Why Your Body Changes in Midlife: Hormones, Blood Sugar & Belly Fat

So welcome back, Senergy listeners. Have you ever looked at yourself and thought, I haven't changed anything, so why has my body changed? You're eating the way you've always been able to eat, you're exercising just as much, maybe even a little more, and suddenly the weight is settling around your middle. You wake up at 3 AM, your energy crashes in the afternoon, and the cravings just feel different. You know, foods you could tolerate—they just don't seem to work for you anymore. And maybe, maybe the most frustrating part is you go in for your healthcare visit, you have your labs drawn, and you're told that everything looks normal. So if this is sounding familiar, today's conversation is just for you because we want you to know that your body isn't failing you. What if your hormones have just changed the rules? So today we are joined by Dr. Christina Insmann. She's an MD. PhD, board-certified gynecologist, certified menopause practitioner through the Menopause Society. She's a physician. She's trained in functional medicine and in nutritional endocrinology. Dr. Insmann earned both her MD and her PhD from the University of Hamburg in Germany. She completed her OB-GYN residency at Sinai Hospital in Baltimore. But what Lori and I especially love about her approach is that she bridges the 2 worlds that women desperately need Brought together the science and the rigor of conventional gynecology with a deeper look at hormones, nutrition, metabolism, and how they're all interconnected. The reason she practices this way is very specific. Throughout her career, Dr. Insmann kept seeing the same women. They would walk through her door, health-conscious, trying to do all the right things, struggling with their weight, exhausted, brain fog, poor sleep, and just losing vitality. And they were being told nothing was wrong because their labs were normal. Dr. Insmann was not satisfied with that answer, and I want you to know Lori and I are not satisfied with that answer either. So instead, she started asking more important questions. She started asking, what are we missing? And that's exactly what we're going to explore today. We're going to connect the dots between estrogen, cortisol, insulin, blood sugar, sleep, muscle and metabolism. We're talking about why the strategies that may have worked in your 35 to 40 year age group is not what your body needs today at age 45, 55, and even beyond. We're going to talk about blood sugar and how blood sugar can start changing even before your traditional labs change, and that may be why they still look normal. We're going to talk about how stress and poor sleep affect insulin and cravings. And what a continuous glucose monitor may help you reveal. We're going to talk about how hormone replacement fits into metabolic health and why muscle mass may be one of the most powerful tools for women as they age. We're also going to tackle questions that so many women are asking. So, okay, I understand that my hormones are changing, but what can I actually do about it? Because this is not about fighting your body or trying harder. It's about understanding what your body is asking for in this season of your life and having the information to respond differently.

So when we think about the woman that comes to the clinic and they're saying, listen, I'm not doing anything differently, but my body's changing, you know, I'm getting heavy, fluffy around the middle. I'm not sleeping as well. But when I went to my doctor, my labs came back normal. What's going on? I bet you've heard that a time or two in your practice.

That's my favorite. Yes. That's like, that's like, you know, 10 points. You know, most frustrating. And I think that's what's frustrating, particularly like the very determined women who have been doing everything right. Because we know, right, someone who has a, you know, a diet that really needs to improve, that is so easy for us. You know, there are simple things you can do, but the frustrating is the woman who has been taking care of herself. She's exercising, eating well, and now she, you know, she's 45 or close to 50, and now she realizes she does everything the same, she eats the same, and now she gets that belly bulge, she feels maybe fatigued. And now what she does, you know, she's cutting calories again because that has worked like for, you know, for the last 30 years, that was always a great intervent— you know, a great intervention. And maybe she even exercises a little bit more, but to her frustration, she actually feels worse. The belly gets a little bit more pronounced, and in the end, they often are fatigued. So, what's happening? So, you know, this is the extreme, but the initial thing, you know, I explain my patients, and I'm sure you do that too, that the estrogen, it's not— it's only a part of that entire story. But yes, the estrogen is that one thing that helps us with the insulin sensitivity. And, you know, very— that's, you know, HRT is not going to help you with losing weight, but, you know, It's, it's, it's that little piece really. So insulin resistance gets worse. So now I explain all the food you, or the calories you eat from carbohydrates that you really digested well before and metabolized. Now they are preferably stored as fat. That's kind of the way I say it in an understanding way. So preferably they're going to be stored as fat because your body can't really absorb that great glucose very well. And however, this is not Oh, this would be great if it's just that. But now when you have this tremendous insulin pressure, so pancreas produces much more insulin than usually because suddenly it's much more glucose around that he tries to stuff into the cells and the cells are not really wanting to gobble it up. And now this high insulin gives additionally the body now the signal, do not burn no fat, but preferably, you know, break down muscle if that that person, that woman needs energy because she hasn't eaten enough. She has been cutting calories. She's exercising. So when usually our body would start to, you know, get our, you know, fat depots, not happening. So now they're breaking down muscle additionally. And that makes that metabolic vicious cycle now even worse because we know, you know, we have heard it now, muscle is a big metabolic organ. It really helps to blunt these blood sugar spikes. Now we are losing that. And these women are exercising even harder now. And that really— and now comes the next bummer. That increases now our cortisol spikes. So neuroendocrine event, I always call it, you know, menopause. So now the cortisol spike. Cortisol already goes up in perimenopause. I'm always saying this body knows something is going on. The hormones do whatever they want. You know, the coworkers progesterone and estrogen, they just don't show up every morning anymore. Progesterone comes whenever it wants. Then estrogen says for 3 I take a couple of days off. So, and the body is like, oh, excuse me, what's going on? So cortisol spikes a little bit. And additionally, now the estrogen that usually helps to calm our cortisol spikes. So the stress hormone from the normal things that we used to enjoy, like maybe we have a stressful job, but we, it was eustress before. You know me, I loved my crazy surgeries, you know, and the nights with the residents were kind of entertaining.

