In this episode, Dr. Eric Osansky welcomes back bestselling author, nurse practitioner, and women’s health expert Cynthia Thurlow to discuss her newest book, The Menopause Gut. Cynthia explains why gut health should be at the center of every conversation about perimenopause and menopause, sharing both the science behind the gut-hormone connection and her own personal journey that inspired the book. Together, they explore how declining estrogen influences immune function, gut permeability, inflammation, and the risk of autoimmune conditions during midlife.
The conversation dives into the important role of the estrobolome, estrogen metabolism, food sensitivities, detoxification, genetics, and the impact of chronic stress on hormonal health. Cynthia also discusses why symptoms such as hot flashes, weight gain, digestive issues, sleep disturbances, and joint pain shouldn’t simply be accepted as “normal aging.” Along the way, she shares practical strategies for improving gut health, increasing fiber intake, supporting the vagus nerve, reducing inflammation, and making personalized decisions about hormone replacement therapy (HRT).
The episode concludes with an empowering message that women don’t have to suffer through perimenopause and menopause. By understanding the connection between hormones, the gut microbiome, metabolism, and thyroid health, it’s possible to improve symptoms and support long-term wellness. If you want a clearer, more balanced understanding of the menopause-gut connection and how it influences thyroid and overall health, you’ll get a lot out of this episode.
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Dr. Eric Osansky:
I am really looking forward to this interview, as I’m welcoming back return guest Cynthia Thurlow. We are discussing her amazing book The Menopause Gut. Cynthia Thurlow is a nurse practitioner, two-time TEDx speaker, international speaker, and CEO and founder of the Everyday Wellness Project. With over 25 years of experience in health and wellness, she is a globally recognized expert in perimenopause, menopause, intermittent fasting, and women’s metabolic health.
Her second TEDx talk, “Intermittent Fasting, Transformational Technique,” has surpassed 15 million views, making it one of the most watched talks on the subject worldwide. She is the host of the top-rated Everyday Wellness podcast and bestselling author of Intermittent Fasting Transformation. Her newest book, The Menopause Gut: Balance Your Microbiome to Reclaim Your Health in Midlife and Beyond, presents a paradigm-shifting, gut-first framework for understanding and navigating the perimenopause and menopause transition. Welcome back, Cynthia.
Cynthia Thurlow:
Thanks, Eric. I’ve been looking forward to our conversation.
Dr. Eric:
Same here. I also need to congratulate you because recently, this week, your podcast was named the Best Wellness Podcast in America. Congrats on that.
Cynthia:
It was a little surreal. I was away on vacation, so my team was texting me. I think it’s definitely one of these accolades that I take to heart. You can’t buy your way into it. You can’t buy your way into the contest. It really speaks to the community that I’ve built with Everyday Wellness. I’m really proud of that. Thank you.
Dr. Eric:
You’re welcome. Let’s talk about The Menopause Gut first. What motivated you to write this book? Your first book is different than this one.
Cynthia:
The honest answer is I wrote my first book. It was published in 2022. For the next several years, my editor would episodically ask me if I thought I had another book in me. My answer was always “No,” resoundingly, absolutely not.
Then I started to really reflect on a lot of the guests I had interviewed. I take something tangible away from every guest. I had interviewed a microbiome expert, a nitric oxide expert, a litany of clinicians and science writers. I said to my editor, “I think there is a conversation around the gut that is not being had. Here are the arguments I think I could make throughout the book.”
With one page of my ideas, mind you, a normal book proposal is 80-100 pages, which is what my first book was, 100 pages of content. This was literally just a page. As soon as she read it, she said, “I want to greenlight the project and immediately start writing.” That was May or June 2024. That is where things stem from.
There is a larger conversation not being had. Not enough people were focused on the gut. I am myopically focused on the gut. From my perspective, it was both clinical insights I was seeing from patients, both on lab work and patient complaints. Then this concurrent layer of guests who had shared information with me on the podcast that really created the opportunity for me to feel like I had something tangible that I could share that would help other clinicians as well as the lay public. I started writing in 2024, finished in 2025, published in 2026.
I’m really proud of the book. It’s a love letter to women. It’s the book I wish I had 10 years ago, to be totally honest with you.
Dr. Eric:
I’m sure this was also a little bit of a motivating factor: You had your own personal gut healing journey years ago, correct?
Cynthia:
I did. In 2018, my husband and I took a romantic 15th anniversary trip to Morocco and Spain. In Morocco, we ate the same food, did the same activities. One of us got deathly sick from food poisoning, and the other did not.
I don’t think I fully appreciated at the time of that trip how much my hormones were impacting my immune system and my gut. It was only until after the fact, because that trip led to, a few months later, a 13-day hospitalization, which I always say is the rebirth of me as a human being. There was the me before and the me after.
I really used that as an opportunity. I was a traditional, allopathic-trained nurse practitioner. Arguably trained at one of the leading medical institutions in the U.S. I had integrative training. No one prepared me for not only perimenopause, but what was actually happening at a cellular level in the gut. That personal experience translated into a desire and interest in working with my patients to better understand things.
There is always this personal and professional experience that I think gently guides us toward certain topics. I always say that a little bit of suffering in 2018 and 2019 led to the birth of this book for sure.
Dr. Eric:
As you know, there is a lot of books out there on perimenopause. As we were chatting before pressing Record, there are more books being released on the gut microbiome. I think this is the first book that ties both of them together. Can you start out by talking about the relationship between estrogen and how it relates to gut health?
