The Hormone Expert: The Hidden "Gut Bacteria" Destroying Your Hormones!

I think perimenopause is a litmus test of how well we take care of ourselves. We take our hormones for granted until they start declining. Women do really well in their teens, 20s, and 30s compensating. They get into their 40s, and as their hormones are changing, as the neurotransmitters are changing, it changes the way you perceive the world and yourself. If we don't change our lifestyle in response to changes in our physiology, it's gonna make it a whole lot harder to, you know, get through perimenopause into menopause. Many women that actually need progesterone replacement actually are being prescribed anxiety meds and, and depressive meds. I think a lot of what changes for women is their perception of self. I used to be able to handle X, Y, and Z, and now I feel so much less capable. The PAUSE piece is really helping women understand you need to start changing your lifestyle to match your physiology.

For millions of women, hitting the age of 40 brings a load of symptoms and problems. Unexplained bloating, stubborn weight gain, brain fog, and numerous other health issues, emotional ups and downs, even though their lifestyle hasn't changed. And today I'm joined by nurse practitioner and health expert Cynthia Thurlow. She's a bestselling author, and today we're going to uncover exactly why during perimenopause and menopause your hormones can be out of balance, how to bring them back into balance using food, herbs, and lifestyle medicine. And we'll specifically dive into how the liver and the gut microbiome play a key role in bringing your hormones back into balance. Cynthia, welcome to the show.

Thanks for having me.

Well, I'm excited for this conversation because this has been a, uh, a topic I've been really passionate about is helping women and entire families heal and balance their hormones. And for so many women today, they're dealing with symptoms because of perimenopause and menopause. And this is something you've helped a lot of women with. You've really walked them through how to naturally, in most cases, heal and balance their hormones. I've got a lot of questions for you today about everything from hormone replacement therapy, the top vitamins and supplements for perimenopause and menopause, the root causes. But that's sort of where I'd like to start in getting into is Most people today, when they think about hormone issues or menopause, they think, well, this is just natural. This is the way it should be. I'm going to have these symptoms. My doctor said, hey, this is menopause. You know, this is just the way it is. Is that reality?

I think that menopause, if you live long enough, is a natural process. That is correct. But it's not optimal in the sense that we really do have to adjust our lifestyle. We have to adjust our nutrition. We need to address our quality of sleep, how we manage our stress, boundaries, as well as looking seriously at targeted supplementation, plus or minus hormone replacement therapy, because utilizing those levers are going to be a differentiator for who's just surviving through middle age and beyond, and those that are thriving.

Yeah, you know, one of the things I've really encouraged, encouraged my patients to do is not turn to hormone replacement therapy first. It's not to say that for some women it's not beneficial, because I think there is a group that it's beneficial for. More, but it's never the thing I like to do first because oftentimes there's underlying insulin issues, liver issues, or as you've talked about for many years now, gut issues that could— that can be the underlying cause. So when you think about if a woman's going through menopause, well, first talk to me about what's happening physiologically that can actually cause these symptoms that women have, like dryness and hot flashes and some of the other major symptoms that a lot of women are experiencing.

Yeah, I mean, I always think about perimenopause from the perspective of what really is differentiator, the beginning of perimenopause. It's that our ovaries are making less progesterone, and that can show up as 1 to 2 weeks before you get your menstrual cycle, you suddenly start having more anxiety, more depression. You can get mood changes, you may feel more anxious, you may also have sleep alteration. So that is definitely a direct byproduct of not just that loss of progesterone, but also changes in a key neurotransmitter called GABA, which is our main inhibitory neurotransmitter. So there's that piece. Then there's also estradiol. It's our predominant form of estrogen that our bodies make up until menopause. And so as estradiol levels are changing, we may see— and, you know, traditional allopathic medicine doesn't like this phrase, but I'm going to use it— relative estrogen dominance, because we have less progesterone and we have relatively more circulating estradiol. And there's actual research to demonstrate that our estradiol levels can be 20 to 30% higher in perimenopause, which is what provokes a lot of symptoms. We may have brain fog, we may have breast tenderness, we may deal with the dreaded weight loss resistance, we may have a lot of vasomotor symptoms. So hot flashes, night sweats, for a lot of women, they start seeing much heavier menstrual cycles, and that can be bothersome and troublesome. Then we really start thinking about digestive changes, bloating, constipation, or diarrhea. They might have an alternation between, like IBS, SAT patterns, alternating between constipation and diarrhea, and that's just the tipping point. So when I'm thinking about what are the, some of the key things that we start seeing pretty quickly as we're navigating early to mid-perimenopause, those are the typical things that I'm seeing. Not to mention the fact, if we're having alterations in sleep, we are also going to have alterations in cortisol.

That's right.

And cortisol, as I always say, it's not a bad hormone, but it gets a bad rap. Helping women understand that when cortisol is high, over time, it is going to lead to elevated levels of glucose. So you will become, progressively more insulin resistant. That can also be worsened by changes in estrogen and changes in muscle mass. But cortisol is also catabolic. So if over time you're super stressed all the time, you're not managing your stress appropriately, you're going to get breakdown of that very precious muscle tissue. So sarcopenia starts to unwind, this muscle loss with aging. Not to mention the fact high cortisol is going to beget changes in immune system function, which means you're going to be more susceptible to getting sick. You're also going to be more susceptible to leaky gut. And leaky gut is really at the basis for autoimmune conditions, and women are 4 to 5 times more likely to deal with that. So it really becomes this domino effect of hormonal changes, not just progesterone, estrogen, testosterone, but also these other key hormones— cortisol, glucose— and understanding how they influence and can worsen some of these symptoms that we're experiencing midlife?

