I have the privilege of connecting with Dr. Suzanne Fenske today. She is an integrative gynecologist, double-board certified in obstetrics, gynecology, and integrative medicine, and fellowship-trained in minimally invasive gynecologic surgery and functional medicine. She established her practice, Tara MD, to empower women to take charge of their health and well-being by combining modern and integrative medicine to offer enhanced care, more time, and improved services.
In our discussion today, we explore menopausal advocacy, addressing the lesser-known symptoms of perimenopause and menopause and medical gaslighting.
We discuss detoxification, looking at the significance of the vaginal, uterine, and urinary tract microbiome and factors that could negatively impact it. We also cover the critical role of the estrobolome, the importance of nourishing the body during perimenopause and menopause, and common reasons for weight loss resistance.
I am confident you will find this conversation with Dr. Suzanne Fenske as insightful and enjoyable as I did.
IN THIS EPISODE YOU WILL LEARN:
Some of the less common symptoms of perimenopause and menopause and how they affect the lives of women
How estrogen metabolism can impact gut health
Identifying and addressing underlying causes of inflammation
How inflammation and food intolerances can lead to weight gain
Modern lifestyles practices that can disrupt the vaginal microbiome
Dietary recommendations for improving hormone metabolism
Why women should focus on nourishing their bodies instead of following trendy diets
The benefits of tracking macros to identify areas for improvement
How cortisol imbalances in perimenopausal women can lead to cravings and fatigue
How alcohol impacts sleep quality
The benefits and risks of testosterone for women
Bio:
Dr. Suzanne Fenske is an integrative gynecologist. She is double board-certified in obstetrics and gynecology as well as integrative medicine. She is also fellowship-trained in minimally invasive gynecologic surgery and functional medicine. Dr. Fenske is also a certified menopause provider through the menopause society. Dr. Fenske founded Tara MD in 2021 to help women take control of their health and well-being by blending the best of modern and integrative medicine through more care, time, and services.
“I start with every woman in perimenopause and menopause talking about their protein goal, based on their ideal body weight.”
-Dr. Suzanne Fenske
Connect with Cynthia Thurlow
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Check out Cynthia’s website
Submit your questions to support@cynthiathurlow.com
Connect with Dr. Suzanne Fenske
On the Tara MD website
On Instagram
Transcript:
Cynthia Thurlow: [00:00:02] Welcome to Everyday Wellness podcast. I'm your host, Nurse Practitioner Cynthia Thurlow. This podcast is designed to educate, empower, and inspire you to achieve your health and wellness goals. My goal and intent is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives.
[00:00:29] Today, I had the honor of connecting with Dr. Suzanne Fenske, who is an integrative gynecologist and she is double board certified in obstetrics and gynecology as well as integrative medicine. She is also fellowship trained in minimally invasive gynecologic surgery and functional medicine. She founded TaraMD to help women take control of their health and well-being by blending the best of modern and integrated medicine through more care, time and services.
[00:00:57] Today, we spoke at great length about menopausal advocacy, less common symptoms related to perimenopause and menopause, as well as gaslighting, the impact of detoxification in the body, the importance of the vaginal, uterine and urinary tract microbiome, and things that can adversely impact this, why the estrobolome is so important, why nourishing your body is so vitally important in perimenopause and menopause. And lastly, the role of weight loss resistance and common reasons for why this becomes problematic. I know you will enjoy this conversation as much as I did recording it.
[00:01:39] Well Dr. Fenske, welcome to Everyday Wellness. I've really been looking forward to this conversation.
Dr. Suzanne Fenske: [00:01:44] Me too. Thank you so much for having me.
Cynthia Thurlow: [00:01:46] Absolutely. And we were talking before we started recording about how there's growing menopausal advocacy or even perimenopausal advocacy. But why do we still not talk enough about what is happening in women's bodies as they are navigating middle age? I still feel like there's a degree of shame and secrecy and ageism, and I'm sure through the trajectory of your own career, you're probably seeing that it's getting a little bit better, but we're still not there.
Dr. Suzanne Fenske: [00:02:16] 100%. I think that definitely you touched on it. There's still shame associated with it. I think that we as women are just so focused on everything appearing so perfect on the outside that having to deal with all of the symptoms of perimenopause and menopause and even talking about it with our friends and families is just really shameful still. And then I think that there's still just so much confusion about the data, about the studies, about the risks, about the benefits, not just for women going through perimenopause and menopause, but even for the providers who are providing care for it.
Cynthia Thurlow: [00:02:50] Yeah. And it's interesting. It's without question across social media, there's still fear about taking hormones. There is still great misunderstanding across our traditionally trained allopathic peers. And this isn't designed to be critical of anyone. It's just been interesting because I finished my training in late 2000. And so in 2002, when the Women's Health Initiative came out, I was in clinical cardiology. And I just remember how many women were talking to me about being taken off of all of their HRT and how miserable they were. And of course, I was incredibly sympathetic to what they were experiencing. But being in cardiology, we didn't want touch that with a 10-foot pole. And then as I started getting older myself, there's a lot about women in their late 30s, early 40s that started making a great deal more sense.
[00:03:47] And so, when we're talking about navigating the beginning stages of perimenopause, what are some of the more unusual symptoms that your patients will experience? I think it's not uncommon for women to hear about sleep disturbances and potentially having changes in their menstrual cycles. But for you clinically, as a GYN, what are some of the less known or less common things that we're talking about as a community of women that are navigating these changes?
