S1 E14: Menopause with Wise and Well


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Amanda: Hey, this is Amanda, women’s health dietitian.
Emily: And I’m Emily, nutritional therapy practitioner.
Amanda: And this is the Are You Menstrual? podcast where we help you navigate the confusing world of women’s hormones and teach you how to have healthy periods.
Emily: Each week we will be diving into a different topic on women’s health and sharing our perspective using nutrition, female physiology, and metabolic health.
Amanda: Our goal is to help you wade through conflicting health information and empower you on your healing journey.
Emily: We hope you enjoy it. 

Amanda: We have a very special episode for you this week focusing on midlife women and peri and postmenopause with Maria and Kristin from Wise and Well. Maria, an FDN practitioner and Kristin a board-certified nutritionist are plain-spoken friends and practitioners who share a passion for women’s health, especially women’s health at midlife, as both are themselves menopausal. They’ve refined the art and science of thriving as a midlife woman based on both clinical and personal experience. They combine individualized nutrition and lifestyle changes tailored to midlife women’s needs with mindset coaching, lab testing, and hormone replacement therapy education to help women thrive so that they can stop or prevent their health from spinning out of control.

You guys do a lot. I’m very excited to have you here. We’ve been Instagram friends for a long time. So tell us more of your own specific background and story and just what is midlife women’s health? What, why do you guys focus on that?

Maria: My story, I’ll try to keep it super brief, is I started noticing some changes to my health, my mood, my body…was probably about 42, 43—didn’t like it. And so I set out to do something about it and I knew that I wasn’t going to see… I was kind of holistically minded growing up so I knew I just didn’t want to get a prescription. And so I trekked into New York City to see a medical doctor who I thought I did my research but didn’t really end up being a very empowering good visit even though it was a holistic medical doctor, had published several books. Just to give you an idea of how desperate I was. I literally had my appointment on December 26 the day after Christmas in New York City, can’t hail a cab, it’s still very busy. I left that office visit feeling like I wasn’t entirely heard, like I was being sold a lot of supplements, and just like a, like a fire hose plan, like learning through a fire hose, drinking through a fire hose. And it was at that point where I decided like, oh, no, there’s got to be something better. And that’s when I went back to school. So then I got, you know, mentored by doctors and I did very high level programs. I’ve done like a menopause program that is actually just for physicians, but I was allowed to audit it. Not that I’m going to be writing hormone prescriptions anytime soon. But I learned a lot. It’s, it was for doctors, Kristin and I have both been mentored by, you know, endocrinologist that has been in the field for over 20 years, and several programs. And now here we are helping women with perimenopause and menopause.

Kritstin: So mine is similar but it’s interesting because I was not holistically minded. I’ll be the first one to admit it. I came from a very conventional background. I’m actually an attorney, that’s what I did for the first part of my adult life. Loved it, worked in securities industry. And we moved down to Boston from the Midwest, and I got involved in competitive rowing. And I was a pretty high-level athlete and competing regularly all over national level, on the world level, and that meant I was training a lot. And now this was my 30s, I did not know better. It’s really intense, particularly intense cardio, and my health started to plummet. Now my performance was really important to me, right, so I start kind of investigating what is going wrong. More from this, like, I don’t want to not perform, not seeing the forest through the trees, which that I also was like declining in a sex life. And I was a real raging, you know what to my kids, and that I felt like everything that I ate I needed to work off with, you know, caloric expenditure. And so I was kind of playing this whack-a-mole, and I thought I knew what was happening. And I figured that when things started to not work with what I was doing, there must be something wrong in my body, which could not be of course, anything that I was doing.

