Ep. 513 Fasting Doesn’t Work the Same After 35 – The Shocking Truth About Hormones, Hunger & Aging with Dr. Stephanie Estima

I am thrilled to reconnect with my dear friend, Dr. Stephanie Estima, today.

In this episode, we dive into questions from listeners once more, exploring topics that range from navigating the challenges of perimenopause and parenting to shifting perspectives on fasting, nutrition, and changes in hunger and thirst cues, especially during perimenopause and menopause. We also examine how dairy may become an inflammatory food item in midlife, the benefits of hormesis, hormone therapy, and so much more.

Our conversation today is honest and warm, so it is like sitting down with two close friends. Both Stephanie and I look forward to sharing many more of these Q&A sessions with you in the future.

IN THIS EPISODE, YOU WILL LEARN:

• Some advice for mothers navigating perimenopause 

• How to adjust your fasting in midlife

• What perimenopause and menopause mean for satiety and hydration signals, and how to adapt

• Why some women find dairy problematic in midlife, and how to experiment with reducing it

• How hormesis builds resilience, and how stressors, like exercise, fasting, and cold/heat exposure, can improve metabolic and overall health

• What you need to consider with hormones like DHEA and pregnenolone

• How women with MTHFR can support methylation and detox pathways

• The benefits of combining strength training, Zone 2 cardio, and occasional HIIT for fitness in midlife

• Why you should embrace your callouses as badges of honor instead of trying to remove them

• The value of micro-dosing with peptides and GLP-1s

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“Full-body workouts twice a week can be incredibly effective.”

– Stephanie Estima

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Connect with Cynthia Thurlow  

• Follow on⁠ X⁠,⁠ Instagram⁠ &⁠ LinkedIn⁠

• Check out Cynthia’s⁠ website⁠

• Submit your questions to ⁠support@cynthiathurlow.com⁠

Connect with Dr. Stephanie Estima

• On Instagram

• On her weekly podcast, Better! With Dr. Stephanie

Transcript:

Cynthia Thurlow: [0:00:02] 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. 

[0:00:29] Today, I had the honor of reconnecting with dear friend Dr. Stephanie Estima where we dove into listeners questions once again that ran the gamut between navigating perimenopause and parenting, our shifting perspectives on fasting and nutrition, understanding hunger and thirst cues, especially as they change in perimenopause and menopause, how dairy can potentially be an inflammatory food item in middle age, the benefits of hormesis, navigating hormone therapy, and so much more. 

[0:01:04] This is one of those conversations where you're going to feel like you're sitting down and listening to two close girlfriends dive into some of these topics. As Stephanie and I discuss, we will definitely be doing these with greater regularity. There is so much synergy between our communities and obviously we love having opportunities to serve all of you at a deeper and greater level. 

Dr. Stephanie Estima: [0:01:28] Cynthia, I'm so happy to be doing she said, she said with you again.

Cynthia Thurlow: [0:01:32] I can't imagine where else I would want to be this Friday afternoon recording with you. 

Dr. Stephanie Estima: [0:01:37] Yeah. Last time we did this, our AV tech told us was April. So, we are going to make sure that we do this more often because every time I get together with you, I have a grand old time and I know that our listeners also love to hear it as well. And we've been polling people for questions. And man, we have a lot of questions to get to today, so where would you like to start? 

Cynthia Thurlow: [0:01:57] I would love to start with any advice for a 45-year-old navigating perimenopause with a 4-year-old, that's a lot. 

Dr. Stephanie Estima: [0:02:07] First of all, congratulations.

[laughter]

Dr. Stephanie Estima: [0:02:10] Are you finding this, Cynthia, that there's more and more women in perimenopause having their first child. So, they are 40, 42, 44, 48 and they have a toddler at home and it's like what is it postpartum? Is it perimenopause? Like which one is it? Are you finding more and more of that in your community? 

Cynthia Thurlow: [0:02:30] Absolutely. But to be completely transparent, I had my second at 36- 

Dr. Stephanie Estima: [0:02:35] Mm-hmm. 

Cynthia Thurlow: [0:02:35] -and I would probably guess a lot of the symptoms that I experienced at 36 as a thin phenotype PCOS, so we’re probably more a reflection of low progesterone that was just magnified in that postpartum state. And so, I'm particularly sensitive to people like this because perimenopause is a wild ride. It is not for the faint of heart and I think about the additional demands for all of us with little people at home and you have to feed them and bathe them and dress them and there's just a lot of hands on--

Dr. Stephanie Estima: [0:03:12] Lack of sleep. There's no sleep. 

Cynthia Thurlow: [0:03:14] The hands-on parenting piece. And I think not enough of us talk about the wonderful, deliriously tiring aspects of parenting. I say all the time, I would go back to that stage in a heartbeat because I've loved every stage. But I think many of us don't talk about how hard it is. And I say this, whether you work outside the home or not, that being a parent is in many instances, especially when you have preschool or toddler or early elementary school age children, is exhausting, truly. But it is this wonderful dance that you have where you're trying to find some degree of balance. And then you add in the fluctuations of hormones that are starting to shift in your late 30s, early 40s, and I think it could make it even more challenging. 

I reflect back on even I'm 54, even 10 years ago that's when I really started to feel perimenopause, like in my toes. I was like, something is up. And my kids at that time were 10 and 8 and it was tough. So, I think it's even more challenging when you have younger kiddos for sure. 

Dr. Stephanie Estima: [0:04:26] Yeah, I agree with everything you're saying. Sometimes I feel-- I find myself lately thinking about just being nostalgic with-- my kids now are teenagers and wanting to do normal teenage stuff, which is like hanging out with their friends and they're really entrenched in their extracurricular activities. I'm like, “Oh, there was a time not too long ago when I was like everything to them,” and there can be that nostalgia. 

[0:04:48] But to your point, I was also so bagged, I was so tired. Even if they had regular sleep-- Like one cold would throw off their sleeping. And the demand that you know emotional and physical and psychological demand doubles on you. 

[0:05:04] So, for her, as a 45-year-old woman navigating perimenopause, what couple truths that we know is that as you already mentioned, her progesterone levels are low. So, they're steadily declining and have been for probably about a decade at this point. So, she's probably going to find that her resilience and the things that set her off the bar for that is going to be much lower, like that tripwire is going to be much lower than what it otherwise might be, so just being aware of that.

[0:05:31] You and I talk about this all the time, but one of my saving graces, like totally got into fitness for aesthetics, but stayed for the mental fitness and the mental strength and the clarity that it gives me. So, in whatever small little five-minute moment that you have, if there can be some body weight squats or some sit ups or some push-ups, even with the baby, like your four-year-old. I was still carrying my four-year-old-- you walk across--

Cynthia Thurlow: [0:06:01] Same.

Dr. Stephanie Estima: [0:06:01] -like maybe they would and you're holding them. So, you can do squats, lunges with the babies. We used to do something-- I used to do something with my kids called Kitty bell, what did I call them? Kitty Bell swings. So, kettlebell swings. So, I would like take the kid and I would like strap them into my arms and I would swing them up and down and I would do a little squat in between, so those are my Kitty Bell swings. 

[0:06:21] So there's like little ways that you can get in activity, which I think obviously is going to be great for your blood sugar regulation and your energy, but it's also going to be a way for you to connect. Like 4-year-olds are rambunctious. They want to run around and so you can match them and play with them by integrating some movements, that's how I would approach that. 

[0:06:40] And then maybe the other thing I would say is just be really gentle with yourself. We're so hard, myself included, so hard on ourselves at every stage of the parenting game and the extracurricular activities and am I doing the right thing? Oh, I got mad at my-- I snapped at my husband or snapped at my kid, like we're so hard on ourselves. So, I would just say as much as you can giving-- Like being merciful with yourself and giving yourself some grace, I think is maybe the most important thing. Nobody wants to hear that, but I would say, you know, giving yourself a break. 

Cynthia Thurlow: [0:07:14] Yeah, I would say-- We both have all boys and I made it really clear to my boys that being physically active was important for all of us. And so, we would go to the park. We would go to the library. We would walk through the neighborhood. We had a lot of trails. And so, for me it was this physicality, like how can I get my physical needs met with being physically active amongst doing activities with them and telling them how important it was for their bodies. Like, you sleep better when you exercise. And so, I sleep better when I exercise. 

[0:07:49] I think the one thing that I would say is that a lot of 45-year-olds are actually at a point where they should consider the addition of hormone replacement therapy. So, even if it is for one week out of the month, buffering the effects of that drop in progesterone. You already have less circulating progesterone in the luteal phase. But many people, even if it's 50 or 100 g of oral progesterone therapy can be very, very helpful, can help with the really heavy cycles, a lot of the estrogen dominance-type symptoms that we experience that for a lot of women are really bothersome. The bloating, breast tenderness, very heavy cycles. I used to call them the crime scene periods, [Dr. Estima laughs] but all those things are real issues.