Dr. Suzanne Fenske: [00:04:20] Yeah. I think that people have become a lot more-- it's kind of a humorous topic to talk about hot flashes and night sweats and the brain fog. Less humorous and less talked about are some-- There's some very strange symptoms. There's change in body odor, which, when I say it to women, they're like, “Oh, my gosh, that explains it. Yes, I stink now.” I personally had this strange, itchy palm, one that persisted and of course, it kind of falls into the dry, itchy skin. The neurological sensations that go on and change during perimenopause and menopause. But even myself, it took me a while to kind of link the two together, that this is one of my perimenopause symptoms. But I think that the mental health is still just not really talked about.
[00:05:05] It's just kind of this assumption that we as women, kind of gaslight ourselves with it and say that this is a difficult time. Like you were saying earlier on before we started recording that empty nesting. I'm about to empty nest. And that explains it or my career this that kind of explains the changes that I've had in mental health. But I think that's one of the symptoms that really needs to be brought to the forefront and really openly discussed are the mental health changes. Because it's not just anxiety and depression, which in and of itself are enough, but even just complete lack of desire to do all the things you normally would want to do in life. There's just sort of this apathy that is very common that comes with perimenopause.
[00:05:49] That's a really important symptom for women to be aware of that it's not just hot flashes and night sweats and brain fog and sleep disturbances, but it is these sorts of out there symptoms, the electrical sensations, heart palpitations. I can't tell you how many women have gone and seen cardiologists during this time because they're having heart palpitations and so fearful that they're having cardiac changes now and the mental health changes. Because I think that if we even just spoke about it amongst ourselves and brought it more to the forefront, there would be less shame associated with it.
Cynthia Thurlow: [00:06:22] Now, I couldn’t agree more. And I think in many ways that the degree of anxiety that I hear women expressing, especially in early to mid perimenopause, when they’re in that luteal phase and they have less progesterone, and they’re wondering why they’re waking up anxious. They’re struggling to get through their day. And I think on a lot of levels that this lack of awareness and lack of information that's available to women. I've had women tell me they thought they were losing their minds, but in essence, it was this loss of estrogen, or it was this relative estrogen dominance, given the fact that progesterone and estradiol are designed to balance one another out. But as we're navigating these changes, that can be so important. And you mentioned the apathy, anhedonia, just not having a desire to do things.
[00:07:12] We don't talk enough about testosterone, although I feel like in many ways, the pellet industry, and I don't mean to kind of poke focus on this, but I'm going to talk about it. I feel like I meet a lot of women who will come to me and they'll say, “Well, I was seeing this provider, and I felt great when I first got a testosterone pellet, and then they felt like they were constantly chasing that feeling. They initially felt good and then they were constantly chasing that feeling. And I always like to explain to patients, like understanding what's going on upstream is it chronic stress that you're dealing with, you're not dealing with the stress, and that's going to deplete sex hormones further. But I think in a lot of ways, we're starting to talk more about the need to be aware of how important testosterone is for women. You know, that motivation hormone, I think everyone thinks about it in terms of libido. And yes, that's important, but being able to build and maintain muscle, just thinking about the executive functioning that goes along with testosterone as well and how that plays in with mood disorders.
[00:08:15] And it's interesting. I just interviewed Dr. Felice Gersh, I think for the fourth time, and this time she talked a lot about the loss of estrogen in and of itself in the heart will drive arrhythmias like atrial fibrillation. And I know my community has heard me talk about this before, but I think about how many patients I took care of over 16 years in cardiology that what they probably needed more than anything was some estrogen replacement therapy that probably would have improved their paroxysmal, which is atrial fibrillation that comes and goes, or they're persistent atrial fibrillation. And so, the heart palpitations, lots and lots of workups that for many women yield nothing significant, but what they're experiencing is real. And so, I love that you touched on that. And something that I thought was interesting is that estrogen plays a role in serotonin and dopamine signaling. So, it's not just the estrogen and the progesterone, it's that the neurotransmitters are also impacted.
[00:09:11] So when you're working with women in your practice and you're helping them understand the interrelationship between the natural kind of evolution of the aging process, but also things like gut health. Because if your gut isn't healthy, that can further exacerbate these changes with not only depression, but also estrogen metabolism.
Dr. Suzanne Fenske: [00:09:32] Absolutely. And Phase 3 of estrogen metabolism takes place in the gut. So, beta-glucuronidase, which is an enzyme that basically, when you're metabolizing estrogen and removing it, Phase 1 and Phase 2 occur in the liver, but Phase 3 takes place in the gut. When we do some testing that we do in the integrated modality, we're able to look at Phase 1 and Phase 2, estrogen metabolism. But Phase 3, we're not able to, unless you do a gut microbiome analysis. It's so important because not just-- even outside of perimenopause in other hormonal abnormalities, this is an important facet to look at, even when you're talking about something like endometriosis, which is often a disease of estrogen inflammation. And even if you're managing the estrogen, but you're not evaluating the gut symptoms that occur with endometriosis, then with beta-glucuronidase elevation, estrogen is being recirculated into the system.
[00:10:27] So some of those disorders are going to be exacerbated just by that alone with perimenopause and menopause I think that a large portion of my patients will come in saying “Bloating is a major symptom that they have associated with it.” And even then, it's not until you actually question these things. How often are we having a bowel movement? Are you having bloating, heartburn, exacerbation during this time too? All links to the perimenopause and menopausal changes.
Cynthia Thurlow: [00:10:54] Yeah, it's so interesting. And do you have, within your clinical practice, are you using the DUTCH? Are there specific stool tests that you like to look at that you feel like are most helpful when you're trying to get answers for your patients?
