How Cortisol, Gut Health & Estrogen Shape Perimenopause Symptoms

Introduction to The Functional Edge 0:00

However, since as we know, our hormones really rule so many things when we are young, right? You know our mood and of course the hormones and how we feel and we not even maybe the way we attracted to one or the other man, you know all these things. Well, that now goes away and our system has to reshift. Welcome to the Functional Edge. I'm Dr. Julia Ward and this is where science meets real-world strategies for living healthier, sharper, and stronger. From uncovering hidden environmental toxins to unlocking peak performance and mental clarity, we cover it all.

Ready to take control of your health and thrive? Let's dive in. Welcome to the Functional Edge podcast. I'm your host, Dr. Julia Ward, medical director and founder of Balanced Body Function Medicine. Today, we're honored to welcome Dr Christina Ensman to our show. In this episode, Doctor Ensmann will be sharing insights on perimenopause and menopausal as a metabolic and neuroendocrine transition and how stress, cortisol and the gut all play critical roles in the symptoms so many women experience during this stage of life.

So stay tuned for an engaging conversation that promises to empower and inspire your path to wellness. So first of all, thank you so much for being here, Dr. Ensven. Yeah, Thank you for having me. It's really great. I'm excited. Awesome. All right. Well, you're trained in both gynecology and functional medicine, which is a powerful combination. What led you to integrate these two approaches and how has it changed the way you care for women?

Dr. Ensmanu2019s Path to Functional Menopause Care 1:33

Well, you know, as it all happens to us in medicine, at some point, usually the things we have been teaching and preaching, they catch up with us. And that happened to me too, right? Since we all become menopausal, the same thing happened me. I was, faculty at a big university and having a high stress life and I thought this is cool. And then, you know, like mid-40s, then these first symptoms really caught up with me. And it was funny in a way because I had been a menopause practitioner, so really trained by conventional medicine by the Menopausal Society, which I loved.

Great conferences. They're really in there for the women. But they have, you know, they are very hard data on things. And, I've been telling my patients, with the weight, it's not that much. The data says it is just three kilos. There were really no answers when it came to the gastrointestinal symptoms. All of that, that I kind of observed in my patient and I realized I had no good answer. Then, once it hit myself with all the things, and at first, of course, didn't notice what it was. I was rather young, you know, and I thought, like all of my patients, I'm really the poster child of all this, middle-life stress from the divorce and the high-profile job and all that.

And I tried to be a super mom like many of patients and did all kinds of crazy things. I got angry and I had all the symptoms, but I didn't realize it's menopause. So like my patients, I would say, well, it is the stress and the separation and this is why my cycle stops. And well I'm a little bit more hot than I used to be. Usually I use to like one of the person with the cold hands and feet and now I always had like really hot feet all of time. And I first thought it's kind of cool. And then I followed really the heart data.

It's funny because the straw criteria, so the stages of reproductive aging really say once you haven't had your menstrual cycle for six months, you will see your last menstruation period within the next three years. We all know perimenopause can do whatever it wants, you know, the one has cycles all the time. So in my case, that was happening. I had it once, not for six months, and then it came back and I was like, oh, everything is good. Three years later, age 48, That was it. Anyhow, so I just realized I have all these symptoms and the weight gain and GI issues.

And then suddenly once it hit myself, I thought, well, this is not good enough of an answer. That is when I was like, okay, now I'm going to explore why do my patients have the GI issues. There must be a link. You know, so many questions I had. So that's when i started, you know to, explore the functional medicine toolbox, I call it. And I left my really high profile position. I said, i'm gonna redo this and let me think about that. Again, that was just not possible. When you're in a job like this, and many of our listeners might know that, They suck you up with all your brain when you have so much to do, your entire RAM goes.

You can't even think about what do you really want or what would be good for you. So yes, I left that and then reorientated myself, educated myself in functional medicine, and later on got a different position. That was just more to what I wanted to, which was really focused very integrating the conventional medicare as well as the whole list or functional medicine approach for menopausal care. And I always want to say, you know, functional in my mind is not granola bar. You know we are looking at science, we really look at really good tests, pathophysiology, biochemistry.

We try to understand what is really going on in the cells. And this is why we say that the root cause that everyone is saying now, it really means you're looking very deep how your body is actually functioning instead of playing this walking mole. Actually, a patient of mine called it like this, the walking-mole game. You know, one symptom comes up, you slap on it, another medication. We just really try to understand. And I always want to let people know that many concepts that we started in functional medicine, and I would like to mention the gut microbiome.

