Midlife Wake-Up Call: Why Doing LESS Is Important For Longevity l Cynthia Thurlow l Ep #432

Introduction to perimenopause and midlife change 0:00

Natalie Nidam, your host. There's a moment that so many women hit in their 40s when they look in the mirror and think, who is this? Now that's exactly what we're unpacking today with Cynthia Thurlow. Why perimenopause can feel like total chaos, but is actually a powerful wake up call. Now, men, before you skip this episode, if you want to know what your wife, girlfriend, or even work colleagues are going through, you might just want it to stick around here. We get into the hidden drivers behind weight gain, sleep issues, and brain fog, including how estrogen loss affects your gut, your immune system, Cynthia also shares why high achieving women often struggled the most during this phase and why the old push harder mindset completely backfires.

Now this conversation is equal part science and reality check, and it might completely change how you think about midlife. And Cynthia Thurlow has a new book out, which you might really want to check out. It is called Menopause Gut, or The Menopus Gut. All right, but first you're going to want listen to the episode. Of course. Now, this episode is brought to you by Sunlight and Saunas, Mass Zymes by Bioptimizers, and by Oracle by Wizard Sciences, all with special offers just for you. Check out the show notes below for details and enjoy the Show.

Cynthia Thurlow, welcome back to the shows. It is an absolute pleasure to have you back here today. So good to be here now. Thanks for having me. Well, you know, these are big important conversations. And I think maybe before we jump into anything else, without launching into major details, like at a high level, This question is coming from me being at an event this week and starting to really think about menopause and perimenopaus in a different way, and particularly maybe peri-menopase, because that is the most tumultuous transition, if you will, next to puberty in women's life.

But what is cost to women of unaddressed Perry menopause and maybe not just to them, but to the people around them. Such a great question. I think of Perry Menopaus is a litmus test. It's a Litmus Test of how well you take care of yourself, how while you're in alignment with your values and your choices, I think for a lot of women perimenopause is the first time in their adult lives that they start to question everything because in those declining hormones and changes in neurotransmitters, I Think for A lot Of Women It Is Perhaps the First Time in Their Adult Lives Where They Get Clarity on What is Working Well for Them and Not and So I, Think For So Many Women their strategies and their patterns of behavior that work well as a teenager, 20 and 30 something suddenly no longer work quite as well and can become incredibly maladaptive.

And I'm really speaking to the women that are very high achieving have been incredibly successful in any capacity of their lives, where they suddenly look in the mirror and they're like, not only do I not feel like myself, I can't identify with the person I am today. And so I really think about perimenopause as this hormonal chaos period in our lives. Very different than puberty. I think puverty we go into, we're just kind of stumbling, bumbling forward. Whereas in perimenopause, we've had 30 plus years of life to be able to reflect on and say, am I happy with my partner?

Am I happy in my job? Am happy energetically with where I am at this point in life? And so I think it's an invitation for us as women to really reflect on what is working for and what isn't. I know for myself personally that as a performed people pleaser, one of the reasons why I was such a successful nurse practitioner working in predominantly a male-dominated field of cardiology was that I incredibly accommodating. And I think for so many women, one thing that they find, they their voices in middle age, and they stop looking back.

They're just like, I'm only looking forward. And this means that I am going to be clear about what I like and I don't like. I will get clarity on my relationships. And it's why I think in many instances, women start making some pretty dramatic changes. And when I say that, it doesn't per se mean that women leave their job or they leave partner or spouse, but they get tremendous clarity about what they want and what don't want. That can be empowering and also terrifying. I thing for so many women, its perhaps the first time in their lives that they're doing exactly what want, and I that that is you know,

Why women feel unrecognized in perimenopause 4:46

perhaps for those of us in our lives that are used to us maybe playing small and being incredibly accommodating and just doing what we're told, all of a sudden we are questioning our relationships with family members and we question relationships at work and questioning what were doing and trying to figure out what serves us and no longer serves. So I look at this time in a woman's life as a great awakening. It's a good opportunity to course correct and change the narrative for ourselves and That's something that I don't per se see a lot of people talking about.

You know, we talk a about hormone replacement therapy and supplements and peptides and things that are clearly very important, maybe very clear. But all of a sudden, it's like, are we really asking women what they want at this time in their lives? Yeah. I think you, I mean, that's beautifully said. The tricky thing is, and maybe this is where, we'll dovetail into the meat of the episode, but I this where maybe it is important for women to get access to the care they need at this time so that they can have the clarity, right?

If your hormones are all over the map and kind of running the show and running you into ground because you're not sleeping, because don't feel like yourself, your moody or whatever, all the things that can come with perimenopause when in a world where too many women are still being told by their doctors, oh well, you're in peri-menopaus, strap yourself in and hang on for the ride kind of thing. That's where I think the greatest disservice maybe is being done to women is by not offering them the support, whether it's a supplement, lifestyle, bioidentical hormones, conventional, whatever, without acknowledging and giving them that support.

we're now in a position of going through this transition where the way you describe it can be so incredibly positive moving forward, but it's kind of like asking a drunk person to make a good decision. And let me be clear, I'm 54 years old. I can tell you 12 years ago, I was given four options when I talked to my GYN about my periods being heavy. I told oral contraceptives, an IUD, and ablation, or I'm done having kids, just take your uterus out. You don't need it anyway. And those are the only options I provided.

Cynthia, you should just be expected to gain weight from here on out, you're 42 years old. This should be normal. And I just said, I refuse to accept all of that. Like there has to be a better plan, a a way. So I fired that GYN and found a wonderful midwife who was much more alignment with where I wanted to. I want any woman that's listening to this conversation to know you do not have to care that is not in alignment with your true values. And if anyone listening decided to take the oral contraceptives or the IED or do the ablation hysterectomy, that's the right choice for you.

That's great. It wasn't for me and even as a licensed medical provider. those were the options I was given. Now granted, 12 years ago, we weren't having these kinds of conversations quite as openly. And I think we've made great strides over the last five to 10 years, but I, I thinking in many instances, there are still women being told, shut up, take the oral contraceptive. You expect your sleep to be bad. So what if you can't feel like you feel, like, you're losing your mind? We're going to put you on an antidepressant, and we're gonna treat you with anti-anxiety meds.

Uh, And you just have to accept things as they are. a really terrible way to reframe middle age and beyond, that you just have to accept things as they are with no alternatives and no other options. Yeah, especially when we know that there are alternatives and options. So would that moment be the moment when you really figured out or you got clarity on how underserved women in midlife were? Absolutely. Is that kind of when the bulb went off or was there some other? No, I mean, it was then and then it I was like, okay, well, let's reflect on what little information I received in my medical training about menopause, like next to nothing.