You know, I, I, I always like to look at things in terms of a cascade. Like, what is that thing that's tipping off everything else? And as I— one of the things I do at my clinics is I look at so much blood work, and I see cortisol being one of these hormones that affects every other hormone. And, you know, I went through this on a recent podcast. I went through the, you know, what some researchers years ago called the cortisol steel sort of cascade, right? And so you have, you know, you've got your, uh, you know, you've got your pregnenolone and sort of how that breaks down then into progesterone and then the other sex hormones. But cortisol is like, hey, I'm going to take all the resources from all— from progesterone, from testosterone, from all these other hormones and take them myself. And that starts to deplete that progesterone. But I think, I mean, that's— that is such a key thing, you know. And one of the things I thought about as you were talking here, as I was thinking about my own mom My mom, the first time she was diagnosed with cancer, was 41 years old. Wow. And, and it just reminds me of like so many of the patients I care for, and a lot of the women you care for that are entering perimenopause. My mom was in perimenopause, uh, and she was— had, you know, 3 kids. She was stressed, definitely high cortisol, high estrogen, low progesterone, all of those issues. And that even led to cancer. And you think about part of what can happen there too. And that connection between the liver and the gut, her not detoxifying well— by the way, her number one symptom she would have told you that she was dealing with and struggling with right before her cancer diagnosis, and then especially after, was even bigger problem, was chronic constipation.

Yeah.

And this is something you write about in your book, how our gut microbiome, and especially the health of our bowel movements and constipation, is a key factor in You know, and even in our hormonal health.

Yeah. And it's so interesting that we have normalized women being constipated because I know when I'm having conversations, I'll say, help me understand what constipation means to you, because you and I may say, I think you should be pooping every day. That should be normalized. Yeah. I have patients that think it's normal because it's their normal to poop 2 or 3 times a week. And so when you start thinking about the fact that if we are not able to properly package up Estrogen, like, let's use that as an example. There's a part of the microbiome where there's specific bacteria in the estrobolome that help us break down and package up estrogen, which we should be able to then eliminate through our feces, our poop. But for a lot of people, if their microbiome is not optimal heading into middle age, that can make it worse. You can recirculate some of these estrogens, which can magnify those symptoms, not just the hot flashes, vasomotor symptoms, but a lot of the brain fog and other symptoms that women experience. Normalizing, helping women understand we have two phases of detoxification in our liver. And really then it goes to the gut. And so the gut microbiome is critically important, the health of that microbiome for whether or not we are able to effectively break down, package up, and poop out that excess estrogen.

I think a lot of people maybe have a hard time. And by the way, I think this is going to be so key for everyone to understand. I think a lot of people don't think of estrogen because it's a hormone. They don't think of, oh, I need to detoxify. I think they're thinking, oh, I need to detoxify of forever chemicals and glyphosate and heavy metals like mercury. I need to detoxify those. But we need to detoxify estrogen. You know, I recently did a podcast on how to do a parasite cleanse, and there's— there were several steps that you can't miss if you want to properly detoxify. And one of those things was like, have a binder, you know, certain types of fiber, like it'll help with that. But estrogen is the same thing because your liver takes all this estrogen that you have too much of, it packages it puts it in your gut and says, okay, now get rid of it. But if you have the wrong type of bacteria in your gut, you can— your body can create these enzymes that basically then this estrogen breaks apart. It can recirculate in your body. So you have all this excess estrogen, increases your risk of breast cancer, can cause these menopausal symptoms, all these issues. But walk me through, I mean, do you have a process for women or some key things in terms of what do women need to do to detoxify excess estrogen properly?

Well, I think, you know, from the perspective, we have key organs for detoxification in the body. So our skin, our liver, our lungs, our bowels. So, you know, defecation, pooping, and as well as urination. But there are things that make it harder, like if you're chronically dehydrated. So number one, like really easy thing to think about, are you properly hydrating your body? And I think most of us walk around being chronically dehydrated. You add in the changes that are happening with estrogen as it's declining, we lose our ability to stay as well hydrated. Like, we actually physiologically, in the presence of less estrogen, high FSH, follicular stimulating hormone, our bodies become much less efficient at staying hydrated. So we become physiologically more challenged, but not impossible. So number 1, hydration. Number 2 is thinking thoughtfully about fiber. And I know fiber has now become the new F word. Depending on who I'm talking to, they're like, don't talk about fiber. We don't need fiber. We do need fiber. Fiber is very important for a variety of things, but as our hormones are declining, as the microbiome is changing, we need fiber because our production of something called short-chain fatty acids declines. These are important signaling molecules, and one of the things that they do is they help reduce inflammation. They help with endogenous GLP-1 regulation. I know these drugs are very popular right now, but they're also important for signaling molecules. They can cross the blood-brain barrier like butyrate can. So fiber becomes important because along with bile, which is designed to break down and emulsify fats, as estrogen's declining, again, we start taking a hit with being able to break down and, and process fats. So fiber is helpful for binding to these bile acids and effectively helping us package up the extra excess estrogen and excrete it from our bodies, poop it out. So when I'm thinking about how detoxification works, it's helping women understand we wanna sweat, so we wanna make sure we're exercising. We want to make sure that we're staying hydrated, that if we have access to things like sauna, that can be very beneficial. Dry brushing. Also helping women understand that the fiber piece becomes important. And for everyone that's listening, fiber is very bioindividual. What Josh may be able to consume on a daily basis might be different than what I do, as well as our spouses and other people, patients that we take care of. Also thinking thoughtfully about cruciferous vegetables. Thinking thoughtfully about, you know, bitter plants. So whether it's radicchio or frise or arugula, like those bitter compounds are gonna be very helpful and beneficial to supporting detoxification efforts. And I think, you know, there's those other piece of what genetics play a role in. Like I have something called MTHFR, which 70% of the population has. I have to work a little harder at phase 2 detoxification. So having a sense of what your personal, things that you struggle with, but also understand there's a lot that we can do before we even get to supplements, before we even get to utilizing medications or even hormone replacement therapy. There are things that we can do nutritionally. I would say one other thing that's important is the management of stress. I think for so many of us, we go throughout our lives, we're like, oh, I meditate for 5 minutes on Thursdays. It's so much more unique than that. It's really helping women understand as our hormones are declining, we have to work harder at stress management. So for years, I used to dictate in the hospital or in the office and eat at the same time. Not an optimal way to set your body up for digestion because digestion starts in our brains, not our mouths. Yeah. If I were to ask kids or most adults, they would say, "Oh, my mouth salivates when I smell something delicious." That's true, but actually it's under the control of the parasympathetic nervous system. But most of us are eating off our kids' plate, we're eating in the car, we're yelling at our spouse while we're trying to eat a meal. And so digestion, understanding that we want to be on that, that side of the autonomic nervous system, the parasympathetic, because that is what allows us to, um, absorb nutrients, break nutrients down, secrete enough hydrochloric acid in the stomach to break protein into amino acids, ensure that we're secreting digestive enzymes. So if we're chronically stressed, we're not actually able to break down, assimilate, absorb, detoxify, or even eliminate properly. And that's a part of the conversation that I oftentimes think is really left out because people are like, it's not important, digestion just happens. No, we actually have to foster it. We have to work towards it because it is quite important.