Right.

Now the body is saying, well, this is really not so good for you anymore. And that estrogen that used to calm that cortisol down, you know, like doesn't let it spike up so high and calms it down pretty quick. Now that doesn't work anymore. And the woman might not eat enough. Now she is exercising a little bit too much for what she's actually eating, which also now pushes the cortisol higher. And now when the cortisol is high, well, there are great Cortisol receptors in our belly stores. And now this is where the fat gets stored. So this is just one little piece of that entire conundrum. There are more pieces to it, but this is, you know, when she comes and says, well, I'm doing everything the same that I did before and now I'm gaining weight. Well, that is what's really going on in some of these major players.

And it's a vicious cycle. It's a vicious cycle.

Right. Yes. Yeah. And so we hear that a lot. So they think they need to double down, right? They think they're not doing enough exercise. They think they need to be working harder. And a lot of times they create an ongoing progression of what's already started. They feed the fire of what's already started. And that can be extremely frustrating for them because they think they are doing so much right to help themselves out.

It's terrible, but often it's our, you know, just to spin that thought further. So I'm really calculating with my patients now their, what's called the energy availability. Now, you know, I'm sure you know what that is. So I really, and you know, I have to use apps like Cronometer to really make them track for 2 weeks, what do you eat every day? So I can show them what is actually their weekly, what do they actually take in in calories? What would be their requirement based, you know, on the crazy amount of exercise? For my feeling, they do. Me, you have to push me to exercise. But these women are really driven. I'm sometimes really jealous. So, and then we have this tremendous, you know, energy deficit. So, and so I have to explain them, your body really has decreased that basic metabolic rate over decades already. So all these online calorie calculators really don't fit you anymore because if that calculator thinks you are still, you know, in your mid-30s and, you know, we just cut some calories and, You're gonna lose it, but it doesn't realize when that calculator says, "Well, eat 200 calories less," your basic metabolic rate is long even below that. So there is really nothing you can cut, and your body is just on this maintenance mode, like you know always you know trying to you know give give your organs enough so you can function. But it gets then even worse. So in the end, I see often that it's really a cause of that. Severe fatigue that many of these midlife women really report. You know, and sure, you know, I do micronutrient analysis and we look at the gut and all of this, but more and more women, I just realize now they're not eating enough. And there's no way to prove it unless you really make them track it because, you know, they feel they eat normal. They have always, you know, this is just normal for them and they're even full because digestive function has slowed down. So, and then I'm just wondering, how crazy is that? What kind of corset have we been pressed into that we are trying so desperately over, you know, decades to fit in? And then the distress that's causing, you know, even women, I feel, you know, they look great, but they know, you know, they gained a couple of pounds. It causes such a distress. And I certainly, I can relate to that. There are just so many questions suddenly coming up in midlife. I think it's fascinating and often sometimes just clearing. I'm like, wow, there are so many things going in there from how we are primed, the role in society, how we think we have to look like. And that, you know, we hustle in midlife like crazy, you know, from the family and the children and the job. And we are so proud of ourselves and we don't realize how exhausted we really arrive in midlife. And then we think we have to— have to push our body even harder. Like, you know, let's do a triathlon. Finally, I have a little time in midlife. The kids are out of the house. These are the women I see then, right? So they're not doing better. So, yeah.

So you mentioned measuring the food or having them measure and track their food. I love that. That's one of the things that we do too is having them track and trend. Are you using any continuous glucose monitoring to see like what they're doing in the way of glucose management as a reflection of Absolutely.

Yes. That's the first thing I do. But, you know, some of these— so that, you know, continuous glucose monitoring, if we find things there, oh, this is so easy. I love that, right? So then you just— when they're at that stage, I'm like, that's perfect. You know, we talk about how to, you know, change your diet, how to increase your greens and veggies, how to combine your foods, how to avoid these blood sugar spikes. That is a perfect stage because these women lose weight, as you know. If the only problem is that insulin resistance, I think that's fantastic. And these are also the women, you know, when, you know, intermittent fasting might work really well, right? If you really just have that metabolic concern, otherwise there's no fatigue, no major cortisol signal. So that is really, you know, I think that's very grateful to do that. I think it gets more complex when these women have these cortisol and they can't sleep, they're fatigued. When I know by their symptoms, their cortisol is doing whatever it wants because now, you know, and maybe they have been fasting and now I have to explain for you that long fasting is not good at all, right? They do 16, 18 hours fasting because they want to get where they want to go. And now I have to explain whatever you have been reading or listening to on podcasts, this is not for you. It's making your problem even worse because your body is— that fasting is stressful, not eating enough is stressful. So yes. So, but yeah, continuous glucose monitor, I love it. I've been, you know, I've been wearing this for many years in the past. I've long stopped it, but that was— that is a lovely tool really. And if that's the only thing you need, that's fantastic. But the other thing is once, you know, women, once they are so underfueled and Then the hemoglobin A1C is normal. And even the fasting insulin that can be so sensitive might even be low. And they still are in a way insulin resistant. And at the same time, they're underfueled. So I think that's where, you know, that's where we're getting really deep in the weeds there. But it exists. We just have to tell people, you know, you are not all the same. You're all wonderful butterflies, but you arrive in midlife, most of you are a little bit stressed, but you know, in what stage you are and how to heal your metabolism, that needs a very nuanced approach. There is just not one social media version that's going to help all of you.

