September 10, 2025 • 51 mins
Midlife can be the worst when it comes to weight gain. If you are wondering what the ehck is going on with your metabolism and how your hormones might play a role, this episode is for you!
I’m joined by Dr. Gillian Goddard, an endocrinologist and an adjunct assistant professor of medicine at the NYU Grossman School of Medicine. She has more than 15 years of clinical experience and a particular expertise in endocrine diseases affecting women during the reproductive years, pregnancy and through perimenopause.
She helps us understand the nuances of hormone interaction during the menopause transition (which includes all those lovely years before as well known as perimenopause!). We discuss why weight gain happens and what we can do specifically in this time to combat it.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
This is the Eat Well Think WellLive Well podcast.
(00:02):
I am Lisa Salisbury and this isepisode 160 Midlife Metabolism
with Dr.
Jillian Goddard.
Welcome to eat well.
Well, the podcast for busy womenwho want to lose weight without
constantly counting, tracking,or stressing over every bite.
I'm Lisa Salsbury, a certifiedhealth weight loss and life
(00:24):
coach, and most importantly, arecovered chronic dieter here.
You'll learn to listen to yourbody and uncover the reasons
you're reaching for food.
When you're not truly hungry,freeing you to focus on a
healthier, more fulfillingapproach to eating.
Lisa (00:39):
welcome back to the Eat Well Think Well Live Well
podcast.
I am so excited to be talking toDr.
Jillian Goddard.
She's an endocrinologist and anadjunct assistant professor at
Grossman School of Medicine.
Did I get all that right?
Dr. Gillian Goddard (00:51):
Mostly, yeah,
Lisa (00:52):
Mostly.
Okay.
You correct me.
Let's, let's hear from you.
Introduce yourself a little bit.
Tell us about who you are andwhat you do.
Dr. Gillian Goddard (01:02):
Sure.
Absolutely.
So as you said, I'm anendocrinologist and a professor
at NYU.
uh, write a newsletter calledHot Flash, which is all about
women's hormonal health, notjust about menopause and
perimenopause, but sort ofeverything from puberty through
menopause, and I'm so excited tobe here.
Lisa (01:24):
Great.
Okay.
Well, as a lot of my listenersare in midlife, less of us in
puberty, it's like, what dopeople call it?
Like second puberty or,
Dr. Gillian Goddard (01:33):
Something like that.
And sometimes if you yourselfare in midlife, you live with
someone in puberty, so there'slots of crossover there.
Lisa (01:42):
Yes, I'm familiar with that.
I have two, two girls, so, um,17 and 20.
So yeah, we are definitely inthat crossover time.
So obviously the main feature ofperimenopause going into
menopause is the hormonalchanges.
That's what causes all of the,problems.
(02:04):
So, let's just talk about that,like a little bit of education
on how those hormonal changes ofperimenopause, like what
happens.
generally, and then specificallywe wanna talk about how those
affect our metabolism sincethat's, you know, a lot of what
we talk about on this podcast isweight loss and, things that
affect it.
Dr. Gillian Goddard (02:25):
Absolutely.
So.
I think the best way to thinkabout perimenopause is from the
point of view of your ovaries.
Women and girls are born withall the eggs that they will ever
have, and from your first periodonward, you are maturing eggs
and ovulating approximately oncea month, barring.
(02:49):
You know, events like pregnancy,and as we get into our,
typically into our late fortiesand early fifties, the numbers
of eggs that are left in ourovaries are starting to dwindle.
In addition to that, the way ourhormonal system works is the,
the, the young healthy, likebest quality eggs get ovulated.
(03:12):
First, and so again, by the timewe're in our late forties and
early fifties, not only arethere fewer eggs, but the
quality is lower.
And the reason that's
Lisa (03:22):
Sorry, I'm gonna interrupt you.
The body just naturally choosesthose.
Dr. Gillian Goddard (03:27):
kind of.
It's more that they kind ofraise their hand,
Lisa (03:31):
That's fascinating.
I did not know that.
Which is why we're more fertilewhen we're younger because of
the quality of the egg.
Fascinating.
Okay.
Carry on.
Dr. Gillian Goddard (03:41):
So those old low quality last kids picked
for the team, eggs that are leftin our ovaries in our forties
and fifties need a lot more.
Hormonal drive to get them tomature and prepare for
ovulation.
Um, and the hormone that doesthat is called follicle
(04:03):
stimulating hormone, FSH.
And so you need much, much moreFS, H to drive those eggs to.
And FSH also tells the ovariesto make estrogen.
And so what happens inperimenopause is you get these
big spikes in estrogen and thesebig drops in estrogen.
(04:23):
And that is a lot of what drivesthe symptoms that we are having,
during perimenopause and earlymenopause.
And then As the eggs get evenfewer by the time you're down
to, you know, under a thousandeggs at that point, sometimes it
takes so long to get an eggready to go that the wires get
(04:45):
crossed and you have a periodwithout ovulating.
That's called an anovulatorycycle and sometimes you might go
many months.
Without a period because you'renot ovulating.
'cause the eggs just can't getready quickly enough and be
ready to ovulate.
and then finally you run out ofeggs essentially, and you have
(05:07):
your last menstrual period.
And the ovaries kind of start tosay they're done and start to
shut down, but.