Cynthia:
It’s really interesting. Estrogen interfaces with our immune system. Obviously, there are other hormones at play as well. Estrogen is this main immunomodulatory hormone. As estrogen is declining, our immune system starts to unwind. We have both a less sophisticated part of our immune system and a more sophisticated. There is the innate and the acquired. The loss of estrogen impacts both of them. We don’t fight off opportunistic infections quite as well. We are more prone to autoimmune disease risk. We know that women are 4-5x more likely to experience autoimmune diseases in midlife.
Estrogen is also important for the small intestinal lining. Our small intestine has a lining that is only one cell layer thick. If you think about the boundary of the small intestinal lining, it’s like a brick-and-mortar mechanism. The estrogen is the mortar. As estrogen is declining, we are more likely to see the leaky gut, the provoked immune response, the autoimmune disease risk.
I really think about estrogen beyond the bone, brain, and heart effects that the menopause-focused clinicians really focus in on. It’s very important.
I will say that equally so, if not more so, the gut microbiome ability to be able to effectively fight off opportunistic infections, ensure that we’re less likely to deal with autoimmune disease risk, is really the effects of this immunomodulatory properties of estrogen.
Also, progesterone plays a role. Secondary to that, testosterone. The immune system is invisible, and the microbiome is invisible, so we don’t think about them the way we think about bone, brain, and heart effects. I think at some point, we will have an indication for hormone replacement therapy (HRT) to help bolster the effects of these changes in hormones that are happening in midlife.
Estrogen is a main immunomodulatory hormone, one that is probably not discussed enough. It’s not a sexy topic. The immune system is complicated. It’s not nearly as straightforward as a lot of the other systems in the body.
Dr. Eric:
When it is talked about, sometimes it gets a bad rap. You hear about estrogen dominance. Both men and women think about estrogen as being bad. Why do you think that is? Of course there are xenoestrogens, the microplastics. You don’t want any hormone to be in excess. Like you said, it’s important for immunomodulating purposes, bone density, so many other purposes. Why do you think there is that negative perception by some people, including practitioners?
Cynthia:
When people hear the term “estrogen dominant,” they automatically assume that’s a negative thing. it’s always in context. Up until menopause, women have the beautiful synergy of progesterone and estrogen playing this very delicate balance throughout their follicular phase and luteal phase and ovulation. For a lot of people, it’s easy to think about it as estrogen is just dominant, and that’s what’s driving symptoms. But it’s far more complicated than that. It’s a much more nuanced conversation.
There are times in a woman’s menstrual cycle where you will have higher levels of estrogen. That is typically in the follicular phase. There is a time in the menstrual cycle where we will have less circulating estrogen density, the luteal phase, where progesterone dominates. There is a synergy to the cycle of life.
When we talk about estrogen dominance, it’s typically in the context of someone who is not properly clearing their estrogen. I think a lot about the estrobolome, which is this estrogen processing center of the microbiome. It can be heavily influenced by both exogenous estrogens, so estrogen mimicking chemicals, chemicals we find in our personal care products, food, and environment, as well as endogenous, the type of estrogen, like estradiol, which is the predominant form of estrogen our bodies make up until menopause.
I think it’s always the context of what’s going on with the health of the microbiome, what’s going on with the health of specifically the estrobolome. Can you effectively break down and eliminate estrogens?
We know that our bodies are heavily influenced by synthetic, non-bioidentical hormones. Think about oral contraceptives, IUDs, things that help manage and mitigate symptoms for a lot of women. Certainly, our generation, almost every girlfriend of mine was on oral contraceptives for years, for heavy cycles, irregular cycles, breast tenderness, acne, contraception, plus or minus any of the above. We know that exposure at young ages can heavily influence the health of the estrobolome.
There are many factors that influence the estrogen dominant effect. Some of it can be genetics. Some people, like I am homozygous for MTHFR. This is something that is genetically mediated. I don’t stress about it. I know I have to do a little bit extra to support detoxification pathways in my body.
Yes, we detoxify naturally through feces, urine, sweat, breathing, living. But with our modern-day lifestyles, when we are thinking about the estrobolome, thinking about detoxification, things can absolutely be put a little bit off rails by virtue of our modern-day lifestyles.
For a lot of women, it’s helping them understand that when we hear that term “estrogen dominance,” it is almost always said in a very negative light. “Oh, she’s estrogen dominant because she is weight loss resistant, because she has tender breasts, because she has heavy menstrual cycles.”
What is on the other side of that is why is there an imbalance between estrogen and progesterone? Is it perimenopause? Is it because someone is exposed to too many endocrine mimicking chemicals? We know that these chemicals, these xenoestrogens can be 1,000x more potent than the hormone itself. There is a lot in the conversation.
I always say social media would like us to think that these topics are simple. They’re not simple. They’re nuanced. That’s why it’s really important for women to work with clinicians who are nuance experts. That’s really going to be a differentiator for the quality of care that we’re receiving in midlife.
I’m the first person to say, listen, I was of the generation where we all got put on oral contraceptives to fix our menstrual cycles. There is nothing we can do about what happened in the past. I’m sure my estrobolome was not optimized. I’m not sure my gut microbiome was not optimized. I didn’t know. But we can only look forward.
