I am privileged to have Dr. Jessica Shepherd, a menopause expert and board-certified OB/GYN, join me on the podcast today. Dr. Shepherd is the author of the newly released book Generation M and has won many awards for her work as a physician and leader in women's health.
In our conversation, we dive into the challenges women face in talking openly about menopause and ovarian senescence, discussing the societal perspectives that shape those attitudes and contributing factors to accelerated aging during the menopause transition. We look at the findings of the SWAN study and discuss common symptoms of perimenopause and menopause, weight-loss resistance, estrogen and metabolic health, bone health, and the risks of osteoporosis and fractures. We also explore concerns around bladder health and urosepsis, the gut-brain connection, exercises for bone health, and the importance of a personalized approach to hormone replacement therapy.
You will not want to miss this rich and informative discussion with Dr. Jessica Shepherd.
IN THIS EPISODE YOU WILL LEARN:
How social conditioning impacts women’s perspectives on their value and worth, especially during reproductive years
The benefits of weight training for maintaining ovarian health
How menopause treatment and management varies for women of different ethnicities
The most problematic symptoms women face during menopause
How declining estrogen impacts weight gain and muscle loss
How proactively addressing menopause symptoms improves the quality of life for women
The benefits of hormone replacement therapy for improving bone density and reducing the risk of fractures
Why estrogen is essential for bladder health
The role of the gut microbiome in cognitive function
Why a holistic approach to health is critical for women
“Lifestyle choices are the fundamental basis of what our life looks like as we age.”
-Dr. Jessica Shepherd
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Connect with Dr. Jessica Shepherd
On Instagram: Jessica Shepherd or Modern Meno
Dr. Shepherd’s new book, Generation M, is available in-store or online from Barnes and Noble or on Amazon.
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 friend and colleague, Dr. Jessica Shepherd, a menopause expert and board-certified OB/GYN who's won numerous awards for her work as a physician and leader in women's health. She's also the author of the new book Generation M.
[00:00:44] Today, we spoke about why women are so uncomfortable discussing ovarian senescence and menopause due to social conditioning, values and perspectives around aging, contributors to the acceleration of the aging process, especially the transition into menopause, the impact of the SWAN study, common symptoms that Dr. Shepherd sees in clinical practice in perimenopause and menopause, the impact of weight loss resistance, the role of estrogen and metabolic health, the impact of bone health where 50% of women over the age of 50 will have an osteoporotic fracture and the impact on disability, the fact that one in four women will fall over the age of 65 and if you are osteoporotic, it's even greater, what forms of exercise are beneficial for bone health, the role of bladder health, concerns surrounding urosepsis, urinary tract infections, incontinence and more, why the gut microbiome is so important as we navigate this transitional time in our lives, the gut-brain connection and lastly, controversies around hormone replacement therapy and why a bio-individual approach is so critically important. I know you will love this conversation as much as I did, recording it.
[00:02:00] Dr. Shepherd, so good to see you again. I'm so glad to have you on the podcast.
Dr. Jessica Shepherd: [00:02:05] I am so glad to be here. I think that we really got to connect when we were together last and I have been so excited to just spend some time with you here on your special space.
Cynthia Thurlow: [00:02:16] Yeah, I feel like there's always these very serendipitous opportunities in the health and wellness space and certainly meeting you and speaking on a panel with you, the recognition of how much alignment there is and the way that we look at caring for middle-aged women and your philosophies and so I'm very grateful to be able to share your wisdom and your new book with my community. One of the things that really stood out as I was reading your book is you talk quite a bit about these uncomfortable feelings that women have around the aging process, ovarian senescence, menopause. Where do you think that stems from?
Dr. Jessica Shepherd: [00:02:52] Oh, that is a great question to start with. And there's so many answers to that. I think one thing that we seem to carry throughout our lives with us and then it manifests at this midlife stage is how we're conditioned socially. I think there's a lot of socialization around why we believe, as women, who we are, what our value is, what our worth is. And a lot of that is spent on the narrative in reproductive years. And so, if everything that you watch and everything that's told to you or expected of you is around that timeframe, then no one's really preparing you for the aftermath of that. And this is exactly what you could stage midlife is as the aftermath after reproductive years. But what do you do with that? How do you lean into that?
[00:03:41] And because we have considered menopause again and this other transition that is the end of something that was so celebrated then, obviously there's going to be a context around that, that this is now not celebrated, which it really isn't. And so, I think that's the socialization part, but also with life in general, aging is not something that we really deem as a badge of honor. Now some cultures do, and when I say this, I really am referring more to the western world, is that we look at aging as something that is of detriment of that is not good. And so that comes with it. So, it's actually compounded when you think of like this layer cake of all these things that lead up into midlife. But I think those are two pivotal things that lean into why we look at perimenopause and menopause as that.
Cynthia Thurlow: [00:04:33] Well, and it's interesting because I was having a conversation with my mom last night and she was saying that there was so much shame in her generation about even admitting your age, admitting that you are no longer menstruating. And she said, “My hope is that your generation will start to change that narrative.” So, I agree with you that there's a significant degree of social conditioning. I think that women in many ways are so objectified that when they become, and I'll use the terminology that many of my patients use, they feel invisible. They feel as if they don't get the respect or attention, and I'm not necessarily referring to objectification, but the attention that they once received that they then feel like they are devalued. And I think this is an important conversation to have because I know that my mother told me she was 30 years old until I was in my 20s. Of course, by then I knew she wasn't 30 years old, but I remember that was--- [crosstalk]
Dr. Jessica Shepherd: [00:05:29] Look I figured it out eventually.
