Perimenopause Sleep Hormones: Cynthia Thurlow on Why Rest Changes First

Dr. Brighten: [00:00:00] If I was to start hormones, I'm increasing my risk of cancer, specifically breast cancer. What do you say to that? 

Cynthia Thurlow: Oh, I think that's been disproven. Unfortunately, there's been a lot of misinformation propagated that hormone replacement therapy is going to then cause X, Y, Z cancer. There's certainly research that's evolving that's suggestive of the fact that if estrogen was driving cancers, we would be seeing a lot more younger people with breast cancer.

Narrator: Cynthia Thurlow is a true force in women's wellness. She's a nurse practitioner, author, podcast host, and internationally recognized expert whose TEDx talk on intermittent fasting has been viewed more than 15 million times. 

Dr. Brighten: When should women be thinking about estrogen therapy? 

Cynthia Thurlow: Yeah, and so this is really nuanced.

Is she having a lot of brain fog? Is she finding that she's having all those achy joints and a lot of musculoskeletal pain? She's more likely to develop. 

Dr. Brighten: Why do some women coast through menopause and others feel completely wrecked? 

Cynthia Thurlow: I think a lot of it has to do with lifestyle. [00:01:00] A ton of it has to do with how well we take care of ourselves.

And I always remind women the word pause is there intentionally at a time in our lives, whether it's perimenopause or menopause, to really get reacquainted with what is working for us in our times in that time versus what's not working. The women that are thriving in menopause are the women that have figured out for themselves what they need to change about lifestyle first and foremost.

Dr. Brighten: So in the context of all the lifestyle changes, if someone's listening right now, what would you challenge them to? What would you say is like. If you're struggling right now in perimenopause, this is the one thing I would say focus on starting tomorrow. 

Cynthia Thurlow: Oh, absolutely. Sleep without question, sleep is foundational.

If you don't get your sleep right, you're not going to fix your energy issues. You're not gonna fix your insulin resistance, you're not gonna fix your food choices in the morning. You're not gonna have the energy to exercise, and so sleep is foundational an additional 30 to 60 minutes a night, and then maybe we need to add more than that.

Then we have [00:02:00] another carrot to incentivize you to like work towards that, and then we'll keep adding things as we go. 

Dr. Brighten: Mm-hmm. I wanna say for people listening that you are not the only ones resisting sleep. Because I found time, and again, I would lecture at conferences and doctors and clinicians would just be like, oh, sleep.

Yeah, of course they tell my patients to sleep. So I created this whole like diagram that I started teaching on at conferences. I put it in my book as this normal showing inflammation, rising insulin resistance rising, showing how without quality sleep. You can absolutely not fix a single hormone in someone's body, and they're all like, oh, just tell me the one magic thing to get her estrogen optimized.

And I'm like, it's sleep. 

Cynthia Thurlow: Mm-hmm. 

Dr. Brighten: However. We're talking perimenopause, progesterone's out the window. GABA's not getting stimulated. You're like, I can't fall asleep. I can't stay asleep. Yeah. These damn hot flashes have me up. So how do women get better sleep? 

Cynthia Thurlow: Yeah, I mean, I would say absolutely. You know, we, we talk about sleep hygiene, which again, is not sexy.

We talk about things that they can do to, 

Dr. Brighten: [00:03:00] but if you wanna be sexy, do the sleep hygiene. Yeah, 

Cynthia Thurlow: exactly. Exactly. Sleep hygiene, number one. Number two, it's like having a conversation with your partner. Because I know for myself, when I started saying to my husband, I need the thermostat to be at 65 when I sleep, he was like, whoa, that's cold.

And I was like, well, do you want me to sleep? 

Dr. Brighten: Yeah. 

Cynthia Thurlow: And so making sure your partner, if you have a partner, is kind of looped in because it is very important you have a supportive partner at this time in your life. I would say the other thing is. You know, maybe it's time to start hormone replacement therapy.

Mm-hmm. You know, for a lot of women that one to two weeks of oral progesterone is life changing. Mm-hmm. You know, plus or minus do they need some estrogen? Not everyone does. And I think that is such a bio-individual approach. And then I have very targeted supplements that I like to, I, I layer them in gently.

I am not like giving them six supplements and saying we are gonna start all these things at once. Mm-hmm. But I do find melatonin in the right pers right person can be very helpful. My acetol, my acetol for me personally has been completely life changing. Mm-hmm. [00:04:00] Like to the point where I'm like, this is amazing.

But I think, you know, adaptogenic herbs like ashwagandha, relo, rhodiola can be very, very helpful. You know, there are lots of sleep gadgets that are out there. But I sometimes will have patients, I want you to meditate or, you know, do box breaths, you know, for five minutes before you go to bed. Legs up the wall.

Mm-hmm. Keep it really simple. Don't make it complicated. I think in a lot of instances, those kind of basic foundational elements are most important. And then if we are really getting stuck, you know, we can consider other options, but I like to keep it simple and I think I also wanna keep it super cost effective.

Dr. Brighten: If you hit perimenopause and you haven't made those lifestyle changes, is it too late for you? 

Cynthia Thurlow: Absolutely not. You can always improve your quality of life. 

Dr. Brighten: You've talked about how far behind conventional medicine is. From the current science, we have roughly 20 years behind. Mm-hmm. In practice where the science is at, what is the.

Biggest mistake clinicians are making with perimenopausal women? 

Cynthia Thurlow: Oh, I think in a lot of [00:05:00] instances they're thinking they don't need hormones to learn in menopause. Mm-hmm. I think that is clearly an issue, and we actually know women do better if we initiate it earlier. 

Dr. Brighten: Let's talk about when is the best time to initiate hormone therapy?

Cynthia Thurlow: I think when women become symptomatic. Mm-hmm. I think when a woman says to you, I'm never been anxious or depressed, I'm now anxious or depressed, the two weeks of my two, you know, in the luteal phase, or especially the week before my cycle, or my sleep is terrible during, you know, right before my cycle starts.

I mean, that is the time to start. I mean, progesterone is so benign. Mm-hmm. I mean, there's a whole subset, small minority of women that react differently, but in most instances that. Progesterone, that oral progesterone starting at 50 milligrams, a hundred milligrams can be life changing for these women. So I think in a lot of levels, like initiating HRT earlier in the process, you could be in your late thirties and need it.

Like I don't think we should arbitrarily say, oh, you're not old enough. 

Dr. Brighten: Mm-hmm. 

Cynthia Thurlow: To need HRT when we know there are plenty of women out there that have. [00:06:00] PCOS and probably would benefit from progesterone being started at an earlier stage than waiting until they're in throes of perimenopause and they're miserable.

Dr. Brighten: Yeah. Well, and you come from a cardio background, so you can appreciate that. We wouldn't say, Hmm, you're too young, or you're, you know, we wouldn't, we would say, what is your family history? Mm-hmm. What is your history? What's been your experience? But for some reason, perimenopause or anything that's relegated as a women's lady parts issue gets chalked up to No, no, no.

We have this narrowly defined bracket, and if you don't fit into it, you are wrong. You are wrong. Not our understanding around this. 

Cynthia Thurlow: Yeah. I mean, that whole bikini medicine mindset is detrimental to women ultimately. I mean, I think about lost opportunities with patients. Like I finished my training in 2001, so coming out right before the WHI was published.

Mm-hmm. And in cardiology, you better believe how many of my patients were crying because all of a sudden they, you know, they were taken off their estrogen, their progesterone was stopped and, you know, yeah. They, they went [00:07:00] back to having essentially musculoskeletal syndrome of menopause. Mm-hmm. Or, you know, they had terrible hot flashes or they were struggling, you know, psychologically.

And so I, I think that one of the biggest misconceptions that has contributed to women's suffering is that we don't understand that some women are gonna need HRT away earlier. And we have this whole subset of women that each one of us might need something different. Suffering is not necessary. And I think in a lot of ways we've been conditioned to believe that suffering is just part of the process of aging.

Dr. Brighten: Well, I think as women, we've been conditioned to believe that suffering is part of our, like operating mode, like the default mode of women. The day you get your period, it's, oh, it's painful. Welcome to womanhood. How many women with, I mean, you can name, you know, endometriosis, fibroids, PCOS, having all these conditions.

Mm-hmm. And they prevent, they present with these symptoms and their doctor's like, well this is just being a woman and the only thing we can do for you is the pill. I wanna talk. Well, you know, [00:08:00] you mentioned musculoskeletal syndrome of menopause. For people who are not familiar with that, let's. Define that briefly because I wanna talk about estrogen as well.

Cynthia Thurlow: Yeah. So this is something that Vonda Wright and her, um, her group have kind of really talked about and they're format on the research. It's really speaking to this inflammatory process and this low estrogen state. Mm-hmm. Where we are getting arthralgias, myalgias. So muscle aches, joint pain, um, in a lot of instances, debilitating frozen shoulder is something, you know, this end capsulitis where people get these adhesive a capsulitis.

But helping women understand that just like every other organ system or body system changes in this low estrogen state, so do our muscles in our joints. Mm-hmm. And I think it's very validating because how many women are just told, oh, it's just arthritis. 

Dr. Brighten: Yeah. 

