GLP-1 Weight Loss in Menopause: How HRT Amplifies Results

[00:00:00] 

Dr. Brighten: When we talk about midlife women and metabolic health, one of the most common frustrations that I hear as a clinician is I'm doing what's always worked for me, but my body isn't responding anymore,

there's a good reason for that.

The

transition from perimenopause to menopause fundamentally changes the hormonal architecture that underpins our metabolism. And today I'm gonna walk you through what's happening metabolically in perimenopause and menopause, and how changing hormones are influencing your changing waistline.

So in this episode, we are gonna talk about GLP ones.

I

wanna be really clear, I'm not trying to sell you on GLP ones. No one pays me who manufactures GLP ones,

and

I am not going to recommend that just anyone uses these. But I have done episodes on the Dr. Brighten show already on insulin resistance. I will link to that on [00:01:00] perimenopause weight loss, which you can do with nutrition and exercise.

. But a question I've been getting over and over is where do GLP ones fit into perimenopause and menopause? Not just with weight loss, but in terms of what they can do for our brain health and our cardiovascular health?

So we are going to talk about your heart and your brain and where GLP ones fit into this. And I'm gonna be taking you through understanding how these are implemented. And as always, you will find the studies linked in the show [email protected]. 

So here's the roadmap of where we're going. In today's podcast, we're gonna talk about what's happening metabolically in perimenopause and menopause, and how changing hormones are influencing your metabolic health, and what is happening with visceral adiposity, so the fat that likes to pack around our organs.

We're gonna talk about GLP one receptor agonists like Semaglutide, aka ozempic. We're gonna talk about how they work and how they differ from one another. I'm also gonna take you through some of the [00:02:00] newer research about brain and heart benefits. We're gonna talk about the combination of GLP one therapy with hormone therapy, and how this may be a clinically synergistic strategy that is backed by emerging evidence.

Again, see the show [email protected]. I'll link to these studies for you. And then I'm gonna go through the exact steps of what to test before starting medications and what things we should be monitoring. Now, if you're new here. Hi. Welcome to the Dr. Brighten Show. I'm your host, Dr. Jolene Brighten. I'm board certified in naturopathic endocrinology, which means I'm a integrative hormone doctor, who's also a menopause certified practitioner.

I'm also a sex counselor and a nutrition scientist. Wherever you're listening right now, if I can ask you to just take 30 seconds, leave me a review. Maybe you're on YouTube, you can hit subscribe. Leave me a comment. I know these are little acts. They don't seem like they're that big of a thing to do, but to [00:03:00] us, they are huge.

They support myself and my team in getting this information out to women who need it everywhere. As you know on the Dr. Brighten show, We aim to always deliver you the most practical advice that you can apply in your life. And so as always, thank you for your support.

Thank you for being here, and let's get into it.

Starting

with the metabolic shifts in perimenopause and menopause, this is something we don't talk enough about. I've talked about it in a lot of episodes. I'll link to those, but we need to talk about it more. So by the time a woman reaches her late forties to early fifties. Estrogen, progesterone are no longer fluctuating wildly.

They're trending towards the sustained decline, and that decline starts to rewire metabolic physiology in several ways. So for every gym, bro, that tells women, you just are not disciplined. It's not your hormones. Listen to this part. Okay? when you lose estrogen, [00:04:00] you lose its insulin sensitizing effect.

So. Estrogen enhances glucose uptake in the muscle. It improves how your liver is working with insulin. It supports mitochondrial function. So when it falls, we're gonna see reduced glucose being pooled out of the bloodstream, increased liver output of glucose and adrift towards insulin resistance. Then we see a shift in fat distribution.

So even without significant weight gain, not weight, not because you're eating more or moving less, there's an increase in visceral fat being deposited. So that's around your organs,

now this conversation is not cosmetic, okay? Because when we're talking about visceral fat, I mean you probably care, uh, about how your waistline looks, and that's fine for you. But for me as a doctor, what I'm concerned about is that this fat is inflammatory and metabolically active, and it is driving risk for cardiovascular disease type two [00:05:00] diabetes, fatty liver disease.

It's a mess. Okay? And I talk about this extensively in the perimenopause weight loss episode, which I will link to in the show [email protected]. But what I want you to understand is this, visceral fat is sabotaging your metabolic health, your cardiovascular health, your brain health is bad news. Bad news, okay?

The other thing that's happening. We see sarcopenia accelerating. So muscle loss speeds up after menopause often one to 2% per year, and that reduces our resting energy, expenditure and glucose disposal capacity. So what does that mean? We're losing muscle and now our metabolism is shifting and our ability to control our blood sugar is shifting as well.

That's super problematic. This is why we have to strength train always our entire life, but especially in perimenopause and [00:06:00] menopause. And as you're gonna learn in this episode, GLP ones without a strength training program is a disaster. That's a bad idea, and we don't wanna be doing that again. I'm gonna talk about GLP ones, but I'm not a cheerleader for GLP ones.

Do they have promise? Do they look amazing like in certain populations? Absolutely. But we do have to talk about the nuance of how these drugs are being used.

Now, the other thing that does happen in perimenopause, menopause. So when estrogen levels are going down, this isn't happening in early perimenopause, but it is happening in the later half. Estrogen is diminished. So we see that our appetite signaling changes. So the hypothalamic satiety pathways and dopamine reward circuits are changing.

And because that, that weakens our ability to really perceive early hunger cues and

And we're also seeing a hormone [00:07:00] ghrelin. Its regulation is also shifting, and so hunger cues are changing. Postal satiety, the signal that we're fooled, that's changing, and all of this together, these changes explain why just eat less and move more, becomes metabolically inefficient for many women midlife.

