The Estrogen Cliff: Why Women Must Lift Heavy Now

So this is how it works.

So both men and women build bone and peak about up to 25, sometimes 30.

And then bone loss plateaus for a little while.

Men continue to lose about 1% a year.

So men do not arrive with hip fractures or devastating fractures until their 70s or 80s or older.

Women also decline slowly until we lose our estrogen.

And then the rate of decline, and I'll tell you why it happens for bone, doubles or triples such that you will lose 15 to 20% of your bone density during your perimenopausal period just from loss of estrogen alone because estrogen plays many roles.

I've already talked about estrogen being a huge anti-inflammatory.

Bones are very sensitive to inflammatory chemicals in your body.

Estrogen also directly affects the balance of the two main cells that subtract minerals from bone, the osteoclast, and the cell that builds the bone, the osteoblast.

And in well-hormoned times, there is a balance.

The body loves balance.

We take what we need, we build it back.

But because estrogen has such a profound effect on the osteoclast, the Pac-Man bone-eating cell...

there's an unbalance and we take more bone than we're capable of building.

We're still building bone, but the rate cannot keep up with this.

So with the inflammation, with the direct effects on the osteoclasts, women will lose bone density if they do nothing.

Well, number one, they're going to lose bone density, but they must do something about it.

The reason it's so critical is

for a 33-year-old is because you still have your estrogen.

So let's learn how to lift heavy.

Let's take advantage of the estrogen circulating.

Let's learn to have a jumping practice and impact our bones, right?

So the way our body tells our bones to build more

is there's another little cell called the osteocyte.

It sits encased in bone, but it's connected to these other cells by little tunnels that contain fluid.

When you jump, the biomechanical impulse of that fluid shifting in the little tunnels is translated into a biochemical stimulation that tells the bone, oh my God, she's jumping around.

I need to build more bone.

So we need that impact to,

to stimulate the laying down of more bone.

I was looking at this graph, which is what you were describing.

Men and women aren't that far away in terms of

So, this is showing the fact that because of the way testosterone interacts with a man's bones, he will peak at a higher bone mass than a woman will.

So, he's starting at a higher level.

So the most popular class for females right now, I just saw this statistic somewhere, is Pilates.

And my daughter loves her Legree and gets on that machine.

It's like, you know...

Where does that fall in all of this?

I have a lot of Pilates.

There's a social aspect to it.

Pilates people hate you.

Yeah, because we did this reel talking about how Pilates was not appropriate as strength training, especially as rehab.

When we look at Pilates, it's a complement to true strength training.

What I mean by true strength training is you're lifting a load that's heavy in multiple planes.

With Pilates, it's really good for isometric control, core strength, balance, proprioception, but it isn't a stress that's going to create adequate muscle gain and strength of the bone, which is what we want from strength training.

So just like yoga, Pilates has a place.

It does definitely fit in the scheme of things, especially from the social and the fact that it does give you control and proprioception, but it isn't the be-all, end-all for strength.

People that do Pilates frequently will be shouting, Stacey, it hurts so much.

I know.

Well, I'm sure it's hard.

The times I've done it, it's not easy.

It isn't easy.

But it doesn't set you up not to be frail.

It is not building strength and power.

And I have women who have done so many Pilates, 1,500.

It's like a badge.

They count their classes.

1,500 at the deficit of anything else.

It's all that goes on.

And I think that is another – you've got to mix it up, number one.

Number two –

I say the same thing, so I'm not very popular in those crowds, but it's great for the standard that I ask people do of flexibility and joint range of motion so that you don't become really stiff and hunched over and shuffling old person.

But it will never give you strength and power in the way to protect yourself from falling down.

Because there's not enough weight?

No.

For the most part, yes.

And we also have to think about when you're doing strength training, you're creating a multidirectional force through the muscle and the tendons and the bones.

With Pilates, especially if you're looking at the reformer, it's not multidirectional in the movements.

Each movement is one plane.

Up, down.

Yeah.

You can be in different planes, but each motion isn't multiplanar.

So if we think about what are we trying to get out of Pilates, we're getting neuromuscular control, we're getting core strength, we're getting some breath work and all that is beneficial.

We start getting into perimenopause and we start getting into menopause.

This is where we have to really carefully look at volume versus intensity.