If you’re listening, like, “Oh my god, I was on the pill for 20 years,” many of us were on the pill for many years. There is nothing we can do about it now. We can just look forward. There is a lot we can do. Obviously, in The Menopause Gut, this is a lot of what I’m talking about. What are the things we can do proactively to support our bodies in this stage and beyond?
Dr. Eric:
You mentioned genetics. It’s complex, and genetics adds to that. I have the C677T homozygous MTHFR genetic variation. I found out I had elevated homocysteine, and then I did the testing. The good news is that we can support it. We can’t change the genetics, but we can support the genetics. You’re right. Definitely could get complex.
For some people, they have never heard of the estrobolome. Can you repeat what it is and talk more about the importance of it?
Cynthia:
The funny thing is that during the course of the book launch, I had multiple male podcast hosts ask me if I made the name up. No, I did not. It’s been around for about 12 years. The estrobolome is an estrogen processing center of the microbiome. It’s specific bacteria that are designed to help effectively detoxify, package up, and poop out estrogen. That is an oversimplification. There are two steps to detoxification in the liver. The third step is in the gut. This is all managed and mitigated by bile acid sequestrants.
One of the fun facts I didn’t mention is that as estrogen is declining in the latter stages of perimenopause and menopause, you may not effectively break down fat in your diet. This is when a lot of patients will describe how they feel when they eat a higher fat diet.
If you can’t effectively break down and package up your estrogen, you can recirculate it. This estrogen dominance conversation becomes a larger piece of the conversation because a lot of the symptoms that women experience—breast tenderness, brain fog, skin manifestations, weight loss resistance, etc.—can be a sign that maybe your detoxification pathways are not optimal.
When I talk about the liver, let’s back up a little bit. The liver is the main site in the body for breaking down compounds. Usually, phase one is breaking down compounds in a water-soluble compound. They go to phase two, and they can be sent to utilize with bile. The bile will help with estrogen, break it down, and package it up like a present. That is done in the gut.
If you have genetic susceptibility, or you are someone who eats a lot of highly processed foods, or you’re chronically stressed, it’s adding stress to the system that is already in midlife a little bit overburdened. Liver does a lot. Gut does a lot.
I think for a lot of people, they don’t understand that something as simple as if you have a daily bowel movement. I had friends in nursing school who thought it was normal to poop twice a week. I would say all the time, “What do you think is happening if you are not effectively able to package up and process excess estrogen or waste in your body?” It’s getting recirculated. That can magnify symptoms.
When we talk about the estrobolome, it’s with the understanding that this is an estrogen processing center of the gut. It is influenced by synthetic hormones. If you were on oral contraceptives for 10, 15, 20 years, that can influence the health of the microbiome. If you have a lot of inflammation, if you are someone who eats a highly processed diet, if you are chronically stressed, all these things can influence these processes that are supposed to go on naturally within our bodies.
We can’t do anything about the past, but the estrobolome is very important. There are a lot of things we can do to nurture it and support the health of it without having to feel like we’re overthinking the whole process. The estrobolome is important. Certainly, it is something that is unique to our physiology.
If we are talking about magnification of symptoms, a lot of perimenopausal women really struggle. I was certainly one of them. I had tender breasts, really heavy menstrual cycles. I started getting weird hives, which I had never experienced before. I was weight loss resistant in early perimenopause.
For a lot of women, it’s both frustrating and validating to be told perimenopause can last anywhere from 5-10 years. Good luck because we don’t really know how we need to address this constellation of symptoms. The estrobolome and the microbiome play a huge role in the degree of symptomology we experience. The research supports that.
I’ll give you an example. For a lot of my patients, the ones who are having the worst symptoms—night sweats, hot flashes—in many instances, they are also people who have the most unhealthy microbiomes. Understanding that there is this interplay and influx between the symptoms we experience and the health of our bodies themselves.
Oftentimes, we are told that women should just suffer through a lot of hot flashes. It’s one thing if it’s a short span of your adult lifetime in perimenopause or menopause, where you are having a couple hot flashes. That’s one thing. If it’s disrupting your sleep, and you’re getting them all day long. We know that there are some racial disparities. We know that African American women are more likely to have a protracted course of hot flashes, vasomotor symptoms, than some other women.
I always remind women that if you have a persistent symptom, it’s a sign something is off. We know women who have more hot flashes are more likely to experience worsened cardiovascular disease outcomes. I always say hot flashes are not benign. If you are experiencing them episodically, I have a friend who says “Every time I have a glass of alcohol, I have a hot flash.” There is a cause and effect there, whether or not it is a reflection of blood sugar dysregulation or the consumption of alcohol.
I always tell patients persistent symptoms are things we don’t want to ignore. They can be a sign that the microbiome is not optimal, including the estrobolome.
Dr. Eric:
Getting back to the hot flashes. You said if someone has persistent hot flashes, that means there is increased risk of cardiovascular disease. Is that because they are usually going to have low estrogen leading to the hot flashes? Is there a different reason behind that?
Cynthia:
The correlational pattern that we’re seeing is poor metabolic health. A lot of women will have vasomotor symptoms that are precipitated by blood sugar dysregulation. When they’re persistent, it’s a sign of a metabolic health piece.
I start to think about insulin levels, glucose levels. The variability in insulin and glucose levels can also drive inflammation, oxidative stress, and endothelial level. We know the lining of the blood vessels, the endothelium, is very susceptible to not only changes in estrogen, which impact nitric oxide signaling, which impact whether or not we can vasodilate, whether we can expand or contract the vessel itself.
