For this Doctor Talks. I have a really wonderful guest, Doctor Becky Lynn, who is a board certified gynecologist and obesity medicine specialist. She is the founder and CEO of Avaaz Women's Health, as well as an adjunct associate professor of Ob-Gyn at Saint Louis University.

And she is also a menopause Society certified physician. So we are going to talk about all things menopause and weight related. Thank you so much for joining me, Doctor Lynn.

Thank you so much for having me. So let's start off with some of just the the basics here. So we're all on the same page, which is what happens in perimenopause and menopause that contributes to weight gain.

Yeah so many things. So basically women go from having nice normal cyclical changes in their hormones, in their reproductive years, in their 20s and 30s to erate like big swings up and down in hormones in their 40s.

And these cause a lot of symptoms, classic perimenopausal symptoms. So hot flashes, night sweats, lack of sleep, irritability. So, and women can have many, many of these symptoms.

It's typically not just hot flashes and night sweats, but it sort of leads to this downward spiral that contributes to weight gain. So if a woman is not sleeping because she's having night sweats, then lack of sleep contributes to weight gain.

Lack of sleep contributes to feeling unmotivated to get to the gym, feeling irritable, or maybe depressed. They're feeling depressed. So they're unmotivated to get out to eat right?

And that can, lead to weight gain. And there's a variety of, hormonal changes that, that affect, how a woman gains weight around this time. It's super common.

So, estrogen plays a role in insulin sensitivity. So estrogen improves how well your insulin works. So it's about this time where estrogen levels are waning.

So insulin isn't working as well. And then also as women age we naturally lose muscle and muscle burns more calories than fat at rest. So every year if you lose a little bit of muscle, your metabolic rate, all else being equal is going to slow down.

So it's sort of unfair for women in their, you know, 40s, late 40s, they get hit like a truck with all of these symptoms. And then who wants to gain weight?

Nobody wants to gain weight. But it's this conglomerate conglomeration of symptoms that really contributes to weight gain around perimenopause and menopause.

So let's talk about what some of the solutions are. Right. So I think we have established and I've interviewed a few experts on menopause for the summit that absolutely a very real thing.

That weight gain is part of menopause for so many women. But like, what can we do about it? Yeah. So my approach to weight gain, you know, I follow the Obesity Medicine Association approach, healthy eating, exercise behavior all changes.

And then I do use medicine if people meet criteria, if it's something that they want to do, if they're, good candidates, I always start with how you're eating, you know, avoiding processed foods and eating lots of fruits and vegetables, and low sugar and things like that.

So, so in my clinic we have a dietitian. And so our dietitian is very well versed in helping menopausal women figure out the right amount of proteins and carbs and fats and the right amount of calories.

I also talk a ton, a ton about, exercise, both cardio and strength training. But when women have limited time, if they're busy, if they're, you know, working mom and they just don't have time, I really focus on that strength training because of that muscle loss for women in the perimenopause and menopausal years.

So if you have limited time, you know, a lot of women in the menopause, time now we're around in the Jane Fonda era, including me. So we all think about cardio is the calorie burner for weight loss.

But really, we we need to be, at this point in our lives, focusing on, the strength training. I will typically always screen for insulin resistance, because this is when it shows up.

And a lot of times women struggle. They don't understand why they're not eating much, they're exercising and they're gaining weight. And so some women are reassured when they find something that's contributing to the weight gain.

We don't want to find anything. We don't want them to be insulin resistant. And also, if we find out that they do have that, we can tailor our, our weight loss plan knowing that they have, insulin resistance.

And then we if, like I said, if they meet the criteria, we will discuss some of the weight loss medicines, go through the risks, benefits and side effects and see if, one of the medicines can help them lose weight.

And then, we can talk about those medications as well. But hormone replacement is often another part of all this. And we can talk about how it can help all the symptoms, but specifically in terms of, weight, what can women expect from hormone replacement when it comes to weight?

Yeah. So there's two main roles that hormones play. One is an insulin sensitivity. So estrogen can improve insulin sensitivity. And estrogen also affects your body composition.

So around the time of menopause this is when women start to develop more visceral fat. Or their fat goes to their middle. They have more of an apple shape as opposed to a pear shape where fat goes to bust, bum and hips.

