Episode 91 | Dr. Felice Gersh, M.D. | Pre and Post Menopause… What You Need to Know

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Dr. Felice Gersh is back on the podcast by popular demand! She’s been on the show twice before sharing science-backed information on intermittent fasting, and today’s podcast is all about the Big M… menopause.

In this episode, we discuss step-by-step approaches that guide you through the menopausal phases (pre and post), and how to handle everything from hot flashes to fuzzy thinking… from irritability to insomnia.

This show is full of straightforward and practical advice that every woman needs to take control short-term symptoms and long-term health.

I asked the Fit Over 40 Facebook group which topics of the book they’d be most interested in discussing, and the answers came in loud and clear…

  • Weight gain
  • Body shape change
  • Sex drive decrease
  • Joint pain
  • Appetite fluctuations

….We’ll dive into all of those topics in today’s NEW Art of Living episode!

Her new book, Menopause: 50 Things You Need to Know is full of information that prepares you for what lies ahead in the menopausal journey (pre and post), and find solutions for all of the symptoms.

Dr. Felice Gersh is board-certified in both OBGYN and integrative medicine. She’s the director of the Integrative Medical Group of Irving, a comprehensive women’ health care practice. As a clinical assistant professor, she teaches students and residents, as well as lectures across the country.


Kathy Smith: Hi, I’m Kathy Smith, and welcome to On Health: The Art of Living where each week I bring you the latest information on how to live a great life. How to be healthier, more vibrant, and a more passion-driven life. 

Now, I’m thrilled today to have one of the most popular podcast guests: Dr. Felice Gersh. She’s been on the show before, and we’ve talked about intermittent fasting, but now she’s got something great. She’s launched a new book called Menopause: 50 Things You Need to Know. It’s a fantastic overview about what you go through during menopause. 

Now, I asked my Facebook group what topics in the book they’d be most interested in discussing, and their answers came back loud and clear. Their top concerns are about weight gain and body shape change, about sex drive and how it decreases as we age, about joint pain, and appetite fluctuations. So, understanding why and how menopause empowers you to take more charge of this journey. The book is full of all kinds of information that can tell you what to expect, and what you can do about the major symptoms during the three stages of menopause: pre, menopause, and post. 

So, let me tell you about Dr. Felice. We’ve had her on the show. I love her to death. She is brilliant, this woman. She’s a board-certified OBGYN in integrative medicine. She’s a director of Integrative Medical Group in Irvine, and she loves teaching students and residents all across the world. She loves teaching them about the importance of creating a healthy environment within a female body. 

So, with that, let’s welcome Felice. 

So, Felice, welcome to the show again. 

Dr. Felice Gersh: Well, thank you. I love being back and talking about this critically important topic to every single woman, whether she’s in menopause now or approaching it in some timeline. Every woman deals with menopause at some time, and then [0:02:00] for the rest of her life. 

Kathy Smith: It’s good to note that she deals with menopause, but the family, the kids, the husband, the significant others, everybody else deals with it also. Right? So, it’s a good topic for all of us to just be out in the open because it impacts so many people. 

But let’s talk about… As I mentioned, we threw this out to the Facebook group, and it seems like menopause comes with changes, but also aging comes with changes. So, talk to us a little bit about what can be attributed to menopause and what is attributed to aging. Are they sort of combined? Do we sort of combine the two at times? 

Dr. Felice Gersh: Absolutely. I can’t separate them one bit. This has been really to the detriment of women is that so many things that happen to women as they age have been attributed to the number of years a woman has lived, rather than to what I think of it as a set of accumulating deficiencies. 

It starts with the deficiency of hormones. The primary will say at the top of the pyramid is estrogen in the form of estradiol that’s made by the ovaries. Which, of course, cease to make this hormone and the progesterone that is sort of its side-kick as women progress through the menopausal transition and thereafter. When you lose this production of estrogen, you really lose your sense of metabolical homeostasis – which is really about the production distribution and storage of energy. Of course, the form of energy that we take in is food. Right? So, it’s about how your body utilizes food to create energy. That affects every single organ system in the body. When you have problems involving metabolism, and each organ system [0:04:00] is in some way impaired to some degree, you end up getting a host of other deficiencies involving nutrient deficiencies. Other hormonal deficiencies in the sense that the hormones themselves may not work essentially the same because the receptors are now modified in some way. So, the hormones don’t work on the target receptor in the same way. 

So, as you age, you accumulate this sort of just vast array of deficiencies which contribute to a problem in every single organ system. We need to think of aging in that sense rather than just how many years have you lived, but how many deficiencies have you accrued? 

Kathy Smith: Okay. Well, let’s talk about deficiencies as it relates to weight gain. So, let’s get back to the weight gain. Also, this idea of body shape. Like, women gain weight, but they also say, “My body just seems to be changing, you know, where the fat or where everything is distributed.” So, what’s happening inside that causes that?

Dr. Felice Gersh: Well, it turns out that estrogen is the key player in terms of metabolism – which, as I mentioned, is it’s about energy utilization/distribution. Which, of course, relates to adipose tissue or fat. So, every girl knows that as she is going through puberty, her body changes in all sorts of interesting ways, and fat starts to be deposited in very “female” ways, like around the hips and butt, and she gets a little waistline. That’s all estrogen-driven. So, when you lose estrogen, you go into this sort of default state which is belly fat. So, every woman will see to some degree her body morphing in this very undesirable way as she loses her cute little hourglass figure. She loses her little waistline. 

Instead, she [0:06:00] starts getting the muffin top, she gets this belly fat, and loses her waistline. This fat is also involving the visceral organs, the internal organs. This is highly inflammatory fat. It gets infiltrated with white blood cells that are then triggered to produce other inflammatory products, like inflammatory cytokines that create this chronic state of low-level inflammation that drives many of the detriments involved with aging that we think about. That is a huge deal for women. 