Cynthia Thurlow: When it's, no, you actually have low estrogen and that is what's driving the inflammatory process that you're experiencing that would be remedied by something as simple as estrogen.

Dr. Brighten: Yeah. Well, and then you have all the gym bros who show up in their shirtless profile pics on the [00:09:00] gram, and they're like. You are just lazy. Yep. It is not your hormones. You are being lazy. Stop making excuses why you can't work out. And I'm like, I would like every joint in your body to be inflamed when your gonads go.

Like I would love to see how you perform them. Mm-hmm. And so I think we have to validate what women's experiences are. We don't have the research to say that we've got more research, that it's not necessary to listen to women at all. I think we need to listen to them, validate them. Mm-hmm. And wanna talk about the nuance around estrogen and starting that.

So we talked about some of the symptoms of low progesterone. When to consider that. When should women be thinking about estrogen therapy? 

Cynthia Thurlow: Yeah. And so this is really nuanced because we know that, uh, you know, our estradiol levels fluctuate 20 to 30% higher in, in perimenopause. Mm-hmm. Which can contribute to a lot of the symptoms that women experience.

You know, I think it really comes down to when the woman has declared herself, like, is she having a lot of brain fog? Is she feeling cognitively not [00:10:00] as sharp? Is she struggling with word finding? Is she finding that she's having all those achy joints and a lot of musculoskeletal pain? She's suddenly experiencing, like she's more likely to develop, um, opportunistic infections.

Mm-hmm. Like all of a sudden it just, she's getting sick all the time and we know there's this complex in a relationship between estradiol and our immune system. And so I look at it as what are the symptoms they're experiencing? I always get a little more concerned about the neurocognitive effects. Like I'm much faster to start talking about estradiol replacement.

For some women, they're, maybe they're having a little genital urinary symptoms. I'm like, okay, we can, we can generally address that with vaginal estrogen and vaginal DHEA. But I think for a lot of women, like the issue surrounding, you know, when do we start transdermal estrogen? I think for a lot of my thinner patients, when they start, they're, they're itchy.

They're like, why am I so itchy? Mm-hmm. My ears are itchy. My anus is itchy. What's going on? I'm getting weird rashes. You know, there certainly can be this [00:11:00] constellation of symptoms, but for most people, the other thing that I would add is palpitations. Like how many of my patients, they may start having palpitations during their cycle.

Mm-hmm. When they're, you know, transitioning in the luteal phase and you know, they have less. Um, less estradiol, kind of estradiol is dropping. I think for a lot of women, palpitations can be particularly bothersome, especially if we've done a big work app and we've made sure there's nothing concerning going on.

Mm-hmm. Um, palpitations is a big one. Like that can be really annoying and bothersome. And what do we do in traditional cardiology? We're like, you just need to take your beta blocker. 

Dr. Brighten: Yeah. 

Cynthia Thurlow: Like, oh, and there's not a a million side effects from that. Don't stop taking your beta blocker. Mm-hmm. Or if you take one.

But I think for a lot of women, it, it's, it's very much dependent on. What's bothering them? 'cause some people may say, I don't care if I itch. Mm-hmm. I don't care if I sometimes struggle with word finding. I mean, I'm usually saying like, this is clear like your, your brain is trying to recalibrate in this lower estradiol state.

Dr. Brighten: Yeah. 

Cynthia Thurlow: But I'm like, I'd rather get you started earlier rather than later. 

Dr. Brighten: Mm-hmm. Women listening [00:12:00] to this might have a fear if I was to start hormones, I'm increasing my risk of cancer. Specifically breast cancer. What do you say to that? 

Cynthia Thurlow: Oh, I think that's been disproven. I, I think unfortunately, unfortunately there's been a lot of misinformation propagated and we never want the message to be that hormones in particular, like hormone replacement therapy is going to then cause X, y, Z cancer.

I think there's certainly reacher research that's evolving that's suggestive of the fact that. If estrogen was driving cancers, then we would be seeing a lot of younger people. And I'm not suggesting we don't see younger people with breast cancer, but we would be seeing a lot more younger people with breast cancers.

And so perhaps it is that low estrogen state that is problematic. I mean, I even, I talked to re blooming about this, that is it, that lower estrogen state that is making women more susceptible to breast cancer. So. Mm-hmm. You know, from my, from my perspective, um, we never want, we want everyone to get appropriate risk stratification screening.

'cause [00:13:00] there are genetic things that can make us more likely to develop certain types of cancers. But I think in an appropriately screened patient, we go over the pros and cons. Um, you know, things like transdermal estrogen or estradiol are incredibly safe and incredibly beneficial long term. 

Dr. Brighten: I have a really unique opportunity to be speaking to you because you have a cardiology background.

Mm-hmm. And I think you bring a level of nuance that a lot of practitioners don't have in that arena. There are prota practitioners who will say, you should use oral estradiol because of the cardio protection. And I wanna hear your thoughts on that. What are your thoughts on oral estradiol and what are your thoughts on using the birth control pill, specifically oral contraceptive pills?

Cynthia Thurlow: I would say number one, when we talk about oral estradiol, it's always in the context of. Has that patient not been able to manage their symptoms or their bone protection, et cetera, on transdermal options. That's number one, because I've, I have seen a few women that, whether it's the adhesive, whether it's the absorption rate of their skin, they just have not [00:14:00] done well.

Dr. Brighten: Mm-hmm. 

Cynthia Thurlow: And then concomitantly, like, what are their other risk factors? Does someone have high lp, little a and maybe, you know, we need to give them, we need to be buffering them with a bit more oral estradiol. I think it is a very bio individual question. The other thing is, if someone's ever had a propensity for clots, I'm like, Hmm.

Oral estradiol prob, even though we know it is intrinsically a safe drug to use 

Dr. Brighten: mm-hmm. 

Cynthia Thurlow: Or hormone to use, I think that there, there's a degree of caution, whereas with transdermal estrogen, it's. Pretty safe across the board. Mm-hmm. Oral estradiol, I think you really have to screen patients well and sometimes starting them at 0.5 milligrams and monitoring them to see how they feel.

I do have a few women that have high lp, little A that are not yet comfortable, don't want to think about PCSK nine inhibitors as an example. Mm-hmm. And interestingly enough, I interviewed Dr. Tom Dayspring, and so he's this renowned lipidologist and he said, do you know that, uh, actually estradiol is a mild PCSK nine [00:15:00] inhibitor.

Mm-hmm. And so. Thinking about it in that context for people that, you know, are trying to buffer risk factors, risk stratification around heart disease. I think it is a very, um, individualized conversation, very bio individual approach. Mm-hmm. And then really getting patient buy-in to make sure that's the right decision for them.

I have a couple women that's just the right decision for them, and they're comfortable saying, I know that I'm at a slightly higher risk for having some type of a thromboembolic event, but I'm very aware of my body and how I feel, and if I have a problem, I'm gonna let you know immediately. 

Dr. Brighten: Mm-hmm. 

Cynthia Thurlow: Um, when we talk about oral contraceptives, oral contraceptives are controversial, right?

I think that there's the side of me that says, um, I want women to have reliable contraception because that's very important when we, when and if we decide to have children. On the other side. I know so much more now about oral contraceptives. Do I think oral contraceptives are gonna take the place of HRT?

Absolutely not. It could tell you how many women are in programs or mention to me online, Hey, I finally got on [00:16:00] HRT, and when they tell us what they're on, I'm like, oh, 

Dr. Brighten: I know, I feel this. 

Cynthia Thurlow: I'm like, 

Dr. Brighten: wah, 

Cynthia Thurlow: wah w Well, 

Dr. Brighten: and I think it's a, it's a problem. It's a phenomenon. I've actually noticed a lot more in like the last three to five years, and it's very concerning to me.

How many, and I'm not calling out gynecologists as a whole mm-hmm. But they tend to be gynecologists. Mm-hmm. Are advertising perimenopause, menopausal care. And the only prescriptions they write are oral contraceptive pills and SSRIs. 

Mm-hmm. 

And SSRIs certainly we know from the data they can help with some of the symptoms.

However, they're never gonna protect your bones. And we have much better, safer options. Mm-hmm. And what's interesting is the narrative that. I often see Parroted and I say Parroted 'cause I don't think if they actually thought it through, they keep saying it is. They're like, well oral contraceptive pills in a menopausal woman just moderately raises, clotting factors.

But if she was pregnant and I'm like, but she can't be pregnant, 

right? 

Why are we making the [00:17:00] comparison to a menopausal woman being pregnant? Well, if she was pregnant then her clotting risk would be much higher. But like slow the roll on that because these pills were never designed for her. Right. It was never designed to treat this patient population.

And also that's a false equivalency. She can't be pregnant, so this is no longer the thing we compare it to. We compare it to her baseline and we compare it to, do we have safer options. I think the problem is as well, is that. Sometimes it is the best a doctor can do. Yep. Because insurance, because of all of the blockades that exist to keep women from getting the healthcare they need.

Cynthia Thurlow: Yeah. And I think the other thing is just helping women understand like there's bioidentical hormones. 

Dr. Brighten: Mm-hmm. 