Our estrogen levels can stilloccasionally like spike up and
drop even after our lastmenstrual period.
And it is actually not therising estrogen, but really the
dropping estrogen that tends tocreate a lot of the symptoms
(05:27):
that we have in perimenopause.
The classic ones that peoplethink of, like hot flushes,
night sweats, and sleepdisruption.
But the other thing that happensis our estrogen levels drop and
our androgen levels, those arehormones that we typically
associate with men liketestosterone.
Our androgen levels oftentimesstay about the same, and so
(05:50):
estrogen levels drop, butandrogen levels stay the same.
So the balance, the ratiobetween androgen levels and
estrogen shifts towardandrogens.
And androgens promote weightgain in our midsection around
our organs.
Estrogen promotes weight gainaround our hips, thighs, and in
(06:14):
our breasts.
and so we get this shift from asort of weight gain more in the
hips and thighs to this weightgain in the midsection.
And the, that's super importantfor everything that happens to
us metabolically after that,because it's weight gain in the
midsection that changes how wemetabolize carbohydrates.
(06:37):
That changes, you know, How wellour body is able to use
carbohydrates and how muchinsulin we need to use
carbohydrates.
it also has some effects onmuscle mass.
So, on average women lose abouta pound to two pounds of muscle
(06:59):
mass during the perimenopausaltransition.
And if you gain fat in yourmidsection and you lose muscle
mass, you pick up some insulinresistance and you lose some
basal metabolic rate, so yourmetabolism slows, you're burning
less calories at rest.
and when you consumecarbohydrates, you're needing a
(07:20):
lot of insulin to utilize them,and so they preferentially get
stored in your midsection, whichcauses more weight gain in your
midsection, and then you justend up on this vicious cycle
where you become more insulinresistant, you gain more weight
in your midsection.
On and on and on.
Un until you break the cycle.
Doesn't it sound fun?
Lisa (07:40):
Okay.
Yeah.
Oh, dear.
Okay.
so I have questions.
Dr. Gillian Goddard (07:45):
Sure.
Lisa (07:46):
First of all, and this is actually just like a curiosity
question, not really even onthis topic.
You said when you get down tounder a thousand eggs, I used to
think, and I I might be like, Iwas today years old when I
learned this.
I used to think that you had theexact, like the number of eggs
and you released one per cycle.
But I learned recently thatthat's not exactly true.
(08:07):
'cause I'm thinking a thousandeggs, that's, you still got
plenty, like that's a lot ofcycles.
But
Dr. Gillian Goddard (08:12):
That's three years or something, right?
More than,
Lisa (08:16):
more, yeah.
Way.
So how, how many eggs do youtypically release?
Because a thousand eggs seemslike still a lot left.
Dr. Gillian Goddard (08:23):
So you start, most women start life
with something in theneighborhood of.
600,000 eggs, which sounds likeyou should be able to ovulate
for like a millennium.
But what actually happens is awhole group of eggs, start down
the process of maturation.
(08:44):
So at the beginning, you mighthave 50 or a hundred eggs
starting down this process.
But over the course of thematuration process, many of them
will die off and there's achemical process that occurs
within the ovary so that some ofthose eggs spontaneously, like
(09:05):
they stop growing and they, theykind of just.
Involute and get taken care ofby the, the body's system for
cleaning up old cells so thatyou get to, you end up with a
dominant follicle, and thatdominant follicle is the
follicle that ovulates, so youonly ovulate typically one egg a
month.
(09:26):
There are exceptions to that.
Sometimes some women ovulate twoeggs per month, and that's, you
know.
Lisa (09:32):
get twins.
Dr. Gillian Goddard (09:34):
Outside of IVF?
Yes, that, that's one of thenatural ways we get twins.
but most of the time you ovulateonly one egg, but many more eggs
are starting down that process.
So a thousand eggs is, you know,enough to get you through three
to five years probably.
Lisa (09:53):
Okay.
Okay.
That makes, that makes a lotmore sense because I was like,
but how can you release morethan one egg?
We would have way more multiplebirths.
But it's not that you releasemore than one, it's just that,
more than that there's a bigOkay.
Ghost, you, you heard her?
I won't restate.
So that's, that's really just,that's just interesting.
I just like learning about thewomen's body.
(10:13):
So, Okay, so my next questionabout this, like estrogen versus
testosterone balance is that wehave seen a lot in, You know,
I'm sure a lot of my listenersare on Instagram and with a lot
of menopause influencers.
So there's a, a lot of push withhormonal replacement therapy,
which I am on, and I really, I'mthriving on, especially
(10:35):
progesterone at night.
I love that she's nodding.
If you're not watching video,she's nodding along so we can
talk about.
Dr. Gillian Goddard (10:42):
therapy is fantastic.
Lisa (10:44):
Okay, but why then is testosterone?
One of the things that I've beenrecommend, I, I've been on and
off of it.
I am, I'm like, I mostly becauseI'm not sure I'm seeing the
results for the cost and becausemy estrogen and progesterone are
like basically covered a hundredpercent by my insurance.
But testosterone, my doctorwon't prescribe the, the mail
(11:05):
version because that's an
Dr. Gillian Goddard (11:07):
by her insurance, even if she did.