I suspect it’s a real reflection of metabolic health issues. Given the fact that the last statistic I saw was 92-93% of Americans are not metabolically healthy. You’re really talking about most women are heading into perimenopause and menopause at a disadvantage already.
Just like any symptom, if you have a painful foot once a week, that is very different than a persistent painful foot every day of the week. If you’re having persistent bothersome hot flashes all night long, all day long, that is a sign that you need to get things checked out. We shouldn’t be thinking of vasomotor symptoms as benign.
The way that I was taught years ago is they are going to happen, not a big deal. I can remember exactly where I was in 2018 when I had my first hot flash. It stopped me in my tracks. What was that?
Dr. Eric:
Getting back to estrogen metabolism. How do you determine if someone has problems metabolizing estrogen? Do you do a DUTCH test? Do you look at elevated beta glucuronidase on a comprehensive stool test?
Cynthia:
I would say I do a lot less DUTCH testing now than I did before. If I’m really looking at pathways. I used to use stool testing. Now I’m doing microbiome testing. There are a couple different ways to, if you really suspect someone has an issue.
The higher level of thinking is I don’t apply the same testing to everybody. Years ago, when I was learning how to use these integrative medicine tests, I had a pretty consistent pattern of what I would use with middle-aged women. Now that I know a little bit more, it’s more microbiome testing. Yes, on a regular stool test, you can see elevated beta glucuronidase, which can be a clue that you may not be detoxifying properly.
When you’re looking at a DUTCH test and looking at phase one versus phase two, when you are thinking thoughtfully about metabolites, getting a sense of what could be going on with this woman personally, I like the DUTCH for specific purposes. I like serum blood testing for other things to look at. In many instances, even if the DUTCH or stool testing doesn’t suggest they have a mismatched pattern, usually they’re having enough symptoms that lead me to believe that there’s probably a detoxification pattern that is just not optimal.
Let me be clear. There are lots of bozos online that try to convince you that you need the box, bag, can of their product to help you detoxify. I think it’s a more sophisticated conversation.
This nuanced conversation about how to address someone who has MTHFR. I know that I have to do a couple extra things to support. I don’t take methylated vitamins. I haven’t found that to be helpful for me personally. I didn’t have elevated homocysteine although I have plenty of MTHFR patients who do.
This bioindividual approach. There is usually this question of what are the symptoms you’re experiencing? Before I knew I had MTHFR, I had a well-meaning integrative medicine provider who put me on a slew of supplements that sped up phase one and phase two. Because I have MTHFR, phase two doesn’t work quite as effectively. I was almost suicidally depressed. I have never been depressed in my life.
If you speed up phase one detoxification in the liver without ensuring that the person can properly accommodate the increased speed of phase one, and their phase two doesn’t work effectively, that can build up toxins in your bloodstream, which can contribute to symptoms.
When I say I have never been clinically depressed in my entire life, and I went from feeling fairly good to feeling pretty bad pretty quickly. I remember it required an emergency visit. We stopped every single supplement I was on. I had all these IVs and these other things. That is when it was explained to me this is what happened because this practitioner didn’t know any better. It’s fine. That’s how we learn.
But it’s why I’m mentioning this in the context of the conversation to say there are lots of bozos out there who don’t know what they don’t know. Although I don’t think they intend to hurt patients, they don’t know enough to be able to anticipate we may have to slow this down because if the freight train starts moving along too quickly, and your body can’t properly set in motion the next step of this detoxification process, that can be a problem.
When I use the word “bozo,” I’m saying that as respectfully as I can. I’d like to use stronger language. I won’t because we’re going to keep this podcast PG.
Dr. Eric:
It’s well said. It’s important that you said there is no one size fits all.
Cynthia:
No.
Dr. Eric:
You’re right. I think I learned from Dr. Ben Lynch that just because you have normal homocysteine doesn’t rule out methylation problems. If you have elevated homocysteine. In my case, I don’t even know if it was elevated because you know those reference ranges, it depends on the lab. Some of them will go up to 17.
Cynthia:
They’re usually based on men, too. That’s the other piece. There are women. Generally, the lab values are based on men. Bigger people, generally speaking. There is not always a gender acclimation for women. You have to think about that from that perspective, too.
Dr. Eric:
Good point as well. You also mentioned in the book food sensitivities. My wife actually developed around perimenopause dairy sensitivities. You talk about how common that is. I’m guilty a lot of times just thinking about the gut when thinking about food sensitivities. You talk about the importance of estrogen here. Can you expand on that?
Cynthia:
I think it’s very common for women in midlife to feel like they suddenly don’t tolerate foods the same way. In fact, I was just having a conversation on the last podcast I was on with a man who is probably in our age range. He said, “Gosh, my dad used to tell me that when he got into his 40s and 50s, he didn’t tolerate the same foods. I just assumed men were excluded from this andropause conversation.”
When we are talking about underlying food sensitivities, it’s looking at the gut and saying, can you properly break down, absorb, assimilate food that you’re eating? For a lot of women, dairy is proliferative in our food supply. It’s a subsidized food. There is cheese in everything. We get sensitized over time.