So um, I went to my very conventionally minded practitioner at Mass General Hospital and begged her essentially to find something wrong with me. And unlike Maria’s experience, where they’re more than happy to spend your money and do a whole bunch of tests, they refused to do my tests. And, you know, Marie, and I have found that women are either one of us or the other in terms of their experience with practitioners. Mine looked at me and said, you’re too young, I’m not going to do hormone testing. Then I thought, well, maybe I have Lyme disease. You know, could you do autoimmune testing? Could you do something? No. Could you look at my thyroid, looked at my thyroid. I didn’t know back then that what she was looking at was in this lab reference range of normal that was actually quite sub optimal. And so I went back to her over and over again. And she finally said to me, Kris, you’ve been here like six times last eight months, there’s nothing wrong with you, you are fine. And that was literally like the biggest punch in the gut. Because I knew that I wasn’t fine. I knew that I was having this, like weight battle with me internally. And I was like, but I work out and I eat healthy, and I’m paleo, and I do all these perfect things…what is wrong, I don’t sleep, you know, all these things. And it was really being burned by conventional medicine that got me to say, you know, I, no one’s going to be the captain of this ship but me obviously, and I’m gonna have to step back and figure it out.

So like, Maria, I decided to go back to school, much to my husband’s horror at the time, because when you have a law degree, like, what else do you need, but, you know, went back to nutrition school started to work with clients one-on-one kind of a generalized space. And what I realized is the vast majority of the most desperate people were my female clients around midlife, and they felt like the goalposts were changing, someone was absolutely messing with them, and nobody was listening. And that resonated so strongly with me. So that’s when I started to seek the additional training, specifically into hormones, specifically into midlife, you know, getting trained to read tests, taking my nutrition program up a notch to getting board-certified, and those sorts of things. That’s how I came upon Maria. And, you know, we found that we had a very similar passion, we had a very similar to be honest kind of simmering frustration and anger at the system. And we just decided, look, we’re going to combine forces and take care of these women because nobody is listening, you know. So that’s how I came to it. And we love what we do. I mean, women are phenomenal caregivers, except when it comes to themselves, so…

Amanda: Ugh that’s so true. That, like gets you, you know, as soon as you said that, I was like, yikes, that’s too accurate. So it’s, it’s pretty wild that both of you had completely different lives and careers. And then because you had no one to help you, you had to actually go back to school and do it yourselves. Like that’s, that shows, I feel like that’s a good summary of how the, I mean, there’s a lack of women’s health care in general, but then this, we have this whole population that’s just completely getting pushed aside and dismissed like you guys going to two different women, two different doctors, different states, and getting like, dismissed in different ways, basically, you know, so that is very, very interesting. And just like, shows you how big this is that you had to actually change your whole careers in order to figure out your own health issues…that’s pretty aggressive I feel like, but also sometimes can be really necessary. Funny thing, Kristin, I rowed at UConn…

Kristin: You’re kidding me?

Amanda: No, yeah I did. 

Kristin: Oh so you get it. You know what the damage we did our bodies.

Amanda: Oh I know. You said rowing, I was like, oh, gosh, I’m getting like, flashbacks. Um, we have an erg in our garage. And like, I still row and stuff but that’s so funny.

So that’s like your background. I think it’s great to hear. I know way too many women. Unfortunately, you’re probably going to relate to that. Why don’t you guys tell us, because when I posted a question box on Instagram, because I was like, okay, what do people want to know about this specific topic? I mean, we are focusing on peri and postmenopause, but then also like kind of leading up to that time. And a lot of women were just like, what’s happening? You know, like, they go to the doctor and the doctor cannot tell them what’s actually happening. So what is happening during that transition into peri and postmenopause?

Maria: So the, the issue with why the doctor can’t tell them is because we kind of function on a you either have a disease or you don’t, right. You have a syndrome or you don’t, right? We could argue about the whole syndrome, but it’s sort of like, you know, you’re diagnosed or you’re not, there’s like very little room for gray area. And while perimenopause or menopause is not a sickness by any means or an illness or a disease, it comes with some pretty profound physiological and sometimes psychological changes. And, and, but you know, because we don’t have that in the, in the DSM, or whatever it’s called, you know, women are often pushed aside, or they’re given things for their symptoms without really kind of being empowered to understand what’s going on. And so what is going on is that it’s a very slow process of ovarian senescence. And the ovaries are, you know, slowly, slowly starting to kind of shut down, so to speak, that is what happens. I mean, it sounds…

Kristin: And it’s normal, it doesn’t mean your ovaries are broken. It’s totally normal.