Lisa (11:10):
Well, it's just a lot cheaper than the compounding
version that I have to chooseanyway, point being.
It's a little bit of a, of acost for me.
And so I have been kind of onand off about it and, but what
I'm kind of paranoid about, nowthat you've said this and I, I
just think people that might beon testosterone might think,
well, why would I want to be ontestosterone if that's gonna
(11:32):
cause weight gain around themiddle?
So how would that play into it?
Why would we be, you know,recommended to be on a
testosterone replacement?
Dr. Gillian Goddard (11:42):
I think this confuses a lot of people.
So I'll say a couple of thingsabout this.
Not everyone's testosteronestays the same in perimenopause.
Some people's testosteroneactually rises during the
perimenopause.
In early menopause, some womenstays approximately the same and
some women's testosteroneactually falls.
And so if your testosteronelevels are very low and you're
(12:04):
symptomatic because of that.
then adding testosterone may behelpful.
That said, the only thingtestosterone has really been
studied for in women is,hypoactive sexual desire
disorder, which put much moresimply is low desire for sex and
difficulty getting aroused.
Lisa (12:25):
Loss of libido.
Yeah.
Dr. Gillian Goddard (12:27):
Yeah.
Not really wanting to have sexand when you do not feeling all
that satisfied by it.
And that's actually the onlything that testosterone has
really been proven in theliterature to do.
but you're right, there's notestosterone that has been
approved in a formulation dosedfor women.
And so your two options arecompounded testosterone, which
(12:50):
you get at a compoundingpharmacy.
The big challenge, there's twobig challenges there.
One is cost, as you mentioned,and the other is that
compounding pharmacies vary agreat deal in their, quality
control and reliability.
They're not, the way they'relicensed is very variable.
or you can use testosteroneformulated for men and just use
(13:13):
really tiny doses of it, which
Lisa (13:15):
Yeah.
Dr. Gillian Goddard (13:16):
It's messy and, and inelegant and not, but
I have lots of patients who doit because it is quite a bit
cheaper.
there has been talk aboutgetting a product for women on
the market, but I think we're along ways away from that,
happening partly because apharmaceutical would have to get
behind it
Lisa (13:35):
yeah.
Yeah.
And a lot more studies donebecause, so.
Dr. Gillian Goddard (13:39):
studies.
Lisa (13:41):
So if someone were like, okay, but I do have, you know,
the loss of libido, it bothersme.
I can't orgasm.
I'd really like to try it.
Are they risking midsectionweight gain by using it?
Dr. Gillian Goddard (13:54):
Not if you're careful with the dosing.
So
Lisa (13:58):
Mm-hmm.
Dr. Gillian Goddard (13:59):
one, so one thing that can happen when you
take testosterone is you can getthe, make the doses very high.
So they're higher than like atypical woman's.
testosterone would be, and thereyou may get into trouble with
side effects, including someweight gain.
if you're getting, taking thelevels and you're moving them
from sort of low to, you know,more middle of the road for a
(14:22):
typical female level, you don'ttend to see weight gain issues
with that.
And the question is sort of why,right?
some of this is because there's.
Other factors at play that we'rejust starting to understand,
around FSH and the role of FSHoutside of the ovary.
(14:42):
So I told you FSH tells theovary to mature an egg and make
estrogen.
there's some.
A growing body of literature, Ithink is the way I would put it.
about FSH and FSH receptorsoutside of the ovary having
potentially being related tometabolic changes we see.
Women in perimenopause becausewhat happens to FSH in
(15:07):
perimenopause and menopause isthat it can rise very high.
and so FSH may actually beacting in other parts of our
body, including in this case,importantly the adrenal gland,
to have impacts on.
Our metabolism, our bloodpressure, our cholesterol, that
are mitigated by that hormonedirectly, and not by this
(15:28):
mismatch between estrogen andtestosterone.
Lisa (15:33):
Okay, so it's my understanding that.
Menopause hormone replacementtherapy or HRT or however you
want to call it, is not ametabolism or weight loss fix.
We don't get prescribed thesethings because we've gained
weight.
How though, could they help inweight maintenance or are they a
(15:55):
factor?
Because I've heard people sayoh, well I'm gonna get on, HRT
and try and lose some weight,and I'm like, those are two.
Separate things, and yet ourhormones are connected to our
metabolism.
So what role does that have?
Dr. Gillian Goddard (16:11):
So that's actually why people got
interested.
It in, in FSH as a potentialmitigating factor with all of
this to begin with is peopledidn't understand.
If you give women back, thereason we don't use estrogen to
help women in menopause andperimenopause lose weight is
because it doesn't work.
there's lots of data to showthat it doesn't work,
Lisa (16:32):
And it works for a lot of other things, like
Dr. Gillian Goddard (16:35):
it's great for hot licious, night sweats,
Lisa (16:38):
great.
Dr. Gillian Goddard (16:39):
brain fog, muscle aches, joint pain, your
hormone replacement will helpyou with all of that, but it
does not help women lose weight.
and so the question was, well,why doesn't it?
And, and we think that this iswhere FSH comes into play
because when you take hormonereplacement therapy, you do not
typically suppress.
(17:00):
Your FSH, so you don't typicallyget a lower FSH from taking
estrogen.
and so that may be part of theissue.