So, having this alteration in fat in terms of its distribution is only the visible signs that are happening because under the surface – literally under the surface – the fat tissue, which is very complex… It’s now understood that adipose tissue is not just about cushioning or about energy storage. It’s also a complex endocrine organ, and it makes different types of hormones. 

For example, one hormone that’s made by adipose tissue is called adiponectin. This particular hormone is also driven by estradiol – estrogen from the ovaries – to help us to burn fat. So, after menopause, you actually have sort of, we’ll say, a handicap in the ability to create energy from fat. You don’t actually do it as well as you used to. The default position if you don’t burn fat is to store fat. So, after menopause, you’re more prone to maintaining that fat on your body. It makes it so hard to lose it. 

In addition, another hormone that’s controlled by estrogen in large measure that’s made by fat tissue is leptin – which you may have heard of. Leptin actually lowers appetite. So, it helps to regulate appetite. So, after menopause, you don’t have proper production and function of this critical hormone (leptin), so then you develop more appetite dysregulation, [0:08:00] which leads to cravings and binges and so many of the problems that are associated with additional weight gain. So, it’s like the multi-whammy situation where you have the default of belly fat being accumulated; you don’t burn fat and create energy well; and you lose your appetite regulation. That’s just the beginning of what happens. 

So, you know, every woman I see comes in and says, “I don’t know what’s happening! I’m actually exercising more. I’m cutting back on what I’m eating, and I keep gaining weight in these really undesirable locations.” Now you know. It’s all about the loss of this vital hormone: estradiol. That just is something that’s really important for all women to know. Everything in the body of a female – whether we want it or not – this is what nature gave us. It’s designed for the purpose of optimal survival and optimum reproductive success. 

Like, for example, you want to have fat – right? – if you’re going to have a baby.  So, pregnancy is actually a bit of a pro-inflammatory state. Any time you develop more inflammation, you’re going to have more insulin resistance, and you’re going to put on more body fat. 

Well, menopause is also a pro-inflammatory state but with a different end. You know, it’s not to help create fat stores so that you can feed a baby when you’re nursing. Here, when you lose your estrogen, it’s a little different scenario, but you get a similar outcome. You get a chronic state of inflammation that never ends. You don’t deliver any baby that ends it! Then, you end up getting this lifetime – of the rest of your lifetime – difficulty in burning fat and fat accumulation. All of this happens that promotes, then, the cardiovascular diseases that are still the number one killer of women as they age. 

Kathy Smith: Well, there’s a lot to [0:10:00] unpack there. So, I love that description. Let’s go back. A couple things. 

In the book, again, as a reminder, you go through 50 different changes that women go through. But what I like about the way that it’s laid out – and I want to emphasize this – it’s that you not only talk about why it’s happening, but then you talk about ways to treat it or prevent it. So, I want to make sure that we talk right now about with the weight gain and the body changes, I want to talk about how we can prevent that. What else can we be doing? I know we’ll probably jump into intermittent fasting, if I’m not mistaken. But then I want to move on into also this idea – so, I don’t want to forget about it – about the inflammation, and all the other changes that are happening in your body. 

But let’s just stay with the weight gain and the body change. What should we be doing? 

Dr. Felice Gersh: Well, everything sort of interrelates. Everything is interconnected. One of the other things that also impairs our metabolism, our ability to burn fat, is a loss of proper regulation of our circadian rhythm. That’s related to the master clock that sits in the brain atop the optic nerve, and senses light and also nutrient status. Also, in large measure, controlled by estrogen. 

So, after menopause, women, actually, essentially are living like a life on jetlag. So, when we live a life of jetlag, we also promote this dysfunction of our metabolic homeostasis – out ability to properly regulate energy metabolism. 

So, one way – I call it the “backdoor way” – of helping to regulate metabolism and get our weight under control during the menopause years is to use the clock genes that are embedded in virtually every cell in our body. They can be controlled [0:12:00] by the time you eat and, also, whether you’re eating or not – which actually acts as sort of a gut reset and the gut microbiome. That’s why, I mean, it gets so complex. But the gut microbiome changes as well as you go into menopause, and you get more of an abnormal microbiome, which causes leaky gut – which then promotes even more inflammation. So, it’s like a feed-forward, sort of a snowball effect. Right.

Kathy Smith: By the way, on the show, we’ve had, you know, Dr. Zach Bush, and we’ve had Dr. William Bulsiewicz (Dr. B). So, we’ve talked a lot about that biome, but I feel like we can never talk enough about it because it’s just one of those things that – just for me – between the brain, body, entire connection of wellbeing… When I really targeted my gut health, I saw major changes in my vitality, in my body composition, after menopause. So, it really is an important point. 

But let’s just talk about the intermittent fasting. Let’s stick with that for a second. The thing I do want to tell you, Felice, you are responsible, my darling, for getting me to move back my dinner hour by 15-30 minutes every day. Not every day, but, you know, over a period of time. So, now I am – I thought I could never do it. When I interviewed you a year ago, I thought, “It’s not possible!” Now, my biggest meal of the day is usually sometime before four o’clock. 

Dr. Felice Gersh: Wow!

Kathy Smith: I know. Which, for me, the exceptions are probably two days a week when I’m going out, let’s say, but even then I have my bigger meal, and I have a smaller meal when I go out. That’s because of you, and I thought there was no way that I could do that. It’s made a huge difference with my sleep! 

Dr. Felice Gersh: Well, it is, and we’re going to get into that! 

So, what I wanted to tell all of your audience [0:14:00] is that those little microbes that live in our gut – this doesn’t get talked about enough – they also have clock genes. They don’t know what time it is, but they can actually function better if you feed them on a schedule. So, you’re going to get a better gut reaction, a better gut microbiome, and reduce that leaky gut if you feed your little best friends (those microbes, those trillions of microbes) on a time schedule. They actually do much better in terms of making melatonin if you don’t feed them at night. They’re just amazing in that they have – like every living creature on earth – clock genes. 