[0:08:31] And the other thing I would say is at 45, I probably, if you are drinking, I would say just be mindful of the impact of alcohol on your sleep quality, because sleep is so foundational to our health. That's the other side of that loss of progesterone, more anxiety, more depression, more potentiality of insomnia. If you feel like when you drink alcohol it's eroding your sleep quality, you may want to cut back or eliminate. And I think we have this mommy drinking culture. Maybe this is a larger conversation-

Dr. Stephanie Estima: [0:09:00] Yeah. 

Cynthia Thurlow: [0:09:01] -this mommy drinking culture. And there's no judgment when I say this, but many women in order to cope with the stress of parenting, sometimes we'll get accustomed to having a glass, two, three, four a night of wine or a beverage. And cumulatively, over time we know that there are very little to few positive net effects of the consumption of alcohol at this point. And knowing what it's doing to us in terms of our sleep quality and our metabolism of hormones and detoxification in the body. If you're noticing that, “Oh, that night that I have a glass of wine, once the kids go to bed, those are the nights my sleep is worse,” just understanding that is a byproduct of ethanol and our bodies prioritize it as a toxin first and foremost. So just something to consider. And if you're not drinking, great. If you are drinking, just something to consider. 

Dr. Stephanie Estima: [0:09:53] Yeah, I completely agree with you. I have come to maybe a harder stance, which I know people will don't like, but I don't actually see the value in alcohol. I think that there's a sensitization too, where alcohol tends to hit differently in midlife than maybe what it did in your 20s and your 30s. And to your point, like the liver is going to prioritize that to turn it into its intermediates and to be able to expel it from the body. But I really don't see-- if there's-- if you're trying-- if it's a coping strategy, if you feel like it's the only way that you can unwind. I know that there are different ways that you can find strategies to cope with the stressors in your life. I do think that's a maladaptive. 

[0:10:32] And I'm saying this with love. It's like I'm not calling you out, I'm calling you up. It's like I think that there can be a better strategy that you can find to deal with the stressors of raising a child or maybe whatever the situation might be. I would take a hard look at what are some of the other things that you might think about replacing that glass of wine with. Maybe there's a walking club. Maybe there's a pickleball. We know in midlife, pickleball becomes all of our personalities to some extent. [laughs] 

[0:10:58] Is there something, is that you can find, you know a community, like a way of bonding with other people, other mommies. Other moms with 4-year-olds. You can have something that's not alcohol. I really feel like in terms of the-- as you were saying like the metabolic consequences, certainly body composition consequences as well if you're concerned with that. Sleep, as you've mentioned. Energy, yeah, I don't really feel like there's a place for alcohol for women in midlife at all. 

Cynthia Thurlow: [0:11:22] Yeah, it's interesting. I don't know if it was 2022 or 2023, but Huberman did a really excellent review on the effects of alcohol and the research behind alcohol. And I remember it probably took me two days to listen to because his podcasts are so long. And after I finished, I said to my husband, I really think you should listen to this. And he looked at me and he said, “I have one or two drinks a week.” And he's like, “I enjoy them so much, I'm not willing to give it up.” And I said, “Oh, I'm not doing it from that perspective.” 

[0:11:50] I just think that I was schooled, especially in cardiology when we were telling patients, “Oh, you should have a glass of red wine every night. There are all these benefits,” and the jokes on us because you'd have to drink gallons of wine to get the resveratrol benefits that we used to tell patients. And so much to your point, sometimes I have patients that just say simply eliminating alcohol from their diet is what leads to weight loss because they just don't realize the long-term net impact of this inflammatory substance which is making it harder for their body to be able to properly regulate their blood sugar and process the foods they're consuming. And so, I agree with you. Just having an honest conversation with yourself I think is really valuable. 

[0:12:39] And for full transparency, I gave up alcohol. Not that I ever had a problem with it. During the pandemic because I was such a social drinker, I would have like a martini once a month. I just said, “I don't need it.” And what's amazing to me, and I don't know if this has been your experience, but not in the health and wellness community. But when I go to events or business events outside of that community, people are incredibly triggered. If you say you don't drink, I don't know why. I always say, “Listen, you do you. If that works for you, that's great,” but I find that's sometimes surprising. 

Dr. Stephanie Estima: [0:13:13] Yeah, I have people always, when we go to dinner, it's like, “Oh, what are you going to get?” [laughs] I’m like “Get what you want, I don't care.” 

Cynthia Thurlow: [0:13:20] Water with a lime.

Dr. Stephanie Estima: [0:13:21] Yeah, yeah. I'm not going to judge you if you get the burger and fries. Fine, I have burger and fries here and there, like get what you want. Just because I happen to really talk a lot about nutrition and really care about it. Because we're out for dinner, I'm definitely not going to pick a part your meal, have whatever you want. And especially if you're out at dinner, the first thing that people bring you is the wine. The wine menu as well, so I'm like, “I'm just going to have some sparkling water with lime.” That's what I'm going to do. 

[0:13:48] Okay. So, I think hopefully this advice for this 45-year-old navigating perimenopause with a 4-year-old. Hopefully some of that is tangible for you. There's a question here that I thought was really juicy. The question is, “It seems that you've both changed your minds a bit on fasting. Let's hear why.” We were talking a little bit about this in the pre-chat but I'd love for you to-- if you want to go first, I can go first as well. But you want to take it and then I'll add in if there is anything to add. 

Cynthia Thurlow: [0:14:15] I'm happy to tackle this. Very transparently, I lost my dad last June and one of the things that contributed to my father's death was the loss of muscle mass, the frailty which led to falls, which ultimately led to pretty significant head bleeds. And it really weighed heavily on me because my father and I looked very similar. We had very similar body habitus. My dad's on the thinner side. He wasn't a very big person. He just got tinier with age, you know, they just kind of get smaller and more diminutive. 

[0:14:51] I think the process of being in the trauma ICU and talking to the physicians that were caring for him and making decisions about his care because I was his medical power of attorney and honoring what he wanted, it left me with this impression of if I don't change what I'm doing, I will have the same outcome as my father. And I have chills when I think about it. But it left such an impression that I left that hospital that very first night at 4 o’clock in the morning. And I said to my husband, “I am hiring a personal trainer.” 

[0:15:24] And let me be clear, I have exercised for 20 plus years. I have never been a couch potato. I enjoy exercising. [laughs] I just was not lifting heavy enough, intensely enough to be able to stimulate muscle protein synthesis. And the realization I came to and I picked out a trainer who trains middle-aged women and knows exactly what to do. She's an exercise physiologist. She's excellent. And when we talked about my goals and how to get there, the first thing she asked me was, “What do you think about not fasting as much?” And I said, “I am willing to do whatever it takes.” 

[0:16:03] And so, part of my building muscle mass as a menopausal female was the realization that in order to get through three boluses of protein into my body every single day, as I needed to have 12 hours of digestive rest and that's what I call it. Does this mean when I travel I may not intermittent fast? Of course, I mean sometimes it's out of convenience but the goals are to build muscle. And the way that I'm going to build muscle is by being intentional about how I lift, how I sleep, my HRT and my protein intake. And so, I am very transparent when I share that I personally am fasting with a rarity. It is not my day-to-day. And I've been able to put on 4 pounds of muscle in the past nearly year and that's significant at this stage of life. It is way, way harder. But I do feel that my father's death and what precipitated his death really shifted my perspective.

[0:17:04] And my brother and I talk very openly about this. My brother doesn't intermittent fast but I recall him saying that the loss of a parent, especially in middle age can be complicated. It's a complicated set of emotions that you experience. I think we just assume our parents are going to live a long time. And so even though I had a very complicated relationship with my dad, his death played a large role in my decision to stop fasting with regularity. Doesn't mean that I don't believe it's a good strategy, I just think it is one of many strategies. But for me at this stage of life my priorities have shifted. 

[0:17:41] And because frankly I'm already a lean person, I think what I get concerned about is when I see very lean middle-aged women who are-- They're ready to die on that sword. They're like I'm going to fast 18 to 24 hours a day, I'm going to have my OMAD and don't tell me that I shouldn't be doing this. And so, each one of us have to decide for ourselves what makes the most sense and we're allowed to change our minds and I think that's very important. 