There's no mention of perimenopausal. No one prepared me. And I like if I'm not prepared, then none of my patients are prepared. At that time, and I am not exaggerating when I say this, I cannot think of maybe other... I bought Suzanne Summer's book. Yeah, she was a pioneer in this space. And I bought her books and I'm trying to think if there was anyone else who had much of anything at that time and just wanted to read voraciously. So I think on a lot of levels, it brought me to the realization that my lifestyle no longer suited my physiology.

That was very hard. Reckoning to have because I loved everything about being a nurse practitioner working in cardiology but the stress of my job because the NPS in my practice was a very large cardiologist practice we did inpatient outpatient management we function like residents we were incredibly autonomous. The stress of my job, combined with little kids, with a husband who traveled, not enough sleep, being hardcore paleo, so I was really low-carbohydrate, really intense exercise, was no longer in alignment with my physiology.

incredibly lost in space. Like, where am I going? I don't know who to talk to. You know, I stumbled into a functional medicine practice. Thank God. I had a great nurse midwife. Shout out to Courtney that lives in Northern Virginia. And I think that was the beginning, but there were so many other women who felt exactly like I did, which is why when I left traditional allopathic medicine 10 years ago, April 1st will be exactly 10 year. So it's hard to remember on that. Yeah, exactly. That's a big milestone.

No one was talking about these things. And I think that I think in many ways there's been a groundswell of women like Gen X is just not sitting down or shutting up. We're just speaking up and out and hoping that this helps younger generations and helps women advocate for themselves because it is not acceptable. The kind of patriarchal medical system, the way that it has created, and I'm paraphrasing from other guests I've had on my podcast who've said as medical providers themselves, especially male physicians, no man would put up with what women have put out with.

Full stop. So I think that this generation is speaking up and out so that more women are aware that there are more options than suffer in silence, shut up, accept things as they are, which we're definitely not doing that. If you're using a sauna and you are not following a specific protocol around it, you ARE sweating, but you may not actually be supporting detoxification properly.

Hormonal shifts, immune changes, and leaky gut 11:54

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That's n-a-t-n-i-d-e-m dot com forward-slash sauna and check it out for yourself. physicians are not being trained in school that perimenopause is really anything, or if it is, I don't even think it's mentioned. So you talk about middle pause. Let's define that. What does that really Why did we need another pause? Like we have a perimenopause, we a menopausus. What's middle-pause? Do you want me to give you my honest answer? Yeah. Because I was so tired in writing the book to say peri-menopose and menapause that I just decided I'm just going to coin this phrase because it defines middle age and then you throw the word pause in there and it's very descriptive but it is less of a mouthful.

I mean it really synopsizing the experiences that women have from mid to late 30s into the menopausal transition and typifies the experiences that we have. It's not just a physiological shift, it is a psychological shift. it's a spiritual shift and so middle pause was really born out of my desire to shorten Perry menopause and menobause, because I felt like I kept saying that over and over again in the book. And so middle pause, this makes sense. It's short, it's, short and sweet. So that's literally how it came about, just to shorten the phrase.

Because I would literally just start writing Perry slash menopus because, I was saying it over, and, over. Right, right, Right. But, you know, wanting to be concise is really what that was born from, but it still represents the same experience for women. So a lot of people, and I mean, I'm sure, you know, as far as physicians will go, typically who haven't gotten the training, it's, this is all about your period stopping, right? But what's really happening kind of on a hormonal level, on the metabolic level.

Even on an immunologic level like. What can you help? Let's take the audience through what does this really mean? Physically like you've talked about spiritual emotional we can get to that but let's talk because you know as you had said earlier Your doctor said to you and yeah, guess what? You're gonna be packing on some weight Which frankly is more insight than a lot of women get most women just wake up one morning look down and go where did this all come from? Yeah, this is not me That's part of the not recognizing yourself.

So can we kind of enlighten women or listeners, because maybe men are listening to this too, to try and understand what the heck is happening with their partners, what's really happening here on a hormonal, metabolic, and immunological level? Yeah, I mean, it's interesting. We know what really constitutes the beginning of perimenopause is this reduction of progesterone. And for many women, this shows up as trouble sleeping, maybe more anxiety, more mood disorders around their menstrual cycle. But I think at a larger, like kind of macro level, we're really looking at As we see these declines in hormones and changes in neurotransmitters, it impacts every single system of the body.

It is not just bikini medicine. It has catastrophic effects on the body. that's good or bad. I had to map things out on a whiteboard because it can get very complicated. But one of the markers of aging process is something called immunosenescence, which is really speaking to aging of immune system that happens right along with us. And one the big kind of shifts in the immune systems is this decline in estrogen. So yes, in perimenopause, you get 20 to 30% higher levels of estrogen depending on where you are in your cycle, depending the cycle.

And as estrogen is declining, all of a sudden, we're starting to see this domino effect in the immune system. So we see, at a very basic level, more inflammation. The term, inflammation, which a lot of people hate, but is a great way of expressing the aging of the system drives inflammation as estrogens declining at the very base level. When we talk about digestion, this is just one example. The small intestinal lining, which is where we get most of the absorption assimilation of nutrients across that small intestine lining.

Estrogen acts like if we have a brick and mortar system to describe these tight junctions, estrogen acts as the mortar in between the bricks. So, as estrogen is declining, we get more leaky gut. When we have leakey gut, food particles leak into the bloodstream and trigger an immune response. So already, women will start seeing more bloating, more digestive issues as a direct impact of this increase in leak gut is important because with leaki gut we got linked to autoimmune conditions. A thousand years ago, when I finished my training, there were probably 20 or 30 recognized autoimmune conditions.

Now there are over a hundred things like long haul COVID, chronic Lyme. Once you have one auto immune condition, you're more likely to have others. And women are four to five times more, likely, to experience auto-immune, conditions in perimenopause and menopausal. That is significant and something that's really worth mentioning. It's why I see so much Hashimoto's, celiac, lupus, rheumatoid arthritis, psoriasis, et cetera. But that provocation of the immune system, our immune systems becomes a little cranky.

We start to see some other symptoms that will come up. You know, there are T-helper cells, and we start become a bit T helper one dominant, which really represents this immunity, this kind of inflammatory process, the autoimmunity. What's interesting, if you look at the research, I don't say this to be controversial because as soon as you say the word vaccine, people get kind flummox. One of the reasons why vaccines aren't quite as effective as we get older is that we cannot launch the same immune response.