Maria: It’s totally, everything we’re mentioning is totally normal. You know, even if we lived in, you know, in a bubble, and we had perfect food and water, I mean, we would still probably have some of these symptoms, they’re probably a lot worse because of the expectations and you know, the stress that we put ourselves in and the kind of denatured food that we tend to eat, but you know, these changes are normal. And so you know, the, the first kind of change we can put our finger on, is that progesterone drops, okay, so then we have this like relative state of estrogen dominance, and it doesn’t necessarily mean we have too much estrogen. In fact, it rarely means that, sometimes it could mean it, but it rarely means that. You know, we get some symptoms from that. So we may not sleep well, we may feel anxious, we may have menstrual flooding, we may get headaches, things like that. And so but what, what most women don’t realize is that so progesterone drops, and once it drops, it’s not coming back. Estrogen will fluctuate, but progesterone really doesn’t come back. What a lot of women don’t realize, and Amanda, we focus so heavily on estrogen dominance, and it is a thing, it’s just not that big of a thing for women once they reach a certain age or stage, because that age is going to be different for everyone. Because what’s happening is that your estrogen is actually dropping, okay, it’s circulating, right, up and down. But it is also dropping, it’s just you don’t really quite see that drop as much. And that brings changes, so that can bring hot flashes that can bring mood issues that can bring weight issues.

Kristin: Yeah, so as Maria said, we have this relative estrogen dominance. And you know, one of the things that I think happened, just only recently is that we started talking about the cycle of hormones in a woman’s body. Maria and I didn’t have that, our mothers didn’t have that, and probably the generation between, you know, us and kind of the 20-somethings of today didn’t have it, you know. Your generation is just starting, those 30s, you know, you’re starting to be more aware of what does the release of hormones over a monthly cycle look like? We didn’t have the benefit of that. So we had no idea that we had these sort of different surges of estrogen over the course of 28 days and a different surge of progesterone. And so women just think that, you know, it’s too much estrogen all the time. And when Maria said the relative it’s, you know, this, this progesterone is in decline, and your estrogen is kind of fluctuating, but it’s kind of fluctuating with a little bit a little less life. Right. And so the progesterone is not there to blunt it. And that’s why we feel the estrogen, right?

And, you know, it’s there’s so many things that go into it. But estrogen is a signaler in our body well beyond our fertility. And it’s changing how we process carbohydrates, it’s changing where we store fat, it’s changing, you know, our cardiovascular fitness, our mental cognition, all of those things. So women start to feel these things happening. They don’t really understand why and no one would assume that it’s actually estrogen in decline and not surging estrogen. Yes, it can be kind of doing this erratic nature during the midlife transition. But it’s really not about having a lot of estrogen or too much. It’s about having almost no progesterone, and then sort of a, you know, slow, gasping death of the ovaries. And that creates that moving the goalposts feeling right, that creates that lost, what is happening in my body, and we, we don’t talk about it as women. So we start to feel really isolated in this experience. And that’s why you know, we think what you’re doing and so many ladies who are trying to get women to understand their cycle today is so critical to how they’re going to experience midlife.

Amanda: I think the tricky thing, though, is because there’s, now this information is getting out there, which is amazing, I do, it’s so important, but a lot of midlife women think that it applies to them. Like they think that everything that…I mean and not that it, nothing I’m saying, ever talking about applies, like, of course, like stress management, minerals…completely essential, all that stuff. But it’s gonna be a little bit different. And some things might not be enough, you know? So like the progesterone thing, and I’m sure you guys saw that question and like laughed, because I love when you guys talk about this. The whole thing that’s happening is it’s normal, this decline in progesterone and then it looks like you have estrogen dominance. That’s what makes women so symptomatic during this time. So talk about the whole progesterone piece, and I’m curious, Maria, since like you’re, that doctor you initially went to try to put you on a bunch of supplements. Did they do anything to try to… were those supplements to like boost progesterone?

