Menopause Gut Health Explained: Leaky Gut, Bloating & Weight Gain with Cynthia Thurlow
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Show Snapshot:
Bloated. Foggy. Stuck at a weight that won't budge no matter what you try. Most women blame their hormones and stop there — but nurse practitioner Cynthia Thurlow says the real story runs through your gut just as much as your ovaries. She joins Katie to unpack the science behind her new bestseller, The Menopause Gut.
In this episode:
What "leaky gut" actually means (medically, not just online)
The estrobolome: the gut-hormone connection nobody explains well
The surprising gut-bone health link
Which gut health tests are worth requesting — and which are a waste of money
About Cynthia Thurlow: Cynthia Thurlow is a nurse practitioner and author of “The Menopause Gut,” which explores the connection between gut health, hormones, and metabolism at midlife. She's the host of the Everyday Wellness podcast, recently named America's Best Wellness Podcast, and her TEDx talk on intermittent fasting has more than 15 million views.
Show Links:
Follow Cynthia:
Cynthia’s Book:
The Menopause Gut: Balance Your Microbiome to Reclaim Your Health in Midlife and Beyond
Cynthia’s Podcast:
Everyday Wellness with Cynthia Thurlow
Quotable:
Transcript:
Katie Fogarty[0:03]
Welcome to A Certain Age, a show for women who are unafraid to age out loud. I'm your host, Katie Fogarty. Beauties, what if the bloating, the brain fog, the stubborn weight, and the sleepless nights aren't your hormones failing you, but your gut asking for help? Today we are doing a gut check, diving into the world of the gut microbiome and the key role it plays in optimal midlife health for women — and we are doing it with a world-class pro. My guest today is Cynthia Thurlow, a nurse practitioner, best-selling author, a TEDx speaker with millions of views, host of the mega-popular podcast Everyday Wellness, and one of the most trusted voices in women's midlife health. Cynthia's newest bestseller, “The Menopause Gut,” reveals that as estrogen exits the building, the gut microbiome becomes the body's new control center, quietly governing everything from how you metabolize food and manage weight to how clearly you think, how well you sleep, how stable your mood is, and even how your immune system holds up. Today we're exploring questions I know you have — questions like: why on earth have our lifelong health and fitness routines started quiet-quitting on us in midlife? Will we ever sleep through the night again? And who invited unwanted roommates like brain fog, anxiety, and brittle bones to move in and make our lives miserable? Plus, what are the do-not-miss tests and labs for managing your gut health — aka, should we be doing stool testing? If you've jumped on the HRT and protein bandwagons and are still not feeling like yourself, stick around, we have a conversation for you. Welcome to A Certain Age, Cynthia.
Cynthia Thurlow[1:49]
Thanks so much for having me, Katie.
Katie Fogarty[1:51]
I'm very excited about this. First of all, congratulations — the book is a bestseller. I know it's been out for one month in the world today. It's so needed, “The Menopause Gut.” What about midlife and the gut microbiome makes this phase of life the new body control center, and why is that reframe so key for women in midlife?
Cynthia Thurlow[2:11]
Well, I think that we — and I say "we" as a collective — have thought that this decline in hormones and changes in neurotransmitters just impact a couple of body systems, and I'll be totally transparent and tell you that I think the gut is the missing link, and here's why. The gut microbiome is 40 trillion bacteria, viruses, fungi, and protozoa that intersect with every single cell and organ system in the body. To give you some perspective, there's a gut-ovarian axis that's actually very influential, and when we go into perimenopause and menopause there's a gut-bone axis, so if your gut isn't healthy, you won't have healthy bones. From a very basic level, we're imprinted at birth — whether it's a vaginal delivery or a C-section, whether we're breastfed or bottle-fed, that's a big imprinting — and there are three key times in a woman's life where we see significant changes and shifts in the microbiome. Not surprisingly, puberty is number one, heavily influenced by estrogen, progesterone, and testosterone. Pregnancy is another big inflection point — these are the "3 Ps" that Dr. Lisa Mosconi speaks to — and then the last one is perimenopause. Not surprisingly, just as our hormones ramp up in puberty, as they're declining it's impacting every single organ system in our bodies. I find for so many women who come to me, they're like, "I'm focusing on sleep, I'm trying to manage my stress, I intermittent fast, I try to exercise, I've got my estrogen patch on — why am I still not feeling well?" So it's about helping women understand there are many pieces to this puzzle of midlife, but the gut microbiome really needs to be an area of focus, because there's a lot we do unknowingly that can impact the health of the microbiome — things that can be beneficial, things that can be detrimental. The other thing to really consider is that 70 to 80% of our immune system is housed in our gut, and I think a lot of women don't understand that as estrogen is exiting the building — proverbially, figuratively, and factually — we start to see these subtle shifts in our immune system: more autoimmune conditions, more susceptibility to infections. Because the gut microbiome isn't as tangible as the heart, the bones, or the brain, I think for many people this invisible city doesn't register as being as impactful as it is.
Katie Fogarty[4:38]
I was surprised by that number — I read it in the book and it jumped out at me: 70% of our immune system resides in the gut. You mentioned earlier there's a gut-ovarian axis, there's a gut-bone axis — what is the gut-immune axis? Can we expand on that a little bit?
