One of the things that hasn't gotten a lot of attention in the menopause space is the gut. It's one of those symptoms that you may have not even thought was related to this stage in life. You may find that you have diarrhea, constipation, and less tolerance with certain foods. Or like my guest Cynthia Thurlow, one bout of food poisoning can turn your gut upside down and have lasting effects for years.

Cynthia is a nurse practitioner and metabolic health expert who explains why the gut matters in midlife and also gives us education on what is actually going on. How estrogen and progesterone directly impact your gut bacteria, motility, and inflammation. And while there are many modalities to treating it, some with good intentions moving from pharmaceutical drugs to vitamins isn't really giving the relief that many women are looking for.

We get into the gut-brain connection, why fiber might be causing bloating, and how to start with the basics to getting your gut health on a good path.

Highlights

• The gut microbiome contains 40 trillion bacteria, viruses, fungi, and protozoa. There are actually more cells in your microbiome than in your entire body.
• Most of the communication on the gut-brain axis goes from gut to brain, not the other way around. What happens in your gut directly affects your brain and mood.
• Ninety-five percent of patients don't eat enough protein. That's problem number one before worrying about fiber or any other intervention.
• Sitting down to eat and taking four to five deep breaths before meals shifts you out of sympathetic and into parasympathetic mode. This alone can improve digestion.
• There's a direct connection between gut microbiome health and vaginal microbiome health. They're not separate systems.
• Screening for adverse childhood events and trauma changes how you approach treatment because it rewires the autonomic nervous system and affects gut health.

If you're experiencing digestive changes during perimenopause or menopause, this episode is for you. Understanding your gut is the first step to feeling better. If you found this helpful, please subscribe so you don't miss future conversations about what real midlife health looks like.

Note: We experienced some audio technical difficulties during this recording. We've worked to enhance the sound quality as much as possible. Thank you for your patience and for listening.

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I'm Dr. Smeena Rahman, sex med gynecologist menopause specialist in downtown Chicago. Today I'm super excited to have a good a friend and colleague that is gonna talk to us about why it feels like our body has changed overnight when you turn 40. because your digestion might be off, you might be bloated, gaining weight in the midsection, all the things.

Wondering what is it exactly that's causing this? Is it hormones? Is it gut? Is it stress? Is it both? Is it everything all at once? we're gonna get into all that. So I am just super excited to bring in Cynthia Thurlow. I was had the pleasure of being on her podcast. She's a nurse practitioner, also a a metabolic health expert as well as author of the new book that has just been released, The Menopause Gut.

Where she breaks out on how hormone changes in perimenopause and menopause directly impact digestion, inflammation, metabolism, overall health. Thank you, Cynthia, for being here. Finally, we are doing this. Cancellations time and time again. so I want to get right into it. I wanna talk about, well, you know, my n name on Instagram is Gyno Girl, so I love superheroes, I love backstories.

Thanks for having me.

I love, you know, what is your backstory. So I'll always have to start with why. Like why did you how did how why and how did you come into the space of midlife healthcare with women and then specifically when it comes to GI issues? I know in your book you talk about your experiences, but let's let's let let's educate the audience about why your why what your why is. Yeah, absolutely. And to give everyone some perspective, I'm someone that's been

Yeah, absolutely. And to give everyone some perspective, I'm someone that spent, gosh, 20 years between ER medicine and cardiology, first as a ER and trauma nurse in H30 Baltimore, and then for 16 years working in clinical cardiology as an MP. And as I like to tell everyone, I'm a reformed adrenaline junkie. And about 10 years ago, I got really tired of just writing tons and tons of prescriptions for lifestyle as medicine related issues. And so I was that

Gosh, twenty years between ER medicine and cardiology, first as a ER and trauma nurse in Nish City Baltimore, and then for fifteen years working on clinical cardiology as MNP. And as I like to start when I'm a reformed adrenaline junkie. And about ten years ago, I got really tired of just writing tons and tons of prescriptions for lifestyle medicine related issues. And so I was that typical perimenopausal female who was woefully unprepared.

typical perimenopausal female who was woefully unprepared. my lifestyle no longer matched my physiology. And so I I took a massive leap of faith and really kind of dove into the perimenopause menopause space as a perimenopausal female and built up a business with direct patient care group programs, did a couple TED talks, wrote a couple books, but

my lifestyle no longer matched my physiology. And so I I took a math view space and really kind of dove into the perimenopause case as a perimenopause female and built up a business with direct patient care group programs, did a couple TED talks, wrote a couple books. But I think because I have a podcast myself, it's allowed me an opportunity to really interview all these outlets and scientists and

I think because I have a podcast myself, it's allowed me an opportunity to really interview all these thought leaders and scientists and physicians and nurse practitioners and experts. And it became very clear to me, both from my experience working with patients, but also talking to experts that the microbiome, really, it's been the last five to ten years, it's this burdening area of research, but it helps explain why so many women have bloating.

physicians and nurse practitioners and experts. And it became very clear to me both from my experience working with patients, but also talking to experts that the microbiome, really it's been the last five to ten years, is this burgeoning area of research. But it helps explain why so many women have bloating, constipation, diarrhea, underlying food sensitivities, brain fog, you know just the kind of conventional perspectives that it's all driven by

constipation, diarrhea, underlying food sensitivities, brain fog, beyond just the kind of conventional perspectives that it's all driven by you eat too fast, you're too active, you're too stressed. And so during the course of the past gosh two years, when I really dove in the research, it was definitely evident to me as we are losing progesterone, estradiol, we get a lot of alterations in motility, changes in insulin sensitivity.

You eat too fast, you're too active, you're too stressed. And so during the course of the past gosh, two years, when I really dove in the research, it was definitely evident to me as we are losing progesterone, ethyl, we get a lot of alterations in motility, change influence sensitivity. And we just don't feel the same. And it's not something that's contrived in our heads, but it's real. I am the first person to say I do a thing.

And we just don't feel the same. And it's not something that's contrived in our heads. It is real. I am the first person to say that doing elimination diet in 2020 14 and then again in 2018 just provided a lot of insight into how my body was reacting to it. And then I always say the power I experiment on myself and then put patients. And so it's

diet in 2020 14 and then again 15 just provided a lot of insight into how my body was reacting and then I always say the power I experiment on myself and then and so it's insightful but I would actually argue that with that microbiome intersection with a reflection point of the working system in our body and everything

insightful but I would actually argue that the gut microbiome intersection or a reflection point between every organ system in our body and every cell and so the more that we understand the gut microbiome the more the rest of the body makes sense to me and it wasn't something that I learned during any of my training years ago but really it's been on the fly the last five to ten years. And I would argue that there's a lot to this hormonal milieu

And so the more that we understand that microbiome, the more the rest of the body makes sense to me. And it wasn't something that I learned any of my training years ago, but really it's been on the fly the last five to ten years. And I would argue that there's a lot to this hormonal milieu of menopause and menopause. But in many instances, a lot of the symptoms my patients are experiencing are really a reflection of the health of the microbiome or the allergy of the microbiome.

menopause and menopause, but in many instances, a lot of the symptoms my patients are experiencing are really a reflection of the health of the microbiome or the microbiome.

Mm. No, I think it's totally true. And I think, you know, there's so many properties within our hormones and how they interact with each. I would say, like, you know, the the hormones are only as good as the receptors that interact with the at the tissue level. And so we don't know how your body's gonna respond at different tissues and the gut microbiome for sure, you know, takes a hit for so many people with inflammation.

What let's just first define like when you say menopause gut, what are you talking about? It's really speaking to how the gut microbiome changes in perimenopause and menopause. So not surprisingly, the gut microbiome is 40 trillion bacteria, viruses, and fungi and protozoa that accompany large intestine or colon. So it is a mini-city. There's actually more cells in the microbiome than there are human cells. So to give you a sense.

