Weight Loss Resistance and Final Thoughts

Welcome to Everyday Wellness podcast. I'm your host, nurse practitioner, Cynthia Thurlow This podcast is designed to educate, empower and inspire you to achieve your health and wellness goals. My goal and intent is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives I had the honor of recording in person with friend and colleague, Emily Sedri She's a board certified women's health nurse practitioner and a certified nurse midwife She's also the founder of Aurellia Health, a private women's health practice In the Van Aken District in Shaker Heights, Ohio, with telehealth services specializing in hormones and weight loss support for women ages thirty five to fifty five. She' also trained in functional medicine and is one of the leading hormone experts building a practice around what she calls a hormones first approach. Today, we had an extensive conversation talking about nurse practitioner training, our scope of practice and professional support And the key differences between being a nurse practitioner and a midwife, anticipatory guidance and limitations of conventional midlife care and advocacy Symptom care versus personalized care and why she endeavors to be highly precision oriented, the value of MIRA monitoring and how it allows for precision hormone replacement therapy management in perimenopause and key changes that she sees in early periimenopause that are not just about progesterone shifts the value of patterning with hormones, the impact of cyclic versus static versus physiologic dosing of HRT The influence of progestin IUDs Triends in healthcare and last but not least, less common reasons for why she sees women in midlife becoming weight loss resistant. This is a truly invaluable conversation, one you will listen to likely more than once Emily,' such a pleasure to have you. Welcome to Everyday Wellness. Thank you so much for having me. It's truly an honor to be here. Yeah, for my community, we met in December of twenty twenty five at A four M and you were just so gracious and kind and came up to me and were like, I want to support you. I want to help support your book launch. I have been following you. And so you were the first nurse practitioner that I've had in studio, which is really exciting because I think that one of the things about us as a profession is that it's so important that we're supporting one another because we are pioneers, even though nurse practitioners have been in existence for over sixty years. Let's be honest, it's still a little bit of the wild wild West. Yeah. and there's such a disparity, I think, across the nation of like the way that people are practicing, how they were trained. I was trained to be really autonomous and practice at the top of my scope. Not everybody was and I love the work that you're doing, and I think we absolutely have to support each other because our strength is in numbers And we're still pretty marginalized in the broader medical system and people still think of us as physician extenders instead of independent practitioners and independent thinkers. And so anytime I can support platforms that further that cause, I'm so happy to do it. Yeah, you know, it's interesting because I think that Until this book launch, I didn't feel a little bit of a glass ceiling. And with this book launch, I did, which was something I had not experienced with my first book. And so I found that really interesting. And I'm speaking from the place of Mainstream media, national media It was never overtly stated But The only platform that I see most NPs being kind of elevated to is at least like regional news, like regional like L.A, New York, you know, Atlanta, Dallas, et cetera. But getting on national TV, they're not yet fully comfortable. They seem to still be pigeonholed into thinking it has to be a medical doctor or a PhD researcher In your training, what was it about your training that really encouraged you to be thinking about being fully autonomous or at least thinking that you are capable of doing more than just what's widgeted into kind of a traditional nurse practitioner model. Yeah, it was Midwifery. Because Midwifery is really kind of a separate profession from you know advanced practice nursing. and historically, the way that midwives kind of codified and you know made themselves legitimate they hopped on to Nursing and advanced practice nursing to find some kind of professional organization to like ride their coattails. But from a sle level, midwives really consider themselves an independent standalone profession And in fact, there's a lot of debate within Midwifery as to whether or not you even need to be an RN to be a midwife. And there are paths to direct Midwifery where they get the same master's degree, have the same prescriptive privileges. and several states actually, Virginia is one of the states that just passed the CM legislation, so CMs can practice here. And that's how it is in the UK right and across the world Midwives are not nurses, right? It's a separate profession. So being raised by some of the most powerful independent midwives in the profession who really lit fires underneath all of us, that it was our job to not only be good practitioners, but to be political activists. It was non negotiable. In fact, I think it was a prerequisite for even being accepted to pen was like how much are you going contribute to our profession? Because if you don't We don't have a chance, right? And especially because many of these women that were sort of a boomer generation, they were so marginalized and they fought so hard and sacrificed so much so that we could practice the way that we can today Sometimes I think we forget that, like what came before us to allow us to do what we do now. So I always knew that I wanted to do more than just catch babies. I loved The integrative side of Midwifree, I loved how much we respected physiology with respect to birth, but I didn't like how we were just co opting ACO guidelines for our GYN management But I didn't imagine that I would fully transition into where I have today. but Um, Yeah, I still feel in my heart like that is kind of who I am as a midwife. with these credentials that allow me to do what I do, but what I identify with is that profession. Yeah. And for the benefit of listeners, so I'm sure listeners know there are different. There's adult geriatric, there's primary care, there's acute care, there's women's health. Talk to me about how women's health nurse practitioner training differs from midwiffery because I think that this is an important distinction, and it's not that one is better than the other, but there are very distinct roles. Yeah. Yeah. So actually at many of the schools, Yale does this, I believe Columbia does this UPen does this, the WHNPs and the CNMs train together So we take, you know antipartum, so learning prenatal care, we take GAN well woman, we learn also primary care. So WHNPs can do full scope primary care for women. which I think a lot of people don't know. Its like it extends beyond GYN. But I always liked that primary care perspective because You can't like we can't compartmentalize people and our reproductive organs and now of course, our ovarian function, right affects our whole system. So why shouldn't they be part and parcel to one another So what happens is you all go through the program together and then at the point when you finish antipartum care, the WHNPs go off and finish their integration and the CNMs continue and do another semester. So really it's not that different. and WHNPs can do everything that midwives do except for the actual catching of the baby. But they do postpartum and all of those other parts. The catching of the baby catching that baby. That is so tried and true. And it's interesting. Call the Midwife is one of my favorite series. have said to my husband more often than not, I think had I not trained in Baltimore, I think I probably would have been a women's health nurse practitioner up front, but I saw such crazy things in the inner city that my only way of dealing with it was I was like, I'm just dealing with adults. I can't manage the kids stuff. I can't manage the teenagers It was so traumatizing. as an ER nurse and a trauma nurse that I think that was just the way my little empath brain needed to go. But I think for so many people There's a preference to see nurse practitioners and midwives for care. and certainly It has been my clinical experience, my personal experience that when I was in the throwes of perimenopause, it wasn't my GYN, who I loved It was the midwife that I got connected to that really showed me what was possible And I think when women reach out to me that are looking for providers, I'm like, it is not per se necessarily their credentials, whether it's an NP, whether it's an MD, whether it's a PA, it's just finding people that are in alignment with your goals Something I hear constantly from women in our community and something I understand personally is this Nothing about your effort has changed and yet our bodies are responding differently Your midsection feels different. Your blood sugar is much less stable and your cravings may have shifted And let's be honest, your energy probably isn't what it used to be As a nurse practitioner with over twenty five years of experience, I want to be completely transparent with you about why Estrogen is one of the body's master regulators of metabolic health The influences how we store fat, how our tissues respond to blood sugar changes, and how efficiently our metabolism functions at the cellular level As estrogen shifts during perimenopause and menopause, the same lifestyle choices, diet, exercise, sleep genuinely do not produce the same results. This isn't a failure of effort. 