Maria: No, I don’t think they were, because I actually had that doctor, I was also prescribed, interestingly enough hormone replacement therapy. Remember, I was 43 which is pretty young, which I now that I think back I think I probably should have started at about 45 and not 50, but that’s a whole other conversation. Maybe we can get into that later. No, I don’t think so. I remember getting super high dose vitamin D but yeah, we can definitely talk about the, the whole progesterone. I think there’s a lot of misinformation about progesterone. I believe that when you, you know, you can if you’re a, you’re a healthy body and a young fertile woman, you know, and you work on the pillars of health, you give yourself the best chance for your body to do what it’s supposed to do, which is to make progesterone, right. And I remember getting tremendous help when I had PMS using something like chaste tree, right, but that, that, that fell off. Like I feel firmly, believe I’ve read it, I’ve experienced myself, we lose ovarian response to chaste tree at a certain point. So you know, those, those things are fine. Do you need vitamin C? Yes, maybe mild aerobic exercise, but like, it’s kind of as you age, that stuff has minimal effect at best.

Kristin: Yeah, it frustrates us to see this, you know, eat yams, and you’re going to support your progesterone. Same thing with anyone telling a woman 40 or north of 40 that she can balance her hormones…literally makes Maria and me want to throttle them. And I’m not going to make friends saying that, but I’m sorry. It’s, it’s so misleading. And it frustrates us because midlife women are misled with so many other things to begin with. And it’s sort of this message that like, if you’re unable to balance your hormones after incorporating all these interventions, you’re doing it wrong. And that is so unfair to a woman, because there is no balanced hormones in midlife—that’s the hallmark of midlife is unbalanced hormones. So you know, between, you know, suddenly raising progesterone sufficiency from the dead, once your ovaries start to go into senescence, or being able to create this balanced hormonal environment in midlife. Those are two complete misconceptions that we just want women to hear. Like, it’s okay that it’s not working for you, it actually isn’t going to work for you, you know. We can mitigate how you experience those things, but we can’t reverse those things.

Amanda: And I think that’s kind of a message that a lot of people get is, like, it’s like, you shouldn’t have any of these symptoms. It’s not necessarily normal. I think I’m a big person where I try not to get like, let my clients, the women in my community obsess over symptoms, because I’m like, guys, guys, we gotta, we got to rein it in. We need to calm down, symptoms are communication from our bodies trying to tell us what they need. But I think that’s, you know, if you go to the doctor, they ask you what’s wrong, and that’s kind of the only thing that they’re going off of, so I get it.

So let’s go into the HRT stuff, because I feel like this is kind of what I know you guys the most for is being very outspoken about this, and providing really good education. And I think this is probably the most common question that we got in the question box is, is HRT okay, for everyone? How do I know if I should or should not do it? When do you start HRT, all that kind of stuff?

Maria: Well, it’s going to be different for each woman. But the thing is, we will say you do not have to be fully menopausal. And just, just in order that we define terms here, menopause is 12 months without a period. It’s not, you know, you’re menstruating five times a year, you, you’re skipping, like people will go to the doctor, the doctor might test FSH see that it’s high. And the doctor will say, well, you’re in menopause. I mean, it becomes like a war of words at that point. And it’s somewhat irrelevant in terms, you know, because it’s really this kind of continuum, right? It’s like there’s this changing. So it’s just like a technicality. You’re in menopause. When you look at the rearview mirror, and you see you’ve gone 12 months without a period. All right, anything leading up to that those changes those alterations in mood and weight, in menstrual cycle, that’s perimenopause—that can last anywhere from two to I’ve heard like people say, up to 12 years. I’m a little suspect on that. But you know, we’ll say like, two to five years is going to be more, a little bit more common.

Kristin: Yeah. And when it happens is largely genetic. You know, and that’s hard for women to kind of hear, you know. A lot of our mother’s generation they had full hysterectomies at younger ages. You know, they got their tubes tied and uterus taken out when they had their last baby, you know, some sort of, sort of premature onset of menopause created by something that happened to them. And so a lot of us are flying blind, right? Or our mothers never talked about it. And you know, that’s really hard, because then when you’re asking, let’s say, a 60, 70, 80 year-old mom, when you did you go into menopause? They just kind of look at you like, oh, remember, you know. And I know even I forget Maria’s mom situation, mine, mine had a full hysterectomy at 32 years old. So I had zero clue when I was going to be going into menopause. And so we’d like to tell ladies like, look, you can, as we said, mitigate your experience of midlife and what life feels like when you hit menopause. And that may help, I don’t wanna say lengthen it, but, but delay the time at which you’re finally 12 months without a period. But at some point, it’s going to happen for everyone. And you know, for some women, if it’s happening at 44, it’s not a failure on your part. There’s nothing you did, you know, and those of you who still have a full cycle at 52, 53, lucky you, but you know, it’s anywhere sort of in that bracketing of age that you can expect it and that’s why we try in women like get out in front of it. But don’t wait till you hit the wall.