And it's very dangerous. This, this just eat less, move more mentality can lead to eating disorders and is sometimes I see, I see people across the board, whether it's physicians, dieticians, uh, personal trainers. I don't know if they're actually allowed to be prescribing, uh, caloric deficits in diets, but some things they're putting women on a thousand to 1200 calorie diets.

Good

luck getting enough protein on that kind of diet, good luck. But also when we put people on such a significant caloric deficit, that also starts to have negative impact on their hormones, like their thyroid. And so, you know, a lot of people argue [00:08:00] that GLP ones, the reason why they work is 'cause you stop eating so much.

And yeah, that's definitely part of it, but that's only part of it. It's part of the story. So let's talk about what GLP ones are doing in our system.

GLP one stands for glucagon-like peptide one, and this peptide is secreted in the gut in response to nutrient intake. Now the pharmaceutical GLP one receptor agonists, they mimic this natural occurring GLP one and they amplify its effects.

So the effects that we're talking about is pancreatic effects, so enhanced glucose dependent insulin secretion and suppressed glucagon during hypoglycemia. So what does that mean? That is enhancing insulin secretion when there's glucose, and it's suppressing you from taking , the storage form of sugar and liberating that into glucose.

Then there are central nervous system [00:09:00] effects. So it acts on the hypothalamic appetite centers to reduce hunger and increase the sense of being full. So this is why when people are on larger doses, they can stop eating altogether. It's not a good thing. That should not be the goal.

Now there's also GI effects. It can delay gastric emptying. You may have heard this. This is also why people will fill full longer, and so it'll make you feel full longer, but also it can delay any kind of glucose peaks from you absorbing the meal you just ate. And then there's also cardiometabolic benefits.

So in certain populations we've seen a reduction in cardiovascular events, improved lipids and blood pressure profiles, and I'll talk a little bit more about that later on in the episode. 'cause I think this could show some promise. When we are in our menopausal years, when we are at a very high risk of cardiovascular events, we know that's the leading cause of death of women when they pass menopause 

When anyone [00:10:00] talks about GLP ones, everyone just thinks like ozempic, sometimes wegovy, those are semaglutide and those are given as a weekly injection. They can help with significant weight loss and they've shown some benefits in cardiovascular outcomes.

But there are other GLP ones. So there's Liraglutide, which is a daily injection. Uh, it's really good at appetite suppression, less potent with weight loss compared to Ozempic Tirzepatide, which is Manjaro or Zep.

Bone.

That is a dual GLP one GIP agonist. And that one has been shown to be like chef's kiss, like superior for weight loss in trials when it's compared to Semaglutide Tide.

Then there's dulaglutide, which are weekly injections. Moderate weight loss, strong glycemic effects, so good for blood sugar control. And so when we're talking about GLP [00:11:00] ones, we're actually talking about quite a few medications here. 

Now, recently there's been some new research coming out that makes a pretty good case for combining hormone replacement therapy or menopause, , hormone therapy with GLP one therapy. And from mechanistic standpoint, everything we talked about previously about what estrogen does and how changing estrogen changes our metabolism, I think you can start to piece together like why this might be a good idea.

But I'm gonna, I'm gonna help you put together the full picture here of what's going on.

So when it comes to estrogen hormone replacement therapy, that is helping restore the insulin sensitizing effects of estrogen, we also know that estrogen HRT can improve lipid profiles and it can blunt the visceral fat accumulation that we typically see in menopause.

So put that together with everything we just talked about with GLP ones, how they can help with caloric access. 'cause yes, they can do that, but they can [00:12:00] address appetite dysregulation, they can help with their blood sugar. And that's all independent of estrogen pathways that, you know, when you look at that together, they may address metabolic dysfunction from complimentary angles and help improve insulin's action, reduce caloric load shift fat distribution, help with that metabolic profile of visceral fat.

And so, um, at the Mayo Clinic, they did a retrospective cohort study.

So

they looked back at over a hundred post-menopausal women who were on semaglutide for at least three months. And then they looked at who was also on hormone replacement therapy, and that was either oral or transdermal estradiol, not vaginal estradiol.

Okay. And they also looked at who was on progesterone as well. 

So they looked at who's on Semaglutide, ozempic. Is the common one that most of us [00:13:00] know. And then they said, okay, and what kind of hormone therapy are you using? What was interesting was that at every time point that they measured these people, the hormone therapy users lost significantly more total body weight.

So they were having better outcomes, uh, with the intended, with the intent to lose weight. A higher proportion of the hormone therapy users achieved the weight loss that they were aiming for within one year. and what was also interesting is that these differences persisted after adjustment for confounding variables.

So when they looked at age, baseline weight, type two diabetes, behavioral support, dietician support, that didn't have an impact,

so accounting for all of that, the people in hormone replacement therapy still had better intended outcomes, which the intention was to lose weight. When they were combining semaglutide [00:14:00] and hormone therapy, there was no difference in the outcomes, whether it was oral or transdermal estrogen or whether they used progesterone or not.

So it didn't matter whether it was progesterone or not. This points to estrogen is really, that's the one we wanna really looking towards. And then oral and transdermal, it didn't seem to make a difference. Okay. So. But we typically use transdermal. So why would they be using oral? Some clinicians still use oral.

I'm not a fan of oral. If we can avoid it, because oral can raise clotting factors that could put you at risk for adverse outcomes, and it gets metabolized by the liver. And so the dosages have to be different. However, there are some people speculating that cardio outcomes may be better if we're using oral estrogen.

And so that may change. We may screen people for clotting disorders and decide in the future that certain people should be using oral estrogen. So I just, [00:15:00] I wanna share all that with you because while I say like right now, like, Hmm, not totally a fan of using that, I reserve the right to change my mind as new data comes in and we find that we can do better for women. so what this study suggests is that when hormone therapy is clinically indicated and you combine it with GLP one therapy, that may yield an additive or synergistic effect on weight loss.