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For women who want to remain strong, capable and resilient for decades to come, this is an essential area of research worth knowing about Visit timeline. com and use code Cynthia for twenty percent off your order. Again, that's timeline d. com and use code Cynthia for twenty percent off your order This is one of my foundational supplements that I never miss So when you're talking to women or connecting with women online What are some of the things that you make in terms of not giving medical advice, but helping them navigate selecting a provider that's going to be in alignment with what their goals are because let's be transparent. Women in midlife, women north of thirty five. or struggling And I think that there is a lack of transparency about what we should have anticipatory guidance And then on the other side of that is that just frank and overt providers that are frustrated in a system that's not working well, just saying expect to gain weight, expect to be tired, expect to not sleep well. And oh, if you have a whiff of a family member that has some type of reproductive cancer, breast cancer, or others HRT is not appropriate for you. So there's so much misinformation being given out. Is it any surprise that our patients are confused No, it it's a real struggle. I think that the first thing I tell women to do, whether they're working with me or just coming to me for advice is to take all providers off a pedestal M We really have this idea that people in a white coat know everything. and you know, it's important to recognize that OBGYN's are really important additions to the medical field and we need their surgical capabilities But they don't know that much about hormones. and neither do endocrinologists, unfortunately, not not the female hormonal system. There's not the broad recognition for estrogen deficiency that it deserves across the lifespan, right? Because we're not just talking about the midlife transition. It's across the lifespan. There's a real under recognition of the necessity of estrogen exposure Um And so I just Try to humanize the whole experience for people and say, like this person is this is what their training entails. It's eighty to ninety percent. and pregnancy, right? and surgery. And so they mean really well. And I think that's so hard for women because we have a lot of attachment stuff, right? We're so emotional and it's a great thing But then we feel guilty, you know, if we don't take their advice or go to someone else and like you don't owe anything, know to your provider, right? Its Re they're too busy.. They're probably noting that you don't come back. Yes. And you know that just I really want people to own and to grow into that idea being their own best primary care provider somethingomething that Katie Wells has always said. and I always said that too when I was a midwife. I prenatal care, we need a rebrand. Like I'm not really doing your prenatal care. you are. Like it's your choices every day all day. I'm kind of doing prenatal surveillance You know, in that like mindset shift of who owns this, who owns the well beinging of you and your pregnancy, it's you. And it's the same across the lifespan So be smart, you know, be judicious, be discerning And interview a lot of people, right and find the person who can serve you, but because our infrastructure and medicine is what it is. People don't know where to go who is the person to go to, especially between thirty five and forty five. I think it's a little clearer. if you're fifty and menopausal and you just want a straightforward kind of conventional approach Most hospitals now have like a menopause person. So you can go there and get kind of a traditional approach, but what about everybody else? You Where are you supposed to go? I don't think most people know the answer to that. Well, and I mean, many of us, I had my second child at thirty six. So I was probably, I'm guessing, you know, in my late thirties, probably in early peri menopause and like nothing really prepared me. We had no conversations So I'm trained is adult primary care, which everyone's always shocked by. But in the nineteen nineties, my program director said, do not do an acute care certification. You will never see nurse practitioners working in hospitals. And this is like Johns Hopkins, yes And so I was sitting on the fence thinking, I'm so interested in urgent emergent medicine. like it just makes more sense. And she said, you'll never see nurse practitioners. And the irony being, that's all I did, right Conventionally for twenty years was kind of hospital, cardiology medicine until I didn't. But I think that There is this lack of information. Even for licensed medical providers, I don't remember ever having a conversation other than, you know, eventually a woman will stop menstruating, she'll go into a menopause and she falls off a cliff. And that was as much of a conversation as I had because I still have my books, like back in the day when we had to buy books. I still have them because I don't know why I kept them, but I did. and I was skimming through them thinking, was there any like nugget of information? There was nothing. There was no differentiator between menstruating women, non menstruating women and menopausal women. Is it any surprise that even the providers don't know in terms of providing anticipatory guidance? And especially for the women in that thirty five to late forties time range because They're the ones that are typically the most symptomatic, suffering the most, and whether it's being prescribed antidepressants when they need some progesterone, whether it's You know, someone not really knowing what to do with estrogen therapy and plus or minus adding in some testosterone, what I'm starting to see are a lot of women that are just given testosterone And I'm like, are we wondering why this young woman has low testosterone? Are they chronically stressed Are they dealing with latent insulin resistance? which we know there's a huge metabolic health problem. So when you're thinking about your approach to Younger middle aged women. How do you tease out what the first step is for them Hm I mean, I think the first step is just a systemic evaluation. Right? It it's how we have to start moving beyond symptom care. It's just It's sad, honestly, you know, We deserve so much better. And' like let's give a band aid. you're having vaginal symptoms, we give you vaginal estrogen. you're having, you know you're depressed, let's give you antidepressant. I mean, even using birth control and synthetic progestines, it's all symptom based management, right? And And it's not that it's wrong. It's just that then we miss the opportunity to ask What's causing this and when I fix the cause, then what do I get to optimize as an adjacent issue And that's the part that I'm really interested in, right? That we really we've started having this conversation around the fifth vital sign being the menstrual cycle, But then it kind of we stop talking about it that way Right? And then it just becomes something to manage. Well, if someone's having heavy bleeding, I know that you've talked about having really heavy cycles early and probably perimenopausey, you didn't even know at the time, right? Well, what systemically is happening because of this imbalance and because of this thing that's falling apart? And I think we're just missing a huge opportunity. And as long as we stay in the HRT as a symptom reliever camp and we don't open our minds to anything else We're missing that crucial opportunity to help women be healthier. and that's the true longevity conversation. If you ask me, it's not about All of these fancy biohacks, it's about When we start to see changes in our presentation on our menstrual cycle, what else is falling apart. And so often you're seeing slightly rising LDL You're seeing changes in thyroid physiology. you're seeing changes in insulin resistance early on. And You know, ninety nine percent of the time these are being written off for people or they're being treated as completely separate issues. And so my first step is doing comprehensive lab work. and then something I really love to do, especially for the early pererry population still cycling, is mirror monitoring. It's changed my practice, to be honest. It's really the first time that we're seeing this menstrual physiology in real time in a continuous fashion. right? We used to have to do Dutch cycle mapping It was hundred dollars. You'd have to send it in. you'd wait all this time, You don't know what things look like from cycle to cycle. And now we're really seeing the correlation between these early signs of perimenopause, which are insulin resistance, cognitive changes, loss of stress resilience, building anxiety, sleep architecture changes And like the belly fat, like these are the early signs that are truly hormonal in origin And you're seeing what the changes are in the mirror that correlate to that. even in a woman that has perfect twenty eight day cycles, she has changes in her patterns. And so it's really just educating her on what that whole picture is and then discussing what the options are for solving it for it And how do you track that or help her track that How do you track it on the mirror? Yeah. So the mirror is a home urine test. Okay, R. So this is new for me. That's why., you have to know about the mirror. honestly, it's, I think one of the biggest clinical breakthroughs that we've made in hormone medicine. So there's a couple of other companies that do it. I think Mirr an interface is the best. And so you have these sticks Kind of like if you were doing LH predictor stickics for pregnancy and it measures FSH LH E three G, so it's an estrovyile metabolite and PG, which is okay progesterone metabolite. And you can do it without the FSH as well, but for