So, by timing your eating – so, we call it time-restricted eating, when you eat the clock. Eat to the beat, I say. So, you stop eating early. You have that long fast at least 13 hours from dinner to breakfast, and then you stop snacking. So, every time you eat, you’re going to put in food that’s going to in some way negatively impact your blood sugar and your insulin. 

So, you don’t want to have elevated insulin throughout the day. Insulin is vital to our survival, but if you have chronically elevated insulin, you’re going to promote fat production and storage all the time. So, you’ve got to get your insulin down and your blood sugar down into just sort of that quiet, baseline level. So, you only eat no more than three times a day. If you get advanced, you could even have two meals a day where you’re not doing caloric restriction or nutrient deprivation at all. You’re just combining your food into two or three times a day. Stop snacking altogether. If you absolutely have to snack, it should be something that is least likely to elevate your blood sugar, something that is predominantly fat, like olives.   

Kathy Smith: [0:16:00] [inaudible]

Dr. Felice Gersh: Exactly. 

Kathy Smith: Or some almonds, or something that…

Dr. Felice Gersh: [inaudible]

Kathy Smith: But you’re right. I mean, that’s still… I think my 2022 goal is still the snacking thing. I intermittent fast. I have no problem with the 13-14 hours between dinner and breakfast. There’s no problem there. It’s just that I am… I like to put things in my mouth. But, I feel so much better – and my gut feels so much better – when, honestly, I’m the two meals. If I have to have something in between that, to your point, it’s some olives or almonds or something like that. Then, my brain function, my weight. I see the clarity in my eyes. I see I’m not retaining water the same way. So, very powerful. The snacking thing is something that I think we can all discuss more because intermittent fasting, we think of it so much as this long break between meals – which, it is – but we don’t talk enough about don’t be putting things in your mouth. 

Do you recommend a blood glucose monitor? 

Dr. Felice Gersh: I do recommend them all the time. There’s actually some published data saying that if you don’t have diabetes, it may not be as useful as if you do have diabetes. But I find it’s helpful because we now know that the individuals’ gut microbial makeup can actually determine the glucose response of specific foods. So, it’s like the most ultimate and personalized precision medicine to find out what specific foods have what effect on your blood sugar elevation. 

So, I think it’s useful. It also makes people kind of aware and think about what they’re eating. So, I think that’s useful, too. It’s important for people to know that it’s sort of like the total makeup of the food that often has the effect. That’s why we want to make sure that every meal has got all the different types of food groups, and the optimal amounts of polyphenols [0:18:00] and antioxidants, so that our bodies will have the proper response. But I do use a lot of them, and I think it helps people to sort of become much more aware of what they’re consuming and when. Because if you’ve got to keep checking your blood sugar, you’re going to think, “Do I really want to eat this?” 

So, anything that’s going to make you be really aware is going to be very helpful. 

So, we need to think of fasting in many ways. Every time you’re not eating, technically you’re fasting. So, the 24-hour day when we decide when we’re going to eat and when we’re going to fast is part of what we would call time-restricted eating. Then, if we have multi-day fasts or, my favorite, which would be a fasting-mimicking diet because it’s much more practical to get people to do that than to just do a water fast. That gives you a different type of benefit. Where, if you do a multi-day fast, you can trigger what’s called autophagy, which is also estrogen-related. So many people don’t realize that autophagy – which is a cellular rejuvenation process… It’s kind of like cellular rehab. You’re going to, like, work to optimize the individual health of every cell in your body. It’s also very essential and won’t come into play unless you have a longer fast. Usually closer to three, four days of fasting. Then, you get this amazing process called autophagy, and also where you trigger apoptosis, which is killing off those yucky, old, pro-inflammatory senescence or aging cells. 

So, everything in the body is about – like, the Chinese got it right. I don’t know how they were so smart. You know, the Yin Yang. A lot of cultures, that’s sort of this balance. You know, push/pull, hot/cold, and eat/not eat. 

So, it’s really important in women who are transitioning into menopause because they have this menopausal-related metabolic challenge, we’ll call it, that they need to pull every trick out of the hat to optimize their [0:20:00] ability to use energy properly so that they can burn the fat. It’s a different skillset to make fat and store fat than to burn fat. We don’t want to get dependent on just burning glucose because that’s the easiest one. But, in order to burn fat, you’ve got to get your insulin… Like I say over and over, you’ve got to get your glucose and insulin down into those baseline, healthy levels in order to trigger fat-burning. 

By combining time-restricted eating – where you don’t eat many times during the day, you get that multi-hour fast at night – and then you combine that with some multi-day fasting – where you can do a water fast for three or four days, or the fasting-mimicking diet – then you’ll get extra help. Now, there are published articles on the fasting-mimicking diet that it really can help with weight loss. This is so important. We need to get more studies involving menopausal women because it’s really a unique population, but I’ve seen it in my own practice where it is so beneficial. Certainly, that’s what I do for myself because I’m in that category! 

Kathy Smith: It’s powerful! I’m glad you brought it up because we’ve had Valter Longo on the show, and we’ve talked about the fasting-mimicking diet. I like to do it. I’m actually going to do one in January, and I’d like about every six to nine months, I will go on a three-to-four day because of my body and the amount of weight I have. I don’t want to lose a lot of weight, etcetera. But, for me, it’s not about weight loss. To your point, it feels like every cell in my body is regenerating. But I’m glad you brought it up. We’ll put it in the liner notes. You know, if anybody wants to reach out and ask me anything more about that…

Before we get off this, though, what [0:22:00] blood glucose monitor are you recommending? 

Dr. Felice Gersh: Well, I usually use the FreeStyle Libre. That’s the most readily available. They have it at all the different drug stores. Sometimes – not always – it’s going to be covered by insurance, but it’s quite affordable. So, the FreeStyle Libre is the one that I utilize the most, and there are others on the market. It’s very simple to use, and everyone can try it. You know, that’s like the best kind of self-biohacking that there is: to see how your blood sugar reacts. It’s really great. 