That was around when I, back in Germany in the 90s, I wrote my doctoral thesis. It was about skin and atropic dermatitis. But that data was already there, my gut micro biome, and we were still laughing about that. You know, this was for 20 more years. No conventional physician could come with the importance of the gap microbiomes, which is now perfectly mainstream. And some of my GI colleagues, you know I can even see in their note the word SIBO. So I'm always saying there are many things that might make it, you know, get recognized.

It just takes so tremendously long in conventional medicine, often to the advantage to our patients. So that was a very long answer to your question. Well, I think I can totally relate to that is also kind of what got me into functional medicine as well, is my own struggles getting through perimenopause and not finding the answer in traditional medicine like I was trained, like nothing really had much of an answer. It was just like, yeah, you're going through this, it's too bad, but you suck it up.

You'll be okay, kind of, and you're like, no.

Menopause as a Metabolic and Neuroendocrine Shift 6:54

There's got to be a better way. And that's how I found functional medicine. It just seemed to make so much more sense to treat the root cause rather than just giving a drug for a symptom. Yeah. And I also think, you know, our generation of women, they are so much more, thanks goodness, so outspoken and they, stand up for themselves and advocate. So that's why now the conventional medicine often falls so short because we have answers and these ladies, And you might agree with it or not as a physician, but you have to acknowledge it.

There needs to be, you know, an answer. And these women, they're motivated. They want to do something. they are willing. Perfect patients, many of them, really. Yeah. If you then have no answer and have nothing to offer, that is just very unsatisfactory. Yeah, yeah, absolutely. All right, well, you often talk about menopause as more than just a hormonal shift. As a metabolic and neuroendocrine transition, can you help us understand what's really happening in the body during that time? Yeah. So, I really call it that way because we tend to focus so on this, the estrogen, that my hormones need to be checked, right?

The patients come, like, my homes need, and I'm like... Well, you know, so the truth is, of course, the estrogen affects so many things as we know today. It affects our insulin sensitivity, say hello to problems with weight, it affects to our fat distribution, It effects our inflammatory tone and it does affect mitochondrial health or function amongst many other things. So when that now, the estrogen, first goes into this perimenopausal roller coaster and then slowly moves out, I want to say, it's an entire system starts to shift.

And I always say it not like, oh my God, this is terrible. Women sometimes come crying to my office because they think they're going to become men. Literally, they ask me, am I going become a man now? I'm like no. Your genome is X, X. You're not going to become a man. Your just a woman in midlife. However, that system shifts and I always say it's maybe the shift of freedom for us women because you always have to think this whole reproductive function that we get for 30 years, reproducing or producing an egg every month and releasing that.

This takes energy from our body. We don't realize that. That takes, you know, energy. And of course, the nature probably figured out that's kind of a risk. You know we don' want to have children until we are 70 years old because what are the young ladies going to do if we're doing this until 60 years and risking our lives as we get older? I always like to see it like this. However, so nature, you know, says no. You women in middle life, if you have other things to do than dealing with that, I'm transitioning you into the post-menopause.

I basically take this reproduction away. Since, as we know, our hormones really rule so many things when we are younger, right? You know our mood and of course the hormones and how we feel and we're not even maybe the way we attracted to one or the other man, you know all these things. Well, that now goes away and our system has to reshift. So, first in terms of estrogen and then that neuroendocrine part is now the cortisol, or stress axis. So while all the sex hormones tend to decrease, the one hormone that tends to go up or does go is the cortisol.

So our stress axis becomes dysregulated. And the reason is that estrogen provided that buffering to that system. We could tolerate basically how much cortisol rises and how long it stays elevated from whatever stressful event we have that was kind of modulated by estrogen. And that now also goes away. So now suddenly our stress response, the cortisol, spikes much higher and stays elevated much longer. And then this chronically elevated cortisol is then what causes our first, it has effect on our thermoregulatory center.

So say hello to hot flashes. It increases our inflammatory tone, right? So here's when we have the joint ache, so it adds to it and that's awesome. So our abdominal fat has a lot of cortisol receptors and that adds then to that, you know, that change of physique in addition that the high cortisol level then again kind of pushes more the insulin resistance. So it's that vicious cycle. in a perimenopause that we have just to be, or now we the advantage that you know about it and we to prepare for that and make some adjustments.

Otherwise, our body is going to do things with us that don't want to happen. So, yes, that's it. Yeah. And I think that answers my next question was, was why is it that women seem to become more sensitive to stress in midlife? And so I can see now, you know, the estrogen is having an impact on that as well. Yeah, and the thing is, we keep pushing. That's the other thing. So we are like, to continue to do this and be super mom. And then the next thing that happens, you know, the women notice the ones who are already very active.