It's really speaking to how the gut microbiome changes in perimenopause and menopause. So not surprisingly, the gut microbiome is 40 trillion bacteria, viruses, and fungi and protozoa that accompany the large intestine or colon. So it is a mini city. There's actually more cells in the microbiome than there are human cells. So to give you a sense, but it's not as tangible as a heart, a lung, a vagina, a uterus. And so because of that, people really don't fully understand.

But it's not as tangible as a heart, a lung, a vagina, a uterus. And so because of that, people really don't fully under appreciate why it's so important. But when I speak to the changes that are happening in the microbiome, it's really the understanding that as estrogen declines, one example, we get changes in diversity. So the beneficial bacteria start to disappear. We have more inflammation.

Or appreciate why it's so important. But when I speak to the changes that are happening in the microbiome, it's really understanding that as estrogen declines, one example, we get changes in diversity. So the beneficial bacteria start to disappear. We have more inflammation. We get changes in immune system function, which makes us more susceptible to opportunistic infections. We get changes in key signaling molecules like short-chain fatty acids, which

We get changes in immune system function, which makes us more susceptible to opportunistic infections. We get changes in case signaling molecules like short-chain fatty acids, which for everyone listening, this is why fiber becomes so important in midlife. fiber actually ferments in the large intestine. These short chain fatty acids are responsible for many things. Some can cross the blood-brain barrier, some are responsible for endogenous.

For everyone listening, this is why fiber becomes so important in midlife. fiber actually ferments in the large intestine. These short chain fatty acids are responsible for many things. Some can cross the blood and brain barrier, some are responsible for endogenous GLP1 stimulation, reduction in inflammation, mucus production. And so when I talk about the menopause bed, it's really the transitional point of perimenopause to menopause. So

reduction in inflammation, mucus production. And so when I talk about the menopause gut, it's really the transitional point of perimenopause to menopause. So mid to late 30s into early 50s and beyond. And it helps explain a lot of the symptoms that patients experience. But as I remind my patients all the time, the gut microbiome interfaces with every single organ system. There's a gut ovarian access, we got bone access, we've got brain access, etc, etc. So

mid to late 30s into early 50s and beyond. And it helps explain a lot of the symptoms that patients experience. But as I remind my patients all the time, the gut microbiome interfaces with every single organ system. There's a gut ovarian access, a gut bone access, a gut brain access, et cetera, et cetera. So there's very much this synergistic relationship and nothing exists in a vacuum as much as

There's very much this synergistic relationship and nothing exists in a vacuum as much as we might have been trained to believe that everything exists in a siloed bucket depending on their specialty. But I would actually argue that everything that are faces with the microbiome. So the more we can do proactively to offset what's happening hormonally and changes in neurotransmitters, probably the less symptoms our patients are going to experience and the better they're going to feel. Yeah, for sure.

We might have been trained to believe that everything exists in a siloed bucket depending on our specialty. But I would actually argue that everything interfaces with the microbiome. So the more we can do proactively to offset what's happening hormonally and changes in neurotransmitters, probably the less symptoms our patients are going to experience and the better they're going to feel.

you know, in your book you talk about your story and how you kind of like came to realize some of what was happening. you know, when you talk about some of the instances where you had issues around your GI tract and your gut. Mm do you want to talk to the listeners about sort sort of this personal battle that you had for a while?

You're breaking up a little bit. I don't know if

You're breaking up a little bit. don't know if Did you hear me? No, I it was like you you got no, because it's it's yeah, there was like a connection thing that started Okay. Yeah. you know, Cynthia, in your book you talk a little bit about your own, you know, struggles as you were entering this phase and really the GI struggles that landed you in, you know, different urgent cares and all the things. Do you wanna tell the listeners a little bit about that and how that was such an impetus for you to kind of be like

No, I it was like you you got stuck. I didn't hear you. Yeah.

Why don't we know more about this? Why aren't people talking about this? Yeah, I love how life imitates art. So I went on this romantic trip to Morocco with my husband. We ate the same food, we did the same activities. One of us got really terrible food poisoning. And I actually wasn't feeling well for the duration of our trip, even going on to Spain, coming home. And it kind of set me up. I picked up a friend in Morocco and I say a friend is in

Yeah, I I love how life imitates art. So I went on this romantic trip to Morocco with my husband. We ate the same food, we did the same activities. One of us got really terrible food poisoning. And I actually wasn't feeling well for the duration of our trip, even going on to Spain, coming home. And it kind of set me up. I picked up a friend in Morocco, and I say a friend is an an air quote friend here. I didn't yet notice.

an air quote friend Yardia didn't yet notice. But it buttoned me up for a second dot of food poisoning a few months later and then ultimately a 13 day hospitalization in the hospital where I had a ruptured appendix, a whole school of complications, and the working hypothesis all the way along was the giardia that you picked up in Morocco was probably kind of brewing along over the past several months and probably contributed to why

But it set me up for a second out of food poisoning a few months later and then ultimately a 13-day hospitalization in the hospital where I had a ruptured appendix, a whole slew of complications. And the working hypothesis all the way along was the ajarity of that you picked up in Morocco was probably kind of brewing along over the past several months and probably contributed to why you ended up having this lengthy hospitalization. I had a small ballad correction, I had pancalitis, I had a fistula.

you ended up having this lengthy hospitalization. I had a small bowel fraction of cankylitis. I had the fistula. I mean, I was so sick. And I even was so sick that when I left the hospital, I

I mean, I was so sick. And I even was so sick that when I left the hospital, I didn't have a appendectomy. I actually come had to come back six weeks later because I was too sick to take it out. So I was sent home. And the entire time I kept saying, How does someone that's as healthy as I am get so sick? So that was number one. And then you know, obviously six weeks later I had my appendix out. But I remember saying to the gastroenterologist, the surgeon, the infectious disease specialist.

Later because I was too sick to take it out. So I was sent home. And the entire time I kept saying, How does someone that's as healthy as I am get so sick? That was number one. And then you know, obviously six weeks later I had my appendix out. But I remember saying to the gastroenterologist, the surgeon, the infectious disease specialist, I was like, What would have happened if I had been any other forty something year old person? And they're like, You probably would have died. So

I was like, what would have happened if I had been any other forty something year old person? And they're like, You probably would have died. So I'm not minimizing my experience, but when I reflected back on it, it's I don't think I had any idea how profoundly our immune system changes and our gut permeability changes because I obviously was exposed to a pathogen.

Not minimizing my experience, but when I reflected back on it, it's just I don't think I had any idea how profoundly our immune system changes and our gut permeability changes because I obviously was exposed to a pathogen. There was a massive amount of endotoxin yet, so lipopolysaccharides moved into my bloodstream, triggered immune response, contributed to a working like the gut, and made me quite sick. And so that got me curious.

There was a massive amount of endotoxinia, so little polysaccharides leaked into my bloodstream, triggered immune response, contributed to a worse than leaky gut, and made me quite sick. And so that got me curious to better understand physiology because I think for many people, even health care providers themselves, we tend to think about perimenopause and menopause through a lens of brain bone and heart health solely. And what I have learned that

better understand the physiology because I think for many people, even health providers themselves, we tend to think about your menopause and menopause through a lens of brain bone and heart health. Yeah. Solely. Yeah. And that's only just recently. And that's just recently. Like I feel like before it was just like your you know your cycle stop and you have hop lashes. Right. It's like you're cliff and that's all that happens. But I now very humbly say it is a systemic change.

Yeah and and

Right. It's like you f off a cliff and that's all that happens. But I now very humbly say it is a systemic change. And the immune system was certainly something that I didn't fully appreciate enough because we just assume it works, right? We just feel like we fight out perfections, we feel better. and yet now I understand it at a level that I never never thought I would through the lens of what's changing specifically as estrogen and progesterone are declining that just make you so much more susceptible.