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Well, because progesterone is, um, you know, when I think about estrogen and progesterone, they're designed to balance each other out. There's key attributes of both. I always say that estrogen's kind of the queen. We know so much about estrogen, we talk about it a lot. You know, progesterone is equally important, and I think largely because of the fact that You know, when progesterone predominates in our menstrual cycle, we tend to need to back off on the intensity of our exercise. We might need to increase our carbohydrate intake. We may need to be doing more relaxing because it is the hormone that is connected with GABA, you know, this main inhibitory neurotransmitter and how important that is for us to feel like we can relax and we feel at peace.

Can I just jump in and say this? Like, when I first opened my practice, functional medicine practice, about 20 years ago, I think the thing that I noticed the most in taking care of a lot of women, especially Gen X women coming in, I would say, like, I kept hearing some of the same words. One, I noticed that they were physically, I would say, frazzled. It was like they were just so busy. But I'd hear words like, "I'm overwhelmed." Yes. Like, that was the number one keyword I would hear them saying, you know, constantly.

Yeah. And it's interesting because I think many of us forget these hormones also work in conjunction with neurotransmitters, and the bulk of our neurotransmitters are produced in the gut. So as the gut is changing, GABA takes a hit, things like dopamine take a hit, serotonin. So that also worsens sleep quality. But when I think about the things about progesterone that I think are most beneficial is that replacing, replenishing progesterone for a lot of women will improve their other symptoms that they're experiencing. So if you are feeling less anxious, if you are not feeling depressed or feeling almost like a flat mood, we'll use the term anhedonia in traditional medicine. Helping women understand that a lot of the changes they are experiencing at the very beginning of perimenopause are largely a reflection of changes in sleep quality, changes in mood that are oftentimes band-aided with, and I'm gonna just say this, some people need to be on medication. I don't want anyone to feel any sense of shame, but many women that actually need progesterone replacement actually are being prescribed anxiety meds and depressive meds. And they might still need those as well. But I think a lot of what changes for women is their perception of self. I used to be able to handle X, Y, and Z, and now I feel so much less capable. And so your point about the boundaries piece and getting really clear and intentional, I really think of it as it's, you know, the perimenopause, like the pause piece is really helping women understand you need to start changing your lifestyle to match your physiology. I think perimenopause is a litmus test of how well we take care of ourselves. We do a great job of taking care of everyone else in our lives, but in many instances, we're not taking care of ourselves. And so this is an opportunity, as progesterone is changing, for us to show up differently. Maybe you go to bed 30 minutes earlier. Maybe you say yes to less. And you— unless it's a hell yes, it's a hell no. And so helping women understand that the way to support progesterone— and we could talk about, you know, progesterone-supportive foods, but really, in essence, what we are inviting women to do is to take more off of our plate. Yeah. At this time.

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I do.

So I had Barbara on the podcast last year, and we talked about numerous things, and I was so impressed with her. By the way, her ability to quote the Bible and scripture was amazing. Her hormonal knowledge, women's health knowledge, was just— natural health was all very impressive. But when I asked her about female hormones or hormones in general, what the single most important hormone was, I tend to lean towards cortisol. But she was very much like, no, you have to balance progesterone. She was like, that is the key hormone that she found in women that you really need to, to focus on.

Well, and it's interesting for me, you know, having worked with tens of thousands of women over the past 10 years, I can tell just based on behavioral and communication patterns the people that probably are not getting sufficient amounts of progesterone, much more so like estrogen can show up as like word finding and brain fog. But progesterone is the— are you relaxed and calm? Are you able to communicate effectively and not feel like you're, you know, you're jumping through the screen? And so I think for a lot of women, they're surprised to know because we take our hormones for granted until they start declining. We don't even think about it because they're just working for us. And if we don't change our physiology, if we don't change our lifestyle in response to changes in our physiology,, it's gonna make it a whole lot harder to, you know, get through perimenopause into menopause.