And so I think it's important for people to understand as estrogen is declining, we're more likely to experience opportunistic infections. We're likely more to have leaky gut. The other thing that's really interesting about the immune system, and I thing about something that is really helpful to genitourinary syndrome of menopause. Super sexy. It's not a question of if but when. We will all develop it. And as estrogen is declining in the vagina, it impacts the healthy lactobacilli. So these very important beneficial species that are there, when the pH changes in absence of estrogen being there or decline in estrogen, It drives a lot of the symptoms women experience.

chronic urinary tract infections, more pelvic floor issues. And I think getting up at night to pee also very common to see in the setting of loss of estrogen. So estrogen acts as a helpful for the barrier, also helpful supporting the microbiome constituency, not just in vagina, but also in gut microbiomes and elsewhere. And so I think a lot of people are surprised to know that estrogen and the immune system go together. And I'm going to give you a terrible analogy like peanut butter and jelly. I know maybe not something that everyone loves, but I about it in that regard that they are so intertwined that it's helpful to understand that As your estrogen is declining and mid to late perimenopause, you're going to see more opportunistic infections, and that includes in the gut as well.

And so sometimes people will say, I start off the book talking about this romantic trip to Morocco and how I got sick, definitely sick and my husband didn't. And so I didn't know at that time that this loss of estrogen was driving a lot of these changes in the immune system. So, I mean, the system and estrogen really are integral together. And there's a whole lot more to the conversation, but that is probably one of those more tangible ways that people can understand this is what starts to happen.

Estrogen is important for a lot of things that go on in the body. It's important from nitric oxide signaling. So even in a gut, patients will tell me, I feel like my food just doesn't digest as well, helping them understand that as progesterone declines, it impacts smooth muscle contractility and as estrogen declives, we have less nitrous oxide. A lot people think about that in terms of endothelial function, which is still very important, but also really important innervation in gut. Yes, you're not You're not imagining things.

Your digestive capacity will shift. You ability to break down healthy fats because estrogen interacts with bile. So being able to breakdown and emulsify fats will also change. And the domino effect goes on and on. I think these are probably lesser known things about estrogen. Yes, it's important for bone function. It helps bone build up. estrogen helps with osteoplastic activity and it's meant to balance each other out. But that is like one of the lesser known. And I say this because I've now spoken on 70 plus podcasts in getting the word out about this book.

almost always, when I talk about the digestive aspects of the immune system vis-a-vis estrogen loss, people are like, oh my God, I just think about it as bone. I think it about as heart. And I'm like guys, it's so much more than that. There's no cell in the body that is not impacted by estrogen progesterone loss and testosterone loss in most women. Not every woman still has to require hormone replacement therapy for testosterone, but most, if not all, the rest of us do for both estradiol and pro testosterone.

And I think it's important because, you know, unfortunately, there's this prevailing thought process in the health and wellness space that you just slap on an estrogen patch and everything's magically fixed. And I'm here to tell you, it is a much larger, more nuanced conversation than that. I was taking a couple of notes as you were speaking. And one of the things that when you are talking about the leaky gut, there are a lot of people that will say, if you have a leky gut you'll have lekey brain.

Correct. Which would have, again, which also would link the loss of estrogen to this brain fog and this lack of cognitive ability that women report to the point where you know in extreme situations you have women who actually believe that they're somehow going through early onset dementia or something when really

Metabolic slowdown, belly fat, and muscle loss 23:00

there's you would have this double whammy of the loss of estrogen possible excess kind of like neuro inflammation because the immune system is all cranky because of things getting in that shouldn't get in, you know, these highly medical terms. Yeah, no, I think that's an important, there's the vagus nerve that it innovates its bi-directional relationship between the gut and the brain. So you're absolutely correct. If you have leaky gut, probably have a leky brain, the brand is designed to be impermeable.

I actually had a guest on the podcast who said if GABA works for you, You have Scott's share. I'll bet you as Dr. Scott share, I was like, if you have a leaky gut and you know, GABA works for you, you probably have lekey brain and I So, I think it's helpful for people to know that this bidirectional relationship between the gut and the brain is really important. So if you can imagine if your gut's inflamed, your brain's also inflame. And I really think inflammation is at the basis for nearly all disease states, especially chronic disease state.

There could be a million reasons why they're more inflamed on this continuum of inflammatory processes, but it's not at all surprising to know that these organ systems don't exist in vacuums. And that was kind of how I was trained was that this is your neurology bucket and this your cardiology bucket, and here's your renal bucket. Yet we now know there's complex interplay between all of these organs systems and the gut and chronically stressed and not able to properly regulate your autonomic nervous system, that is going to make navigating this transition in your life 10 times harder.

I mean, I say this as a card carrying type A intense person, not surprisingly, former adrenaline junkie that it made my perimenopause transition until I was able master things. made it a whole lot harder. And it's kind of this, and I don't know if you see this with your clients or the community that you interact with, but the women who are the most detail-oriented, conscientious, thoughtful, I didn't want to use the word obsessive because I wouldn't describe myself as that, just like an intense person.

It is hard that when you get into this transitional period that all of a sudden I'm going to say to you, do less. Not do more, don't do fasting, do less. That is completely contrary to what we have been taught and told. And that's one of those backwards things that can be very hard for women to wrap their head around. Like, wait a minute. In the past, if I calorically restricted and exercise more and just did more, more more. It worked. And all of a sudden you realize your body's like, no, it's actually have to do the exact opposite in order to master this middle age piece and do so in a way where you feel good.

Yeah. Well, I think it's part of it is we've been so used to muscling through things, right? We can muscle through you muscle, through childbirth, you muscled through sleep deprivation. You hustled in your job and now, and it not even, definitely you have to do less, but in order to less and not suffer terrible consequences, You have get smarter. So you have to do less of everything and you to choose what's really important and prioritize the most important stuff. And nobody wants to make those choices.

Nobody wants cut anything out. So on the metabolic side though, let's maybe touch on that a little bit because you did a great job on immune system which interestingly enough is going to affect metabolism because inflammation is a pain point to metabolic balance. But the metabolic transition that happens that your doctor alluded to, but many women don't even get a notice on that one, which also affects the brain. Absolutely. And I mean, I was in cardiology, so I got a bird's eye view. Like, why are all my patients in their 40s and 50s?

