The Midlife Shift No One Explains: Stress, Hormones, and Metabolism

Podcast Introduction and Guest Background 0:00

The most important thing is making them understand that impact of stress and what these stressors are. Let's talk about you have to exercise less and they do their peloton class like five times a week. And they have anxiety, you know, anxiety when I say, oh, probably, scale it down a little bit. There's a lot of reassurance, a lots of talking and just telling, really, women want to be empowered these days. They don't want have someone who just tells them do this, do that. That's smart, they are reading.

So they really need someone to explain what is the, what you said, the pathophysiology really behind it. This is not granola, but we really have, we actually have data and we can show that, so that's how I approach that Welcome to My MD Unscripted, where healthcare gets personal and the script gets tossed. I'm Dr. Clint Carter, ER doctor turned to direct primary care freedom fighters on a mission to challenge how our healthcare system treats patients in America. In every episode, my expert guests and I dive into real conversations about what's broken and how we can fix it by making healthcare about people, not just managing disease.

It's time to rethink what healthcare should be and Hello y'all and welcome back to the My MD Unscripted podcast. I'm your host, Dr. Clint Carter, and I am privileged today to be joined by Dr Christina Innsman. This is going to an educational one for me as well. We do a lot of this, but I know that we're going be able to do it a better after today. Dr Kristina is a board certified gynecologist that's certified in menopause with the Menopausal Society and does functional medicine and brings it all for women's health with conventional gynecology and functional all kind of coming together.

So I can't wait to have that talk. My question that I want to start with, and then I'll throw it to you, Christina, is Why is it that so many people, so women feel like their body completely betrays them in their forties and beyond? With that, introduce yourself properly and let's get going. Yes. Hello. Thanks for the introduction, Clint. I'm Dr. Christina Ensman. You'll hear it. And I know you're going to be wondering, I am originally from Germany, have been, however, over 20 years in the US. So my, you know, my med school was indeed in Germany.

But I did my training here and that's that. so I have a doctoral thesis in German. Awesome. and I've been working a lot in university medicine. And since a couple of years I mostly do functional medicine in combination with menopausal medicine. So that's that for the introduction. I mean, how did you end up going from, well, I'm sure there's a whole story on how you ended up from Germany to the United States, but how about how do you go from like classic gynecology to getting into the functional side of things?

From Conventional Gynecology to Functional Menopause Care 2:54

Oh yeah, how it often is we have to feel the pain ourselves. So yes, I was also tendering, you know, menopause a little bit earlier. I working at a university, so high stress job. And I thought, well, no, not sure what's going on. But so, and I wasn't really trained, in conventional menopus medicine, North American Menopausal Society, loved it and had plenty of patients. There were always a couple of blind spots that I really Official data didn't have good answers from the GI symptoms. I mean, all my patients had GI systems, nothing written in conventional medicine.

The weight was always, yeah, it's only a couple of pounds they're really gaining, but that was never a really satisfactory answer. And I gave this to my patient until I did it myself. And then I was like, moment, that can't be really the thing. And that's when I, you know, opened the toolbox of functional medicine and I finally could help myself and could really help my patients. It was just also intellectually so interesting because finally it was not just, this is just the way it is, but it's like there are actually explanations and we can fix it.

But I myself, you know, had all the symptoms and was angry and I had, hot flashes, I'm not so sure. I used to be cold, so I was just very warm all of the time. And I remember at that time I got myself a lot of collection of nice long boots, finally, and couldn't wear them at work because my feet would get so hot. I didn't realize that this was menopause, I had no idea. I was thinking this is stress and was funny. So I myself as a practitioner was in complete denial knowing so much about menopus and it really, it didn´t click until much later.

Well, that does explain it though. You spend that much money on boots and you can't wear them. We have a real emergency on our hands, right? I mean, this important. That was very rude, yeah. Well, and one thing that I think a lot of providers, we'll say docs, because in functional medicine, there's all kinds of provide on the table from pharmacists to chiropractors and nurse practitioners and the whole gamut, but especially my My MDs and DOs, they go from normal practice or regular insurance based residency training and they get into the functional world, usually out of desperation.

I think I know that as I get further and further into sort of the function stuff is that I just love how science-based it is. a little fuzzy and touchy feely and, and um, you know, granola, but there's so much science. And so when I started, I love how you mentioned that it just feeds the curiosity. You can just keep asking why. Yeah. That's just the way it is. You get, there's another rabbit hole to go down in another one. So what are some of the rabbit holes that you went down as you started looking into the functional?