And your immune system was certainly something that I didn't fully appreciate enough. Just assume it works, right? We just feel like we fight out infections, we feel better. and yet now I understand it at a level that I never never thought I would have through the lens of what's changing specifically as estrogen and progesterone are declining that just make me so much more susceptible to opportunistic infections. And the best way I can explain it is

to opportunistic infections. And the best way I can explain it is generally ruptured appendix is happening in younger patients. Like I was on like a very kind of older age of prevalence and incidence. And you know, all I was told over and over again was like, the GRD has just started the process. It probably would have happened anyway. Having said that. So for me, it began a journey of

Generally, rupture dependics would happen in younger patients. Like I was on like a very kind of older age of prevalence and incidence. And you know, all I was told over and over again was, the GRD has just started the process. It probably would have happened anyway. Having said that. So for me, it began a journey of exploration of like what's really happening at a cellular level. And then also very transparently, when you go from being so sick and you're on

exploration of like what's really happening at a cellular level and then also very transparently when you go from being so sick and you're on like six plus weeks of antibiotics, antifungals, and you survive, you're like, okay, the that's great. But now I have chronic diarrhea and I was full carnivore for nine months. And it took me 18 months to tolerate a cooked vegetable. And so when patients now say to me, I don't tolerate fiber, there's already bells and whistles going

Like six plus weeks of antibiotics, antifungal, and you survive, you're like, okay, that that's great. But now I'll have chronic diarrhea and I was full-solivore for nine months, and it took me 18 months to tolerate a cooked vegetable. And so when patients now say to me, I don't tolerate fiber, there's already bells and whistles going off in my head. Because if the microbiome has been so decimated that someone is unable to tolerate fiber, it's a sense that

my head because if the microbiome has been so decimated that someone is unable to tolerate fiber, it's a sense that or gives you a sense that there is a significant change. So like every brush border enzyme, everything intrinsically that was part of my microbiome and my gastrointestinal tract had been decimated to save my life. And so it really just speaks to number one, building awareness about how the gut changes number two,

Or it gives you a sense that there is a significant change. So, like every brush border enzyme, everything intrinsically that was part of my microbiome and my gastrointestinal tract had been designated to save my life. And so it really just speaks to number one, building awareness about how that changes. Number two, the humility to understand that even as medical providers, sometimes we don't know everything. And then number three, what I've been able to do in terms of

the humility to understand that even as licensed medical providers, sometimes we don't know everything. And then number three, what I've been able to do in terms of healing my own gut over the past seven years has been pretty incredible. But it's information that ultimately benefits patients and became really the basis of the book.

feeling my own gut over the past seven years has been pretty incredible, but it's information ultimately benefits patients and became really the basis of the book. Yeah, no, that's great. And I feel like, you know, with all that we know about, you know, perimenopause, menopause, and we know that, you know, there's so many inflammatory conditions that are hormonally susceptible, right? Like endometriosis is truly a full systemic condition that is you know, inflammatory in nature.

that has been lumped into the GYN only space, but it really can impact people from head to toe, the same as what we now refer to as polyendocrine metabolic ovarian syndrome, which is formerly known as PCOS. And so I think that we have all these inflammatory symptoms that, you know, we likely are now even more and more thinking about through the lens of even mast cells that are active, you know, in the gut and epithelium or, you know,

in the vulvo vaginal vestibule, you know, we see these mast cells that, you know, really do degranulate nerve growth factors and inflammatory factors and all the things that, you know, it and make and and and they're regulated by hormones. So it makes you think about all the times of hormonal suscepti susceptibility that women experience and how if they have these inflammatory sort of like conditions that are really

dictating their systemic the way their system's gonna respond, how it can really like decimate the the the the gut i issues, right? Like it can really impact them significantly to the point where I think everything gets lumped in this box of IBS, irritable bowel syndrome, which is like really an you know a diagnosis of exclusion once you've ruled out any any other causes. Right. And so

you know, for s for those of us that treat things in in the GYN space like endometriosis and some of these other inflammatory conditions, we know they're intricately linked. And so, and all of these things are hormonally susceptible. So I think it's very interesting to think about the gut in that capacity as well. Yeah, and I I think it's interesting that we're now having a much more progressive view on endometriosis as an autoimmune condition, that MLS is finally respect and

Yeah, and I I think it's it's so interesting that we're now having a much more progressive view on endometriosis as an autoimmune condition, that PMOS is finally giving the respect and quite frankly, the focus on metabolic health that it always should have had. And I think for a lot of women it's invalidating to know that endometriosis is far more can more common than previously thought. That PMOS

quite frankly, the focus on metabolic health that it always should have had. And for a lot of women it's no that endometriosis is far more can more common than previously thought. That PMOS is a number one endocrine disorder that we see here in the United States, not hypothyroidism as commonly thought to be the case with diabetes. And so I think it really speaks to being able to serve women at a higher level and with greater awareness. Like I I feel like our generation

the netherland endocrine disorder that we see here in the United States, not hypothyroidism, which is commonly thought to be the case with diabetes. And so I think it really speaks to being able to serve women at a higher level and with greater awareness. Like I I feel like our generation of women are just doing a much better job of advocating for ourselves as well as our patients, demanding better care, which will ultimately lead to

Women are just doing a much better job of advocating for ourselves as well as their patients, demanding better care, which would ultimately lead to future generations really benefiting from our own advocacy and and standing up not only for ourselves, but for the quality of care that our patients should be receiving. And, you know, I think a great deal about the baby baby boomer generation, which is my mom's generation.

future generations really benefiting from our own advocacy and and standing up not only for ourselves but for the quality of care that our patients should be receiving. And, you know, I think a great deal about the baby baby boomer generation, which is my mom's generation, and how so many of them were impacted by the women's health initiative. I feel like we will be doing Mia Culpa forever. but but also looking at their quality of life and how grateful they are that our generation is really

And how so many of them were impacted by the Women's Health Initiative. I feel you will be giving me a culpa forever. I know. but but also looking at their quality of life and how grateful they are that our generation is really helping to drive better outcomes for patients ultimately and getting greater clarity about a lot of these diagnoses of exclusion, whether it's fibromyalgia, whether it's endometriosis.

helping to drive better outcomes for patients ultimately and getting greater clarity about a lot of these diagnoses of exclusion, whether it's fibromyalgia, whether it's endometriosis. I was talking to a colleague who's a GYN male GYN recently and he was saying, he's older than I am, but he said endometriosis was thought of as just a uterine problem. And now we acknowledge that it is far more profound than that. And he said, I'm so grateful because I realized that years ago, but

I was talking to a colleague who's a GYN, male GYN recently, and he was saying he's older than I am, but he said endometriosis was thought of as just a uterine problem and now we acknowledge that it is far more profound than that. And he said, I'm so grateful because I realized that years ago. Yeah, same. Everyone else just wants to look at it as a container. This is a GYN problem. You know what it's a systemic health issue. Right. And I think, you know, that is consistently

Everyone else just wants to look at it as a container. This is a GYN problem. You know what it's a systemic health issue.