Dr. Suzanne Fenske: [00:11:07] I do. I don't think it's a requirement. I think that, most importantly, listening to the woman, listening to the symptoms. And these testing, as important as they are and as helpful as they are, can be very costly. So, it's very easy when you're feeling absolutely miserable to want to do every single test possible, but financially prohibitive. So, you don't necessarily need the tests. But I do, do the DUTCH test very often in my practice. I liked that over sort of saliva testing because I'm able to evaluate the metabolites too, and to see whether or not women are metabolizing. Like I'd mentioned phase 1 and phase 2 properly. So, I know that if I start them on hormone replacement therapy, they're going to feel fantastic and not feel worse, because we all had those patients that start hormones and actually feel worse on hormones.
[00:11:52] And often it comes down to either how they're metabolizing it, whether how they're metabolizing it in the liver, or how they're metabolizing it in the gut. For gut testing, I question this in my intake, but if I have a woman comes in complaining of constipation, of bloating, then I do both the GI map test as well as the Vibrant America Gut Zoomer test. And find that very often, more often than not, there's definitely abnormalities that are found in these testings. It's very rare that I get that actually, I have somebody who has this perfect gut microbiome analysis.
Cynthia Thurlow: [00:12:27] Yeah. I don't think I've seen any of those. And interestingly enough, I've been working with one woman and she wanted to know, on the continuum of stool tests, you've looked at, “Where does mine fall?” And I said, “Pretty average.” But to reassure you that what you're experiencing is real and there are definitely things that are contributing to the bloating, to the constipation, to the weight gain, weight loss resistance, which I think is such a huge pain point for women, and certainly a lot of women get gaslit over the weight gain. I know personally, in my early 40s, I remember having a conversation with a provider and they were like, “Well, Cynthia, you're just 42, you're 43. This is just the way things are.” And I looked at them like they had two heads. And I said, “No. The fact that I'm struggling with weight loss resistance is telling me that something is not balanced in my body. And figuring out what that is going to be certainly very important.”
[00:13:18] For me, it was relatively easy to figure out that it was a dairy insensitivity. And so, removing dairy, I jokingly call it the five pound dairy. But for a lot of patients, they unknowingly are consuming relatively healthy foods, but not healthy per se for their body. It may be something that is creating some degree of inflammation. They may be intolerant to it. Unfortunately, things maybe we could consume easily in our 20s and 30s. Now, as we're getting older, it doesn't agree with us anymore. And coming to terms with that and understanding why that's happening.
[00:13:50] Now, we touched on the microbiome a bit, but what I find fascinating is that certainly when I did my training, we knew very little about the microbiome. And now there's an explosion of information. And it's not just the gut. It's looking at the vagina, it's looking at the uterus, it's looking at the urinary tract. And so, what are some of the things about our modern-day lifestyles that can impact these different microbiomes from a GYN lens that you think have the greatest propensity for disrupting a healthy microbiome?
Dr. Suzanne Fenske: [00:14:21] I still think that we know very little about microbiomes in general. At least it's being discussed and brought to the forefront and more focus is being put into it. But I'm still surprised, even in the gynecological world, how little we know about the microbiome. I do feel that there's a lot that needs to be evaluated in regards to the vaginal microbiome, because what I see oftentimes even in the earlier stages of perimenopause, there's a lot more recurrence of infections. There's a lot more of all of a sudden, I'm having bacterial vaginosis infections. I've never had this before in my life. All of a sudden having yeast infections, I've never had this before in my life. And we do know, obviously, that the hormones completely have an interplay and affect the pH, and pH being imbalanced is going to encourage growth of one thing or discourage growth of another. But definitely during that perimenopausal transition, the earlier stages, recurrent vaginal infections, is something that I see day in and day out.
Cynthia Thurlow: [00:15:15] Now, what do you think about the net impact of whether or not a woman has been able to have vaginal deliveries versus having C-sections in terms of the net impact on that future child's microbiome development or whether the baby's been breastfed or not breastfed? And again, this is not a pejorative statement. I had two breech kids that were big, I had two C-sections. They wouldn't have come out any other way. They were breastfed. But I know that we tend to feel a lot of guilt irrespective of how we delivered our children or how we nursed our children or fed our children. But understanding that these things do, based on the research, have a net impact on our future offspring's microbiomes as a whole.
Dr. Suzanne Fenske: [00:15:59] Absolutely. I think that, again this is caution when we talk about these topics, because it shouldn't be a matter of blame in any way. There's multiple things that we can do for our future children to ensure better outcomes. One facet, yes, is that we know, we know based on the data that even if you do vaginal swabs after a cesarean delivery and then put it in the nasal of the baby, that's going to transfer that microbiome over, and we know it improves health management and improves the immune system long term too. And we have that data behind it. Does it mean that, did you fail if you didn't have a vaginal delivery? Absolutely not. But then we can take that information and you can be that person that, although it might come across as being strange, saying that I want to do a vaginal swab and I want to put that in the nostrils of my baby and transfer that microbiome over.
Cynthia Thurlow: [00:16:54] I think that definitely for a lot of people that are listening, I had friends that desperately wanted to nurse, were unable to nurse. People who wanted to have vaginal deliveries ended up with C-section. So from my perspective, the greatest and most important thing for deliveries is having a healthy delivery. And I know as an OB-GYN, that's probably a great deal of your focus as well. What are some of the things that you see clinically that can disrupt the microbiome, not just related to the aging process, but whether it's stress or nutrition, what are some of the most common things that you see that can be nonbeneficial to our microbiome?