Cynthia Thurlow: [00:05:31] [laughs] Exactly. But I think it goes with the prevailing philosophy, as you stated, that there are other cultures that really value their elders. They value people that have wisdom and knowledge and value and have a lot of experience. And sometimes in other cultures, that per se is not valued in the same way.
Dr. Jessica Shepherd: [00:05:49] Yeah.
Cynthia Thurlow: [00:05:50] Now, when I'm thinking about things that contribute to the acceleration of the aging process as a GYN, let's talk about some of the lifestyle pieces that can accelerate the aging process. Maybe things that are not as obvious then, smoking as an example. We know that smoking ages the ovaries at an accelerated pace. What are some of the things that when you're talking to a patient, that are red flags that allow you to hone in and make sure you're offering some caution around some of their lifestyle choices?
Dr. Jessica Shepherd: [00:06:22] Yeah. Lifestyle choices, to me, are one of the fundamental bases of what our life gets to look like as we age. Obviously, we have no control over what age will pass, but we do have control over as we age, that we get to design and craft just how sustainable our lifestyle is, but also how our body does in that aging process. Because you do have biological factors, which I would probably categorize as the uncontrollable part of the things that you don't have control over in the aging process. And then you have the things that which is what you're asking is of control. And I think one of the things I firmly believe has a deep impact on how we age. And if we're thinking, even ovarian health is nutrition and exercise.
[00:07:12] And that is what I talk about all the time. I mean, if you think of all chronic diseases, 7/10 are preventable. And a lot of those are preventable from those lifestyle things such as nutrition and exercise. But coming back to women is we, again, did not prepare women for this aftermath of reproductive years. And that's actually when a lot of the things that we were doing in the reproductive years do need to change. So, I'll give you a few examples. When we think of exercise, we are coming out of the phase of heavy cardiovascular. Not to say that it's not important. It's just that it needs to make a shift.
[00:07:47] So, we're coming out of the Richard Simmons, Jane Fonda era, where we're wearing our headbands and wristbands and jumping around for an hour, and we somehow think that we needed to increase the time of jumping around and running on treadmills, etc. And actually, it's opposite. It's now, we need to focus on our muscle, which is significantly decreasing, which has a tie to ovarian function as well because of the estrogen, is that exercise and weight training is going to now create that. When we think of that catabolic portion of what we want for our muscles to build them back up and so that is also a new feature that I find many women are surprised at. And really, we're at the early phases of how to actually emphasize that message, how to craft that message in the right way.
[00:08:34] But weight training is one of those things that I always say it's sexualized in. Weight training is for men, cardiovascular is for women. But really, women do need that. The other thing for nutrition is that shift in protein and in fiber and also supplementation. This is actually one of the things that Eudaimonia when we were in West Palm beach is we don't want to necessarily wait until the tank is empty before we supplement. We want to sustain that supplementation of the things that our bodies thrive on. And so there needs to be a shift in our protein intake, which again, is going to help with muscle mass, but also supplementation and not waiting until it's depleted before we're going to supplement it. So that would be like, our vitamin D, fiber is obviously very good for that as well. Vitamin B12 is very important.
[00:09:21] And also creatine, I think creatine is something that we don't again, put in our mental catalog of the thing that's going to sustain the protein, which is then going to help when you do the weight lifting, that's going to build the muscle. So, everything is connected in the body. I love that song. What is it? The hip bones connected to the—[crosstalk]
Cynthia Thurlow: [00:09:39] Thigh bone?
Dr. Jessica Shepherd: [00:09:39] Yeah, that one. Yeah, that song that I don't know.
[laughter]
[00:09:41] But that's really how the body functions. But somehow, and we've done this in medicine too. We have really separated our body out into these separate parts when really, it's all connected. But we don't teach that way. And therefore, patients in the population don't believe their body actually runs that way.
Cynthia Thurlow: [00:10:00] Well, it's very siloed and I talk about this a lot on the podcast that, when I was in clinical cardiology, I would sometimes get admonished if I called in a urology consult for a patient in the hospital because they were never on our service. That was one of the, I don't know if you know this about cardiology. The joke was you never wanted to have the patient on your service. You only wanted to be a consultant [crosstalk] for listeners. What that means is you are not ultimately responsible for being the quarterback of the care. You just come in as a consultant, you give your siloed, myopic view and you leave. But I would sometimes call in urology or I'd have another specialist come in. And my docs were always so upset with me. They're like, “Cynthia, this is not your responsibility.”
[00:10:41] And I said, “But this problem is impacting a lot of things, not to mention the fact their heart disease or their arrhythmias or these other things.” But the way that traditional allopathic medicine is designed to be right now, it is very myopic. It is very siloed. And I agree with you wholeheartedly that we are systemic organisms and every muscle, every tissue, every organ interacts with our entire body. And so important to be thinking broadly. Now, in the context of the book, you talk about a particular study called the SWAN study, probably not one we have talked about on the podcast before, but very important. Discussing racial differences, things that are unique to Caucasian, African American, Asian women, indigenous Americans, and how that impacts the way that they experience menopause, I thought was really interesting.