Then, when you combine this nutritional type of approach – and, of course, the food that you eat matters greatly. We know that if you eat foods that are filled with antioxidants and polyphenols – so, that’s basically a plant-heavy diet focused on all kinds of plants, and you eat foods that are filled with different types of fiber so that that’s the food that the lovely little microbes like to ferment. You’re going to get much better results than, obviously, eating a standard processed American diet of that kind of food is not going to do. You know, it becomes worse. 

Then, when you add in exercise… I mean, you cannot talk about weight control and fat distribution on the female body and not bring up exercise. There’s now data that if you exercise in the morning, you’re more prone to losing weight. You can even exercise on a fast but then have breakfast afterward. That will also definitely rev up your metabolism. 

Then, sleep is so essential. People who are not menopausal at all, if they don’t get enough sleep, they’re going to gain weight because you just have to get sleep. It’s very important for every function in your body. Your immune system is quite different at night than it is during the day. Our metabolism is different at night than in the day. Our hormones are different. Blood flow is different. So, we definitely [0:24:00] need to work on sleep. Hygiene. That means doing all the things to help us to relax so that we can fall asleep. Make the environment in our bedroom to be ideal for sleep. Make the room really dark. In fact, melatonin is such a critical hormone, and it’s involved not just in sleep and as a potent antioxidant, but we now know it’s heavily related to glucose metabolism, which is so important when you’re talking about maintaining weight and basic overall body health in every situation, in every organ system. So, we have to focus on the fundamentals more than ever when we’re going into menopause as women to maintain every aspect of our health. 

Kathy Smith: Well, speaking of fundamentals, and speaking of sleep, this is a great segue into what else you could do in the bedroom – which is sex. But so many women… In our poll, they say their libido just seems out of sync with their partner’s, and it can be distressing. We know that there are many barriers to intimacy when it comes to female sexuality. It could be exhaustion, it could be stress. The libido is very, very complex. But what really starts to happen? Because I have actually had men come up to me and start talking to me about their wives and asking what they can do because they feel that their wives don’t want to have sex with them anymore. They feel like they’ve lost that connection. 

So, tell us what’s going on and what we can do about it. 

Dr. Felice Gersh: Well, nature is really not interested. Once you recognize, like I mentioned, that it’s all about optimal survival for the purpose of procreation, which is not going to happen once you’re in menopause. So, nature kind of just doesn’t really have a plan. So, we have to create our own plan because the natural course of things is for libido to go down as women age, but we don’t want that. You know, as humans, [0:26:00] we really want to be determining most every aspect of our life. 

So, what can we do? Honestly, I am very much in favor of hormone therapy. We know that this has not been discussed as much as it should be, that estrogen is actually very key to having a sexual drive for women and sexual response. Estrogen is also very involved with oxytocin, which is sort of like a hormone/peptide. Which, it’s really about the length of the amino acid chains, but it’s a little signaling agent that is very involved in creating love and bonding and also orgasms. You need to have proper estrogen. 

Now, no matter what we do – even when we take hormones and we take estrogen, and I’ll talk in a moment about testosterone too because they work in beautiful synergy – we’re never going to be the same like we’re 25. So, we, once again, have to pull every trick out of the toolbox. 

Another one is eating foods that are phtyo-estrogen. So, that is like an amazing thing that nature gave us: foods that actually can bind to our estrogen receptors. There was an interesting study just a couple of months or so ago that showed that if a woman ate organic, whole soy – about a cup a day, so this could be edamame or tofu – that, in the course of 12 weeks, almost all the night sweats and hot flashes (which is big, definitely a libido killer, and a huge number of women will suffer from night sweats and hot flashes, and then they don’t sleep; it’s just misery). They found that in women who didn’t even take hormones, that if they ate this high phtyo-estrogen (you can try flax seeds, that type of thing, even pomegranates have an effect on estrogen receptors), and it tremendously helped. So, we can use food as one of our main weapons to fight all the negative [0:28:00] effects on our sex drive and night sweats and hot flashes so that we can feel sexy. Also, when, of course, we have self-esteem. When we look in the mirror and we don’t really feel repulsed, we say, “I like myself.” Right? And we feel good about how we look and how we feel. That’s going to really have a big impact. 

Women do not feel sexy and have a sex drive when they’re chronically tired. That is a big thing that women face because they really don’t sleep well. So, it gets back to sleep. 

So, having proper nutrition and sleep and body, self-esteem, are all going to go a long way. But even in the presence of those things – which usually come as a package deal – our hormones are declining. That really affects the actual mechanisms involved in female sexual arousal and response. 

So, estrogen in the form of hormone replacement therapy, using topical estradiol as a patch or gel or cream, and combining it always with progesterone (which also has many wonderful effects and helps us to sleep better, and it’s great for our brains; it’s very neuro-protective), and then we add in the proper foods we can actually do a great deal of good. 

Now, testosterone also…

Kathy Smith: Before you jump to testosterone, let me just ask you… I know there’s been controversy over the last 20 years. So, I wrote my book on menopause (Moving Through Menopause), wow, it’s going on 20 years ago when I was on the Oprah Winfrey show. Oprah was… I had, you know, shot my book up to New York Times Bestseller, but part of the reason why Oprah was so into it at that point was because she was having heart palpitations, and it was misdiagnosed because we weren’t talking about this as much. You know? We still are confusing certain of these symptoms in our [0:30:00] lives! 

So, before you jump into testosterone, way back then I interviewed eight doctors on to hormone replace or not. It was – I cannot tell you, Felice – it was split down the middle to the extremes. Then, the health initiative came out, and they shut the study down because of certain aspects – which we know about and understand the background of that now. 

But now I understand from your book and what I’m reading that it’s switched, and the pendulum has swayed back to good hormone replacement, if done properly, can be very, very helpful. It sounds like that’s where you believe and where you stand on the subject. 