Dr. Suzanne Fenske: [00:17:31] So vaginal douches products, deodorants, any of these products that we apply in the vagina, it's unnecessary. And these definitely affect the microbiome, even having not capturing an infection. There are certain infections that we see, like urea, plasma, mycoplasma that we see in certain cultures, but they're not routinely screened. If you go in with symptoms of having a yeast infection and you get a culture done, usually the cultures are going to look for bacterial vaginosis, yeast. Obviously, it's actually transmitted infections, but most of them don't actually do a deeper dive and evaluate for the imbalances of other aspects of microbiome, like mycoplasma, ureaplasma, which can also be found in the urogenital tract. But what we see is that what I very often see, because I always screen for those, is that they're going to keep having recurrence of other infections.
[00:18:21] It's sort of this vicious circle that if you have presence of ureaplasma or mycoplasma and it's not treated, then there's more of a presence also to bacterial vaginosis. And then as you get more bacterial vaginosis, which makes the pH of the vagina more basic, you develop your own yeast and grow your own yeast to bring the pH back to its normal value. And then you have a yeast infection too. So, in addition to obviously, the products that we put on our bodies that are unnecessary, even not getting an accurate diagnosis. And if you're someone who's having recurrent infection, is making sure you have a more broad-spectrum panel culture to see if there's any other thing that's really causing the infections to recur.
Cynthia Thurlow: [00:19:03] Yeah. And I can't tell you how many older women I saw that were on oral prophylactic UTI antibiotics because they had chronic recurrent UTIs, which probably could have been completely ameliorated with vaginal estrogen [crosstalk] as an example. I think now the joke is that vaginal estrogen should be over the counter because so many women would benefit from it. Obviously, we don't want to take out the diagnostic piece. It's still important if someone's having symptoms to be evaluated. But I think about how many of my patients were on chronic low-level antibiotic therapy in an effort to decrease the likelihood that they would be dealing with chronic UTIs. In fact, I have a family member who spent, I don't know, two weeks in the hospital becoming uroseptic.
[00:19:48] So for listeners, this is a family member who had a urinary tract infection, was trying to treat it at home, didn't treat it at home, ended up creating an infection in her blood. She ended up in the hospital because her family members went to see her. And oftentimes, you can see in older patients, they will actually get mental status changes as a reflection of having a sepsis. And so this lovely, wonderful family member jokingly said, “For the rest of my life, I will never ignore having urinary tract infection.” And so, she's a great example of someone that you know vaginal estrogen probably would have helped her enormously because it's been this chronic kind of unrelenting thing that's been ongoing. Now, when we're talking about, you know you mentioned beta-glucuronidase.
[00:20:31] We touched a little bit on these different phases of detoxification, some that occur in the liver, some that are in the gut. I think it's helpful to talk about the estrobolome such a strange word, but one that's so important. Talking about this complex interrelationship between estrogen and the microbiome and why that's so important. I think this is one of these high-level concepts, but one that when women understand why it's so important, it explains why managing stress, eating certain nutrient dense diet, managing things in a way that is going to support the proper breakdown and removal of estrogen from our gut.
Dr. Suzanne Fenske: [00:21:11] Yeah. I think that's one of the benefits of doing gut microbiome testing, is that it allows us to make the changes in our diet and see the difference in it. So, one of the issues that we often see is that most of us eat the same diet day in, day out, same thing for breakfast, same thing for lunch, same thing for dinner. And it may be a healthy diet. You may be eating your vegetables, your protein, getting your protein goals. But having the same food all the time is not going to make the trillions of bacteria that live in the gut happy. Variety of diet is one of the things that we've seen that's happy. Fiber intake is one of the things that we often see decline.
[00:21:46] I think that the stats are that the average American consumes about 9 g of fiber a day. And really, we should have a goal of at least 25 g of fiber a day. But really more soared towards the 35 g of fiber a day is going to be more ideal. And this has a direct impact also on our hormones and how we metabolize our hormones, how we break down our hormones, how we move hormones through our body, as well as obviously making the gut microbiome, the trillions of bacteria happy and therefore producing short chain fatty acids and creating a healthier gut at large.
Cynthia Thurlow: [00:22:18] Yeah. It's really interesting to me how we’ve,-- I feel like things are starting to shift a bit as opposed to pushing a lot of fiber supplements, getting our fiber from our diet as much as possible, adding in ferments. And it's interesting, the research that's been evolving most recently, really talking about how if you're on antibiotic therapy as an example, it is superior to utilize fermented vegetables or fermented foods over probiotics and I think it's so easy when we don't have to think about the food, but I think there's a place for targeted probiotic therapy. But I also think for everyone listening, understanding those fermented foods and you don't necessarily need a lot of them, it could be two tablespoons of sauerkraut or it could be low-sugar kombucha or if you tolerate dairy having some fermented dairy. I think in a lot of ways it's such a supportive way to show that we are trying to support the gut microbiome. And certainly, the more I learn about the immune system changes that are occurring as we're losing estrogen in the gut and throughout our bodies, it makes me understand why food really is medicine and why we should all, instead of prioritizing the supplements, we should really prioritize the food and then targeted supplementation when it's necessary.
[00:23:41] With that being said, “Do you have favorite fiber-laden products?” Like people were asking about resistant starch you know, you hear a lot about green banana flour and potato starch. And when you're trying to help your patients round out their options, “Do you have some favorites beyond the obvious vegetables, fruit, etc.?”