the Perry population, I'd love to see the FSH. So you can do it every day, every other day. Obviously in Perry, I like to them to do it for the duration of the cycle and not just around ovulation because we have no idea when that's going to occur if at all, R, if at all. But so they just pee on it or you dunk it in a little thing and then it uploads to your app.. And so then on the provider side, we can see that in real time on the bke end. And so we can track their entire cycle and see are they having a preabulatory peak? And that's one of the first things to go, actually. You know, we tell we hear all the time and this is what I was taught like and it's still the predominant dogma. Like once someone's fifty or once they're menopausal, that's when you can start estrogen because before that, progesterone declines first Estrogens about the same are high And I have to tell you from clinical data of now seeing hundreds of MERA patients, it's not true It's not what's happening. First, they're having follicular flattening So that estradial curve is flattening out and that's really important because when estradial peaks, it peaks four x before you ovulate And that four X peak turns over, right? It's helpful for the endothelial function. It produces nitric oxide. It sensitizes cells to insulin It's very dynamic. It's important for the immune system. right. And when that goes away That's actually another predicator of heavy bleeding because it's also what prepares progesterone receptors in the uterine lightining. So heavy bleeding is not this thing that's very linear with high estrogen. In fact, it's quite the opposite We often are replacing estrogen to reduce heavy bleeding. So I think this is significant because there's still this thought process that that, you know this high protracted period of time of estrdiol levels that are including all these other symptoms. and what you're saying is It's we're getting flattening and changes to the normal distribution of specific hormones that are driving. So when you start think, when you talk about endithelial function When you're talking about changes to nitric oxide production, you're talking about upping our risk of cardiovascular disease. And since we know one in three women will die of heart disease. And we we have been telling women for a long time, don't start hormones till menopause. This is why it makes sense. to start them much earlier. So I think this is really significant for listeners. And if you're already in menopause, don't stress about it. But if you are not yet in menopause, this is something you really want to listen to. Yeah. And I think, you know I have such an obsession with the endocrine system because I loved The oxytocin cycle and circuitry in labor was like the first thing that got me lit up and made me decide to be a midwife And so I love how everything has this pattern and this receptor behavior and this feedback loop And we have respect with regards to many of the other systems like cortisol curve. We know that a flattened cortisol curve is one of the biggest risk factors for cardiovascular disease. Why aren't we talking about patterning with our reproductive hormones in the same way that we're talking about patterning for everything else. We understand the pattern with blood glucose We understand with CGM, right that there are specific patterns that are associated with worse outcomes, right? A fasting blood sugar is one of the biggest indicators, even more so than postparendial. So we have this respect, right for other systems, but with are reproductive hormones, we're just talking about them as sort of like presence or absence And the pattern is so important. This nuance is very important. I think for everyone, even clinicians that are listening, that there's something to take away from this conversation. There's this whole other nuance about perimenopause that I think is kind of lost in translation And I think about how fortunate I am that I get to interview people like yourself and other experts And you're the first person that I have interviewed that's had this nuanced conversation around these patterns and the endocrine system and hormones. And it's not to suggest that other people haven't thought about it as well, but in the context of a conversation on the podcast that I think can be very helpful for women Eespecially this very much this bio individual approach because I think perienopause is a litmus test for so much that is going well or not well in your personal life. A lot of the women that are super high functioning, super high achieving They have all these adaptive mechanisms that start to unravel in perimenopause because as our physiology is changing, as our hormones is changing, as our neurotransmitters are changing, we just don't cope quite as well So when we're thinking about whether it's perimenopause or menopause, talking about hormone replacement therapy. And I brought up some statistics and I'm going to look at this paper because I will not remember all of this So we've had a twenty six percent HRT prescription increase for women forty five to fifty four between July of twenty twenty five and February of twenty twenty six. So forty five percent? Yep. twenty six percent. twenty six There's one hundred and eighty four point two percent increase in HRT since twenty eighteen. So things are heading in a specific direction. and then interestingly enough The projected global HRT market growth from twenty twenty four to twenty thirty three is expected to be from twenty two point two billion to thirty eight point one billion. And that's conservative estimates. People are getting The message The question is I think as a clinician and myself, it's that we have so many differing opinions when to start, how to start, There's the camp of static dosing. There's a camp of rhythmic dosing. and then there's this Wiley protocol that I will just say is that kind of on the extreme end of prescriptive recommendations and probably not something you or I would necessarily recommend But let's start off talking about how we approach prescribing HRT kind of broadly, and then let's narrow the lens a little bit because I think most of our listeners are very familiarized with You know this is what I put my estrogen patch on. I take oral progesterone six days out of the week, I plus or minus testosterone but help differentiate that from this kind of rhythmic dosing that I know that you have talked quite a bit about. Yeah. so actually Wiley I wouldn't say is practiced by too many people anymore. It was saying extreme fringe. Yeah. well but interestingly, like I don't so Wiley Protocol was first sort of ideated by a woman named T.S. Wiley, who was an anthropologist. She really had almost like this I don't I don't know her, but like a very broad I think that she brought a really important thing into conversation. know asking the question, if something has functioned in this rhythm, why are we not replicating it?? But that book, her book came out the year of the WHI Right? So it kind of just got lost and nobody really talked about it. But there were a lot of physicians, particularly in California that we're experimenting with practicing this way, including the one that co authored the book with her, Dr. Julie Tagucci, who's a medical oncologist who has now for over twenty years been treating women, you know post their cancer journeys that no one else would treat. And all she's ever done is rhythmic dosing. So now sort of the terminology is physiologic HRT And that's what You know, most people are calling what they're doing and it comes from Wy, but it's a little bit different. U not Not categorically different though. It's essentially the same thing with a lot more information and a lot more clinical experience. Um, Cyclic dosing just means on and off progesterone R, usually with flat standard estrovile dosing static dosing means same progesterone and estrogen every day. So we have static, cyclic, and then we have physiologic physiologic aims to primarily reproduce that astrdial peak that would happen preobulatory because that has certain systemic theoretical benefits, right? We know that in a physiologic circumstance when you're ovulating on your own that that is a predicator for so many important processes. We don't have write randomized controlled trials on the use of a physiologically RT approach. Although the The First study that will be published is forthcoming and it will be on bone outcomes with people which is really and it's also so measurable, right? because we get such quantitative data around bone. So comparing static dosing to physiologic dosing. So that will be really exciting and the outcomes are pretty astounding. And I know our mutual friend, Dr. Doug Lucas, like has seen the same thing in practice, right? That it outperforms all the time The primary difference with physiologic dosing versus a static approach You could argue that Cyclic may kind of do some of this, depending on the person, is really that it has respect for receptor activity right? That there's not a time in our lives prior to know menopause, really that we're getting progesterone exposure all of the time. And so it is potentially diminishing some of the benefits of estrogen I think one of the reasons that We need to use progesterone daily in a static approach is because the estradile doses are so low Right? And I think it's important for people to remember that when the patch was first developed, it was FD approved for Hot flashes, right? And so symptom resolution of hot flashes was the only outcome That was it. We weren't having this like longevity conversation, this chronic disease prevention conversation. In fact, I mean, in the guidelines, it still isn't really Standardized, right? There's not standard guidelines around prevention and HRT is prevention