For this DrTalks I have a really wonderful guest for you. It's Dr. Rebecca Dunsmoor-Su. She is an OBGYN and also a menopause specialist certified through the Menopause Society, and she is the chief medical officer of genetics.

She's going to talk to us all about perimenopause. Menopause. Wait, what you need to know. Thank you so much for joining us, Dr. Dunsmoor-Su Thank you for having me.

So let's talk about what happens at menopause. We have so many women who come in to my clinic, and I'm quite sure to yours, who will have this sudden weight gain that they experience or a change in their body during menopause.

What is happening there? A lot is happening, actually. As you can imagine, perimenopause and into menopause is a huge transition physiologically. A lot of things are changing and there are a lot of things that impact weight during that transition.

From a hormone perspective. So we think of perimenopause and menopause as a hormone shift. And most women think their hormones go from here and they come down to here.

And that's the menopausal transition in a straight line down. What actually happens first in perimenopause is hormones go up and down and up and down and up even higher and down.

And that has a lot of impact on many systems. So it has an impact on your muscle building. So you no longer build lean muscle as well. And that continues throughout your menopause.

That has a huge impact on your sleep patterns and your sleep. Not only the patterns, but the amount of sleep you get, which has a huge impact on metabolism.

It's a hugely stressful thing. So your cortisol levels are high. So all of these things are sort of adding up to make it easier to gain weight. And you add that then to also the natural slowing of metabolism, of aging that's happening at the same time.

The other thing that I like to tell people is that during this perimenopause especially, but even in the menopause, you know, our testosterone doesn't change, but our estrogen going up and down changes some other factors in our blood.

With that says, read a little bit more of that testosterone. So many women notice acne during perimenopause. They start to get chin hairs. That's partly testosterone.

We also start gaining our weight around our middles, which is a very male pattern because we're seeing just that little bit more. That's also sort of to do with cortisol as well.

So all of these things add up to not only weight gain, but redistribution in a way that we really don't like. And it can feel very uncontrolled. And it can.

Every woman who comes to talk to me says, I haven't changed anything, and now I've gained 15 pounds and it's all right here. And what I say to her is this.

Because we haven't changed anything, this is a time of life and we actually need to start changing things for the better. Oh, I love that. That's a good way to think about it, right?

Like I haven't changed anything, but my body is changing. So so we need to change something to make up for or acknowledge that our bodies have changed.

Right. And I think the other important thing about that is when we talk about the changes we need to make during this time period, yes, they can benefit weight and body shape, but more importantly, they benefit our long term health.

This is a great time of life to start thinking about our cardiovascular health and how we're eating, and how we're moving our bodies to support that. It's a great time to start thinking about our bone health, because this is sort of the time when we start losing bone mass.

All these things play in and actually have a synergistic effect. So changing these things actually has a lot of benefit long term. That weights just that thing we sort of see or notice is the person.

Yeah. But but it's a sign that like there's a bunch of other things going on with their body and it's a good time to sort of take charge of our health, focus on our health and, and then like three for the rest of our lives.

Exactly. Exactly that. And I think that, you know, I always talk to women with the fact that most people gain, on average, 15 to 20 pounds for the menopausal transition.

This is not terrible. It's not a terrible, huge amount of weight. It's probably not a terribly unhealthy amount of weight, even though it's in the middle, because they there have been some small studies.

One came out of UCLA several years ago that tell us women's middle weight is not the same as men's. It doesn't tend to be as visceral. It's more external.

And actually fat cells make a little bit of estrogen as we go into menopause. And it may actually be a little bit supportive of cardiovascular health.

So I'm not so worried about the weight from a health perspective, if it's just 1,015 pounds. But we are so socialized to hate our bodies and hate any change in it that it can be really psychologically harmful and hard to handle.

I think that's a really powerful message to hear that to some degree, that weight gain is part Lee normal in menopause, right? And it may not necessarily be a problem.

Right? It it may be bothersome. It might be a change in your body. But we don't have to assume that that weight gain is, is necessarily a bad thing or that you need to get back to the same weight you were when you were 35 or something.

That may not be necessary. We're not supposed to actually be the same that we were at 25 when we're 55. You know, our bodies are changing and it has different needs.

And one of the things I tell people is estrogens are really healthy hormone for us. We've had it our whole lives, and our ovaries are not going to be making estradiol, which is the main active form of estrogen anymore.