Probably one of the bigger problems for people navigating the healthcare system, especially women who are oftentimes dismissed because of their symptoms, is really the fact that, like, you know, if you go to like, you know, you're trying to get some evidence-based care, so much of our care is siloed, right? Like, you're a specialist in this, you're a specialist in that, you know, this is a specialty clinic for that. That, you know, who's making who's making the connections with everything? And that's why, like, for someone like

myself and you know, and for others like your yourself as well that we do treat menopause, which we know perimenopause is full body systemic issue because we have hormones all over our body, receptors all over our body for estrogen, testosterone, all the things. And so understanding that, you know, we can't continue to just see like I'm a gynecologist. I'm I used to joke like my area is right here, like the pelvis and blood. But like now I don't say I never say that anymore because I'm always like, no, I mean everything that we know about hormones and these times of

hormonal susceptibility like perimenopause and going from pregnancy to postpartum or you know puberty, all the things, all the peas. you know, we know that these are times where like people have full body sort of situations happening, like s systemic issues that are being impacted, their mental health is being affected, their cognitive health, their you know, their muscoskeletal health, their sexual health, all the things. And so it's really we can't we can no longer afford to continue to silo ourselves.

without considering other systems and how they interplay, which I think is the whole point of a lot of what you're saying your gut. menopause put that book. And I think you said that so beautifully that we are all interconnected and any provider that's thinking of siloed care, especially as a person to midlife women, is really missing a boat. Like I'll give you an example, I have a I just die that turned into play and when I was having a conversation with my ophthalmologist

Yeah, no, and and I think you said that so beautifully that we are all interconnected and any provider that's thinking of siloed care, especially as it pertains to midlife women, is really missing the vote. Like I'll give you an example. I have a I just die that turned into a Plazian and when I was having a conversation with my ophthalmologist, she very astinely stated, Well you realize estrogen is involved with those median glands.

She very simply stated, well, you realize estrogen is involved with those medium glands. Yeah. And that's probably why you've had your second sky in two years. And now we need to And why you want to scratch your eyes out every day because of the dryness. Exactly. I'm like this darn gland. So you're controlled by estrogen. But I I think it's time for all of us to realize, even as this middle aged women, that it's all interconnected. There's no siloed approach to care. And if people are still

And that's probably why you've had your second sky in two years. And now we need to, you know, look at the exactly. Exactly. I'm like those darn glands, but you know, controlled by estrogen. But I I think it's time for all of us to realize, even as just middle aged women, that it's all interconnected. There's no siloed approach to care. And if people are still working in a very siloed approach, when they take care of middle aged women, they're gonna miss opportunities to serve them.

working in a very pilot approach when they take care of middle-age women, they're gonna miss opportunities to serve them. Absolutely. I mean I think it's wonderful. I had a discussion with Pam, Dr. Pam Maida this morning, you know, she's an orthopedic surgeon. And when we were talking and she was saying that, like, you know, I asked people when their last menstrual was and da da da, because we know about the musculoskeletal syndrome and menopause. And even my husband who's interventional pain sports medicine, when he's treating frozen shoulder or these joint issues, he's always like, well

You know, are you still menstruating? And people are like, Why is this guy screaming? But again, like you can't separate a joint from this full person, right? Like, and so I think that it's really important that you know this awareness is happening. It's wonderful. and and so to your point, when we talk about the gut and the brain access, like can we talk about that a little bit? Yeah, I think people are surprised to know that there is this wonderful vagus nerve. It's the cranial nerve, longest nerve in the body that runs through the brain. Can you hold on one second? My

Amazing.

Yeah, I think people are surprised to know that there is this wonderful vagus nerve. It's the cranial nerve, longest nerve in the body that runs from the brainstem through the digestive

I I have a son in the air for time. I'm so sorry, hold on. Yeah. When? What time? Like six. yeah, maybe it was told you I was at home instead of my normal location. I get it. I'm like, why are you bothering? Adult son and I'm like, we're bothered that night. Yeah. Sorry. I'm sorry to worry.

No, no, no. I get it. Sometimes it's me. You know, I'm like looking at my adult son and I'm like, hold on a second. but when we're talking about this gut brain access, we're really speaking to the vagus nerve. It's the longest nerve in the body, one of the cranial nerves runs from the brainstem through the digestive system, innervates nearly every organ, and is really in responsible for this communicate bi-directional communication. Interestingly enough, most of the communication is

The vagus nerve. It's the longest nerve in the body, one of the cranial nerves runs from the brain stem through the digestive system, innervates nearly every organ, and is really responsible for this bi-directional communication. Interestingly enough, most of the communication is so it's going from the gut to the brain, not the opposite, which is what most of us are led to believe. But I remind women that what's on in the gut doesn't stay in the gut. It's not like

So it's going from the gut to the brain, not the opposite, which is what most of us are led to believe. But I remind women that what's going on in the gut doesn't stay in the gut. It's not like, you know, Las Vegas. And so if you're dealing with a lot of inflammation, a lot of opportunistic infections, you've got leaky gut, you very likely are going to have transmission of that information to the brain. So I always say the blood brain barrier is designed to be impermeable. But more often than not, if you've got a leaky gut, you've got a

No, Las Vegas. So if you're dealing with a lot of inflammation, a lot of opportunistic infections, you've got leaky gut, you very likely are going to have transmission of that information to the brain. And so I always say the blood brain barrier is designed to be impermeable. But more often than not, if you've got a leaky gut, you've got a leaky brain, for lack of a better way to explain it. And so you can experience neurologic symptoms as a reflection of what's going on in the gut. So if you

leaky brain, for lack of a better way to explain it. And so you can experience neurologic symptoms as a reflection of what's going on in the gut. So if you have a lot of inflammation, I could show up as brain fog, it can show up as changes in cognition, memory, learning, word finding, anything related to that is not just solely related to a change in estrogen, although it can be exacerbated by that for sure.

have a lot of inflammation. I could show up in brain fog, it can show up in changes in cognition, memory, learning, word finding, anything related to that is not just solely related to a change in estrogen, although it can be exacerbated by that for sure. The other thing that I think is really intrinsically interesting is the bulk of the neurotransmitters that our body makes GABA, serotonin, dopamine, et cetera, made in the gut. And what I find infinitely interesting is

The other thing that I think is really intrinsically interesting is the bulk of the neurotransmitters that our body makes, GABA, serotonin, dopamine, et cetera, are made in the gut. And what I find infinitely interesting is gosh, this was really dating myself. Back in the nineteen nineties, when we were learning about selective serotonin SSRIs that act in the brain.

Gosh, this was really dating myself back in the nineteen nineties. When we were learning about the old nineteen hundreds. SSRIs that act in the brain, it with the understanding that actually the bulk of these neurotransmitters are created in the gut. So when someone's having mood changes, more anxiety, more ability, more irritability, more depression pick symptoms, even O C D type type symptoms, I'm automatically thinking

With the understanding that actually the bulk of these neurotransmitters are created in the gut. So when someone's having mood changes, more anxiety, more ability, more irritability, more depression type symptoms, even OCD type type symptoms, I'm automatically thinking this may not just be a hormonal piece. This may actually be a contributory issue with gut inflammation or opportunistic infection. So I think the gut brain access is fascinating. I think that it is

This may not just be a hormonal piece, this may actually be a contributory issue with gut inflammation or opportunistic infection. So I think the gut brain access is fascinating. I think that it is becoming more well known if you see misconnections, but gut brain health is so so connected, so important, so vital. And when we're talking about perimenopause, yes, a decline in progesterone can absolutely change.

becoming more well known that people are making those connections, but gut brain health is so so connected, so important, so vital. And when we're talking about perimenopause, yes, a decline in progesterone can absolutely change insulin sensitivity, can excuse me, can change GABA signaling, can impact anxiety, depression, sleep.

insulin sensitivity can excuse me can change Java signaling, can impact anxiety, depression, sleep. But it can also be a neurotransmitter problem. And so it's always a little bit of a piece of a puzzle depending on the symptoms the patient's experiencing. And then determining what's the most leverage role. Do we add some progesterone? Do we work on your gut health? Probably we'll do work concurrently. But with the acknowledgement that healthy neurotransmitters are made in a healthy gut.

But it can also be a neurotransmitter problem. And so it's always a little bit of a piece of a puzzle depending on the symptoms a patient's experiencing. And then determining what's the first lever to pull. Do we add some progesterone? Do we work on your gut health? Probably we'll do both concurrently. But with the acknowledgement that healthy neurotransmitters are made in a healthy gut. And if you're eating standard American diet, drinking a lot of alcohol, smoking, toxic relationships, you have no boundaries.