What were some the eye-opening things as we started going down the Functional Pathway that changed the, I guess, the you took care of yourself, but also the ways you take care your patients? I think one big, so gastrointestinal, when I really started looking into this, there wasn't really much out there. It came very slowly, the effect of estrogen on our gut microbiome, how the astroblom changes, why that can cause GI symptoms, leaky gut, food sensitivity. That was something that was very satisfactory to finally be able to address that.

and help, you know, these patients who had colonoscopies, all of that, often unable to eat anything. I was startled by it. Finally, I got that. The other thing, the other stepchild were these cardiovascular symptoms that these women, never tell anyone, please go always to the cardiologist first. But you these woman wearing Holter monitors, going from one cardiologists to having these computations, panic attacks. So that was the other very satisfactory piece to kind of understand. And ultimately, so more recently, I'm really looking a lot of the effect on stress.

So, you know, always figured it out, there must be something and then in the last couple of years and now becoming mainstream,

Gut Health, Estrobolome, and Menopause 7:18

You can read it everywhere, the cortisol and the insulin, cortisol, and hot flashes. But you know, now everything goes so quickly with social media. About a couple of years ago, I was just scratching my head until I finally know someone talked about it. I'm like, yeah, exactly. Tell me now more about, it I want to really understand it, but I think the big thing is really how this our stress access, how does really affects the hormones, affects our metabolic health, affect so many, much more things than we thought.

And it's so difficult to grasp. So I really try to make it accessible to understand, you know, in what forms can really, can stress really hit us and why it is so important. Yeah, I think those are two big things, right? The gut health bit, because everyone's talking about, you know, the gut, it's getting more and more mainstream, but the, so microbiome is the word that most of the listeners will be familiar with. And it just talking, about all the bacteria that live in your, your intestines that are part of normal life.

Having a healthy microbiomes is good for gut help, also inflammation and brain health and all of those things. The hormones, all that stuff. Specifically within that, there's the estrobolum that I was much less familiar with. So how does that and I know that a lot of our listeners won't be, tell me more about how that works and how it impacts how you take care of your folks. Yeah. So the estrobolome, it means the estrogen-dependent or estrogen loving bacteria. And as you know, our estrogen first becomes a roller coaster and perimenopause and then slowly moves out.

That substrate goes away for these certain type of bacteria, so that's basically a big bacterial tribes. They move out and But I always explain it leaves like a little gap and that other bacteria then move in. So when we have data, it's very clear that the postmenopausal gut microbiome looks like the one of men. Nothing bad about it. That's just what it is because it lacking these estrogen-dependent bacteria. And I always try to explain, it's a very vulnerable time when these bacteria move out. They affect our transmitters, they affect estrogen metabolism, They effect how we metabolize our food.

So, and if now the wrong bacteria moves in, or we are stressed, so there are other factors that this gut can't rebalance. It's natural transition. Nothing wrong about the midlife transition, but it is like a little shaky system. So if we are not in balance, then other bacteria move in, or the more inflammatory bacteria take over the place, and now it can come to what's called the leaky gut, can to gut barrier breakdown. And suddenly we have food sensitivities, you know, that's kind of the red hole it goes down.

That makes sense. Yeah, for sure. What about estrogen replacement? Does that, if a woman's on, you know, say some bioidentical or otherwise relatively healthy version of estrogen replacements, does that allow the gut to reset? Is, are there certain probiotics you recommend or do we just try to settle in with a healthy, what men have always had, in a non-estrogen dependent biome? So with hormonal replacement therapy, I always prescribe it a lot, but it's not like, you know, it can't fix everything.

I'll always say it is a grand band aid solution, right? But you should always think like maybe it sometimes you want to stop it. Even there's no hard data that we really have to, But I'm like well, maybe at some point you could consider if you can. So then you don't want it to be back to square one. That's the first thing I tell my patients.

Stress, Cortisol, and Metabolic Changes in Midlife 11:18

This is lovely thing. It's going to work. But also, well, it doesn't work always for everything. But we are also not bringing these estrogen levels with HRT up to women who's 25 years old, right? We are going to give, like I say, the minimal level of estrogen to protect the bones. You know, for many women that works very well. It helps for the hot flashes. it helps the gut. Yeah. It helps, you know, the mood. However, if women have what I call, we all arrive in midlife with a certain baggage of health depth, I'd call it.