Dr. Felice Gersh: Right. Once you recognize women go through menopause at different ages within a certain spectrum… But it could be in the total, normal realm of the timing, it could be age 45. It could be age 55. It could be age 57. So, basically, one healthy, considered normal-spectrum woman in terms of menopause, could go into menopause a decade before another woman! So, does that mean the woman who has her own natural hormones for another decade, those hormones suddenly became evil? Of course not. The problem was when they did the women’s health initiative – and the people who were the lead investigators have backtracked a lot, just not loudly enough. Which is really sad. 

They used hormones that are never present in a human female body. A hormone is just… It depends on how you define “hormone.” If you talk about it as a human, bio-identical hormone, they didn’t use anything that would be getting that label. If you talk about chemicals that can bind to hormone receptors – which also include, you know, endocrine disruptors like plastics and BPA and phthalates – then, yes, they are hormones. So, it’s really kind of weird. They used things that would never naturally [0:32:00] be in a human body, and it turned out that the progestin – which is a made-up word for a synthetic not-human progesterone – actually had some really negative effects. Really negative. That they could increase the risk of breast cancer and heart disease. That’s what they used! Then, the estrogen formulation they used was an oral version of what the horse was trying to get rid of – the pregnant horse is now putting out these conjugated… It means it went through the liver to get rid of it, and it’s a whole array of different stuff coming out of a pregnant horse’s urine. They just dried it up and made it into a tablet, and they sent it to humans. 

It has a totally different effect because when it gets into the female’s bloodstream, the human female, it actually is not the same as estradiol. It’s not. It’s a different compound, so it binds to the receptors in a different way, and it actually increases blood clotting by 400%. So, it increased blood clots, which then can translate into more strokes and into vascular problems, which then can affect brain function. They used an elderly population – not women. In fact, they excluded women who had night sweats and hot flashes because they figured that they would figure out that they were in the group that was either getting or not getting hormones based on what happened to those symptoms. 

So, it was like a weird population of patients. Many of them had preexisting cardiovascular disease and were on pharmaceuticals. It doesn’t relate to giving women human bioidentical hormones that are truly the kind that are the same as what the ovary makes, and trying to give it in a way that is somewhat mimicking what the human female body was designed to do. Which is not having the same hormone levels every day. You know, doing this pulse-progesterone, which is physiologic. 

So, they did everything wrong in that study with the [0:34:00] best of intentions. Then, they attributed the results inappropriately, even though their studies said, “The results of this study only apply to what was used.” Then, they attributed it to every kind of hormone for years and years to come, including human-identical hormones. But it poisoned the well so much that people were so afraid of hormones that even the doctors who did some studies later, they used such tiny doses of estrogen that, of course, it’s like you do a study on the benefit of vegetables, and you say, “Take one bite of vegetables a month.” Then, you say, “Nah, they don’t really do anything.” It’s like, wait a minute. That’s a subtherapeutic dose. 

So they used, even then, many of the studies used oral estrogen – which ends up going into the bloodstream in a different format because it gets altered by the liver. They used progesterone inappropriately. They often used other progestins, which is a made-up, you know, kind of synthetic progesterone. So, it’s all kinds of crazy stuff that was going on. 

So, we now know, though, that the pendulum, like you said, is swinging back as we’re recognizing that when you give hormones that are the type that the human body was designed to have, you actually then get the results that you are looking to achieve. So, we know that it’s a whole different scenario now, but it’s been a long and hard battle, and a long road to get to here. 

Kathy Smith: Well, it’s interesting, everything you’ve said. I want to jump back to testosterone because I know people listening are going to want to hear about testosterone as it relates to sex. But, to finish off estrogen, what is the window? Is there a time period where if you didn’t…? If you’re post-menopausal but you haven’t started on any hormone replacement therapy, is there a window that you can still start it, or if you haven’t started after five or six years, then that window closes? 

Dr. Felice Gersh: [0:36:00] So, the general will say that the conventional approach now is a decade. Now, where does that even come from? Well, it comes from some studies, which used (once again) the wrong doses – like, way too tiny of a dose – that achieved levels of estrogen in the blood that was not much different than a menopausal woman’s level. So, it was very, very under-dosed, and you’re not going to get the same effects. So, they did not show any harm, by the way, in giving older women all the hormones. They just didn’t show benefit. But, once again, they didn’t give adequate dosing. 

So, this is my personal opinion. So, the conventional approach is you have a window of 10 years from the time your period stops into when you can get benefits from going on hormone therapy. Now, my personal opinion is that that’s bunk. I’ll tell you why. Because the idea is that the estrogen receptors, they no longer work, and you’re already having problems, and you’re not going to fix anything. I don’t think you’re going to get the same degree of benefit because estrogen doesn’t’ make everything turn back. It doesn’t turn back the clock and then put you back where you started. But this is what I’m looking at: the vagina. Okay. 

So, the current opinion – this is all conventional approach – is that every woman at every age can benefit from vaginal estrogen therapy. At any age! Including, like, women in their mid-70s or even older to help reduce recurrent urinary tract infections, irritation, and sexual dysfunction. 

So, if you can get…

Kathy Smith: Atrophy? 

Dr. Felice Gersh: Right. Yeah. So, which now they’ve changed the name. We all call it vaginal atrophy. They changed it to the genital urinary syndrome of the menopause. There are committees that do nothing but change names. You know? It’s like, don’t you have anything better to do? 

So, basically, yes. The vaginal atrophy. They recommend it at every age, no matter how many years [0:38:00] (decades) you’ve been out of menopause. Guess what you get? You get benefit. The vagina does get benefit. 

Kathy Smith: This is prescription? 

Dr. Felice Gersh: This is prescription estrogen. The vagina gets better. 