Cynthia Thurlow[4:53]
Absolutely, and I think estrogen really is the key player here. The predominant form of estrogen our bodies make up until menopause is called estradiol, and estradiol and the immune system are so interwoven. If you think about estrogen as this mediator — as estrogen is declining, we start to see more inflammation, or "inflammaging," a term a lot of my allopathic peers hate to hear but that's a good descriptor. Estrogen interfaces with the immune system: think about the small intestinal lining, which is one cell layer thick. In that brick-and-mortar mechanism of the small intestinal lining, estrogen is the mortar, so as estrogen levels decline we start to see more food particles leaking into the bloodstream. This is the bloating, the underlying new food sensitivities that women experience. The other thing that's interesting is that as estrogen declines, it provokes the immune system — the bloodstream and the immune system sit right alongside one another, so when you're leaking food particles into your bloodstream, or you get food poisoning, like I did at the beginning of the book talking about Morocco, it provokes the immune system, and once the immune system gets tripped off it can raise the alarms for inflammation in the body. Not all inflammation is bad, but understanding why we see four to five times more autoimmune conditions in midlife comes down to these changes and shifts in our immune system. We have a primary, basic level of immune system — the skin, the cilia in our nose, mucus — designed to protect us. It's not very targeted, it's crude, but it's effective. And there's a second line, the acquired immune system — antibodies, antigens — the "trained" immune system that's very targeted and precise. What happens in midlife, with these changes in estrogen and this provocation of inflammation, is that these defenses don't work quite as efficiently. You saw this during the pandemic — the people who didn't do well if they contracted the virus were generally older individuals, a lot of them women, because our immune systems don't work quite as effectively. If we look at the research, we don't fight off viruses as well in midlife with these hormonal changes, and we don't have as much vaccine efficacy — I don't say this to be controversial, it's just what the research shows. That's why every time you go to CVS or your local pharmacy, they're encouraging you to get a shingles vaccine, a flu vaccine, a pneumonia vaccine — because they know that as we get older, our bodies aren't as good at fighting off infection. We get a tripped-up immune system that's largely impacted by these changes in estrogen. Here's another example: women in perimenopause, where estrogen can run 20 to 30% higher in a cycle, may get a tripped-off immune system with more of a histamine response — depending on where they are in their cycle, they may have more hives, more nasal congestion, more abdominal cramping, and that can be a byproduct of high estrogen, high histamine, more provocation of these symptoms. I remind women all the time that estrogen fluctuates throughout our menstrual cycle, and then we go into a period where we have less circulating estrogen — that's when we start seeing more immune system dysregulation. This is why those lifestyle pieces, and why HRT, become an even more essential part of the conversation.
Katie Fogarty[8:35]
In the book you refer to some of these as "enemies at the gate," and you mentioned earlier we might leak food particles — I want to ask you about the phrase "leaky gut." We hear this a lot, it's in the zeitgeist, but walk us through what that means and what it means to a woman who's experiencing it.
Cynthia Thurlow[8:53]
Yeah, so what most people are really referring to is small intestinal hyperpermeability, which is a fancy way of saying leaky gut. Remember, earlier I talked about how estrogen is the mortar in that one-cell-layer-thick small intestinal lining — that lining can very easily be breached by antibiotic use, even if it's appropriately given, by toxins we're exposed to in our environment or in personal care products, and by chronic stress — this is huge. When I read the research on how chronic stress impacts leaky gut, it makes a great deal of sense why adverse childhood events and PTSD can down-regulate our health in really profound and negative ways. Leaky gut then leads to a down-regulated immune system — whether you're exposed to a food-borne pathogen, whether you get food poisoning, whether you get a round of antibiotics, the leaky gut is provoked by this estrogen down-regulation, and you leak food particles, or you leak endotoxin — lipopolysaccharides — into your blood, and this provokes the inflammation we talked about earlier. But it also makes us four to five times more likely to develop autoimmune conditions. So you have this superimposed effect: as estrogen is declining, the mechanical barrier to the outside world is breached, then it's compounded by these hormonal changes, then you layer in other issues. There are very few women I've worked with, Katie, who didn't already have an autoimmune condition, and once you have one, you're more likely to have others. A lot of patients are surprised — they're like, "Okay, I got psoriasis at 20, alopecia areata at 30, at 40 I got diagnosed with Hashimoto's," and then in their 50s maybe they get a diagnosis of lupus. Our immune system is designed to be protective — it's what actually protects the fetus when we're pregnant — but that cranky immune system can come full circle in the perimenopause-to-menopause transition, when there's less estrogen and progesterone circulating and the protective mechanisms of those hormones aren't there anymore. So we're much more susceptible to the autoimmune piece, and a lot of the symptoms women experience can be inordinately frustrating for many.
Katie Fogarty[11:17]
Yeah, cranky immune system — I'm picturing a curmudgeon in a rocking chair on a front porch, wagging a finger and wreaking havoc. So we're going to get into how we can help make our immune system and our gut more resilient, how we can protect ourselves against some of these enemies at the gate, and really impact many of the hormonal symptoms women experience, like brain fog, loss of energy, maybe low libido, a whole range of things. But before we move on, I want to do another stage-setting question. You said estrogen is the mortar, which is a great visual image. I want to ask you about a word that appears in the book and is also in the zeitgeist: the estrobolome. This has been bubbling up more frequently, but it may still be new to many of our listeners — I'd love a quick definition, and then let's talk about how this changes as we move through perimenopause.
Cynthia Thurlow[12:08]
Yeah, the estrobolome isn't a word I made up — I've been asked that before. It's a great word.
Katie Fogarty[12:12]
But I know what I mean, because I read the book — I want our listeners to be caught up.
Cynthia Thurlow[12:16]
So the estrobolome refers to a special part of the microbiome — bacteria whose role is to help us break down, package up, and get rid of excess estrogen. As you can imagine, this is very much a Goldilocks effect: we want enough estrogen so that we're able to stimulate receptors in the body, but we don't want too much, because that can provoke a lot of the symptoms Katie already mentioned — brain fog, breast tenderness, digestive issues, the dreaded weight-loss resistance. When these particular bacteria are optimal, they create that Goldilocks effect, but when they're not working well — when you're not able to effectively break down, package up, and eliminate that estrogen — it gets recirculated and drives a lot of the symptoms women experience. In the setting of declining hormones, it seems a little counterintuitive, but the estrobolome doesn't work quite as well. One thing I think is really interesting for listeners to understand is that estrogen and bile acids go together — bile acids are designed to help break down and emulsify fats. A lot of women, as they start to notice changes in digestion, more bloating, more food sensitivities, don't make the connection to the health of the estrobolome. If it's not optimized or properly supported, women get a magnification of symptoms — something even I wasn't fully aware of ten years ago. I always say this book was written as a love letter to women, but it's also the book I needed ten years ago. I think for so many women, they think about their food when they eat, and maybe about digestion the next day when they use the bathroom, but they're not really thinking about digestion in any capacity until they start having a lot of symptoms — and the estrobolome is a very important aspect of the microbiome.