Dr. Suzanne Fenske: [00:23:59] I do tend to really encourage food as being the main source of the fiber. There are certain products that I will use supplement wise, and things like, if we're trying to increase the short-chain fatty acids, I'll use paleo fiber, which is one of the supplements that I do like. But again, touch on what you said, dietary is the most important way to do it. And even using the green bananas to increase short chain fatty acids, I’ll have women mix that into their smoothies.
Cynthia Thurlow: [00:24:26] Yeah. And it’s interesting, I think we have become so paranoid of carbohydrates in general. And I say this lovingly, someone was shocked when I had a plate-- I was on vacation and I had some tropical fruit on a plate for my first meal of the day, and people were shocked. And I said, “Fruit is not the enemy.” Now, granted, I had a few diabetic patients that would tell me things like, “Yeah, I was told it's okay to have a banana.” And I would say, “Okay, well, how many bananas did you have in a day?” And this one lovely diabetic patient said, “Oh, well, the diabetes educator said, it's okay to have as many as I wanted.” And I said, “Well, how many did you have?” And he said, “I had six.” And I said, “Six bananas in a day?” And I said, “Okay, let's think about this.”
[00:25:06] So one banana is probably 30 g of sugar. And I said, “You had six, and we're supposed to keep your threshold of carbohydrate under X.” And he said, “I had no idea. No one had educated me on this.” So, I don't want anyone to be fearful of sugar, but if we know you are diabetic or noninsulin sensitive, you probably need more non-starchy vegetables and less fruit. And I think as a culture, we love sweet. And so, it's been my experience that patients will eat all the fruit they want and then sometimes avoid the vegetables. And I always say bitter compounds are good. It's polyphenol rich foods. Things that are vibrantly pigmented have more of them. And maybe it's a three to one, like three non-starchy vegetables to a piece of fruit.
[00:25:50] And if you do it that way, more often than not, I feel like we're able to buffer some of these choices. Have you found that when we become rigidly dogmatic about nutrition, and I say this with great love and reverence, because I have lots of friends all across the spectrum of nutritional paradigms that they align themselves with. And probably at some point, I was more low carb than anything else. But now I'm starting to move away from that for different reasons. Do you find that most of your patients do best on an omnivorous diet with a good amount of healthy protein, the right types of fats, non-starchy vegetables? Or do you tend to push them in one direction if they're a seemingly more insulin resistant or dealing with more metabolic problems?
Dr. Suzanne Fenske: [00:26:34] Yeah. I think that you're so right. I think that we're still actually dealing with the ramifications of low carbohydrate and what that means. And again, there should be a decrease in the carbohydrates that we, as Americans generally consume, but it comes down to what you're consuming and what carbohydrates you're consuming, and not that all carbohydrates are bad. Most women, even when I bring up trying to encourage a bit more carbohydrate intake in their diet, their innate gut reaction is very hesitant. That goes against-- already have the menopausal and perimenopausal weight gain, and now you're telling me that I'm under nourishing myself with carbohydrates, which is going to just exacerbate my weight gain even more so and that's a common issue and I do understand it. Because we're still very much a low carbohydrate nation as being the way in which to attain your fitness goals, to attain your aesthetic goals is to be low carbohydrate.
[00:27:30] I think that for the importance of thyroid health, we need to take in carbohydrates. And what we have found is that's become sort of an issue. And when you enter into perimenopause and menopause, thyroid disorders rise drastically. So that's the point where you're also now cutting carbohydrates down significantly and not nourishing your thyroid to be able to produce the thyroid hormone. I generally recommend lower or more moderate carbohydrate diet. And this is very specific to each woman, but generally, at least 100 g of carbohydrates should be in your daily diet. The ideal is, yes, cut out the simple sugars, cut out those things but having your sweet potato, having your fruits and vegetables, fruits in moderation again, pairing them too is really the most important. If you really want to focus on insulin resistance, then it's how we pair it. Having your cottage cheese with your blueberries, and choosing certain fruits and vegetables being aware of the nutritional value of them. The higher fiber is going to obviously cut that insulin spike too, and avoid the insulin resistance so then you're able to get the nutrition that you need as well as the body goals that you have.
Cynthia Thurlow: [00:28:38] Yeah. It's so interesting that we have just become a culture where there is fear around eating too much. There's fear around eating too little. There is this zone of, I don't even want to say that it's per se, it's orthorexia, but people that are almost paralyzed when they go out to dinner or they're fearful to eat at an event because they don't know what every single ingredient is. And I oftentimes will remind people that the goal is to nourish our bodies first and foremost, to find what works best for each one of us. This is where bio-individuality rules. I have some clients and patients that do really well with a high-protein diet and moderate carbs. I have others that are very physically active, and they actually need more high-quality carbs in their diets. And encouraging people to be open to the possibility that maybe what worked for you five plus years ago may not be working now. I'm certainly known for intermittent fasting and I do less fasting now than I ever have. And it's not that I don't think fasting is effective. It's that sometimes you can whittle yourself down to such a little amount of food that you realize you're not eating enough. You know, it's that nourishment piece. And I think many people forget about that. Now weight loss resistance--
Dr. Suzanne Fenske: [00:29:51] I think that you're right. I think that if we changed our paradigm, if we actually just thought about instead of focusing on this is off limits, this is on limits, this is healthy, this is not healthy. Focusing on just nourishing your body, that each meal that you sit down to, that, yeah you're still going to be human. Once in a while, you're going to want your slice of pizza or your pizza cake, but that in general, each meal is nourishing your body, and that's the purpose of why you're consuming the food. So, trying to consume food that is as healthy and wholesome as possible really would change the way that we view off limits, on limits, even just the obsession that we have with food, nutrition, and diet. Because when it comes down to it, when you look at studies, after studies looking at diets that work, diets that don't work, ultimately any diet can work. And even when they did the comparison, looking at sort of the low-carbohydrate diet versus the low fat, higher carbohydrate diet, the both populations were at the same goal in the end.