So Many times the patch dose is too low, right to produce physiologic benefit, which I know that your audience understands And we see typically that, you know, with The highest dose patch, right? even many people still don't fall into a range that is going to confer bone protection So and particularly in a perimenopause population, I think this population againgain for so long has just been put into the bucket of management. Y. And everyone is continuing to perpetuate this conversation that perimenopause is all about loss of progesterone and that estrogen is the same or higher And again, it's just not true. And the first signs of perimenopause that we're seeing, these that we just talked about the insulin resistance and the mental cognitive changes are all estrogen driven. right? So we again have to look broader at the patterning and not just a single serum level, because in fact, your day twenty one estrogen often will show the best picture becausecause you because of the way that the brain works, when it doesn't get its needs met in the first half of the cycle, it's working really, really hard and kind of has a delayed surge of estrogen. So you might have a day twenty one Esther Dial of two hundred. And then you're being told that you have estrogen dominance. and in the meantime, your pre obvulatory estrogidial is sixty Right? Difference. Yeah, and that's causing these symptoms, right? And progesterone only may alleviate some of the symptoms, may help with some of the heavy bleeding, but it's not going to correct the cognitive issues. It may help you sleep for half the month Right? But Do all women sleep for only half the month when they're thirty one years old No, they sleep well all the time, right? Because estrogen is such a modulator of the circadian rhythm. Yeah. So I just think that there's nothing wrong per se. I think it's great that there's more access. I think that there's always going be people and they're kind of my people that want to understand like the best coolest, most advanced, most theoretically beneficial way to do this, and also one that really respects that our body has any intelligence around how it's designed these systems to work And they desire to replicate that whenever possible Yeah, and I think that You know, certainly Dr. Felice Gersh is a good example. someomeone who talks a lot about this in a very respectful, I think she's one of the smartest physicians I've ever met, like she really challenges conventional wisdom in a very thoughtful, respectable way. And she was saying to me, Cynthia, you understand the way growth factors and all these things that are happening when we have these physiologic, cyclical patterns versus if it's static, we're not having that same concern. My only concern when someone says physiologic or rhythmic dosing is, I think most of us that are menopause are like, I don't want to get menstual cy. don't to, it is' a menstualycle You don't want tove. don't a belieleve. You've gotten many years away from doing that And she said, well, I think isn't that a small price to pay for some of these physiologic benefits? And then, we had the conversation ER alpha, ER beta, and how these different receptors need to be stimulated. And for listeners, one is kind of ramping up growth, one is kind of dialing down growth And to your point I think we have whittled perimenopause down to low progesterone, relative high estrogen. That's the whole reason why everyone's having symptoms. And to your point about the fact that it could very very likely be that your estrogen is low in a portion of your cycle that is driving a lot of those symptoms. It may not just be from know subtherapeutic progesterone levels and early perimenopause, I think that's a significant distinction. And so are you a fan of estrogen patches and gels and sprays or are you in the camp of I want compounded products. And the reason why I'm asking this is that And I've actually brought my integrative medicine doc around on this because no matter what dose I was on of compounded estrdol and estrol, it didn't matter. I could not get my levels therapeutic. We tried different bases. All this stuff was compound. and I finally said, canan I just try a patch? Becauseuse I said, I just want to know that my bones are protected, at least enough that I'm not worrying about it. And so sure enough, like a duck to water on the estrogen patch, my skin absorbed the estrogen, my estrogen levels ab, I felt better. And so I think that there's very much this bioindividual approach. But I'm curious like what is your As a practicing clinician, what are your preferred options as a starting point. Yeah. I think for menopausal patients or very late perimenopausal patients where we're not interested in preserving ovulation Um Especially if you're going a static approach, the patch is really effective for that. Oftentimes, the point point one patch is still not sufficient, right? So we're coming up with creative ways to get the level even higher in static patients And we also find that it works as a really good basement for the people who are doing physiologic Because it just brings everything up a little higher and then we have less cream burden when we're using a trans buren Cam burden. cream burden I love real struggle. Someone is tired of rubbing it on multiple appages. And it's voluminous, you know. We do a ten milligram per milliliter formulation, we even go up to twenty milligrams per milliliter if we have to. Although more I'm more often now going to injections if someone isn't doing well on the initial concentration. becausecause if you're not doing well on that concentration, it's probably an absorption issue. So I do like the patch, especially as like a baseline. know keeps people from kind of cycling up and down And a lot of women will be symptomatic if they're only applying twice a day, depending on how fast they're absorbing. So many, many of our patients, especially the older patients are on a patch plus a transdermal estrogen to reproduce that peak Then with our younger patients, what I've actually found is that when you apply a patch Early in perimenopause. I mean, we're seeing people thirty eight to forty three is kind of a really common window. I think forty one to forty three, there is a particular kind of deceleration phase that happens That's when so many women start complaining of metabolic issues. I'm sure you see that age group as like a common raising their head. Vy frustrated. Right Extremely frustrated. What we see in those patients is that some of them have some menstrual changes, many of them do not When you look at their mirror data, they're having a lot of morphologic changes to their pattern When you put an estrogen patch on initially, it brings the whole cycle up and it helps And they have a nice rhythm, but within two to three months, it flattens them out. So they look just like a menopausal woman on their tracking. and they actually feel worse three months later because now they're just eighty every day The restroaled levels eighty all the time. and it's actually less estrogen than they were getting before. It's just flatter. And so they feel that way. they feel flat And so we I tend not to use it and especially women that we're trying to preserve ovulation who have a sensitive HPO access because that little bit of input, the pituitary is like, o, finally. know someone's taking over. it's like a self drive. Hp me out. helpp me out. Yeah. I've been working so hard. you see this with thyroid medication too, right? You start a little bit, it works initially then their own TSH is like, I forget it. I've worked hard for a while. I'm going to just let you take over. So with the younger women, we actually really like to do just a transdermal cream. I do this as well. I still ovulate most of the time, right? In fact, it actually can be ovulation anc for many people to haveing. Yeah, that reproduction of that peak. and we even do it sometimes in fertility patients for three months, like as a fertility preparation This is fascinating. It's I mean, the powers of Estrodial are just where it's it's Mind blowing. Well, it's interesting because as I was writing the menopause gut, I started thinking about what does the research say about the gut microbiome? What is the research saying about immune system function, especially with regard to estrodialome, like we don't yet have a clinical indication, but I think it will come in time. because Estadial is thought of as our superpower and it is. but there's so much more to the conversation, like this very nuanced conversation that we're having today because I think there has been this thought process of, oh You're a perimenopausal woman, so you just need an estrogen patch for like two weeks out of the month and you need you need some progesterone for like seven to fourteen days, and then plus or minus, maybe you need some testosterone, but that reductionistic thinking is not honoring our physiology No. And I mean, I really struggle with the daily progesterone use in perimenopause. Some people maintain ovulation through that, some people don't. but You know, it's sort of ant metabolic approach to give daily progesterone. It desensitizes the cells to insulin, right? It's this like pseudo pregnancy state. A lot of women, even one hundred milligrams of progesterone are their serum levels are twenty or thirty ight That's higher than you would physiologically be even on your peak day. And I just don't think that we're asking the question enough, especially for the oral users is like what's the consequence of forty, fifty years of exposure to daily progesterone? We don't know because we haven't had women on it for that long. It's interesting. know Felice came on at the end of December and I think I released her two podcasts on progesterone midway through