Kathy Smith: The vagina. So, that gets back to the sexual. Let’s go from the cream to the testosterone. So, you get the cream, and now you’re revving up the vagina. You’re making it more lubricated, I guess. I don’t know. Lubricated, probably not… 

Dr. Felice Gersh: No, it does!

Kathy Smith: But you’re adding to the health of the vagina. So, honestly, I’m not doing any vaginal cream. So, would you recommend the patch? If you’re doing the patch – estradiol patch – does that…? Then you don’t need the vaginal cream, or do you need both? 

Dr. Felice Gersh: If you get the serum levels up to an adequate level, like closer to… Well, it has to be over 50. Okay? If you measure the picograms of estradiol, it has to be over 50, preferably getting a little bit closer to 100. In many women, that will be an adequate level to restore the vagina over time. But, if you want to jumpstart it – and some women, depending on the status of the vagina, they need to have more. You can give the local application of estrogen. The thing about it is that you can give it at any age. What does that show? It shows that the receptors in the vagina – which are not unique to any other organ system, right? Nature didn’t make it so only the vagina can have benefit from estrogen if you’re 20 years out. So, to me, if the vagina can benefit from estrogen at any stage of the game, so can every other organ system. 

So, that is why I think that ever woman at any stage can still benefit from starting hormones, even if it’s late in the game, because the vagina will benefit.

Now, the vagina actually will become more lubricated because the way the vagina naturally lubricates is through a process called transudation. So, [0:40:00] the blood that is circulating involves both red blood cells and the liquidy part, which is the serum. That will actually ooze out from the blood vessels, through the vaginal wall, into the vaginal lumen to create lubrication – but it doesn’t work properly if you don’t have proper estrogen in the vagina. In addition, what happens is the lining cells of the vagina, when they have proper estrogen, those lining cells actually make food called glycogen that feeds the vaginal microbe so that you get a healthy vaginal microbiome, which then works in a feed-forward mechanism to improve the health and protect the bladder. Then, to make the vagina more acid. Because what happens is when you have the glycogen made by these healthy rejuvenated estrogenized lining cells, the glycogen feeds the microbe set (that love it), and the healthy ones that are the lactobacilli. Then, when they ferment the glycogen, they make lactic acid. Which gets the pH of the vagina into an acid pH, which is so important for then promoting more vaginal health. 

So, it’s so important. Here’s another little trick of the trade. If you use vaginal DHEA. DHEA is an adrenal androgen. So, it’s made by the adrenal gland, but we can give DHEA… A lot of people use it orally as well or through the skin as sort of an anti-aging thing because it’s anabolic. It builds tissues, muscles, ligaments. In the vagina, it’s been shown that it actually thickens and sort of rejuvenates all of the tissues of the vagina, and not just the lining cells like estrogen, but also the underlying tissue like the dermis. In studies that came out of Canada, it showed that it increased sex drive and sexual response. So, it’s sort of like [0:42:00] [inaudible]. 

Kathy Smith: Is that prescription or is that over the counter? 

Dr. Felice Gersh: Well, the best ones would be prescription-strength. There is a product that’s over the counter, but in order to get optimal production and sort of standardization, I always use a compounding pharmacy. There’s also a prescription one that’s a tablet that you can get (Intrinsa). I find the compounded cream to work better in my patients. I can also control the dosing better because it’s customized, and I can control the dose better. I do a loading dose, where I give like 10 milligrams of vaginal DHEA cream, and they use it every night for two weeks. That’s sort of to get things going. Then, I drop it to maybe three times a week. 

The nice thing about DHEA is that if it gets on the guy, if there’s a guy involved and it rubs off on him, it’s good for him! It’s an anabolic steroid that’s an androgen. Right? So, it’s good for the guy if it rubs off. We don’t really want our estrogen vaginal cream to rub off on the guy, so we’ve got to deal with that issue. But this is so perfect. The vaginal DHEA cream has really become a mainstay of my practice for sexual rejuvenation and vaginal rejuvenation, how they all go together. 

Kathy Smith: Good insight. 

So, I know we are running long here, so I want to make sure we tackle joint pain for a sec. You know, just a top line on joint pain, which will tie into some of the other things we talked about. But just give us a one minute on testosterone. 

Dr. Felice Gersh: Absolutely. So, testosterone declines completely separately from the menopause. In fact, by age 40, the average woman’s testosterone is half what it was when she was 20. So, nature wants women’s sex drive to kind of diminish as she gets into the sort of post-optimal fertile years. But we don’t like that, once again. 

Kathy Smith: [0:44:00] It also impacts muscle mass. 

Dr. Felice Gersh: It does! 

Kathy Smith: That’s why I’m interested in it because it starts diminishing, but that’s one of the reasons why we need to talk about lifting weights and staying strong – and testosterone plays a part in that. 

Dr. Felice Gersh: Absolutely. Estrogen is very key to bone health, muscle health, ligament health as well. They both intersect each other so much. Testosterone, because it declines earlier than the estrogen declines, you can start having loss of muscle. You know, that sarcopenia, which is so insidious in women, and we know that fitness status is a vital sign of health. The status of a woman’s fitness – her strength, her agility, her balance – really predicts all-cause mortality, in many ways more than, say, her blood pressure. Which, of course, is also very important. 

So, maintaining muscle mass and lean body tissues to be healthy is so critical. Testosterone is definitely a big part of that, and it goes down by age – like I said – 40. It’s half. So, measuring testosterone. If you’re sort of in the bottom… And nobody knows exactly because the research on women is so limited. But, if you’re in, like, the bottom quartile. So, you’re in like the bottom 25th percentile for the reference range, that is like a red flag. Maybe you would benefit from testosterone supplementation. But, as well, they’ve shown that women do so amazingly well with weight resistance training. They maximize the testosterone that they have because they’re not going to zero. They’re going down, but you can use the body tissues that you have to really grow them. They’ve shown that you can do tremendous benefits for your body by doing weight training for your muscle mass. This will help you in so many ways. 