Cynthia Thurlow: And then there's synthetic hormones. And even, I was just talking to fleek about this. I said, um, 

Dr. Brighten: oh, she'll go off forever about that. And I'm grateful for her work. 

Cynthia Thurlow: I was talking to a male today who asked the question in a podcast interview.

Mm-hmm. He said, um, tell me what oral contraceptives do to the gut microbiome. 

Dr. Brighten: Oh. And so, I mean, I wrote a whole chapter in my book 

Cynthia Thurlow: on this. Yeah. And so I, I just said, well, [00:18:00] they're not bioidentical hormones. Yeah. I said, you know, there's this endocrine mimicking chemical issue. They're, they, they can erode the microbial diversity.

I said, there's a lot that happens. Mm-hmm. And I don't want anyone to feel shamed if they, if they're on the, I mean, it is what it is, but it allows us to properly counsel patients when we say, Hey. I'm going to give you an oral contraceptive 'cause you're still menstruating, you're concerned about pregnancy.

That is a very different conversation than someone marketing it as hormonal replacement therapy when it's not. Mm-hmm. It really isn't. And what's interesting is an oral contraceptive pill, and certainly you would know better than I would, is at a higher dose than what you would give her HRT. 

Dr. Brighten: Absolutely.

Cynthia Thurlow: So this is a very different animal, if you will. And I I, I was thinking about one of my best friends from high school, she never didn't wanna have children divorced, was like, I'm still sexually active. I wanna make sure that I'm protected. Now I'm 54 years old. I think it's highly unlikely that you are still ovulating.

And I said, I, I, I would have a [00:19:00] conversation with your provider about you've been on oral contraceptive for. 30 plus years. Mm-hmm. Maybe it's time to see if, if anything's gonna happen, you might already be in menopause and it would be more appropriate to have you on hormone replacement therapy. 

Dr. Brighten: Yeah. 

Cynthia Thurlow: And she said, my GYN told me this is hormone replacement therapy.

Dr. Brighten: Mm-hmm. 

Cynthia Thurlow: And I was like, oh boy. 

Dr. Brighten: I also get very concerned in the context of the recent research coming out, showing us that there is a risk of breast cancer, which we think is due to the progestogen, um, not bioidentical progesterone, but the progestogen that you find in many forms of hormonal contraceptives.

And we're giving those to women. We say the pill don't question it. It's very mild. Like don't worry about it. But at the same time, we're seeing hormone therapy be vilified. And to me I'm like, this is very good marketing. Whoever got like this marketing agenda put in front of every provider and then repeated like they deserve a bonus.

Yeah. 'cause they did [00:20:00] a really good job, but it's not the reality of what we're dealing with. I wanna shift to talking more about the microbiome because this is something, so when I wrote Beyond the Pill and I came across the research of how it is altering our microbiome, I'm like, this is serious.

Especially when you consider, you come off, you get pregnant. Mm-hmm. You're passing that microbiome onto your baby, like, we should be considering this more. I have great concerns with giving a woman who's in menopause, oral contraceptive pills. Mm-hmm. And the alterations to the microbiome that could occur.

Tell the listeners what is so unique about the menopause gut. 

Cynthia Thurlow: Yeah. So when we're in this perimenopause to menopause transition. Not surprisingly, we get adjustments in our estradiol levels. And that's where the best research is really speaking to what estrogen does in the gut. And when I say estradiol, that's the predominant form estrogen our bodies make till menopause.

But it starts with, it changes the diversity. So the keystone bacteria that have been with us, hopefully since the beginning of our lives start to shift and it goes to more pro-inflammatory [00:21:00] species, we lose the ability to, you know, this reduction in inflammation just gets unbuffered. Mm-hmm. We tend to be more inflammatory.

There tends to be more leaky gut. Leaky gut, you know, than leading to latent. Um, and helping people understand, like when you look at the small intestinal lining, it's one cell layer thick. And on the other side of that one cell layer thick is the immune system. So when the leaky gut starts, it activates the immune system, which gets ramped up.

That's when you, when all. Start describing like bloating and digestive issues and mm-hmm. Maybe they have underlying food sensitivities because of the changes in estrogen, we start making less short chain fatty acids. And maybe people don't understand what, you know, butyrate, proprie acetate do, but these are very important because they, you know, they, along with fibrous foods that we eat, are helping to provide food to the colonocytes in our colon.

Dr. Brighten: Mm-hmm. 

Cynthia Thurlow: And so some of these in particular are involved with endogenous GLP one, uh, regulation. So GLP one's [00:22:00] drugs are having a, a, a huge focus right now because they're changing the narrative with a lot of patients. But if we suddenly aren't producing as much short chain fatty acids, again, it's another hit to that inflammatory role.

It makes it harder for us to feed the appropriate colonocytes. So it's like the microbiome just goes on this domino effect. Mm-hmm. You know, we're more likely to, to get sick from opportunistic infections, vaccines become less effective. Mm-hmm. So if someone is told, you know, you're immunocompromised and you need to take a, a shingles vaccine or some other vaccine is not, you're not gonna be able to ramp up the immune system the way that you once did.

So it really becomes this kind of domino effect that goes on in the gut that for many people, they just don't start making those connections. I mean, the other thing is when the gut, um, access starts to shift, it means our bone health starts to shift. Our bone health is largely dependent on the health of that gut microbiome.

It also impacts the microbiome of the vagina. Mm-hmm. So we know that as we're losing lactobacillus species, which is a direct reflection of this change in estradiol, [00:23:00] all of a sudden the pH goes up. You know, women start having more genital urinary symptoms and by the age of 60, most, if not all of us will.

So I always say, if you haven't gotten there yet, statistically you will. So it really becomes this domino effect. Not to mention the fact the vagus nerve is the communication gateway between the brain and the gut. Mm-hmm. And all of a sudden, you know, women start experiencing more anxiety, more depression with less estrogen.

They're not making as much serotonin. And so suddenly that irritability, that feeling, cranky feeling like you're not yourself. I mean, there's all these alterations in the neurochemistry neuroanatomy of the gut. And so this direct communication that goes on with our brain is, you know, it can lead to, you know, if you have an inflamed gut, if you've got leaky gut, you've got leaky brain.

Mm-hmm. I think a lot of people don't realize that the blood brain barrier is designed to protect the brain, but once it's been breached in the gut, the research is certainly suggesting we then get leaky brain. Mm-hmm. So it means that. You may not understand it at a, at a, the level that you and I are talking about it, but more [00:24:00] inflammation, brain fog.

I mean, all these symptoms that women experience sometimes just gets chalked up to one hormone changing, but I'm like, no. It's so complex and so nuanced. There's not one area of the body that is not impacted by the gut microbiome, and it's this full on domino effect that just starts and just, it's like, it just adds layers after layer after layer.

Dr. Brighten: Mm-hmm. We see it so common for women in their forties to get a new diagnosis of IBS. And to be told, that's it. There's nothing you can do. Maybe we can give you some motility drugs, like, you know, you, maybe you should modify your diet, but what can women be doing if they're starting to notice these gut changes?

Cynthia Thurlow: Yeah. I would say, you know, first and foremost when someone starts reporting new bloating or they feel like they may be, have a new food tolerance into. I'm like, okay, we need to back things up. You know, we really like, I'm a huge fan of stool testing. 

Dr. Brighten: Mm-hmm. 

Cynthia Thurlow: I'm a huge fan. It doesn't necessarily have to be food sensitivity testing, but really getting grant like, keep a diary of, you know, if you eat X food and then you notice you have this constellation of [00:25:00] symptoms, understanding that that could be contributory.

The other thing is, as estrogen's changing, so does nitric oxide production. Mm-hmm. And so the innervation of the gut may change. Women will tell me, I don't feel as hungry. I don't feel like, I feel like it takes longer to digest my food. And so whether that's a digestive fire issue, whether it's underlying food sensitivities, whether it's a stool test, I think it starts from a very basic level.

Like before we even do testing, are you in a parasympathetic state when you're eating? How many of us stand up when we're eating? How many people, like I used to round on patients with a protein bar. I mean, I think about this now, it makes me cringe. But how many of us are never sitting down to eat a meal?

'cause we're. Eating in the car, we're feeding our kids and standing up. So helping women understand like this kind of top down approach, if your body is in a sympathetic state and you're eating, you're not gonna, you're not gonna break down or assimilate your nutrients, you're not gonna be able to, um, detoxify properly.

I mean, it's, it really is this, again, the domino effect that we see in so many issues. But I would say, you know, take five breaths [00:26:00] before you eat your food. Mm-hmm. You know, try to get yourself in a parasympathetic state. Try to sit down and eat, try to spend, you know, 10 or 15 minutes sitting down. I think many women perceive that to be a luxury.

And what's ironic is when I made that pivot from traditional allopathic medicine nine years ago, one of the things I started doing immediately was I was like, I would literally sit and eat my lunch. Like it was a coveted 15 or 20 minutes of my day. 

Dr. Brighten: Yeah. 

Cynthia Thurlow: And that was something I'd never been able to do.

I made a big difference in my digestion. But when I'm working with women, we'll sometimes start there and then kind of work backwards. Like, tell me about, you know, is it every meal that you have these symptoms, or is it just the last meal of the day? Are you eating too close to bedtime? Are you eating too large of a meal, too close to bedtime?