[00:30:51] So really kind of just focusing back on nourishing your body, putting what you need into your body. That's why I do think it's important for a period of time, even just two weeks, so that it doesn't become an obsession of tracking and having certain macronutrient goals. So that you can see that, “Okay, I really have to consume a lot more of this. I really wasn't consuming that much fiber. I was consuming 9 g of fiber in the day.” So, if I focus, you know it’s breakfast, it's lunch as opposed to having the fear associated with food, focusing on, “Okay, I want to make sure that I'm going to be consuming about 10 g of fiber with this meal. So, what am I going to do to get there?” And even changing the way that-- when I was growing up and you too probably, the way vegetables were prepared, I hated brussels sprouts when I was a child.
[00:31:36] My mother would steam them and present them to me, and they were disgusting.
And now it's one of my favorite side dishes because you roast them with some good oil, high smoke point oil, like an olive oil or avocado oil even better. And some good seasoning on top, and it's the best. So, if we're able to just as a society, focus less on, I want to lose 10 pounds and what's going to be the most trendy way right now to get a there, and that's low carbohydrate or this and that, and focusing more on the nutritional goals. It's going to really make us much more body positive and it's going to be a much more of a natural process.
Cynthia Thurlow: [00:32:15] I couldn't agree with you more. And it's funny, I oftentimes too will suggest tracking macros just to build awareness, not to do it forever and ever and ever because even I would get fatigued if I had to track every bit of food I put in my mouth. But I think for a lot of women, it's helping them understand that most of us are under eating protein. We're probably overeating the wrong types of carbs and maybe not cognizant of the types of fats that we're consuming. And I think for everyone listening, I do better personally with a lower fat protein, like I will do better with a chicken breast or a piece of filet or a lean piece of fish. I do much better with leaner protein than other people do. And I think on the flipside of that I have plenty of patients that love having a ribeye and want all the salmon they can get, and I like salmon too.
[00:33:06] But the caveat I'm trying to make is that for each one of us, it's helping determine where we are on this trajectory. And I think tracking our macros, even for a week or two, can be very helpful for determining, I don't want to use the word deficiencies, but looking where we could do some things to improve upon what we're already doing, quite frankly and quite transparently, that's one of the reasons why I stopped doing long fasts or wider you know having these very, very tight feeding windows, it was nearly impossible to get enough protein. And we know as we're getting older, we need more protein, not less, especially to stimulate muscle protein synthesis. And one of the most common issues that women at this stage of life have is weight loss resistance, which can be from a myriad of multifactorial reasons for why this is occurring.
[00:33:56] When you are working with your patients, what are some of the low-lying fruit, the kind of easy little things that they can do right away that may perhaps get them stimulated to start releasing some weight, and again helping everyone understand the way that you successfully lose body fat and not as much muscles, it has to be low and slow, it has to be a gradual-- Anyone that's telling you're going to lose 10 pounds immediately, that's not sustainable. We want is for you to be at a healthy weight, addressing the weight loss resistance, to find out what could be an easy reason for why this is occurring and try to work beyond that and help you navigate perimenopause and menopause successfully.
Dr. Suzanne Fenske: [00:34:42] I start off with protein, I do. That's what I do nowadays. I start off with protein. I feel like it's a very-- It just makes it easier. It becomes less, “What am I doing wrong?” And it becomes more, “Oh, you know what? I actually am not consuming enough protein.” The benefits on the flipside right, between us that we know, is that it's going to increase satiety. So naturally you're going to snack less, you're going to feel more full if you consume the protein that you should be for your macronutrient goals. So, the first thing that I always start off with, every single woman in perimenopause and menopause is talk about their protein goal based on their weight, their ideal body weight, as well as I tend to use 0.8 to 1 g of protein per ideal body weight. That's the range that I generally use as my macronutrient goal. And I think that the two things that I'll focus on is fiber goal and protein goal and make it very simple and start there.
[00:35:30] It's amazing how much that changes everything else. Automatically, the carbohydrates that you're taking in are going to decrease because you now have this goal of what fiber you're going to consume. And if you need to have fiber goals, then you're going to consume more vegetables to meet those fiber goals, because that slice of bread is not going to meet that fiber goal. If you're consuming enough protein, you have less of that hunger after you eat. So, if you have a higher carbohydrate meal, then an hour later, you have that drop in reactive hypoglycemia, you're hungry again. If you're focusing on protein; you don't have that reactive hypoglycemia so you don't have that.
[00:36:10] So, I always start off really easy with women because everyone's trying hard. Everyone comes in my office. It's very rare that someone comes into the office saying that, “I'm eating two bags of chips every single day, and I don't understand where I gained this weight.” Most of the women that I see are doing the things, but it's just not working for them anymore. So, when you put it back into perspective of protein and fiber, those are the two things that I always start off with as goals.
Cynthia Thurlow: [00:36:34] Yeah. I think that's such a reasonable and feasible first step. How does chronic stress play into the weight loss resistance piece, especially we’re four years after the pandemic? But I always say everyone has had more stress, not less, over the last several years. But how does chronic stress exacerbate this issue?