So that means if we're doing lots of stuff, or are we doing really purposeful high intensity versus low intensity?

Because we're trying to create what we call a polarization of the training so that when we hit high intensities, we're actually hitting the intensities we need to create change.

But on the other side of it, we want to hit really low intensity so that we can have recovery.

It gets harder to recover as we get older, regardless if you're male or female.

But in perimenopause, we don't have the benefit of estrogen supporting anti-inflammatory responses.

So we have to be very cognizant that we need more recovery.

So I'll give you an example.

So my office, my orthopedic office, is in a fabulous performance center.

Outside my windows, I have floor-to-ceiling windows, there's a football field inside.

That field is filled seven days a week with people taking a class called Ignite.

Ignite has a lot of midlife women in it who are never exercising at low enough intensity to recover.

and never exercising at peak intensity to change their body.

So what happens, five or seven days a week, they're out doing moderate, mid-range exercise,

intensity training but they're not seeing body changes they're not seeing recomposition they're hurt every three weeks and in my office wondering why they're hurt because they're doing a lot of reps of medium intensity so they're not really recovering and they're not intense enough to really change their physiology but

That's really common.

There are whole brands built around mid-intensity.

And that falls into the whole sociocultural thing where we've grown up that if you don't have a good sweat sesh and feel completely smashed when you leave, it wasn't a good workout.

But that's a misconception.

Right.

So they are smashed.

They're dripping as sweat, but it's not at peak heart rate ranges for short bursts of time, right?

So I know, look, it's very confusing because...

I don't know, 20 years people have, as they've switched from only cardio, they're like, now we're going to do high intensity, which is fine.

I'm not opposed to that word.

It's just that, how do you define that?

What is high intensity?

And so like you, because I've read your books that-

Should women exercise differently across the menstrual cycle?

So this is the nuance.

And this is something if you'd asked me maybe five years ago, I would have said, sure, from a molecular level, we see that there are certain things that happen with estrogen being in isolation for the most part.

And then when you have estrogen progesterone, we see their metabolic shifts, we see their temperature shifts.

But the caveat is we don't know if a woman ovulates or not.

And I'm sure that Natalie can give some stats about the anovulatory incidences in most women.

If we were to understand and know when a woman ovulates, in addition to how she feels across her cycle, then she can individually tailor her menstrual cycle to her training.

But for general plan, we can't do that.

I think it's important that, you know, building muscle, using muscle, consistency is a huge part of effectiveness when it comes to exercise or to building strength.

And so one fear we have when we say do this in one phase of your cycle and do that in another phase is that if, you know, 15% of patients are not ovulating or they have no idea when their follicular and luteal phases are, are they then doing overall less because they're waiting on this directive to tell them what?

What is not untrue, though, and how I frame this to patients is that strength and resistance training should be the core of what you're doing, regardless of the phase of the cycle you're in, regardless if you're pregnant, regardless if we're doing fertility treatments, building muscle, using your muscle.

Now, what you do on other days is where you should allow yourself to say, how do I feel this day?

What do I need this day?

And be OK with giving yourself the grace that that may look different.

on your period, in your follicular phase, in your luteal phase, and saying doing something and moving your body is still ultimately, we're all going to agree, better than sitting on the couch.

Many women will say they have more energy in that late follicular phase.

And so if you are looking at your workout structure, this is a day I want to try heavier weights or more reps.

It can be smart to put that in a time where you have a higher chance of being successful.

That's how I explain it.

I'm like, if you have...

your own data and you know which days you feel really fantastic that's where you want to put your higher intensity your heavier lifting because you know that you're going to hit those training metrics what we don't want is for someone to go in to do a high intensity session on days they feel flat because then they won't hit the metrics that they need to to get the stimulus we're after can you explain this to me like i'm a 10 year old in terms of where in the cycle typically women will have more energy and really be able to push themselves

Right here, five to seven days before ovulation.

Some women feel really great around ovulation.

Some have a transient where they'll feel really awful on and around ovulation and maybe 24 hours later, they feel really fantastic.

Most women are variable through the early luteal phase.

So if we think about day 6 to 14, that's when we see women feel really robust and strong and feel like they can take on the world.

Because estrogen is rising.

Yeah, exactly.

And you see the physiologic changes, heart rate variability, resting heart rate.

Your immune system is more prone to taking on virus and bacteria.