[0:18:09] I feel a tremendous sense of responsibility to my community that I be honest about things that I'm doing differently and explaining why and saying if you are still fasting and you are building muscle and you feel good, that's great. But it was nearly impossible for me to build muscle eating two meals a day. And when I say impossible-- And this is with I'm on the hormone replacement therapy, I sleep really well, I do everything else well. I needed that third bolus of protein to be able to hit the macros that I needed to build muscle and to be serious about it, like I jokingly say “It's like a second job. It's like, okay, what's my third bolus of protein going to be tonight?” So, I'm always thinking about it. I'm curious what your thoughts are. 

Dr. Stephanie Estima: [0:18:54] There is a meme I just saw the other day. It's like, “Did anyone ever ask protein if they wanted to be in all this stuff?” [laughs] Which I thought is really funny. So, first of all, thank you so much for your openness and your transparency and your honesty around your father. Of course, I know, just being your friend, watching you go through it and navigate all the things that can come with the parent passing. 

[0:19:19] And I share your view, especially with women in midlife, where I still feel we are failing women, is that women, I think that they are understanding that they need to build muscle, that they need to build strong, healthy bones, I think that people understand that, but I don't think that the application is quite there yet. I don't really see a lot of women applying the principles of progressive overload in the gym and lifting heavy and heavy weights to reach that 15 pounds and they stay there, they never really want to push past it, they don't understand what that's like. 

[0:19:58] And, to your point, I think that in order to build muscle, the very basics is you just need to be able to give the muscle some substrate in order to assemble protein. So, if you are not consuming enough calories, your body is not going to have the-- Just not the building blocks. There're no building blocks to build. So, you are essentially wasting your time, especially if that the goal is hypertrophy, if it's muscle hypertrophy. 

[0:20:25] So, in terms of fasting, I don't have a view that it's bad. I don't have a view that it's good. I think it is a tool of many. So, if you feel, in your case, you were feeling like, “Hey, I can't get that third feeding of protein to meet my protein goals or I can't get it in the two feedings that I was doing a day,” because that is actually quite a tall order if you're trying to get in 100 g, let's say 100 or 120 g of protein a day, like 60 g of protein every meal like that's a lot, that's quite heavy. But if you're not able to do that and you need to spread that out over one or more meals, then by default your fasting window has to extend.

[0:21:05] And I think that you were talking about your father being-- They just tend to get a little bit smaller and smaller and more diminutive was the word that you used over time. It's like we-- I think in our 20s and our 30s women are just brow-beaten to think about being as small and as skinny as possible and it's like that's a really terrible look when you're 70. Like to be skinny when you're 70, like, no thanks. I don't want to be skinny when I'm 70. I want to be a jacked grandmother. [laughs] That's what I want to be. So, I want to be able to fill out my muscles as much as I can. And in order to do that, you need to eat. 

[0:21:41] And I like you-- I probably have something like maybe 40 g to 50 g of protein in a sitting. And I do that over three to four’ish meals a day. And so that's-- So I fast overnight like we all do. So, if I'm fasting for eight-- Sleep for eight hours, that's eight hours of fasting right there and then block in two or three more hours before I go to bed because I usually don't eat right before I go to bed. So, I'm at about 10, 11, sometimes 12 hours where I'm not eating anyway. So, I still feel like I'm fasting but it's not eating into the day anymore.

[0:22:20] And so, the other thing I wanted to just mention, and I'd love for you to expand on this maybe a little bit too, is this OMAD, if there's one thing I really don't-- Because I think that fasting got out of control. I think that for a while a lot of the-- Like the autophagy and the breaking your psychological relationship to always feeding, like all of those things are very popular. And I think that there are certain maybe individuals in the space that really just took it to like the n’th degree and it just became like ridiculous. The OMAD, the one meal a day phenomenon. I don't know what you think about this, but I personally dislike this the most.

[0:23:00] Other than a multi-day fast where you're not eating for many days, I very much dislike that, especially for women in midlife. But the principle of just having one big meal a day, I think again, I'll preface it by saying if it works for you, okay. But I do feel like with the cohort that we're in, these women in midlife, it does start to look a little bit like a binge. It starts to look like, “Okay, so I have one meal, so I'm going to have this huge meal,” and you sort of lose control and overeat, so I really dislike that, especially for women with any amount of body dysmorphia. Anybody who's really struggled, which is basically all of us by the way, we all have some degree of body dysmorphia. So, I feel I don't think it's possible to get in all your nutrients in one sitting, that's one. And then the other thing is I feel like it has a bit of a, “Okay, I've opened up the floodgates. I can eat everything I want for one meal,” and go like it feels a little bit like a bin. It feels like a bit bingy to me.

Cynthia Thurlow: [0:23:57] I'm glad that you bringing this up and the only time I really take a lot of heat across social media is when I talk about OMAD because it really triggers people who use this strategy, embrace it and are unwilling to consider the possibility that they are chronically, calorically restricted. 

[0:24:15] There's a twofold issue. Number one, I think there are people who hide their latent eating disorders in OMAD, that's number one. I'm really poking a bear by saying this, but I think there are a lot of people who have latent underlying eating disorders and OMAD is the bucket in which they put themselves. So, I think there's some people who just don't eat, but they say that they eat one meal a day. 

[0:24:36] I think there's also a group of individuals who have whittled their way down to 600, 700 calories a day and they're legitimately honest when they say to me, “I am not hungry for more food,” and it's because they have chronically under fueled their body. And so that is a huge problem. I go back to the same thing about I see many people's future. So, your listeners, my listeners know I spent 16 years in cardiology. You better believe when I'm rounding in the hospital, the things I saw 52-year-olds who couldn't get off a bedside commode, 60-year-olds that had already fallen and broken their hip or their shoulder or their wrist. 

[0:25:19] And so, the concept of frailty, muscle loss is not a question of if but when. If you are not actively working against it. And what many people don't realize, they're like, “I'm skinny, I'm exactly the size I want to be,” but if you have no muscle mass on your body, you are putting yourself at risk for frailty and frailty leads to falls. What does this mean? I think sometimes when we think about our grandparents, my grandmothers got frail as they got older, but they didn't know any better. Frailty is when people look like-- You see people walking, they may shuffle when they walk. They just look like if you accidentally bumped into them, they might fall over. That can show up as someone not being able to get out of a seat or not be able-- You see people in the airport getting off an airplane, they're walking very slowly and purposefully. 

[0:26:06] And so, I think about the long-term effects. I know Vonda does a really nice job talking about this as well, that if you're not feeling your body, you're setting yourself up to worsen muscle loss with aging because your body will catabolize the muscle that you do have. You will lead to more insulin loss-- insulin sensitivity loss, which is insulin resistance. And then the other piece of that is the frailty piece. And it's insidious, it sneaks up on you. It is not the slow growing process, it is evolving in front of you without you realizing it. That's why as much as my husband hates doing unilateral work and hates doing yoga and hates doing flexibility training, it is so important, even proprioception, our ability to know where we are in time and space. Sometimes my trainer will have me close my eyes when I'm doing exercises so that I recall where I am in time and space. 

[0:27:02] And so, when I talk about not liking OMAD, it's because I see what's coming for people when they aren't eating enough food. And that is the concern is that over time your body will make use of what reserves are there and that means your muscles. And before you know it, you do a bioimpedance reading or you get a DEXA scan and your skinny fat.

[0:27:25] Now how many of these women I see in classes occasionally, I don't want to pick on any one class, but women that are doing two or three classes a day and they're tiny, but there's no muscle mass on their bodies, and so I just-- If you were doing OMAD episodically, occasionally, that's not what I'm speaking to, it's just chronically, habitually, I'm worried that you're not eating enough. And I'm genuinely worried that you're going to put yourself at risk for frailty and then you'll lead to falls. 

[0:27:53] And we know if we look at the prognostic indicators related to falls and breaking bones, your mortality and morbidity is negatively impacted with that. With your first hip fracture, 20% to 30% of those people will never get home from the hospital. And so, I just want people to be thinking about that. I think that maybe now there's greater awareness about this, but I've just decided that I need to do a better job of talking about the long-term effects of not eating enough food and not prioritizing strength training. 

Dr. Stephanie Estima: [0:28:26] And I don't think that people think-- I've said this before on the show. I think that humans typically think linearly. We say, “Oh, well, I'm 40 now, so it's just a little bit worse than when I was 30. And now I'm 50 and it's just a little bit worse than when I was 40.” If you are not putting in the work strength training as we're talking about and eating enough food, there's an exponential decline that I don't think people see coming. Like there is a cliff that you are barreling towards and you will fall off it before you even realize what's happening. 

[0:28:56] So, I think that's an important thing to consider as well. Like if you were not eating enough food in order to assemble muscle, proteins that eventually become muscle, it may not affect you when you're 40, it may not affect you when you're 50, but you're going to start to see it when you're 60, you're going to start to see it when you're 70, you're definitely going to see it when you're 80 if you make it that far. 