And if you're eating standard American diet, making a lot of alcohol, smoking, toxic relationships, you're having boundaries, a lot of chronic stress is not going to help that microbiome either. And so I think on a lot of different levels, very comprehensively when we're talking to our patients about how the gut brain acts influences not just our perception itself, but how we interact with our environment as well. And can lead to symptoms or can improve symptoms depending on what interventions we use.

chronic stress is not gonna help that microbiome either. And so I think on a lot of different levels it's really thinking very comprehensively when we're talking to our patients about how the gut brain acts influences not just our perception of self but how we interact with our environment as well. And can lead to symptoms or can improve symptoms depending on what interventions we use.

No, totally. I think it's true. I mean, you know, to the point of this like you know, diagnosis of exclusion that's always been irritable bowel syndrome, it's it's not totally off in the fact that when people get stressed more stressed and they have more you know, anxiety. a lot of people hold that internally, right? And so, there's definitely that correlation, but I think it's it's bigger picture than just

in your head, right? It's it's it's you can't disconnect it is the point, right? Like I think what's happened so much in women's health, and you and you know this just as well as I do is that you know we've had this historical sort of baseline systemic, you know, sexism that has existed with regard to how we view women's health care and the chronic dismissal that happens time and time again for symptoms that we don't have automatic researched answer for. Like

you've like for for me in my area of what I treat on a day to day basis, something like sexual pain, which we've you know, you always tell people relax, you know, not we I never told anyone this, but like people have always been told, okay, you know, you'd relax, have a glass of wine, like, you know, do things that are, you know, gonna stimulate you know, your relationship and all the things, which, you know, all those factors are important, but we have biologic reasons that people have sexual pain. We have pelvic fluorys, we have

Yeah.

hormonal changes. We have too many nerve endings at the opening of the vagina at the vulvar vestibule. So there's significant issues that occur, but that's not to say that we should exclude, you know, the component of your mood and mental health either. You know? So I think it's a fine balance of just, okay, this is all in your head. So go see a psychiatrist versus, okay, part of of course, I mean it's like anyone, right, in chronic pain. Chronic pain patients have depression and they have anxiety. And it takes them

A lot of intestinal fortitude. The patients I see that I'm their seventh or eighth pa provider, you know, it takes them a lot of intestinal fortitude to tell their story again because they're afraid to get dismissed over and over again, right? So I think we can't dismiss that portion. I mean, how do you navigate that with your patients? 'Cause I mean, that's probably what they've been told, right? This is in your head. You need to see psychiatry, you need to see a therapist. And Yeah, I think I think half the

Yeah, I think I think half the

challenge is just listening to our patients because when we're in a traditional environment where we're seeing a new patient every 10 or 15 minutes and you know we've got the hand on the door and you're like, please don't ask me. And it's not because I don't want to listen, but if you if we diverge from the focus of the conversation, it then makes me it's that domino effect of everyone thinking, okay, the next patient's gonna be late and then it becomes the entire day. But I always even say to to not just other patients or clients, but to other nurse practitioners, other physicists

challenge is just listening to our patients. Because when we're in a traditional environment where we're thinking commission every 10 or 15 minutes and you know we've got the hand on the door and you're like, please don't ask me. And it's not because I don't want to listen, but you if we diverge from the focus of the conversation, it then makes me it's that domino effect of everyone thinking, okay, the next patient's gonna be late and then it becomes the entire day. But I always even say to to not just other patients or clients, but

To other nurse practitioners, other physicians that I interact with, I'm like ninety percent is just listening to the patient in a safe space, in a non-judgmental space. And to your point about how many women have been dismissed, whether it's pain, sexual dysfunction, digestive issues, mental health issues, they have tried to create safe spaces to share their concerns, but they're either

That I interact with, I'm like 90% is just listening to the patient in a safe space, in a non-judgmental space. And to your point about how many women have been dismissed, whether it's pain, sexual dysfunction, digestive issues, mental health issues, they have tried to create safe spaces to share their concerns, but they're either they're either being viewed as, okay, well, I'm trying to figure out where to put this patient into a bucket. So are they in a pain bucket?

They're either being viewed as, okay, well, I'm trying to figure out where to put the patient into a bucket. So are they in a pain bucket? Are they in a mental health bucket? Are they in multiple buckets? I think for many in many instances, patients are they're so concerned that they're not going to be able to speak their truth or they're not going to be supported in a way that it's going to allow them the opportunity to share what they're concerned about, especially for someone that has

Are they in a mental health bucket? Are they in multiple buckets? I think for many in many instances, patients are they're so concerned that they're not going to be able to speak their truth or they're not going to be supported in a way that is going to allow them the opportunity to share what they're concerned about, especially for someone that has high ACE scores, PTSD history. for a lot of these patients, feeling a sense of

My A scores, PTSD history, for a lot of these patients, feeling a sense of comfort in in sharing and disclosing very personal things, things that they might otherwise not even speak to their spouse about, or even close friends. I think creating that environment where patients feel comfortable to share is number one. And then it's okay to not know exactly what's going on with a patient, but saying, Okay, well, I'm not a hundred percent sure what the next epic is gonna be, but I'm gonna find out or

comfort in in sharing and disclosing very personal things, things that they might otherwise not even speak to their staff about, or even a close friend. So I think creating that environment where patients feel comfortable to share is number one. And then it's okay to not know exactly what's going on with the patient, but saying, okay, well I'm not a hundred percent sure what the next step needs to be, but I'm gonna find out. Or if I'm not the right person, I'm gonna make sure I get you to the right person.

I'm not the right person, I'm the right I'm gonna help you find someone. because inevitably in my line of work, sometimes somebody needs to be gastroenterology, sometimes somebody needs to see hematology, somebody needs to see a gynecologic expert. And I have no problems making referrals. But I think in many ways, kind of the patriarchal nature of medicine has allowed many women to experience a lot of pain, a lack of communication, an acceptance of this is just the way things are, just accept it.

Because inevitably in my line of work, sometimes someone needs to see gastroenterology, sometimes someone needs to see hematology, someone needs to see a gynecologic expert. And I have no problems making referrals. But I think in many ways, kind of the patriarchal nature of medicine has allowed many women to experience a lot of pain, a lack of communication, and acceptance of this is just the way things are, just accept it. I think even for myself, you know, even my experience

Even for myself, you know, even my experience when I went from reproductive endophrenology trying to get pregnant to a specialist during my pregnancies and I ha just happen to have male providers who were great. But there were definitely moments even with as much information as I knew, I was like, we're just assuming that everything hurts, every intervention hurts, everything hurts. I don't really explain the team the in what to expect. Yeah. And so I just share that just to say that even

When I went from reproductive endophrenology trying to get pregnant to a specialist during my pregnancies. And I ha just happened to have male providers who were great. But there were definitely moments that even with as much information as I knew, I was like, We're just assuming that everything hurts, every intervention hurts, everything hurts. And so I just share that just to say that even

Even a licensed medical provider can sometimes not even articulate or feel comfortable in an environment to share how they're feeling if they don't feel safe. You know, I don't feel safe because maybe someone has experienced some type of sexual trauma or sexual abuse. And I don't mean to get off on this tangent, but it's relevant to the gut because we know that ex you know, adverse childhood events, I A scores, CTSD will rewire autonomic nervous system.