There's stuff we have, dragging along, it's underlying. And estrogen is this big buffer. It's like this fire extinguisher. it helps with the inflammation. Yeah. helps to buffer stress response. So that's now going away. These things are going to show up. Suddenly there are joint pains. Not everyone gets them. I think it's always important to mention that. So I it is a big chance in midlife to really actually figure out what do we have accumulated? Let's really recalibrate. We live from then on a really happy and healthy and hopefully life without many health complaints, either with HRT or we continue to live happy if we decide we're going to wean it out.

That's my goal and that's how I see it. Well, without the buffer, stress goes up, you know, all the little stressors become big stressers. And then that kind of leads you to point two of the, this stress axis. It goes from the brain all of way to the adrenal gland and the other hormones are involved. How does that all interplay for that second part that you were talking about? Yeah, so the stress axis is, this menopausal transition is this metabolic neuroendocrine event really. Because with estrogen, we become less insulin sensitive, meaning carbohydrates we eat are now preferably stored as fat.

And with that, cortisol level rises. Cortisol rises because the body realizes something is going on. The hormones are not doing what they were doing before. And estrogen is also this buffer in the stress response. Before estrogen helped when we got angry, the spike of cortisol wasn't set at high and it would then go faster away. So this went away now too. Now we are more stress reactive and we become metabolically unhealthier because estrogen also affects fat distribution. So now we get more belly fat, cortisol does that too.

Belly fat has a lot of cortisol receptors. And at the same time, propensity for inflammation is turned up with that cortisol. So now things that we were able to tolerate before, from our crying children, to the dogs that need the vet, the husband, we can't tolerate that anymore. We are not so stress resilient. My women then tell me they can just, they cannot recover. And that's one more thing to stress, because we always think about stress about that, you know, circumstantial Stress, but stress is also micronutrient deficiencies.

If women stopped eating enough because they are trying to maintain their weight and they're probably used to cutting calories. And some women are really good at that. They're cutting more and more calories and their wondering why don't I lose weight because the body is stressed. The cortisol goes really up. And then the other thing I like to tell my patients, I have many very active patients. They over-exercise and that is really very unpopular. You know, once I realized that, Link, these women who are exercising much more than I ever did and, oh, they would not lose weight.

It's all the opposite. That feels terrible. So that it's also stress. Although these, women, we have to explain, you have to scale back. And they do that and then they're actually able to lose weight. But it's a very finicky and you have to be a lot of, you know, gentle feel to really find the right way. So yes, so that is how the stress really affects all of that. The high cortisol levels are going to affect your gut microbiome. There's the direct connection from the gut to the brain. And we know when we are stressed, we don't want to eat and there's a reason, or when are in love or whatever it is, it's very sensitive.

So this is how it really all connects. And it so connects, I mean, you just came full circle back to the gut, but you know. You get to a certain point in life, you get into middle age and all of a sudden you're doing all the same things you always did and now you are gaining weight. You can't lose weight, things hurt that they shouldn't hurt. Their regular residency training doctor is like, well you just getting a little older. Things are getting harder. That's just kind of how it's going to be.

It's gonna be all right. You know, I've got a good friend and her secret to success is she just keeps her standards really low so that she's never disappointed. And then she is always happy. Well, okay. There are times where that is actually wise, but in this case, the connection between the gut and the stress and you know, the estrogen and lack thereof and cortisol going up, makes your insulin go up which makes you store more fat which is inflammatory and has all the cortisol receptors which then increases your cortisol which increases you insulin and makes store you more fats.

So it's kind of a cycle that's you're getting more visceral fat, cortisol makes it use don't sleep as well, so you've got sleep or lack thereof as a stressor, you got over-exercise, got under-eating because you're just doing everything you can to lose weight. And not only you are not losing weight, but you feel terrible. So where do you break into that cycle? And then the gut biome and the estrobolome, and changes there. Where do break in to this cycle and kind of make a real difference for your patients?

Yeah. So for my patients, because again, there are like these midlife patients who have plenty of issues accumulated. Often they were already, that's my favorite actually to be angry at, they started on stimulants already because they are so fatigued. They usually have a couple of years on stimulus. some antidepressives, so, and I don't want to leave any stone unturned. So I do very extensive functional, So, I really look at their micronutrient deficiencies. I look their hormone levels. Look at that cortisol awakening response.

Very sensitive testing of their stress axis. Do a very comprehensive blood work, gut health testing and food sensitivity testing because they are driven. So I want to fix things fast. I really want a roadmap. And I do environmental toxin testing and I'm always shocked what I find. Many of these environmental toxins can also drive stress in the system, can drive mitochondrial dysfunction. Let's say fatigue, oxidative stress.