So it's really getting all the details and then determining like, what's the next kind of approach we need to take? But almost always, there's some diagnostic testing in there. 

Dr. Brighten: Is there anything in the literature that's been shown to prevent the loss of microbial diversity as estrogen begins as descend?

Cynthia Thurlow: Well, the, uh, research around the [00:27:00] microbiome and estrogen is evolving. I mean, there's some postulated, like we think HRT, it's not a primary indication yet, but there mm-hmm. There is a suggestion that transdermal estrogen as and as an example, may be beneficial long term for helping to support that microbial change.

I think the. Bigger conversation is what are you doing before then? 

Dr. Brighten: Mm-hmm. 

Cynthia Thurlow: Like, you know, it's the antibiotics, it's the chronic stress, it's, you know, exposure to glyphosate. I mean, there's a lot of other things that I think certainly contribute that we can be doing up way before we get to perimenopause and menopause.

And I think for so many women, they're not, it's not on the radar. I mean, when I was learning about, you know, the two sentences I got in my nurse practitioner program about menopause, literally that's about as much as we had. Um, I was like, that's so far off. I don't need to think about that. 

Dr. Brighten: Oh man. I hear that from women who are like 38 and they're like, that's so far from now.

And I'm like, as someone in their forties, it will be here before you know it. Yes, unfortunately. 

Cynthia Thurlow: Yeah. And you better think about it [00:28:00] sooner rather than later. So I think it's that, you know, that disconnect from our brains, like, oh, it's so far away. I don't need to worry about it right now. But I think there's a lot we can do before we ever get to perimenopause that can optimize things so that we have an easier transition.

Mm-hmm. But certainly the, the research is looking like there will ultimately be an indication for estradiol therapy being, uh, a primary preventative source. So that microbial shift, but we're not there yet. I think there's, so much of the research is focused on like bone, appropriately, brain, heart health, but all these other indicators I think are, will eventually come to pass.

Dr. Brighten: Yeah. I have seen smaller studies on primary ovarian insufficiency, which is when you lose your period. Typically for good. Mm-hmm. It can come back sometimes before age 45. And I have seen estrogen as an intervention, restoring to some degree the microbial diversity. Mm-hmm. In the gut. And I'm like, look, if we can do that in a 30 something and all the studies are looking at is estrogen, then what if we do that?

You know? And [00:29:00] somebody who has been eating a very diverse diet, who's been doing the you food hygiene that you've been talking about, like what impact can we have? Women have already been taking the steps towards health every day in their life. 

Cynthia Thurlow: Well, I think for a lot of women it, it's that, well, I know I certainly had this amnesia effect of like, oh, I'm in mid my mid forties.

Yeah. I might be in perimenopause. But I think for a lot of women, it's not until things get tough that they're like, oh, okay, maybe I need to change what's going on. But I think for a lot of women, because they can't see their microbiome, they don't think about it. Mm-hmm. Like they can see a, well, hopefully they don't, can't see a bone.

But most of us can envision a bone. We can think about our heart, we can think about our brains. But the micro, the microbiome seems kind of intangible. 

Dr. Brighten: Yeah. 

Cynthia Thurlow: And so for a lot of people, they're like, I don't even know where that is. Mm-hmm. What is that? Where is it? What is, what does it mean? Why is it important?

And I think be in, unless we're tending to it, we're probably not thinking about it. 

Dr. Brighten: How do you recommend women tend to their microbiome? 

Cynthia Thurlow: That's a great question. Well, I [00:30:00] mean, it goes back to those basics that I, I kind of always talk about like sleep is important and stress management is very important.

Dr. Brighten: Casey, you didn't start with food. I want everybody to tune into that because most people start with food, but I think a lot of people listening don't make the connection. Mm-hmm. That literally every aspect of what you do in a day, no pressure impacts your microbiome. 

Cynthia Thurlow: Yeah. And, and I think for a lot of people it's just, it's reassuring to know if they're hearing the same consistent message, sleep, stress, nutrition, exercise, you know, dealing with your stuff.

So if you've got a trauma history like I did, I mean, there's a lot of, a lot of things that you can do, but I think that, you know, on a very tangible level. Like, it doesn't mean that you have pristine sleep every single night. Mm-hmm. But you should be focusing on high quality sleep. You should be focusing on managing your stress, because we know that stress, chronic stress has a lot to do with leaky gut, lowering your immunity.

Mm-hmm. I mean, if you have a lot of chronic stress, you are [00:31:00] going to lower your sex hormones. I mean, I hate to kind of lump all the sex, the hormones just there. But I think for a lot of people and the hierarchy of needs, your body is going to prioritize survival over having sexual intercourse or bonding.

Mm-hmm. And so I think for a lot of people, they don't make that connection that, you know, chronic stress can lower their testosterone and lower, I mean, it has this kind of. Again, that domino effect that I like to refer to, that it's never just one thing. 

Dr. Brighten: Mm-hmm. 

Cynthia Thurlow: I would say the other thing is being conscientious about the quality of your food.

Being conscientious about the quality of your water. You know, get your water tested. It doesn't necessarily that everyone needs a fancy reverse osmosis system. That might not be what you need. But I think for a lot of people it's the, it's the chronic exposure of pesticides, herbicides, chemicals over time that I think can be more problematic as we get older.

Like I always say, the toxin bucket gets filled throughout our lifetime. And it's usually by the time we're in middle age that maybe, you know, maybe it's heavy metals. I mean, there's a lot of things. Maybe it's mold and mycotoxins, you know, there's a lot, maybe it's a tickborne illness. There's a [00:32:00] lot of things that can overflow that bucket.

Mm-hmm. So it's that nuanced approach, but the basics always apply. 

Dr. Brighten: Why is this? Sign or symptoms that women can be looking for to identify that that toxin, buck bucket is overburdened? 

Cynthia Thurlow: Yeah, I mean, I think a lot of, a lot of like neurocognitive effects. Mm-hmm. Um, you know, for many people they may not realize that, um, the brain fog they're experiencing can be problematic.

They may have, you know, the, the detoxification piece, you know, there's. Genetic susceptibility. People that don't detoxify well, maybe they've got M-T-H-F-R, maybe they've got compte SNPs that are contributing to why, you know? Yes, our livers are designed to break down and detoxify things. There's two phases in liver and then it goes to the gut If your liver isn't processing things properly.

Um, I think about headaches, I think about the neurocognitive stuff. I think about people that will tell me, um, they're not pooping every day. 

Dr. Brighten: Mm-hmm. 

Cynthia Thurlow: And I know poop is not an exciting topic for most people, but I would say if you're not detoxifying on a daily [00:33:00] basis, and yes, our bodies are designed to poop and pee and breathe and sweat and all those things should happen, but there's a lot that can contribute to why that's not.

Functioning optimally and in the gut you've got the estrobolome. Mm-hmm. And so it's always this piece of maybe, you know, phase one, phase two are okay, but you get to the estrobolome and the estrobolome, which is what is designed to package up and get rid, it's like a present package, up the present, get rid of it into your, and your poop.

For a lot of people, they don't go to the bathroom every day. Mm-hmm. Or they don't realize that, you know, they have, uh, their estrobolome is not optimized. Maybe they've got high beta glucuronidase, they're not able to actually break down, um, the estrogen in a way that they can break it down and get rid of it.

And so. I think that there's a lot of different things. Weight loss, resistance, bloating, constipation, diarrhea, I mean any digestive symptom, um, skin manifestations for sure. And, and that's very bio individual, but I see a lot of like odd symptoms that women will experience. So I think it can be as unique as the individual, but those are the things I see with greater [00:34:00] consistency.

Dr. Brighten: Mm-hmm. For women who are listening, their Dr. May have told them, it doesn't matter if you poop every day. That's, and we see. Self-proclaimed hormone experts on social media saying the same thing. It's actually not that important to have a bowel movement every day. I want you to talk a little bit about that, because I think we take for granted the things the body does kind of on autopilot, right?

Like when we talk about deep breathing and people kind of dismiss that, they're like, it's breathing, like it's breathing, so what? And like it's pooping, like, right? My body should just do that. So can you talk a little bit more about that and what you typically see with your patients? 

Cynthia Thurlow: Yeah. I mean, so I always get a sense of like, do you have a bowel movement every day?

And I would say 80% of the time. It's a no. 

Dr. Brighten: Mm-hmm. 

Cynthia Thurlow: And so whatever our normal is, is what we assume is normal. So that's number one. Like maybe you haven't been a daily pooper your entire life, but it's almost always a reflection of are you hydrated? Are you someone that is, you know, if, if you're in a stressed state.

Your body doesn't feel [00:35:00] safe, you're not gonna poop. So if you're someone that gets up in the morning and you immediately like rush to work and then you go to work and you're rushing around all day long, I mean, you may not have allowed your body to be in a relaxed state to go to the bathroom. So that's a secondary, you know, issue that can be problematic.

Sometimes it's the ultra process diets. I mean, if you're eating a low residue diet that has like five grams of fiber in it, you may not go to the bathroom regularly. Mm-hmm. And so, um, I, I always argue with the carnivores 'cause they're like, you don't need to poop every day. It's not important. And I'm like, okay, 

Dr. Brighten: some of those bros are eating raw chicken, so I would not take any advice from them.