You know, one of the things I've taught for a long time, and I know you do this in your book and you talk about this as well, which is one of the reasons I wanted to have you on, is really focusing on food as a form of medicine for our hormones. You know, I was thinking about and looking at the Japanese diet and looking at some of the predominant foods in there. And so you have things like fish is of course highly consumed, but they actually also consume a lot of, in terms of their carbohydrates, most consumed are rice and sweet potatoes. And what's interesting about rice is it supports GABA. Sweet potatoes can, or yams, support some level of progesterone, or giving the building blocks there. So, you know, of all countries where women are going through and having the least symptoms during menopause, Japan, the area of Okinawa, is very high on that list. But I look at their diet, and it is a form of medicine. It's supporting them as they're going through, you know, this, this phase in life.

Well, and what I think is so interesting about their culture is they— well, like most westernized culture, there is processed foods, but they tend to be very conscientious about the quality of foods that they're eating. And so, yes, they're eating carbohydrate-dense rice and sweet potatoes, but they probably are not eating the volume of processed carbohydrates that most Americans are. And I think that is at the basis, you know, there's been a lot of pushback about carbohydrates in general, and people are sometimes shocked to hear that I'm oftentimes encouraging women to liberalize their healthy carbohydrates.

Wow.

Because they have dialed in so much on carbs are bad, I only need to worry about protein and fat. And I'm like, no, no, no, you actually need a balance of each, and it's very bio-individual. But I think your point is an excellent one, because we have convinced women that all carbs are bad in many instances. And I'm here to tell you, a proper portion of carbohydrates can make the difference between sleeping well and not sleeping well. Yeah. For many patients that are really, really sensitive to carbohydrate intake and carbohydrate load.

I saw, you know, when the paleo diet became really popular. That is when I started seeing a lot of women with these hormonal crashes, with actually some of them with infertility issues, major health problems, because it was like, oh, I mean, most of those women that went paleo, it was like no carb. I mean, they went from, you know, whatever flour they were using to almond flour, right? They made all of these switches. And so it really does come down to— and I love that you're using the word bio-individual— it comes down to this personalized nutrition. Everybody's unique. We need to dial it in for everybody. And let me ask you, how do you do that in your practice, you know, in working with women in terms of finding what uniquely they need to be eating and supplementing with?

Well, I think it's starting with key themes. So number one, we all know we need more protein. I think, I think we have— that has definitely trickled down into, you know, media. People understand more protein for muscle protein synthesis because we are working at a little bit of a disadvantage. Women have less lean muscle tissue than men. So heading into perimenopause, understanding we're losing anywhere from 3 to 8% of our muscle mass each decade really is a wake-up call. So protein, no less than 30 grams of protein with each meal, that's kind of a, a standard basis. Number 2 is thinking thoughtfully about carbohydrates. I'm not anti-carb. If someone is obese or overweight and we know that they have weight they have to lose, then we're talking about portions of carbohydrate and getting really clear and intentional. I want the bulk of your carbohydrates to be coming from fibrous vegetables. And I would say it's a 3-to-1 ratio, 3 vegetables to 1 piece of fruit. It doesn't mean fruit is bad, it just means we have a propensity as Americans to eat sweet things, and fruit usually is where people eat the bulk of their carbohydrates. So 3 vegetables to 1 piece of fruit, being thoughtful. Like, I don't necessarily break it down by soluble versus insoluble, or looking even at, you know, ferment— ferments. Sure, eat more of them. It's getting clear and intentional about fermented foods and, and probiotic-rich foods. So that may look like a tablespoon or two of sauerkraut, that may be low-sugar kombucha, that may be fermented dairy if they tolerate dairy. You know, just being clear and intentional as a starting point. Now, fats are something that I think, again, are also very bioindividual. I'm someone that doesn't do well with saturated fat, although I do have a little bit of it in my diet. I do better with monounsaturated fats, so Getting clear about, you know, are we getting our healthy fats in our protein? Like, if you have a salmon steak or a ribeye, you don't need to add copious amounts of fat. That is the fat memo that I think many women get wrong, because it's interesting, if you look at the research, two women can have a ketogenic diet, which we would arguably say is higher fat, moderate protein, and then less carbohydrates. One woman goes on that diet and does really well. She loses weight, she feels great. The other woman, same diet, same macros, will actually gain weight. And it could have something to do with how her body breaks down and absorbs nutrients. So really looking at the microbiome, which I think is important, but key concepts are adequate protein intake, getting most of your fiber from fibrous vegetables, you know, looking thoughtfully at, you know, flax and chia seeds, or looking at lentils or beans or other legumes. It doesn't have to be copious amounts. And then those ferments and probiotics, that's usually a good starting point. And then not getting obsessive about the fat piece, because a lot of the fat is in the foods that you're— if you're having macadamia nuts or you're having nuts, you're getting healthy fats in those things. So not obsessing over fats, but just making sure it's incorporated either into the protein or adding it in as a supplement.

Yeah, yeah, that's fantastic. Use a word earlier, and I'd love for you to explain what it means: estrobolome.