But our fat cells continue to make estrogen E1, which can be converted into estradiol. So having a little bit of weight around can actually support possibly cardiovascular health, possibly bone health.

So you know, your body is just trying to help you. It's being helpful. We just really don't like it. You don't like it. But, you know, I think a fair question to ask, would be like, how do you know if you need to lose that weight in menopause?

Right. Okay. I've gained 15 pounds, let's say. How do I know if that is okay, if I should just adjust my expectations? And this is my new body, or if it really is a problematic weight gain?

A lot of that depends on where we're starting from. And I tend to focus not so much on the absolute weight gain. I tend to focus on how is it impacting your life?

Are you still able to be active and move your body and feel comfortable while moving your body or your joints hurting more now, and is that impeding you because that's a problem, you know, are you having sleep apnea?

Are you having increased reflux or or heartburn? There are other signs that this weight is actually having a health impact that we need to pay attention to.

And a lot of it depends on your personal health status, you know, are you prone to pre-diabetes or diabetes? Do we need to think about that? What is your cholesterol?

Because that changes with the menopausal transition as well. So all of these things play into it. And I tend to try to not focus so much on the absolute weight itself.

But your overall health status and how do we improve that to the best of our ability? I love that, and I couldn't agree more that it's it's really individual.

Right. We have to look at what are your symptoms. How do you feel? What does your blood work show? What are your health risks to know if 15 pounds is a problem for you or not?

Because for some people it is. And for some people it's like, let's be kind to ourselves, let's focus on the other health things that happen along with menopause so that we can continue to feel, well, thrive.

And, you know, live, live to be 90 are however old or we're hoping to live and be healthy. Yeah. If somebody starts at 95 pounds and puts on 15 pounds, they're probably going to be fine.

But if somebody was on the borderline of diabetes and puts on 15 pounds, that can be the difference. One of the things you mentioned, early on, is that there's these increases in cortisol that can occur and that there are sleep disturbances that can occur.

And that that all adds to this weight gain, process during menopause. Can you talk a little bit more about that and what the solutions are to that. Right.

So all of this is interlinked is the fundamental message. All of our hormonal systems, whether it be ovaries, adrenals, thyroid, they all talk to each other and they're interlinked.

And they're all very related to our overall health status. So as I as I like to explain it, you know, I think probably the fundamental thing here is sleep.

Sleep is so fundamental for people. And we have there are good studies that tell us that if you're not sleeping around seven hours a night, that your basal metabolic rate goes down.

There are good studies that tell us if you're not sleeping adequately. There are other, hormones like leptin and ghrelin that go up that make you hungry.

But also the purpose of that really deep sleep, especially around 2 or 3:00 in the morning, which is when most perimenopausal women are waking up and can't get back to sleep, is that's the time period where your cortisol goes to its lowest at night.

And so you get down into that low cortisol state and then it comes up during the day. And that's normal and functional. But then it goes back down. And so you get. A break.

From all that cortisol stimulation which tells your body to sort of store fat because there is danger if you're not getting that sleep pattern and you're not going down, then you're never really getting that rest or that break from stress.

The solution is not a pill, and it's not a supplement because none of those things are going to change this. The solution is actually fundamentally fixing sleep and fundamentally fixing stress in our lives. And that's really hard to do.

And, you know, I, a lot of women come to me on multiple sleeping pills or trying supplements or other things to get them to sleep. The one intervention that we have really good data for, for sleep is cognitive behavioral therapy for insomnia.

It's hard work, but it changes your sleep patterns. And really actually, over the long term helps with, sleep and longevity. It also is a great meditation.

So for for. People who maybe haven't heard that term before, cognitive behavioral therapy, can you explain like what that is what people might expect if they decide, that that's what they're going to do to improve sleep?

Yeah. So cognitive behavioral therapy is a style of therapy that looks at your activities and patterns and then looks where you can make improvements in those patterns to impact how you feel or how you're sleeping.

So many people may have heard of it as a therapy technique for depression or for people who have, say, anxiety, because then you examine the patterns that are stimulating it and you make changes in those patterns.

Same thing applies to sleep, although it's very specific to sleep. So it looks at how are you going to bed? What are you doing in the hour before? How are you getting into bed?