That's potentially due to improved body composition quality, so more lean muscle mass preservation, less visceral fat, and better metabolic flexibility.

. So that's the weight loss meets hormone therapy component that I think is important to consider when women are in menopause. But I do wanna talk about potential brain and heart health benefits as well that we're starting to see in the research, because I think, okay, so weight loss is important in some instances, but I think these drugs are also showing benefit for both brain and heart health, and we should be [00:16:00] considering that as well in menopause therapy.

There's lots of clinicians who are starting to use just a low dose. Some people call it microdosing, that term. Is not universally defined. And I always have to ask people, like, when you say microdosing, what do you mean? Because it's, it's different for every provider, but what I'm seeing a lot of providers doing, myself included, is using just the starting dose of these GLP ones and staying there.

So that what we're getting is the anti-inflammatory benefit. We're getting a little blood sugar sensitization, we're getting a little bit of the benefit without the weight loss, without trying to push people into losing weight. 'cause not everybody needs to lose weight, but you know, for example, we're seeing.

Women with endometriosis reporting less pain, less inflammation when using GLP ones. Um, a lot of these things are accidental, uh, where people like, my autoimmune disease is getting better, my allergies are getting better. There's something going on with the [00:17:00] immune system there. And so I think there's a lot of stigma around GLP ones.

I think immediately people are like, oh, these are just for weight loss. Like only obese people should use these. Or, um, these are just, you know, for people who are diabetic. And if you are taking these medications, you're taking it away from diabetics. And, and I get that train of thought, but usually when I ask people like, where is this coming from?

They say, well, it's not FDA approved. And then I ask some of these people, so if you need testosterone, 'cause your testosterone's low as a woman and you don't have symptoms of low libido, but you have. Low mood. You're depressed, you're losing muscle mass. You lack motivation. You can't set boundaries. You're not happy.

Like would you want to have testosterone? If that's the reason. Yeah, of course. That's an off-label use of testosterone. And in fact, we have a lot of drugs that are off-label use. You know, we're using GLP ones a lot in women with PCOS, even if they have lean PCOS. So, which is [00:18:00] kind of like, not a great term, but it is the way that it gets described in medicine.

But GLP ones being used in people who are not overweight, but they have PCOS because mechanistically, we know that roughly 70% of those with PCOS have insulin resistance. That insulin is stimulating their ovaries to make testosterones causing ovulatory dysfunction. If you can bring in something like we've used metformin in the past, that could cause a lot of GI issues, so maybe GLP ones, and that helps somebody restore their ovulatory function, protect them from the adverse cardiovascular changes that can happen with PCOS, like that's fantastic.

I don't get the stigma of saying people with PCOS shouldn't use it 'cause it's off-label. When we use spironolactone off-label for women in PCOS to control their hair, the, the hair that's growing on their chin, their chest, their abdomen, the hair loss that they're having, that drug was for cardiovascular conditions.

But then we found out that it can help with [00:19:00] herm, with the, uh, the excess hair growth in places that you don't want it. So I ask that you keep an open mind. Again, I'm not trying to push GLP ones on anyone. I've just had a lot of questions about it, so I wanted to do an episode about it. Um, but I also think that there's a lot of stigma when there shouldn't be, and these medications are really helping a lot of people.

And just because something is being used off-label from what the FDA approved doesn't mean we can't use it. We do it all the time in women's medicine all the time. And I mean, when I look at like hormone replacement therapy, I mean. Wow. Like, wow, we've come a long way and still not far enough in terms of FDA approval.

And just because the FDA didn't approve something doesn't mean that I would withhold something from you that could potentially help you. Okay. With that tangent out of the way, uh, let's get into like what's going on with the brain research.

Menopause [00:20:00] brain is something that a lot of women talk about when they experience the brain fog, the losing words, mid sentence, feeling like they, um, start a project, they can't follow through on the project 'cause their brain just runs outta steam. Now what's interesting is that GLP ones. In the brain may reduce inflammation.

They may help with steady energy use. They may nudge reward circuits that drive our urges, and that may explain why some people notice less food noise, thoughts and why research is starting to test GLP ones in Alzheimer's disease and even alcohol use disorder. Now, where we're at today is that we do have some encouraging signals in both imaging and some small trials.

I just want you to know we're still waiting on big definitive results here, especially when we talk about Alzheimer's. So we do not prescribe GLP [00:21:00] ones, uh, for just cognitive benefits right now. Um, any brain benefits that you're getting is like a bonus, but. Knowing that DLP ones may improve blood pressure.

Uh, they are improving weight, blood sugar, liver health, sleep apnea in some people. All of these protect the brain in the long haul. So those indirect winds we are starting to look at like, wow, there's some benefit to your brain as well. Now we still are saying use GLP ones for what they are intended for, which is metabolic health and weight.

But research is starting to consider brain benefits as very promising, but not necessarily proven yet. But I do think it is something that we should be looking at because there are people who have insulin dysregulation even though they're not obese and they're not overweight. We know that insulin dysregulation can contribute to the development of Alzheimer's disease, dementia.[00:22:00] 

The other thing that's interesting about seeing that they're lowering inflammation, they're helping with brain energy, is that this may show promise for women who have A DHD because we know women who have A DHD, they struggle with brain energy and neuroinflammation. And that in some cases of A DHD like that neuroinflammation can really get amped up and hijack the brain.

So these are interesting areas that I definitely, um, like want to keep tracking because I think that if we can prevent neurodegenerative disease, then we need to start having a conversation in women's health if this is a tool to do that. And why is that?