Yes. I wish it was that simple, right?

Yeah. Yes.

I'm so glad that you said that. And that's something that's so important to the clients that we get the opportunity to treat is helping them understand that, that you— there are many nuances and that you are— and I love what you said, these Beautiful butterflies, right? You are. There's uniqueness in that, and that really does drive the need to dig deeper to understand so many factors about your patient, right? So I want to step back a little bit and get to know you a little bit more. Explain what you do, what your practice is, and kind of what you're— we all have a story. So Tell us a little bit about your story.

Absolutely. So first of all, I'm German, as you can hear, but I've been living in the US since like over 20 years. I ended up here by accident. But then I worked a long time as faculty for a big university system. And very right after, out of, you know, I had to do my residency here in the US again. So I was a little older. I had 2 children here. And then right after residency, I really specialized right away, or, you know, I got the certification from the Menopause Society. You know, I don't even know what it was. I think I just saw many midlife women and I felt not prepared for that. And I just enjoyed that, these women a lot. So then I was practicing, you know, standard menopause medicine already, you know, fantastic. And I always like to tell people, because right now everyone acts like hormone replacement therapy is all new again. And I always want to say, no, people, we have been doing this since 20 years. It never went away. Like, you know, the noise went away and people, the noise, everyone being scared, that was, was just louder. But we menopause practitioners have been out there since ever and been prescribing hormones. So that's it. I did this for, you know, a long time. And, you know, but I noticed, you know, a trend, which is like that these women got the gut issues and they had these, you know, and I was like, you know, now everyone knows, sure, you get gut issues in perimenopause very frequently. But back then no one had made that link. I only saw this in my practice and I was really baffled by it. You know, they had the colonoscopies and Could barely eat sometimes, and they all had the diagnosis of IBS. And I'm like, what, really? So there was that. So there were a couple of things when I was starting to wonder, or, you know, these very severe palpitations. You know, everyone had a Holter monitor, so this long-term monitor, and it was like, what? So, and then menopause, you know, came earlier for me. I was around 45 when I was really in deep perimenopause suddenly. And I didn't notice because I was busy, right? I had a thousand things. To do. And I thought, well, I'm stressed. And then, however, the funny thing was I was working in residency clinic and I had, you know, I had these chic long boots. Finally, I found some boots that, you know, that fitted my really skinny legs. Oh my God, I got so hot. I wanted to tear these things off my legs, right? So this was really, I think, the first moment when I, you know, usually I'm that cold person and I was like, What is going on? So, and then, you know, I, you know, it became more apparent what's going on. And there came, you know, this menopausal rage, all these things. And suddenly I felt, you know, many of these advices I've given my patients over the decade about, you know, yes, there is some weight gain, but it's only like 3 kilos in average, right? So we have data for all of these things. I just, it wasn't good enough for me anymore. Once, you know, it was myself, I was like, well, this is like silly. Why don't we have better answers? For here. And that's when I, you know, I, I looked into the toolbox of functional medicine and that's kind of my expanded my knowledge there. And that's when I, you know, left my own, my own job, that big university system and, you know, changed to a different system. And ultimately I actually, I left all corporate medicine. I now have my, so I see patients in practice twice a week, but mostly I do the functional work really online. So that's how I'm operating right now, and that really was to have more time to read. You know, not being pulled in all directions all the time, but have time to get better for my patients and do the things how I enjoy them. Like I, you know, I do tell my my patients also to find, you know, to start early on to just think about what do you have to do in terms of your stress and your job that you're not completely worn out. And when you arrive in midlife, so and then what I do is I do you know I do really deep functional functional testing. So I do you know very comprehensive blood panel, and then there comes micronutrient testing. I do you know metabolic hormone testing. So we look at the metabolites. I do stress axis testing. You know consistent with what I've been telling you. I some you know you know it. We can often tell exactly what's going on with these women, but sometimes we need to show it to them. Like, and, you know, I sometimes want to know how bad is the stress axis regulation. I am becoming a very big fan of environmental toxin testing because, you know, I think many of, you know, we, in the end, every, our symptoms are due to oxidative stress, mitochondrial dysfunction. But then the question is like, what is really driving that? You know, it's not just that the estrogen goes away, right? Yeah. So, environmental toxin testing, I have become a big fan. And then, genetic testing, if someone really wants to dig deep and then we wanna know the future risk factors. And again, just so, because as you know, we can fix all these things. We can, as long as we have the eyes wide open, there are so many things we can do to prevent the risks that our kind of genetic variability has given to us. So, that's how I work.

Yep, you're in like company. You know, here's, here's what you're saying is that we're complex beings. And when we're really working with individuals, it's having to do pulling from that toolbox and really applying and gaining information and meeting them where they're at and helping them walk through that journey. And it's not about one test and it's not about one treatment plan. It's about putting that whole picture together. And that takes a lot of time. That takes a lot of energy. But you're in like company. And, you know, so again, thanks for being here to explore a little bit deeper. I know, Kelly, you had a ton of questions.