However, I do think women whoare taking hormone replacement
for other indications sometimessee that their metabolic changes
(17:21):
are less dramatic.
and so They may not lose weight,but they also may not gain as
much weight as the typical womandoes in in perimenopause.
Lisa (17:33):
Yeah.
Possible though, that that couldbe a correlation factor because
people that are pursuing HRT arealso those that are living
typically gonna be living a morehealthy lifestyle.
They're typically the ones thatare gonna going to already be
exercising and, and eating thethings and, right.
So it's, it's a confusing,
Dr. Gillian Goddard (17:55):
it is, and we don't have nearly enough.
You know, clinical trial data,like randomized clinical trial
data, around any of these issuesbecause for 20 years we didn't
do clinical trials, inperimenopausal women with
hormone replacement therapy,because of the women's health
initiative.
And so we're just starting tosee those types of clinical
(18:16):
trials really get going again.
And so all we really have areobservational studies from the
last 20 years or so, which.
You cannot sort out causationversus correlation with an
observational study.
Unfortunately,
Lisa (18:33):
So, I mean, percentage wise, really, except for from
what I, I understand the last,you know, handful of years, the
percentage of women on HRT hasbeen so low.
Dr. Gillian Goddard (18:45):
between 19 or between 20, 24, which was the
year that the Women's HealthInitiative study was paused,
and.
Basically women throughout theirHRT on, on mass, like in a
single day, because of the mediacoverage of the study.
between that,
Lisa (19:04):
20, 24 was just last year.
Dr. Gillian Goddard (19:06):
2004, sorry.
Between 2004 and 2020.
Sorry, I misspoke.
Lisa (19:12):
okay.
Dr. Gillian Goddard (19:12):
So in those, in, in those years
between when the Women's HealthInitiative study came out and
2020.
Four to 5% of women were takinghormone replacement therapy.
80% of women have hot flushesand night sweats, and four to 5%
of women were taking hormonereplacement therapy.
So when people talk about like,oh, we should be using it for
(19:35):
this and that and the other, I'mlike, how about we just start by
treating the symptoms that womenare having that we know it works
for?
Lisa (19:42):
Yeah.
Well, and another one I'm superpassionate about, like all my
friends know, I'm like, are, areyou on vaginal estrogen though?
Because everyone can be onvaginal estro.
And this is kind of off topicfrom what we're, what you and I
are trying to talk about with.
you know, metabolism and, andthese changes.
But honestly, anytime I can plugthat, like, it's so safe.
(20:03):
It's a microdose and
Dr. Gillian Goddard (20:06):
safe For women who have had estrogen
receptor positive breast cancer,it does not affect breast cancer
risk.
Lisa (20:12):
yeah, like I just want you to say that again.
Like, we have an endocrinologisthere telling us it is safe.
It
Dr. Gillian Goddard (20:22):
Vaginal, estrogen is safe for everyone.
We even now think it's safe forthe vast majority of women who
had estrogen receptor positivebreast cancer.
Lisa (20:33):
Yeah.
Okay.
And why would a person want touse vaginal estrogen?
Dr. Gillian Goddard (20:41):
because vaginal dryness is very common
and can lead to a whole host ofundesirable symptoms, when our
vaginal va vaginal lining andour vulva and the muscles that
support our vagina and vulvadon't have estrogen, they dry
out.
(21:01):
When they dry out, they thin andthey stick together.
One of my patients once saidthat her vagina felt like two
pieces of Velcro being pulledapart when she moved.
you, you can start to getatrophies.
You can actually start to getbreakdown of the tissues and not
be able to.
Insert anything in the vagina, aspeculum, a finger, a penis, if
(21:26):
that's something that you'reinterested in doing.
So sex can become veryuncomfortable.
it disrupts the The flora, thebacteria that grow in the vagina
so you can get yeast infections.
And then my all time favorite isthat the slumping down of the
vagina actually pulls the anusand the urethra closer together.
(21:48):
So it's easier to get urinarytract infections too, because
you get bacteria from the anusinto your urethra.
So.
And then your, your, I mean, Icould go on and on.
Your
Lisa (22:00):
Yeah, I know.
I.
Dr. Gillian Goddard (22:02):
press on your bladder and
Lisa (22:04):
It's, it just, it affects the entire area down there.
It's not just for vaginaldryness, although that is, I,
I've gotten to be almost sosensitive that I'm, I, because
it's just a twice a week.
And so I can tell like when it'stime, like my body will tell me
it's time.
Don't forget your dose today.
but even, you know, if,especially.
(22:25):
It's so cheap.
So if you are having troublelike with in, with intercourse
and you can't do testosterone,like start with vaginal
estrogen, that will increaseyour comfort.
To the point that you, you mightsolve your problem there.
I mean, I don't know.
You know, it depends on whatyour problem is, but if it's
just a comfort issue, start withvaginal estrogen because it's
(22:46):
dirt cheap and, will really makesuch big difference.
So anyway, I, I just lovetalking about HRT, like
sometimes I think I shouldswitch over to a menopause
podcast, but I, it's just, itjust makes such a difference
and,
Dr. Gillian Goddard (22:59):
big fan.
Lisa (23:00):
So yes, we could talk a long time, but let's, let's get
back to like the, the metabolicchanges that we wanted to
discuss.