Dr. Suzanne Fenske: [00:36:55] We have symptoms, right? So, if you say to me that I have so much sugar cravings, okay, there is actually a sign that your cortisol is elevated, if with chronic stress oftentimes this is why I like to do a DUTCH test if I can, is especially in the perimenopausal time period, as you see the adrenal component. So, you see those cortisol spikes that are happening at night, that reverse pattern where instead of having that morning rise in cortisol and then slowly goes down into the evening. Oftentimes when I do the DUTCH test, I will actually see very low cortisol during the course of the day. And women will say, “I have extreme fatigue during the day. I want to take a nap in the afternoon.” And then all of a sudden, wired but tired at night.
[00:37:37] So exhausted all day, but then can't go to sleep at night. And I think that if you don't take care of this aspect of things as well, then weight loss goals is just one aspect. The weight loss goals will not be met. It's very, very, very hard. The other thing that we see right during this time is obviously insulin resistance rise. And as estrogen declines, insulin resistance rises. So, I will focus a lot when I look at a whole picture of a woman who comes into perimenopause at looking at the cortisol values. And again, if you are someone who financially can put those resources into doing a DUTCH test, for example, then provider who's aware to ask the questions that, “Are you finding that you're craving this or you're craving sugar, are you finding that it's very hard to get up and go in the morning.” If a woman's saying, “At night, I'm so tired, my mind's going a mile a minute.” These are all your signs of what your cortisol pattern is doing.
Cynthia Thurlow: [00:38:32] Yeah. And certainly not headed in the right direction.
Dr. Suzanne Fenske: [00:38:35] Yeah.
Cynthia Thurlow: [00:38:36] We know that the influence of sleep quality is so important, not just for brain health, but for overall health. Talk to us about alcohol. What is your position on alcohol for women at this stage of life? And I talk about this lovingly, and my community knows that is one thing I don't do because it just for me disrupts my sleep so much. But I'm sure for you, when you're talking to your patients, a lot of women consume alcohol to fall asleep, not knowing that it's undermining their sleep quality.
Dr. Suzanne Fenske: [00:39:06] Mm-hmm. But those same women are going to say that two hours later they wake up in the middle of the night wide awake. So, they're able to fall asleep because of the alcohol, but they're not able to stay asleep because of alcohol. In general, I live my life very kind of moderation. I'm going to say to a woman that if you're going to consume alcohol because you're going out with friends and you want to have a drink, just know that you're probably going to pay the price and there are better ways to consume it. Most women will notice, unfortunately, that wine is really not your friend during this time and period of your life. And a better way to do is going to be that if you want to consume alcohol, doing sort of the clear spirits and mixing it with seltzer, honestly is the way to go, because at least you're hydrating during the course of it too, and you're having less of that effect. So, choosing the right alcohol and the amount of. And then, yes, the not popular thing [chuckles] is that you do have to limit alcohol consumption and be aware that you're going to pay the price if you do consume alcohol.
Cynthia Thurlow: [00:40:01] Yeah. It's one of those things that I think for me it was-- I've never been a big drinker, but I just recall in my early 40s, it took a while for me to realize, like, “What is it that I just did?” That now ensured that I look at my metrics on my Oura, on my deep sleep bottomed out, my HRV is terrible, my heart rate variability clearly is an issue, my pulse rate wasn't where it normally is. And so, for a lot of people listening, understanding what we're saying is if you choose to drink, do so responsibly. You mentioned the clear alcohol, and I always say clear spirits are going to better, but make sure you're hydrating around that. Make sure you've had food, because you don't make good decisions around alcohol consumption if you're drinking on an empty stomach, have a meal around it, it will help buffer some of the effects. What are your thoughts on nutrient deficiencies vis-a-vis looking at adrenal health as it pertains to this challenging life? We know that we become less stress resilient. We know that our adrenals kind of step in to be this emergency backup system as our ovaries are making less progesterone. What do you like to focus on in terms of adrenal health to support women at this stage?
Dr. Suzanne Fenske: [00:41:12] So I do love to use, but I do use adaptogens. So, I will use adaptogens selectively for women during this time too, because I think that there's a lot of lifestyle things that I always will teach women during this to employ. But it's helpful to have those aids during that time too. But what's really important with every single woman that comes in, I kind of have these set pillars that I go through. And one of the pillars is stress management. And this means what are you doing on a day-to-day basis to manage your stress and what are you doing in the moment? And I think that's one of the reasons why women during perimenopause and menopause kind of turn to alcohol as much, because it's known right if you have a drink, you're going to feel more relaxed. And it's an immediate thing. And it's a lack of sort of, even in our society, focusing in on day in, day out stress management skills and what are we doing to make that better?
[00:42:05] So, it's as simple as, and there's things, that don't jive with people. Journaling may not be something that jives with you. And it's funny when I ask women, “What do you do for stress management?” Everyone thinks that I'm looking, it's kind of like pleasing the teacher, right? [Cynthia laughs] So everyone looks-- everyone assumes I'm looking for the answer, meditation. And meditation does not have to be everybody's stress management modality, but even something as simple as breath work. So, I teach every single woman who comes into my office, whatever age you're at, whatever stage you're at of breath work, and whether it's box breathing, whether it's 4-7-8, I teach them usually those two ones. And then whatever kind of jives with them and say you have a homework assignment. Every morning you're going to do a certain set of breath work exercises, and every night you're going to do a set of certain breath work exercises.