For many women, it’s cow milk dairy in particular that can become problematic. We know the proteins in goat and sheep’s milk are a little smaller. I have a lot of patients who do fine with goat and sheep’s milk, yogurt, and cheese, but not cow milk dairy.
For a lot of individuals, it goes back to what is changing in the gut. We are getting changes in the species of keystone bacteria, so we have more inflammation, more opportunistic organisms. We get changes in inflammatory patterns. We are already inflamed as these hormones are declining, especially estrogen. Estrogen and progesterone are designed to be anti-inflammatory in terms of when they are in balance within a cycle.
I remind people all the time that as estrogen is declining, more leaky gut, more autoimmune disease risk, more inflammatory cytokines. You can eat something that is intrinsically healthy. If you have a leaky gut, if that small intestinal lining has been compromised, and you are leaking food particles into your bloodstream, it’s triggering an immune response. It explains why women are developing things.
I developed hives. I had not had hives my entire life. Depending on where I was in my cycle, and we know estrogen levels can be 20-30% higher in perimenopause than in any time in our lives, it can provoke a lot of mast cell degranulation, histamine response. Women will say, “I get a rash. I get hives. I get nasal congestion. I get abdominal cramping.” That is a direct reflection of the properties of mast cell degranulation and histamine response in the setting of higher levels of estrogen. I find for a lot of women that tends to quiet down as they navigate late perimenopause and menopause.
There are plenty of women who remain really sensitive to histamine, which is a signaling molecule. They remain sensitive to histamine even in menopause. That can be a combination of environmental factors, genetic factors.
For a lot of women, they’re conditioned to believe that if you have ever had high estrogen, high histamine, mast cell degranulation issue, that means you have to eat a low histamine diet. I actually don’t believe that. Once you start healing the gut and really focusing on the gut microbiome-
Just like in 2018, I had to go completely dairy-free. I didn’t even eat much dairy. It has only been in the last year that I have been able to occasionally have a little bit of cheese if I’m traveling. If I’m in the airport and stuck with no food options, I can have a bag of pistachios and a couple mozzarella sticks if I’m desperate for food. I can combine food enough to get at least 30g of protein. Other than that, I tend to avoid dairy. A lot of my patients do, too.
Dairy, because of its specific properties, can be very addictive. Some patients find it’s harder to stop consuming dairy than it is to stop gluten.
Dr. Eric:
I find that, too. There are some people who have no problems giving up gluten, but dairy is a bigger challenge. Coffee, too.
Cynthia:
Coffee is so bioindividual. It bothers some people but not everybody.
Dr. Eric:
Yeah. Getting to the genetics. Some people are slow metabolizers.
Cynthia:
I’m a fast metabolizer.
Dr. Eric:
You’re a fast metabolizer?
Cynthia:
Yep. So is my younger son. He can have a double espresso at 9pm and still sleep.
Dr. Eric:
I’m a fast metabolizer, but I don’t drink coffee. I drink green tea. I wish I could pass that part of my genetics onto someone else.
If someone balances the hormones, heals the gut, they may be able to overcome the sensitivities. It’s complex. It’s not always that simple. Those are good places to start, focusing on gut health, balancing the hormones.
Cynthia:
We are all a work in progress. I am the first person to say I am not perfect. 90% of the time, I can eat super clean. I don’t feel deprived. But I acknowledge that not everyone is that way. I will say to patients, “Whatever your 90/10 or 80/20 is.” Some people do better having a little more flexibility in their diet. Other people need to be more rigid. It’s knowing your personality.
I don’t feel deprived eating the way I do. If I did, I could understand why it would be harder to be compliant. I have other patients who need more flexibility in their lifestyle. Otherwise, it’s not sustainable. That is the true tell.
This is why things like Whole 30 or a lot of these elimination diets are not designed to be forever. They are designed to be temporary and short-term. I don’t think we’re meant to eat super low carb forever. I don’t think we’re meant to be ketogenic forever. I know that can be very inflammatory. People get rigidly dogmatic about their nutrition.
Listen. I have interviewed too many researchers. There was a microbiome researcher that I interviewed who was delightful. She said in the absence of carbohydrates, people who don’t consume any carbs, what putrefies as a source of fermentation is protein. It’s not designed to be putrefied. It’s not designed to be fermented. The body is innately designed for us to be omnivorous. I think we are designed to have a variety of macronutrients and micronutrients.
There is a degree of bioindividuality. Eric, I’m sure if you and I ate similarly, it would work well for one of us and maybe not both of us. I tell everyone I do better with a higher carb diet and lower fat diet. It also is very aligned with my genetics. If you look at my genetics, I hyperabsorb cholesterol. It explains why when I eat a duck or ribeye, I don’t feel good. It has nothing to do with my gallbladder; it’s fine. It has everything to do with the way my body addresses saturated fat and cholesterol.
Dr. Eric:
Getting back to dairy. I want to put you on the spot a little bit with dairy and calcium. You also talk about bone health. If you have low estrogen, that also could be a problem with bone health. You do need enough calcium. For someone like you who is eating minimal calcium, are you supplementing with calcium then? Or just relying on other sources of calcium?
Cynthia:
I don’t believe in calcium supplementation. There is a lot of evidence to suggest it can end up deposited in your blood vessels. You get more calcium from sardines, citrus fruits, green leafy vegetables.
The other piece of the conversation that I think a lot of people don’t know, and I spend an entire chapter talking about bone health, is that yet another reason why we need fiber in our diets, especially in midlife, is when we consume fiber, it goes through our digestive system, gets in our large intestine or colon, where it ferments into a short chain fatty acid.