I like because salmonella is real. Yeah. 

Cynthia Thurlow: I've had that. It's not fun. Um, and, and so I, I think that when I, when I'm looking at what are the optimal ways that our body should function 

Dr. Brighten: mm-hmm. 

Cynthia Thurlow: Having a bowel movement every day is not an unreasonable effort, but I, I think for a lot of people, they kind of get to this point where they're like, I don't wanna talk about it.

Whatever. My normal is normal. 

Dr. Brighten: Mm-hmm. 

Cynthia Thurlow: They, you know, they, but the contributory factors are, are you chronically stressed? [00:36:00] Are you hydrated? And hydration is like, so underrated. I tell people all the time, I mean, I'm a great example. I'm not properly hydrated today 'cause I've been doing a lot of talking. 

Dr. Brighten: And also welcome to Vegas.

Cynthia Thurlow: Yes, exactly. And it's like so dry here. I would say it's so dry and I'm, I'm an east coaster and so it's, it's like this whole thing. What's your diet like if you eat no fiber or low to no fiber, which is the standard American diet. And you know, the recommendations are certainly pushing that 25 to 30 grams a day.

Dr. Brighten: Mm-hmm. 

Cynthia Thurlow: What does fiber do? Fiber like feeds the colonocytes. I mean, there's a, I mean there's different types of fiber, but ultimately it's feeding these cells in our colon. But getting back to the poop conversation. When someone's not pooping, it's, I start thinking what else is going on in their gut?

Mm-hmm. Do they have a latent infection? Is there some this opportunistic infection that's problematic? Do they not have enough digestive fire? Are they someone that's eaten like a no fat diet? 'cause they're paranoid of fat and so their bile is viscous. And you know, we know the bile helps break down an emulsify fats, and so if they start reintroducing fats, [00:37:00] sometimes they get constipated.

And so it, it's just really looking at the whole picture to decide like, what's the contributory piece? But I'll be the first person to say, not pooping is not normal. 

Dr. Brighten: Mm-hmm. 

Cynthia Thurlow: And if it's new, it needs to be investigated. 

Dr. Brighten: Absolutely. So that's something I get very concerned about when doctors are so flippantly dismissive of not pooping every day.

Cynthia Thurlow: Mm-hmm. 

Dr. Brighten: One, if it's a change that could be a sign of ovarian cancer, like that's very serious to take in a, in a postmenopausal woman. And I mean, perhaps even before then. But the other thing too is that we know neurodegenerative diseases often manifest with motility issues in the gut. Mm-hmm. The enteric nervous system of the gut is what is affected first, and we just ignore that.

Mm-hmm. And then we act shocked. Like, we never saw Alzheimer's coming, we didn't see Parkinson's coming. We didn't see this coming. And it's like, yes, you did. She said it to you, but likely you had 30 plus patients in a day. And you [00:38:00] were like, are you gonna die? Yes or no? Okay. Like, let's keep moving because that's the system that doctors have been set in.

And I frame it in that way purposely for people listening because they think that. We have a really great system of insurance, pharmaceutical company legislators, and they've all made the doctors and the healthcare practitioners really the villain. But everybody went to like medical school to their different programs to help people.

Mm-hmm. And then they got stuck into a paradigm that doesn't match what the intention or even the intended impact is of that provider. 

Cynthia Thurlow: Well, and I think there's also this degree of cognitive dissonance. You bring up such a good point about the, an enteric nervous system. And I think for a lot of people, like I even said in my talk today, I was like, when you look at what's changing in the innervation of the gut, like both progesterone and estradiol have innervation in the gut, and as those alterations in hormones are changing, nitric oxide production goes down.

All of a sudden the motility piece becomes problematic. Mm-hmm. And patients will say, [00:39:00] I don't, I feel like if I eat a little bit of food, I feel full. 

Dr. Brighten: Mm-hmm. 

Cynthia Thurlow: Huge red flag. For me personally. It's like I start thinking, okay, well we need to, we hopefully it's nothing and let's like work through this. 

Dr. Brighten: If you're clinician listening, this is a red flag.

Yeah. Not just for her, for all of 

Cynthia Thurlow: us. Yes, exactly. I start thinking like, what else is going on? Like, do they have a latent gastroparesis? I mean, there's a lot of things that can go on, but I think on a lot of different levels. When motility is not working optimally. 

Dr. Brighten: Mm-hmm. 

Cynthia Thurlow: It's a bigger problem. And I think that as someone who just had a colonoscopy, thank you.

My parents. 'cause I inherited some crappy genetics. I've been getting colonoscopy since my th since my thirties. It's kind 

Dr. Brighten: of, oh man, I'm coming up on the, like my deadline. 

Cynthia Thurlow: Yeah. It, well, the worst part's, the prep, which is the truth. 

Dr. Brighten: Yeah. And it's true. Well in the US it's actually like pretty bad. But other countries like are not hitting it as hard as the US is.

Cynthia Thurlow: I have a new gastroenterologist and he's amazing. Yeah. I was like, thank you for not making me have to like eat a crap diet for an entire week in order to prep. 

Dr. Brighten: Yeah. 

Cynthia Thurlow: This one's far more laid back and so we, 

Dr. Brighten: we Okay. Make your point, but I want, I [00:40:00] think we should explain what we're talking about with colonoscopy.

Cynthia Thurlow: Yeah, yeah, yeah. So, so what's interesting is I was having a conversation with my GI doc before my colonoscopy and I said, oh, you know, it's interesting today, literally as I was complaining about my prep, there's a, a young, uh. Country music star who died of colorectal cancer Yeah. Diagnosed at 38, died at 45.

And I was like, I'm just gonna shut up because I am grateful that I get to have a colonoscopy. Yeah. To make sure I don't have a pre-cancerous polyp. But I think for a lot of people, um, they fear these screening modalities and I'm like, listen, colonscopies are both curative and diagnostics. Mm-hmm. So hopefully you only have to do it once every 10 years.

I have to do them every five. But I, I think that when I say the worst part is the prep, it's because they give you medication that forces you to evacuate the contents of your digestive system. And it's not pleasant or fun. But then you go and you have a very nice nap and then it's over with. 

Dr. Brighten: Yeah. And you're hanging out at your house for a while as you prep for this.

So it's something that like, don't, don't go to your kids' soccer game. No. [00:41:00] Or prepping for 

Cynthia Thurlow: colonoscopy. It's your home. No, no. Your home. Yeah. It's like you start at 7:00 PM and you get up at 3:00 AM for the second dose and then it's done and over with. 

Dr. Brighten: Yeah. Well, for people who are afraid of that, I think that is something that's really common.

Or you've had a traumatic experience. Mm-hmm. I think this happens a lot in gynecology. Mm-hmm. Somebody clamped your cervix with the speculum, or the doctor did not ask consent and communicate well and just, you know, shoved a speculum inside of you like the, it's these kinds of things that I think we don't talk enough about.

Mm-hmm. That women have experienced trauma, so they wanna avoid the doctor or they have fear, or they're not getting an informed consent, or they think. The known is gonna be scarier than the unknown. So what would you say to women listening about colonoscopies, about getting screening exams? 

Cynthia Thurlow: Yeah. I would say that, you know, if you are worried or stressed or concerned, I would've a conversation with your provider first and foremost.

Because more often than not, [00:42:00] they'll probably walk you through the entire process. Mm-hmm. Like, this is what you're going to do. You know, they give you a long list of instructions, but they're gonna tell you like the day before you drink bone broth, or you just have clear liquids, and then you're going to take two doses of this medication.

You're gonna spend some time in your bathroom, you're gonna come in the following morning, you're gonna get, you know, they're gonna give you wonderful propofol, you'll forget everything, and then it's over with. Mm-hmm. But I, I think that, you know, the, the greater concern is, and I feel like it, this is more problematic now than ever.

'cause I shared my entire experience on social media and the questions I were getting were phenomenal. People were like, oh. What's the rate of perforation? Mm-hmm. Like first of all, like you know that, so I 

Dr. Brighten: smart people. 

Cynthia Thurlow: I love 

Dr. Brighten: that. 

Cynthia Thurlow: Set me down a rabbit hole. And actually when I read it was such a small. It was such a small, um, so first let me back up.

In the hands of a qualified gastroenterologist, it's a slim to none experience, but you have to be properly screened. Like we don't do colonoscopies on 80-year-old women. 

Dr. Brighten: Mm-hmm. 

Cynthia Thurlow: We try to avoid doing it on frail people. We try to [00:43:00] avoid doing it on people who are actively sick for the purposes of, we don't wanna go into something that's already inflamed or problematic.

Mm-hmm. And I think that's why the screening piece is so important. Like screening, before you ever have a procedure in the hands of a board certified, fully qualified, experienced gastroenterologist, and that's the only people that should be doing this. Um, the incident should be like 0.05%. Mm-hmm. I mean, it's very, very small.

It's less 

Dr. Brighten: than an IUD. 

Cynthia Thurlow: Correct. 

Dr. Brighten: Yeah. 

Cynthia Thurlow: And so I, I think that, you know, putting that to rest, and I did a whole podcast on it because I got so many questions. 