Everyone loves this word, and it's not estrobalomy. I actually had a, a podcast host say the estrobalomy, and it took a while for me to regain my composure, but it's a part of the microbiome. It's an estrogen processing center. It's actual bacteria that are designed to break down and allow us to package up and get rid of estrogen. And so for a lot of people, the estrobilum, the health of the estrobilum, is largely dependent on all those lifestyle things that we've talked about. It's dependent on, you know, where is the microbiome in terms of diversity, inflammatory species heading into perimenopause. This is why it's important to educate younger women. It's not just a middle-aged woman conversation. But the estrobolome is instrumental for the specific bacteria that help break down estrogen. There's a specific enzyme called beta-glucuronidase, and it's the Goldilocks effect. If you have enough beta-glucuronidase, you can break down and package up the estrogen. If you don't, it can be a sign that you may recirculate this estrogen. And so sometimes when we're doing diagnostic testing, as I'm sure you do in your practice, you can see high beta-glucuronidase, which can be a sign that their detoxification pathways, or their detoxification overall needs additional support. But a really important, essential, uh, part of the conversation, and no, I did not make this name up, someone else far smarter than me, more than 10 years ago, came up with the term estrobolone. But it is speaking about the microbiome and specifically the bacteria there that are helping to break down, cleave, and get rid of the excess estrogen.

Well, it's incredibly important, you know, and, and that's one thing I know that you've really talked about is like one of the number one, if not the number one organ that is is responsible for hormone balance is your gut microbiome. And part of that is the estrobolome. And so I, I, I, I am in really strong agreement. Now, I would say that I, I think of it a little bit more in terms of just the— and you think of it this way too, but just in, in verbalizing this, just the entire process of digestion. Because I would say the liver is equally important, and they're kind of partners in the liver and the gut in making this all happen, right? In terms of what happens in the body. You know, I also think about You know, I work with so many women with hypothyroidism, and we see this issue with the conversion of T4 to T3. By the way, you might have seen this study. The study came out about a month ago. It was in JAMA. It was in a study out of Yale where they said— I mean, this is crazy— 21 million women today on levothyroxine possibly should not be on the drug at all. 20— I mean, they said like 90% of women, it's not supporting them. But it is causing depletions in selenium, zinc, certain B vitamins. So women have been on levothyroxine, this thyroid medication, for years, some of them 20 years. And it's slowly been causing these other health issues, making maybe their thyroid issues worse. So when they get on— get off it around menopause, they're like, well, either I feel better or my symptoms didn't change at all. And I've been on this drug that long.

Well, it's interesting. So Synthroid is synthetic thyroid hormone. And what's interesting to me is I had patients that loved Synthroid and were like, we— they would go in the hospital, they're like, I will not take a generic. I only want trade name Synthroid. Yeah, but just giving a medication doesn't necessarily mean that your body knows what to do with it. So when you're giving Synthroid, this is synthetic T4, your body still has to take that and make it into usable energy, which is T3. And I think for a lot of individuals, they're given these medications, they don't necessarily feel better, and they're continued on them because they don't know any differently.. And so I think that there's very much this bio-individual approach, but also understanding the health of your microbiome has a lot to do with whether or not your body can effectively convert T4 to T3, which is the usable form of the thyroid hormone. Not to mention the fact with our depleted soil and other things that are going on in our modern-day food system, people are already dealing with lower levels of cofactors for thyroid hormone, whether it's iron, whether it's magnesium, whether it's selenium, zinc, etc. And so it's really looking at a— I think it's a bigger issue.

Yeah. And I think for a lot of women that will get on T4, levothyroxine or Synthroid, sometimes they'll notice a difference at first because, okay, you're flooding the body, but then sometimes the body kind of adapts or you didn't take care of the underlying issue, like the high cortisol or something like that. So then you have other sort of problems compiling where you've just sort of covered up, you know, maybe some of these baseline symptoms with the drug. And, and this is why I am more in favor of like a woman using Nature-Throid or Armor or something like that that does have T3 in it and that combination. But overall, what I found is if you are changing your lifestyle, eating the right diet, taking the right supplements like selenium and the other things, most of the time you'll see bigger improvements to where you don't need to be on the thyroid drug. But I remember, I— there are a lot of women who their doctors have told them You'll be on this drug the rest of your life. It will never, ever change or improve.

Well, it's interesting to me. So I will transparently say that 10 years ago, my functional med nurse practitioner was like, you need thyroid medicine. Like, your thyroid numbers are terrible. And we were looking at them and I said, I don't want to be on medicine for the rest of my life. So for 6 months, I was taking a thyroid glandular. I was using all these cofactors. And 6 months in, I realized, I was like, I am exhausted. I cannot function. My hair is falling out. I'm losing my eyebrows. What is going on? I'm also weight loss resistant, which was probably my largest impetus for like, okay, there's something clearly going on here. When I got started on Nature Thyroid, it was as if a light bulb turned on in my brain. Yeah, yeah, it was that dramatic. And so I always remind women, I think for many of us, we're like, I don't want to be on medication, but I think we have to think about hormones differently. I think we have to be thinking that if you need it and you benefit from it and you see improvement intrinsically on labs and in terms of symptoms, that's great. But to your point, a lot of patients— and in traditional allopathic medicine, when I was still in that role, Synthroid was what everyone used. But we didn't understand that sometimes patients can't actually convert it to a usable form of hormone. And that's where I think these Nature Thyroid and Armor can be helpful, or even compounded medications that are made— they're specifically tailored for the patient. I think for a lot of women, it's helping them understand there's no shame if you need meds. But we need to make sure you actually feel better on the meds.

Yeah, yeah, I agree. And, and for me, and I'm not saying— and just to be clear, I do think there's a time and place for, for those. But here's my methodology. It's let's change your diet, let's change your lifestyle, let's take all the right supplements, let's do the blood work, let's see exactly what you're deficient in. I found 80% of the time it will get you there. And then if we don't, well, then we'll do this for a period of time, and maybe the reason why it's not being fixed is you're going through a really stressful time in your life, cortisol staying high, But a lot of times after a couple of years, maybe we're out of that phase and we can find a way to wean you off that over time. But that's not the mindset of most doctors, Dave. And it's just— it's not that.