the year and Everyone listened to it, and then they were like, well, wait a minute, does this mean that this is dangerous because allopregnanolone levels are so high. And so I dove into the research and I was like, it seems that the sweet spot for the research is suggesting that it's not akin to taking a benzodiazepine, so valiumativan, Xanax However, we don't know. you know, we've had rap models You know, obviously, I've been on two hundred milligrams of progesterone for so long. It works for me. and we're not making any changes right now, but I think what you're speaking to is definitely for these Ay menopausal women And by no means am I suggesting anyone needs to panic? The beautiful thing is that We have many opportunities to shift gears. It doesn't mean that because you heard one conversation, that anything you're doing is wrong. it's like if it's working for you, great. If it's not, just know that there are other options that are certainly available. Yeah. and it's about how you're feeling. You know. Like I think for for so many women, especially these younger women that are put on a static approach, just because they find a well meaning provider and that's what they know And they just know that, know, well, I'll just give you progesterone every day because you're having a lot of sleep issues, right? They don't understand how important estrogen is to sleep architecture. And now you've been on this static approach to daily progesterone and you're not feeling great a few years in. It's just an opportunity to like say, is there a different way that I could do this? Yeah Absolutely. And I think for a lot of people, sleep becomes such a large piece of the conversation Definitely in my late thirties. and I assumed it was because I had two kids twenty six months apart that I was like, off course I shouldn't be sleeping and my husband travels all the time and my job is stressful. and so I shouldn't sleep well. but I think for so many of us, hopefully The women that are ten, fifteen, twenty years younger than my generation are at least watching what's happening. and at least taking note of it because I think that You know, one of our mutual friends, Dr. Heather Quails, encouraged me to take the NAMS exam, which I took. And I was shocked. So the North American Menopause Society were kind of conditioned to believe that every clinician who has certified through them is knowledgeable about HRT. I'm here to tell you that that test did not test my ability to prescribe HRT. test? Correct. In fact, there were so many questions about things that I was like, I will never have to prescribe X, but that is what I was asked about. And it was like everything else other than HRT to prescribe So I think that finding someone who's knowledgeable like The conversations that we're having here probably requires a little bit of effort. unfortunately. It's like we can't just assume everyone that is certified by a particular organization is particularly savvy beyond the As I always say, slapping on an estrogen patch and then calling it a day, there's a larger conversation here that needs to be had. Yeah. And I think there's such a grassroots movement and all the people who are getting themselves educated are going to the leaders and saying like, what are you seeing? And the thing that's most attractive to me right now is the provider that veen thousands of patients over a long period of time. I just want to sit in a room with them and ask them all the questions. What are the patterns that you're seeing, right? And people forget that in that table of know hierarchy of evidence that we learn, right Clinical experience is part of that. Y, right? It's not nothing. okay? You can't like We were talking about the evidence based bullies, you know, that is a form of evidence, right? is clinical experience. So you can't discard that. If you've seen a pattern over and over and over again, Right? Well, it would be great if you would write it up, but also like the reality is that many providers are so busy that you have to just corner them and like extract the beautiful knowledge from their brain. know what you've done for a living. Yeah. Well, it's interesting. So it's this kind of daunting realization that if we're seeing things in clinical practice, but we're not actually sharing it with others It's a way that you can kind of expedite someone's learning process by saying You know, for the past ten years, myopically working with perimenopause and menopause females, looking at Tens of thousands of stool tests and microbiome tests. And for me, two years ago, saying to my editor, I think there's a larger piece of the conversation that's not being had. So let's talk about the gut because I'm the first person to say that what I have realized over the past ten years is that this is this key modulator of information in the body And it helps explain why a lot of these women that get an estrogen patch or get oral micronized progesterone, plus or minus testosterone or whatever intervention we're doing, it doesn't necessarily work really well for everyone. And I think a lot of it has to do with the cross talk mechanisms between the gut and the ovaries, the gut and the bone, the gut and the brain And that interplay becomes a larger piece of the conversation. Yeah. And we're also dealing with a population that's been so adulterated. right? The pervasive use of birth control for ten, twenty years, right? What does that do to receptors? What does that do to the uterine line? What does that do to the thyroid? too the gut? So that's the real challenge is that it's not as simple and practicing in the way that I do with such specificity and precision You know, it's not as straightforward as like everyone's just a healthy blank slate and then they hit perimenopause and they start to have hormonal issues. It's like they had all of this stuff. They have this long history And that's why I think that actually primary careres, we know it is not going to exist in the same way in fifty years. because as you cited with all of those numbers on HRT utilization It's a primary care issue and we're going to have to start to see the whole health through the lens of what is happening with ovarian function. And I love that different providers are bringing that into the conversation. POI, early menopause, like it doesn't matter the age, right? We should always be asking What's happening with hormones sufficiency? We see this with PCOS patients, right where they were just slapped on a progestin for years and they were estrogen deficient, and that was driving and propagating and furthering their insulin resistance and their metabolic issues and you know, their depression, cognition L term loss. E Yeahah. I mean, it's just astounding. The lack of fluency that we have as a medical you know organ as a medical community for really respectfully seeing women through the lens of their endocrine function. We have to We have to get there. Yeah, I mean, I think about my generation. I was born in the seventies, grew up in the eighties and nineties, and I can't think of one girlfriend that was not on the pill for and fifteen twenty years And so, you know, the one thing that I was incredibly disturbed by and as someone who was started on Oral contraceptives at like sixteen, not for pregnancy prevention, but because I had very irregular cycles. The working hypothesis is thin phenotype PCOS, which is now PMOS, never was insulin resistant, never had any polycystic evidence on an ultrasound but was on oral contraceptives at a time when most of us are trying to reach our peak bone and muscle mass So we have generations of women that probablyroably are behind the eight ball before they even get to perimenopause in terms of peak bone development and kept in that low estrodial state. So how is that impacting the microbiome, our immune system regulation, our autoimmune disease risk Thinking about Dpo Pvera has a black box warning And I remember in inner city Baltimore. I worked at Planned Parenthood, volunteered there. And I remember asking, like why aren't we recommending at the time, depot more often, if women or haavving remember are forgetting to take the oral contraceptive every day And the medical director was kind of like, well, we have this identified for specific people just to make sure they don't get pregnant. like this very pejorative patriarchal perspective And I was like, oh my God, but we didn't even talk to patients about bone risk. And yet it's a black box warning. which is supposed to be reversible after discontinuation, but do we really know that? And so I'm curious as a women's health expert, what are your thoughts around oral contraceptive use for protracted periods of time when we're now starting to realize there's more to the conversation than just You know Fixing fixing, fixing symptoms, addressing irregular cycles And let's take the contraceptive piece out of it because I did never want the message to be that I'm not pro women having choices or pro contraception. I think that's very important. I of all boys, but I always say if I were to have all girls, I would want them to have choices and options for their needs But I think now I look at things very differently as a middle aged woman than I would have as a twenty year old female. Yeah, I think again, it's that we are we properly investigating Are we doing a thyroid workup on these women? Are we, you know, asking about what their levels even are, you know And when I was in school, the Marinna IUD was like the best thing that had ever happened to medicine. And I came out like a warrior to get as many people on a Marinna and you know larks. That was all the rage. And we were taught in clinic not to take it out on the first request Right to make them come back Right? So it's all about like, how long can you get