So I always think they're the three different types. The ones that are, already, very, active, they are exercising and they running the runners. Then there are the other ones, who haven't been doing much exercise and then there's something in between.

Stress, Cortisol, and Midlife Sensitivity 12:24

But the one's like the runner's, these are other one who get in trouble. I mentioned that, that's also adding to stress. When we say stress colloquially, we always think about the husband, the kids and the dogs and maybe the employer. But what's also stress is exercise, good exercise or too much exercise. It can be nutrition. These women, they are educated, following healthy diets and over the decades they don't even realize they eat enough anymore. that's also stress. So all of that rises this cortisol tone and, you know, micronutrient deficiencies when we get a little bit more into it or environmental toxins.

But the runners, when they are doing more or finally in midlife, they have more time and now they sign up for a triathlon. That's my favorite. And then they come. We're like, oh my God, I'm so exhausted. I do so much exercise and that belly fat, it gets bigger and bigger. Yeah, kind of like the perfect storm when you have a lot more stress increased, you're not really recognizing that it is more stressed increased because it doesn't feel like a lots of emotional stress, but it's still stress. Yeah, and then that just affects everything as far as, you know, increasing weight gain and everything else.

So I get a lot of women that say, I feel like my body just doesn't handle stress the way it used to. What would you say is driving this change? I mean, partly cortisol, yeah. It's that this buffering goes away. First, the estrogen that helps to deal with things goes. Actually, estrogen is like the big fire extinguisher in our life. We arrive in midlife with a certain, I call it the health baggage. Whatever it is, inflammation that we have the propensity to. or we have already gut issues, we already have insulin resistance.

But estrogen has been helping out with all of that, right? It's a little, you know, helping with the inflammation, keeping the insulin kind of inject, and helping your joints. So it really, it didn't notice much. And then that estrogen moves out and this is when all these things suddenly show up. It is not like, oh, this all new. You know, there was women come in panic, they think, oh God, their falling apart because they're getting all of these things now. And I'm like, no, you're not getting these thing.

So you had them already. It's just now, it's showing what was underlying and that's actually good. I always liked the positive spin because now we can address these and can fix it. Then you can live the next 50 years without your estrogen and it is no problem. You have these address. So, well, thanks a lot. Estrogen helps. And then, of course, there's chronically elevated cortisol. Now, we say cortisol is by itself already elevated because it realizes in midlife there is something going on, right?

Hormones are doing whatever they want. That already causes, it alone causes that elevated cortisol level. And now when you have the chronic stress, you just don't recover so well, right? Even the wounds are not healing that well anymore. So your body is in this chronic, stress response. As we all know these days, we need cortisol. It's important. When we actually have a stressful event, when we have to run or we to deal with something, but we had to come down from it. If that is happening anymore, You know, that's when we get this, what we call the stress axis dysregulation.

Yeah. So symptoms like weight gain, poor sleep, anxiety, brain fog. I mean, they're often blamed just on hormones. And I frequently do get women that come in and say, I know it's just my hormones, if you could just tune up my hormone, everything else would be great. But there's other factors going on here, right? Yeah. And, you know, cortisol in terms of brain, like cortisol directly affects the hippocampus. So this is when it directly effects cognition, literally. Yes, there's also estrogen that helps, shovel the sugar in the brain and that help, but cortisol really starts with that.

dysregulation of the hippocampus, then additionally it lowers or it increases the sensitivity of thermoregulatory center in our brainstem that is usually actually blocked by estrogen. So these receptors are blocked estrogen, now of course we know estrogen goes away. Cortisol dysreglates this whole system and makes it more sensitive and now the next thing is Insulin.

Gut Health, Dysbiosis, and Hormonal Balance 17:00

So if we eat sugar and our blood sugar is rising and insulin goes up, it actually blocks directly to the thermoregulatory center where in the past the estrogen was sitting. Say, hello, hot flash. This is why when these women who have this very high sugar diet, they're going to have more hot flashes. Even the diabetics on insulin. So, you know, that is that. And then exactly brain fog, I said, it also has a lot to do with cortisol. In the gut, right, gut system, is the brain access. So once, there's a whole new area, but now when the microbes move out that were estrogen-dependent, so they struggle on.

and other bacteria move in, it's a vulnerable phase. It's very normal to go through that phase, but then we can get that gut barrier breakdown. Also, we know when we are stressed, you don't want to eat, so we no stress has an effect on that, on our gut, which is like the biggest, big part of our brain. So this now connects directly back to our brains. If we have gut dysbiosis, literally stresses our So it's like a big puzzle and each of these, you know, is a piece of it. And having said this, yes, for some women we prescribe, astrogen and we basically give them that fire extinguisher back and that works pretty well.