Katie Fogarty[14:11]
Cynthia, we're heading into a quick break, but when we come back I want to talk about the steps we can take to optimize and support our gut health. We'll be back in just a minute. Cynthia, we're back from the break. Before we went into it, you were sharing that you wrote this book as a love letter to women — the book you needed ten years ago, the one you want to put in the hands of a woman today. Tell us what you're hoping to achieve with this book — what is a reader going to get when they move through it?
Cynthia Thurlow[14:36]
Yeah, I mean, it's really unpacking the science around the microbiome, but doing it in a way that's very accessible. So I spend time talking about the microbiome, the inflection points throughout our lifetime, hormones, the immune system — and let me be clear, the immune system is really complicated, but through many, many months of writing I tried to make the information really accessible so people could walk away talking about the gut-ovarian axis, because that was really new information to me. I had no idea how interrelated it was. I talk about hormones, walk women through the lifestyle pieces that are so important, the science behind sleep and the microbiome, stress and the microbiome, nutrition, the role of fiber — I think everyone's gotten the protein memo, but how important fiber is — the right types of exercise, and then I get into the WHI, hormones, supplements, and testing, because I think about it from a very integrative lens. It's all important — you can't successfully navigate perimenopause and menopause just by slapping on an estrogen patch, you really do have to adjust lifestyle, and for a lot of women they're surprised at how much better they feel when they do. So when you ask what I hope women will get out of this book, it's nuance in the conversation around midlife. It's important for women to understand, irrespective of where they are in this trajectory — whether they're in their 30s, there's still a lot of good information they can act on proactively, or women who've been in menopause for ten, fifteen, or twenty years, there's still information in the book that can help get them back on track. For a lot of women there's just so much noise in the midlife space, so it's about helping break through: where's the science, what's the stuff that really works and is particularly effective, and how can we safely integrate this into our lifestyle? One thing that was very important to me was not just having a bunch of gadgets in the chapters. Yes, we all love gadgets, they're fun, but it really starts from the most basic things that will move the needle to improve sleep, all the way up to the gadgets — because I have some people who are already doing the basics and want the more advanced recommendations, and I have others who are like, "I don't have the time, inclination, or desire to buy anything — what are the basic things I need to be doing to support my microbiome?"
Katie Fogarty[17:04]
The book has something for everyone, and one of the things I enjoy is that you feature first-person stories about women you've had in your clinical practice, or encountered in writing this book, that really illustrate what's going on. It's written in a very simple, clear fashion, but I also had the impression, reading it, that you're treating the reader with so much respect — it's very thoughtful, there's a lot of science in it, and I don't mean that to sound scary. Anyone who's thinking, "Oh my gosh, I haven't thought about this stuff since eighth-grade biology" — you treat the reader with a lot of respect. This isn't surface-level stuff, it's easy to move through and it's clear, but there's a lot of great information. I've read a lot of books about menopause and women's health since I launched this podcast five years ago, and I learned something on every page, so I really enjoyed it and I'm excited for this conversation, because I think my listeners will really love this book, The Menopause Gut. So let's get into some of the lifestyle choices, because I know people want to leave with tools. Let's start with what surprised you most about the gut-ovarian axis link, since you said you learned a lot writing this book. Give us your takeaways from that, and what's something within our control that we can do to help optimize that dynamic?
Cynthia Thurlow[18:22]
Yeah, I trained in inner-city Baltimore, arguably one of the toughest places to work as a clinician in the United States, just because of so many social issues combined with a lot of abject violence, and we learned a lot about "big-T" trauma — rape, murder, suicide — no one questions that that's traumatic. What I didn't fully appreciate until I sat down to write this book was the influence of "little-t" trauma — abuse, neglect, addiction — and how that imprints children and young adults. When I was really looking at the research, I felt a heavy responsibility to make sure one of the big takeaways was: we have no control over how we grew up. As children we're totally dependent on our parents or caretakers. But what's interesting is that children who experience a high degree of adverse childhood events — there was a joint study between Kaiser Permanente and the CDC, anyone can go online and take a very quick quiz — demonstrated that children with high adverse childhood event scores are at greater risk for autoimmune conditions, greater risk for poor metabolic health, eating disorders, and addictive behaviors, and it can age the ovaries, because that chronic stress children are exposed to rewires their autonomic nervous system. The sympathetic side of our nervous system is fight, flight, freeze, or fawn — if you're being chased by a rabid animal, that is what your body perceives because of the chronic stress, and it rewires your nervous system. So even if you look calm on the outside, your body is running a marathon. Cortisol gets a bad rap as a hormone, but it's not a bad hormone — if it's chronically elevated, though, it catabolizes muscle, it impacts your immune system — hello, autoimmune conditions — and it can also age your ovaries. So the big takeaway for me writing that chapter was the realization that our experiences as younger people — as children, as young adults — can age the ovaries faster, and that, to me, was terrifying. It also makes sense to me clinically, because I have a lot of colleagues who worked in the ER, in surgical specialties, ob-gyns delivering babies in the middle of the night, and so on, who went into menopause well before the average age of 51. I have many colleagues, patients, and personal friends — myself included — who went into menopause a lot earlier than that average age of 51. So maybe the thing to do is build awareness around this, while also understanding that there are things we can control and things we can't. I look at this as a reflection point: this allows us to educate younger people and gives us greater awareness of our own trajectory, so we can make different choices for ourselves. Our past is not our destiny.
Katie Fogarty[21:48]
Yeah, that's an absolutely fascinating insight. And for listeners who may not have experienced trauma firsthand, but who work in a field where you're responding to it — as a nurse, a clinician, a police officer, in the armed forces, responding to natural disasters — be aware of the role chronic stress can play. I think we've gotten the message that it impacts mental health, but that it can also impact reproductive health, and lead to earlier menopause and what that does to the body, is something so important to be aware of. That was a fascinating chapter to read. Let's move into something that's maybe more common for women too, which is brain fog, anxiety, and depression, which can spike for many women in midlife. This is often chalked up to stress, and stress certainly does play a role, but the gut-brain axis is also at play here. What would you want every woman listening to know about how her mental clarity and mood are impacted by what's going on in the gut microbiome?