this person to keep this in And you know, I think it I think like all things, it came from a well intended place. you know, it's really important that women have autonomy around They're child bearing and it can ruin people's lives, right too have that taken away. And a lot of women don't have autonomy in their family system and you maybe don't have a relationship where they feel like they can refuse intercourse. And you we just don't understand what's happening for people and we want to be able to help them protect themselves I believe all of that and I think that There's a reckoning that needs to happen around the lack of informed consent. You know, not really telling people that it's not a systemic it's not systemically absorbed. And you know that if you're having hair loss or depression or any of these things, like it's all in your head and it's really just stays localized in the uterus. We give hormones vaginally for systemic absorption. right? The idea that it's local is, I think, really silly, It doesn't make physiologic sense And so I just think that in general, we have always downplayed the importance of these essential female hormones for general health. What specialty is making that a priority Right, notot really any The thyroid is like you talk to an endocrinologist. They know everything about thyroid and insulin, but when it comes to estrogen It's just like a here or there. It doesn't matter. you know, It's not important. And I think that that is going to be the downstream benefit of the menopause movement. And you hear a lot of the leaders in the menopause space talking about this and saying that they're a little bit regretful about the way that they counseled in the past. and you know, around around what happens when you shut down the HPO access for women for so long. So I I just wantanna sit back and watch, to be honest, see what happens over the next twenty, thirty years But you know young women because of the internet, right are a lot more empowered around what they want to know about their bodies. I mean, I have so many patients whose daughters are doing the mirror monitor. They're wearing temperature tracking. they understand their ovulation. We were never taught that. And I think it's fantastic, right? Anytime that we're giving information back to the people R And there's this democratization that's happening across all sects of healthcare. I think it's wonderful because it also pushes providers to have real conversations. we don't we're not owning all the information anymore. right? AI is doing that as well. So We have to get into right relationship with our patients. And truly, with all of this conversation I can make the choices that I want for my body, but it was the same with attending births, right? I chose to have my children at home. That was my choice. That was what worked for me. But I delivered babies in the hospital. And ultimately, I don't care if you chose to, you know, birth unmedicated, medicated, have a plan C section. All that I really care about is that you felt cared for in in right relationship with your provider, like you were informed, like you were loved in the process and that actually is like what What the data shows about women's satisfaction in childbirth is all about how they were cared for and not what their actual outcomes were. They could have a traumatic situation and circumstance in their birth, but if they were well cared for, they would score high satisfaction. And I think it's the same with all of this. it's not about whether or not you want to do daily progesterone or physiologic dosing or you want to use birth control. I want you to feel really like I supported you and I asked you what you wanted And you know, ultimately, people don't come to me who want to use birth control and pererimmentaps because they can just go to their normal person, right? But even if they did, right, it's not about me. It's about you feeling really good about your choices. I think that's a really important distinction. And one thing I want to touch on that's kind of in the zeitgeist of social media right now is doctor Natalie Crawford, who's been a guest in the podcast, who I know personally She's a reproductive endocrinologist based out of Austin And I was at an event, I was at a dinner, sat across from her. and she was talking about and recognizing she's a specialist. So she's seeing people that are already having trouble getting pregnant. And she mentioned that know she's starting to see more uterine scarring from people that have used IUDs. And that has kind of gotten into the realm of social media and people have strong opinions about it I'm curious if you have an opinion on it, not putting you on the spot. But obviously as someone who's a women's health expert, if you have opinions about the potentiality of scarring in the uterus from an IUD. Well, I mean, I did post something several months ago about how I use pretty strong language I said that the Marin IUD like has played out in some situations as a form of oppression simply because of what I just talked about about the informed consent, right? And people just not You know being told things like it's not systemic, it's just a little bit of progesterone, like it has no impact on you. know, and these people are having changes to their estrogen patternning, they're having all these symptoms And then the whole thing about not taking it out if you're told, right? And I was really like outing myself as like I used to do this and I think that it's wrong. And if you had these experiences on a marine, I want to validate you I I mean, the cancel culture that I experienced in that of like, I'm a right wing X and, Y Z and like, you know, just the assumptions that were made about my Pershood and belief system was astounding And I understand, like no one's trying to take away your birth control options. I'm just trying to elucidate sort of what my experience was. And I applaud Natalie for doing the same I have not definitely not working in the same sub specialty as her. so I'm not seeing that, but from a pathophysiologic and pharmacologic perspective, it makes a lot of sense, right? And it's a high concentration of progestin, right for a significant amount of time. And I think one of the questions that we're not asking with these forms of birth control is like You know, if we're studying it, like how long are the studies going on for,? And what are the outcome measures that we're looking for? But if you have that exposure for seven years, if it's in there for seven years, like does the body remember as well,? Does the receptor activity come back on when it's been hit with this High affinity synthetic progestin for so long, how long does it take for that to change, right? We see that also with people who've used different SSRIs or atypical antidepressants, right that that there what are the ch what are the subtle changes long term? likeike can we get the neurotransmitter function back? you know? I just think that we need a collective sort of a pack to to have more curiosity. and I always say that the best quality and how I identify a really good provider is humility And patients appreciate more than anything when you lead with like, I actually don't know.. you know, And like I'm not sure about this. think Like we are past the point where like the I know everything is the way to go. and you know, the more that we can be vulnerable together and kind of like cultivate our inner Berne brown, you know and admit what we don't know and be curious and listen and open, like we're all gonna to advance so much faster. Well, and I think that's so important. I mean just like during this conversation, I was like, no, I don't know what Mor is. so tell me about this because I did a post on Substack talking about You know When I was in perimenopause of all processes, you wait until menopause. And so I follow those recommendations. and I reflect back on twenty five years as a nurse practitioner realizing A lot of those patients I saw in cardiology, they were in the I was finished my program in two thousand one. So two thousand two, WHA is published. And the fallout from that, not just with my mother, my mother's generation, but so many of my patients telling me they couldn't sleep. they had achy joints, they just didn't feel well. whyy were they having more cardiovascular disease events, you know, vasospasm, et cetera. And it's like these missed opportunities It's their fault, Cynthia. Yeah, Did you know that? Yeah. Eactly. Well, I remember one time, so probably not surprisingly people would know that most clinicians in cardiology are men. So nurse practitioners service all women to female cardiologists who were just badasses, because can you imagine subjecting yourself to a residency with all men where you're just having to fight for everything to just have a voice? And I recall any timee I would bring up with my colleagues, most of whom are still in that very patriarchal age range. And they'd be like, oh, this is cute. The nurse practitioner wants to talk about food. Oh, oh, the nurse practitioner wants to talk about HRT. donon't talk about HRT. Don't talk about these things It's stay in your lane. And so for many of us, you know, and especially at the peak of my astrogen years when I was still a people pleaser, and would just, you know, why was I such a good MP I generally just wanted people to like me and be happy. And so you kind of go with the show. So I think when we're talking about humility and having conversations around being curious and acknowledging what you don't know. Yeah. Like how often have I said to patients, You know, I don't know, but I'm going to find out who you need to connect with or What's the next step? I will find that out for you. I think patients respect that. They respect it a whole lot more than