Because more than 60% of the dementia patients are women. It's us who are getting dementia at a higher rate. And so perhaps these drugs may be an early intervention, especially when we consider coupling it with hormone therapy to be able to prevent dementia. [00:23:00] Again, I'm not saying it absolutely will, and I'm not making any promises here.

I'm just bringing up, Hey, look, this is what the research is starting to point towards. The bottom line is GLP ones may help protect the brain over the long haul, but we don't have big studies yet to tell us who is this true for? Is it true for everyone? Does it have as many benefits as we expect? And do the benefits outweigh the risk because no medication is without side effects.

Now, when it comes to heart health, there's been some large clinical trials that have shown a reduced risk in major heart events, and that's a really big deal for women. As cardiovascular risk climbs after menopause, we know that when we lose our estrogen, our risk for cardiovascular events goes up, up, up.

And it is the leasing leading cause of death. I mean, everybody is always afraid of breast cancer. 'cause there's so much awareness about it, but we're not talking enough about cardiovascular disease. And that's [00:24:00] not to say we shouldn't talk about breast cancer. Yeah, we should talk about that. We should talk about all the things that are a threat to our existence so that we can have the best practices to try to mitigate risk and avoid those if at all possible.

But I think more women need to be aware that cardiovascular risk is very serious when we go into our menopausal year. So, and for people, if you know, I just realized like I'm using perimenopause menopause and I'm just like assuming we're all on the same page. Maybe I should have said this definition at the beginning.

I apologize. Let me just do it real quick. Perimenopause is the transition years leading up to menopause. Menopause is 12 consecutive months with no period, boom, happy anniversary of no period. You are in menopause and the next day you are postmenopausal. And so that's what I mean when I'm saying all of these terms.

And I apologize, I should not just assume that you've been listening to the Dr. Bright show since the beginning and know everything that I'm talking about. So sorry about that. Okay. Let's talk more heart health.

You may have seen [00:25:00] headlines that are like in people who are overweight or obese and have established heart disease but no diabetes. The weekly semaglutide injections reduced heart attack, stroke, and cardiovascular death by about 20% compared to placebo. And that came from a recent trial

that

was published in the New England Journal of Medicine. And I will go ahead and link to that. And what's interesting is that this heart protection that we're seeing isn't just like a one-off, like one trial showed it and no others. In people with type two diabetes and are at cardiovascular risk, several GLP ones cut major events too.

So liraglutide that we talked about before has been shown to lower the combined risk of cardiovascular death, heart attack, and stroke. Semaglutide has also reduced those same events. Dulaglutide showed benefit, even in broader lower risk diabetes populations. So we [00:26:00] are seeing consistently that there are benefits for heart health.

Across multiple trials and medicines. In this class, we're seeing less of the big three heart outcomes, which is heart attack, stroke, and cardiovascular death. So this may be another reason that we would want to consider using GLP ones in our perimenopause, menopause postmenopausal population. So what is going on mechanistically?

What is thought to be happening is that there's a combination effect. We're seeing lower weight and visceral fat specifically means less strain on the heart and our blood vessels overall. It's also hypothesized that the smoother blood sugars, so none of this like ah, throughout the day and the modest blood pressure improvements are also giving benefits for the cardiovascular system.[00:27:00] 

And as I mentioned before,

GLP

ones can be anti-inflammatory, and this anti-inflammatory signaling seems to matter for our arterial arterial health. And that makes sense because we know the inflammatory theory of atherosclerosis isn't that you eat fat and so you get heart disease. It is that. You have elevated small particles of your LDL cholesterol and that meets the immune system.

We get inflammation and then we get these plaques that are just big and angry in the heart. It's not a good scene. And so the combination, uh, and if we go back to thinking about like, oh, and estrogen can help with your lipid profile and these GLP ones may able to help with that and estrogen GLP ones can help with inflammation like that may show significant promise for cardiovascular health in women.

I'm not saying do this, by the way, if you're healthy, no risk at all. Uh, person. These people have had risk or they had [00:28:00] established heart disease. Um, and I think that when we look at, you know, a lot of times women are told things like eat a vegan diet. Um, and then they're like, well, what about my muscle mass?

Or. You know, they're put on, you know, different medications. If we could have something coming in early on that's getting at the root of issues, or even as complimentary, like that could show a lot of promise in women's health. Now, I feel like I'm beating this drum over and over, but after menopause, the risk of heart disease rises. So we have to keep that in mind when we're considering what we're starting to see in these trials. If you are overweight, specifically having increased visceral adiposity, you are diabetic or you have pre-diabetes, again, go back to the insulin, uh, show.

I'll link to it so you know exactly what labs I'm talking about and what those markers should be. If you have prior heart events, then your clinician may want to consider GLP ones as part of like a comprehensive plan, right? We still have to do lifestyle, sleep resistance training. [00:29:00] We have to protect our muscle mass.

Um, and hormone therapy should be part of that conversation. Now, as I say, all of this for people who are definitely GLP one skeptics, I want you to know the goal is not just a smaller body, it's a strong body. It's better heart protection, better metabolic control.

And as we're seeing the influence of these big trials, this is why many cardiology guidelines are now considering GLP ones in high risk patients. So your clinician may not be aware of these things, and it might be important for you to bring up because you're at risk. And again, just bears repeating.

I'm not talking about just anyone. I'm talking about people who have a risk that we can practice some preventative medicine with. And yeah, sometimes that requires a pharmaceutical 'cause it's better than heart surgery when we start looking at the tier of med medical interventions, right? We always want nutrition and lifestyle to be our foundation and sometimes we need a drug.

But boy, if we can avoid surgery, I definitely wanna do that [00:30:00] for you.