So we've got these metabolicchanges and all of these
hormones are kind of doing whatthey do in this midlife time,
and we get that resulting changein body composition, so we get a
little bit more fat.
(23:21):
A little bit less muscle, one totwo pounds of muscle.
Doesn't sound like a whole lot,but is this happening?
Like every year we're losing oneto two pounds of muscle or every
decade.
Like, and what can we do aboutthat?
Dr. Gillian Goddard (23:33):
So the best data that we have around around.
Body composition changes inperimenopause really
specifically looks at the fiveyears before the last menstrual
period and the five years afterthe last menstrual period.
So a 10 year time with yourperiod, your last period, is
that the midpoint of that time.
(23:55):
And so that one to two pounds ofmuscle is, over that 10 year
period.
People do tend to lose muscle asthey age too.
So men lose muscle as they age.
Also, not just women, it tendsto be more gradual.
but you, it, it only gets harderand harder to maintain muscle
(24:19):
mass as we age because itbecomes such a, again, like so
many of these things, it becomessuch a cycle because then.
If it's hard to use yourmuscles, then you don't use
them.
And the less you use them, theless you will have.
So this is where, and I knoweveryone's talking about this
right now, but this is wherestrength training is so very
(24:39):
important, for women in midlifebecause the best way to keep the
muscle that you have and to.
Keep the metabolic benefit ofthat muscle is to actively do
things, to use it and build it.
the recommendation is at leasttwo non-consecutive days a week,
(25:00):
doing 30 to 60 minutes ofstrength training.
that can look like a lot ofdifferent things.
It does not have to look likeyou in the gym.
Pumping iron, although if youenjoy that, like it, it
definitely works.
my, I, I use Pilates as mystrength training and my
(25:20):
instructor knows that my goalis.
Is to use it as my strengthtraining.
you, there's lots of differentways you can do it.
You can use body weight, you canuse exercise bands.
You just have to be using thosemuscles.
one of the things that's gottenvery popular, is weighted vests.
There's zero data for that.
(25:42):
I wish, I wish it was so easythat you could just strap your
weight and fast on and go for awalk.
there's no data that it actuallyworks and it actually misses a
really important muscle group,which is like your upper core
and your, and your arms.
and.
I can't tell you how many littleold ladies I've seen who slip
(26:03):
and fall on the ice on theiroutstretched hand and they break
their wrist or they break theirhumerus or they break their
shoulder, or, and awaited vestisn't gonna help you with that.
So,
Lisa (26:13):
Because you're not using
Dr. Gillian Goddard (26:15):
'cause you're not using, you're right,
you're not carrying the weightwith your arms
Lisa (26:20):
I,
Dr. Gillian Goddard (26:21):
upper
Lisa (26:22):
so if anybody in my own neighborhood listens to this
podcast, they're gonna be like,but wait, we've seen you.
I do use a weighted vest for aparticular reason.
And it is because I sometimesjust wanna go for a long walk
and be out in nature because Ienjoy that and because, well,
it's good for my dog and I can'tget my heart rate up to the
(26:45):
point that I want it to be at orthe amount of time I'm spending.
I don't wanna just go for aleisurely walk and then have to
also work out later.
Like I want it to be my cardiofor the day.
And so I use a weighted vest toincrease my, my heart rate.
And so I just kind of wanna like
Dr. Gillian Goddard (27:01):
for that,
Lisa (27:02):
Like a post-it note.
what,
Dr. Gillian Goddard (27:05):
You're like, I'm don't think I'm
strength training.
Lisa (27:07):
yeah.
I, I have done, like, there's anold episode on my podcast, about
rocking, which is kind of like alittle bit more like a, like a
lot more weight.
I, I feel like that's probably alittle bit different category
than a, you know, a five oreight
Dr. Gillian Goddard (27:23):
Than what you usually see people out like
on your
Lisa (27:26):
Yes.
So.
Dr. Gillian Goddard (27:28):
trail?
Lisa (27:28):
Right.
So if you are using a weightedvest to increase your heart
rate, go for it.
Do it,
Dr. Gillian Goddard (27:36):
we know that increasing your heart rate
is important, but it does notreplace your strength training.
Lisa (27:42):
Yeah.
And also you don't wear yourweighted vest to do deadlifts.
Like it's not doing any good.
Like, don't do that.
It's not, there's no use for it.
Just, just lift heavier if youneed more of a challenge.
Dr. Gillian Goddard (27:55):
Yep.
Agreed.
Lisa (27:57):
Okay.
All right.
So the other thing I thinkthat's confusing about these
guidelines, is when I am in thegym lifting, I take the rest
periods, right?
It's like my program, it's like,do these lifts and rest two
minutes, but then I'm in therefor, you know, 45 minutes.
All of those 45 minutes counttowards this 30 to 60 minute
(28:18):
recommendation.
Even though some of thoseminutes I'm standing around.
Dr. Gillian Goddard (28:22):
Yes, I know it feels really weird to be
like.
To be like I, it's a 45 minuteworkout and I didn't exercise
for all of those 45 minutes.
I think there's a certain likesubset of us who are like rule
followers and wanna like get thegold star that we're like, that
doesn't feel quite right.
(28:42):
It is, it is.
The guideline does not say youdon't get to rest.