What is your bedroom situation look like? What are you doing? If you wake in the middle of the night? What other things are going on in your life that need to be addressed?

And then it it works on those things to help improve your overall sleep pattern. One of the things I recommend to people to sort of give it a try without too much commitment is there's a free app for this, there's an app for it.

It's called CBT. I coach. So cognitive behavioral therapy for insomnia coach. And the app was developed actually by the VA for veterans with PTSD. So it's free to everybody.

And you can just go in the App Store or the Google Play Store and download it and give it a try, and it just tracks your sleep patterns and all the different things that you do for a little while, and then starts to make recommendations for how to improve.

I actually recommend that exact same app, and say the exact same thing that the VA created it for their patients. And, you know, the patients I've had who commit to using it and do what it says, have really good results.

And so, you know, it sounds kind of silly that like an app or just tracking your sleep and, and changing a little bit of your patterns can affect your sleep that much for, for a lot of people, it really, really works.

And like you said, it is the thing we have the most evidence for. Which means like the science has also proven that it works. Yeah, and it is work. I don't want to I don't want to shortchange it.

It takes work. But now is the best time in your life, especially when perimenopause and menopause to make these changes, because sleep is also ultimately related to longevity.

And if you don't sleep well and you continue to not sleep well for the next 20 years, you may lose years of your life. So make the changes now so that you get the benefit long term.

You get that that long term benefit. And then like you said, you know, a lot of hunger hormones are regulated by that sleep. And so if you're getting more sleep you're actually hungry.

Or and they have really good studies that show that. Right. Like people eat more and it's like even a little bit less sleep like 20 or 30 minutes less than people need and they eat more at the next day.

So, this is so good stuff. It's not like they eat more spinach, right? Ukraine goes carbs and the salt in the sugar. So I think, you know, we've heard that from a few guests on on this that sleep is key.

And thank you for sharing that app because again, that's a real tangible thing. People can can start using. What else do we know about the interplay of hormones during this time period, especially as it relates to some of the metabolic hormones, weight, related hormones, insulin?

How does that play in. Yes, this is important. So there are a couple different things that happen with that transition to menopause in terms of our metabolism and how we process both calorie and sugar.

So and insulin, first of all, as estrogen goes down during the menopause, we actually start to lose muscle mass and a slightly higher rate. Now there is a natural loss of muscle mass as we age that's happening to everybody.

But there's an inflection for women. So we have sort of this sudden loss of lean muscle mass. And that's important because lean muscle mass really burdens calorie.

So if you're not actively building that muscle mass back, it becomes much harder to lose weight. So that's one thing that's going on. We have good studies that tell us that insulin resistance rises with the menopausal transition.

So it speaks to an interaction that we don't fully understand between estrogen and insulin and some of the precursor hormones there. And so especially in women who may have a higher risk for diabetes, like polycystic ovarian syndrome women or metabolic syndrome women, we can see an answer, an increase in diabetic, diagnoses of 17 to 30% with the menopausal transition.

And that's going to be yeah, that's a lot of change. And, you know, like I said before, all of our endocrine systems interact, right? They're all talking to each other.

We know that estrogen and thyroid hormone talk to each other. And a lot of this transitional time is hard because estrogen is going up and down. So you can see fluctuations and everything else as well.

Once we get into full menopause, things settle out and we get to a new steady state. But perimenopause especially can be a really hard time for a lot of these things.

And then what, you know, so we know this is happening. What solutions do we have to this insulin resistance for women who who go through that at the same time that they're going through a perimenopause and menopause? Yes.

So a couple of different solutions that we have. One is actually hormone therapy. So those same studies that looked at the increase in insulin resistance and the increase in diabetes also showed that, hormone therapy can up to 30% prevent that.

So and those are good level one randomized controlled trials that show that it absolutely can help. So if somebody is a good candidate for any other reason, this can be a great aid.

Exercise. Exercise is great for insulin and for managing your insulin and your insulin resistance. And really focusing on exercise and building lean muscle mass can be a huge help.

Thinking about how you're eating, obviously. And then the medications that manage, diabetes or insulin resistance. So things like metformin or even the GLP one type medications, if someone's pre-diabetic or diabetic, they can be a help during this time as well.

Awesome. So there is lots of hope, lots of solutions. For this navigable, what do you say. If not inevitable? Not inevitable. But but need to recognize that.