Even a licensed medical provider can sometimes not even articulate or feel comfortable in an environment to share how they're feeling. They don't feel safe. You know, if I don't feel safe because maybe someone has experienced some type of sexual trauma or sexual abuse. I don't mean to get off on this tangent, but it's relevant to the gut because we know that it you know, adverse childhood events like or PTSD will rewire autonomic nervous system.

absolutely makes us more susceptible to chronic pain related issues, poor metabolic health, disorder relationships with food, contributes to high autoimmune disease risk. And sometimes we're not at we're not screening our patients properly. That's the point of what I'm trying to make. But sometimes, and I'm not suggesting you do this, but I think there are those of us that sometimes we're not thinking that way. And until someone gives us an indication that that's a concern of theirs.

absolutely makes us more susceptible to chronic pain related issues, poor metabolic health, sort of relationships of food, contributes to high autoimmune disease risk. And sometimes we're not at we're not treating our patients properly. That's the point of what I'm trying to make. Sometimes, and I'm not suggesting you do that, but I think there are those of us that sometimes not thinking that way. And until someone gives us an indication that that's a concern of theirs, sometimes we're not doing a great job as

Sometimes we're not doing a great job of screening. And I think screening for PTSD, trauma, adverse childhood events is certainly really part of the conversation. I know for myself I do screen now. And I would say easily forty percent of my patients have high A scores. So I already know what they're at risk for. And it allows me to deliver quite honestly better care. And in some instances, they've been

And I think screening for PTSD, trauma, adverse child management is certainly really part of the conversation. I know for myself I do screen down. Yeah. And I would say easily forty percent of my patients have high A scores. So I already know they're gonna go. And it allows me to deliver quite honestly better care. And in some instances they've been

They've had an entire lifetime of subjugating themselves for such a long period of time. I feel like perimenopause is the time that all of that falls away because all those compensatory behaviors mechanisms that they've used to be successful individuals start to fall away when the hormones change, the neurotransmitters change, their physiology changes, and their coping skills just don't allow them to keep everything contained. All of a sudden it becomes messy. And messy isn't necessarily bad.

They've had an entire lifetime of subjugating themselves for such a long period of time. I feel like thirty menopause is the time that all of that falls away because all those compensatory behaviors, mechanisms that they've used to be successful individuals start to fall away when the hormones change, the neurotransmitters change, or physiology changes and their coping skills just don't allow them to keep everything contained. All of a sudden it becomes messy. Well, that scaffold kinda goes away. Whatever scaffolds that we have, you know kind of just like

Yeah.

gets pulled from underneath us like and people really struggle. Now to your point about the patients too and and as as clinicians and looking at these patients, I mean, there's actually a term I think it was count coined in the nineteen eighties, this term called the heart sink patient, which is like where clinicians, doctors, you know, nurse practitioners, whatever, when you see a a patient with a chief complaint of, you know, GI distress or, you know, pelvic pain, sexual pain, endometriosis, those

Exactly.

pa and even patients know that they're considered heart sink patients, which is devastating. But it it's like your heart sinks because you're in a system where you have to see 30 patients a day that you haven't we haven't done enough research to know the answers, or if there are answers out there, you know, you are you haven't had the chance to get up to date enough to know the answers to get to help the patients. And so I think it it goes back to, you know, having a little bit of you know, cultural humility and understanding that

You know, and and this is you know something I the lens I try to practice within is just like, okay, I know a lot, I don't know everything, and I wanna make sure that I'm listening to you to be able to get you to the best person and I'm happy to be your quarterback in the scenario and make sure that we're, you know, talking to the right people. But I think it's I think that's the key the humility piece. I think that I I've always been a patient I don't know everything, but

I think that's the key, the humility piece. I think that I I've always said to patients, I don't know everything, but I know that if I don't know, I will find the person that does know. And I think that that conveys such a degree of compassion to patients to say, I'm humble enough to say I don't have all the answers, but by the same token, I'm committed to being your advocate.

I know that if I don't know, I will find the person that does know. And I think that that conveys such a degree of compassion to patience to say, I'm humble enough to say I don't have all the answers by the same token. I'm committed to being your advocate in this circumstance. And I think for a lot of women that can be, you know, life changing, life defining for them. To feel like someone's finally seeing them for who they are and want

in this circumstance. And I think for a lot of women that can be, you know, life changing, life defining for them to feel like someone's finally seeing them for who they are and wants to genuinely help them. Instead of the, my gosh, I have the handle on the door. Like I I speak very openly that when I worked in cardiology, I had a colleague that used to say to me, He who has the list is in control. So if a patient comes in with a list, you need to get the list because you control the conversation.

genuinely help them instead of be my gosh I have the handle on the board. Yeah. I I speak very openly that when I worked in cardiology, I had a colleague that used to say to me, he who has the list is in control. So if a patient comes in with a list, you need to get the list because you control the conversation. And I understand intellectually why he said that to me when I was a younger nurse practitioner, but when I say that now it makes me

And I understand intellectually why he said that to me when I was a younger nurse practitioner, but when I say that now, it makes me cringe because what you're essentially saying is I'm controlling the conversation so that I don't have to spend too much time in this room.

fringe. Yeah. Because what you're essentially saying is I'm controlling the conversation so that I don't have to spend too much time in this room. Yeah. Yeah. No, that's true too. I mean and that's just sort of like the epistemic injustice that we know exists on a day to day basis with with our with our patients. So tell me like what you w where where do you start when you have someone that has had s gut disruption

There's com coming you new inflammation, new bowel dysfunction, can't tolerate fiber like they used to, can't do this and that. Like, do you start with an elimination diet? absolutely. I think that in a food diary, not forever. The food diary can feel really tedious, but it's like I want to know exactly what your symptoms are when you eat breakfast, what are the foods you're eating, and how do you feel an hour later? Yeah, same thing with lunch and dinner. And so I find that I get good buy in.

absolutely. I think that in a food diary, not forever. The food diary can feel really tedious, but it's like I wanna know exactly what your symptoms are. When you eat breakfast, what are the foods you're eating and how do you feel an hour later? Yeah, same thing with lunch and dinner. And so I find that I get good buy in with a elimination diet if slowly. Like if I just say to someone, do a whole thirty most people can't out that many things. I will sometimes start with gluten or dairy.

with a elimination diet if only like if I just say to someone, do a whole 30 people can't that many things. But I will sometimes start with gluten or dairy. Those are pretty hard for most people to do because they have to re engineer their pills and depending on someone's background, dairy can be a big part of their diet. Like I do find that those two interventions along with some alcohol, plus or minus sugar, very helpful. It's also starting

those are pretty hard for most people to do because they have to re engineer their meals and depending on someone's background, dairy can be a big part of their diet. But I do find that those two interventions along with some alcohol, plus or minus sugar, can be very helpful. It's also starting with the basics, like I always say major in the majors. Before my patients buy an aura ring or a loop band or some expensive gym equipment, I'm like, listen

Basics. Like I was thinking major and majors. Before my patients buy an aura ring or a loop band or some expensive gym equipment, I'm like, listen, I want you to have at least one or two meals a day where you are seated while you're eating, not dictating and eating, not eating in the car, not eating when you're younger than your kids. sit and take four to five deep breaths before you start eating so that you're trying to get your brain into out of a sympathetic and the parasites.

I want you to have at least one or two meals a day where you are seated while you're eating, not dictating and eating, not eating in the car, not eating while you're young with your kids. sit and take four to five deep breaths before you start eating so that you're trying to get your brain into out of the sympathetic into the parasympathetic or taking a walk after a meal or drinking more water, like something that is so simple, almost seems trite.

Or that's good. Or drinking more water. Like something that is so simple, almost seems trite, can make a big difference. When someone tells me they're having energy issues and they're tired, I'm like, Are you dehydrated? We know that we as we're losing estrogen, we're losing control of these varoreceptors. We are not as physiologically aware of when we become dehydrated. For sure. So hydration.