Dr. Jessica Shepherd: [00:11:35] I actually feel that the SWAN study is one of those pivotal studies that really allows women of all ethnicities to be seen. Because many times, when we look at evidence-based medicine, when you look at the population, a lot of times it's very monolithic, whatever that population is. But the only way we can truly give context to and allow women to of all to see, feel seen and heard is that's how we would have to conduct our studies. So, the SWAN study, what they were looking at women, I think from up until 2012 or something like that, I can't remember the year it ended, but looking at the actual symptoms of women as they go through menopause. And typically, I'll give you an example, hot flashes and night sweats are probably the most common that we talk about and most experienced.
[00:12:25] Looking at women from five different ethnicities. And they looked at Japanese women, they looked at Caucasian women, black women, Hispanic Women and Native American women. And from that they found that black women and Hispanic women had the longest duration of hot flashes and night sweats at clocking out at 10 years, 10.1 years for black women. And I think it was like 7.9 years for Hispanic women, as opposed to Japanese women and white women who were somewhere in the category of 4 to 5.5 years. So, if it doesn't necessarily mean that all black women are going to have it for 10 years, but that was what the average was coming in at, so it actually could have been a little bit more.
[00:13:05] What that really shows is now when you look at treatment and management. So, who now are most exposed to or have the resources to get management when we think of maybe HRT or even just being able to express to your doctor that you're having these symptoms? Black women will usually have the least resources and Hispanic women as well. So, look at that gap already when we think of who suffers the most, but who has the least access to.
[00:13:31] And so the reason why in Generation M, I really wanted it to be written for all women is one that any woman can read it and feel like some sense of being involved in the project of perimenopause and menopause through Generation M, but also understanding, “Oh, my goodness, this is why I feel this way or I'm not abnormal for bringing this up to my doctor, or maybe I am in my latter 50s and still having these issues.” And that may be just because of your ethnicity. And I think that we have to allow all women to feel included in this community. And if we don't do that, then again, we're going to create this widening gap of who should be treated, who should not be treated, what is okay to bring up in a doctor's office, what's not okay.
[00:14:20] And I think that we need to be able to support and the community that I wanted to create within Generation M is that every woman can support a woman no matter what her journey looks like in perimenopause and menopause, because they will be vastly different. I can tell you, even from the patients that I see, you know, my practice really is only focused on midlife. Every patient who walks in has a different story, but collectively together, they are all similar, but they're just different variances, intensities, and how they impact their actual life. That is the most important part when you think of perimenopause and menopause. It's not the fact that you have a symptom or that we're trying to prevent diseases in the future is for that individual, how is it impacting your life? And also, where do you see yourself in the future in 70, 80, and 90? Because that answer is also different as well. And so those objectives need to really be looked at and curated so that we're meeting each individual where they are.
Cynthia Thurlow: [00:15:15] Yeah, I think that concept of bio-individuality really rings true, certainly in these circumstances. One of the quotes you have in the book is “No two women will experience menopause at the same time in the same way.” And what you just stated really amplifies that. So, I had a guest on, her name is Andrea Donsky. She does quite a bit of research and has done some research around the symptoms of perimenopause and menopause. There's over a hundred of them. In your clinical experience, beyond hot flashes and vasomotor symptoms, what would you say are the top two or three that seem to be consistently problematic for women as they're navigating this time in their lives?
Dr. Jessica Shepherd: [00:15:54] Yeah, I saw a few patients yesterday, and again, they all had different stories, but the one thing that rose to the top was this. And I like to say it this way because I'm very [laughs] holistic in how I practice medicine, but I do believe in the holistic part of Eastern medicine and who we are as people. And I think the sense of self, the sense of self is something that comes up so often. And even for myself who's perimenopausal, there are very vivid moments that I've had throughout this transition of this sense of self and who am I and where am I and how do I feel about myself? And a lot of that actually has to do with the fluctuation of mood and neurotransmitters that occur during this time.
[00:16:36] That's why I really believe that this phase is a pivotal time to make it a moment of awakening and not to pull away from it, but actually to lean into it. And I think because of the way that our brains are structured and how we see these changes, because of the decline in estrogen and progesterone and testosterone offsets, how our neurotransmitters are actually functioning. So that dopamine and the serotonin and how they're circulating really does have an impact on our mind, our thoughts, our belief, our core system. And that's when I believe that the mind body connection is so important. If we don't bring that aspect into perimenopause and menopause. That is why a lot of women later on in life really don't push through and become that better version of themselves is because this is that time in which they were not valued, dismissed, misunderstood, and a lot of it had to do with sense of self.
Cynthia Thurlow: [00:17:35] Oh, that's such a good point. And, I reflect back on when I was in my probably early 40s, in the throes of perimenopause, and definitely felt like all the advice I'd always given my own patients was no longer working. And I kept thinking to myself, there's something that I did not learn across this journey. And so that's why I feel so passionate about helping other women navigate this time. And to say to everyone, I feel like menopause has been a heck of a lot easier than perimenopause when there was so much fluctuation in estrogen. And I think that's what drove a lot of the symptoms that I personally experienced.
[00:18:09] But what are the things that I think for a lot of individuals, certainly the women that come into programs or that we're talking to online, that seems to be one of the biggest pain points is weight loss resistance. Trying to figure out why the concept of calories in, calories out really, and the bros that are out there, the bro science guys that just, 25-year-old trainers that try to just say to women, “Hey, you just need to eat less and exercise more.”