Cynthia Thurlow[22:48]
Yeah, it's so interesting that the bulk of our neurotransmitters — serotonin, dopamine, GABA, and so on — are produced in the gut microbiome, so it's probably not surprising that as our hormones decline — in particular, progesterone interplays with GABA, and estrogen interplays with dopamine and serotonin — you may see alterations in mood, you may be more irritable, more anxious, more depressed, you may have overt insomnia, changes in appetite, all vis-à-vis these changes in the gut. What I find really interesting is there's an important nerve called the vagus nerve — it runs from the brainstem all the way through the digestive system into the gut, and fascinatingly, the bulk of the information travels up from the gut to the brain. Think about when you're nervous and talk about "butterflies in your stomach" — that's this complex, bidirectional relationship between the vagus nerve and the brain. There's nothing that goes on in the gut and the brain that isn't transmitted back and forth. So if the bulk of our neurotransmitters are made in the gut, and we're having mood disorders, mood disruption, insomnia, anxiety, depression, it's very likely not a brain issue — it's very likely something going on in the gut. Same thing with inflammation: acute inflammation is good, chronic inflammation is not, and a lot of the brain fog I see is really a byproduct of chronic inflammation, inflammatory foods, chronic stress, poor digestive health, all of which gets referred from the gut to the brain. The other thing to think about: we've talked a lot about leaky gut — if you have a leaky gut, you very likely have a "leaky brain" too, meaning the blood-brain barrier, which is designed to be impermeable, but you can get a leaky blood-brain barrier just like you can get a leaky gut. So I remind people all the time, more often than not, when we fix what's driving the inflammation or the neurotransmitter imbalances — usually with lifestyle changes plus some HRT plus changes to food and other things — those symptoms often get a whole lot better. The vagus nerve is really important, not just for communication pathways in this bidirectional relationship, but also for quieting the nervous system, and that becomes even more important for women in midlife.
Katie Fogarty[25:21]
So let's talk about some foods that are good for the gut and good for the brain, and then maybe move into things to avoid that cause inflammation and can exacerbate problems that onset in midlife.
Cynthia Thurlow[25:34]
Yeah, I think we can keep it really simple. Obviously fiber — and I don't mean your grandmother's Metamucil, which I used to see my grandmother drinking in the 1980s — I mean really thinking about food-based sources of fiber: lentils, beans, an apple, a pear, or even flax and chia seeds, which is usually my go-to recommendation, a gentle option. Think thoughtfully about fermented foods — if you're dairy-sensitive there are so many other options, but miso, tempeh, low-sugar kombucha, and if you tolerate dairy, full-fat dairy. Fermented vegetables are really important too — you don't need a lot, sometimes just two tablespoons with your meal, because you're introducing probiotics into the microbiome. Also think about brightly pigmented fruits and vegetables — that ties into the fiber piece, but color is important. There are polyphenols, signaling molecules, in these foods that are very important for the microbiome — walnuts, pomegranates, strawberries, all really important. Extra virgin olive oil — you want things to be bitter, we don't want to just gravitate toward sweet foods. Most of my patients really like fruit, and that's great, but we should be having three vegetables to one piece of fruit. We really want that peppery bite from extra virgin olive oil on something like radicchio — again, signaling molecules from those polyphenols. That's a good starting point in terms of food. The other thing that layers in with food consumption is understanding that digestion starts in our brains. If I ask an adult or a child where digestion starts, they'll say, "Oh, my mouth, because it waters." I say, "You're close, but we literally have to be on the parasympathetic side of our nervous system in order to properly absorb, break down, assimilate, and detoxify." We can't do that if our body is chronically stressed. I think about all the years I stood and dictated charts, or ate a protein bar while writing a hospital note — that's not the way to digest your food. Taking four or five deep breaths before you eat, or saying grace if that's part of your practice at home — those things can be very beneficial for getting your body out of that sympathetic state and into a state where you're actually nourishing your body. I know that seems overly simplistic, but I'm telling you, it makes a big difference. Even getting off your iPhone or iPad, not being distracted while you eat a meal, just looking at the trees outside or something green — it can be really helpful.
Katie Fogarty[28:19]
The book is chock-full of great tips, like this idea of taking four or five breaths before you eat. One thing that jumped out at me — I think with fermented foods, maybe it was sauerkraut or pickles — you take a shot of the pickle juice after a workout, and I thought, that's a good idea, I'd never thought about that. I've been adding sauerkraut, some beautiful — I don't want to say "designer sauerkraut," that sounds crazy — but not the sauerkraut you slap on a hot dog, delicious sauerkrauts from specialty shops. The idea of using the juice is so smart, and I think you even suggested adding it to a mocktail — I haven't done that, but I'm certainly open to it. So, lots of great ideas about how to incorporate these gut- and brain-positive foods into your diet. Let's touch on what we should avoid. I think we know processed food, we know sugar — walk us through your "try to avoid" list.
Cynthia Thurlow[29:18]
Yeah, in addition to that, I'd say really examine your relationship with alcohol. I know this can be triggering for some people, but there are no health benefits from consuming alcohol — it's not only a toxin, it can also damage the microbiome. So I always remind people, if it's a celebration — someone's getting married, it's your child's birthday, they graduated from high school or college — enjoy the glass of alcohol, but don't let it become a crutch for otherwise not being able to deal with your stress. I always say "mommy drinking culture" is a real problem, and I think a lot of women don't realize the effects of alcohol on the microbiome. Number two, I'd say don't unnecessarily take antibiotics you don't need — there's a time and a place, let me be really clear, I'm not anti-antibiotic, but we live in a world where none of us like being sick, and there's a lot of pressure. When I was still seeing patients in the hospital, they'd say, "I've been sick for two days, I can't tolerate being sick anymore," and I'd say, "Well, you probably have a virus and antibiotics are ineffective," but many clinicians feel tremendous pressure when patients demand antibiotics. We shouldn't be using them arbitrarily — we should reserve them for when they're most necessary. I can't overemphasize the chronic stress piece. We become less stress-resilient in midlife — it's not that we're incapable, it's that our physiology changes and we need to adapt to that. Sometimes life happens — we get hospitalized, someone in the family gets sick, we go through a divorce, a move, we lose our job — whatever it is, we have to manage our stress proactively, because we know from the science that elevated cortisol over time can lead to leaky gut. So I remind women all the time: find something you like and do it often. My husband and I have three dogs, which makes it sound like we're crazy, but we walk them every morning, and it's become part of our morning ritual — I crave it. Connection with nature, for me, is incredibly peaceful, it reroutes my nervous system, and I try to get connection to nature multiple times throughout the day. It doesn't have to be dramatic — legs up the wall, box breathing — you don't necessarily need a gadget to get yourself out of fight-or-flight. For a lot of people, they just realize they have to do more at this stage of life than they ever did before — hugging your pet, hugging your loved one, you get a little release of oxytocin. It's very temporary, but it can be very helpful, and oxytocin also helps lower cortisol, which helps your gut.