It's always important to keep in mind as well that prescription medicines have real side effects. So, uh, the, you know, these are prescription in the us there's other countries where you can get them yourselves, but you really wanna do this under a practitioner supervision. Now, some of the most common side effects that people have, especially when the dose rises too fast, nausea, constipation, filling full, you, you can't eat enough food in the day.

Uh, the other thing is that I think we just need to say that, you know, these are not for everyone. There are rare thyroid tumors. Uh, if you have a history of pancreatitis, you to talk to your provider because you could be at higher risk. And I just really should just underscore that like. You need to talk to your provider who knows your history.

I know there's some boutique like medical clinics out there that are just like, we prescribed GLP ones to everyone and they're not doing their due diligence. 'cause there's a lot of money to be made here. [00:31:00] And I, I don't, I don't recommend that. Honestly. I really think like there are people who get desperate 'cause their doctor will not prescribe these things.

But I think that you, if you're gonna see someone new, they need to do a full history, a family history, a personal history, and really understand your risk and be able to answer all of your questions and be there for you when you do have side effects. If you do have side effects, you might not, but someone needs to be there caring for you.

Before we go into how are these, uh, typically prescribed and, and what you should be aware of and what you should be testing for. First, I just want to like summarize, like sum this up is that these gbl ones have shown meaningful protection for your heart and your brain. And if heart health is on your mind, especially if you're menopause, then have a conversation with your clinician.

If you are somebody who has a family history, you're at higher risk for these things and you are edging towards menopause, you're already there. Make sure your [00:32:00] clinician can talk to you beyond GLP ones, but also talk to you about hormone replacement therapy because they may work together synergistically and provide you the most benefit.

Now, before prescribing anything. Whether it's hormone therapy or GLP ones, you wanna have a clear understanding of your metabolic baseline, your hormonal status, your family history, your personal history. So you wanna make sure provider gets all of that lab testing. That's a good idea to have done. Let's go through that.

I think it's smart to have a fasting insulin, a hemoglobin A1C, get a full lipid profile and look at inflammatory markers like C-reactive protein. I also think it's really important for women to understand their body composition and uh, so that can be an in-body machine. Some clinics have that and getting a DEXA scan, just know your bone health because [00:33:00] there are people who go on GP GLP ones, they don't eat enough and they start losing their bone.

We don't want that. Okay. I would rather you. Ha like have more meat on your bones than lose your bones. Like I would rather see you have, you know, more body fat to a point, right? Because it's too much and we, and in the wrong places we can have cardiometabolic issues, but it is better to be a little heavier than to lose bone.

We know this from mortality studies, like you are more likely to be past tense if you lose your bone mass. So get the dexa. I think it's a good idea for everyone to get a DEXA in their forties just to know what their baseline is. And that's really what this testing is. Get your baseline. 'cause you can celebrate some wins if you have them.

But you can also understand if adverse things are happening.

We want to get a starting point so you can track whether weight loss is coming primarily from fat or if it's coming from lean [00:34:00] tissue, your muscle, if you're having any bone loss. This is super critical for women in midlife. And then of course, if you're considering hormone replacement therapy, we wanna confirm your menopausal status or where you're at.

We can do that a lot from history. Um, we can also check like an FSH, an estradiol, to see and confirm like, are you in fact in menopause? But if you haven't had a period in 12 months and you're over 45, your menopause. So, um, not having labs is not necessarily a hurdle that you have to overcome.

If you wanna get hormone replacement therapy, I think it's a good idea to have baseline labs and to track labs when you're doing therapy. But as of right now, the guidelines do not say like, you have to have labs first, so to assess metabolic and hormone status. We want to look at fasting insulin, hemoglobin A1C, A lipid profile, and uh, H-S-C-R-P, which is highly sensitive.

C-reactive protein. When you get your lipid profile, you can get as part as of a comp metabolic panel, and then that can also show us [00:35:00] liver and kidney function as well. And then body composition, dexascan. These are really important to have as baselines.

And as I, I should just say with the con metabolic looking at the liver and the A-L-T-A-S-T and GGT that can help us understand fatty liver in fatty liver disease in postmenopausal women. That's why I said like get it as part of a con metabolic panel. Now the other thing I think is important is also getting a full thyroid panel.

I have an upcoming episode with Dr. Christine Marin, where we go through thyroid health in detail and she talks a lot about GLP ones and thyroid, um, themself. I also have an episode with Nicole McPherson, who is also a thyroid specialist using GLP ones, and I will make sure that I have the link for that one.

So there is, if you're like a thyroid patient and you're like, say more, and I'm afraid of thyroid cancer at girl, I got you gonna have it all on the Dr. Brighten show for you. I.

But in terms of thyroid testing, [00:36:00] TSH, which your brain says to your thyroid, how does it respond? That's a free T four. What does your body do with it? That's a free T three and because the number one cause of hypothyroidism is Hashimoto thyroiditis in the United States, TPO and thyroid globulin antibodies.

Now, when it comes to sex hormones, I did talk about, um, estradiol, but I do want to mention that getting a total and free testosterone along with sex hormone binding globulin and DHA sulfate can also be a really good baseline to have because so often when it comes to women's health, it's all about that estrogen, maybe about the progesterone, and everybody forgets testosterone.

It is gonna be very hard if somebody puts you on a GLP one for you to be building muscle mass if you do not have sufficient testosterone. So we need to check testosterone as well. We wanna be looking at you comprehensively. If you're gonna use a GLP one and we're gonna say, Hey, keep your muscle mass, make sure you work out.

We need to make sure that you have your hormone allies to do that as well.

I should just also [00:37:00] mention that I said like, oh, if you're over 45 and you've lost your period, uh, you're in menopause. If you are under 45 and you've had your ovaries removed, you are also in menopause. So, uh, surgical, menopause, uh, chemical menopause, these are also confirmation enough we don't have to do lab testing, but if your doctor does do lab testing, if you caught my perimenopause episode, I will link to it in the show notes.