Yeah, no, absolutely. And I think, you know, for each one of us as individuals, something that works for you or 5 people over here might be very different than what works for me. And that's where I think honoring our own bio-individuality. And quite honestly, I have patients that will say to me, I want to do everything I can to avoid taking medicine. And I'm like, we can work with that. Yeah, but if we get to a point where you're going to benefit from a medication, I want you to feel no sense of shame for that being the case.

Yeah, yeah, it makes sense. So when women start going through this perimenopausal, menopausal period, you know, there are things that I know we want to do to start to support the body. What are some of the things— we talked a little about food, we talked about fiber, increasing protein, uh, you know, eating more probiotic-rich foods. I know these are all important, What are some things people can do from a supplement standpoint? Are there any more, even more essential vitamins, nutrients, other compounds that can really benefit women?

Well, I think at a very basic level, almost every patient I interact with needs magnesium replacement. It has 400 enzymatic reactions in the body. And as a former cardiology nerd, there are very few women I interact with that don't need magnesium. So magnesium is number, number one. Vitamin D, being thoughtful about that. I would say that adaptogenic herbs are some of my favorite things to use because they are so tonifying for cortisol. So we've talked a lot around cortisol, but there are specific adaptogenic herbs. These are natural plant-based compounds that can help tonify. If you need to be stimulated, like you're feeling tired, ashwagandha is great because it can be both stimulating and also tonifying, meaning it can help raise cortisol, can help balance cortisol. And I think that's always a good one. If someone's struggling with sleep, we start thinking about rhodiola, relora, as being fantastic options. Adaptogenic herbs, I think a lot about creatine monohydrate, and I think many people, like the gym bros, know it's good for strength gains, but the research is starting to evolve in a way that it's very thoughtful. It can help for jet lag, sleep architecture. How many women in middle age are struggling with sleep issues? Also bone health, but obviously you need higher doses if you wanna cross the blood-brain barrier. Yeah. And so typically we're saying 8 to 10 grams is what we are looking at if we wanna be able to do brain, bone, support, and also some emerging research about the gut microbiome. So I think creatine is one of these supplements that can hit multiple things, and I love when supplements have more than one indication. I also think about digestive support. So if I suspect someone needs hydrochloric acid or pepsin, looking at digestive enzymes, one of my favorite supplements for middle-aged women is TUDCA, which is an acronym But it is helpful for bile acid support, but also mitochondrial support. And really at the basis for a lot of the symptoms women experience in midlife, and frankly for men too, is mitochondrial dysfunction. So I think a great deal about that. I would say other things like urolithin A, we know most people can't get enough from the food, unfortunately. Our microbiomes are largely dependent on that. So, you know, yes, you can have pomegranates, yes, you can have walnuts, but urolithin A can be very helpful for upregulating mitophagy. Which is getting rid of those diseased, disordered mitochondria, which are the powerhouses of our cells. But those are like, maybe myoinositol too, because it helps a lot of women sleep. I think, you know, before the GLP-1s came around, we would talk about myoinositol for blood sugar support, or berberine, which are still helpful to a point. But I think about myoinositol as a total game changer for sleep support in many, many ways. Those are things that I think about, like most women benefit from those, even if it's just transiently. Like maybe someone just takes the adaptogens adaptogenic herbs around stressful circumstances. But those are the things I'm thinking about. Now, obviously, there are more things that I love, but I try to keep it kind of condensed. Do you need digestive support? Do you need sleep support? What's going to be a multifactorial supplement that you can use? And that's why I think creatine is such a great option.

And I think for women, being able to pinpoint, as you talked about, this personalized medicine of figuring out what is it that your body needs most— listen, you can't take 100 supplements. But being able to key in on, is it cortisol? Is it a nutrient deficiency? Is it really driven by estrogen or progesterone just dropping so suddenly? Then there's black cohosh and red clover, and a lot of those sort of herbs can be great. But overall, I love— I mean, a lot of these adaptogenic herbs that are getting cortisol back in balance, because that is, of course, incredibly important to your point there as well.

Josh, people always ask me about fiber, like fiber supplements. And I would say try to get it from food-based sources first. If you're really deficient and you're really struggling, then we try to keep it simple, like psyllium husk. Organic psyllium husk is a good option. Yeah, fresh ground flax and chia seeds. I think that is so gentle. I'm like, I always say to people, I'm like, listen, put it in a smoothie and call it a day. It's such an easy way to bump up not only your protein intake but also giving you some good fiber intake as well.