One of the things that short chain fatty acids do is stabilize osteoclastic activity. Osteoclastic activity is bone breakdown. What happens up until menopause is that estrogen is osteoblastic, so it’s building bone. Progesterone is osteoclastic, so it’s bone breakdown. They are designed to balance each other out, like a seesaw or symphony.
What happens in the decline of estrogen is that the bone building capacity doesn’t keep up with bone breakdown. Short chain fatty acids, especially things like butyrate, can stabilize bone health.
When people tell me fiber is irrelevant, then you don’t understand the physiology that is changing in our bodies. Men are largely protected from bone health-related issues until the age of 60. Women, the first few years of menopause, we see an acceleration in bone breakdown. Yet another reason to get fiber into your diet is to help support those bones.
It’s a misconception that we need dairy for calcium intake. That is a byproduct of the dairy industry. There are far better sources of calcium in sardines, citrus fruits, green leafy vegetables. Those are things that I try to incorporate into my diet.
Dr. Eric:
Okay. It’s a common question. There are definitely other food sources. Appreciate getting your perspective.
Stress, trauma can also have an impact on both the hormones and the gut. We don’t want to give away everything; we want people to read your book. Can you briefly talk about the impact of chronic stress, trauma, maybe a few tips on what people can do?
Cynthia:
Anyone listening can get access to Adverse Childhood Events Scoring online. It was a joint venture between Kaiser Permanente and the CDC. It’s a very quick quiz that can give you a sense of whether or not adverse childhood events have had a large impact.
When I trained in inner-city Baltimore at Johns Hopkins, we talked about Trauma: murder, suicide. No question those are impactful. What I find really interesting and compelling is the emerging research around trauma: addiction, neglect, abuse, how that can imprint itself on a child and young adult.
We know now that individuals with high A scores are at greater risk for earlier menopause, specific types of cancers, disordered relationships with food, poor metabolic health. In many instances, it can age your ovaries faster.
When we talk about the role of cortisol, cortisol is thought of as a bad hormone. I’m saying “bad” by if you ask the average person, they just assume that. It’s a great, important hormone, but it’s one we have to keep balanced.
Cortisol in small amounts is what allows us to flee from danger, to focus when we are taking an exam, to stay focused when we are dealing with a stressful situation.
Chronically elevated cortisol is caustic. It catabolizes muscle, dysregulates our immune system, contributes to leaky gut. It goes on and on and on. It also can drive ovarian senescence, so ovarian aging can be a byproduct of chronic stress.
What I find is a lot of women, whatever they experience as children or young adults, is they do okay up until perimenopause. In the setting of less hormones, less neurotransmitters, they can’t cope. Those adaptive strategies that we create as women to survive our childhood and young adulthood become very maladaptive. When we talk about women, 70% of divorces are initiated by women in midlife. Really looking at a lot of the changes that we see women undergoing in perimenopause and menopause. It is a direct reflection of these changes in hormones, changes in neurotransmitters.
Let me be clear. Estrogen is a great hormone, but it is a people pleasing hormone. For many of us who are people pleasers, as we navigate midlife, that starts to shed. I say all the time, I was the golden child of my house, but I am now the black sheep. I speak my truth. I don’t do things that my parents want me to do. I do what’s right for me and my family. That puts me, in a large Italian family, at odds with some family members.
For a lot of women, it’s helping them understand you will find your truth. You will find who you are, who you were always meant to be, in perimenopause and menopause. As those hormones are declining, as those neurotransmitters are changing, you cannot force yourself to be a people pleaser anymore.
I can tell when I am close to needing to change my estrogen patch because I get irritable. My son was laughing. We were traveling on the day I had just put a new estrogen patch on. He was like, “God, you’re irritable.” Well, I’m also traveling internationally. There are things beyond our control. There are things not beyond our control. We have to focus on what we can control.
For a lot of people, stress is something they have never had to deal with, or they perceive they don’t have to deal with stress. Stress is meditating for five minutes on a Thursday. One of the things I found to help women be super successful in midlife is finding ways to support their vagus nerve throughout the day.
I have three dogs. Ironically, none of the dogs are in my office right now. They are probably laying on cold tile. I have one dog in particular who if I’m in my office, he comes through every hour or two and wants to be petted. I know things about releasing oxytocin can lower cortisol.
Finding ways, whether it’s gargling, humming, meditation, breathwork, getting your feet on the ground, not when it’s 104 degrees like it is right now. In other circumstances. Finding ways to stimulate your vagus nerve is going to be very beneficial in midlife. It will be a differentiator for a lot of women.
Dr. Eric:
Great advice. I talk a lot about that as well, supporting vagus nerve.
Before wrapping this up, there are a few points I want to touch upon. One, which we don’t have to get into conversation, but I found interesting. You might not have had anybody interviewing you bring this up even though it’s in your book. Frozen shoulder and estrogen. The reason I’m bringing it up is because I wrote an article on frozen shoulder and hyperthyroidism a number of years ago. I might have a solo episode from a number of years ago about it. There is a relationship between thyroid and frozen shoulder. I didn’t realize there was also a relationship between estrogen and frozen shoulder. I personally never experienced frozen shoulder.
Cynthia:
I hope not.
Dr. Eric:
I assume you didn’t either.