Someone just fibbing or being incredibly arrogant, because you and I have both been witnessed to that, where people are just completely unwilling to change their opinion or they're rigidly dogmatic to a point where there is patient harm because they are so unwilling to entertain the possibility that what they learned twenty years ago is no longer relevant. becausecause of the podcast and because of people I connect with like yourself, I am constantly being challenged in a great way, in an incredibly intellectual, helpful way, because I think part of the reason why this podcast is so critically important and these conversations are so important is because someone listening might be like, oh That validates something I'd always thought, or that validates something I hadd been trying myself. and now I have information I can bring to My physician, my nurse practitioner, my PA, my midwife, whomever. and advocate better for themselves So Let's talk a little bit more about the gut. Are you doing microbiome testing and stool testing with your patients? I'm assuming that you are Yeah. What are some of the common patterns that you're seeing in perimenopause that kind of clue you in that the microbiome is changing dynamically in these Changes in shifts in hormones and neurotransmitters. Yeah. Well, a lot of just changes in immune function in the gut. Secretary IGA, calprotectin and just low digestive enzyme output. And I think so much of that is also chronic stress and then the sort of snowball effect of poor sleep and overextension Also not slowing down to eat. In fact, all of our patients work with functional nutrition in our practice. and the first three to four sessions are all about Are you eating without distraction? A you like you putting your phone aside? Are you taking three deep breaths? like the most fundamental basic stuff They need that. Yeah, they need that. And you know, digestive enzymes can help, bitters can help, but ultimately, like it would be nice we really try to lessen supplement dependency. because it all gets really expensive to get older, doesn't it? Well, that functional medicine lens, I mean, I've had patients show up and their're on forty supplements and I'm like Are you happy taking forty supplements? I know personally I don't want to take forty supplements. I mean, that's how I got here, reallyally. When I opened my practice, it was just functional and integrative icine night Looking to be a midlife specialist. I was not like following the tide of the money. I think that there's a boom now and everybody wants to do menopause care because it seems easy. And GLP ones. And GLPs, It was really not any of that. In fact, it was one of my microbiomeentors that first introduced me to GLPs before anybody was talking about them. We were doing them And it was really just that every woman that came into my office was in their head forties and fifties. And I was doing all the things that I learned at IFM And I was, you know, putting them on different kind of IFM diets and You know, the Maito diet and the this and the that and we were doing intermittent fasting. and it was this one moment. I was about a year into practice I had a patient who was deeply in perimenopause and she was wearing a CGM We're doing all the things And she showed me data from a meal where she had some protein and a bowl of Brussels sprouts And her blood sugar spiked like suuper super high from the most Seemingly benign food And it was in that moment that I was like What the F. firstirst of all. like and I had this, you know, you have those moments where like everything zooms out and like time stops. and I just thought like I'm missing something Like this low dose estrogen that I'm giving her, the progesterone, like I'm missing something bigger that's happening to her metabolism because I really am tired of this like paternalistic functional medicine thing of like always putting it back on our fault. like we need to be more strict, We need to be more eliminating. We need to, you know, the elimination diet when I trained in IFM in twenty eighteen was the gold standard, right? It was everybody gets better on elimination diet. But like who is the primary functional medicine patient? It's a woman in her forties and fifties, right? She's resourced, she wants to take care of herself She's got all this hormonal stuff, but we're not seeing her issues through the lens of her underoccrine system And just I knew in that moment that there was something bigger happening, and I was bound and determined to figure it out. And it honestly wasn't until we started really pushing the envelope with our physiologic dosing that we would see recovery of the metabolism to an appropriate place. Yeah, it was just, I love functional medicine and we still are so functionally informed, but I've let go of so much of that um, intensity becausecause it it was reinforcing the exact opposite of what I wanted women to feel. which was that they were at fault or doing something wrong That's an important lens. I think that We certainly in programs and in one on one work, we see women that are like I'm sleeping well I'm managing my stress, which I always put in erir quotes because what managing stress to one person might be very different to another You know, they're eating the anti inflammatory nutrition, plus or minus fasting. They're lifting weights and they're not able to make any of these shifts in body composition or other things that we're really speaking to. And so I think that Your pivot within your practice was so intuitive. And I think this is an important distinction that we never want to be rigidly dogmatic. Like I don't practice the way I did three years ago. Five years ago, ten years ago. I mean, there's things there are themes throughout all of the conversation But I definitely think differently than I once did. and we're designed to be critical thinkers, whether people remember that or not, we're not designed to be You these little icons, like you fit into the peg of a nurse practitioner And what I find interesting in terms of trends for MPs, so let's talk about MPs, in the nineteen nineties, early two thousand 's, there weren't as many of us. Now there's four hundred sixty thousand nurse practitioners And in all the groups that I'm in on social media, it's pretty consistent peopleeople are Thinking a lot about HRT, thinking a lot about GLP ones because they want to help their patients There's a lot on the other side of that are the aesthetics piece. And I think that it's interesting how like there's some continuity in the middle that's not happening What do you see in terms of trends for nurse practitioners in terms of our profession what people are interested in doing. I mean, obviously, I still have friends that are boots on the ground in the hospital, boots on the ground in clinic. But it seems like there's very much a push for autonomous practice. And the autonomous practice model is encouraging people to be very defined about who they are working with. And to your point, it's the forty, fifty plus year old female who has a little more disposable income and maybe has a little bit more bandwidth to think about herself than know when she was in her twenties and thirties. Yeah. I wonder actually what the data is on how many people are fast tracking to an advanced practice and kind of skipping like years nursing. I don know I actually think that in some cases that's a benefit because nurses are taught to like take orders do them and nurse practitioners Hopefully if they have good training, are really taught to be thinkers. I will say that my closest touch to this is hiring because my company is always looking for really good talent And hiring the nurse practitioner role is the hardest position to fill my whole company. Yeah, because honestly the biggest issue, Cynthia, is that I think because of some degree of trauma from work environments So many nurse practitioners have turned off the part of their brain that thinks. and they're so afraid becausecause I don't know, I think we become a scapegoat in many clinical settings Because we are there is a pecking order, especially at the major medical system in my hometown is very clear in its model that NPs are midlevel. They call them that I absolutely hate that. I hate that term. I mean, because again, we bring something unique and dynamic to the profession. We're not just a lesser version of R But that's truly how they categorize them. And that they call them that, like to me, it's derogatory. Not advanced practice providers now levels. They call them the mid levels, right? And I think it's such a shame and it's and it's not obviously it's not advancing the profession, but we have to take that on ourselves We have to stay curious, we have to You know, probablyb more so than our physician counterparts, we have to know what we're talking about. We have to be informed about the literature, and we have to be advocates. I think that my husband doesn't have to be an advocate for himself. know never. He's just got the letters, you know. And I mean, he has zero patient care experience past medical school And yet people listen to him at the dinner table and not me. you know. So there's just we need more people in the profession and I wish sort of like how I wish school teachers made more money. like I wish that There are lots of people who don't want to suffer through medical school because you probably see this and you probably had women who are physicians in your programs and I know on your podcast. And you know the classic functional medic suen question, like, when did it all fall apart? Yeah, right? It's like when I was in medical school or when I was in resesidency. And it it's crazy what we put people through in residency. I mean, OBGYN residents that would come back to work four weeks