Amanda: It’s not that you need to, you’re not even reversing anything. When you guys work with women. You’re just, you’re literally just supporting since the whole reason why this is happening is because of this hormone imbalance which was the perfect way to describe, and I feel like couldn’t that be a diagnosis technically, you know, like, that’s how I feel. Like that’s what they should do for peri and [post]menopause and menopause, it could technically be a hormone imbalance. I feel like that would be helpful. And it’s a good way to look at it and knowing that it’s not necessarily one that you guys have to fix. It’s just something that you’re trying to support as you go through those different transitions.

Maria: And then when you’re finally menopausal I would say, you know, in terms of your estrogen, progesterone, it’s not a balance and it’s not a really a hormone imbalance it’s just…

Kristin: …insufficiency.

Maria: Yeah it’s gone. Yeah, it’s technically balanced. But that’s not necessarily a good thing, either. So, so you did ask, I think you started out by saying like, like, when do you start on some, you know, again, knowing what I now know, I wish I would have started at…I was menopausal by 47. I don’t, I don’t think I started in earnest maybe till I was about 49. Knowing what I now know, I would have started at 45, 46. You do not, do not have to wait until the final menstrual period.

Kristin: Yeah, and a lot of women are like me, I had Mirena, you know. I kind of went cuckoo for Cocoa Puffs after my last kid. And, you know, they were like, here’s an antidepressant, here’s this and I was like hell to the no, it’s not going to happen. So God bless my nurse practitioner who was like, try this, Mirena it might stabilize your moods and a few other things. It did, it was great. But it also meant that I had no clue when I hit menopause. And there’s all too many doctors willing to say, just keep it in, keep it until you’re like 55. And then you’ll just sail through menopause. What I know now makes me so angry that I was told that, because it’s not just the hot flashes, and the weight changes, and the mood changes, and some anxiety, and the things that start to creep up that we’re aware of. What Maria and I are most passionate about with maintaining hormonal sufficiency is the things that you’re not aware of. And by the time you become aware of them, they’re too late. And that’s where we try and educate women that HRT…yes, can help you feel comfortable with those symptoms that you’re feeling. But what it’s also doing is providing you with chronic disease prevention.

You know, we’ve kind of hinted earlier, estrogen is everywhere in the body. It is the woman’s thermostat, it is such a regulator of so many things. What we try and get women to see is it’s regulating your bone health, it’s regulating your brain health, it’s regulating your cardiovascular health. And these things matter. So why wait until you know, we talk about why, why would you withhold insulin from a diabetic until they’re in a coma? Right? Why would you withhold hormones from a woman until she is absolutely shriveled up and miserable. So there is no need to wait once you’ve kind of documented like, hey, I’m in this transition of chaos of hormonally and imbalance and everything else. It’s okay to seek HRT to bring some calm to that chaos. A, it’s going to improve your quality of life right now. But B, it’s going to provide you with some protection as you age. And that’s the piece that we feel so many women are missing. Because we’ll hear women say I didn’t have a single hot flash, I breezed through menopause. Like, okay, how are your bones doing, you know, and, and that’s kind of a harsh reality. But we want to make sure women hear that, because you don’t know that your bones are frail until you’re 70 and you break your hip because you slipped on an icy sidewalk.

Amanda: I think a lot of people are afraid of it, like hormone replacement therapy, though, then that was the big question I got is like is, how do you know if it’s safe for you?