Katie Fogarty[32:06]
Yeah, the dog is such a wonderful — I mean, any pet will do, but dogs get you out rain or shine to move around, and that's so incredibly important. Listeners don't know this, but Cynthia's got one of her three dogs asleep on her feet right now, which she confessed to me before we started recording, which is so great — your dog loves being with you and you love being with your dog, it's a mutual thing that helps your brain. So let's move into sleep now, because that's another big complaint women have. We talked about getting sunshine — the circadian rhythm is so important. How does the gut microbiome connect to circadian rhythm disruption? I think a lot of us — and I'm putting myself on this list — think the circadian rhythm is set by sunshine, not necessarily by the gut. I'd love for you to help women who are still struggling with sleep issues, even though they've tried the blue-light glasses, they're going to bed, they've cut out alcohol — what can we do to better work with our gut to help improve our sleep?
Cynthia Thurlow[33:03]
Yeah, I think sometimes people are surprised to know we have circadian clocks throughout our digestive system and the microbiome, and these little clocks are setting things off — they're very responsive to light cues, as you mentioned, responsive to stress, responsive to the food we eat. When I'm looking beyond the common reasons someone's not sleeping well — remember we talked about the vagus nerve and the bidirectional relationship between the gut and the brain — if you're dealing with a latent infection in the gut, a lot of inflammation, the best example I can use is food poisoning, like I had — I wasn't sleeping well for a long time, because you get this transference of information to the brain. I think a great deal about how chronic stress impacts sleep — in fact, I'll often say, show me a woman who doesn't manage her stress and I'll show you a woman who doesn't sleep. It's that interconnected at this stage of life. So really look at underlying gut health issues, think thoughtfully about managing your stress better, and remember it's not just about replacing hormones — sometimes we have to layer in supplements. I'm a huge fan of magnesium, a huge fan of myo-inositol — I think that's the game-changer sleep supplement for me, and I can adjust it up and down. Think thoughtfully about adaptogenic herbs — for many people, things like Relora or ashwagandha, which can be both tonifying and stimulating, but it's amazing how they work. These are actual herbs, taken in a capsule or a tea, that can quiet the autonomic nervous system and the cortisol response. Not eating too close to bedtime — I know people think of themselves as younger than they are, but you can't eat the way you did at 18, so that anti-inflammatory diet becomes important. Getting off electronics — we're such a connected society, which is both good and bad, but how many people are on their iPad, their computer, or their iPhone in bed, and then wonder why their sleep has gotten dysregulated? It's because that blue light has suppressed their melatonin, increased their cortisol, and their body thinks it's time to stay awake. So there are many things that contribute to sleep issues, not least the chronic stress piece — I can't overemphasize that. For anyone listening who's not yet on HRT, I can often tell on an intake form who is, just based on how their sleep is — progesterone helps us fall asleep, estradiol generally helps us stay asleep — but there's no one-size-fits-all philosophy. The last thing I'd add is for many midlife women who are weight-loss resistant and think, "I just need to exercise more" — you can't do Orange Theory six days a week and think you're going to be fine without enough recovery. I see a lot of women who just don't eat enough, and a lot of women who over-exercise and don't sleep well as a byproduct of these lifestyle choices.
Katie Fogarty[36:01]
Let's talk about body composition changes in midlife, because this is a great segue. I think women are hitting that Orange Theory class six times a week, probably for two reasons: one, they think it's managing their stress, it's their release, or two, they're really concerned about the changes happening to their bodies — we grew up in the '80s, where if you were doing step aerobics, that felt like the cure-all for everything. Some women accept these body changes, some don't, and it can feel relentless and demoralizing. I hear this frequently from listeners — whenever I do a show on weight, metabolic health, or GLP-1s, I can see from the downloads and the listener DMs that this really resonates. You're very clear in your book that body composition changes are not a willpower problem. Talk us through that a little, and what's moving the needle — or causing the needle to shift — as we move into midlife.