Yeah. So I just want to say it's a commitment to ongoing education, too. And I heard you say that without really saying that, the time to read, the time to really dig in and see what is out there. What do we really need to be exploring for these women? Because these women do deserve answers. You know, they've been told you're just getting older. This is part of aging. And as you have discovered in your clinical practice, and Lori and I have, too, There's undercurrents that's driving that oxidative stress. And, if we don't take the time to stop and look, are they being exposed to environmental toxins like mold or bacteria, endotoxins, cyanobacteria, those kind of things, or even heavy metal toxicity that they could have exposure to throughout their lifetime? And, you mentioned earlier that we land in perimenopause, we skid into perimenopause. We've done the career thing, we've done the have the kids thing, we've done to make everything happy thing. Everybody happy thing. And we burn through a lot of our metabolic reserves in doing that. And so, without metabolic reserves and overexposure to toxic burden, and then estrogen starts depleting, it's like the perfect storm for females. And again, they've been dismissed. They haven't really been heard or explored and taught what their bodies are capable of doing and given the tools to rebuild. So I love that you're here. I love that you're an OB-GYN. I love that you saw that in your practice and in yourself, and you're like, those answers are not enough.

I have to keep digging. Absolutely. You know, I also always like to say there are women— you know, I always want to point out that menopause is not like a disease state, and nature hasn't made this for us to be miserable. I always like to frame it like, you know, having children, producing every month an egg— this is a lot of work, right? So basically, midlife nature is saying, hey, hey, girl, you have really done your part. That's it. Now we're gonna— we're gonna turn that off. You leave that hard, heavy lifting to the younger ladies out there. They enjoy, you know, and we let you go on and do, you know, focus, you know, on society or, you know, find some— find other projects. So it's a good thing for us. And I want to say in my, you know, the functional practitioner world, I have plenty of colleagues, you know, they grew up in this anti-hormone time, and they've never been on it. And they, they have no, you know, they're fine. They've— I just want people to know there are people who are, you know, women when they have, you know, controlled their stress. Well, I'm not one of them. But there are clearly women who have done, you know, a better job. Maybe they have a little better genetics. But I think it's really a lot how have you set you up to you come through midlife. So that does exist. That's just for all the other ladies out there to hear that. And that's not to take away from everyone else's suffering. Just so you know, this is not a disease state. And there are many things you can do to prepare yourself that this is kind of an easier transition. And maybe we can talk about that. And I just want to say, I love being in postmenopause. I mean, I think this is fantastic. You know, I don't want to cycle again. I like, you know, you realize later, you know, how you mood would fluctuate. You would never know how you kind of wake up in the morning. And I didn't even think I was particularly cyclical in my moods. But now I'm just every day the same. And I don't know, I love it.

It can be liberating. You know, we spend so much time thinking about how not to get pregnant and how to get pregnant. I mean, that in and of itself can be exhausting. And so I do think it is a very liberating time in life. And to your point, being able to change our focus to pouring into other people, mentoring people, um, how can we serve our community? I love it too. And so I would not want to go back to that time in my life either. So for all of you people going through perimenopause, there's, there's beauty on the other side.

Yes, lots of that. Absolutely. Yeah.

So in saying that, um, you know, just a quick question for you is You know, we get a question a lot. Is there— is it ever too late to be hormone balanced? It's kind of a trick question, but I'm going to ask it.

No, it's never too late.

But I want to hear your opinion because I know you probably get that question.

Of course. So here's what I would say. So first, like, you know, the word hormone balance, that kind of means like in postmenopause, our hormones are supposed to be low. So in postmenopause, hormone balance means your estrogen is low, and that's perfectly fine. So this is the first thing I want to point out. But you are asking if a woman has symptoms, and let's say she's 70 years old and she's beyond that window, would there, you know, could she still explore that? And as you know, you might know, and your listener might have heard these, these strict rules have, you know, softened a little bit. Uh, in— however, I also want to point out that as much as, you know, I think it's— there are still women where hormones are not a good option. And they are, yeah, but it's personalized and it's about risk factors. But I do tell you, sometimes they are 70 years old and, you know, and they're otherwise very healthy biologically, you know, Really, you know, good together, let's say it like this. And let's say they have osteoporosis. And so we have a good reason, you know, and they have tried some other things, or they don't tolerate it. And I even have an endocrinologist I work with. And then she sometimes asks me, she's like, can you give me a little estrogen on top of everything? And so yes, so I think, again, if someone is healthy, they have no risk, they had no breast cancer, you know, they're not hypertensive, and, you know, No major cardiovascular risk factors. I think yes, I would still you know we can sneak these hormones back in, particularly for bone protection. It's very it's very valid. I once had an older lady; she wasn't seventy, maybe she was sixty-five, and she was ten years in menopause, and she had this panic attack like hot flashes. And I have to be honest, I didn't believe this was really hot flash related. You know, I was arguing come on, you know, ten years. This has all. stabilized. I gave— she tried everything. We did adaptogens and tried to, you know, address her cortisol axis. In the end, I gave her some hormones and it fixed it. You know, sometimes you are humbled in medicine, but again, we are all— this is personalized medicine. There is not a one-time solution for all. And so I don't think there's a no-no. And I also think if someone has been on hormones since like 20 years and now they are like 75 or 80, you know, I'm like, well, if You know, if there was no detrimental effect until now and they still have no hypertension. And, you know, I'm like, well, you know, on these tiny doses we give today, like a 0.025 milligram, I'm like, so yes, I think we shouldn't be dogmatic. My own mom, I have to tell you, she's probably, what is she, 78? She hides her age from me, so she confuses me regularly. But I know I tried her for many years. I tried to wean her off estrogen patch. And I failed. I just— she— and now she takes like this lowest dose and she cuts it in half. So if you ask me, it's a homeopathic dose, but she swears it helps her hot flashes. Well, what am I going to say? Like, stop it? You know, no, it's going to drive her nuts. So, so yes, I think we have to, you know, use good clinical, um, you know, judgment, but also be, be reasonable. And then See it in the whole perspective and in the quality of life. Like, if someone gets panic attacks every 10 minutes and some estrogen can help that out, I'm like, yeah, that's going to be just fine. So, that's how I see it.