FSH that's consistently above 25 with a low estradiol. Those ovaries are retired, so that's the brain starting to yell at the ovaries. And the ovaries are like, I'm done here. I will not work another day for you. Once those baseline labs are getting established, so sometimes, you know, with a patient, I'll be like, you got your blood drawn. Great. you're you're starting HRT that day. I'm not gonna wait for the lab results.

If

you're somebody, you're like 52, I'm like, we know. We know you're a menopause and you are a candidate for hormone replacement therapy because we have done our due diligence in working you up.

So we'll go ahead and start [00:38:00] the hormone therapy that is right for them. And oftentimes that is doing both estrogen and progesterone and in some cases testosterone if

warranted.

And

I have episodes on why I talk about why it needs to be estrogen, progesterone together. I will link to those so you can take a deeper dive on the whys of HRT

And why we're often starting the estrogen progesterone is because that's laying the groundwork for the improved insulin sensitivity.

It's

helping sleep, it's mood stability. It's doing all this metabolic intervention, but also helping you rally so you can do the lifestyle, the exercise, the diet, all the stuff you need to be doing to have excellent health.

When it comes to estrogen,

As I said, I'm usually using transdermal topical. That's because we wanna decrease the clot risk. 

And then what I typically do after prescribing is that I will measure estradiol levels usually a couple months later. 'cause we might be adjusting doses earlier on., And the reason for that is [00:39:00] because we wanna make sure that she's reaching therapeutic range, it's not enough just to do symptom control.

'cause we know for like cardiometabolic health, many women need to have certain serum levels of estradiol. Some of the research points to like 60 to a hundred picograms per milliliter when you're using transdermal therapy. But optimal ranges can vary by the individual and by the routes that you're taking.

So is it oral, is it transdermal? Are you using just vaginal estradiol? Like it just depends on your case. So I always want to make that super clear, like I am a doctor but I'm not your doctor, so gotta meet with your doctor because, well, we talk kind of , blank and statements about HRT. It is very nuanced for the individual,

but I do think it's a really good idea that we are measuring serum estradiol. So blood tests, because we know the research is clear that if it is sub-therapeutic levels, even if she's not having hot flashes, [00:40:00] we shouldn't be expecting the full metabolic benefit. And that's what we're talking about here, right?

Visceral adiposity, insulin resistance, inflammation. So

we gotta be checking those levels. Now that's the hormone piece for a menopausal woman, the GLP one piece. Let's talk about that. So if that's considered, you know, a pertinent therapy based on everything we've talked about so far in this episode, right? Not willy-nilly, not just like, Hey, let's just give GLP one to everyone. I don't know if that'll be a thing in the future and this won't age well.

But as of right now, no, we're not doing that. So if GLP one is considered appropriate, uh, because there is persistent visceral adiposity, you know, she's doing everything where she's like, I am eating and I am training and my like, belly fat that's deep will not budge.

If

there's insulin resistance, if there are, uh, metabolic comorbidities, like there's already pre-diabetes type two diabetes, fatty liver disease, there's elevated cardiovascular risk that [00:41:00] is not improving despite trying everything, doing everything right, then that's when GLP ones are considered.

And then of course the, the standard of like, you are obese, you have a larger body and your goal is to try to lose weight. So these are the times where adding a GLP one receptor agonist. Would be considered to help with appetite dysregulation with hyperglycemia. So high blood sugar levels, uh, weight loss resistance.

The things that we see can really impede a postmenopausal woman's body composition and the things that are putting her at risk for adverse cardiovascular outcomes.

So

again, if there is visceral adiposity, there's insulin resistance, there's metabolic comorbidities.

And

let me just say, sometimes we'll try hormone replacement therapy and we're doing lifestyle and it's still not working, and that's when we'll be like, okay, maybe we should consider a GLP one.

So

I

am framing it in this way [00:42:00] because I think that sometimes the perspective, especially as I see people online, is that doctors are just like handing it out like candy. Those people definitely exist. I am not those people. Most of the providers I talk to are not those people. Nobody really wants to start a patient on a drug that isn't clinically indicated.

'cause these are not cheap and also that isn't medically going to shape and change their life for the better. Um, well, you know, these injections are just these tiny little needles, they're not really that big of a deal. Somebody who's gone through IVF, all the IVF ladies are like, right, right. Yeah. Uh, it's still an injection, it's still a weekly injection.

Right. Um, and so we're not being liberal here with how it's being prescribed. It is, uh, very much going through an algorithm in our minds of what is this person's risk factors? What things have they already tried? Because I am always about how do we intervene with the things that [00:43:00] you don't require from me?

Like with your nutrition, with your lifestyle, right? With your exercise, getting good sleep. You don't need me for that. I want you not to need me. I want you to take charge of your health and do fill your best. And what you need me for is prescriptions. And so yeah, my goal is always like, I want you to have that foundation of health.

I want you to be as healthy as possible without needing a prescription, but if a prescription is necessary, I don't wanna withhold that from you if I know that it can be beneficial. But I also am not gonna force it on you because it's your body and it's your decision. And I don't think any provider should force any prescription on a patient at all.

It should be entirely their choice based on having a true informed consent.

And we have to be realistic that these medications alone are not gonna preserve your lean muscle mass. Your, you're not gonna keep your muscle when you're on these if you're not ensuring that you are doing everything to keep your muscle mass. And [00:44:00] so, with all of that said, of me being like, I, I want you to be able to do as much on your own and take charge of your health, let's talk about what

some

providers are not saying and we need to talk a lot more about with GLP one.