[0:29:16] The other thing I wanted to just mention, you mentioned it and I just made a note here I wanted to come back to it, is if you are someone who-- You said, so many women are like, “I'm eating 700 calories a day and I'm not hungry.” You have to understand that your hunger cues and your thirst cues have been ruined. And I say that in the most loving way, like you will have to eat beyond your body telling you that you're hungry, because when you have been so calorically deprived for so long, your hunger cues get messed up. So, you actually have to eat beyond in some cases. The woman who's been eating 700, 800 calories for decades, she's going to have to eat beyond fullness because for her, and when she's not even thinking about food, because for her body has just downgraded that signal because it's not effective, so she's ignored it enough times. Like probably in the beginning when she was 25 or 30, she was hella hungry and then it just becomes muted, so I think that hunger cues as well as thirst cues. And part of this is also declining estrogen. And we can get into like estrogen and ghrelin-- the relationship between estrogen and ghrelin, but I think that your hunger and your thirst cues can be distorted as well, especially if you're someone who's been calorically restricted for a long time.

Cynthia Thurlow: [0:30:25] Yeah, it's interesting, as I was writing in the book, really looking at the research on the impact of estrogen and hydration, and as estrogen is declining, not only just the hunger cues, but also our hydration cues, by the time we get dehydrated, we are way beyond where we should be. So, when you're younger and people get thirsty and they drink and they rehydrate themselves, it is much more effective. It's interesting, the baroreceptors that we have in our neck are all impacted by this loss of estrogen signaling. And the other thing is, when I see women that have whittled themselves down to 500, 600, 700 calories a day, there's a term called reverse dieting. I don't love it, but for many individuals, we literally have them add 100 additional calories of protein a day, like we get that nuanced to try to bring them back out of this chronic caloric deficit.

[0:31:20] And what I find is, especially for these women that have been, you know, they've been habitual scale-- They stun the scale every single day. And whatever that number is so triggering to them, it is hard. It is more psychological support than anything else to help them understand that they have just undernourished their body for such a long period of time that it is going to take a couple months to be able to get them back up to a maintenance caloric intake and then we level off. But that concept of reverse dieting again, you're not going to find lots of research around it. It's more like smaller studies that have been done, anecdotal information, but you can't live in a caloric deficit forever. You just can't.

Dr. Stephanie Estima: [0:32:05] Yeah. And, so many physique competitors that's what they do, right? So, they're doing like double cardio sessions and weightlifting up until their show day. And of course, if you do the binge and you don't do it properly, like you put on because your body is in starving, so, you're going to put on a ton of fat. So that's exactly what they do is they start slowly after like post show, it'll be like you're saying 50 to 100 calories, like depending on the tolerance of the person, but 50 to 100, sometimes even up to 200 calories a day. 

[0:32:36] And then you end up getting to a place if you do it properly where you are consuming way more calories than you ever thought. You're fed and you're happy. So first of all, that's a win. But then your body actually knows what to do with that. And you don't gain weight, you're not gaining fat, like you reset what your maintenance calories can be. So, I think that's also really exciting. I personally, maybe does need a-- I think that maybe the name needs a rebrand, reverse dieting is a bit of a--

Cynthia Thurlow: [0:33:06] It's a terrible name. I wish I could think of another term, but for some people that is really what they need to do and it is a slog. They don't like it, they're unhappy about it, they get triggered on the scale. We go back and forth. 

Dr. Stephanie Estima: [0:33:18] Especially when you start having carbohydrates, because your carbs are going to start-- You just store water with carbs like that's just what happens. So, people will see like a pound or two weight gain and it's like, oh no. It's like, no, just your muscles they're just full. They're just eating, so it's okay. I've talked about this on the show before. When I do legs-- I don't weigh myself often anymore, I just go by how things fit and how I'm feeling and my energy and stuff.

[0:33:44] But when I was weighing myself, I would go up by like 5 pounds, like if I did leg day, the next day or two days later, especially if it was particularly intense, I'd keep five, six pounds on the scale. And it's just because my legs are super inflamed, so they're retaining water and they're healing. And that's just because I pushed them to break down and they're repairing themselves like that is normal. It's normal for your weight to kind-- I'm sure even you don't even have to do leg day because just you could have a really bad night's sleep and you're probably going to weigh more the next day. You can be under just like a big deadline. And maybe your food choices are a little different, you're just going to weigh a little bit more. 

[0:34:22] And so, I think, I know it's like been bludgeoned into our cells at this point, like always looking at the scale. But that is again, like fasting, it's a tool. It is one tool. I much prefer you have a measuring tape. I would much prefer you look at your waist and your hip and then I would compare the two together waist to hip ratio, that is actually a much better tracking tool over time. 

[0:34:48] We can get into visceral fat and we can get into all of that too, which tends to accumulate in midlife as well. But for me measurements are way better and pictures are way better than what the scale says. Because the scale, if you're still menstruating, you're going to be heavier for two weeks in the second half of your cycle, especially right before you bleed. It's the tool I'm not dismissing. I just don't like it. And everybody's on it. Everyone's like, “What am I weighing? Am I gaining weight? Am I losing weight?” It's like, who cares? How do you look? How do you feel? What are your measurements?

Cynthia Thurlow: [0:35:15] Yeah. Unfortunately, we have a very toxic diet culture that has convinced women that we are dialed in on this number. And it governs how women feel about themselves. Very transparently from June of last year until June of this year was probably one of the most stressful years of my adult life.

Dr. Stephanie Estima: [0:35:34] Yeah. 

Cynthia Thurlow: [0:35:35] And inflammation and stress shifts body composition. You better believe, openly my trainer and I were both told talking about it and it wasn't until things quieted down that I was able to de-inflame, be less inflamed. And it wasn't that my diet was bad. It was just the stress of personal things that were ongoing, which thankfully now have all quieted down. 

[0:35:59] But I think for a lot of people, if I didn't know the body composition trumps the number on the scale because that I could intellectualize, this is how much fat free mass I have, this is how much muscle mass I have and I can track that. And when I can track that, that allows me to have a sense of what exactly is going on.

Dr. Stephanie Estima: [0:36:18] Okay, let's-- There's a couple questions I wanted to make sure that we get. There's a bunch of them here. I want to make sure that we get to this gut question. So, there is, “What are your thoughts on dairy products as they relate to gut health and used as a protein source?”

Cynthia Thurlow: [0:36:18] What I would say about dairy, dairy is very bio individual and I believe fervently that goat milk, sheep's milk dairy tends to be less inflammatory. We know that cow's milk for many people can be very inflammatory, so that's kind of the gestalt. Do I find that there are a lot of women that are very sensitive to cow milk dairy? Absolutely. Do I also then also believe that dairy can be a good protein source? Absolutely. What I typically will suggest is that whether it's yogurt, kefir, a slice of cheese, a scoop of sour cream. 

[0:37:10] Someone came after you one day because I mentioned something about sour cream. Whatever the dairy source is, if you tolerate it, you don't feel like you get inflamed, you're not carrying around inflammatory weight. I think dairy can be reasonable. I can tell you very transparently that dairy, for me, I can have a little bit of whey protein a few days away week. I can't push the dairy button often because for me personally, gosh, it's now like seven years ago, I cut dairy out entirely and lost 5 pounds, even though I was not eating dairy very often. 

[0:37:43] So, I always say, like, “This is what has been true for me.” Can I occasionally have a slice of Parmesan cheese on a salad or some whey protein? Yes, but that I can't push it. Do I think that the composition of your gut microbiome, do I think that plays a role in things that we are sensitive to? Absolutely. We know that as we are navigating perimenopause into menopause, we have one cell layer thick in the small intestine. Estrogen is very important for keeping those cells together and not open. 

[0:38:15] When people talk about the concept of leaky gut. That means that small intestinal lining is open and you can leak particles into the bloodstream that generates an inflammatory response, an immune response, and can lead to underlying food sensitivity. So, women will say like, why all of a sudden am I sensitive to dairy or gluten or grains or insert whatever it is, that has a lot to do with it. So, there is a degree of bio individuality. 

[0:38:40] I think that if you suspect you are sensitive to dairy, you probably are. And here's the thing that I find really interesting. My N of a couple thousand. If you struggle to limit or eliminate dairy, it very likely is the composition of your gut microbiome. Those microbes, protozoa, viruses, bacteria, etc., you may be feeding dysbiotic organisms. 

[0:39:04] So, when we talk about dysbiosis, we're talking about, you know, I always say like our microbiome is-- We plant all these beautiful fruits and vegetables and dysbiotic organisms are non-beneficial bacteria, viruses, fungi that grow up in between these beautiful fruits and vegetables in this garden. And so, when I start seeing patients who say, “I tried to cut out dairy, but I craved it so badly, I was like a beacon to the refrigerator.” Sometimes it can be a sign that you have overgrowth of this non-beneficial bacteria and that's where I think stool testing can be helpful. 