Lisa (28:47):
Okay.
Yeah.
Well, and I think too, a lot ofus come from the, little bit,
you know, cardio bunny, steparo.
I mean, I started working outfor like, my first experience
with like regular working outwas like step aerobics.
Dr. Gillian Goddard (29:03):
Right,
Lisa (29:03):
And so, you know, it's like you're working out the
whole time, and so strengthtraining feels really strange
when you've been doing that fora long, long, long time.
Dr. Gillian Goddard (29:14):
Yeah.
Yeah.
And I think, I think some ofthat is generational.
I think you and I are of thegeneration that was like cardio,
cardio, cardio, cardio.
And then like a year ago we werelike, oh, maybe we should
strength train.
Lisa (29:28):
Yeah.
Yes.
So, okay, good.
So yes, it feels like we know,we know everyone's talking about
this, but it's, it's because itreally is clear in the research,
like it's really clear for, formidlife women strength training
is key.
And, and what's sad is you can'tlike, not do your cardio though.
(29:51):
Like, I'm still, like, I'm stilldoing those long walks.
I'm still like in the pool, I swstill swim laps like.
So we just need to balance ourcardio with some strength
training.
Dr. Gillian Goddard (30:03):
That's correct.
We need cardio because we, Imean, it's really important for
your cardiovascular health, foryour blood pressure, and you
know, your heart.
It's, it's really important.
And so yes, we're askingeverybody to fit in an extra
Lisa (30:18):
Yeah.
Dr. Gillian Goddard (30:19):
more stuff.
Lisa (30:20):
Yeah.
okay.
So we're hoping that this sortof mitigates the weight, the
weight gain, but it doesn'treally work for everyone as far
as some of us are still gonnasee some weight gain around this
time.
I can't tell you how many timesI have seen a client who tells
me like.
Well, I guess I would say I'mabout half and half.
(30:41):
Some of my clients come to meand say they struggled with
their weight their whole lives,and other clients come to me and
say, I've never struggled withmy weight until I turned 40,
until I turned, you know, 38,45, all of just right in this
mid range.
And so despite feeling likewe're doing everything right,
we're eating the fiber andwe're, you know, counting the
(31:03):
protein grams and all of that,sometimes.
It feels like we're stillgaining weight, so what are the
options at that point?
What are we doing wrong?
And, you know, in the, like,what else can be done and, and
what would you recommend?
Dr. Gillian Goddard (31:19):
Yeah, I mean, I think one of the things
that's really tricky here is alot of the patients that I see
in my office, They're prettywell educated about their diet.
There may be some, some changesthat they can make, but There's
not any low hanging fruit.
They are really doing the work.
And for a long time we weretaught, this is literally a
(31:43):
board question on the endocrineboards, that if a patient is not
losing weight, if they create acaloric deficit.
It means that they'remiscalculating their calories or
lying or eating more than theythink they are.
And in my experience, thatanswer should be wrong.
(32:06):
It's not.
That's the, that's supposedlythe correct answer, but.
There's so much more going onthat we don't understand about
weight that isn't calories inand calories out.
and, genetics are a hugecomponent.
and, and metabolic syndrome.
And you know, we used to say,well, weight gain causes
(32:26):
metabolic syndrome.
It's becoming more and moreclear that weight gain and
metabolic syndrome are caused bythe same thing.
That is probably an interactionof our genes with our
environment.
and so I think.
You know, sure.
If, if you're eating poorly,then, then changing your diet
(32:46):
can be really helpful.
And I do think sometimes peopleare eating a lot more starch and
carbs than they realize theyare.
And a lot less protein and fiberthan they realize they are.
and so making that shift can behelpful.
Lisa (33:02):
And starting a food, I mean a food journal.
This is like, I preach on thisall the time, like just start
writing it down.
Like you don't even have to havean app.
You don't have to be enteringand, and calculate, like
weighing and measuringeverything.
Just write down what you'reeating.
It'll give you a really clearpicture of like.
Oh yeah.
I really didn't eat a vegetabletoday.
You don't need to weigh andmeasure all of your bread to
(33:22):
notice that there wasn'tanything green.
Dr. Gillian Goddard (33:25):
Yeah, I, I agree with you.
I actually track my intake dailyin a very casual way.
It's just, you know, I had.
I don't know.
I can't even think I had a saladwith chicken for lunch with the,
that's it.
Like, that's the whole entrysalad with chicken.
Lisa (33:42):
Mm-hmm.
Mm-hmm.
Dr. Gillian Goddard (33:44):
complex than that.
but it does, you look back on itand it makes you think like, oh
gosh, like I am really missingprotein today.
I should really focus on gettingsome protein in on my next, my
snack or my dinner or what haveyou.
it does raise your awarenessIt's not judging, like it's just
(34:04):
information.
It's not, I think sometimespeople feel like that you're
being very like punitive aboutit.
It's really, it's just data tohelp you make good decisions.
Lisa (34:16):
Yeah, we can't, we can't make any changes until we see
what's happening currently.
We can't possibly know what todo if we don't know what's
currently going on.
So, yeah.
So that's for starters, butcarry on with some of your other
ideas.
Dr. Gillian Goddard (34:31):
so there's a couple of different things
that people have done over theyears.