Dr. Jessica Shepherd: [00:18:36] Yeah. Sounds so easy, yeah.
Cynthia Thurlow: [00:18:38] Yeah. Why do things get so complicated in middle age?
Dr. Jessica Shepherd: [00:18:42] And this conversation is relevant to probably all women because it's something on the list of things that are like, it was not your fault, you're not in control of this. But metabolically, again, estrogen declining has such an impact on the rest of the body, and that's again, why we have to treat everything systemically and holistically is because estrogen receptors are all over the body. We have really typecast estrogen and progesterone testosterone just to the pelvis. And so again, when the periods end, it's like, “Oh, well, that's the only thing that occurs in menopause.” But when we have all these receptors, specifically estrogen, I'll narrow in on that all over the body, we see metabolically, as estrogen declines, that the ability for insulin and glucose to have this fantabulous relationship is actually altered.
[00:19:30] And a lot of weight gain has to do with the ability of insulin to not function with glucose like it did before, and we become more insulin resistant. And all that really means is glucose is a fuel. It actually is a good thing, and it's what our body thrives on. But if insulin can't get it to where it needs to be, I call it like the foreman and the assembly line shouting out directions. You need to go there, you need to go there. And if glucose doesn't know where to go or it sits in the queue too long, or the foreman's not in and work as much as he used to be, that's where you start to see that glucose starts to sit around a little bit more. It's not utilized effectively. It's not metabolized. So that increases your fat, because glucose just converts to fat once it sits there too long and it's not being used.
[00:20:16] The other thing is that estrogen receptors are in our fat cells, and so are our fat cells are able to shrink or grow large or turn over. That also shifts. And so now a lot of times the fat cells without estrogen, they're like, “Well, I guess we'll just sit here and maybe we'll just get a little bit bigger too.” And you have that migration of the fat from the butt and the hips, which made us look so cute in our 20s and 30s and moves more up to the abdomen. So, think about it as this like car assembly, and nothing's really going right. People aren't showing up to work. Someone put the box of engines where the window shield wipers were, and it's all a mess. That is really what's happening internally. But we do have modalities and we can talk about that later on, how to get everyone back into their position.
Cynthia Thurlow: [00:21:00] Yeah, I think it's so helpful to understand that as these hormones are fluctuating and navigating this new normal, because we know that-- first we see this drop in progesterone, then we have these wild fluctuations of estrogen, sometimes the highest levels of estrogen we have our entire lifetime, which drives so many symptoms. And then there's a couple unicorns who still have and produce enough testosterone in menopause. But that's typically not the majority of women. And you're right, this complex interrelationship between metabolic health and the role of estrogen is so strong and so important. And I think about how estrogen and progesterone and testosterone have gotten so, in many ways, so misunderstood.
[00:21:43] I certainly finished my training right around the time of the Women's Health Initiative coming out [crosstalk]. And I remember, my cardiovascular patients sitting in my office or telling me in the hospital that they were taken off their estrogen and they were having wild symptoms. I mean just so magnified. I would sometimes have women cry to me and just say, I felt so much better. I now have achy joints and my feet hurt and I can barely sleep. And you just start to think about how things have evolved over the last 20 plus years. And I'm so grateful that the pendulum is starting to swing back in the opposite direction.
Dr. Jessica Shepherd: [00:22:21] It's a slow start. It's like a little that we're trying to get some gas in, but we're getting there. [laughs]
Cynthia Thurlow: [00:22:27] How long ago did you finish your training? So, you probably have been able to see this evolve in a wonderful way over the last 5-10 years.
Dr. Jessica Shepherd: [00:22:36] Oh, yeah. When I was finishing it, the WHI had already been reported. And so, it was in the mid to the tail end of pulling everything. And so, it wasn't as pronounced as how you-- It was like one day you went in and then the next day you were like, “Wait, what? What happened?” So, we had been at the point where it was very part of our training now. So, now it came from the shock of it to now we're going to implement it into the actual training of it. So, we're right at the beginning of the vigorous, cannot do this. This is why. And now seeing, fast forward in the last five years, just the beautiful evolution of how we are now able to take a deep sigh of relief.
[00:23:18] For those of us who have known for some time that estrogen really has some benefits in addition to progesterone and testosterone. But being able to be a little bit more forward with it and being able to have the context and the studies that clearly show that estrogen really is so beneficial for women, not only for symptom relief, but also for longevity.
Cynthia Thurlow: [00:23:37] Absolutely, when you're talking to your patients about bone health, I think this is a big topic. We know one in four women will fall after the age of 65 if they have osteoporosis, which is, bone that is poor structurally, the risks are even greater. I have a family member who broke her hip two years ago, fell and broke her femur on the same side. She has not been able to walk since May and it is devastating for her. She's someone who's cognitively sharp, but her body is really failing. Let's talk about what is happening to our bone as we are navigating this menopausal transition. Because this is super significant. Everyone who's listening needs to be aware of bone health risks and what we can do to offset this transitional time.