[0:39:35] So big messaging is, is dairy okay? It depends. If you suspect that you're sensitive, eliminate it and see how you feel. Third, I would say if you absolutely positively want to consume dairy, maybe try sheep’s and goat milk varieties. Like I love Manchego, that is like my favorite cheese in the world. I don't eat it anymore because it's easy to overeat it. And frankly, I try to avoid dairy as much as I can. But that N of 1 experiment I think can be very helpful for a lot of people, but I do find that most women benefit from limiting or eliminating dairy as a group. What are your thoughts? 

Dr. Stephanie Estima: [0:40:15] I agree 100% with what you're saying. It's like I have nothing further to add. It's like if it works for you, awesome. Cottage cheese it's having its moment, so it's in everything from pizza. It could be a base for pizza. It can be cooked. I've used so many cottage cheese recipes as well. 

[0:40:36] I typically am good with most dairy. I find ice cream kind of gets me, but things like cheese. I don't actually have a lot of cheese, I don't crave it, I don’t-- The only thing I really like Parmesan, like the Parmigiano Reggiano from the big wheel and whatever. But I don't have a lot of it in my daily life. Cottage cheese and yogurt. I certainly have a lot of Greek yogurt. I definitely have that daily. But I think if you can tolerate it, great. If you can't tolerate it, you can find something else. You can find other ways to substitute your protein. If you're eating animal-based products, it can be in fish, poultry, lamb, beef and all those things. You can certainly get the appropriate amount of protein. You don't have to be having dairy products. Although it is a really nice way top up. It is a really nice way top the protein requirement, if you can. 

[0:41:28] Like, what I have found that I like to do, especially with Greek yogurt and with cottage cheese, is I like to make them into desserts. I bake with them. And I find that it's a way for me to still have sweetness. I still have a lot of baked goods in the home and I'm getting my protein points with it. So, if you're able to tolerate it, awesome. If not, everything that you just said, it's fantastic.

Cynthia Thurlow: [0:41:48] Well, and I love to watch you in the kitchen creating all these concoctions because-- Let's be transparent and just say that we like to have sweet things on occasion. We just want it to be like the healthiest version of whatever it is we're craving. And I think that if you tolerate dairy. My husband loves cottage cheese. There is something about the appearance of cottage cheese. I can't do it. 

Dr. Stephanie Estima: [0:42:09] You can't do it. [laughs] 

Cynthia Thurlow: [0:42:11] I just can't do it. I can't. It's like a visceral response. I'm like, “Can't do it. Can't do it. But I respect the fact that you love it.” And my husband loves it. 

Dr. Stephanie Estima: [0:42:18] Love it. Yeah, no. I really don't love the chunks, but I definitely love it blended. So, I make like an awesome pudding, but actually put whey protein. I put protein in it. I put some maple syrup. I put some-- blend it so I don't see the little chunks of the thing. 

Cynthia Thurlow: [0:42:32] Yeah, the curds. It's the curds that get me.

Dr. Stephanie Estima: [0:42:33] Curds. Yeah. So, yeah, I love that. And I think it's a way for me because I want to eat well. I feel I want to enjoy everything that I eat and I don't want to feel like trash after. So I know that if I have like a super sweet chocolate cake, it's going to feel good in the moment and then an hour or two later I'm going to be zonked, I'm going to have no energy, I'm not going to feel great. So, if I am going to have dessert, I definitely want it to taste good, that's number one. But then I also don't want it to-- I don't want to pay for it afterwards. So yeah, that's how I feel about yogurt and cottage cheese.

[0:43:10] All right, let's go on to so many more here. Here's a question on cold plunging. “Cold plunging or cold shower after a workout, is it okay for women? I thought it wasn't, but I recently heard that it was key.”

Cynthia Thurlow: [0:43:21] My understanding about cold plunging is obviously if you like walk or you do high intensity interval training, probably okay. The concern is if you strength train, you don't want to be cold plunging within four hours. I think that's-- my understanding is there's that four-hour anabolic window that you don't want to blunt. 

Dr. Stephanie Estima: [0:43:41] Yeah. So, it's acutely inflammatory. So, we have to know that HIIT training, any type of high intensity exercise, so strength training, you're doing interval-- Like sprints on a track or whatever, you're on the bike and anything like that, all of that is acutely inflammatory and so there's an adaptation response. So, I was mentioning before, when I do legs, I'm like 5 pounds heavier. It's because I have completely ripped up the muscle. And there's this inflammatory and immunologic response that has to happen afterwards in order to adapt to it. So, what you're referring to is when you blunt that. So, when you get into a cold plunge, of course you are diverting the blood away from the periphery which would be in the muscle, like in your musculoskeletal system and you're going to blunt that adaptive response. 

[0:44:28] Now where it can be helpful after high intensity exercise is if for example, you're in a tournament, like you're doing a HYROX, there's like some event where it's a multiday event and you need to recover very quickly before the next time that you go at it. So, my kids have done, like, where there's soccer tournaments and it's like three, four games a day. And then the next day at three, four games a day, they come home and they cold plunge, because I'm trying to help them recover. I'm actually trying to blunt that acute inflammatory response so that they can go and do it again. So that's where I would say cold plunging immediately afterwards is helpful. It's like if you're competing in something and you need to recover really quickly. 

[0:45:18] If your goal is hypertrophy, though, I would definitely stay away four hours, like you said, is the number at least four hours, preferably six, that you would stay away from the cold plunge afterwards. Because, again, you want that adaptive response. Anything else I want to say? No, I think that's it, like cold plunging. 

[0:45:36] And the other thing I'll say for women specifically is we don't need to be cold plunging like the bros. So, guys can get down to gosh, they can probably get down to like 30, 35, 40 Fahrenheit. For women, gosh, I can't do that in Celsius off the top of my head. But for women, 50, 55 Fahrenheit, which I know is about 12, 13 centigrade, that's more than enough. We don't need to be cold plunging at zero centigrade or we don't need to be going to 30 Fahrenheit in the way that men do. We actually don't tolerate the cold as men do. We actually have a much higher stress response than is necessary. And for women in midlife, like, you're already stressed out, so it doesn't need to be as cold and as frigid. 

Cynthia Thurlow: [0:46:20] Well, and the other thing that I would say is I would question why anyone, any woman in middle age should be doing cold plunging with any regularity. I think 15 to 30 seconds of cold water at the end of your shower, doing cryotherapy, which tends to be a little less stressful on the body. I think about all the people that are not sleeping well, aren't managing their stress, are chronically, habitually stressed out. You have to think about whether it's intermittent fasting, cold plunging, heat therapies, these are forms of hormesis. And it's all about the Goldilocks effect of the right amount of stress at the right time. 

[0:46:58] And so, I actually caution women, especially those that maybe you've got newly diagnosed hypothyroidism, you've got a new autoimmune condition, please, please, please do not add gasoline to the fire. Just think about where you are in time and space. And if you're on vacation and you want a cold plunge and you've been sleeping well and feel great, by all means. 

[0:47:20] There was a hotel that we stayed at in Switzerland, and they had these thermal baths, and you could go from being in hot to cold. And there was no one else in there, so, my husband and I were enjoying going back and forth. And I said to him, “I don't need to cold plunge with any regularity. That will send my cortisol through the roof.” 

[0:47:39] And I know even Dr. Stacy Sims, who we both have interviewed, talks about how women are just much more sensitive to the effects of cold. So, if you're choosing to have cold exposure, maybe start off with a little bit of cold at the end of your shower, cryotherapy, which is two to three minutes. That's actually my preferred way of stressing myself. But I'm very conscious of how I utilize that hormetic stressor. I'm very conscientious. It is not the day where I've got five podcasts to do, and I'm running around and I'm up early and that is not the day I add in cold therapy. It's a day where it's like a Saturday and I don't have much on my calendar, and I'm like, “Okay, I'm just going to go in. I didn't lift today, so I have ultimate flexibility.” So just being conscientious about how you use hormesis in your personal life. I think it makes a big difference. We want it to be beneficial and not overtly stressful. 

Dr. Stephanie Estima: [0:48:31] I prefer heat any day of the week-

Cynthia Thurlow: [0:48:32] Me too.

Dr. Stephanie Estima: [0:48:33] -to cold. I really love sauna. I actually love sauna if I have enough time, it doesn't always happen, but after a weightlifting session, sauna is so delicious, I love that. And the other thing that you can do is just move to the east coast and go outside in the winter without a jacket. There's your cold touch. [laughs] That's like if you really want tough it out, move to the east coast, wait for December, January, February, and just go outside for 10 seconds [laughs] and remove your jacket. 