I think that, Medications ingeneral have been underutilized,
although I think that pendulumhas really swung in the last few
years.
Now, I would argue medicationsare probably overutilized, but
if you are someone who isfollowing a healthy diet.
(34:58):
And a, what is a healthy diet?
A diet that is low in refinedcarbohydrates and simple sugars,
high in fruit, vegetables,fiber, and lean proteins and
healthy fats.
It, it doesn't have to be morecomplicated than that either.
there's no like right diet, it'smore of a concept.
(35:20):
but if you're doing that andyou're exercising and nothing is
happening, or perhaps you'reeven gaining weight and you're
getting told that you have highblood pressure or you're
pre-diabetic, or yourcholesterol is rising, or you
have fatty liver, which are, Imean, all of these metabolic
changes that can come withmidlife.
(35:40):
This is really where I start tothink about medications.
and until fairly recently, wedidn't have a lot of great
options, but in the last 10years we've had GLP one receptor
agonists.
So, I mean these are, this isOzempic and Wegovy and Mojarro
(36:03):
and UND are slightly different,but kind of fall under the same
umbrella.
and the newer ones, the Ozempic,wegovy, mounjaro, Zep Bound are
much more effective than theolder ones.
But the concept of using thesemedicines for weight loss is, is
actually not new.
(36:25):
it really didn't start with KimKardashian.
Lisa (36:28):
Right.
Dr. Gillian Goddard (36:30):
have been using, have been using these
medicines for weight loss.
for more than a decade andoff-label for probably close to
two decades.
Lisa (36:40):
Yeah.
Well, GLP ones as a class wereinvented, I think 20 some years
ago.
Dr. Gillian Goddard (36:45):
first GLP one was approved in 2005.
It was called Byta.
It didn't do much for weightloss.
it was a diabetes medicine andthe reason you don't hear a lot
about it is'cause it was a twicea day injection, so it was hard
to even get diabetics to use it.
Lisa (37:00):
Yeah.
Goodness.
Dr. Gillian Goddard (37:02):
But not long after that.
In 2010, liraglutide wasapproved.
That's Victoza and Saxenda.
It was approved for diabetes in2010.
People were using it for weightloss basically from the minute
it was approved, and it actuallygot a weight loss indication in
2014.
So this idea is, is not new.
(37:24):
it's just been very widelyadopted.
Lisa (37:26):
Yes.
Which leads us to yes, they areexcellent.
Very useful in midlife.
lot of combinations that we'reseeing, like you're on hormone
replacement therapy and you'reon a GLP one can be very helpful
for midlife weight gain.
As opposed to someone who,suffers with a disease of
obesity who will likely be on aGLP one for their entire life.
(37:50):
It's my understanding that thosethat struggle with just some
midlife, like just in the lastcouple years, might be able to
use it more short term.
Dr. Gillian Goddard (37:59):
Yeah, that's my experience too.
I find that.
You know, the, the people whoreally got some midlife weight
gain and maybe it crept on andthey kind of, I feel like I, I
see this woman a lot.
She comes in, she's maybe earlyfifties, and she almost didn't
(38:19):
notice at first that because itwas, it's so insidious.
It's like a couple pounds, acouple pounds, a couple pounds
until you've gained 20 pounds.
and.
And oftentimes those women.
Have healthy habits or by thetime they get to me, they have
healthy habits.
They've already seen, someone tohelp them with their diet.
(38:43):
those people tend, those womenin particular tend to do quite
well with GLP ones and I oftenhave my patients come off of
them.
the one exception to that iswomen who.
had gestational diabetes andthen have started to develop
some blood sugar changes inmidlife.
a lot of those women tend toneed to stay on GLP one's longer
(39:06):
term, not for weight, but forblood sugar management to avoid
getting diabetes.
And they have been proven tosignificantly reduce your risk
of getting diabetes if you'repre-diabetic.
Lisa (39:19):
So, and that's an interesting feature about GLP
ones.
It's not just, they don't justwork by suppressing your
appetite.
There's, there's other o otherthings as, as the layman and me,
it's going to, she'll tell uswhat the other things are, but
there's other things that theydo to help with the metabolism.
Is that correct?
Dr. Gillian Goddard (39:39):
Absolutely.
So I actually think that theappetite suppressant effects are
some of the least importantthings that they do, especially
for people who are alreadyfollowing a fairly, a fairly
healthy diet.
They, they will reduce intake,particularly at first because
you just feel full faster andyou stay feeling full longer.
(40:01):
but they also, they.
They make your body moresensitive to insulin.
And insulin as a hormone doesn'tjust so it's main thing that
everybody thinks of it for isthat it helps your cells take up
sugar from your blood, so ithelps keep your blood sugar
normal and it helps your fatcells and muscle cells take up
sugar.
And your lip.
(40:22):
but insulin has signaling inyour brain, in your satiety
centers, insulin tells yourbody, tells your brain that
you're hungry and that you wantcarbohydrates.
And so if you can reduce insulinresistance, you actually see.
Your central drive for hungerand cravings reduced.
(40:45):
It also changes what you do withsugar when you do consume it.
So when your insulin levels arehigh, you preferentially take up
sugar and store it in yourmidsection is fat, which we've
already talked about isparticularly bad for us from an
overall health perspective.
and instead you're able toutilize that carbohydrate for,
(41:09):
for, ener like physical activityfor your brain.
and so you're not needing toconsume carbohydrates.