And estrogen can affect your body composition in a positive way. Because we know that the apple shape increases your risk for a host of metabolic problems.

Okay, so hormones can. Using hormone replacement, estrogen can help with the body composition to some degree, but then some women may need additional medications are what we call anti-obesity medications colloquially.

Sometimes I'll just say like a weight loss medication. Right. So can you talk about what some of those options are and how you help a woman choose which one makes sense for them?

Sure. So one thing I do want to say about hormones that I think of the common misconception out there is that, oh, if I get on hormones, I'm going to lose weight.

But it's completely not that simple. Hormones are not weight loss medicines per se. They can help somebody, but they still need to focus on diet, exercise, behavioral changes, things like that.

But they're not in and of themselves. Weight loss, medicines. If somebody wants to use a weight loss medicine, there's a whole host of, of, different choices.

I am a fan of the GLP one agonist, especially if you have insulin resistance, then this is an even better choice. But you don't have to have diabetes or insulin resistance to benefit from, the GLP one agonists.

So these are we go the zap bound. You might have heard them also called ozempic, which is the same thing as with Govi or Mount Jaro. The same thing as, zap bound.

But I find that these medicines work incredibly well. Many people, not everybody, but the majority of people who use the GLP one agonists have success.

And I kind of liken it as a tool you'd never want to just do. Here's your medication. See you later. Like my patients, they work on exercise. We have personal trainers, they meet with our dietitian.

But I really feel like the GLP one agonists help you adopt the healthy lifestyle. They give you the tools and kind of the willpower that you need to make healthy choices.

A lot of my patients tell me they don't crave sweets like they used to. They don't drink as much alcohol as they used to. So, you know, they really kind of help you do the things that you want to do as far as changing your lifestyle.

That's almost the same phrase I used. They let you do the things that you're trying to do or want to do, right? So if you're one of these people where you've optimized everything else, you are eating as healthfully as possible.

But maybe it's really challenging. You have a lot of cravings, or you constantly feel like you're starving. Maybe you've maximized or doing your best with exercise, and it doesn't seem to be adding up or making the impact.

Then these medications really add that next layer and let you do it right. So people will come back and they'll say, I ate half a piece of pizza and I was full, or I'm craving salad, or now I'm satisfied from the salad at lunch.

And it's really powerful to let the med assist people in that way to to actually be able to do those healthy habits that maybe they just weren't ever able to really do to the same degree.

Right? I, I'm 100% with you. Or they felt like they were starving themselves, or they felt like they, you know, because then sometimes people will go off the deep end.

I'm starving, I'm starving, I'm starving. And then, okay, forget it. And I'm going to binge eat and eat everything possible. So these medicines, like you said, help you kind of eat half of what's on your plate without feeling like you're lacking something.

Yeah. And I always will say hunger is real, right? You know, like, we can only do so much to overcome that. And if you have been restricting, you're doing a really strict diet.

You've cut calories, you're doing aggressive fasting, whatever it may be. You may actually just be hungry. Right. And and the second you let your guard down or you get a little tired or that, less healthy options in front of you, it becomes hard to resist that hunger, which is a true body signal that's there to protect us.

Right? We need to eat when we're hungry. And the medications help decrease that hunger. So now you can both be losing weight and still choose, you know, the salad or eat half of the the piece of pizza.

Yeah. So, the GLP one receptor agonist sound like they have a helpful role. Do you use some of the other medications, the, older, more affordable oral medications like phentermine or contrary or any of those medications?

Yeah, I definitely do. You know, it depends on the patient and it depends on their history. It depends on what their insurance is going to cover or what their budget is.

But I do use shamaya a fair amount, which is a combination of fun and topamax. I have a good percentage of people who will lose weight on that one too.

You know, there are some contraindications to these medicines, so which one you choose depends on which one a patient can safely use. But I do use a lot of Kazmir and I do use factor min as well.

And I find you know, not everybody's going to have success with every weight loss medicine. It's like it's like buying shoes. You have to find the one that fits.

So, you know, sometimes it's a little bit of trial and error. Other times it's what their insurance will cover. But those are generally my go to the GLP one agonist Kusama, phentermine and then sometimes I use Cointreau as well.