Cynthia Thurlow: [0:48:58] That's what my husband does. My husband literally will wear one less layer when we walk the dogs in winter. 

Dr. Stephanie Estima: [0:49:03] Yeah. 

Cynthia Thurlow: [0:49:03] He's like, this is my hormesis. 

Dr. Stephanie Estima: [0:49:05] Yeah. There're two questions I want to get to here, best form of testosterone and why? This particular woman 40-year-old, surgical menopause. Should I take cream in the morning, Should I take injections? What are we thinking? 

Cynthia Thurlow: [0:49:18] Well, not every woman in menopause or perimenopause for that matter needs testosterone. About 25% of women still make plenty on their own. And this is why I think testing is important, that's number one. Both estradiol and testosterone can be stimulating. So, I typically will recommend that whether you take it in the morning or midday, that's usually preferred because for some people they can find it stimulating. Obviously, testosterone is very potent in our bodies, so I don't think you need to hit it with a sledgehammer, which is why I'm a fan of transdermal application, whether it is a tenth of the dose of AndroGel, yes. There is no current FDA approved form of testosterone for women, which is criminal. We are working on that. 

[0:50:01] But AndroGel is the male version. It's a little packet. You can pull out one-tenth of the dose and you can use that daily. I preferred compounded options. It's kind of a set it and forget it option and you can get that created at compounding pharmacies. I do see that there are companies out there that are doing subcutaneous, which means a small needle just underneath the skin, you will have more peaks and troughs. And what that means is you will have a greater response in the short term, so if you inject yourself on a Monday, Tuesday, it's going to be higher. And then we talk about the trough, you get this drop off point when it's at its lowest. 

[0:50:35] So peak is the highest level. Trough is at the lowest level. Depending on your clinician, they may want to draw labs at peak. Some of them want to draw it at trough. That depends on the individual. I'm not a fan of sub-- Excuse me, I'm not a fan of intramuscular injections of testosterone and I'm not a fan of pellets. Both are really unpredictable. And I've had women who've had a really great first experience with pellets and then they are constantly chasing that high of how good they felt. They're chasing it forever.

[0:51:07] A pellet almost looks like a grain of rice. It is very tiny. It's put subcutaneously under the skin. Once it's in, it’s in. So that means that if you got too much hormone for you, you are stuck with your side effects until three or four months later. I just think it's not predictable. There's not a lot of research to suggest that is helpful. You'll see a lot of pellet factories, that's what I refer to them as. People that will hang a shingle, they'll convince every woman that they need testosterone. 

[0:51:36] In a lot of instances, we have to be looking at why someone's testosterone is low. If you're a perimenopausal woman or woman in your 30s, are you insulin resistant? Have you been exposed too much endocrine-mimicking chemicals? Are you chronically stressed out? And, I just think know better, do better is the methodology with which I think about hormones. And so, number one is tests, because not everyone needs it. Number two is I prefer transdermal applications. And for a lot of women, that's all they need.

[0:52:05] I use compounded transdermal testosterone, and we're constantly tinkering to figure out what the right dose is for me because sometimes when I test, my testosterone's higher than it is. At other points, which just speaks to bio individuality and how much you absorb of the click of testosterone because they put them in these containers where you do clicks, like one click is one dose and two clicks is another dose, trying to find what's right for you. And it may take a little bit of trial and error, just like other types of hormones. I'm a huge fan of testosterone if you need it. 

Dr. Stephanie Estima: [0:52:36] What about DHEA? I know this is not part of her question, but-- 

Cynthia Thurlow: [0:52:39] Yeah. Yeah. No, I’m a fan of DHEA. I'm a fan of pregnenolone. Pregnenolone is an important hormone for memory and just as a pearl. Pregnenolone levels, we want them greater than 50 mg/dL because that is the level at which we know it helps protect memory. So, big pearl, it's not just the prescribed compounded option. There are also oral supplements, over the counter, that you can take. Pregnenolone is one of these hormones that people can be sensitive to. So, I'm so sensitive, I take drops and not an oral capsule, but there can be, again, that trial and error. But get tested to find out what your levels are. It is very common to see low DHEA, low pregnenolone even in perimenopause and that's why I think testing is helpful. 

Dr. Stephanie Estima: [0:53:23] And so, this actually leads nicely into another question that was asked around opening up pathways for people that struggle with HRT or MHT due to methylation issues. Is there-- And you were mentioning with your own testosterone, sometimes it's high, sometimes it's low. How can we think about methylation or optimizing methylation and opening up, let's say, or optimizing that pathway for someone who is considering getting on HRT or who might already be on it and who has terrible detoxification pathways? 

Cynthia Thurlow: [0:53:52] Yeah. So first and foremost, there are some genetic susceptibility. So obviously if you have an MTHFR defect like I do, I have two copies of A677T, which is the one you don't want. I remind people you are not going to die. Probably 10 years ago there was a lot of information that came out and very complicated supplement regimens for people who have this defect, and I'm like “Timeout. Not everyone needs that.” 

[0:54:15] I think we go back to the basics. I do like testing. So, for me personally-- Testing to see if you have this genetic mutation is helpful. Don't panic if you find out you have it. Like I said 10 years ago, everyone was worked up about it. It just means you have to do a couple extra things. Number two, I like to look at a DUTCH. I know the DUTCH is super controversial, but the DUTCH in particular looks at how you break down your estrogen, but it also looks at phase I and phase II liver detoxification.

[0:54:44] Typically, people that are poor methylators are also people that need phase II detoxification. And there's ways to go about doing this that starts with like simple things like sweating, sauna, hydration and cruciferous vegetables. There's a lot that can go into this and without getting over hampered. It doesn't mean that every single vitamin you take has to be methylated. Not everyone needs methylated vitamins, myself included. And so, I think it really comes down to the basics. 

[0:55:12] Many people get fixated on detoxification because they're gaining weight with hormones. And that's why the first thing I say, before we even think about hormones, we have to be talking about lifestyle. You have to talk about nutrition, exercise, stress management and sleep. You need to talk about gut health because if you can't properly package up and break down excess estrogen. And yes, you can be in late perimenopause or even menopause and you can be low endogenously, meaning your body's making less the estrogen but your body can't package up what's left over. And so, estrogen is like a present. It needs to be packaged up. 

[0:55:50] There's an enzyme called beta-glucuronidase and that helps your body break down excess estrogen and help get rid of it. There's also the estrobolome, which is this uber awkward, strange word that talks about. There's parts of the gut microbiome that are intricately important and focused in on helping you break down this estrogen piece. So, you can be exposed to estrogen in your environment, personal care products, your food. And if you're recirculating estrogen, that can show up as some of the crummy symptoms we get in perimenopause and even menopause, tender breasts, bloating, weight loss resistance, very heavy cycles, things that aren't fun to deal with. And we know that in perimenopause our estrogen levels can be 20% to 30% higher. So, it can be this kind of circuitous pattern back and forth.

[0:56:38] But getting back to the original question, I think diagnostic testing for me personally is very important. Number two is personalizing what you specifically need. I don't need a ton of extra stuff. I do take glutathione. I am very proactive about consuming cruciferous vegetables every single day. I'm very proactive about hydration and electrolytes, magnesium. There are a lot of additional supplements. Some people need things like Calcium D-Glucarate, some people need TUDCA. 

[0:57:08] TUDCA to me is really interesting because with the loss of estrogen we don't package up our bile acids and bile is what helps us break down and emulsify fat. But it's also intricately involved in like mitochondrial health. And so, as we're losing estrogen, it can impact how we break down and emulsify fats but also impacts our mitochondria. So TUDCA can be another thing. Again, I like to test, not guess, like let's figure out what you specifically need. Unfortunately, in our overpopularized health and wellness community what I find is people will sometimes make these generalizations. Will everyone that has MTHFR needs this? I don't believe in that. 

Dr. Stephanie Estima: [0:57:47] Yeah, same. 

Cynthia Thurlow: [0:57:48] Just like I would say not everyone who has a phase I detox defect needs DIM, and not everyone who has a phase II needs Calcium D-Glucarate. So, I think personalized medicine and personalized recommendations are what are most important. But that I would say those are the basics. But testing is important, then deciding what do you need most, and then responding to whatever symptoms you're experiencing. Do I see a lot of women that don't have their detox pathways open? Yes. And when we talk about phase I and phase II in the liver, phase III is the part of the gut. And so, if you're not pooping out your estrogen every day, if it's not packaged up like a little present and shield and packaged off and sent to the colon and then to the rectum, that can be problematic. So sometimes for people, it's as simple as, let's get you pooping every day. Because I can't tell you how many women, we interact with in programs that think it's normal to poop once or twice a week. 