It's FDA approved for hot flashes and this is where it works reliably for, I would say for my practice. Everything else that might be reading, the brain fog, Yes, possibly. However, if there's deep mitochondrial dysfunction, It's not going to do it. So these are my patients, they are on hormones already. They have tried it, it didn't work. This is when we just haven't addressed all the other factors. However, frequently can help with joint pains again because it gives you this little bit soothing of the inflammation.

It gives that back. Yes, I love HRT, but I'm not pushing it on everyone and I am not saying everyone needs it I'm always for looking really what's underlying. So we actually know what is going on. Or I am always saying, well, if you want to stop HRT at some point, you know, then you don't want start at square one. We want do our housekeeping and really make sure we are at a better place than we were before. Yeah, absolutely. And I know, again, you focus a lot on the gut and the microbiome. Can you just explain a little bit more about how that ties into hormonal balance and stress response during this phase of life?

So, you know, as I mentioned, big microbiome, right, has all kind of bacteria, but a big part is estrogen dependent as long as we are young. So once, the estrogen goes away, these bacteria tribes, they, this families, I say move out and instead other tribes move in. And that is now, it's a vulnerable phase and this can be good other bacteria or not so good bacteria. Our gut is vulnerable in that phase. So it can come again for the cortisol tone. Our digestive function is not so good anymore, so it came to gut barrier breakdown, what's then called a leak.

And now suddenly there are food sensitivities. Oh, common stuff we eat all day long, you know, suddenly cause autoimmune complexes. And, there are some foods like gluten and dairy, they are more common, the culprits, because they're just very irritating, I want to say, or, to cause more inflammation, but there can be random other things. And now the moment we have inflammation in our gut, that is stress to the body. So then, you know, it's stress through the bottom, and it can also show up inflammation of our joints.

Also, if we had gut dysbiosis, so now if you have the wrong bacteria or too many of one sort, then that's when we can get mood disorders, right? So no one thinks about that really a lot of the serotonin is actually produced in the gut. from gut bacteria. Serotonin, again, for everyone else out there, it's like what we're trying, that is that neurotransmitter we trying to elevate when we give you antidepressants. Many of them, what they target is keeping the serotonine up, but it actually produced by gut criteria.

And there are actually studies, they show that, literally that treatment of depression and mood disorders is linked to gut dysbiosis. So we know that already. It's gonna affect that. and, of course, digestion. And how did the question start? I always, I don't know. Yeah, no, you got it. I think we covered that. Well, a lot of women come to me and they're frustrated because they feel like they are eating well. A lot people do feel they have a good diet and their exercising and just not seeing results.

So, when cortisol or the stress axis is a missing piece, what does that look like clinically?

Testing for Root Causes in Midlife Women 22:00

This is the woman, she exercises and she eats clean. She's very focused, but then in the morning, either she still wakes up okay or she's already tired in morning. So it shows itself as a lot of fatigue that she didn't have before. And then many women at night and they get like the second wind, right? They're actually so exhausted and then suddenly at nighttime they can't sleep. The other variation is, and you know, this whole, what you call the HPA dysfunction, so stress axis dysregulation. It's not that we don't have enough cortisol.

I always want to clarify that because some women then go to their regular doctor and, oh, that cortisol was fine. And I'm like, yeah, it's like that you don' have cortisol in your cortisol bucket. Yeah. So the other thing then is at night. So when this cortisol axis is dysregulated and it has an inverse relationship with melatonin. A lot of cortisol, not enough melotonin, so sleep is disrupted. And then you get this 2 to 3 a.m. early morning awakenings when then suddenly that cortisol spikes up.

It's a very typical fatigue. But then you can't sleep, can fall asleep or wake up in the middle of the night. You wake, you feel exhausted. Your gaining weight, typical around the belly, that is a typical belly distribution. you also feel like you're getting weak. So because I haven't mentioned that yet, and that's one thing I always want people to understand when they over exercise under cortisol stress. So cortisol really makes our insulin rise. So that means all the carbohydrates, also the healthy ones, basically the signal is do store that preferably as fat.

That is the first. Even the few carbohydrates these women are eating, they're going to be stored as that and they are going be store right in the belly fat, so this is a first slap we get. The second is if that cortisol is elevated and insulin is around all of the time, the second signal Do not burn fat. Preferably if you need extra energy because you're just running a marathon again, please break down muscle. So basically now if we need additional energy, because we're running on fumes, muscle is going to be broken down.