Cynthia:
No, I haven’t. I think I have been pretty fortunate in terms of not really having a lot of tangible issues other than eye issues. That’s my new thing. Without boring your listeners, you have glands in your eyes called meibomian glands. With the loss of estrogen, you can have changes in the gland and how it secretes this waxy substance that is designed to lubricate. I have had three chalazions over the past eight years, which doesn’t sound like a lot. The ophthalmologist was explaining to me why this happens. Okay, that’s probably my one thing.
When we’re talking about adhesive capsulitis or frozen shoulder, yes, that is generally a reflection of a low estrogen state. It’s something that Dr. Vonda Wright describes in the musculoskeletal syndrome of menopause that I talk about in the book. For a lot of women, that’s joint pain, muscle pain, a constellation of joint-related discomfort. A lot of times, patients were just told they had osteoarthritis that they just had to deal with.
What I find interesting is right before I started HRT, I had very irregularly some pain in my right knee. I played varsity sports in high school and have never had a problem. I remember as soon as I started taking estrogen, that all went away. A lot of the aches and pains that people in midlife and beyond experience are likely a reflection of shifts in hormones, in particular estrogen.
Dr. Eric:
Speaking of HRT, it’s probably a good idea to- Let me ask you the question. When do you think a woman should consider HRT? Do you have the perspective that all women who hit perimenopause and especially menopause should consider HRT?
Cynthia:
Here is my take. I think every single woman should have a conversation and make an educated decision for herself. I find that most women who follow me are probably on HRT, if they were within the time frame. There are women who are my mother’s age. When I use the term “missed the window,” they are 30 years into menopause. I’m sure they could start vaginal estrogen at any time. That won’t be a problem.
There is a whole slew of things that we have to do in terms of risk factor to rule out other issues. It’s not about progesterone. It’s more about estrogen. Starting estrogen in a low estrogen state, when those receptors haven’t really been stimulated by estrogen for a long period of time. We are very likely seeing some degree of inflammation, oxidative stress. In the beginning of some degree, atherosclerosis, which is heart disease. That is the #1 killer of women, whether people talk about that openly or not. That is probably what is going to kill most of us.
I think there is value in starting HRT in perimenopause. Frankly, whenever a woman starts becoming symptomatic. Maybe it’s cycling 1-2 weeks of oral micronized progesterone. Then adding estrogen later.
The one thing I have learned is a lot of women suffer in perimenopause needlessly. It’s because of the ignorance of health care providers. I say that with respect. Things are changing. The direction of things is changing. Practitioners, prescribers are becoming much more aware of what options are available. The days of letting women suffer through perimenopause and then maybe dangling a little bit of HRT in front of them, those days are gone. Now we are at a point where a lot of individuals are far more savvy.
Certain listeners to my podcast know I’m loud and proud. Every woman deserves to have an informed conversation. From there, they can make a fully informed decision about whether or not they want to start HRT. They can change their mind in a year or two. It’s not hard and fast.
I have a lot of women in my community who are 10 years into menopause. There is this whole timing hypothesis theory, which intellectually I understand, but I still think it’s BS. There is an optimal time to start. I get that intellectually. But some people didn’t know. If they are 11 years and one day into menopause, does that mean they shouldn’t be offered HRT? Absolutely not. They should get an appropriate risk factor screening. That may involve bloodwork and diagnostics. But everyone deserves to have a conversation.
I cannot fathom personally what my sleep would be like if I weren’t taking HRT. I know on intake forms who is on HRT and who is not. It’s that clear. From my perspective, starting earlier is going to have greater benefits.
Getting really clear and intentional, there is a lot of FDA things that are covered by insurance, and there are lots of compounded stuff. I think it’s really dependent on what the patient and provider decide together. Some patients are like, “I want sustained release progesterone.” That’s great. That’s compounded. That will be out of pocket and probably more expensive. If that’s okay with you, we can make it happen. If you have a peanut allergy, you have to have compounded progesterone because there is peanut oil. That’s what oral micronized progesterone is created in.
Right now, we have a patch shortage in the U.S. I’m sorry, you’re catching me on a day when I’m feeling a little salty. I’m old enough to have been around when Viagra came out. I bet you there will never be a Viagra shortage in the U.S. I’ll be darned if there isn’t an estrogen patch shortage because it’s not profitable.
I always remind women that misogyny is part of the patriarchy of traditional medicine. That doesn’t mean we have to sit back and accept it. There are always answers. There are always other options. Suffering is optional.
Dr. Eric:
Getting back to the cardiovascular health. Do you find that sometimes HRT will help? If women have elevated lipoprotein A or B?
Cynthia:
The data suggests that first of all, LP(a) is largely genetic. We know it’s 7-8x more pathogenic than LDL. That’s significant. There is some research to suggest that estradiol is a weak PCSK9 inhibitor. I just said a bunch of alphabet soup.
Estradiol is the bioequivalent option for estrogen. PCSK9 inhibitors are a class of drugs that are really expensive that are designed to weakly impact LP(a), anywhere from 16-25%. Not that great. I think oral estradiol is what is thought to be most efficacious potentially for lowering LP(a). Not everyone tolerates oral estradiol. I think most women are getting transdermal approaches.