And, I mean, the reality is hormones don't act in silos, right? So, you've already talked today about adrenal hormones, and we talked stress hormones and pancreas, right? glucose and insulin hormones, and then we have the thyroid, and we have the cascade of hormones, right? It's a symphony. And so it's balancing all of those hormones rather than putting those blindfolds on and only treating sex hormones, which are typically downstream from all of the others.

I like, I like that framing because, yes, so, you know, our insulin, our hormones, our cortisol, and hormones. And I wanted to say, so if I So, when I see, you know, someone is 70 and then the primary care physician sends them, oh, she has hot flashes now, it's menopause. You know, what I look at, like you do probably too, I look at the hemoglobin A1C and we address the stress factors because that, in my opinion, is most of the time, you know, usually the hemoglobin A1C is elevated. So, it's the blood sugar. And, I explain them, look, that insulin docks right at the thermoregulatory center where the estrogen used to block. So if you're having your, you know, you're eating your sweets, that's what's going to give you, you know, the hot flashes. And of course, cortisol. Also, if they had, you know, traumatic life, that's— there's things we can't fix, but it's— I think it's helpful to know and address and, you know, open your eyes towards these stressors.

Yes. And you mentioned being humble, right? I mean, how many times have you, Kelly, and I talked about, you know, just The things we've learned through being willing to listen to our clients and engaging in conversation with them, because things that I would've said historically I would never consider doing, you hear them and go, well, I mean, this makes sense, right? And if it makes sense, I mean, you know, maybe we didn't read it over here, right? But it makes sense. Let's apply this variable change. Let's see. And they've taught us so much in that.

Yeah, they have. So can we turn the lens a little bit to osteoporosis? Because you did mention that. And I just feel like that's such an under— I don't know, in our area, it's very overlooked until they have frank osteoporosis disease state. Now we need Prolia, right? And I encourage all of my patients to get their bone density early and sequentially so that we can monitor over time and see what And you mentioned hormones in the way of preventing osteoporosis. From my perspective, osteoporosis is an inflammatory disease state. It's an inflammatory condition. So anything that we can do to control for inflammation is beneficial. What has been your experience in the world of hormone replacement therapy as it relates to osteoporosis?

Well, as you know, that is one of the FDA-approved approved indications for HRT is actually after heart failure. It's actually prevention of osteoporosis. So, so we even have really solid data for that. However, so first of all, I always want to know, not every woman is going to get osteoporosis because you're not on hormones. Because right now people get panicked, like, you know, they think everyone's gonna break a bone. I'm like, no, this is a very important topic, but not everyone's gonna break a bone. Because— and then I tell them, I have had patients that have been been decades on HRT, really high dose, old-fashioned, they have developed osteoporosis. So that's when I, you know, well, there's much more behind that than just estrogen. It is just a little cofactor. So yes, inflammation. And as we know now, so inflammatory foods. Some people might argue, you know, gluten might be a bigger piece of that. When some women— we know the Canadians have taken out the recommendation of dairy for calcium to prevention of osteoporosis because they have long seen populations who eat more dairy have actually more fractures. Again, sure, dairy has calcium, but there is something else clearly that plays a role in that dairy. So yeah, so anti-inflammation, we know now that gut health is super important. That's why everyone with osteoporosis, I do do a gut health test. I look exactly what's going on in there. Digestion is super important.

Yeah.

because if you're not digesting all the great foods you eat and your protein, it's, you know, or your collagen powder, whatever it is you do, it's not going to reach you if you can't properly break it down. So, and of course, you know, the exercise. But again, I think the biggest thing is always the stress. I think the stress is going to break everything down, including your bones. And again, if that's overexercise or the environmental stressors or, you know, the environmental toxins, toxins, um, or just you had stress in your life, post-traumatic stress disorder, that, that sets you up, that, that is a risk factor. So I think it's very important to think about that. And yes, do, you know, bone strengthening exercise or weight-bearing exercise. But again, some women, they get so, um, vicious with it, then they get up at 4:30 in the morning to have time to, prior to work, to get an hour to the gym to do this every day. I'm like, No, this is not anti-inflammatory. That's not gonna help your muscles. They need to recover, you know? So again, sometimes I'm like, do you need another app so I show you that you need that recovery time? So again, I think we have to be, to take a step back, look at us, look at our health and our, how we are set up. And then maybe we need a friend to look at it for us.

Yeah.

You know, or of course our physician and help us to put things in the right perspective. Because again, some people might, you know, be on all kinds of bone medications, but they eat a very poor diet. They eat sugar and juices. And I'm like, well, you know, all that Prolia is not gonna— probably not gonna help much. So, or there would be better things to do that would actually help your bones tremendously. So. That's my take on that.

Yeah. So you've mentioned stress a few times, and for our listeners, I just want to define that because I think when people hear stress, they think about just situational stressors, right? And the demand on their day, but it goes much deeper than that. So there's chemical stressors and there's physiological stressors. So even having poor blood sugar control is a stressor to the body. Being anemic is a stressor to the body. And so we have to broaden that lens and we look at what are our stressors, what are the stressors that we can control, we can resolve those physiological stressors, controlling blood sugar, resolving anemia, working on gut digestion, hugely impactful when it comes to helping our stress response recover, right? And then, as your point, getting a friend to help you look at things, look at your life from outside in, and what are the things that maybe we could let go of, right? Release, forgive, move on so that we're not carrying around so much of that stress. And then you mentioned past traumas. Post-traumatic stress disorder is a big deal. You know, sometimes that does prime our system to stay perpetually in that stress loop. So even working with a professional that deals with PTSD and trauma to help you resolve some of that trauma and develop ways of living with that trauma.