Now we are basically in a catabolic state. No matter what we do, we always going break-down muscle and kind of hang on to our fat, and that is the vicious cycle that we have to disrupt. So yeah, so that is a typical thing, this weakness, you know, they're like, I can't build muscle. And additionally, only I have problems, with my throws, backs. So, yeah. These are the women that are doing cardio, and they are just not able to build muscles, And they break down so their resting metabolism goes down.

And what we haven't mentioned yet is the low libido, right? So no sex drive, like, gone. Right, absolutely. Yeah. And I always tell people in general that sex tribe is sort of like the cherry on top of our overall health. If everything isn't lining up nicely, and it sort makes sense. You're not going to be in reproductive mode if you're in survival mode. if your stress, your body's just not in that place. And the biochemistry behind it is that basically the building blocks for our stress hormone and the sex hormone is the same molecule, right?

So that's basically, if we don't have enough for both, of course the body keeps us alive with building cortisol. And as you say, like sex, you don t need sex. They bought it, but that's what it is. So yes, exactly. It's just saying that you don't need this for surviving right now. Yeah. When you're doing a deeper root cause evaluation, what are you looking at that might be missed in a conventional visit, especially when it comes to adrenal function and cortisol patterns? Yeah, so I really like the cortisol awakening response.

It's not even that, you know, I can look at patients, or I think I already know it's dysregulated, but people want to see it. And in a way, of course, to I want see kind of what stage we are. So, yes, cortisol, awakening, response that I usually get with You know, we know the Dutch test, dried urine test of comprehensive hormones. I just want to really exactly see what's going on with the hormones and what is the cortisol really doing throughout the day. And I love the test because, you know you do it over a day and it's done at home.

It's from urine and some saliva. So I loved that they can really do that while they are at at their usual environment and not, when they're like rushing to a lab or who knows what and which is, you have to interpret in bad context and I really see what it's doing when you're at home and doing your usual thing. So this is one of my favorite and the other thing definitely for fatigue is like a micronutrient testing, right? Like when we really look at the metabolites of the body, so I understand what is actually arriving in the cells, which is just not, you can't compare that with what you get from a regular lab, from regular blood.

So this is a functional test, you know, and I think this was so helpful also to look at the mitochondrial health, oxidative stress. It just gives me so much information to understand where do we have to work? Where is the problem really sitting? And of course, if they have GI issues, then I like a gut health test and a food sensitivity test. And if we really want to do the whole, we want leave no stone unturned, I do an environmental, very extensive environmental toxin test,

Practical Advice for Women in Their 40s 27:30

and I look at genetics because I love to look that. So we know why, often it explains why someone ends up at that place faster than the neighbor, for example. Yeah, absolutely. Well, if you could go back and tell every woman in her 40s one thing about her body and her stress response before entering perimenopause, what would it be? Well I would say, look, your body is going to start handling stress very differently and you have to pay attention. So if you're not willing to look and you just want to continue with doing everything at high speed, do a thousand things at the same time, your body is going to deal with it.

It's going adapt. And that's not going be the direction you want it to go. So I strongly recommend you pay attention. Also, I think nutrition is a big one that adds to stress. In the end, that is when we don't eat well. So these are the things I would recommend everyone to start paying attention really in their thirties. And you know that probably there are some women, you only have to tell them to quit the sugar and they're really doing perfectly fine. So sometimes it's easy tweaks and better you start them early than, than 10 years later when you're hit with so hard of symptoms.

Yeah, yeah, absolutely. Well, this has been so informative and so helpful. Thank you very much for being here. And thank you everyone for joining me on The Functional Edge. I hope today's episode gave you fresh insights and practical tools to level up your life. Before we go, please let me know, or I will put in the show notes too, how do people get in touch with you if they want to come see you as a patient? Or do some patients via telemed, I should say. Are you telling it? Yeah. You know, I do some regular patients only half a day a week in Maryland.

But yes, so all that functional stuff Ido online, shoot me an email, contact at drchristinaensman.com and my website is dr.christenaensmann. com.

Closing Remarks and Contact Information 29:30

Perfect. Yes. Awesome, awesome. Well, if you found this conversation helpful, I would love for you to hit subscribe, share it with someone who might benefit and leave a review. It truly helps us reach more people and continue bringing meaningful root cause health insights to those who need them most. For resources, updates and behind the scenes content, visit drjuliaward.com. And until next time, stay strong, Thank you for joining me on the Functional Edge. I hope today's episode gave you fresh insights and practical tools to level up your life.

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