When we are dealing with APO lipoprotein B or ApoB, the question is, are you a hyper absorber or a hyper synthesizer? There is something called the Boston Heart Cholesterol Balance Test. Every woman listening who has an elevated LDL or ApoB needs this test. It’s less than $100. I have no affiliation with them. It can determine whether or not you hyper absorb cholesterol like a sponge, which is me, versus you create too much cholesterol, which is a hyper synthesizer.
If you are a hyper absorber, a statin won’t do anything. What you need is a drug called ezetimibe or Zetia. It’s dirt cheap. It used not to be; it used to be quite expensive. That’s what I take. At the site of the small intestine, it blocks the absorption of cholesterol, not so you don’t act like yourself, but it will help drop the ApoB. If your LP(a) is elevated, take solosin, knowing it’s largely genetic. It’s important still to do all the lifestyle things. Then have a conversation with a licensed medical prescriber who can help you navigate next steps.
I personally had a high ApoB and high LDL. My LDL was high my entire life. Now that I know that I hyper absorb cholesterol, my ApoB is perfect, and my LDL is much lower. I have a genetic high LP(a). My husband has it. My kids have it. I don’t freak out about it. I’ve had a CAC. I’ve had a CT angio. A CAC is a Coronary Artery Calcification. That is the next step.
If you have high LP(a), and your metabolic health parameters look okay, you need a CAC, which looks at heart plaque, but more importantly, you need a CT angio, which looks at soft plaque. That is the stuff that breaks off and occludes arteries. You need those to govern whether or not you need to get really aggressive. Thankfully, my numbers are perfect. I am not stressing about my LP(a).
I am saying this is my personal choice. If you’re listening to this and have a high LP(a), that’s not the right decision for you. Work with your medical professional to figure out what the right decision is for you. The days of putting patients with high LDL on statins, I would push back against that. It’s not to suggest there is not an appropriate utilization of these drugs, but they are overprescribed. They have a lot of systemic effects.
I’m not telling you to stop your statin if you’re taking it. I’m just saying we have to make good decisions and educated decisions. If your provider is reflexively putting you on a statin without looking at all those other things I talked about, you need a new provider.
Dr. Eric:
I agree. There is so much more we could discuss. Anything really burning that you want to discuss? Any final words of wisdom? I know you have a chapter about ovarian aging. People could read the book for that. Again, you have so much great information in the book. We’re not going to cover everything. Before we finally wrap up, anything else that you want to cover?
Cynthia:
Thank you, Eric. I will preemptively apologize. I am not normally this salty. I don’t know if it’s the heat or if it’s my third back-to-back podcast. I am not restraining. The people pleasing tendencies are gone.
The biggest thing is if you have listened through this entire podcast, there is a lot you can do. I don’t ever want to leave any human with the feeling that they have to change a lot of things all at once.
I always say something as simple as taking 4-5 deep breaths before you sit down and eat a meal can get you into the parasympathetic and ready to absorb, digest, and detoxify. Something as simple as going to bed 30 minutes earlier will help. All these things help your gut. All these things help you. I just got back from vacation with my 18-year-old. I was not going to bed at the normal time that I normally do. That’s okay. That was for the short term.
Lastly, be thoughtful about fiber. If you look at the government guidelines, not every one of my patients can tolerate 25-30g of fiber. What I would say is track what you’re consuming. You can go on Chronometer. I have no affiliation with them. Track your macros for a week. Find out where your fiber intake is. Increase it a little bit. If you are consuming 12g a day, get to 15g. We know fiber is critically important for midlife women for all the reasons we’ve discussed today. I go into greater detail in the book.
For everyone listening, those are three tangible takeaways that just about everyone can use.
Dr. Eric:
Awesome. Thank you so much for this. How can people find out more about you? Tell people where they can get your book. Remind people about your podcast. Also, make sure you tell them about your Substack newsletter, which is also amazing. I want people to sign up for that as well.
Cynthia:
Thank you, Eric. It’s easiest to go to my website, CynthiaThurlow.com. You can get access to all my social media channels. Eric is correct. Substack is a passion project. I am really enjoying connecting with my community there. Substack is a cool place, especially for people who like to read and absorb content.
My podcast is Everyday Wellness. Eric will be a guest next week. Our podcast together will be coming out later this summer, early fall.
The book is The Menopause Gut. It is available everywhere books are sold. If you have a brick-and-mortar business in your area, please give them your business. The online retailers have really, in the past four years, since I published my last book, it’s unbelievable how they have expanded. You can get it on Amazon, Barnes & Noble, Target, Books a Million, everywhere books are sold.
I am really proud of this book. It was a love letter to women. It provides a very unique lens for midlife and beyond.
I would say beyond that, if you decide to catch up with me on social media, send me a DM and let me know that Dr. Eric sent you my direction. I always tell people I’m probably most active on Instagram. I do have a free Facebook group called The Midlife Pause/CynthiaThurlow.
I do have a supplement line with the same name. I created it out of utter frustration of not being able to find supplements that were scientifically formulated and specific for midlife women. I’d love to connect with you.
Dr. Eric:
Wonderful. Thanks again, Cynthia. This was another awesome conversation. Thank you so much. Congratulations on your book. It’s already a huge success. I know it will just be a bigger success. Until your next book. I know you don’t have plans for writing a third book, but you never know.
Cynthia:
Not sure. I will be honest with you. This might be a two and done.
Dr. Eric:
There is plenty of great information for people to learn. Again, thank you so much. I really appreciate this conversation, Cynthia.