Dr. Stephanie Estima: [0:58:44] Oh, I know. 

Cynthia Thurlow: [0:58:45] I'm like, “We want that to be once or twice a day at a minimum.” 

Dr. Stephanie Estima: [0:58:49] Yeah, yeah. Couldn't agree more. I have nothing to add to that.

[laughter]

Dr. Stephanie Estima: [0:58:54]What a complete answer. 

Cynthia Thurlow: [0:58:56] Thank you. 

Dr. Stephanie Estima: [0:58:58] That's awesome. How many days a week do you currently train? 

Cynthia Thurlow: [0:59:02] How do we define training? So, lifting weights?

Dr. Stephanie Estima: [0:59:03] Strength training.  

Cynthia Thurlow: [0:59:04] Yeah. two to three. And then I feel like I'm like a dog with a bone. Right now, I'm enjoying solid core one day a week because it challenges my proprioception, because it's in a dark room and everyone is probably 20 years younger than me. And for me, I love being able to show people what's possible, but I do that more for flexibility and because it forces me to move my body in different ways. 

Dr. Stephanie Estima: [0:59:32] I asked because one of the questions is, “I can only get to the gym two days a week. What should I be doing? She has 75 minutes a day,” which I feel is absolutely luxurious, 75 minutes I feel like there can be so much done. So, I was curious to see what your strength training is. And what about cardio? Are you doing any cardio on? I know you walk a lot and you walk your dogs and stuff.

Cynthia Thurlow: [0:59:55] There's not a flat part of my neighborhood. So, I do Zone 2 training, walking my dogs. Now we have very hot, humid summers, like Louisiana, hot, humid, miserable summer. So sometimes in the summer, I will walk on my treadmill for my sanity. And I might actually watch a movie while I'm doing it. Because with Zone 2, it's meant to be fairly comfortable. I put it two to three incline, I know where my heart rate needs to be. I like Zone 2, I'll be completely transparent. I try to be really good about doing HIIT at least twice a week. I know Vonda wants me to push myself even harder when I do HIIT, but that's probably my least favorite thing I do. Transparently-

Dr. Stephanie Estima: [1:00:36] [laughs] Yeah. 

Cynthia Thurlow: [1:00:38] -I'll just say that's not my favorite thing I do, but it's like eating. When I was a kid, my mother made me lima beans because they were good for me. So, I think about it's like, I got to eat my lima beans. 

Dr. Stephanie Estima: [1:00:47] Just got to punch it out. Yeah, I love that. I think that the strength-- if this girl's like, I have 75 minutes, I can do it twice a week. For me, I would actually concentrate most of that on strength training. That would be my counsel for her. And then any other time that she can get the Zone 2, as you're saying, like the walking, you park a little further in the parking lot. For the training, if she has two days a week, I would say full body both times and then I would just switch it. So, if day one she would do like an upper body push and then a lower body pull and then she might flip it the next time. So, if day two would be an upper body pull, lower body push, that would be my recommendation. 

[1:01:21] And I got to say, two times a week, I can't tell you if you have a properly designed program like it sounds like you do with your trainer, where you are applying the principles of progressive overload, like your form is there. You get the form mastered before you apply the load, you could see unbelievable results, unbelievable results in terms of muscle hypertrophy and strength at a two-day-a-week frequency. 

[1:01:46] I train a little bit more than that just because it's my absolute love. But I'll probably train like four to five times a week, strength training. And then I just have recently taken up track. Like I was actually telling my team, I've taken like a 15-year hiatus. I used to run track. I was 200-meter, 400-meter, I would run, I'd run relay. I was second arm on relay and just pregnancy, children, divorce, life. I just was talking myself, like anytime the opportunity showed itself to run track, I was like, “Eh, I don't. I'll just do something else,” I would always skip it. And just recently, just in the past couple weeks, I've made-- Like there's a track in our neighborhood. It has beautiful, like a nice sport cord, like that bouncy material. Anyway, got on it, did six sprints. And I just remembered how much I loved it. 

[1:02:37] During the sprint, yeah, like my lungs are burning, I'm gasping for air. It is very-- but afterwards I was like, “Oh, my God. I remember how much I love.” Like I used to run. I was running track in university. I loved, loved, loved it. So, I've just recently come back to that. And then on my CAROL Bike, this week I did a 4x4 again, like, just would avoid the 4x4 Norwegian. So, it's four minutes Zone 5. So, it's very heavy resistance. And then you get a three-minute break and then you go back and you do that four times. So, it's like four minutes at Zone 5 and it determines that via your heart rate. 

[1:03:12] And then like you're on the CAROL Bike and you've done tests before, so it knows what your Zone 5 is anyway. And it was so grueling and it was so-- I felt like I was going to die while I was doing it. And then afterwards, I was so proud of myself. I was like, “Oh, yeah, I remember how much I love this. I remember how much I love getting into the pain cave,” knowing it's going to hurt and then coming out the other side of it feeling like literally high, like I'm literally high on endorphins. 

Cynthia Thurlow: [1:03:41] God bless the runners of the world. [Dr. Estima laughs] I ran track. My freshman year in high school, I ran 800 meters and I hated every single minute of it.

[laughter] 

Dr. Stephanie Estima: [1:03:52] Every step of 800 meters. Yes, every meter of 800.

Cynthia Thurlow: [1:03:56] Yeah, I remember. I think when I turned 40, I was going to do a 10K because my husband did a lot of competitive triathlons. And he did Olympic distance and mid distance. And so, I was like, at 40, I'm going to do this and I ended up developing inflammation and synovitis of my hip. And I said to my husband, “You know what? It's God's way of telling me I'm not meant to be a runner.”

[laughter]

Cynthia Thurlow: [1:04:15] So, I still admire that- 

Dr. Stephanie Estima: [1:04:17] No. I probably do that too. 

Cynthia Thurlow: [1:04:18] -and I love it. Yeah. 

Dr. Stephanie Estima: [1:04:19] I would probably end up getting some tenosynovitis somewhere too with the long-distance run. I don't do well with long distance running. It's like the short, quick stuff. I can do the short, quick stuff because I know it's going to be over in 12 minutes. [laughs] 

Cynthia Thurlow: [1:04:30] Well, I have something called FAI. You probably know what that is. So, femoroacetabular impingement. And I guess I have a very mild form of it. So, when I thought I had torn my labrum, I found out my orthopedic surgeon was like, “Oh, good news, bad news. You didn't tear your labrum, but you actually have FAI.” And I guess I have bone spurs. So, he said to me, “The worst thing you could do is start running.” And so, I said, great, because I don't love running, so that was like--

Dr. Stephanie Estima: [1:04:56] Take that to the bank. 

Cynthia Thurlow: [1:04:58] Exactly. I was like, “Let's do something else.” I was like, “Noted.”

Dr. Stephanie Estima: [1:05:03] Yeah, no, the high impact for FAI, not good. Probably could get away with the bike. You could probably get away with bike sprints or like an AssaultBike, even like a skier, obviously a rower. You could probably-- Maybe the rower might bother you a bit, but you could probably get away with those. But like the high impact of track, like running, no, I would agree with him there.

Cynthia Thurlow: [1:05:23] The other thing that's interesting that I realized when I was given that diagnosis was if I listened to how trainers at that time taught me to train when I was squatting, I always said, “I can't get as low to the ground as you want me to.” And actually, my orthopedic surgeon was like, I don't ever want you to do a deep squat. For you, absolutely, positively not because I went through one series of steroids. And if anyone's ever had their hip joint injected, don't ever look at the needle. That is the largest needle I've ever seen other than when I had a spinal anesthesia. Holy cow, I was like, “I never want to go through that again. Not once, not ever.” 

Dr. Stephanie Estima: [1:05:59] Yeah, not once, not ever. And there is a really quick question here. I'll just like to round out the weightlifting on how do you take care of your hands after lifting? So, if you're watching this on YouTube, let's see if you can see my [crosstalk] gnarly, disgusting hands on the other side. And I don't have my nails painted today, so it won't work as well. But I like to always say like glamour on this side and gangster on this side. [laughs] So, my hands on the-- Like when I shake people's hands like I try not to make them bleed, but it's just you got to love your calluses. 

[1:06:28] I remember when I-- in clinic I had several marathoners, but there's one Clive, I remember my patient Clive, he's a long-distance runner and he would say that every time he would go to get a pedicure the ladies would just automatically look at his feet and be like, “Oh my gosh” and they get the little razor thing to start scraping off the calluses and he's like, “Don't touch them. Don't touch them. Because I've worked so hard to get these babies, you know where they are, I need you to keep them,” because it's painful, like when you're developing the calluses, it's actually really painful to develop them. 