Testing, Personalization, and Patient Education 18:30

testing. So that's what I do. And then, you know, then because then I don't have to guess anymore. I want to get, of course I can give them this and that, but I really want know. Let's see which, which are the parameters that in you, we have two really change. improving sleep, you know, all the things that strive our cortisol, the sleep get the right movement, not more, always depends with that person. Help with supplements initially understand how to feed ourselves, of course, then heal the gut.

I'm sure I am not the only one who talks about that, finding the triggers and the food sensitivity. So just recalibrating that system. But I think. The most important thing is making them understand that impact of stress and what these stressors are. Let's talk about, you have to exercise less. And they do their Peloton class like five times a week. Anxiety, when I say, oh, probably, let's scale it down a little bit. There's a lot of reassurance, a lots of talking and just telling, really, women want to be empowered these days.

They don't want have someone who just tells them do this, do that. That's smart, they are reading. So they really need someone to explain what is the, what you said, the pathophysiology really behind it. This is not granola, but we really have, we actually have data and we can show that, so that's how I approach that Well, it sounds like it takes a lot of time and energy and personalization to get that done well. I know like in my practice, we're direct primary care. So people pay us a membership and then we spend, you know, an hour with our patients and really sort of dig into it and look stuff up after they're gone or look up stuff with them.

Kind of go through all of that. So it's a very, you know, my job is, I'm the co-pilot, they're the pilot, right? My job to educate them on where the landmines are and what the options are, and where, in this case, where in the heck their body went and why it is going so haywire. And so it sounds like you do primarily a functional medicine practice now where you're doing a lot of these big, doing the work up on the guts and the hormones and stress hormones, all the things. Is that what you primarily do now?

Yeah, on these, you know, very symptomatic patients. I still have a regular practice. It's my smaller where, someone comes in to just needs HRT. Sure, no problem. But, again, the ones who don't get better on that or have very complex issues, these are the one when I'm offering, okay, let's get this addressed. because otherwise, you know, three years later, we're still trying to doctor around, let's try this, lets try that. They are not happy. I'm not because I could have probably fixed that with more information within a couple of months.

So yes, but I do have a regular practice and my other passion is actually vulvovaginal disease. Haven't mentioned this yet, so I, you know, I deal a lot with vaginal microbiome. I'm also very convinced it's very connected to the gut microbiomes. And I think many things we see in the guts, we actually also see the vagina, many of the pain syndromes. So yes, that's why I always going to see patients because vagina we just have to have a look at. Nice. Well, I mean, yeah, once everything, gosh, obviously that's very hormonal, hormonally dependent part of the body.

Everything starts changing fast between Euroguine with incontinence and those things exacerbating plus just the vaginal health itself with. intimacy and comfort and the different changes. So yeah, that's, you know, in our practice, it's hormone replacement. And then, we have some devices to help kind of with that some, but you tie it all together into a one-stop shop. Are you, as we sort of like wrap up, do you take patients, where are you located and do see patients outside of your area? Yes, so I'm in Maryland, but my office is there like in physical for real people.

They are come to see me that is in, Maryland and close to Baltimore. Yes. I also, you know, online for the functional part, I do them, see them. Okay. Yeah. Well, there's probably, gosh, a ton of people that would love to. would love to get a real functional workout and say, hey, what she's talking about, that's how I feel. Patients who are just not feeling heard, who have been told they're just getting old and they need to eat. Smarter and exercise more and you know, good luck. And here's your antidepressant and here is your Adderall and we're going to band-aid all the symptoms.

So I think getting the opportunity to work with you or someone who does something very similar, it sounds super attractive. What is you practice called and how could they get a hold of you if we need to dig deeper? My website is drchristinaensmann.com and my email is contact at dr-christenaensman. com. You can just write me an email and I can always direct you, you know, then I usually write back. These are the two options to have care with me, the functional part. And I explain a little bit who's a good fit for that.

where to reach me in my regular office. I do some of the global vaginal disease parts online, just so you know.

Practical Tips for Hot Flashes and Midlife Health 24:00

Some of things can really be dealt with. It's kind of edgy, but I was like, no, that's not possible. But it actually is. So many things, particularly if you don't have a good doctor who doesn't really know much about global vaginal issues, I'm probably going to be 80 to 90% able to help you without even having a personal look. And that option exists too, and it's on my website actually, so yes. We'll get all that. We will get your contact in the show notes so that it's easy. It's one click away.