Why are they suddenly gaining weight? One of the things that starts at 40 is that we start losing muscle mass. This is called sarcopenia. And I tell people all the time, the loss of muscle, mass combined with changes in estrogen levels is catastrophic. Why? Because estrogen is an insulin sensitizing hormone. This is such an important point to understand that you can be doing exactly what you did at 35, and at 40 and 45, you could start gaining weight. It's because of a combined net effect of loss of muscle mass, unless you're working against that.

it is understanding that with this loss in insulin sensitivity, all of the sudden, what he ate before is not going to impact you the same way. So women will say, I notice I don't tolerate carbohydrates quite as well. So, we know that I think it's gotten out there that we need more protein as we're getting older. We need protein for muscle protein synthesis, for leucine threshold. I don't necessarily think all the women understand that the quality of our carbohydrates becomes critically important.

And we have to understand, that there's a timing for carbohydrates. Typically, I will say earlier in the day, not 9 o'clock at night. but those processed carbs are not going to agree with you. So the cookies, the candies, breads, pasta, all of a sudden is not as hormonally advantageous. You can't quite buffer it. And so when I talk about this loss of insulin sensitivity, it's going impact whether or not you can build muscle, it's going to impact whether you're able to effectively utilize either stored carbohydrates or stored fat for fuel.

It's gonna impact brain health because we recognize now that dementia and a lot of neurocognitive disorders are a byproduct of a loss of insulin sensitivity in the brain. it's going to impact body composition because we know that typically what happens in the menopausal transition is that we put less subcutaneous, the pesky fat that, we all complain about that. We don't love, you know, this stuff that's on the back of our arms or hips or thighs, that is sub cutaneous fat. That is very different than visceral fat, visceral fat is what is deposited around our main or major organs and tends to be very inflammatory.

It actually secretes cytokines and other inflammatory substances that can further drive more inflammation, more inflammaging, irritate that immune system. And so when I'm thinking about metabolic health, I always use the word catastrophic so that people take it seriously. This will continue to unwind unless you're actively working against it. So this is why we talk about macros and we talked about meal timing and leveraging, maintaining and building muscle. And there are lots of things that tips and tricks that I'm sure you probably talk about with your community with great regularity.

But I think for a lot of women, they don't understand that you can be doing exactly what you used to do, that high intensity interval training, Orange Theory fitness, CrossFit, doing marathons. I get hate mail when I say this, but I am like, listen, when say do less, It is because you will become less stress resilient and your body cannot weather the stress that you were able to get away with in your 20s and 30s. It does not mean you are incapable, it just means your physiology is changing. And so instead of doing six days a week of Orange Theory fitness with no recovery, you're probably going to do two or three days of strength training, do some zone two, get out and walk in the sunshine.

that is me better served for your body composition and your physiology. The other thing that I would say is this is why I'm a huge proponent of lifestyle measures that impact metabolic health, sleep, managing your stress, those macros that i've talked about, exercise, especially strength training, and why I'm a huge proponent of hormone replacement therapy, and certainly the research that is coming out talking about women in menopause that are on HRT plus a GLP-1. And I am not a proponents of saying to people, you have to have a BMI of 30 or 27 with a comorbidity to qualify.

I think that personalized dosing, dare I say the word microdosing, is going to be a way of the future because there is not one patient I have that does not have an autoimmune condition or an inflammatory issue that being on a small personalized dose of a GLP-1 is allowing them to maintain their body composition, meaning more lean mass, less fat free mass. really important.

GLP-1s, body composition, and modern treatment options 31:58

That's why the scale, I usually say the scales a liar, but that's my body composition is so important at this stage of life. So metabolic health for everyone listening is something all of us need to be concerned about. It's one of many reasons why I take HRT, it is why lean into that lifestyle, why talk to my patients about it, and why am also a proponent of leveraging personalized dosing. Notice I'm saying the word personalized Yeah. I think that this is the wave of the future. These drugs are the most powerful drugs of my adult lifetime.

As a prescriber, they're drugs that are going to change the narrative. And I we're going get to a point, and I hate when people say, I'm not on any prescription meds. Well, good for you. But I don't think hormones count. Number one, any of these GLP-1s are going to allow people to live a higher quality of life. And therefore, we can't just limit their use based on whether or not someone has a comorbidity plus their overweight or obese. I think that we have applicability to a larger population that I Yeah, no, I loved you brought out the JLP-1 because I was going to bring it up myself in the sense that you talked about the digestive issues, we talk about sarcopenia, and now there's this sidebar narrative on GLPs that they're going slow down gut motility, they are going cause muscle loss, going do all these horrible things.

And I feel like I've been standing on a soapbox talking myself blue in face, but I think that there are now so many of us in this space saying, it's in the details, people. If they're used properly, they literally can offset some of the most insidious parts of this journey for women. And to your point, whether it is a microdose or just a smaller dose, and even if it isn't someone who is obese, the lowest effective dose that's going to give you the result that that you're looking for and whether that's just reducing inflammation or improving insulin sensitivity or whatever the case and doing all the things the diet the exercise the lifting and so I'm with you and I am so thrilled you brought it up because it's I find it a little exhausting the negative narrative on the GLPs the judgment the the negativity it could we just stop being so dramatic all the time and just get down to brass tacks?

Yeah. You know, like just, and I don't know about you, but generally the people that I see shaming people about using GLP-1s and whatever capacity they are, generally like the gym bros who are like 25 years old. So I'm like. Yeah, so don't talk to me. Right, exactly. I respectfully reserve the right not to have a discussion with a man who's 25-years-old. And I mean, I have two adult sons. They are super lean, super metabolically healthy. they just sneeze and they're metabolocally healthy, and so I like, there's no comparison.

If I look at my husband, who is 56, Yes, 56. I had to think for a second. And I look at my 20-year-old and 18- year- old and I'm like, there's no comparison. They're just biologically at an advantage at the stage of life that they're in. that we are using everything that is available to be able to help patients. And to your point about side effects from GLP-1s, okay, so let's be clear. There are definitely, I call them pill mills or weight loss clinics that are out there that some responsibly and some irresponsibly.

But if your provider is not concurrently saying to you, you must strengthen two or three days a week and you most eat adequate amounts of protein. If they're not including that in the conversation, then they should not be prescribing it. Because unfortunately, even as a healthcare professional myself, I have been at events where I've had formerly obese Colleagues say to me, I will never stop this drug and I'll be damned. I don't care if I've lost muscle mass. It's the first time in my adult life.