So I think, you know, it's kind of an exciting time, for, for women and for menopause management because people are really talking about it now. You know, it used to feel like.

This. Thing that you weren't really supposed to talk about as a woman and that we, you know, we all had to go through, and, and now it seems like you really can't go anywhere without an open conversation and feel people saying like, you know, there's actually treatment, right?

There's hormone replacement. There's other things we can do. You don't have to be miserable, and you don't have to deal with all the side effects that you don't like of going through this time period.

It's absolutely true. You know, I think the pendulum has swung back again towards hormones. Like for a long time we gave everybody hormones because we thought they're the fountain of youth.

And I don't love that analogy because we're not supposed to be young forever. But they did have a lot of benefit. And then then 2002, they had a press conference about a study.

They didn't interpret the data correctly. And I'm not going to take you down that long winding pathway. But they made a press conference and everybody got scared.

And nobody sort of critically reevaluated that for a very long time. And when we actually look at the data, hormones can be incredibly safe and incredibly effective.

And, you know, I like to tell women nobody's taking notes on whether or not you made it through menopause without hormones. Nobody's waiting at the finish line with a blue ribbon for you.

If you're miserable, let's fix that because you don't need to be, and it's not doing you any good. You're not saving yourself from something. You're just harming yourself.

It's increased stress. It's worse. Sleep, all those things that long term can actually hurt. So, you know, I think sometimes we downplay always just the quality of life issue.

But quality of life is actually really, really important. And we deserve. To. You want to live tonight if you're miserable, right. Do you want to live to 90?

If you have pain or energy? Sometimes it seems like the most miserable people make it to 90. A lot of that's genetic. But like you're you're why would you want to live to 90 for that miserable.

Right. So quality of life is worthwhile to treat. But hormones are actually also actually quite safe and can have some health benefits. Now, one hormone that I'll sometimes get questions about, and I'm sure you do as well is testosterone for women.

Then every day. So what role does testosterone have for women? Both, you know, for weight or for any other purposes. Happy to talk about this, because I think there are a lot of myths and a lot of, chatter about testosterone out there.

So what we know about testosterone is it's an important hormone for women. It's an important hormone that's present throughout our lives. It is at its peak in our 20s, and it slowly decreases over the course of our lifespan until our 80s.

That's the same in men as well. Peak in 20s, slowly decreasing over the lifespan to our 80s. There is no dip in it at menopause. Testosterone is not made by the ovaries. It's made by.

I mean some is in the ovary, some is in the adrenals, but it's not the part of the ovary that's going quiescent during menopause. So the different part of the ovary continues to function.

So you still have it. And in fact we're seeing signs of a little bit too much testosterone during the menopausal transition that acne and chin hairs women start to lose hair on their heads.

Sometimes we gain weight around our middles. And so you're not lacking testosterone in this time. It doesn't need to be replaced now. Does it have uses for women?

The answer is there's only one study proven use for testosterone in perimenopausal and postmenopausal women, and that's for increasing libido. It's not because testosterone is our major libido driver.

It's not. Libido is actually quite complicated in us. And a lot of other factors going into why libido dips during this time. But what we know is if we give you a little extra testosterone, it has a side effect of making us slightly hornier.

And that's why it works. We're not using it because you're missing it. We're using it because we know we can do this thing with it. But it needs to be done very carefully.

It needs to be done using FDA regulated medications. It needs to be tested regularly. So you're not going over the normal female level, because the other side of testosterone is if you give too much that chin hair, those chin hairs can become a beard.

You can have permanent male pattern baldness. Your voice can lower, but more importantly, it can have cardiovascular impact. So we really need to be carefully using it if we're using it for that one indication.

Now I see a lot of chatter about it building muscle and making people lose weight and making them feel fantastic. And that does happen. It's an anabolic steroid.

So if you use enough of it, if you get into a low male range, you will start building muscle like a man along with those side effects. And you will feel great for some period of time until you don't anymore.

And you need more. But that's not a reason to use it during this time or use it in that way. That's basically, I hate to use a dirty word, but it's doping there.

I like it, you know, it's a controlled substance for a reason. It's banned in sports for a reason. And as I like to explain to women, not all the things that make us feel good are good for us.