Yeah. And, you know, sometimes it's just stressful midlife breakups, or I that really keeps that stress axis in dysregulated state, or the death of sometimes parents. We are all different. We deal with these things in a very different way. But that all happens at the time when we are transitioning through that midlife. But I wanna say the metabolic stress, I think, apart from the situational stressor, that's my number one, really. I mean, maybe that's even more important than the situational stressors, because I wanna argue the situational stressors conditions you might be— your body might be better able to deal with if you don't have that metabolic stressor like the high lipids and the sugar and the inflammation and the stiffening of the vessels, all of that. Absolutely, yes.

So when evaluating your patients in respect to hormone balance and, you know, helping them achieve this optimal state of vitality, are there specific diagnostic tests that you believe, because I think there's a lot of debate out there, that's why I'm asking the question, diagnostic tests that you believe women should have as a part of their yearly preventative or quarterly or every 3 years? What do you recommend?

Yeah. Well, that's easy. That's a straightforward one because that's easy to obtain. So, hemoglobin A1C, absolutely get it. That average blood sugar and don't go for the conventional cutoff that really should be less than 5.4 or right at 5.4. Then get that together with the fasting insulin because the hemoglobin A1C, if you're not eating regularly or you're skipping meals, it's going to average out, but it's a good— it's easy to get. Fasting insulin, also very easy to get. And that really tells us now, it's much more sensitive. It really tells us how much insulin do you have floating in the morning when it should actually be really low because you haven't been eating. So, and that's, you know, sometimes we call it the pre-insulin resistance. That's kind of the most sensitive marker that even everything still might be looking normal. The moment you eat, you actually have quite some blood sugar spikes. So I definitely would do that. Then I love a regular blood count. So CBC, right? Anemia panel and a metabolic panel. We really look at you know, the bicarb and it's, you know, oxidative stress. I would do a C-reactive protein, the high-sensitive one, which is traditionally, you know, it's a cardiovascular risk factor marker, but it's really good at picking up on inflammation. Having said this, doesn't mean that if it's normal, you don't have no inflammation nowhere, but it's a really good one if, you know, to see if your body is in an inflammatory state. Thyroid, but here I'm you know I do like a thyroid panel. I do every test you can really get from LabCorp in terms of a thyroid. Like the endocrinologist, they're always like, "What is she doing?" Like yeah, I I use that. So I really we want to know more than a TSH and a free T3 and a free T4. We want to see the total hormones and the reverse ones, and you know always the antibodies because as you know we kind of want to pick up if there's an early autoimmune issue going on. That's just a good. Sign for me that maybe I have to look deeper into the gut health when I find autoantibodies. And, you know, in functional medicine, we kind of acknowledge about 20 different disorders of the thyroid. In regular medicine, we have like 2 or 3. So there's a lot of nuances to it that we can pick up, particularly if, you know, patients are being told, oh, your labs are normal, but they still have typical hypothyroid symptoms. And it really is worthwhile having a little deeper look. And then, you know, I do check, of course, FSH, so follicle stimulating hormone, just to get a rough idea, even in perimenopause. I'm, you know, I know it doesn't, it can be all over the place. But it gives me, if I know that person a little bit longer, it gives us a little, you know, long-term view where we are. And sometimes we are surprised. There are women who are in premature ovarian, you know, insufficiency. And I'm like, oh, I actually do have to protect your bones. We actually have to know about that. Just today, I had someone 42 years old. I was like, you know, FSH 85. I'm like, oh, okay. You know, surprise. I like that. And so, yes, I think these are the ones I think everyone is really easy, going to be easy to get. Oh, of course, an iron panel. So I like an iron panel to make sure you're not anemic. That can add to fatigue, to hair loss. So yes, I think these everyone is going to be D, excuse me, but they're gonna get this anyway. I think vitamin D has become mainstream. So yeah, so these are the ones. And then of course we have like different calculators in functional medicine. So you can get so much more out of a regular blood work when you kind of really grind it hard and look at the optimal levels and how it really all relates to each other. So I love to do that. I enjoy that.

Yes. Beyond serum testing, Paps and pelvics and bone densities and preventative health for women as as as a whole. Would you agree that those are still necessary? Absolutely, yes. Talk loudly because we've got to hear this from you, and listening to this need to hear this too because I think there's really bad messaging right now.

No, no, no. Absolutely. So really, so first of all, colon cancer screening. This is really killer number 2 right after breast cancer for women. So do not skip that. We have full colonoscopies or Cologuard tests, poop tests. Insurance pays for this. Some insurance even send it to your home without you even asking for it. Absolutely. But that's gonna be picked up early. Yeah, that can be treated. So colon cancer screening, mammograms, 1 in 8 women. It's, you know, and when people are like, no, I have no family history, it doesn't matter. Most of these women have zero family history. And we don't know what it is these days, the environmental toxins or, you know, the endocrine disruptors. It's everywhere. And women are getting it earlier and earlier. So absolutely, please, mammograms. If you do every 1 or 2 years, I don't care, you know, what guideline you follow. If you have no risk factors, every 2 years is fine. If you're on hormones, I kind of say, well, you know, every year I think is reasonable. If you skip one, you know, it's okay. But please, stick with that. Pap smears, we, you know, they are, they have become, we don't, you know, we don't do them every year. So it's not really a big burden. We do them every 5 years after age 35, because we do the HPV co-testing. If there's no human papillomavirus, there's virtually no cervical cancer. So the testing has become so advanced, but then people forget that they still have to do it at age 60.