That is powerful. Oh, I used to recreationally use XYZ drug. I no longer have a desire to do that. So when I say that I think that there is applicability, especially for at least the second and third generation drugs like terzepotide, I think that it's really exciting. And so I'm all for things that allow people to have freedom, and they allow for people that have autonomy over not just body composition, but metabolic health and all the benefits that I thing for a lot of individuals, maybe they didn't realize at the time, they're like, oh, I shifted body competition a little bit, But oh no, there's so many more benefits than I was even unaware of.

Like the food noise piece is huge for so may patients. There's been you and I have lived long enough that we've seen so many diet fads that have come and gone, you know, volume metrics and, all these gimmicks to try to trickle in. That HCG diet? Yes. Is it HCGs, the 800 calorie destroyer metabolism? Exactly, exactly. And I actually have licensed medical provider colleagues who swear by that, but that's a whole separate conversation. I think for a lot of people, I think that the food freedom, the ability to have agency over their lives to make better decisions, that's beautiful.

That to me is, there's nothing else I can think of in my lifetime of prescribing drugs or even being a licensed medical provider that I could compare to that. I really think it's a revolutionary time period in our history. these issues that people are dealing with are a product of our modern society. It's the constant availability of food and the overwhelming availability, of hyper palatable foods that are the processed food. So just to be clear, in a perfect world, if you're living in the world where you are only eating whole foods and you living outside and doing all the things, you may not be one of those people that needs this.

But if you're living in a big city and you are living the crazy lifestyle and haven't got the best eating habits and doing the hyper palatable thing in the whole nine yards, these medications come in and really start to even out the playing field. Moving on from that, the book is called Menopause Gut. Let's talk about the gut as an organ. topic because it's so top of mind with so many people right now. But let's get into this real connect, and you mentioned it earlier about estrogen affecting the microbiome, the loss of estrogen effecting the micro biome.

Let's kind of reiterate and dive into a little bit more for the audience, this whole connection between the onset of perimenopause and this transition and the gut at a systems level. Because it is going to speak to the vagus nerve again and all that kind Yeah. I mean, I think it's easiest to kind of explain what the gut microbiome is, because for a lot of people, it is totally intangible. They're like, �I know where my brain is.� � I know what my heart is.� ��I think I knew it�s somewhere in the digestive system, but not specifically.� So we're talking about 40 trillion with a T, viruses, bacteria, fungi, and protozoa that encompass part of the large intestine or colon.

So it's really kind of like the bottom part our digestive system. And the thing that I found fascinating while I was writing the book is that the gut microbiome interfaces with every single organ system in the body. Like there's a gut ovarian access. There's gut bone access, there is a brain access etc. etc.. And what I find really interesting was that there are a lot of things we have control over If we live long enough, we will eventually go from perimenopause into menopaus. And the loss of progesterone and estrogen impacts diversity.

So I just talked about those different types of microbes that are in the gut. We get a decline in diversity, so that can drive inflammation. You start seeing more leaky gut, as I mentioned. we also see changes in something called short-chain fatty acids, and I promise these are relevant. They're very important signaling molecules in our bodies. And they do things like create mucus that lines the digestive system, they help reduce inflammation. They're responsible for endogenous GLP-1 regulation, along with some keystone bacteria.

And some of these, including butyrate, can actually cross the blood-brain barrier.

The gut microbiome, estrogen, and detoxification 40:30

So really, really important signaling molecules. But as estrogen declines, So do these important signaling molecules. So there's a lot that changes in the microbiome as we're kind of navigating this perimenopause to menopausal transition. But I remind people there is also an aspect of the micro biome called the astroblome. Or as a host said the other day, it was a guy said, the Astrobalome, which every time I say that now it makes me chuckle. Yes, It just cracked me up. First time this gentleman had ever said it, but it's an estrogen processing center of It is impacted by the quality of foods we eat.

It's impacted my chronic stress. Is impacted the types of medications that we take. And so we ultimately want to think of detoxification, the bulk of estrogen detox, vacation hormonal detox vacation occurs in our liver. So the liver is the main site. it breaks it down into water soluble compounds and goes to the gut. The gut is where it's supposed to be packaged up like a present and we poop it out. That's what should happen. However, if we have a very inflammatory lifestyle, we've had a lot of antibiotics, used a lots of synthetic hormones, etc.

etc., it can get recirculated. So the estrogen that our body is trying to break down and get rid of gets reciculated. This is significant for women because it magnify all of those symptoms. the brain fog, the joint pain, skin issues, it can drive a lot of inflammatory changes, weight loss resistance, breast health issues. And I think it's important for people to know that, yes, you can replace hormones, and yes that's very important, but if your gut is not optimized, your going to still have symptoms.

I will oftentimes tell women Well, women are having a lot of vasomotor symptoms, a lotta hot flashes, lotta night sweats. I'm like, it's more than just replacing hormones. It's really looking at what is going on in the microbiome, because there's a key enzyme called beta-glucuronidase. And if it working properly, It is helping to break down the estrogen and get rid of it. But when we measure beta glucoronodase in stool, if its high, we generally are thinking that there is an issue related to the astroblom and possibly detoxification pathways in a body.

And no, detoxification is not talking about a program in a box. It is actually the fact that we breathe, we sweat, you poop, We pee all in an effort to help rid our body of things that We don't need anymore. And so I think this is sometimes a forgotten kind of thought process around aging and immunosenescence and changes in hormones that The strobilome and the microbiome become really, really important because the one thing that I've already mentioned is that we're constantly sending and relaying information all over the body.

So as you can imagine, if you're not able to properly break down and detoxify, you are going to be sending inflammatory signals to the brain. mood disorders and things like that, I'm already thinking like what is going on at a micro level in the microbiome that's not allowing you to properly clear and assimilate some of these nutrients and byproducts and actually properly eliminate things from the body that should be there. And this is why as unglamorous as it is, it's important to talk about the need to poop.

It is not glamorous or exciting. I was interviewing an expert and I said, you know, how do you define constipation as a gastroenterologist? And she said well really it's, I let the patients kind of define, does this bother me? Like does it bother that I don't poop every day? And I said, well, that would bother me. I generally tell my patients, you should go at least once a day, preferably twice a today. But I would acknowledge, I've had patients that tell me they poop twice the week and they think that's normal.