Then, estrogen also is going to be like the [0:46:00] extra whammy on your musculoskeletal health when you start losing your estrogen. So, every woman needs to be aware. The musculoskeletal system is so under-recognized as critical to a quality of life, as well as healthy longevity issue, for every woman. So, every woman…

Kathy Smith: Well, you know, Felice, my tagline on my website is, “Strong women stay young.” I have to say, we talk about strength training over and over. So, I’m glad. It’s music to my ears that you’re saying that. 

So, one of the common complaints that came in with the Facebook group was feeling joint pain, feeling stiff, and achy. Old traumas seem to flare up more. Normal activities seem to cause more injuries. So, let’s talk about joint pain and why menopause and shifting hormones affect our joints. 

Dr. Felice Gersh: Well, and this is a sad truth that also doesn’t get talked about enough. The vast majority of joint replacements are in women! Women outstrip men in terms of joint injuries and joint replacements. This is a very big deal. Of course, in terms of bone health. By the way, bones are parts of joints. That is sometimes… Like, people think a joint is just ligaments and tendons. But, no. Joints are always the joining of bones, and the health of the bone actually is critical to the health and function of the joint. 

Women, of course, have the biggest incidents of osteoporosis. 80% of all osteoporotic fractures are in women. If you think about, for example, a knee joint, you have the cartilage that covers the bone at each end of the joint. This is true in every joint: the bones. So, you want to have healthy bones. That involves a healthy diet. So, you definitely want to have adequate protein. 

As we get older, we need [0:48:00] to have more protein in our diet. This is very important because you’ve got to be able to maintain what you’ve got to help fight off the effects of aging and loss of hormones. 

Then, estrogen is involved, of course, in bone health. Almost everyone knows that. But estrogen is also very involved in the ligament structure. So, the ligaments, the tendons, the elastin. 

So, the elastin is what gives the flexibility so things bend instead of breaking. So, what happens when we age when we have reduced hormones, and testosterone is of course involved. Everything. These are all working synergistically, and even thyroid hormones. The thyroid hormone receptors are activated by estrogen. So, after menopause, women have normal thyroid levels but they actually may have low thyroid symptoms because the receptors are becoming more resistant in an absence of estrogen. All of these tissues are involved with these hormones and their functionality and their health. 

As you age, the tissues become less flexible because elastin diminishes – which is very, very related to estrogen levels. So, things that used to bend and flex now rip and tear.

So, a lower threshold exists for trauma to create actual injury. 

So, people go out and they do Zumba dancing, they do skiing, they play tennis, and pickleball, and all these activities that shouldn’t be causing all kinds of injuries. Suddenly, they’re getting problems with tendonitis and injuries in their ankles and their knees. It can go down the path of inappropriate surgeries that leads to, then, joint replacements and other surgeries. 

Women, for example, make up the vast majority that get what is called frozen shoulder. It’s like 90% female. They wake up and they can’t put their arm over their head! So, the musculoskeletal system and joints are so [0:50:00] critical, and women are more sensitive to having injuries and having degradation. Osteoarthritis, which is not about just aging. It’s really the tissues become unhealthy inside, and then become inflamed. 

So, we definitely need to be aware that eating the proper diet, taking collagen supplements is actually beneficial. Making sure that you do have proper training. I recommend that every woman, as she’s getting into menopause, that she works with a trained professional. Because I see so many women who say, “Oh, my god. I’m getting belly fat, so I’m going to go out and start running and doing more jogging.” Then, the next thing you know, they’re in a brace with their knee, and they’re ending up having inappropriate surgery. 

By the way, once you’re 50, doing an arthroscopy on your knee and then shoveling out – they call it smoothing out, but really it’s the removal of your cartilage – is like the fast track to getting a knee replacement. It’s not going to fix a torn meniscus, I’m just telling you. It’s just not. 

So, the tissues are already degrading, and you can’t fix it. They actually make things worse. So, be careful about that. So, we don’t want injuries. So, working with a professional who’s going to really help guide you on getting into the proper exercise, that you’re not going to get into trouble and then have joint pain, and then injuries that are going to take you down a path where then you won’t be able to exercise properly. 

So, that’s really important. It’s under-appreciated. 

Kathy Smith: No, I appreciate you saying that. So, if you haven’t been exercising to start back slowly. Start with, you know, gentle movements. Don’t do anything that’s going to overstress your feet – which I see so many people having foot problems. Then, they jump back. Then, the knee, the hip. [0:52:00] I’ve had two friends recently tell me about the frozen shoulder! So, let’s talk. 

I love collagen. You mentioned collagen. We’ve talked about all the other things that really will help your body, which are sleep, appropriate exercise, supplementation (maybe with collagen). But when it comes to joints – especially, let’s say, pain and arthritis – are there dos and don’ts within the dietary realm that you recommend that we either eat more of or less of? 

Dr. Felice Gersh: Well, always a no-no is pro-inflammatory processed foods. So, we don’t want to have anything that’s going to increase system (or total body) inflammation. So, we want to have the most anti-inflammatory diet. That, once again, gets back to foods that have a lot of polyphenols and antioxidants. These are from the world of plants. So, we want to definitely reduce systemic inflammation. Because, when you have inflammation, it’s not just one spot. It’s multiple spots. It’s just interesting how some people will sort of have more inflammation in one spot or another, but it’s everywhere. Okay? It’s in your brain, it’s in your joints, it’s in your blood vessels, and so on. It just may seem more like it’s only in one part, but it’s always in all parts. 

So, an anti-inflammatory diet is really critical. So, eating… I love plant-based proteins. So, I recommend eating lots of legumes, beans, lentils, nuts, and seeds. There is so much coming out now on the benefits of plant-based proteins. Now, I’m not in favor of people being long-term vegans because they end up with a lot of nutrient deficiencies. You have to be really careful about that sort of thing. But, you know, having a little bit of the most optimal, [0:54:00] sustainably raised, and the best type of animal protein. But, not a tremendous amount. Like, a small amount every day of that. 