Can make a big difference. When someone tells me they're having energy issues and they're tired, I'm like, Are you dehydrated? We know that we, as we're losing estrogen, we're losing control of these barrel receptors. So we are not as physiologic aware of when we become dehydrated. It's like by the time we're thirsty, we're probably already dehydrated. So hydration, walking, breath work can be very, very helpful. And then simplifying, like instead of adding more, it's just really the simplification piece of

Breath work can be very, very helpful. And then simplifying. Like instead of adding more, it's just really the simplification piece of like let's focus on a little more protein before we even get to fibers and interventions. Like, try to eat less processed food. Try to eat a little bit more protein. I look at food diaries, 95% of my patients don't eat enough protein. That's problem number one. and it's not that most of them don't tolerate fiber, it's

Like, let's focus on a little more protein before we even get to fibers and interventions. Like, try to eat less processed food. Try to eat a little bit more protein. Cause if I look at food diaries, 95% of my patients don't eat enough protein. That's problem number one. and it's not that most of them don't tolerate fiber, it's just they've been eating such hyper palatable food for so long, which is devoid of fiber. So when they start introducing more fibrous foods,

They've been eating such hyper palatable food for so long, which is devoid of fiber. So when they start introducing more fibrous food, more often than not, they'll say, I get bloated, I feel like I'm fluffy, I got constipated. And like when we don't go from 10 grams of fiber a day to 30, we'll definitely show the effects of that. But let's kind of keep a food diary, track our macros, then from there we can make decisions. And I tend to go pretty slowly with fiber.

More often than not, they'll say, I get bloated, I feel like I'm puffy, I got constipated. And like, well, we don't go from ten grams of fiber a day to thirty. You'll definitely feel the effects of that. But let's kind of keep a food diary, track our macros, then from there we can make decisions. And I tend to go pretty slowly with fiber and I tend to stick with things that I know are pretty well tolerated, like fresh gran flax and fia seeds.

And I tend to stick with things that I know are pretty well tolerated, like fresh ground flax and PSCs, you know, cooked vegetables. Like most people want to have this big crude platter and I'm like, listen, if you're not fiber if you're pretty fiber sensitive, eating raw vegetables is probably not the direction to go in. Like you are going to get bloated. If I sat down and ate a bunch of raw broccoli cauliflower, I would definitely be bloated. Just because that's not my preferred way to eat them. But

you know, cooked vegetables. Like sometimes people want to have this big cruit de tay platter. And I'm like, listen, if you're not fiber, if you're pretty fiber sensitive, eating raw vegetables is probably not the direction to go in. Like you are going to get bloated. If I sat down and ate a bunch of raw broccoli and cauliflower, I would definitely be bloated. Just because that's not my preferred way to eat them. But really starting with

I can't eat watermelon anymore. I used to love watermelon and it it 'cause it makes me Yeah like But you figure it out, right? You figure it out by Exactly, exactly. And so we kinda go from there. We start with simple things, you move on to diagnostic testing. I mean I'm a fan of microbiome testing. I do think that there's a lot of validity there, but we're also not adding ninety supplements. I mean, that's something that I see a lot in the integrative medicine. I do too, yeah. Is that patients go from, Okay, I'm I'm

Tells you.

Exactly. Exactly. And so we kind of go from there. We start with simple things. We move on to diagnostic testing. I mean, I'm a fan of microbiome testing. I do think that there's a lot of validity there, but also not adding 90 supplements. I mean, that's something that I see a lot in the integrative medicine space, is that patients go from, okay, I'm I'm out of a traditional model, I'm seeing an integrative or functional provider. And the patients come to me and they're on 40 supplements. I'm like, Do you want to be on 40 supplements? And they're like, No.

Out of a traditional model, I'm seeing it in a greater functional provider, and the patients come to me and they're in 40 something. I know. Do you want to be on 40? I just had someone come to me with their GI microbiome reading and they showed me all their supplements. And I like, What? No wonder you can't keep up. Yeah. Yeah, exactly. It's it's overwhelming. So I try to keep it simple. I've learned that we do two or three interventions at every visit, and I get better, I hate to use the word compliance, but

All right.

Yeah, exactly. It's it's overwhelming. So I try to keep it simple. I've learned that we do two or three interventions at every visit and I get better I hate to use the word compliance, but I get better patient buy-in because we're keeping it simple. And then we it's kind of like we're slowly walking into the pool. We're not just jumping in. It's rare for me to find a patient that wants to do everything all up front. That's very rare. But doing it that way.

I get better patient buy-in because we're keeping it simple. And then we it's kind of like we're slowly walking into the field. We're not just jumping in. It's rare for me to find a patient that wants to do everything all at once. That's very rare. I mean, could you do everything all at once? I mean, I always said same to myself, like, I can't even follow half the stuff I tell. I know. And and I think, you know, half the battle is and I'll tell patients, I'm like, listen, it's hard for me to

I know. I know. And and I think, you know, half the battle is and I'll tell patients, I'm like, listen, it's hard for me to integrate ten new supplements into my regimen. Like I don't expect you to do it. Like we'll just do one at a time. If we have five, we're gonna start with digestive support. We're gonna before we even worry about a probiotic, like let's do some more probiotic rich foods, like just keep it really simple.

integrate 10 new supplements into my regimen. Like I don't expect you to do it. Like we'll just do one at a time. If we have five, we're gonna start with digestive support. We're gonna before we even worry about a probiotic, like let's some more probiotic rich food. Like just keep it really simple. Yeah. Because that's sustainable. No one wants to be on 40 supplements. No one wants to be on a complicated regimen. I think most people don't want to have to pay for 10 out of pocket tests every single year. Yeah. mean if there's a year that that happens

Because that's sustainable. No one wants to be on forty supplements. No one wants to be on a complicated regimen. I think most people don't wanna have to pay for ten out of pocket tests every single year. I mean, if there's a year that that happens, that's one thing. But I think most people have budgets and have lives and don't wanna feel like they have to be obsessive about all of these simple little interventions.

That's one thing. But I think most people have budgets and have lives and don't want to feel like they have to be obsessed with about all of these simple little interventions. For sure. No, I love that. I love the small interventions. I love just you know, trying to look at how they're dealing with lifestyle. Tell me where you f where you fall into intermittent fasting. Well, obviously I'm known for intermittent fasting. But I can tell you over the past two years. I've pivoted. My dad died in nineteen four and

Well, obviously I'm known for intermittent fasting, but I can tell you over the past two years I've pivoted. My dad died in twenty twenty-four, and one of the things that contributed to my father's death was significant sarcopenia and falls. I ended up dying of a subdural hematoma. did not want surgery. It was traumatizing as a medical person because I was respectful and agreed that he didn't want an intervention and the trauma surgeon and the

One of the things that contributed to my father's death was significant sarcopenia and falls. He ended up dying of a syndrome hematoma. did not want surgery. It was traumatizing a a medical person because I was respectful and agreed that he didn't want an intervention and the trauma surgeon and the ICU doc were very appreciative because he would have been a typical surgical candidate. But it really left an indelible impression because my dad and I had very similar body habits.

I see doc were very appreciative because he would have been a terrible surgical candidate. But it really left an indelible impression on me because my dad and I had very similar body habits. He's kind of a little guy. and it really impressed upon me. Like if I don't if I don't get more persistent about strength training, like doing it regularly, not making excuses, I'm on a business trip, I'm not gonna worry about it. I hired a personal trainer who comes to my house who I have no excuses.

kind of a little guy. and it really impressed upon me. Like if I don't if I don't get more persistent about strength training, like doing it regularly, not making excuses, I'm on a business trip. I'm not gonna worry about it. I hired a personal trainer who comes to my house, I have no excuses, and I put on four pounds of muscle mass in a year, but that was a lot of work. But going through that just really taught me that

And I put on four pounds of muscle mass in a year, but that was a lot of work. But going through that just really taught me that in order to build muscle, I need to lift regularly and I have to eat enough protein. So this is where I'm I'm coming around to the intermittent fasting piece. When I started tracking my macros, I wasn't consistently getting enough protein in. And so I I now refer to digestive rest, twelve to thirteen hours of digestive rest, which even my very athletic adult sons can do.