Well, then that the problem, right? If you ask them to define it, we normalize what we do, Right? We normalise everything. So I know that what I was practicing as a nutritionist, quite often people didn't know what it felt like. to poop every day. You take someone who poops twice a week and you get their gut optimized and get them moving so that they poop everyday, all of a sudden they realize they've been rocking around feeling like they have a brick in their guts for ages or bloated or they had bad skin or bad breath or all the things.

But that was just the way it is for them. Normal, right? Whatever we we assume that that's normal. And I think that there's a stigma about talking around these subjects. I'm like, listen, there should be nothing over that. There should nothing that truly off topic because I There's so many hormonal changes, neurotransmitter changes. Cellular changes that are occurring at a micro and macro level that if you're not going regularly, you want to be asking, are you dehydrated? Are you chronically stressed?

I have people that tell me they, well, I jokingly call it the non-public pooper. It's the person that as soon as they leave their house, they go on vacation, and they can't go to the bathroom. all the more reason for you to de-stress because you should be able to go to the bathroom on vacation, it should not be this like arduous issue. Yeah, no kidding. It's a thing, that's what people do, they do it all of the time. Let's move over to another, well it's still in the microbiome, but you talk about bacterial translocation.

So how does that kind of tie into the symptoms that women are experiencing but not necessarily connecting back to their gut? Yeah, so when we're talking about bacterial translocation that goes along with leaky gut and oftentimes it's things pathogens were exposed to. I start the book off talking this romantic holiday in Morocco where I got violently ill from food poisoning were evidently there was quite a bit of endotoxin that I ingested and that was what drove a lot of the vomiting and diarrhea and just feeling poorly.

But when you get this translocation, you're actually getting leaky gut and the endo toxin, which is generally caused from gram-negative bacteria, leaks into the bloodstream and provokes a lots of inflammatory cytokines. So it can provoke brain inflammation, it could provoke Just inflammation, like achy joints, you can have brain fog. I mean, those weren't the things that I experienced, but it just magnifies the effects of the bacteria that you ingest. So when you adjust a foodborne illness bacteria and you're vomiting and having diarrhea, your body is trying to get rid of what does not belong as unpleasant as it is.

But at a very cellular level, when you leak endotoxin into your bloodstream, that is what provokes all these other side effects. And so if anyone listening has ever had really bad food poisoning like I've had, I can assure you that every achy body part, every single inflammatory thing, not feeling like you can't think straight, Those are all a byproduct of your body trying to process and get rid of these inflammatory endotoxins. So interleukin 6 will go up, sometimes tumor necrosis factor, things that can be very noxious to our neurologic system, that could be noctious too, our cells and can become problematic.

I think on a very kind of macro level, it's helping people understand that Bacterial translocation is a byproduct usually of a provocation of the immune system, sometimes vis-a-vis ingestion of parasitic friend, like I ingested Giardia. And that's probably what drove it. Yeah, exactly. My little friend that made me so sick. The uninvited friend who, you know, basically cause, it's interesting. I mean, when we get violently ill like that, what we forget, we feel like our body's turned on us. actually your body's trying to protect you.

Correct. And that's a really interesting perspective, right? It's, it's real shift in, in perspective that I wonder if maybe we get through those transitions a little easier. If we didn't forget instantly, if we, didn' assume that our bodies suddenly turned on us, this is a defensive mechanism. This is, I got to keep you alive, dude. It is going to feel ugly, but this what has to happen right now. Yeah, no, I think in the moment, you're probably not thinking that you just want it to end. But after the fact, You're like, i'm grateful that my body knew that this needed to be ejected violently in order to process it.

What's interesting to me is in this setting of food poisoning, foodborne illnesses and middle age, your body doesn't weather it quite as well as it did when you were younger. reaffirms why when you're traveling, you have to be careful and conscientious, which we were, but one of us got food poisoning and the other one didn't. Yeah, well, every once in a while. I mean, I always have a kit when I'm traveling to places like that. And I am sure you did too, but sometimes, anyway, it can happen. It can happened anywhere, trust me.

Can happen anytime, anywhere for sure. I have question for you. There's, there I think in the book you talk a little bit about how estrogen directly affects the microbial diversity and composition of the gut. i don't know that we've touched on that yet. Um, i know we talked about other microbiome helps in detoxifying estrogen metabolites and hopefully moving them out, assuming you have your doors of elimination open, as they used to say back in nutrition school. But what is the impact of estrogen on that microbial diversity, which again, we lose it which is part of the problem with aging.

Yeah, it's interesting. There's research that's coming out that is comparing younger women's microbiomes to perimenopause to menopaus. And what's interested is that women in menopsis and younger woman, their microbiome can resemble one another with the addition of hormone replacement therapy. So it is not yet a clinical indication. I think it will be coming. But when we use the term diversity, we're talking about beneficial bacteria, viruses, fungi. Think about it as you plant a garden. You have fruits and vegetables that you want.

And as your hormones are declining, in particular estrogen, you start seeing a decline and maybe you don't have as much tomatoes that time and, maybe, have less corn that's growing. Maybe the peas don' grow quite as muc. So you have, like, a dec in beneficial bacteria. An what can typically happen is you will have more inflammatory species. So I've talked a lot about how inflammation plays this role throughout the microbiome and this decline in hormones. I always use the term dysbiotic, so non-beneficial bacteria that can grow up in between the fruits and vegetables that you do want.

And one of the things that's really interesting is if you look at the research, the thing that impact diversity are the same things we've been talking about throughout this conversation, chronic stress, antibiotics, ultra processed foods, emulsifiers, additives, artificial sugars can damage the microbiome. And so it really goes without saying that diversity changes through three kind of key times in a woman's life. Number one is puberty.

Bacterial translocation, inflammation, and gut diversity 51:30

Let me precede that by saying, depending on whether or not you're a vaginal delivery or a C-section breastfed or formula fed, It imprints the microbiome. Then we go through puberty. Not surprisingly, young men and young women, their diversity changes in response to these hormones. Pregnancy is another big P. And then last is perimenopause. The irony being by the time we get to menopausal, the micro biome constituents can look very similar to mens again, but it's not advantageous for us. So it goes back to saying that estrogen plays an incredibly important role, progesterone to a lesser extent, and I would argue that there is some immune function benefits of testosterone.

But I think for a lot of individuals, it's helping them understand that until our hormones start to decline and falter, there's a law in the microbiome that is optimal. and then it forms a decline in response to estrogen declining. And we know estrogen kind of comes, that really comes at the tail end of perimenopause. Now, if you're taking hormone replacement therapy, the thought process is that that will lessen the likelihood of the impact of some of those. We don't yet have ranges like we do with bone.