Yeah, I totally So, Cynthia, one of the things that's happening so often today in our conventional medical system is when women have their hormones start to become more imbalanced, more apparently imbalanced, they're running to HRT. And this happened even more so, I saw, in the natural health community. It was funny because I saw when they removed the black box warning, RFK did, I thought to myself, you know what, I understand that. That, that's fine, it makes sense. But also, you know, it was this thing where it's like liberating women, and I thought, well, I, I don't know. I mean, the thing that I worried about with it— I'm just, I'm being real honest, by the way— my heart is very much thinking about my mom who had cancer, my wife, my sister, my patients, and people who I didn't want them to think, oh, well, that just means it's completely safe, it's the first thing I should do, and run out and get hormone replacement therapy. Because I thought some people even in the natural health community kind of came out and that was a little bit of their demeanor. Now listen, everybody's a different opinion. My opinion might be different than yours, but I also want to say I have had 3 women, and we take care of a lot of and support a lot of women with cancer in my clinic, and I had 3 women, they were all in their 30s, got on hormone replacement therapy, and the next year diagnosed with breast cancer. And I see it often. Now, I do want to say that I do like hormone replacement therapy for the right woman at the right time if they're doing the right things. Right. But my— again, my issue has been that— and I'd say the same for TRT for men, right? It's like, okay, your testosterone's low, your free testosterone's low. Let's do some zinc. Let's get vitamin D. Let's get boron. Let's lift weights. Let's get better sleep. You know, let's do what we can. And then if we're still having issues in 3 months, even, okay, there's a time and place, you know, there's a time and place for that. But, but so often today, people just want to do the cookie-cutter thing and just say, it's, oh, fine, everybody, just if you want it, here you go, versus personalizing this for, for women out there. What are your, what are your thoughts on HRT?

Yeah, so I think you bring up some good points. So number one, it is very much a personalized approach. I think that we have whittled perimenopause and menopause down to just slapping on an estrogen patch and peace out. Like, that's all we have to do. It's not to suggest that hormones are not important. I take hormone replacement therapy, so I want to be fully transparent. What I think is important is that when we look kind of globally at women, and certainly when I worked in clinical cardiology, I saw a lot of older women in the ICU that were septic, and they were septic because they had a urinary tract infection, which could have been prevented by something as simple as vaginal estrogen, which stays very localized to the vagina. So I'll just put that out there— 70% reduction in hospitalizations just with vaginal estrogen. So vaginal estrogen for all women, because genitourinary syndrome of menopause is not a question of if but when. So that's like, that's one thing. And even cancer survivors can safely take vaginal estrogen because it's not systemic— ideally is not systemic, it's not supposed to be systemic. When I think we're talking about a larger conversation to Lifestyle, it is lifestyle first. We really have to manage stress, we have to prioritize sleep, we need to eat less often. It doesn't mean everyone's intermittent fasting. We need to eat anti-inflammatory nutrition, we need to lift weights and maintain muscle mass. And then it's also thinking about like, when do we layer in hormones? Is that appropriate? Is that what the woman wants? Number one, I think fully informed consent is talking about here are the pros and cons. We know that estrogen can be primary prevention for osteoporosis, which is a bone disease, and we don't want that to happen. So it's helping women understand, do we start with oral progesterone when you're in your early 40s, when you can't sleep and you have anxiety and depression? I think that is reasonable. I think that, you know, do we layer in estrogen? Is that appropriate for you? So again, it's this ongoing conversation. Yeah. What are the benefits? What are the looking at estrogen therapy and saying, what are the benefits of estrogen therapy? Are you going to get improvement in cognition? Are you gonna have less brain fog? Are you gonna be able to, uh, not struggle with word finding? Are you someone that is going to be able to protect your bones? Are you going to have, um, you know, improved skin? Are you going to have a reduction in cardiovascular disease? That is the number one killer of women. One in three women will die of heart disease. So I start to talk about helping women understand, like, if you're making this decision, whether it's to take HRT or not, understanding that there is still this inflammatory process that is going on behind the scenes, changes in immune system function. We didn't even touch on that, but the immune system starts to unwind. 4 to 5 times more likely to develop autoimmune conditions in midlife. So when I'm talking to women, helping educate them about changes to brain health, changes to bone health, changes to heart health, microbiome, immune system function, um, mood piece. And not, not to mention the superficial stuff. Like, we know as we're losing, uh, estrogen, we're losing collagen and elastin, so we'll start seeing changes in our skin as well as body composition. It's like, what are we going to do to augment for that? And so I think that's part of the conversation. We're not looking to replenish hormones back to when we were 20. What we're doing is to provide enough hormones so that we're reducing symptoms and protecting all those body systems I just talked about. And unfortunately, I think that a lot of people just think about HRT as bone, brain, heart health. And I'm like, no, no, no, these hormones touch every single cell in the body. And so I think as I understand more about the conversation, it's just helping women understand, here are your options, what are you comfortable with? And it's no longer this 5-year window, like you go into menopause at 47, you can only start hormones within that 5-year window. We know that it's also about, like, risk stratification. So if someone's 60 and they're 10 years into menopause, can they think about HRT? Yes, but, you know, it requires a cardiovascular risk evaluation. They'll probably do— you know, I prefer doing CT angio or CLEARLY, but you can also do a coronary artery calcification scan, which is not invasive and very inexpensive, but really getting a sense of what's your personal risk, what are you comfortable with, and then getting clear and intentional about what you desire to do and matching you up with a clinician that can help you with that.

Yeah, yeah, it makes sense. Again, the whole thing I've been trying to preach here for a long time is let's get your own body working again to its ideal state and then see where we're at. And, and that's, and that's not what I see being done most of the time, you know. And it's like, okay, if cortisol is too high, if estrogen's too high, if your gut is off, is your liver's off, Let's do everything we can to naturally fix those things. And then if you still need there, then, hey, I'm glad it's there. But that's again, that's, that's happening in, you know, less than 10% of cases, unfortunately. Good news is, as we've been talking about, there are so many natural things that people can do to balance their hormones. Last question I have for you, and this is something that I know you've written about and it's something that I talk about on the show to a degree, but you really hit on it in a different way, and that is is how stress can impact, and not even stress that we're having today, but stress that people have had 20, 30, 40 years ago, how that's impacting their hormonal health and actually causing organs to age more quickly.