Dr. Jessica Shepherd: [00:24:25] Yeah, so osteoporosis and osteopenia, which I'll just share my gripe before I start, is that the fact that we do DEXA scans to check for it at 65 and annoys the hell out of me. But nonetheless, when we think of bone health, our bone is really organ of vitality in the sense of when we get older, that really is our stability in addition to muscle. So, when estrogen starts to decline again, that relationship of estrogen receptors on the bone being able to make sure that we're increasing our osteoblast, which is going to build our bone up, we start to see a shift again in that relationship between the cells that build bone up and that breaks it down. And you'll start to see more of the cells that break it down, have a priority.
[00:25:09] And that's what we start to see, over the course now of what, 20 years, when we get into our 60s and 70s, our bone foundation and structure has demineralized to such a degree that even at the smallest fall, it’s like powdered, just like blows the bone apart. And so, the studies clearly show that estrogen is directly correlated to bone strength. And so, without women having this one knowledge base and fundamentally knowing that, “Well, if it's going to protect my bone and help my bone strength, why wouldn't I take it?” But also taking away the scare tactic that was used for 20 years. Estrogen causes breast cancer and everything comes with risk.
[00:25:55] But now that we can identify what that risk is, which really is not a significant risk to, say, breast cancer, but it creates such a huge benefit to bone strength. That's where I like to drive the conversation is because everyone at the end of the day has a choice in what they would like to take, partake in how much they would like to do. And when you're able to present everything to the forefront, that's when I think that we're able to give better ideation around making decisions and patients having agency versus giving it in only certain subsegments of information which can either be for or against. And it should be brought together so the patient can therefore decide, what do I want my life to look like? What are my risks when I get older and what am I willing to take a risk on for me individually.
Cynthia Thurlow: [00:26:43] I think it's so important and I think about the fact that certainly my generation we were started on oral contraceptives at a young age, late 20s, early 20s, late teens, wherever that fell and missed out on peak bone and muscle mass building. So, I think my generation, there's a lot of women who started out perimenopause, osteopenic and we recognize this is not technically a diagnosis, but when they're comparing 50-year-old bone to 25-year-old bone, you know that you're at a disadvantage already. But when I think about, as you stated appropriately, women not getting DEXAs until they're 65, it's like a shot in the dark. You don't know, it's like a ticking time bomb.
[00:27:23] If you know at 40 or 50 that you have work you need to do, it can help you with the, as you mentioned, agency being able to make decisions with your clinician, but be able to say maybe I really need to think about hormone replacement therapy because I'm already osteopenic. I missed out on those benefits in my 20s and 30s and now I recognize how important it is to have healthy bone. What types of exercise do you like to counsel patients on for bone building specifically?
Dr. Jessica Shepherd: [00:27:52] Yeah, for bone building and also for improvement in muscle as well, in bulk of muscle, meaning strength. So, one, building up your bone for improving quality of bone, but also building your muscle for strength is going to be your weight training. So, any type of resistance training and so the goal is to get one, get you there safely with heavy, so please don't go squat like 100 and what, 100 and 60 pounds tomorrow in the gym. But the other part of that is resistance training can be just with your body, right? So, whether that's push-ups, whether that's lunges, but also with things like Pilates and water aerobics are also helpful as well.
[00:28:29] Because I think the other thing that I've seen start to happen here is as we're new in this wave of information and understanding really what perimenopause and menopause is and estrogen, is that we are trying to get the message out in a big way. And sometimes we only focus on one part of something. And so, the message might sound like right now only eat protein and just lift heavy weights. When really the message is understanding the importance of it, but not taking away from some of the other features that also need to be included. And that's why when we hear like lift heavy and I say it all the time, lift heavy shit. But I think also Pilates is okay to do. And I think that other resistance training exercises are easy or okay to do as well as cardiovascular.
[00:29:18] And so weight training, to me, is one of the easiest ways as far as results, one of the easiest ways that you can improve bone and also maximize on increasing your lean muscle mass.
Cynthia Thurlow: [00:29:29] Yeah. And I think for a lot of women, it's still that prevailing philosophy of, “Oh, I need to just go run 5 or 10 miles. That's what I need to do to maintain body composition.” And it's not to suggest we're telling patients we want you to be couch potatoes, but understanding that we start having this acceleration of muscle loss after the age of 40, that's called sarcopenia. It's not a question of if, but when it will happen. And what goes along with muscle loss over time is this risk for frailty. And frailty is something we all want to avoid. We probably all have loved ones that are older that we see them and they either don't move very efficiently. I've been in multiple airports over the past few days, and I'm oftentimes stunned and humbled by some of the people I see walk in and off the plane. And I'm like, “Gosh, all they would need is to lose their balance, and they look like they would just fall over and break.”
Dr. Jessica Shepherd: [00:30:22] Yeah, yeah.
Cynthia Thurlow: [00:30:23] We want to avoid that at all costs.
Dr. Jessica Shepherd: [00:30:25] At all costs.
Cynthia Thurlow: [00:30:27] That muscle piece and the avoidance of frailty is so, so important. It is not just about aesthetics. Now, I want to pivot a little bit about some questions that came in around bladder health. I know it's a super sexy topic, but one that I know you are talking to your patients about all the time. Let's talk about what's changing in our genitourinary system as we are navigating this transitional time. Because many women are oftentimes too embarrassed to talk about these symptoms, dryness, lack of lubrication, painful sex, etc. But there are many things that can be done to improve these symptoms even if you are slightly uncomfortable having the conversation with your provider.