Yeah. So we have this whole menu of options. And so you know, if you've already tried one and it didn't work or you didn't like it, regardless of whether that was one of the injectable medications or was a pill that you took years ago, there are lots of different options.

And so if you work with someone who who knows those options, we can help you pick the one that makes the most sense for you. And it may not be the same one that worked really well for your neighbor or your best friend or your sister, right?

Sometimes where people come in that this worked really well for my, you know, my sister. Well, you have a different body. Like, maybe we need to try something else for you. Yes.

So what is what is the goal with weight loss in, menopause. So, you know, sometimes people will come to me and they want to weigh the same they did when they were 22.

Or like, how do we know if we're at a healthy weight at this stage in life? Yeah. So when I work with my patients, I never say, I never said, okay, we have to get to this number.

It's really how you feel, how you feel about how you look, what you know, how you feel about your health. What are your what is your cholesterol doing?

I don't like to set a number. And many times I hear women do this a lot. They'll say, oh, but when I was 20, I weighed X, and I do a lot of explaining that it's it's not realistic to try and get to what you were at when you were 20.

And it oftentimes doesn't look good. And someone who's 50 faces get very thin and gaunt and, you know, you have a lot of women have the idea, I want to be what I was when I was 20.

So, you know, I try and set realistic expectations. And usually it's not what you were when when you were 20. And most women that I see will get to a point where they're content with how they look.

They know it's, you know, a good range. They're not what they were when they were 20, but they feel good and they look good. And I think we we focus a lot on the health benefits of losing weight, which I'm 100% all about.

That is so important. But I also feel like helping somebody feel good about themselves and how they look. And giving them confidence is equally as important as getting your cholesterol in line, getting rid of diabetes, lowering your blood pressure.

And that does a world of good for women's self-confidence and how we feel about ourselves. So yeah, I love that. I see the same thing. You know, several years ago I had this one woman who came in.

She was actually was a postmenopausal woman, and she was like, you know, doctor Frank Avila. I actually think I need to regain a few pounds. Like, I think I overshot, like I'm more than happy with where I'm at.

And I kind of had this, like, mini, like explosion in my brain because I realized that after many years of doing this, this was the first person who'd come back and actually was like, happy with where they were right now.

All of my patients always felt like they had to lose more. They had to lose more. They always had to be losing more. And, I do try to focus on that as well.

Like, let's focus on do we feel good, focus on being confident because even, you know, thin women, lean women, women at a healthy weight on the BMI can feel very unconfident about their body.

And like we need to get over that, right? We need to feel good with different shapes, different sizes, different skin tones, different hair. Like we need to let all the body image drama go and focus on how we feel.

And if we're going to live longer and live better in the body we're in. Yeah, 100%, I totally agree. And I feel like most people are open to realizing that, you know, the weight that they were at 20 is not where they feel the best or look the best.

Now, one other thing I think that's worth, reiterating is that number on this scale is just one number, right? So you mentioned that there's body composition that changes in menopause, that are muscle mass can go down.

And our adipose tissue, our fat tissue can go up. And where we store that fat particularly around our belly can also go up in this time period. And so even if this scale has the number you had in the past, the body composition could have changed.

Can you talk a little bit more about what women can do to make sure they're having the right body composition, that balance of muscle? Yes. So it is so important, and I can't say this enough to build muscle.

And for a variety of reasons, to keep your bones strong, to help prevent frailty and falls going forward. I mean, muscle is the key to launch levity. And muscle weighs more than fat.

So, you know, this is where the whole discussion of the BMI is so not perfect, right? It is so not perfect. It was created with white men. And if you're a more muscular person, your BMI is going to show up higher.

And if you're less muscular, you you might still be overweight. But your BMI could be in the normal range. So I really think it's so important when people are losing weight to maintain their muscle mass, if not build their muscle mass.

And that and and strength training is really important for maintaining weight. And I always say, and I'm sure you say this too, that the hardest part of this whole thing is weight maintenance, like losing the weight.

It's not easy. I never want to say it's easy, although GP's make it easier than it has been. But weight maintenance is the hardest and so building and maintaining muscle is the key to weight maintenance and longevity.

Thank you for bringing that up because actually I don't think we have talked about that enough that there's losing weight, which is very hard. But then there's keeping it off, which anyone who's ever tried to lose weight, if you're listening to this, it's probably because you know you are either doing it for the first time or you've done it before.