Yeah, you know, Josh, this is a— this is one of the aspects of writing the book that I found shocking, was that understanding the research that is done, there was a joint venture between Kaiser Permanente and the CDC looking at adverse childhood events, and anyone watching or listening can go online and you can get access to a fairly short quiz. But individuals with high ACE scores, so adverse childhood events, are at greater risk for poor metabolic health, certain types of cancers, distorted relationships with food, and earlier menopause because our ovaries are our most mitochondrial dense organ in our bodies. We've been talking a lot about cortisol. Cortisol is not a bad hormone, but it gets a bad rap. And if we understand physiologically what's happening when we are chronically activated in our sympathetic nervous system over time, that is rewiring our autonomic nervous system, that is rewiring our perception of stress. So if you have a high ACE score like I do growing up, and not even— I'm a very, you know, on paper, from what everyone can see, very successful. Women do really well in their teens, 20s, and 30s compensating. They get into their 40s, and as their hormones are changing, the neurotransmitters are changing,, it changes the way you perceive the world and yourself. And so I always say that, you know, many women who are really well-regulated in their earlier years start to unwind in midlife. And a lot of it has to do with significant underlying trauma or even PTSD that is unwinding as our physiology is changing. We just don't regulate quite as effectively. That doesn't mean that that's the end. It just means that we have to work a little harder. For me, I left traditional allopathic medicine 10 years ago, had a lot to do with, like, I could not manage the stress of that work anymore. And I think for a lot of women, it's helping them understand chronic stress ages our ovaries, full stop. And so most mitochondrial— or mitochondrial dense organ in our bodies, it's the canary in the coal mine. So when I see women that are going into menopause early or going in at 45, 46, 47, 48, maybe that's naturally where they were going to be. But more often than not, when we start unpacking their childhood, their young adulthood, almost always having significant, significant PTSD or trauma that is, I think, contributing to what they are experiencing at a younger age. Average age of menopause in the United States is 51. 45 is quite different. That means you're going 6 additional years without those protective hormones.

Well, you know, I think about this. There are phases in your life where you really notice, okay, you're aging more quickly. You know, I've talked about this and you've talked about this in terms of all these excess chemicals in our food supply and how women are hitting, uh, you know, girls are hitting menses way earlier than they should. I mean, if you look back, a lot of times it's 11 years old, 12 years old, 13. It should be closer to 16, uh, or 17. I mean, much, much later on. And then you have this other shift, as you're talking about, in life where your hormones are diving down so much quicker. And this is a sign of premature aging. You're aging more quickly. You know, in Chinese medicine, area of the body is tied with fear. And so if there's a lot of fear in your life and, you know, narratives from the past or beating yourself up, negative self-talk, you actually are aging that organ more quickly. You know, there's a study a few years ago that found that, you know, we can look at blood work too and look at certain markers to see that for most people, they have one organ aging more quickly than another. And so for you, if it's your ovaries, if it's your reproductive organs, it's going to impact your whole body. You're entire— not only are your ovaries aging more quickly because they're so responsible for things like estrogen, And progesterone, it causes your whole body to age more quickly. So it's a really big deal for longevity as well. Yeah.

And I think, you know, the, the big takeaway I want, you know, if someone is listening and they're like, yeah, I did, I grew up and I had an abusive parent, or I was, I was physically neglected, or there was significant abuse, it's helping them understand, like, you can come out on the other side. That is not— I don't want the message to be that it's doom and gloom. It's understanding you have to do a little more work, like you genuinely have to do a little bit of extra. But I think for most women, they want to feel regulated. They want to feel good in their bodies. They want to have good interpersonal relationship skills. I always look at the statistic that 70% of divorces are initiated by women. How many of those divorces are initiated by individuals that are dealing with all the neurotransmitter change, the hormonal fluctuations, and their ability to compensate is just not what it was when they were younger?

I mean, this is a much deeper, deeper topic here. I think part of this has to do with the sort of lack of, uh, biblical literacy. Like, in school, people used to actually have a lot more Christian education, and then they had— they learned stories of the Bible and had a relationship with Jesus. And so they were able— better able to balance themselves. I mean, sort of that spiritual wisdom and understanding allows you to better regulate your emotions and hormones. That's actually been pulled out of schools. That, that's a whole nother show, a whole nother topic. But I actually think that's another reason why there's sometimes this level of emotional instability or having trouble regulating emotions is because if you don't believe in a God who's protecting you and for you and surrounding you, of course you're gonna have a greater level of fear and anxiousness and worry in your life. And so I think that's important as well. Well, I've loved this conversation, and Cynthia, I really appreciate you coming on. I wanna encourage everybody, check out Cynthia's new book just released here recently called called The Menopause Gut. Really walks you through how to fly through menopause, the right foods to start eating, a lot of what we talked about, but going in more depth here, uh, in her new book. It's in bookstores nationwide. It's on amazon.com. Again, it's called The Menopause Gut. Also, you can find more about Cynthia on her, uh, Instagram page and her social channels. Again, check out Cynthia Thurlow there as well. I want to say thank you everybody for tuning in here to the Dr. Josh Axe Show. Remember, every week we're diving deep into the science and principles of how you can heal physically, mentally, and spiritually. Also, make sure to subscribe, like, and share, and leave a 5-star review on Apple Podcasts. I can't wait to see you on the next episode. Hey, if you're watching on YouTube, I'd love to know what is the number one thing that Cynthia shared, uh, today, or that we talked about when it comes to healing your hormones, supporting your body as you go through perimenopause and menopause. We'd love to hear from you if there's any action steps you're going to take, anything you learned, and what you're gonna do about it.