Like we now for bone protection, we want your estradiol levels to be anywhere from 60 to 100 picograms per ml. I know the US related Numbers, I'm not sure if they're the same in Canada, but I think for a lot of individuals, this is the direction that research will be going that will eventually get to a point where we'll say to confer protection for leaky gut, bacterial translocation, all these other things, we want to maintain an estradiol level of 60 picograms per ml now that could change but I think that's the direction that I see Richard's going in and I've certainly I ask all of the I Ask all the microbiome experts like do you think it's coming?

Because certainly the research that they've seen sounds very encouraging and they said yes, of course There'll be lots of benefits beyond just bone brain and heart health that is where I Think most of their research dollars have been planted at this. Yeah Well, I mean, once you get to arrange for any of those systems, you're just going to want to maintain it anyway. And it's going be the lowest one is going become the new threshold that you don't want fall below. Even if the brain needs more. You might shoot higher, but you definitely don' t want go below whatever that one threshold is.

So, okay, so let's talk about belly fat. Let's about this, you know, where's this belly coming from? Is it the insulin resistance, the elevated cortisol, lack of sleep, is there something else? I mean, we've already distinguished the visceral fat which we don't see, which is much more harmful, but the most vexing fat really, let face it, it is the pooch. Nobody wants to, especially if you went through most of your life without a pooch or minimal pootch and now all of a sudden you've got this big poach and you're like, what the heck?

And probably it's the pootch that gets a lot of women into the doctor complaining. Yeah. I mean, I can tell you that when my editor pitched the book title idea to me, my initial response was no. but it's a double entendre. So here it is talking about the menopause gut and then the pooch that you alluded to. I think it multi-factorial, which is a fancy way of saying, I thing it multiple things. It's declines in testosterone, it declins in estrogen, changes in insulin sensitivity, a loss of muscle mass, the lack of carb sensitivity.

A lot of women are still eating far too much carbohydrate for their physiology. And by that, I mean, what is a rough estimate? I would say if you are insulin sensitive, you can probably handle about 30 grams of carbohydrate. What do I see women eating? 50, 100, and then they do that regularly, not just around workouts or recovery. I think that that is problem. The lack of sleep, because I remind women that sleep and the microbiome health are intricately interwoven, it's also interwove in an insulin sensitivity.

and glucose disposal. And so that's another one. But the chronic stress piece plus trauma, when I have a woman that we have looked at everything, I mean, we've done the gut test and we looked, you know, at inflammatory markers. We've What was your childhood like? You know, when we talk about adverse childhood events, which was a joint venture between the CDC and Kaiser Permanente here in the United States, anyone that's listening can get online and get access to a very short quiz. I have an A score of nine.

That is significant. And so I remind people that in my medical training, I trained in inner city Baltimore. We talked a lot about big T-trauma, rape, murder, suicide. There's no question that's traumatizing, right? And trauma is a wound, but equally corrosive and bothersome is little T trauma. You know, that's neglect, addiction, abuse, bullying. And for each one of us, it might look a little bit different. So I think for a lot of women, they hold it together in their teens, 20s and 30s. They've created patterns to be able to deal with their stuff, because we all have stuff.

None of use are perfect. The wheels fall off the bus in perimenopause, meaning For so many of these women, I talked about the litmus test for taking care of yourself. For a lot of women in the setting of a decline in hormones, changes in neurotransmitters, all of the sudden, they can't cope quite as well. And so this is a reawakening for women. Whether it is getting somatic therapy, whether it's dealing with a trauma specialist, weather it doing talk therapy whether doing reiki work, cleaning up your toxic family slash spouse or significant other or job.

For a lot of people, that is the missing link. I think for far too many women, I thing now we're having conversations around this. It was the thing, quite honestly, Nat, when I was writing the book, and I kind of sat back and was like, Whoa, like when you start looking at the research and something that I didn't mention that, The gut ovarian access plays a role in when you go into menopause. Guess what ages your ovaries? Lots of things. Toxins, smoking, chronic stress. If you look at the research on people that experienced stress, like sexual abuse and things like that, go on to have families where their children are sexually abused.

There's one research article, women will go in to menoppause eight years earlier. So I think when I'm talking to women and they tell me they went into menopause at 45, 47, 48, way before the average here in the US, which is 51. I'm always thinking, what happened in your youth? Did you have a really stressful job? I have met clinicians, GYNs, people who are up delivering babies in the middle of the night, ER doctors who were working in really high acuity jobs. That will age the ovaries. And so we don't think enough about the impact of ovary.

It's the most mitochondrial dense organ in a woman's body. I think we need to be really proactive about starting the conversations earlier, because I do think, I firmly believe that that trauma piece is the missing link for a lot of women, and understanding how chronic stress impacts the microbiome, how it impacts that gut ovarian access, How it impact the brain. I think for lot women that is missing. not just for the gut, but for everything that many women really get frustrated with. Like I actually was talking to a girlfriend the other day and she said, I had three kids, everything got all stretched out.

And she's like, now I'm in menopause and I am dealing with more issues. I was like yeah, it's a not so fun part that maybe more of us don't talk about enough. But we can help. There's ways to help, right? And I think that's part of what the book is about. The book about building awareness, helping people to feel heard and seen. And now there's this whole rebuild, so if the gut is the central organ, where do we really start on rebuilding it? Actually, another question would be, do you think if women started rebuilding their gut or taking care of their guts earlier, Could it make this, because in case somebody's listening to this and, you know, just had it on the card, not realizing it was maybe targeting older people.

If you're listening Is there, should you be, you know, if you take better care of your gut now, will, could it potentially make that transition easier? And then if we didn't listen to this in our 20s and 30s, and we're already in the middle of the storm, what can we do to really help? Because I think one of things, one the macros we did not talk about was fiber. And a lot of people will say fiber will be the next macro that everybody becomes obsessed with, which frankly I wish we would stop getting obsessed one thing and start talking about all the things.

Absolutely. No, no, I agree with you. Back to the original questions here. We started this part earlier. Will that make things easier? And if we didn't, what should we be focusing on? Yeah. So number one, absolutely anything that you can be doing to improve the health of your gut microbiome is going to make everything infinitely easier. And we didn't talk about fiber, but that is usually at the forefront of my conversations I've been having. We need fiber even more in menopause and the decline of short chain fatty acids because that's what the gut, the colon will ferment and then from there your body makes short-chain fatty acid.

So even important in the declines of hormones.