And keeping the weight up is really the challenging part. So I heard one really important thing there, which is muscle strength training. Making sure we have the muscle mass is important for maintenance.

What other tips do you give to your patients to help them be successful for maintenance for long term? I really focus on, you know, creating healthy habits, making things a habit.

And that kind of goes back to it's hard to break habits. And so, so this kind of goes back to like the medicine the GLP one. It gives you the tools to break that bad habit and get out of that.

Oh I always drive by McDonald's every Tuesday at five and I always stop or I always get that like super fancy Starbucks with, you know, a whole bunch of sugar and whipped cream and all of that.

And it's a habit. So, I really focus on correcting those habits, getting into good, healthy habits so that the healthy things become a habit, just like the unhealthy things were a habit before.

Because once they're in place, they're easier to kind of stick with them. Yeah, I always try to find habits that someone is already doing and say, you know, how how have you made that a habit?

How do we replicate that moving forward? So the vast majority of my patients brush their teeth twice a day, right. Most of us do that as adults. And so and we just do it automatically, right?

We we get up, we brush our teeth, we do it before we go to bed. Some people are superstars and are doing it after every meal, right? But it's become a habit. We don't think about it.

We just do it. And so trying to make our whole life like that in terms of our health behaviors, whether that's exercise or strength training, whether it's what we're eating for lunch, whether it's our snacks, like how do we automate it so that we don't have to make a choice ten times a day on what we're eating?

It's just it's already made for us. Yeah, I love that. And the other thing I like to do is set small goals, like really small goals, because especially when it comes to exercise, sometimes I'll see my patients back and they'll be like, oh, Doctor Lin, I just I didn't have time to go to the gym.

I just didn't have time. I don't have an hour in my day where I can actually, like, drive there and do this class and come home and I'm like, you know, you don't need an hour.

Start with like five minutes. Start with a small, small goal because five minutes is better than nothing. And this may sound totally silly and I don't know if anybody's taking me up on this offer, but I'm like, put your weights by the toilet.

If you're sitting there and you do some curls or, you know, some lifting like that, just a little bit is better than nothing, and then you make a goal that's attainable, right?

That's reachable. And then they're like, hey, I can do that. So maybe next time I'll do it for ten minutes or whatever. But I find that people sometimes have this roadblock, oh, I don't have an hour to go to the gym.

I don't have an hour to set aside, but it's you don't need an hour. Five minutes is better than nothing. Anything is better than nothing. And I, like we said in general about small habits.

Right? And, when we think about maintenance, the key really is to pick things that are sustainable, things that you can keep doing. And so you might have a week or maybe, everything in your life is aligned.

Maybe there's less work or less family commitments. And now you can go to the gym every day for an hour. Is that something you'll be able to do forever, right?

Or or not? Same thing with like meal prepping. Sometimes people will get into like these really elaborate meal prepping things and, and then all of a sudden they get busy and they, they can't do it and it becomes all or nothing, black or white or really strict diets.

Right? They're like, you know, doing some really, really strict diet. And then like, life happens and they can't stick with it or they're traveling and they're like, well, what am I supposed to eat?

Nothing at the airport fits with my plan. And so picking things that are sustainable lets you do them much longer than if you do really, really aggressive, really intense things that you may not be able to do every day forever.

Absolutely, absolutely. And then that sort of made me think of one thing sometimes, like if you're at the airport and you can't stick to your diet and you eat, let's say you got a cookie or some processed cookie, which we all know is not great, but nobody's perfect, right?

We can't all be perfect. And I feel like sometimes those those people who are it's all or nothing might say, oh, I ruined it. It's all over, I earned it.

I'm like, no, you still won because you didn't eat ten cookies. You just had one won. So that's a win. You went to the airport where there were no healthy choices and you only got one cookie.

So you kind of have to, like, reframe it in a positive light, I love it. Yeah. Give yourself credit, right. Give yourself credit when you have done the five minutes of the workout, when you only ate one cookie, when maybe before you would have eaten 2 or 3, or that would have just been the dessert on top of something.

So, yes, being kind to yourself goes a long way in this process. You've mentioned food a little bit, but I would love to get your take, and I don't think there's a right answer here on what is the best way, especially in menopause, to eat.