[00:42:52] And then during the course of the day, when you're at work, when you're running around with the kids, when you're having a moment, you're going to take a moment, you're going to go to the restroom, and you're going to do a set of your breath work exercises again. And I myself do this during the course of my day. I'm seeing patients and if I feel like I'm getting a bit stressed out, I'm not performing the way that I want to, my head just feels very cluttered, I will go to the restroom because no one bothers you there and yeah, and no one knows what I'm doing in there. Do three rounds of box breathing or a 4-7-8 and come back into it. So, I do use adaptogens. But I also teach stress management skills, which are very important.
Cynthia Thurlow: [00:43:32] Oh, it's absolutely vital. I don't think enough clinicians are talking to their patients. I jokingly will say, “Stress management is not five minutes of meditation once a week. It needs to be something that appeals to you and that you can do.” Like I know for myself now it's warm, so grounding, connection to nature, getting out in the morning is really important. And I do a lot of breath work because totally admit, I'm going to admit this to the entire community. I struggle with sitting down and doing meditation for 15 or 20 minutes. I keep saying eventually I will go to a Joe Dispenza event because I do feel that there's a lot of value in it. But the thought of meditating for a whole week or throughout an entire week is a little daunting. So, I completely understand and appreciate how thoughtful you are in saying, “If journaling doesn't work for you or coloring doesn't work for you, find the thing that you enjoy and embrace it.”
[00:44:24] Lastly, I'd love to talk about testosterone. We know that when we're talking about hormone replacement therapy, there's a lot of discussions around estrogen and progesterone therapy and I feel like testosterone is maybe having a moment. Unfortunately, it's still not. There is not an FDA approved type of testosterone for women. So, they're either using little packets of AndroGel, which I can't even fathom how easy or not easy that is, to get a 10th of the dose for yourself, or they're having products compounded.
Dr. Suzanne Fenske: [00:44:54] Right.
Cynthia Thurlow: [00:44:55] And obviously there's other options beyond that which are beyond the scope of our discussion. But what are your thoughts around testosterone? Are you finding for women that’s kind of the missing link in terms of HRT management and kind of improving the trajectory of perimenopause into menopause.
Dr. Suzanne Fenske: [00:45:12] Yeah. In general, I am a big advocate of testosterone. I don’t believe every single woman needs it. And I think that it is important actually to do laboratory values and assess where your physiological range is. So, I don't do pellet therapy because of the super physiological ranges and perhaps things will get better in the future. And this is not to say anything negative about that if that's what you choose to do. But as a practitioner, I've seen so many women come to me with these 500 on their testosterone, which is male level, 300 and above is male level. Whether someone is slightly super physiological or slightly above the normal physiological range for testosterone and that what feels right for them. That's fine as long as they don't have the negative side effects with it.
[00:46:01] But these levels that go into the hundreds and hundreds are just dangerous, in my opinion. But very often, I think it is the missing thing, very often. And again, like you said, “Women will focus on libido as being the missing piece of the puzzle of that.” It's improved often when they start hormone replacement therapy, even estrogen alone is going to improve it to some aspect, but still not to the point. And what I will see is vigor, vitality, energy, ability to put on muscle and maintain their muscle as well as libido. Cognition too, are all really helped with addition of testosterone if the values are low on blood work. And in that way, I'll follow it. And women will often feel significantly better with testosterone being that missing piece for them.
Cynthia Thurlow: [00:46:47] Yeah. I'm so glad that it's something that more and more clinicians are talking about, because I feel like in many ways, for many, many years, there just wasn't enough emphasis. And for the benefit of listeners to understand the side effects of having super physiologic testosterone in women can have the potential, and I want to emphasize potential to be catastrophic. I was speaking to Dr. Pam Smith, and she's one of these anti-aging experts, and she said, “I cannot tell you how many women I've seen who've had, young women, late 30s, early 40s, that are getting pellet therapy, and in some instances, they're so super physiologic, they're actually having cardiac events.” Some of these women were having myocardial infarctions or heart attacks. And so, it can be a heart manifestation. But I've seen women with voice changes that don't go away. Clitoromegaly, so they'll get an enlarged clitoris. What are some of the other changes? Have you seen many of the extreme manifestations of having that super physiologic testosterone level?
Dr. Suzanne Fenske: [00:47:48] Yeah. I've seen rage and life-altering rage. Women will come in saying that they have no control over their emotion, and they have rage, acne, hair loss. And women are already battling hair loss during perimenopause, which is another common symptom of perimenopause and menopause is hair loss. And high level super physiological levels of testosterone cause hair loss as well. And then, yes, compounded by the fact I had a woman come in, and again, when I did her blood work, she had these super physiological ranges, had been doing pellet therapy, but she had terrible, terrible, terrible acne as well as hair growth on her body in places that you don't want hair growth to be. So, testosterone everything in life, all medications and all things have risks and benefits and just being informed and knowledgeable about them. But testosterone in physiological ranges is super beneficial to the body.
Cynthia Thurlow: [00:48:40] Well, thank you. This has been such an amazing discussion. Please let listeners know how to find you, how to work with you if they are in the New York City area and would like to work with you directly.
Dr. Suzanne Fenske: [00:48:51] Thank you. Thank you for having me. It's been wonderful. So, my practice is TaraMD, T-A-R-A-M-D. My website is taramd.com. and I'm on Instagram with @taramd4women.
Cynthia Thurlow: [00:49:04] Awesome. It's been such a pleasure.
Dr. Suzanne Fenske: [00:49:06] Thank you. Have a good one.
Cynthia Thurlow: [00:49:07] You too.
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