That's a problem. I think I hate to interrupt there. But listen, So many women have gotten the message that if they're not getting a pap smear, they don't need a pelvic exam. Yeah. And I think that's a problem because then they lose touch with really what's going on in the way of, you know, the pelvic floor. And so I hope to see that turnaround where we're not just getting a pelvic exam during a pap smear.

Yeah. Pelvic exams too. So at 65, the pap smear per se, we can discontinue, but this is just You women, you don't even notice that we do that. This is just, you know, us doing extra swap. The important stuff is really that pelvic exam when we really, you know, every 2 years let someone have a look at your vulva. I find vulvar cancers, you know, the woman says it itches a little bit, the primary care gives them some creams for years, and finally I see that and I'm like, well, why didn't you come? So yes, let us have a gentle look in the vagina that is, you know, not a burden. We just have a quick look at the cervix, make sure there's no polyp. And the good thing is if I see vaginal atrophy that can be easily treated, right? If you have dryness with intercourse or you have recurrent urinary tract infection, urinary frequency, this can be easily treated with, you know, vaginal estrogen or testosterone. This is not considered hormone replacement therapy so that you can take this until the end of your days. And this is just local, but it's so effective. So yes, absolutely come to your doctor because also, you know, hey, maybe you have a new sexual partner. Right? You want to know where to go. This shouldn't be like, oh, I feel weird about it. No, you should have the— I go to my GYN, hey doc, I need some STD screening. Oh, look, I have a new partner and now the vagina doesn't feel so good. You know, and I'm like, oh good, let's give you a little bit extra estrogen. That's going to be all much better. So this is really your quality of life you put kind of at risk if you, you know, you don't have someone you trust. And I also want to say, you know, to, you know, it's important sometimes that patients come back to a provider with the same complaint, you know, don't give up if that provider the first time might brush you off. It's not because we're trying to— sometimes it's, we observe, we are like, we do one thing, you come back, you still have the, you know, we step it up. That's also how, like, we are trained in conventional medicine. And, you know, even a provider who's not so comfortable with hormones, you know, once you come again, and, you know, and that person that also trusts you and know, hey, you actually, you know, they are willing to work with you. So that's the other thing I would like you to know. Don't be like, oh, that's not good. And then you don't go there again. That's, that's not helpful for anyone. Because, you know, healthcare, it is a good thing, you know, these, these, these major things where we have good data, you don't want to dismiss that. This is like you have, you know, an Like auto insurance that, you know, it pays for the big things, you know. And then, you know, sure, if you want some detail work on your car, you might have to find someone else, pay out of pocket. If you say, I need a little bit to look a little deeper because this is now me, I'm different than, you know, the big health data. So that's how I see it.

I love it. So one more question about that screening process. What about bone density? So, bone density screening, when are you recommending that a woman have her first, and then how often should she follow? And I know some of that's based on results, but just in general.

Yeah, no, I— thanks. I forgot the bone density screening the moment I realized you mentioned it. So the official guideline is age 65. I'm gonna— and I just want to explain why that is. This really is because, like conventional medicine, we try to get someone when we are likely to find an more likely to find an abnormality in the big population. So age 65, because around, you know, the most bone loss occurs at the very, the first couple of years after menopause, and then it comes to a plateau. So 10 years later, we are kind of at, you know, we still lose a little bit every year, but the big bone loss has already occurred. So that was the original thinking. We want to pick up the women there and then, you know, then just basically treat if they need it. So. And now, while this is still the official guideline, it always said if there's risk factor like family history of osteoporosis, or your parents broke bones, you have broken bones, there were low-impact fractures, you have autoimmune disease, you have been on cortisone, all this, you could go for an earlier bone density scan. So now the new trend is that we are, because we are more, Before, we were kind of completely, you know, never talked about bones, and now everyone is concerned about their bones. It always goes in extremes. So now I do, you know, I ask— I don't tell people at age 50 because I'm— unless there's a family history, because if they're still cycling, I kind of assume the bones are really still okay. But I would at 55, so 5 years in, that's when I kind of would send someone. And then of course, and then we follow up. So that's very early on, like, you know, even before the last menstrual period. And, you know, someone who was anorexic in the past, definitely someone who has, you know, unexplained low-impact fractures. But just again, because I'm like, well, you know, we are no longer likely to find something that early on because the bone loss has— there's nothing has occurred yet. So I would say do it a little earlier, definitely 10 years earlier than 65.

Yeah, I don't know that anyone's set an age, but I know women reach peak at 30. You know, their peak bone mass typically is around age 30. And I think there would be value in having a screen early to know what was your peak. So we have an idea what the trajectory of loss is. But I know technology changes so much. Are we even going to be comparing apples to apples? That's where I get stuck. Like, you know, in 20 years, are we even looking at the same type of scan to even make an So, bottom line, I wish we had a better way of looking at bone health. I feel like—

Yeah. And, you know, they can regain, you know, because we know all this bone loss we get, let's say they're on Depo-Provera, some kind, you know, we know they regain that. So, I think there is some, yes, there is this, you know, the maximum bone bank you get, but I think there is a little fluctuation, you know, post, after childbirth when you kind of, you know, you are breastfeeding, less feeding, you might have bone loss. So, you know, I think, yeah, sure, we like to know when you were at your peak. The question is, is that still really significant? We just need to know when, you know, when you start losing it, that you get into the break area. So anyhow, I agree, there's a lot of things we still have to learn.