Cynthia Thurlow[37:00]
Yeah, I know it's so frustrating. I've had two stretches in ten years where I was completely weight-loss resistant, and not being a very tall person, it shows much more on me than it does on my taller friends — I've been there personally. Number one, we have to look at the sleep piece — sleep is foundational to our health. I cannot get women to lose weight if they're not sleeping through the night, it really is that important. So for anyone listening who feels like Cynthia's now talked about a dozen different things — focus on sleep first. Number two is that chronic stress piece I've mentioned over and over. Cortisol is not a bad hormone, but when cortisol is elevated, so is glucose, so is insulin, and you cannot tap into fat stores. If you're chronically stressed out, you're not going to be able to move the needle on body composition. As we navigate the perimenopause-to-menopause transition we're losing muscle mass, which impacts insulin sensitivity — muscle is this massive organ of longevity, it's also a glucose reservoir, a glucose sink if you want to think of it that way. As we see changes in muscle mass and changes in estrogen, insulin sensitivity becomes much more challenging. That's why women tell me, "At 45 I'm doing exactly what I did at 40 and nothing is changing" — it's because your physiology is changing. The next thing to think about — and it doesn't have to mean intermittent fasting, I talk in the book about digestive rest, which is what I do — although I'm known for intermittent fasting, most women are eating too frequently, eating too many carbohydrates, and most of those carbohydrates aren't sweet potatoes, they're processed carbs. So: not enough protein, too little fiber, too much carbohydrate. I'll often tell women I want them consuming no less than 30 to 50 grams of protein in a meal — if you're not there right now, that's okay, but we want to be thoughtful about protein intake because we need more as we get older. Fiber becomes a larger part of the conversation, and don't believe anyone who tells you fiber isn't necessary — if you look at the science, which I talk about extensively in the book, fiber becomes very, very important. The other thing to think about is hydration — such a simple thing, but so many women are chronically dehydrated, and as estrogen levels go down and follicle-stimulating hormone goes up, we start to lose those thirst receptors. I know, for myself, with a little bit of mild dysautonomia, I have to be super proactive about staying hydrated — my whole family makes fun of me, but that's okay, no one should feel ashamed for trying to stay hydrated. The other thing to consider is these inflammatory foods we've danced around — processed foods, hyper-palatable foods. That doesn't mean if you're traveling, you're in an airport, and your option is a protein bar or nothing, don't eat the protein bar — eat the protein bar, don't stress about it. I think about this as 80/20: 80% of the time we want to eat real, nutrient-dense whole foods, and 20% of the time, enjoy the cake on a birthday, enjoy the glass of wine, and move forward. The next thing to think about is that we grew up in an age conditioned to believe that thin is in, skinny is where it's at, do all the cardio — there's nothing further from the truth for midlife bodies. We need to be maintaining and building muscle, which means two to three days of strength training. I'd add layering in some zone-two training — I live in a very hilly part of my state, so just walking my dogs gives me zone-two training because it's so hilly. Flexibility work is also important, whether that's yoga, Pilates, or whatever you enjoy.
Cynthia Thurlow[40:32]
The other thing to think about is that as we get older, we're losing subcutaneous fat — the pesky fat we don't like, that we can pinch — and gaining visceral fat, which is the bad fat around our vital organs. It's inflammatory, it produces its own inflammatory cytokines and other particles. This is the stuff we want to avoid like our lives depend on it, because it does — it will significantly change our metabolic health, which is why body composition readings are really important for everyone. I'm not saying your scale at home isn't a valuable tool, but body composition estimations — looking at fat-free mass to muscle mass — are what's most important. Everyone should be doing this at least quarterly; if your healthcare practitioner's office doesn't have a scanner, you can buy some of these scales relatively inexpensively. You want a sense of where your fat-free mass to muscle mass is — we want muscle mass maintained or gained, and we want fat-free mass to stay as low as comfortably possible. Beyond that, we're really talking about gut health — this is where microbiome and stool testing can be particularly helpful to give us insight into whether there's something else going on in the microbiome. Elimination diets, which I didn't touch on when talking about nutrition, can also be valuable — is it gluten, is it grains, is it dairy, is it sugar, is it alcohol, what's driving inflammation in my body? A 30-day elimination diet can be very valuable. And then thinking thoughtfully about hormone replacement therapy again — I can often tell on intake forms who's on HRT and who isn't. The other side of that is these very powerful GLP-1 drugs — I am very pro-peptide, I'm not anti-peptide, and I think if they're used judiciously they can be total game-changers for women. But it always has to be in the context that when I'm prescribing these drugs, it's absolutely, positively concurrent with doing no less than 100 grams of protein a day and strength training two to three days a week — that's the responsible way to prescribe these drugs. If someone's not giving those instructions, I'd run — find a practitioner who knows what they're doing and will make sure you're not losing muscle, because when you lose weight you're likely to lose a little muscle too, but you want that buffered as much as possible so it's much less likely to happen.
Katie Fogarty[42:55]
Absolutely — we covered this on the show, I had Dr. Rocio Salas-Whalen on, and I know she's been on your podcast as well. She came on to talk about GLP-1s and weight loss and gave us a great primer on this, and she emphasized the importance of working with a practitioner who's watching your muscle and musculoskeletal health as you use these drugs — so that's another great reminder, thank you. I said at the top of the show that I learned something on every page of the book — you mentioned the importance of hydration, and I was really surprised to learn that as we lose estrogen, our thirst signals change too. Literally, when I read that, I got up and had a big glass of water. So thank you, because we need these reminders, which is why these conversations, and why spending time with this book, are so important. I think it would be a great addition to any woman's midlife bookshelf, so you can refer back to it and move through the different sections as they apply to different parts of your life. I want to switch gears now and talk a little about testing. You mentioned things like inflated cortisol, glucose levels, or insulin sensitivity that we need to worry about as we move through midlife, and some of these issues show up when we try to button our jeans, step on a scale, can't get out of bed, or can't sleep. We know something's wrong, but to actually put our finger on what it is, we sometimes need to do testing. You have an entire chapter on testing in the book, which is a do-not-miss — we can't cover everything here, but I'd love to hit the biggies, and you mentioned stool testing a minute ago. Let's make sure we cover that.
Cynthia Thurlow[44:30]
For me — obviously I'm microbiome-centric — I'd say either microbiome testing with Tiny Health, I'll just use that brand name, because I think they're leading the science —
Katie Fogarty[44:42]
Can you repeat that for us, Cynthia, so we don't miss it?