Maria: So the Dutch test can give us a clue, okay, how we methylate estrogen and how we break it down into its metabolites can certainly give us…if you don’t do that well, it’s, you’re not ruled out from it. But it means we’ve got to pay more attention. And we’ve got to be more careful. And, and that leads to the next thing, which is like, we’re huge fans of HRT, but do not step into that without knowing what you’re doing. Because what happens, Amanda, is a lot of women will go get a freaking pellet. They’re happy as anything for three to six months or a year. I tell all the people who come to me and say, well, I love my pellet. I’m like, come back to me in five years, you know, we’re totally like, HRT is a long-term thing, in our opinion. So you need to find a sustainable solution. So yeah, HRT is great, but you know, the lifestyle things matter as much, if not more, and you know, you just, you cannot go into as well. I don’t want to say cannot, should not go into HRT with pre-insulin resistance and you know, drinking wine two times a week and, you know, eating a crap food diet. And also you need to kind of really understand the process and have your expectations dialed in.

Kristin: Yeah, I mean, we talked about plenty, you can’t, you know, out diet no workout. You can’t work out a crappy diet, right. The same thing applies for HRT. You cannot just apply HRT to a woman’s physiology without dialing in the sleep, the nutrition, the lifestyle, you know. I know it’s not going to be popular to say but you got to drop the Orangetheory fitness, you got to stop the Peloton, you know, there’s things…you know, Maria said, you’re in a default state of imbalance, you’re also in a default state of inflammation. So you need to start looking at what are the lifestyle things that you take on right now that add to inflammation. What’s spiking your cortisol? What’s catabolic to your muscle tissue? Those sorts of things need to be concurrently dialed in as you proceed to look at balancing your hormones or restoring your hormones with HRT. So that’s a huge piece of it. And that’s why, you know, a lot of women will be like, can you just tell me what HRT we need? We’re like, I don’t know, what do you eat? You know, how do you sleep? Do you sleep? You know, and that’s a huge piece. Sleep is elusive for midlife women. So we’re pretty adamant that HRT is amazing. But it is not the end all be all unless you’ve dialed everything else in.

Mid-Episode Ad 25:57 
Hey, Amanda here, just giving you a quick break, hopefully a break for your brain in the middle of this podcast episode to remind you that if you haven’t gone through our free training, Optimizing Hormone Health Through Mineral Balance, we really do recommend starting there. And the main reason for that is because you’re going to hear us say things like mineral foundation, having a solid foundation, are you putting the foundations in place, especially as we get deeper and deeper into different hormonal topics and specific imbalances in the body. The mineral foundation is always going to be so essential. So if you haven’t watched the free training, you can find it in our show notes or you can go to hormonehealingrd.com and it’s going to be right on that front page there. But we really recommend starting there so that you can understand how is your current mineral status, how do you assess this, and how to get started with all that just so you can get as much as you possibly can out of the rest of the podcast episodes. But that’s it. I hope you enjoy the rest of this episode.

Amanda: That’s how I look at supplements, like, people are always asking, like, what supplement should I take? I’m like, what do you eat? You know, like what’s, what kind of stressors do you have? So, I, it, they work so much better if you already have all that like really solid foundation in place. So it’s the same like mindset, is it seems like is applied to that hormone replacement therapy as well.

Kristin: Well, that and also, unlike supplements, HRT can go bad on a woman who doesn’t have good estrogen detox, who doesn’t have good adrenal function, who doesn’t have good inflammatory control. You can’t expect HRT to correct for those things. And you can actually sometimes have it amplify, because if you’re not pooping, guess what, you’re going to start recirculating your estrogen, right? So there’s all of these things that matter. And they’re not mattering just because we’re trying to optimize and like, you’re in charge, and then we’ll supplement. This is truly like, it’s a, you know, a synchrony that you need to achieve by putting action into one thing while taking on this HRT. So, you know, we, we don’t even send out testing for women who are working with us until they’re a good four weeks into having a little skin in the game and making some changes.

Amanda: Because it’s all gonna change anyway, you know, once they make those changes. So it’s kind of like I do the same thing. I don’t do hormone testing right away, because I’m like, you guys it’s gonna change so much. And then you’re gonna have to shell out all that money for another Dutch test. Like, what’s the point? That’s really interesting. So what about for women that are nervous as far as like hormone replacement therapy and like cancer? That was a question I got quite a few times.

Maria: Yeah it’s a great question. So the whole Women’s Health Initiative that hit the news, I think in 2002

Amanda Montalvo

Amanda Montalvo is a women's health dietitian who helps women find the root cause of hormone imbalances and regain healthy menstrual cycles.

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