyone, and Substack is written really to help women better understand their physiology. So a lot of the things we talked about on the podcast today, I unpack in greater detail detail there as well. But if you listen to the podcast and you decide to purchase the book and reach out, please let me know.

Well, thank you. I purchased my copy right before we started. So thank you for doing this work. Thank you for sharing. You know, if you're a male watching this and you have, you know, a loved one who's approaching menopause, this could be a great gift for them and maybe even a great gift for yourself to understand them better and support them on the journey. And certainly if you're a female watching this, this is a must-have. And Cynthia, you've written a book prior to this about fasting. That's a, a lot of your work is in that area. And this is wonderful to see how you're helping women now, just, you know, leaning more into that journey that all of us, you know, men and women go through hormonal changes as we age. And it's wonderful to see now that women have a tool that they can empower themselves with. So thank you once again. So much love and gratitude for our time together, and I look forward to seeing you in person so I can give you a big hug. Yes, absolutely, Sachin. Thanks again. My pleasure. Have a great day. You too.

All right. We did it. That was awesome. I'm laughing because I have one of my dogs is like sitting underneath my desk and he was whining because this dog knows it's 5 o'clock and it was time to walk. You can wait.

You can wait to eat. Good Lord. Good Lord. Amazing. Well, I'll, I'll let you, I'll let you run.

I know we went a few minutes over. That's okay. I enjoyed it. I mean, you've got a whole different conversation out of me. At one point, I was like, you know, you hope that the people that are listening to that are like open to the possibility that, you know, a lot of what we learn in middle age is really figuring out like, are our habits adaptive or maladaptive? Because I think that's a huge transition. Some people are willing to kind of make some changes and others really struggle.

Struggle with that. Awesome. Well, I'll, um, get this out as soon as possible and post it, and I'll tag you online when we do that.

Awesome. Thanks, Sachin. All right, good to see you.

Have a good day. Bye-bye.