It's not pro-inflammatory, so you have that working for you.

Your core temperature is lower.

You can access carbohydrate a lot easier, so you have more availability for fueling to hit high intensities.

Then when we see with ovulation, like I said, some women feel really fantastic right around the time of ovulation because of the estrogen surge.

Some have transient where they don't feel so great.

When that follicle ruptures and the egg is released, the granulosa cells that are surrounding it, which is what actually makes estrogen, get disrupted.

And so some women feel that transient breakage and their estrogens dropping before it reforms to become the corpus luteum and make again.

So you have this...

high peak estrogen and then some women are really sensitive to these hormonal changes and they feel that drop so that ovulation day may not always be your very best feeling day which makes women feel like it should be and like something's wrong with them on a side note we did um

survey on women experiencing pain on ovulation because it's something that was never talked about.

Middle schmertz.

Yes, exactly.

Middle schmertz.

Middle schmertz.

We had, so you can feel the follicle rupturing and that's called middle schmertz.

So it's German for in the middle because it tends to happen in the middle of your cycle when you ovulate.

And it's painful.

It's a pain.

It can be.

It's just a pain.

It's like a cyst bursting inside your body.

And then some women are down for the count because of it.

So they don't plan any physical activity around that because they just can't, from a physical and mental standpoint, put themselves through anything.

So that's why I'm saying like ovulation, some women feel bulletproof.

Other women have this transient feeling of really flatness and pain.

And then afterwards in these...

early luteal phase so day 16 to about day 22 is variable well some women will feel like on top of the world still other women will feel i can't quite hit eye intensities and then in general these few days about day 24 to 27 before those hormones actually drop this is where you have your pms your premenstrual syndrome and cramping and fatigue and a lot of women are like not so great

That's when your progesterone.

When both of them drop.

I just love how you guys explain it because what I see on social media is absolutes.

You must do this doing follicular.

You must do this at ovulation.

You must.

And I'm just like, really?

You know, and so I love how you're like, well, some women, it may affect them this way and others this.

The way I like to approach nutrition for people is first having people notice what they're eating.

And then from that, break it down into, well, how much of it is protein?

How much of it is fat?

How much is carbs?

Without that kind of education, it's almost meaningless.

So when we've done that, and I'm making recommendations for protein diets.

We will not build the muscle we need to build.

We will not get stronger the way we're capable of getting stronger, A, if we're not eating enough, and B, if we're not taking enough protein.

So the RDA recommendations of 0.8 grams per kilogram is survival doses of protein, like sitting on a chair like a mushroom.

Preventing malnutrition is the goal of it.

It is not for active people.

It is not for living your best life people. 0.8.

The recommended daily intake.

Is 0.8 grams per kilogram of lean body mass.

So it's low.

It's very low.

So the research supports, easily supports, let's use pounds, 0.86 grams per pound for lifting people.

I recommend over a gram, a gram for ideal pound because-

I'm presuming that the people I'm taking care of are going to start being active, that we're trying to build muscle, that we're not in starvation mode.

So 0.8 grams per pound of

I recommend one gram per ideal pound.

So there's some other resources come out looking at skinny fat.

So that's normal weight obesity.

So not as we're talking.

Normal BMI.

Normal BMI, but internal high body fat.

And what happens is they have low muscle mass.

Low muscle mass.

So they took...

A group of women split them up.

So you had a control group and then you had this intervention group.

And the only change they made, there's no exercise, and the only change they made was they brought the intervention group up to 1.6 grams of protein per kilogram.

Which is 0.8 per pound.

And over the course of 12 weeks...

of eating that protein intake, this intervention group completely recomped their body.

So their muscle quality came up, body fat went down.

Control group, of course, nothing happened.

So it just shows the importance of having that higher protein intake just to support basic muscle function.

And the frailty data out of the WHI, so the Women's Health Initiative, looked at multiple things, not just breast cancer and heart disease, but they followed these women even off of HRT for decades.

And when they looked at frailty scores in the elderly and protein intake above 1.6 grams per kilogram, had the lowest frailty scores just based on protein intake alone.

What about fasting?

I know so many people that are doing water fasts and juice fasts and it's- Have they told you why?

I've had an evolution with the way I think about fasting.

When I first kind of was stepping out of the box and what's happening in menopause and why was my body composition, I didn't know what to call it back then, but what was all this going on that was new?