And you know, visiting the website I've been there, it is super informative and email sounds like the way to get going. But in them meantime, while they're listening right now, what are some takeaways that you would say Hey, if they're having a lot of these, you know, basically it's everything, right? Between stress and emotions and you, know basal instability and hot flashes and that kind of thing. What would you have our folks do? If someone's listening right now, what are some easy things they could do for themselves right.

Hot flashes, the first thing, quit the sugar. The sugar and the carbohydrate. I mean, you know, they're good carbohydrates, but if you eat a lot of sugar, that needs to go. If you're otherwise very carbohydrate heavy, I'm not hating on carbohydrates at all. They are important for many things, But give it a try. Many of my patients just quitting the sugars, They needed nothing else from me ever. So the sugar, hot flashes, right? So this causes this blood sugar up and down and what then causes the high insulin.

Insulin stimulates the thermoregulatory center in our brainstem. So where the estrogen blocks that before now insulin, whenever you have your cookie, you're going to have a hot flash. Quit the alcohol. Again, I have nothing against alcohol, you know, have your alcohol with your friends, but just then know you're going to have hot flashes at night. So don't come back and call me the next day and complain. Enjoy your, alcohol but you going have, hot flashers again, stimulate the regulatory center.

Then protect your sleep. And I know this is easily said because that's the first thing that goes away. But circadian rhythm really, many women, we are on our screens. We don' realize how important that is. So really go for that. And of course, you know, hydration. So these are the first things I say. Then I want to say, if you're in your thesis, I think it's important to know that the stress axis is going to change. There's going be a shift. If you keep going the way you have been going in the same pace, doing everything at the time, your body is gonna adapt.

That's not gonna be the direction you want that to go. I really think if your in you thesis Think about it. You just have to change some things with some knowledge and it's going to be fine. But if you keep pushing, your body is going complain. That's great. And if, you're not exercising, exercise, but notably, if your over-exercising, You might need to back off and that's gonna be a very personal response, But, If you feel like, You're like, I exercise as much as I can possibly exercise and it's not working and I'm not feeling well.

I am not losing weight and not getting a chance at one. It sounds like we need to potentially have conversation about backing off on exercise, as well as sleep. And then Dr. Phil good over here is telling us that we can't have our sugar or our alcohol. This is getting serious, Christina. You can, but just then don't complain if you have a hot flash. Don't be so proud. Go for it. Just no complaint. Yeah. I think one thing we should mention, because with the exercise, so the cardiovascular exercise.

So when we run, right? The tread, all that is what we have to be careful. The other thing that's actually pretty good is the bone building exercise or the muscle building exercises. If I had something, I would say cut that cardiovascular running, do a little bit more easy weights. That is a good way to get through that midlife transition. And you know, later on, when you're through this, the body has adjusted and all this, you know, chaos has settled down. No one is saying you might not be able to run more again, but give your body a little break and listen.

I think that's the important message. Agreed. And that muscle mass that you're building. While doing resistance training is building your bones, but it's building muscle.

Closing Remarks and Contact Information 28:30

And when you build that muscle, that muscles is also metabolic tissue. So now your weight's going to be easier to control. You have more mitochondria, you're going feel better, and you are going have energy. Then in the long term, if we're at midlife now, muscle is the currency of longevity. keep getting that strength and then keeping it going forward. Never, never too late to start training now for the next decade and the Next decade, and The next decades. So, yeah. Well, Christina, that was, That was a fun, I mean, we went right into it right off the top.

What, are there any other takeaways before we let you go? But that, this has been great. No, no, No. I think we, uh, We got it all. Yeah, we, I mean, so the, for me, some of the takeaways are the estrogen dependent microbiome. I had never really thought through that and how that changes the way your gut responds on top of, the fact that you don't have the estrogen to buffer the stress, on the top, of fact, that now you're going to have more cortisol and the body fat deposition and. So I think for sure, I really appreciate you coming on.

I know it's going to help my patients and I there's gonna be a subset of folks that are gonna want to reach out to you directly. So once again, we've got all of that on the show notes so that we can go, you can see Dr. Kristina at drkristinainsman.com and then gosh, will have you back on sometime. You did a great job. Thank you so much for coming. Thanks for joining me today on My MD Unscripted. I hope today's conversation opened your mind and inspired you to imagine a better path for your health and therefore life.

If you found value in this episode, be sure to subscribe, leave a review, and share it with someone passionate about transforming healthcare. Real change starts with real conversation, so let's keep on going. Until next time, stay well,