[1:06:59] And for me, these calluses, yes, they don't look aesthetically whatever, but when I'm doing pull ups, they save me, otherwise, I'd be ripping and bleeding all over the place. So, I would say, I moisturize my hands like everyone else, but I specifically do not try to get rid of these. Like these are my-- they're my little badges of honor and they help when I go back to the gym. 

Cynthia Thurlow: [1:07:22] I'm almost embarrassed to say this out loud but I'm going to say it. So, I have a 70-pound Bernedoodle and walking said 70-pound Bernedoodle, I have more calluses from walking him because although he is on a-- He's on an appropriate collar, he's been trained, he is still in this reactive and it's more fear reactive, he's not going to hurt anyone, but he's so big. If I'm not paying attention when I walk him, he will pull me off my feet. 

Dr. Stephanie Estima: [1:07:45] Yeah. 

Cynthia Thurlow: [1:07:47] And so it becomes this, why do I have calluses? Part of it is weight training and part of it is walking him because he's massive. 

Dr. Stephanie Estima: [1:07:56] I love that. I think that's so cute. There's nothing to be embarrassed about with that. [Cynthia laughs] I think that you have a spirited dog. 

Cynthia Thurlow: [1:08:00] One of my neighbors was like, “Should you be walking him?” And I was like, “I take great offense at that comment.” 

Dr. Stephanie Estima: [laughs] And oh, there was a question on peptides. Where was that? I wanted to make sure that we get to that because I know you're super excited about peptides. 

Cynthia Thurlow: [1:08:15] New fav’s on peptides and microdosing GLP-1s and early peri--I'm assuming perimenopause phase and hormones are slightly off. Here is my gestalt on peptides. I am absolutely fascinated. I've taken two courses. I'm reading every book I can get my hands on. I'm knee deep in the research. I think that if used judiciously and appropriately, I think peptides are the icing on the cake. I'm not just referring to GLP-1s, although I think GLP-1s are a gateway to understanding how these drugs can be used to modulate different things. And let me be clear about what that is. 

[1:08:52] So, I think most people are familiarized with Ozempic and Tirzepatide. Ozempic is this first generation. Tirzepatide works a little differently, that's a second-generation drug. I think we are familiarized with them for the weight loss industry. But what I find really interesting is I like to call it personalized dosing, but people sometimes use the term microdose. And what this means is that there's a standard conventional starting dose for these drugs. And instead of starting there, people are starting at half the of that dose or a quarter of that dose and seeing profound impact on microbiome endothelial function, which is the lining of our blood vessels. We're seeing improvement in bone health. We're looking at improvement in autoimmune markers. I personally am micro dosing a very tiny dose of Tirzepatide to see if I can drop my Lp(a). And that is my N of 1 experiment. It may not work, but [laughs] we will see.

[1:09:44] And so I think that the possibility exists that these drugs could be-- are truly revolutionary, but also that there are other uses that we haven't yet discovered or really thought of. But I want to be really clear, these drugs should not be used for people who already have latent eating disorders, like someone who's already not eating, taking the drug so that they don't eat at all. I think what I understand about these drugs from many patients is that they quiet food noise in the brain. We know that Tirzepatide in particular, we know that we have GLP-1 receptors throughout our bodies, mostly in the L-cells in the small intestine and colon, but also in the brain. And so, we know that it can act on receptors in the brain where we trigger cravings. And so that is what I think is really magical for people who maybe have a ton of food noise and can't make good food choices because their brain is always thinking about the fun food they really want to be eating instead of the steak and broccoli. 

[1:10:38] The other side of that is thin people who just want to be thinner. And these drugs, obviously there are insurance indications and generally that has to be someone who's of a certain BMI and or has a concomitant metabolic health issue. And most other people cannot get their insurance companies to pay for it. But people will pay out of pocket for these drugs whether they get it compounded or otherwise. And so, my concern is are there people out there that are going to put themselves in the same position where they were chronically, habitually undereating over time? The people that were in this relative energy deficiency, are they just magnifying that? We have a culture that really glorifies thinness over strength and being strong. 

[1:11:16] And I'm really getting back to our original conversation around if you're chronically under nourishing your body, what is the net impact? And that's why I think that judicious use of these medications has to include information about adequate protein intake and strength training. I see far too many women, I'm not calling anyone out that I know are using these drugs because they want to be thin, but they're not strength training and they're not focused on their macros. And I think we will ultimately see a lot of untoward long-term health effects if people are not including the protein and the strength training piece. 

[1:11:54] I think that is part of my concern and I have to believe, I hope most people that are using these drugs are being conscientious about those two metrics because it can make a world of difference. We know when you lose body fat, you're losing some muscle mass and that's why those bioimpedance readings, Bod Pods, DEXA scans are going to be very important so that we can track those metrics over time because that is what's really objective. You stand on a scale that just gives you one metric. When you're looking at bioimpedance readings, you're getting more objective information about body composition and that's what really key. 

Dr. Stephanie Estima: [1:12:25] Yeah, and I think there's a dosing, maybe a mismanagement problem potentially that we're seeing as well. So, I think that I love the idea of a medication that can help somebody get going. So maybe like as you were saying, reducing some of the food noise and some of the rumination that can happen and getting that dopaminergic high of seeing some weight loss from being in a caloric deficit and then using it as a motivational bridge for you to say, “Okay, and now I want to learn about strength training. And now I want to learn about how I can build my-- I can eat more nutritious whole foods and whole meals and start cooking maybe more at home rather than ordering uber eats or eating out or whatever the case may be.” So, I think that there's a--

[1:13:11] And I've spoken to Tyna Moore about this quite a bit, who I think originally maybe coined the term microdosing around it, but her research with her patient population and I think her mentor as well, talked about some of the rejuvenative properties that medication has, particularly brain, Parkinson's, Alzheimer's and then certain areas of the brain, potential for regeneration there as well. So, I'm very excited about it from that perspective, exactly what you said--

[1:13:38] I think that there is a-- We must be very, very careful that we are not just sending women who are already chronically calorically deprived just in their quest to be skinny to get skinnier. And you see this perversion unfortunately, in Hollywood, you see lots of-- Even stars who were body positive and now they're 10 sizes smaller. I think we want to be making sure that we're doing it for the right reasons. You're not doing it just because you're Keeping Up With The Kardashian-- Like you're not some TV show, whatever, and you're just trying to be as skinny as possible because that's going to sell whatever you're selling. 

Cynthia Thurlow: [1:14:18] Yeah, I think that-- I go back to my cardiology brain and the effects of GLP-1s post MI. So, people who have had a heart attack, we know that their outcome data tends to better. We look at women that are on hormone replacement therapy concurrently taking HRT are getting better outcomes and are responding better than those that are not on HRT. And I think they're looking at predominantly menopausal women. So, I think that it always goes back to judicious and appropriate prescribing practices. 

[1:14:48] And unfortunately, in our culture, people get just about anything that they want anyway, anytime. There was a documentary, I'm embarrassed to admit. I'm a documentary nerd. I love to learn. And it was looking at how people that can no longer-- Like their insurance company no longer pays for the drug, how do they go about getting it? And there were people who were getting. It could have been anything. They were receiving powders at home that they had to reconstitute. For listeners, this is when you have to add distilled water to a product, shake it up, and then it's able to be utilized. And so, I think that the concept of let the buyer beware, making sure that you're really getting it from within the United States, real pharmacies, not getting stuff off the black market, God forbid, buying stuff from China, because you never know what you're getting. 

Dr. Stephanie Estima: [1:15:33] Yep. Yep, man. Second AMA, she said, I think we should wrap-- Like, this is such a wonderful place to wrap. We've been going at it now for an hour and 20, 25ish. Any final thoughts, any final thoughts on anything that we've talked about today or anything that you are feeling that you'd like to share?

Cynthia Thurlow: [1:15:49] Yeah, no, I would say keep the great questions coming because there were far more than we could actually answer in one AMA, but I love the kind of camaraderie between our communities and so many shared interests, and so I'm so grateful and appreciative of your friendship and grateful that we could collaborate today. And hopefully, as I always say, hopefully, it's one of many opportunities to do the she said, she saids.

Dr. Stephanie Estima: [1:16:12] Yeah, I love this format. I love getting to spend time with you and I love polling our audiences, answering questions, like the most burning questions that they have. Certainly, they know you and I as podcast host, but of course, we also have our own philosophical premise and approach to health and wellness. So, I think this is a really wonderful way to showcase that. And like I always say, any time with you is time well spent. So just happy to be able to do it. So, thank you today, Cynthia. 

Cynthia Thurlow: [1:16:37] Likewise, of course. 

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