Rebuilding gut health and thriving in midlife 1:01:00

I think from a very macro level, I always say major in majors, Sleep, stress, nutrition, exercise before just about anything else. Because if you can major and the research is solid, like I spent a chapter on each one of those areas, everything I've talked about, there's a full chapter. I talked. About the. Research on the gut microbiome and sleep quality, why it's important to get at least seven to eight hours a night, and why. It's. Important. And I hope I made the argument even talking about the trauma piece.

Stress is insidious and most women who are not sleeping, it is because they do not manage their stress. Full stop. Nutrition, protein, and fiber become really important. It's the Goldilocks effect. So when we talk about right amount of exercise, right about of hormetic stress at the right time, it means if you do not sleep, do you not go out and try to do high intensity animal training? Let's be smart. I think there are far too many women who don't check in with themselves. And then they still are like, well, today is the day I'm supposed to really my personal best on high-intensity animal-training.

No. Today is a day you go walk outside in sunshine and do a recovery day. So at a very kind of macro level, major in the majors. Don't get caught up in buying the next gadget, which I love gadgets. I know you love gadget. But I'm like, don't be caught in that until you've mastered the basics. Because if you dial those in, you're going to have much greater success when you start layering in all these other aspects of what I think are critically important for perimenopause and menopausal gut microbiome effects.

So don't get caught in the bright shiny objects, focus on the majors, get those dialed in, and then you get to have fun and play. Yeah. No, I love that. And I think you talk about four things in a book also. So there was the fiber diversity, the fermented foods, which are really important as well. I Think with the Fiber, one caveat maybe to mention to the audience, if we're aiming for 30 to 35 and it comes to your attention, you're consuming five. Go up in increments of five ladies. Don't just jump into 30 to 35. I might actually say not to do, you know, figure out where you are as a baseline and go up by two or three, because it's time for those to adapt.

And so if you try to go too fast and there's a lot of awareness around fiber and people sell me, send me free stuff all the time, just like I'm sure they do you. and I was having my, my husband try these fiber gummies that have been sent to me because I wasn't like, I won't eat those, but you can try them. And he was telling me, he's like, well, first of all, they taste good. I'm like well that's great. They're probably sweetened with a ton of sugar. But before you even think about adding a fiber supplement, please try to get it from some beans, some legumes.

Vegetables. Yeah. Right. Exactly. Or my ninja is a fresh ground tablespoon of flax. and chia seeds. For whatever reason, my patients tolerate that really easily. I do it every day. It just bumps up your fiber intake. You get a little bit of plant-based protein and it's very well tolerated versus people say to me, oh, I've got to have mycilium husk. Before you even do that, just try to get it from food, please. Because the bloating that patients describe to be is generally because they've gone up too quickly, too too fast.

And so they have to back off. In fact, we have like all these resources that we created as benefits of people to buy the book. One of the things where I was laughing about with my team, I'm like, you cannot tell people the increase their fiber by 10 to 15 grams a day. They'll be mad at us. I said it needs to start slowly. So find out where you are and increase it by two to three grams until you tolerate that and then go up from there. Of course. Cool. Okay, sorry, I'm rushing you because we're coming up on time.

And I have three fast quick fire questions I want to ask you before we send people to buy the book. Because at this point, if they don't know that they need to read the books, they should know. So if women understood just one thing about the connection between their gut and hormones, what do you want it to be? Just one? I think that They need To understand the interplay between stress and their microbiome. I think that there's a lot of lip service around like, I do five minutes of meditation once a week.

You need to find things that you like to do and do them often. So stress management is critically important for the gut and for your hormones. Perfect. Do you think, or would you position menopause as less of a decline and perhaps more of recalibration that we've just misunderstood or misdescribed? I think I'm very much a glass half full kind of person. And so when people like whine about, you know, how awful perimenopause and menopauses. I'm like, come on, ladies, like your brain hears everything that you're saying.

What do you think is happening internally when you are saying that? Do I think that I got everything right in peri-menopose? Absolutely not. But when I talk about it, I always say, don't do what I did. These are the lessons I had to learn And like, quite frankly, I am so much happier like 10 years later. Oh my god, i'm so Much happier. So I think that we have to reframe it in a positive light because you may spend Not just a third but half of your lifetime if you go into like I was 48 So,I was fairly young like i might live half my lifetime in menopause I don't want to frame it as a terrible time in my life.

If anything i've found my voice I'm like put up with anything anymore Love it. It's a rebirth, right? And that was the final piece, really. Can you share with us what does thriving, not just surviving, actually look like on the other side of this transition? Oh, I think that number one, you're clear about what you want to do and how you wanna do it, and I'm not saying that to sound like broad and nebulous, but I know how I want to spend my time, I knew who I wanna spend time with, what I don't wanna do.

I have such healthy boundaries and the value of learning to say no is so freeing without explanation like, no I do not wanna to do that. So I think for a lot of women it's the realization that Thriving for each one of us might look a little different. I think that I fully embrace my introvertedness, which I know people are always surprised to hear. Like I am, I like quiet. My husband and I both like quite. We have a quiet house. we live in a very hilly part of our state where it's quiet and beautiful.

And I've just been able to identify that what works for you Nat or someone else is totally great. Might not work for me. and just embraced my own sense of weirdness. So part thriving is embracing my unique attributes and not apologizing for them. Beautiful. Cynthia, where can people find you? Where can they find your work? And where, most importantly, can we get their hands on the book? Oh, thank you, Nat. It's been such a pleasure connecting with you. Thank you again for having me. Easiest to go to my website www.CynthiaThurlow.com at the banner on top.

You can click to order a copy of the menopause gut from your favorite retailer. I'm happy to report that we now have international rights for Spain, Poland, China, and Turkey we just picked up. So it's a national book, which is exciting, especially, you know, we're still in pre-sale. I'm active across social media. I most active on Instagram, much to my team's dismay because they're younger than me. They want me to be more active. On TikTok, I do a free Facebook group called the Midlife Pause. It just doesn't resonate with me, the midlife pause backslash my name.

it's a Free Community for men and women. There's no drama in that group. i personally answer questions as does my lead clinician, my other advanced practice nurse that's on my Team a couple days a week. And my podcast is Everyday Wellness. And I'm excited to say that we're going to grab Nat and have Nat on later this year to talk all about all the things that she's so knowledgeable about that. We were talking about in the pre-chat that I need to share with my community that are super cool. So thank you again for having me.

Cynthia, thank so much. Thank you for taking the time. I know how crazy your life is right now, so we will let you go.