Cynthia Thurlow[44:43]
Yeah, Tiny Health is the company — there's a consumer test you can order without a practitioner, and then there's a professional test you do through a practitioner, or something like the GI-MAP, there's a Genova test, there's a Doctor's Data test — those are the traditional stool tests, and they give valuable information, but I think the science is heading in this microbiome direction and it can be very insightful. Transparently, I wasn't aware of Tiny Health until after I wrote the book, so it's not in the book, I'll share that. But I always start with stool testing, because I want to know: what's your digestive capacity, what are your inflammatory markers, do you have a lot of dysbiosis — which is like weeds in the garden of the microbiome — do you have a latent infection, do you have H. pylori, do you have Candida, do you have a parasite or a worm? Those don't happen very often, but they're not all that uncommon. Moving on from there, I still use dried urine and saliva testing. When we're looking at cortisol, saliva testing is particularly helpful because you can get a 24-hour pattern of what's going on with cortisol. Cortisol is a hormone with a predictable pattern throughout the day — highest in the morning, ebbing and flowing throughout the day, lowest at night. That's what should be happening, but a traditional allopathic cortisol blood test just gives you a snapshot of that exact second on that exact day — you don't know what the distribution looks like over 24 hours. So looking at saliva cortisol, I think, is very helpful. A lot of people ask me about the DUTCH test — I used to use it much more often than I do now, I still use it, but not as frequently — when I want to look at estrogen detoxification pathways, or a urine-and-saliva superimposed cortisol distribution, that can be very helpful. But it's a test where, if anyone's listening, I'd ask your practitioner how many of these they've read — I've looked at thousands, but it took me getting to anywhere from 50 to 100 before I felt really comfortable evaluating that test, it has a lot of nuance. Beyond that, there's food sensitivity testing — is that helpful? There are definitely people who can develop food allergies in midlife, unfortunately, and those are people I'll generally refer to a formal allergist to get worked up, because that's their area of expertise. Beyond that, it's really thinking thoughtfully about fatty acid analysis, micronutrient testing — I do think those more nuanced tests have validity and can be helpful, but always in the context that they're not the first test I do, usually it's after we've done the bigger tests, created a plan, and zeroed in on what we need to do, that I start layering in a test like that. And the unfortunate thing — I'm hoping insurance will eventually change, but we're not there yet — is that not all insurance companies cover these tests, so a lot of them are out-of-pocket expenses, so I try to be very thoughtful and judicious. I have some women in my practice who want to do every test, and I'm like, that's fine, we can do that. I have other women who say, "I only want to do one test every six months."
Cynthia Thurlow[47:52]
I'm like, great, then let's figure out what that one test really needs to be, because ultimately the one thing to remember with out-of-pocket testing is: what are you going to do with that information? Is it going to change your lifestyle habits, or what you're doing? If the answer is no, then I'd question whether there's a need to do the test. I have a wonderful spouse I've been married to for 23 years, and sometimes when I try to "guinea pig" him with testing, he'll say to me, "I'm not going to change anything I'm doing, so —"
Katie Fogarty[48:22]
He's honest.
Cynthia Thurlow[48:23]
Exactly, he's very honest.
Katie Fogarty[48:24]
Saving you some money, exactly.
Cynthia Thurlow[48:26]
And so I say, well, fine, we're not going to do that. It's always in the context of what you're interested in, what would be of greatest value to you, and then working with your provider to determine what that next test should be.
Katie Fogarty[48:39]
And when you say working with your provider — you mentioned some of these tests aren't covered by insurance — is a woman getting this from her average GP? Should she be working with a nutritionist, an integrative physician? Where does she get the support from a clinician to move these tests forward?
Cynthia Thurlow[48:56]
Yeah, I mean, I think it's interesting nowadays — as someone who prescribes and is a licensed medical provider, I think it's a great thing that consumers have options outside the context of their relationship with a provider. The problem is they don't always know what to do with the information. I'd say the average allopathic provider isn't offering all these types of testing — generally you're working with someone with integrative or functional medicine training, like I have, as well as physician peers, other nurse practitioners, PAs. If you're working with someone who isn't licensed, that's okay, but I'd be very clear about their training, how many of these tests they've looked at — I have people on my team who are health coaches who are incredible, and I give them a very narrow scope of what I want them to do with my patients. So as long as there's oversight by a licensed medical provider, I think that's great. My concern is never that people don't have access to options — my concern is always: if you do a test and don't have a provider who can help interpret it for you, is that valuable, unless you yourself are already trained in this area? That's where I sometimes see consumers spinning their wheels — they'll say, "I did testing through XYZ company, I was able to draw my own labs, but now I don't know how to interpret it." That's a problem. There's definitely an access-to-care problem in the United States — I'd be remiss not to address that, because as someone who's been in medicine for almost 30 years, 25 of those as a nurse practitioner, I think we're entering a time where a lot of people are leaving internal medicine, primary care, and family practice to go into concierge programs, and we very much have a have and have-not existence right now, which I find deeply troubling, because there are people who really need good access to good internal medicine, and providers are leaving in droves because reimbursement is poor. I know that wasn't quite the context of the conversation.
Katie Fogarty[50:55]
No, it's so important — we want to be smarter patients, and we need to understand the system we're operating within.
Cynthia Thurlow[51:02]
So reimbursement is really poor — the volume of patients you have to see in an hour to pay your bills, it's like we keep getting compressed for time. I recall even when I was in clinical cardiology, you'd have time to talk about one or two problems, and then a patient would have to come back because you'd have a 15-minute appointment and none of my patients were uncomplicated. But I think for a lot of my peers, when I talk to them, it isn't that they don't want to spend time with the patient — it's that they're obligated to see a certain number of patients per hour, and if they're not, they get penalized, or they get such poor reimbursement it becomes very hard to keep the lights on. So there's this duality right now — people go into medicine because they want to help people, period, end of story, and I think most practitioners are frustrated with the current system, frustrated with the current degree of reimbursement, and feel like they don't have a voice. People are going outside the traditional medical model, they're not taking insurance — I don't take insurance anymore, and I have people almost daily who say, "I'd love to see you, do you take insurance?" and I say, we don't anymore, because to give you some perspective, if I took insurance I'd have to hire someone full-time just to deal with insurance claims.
Katie Fogarty[52:14]
And also be telling your patients, "No, I can't do that test, because they won't cover it." I hear this all the time from doctors on the show, and doctors in my own life, and I agree with your assessment — people go into medicine because they want to make a difference, not to throw up roadblocks for people. And sometimes people say they dislike people going into concierge systems, and well — maybe that person really wants to spend an hour with their patients moving the needle, it's not simply about lining pockets, and if anyone's lining pockets it's the big corporations managing our healthcare. But I really appreciate your perspective — it's very important for listeners to understand the system within which we're trying to get our best health advice, and thank you for flagging this, because it's an important and unfortunate part of the conversation. It's hard to find the healthcare we need and deserve, which is why it's incumbent on us to become smarter, and books like this, and conversations like this, help make us more educated. So, we're nearing the end of our time together, Cynthia, but I want to turn very quickly to your supplement chapter — this is incredibly comprehensive, a mini-encyclopedia on supplementation across different aspects of health, in support of active lifestyle choices with food and other things. I wanted to ask about one specific supplement before I say goodbye, because I hadn't heard of it, and I hope I'm pronouncing this correctly — urolithin A, am I saying that right?