Yes. And I do think that, you know, low lean skeletal mass, muscle mass, We can extrapolate from that data too is where is a person in respect to their bones too. And so, using scanners like— and I don't know if you have a body composition machine as a part of your practice, but having brick-and-mortar practices, we have the beauty of having that, right? And, I do feel like doing that early and monitoring that is really, really important for our patients.

Yeah.

Yeah. I love that you have that. So I don't have it. I'm just— I'm sending patients now to get it done somewhere, and we're actually just trying to figure out. But yes, I mean, if you have that available, of course I would do that because that is a great teaching tool, right? And you can monitor it, and it gives the woman some perspective, you know, in terms of, oh, let's do some, you know, weight-bearing exercise. And, you know, it shows them I'm actually gaining muscle and, you know, not just actually not losing weight, but I'm gaining muscle. It makes them And feel much different about their weight. So I like— congratulations. I would— I'm probably going to think about it. Yes.

And now there are places that you can. I love that you're doing it online. I just had someone the other day who wasn't able to get to our clinic, and they have some resources online that you can connect them with a diagnostic imaging center that has a DEXA scanner that can flip to being able to do body composition. And so it is becoming more accessible. Um, localities that have DI centers, diagnostic imaging centers. So I do like that as well.

Yeah, I love that. I'm actually gonna see in my area, you know, maybe it's easier to get it from like a wellness place. That's probably— yeah, I love that. Great. If I would have that, I would do that too. I have at home like this body composition scale. What do you think about that? Is it good enough? I'm like, I think—

I think it's directing you over time. You know, I think if you have one tool that you're trending over time, it probably isn't as accurate as going to have a full DEXA scan done. But I think that if you're trending yourself, you know, you can see trends.

Yeah. What about— now I have a question actually from what if the patient has really, let's say, a lot of fat tissue in her breast? How is there like— is it complicated for that scanner to still distinguish what is the fat mass or is this only on these at-home Have you ever heard that?

I've not. Have you experienced that, Lori? I haven't really noticed that on our InBody. I feel like it does a pretty good job of assessing where the fat is because it gives you a body measurement segmentally. Yeah, segmentally, so we can see it.

Yeah, it does. But again, there are different levels of machines, right? And the different points of pressure where the InBodies have 8 points of pressure basically, and through algorithms, right, and velocity of current You can see the different types of tissue, if you will, or density that it's traveling through. The problem that I find with some of these machines, particularly with frequency, is that if they have pacemakers or implantable devices that you can't turn off, unfortunately, they can't use the InBody and these frequencies. So, they can, however, use the DEXA scanner, and these DI centers can actually do body composition using the DEXA scanner. So that's kind of a nice ability to do more. You know, more of our patients can do it if they have those.

I like that. I really wanna tell you, I love that body composition scan for another reason now. And now we are gonna go down that rabbit hole, 'cause you know that this is taking this conversation about weight to actually really to health. Like, what is your— because, you know, I was recently on like a cruise or something and they had this scanner, right? And I was like, I would like to lose something. And then they put me on there and they were like, well, we have to lose like, you know, a pound of fat and you have to gain 3 pounds of muscle. And I was like, excuse me, that you meaning I want to lose weight and you say I actually have to gain like 2 pounds net? And I was first like, that is stupid. But of course, then I thought about it, right? And I was like, you know, yeah, you know, I've been also under fueling. I've not, I'm not been metabolically healthy. Yes, I was leaner a couple of years ago, but this was not healthy. So, and I would wish, you know, we wouldn't arrive at age 50 and suddenly have to grind through this whole new thinking. It would be much better. We are 35 and we're going to go on the body scan. And when we are so super thin, actually someone tells us you have to gain muscle and you don't, you know, would be so much better. And then no, get a little bulk up a little bit.

So I love that. Body composition. I mean, we know that, you know, that fat is metabolically active tissue. We know that muscle is the organ system of longevity. And it really is an economical test that really does change the language, is off of weight onto body composition, which is much easier to have a conversation about. Right. That is so important.

Yeah. So thank you so much for your time today. I know we could spend all afternoon chatting it up. This has been awesome. So we always like to ask our guests one parting question. You know, what are— what is the one thing that's made the biggest impact in your health over the course of your life?

I think a continuous glucose monitor, like seeing that, you know, I did this like so many years ago, kind of, I forget to bring this up, but this was for me that, That big, you know, continuous glucose monitor, seeing how sugar affects my blood sugar and how I feel when my blood sugar goes up. When I think, you know, oh, I must— blood sugar must be low because I'm dizzy. And that was the first time I saw, oh no, when I feel dizzy, that blood sugar, that is roaring. So that was for me when I really turned things around and I got a whole new understanding. So that was it for me. The greens and the veggies. The greens and the veggies in my life have turned my life around.

We're geeky too. We love to measure. We both use the continuous glucose monitors personally and in our clinics, and then we use the Oura Ring to track our metrics too. So I love that. Okay, there you go. You're in like company for sure. Yes, that's good.

Well, thank you so much for dedicating You know some of your time today to us and to our community. We have really enjoyed the conversation. Keep doing what you're doing. Keep being out there changing lives and particularly relating to women who just need us. They need us out there. So you keep doing what you're doing, and you do the same.

Likewise, thanks so much.

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