postpartum. They were still bleeding. still had sutures. And they're back on the floor. I think what NPs provide is a naturally more holistic perspective, seeing the whole person And there are a lot of people who I think who became physicians because they just wanted to do the best thing. right? Both of us could have gone to medical school if we wanted to, right? But I was not interested in suffering. Yeah, No. No. And I have too many physicians in my family. and actually, you know, it's ironic my She's only three years older. My older cousin was in medical school when I started to do this pivot. So I was a Bachelor of Arts in foreign affairs pre law. I accepted to law school and then went back and did two years of pre med classes And my cousin said to me She was in the midst of m school. She said, you know you should become. become an NP. and I was like, no I don't want to be a nurse No It was the best decision I ever made. Yeah ision quality I don't know totally. And if I hadn't been for Midwiffery, I don't know that I would have chosen that path because I always was the I'm going to do the best version. But that's what I want people to see is that it's not a less than. Right? it's a different opportunity, especially if you you know, sort of have a specific area of interest. There's so much less, you know, unuseful sort of time of study Eespecially with these kind of combo BSN MSN programs now as well, you don't have to I did a two year nursing program and you don't T do that anymore, you can fast track. So I really do hope that our profession continues to grow and more importantly, I hope it continues to attract really bright, interesting people. whenever I have you college girls come and follow me often and kind of shadow me when they're interested in medicine. And I always tell them like I try to plug the profession you know, because they have a lot of resilience at nineteen, but it's going to be a different story when they're twenty nine and slogging through surgical residency. Yeah You know, and it does it does really, it, I think it's bad for families. it's bad for women, the medical profession systemically needs a lot of change You know, we're an opportunity for that change. Absolutely. It's interesting. How many female physicians I've interviewed on this podcast that are when I say the term retired, they're not retired as GYNs,'re retired as ER doctors, but they get burned out. They get burned out being up all night, the stress of their jobs. Pelice Gst speaks openly. I'm not sharing anything that she has not shared publicly She's like, I went into menopause forty three. She's like I'm fairly certain it was because of years of not sleeping and being up all night you know We compensate really well until perimenopause. and I'm the first person to say I suffered a lot because I was Um, you know O probably exercising more than I should have and too low carb. I was heavily into paleo. and my kids were really young and I had a super stressful job. and how many days did I just not eat? I'd eat like a crappy protein bar standing up and dictating on patients and that becomes the norm. And that's as an NP. So imagine the physician has you and at that time, NPs were not autonomous in our state. I think for a lot of individuals, it's helping them understand that There's nothing midlevel about being an MP, a PA, I hate that term. What's interesting to me is I must have the algorithm perfected, not in a good way on social media because what do I get? are physicians saying, why does this nurse practitioner and then they'll play the little clip and I'm like You're right, You're a DNP. You are a clinical doctor, that is not akin to a medical doctor. I can understand why you're upset, but don't denigate the entire profession because you've got one loose canon because that' certainly. Everybody on IG uses doctor. Oh my God, that's a whole separate conversation. If it takes me more than thirty seconds to figure out someone's training, they're probably not a medical doctor They're not a DO, they're not an MD, they're not an MD. There's some other person that's not a doctor. And it's something that for me because I feel When I go on a podcast or I'm being interviewed and someone calls me doctor, I'm like, No, I' a nurse practitioner. I immediately correct them but these other people use it to their advantage because they assume You're not a doctor of natural medicine. That is not a real thing.'re A chiropractor is not a medical doctor. Although I respect their expertise for what it is. If it takes me more than thirty seconds on your website to figure out what you are, you are not. a medical doctor, and I find that fascinating. Yeah. And I think again, if we just We're proud of what we are. correct. There wouldn't be this sort of, you, hiding. Right. And that's exactly what it is some degree of hiding. Okay Let's run out the conversation talking about the biggest pain point I see for women in midlife is weight loss resistance. So we've talked a lot about the endocrine system and receptors Let's talk about it from your lens What are some of the less common reasons why women become less insulin sensitive become more weight loss resistant in midlife, because I think most people have gotten the memo about sarcopenia and changes in carbohydrate tolerance and sleep and stress. But what are some of the less common reasons why you see this happening? I think alcohol is affecting the body in a different way used to And it used to be like a diet approach to have your whatever, there's like a spinrift alcoholic spinrift, thing I don't even know what it's white claw.. That used to be like the low calorie alcohol approach is not going to work anymore because your liver isn't functioning in the same way So I think that even four drinks a week absolutely can stall someone's weight loss progress and you, you know not I don't like to be in the habit of like taking things away from women, but I think it is important to have that honest conversation. I think that the like significant amount of time that we're spending on screens and with blue light exposure is disrupting our circadian rhythm and that that is the foundational know sort of rhythm and hormonal rhythm in our system. And again, we have such a unstable HPO access at this phase um that that and it sounds so silly to say that, but it truly does change cortisol behavior and pattern. you have to protect your cortisol like a you know, tiny little baby. Yeah You're in this space. So those are big ones. I also think that, you know loss of estrogen signaling, right? There's so many like autoimmune issues that are coming up. We have so many people with undiagnosed Hashimoto's that come into the practice. and so Again, Hashimoto's patient is typically not having weight loss resistance because of caloric. ye you know, deficit issues. E next to nothing. Yeah, they're not eating. It's not that. It's really an inflammatory immune mediated response. This is why people who, you know, I know at some point this is coming off of the FDA restricted list, the peptide thymus Al alpha one is such an immuno mododulator. works really so good. my favorite. workorks so well for weight loss. Wh because weight loss is so immune and mediated. Right Estrodol is a really potent immunoodulator. So thymic peptides, That's why I always say like that's amazing. I actually have some compounded thymus and alpha one here, It's one of my favorite pepttides. And I think to your point, hope and intent, but it's interesting, the thymus gland ends up being a fatty blob of tissue by the time we get to be middle agge. And the thymus is so important for immune regulation. and yet you know, we just, you know, I think there's this very reductionistic perspective on weight loss resistance and midlife physiology. and yet I think that You know, this conversation around thyme peptides and alcohol and Screen time is really valuable because sometimes it's those like low lying fruit things that really make a big difference. I think alcohol is huge. You choo huge. I remember there was a New Year's Eve probablybably more than ten years ago. and I like at the time I could have a vodka martini once a month and be so happy. But there cameame a time where one vodka Martini meant that the whole next day I didn't feel good. Not only to wreck my sleep, but I'd be like feeling like I'd had ten of them And so for a lot of women, it's investigating what is no longer serving you And it's know I know it's sad, but I also think like the when one door closes a window opens is true. And if you're willing to kind of you use your body as a guide, I think it's like so beautiful that way. You know, If your body's telling you that this isn't right for you, then the place that is right is going open up new opportunities. And I would say the last thing is you know, and you talk about this a lot that there's Oftentimes women are carrying like some traumatic things And a lot of it, some of it has to do with like raaising their children. right? One of my closest friends and a nurse in my practice had two children who had a lot of medical issues growing up multiple, multiple surgeries And I, you know, I've talked to her multiple times about how just the the stress that her body has held watching her children go through all that, even though they're great now, like there is a point when We need to work really hard actually to teach the body to release that And we have all different forms of that, right? whether it's a divorce earlier in our life that we didn't even have time to process, right? So creating some time and some containers for yourself and choosing people who can support you and guide you to kind of release some of those things that are no longer serving you. I think does fundamentally change the architecture of your stress response and