Dr. Jessica Shepherd: [00:31:08] Mm-hmm. Bladder health is important. So, just a quick statistic. If you look at nursing homes and admission rates for women specifically, one of the key indicators of how a woman will do in there is actually her bladder health. Because if she has a lot of incontinence, whether it's stress or urge or overactive bladder, that actually leads to One, quality of life. Because you have a lot of moments when you're leaking, but also increase in sepsis because of urinary tract infections. And a lot of times urinary tract infections in older women are very asymptomatic. And then they'll have just like a change in mental status. No one knows what's going on. And really the prime reason why they're having that is that they're septic from a urinary tract infection.
[00:31:55] So, I think again looking at later in life, how do you want to show up later in life? Minimizing frailty, like you just said, minimizing the need to have to go into a nursing home because of mobility factors. And then the other thing too, which we may touch on this a little bit later, is dementia. So, going back to the bladder, you know when you start to decrease estrogen, think of the pelvis or think of a cluster of rooms, and you have one room, if you're sitting in it, you're like, “Oh, I'm in the vagina right now.” And then if you look up above and look at the roof, the floor above you is going to be the bladder, and the floor below you is going to be the rectum.
[00:32:33] So, all the tissue that's in the pelvis, estrogen is usually very predominant, which causes blood flow, increases secretion, the ability for your actual organ, whether it's the vaginal canal or the bladder to contract and to function for what its purpose is. So, when you lose estrogen, you lose a lot of the vascularization to the bladder, your sphincter ability to stay shut and keep open, or even the strength of your bladder to hold urine when you cough, sneeze, laugh, jump, and all the things that are going to increase the chances of you having leakage. And then also the ability for you to decrease your bacteria levels in urine, because you really should. It's filtering process and you want to get out all the bacteria, but if it stays in the bladder, that's what's going to increase your risk for urinary tract infection.
[00:33:22] So, all of those together are directly linked to estrogen. And so, once that declines, then you do start to notice that you have a decline in bladder health. And so putting it right on that list, like you were talking about, Cynthia, functionality when you're older, walking on that plane and being able to hold yourself up because you have good balance or you have strong bone health or being able to do the things that you want to because you don't have to worry about your bladder, like, that's how I think if we were able to reconstruct the concept of healthcare or health discussions with women, I think that they would have an easier time understanding why they need to do the things now versus saying, “This is something that could happen. You should take this medication or you should do this.” That's just not enough to me. I want people to really invest in the reason why they're doing things and want an amazing quality of life as they start to age.
Cynthia Thurlow: [00:34:14] Well. And it's interesting when I reflect back on most of my cardiology patients that were over the age of 65, thousands and thousands of them were on low-dose antibiotic therapy for years and years and years because they had chronic urinary tract infections. And now with this profound realization that a little bit of vaginal estrogen probably would have gone a long way to help prevent, as you mentioned, not just urinary tract infections, but this urosepsis, which means someone gets a urinary tract infection, they get septicemia, so they get a blood infection and that's when grandma or your loved one shows up in the ER and they have no idea where they are, they have no idea who they are and you realize they've got this whopping infection and that then leads to a sequelae of disability-related issues. It can be quite significant. Sometimes these elderly patients end up in the ICU and they don't make it out from something as simple as a urinary tract infection.
Dr. Jessica Shepherd: [00:35:16] Absolutely. I know you've seen it and it's so sad when you see it because you were like trying to bring in every modality that you can and I think it's the sadness for me when I would see those patients. Is that it? You look back and you're like a urinary tract infection caused this patient to be this sick. That to me is really sad. And it actually happens more often than not or than one would think. And again, it's the simple things you think of just like, “Really, I could have maybe improved my bladder health if I had known ABC and started earlier in my life.” And that again goes to the lifestyle part of it. I think, these small incremental steps that we start to make early in our lives, whether that's with our headspace and mental and emotional health, or bladder health or muscle and bone health, that's really how you're going to make the big impact later, is making these small steps in your life from now.
Cynthia Thurlow: [00:36:08] Well, and I love that you talk to your patients about not just this is what will treat this, but helping them understand why it's so important. The sequelae of not addressing this proactively really does become problematic. And for listeners, I have a loved one, she was a female, menopausal female, developed urosepsis, couldn't tell anyone that she had lost vision in an eye. By the time she had been treated enough to be cognizant of the fact that she was in the hospital, she told a loved one, I can't see out of one of my eyes. It turned out she had a retinal hemorrhage. She now has at least a 70% reduction in one of her eyes and the other one is like a 90% reduction. And this is someone who was driving, active, doing all the things simply from urosepsis.
[00:36:56] So I agree with you. Everyone listening just needs to be aware. We don't need to be paranoid, but just understanding this complex interrelationship. And the other thing you mentioned in the book, just to give people an idea, we think about incontinence, overactive bladder, urinary tract infection. But these overactive bladders, these are people that go to the bathroom and then feel like they haven't filled, they haven't emptied their bladder, they go back to the bathroom. That impacts 30 million people. There are 13 million people per year impacted by incontinence. And then 81,000 of us develop bladder cancer. That blew my mind. And it's because we don't talk about these things.
Dr. Jessica Shepherd: [00:37:33] No, we talk about it once it happens right? [crosstalk] And I think that's healthcare in America. We wait till people are sick to treat them, but we haven't placed the emphasis on, let's not even get you there, because we're going to start these conversations, we're going to give you the tools that are more preventative and improving your actual daily lifestyle is going to improve your life overall. We don't treat it that way. We're like, “We'll wait till you're sick, then we'll talk about it.”