In order to build muscle, I need to lift regularly and I have to eat enough protein. So this is where I'm I'm coming around to the intermittent fasting piece. When I started tracking my macros, I wasn't consistently getting enough protein in, and so I I now refer to digestive rest. But that allows me to get three meals in a day. And that allows me to get enough protein. And so it doesn't mean that I don't think that intermittent fasting

But that allows me to get three meals in a day and that allows me to get enough protein. And so it doesn't mean that I don't think that intermittent fasting can be a valuable strategy. But it's in the context of can you get enough protein in? Are you managing your stress? Are you sleeping? Because if you're not doing those two things, you should you have no business doing fasting. And that's why the twelve to thirteen hours I think is helpful. Now the caveat is I do have women that I work

valuable strategy but it's in the context of can you get enough protein in are you managing your stuff are you sleeping because if you're not doing those two things you should you have no business doing fast that's why the twelve to fifteen hours I think is helpful. And a caveat is I do have women that I work with who are not metabolically healthy, significantly overweight and intermittent fasting like compressing their feeding window can be helpful.

who are not metabolically healthy, significantly overweight, and intermittent fasting, like compressing their feeding window, can be helpful from a caloric restriction perspective, provided that they can get enough protein in. So that's always a conversation. So I'm not a huge fan anymore of like very long fasts because I'm so concerned about building and maintaining muscle. And I think for a lot of women, we start to realize in perimenopause and menopause, it just gets a little bit hard.

from a caloric restriction perspective, provided that they can get enough protein in. So that's always the conversation. So I'm not a huge fan anymore of like very long paths because I'm so concerned about building and maintaining muscle. And I think for a lot of people then we start to realize in perimenopause and menopause, it just gets a little bit hard. And that little bit hard to do the differentiator between body composition and really unhealthy body composition because I'm sure that you see it too

And that little bit harder to be the differentiator between healthy body composition and really unhealthy body composition. Because I'm sure that you see it too. I see a lot of women now with the rise of GLP ones. Yes, people are losing weight, which is great. We're starting to see the pendulum swing. Like I remember what the nineteen nineties were like when women were really, really thin.

I see a lot of women now with the rise of DLP ones. Yes, people are losing weight, which is great. Hiding food noise, which is great. We're starting to see the pendulum swing. Like I remember what the nineteen nineties was like when women were really, really thin. Heroine chic. Yeah, exactly. And what I see when I look at people like that, I mean I think Demi Moore is best example I can give that I think everyone probably listening knows. When I see Demi Moore, I prefer not from a place in judgment, but I'm like

Yeah, exactly. And what I see when I look at people like that, I mean, I think Demi Moore is the best example I can give that I think everyone probably listening knows. When I see Demi Moore, I see her not from a place of judgment. But I'm like, sarcopenia leads to frailty, frailty leads to falls, and falls lead to a loss of independence. That is what I can see when I look at her, is she so frail. She looks like a China doll. Like if you knocked her over, she'd break a bone.

Darkopenia leads to frailty, frailty leads to falls, and fault leads to a loss of independence. Yep. That is what I can see when I look at her, is so frail. She looks like a China doll. Like if you knocked her over, she'd break a bone. And so those are the things I think about now as a fifty plus year old woman. I don't want to be that kind of bird with my family. That's why I a lot of things. Like my husband will laugh at and it's not things I do in the house, and I'm like,

And so those are the things I think about now as a fifty plus year old woman. I don't want to be that kind of burden for my family. Like that's why I a lot of things. Like my husband will laugh at at some things I do in the house. And I'm like, listen, I don't want to be that little old lady who falls and breaks a hip. Like I wanna be independent and that's why strength training becomes important. And that's why digestive rest has become a greater focus than intermittent fasting. and and I think for a lot of people they

I don't want to be that little only breaks a hip. I want to be independent and that's why spring training becomes important and that's why digestive rest become a greater focus than intermittent fasting. Yeah. And and I think for a lot of people they respect the fact that I've been very open about that. I mean, obviously I've written a book on fasting for women. It came out four years ago, but I would think no better, do better. Like now I know better and now I do better. But protein and

respect the fact that I've been very open about that. I mean obviously I've written a book on fasting for women. It came out four years ago, but I always think no better, do better. Like now I know better and now I do better. But protein and strength training are really a huge focus of what I do and recommend to people.

strength training are really a huge purpose of what I do and recommend it for perfect I love that well I appreciate you being on today I do something at the end called this is pretty much like a hot take it's a vagilante verdict because my listeners are vagilantes. so what would you what what what's your vagilante verdict? Hot take I'm sorry what's your hot take or vagilante verdict for the pit for the listeners on or one thing that you want them to know

Ha ha ha.

Sorry.

Sorry.

Dr. Sameena Rahman (44:10.164)

for advocacy or, you know, whatever, you know, that the taken with when they when they see their clinicians, or when they're thinking about their own gut health. Yeah. So there's definitely an inner relationship between the health of the gut microbiome and the vaginal microbiome. So that's number one. Number two is it's never too late to have that conversation. Like I just had vaginal microbiome testing and I was like, I'm on vaginal estrogen, might well be perfect. Yeah, I know.

Yeah, so there's definitely an inner relationship between the health of the gut microbiome and the vaginal microbiome. So that's number one. Number two is it's never too late to have that conversation. Like I just had vaginal microbiome testing and I was like, I'm on vaginal estrogen. Mine will be perfect. And I was like, you know what's amazing? I got the results. I met with a clinician and the clinician made some recommendations.

You know what's amazing? I got the results. I met with a clinician and the clinician made some recommendations. And what's amazing to me is the recommendations she made, it's like what's impacting my libido. I'm like, so clearly something is going on there. So you're never too old, it's never too late, and you should never feel ashamed or uncomfortable advocating for your sexuality or advocating for your bubbrovaginal.

And what's amazing to me is the recommendation she made, it's like it's impacting my libido. I'm like, so clearly something is going on there. So you're never too old, it's never too late, and you should never feel ashamed or uncomfortable advocating for your sexuality or advocating for your vulvo vaginal health. That would be kind of my big takeaway. I think sometimes, even for those of us that are licensed medical providers, we're uncomfortable talking about our sexuality.

That would be kind of my big takeaway. I think sometimes even for those of us that are licensed medical providers, we're uncomfortable talking about our sexuality just personally. And it's like we have to kind of check our own comfort level at the door for the benefit of our patients. Yep. A hundred percent. Well, thank you, Cynthia. This has been great. everyone can go out and buy the menopause gut. I think we will put a link here so that you can pick it up and tell everyone where they can find you otherwise.

just personally and it's like we have to kind of check our own comfort level at the door for the benefit of our patients.

Yeah, thank you so much for having me. It's always a pleasure to connect with you. So easiest to go to my website, www.cynthiafolo.com. My podcast is Everyday Wellness. Mina's been a guest on there before, definitely a fan favorite. And I'm active across social media. I would say right now I'm most impassioned about Substack. Like if you really want to get to know me and what I think about a lot of different topics, not just about hormones and not just about

Yeah, thank you so much for having me. It's always a pleasure to connect with you. So easiest to go to my website, www.cynthiafolo.com. My podcast is everyday wellness. Mina's been a guest on there before, definitely a a fan favorite. And I'm active across social media. I would say right now I'm most impassioned about Substack. If you really want to get to know me and what I think about a lot of different topics, not just about hormones and not just about

the gut microbiome, but a lot of different things. Substack is a great place to connect with me. I'm probably most active on Instagram, although my team would probably be more active on TikTok, but they just can't do it.

The gut microbiome, but a lot of different things. Substack is a great place to connect with me. I'm probably most active on Instagram, although my team would be more active on TikTok, but it just can't do it. I know. It's so hard. I know I need to get a team to do much. It's hard. It's hard. Anyway, thank you so much, Cynthia. This has been great. thanks for joining us today, everyone. Remember, I'm Guy and a girl, Dr. Samina Rahman. Remember, I'm here to educate so you could advocate for yourself. Please join me next week.

hard to be everywhere.