Like, do you have recommendations generally about what women should be eating? Yeah. So I generally recommend whole foods. So anything that looks nothing like it did when it came out of the ground, you it's not a good choice like a Cheeto, right?

Looks nothing like a potato. And I always preface this by saying nobody's perfect, right. We can't only eat whole foods 100% of the time. That's not. That's not a reachable goal.

But we want to try and eat whole foods, avoid processed foods and ultra processed foods as much as we can. I put a lot of emphasis on vegetables and fruits and then protein and, protein is really important for weight loss, for weight maintenance.

But it's hard, I think, in the American diet to make sure you're getting enough protein in your diet, because everything that we eat is so carb heavy.

I talk a lot about carbs are not all bad. You know, there there are women that I see, they're like, I don't eat any carbs. Like, well, you know, some carbs. Good.

They give you energy, right? And you need them. So there are good carbs and then there are not so good carbs. But I think in general, my rule is to avoid as much ultra processed foods as possible.

I also, recommend that you avoid a lot of added sugar, so I recommend that women look at the food label women or men, and try, if possible, to keep it under five grams of added sugar.

Because, you know, we all know it says, oh, it's natural. It says healthy on the box. And then you look at the added sugar and you're like, oh my God, I might as well just, you know, I ate a couple sugar cubes. Yes.

And sugar can sneak in anywhere. Right? Absolutely. It's in you're like gummy vitamins. Yeah. Or like I mean, you look at like, pasta sauce or, different chips or crackers.

Like, it's not even just that they were made out of flour. It's like sometimes there's additional sugar added to that, that product, even though it's a savory product.

Yeah. Yeah. And I actually think you know pairing sweet and salty I personally love that taste. So anything like salty you if you look you might see they have added sugar to it to.

Wonderful. So I think we've covered nutrition talked about the importance of strength training. Talked about hormone replacement. We've talked about using medications that can assist with weight loss.

What haven't we covered anything that you feel like we need to talk about here? What have we not covered? I mean, the only other thing I would say, just because I'm a menopause specialist is that not only can hormones play a role in your body composition and how insulin is working, hormones do a world of good.

They're not right for everybody, right? There are contraindications to hormone use, but there's a lot of other health benefits in the right woman at the right time.

They keep your bones strong. They can lower your risk of cardiovascular disease. They're good for your brain, your skin, your hair, your nails, your vagina, your bladder.

So, you know, it's it's worth having that discussion, I think, with the menopause specialist, because I feel like hormones have gotten a very bad reputation over the last 20 years.

There's this idea that they're bad or that they cause cancer or, you know, or you shouldn't use them. And that's a zombie idea. It just won't die. But the hormone preparations that we use now are different from the ones where those risks came from.

Right? There was that big study, 20 years ago or so, the Women's Health Initiative. So there are women who for whom the benefits are very big and the risks are small.

Now, hormones aren't for everybody. So that's why you need to talk with a practitioner who has some knowledge about menopause and an understanding of hormones.

But they certainly can do a world of good, not just in the weight loss arena. Yes, I think that's very powerful because there is more buzz around this than ever.

And anytime there's buzz, there's polarizing, right? So you have a group of people that are saying like, no, no, no. And then there's all sorts of interesting things that have popped up that are probably, maybe unnecessary or too much.

And so speaking with your health care professional about what makes sense for you and like letting go of a lot of the fear around hormones, because for most women, they have a huge benefit, not just for weight. We talked about that.

That's kind of marginal. It makes it a little easier to lose weight. But all these other health benefits as well, that really help us again, live longer and live better.

Absolutely. 100%. Well, Doctor Lin, if people want to connect with you, where can they find you? Yeah. So my website is Évora women.com. So it's e the agent Victor Ohara women.

So w o and e n.com. I'm also on Facebook, YouTube, TikTok and Instagram. So on Facebook and Instagram I'm Becky Caitlin, MD. Évora Women's Health also has a Facebook and Instagram on TikTok.

I think I'm Doctor Dot Becky Lynch, and on YouTube, if you search Doctor Becky Lynch, you'll find me wonderful. Well, thank you so much Doctor Lynn.

Navigating Obesity Through Menopause