Dr. Brighten: Mm-hmm. 

Cynthia Thurlow: And the amount of people that were like, oh, I've been putting it off because I just didn't wanna deal with it. And I was like, it's kind of like.

Whether we're getting our teeth cleaned or getting a pelvic exam or um, any other screening modality. It's like sometimes we just have to be open and honest with our providers about what our concerns are, discuss the risks and benefits, and then make a decision from there. And to me, a colonoscopy is such a low risk procedure and an otherwise healthy patient that, you know, we're seeing more and more [00:44:00] colorectal cancer in younger and younger patients.

Yeah. Like people in their thirties, people in their forties. There's a lot of speculation for why that's happening, but it's not a reason not to get screened. I think that's the bigger message is, um, I, I acknowledge that maybe 'cause I, I, I've worked in medicine that I probably have a different perspective.

I'm more of a, you know, it's just one of these things I have to do. But I acknowledge, you know, as you astutely stated, someone has a bad experience with any. Type of medical procedure or person, it can make it more challenging to go back and have a second procedure. Mm-hmm. Or have a second conversation.

And this is when I would say, if you've had a bad experience with a provider, see someone else, get a second opinion and then be very open and honest. Like, I have friends who are trauma-informed providers. Mm-hmm. And so they know how to approach patients that have had a bad situation. 

Dr. Brighten: Yeah. 

Cynthia Thurlow: Um, and I think that that's important.

You have to have that open conversation, whether it's like dental fear or GYN, you know, exam fear or a [00:45:00] colonoscopy or a mammography or whatever it is that you're having done. I think the more honest and open you can be with that provider, the more that they can work with you. Mm-hmm. To explain what's going to happen.

And also take a little bit of extra time so that you're more comfortable. 

Dr. Brighten: I wanna shift the conversation into weight. So a lot of women will say. Eating the same, same workout routine, changed nothing. Everything about my body is changing. What's going on there? 

Cynthia Thurlow: Oh yeah. Hello. Perimenopause and menopause, I mean 

Dr. Brighten: and goodbye estrogen.

Cynthia Thurlow: Yeah, exactly. So I mean, it, it starts, well, I mean there's so many things that contribute. I would say number one, this loss of muscle mass. Mm-hmm. So sarcopenia is muscle loss with aging. It's not a question of if, but when. So by the time we're 40, we're losing, you know, I think it's 8% per decade. Yeah. But people say, oh, that's not a big deal.

It is a big deal because most of us aren't, you know, we're not building muscle in our twenties and thirties. So you get to 40 and all of a sudden you're like, I'm behind the eight ball in terms of [00:46:00] looking at that. And muscle is more than just body composition. It is a glucose reservoir. It's important for insulin sensitivity.

The more muscle mass you have, the more insulin sensitive you are. Mm-hmm. And I think for a lot of people, they don't make that connection. And so I say, you're losing insulin sensitivity and you add to that, you're less physically active. You add to that, you're not sleeping through the night. You add to that you're chronically stressed.

You add to that because you're chronically stressed and your sleep is terrible. You don't make good food choices. You know you're eating ultra processed. Diet, which is, you know, 70% of Americans, that's the bulk of their diet. 

Dr. Brighten: Yeah. 

Cynthia Thurlow: And so we know you eat additional 500 to a thousand calories a day, then you layer in, you know, losing insulin sensitivity, loss of muscle mass, all these other things.

And then you get alterations in your, in you, well, they're not just sex hormones, but you get alterations in estradiol in particular mm-hmm. Alterations in testosterone for most people. And I do find that testosterone people aren't always making the connection that testosterone has a lot to do with body composition.

Yeah. And so these alterations in these [00:47:00] specific hormones tacked on with all these things that are changing. And as you edge closer to menopause, you're more likely to put on not subcutaneous fat, it's visceral fat. And the other ironic and terrible thing that also happens is that. Estradiol is the predominant form of estrogen, but then our body is looking for a solution for less estrogen.

And what does it do? It creates estro rich fat tissue. Mm-hmm. So it's a weaker form of estrogen. So when women say, I've got more body fat and I'm not happy about it, I'm like, well, your bo, your body's looking for a solution to a problem. I would also tack on is as our estradiol is going down and our FSH is going up, so follicular stimulating hormone, that protein leverage hypothesis becomes more mm-hmm.

Critically important. And what that means is if you are not eating enough protein, your body is going to be looking for other sources of calories. And it's not looking for, you know, at nine o'clock at night when you're standing in your pantry, you're gonna, you're gonna grab the chips or the nuts, which nuts aren't intrinsically bad, but they're easy to overeat or you're gonna grab the ice cream or you know, a [00:48:00] block of cheese.

And this is where I start seeing women, like maybe they didn't eat enough calories during the day, certainly not enough protein, they're not satiated and their body is looking for more food. And that's an easy thing to kind of pick, is to say, you know, you have alterations in your appetite. So there's not this dampening, you know, leptin and ghrelin start getting a little bit dysregulated.

And so it's fascinating to me. I think it's never just one thing. Then you could loop in like gut health issues. I mean, there's a lot that can drive that food sensitivities that people don't wanna acknowledge that can make them inflamed. I think there's a lot to the conversation, but it's. I always say it's like multifactorial that there's so much that's contributory.

Dr. Brighten: Yeah. Well let's talk about the nuance of testosterone. Mm-hmm. And body composition. 'cause you're right, I don't think enough people make the connection. Mm-hmm. And I also think that testosterone hormone therapy can be done wrong and can contribute to more problems as well. 

Cynthia Thurlow: I was talking about this today that I'm seeing a lot of people that are on super physiologic testosterone levels.

[00:49:00] Mm-hmm. And, and it's when women start looking androgen eyes, so they start having, you know, their jawline changes, their voice changes. Um, a lot of the changes can be permanent. It may not just be, um, the aesthetics piece. So I think about testosterone is everyone associates it just with libido, but so much of it has to do with like building and maintaining muscle, that executive function piece.

And so when I have women that start saying to me, like, I just feel like my body composition has changed significantly. 

Dr. Brighten: Mm-hmm. 

Cynthia Thurlow: I'm like, all right, time out. We really have to have this conversation. Like, and if you're chronically stressed, that will definitely deplete these hormones. And so testosterone is interesting because again, it goes back to everyone thinks about it as the association between sex and libido.

It's a lot more than that, but it is definitely this body composition piece, muscle mass, lean, you know, having, um, less, uh, body fat, all a byproduct of testosterone. 

Dr. Brighten: Mm-hmm. I was just, we're at a hormone conference. Well, it's not a hormone conference, it's a longevity conference. So that's a hormone conference.

Mm-hmm. To me, if you [00:50:00] wanna live long. And so I've seen lots of our colleagues this weekend and we're all talking about testing our hormones. And I am, I had to have an emergency knee surgery randomly, cartilage fell off my kneecap. Oh. Um, but I'm like, immediately like, is this related to my hormones? I'm gonna get these tested.

And I think, okay, you're about to be 45. Your progesterone's not gonna look so good. Maybe your estrogen might be starting to like wing. Get this done, progesterone's optimal. I'm like, okay, good job this month. Let's see what next month's. Right. Right. Mm-hmm. Um, estrogen's fine. And my testosterone is low, which I was like, I'm not even really filling this, but I just turned in my book manuscript.

Mm-hmm. And I'm like, this is a testament to what stress does to your body. Mm-hmm. And I ended up being like, I'm gonna give myself a little bump of DHEA. Mm-hmm. In the meantime. And the like, boundaries, the assertiveness, like all of the, even my husband was like, [00:51:00] mm-hmm. And this is my wife. And I'm, I didn't even notice like how I had like kind of softened and slightly contracted.

Um, I wasn't noticing necessarily like, oh, like, you know. Like I'm losing all this muscle or anything because it wasn't that significant. Mm-hmm. And for that long of a period of time. But that is certainly another symptom of testosterone we don't talk about. Mm-hmm. Is the psychological symptoms. Oh yeah.

The executive function, how, yeah. How we actually start operating in our body and just Chinese, little bit of DHEA topically. And I'm like, Hmm, okay. Yeah. Got my groove back. I have to work on the stress. That's not gonna outdo the stress. But I think it's important for women to hear that because often we frame things as like perimenopause typically is gonna start progesterone.

Mm-hmm. And we're talking all about estrogen, but we don't talk about that testosterone piece. So for women right now, we've given some examples of like low testosterone. Maybe they're afraid to start testosterone. Maybe their doctor is telling 'em there's no reason to test testosterone. It's not 

Cynthia Thurlow: FDA [00:52:00] approved.

Dr. Brighten: Yeah. Yeah. That's a whole nother, uh, Marty, if you're listening, can we get it together already? Yep. Um, so, okay. What is the first steps, if somebody's coming into you low testosterone, what are the first steps you take them 

Cynthia Thurlow: through? Yeah. I mean, I, if we suspect it's stress mediated mm-hmm. It's like you have to address the stress.

So it's like the elephant in the room. Like, I can give you testosterone. 

Dr. Brighten: Mm-hmm. 