Then, we know that for inflammation, it’s also very important to have omega-3. So, from omega-3 comes what are called the SPNs: the specific pro-resolving mediators. These are a group called protectins and resolvins. What they do is that they actually trigger the end of inflammation and pro-healing in the body. But, so many people are deficient in the omega-3. So, you can get it by eating the omega-3 fatty fishes. You know, like wild salmon. But there aren’t enough wild salmon on the planet to feed everybody. Sardines are another source. A lot of people don’t like sardines. I grew up with sardines, so I actually like them. Of course, you can do supplementation with omega-3. But you can’t actually trigger the pro-resolving, anti-inflammatory status if you don’t have adequate quantities of omega-3 in your body. So, that’s really important to have that as a food source. And just eliminating any processed foods, especially the pro-inflammatory rancid – we’ll call them “oxidized” – oils that you get from all of the commercial foods. 

Now, there’s nothing evil about omega-6, by the way. Omega-6 is the foundation for creating your whole endocannabinoid system, which is really critically important. They are both pro and anti-inflammatory. We call the signaling fatty-acid agents prostaglandins. Some of them are pro-inflammatory, and some of them are anti-inflammatory. So, you want to have the healthiest source of fats in your body that you can possibly get. 

So, if you eat raw, very fresh nuts, [0:56:00] that will be a very healthy source of the omega-6s, which are then used for the body’s anti-inflammatory purposes. But, if they’re rancid, they’re already oxidized or already going to be stuck in the pro-inflammatory mode. So, we definitely want to have a balance. 

Kathy Smith: So, it’s having that balance. 

Dr. Felice Gersh: Absolutely. 

Kathy Smith: It’s having that balance between the omega-6s and 3s. As you say, with the nuts, as soon as I open up a can or I’m somewhere, I can smell if those nuts have been overly processed and maybe have gone rancid, or I can taste it right away. So, for sure the better…

Well, listen. We could go on. I feel like I just had a doctor’s visit! I just feel this is the best. You’re the best! To go through this podcast, and all the tidbits and little moments that we talked about are such powerful recommendations that you gave to the audience. I just really have to thank you for that. 

We are going to remind everybody about the book. I’m going to pull it down here. I have the name, but there’s a tagline here. 

Dr. Felice Gersh: Here, I have it. Can I pick it up? I have a copy right here. 

Kathy Smith: Yeah, put it in front of the audience. Let’s do it! 

Dr. Felice Gersh: It’s a nice little compendium. 

Kathy Smith: Put it closer to the camera lens, just so… Yeah. Bring it down a little bit. Okay, there we go. 50 Things You Need to Know: Menopause. I went through it. I have it. It’s kind of like a little bit of a reference book. 

Dr. Felice Gersh: It is!

Kathy Smith: Whatever issue you’re working on, because not all people have hot flashes, or not all people have night sweats. Whatever it might be, you can thumb to your chapter. There are 50 of them. Find out what to do about that symptom. It’s the short-term and the long-term. I like how you put them into the categories, also. 

So, what is it? It’s perimenopause, menopause, and then post-menopause. 

Dr. Felice Gersh: Yeah. [0:58:00] It’d be like the 10 years preceding menopause, the first 10 years of menopause, and all the years and decades thereafter. 

Kathy Smith: Well, we’ll talk about it some more in our Facebook group, and we’ll do some promotions around it. But, I thank you so much. Big hug from Park City. Thank you so much for joining us, I appreciate it! 

Dr. Felice Gersh: My pleasure. Thanks for the invite! 

Kathy Smith: Oh, my god. It was such a pleasure having Felice on the show today. Now, my big takeaway is that whether you choose to take hormones or not, healthy living can dramatically improve your menopausal experience. Exercise, sleep, stress reduction, and a plant-focused diet help your body function properly. 

On the other hand, smoking, excessive alcohol, a sedentary lifestyle, stress, pollution – it all makes it worse. 

Her book is full of strategies to help you eliminate menopausal symptoms and maintain your heart health, strong body, strong brain, and increase muscle mass. 

Now, where do you get it? Well, the name of the book, once again, is Menopause: 50 Things You Need to Know. You can get it just about anywhere you find books. I found it on Amazon. That’s probably my best bet for you, but you can find it also on her website integrativemgi.com. Once again, integrativemgi.com. 

Now, I want to give a big shoutout to all the folks listening from Fit Over 40 Facebook. Hi, everyone! Now, if you don’t know about Fit Over 40, it’s a free program you can join at kathysmith.com. I love the Fit Over 40 group. We have a great group of women that are just supporting each other through all of these different stages of our lives, and the Fit Over 40 program – which is free, as I mentioned – gives you 14 days of free strength training and pilates and bar method and cardio. So, come check us out. [1:00:00] You will not regret it. 

If you enjoyed this episode, guess what? There’s more! All you have to do is go to wherever you listen to your podcasts, and you can see amazing things about how you stop procrastinating. You check out Patrick Porter’s episode number 94 if procrastination’s your big thing. 

If strength training and how to maintain muscle mass is something that you’re dealing with, then check out Wayne Westcott’s podcast. 

If you want to learn about supplements that everyone over 40 needs to know about, listen to Shawn Wells. I think that’s episode number 74. 

So, the podcast is available on all platforms. Just search “The Art of Living,” whether you’re on Apple, Stitcher, Spotify, and you’ll find all these episodes. You can even say, “Hey, Siri, play the Kathy Smith podcast!” and she’ll play it. She’ll play the latest episode for you.

While you’re at it, don’t forget to leave a review. 

Now, I have to say, I love doing podcasts. I don’t know if most people know this, but it is a labor of love. Part of what keeps me going, keeps the podcast going, is for you guys to shout out and give a good review and tell your friends about it. 

So, for everybody who left a review, thank you. I love reading them. Until next time, here’s your health! Bye-bye.