Cynthia Thurlow[53:39]
Yep.
Katie Fogarty[53:39]
So you call this one of the most exciting developments in mitochondrial health, and I want to know why, and learn more about it from you.
Cynthia Thurlow[53:46]
Yeah, well, it's something I've been taking for probably almost five years — my husband takes it as well — and it's a polyphenol, so —
Katie Fogarty[53:54]
We know it moves the needle, then, if he's willing to take it — we know —
Cynthia Thurlow[53:58]
He doesn't get a choice. Sometimes he doesn't get a choice — I'm like, I'm just going to put your supplements out and you're going to take them. So he takes morning and evening supplements and doesn't complain about it, because he feels good. Urolithin A is a signaling molecule, a polyphenol. Most of us can't get enough from our diet — you can get urolithin A precursors from things like walnuts, pomegranates, and strawberries, but you'd have to eat quite a bit, more than the average person could tolerate in one day, or probably over the course of a week — and our microbiome largely influences whether or not we can produce enough urolithin A. So this is a supplement, in supplement form, that can upregulate mitophagy. When we talk about the mitochondria, mitophagy is the process of getting rid of diseased or disordered organelles, including the mitochondria, and what happens with the aging process is that we don't do as good a job clearing diseased or disordered material in our bodies. That's why intermittent fasting was such a huge focus of my life for such a long period of time, because it can help with this. So supplementing with urolithin A, for a lot of my patients, is a key differentiator for energy, for just feeling better. I always remind people, quality is always important, like it is with any supplement. Urolithin A will probably always be something I take — my husband actually takes more than I do, because he's coming off a pretty significant surgery and illness in 2024 and 2025, so he takes a gram a day, I take 500 milligrams. But quality is certainly important, and it's definitely one of those foundational supplements I don't miss, along with the fact that we know our mitochondria aren't as healthy after age 40 — it supports what my body's trying to do, but gives it additional support. Quite transparently, I'm not a fan of people taking 100 supplements every day — it's better to be really targeted about what you specifically need, and then reassess things every couple of months, or every six to twelve months.
Katie Fogarty[55:57]
And for listeners who are curious about the other foundational supplements Cynthia recommends, obviously The Menopause Gut has that, but she also has a very wonderful and active Instagram presence, which you can follow, where she shares great science-backed health advice each and every week. So, Cynthia, my last question for you: for the woman listening right now — you mentioned sometimes people feel overwhelmed, and you said if you're doing one thing, it's prioritizing sleep. Beyond sleep, what is the next step? What is number two that you want her to focus on — an action she should really think about incorporating into her weekly life that can help support her gut microbiome and reclaim her health in midlife?
Cynthia Thurlow[56:35]
There are probably two things I'd point to. Number one is find ways to reduce your stress — easier said than done, I know — find something you like and do it often, whether it's gargling, humming, anything that stimulates the vagus nerve is going to be helpful for reducing stress. The other side of that is thinking thoughtfully about fiber. I'm not telling anyone listening to go from five grams of fiber a day to 30 — you'll be very unhappy with me. I always say, track for a couple of days, there are lots of free apps online — track where your fiber intake is today, and then just aim to consume more. If you're at 12 grams a day, aim for 14 or 15, and slowly work your way up. Fiber is very bio-individual, but I can tell you, as someone who unfortunately gets colonoscopies every five years because of a bad family history — I had one in 2020 and one in 2025, and the one thing my gastroenterologist said to me was, "What have you done differently?" because I had a picture-perfect colonoscopy. I said great, that's exactly what I expect to hear, and I told him I'd drastically increased my fiber intake. So for a lot of my patients, when they tell me they don't tolerate fiber, that's a sign something's going on with the gut microbiome that we need to address — I've been there myself, personally. The other side of it is finding your own "n of 1" fiber intake — Katie may tolerate 25 grams, I might tolerate 50, someone else tolerates 10 — finding where your own experimentally-determined ideal fiber intake is, and working diligently to try different types of fiber. You don't have to overthink it, I'm not even telling people to think about soluble versus insoluble, we're not even that nuanced. Just consume a little more, because you're really conferring a lot of benefits to your microbiome, especially in the setting of declining hormones. I'm telling you, the research is solid on this — you need fiber in your diet in midlife, largely because of the hormonal changes occurring in the gut that we need to help offset.
Katie Fogarty[58:38]
Yes, small changes can add up to big results, and with colorectal cancers on the rise, it's so important to prioritize fiber and your screenings. It's a great note to end on. Cynthia, thank you so much for your time today — I really enjoyed this conversation, and I learned so much.
Cynthia Thurlow[58:51]
Thanks so much. It's been a pleasure, Katie.
Katie Fogarty[58:54]
This wraps A Certain Age, a show for women who are aging without apology. Cynthia is incredible to spend time with — she is such an encyclopedia of smart, actionable information. I loved her take on "enemies at the gate," what to do, eat, think, and behave to prevent inflammation. I was very intrigued by her calling estrogen "the mortar" — it helps hold our body's functions together, things like our brains, our bones, and more. When estrogen exits the building, there are other things we can do to help optimize our gut health, to help improve our health as we age. I took so many mental notes — “The Menopause Gut” is a phenomenal resource to add to your midlife bookshelf. If you took something away from the show, if you learned something you're going to use in your own life, if you're thinking, "I need to share this with my girlfriends," please let me know in an Apple Podcasts or Spotify review, because reviews help other women find the show. Thanks, as always, for sticking around and joining me this Monday. And, as always, special thanks to Michael Mancini, who composed and produced our theme music. See you next time, and until then — age boldly, beauties.