So number one is you gotta eat protein. And generally we're looking at like 1.2 to 1.6 grams per kilogram of body weight per day. That's gonna be spread across meals. Okay? And that's to maximize protein synthesis. It. And this, sometimes you gotta do protein powders. Um, if you've listened to the podcast, you know, I'm drinking collagen in my coffee.

Uh, that's another thing that I will recommend people to use that collagen isn't complete amino acids. So you can't just put collagen in everything. Like you, you would have to have a complete protein powder. But we have to emphasize protein intake to maintain muscle mass

because

what will make you feel full?

If you heard my [00:45:00] perimenopause weight loss episode, I'm like, each, your fiber and your protein and you'll stay full longer. Well, what are the first things that start to go when people are on GLP ones? Protein and fiber, they start to go because someone's getting full too fast. So they just wanna eat like a cracker because that's easy and easy to digest.

And that I think, is a problem. I think that, you know, in my, in my opinion, my clinical opinion, and in my practice, if you're getting a GLP one, you're getting nutrition specialist to hold your hand through this because you deserve that support and you need to learn what your needs are so you can be successful at home in maintaining your muscle mass, but it's more than just what you eat.

Resistance training is non-negotiable. You have to lift weights. Why? Because lifting weights tells the body, we are prioritizing muscle. You better build it. 'cause this is hard and we need to get stronger.

You

have to have that tension, that friction, that like push the body vibe [00:46:00] to your training to get it to build muscle.

So it's gonna be a minimum of two to three times a week. If you can get up to four, that's gonna be even better. But it depends on how you're training. 'cause if you are working major muscle groups, like let's say Monday, Wednesday, Friday, you're doing full body workout of like chest, back, triceps, biceps, then you're doing legs and glutes and you're doing that three times a week, fantastic.

But you have to be doing it. So strength training, we've gotta combat sarcopenic obesity, whether on GLP ones or not, you're gonna lose muscle. You are gonna lose muscle if you don't do something about it, but you can do something about it,

that

is the beautiful thing. You absolutely can do something about it. Now, also in that strength training, you gotta have balance and mobility moves as well. If you're somebody who has, uh, connective tissue issues, you have, uh, hypermobility work with a physical trainer or occupational therapist because you still need mobility.

You

may need to do it differently. And we all need to challenge our balance [00:47:00] because listen, if you're listening to this podcast, you better not, you better not have a hip fracture, uh, because it is seriously, one of my goals with this podcast is that I,

I'm not blaming you if you do, but one of my goals is to make sure that women know you need to build muscle and you need to work on balance because we wanna avoid hip fractures.

And you can also do that. So I have, um, I have balance boards in my house. These are actually for my A DH ADHD kids 'cause they help them so much. But then I was like, I should just stand on these. Well,

I'm

writing my book, working at my computer. the other thing is that I have a vibration plate. I love the vibration plate.

Um, some people say they lose weight with it. I don't know that there's any efficacy to that. So leave me in the comments if you're like, I did lose weight on a vibration plate. I wanna hear about it.

Um,

I use it. It's great for your lymphatic, it's great just to be jostling, postural muscles. But I will do, um, balance moves on it.

You can also buy a bosu, uh, that's uh, both sides up. It's a half ball you [00:48:00] can stand on that do balance exercises. You can do, um, like one legged deadlifts. Like there are just so many things you can do to challenge your balance. So we want to put pressure on the bones and pressure on the muscles to make your body have to prioritize them in building them. 

I would definitely recommend working with a personal trainer if you don't train regularly or you're totally new to it. there. I feel like personal trainers are getting a really bad reputation on the internet because we're seeing so many men.

Tell me why. It's always a man with a shirtless profile picture who like comes in and is just like, oh really? Dr. Brighten? Yeah. Yeah. You said doctor there, didn't you? And they're telling me hormones have absolutely nothing to do with women's metabolic health. And women are like, I hate personal trainers.

There absolute garbage in the worst. There are fantastic personal trainers out there, physical therapists, registered dieticians, certified nutrition specialists. Like there are fantastic [00:49:00] people out there who totally get that your hormones are part of the equation. And they will say, work with a provider who can help you with your hormones.

And then they're part of this collaborative team and we love them. So if you have a great personal trainer that you know is great with hormone health, drop them in the comments for everybody. Um, I don't expect your personal trainer to manage your hormone health. They are, that's outside their scope. But I do expect your personal trainer to understand that when you're like, my hormones are off and I don't feel great that they're like.

Let's try to train you in a way that's working with your individual physiology.

So yes, I know that there's some really awful, uh, personal trainers out there and I hear it all the time from women who like, are like, these guys on the internet are the worst. But I'm telling you that male or female, there are great personal trainers out there. Um, and so don't lose hope. And I'll link to some, I'll link to some, I'll link to a, a YouTube series too that I also like to use for strength training.

I'll put all that in the show notes cause I think that will help some of you get started. Please do not underestimate sleep [00:50:00] optimization when it comes to metabolic health. Either we know that poor sleep can increase your cortisol, increase your appetite blunt, both metabolic and hormonal benefits

that

you're working so hard to create.

And if you're struggling with sleep,

I

did a two part episode series on how to get better sleep. I'm gonna link to that for you. I've talked about sleep a lot on this podcast,

but

just know that most of us are gonna struggle with inflammation with our metabolic health if we're not getting good sleep.

And that's a reason why I also like using progesterone when we're doing HRT.

So

I've been talking a lot. Let me just like do a quick recap, uh, for some of you taking notes, you, you can check me, did I get it all? Okay. So protein 1.2 to 1.6 grams per kilogram per day.

To

keep your muscle mass resistance training, two to three times a week, add mobility and make sure that we have this a balanced component.