Cynthia Thurlow: [00:37:58] Yeah, no, that's the traditional allopathic model. And my hope is that, giving platforms to work like yourselves will help people start the conversations with their own provider or find a provider that will work in tandem with them based on their goals to avoid things. I do want touch on the microbiome because this is a particular passionate area of mine. What is changing the microbiome as we are navigating this perimenopause into menopause transition, because it is far more important than people realize. The gut microbiome is not just in a vacuum. We have the oral microbiome, the skin microbiome, the vaginal microbiome. They are all connected.
Dr. Jessica Shepherd: [00:38:36] Yeah, well, the gut microbiome to me is one of those very new, fascinating features of medicine and innovation and also leading to technology advancement as well, is that microbiome of the gut is so very important not only because the gut takes up a good portion of our body, but also its responsibility. You have this very long organ. And what it is, I always say that it has a covering or a sheath that looks like a-- on a window. What do you call it? The screen.
Cynthia Thurlow: [00:39:08] Film, yeah.
Dr. Jessica Shepherd: [00:39:10] Yeah, the screen on a window. You remember barely anything can get through it. And that's really what its goal is I'm going to let the stuff that doesn't need to be here out, and I'm going to keep the stuff that needs to be in here good. Estrogen receptors, like we said earlier, all over the body, and they are all along the colon and the intestine. And so, what happens again with a decline in estrogen? It's going to have that shift in that beautiful, I call it like a wine cellar. I say that like the microbiome in the vagina is like a wine cellar. It wants to be at a certain temperature, so the wines are perfect.
[00:39:41] And the decrease in estrogen throws off that pH and that temperature and the ability for the gut to keep in the bacteria that kept everything status quo. And it lets some of that out as well as some of the ones that shouldn't be in there and so that screen gets a little bit bigger, all those little holes get a little bit bigger. And so, the filtration and the ability to process and restore is diminished. With that is going to come increased sensitivity to food. A lot of my patients complain of bloating. You start to have gut and bowel changes. But it also impacts a lot of other parts of your health inflammation. It also has a very big, rich connection with the brain.
[00:40:22] So, you have the gut-brain barrier in where the blood flow of what goes to the brain is again, filtrated through the gut. So, if a lot of things that were not supposed to be there are there, then that also can impact, brain health as well. So, again, this is how our body is so connected. And I want people to view it as such a beautiful relationship between all the organs, because it's a symphony and the symphony wants to sound really, really good. But when you have that trombone that's over there in the corner just like off key and you're just like, “Oh my God,” you want to pay attention to that before, the actual performance begins in practice and when we're practicing, the piece does not sound good. That's the awareness I want people to have. It's like something's off and I need to pay attention to it. So, the symphony of my body and my health is on point.
Cynthia Thurlow: [00:41:09] You mentioned that bidirectional relationship between the gut and the brain. What are some of the more common symptoms women will come to you about that are suggestive of their brain, the fluctuations in estrogen are impacting their cognition, their ability to remember things, they get very forgetful, etc.
Dr. Jessica Shepherd: [00:41:28] Yeah, that gut-brain barrier is also to our cognition, I would say like our executive functioning and I and our executive functioning, is that like you said, that ability to recall memory, what was I doing? Multitasking all of those beautiful things? That is this complex communication system does have a connection between the gut and the brain where the gut microbiome can significantly influence cognitive functions. And so that is where again, looking at hormone replacement therapy in a different way can really- Well, there's two things. I think hormone replacement therapy is important because it restores the levels of estrogen, that keeps everything in check and balance. But also, our nutrition, because that's where we're going to see some of the largest impact is how we're fueling our gut.
[00:42:16] And so if we know what the role of the gut microbiome is and how important it is, then we also have to provide it with the best tools for it to have that function. And so, this is where nutrition really falls into place as we start to age. Because this is the biological part, our bodies just are not going to be able to function as well as they do as we start to age. But we do have control over the availability of the tools that the body would like to still use to function at its best. And that's where nutrition really plays a part in that as well.
Cynthia Thurlow: [00:42:49] Yeah, it's so interesting to me, this probably wasn't the way that I thought when I first started practicing as a nurse or nurse practitioner, but certainly now I always feel like it all starts with food. Like food is so critically important and yet the traditional allopathic model doesn't give it enough credit, but it can make a world of difference, especially in middle age and beyond. I mean, if you are still eating the way that you did as a teenager, the way you ate in college as a middle-aged person--[crosstalk]
Dr. Jessica Shepherd: [00:43:17] Is that a problem?
Cynthia Thurlow: [00:43:18] It's going to be a problem for sure. We've touched on a little bit here and there about hormone replacement therapy. Now obviously I know from our conversations at Eudaimonia that there's a plethora of options and you are a fan of all of them based on what a particular female needs.
Dr. Jessica Shepherd: [00:43:36] Yeah.
Cynthia Thurlow: [00:43:38] Why do you think compounded drugs are coming back in favor? For many people, they may not realize that in the 1930s, 1940s, 60% of drugs were actually compounded until the pharmaceutical boom. Why do you think things are coming back in favor? Is it a limitation of our existing pharmaceutical options? Do you feel like really finding that bio-individual approach, finding what works best for each patient and not having a one size fits all philosophy?