Amen. I mean, I feel like, especially right now with the popularity and and all the conversations around weight and all the things we can do, we see that more and more, right?

People will say, well, but it works. Yeah, okay. There's a lot of things that can work for weight loss that may not be safe, right? I like to make the analogy that cocaine will also make you lose weight, and you will feel fabulous until you do.

Yes. Agreed. I think, or math sometimes. Right. Like those are things that I think would work well too. Yeah. Yeah. So I think that's a really important part of this, right.

Is we have to and this goes really back to what you said in the beginning. Is the weight a problem? Right. Is it something that needs to be solved? Let's use menopause as a time to focus on our health in general, because there is so many opportunities to be healthy.

And when we're making choices about our weight or our health in general, we have to keep the big picture in mind, right? We may get one result that we want, but big picture is the thing we're doing.

Helping our health. Yeah. And oftentimes some of these things will cause long term harm. And we really do need to keep that in front of mind. But I think the whole website is like it doesn't mean that no one should ever use testosterone.

No, there is a use for it, but it needs to be used carefully. Well, gosh, what didn't we talk about here? Is there key points about menopause or perimenopause and weight that you want to make sure everyone is aware of?

Yeah. So a couple of the really phenomenal hints that so I don't know. We have a team of registered dietitian nutritionist who are menopause trained and they work with women on this one on one.

And they have sort of two things that they always work on with people that I think are really critical to start the process of thinking about how our body needs us to change things in this time period.

One is one that they've sort of coined. It's called the Menopause Plate. So when we look at our plate, we don't recommend any fad diets, any starvation diets, because that's only going to work as long as you continue to do it.

And then you gain the weight back. Right. Similar to some of the weight loss medications, it only works as long as you do it. But the menopause plate is a change that you can make.

That's fundamental and you can maintain long term. And it's actually very heart healthy as well. And so when we think about the menopause plate, you have one quarter of the plate is a lean protein.

One quarter of the plate is a complex carbohydrate. So a whole grain or something or a legume something like that. And then the rest of the plate is vegetables.

So half your plate is vegetables. And you can eat as much of those vegetables as you want. So just pile them up. And you know, this takes cooking. It's it's hard.

And the one thing I'm really proud about, our registered dietitian nutritionist is they assess people's what they typically do, what they have access to in their neighborhoods, because there are a lot of people just don't have great access.

They have a lot of hints and tricks for people to find these things in a way that works for them. And that's one thing I love to talk about. The other one is strength training.

We all got really good at running or cycling or doing something cardiovascular, and cardiovascular exercise is critical, although walking is my favorite because I think it's something you can do for the rest of your life, but you need to actually build muscle back.

So even if you start hormone and it allows you to help build muscle, it won't build the muscle for you. Have to do strength training and you have to do increasing strength training and increasing strength training both helps you burn calorie, which is great, but it also supports your bones for long term health and it supports your balance for long term health so you don't fall.

So these are things that long term are going to serve you well. I love it. And simple right. No crazy fad things. Healthy plate real food strength training.

Do you have does your program have like a recommended minimum amount of strength training or resistance training? How do we know if we're getting enough?

Yeah. So it's really individualized because it all really depends on where you're starting from. Yes. You know, some people have been bench pressing for years and they just need to increase, whereas some of us, myself included, maybe haven't been as good with our strength training over the years.

So starting slowly is fine just with bodyweight strength training. So squats, sit ups, push ups, I do my push ups against a desk or a table because I can't do a floor push up at this point.

So, you know, it's just building that muscle. And when it starts to get easy, you add something. You make it lower, you squat lower, you add a kettlebell.

You know, it's just a matter of progressively getting stronger. If people want to learn more about you, connect with you or, Gennev, how can they do that?

Very easy. They go to gennev.com So it's G E N N E V.com And we are a 50 state telehealth service for menopause physicians and registered dietitian nutritionist.

We work together for your best long term health. We do prescriptive hormone therapy. We work on weight with people. We work on lifestyle change for other reasons, even symptom management.

And we're we're happy to see anyone. Perfect in all 50 states. So anyone anywhere. And we take several insurances. Always increasing list depending on your state may depend which insurances we take.

We also have a cash pay option. Wonderful. Well thank you so much.

Rebecca Dunsmoor-Su

The Impact Of Menopause On Weight And Metabolism