Sleep optimization, help improve [00:51:00] appetite produ, uh, help your cortisol levels, help your metabolic health. So we, we wanna have those things in place. A big question I get is about the dosing of GLP one. So let's just say that like the starting dose of your GLP one will depend on which one you're actually using. And then typically there's an increase that'll happen like around a month, but there doesn't have to be. You may stay on just the starting dose and be just fine.

You may increase three months later. So while there are these guidelines, your symptoms and your experience should really guide that. And then you should be being followed up on like every three to six months. There should definitely be follow-ups on your metabolic labs, um, on your, uh, InBody analysis, your DEXA scans.

So we didn't wanna just run them one time. We wanna make sure that we're following up. Sometimes it's gonna be six months later, depending [00:52:00] on what things look like. Sometimes it'll be a year later. It just depends on the labs, the results, what's going on with your health. And then equally important is how you feel.

So are you feeling stronger? Are you feeling weaker? Are you sleeping better? Are you not sleeping at all? Do you have more energy? Your brain's working better? Are you finding that there's brain fog and you need afternoon naps every day? Track these things. They're super important. 'cause the goal isn't just a number on the scale.

The goal is actually metabolic resilience. I, I know you care how you look and that's fine. I'm not saying you shouldn't, but I, as a provider care way more about how your metabolic panel looks about, um, how you are preserving your muscle mass in your bone, how your quality of life is. Um, you know, I think it's really, it's great when women are feeling comfortable in their bodies.

They're fitting into their clothes, like, and they have positive self-esteem because of how their body looks. But I want you to know that the [00:53:00] number on the scale and the pants size and the dress size that you wear is the least interesting thing about you. It is very, very important that we are tracking the things that truly matter for health as well.

So

thin at any cost. Mm-hmm. That, that works at our detriment. 

So just as a recap, GLP ones can have tremendous benefits when used correctly

in

menopause and maybe even perimenopause. They're not at this time considered right for

everyone. We are looking at very specific metabolic markers. We are looking at not just your, uh, weight, but your body composition as well.

When we are considering GLP ones, we wanna be considering your personal history, your family history,

uh,

what is going on in your life right now. Like, are you gonna be able to eat that protein and do strength training? Because like I said [00:54:00] before, being smaller at any cost. Well, no one's telling you how big that cost is.

GLP ones may have benefits for cardiovascular disease,

for,

uh, metabolic disease. We do know they may have, uh, tremendous benefits for brain health. That's like to be determined. But we do know cardiovascular health and metabolic health, they have a tremendous benefit. And if you are in menopause, the weight loss part.

Seems to be very positively impacted by using estrogen hormone therapy. I would also argue that estrogen hormone therapy, progesterone, testosterone, when indicated, is going to have a synergistic effect with these GLP ones. And looking at that full picture is super important. But I always wanna remind you, you can't out supplement and you can't out medicate a lot of conditions without also focusing on nutrition and [00:55:00] lifestyle.

And that is where you hold a lot of the power. So focusing on what you're eating, I will link to a perimenopause weight loss plan for you.

That

is dr Brighten.com/plan, and this is a structured way of eating. It's not super restrictive. I'm not telling you how many calories to take in, and I'm not telling you how many servings you can or can't have.

I'm giving you an anti-inflammatory diet that's focused on nutrient density, helping you get your protein, helping you get your fiber, making sure that you get the right types of fat coming into your diet. And it also talks through the exercise that you can be doing to help support your cardiometabolic health.

I want you to be empowered with that and not feel like you are a failure if you need a medication or that you're stuck with only medications, okay? Like I want you to always have options, and I want to remind you that you are not a failure if you leverage a tool [00:56:00] that's available.

So GLP ones are a tool. Hormone therapy is a tool. These are tools that we can leverage, that we can utilize, that can help us. And I also wanna remind you, you don't have to share your medical history with anyone. I know people are super judgmental where they're like, listen, I'm a naturopathic doctor.

People expect that I should never take a medication or use a medication. And believe me, I get some hate

when

people find out I take a thyroid medication. Why do I get hate? Because people think that natural is the gold standard of everything, we should just be able to do everything naturally, unfortunately.

My immune system murdered a good portion of my thyroid before we ever figured out I had autoimmune disease, and that really sucked. So I don't have the tissue available to make that, and I get to be grateful that I have this medication that allows me to have enough energy that protects my [00:57:00] heart, that protects my brain, and makes it so I can show up as a mom with my kids every day.

I think we have to start reframing things. Like I said, I only wanna use a medication if it's absolutely necessary. I'm a big fan of putting the power in your hands and giving you all the tools and helping you heal yourself. But if your body is unable to make it to the goal that you've defined, that we have defined, and you need a medication, that doesn't mean that you're a failure.

And when we prescribe medications, we always wanna consider how can this patient come off of this as well? Is that gonna be possible with GLP ones people? Say you're gonna be on it for life. The weight is just gonna come back. You know the weight comes back for. The weight comes back. For people

who

were not given support, they didn't meet with a personal trainer,

they

didn't get a registered dietician to help them.

They didn't get the support to help them learn how to live in a way [00:58:00] that supports their body best. And that's where I think we see a failing. And myself and many of the other people you've heard on this podcast,

we

don't see people have to stay on GLP ones for life. We see people be able to transition off successfully.

And is that gonna be true for you? It's just gonna depend. So I hope this episode was helpful for you. Please leave me a comment, leave me a review. I always love hearing from you, and I hope that you're not too upset that I talked about GLP ones because I know there's a lot of anti GLP one people out there.

 

But I hope that this nuance. Helped you and if you wanna see more of the studies, those will be linked in the show [email protected]. And until next time, take care of your hormones so they can take care of you.