And all my patients were having it as well.

And these were my girlfriends.

I worked in a small town with a big university and

These are PhDs and we're running marathons.

We're doing all this stuff and everyone's kind of complaining of the same thing.

And so fasting seemed to be helpful.

And my girlfriends were trying, we all kind of did this fasting thing and I was like super excited about it.

Everybody felt better, blah, blah, blah, blah, blah.

Okay, so fast forward, I'm learning more about hormones, body composition, protein intake, all of these needs.

And suddenly as I'm counseling my patients, I'm realizing I can't meet my own protein goals if I'm trying to fast at the same time.

And I quickly realized if we're looking at health span, if we're looking at body composition, there may not be a lot of room for fasting for these patients, you know, or for my girlfriends, you know.

And it is really difficult for my patients to reach their nutrition goals.

So never at the expense of meeting your basic nutrition goals and your calorie needs.

And it is really, really hard to do while fasting.

So you may get a short-term benefit with weight loss, but there really doesn't—

Dr. Sims can get into the nitty gritty.

But the basic idea of fasting, if we want to use the term fasting, we have to look at it as, are we talking about intermittent fasting or time-restricted eating?

So intermittent fasting is kind of like your water fast, your five-day, two-day, all that kind of crazy stuff, which for the most part men can get away with and have a positive impact on body composition, but women can't.

If we want to talk about time-restricted eating and working with our circadian rhythm, which is optimal, then you have breakfast or food within a half an hour of waking up that helps dampen that ghrelin and cortisol response I talked about before so that everything is coming down, your hormones are starting to work properly, and your body's like, great, I'm ready to go.

I can handle this.

And then you're eating at regular intervals, and I try to have people have protein and fiber at every eating interval so that they are maximizing protein and fiber intake.

Then you have dinner, and then you don't eat after dinner.

What do you mean by every eating interval?

So breakfast, maybe you have a snack.

If we're looking at training or exercise, if you're splitting your breakfast, then you're having some protein and carb before.

You're having the rest of your protein or more protein afterwards, and then you're having –

some protein and some fiber at lunch.

So you're having maybe tempeh or tofu or salmon with salad or fruit and veg.

So every time you're eating, you have a protein and fiber focus.

So time-restricted eating is within a 24-hour period?

So you're looking at, I'm going to eat during the day when my body needs it, and I'm going to stop eating when I finish dinner so I have about a two, maybe three-hour break before I go to bed.

So that when I go to bed, I'm not trying to digest food.

My body can get into the parasympathetic responses it needs to to sleep well for reparation.

And then I eat again at what time?

When you wake up in the morning.

It's typically about 12 hours of eating and 12 hours of not.

So you're trying to follow that circadian rhythm and work with your hormones.

It can also, when you do have that period of time, which maybe that sounds very intuitive, but a lot of people are eating at 10 p.m., they're snacking on food, then they're trying to go to bed, and then they're getting up.

When you give your body a little bit longer, so at 12 hours time, is when your body will really –

efficiently be using up all your glucose, really dropping some of those insulin levels, but it's not so much that it's stressful.

And we're using stress very generically here, but on a cellular level, long periods of fasting for women specifically can be very stressful to the body.

And that's why if you think about Stacey's example of what happened in two fasting periods to, you

Different things are going to happen to your body if it thinks it's being in starvation.

So we don't want to put your body in a starved state.

We're just trying to give it a time period without food so that it can start to process the energy that's available differently.

Why not, though?

What's going to happen?

I understand from what we talked about earlier that my fertility, my cycle is going to change.

But is that it?

Well, there's adaptive stress and then there's stress to the point of you're hurting yourself.

You said that men can do longer fasts.

They can.

They can do longer fasts and it can show to actually be something that might be advantageous for them for how their body is made.

It might increase their focus and some other metrics.

But for women, these longer periods are actually going to promote more visceral fat storage and become pro-inflammatory.

And you said it a little casually, but...

disrupting your hypothalamus and shutting off your hormone system will cause a low estrogen state and that's very problematic as we've talked about so thinking about your body should not be in a starved state so utilizing time restricted eating meaning i'm going to eat within my circadian rhythm the hours that there is sun outside back what how your body is made to function is working with your biology if you're saying i'm going to not eat for three days because i'm doing this fasting period

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