Cynthia Thurlow: But it, it's ultimately, it's just a bandaid. Unless we're also addressing this as well. So, and 

Dr. Brighten: you don't want cortisol to get your friends. 

Cynthia Thurlow: No. You don't want that. So, so I think that's part of the conversation. And I think a lot of women are very interested in transdermal application of, of testosterone.

Very interested, very open to it. Unfortunately, right now, our options are like AndroGel at one 10th of the dose. Mm-hmm. Or we're compounding drugs and, and there's nothing wrong with. Compounding it. It's just, you can get it exactly what you want. And yeah, it's not in an alcohol base, which doesn't, it's, the application process is weird.

Um, and I speak from personal experience 'cause I've now tried both. I'm like, [00:53:00] okay, what do I like better? I think the compounded version's just so much easier. 

Dr. Brighten: Mm-hmm. 

Yeah. 

Cynthia Thurlow: But I think for a lot of women, what I find interesting is not every woman in menopause needs testosterone. They assume they do.

There's certainly some women who still make enough testosterone, which I think is awesome. I'm not one of them. But the other question is, you know, what are the signs of too much testosterone? Yeah. And I think for a lot of women, that's the fear. And I'm like, you're not going to get too high of estro.

Sorry, testosterone levels. If you are using transdermal, it's the super physiologic dosing. 

Dr. Brighten: Mm-hmm. 

Cynthia Thurlow: That we certainly see in this space. Sometimes that I kind of takes my breath away and that's usually injectable, whether it's subcutaneous or intramuscular, that's a different, that's not what we're talking about.

Dr. Brighten: Yeah. And women typically just don't fill as well doing the injections. I mean, once 

Cynthia Thurlow: they get a peak and a trough 

Dr. Brighten: Exactly. That they have the, oh, okay. Like this little bit, we went a little too far. It's very Goldilocks. Right. You're like not ever really hitting that center point and like chilling there for a minute.

[00:54:00] Mm-hmm. It's like too much, too little, too much. And unless you're like, I mean, there are ways that, you know, sometimes it'll be dosed where you're doing more injections. Mm-hmm. Who wants to do more injections during the week, like that's not a good time in terms of testing. Providers will tell women, we test your total testosterone.

That's enough. You're totally fine. Like, it looks good. Why is that not always true? 

Cynthia Thurlow: Well, 'cause that's not what's bioavailable. Mm-hmm. That's why I think testing free testosterone is so helpful. And it's interesting because to me, I like to see both to have a sense of, you know, what exactly is going on.

Much to the same point that, you know, when I'm looking at, you know, other types of hormones, like thyroid hormones, it's not just checking a TSH, I wanna look at a, you know, comprehensively what's going on. And I think for a lot of women, um, understanding that free testosterone is what our body has that they can actually utilize.

It's what's bioavailable. And that's an important distinction. Like, it's almost like if you look at. This is a terrible analogy, but I'm gonna use it. [00:55:00] T four versus T three. So T four is the inactive form of thyroid hormone, and T three is the active form. It's important to have a sense of both so that you can determine like what might be going on.

Is it a conversion problem? Mm-hmm. What could be contributing to this? So I would say if you're lucky enough to get your testosterone tested, please ask your provider to ask for both. Mm-hmm. It is very helpful. 

Dr. Brighten: We've been talking about weight loss. There's a lot of proponents of intermittent fasting for women, telling them that's the golden ticket for weight loss.

What are your thoughts on intermittent fasting? 

Cynthia Thurlow: I think that it's one of many strategies. I don't think it's the perfect strategy for everyone, and I would be the first person to say like, even though this is something I'm known for, I have gotten very nuanced on this topic, meaning, mm-hmm. If you are under the age of 35 versus perimenopause versus menopause, there's a right and a wrong way to do things.

If you're someone that's 35 and under and you're very lean and very athletic, please don't intermittent fast. Mm-hmm. If you have PCOS and you're [00:56:00] obese and you're under 35 and you wanna get pregnant, that may be helpful. That may be beneficial to have some degree of, um, you know, timing in your day in which you don't eat.

You're not. You're not undereating. That's not definitely what, not, that's not what we want the message to be, but it's entirely dependent on where you are in your cycle. Mm-hmm. Same thing with women in perimenopause, but we add in the are you sleeping? Are you managing your stress? Are you able to eat enough food?

Because this omad, one meal a day has gotten very popular and I'm very outspoken against it because I'm like, listen, if you come back from vacation and you did nothing but eat for five days and you wanna just have one meal and call it a day, that is very different than chronically undereating, which we know can be profoundly detrimental.

Mm-hmm. I think that it always goes back to women in perimenopause and menopause. Are you metabolically healthy? Are you still menstruating and then tweaking these things. But I think intermittent, fast, intermittent fasting in many ways, like most. Trending topics has become [00:57:00] the panacea for everything.

Dr. Brighten: Mm-hmm. 

Cynthia Thurlow: And I think some women do it and they feel good, and some women do it and they feel awful. Their sleep goes south, they have tons of cravings, they overeat in their feeding window. It triggers eating disordered behaviors. I mean, it is as individual as we are as women. And so it really has to have be an honest conversation.

Do I intermittent fast? Occasionally I don't do it like I used to do. Mm-hmm. And it's because I'm so focused on building muscle. And so I think for every person it's what are your goals? If you are someone that needs to lose 30 or 40 pounds, it might be a good strategy to use, but make sure that you're doing it around your follicular phase when estrogen predominates in your cycle and you're not doing it the two weeks at the end of your cycle when progesterone predominates.

I think that's kind of the prevailing theme. And what's interesting is I find a lot of menopausal women. It can do really well with fasting if used appropriately, because they don't have as much hormonal fluctuation day to day and week to week like younger women do. And I think on a, uh, I think that I owe it to [00:58:00] your community to say that it's one of many strategies.

It's not the only strategy that can help with weight loss. 

Dr. Brighten: I definitely agree. And I, it's this, it's very much I think is, you know, a theme that we've kind of gone through in this podcast, which is like honoring what's true for you and listening to yourself and also understanding that you might be intermittent and fasting things are going well.

You have a stressful season of your life, it's no longer working for you, and you have to give yourself permission to adapt. Mm-hmm. And our entire species is here because of our ability to adopt. Each of us had an adoptable ancestor, and yet we've reached this place where there's such rigidity mm-hmm. In our society and.

We're, you know, there's the A type personality for sure, but then there's also like the wellness personality who's like orthorexia. Yeah. And this is the thing I have to do and this is the best way. And even in the face of data, which is their own data saying otherwise they don't really give themselves permission to say, Hmm, this worked.

That was [00:59:00] great. Thank you. And now I have to adapt in all of this. 

Cynthia Thurlow: Yeah. I mean, it's interesting. I've spoken very openly. Like last June my dad died and my dad and I were very similar body habitus wise. And I kept saying to myself, you know, after, you know, what contributed to his death? And I share this so that people understand, my dad was very frail.

Mm-hmm. When people are frail, they lead to falls. And whether they get a head bleed or they break a hip, it's a poor prognostic indicator. And so my dad developed multiple head bleeds. Mm-hmm. And based on his, his wishes, we let him pass and, and hospice. And I remember saying to my brother, I was like, if I don't get myself together.

Because I've always been like a leaner, thinner woman. 

Dr. Brighten: Yeah. 

Cynthia Thurlow: I was like, I'm gonna be just like dad, and I don't wanna be just like dad. I don't want that to be my future. And so I got very serious about weight training and what came out of that was getting really serious about three meals a a day. Yeah.

And so I share this, that people understand it's okay if maybe you've been fasting up until this point to course correct. 

Dr. Brighten: Mm-hmm. 

Cynthia Thurlow: Because if you are not focused on [01:00:00] building muscle in middle age. You're going to be one of those statistics, and I don't want that for anyone. 

Dr. Brighten: Let's talk about that. Someone right now listening that's like, well, sometimes I work out, I'm inconsistent.

What is really an ideal strategy for fighting frailty when it comes to exercise and nutrition? 

Cynthia Thurlow: Yeah. I would say number one, it's strength training at least two to three days a week. Mm-hmm. And if you don't know how to strength train, that's okay. Start with body weight exercise and work with a qualified trainer who works with middle aged people so that they know how to safely progress your activity.

Dr. Brighten: Yeah. 

Cynthia Thurlow: Number two, it is. Protein, please eat some protein. And that means tracking your macros. So for transparency, track your macros for a week. What I find is most women, when I ask them to do that, they're consuming 40 to 60 grams of protein a day. Mm-hmm. That is not enough to starve off muscle loss. And so it really becomes this, I want everyone to work towards a hundred grams of protein a day.

Dr. Brighten: Yeah. 

Cynthia Thurlow: And that could be divided over three meals. That could be diet over two. [01:01:00] Today's the day I'm gonna get two meals in and not three. And so it's helping them understand like, this is certainly something you can work towards. But that frailty piece, what people don't understand is the reason why we want you to maintain and build muscle is that frailty leads to a loss of independence.

Dr. Brighten: Mm-hmm. 

Cynthia Thurlow: I don't ever wanna be in a nursing home. I wanna be as independent and strong as long as I can be. 

Dr. Brighten: Yeah. 