Dr. Jessica Shepherd: [00:44:05] Well, great question. I think that there are multiple reasons why compounding is being more seen, more understood and more accepted. And like you said, again in context, decades ago that was really the primary way of getting medications until, pharmaceutical companies pretty much dominated the field. So, now what we're seeing is people are more invested in the N of 1, meaning what is best for me rather than what is best for the whole entire group. And that's where compounding really has the ability to create a customized medication or a customized supplement or hormone, rather than just only limiting to what's available from a prescriptive frame of a pharmaceutical medication.
[00:44:53] But that also relies on who the provider is and understanding the art of compounding as well, in order to make sure that they're able to follow their patient or track and trend their patient in the right way. So, they are getting that effectiveness and quality of the compounded medication. The other thing is that I think that pharma really, from the time that they started, they really did come out trying to say that we want to be in the forefront of who drugs are, what drugs are to the population or the US or whoever, globally. And so that had to be done with fervor and with confidence and coming out big. And that's what they did. And I think now we're starting to see the other side of that, is that two things actually can be true at one time.
[00:45:38] And I think that there is space for both of them at the table. And I don't think it should be this competition. I think that the beauty of someone navigating their health journey, understanding what they think is best for them, should come from knowing both of those fundamental baselines of who they are, what they are, how they provide, how they make them. And you then get to decide. And that might mean that you may go through the course of finding your health journey by trying various kinds of medications from pharmaceuticals and also from compounding, but the only person who's going to know exactly what is best for them is the person who's taking it. And that's why I really, when people come into my practice, I give all the disclaimers, all the information, and at the end I'm like, and here this is. And what do you think is best for you to start with?
[00:46:23] Because they may change their mind or it may not respond the way they wanted to, but guess what? That's because we're all different and we all respond differently. I have to just be responsible to navigate you through that journey in the best way.
Cynthia Thurlow: [00:46:35] I love that. And I think that every woman listening wants to have a provider like that. So, thank you for the work that you do. I think that I would love to end the conversation today talking about perhaps some of the things that have evolved for you as a clinician with regard to hormone replacement therapy. I'll give you an example. I was in the functional integrative training that I've had, I was taught to believe that compounded drugs are like, the top options available. And for full disclosure, what I have humbly realized for myself personally, again, the N of 1, this is what works for me, may not work for anyone else, is that I do better with an estrogen patch than I ever did with compounded estrogen. So much so that the I call it the menopausal fluff that I've been dealing with, it's been so frustrating. I was like, “My body just needed estrogen.” It literally just needed more estrogen. And now I feel completely different. I'm like, “It's amazing to see that.” So, for everyone listening, you can start off with one regimen and you can shift and go to another regimen. You don't have to stay in one lane.
Dr. Jessica Shepherd: [00:47:40] You cannot be forced to do just one thing.
Cynthia Thurlow: [00:47:43] Yes, it's amazing to see that. So, I'm curious for you, what have been perhaps some of the things that you've evolved in or you've changed your mind around things that, in terms of the approach to hormone replacement therapy or different types of modalities.
Dr. Jessica Shepherd: [00:47:57] Yeah. What has really changed my mind again, coming looking at my training years and what was available to me at that time did create this channeling or neuroplasticity in my head of these are the only things that I can recommend. And what I have found is exactly like you said at the N of 1, my patients really have different responses or even ideas of what's best for them initially. But I think that the ability for them to be vulnerable for us to have a safe conversation in the exam room and once they leave, they don't feel as if whatever decision they made and walked out with is going to be the one that they have to stick with. So that has even changed my mind because as a clinician, right. You really want to be sure of what you're telling your patient.
[00:48:45] And I had to be very humble and vulnerable to take a step back and say there are other modalities. And even using compounding for me, very traditional allopathic, I was taught opposite to what I learned in functional medicine as well as compounding is bad. And even being humble and saying, finding out more about compounding and realizing that some of my patients actually did better on that or vice versa even like for you. But I had to lend myself to the opportunity to be vulnerable and being like, I do not know everything and sometimes that's hard for a doctor to say. I say it much more now than I did in the past, but that has allowed me to be curious and I think curiosity breeds growth and the ability for me to connect with my patients better.
Cynthia Thurlow: [00:49:31] Oh, well, thank you so much for your time today. I know there were a couple things that kind of got it, life happens. But I'm so glad were able to make this conversation happen. Please let listeners know how to connect with you if they are in the Dallas area, how to work with you as a patient, how to purchase your new book or follow you on social media.
Dr. Jessica Shepherd: [00:49:47] Yeah. If you're in the Dallas area and I even do Telehealth, the name of my practice is Sanctum Med and Wellness and our website is sanctumwell.com and then for my book, Generation M. So proud of it. And it really was a love letter to all the women that I've seen and also to myself being in perimenopause. You can get that at Barnes & Noble in store or online or you can get it on Amazon. And then if you want to follow me, I'd love to have followers. I'm typically on Instagram @jessicashepherdmd and that's S-H-E-P-H-E-R-D-M-D or Modern Meno, which is really my platform devoted to perimenopause and menopause, that's Modern Meno.
Cynthia Thurlow: [00:50:24] Thank you so much for your time.
Dr. Jessica Shepherd: [00:50:26] Thank you.
Cynthia Thurlow: [00:50:28] If you love this podcast I episode, please leave a rating in review, subscribe and tell a friend.
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