Cynthia Thurlow: And so I, because of taking care of patients for over 25 years, I saw 50 year olds who couldn't get off a bedside toilet in the hospital. Mm-hmm. I saw 55 year olds that would fall and break a hip.

And so I think that it's not just a disease or an issue with 70, 80, 90 year olds. This starts in our forties and fifties. 

Dr. Brighten: Mm-hmm. 

Cynthia Thurlow: So it really needs to be something that we prioritize. 

Dr. Brighten: And I wanna give everyone permission to be so annoyed with having to eat protein in the day because it's something that like, I think we have to sometimes talk about the reality of it, but I don't know about you, but there are some days where I'm like, [01:02:00] okay, I gotta mix protein powder in with my Greek yogurt.

Yeah. So that I can like hit this because I need to get my protein. And I'll have moments where I'm like, this is so annoying. And I'm like, no, but it's good for you. I'm like, no, no, no permission to be like, oh, this is so annoying and I'm gonna do it anyways. 

Cynthia Thurlow: Yeah. 

Dr. Brighten: I'm gonna do it anyways. And I think that.

It's okay to be uncomfortable and it is okay to challenge yourself with having to do hard things like going to the gym. 'cause there are a lot of really rude people out there. Mm-hmm. Who like to make fun of women for body weight exercises, for having your five pound pink weights. Everyone has to start somewhere.

And also if you like pink, then rock your pink weights. So who cares if it makes you happy and it gets you in the gym to do it. But we, there's such this arrogance about the fitness industry sometimes that I think it becomes obstructive. And so women are like, no. Oh, they here the most, I have to lift heavy.

You can't start with heavy. I'm sorry. Yeah. If you're going from couch to, to like [01:03:00] weights, you cannot start with heavy. And it may be starting with two to three pound weights. Mm-hmm. And then you're gonna progressively increase. And you should be proud of yourself for even picking that up. You know, I grew up on, um, I didn't grow up, actually, I, I went to college on the central coast of California.

Jack Le Lane. I don't know if you know him. Yep. I remember him. Big fitness guy. He had a whole morning show and he literally was teaching people to lift cans of like produce, right. Like, like cans of peas. Yep. And as a workout, I worked in a gym. I was a group fitness manager and. And saw the women coming in who were doing jackal lane's, lifting cans of vegetables, who then eventually felt, oh, I can go into the gym.

Yeah. And empowered them, and I think about that. I'm like, that was 20 years ago, and I'm like, that was amazing. We have to continue to bridge that gap and to say like, where you're starting from is a perfect place to start today. Rather than saying, well, it's not good enough if you're not deadlifting 180.

[01:04:00] Like, what about this person? You just have to honor where you're at and then set the goals and go for it. In terms of goals for perimenopause, what would you challenge listeners to do in terms of their microbiome or perhaps it's their hormone health? What is the like key message that you would want women to walk away with?

Cynthia Thurlow: I would say, I think it's really important, like after being so enmeshed in the research. Everyone needs more fiber. 

Dr. Brighten: Mm-hmm. 

Cynthia Thurlow: And so whether it's 30 plant varieties over a week, whether it's getting really granular about, um, you know, eating more fiber dense foods, whether it's trying something new every week, the research is clear about the role of fiber in the microbiome and how important it's for the colonocytes for short chain fatty acid production.

And understanding that as you are making this transition, that microbiome takes a big hit. 

Dr. Brighten: Mm-hmm. 

Cynthia Thurlow: So get accustomed to a. It isn't necessarily that you go [01:05:00] from 10 grams of fiber to 30. I'm not suggesting that, but just be more conscientious. It doesn't mean you add a supplement. I mean, it might be that you add a tablespoon of flax and chia seeds every day to your yogurt or your protein shake, or you just find creative ways to start integrating more of these items into your diet, which is greater awareness.

Dr. Brighten: Mm-hmm. 

Cynthia Thurlow: Not to make it complicated, this is not designed to be complicated. It's just building awareness about the importance of fiber. 

Dr. Brighten: What are the red flags like for you personally that were like, okay. I got a 180 this train or things are gonna be much worse. 

Cynthia Thurlow: Um, I, I think starting with, I was doing really intense, like CrossFit, like exercise at five 30 in the morning, three or four days a week.

And so I would get up at four, I would drive to the gym, I would do my work and I would go, I'd rush home, get the kids ready, shower, get them to school, and then I would go to work. And so I was never getting enough recovery. I was never getting enough rest. And I, and I'd been able to get away with that in my twenties and thirties and all of a sudden it was no longer serving me.

And then you add [01:06:00] in super stressful job where, you know, we function like residents and so we had a lot of responsibility. We're managing very medically complex patients, sometimes flying 'em out of the hospital to another hospital for care. And then I would add in not enough sleep. Mm-hmm. Like, I think I, I, in many instances, my kids were at an age where I would get them to bed at seven or eight and then I would have an hour or two to get stuff done instead of going to bed.

Dr. Brighten: Yeah. 

Cynthia Thurlow: And so I really had to learn like. You need to put yourself to bed. 

Dr. Brighten: Yeah. Okay. So what you described is absolutely so common. Mm-hmm. And we're told you need to exercise. Where are you gonna fit that in? You're gonna sleep less. Mm-hmm. Oh, you've gotta do all your chores at the end of the day, where are you gonna fit that in?

Like, you're gonna sleep less. How are you feeling? And how do patients in your practice feel when it's that aha moment of, okay, I need to make a change? 

Cynthia Thurlow: Um, I, I mean, I think for most people it's a, it's challenging because you, you recognize you need to make the change, but you're like, how do I do this?

Mm-hmm. Like, how do I redo everything that I'm already, uh, you know, my [01:07:00] situation, my rituals, my, you know, I was never a lack of motivation for me. So I was like, how do I rewrite everything that I'm doing? So I started working out from home. I started, you know, adjusting my carbohydrate intake. I started putting myself to bed early.

I was willing to make those changes. I find the most challenging patients are the very, very type a's who've been able to white knuckle it their entire life. And all of a sudden you're telling them. The aspects of your personality that have allowed you to be incredibly successful, you have to pretend like that isn't part of your personality in order to start making these shifts.

So in some of my, you know, patients who are. C-level executives or physicians, I mean, people have very demanding jobs. It's saying, okay, what we need to do is we need to find someone to help you with meal prep. We need to help find like, can a trainer come to your house so that it makes it easier? Like what?

Or can you do workouts from home? Mm-hmm. Finding ways so that as they were identifying. Barriers to making changes. I was like, okay, then we need a [01:08:00] solution. It doesn't necessarily always have to be something that costs additionally, but finding solutions so that they can move forward without feeling like they're, they're penalized.

I mean, I've had some women say that to me, like, I just feel like I'm penalized, like suddenly. Everything that's allowed me to get to where I am and be very successful in life no longer serves me. Like, what do I do? 

Dr. Brighten: Mm-hmm. 

Cynthia Thurlow: And so I think for a lot of women, it's this recalibration, it's this reframing of this time in their lives.

And I think once they, there's a degree of acceptance and that reframe is accepted, all of a sudden it doesn't seem so arduous. Mm-hmm. But if they fight it, if they're unwilling to make changes, then that's a completely different situation. And I, I would love to say that no one ever has that problem, but there are clearly women that really struggle with having to make all these lifestyle changes.

Dr. Brighten: Tell the listeners how your book can help them take those steps every day towards health and maintain the independence that you've spoken to on this episode. 

Cynthia Thurlow: Yeah. I would say that, you know, the, the book kind of walks you [01:09:00] through the science, not in an inaccessible way. That was one like really core theme of the book.

So walks you through. Ovarian aging, we were talking about longevity, walks you through the immune system, walks you through all these key components that we've talked about, and then gets you into the actionable portion of the book. I mean, I spent a lot of time talking about all of these things. I've talked about sleep and stress and nutrition.

We get into supplements, we get into, um, hormone replacement therapy and why that's important. There's lots of resources, but the thing is that it's, it's accessible. Like I read, I mean probably like you do as a podcaster, I read a lot of books in a year. Mm-hmm. And this was really designed to be helpful for not just clinicians, but also women and their loved ones, so they feel empowered and not scared.

Because sometimes the message, sometimes from a podcast might feel scary or overwhelming. And I'm like, listen, we are starting small and working towards big things. And the really cool thing about the microbiome is really small shifts. Have a great deal to do with the [01:10:00] malleability of the microbiome. Like it is very fixable.

It is very fixable in the, in terms of um, not just lifestyle, but also the nutrition piece, the supplements, the, um, hormone replacement therapy. And I unpack the WHI in that book. 'cause I think it's important to give people context and then lots of resources, things that they can, you know, look into and learn more about.

Dr. Brighten: Yeah. And I would encourage listeners, if you have a practitioner in your life that you feel isn't listened to, isn't getting it, this is a great book. You can give it to them. You can leave it in their waiting room because as we've seen when enough women get vocal, change is created in healthcare. And this book is certainly a tool for you to get educated, get empowered, but you can also use it to help your provider, help more women.

So thank you so much for coming on the show. 

Cynthia Thurlow: Thank you so much. It's worked out perfectly. 

Dr. Brighten: Thank you so much for joining the conversation. If you could like, 

 

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