You're not on this rollercoaster of eat carbohydrates.
They all get taken up by mymidsection and turned into fat,
and my blood sugar drops, andthen I feel.
Hungry and I crave carbs andthen I get back on the
(41:30):
rollercoaster.
So it really helps you even outthose blood sugars so that
you're not constantly feelingthe need to consume those carbs
just to kind of maintain, tokeep yourself feeling okay.
and the rollercoaster feelscrummy.
So a lot of times people saythey feel so much better when
they're on these medicines'causethey didn't even realize that
(41:53):
they were on that sort of.
Rollercoaster ride from the, youknow, the minute they started
eating when they got up in themorning.
So, it also slows gut transittimes, not just out of your
stomach, but into your gut andhow carbohydrates get absorbed
from your gut into yourbloodstream.
And all of those things havesignificant impacts on why they
(42:15):
work.
They've actually done somestudies.
I actually think these are,nobody ever talks about these
studies, but I really like them.
So anytime you make a drug thatblocks a receptor or, or turns
on a receptor, so in this casethese drugs turn on a receptor.
They act like the hormone GLPone, which is a hormone we all
have in our bodies.
they act like that hormone andthey bind to these receptors.
(42:39):
Anytime you make a drug thatworks that way, one of the
potential downsides is that thecells just start making more of
those receptors.
And so they've actually lookedat the body and looked at
different tissue types to seehow they respond to GLP ones.
And our gut does upregulate ourreceptors.
So when you start taking a GLPone, you might feel really
(43:01):
nauseated.
You might get really constipateconstipated.
then the receptors upregulate,so there's more GLP one
receptors and those side effectsgo away.
That's also why sometimespeople.
Panic because they aren'tgetting that real big sense of
fullness anymore.
but the other thing, but thenwhen they look at the brain and
(43:22):
our brains, the receptors don'tchange.
And so all the effects aroundsatiety in the brain and
cravings in the brain are notchanging,
Lisa (43:31):
and the food noise
Dr. Gillian Goddard (43:32):
Yeah, the food noise is amazing.
Yeah.
Lisa (43:35):
Yeah.
So that's why, the protocol isto continue to go up in dose
because the receptors increase.
Dr. Gillian Goddard (43:42):
protocol is to continue to go up in dose
because when you do, I'm not abig fan of the protocol.
when you do a clinical trial,your goal is to show that the
medication is as effective asyou possibly can in the shortest
possible time, because your goalis to have the data that you
need to go to the FDA and say.
(44:04):
Look, our drug works approve usso that we can start selling it
and making back our money.
pharmaceutical companies are.
businesses, there's no doubtabout that.
and so when they did thesetrials for, with both wiggle Ovy
and Zeep, they had very strictprotocols around, up, up,
titrating the dose.
(44:24):
And if you couldn't tolerate theup titration, they, you were out
of the trial essentially.
and it was because they wantedto get the biggest effect
possible in a reasonable amountof time.
I actually think.
People.
Can titrate up the dose muchmore slowly, and we would see a
lot fewer complications withthese medications if people did.
(44:47):
I usually only increase the doseif people aren't losing about a
pound a week.
Depending on patient's sideeffects profile.
So if someone's losing moreslowly than a pound a week or
they're having a lot of sideeffects, we may decide to
increase or, or not increase thedose based on that.
and so I have patients who areon very middling doses who have
(45:10):
done incredibly well withoutgoing on a very high dose.
I think it.
Lisa (45:14):
another feature of pharmaceuticals, which is to use
the lowest possible dose to getthe effect that you want, which
really, although that doesn'tmake the money.
And get it to the DA veryquickly.
It, it is the safest route.
Yeah.
Dr. Gillian Goddard (45:29):
Yeah, I mean, I just think that there's,
if you are getting the desiredeffect,
Lisa (45:35):
Mm-hmm.
Dr. Gillian Goddard (45:35):
why would you increase the dose?
It just doesn't make any senseto me.
You're all you're gonna do isget more side effects.
You're not necessarily going toget a bigger effect.
And in, in real life, we are notlimited to the 72 weeks or
whatever it was that most ofthese trials were.
(45:56):
You can be on these medicinesfor an unlimited period of time
for as long as you need'em.
And so, you know, I always.
You read about all the horribleside effects that people are
having, especially vomiting.
I always tell my patients, ifyou're vomiting, I wanna know
about it.
You should not.
You can be nauseated.
You should not be vomitingbecause that is a sign that
(46:17):
you're increasing the dose tooquickly.
Lisa (46:19):
I, I had a client that w finally quit because of the
vomiting.
And I was, I just felt so badbecause there I couldn't do
anything'cause I'm not thedoctor, you know?
And I'm like, okay, but youshouldn't be vomiting.
Like, don't do that.
We gotta do, and finally theyjust quit the
Dr. Gillian Goddard (46:35):
I know.
I mean, that's what I worryabout.
Yeah.
I feel like the patients who arereally sensitive to these
medicines honestly often doreally, really well because
they're very sensitive to themand we don't need to ratchet up
the dose for them to get thedesire result, so
Lisa (46:56):
So as with any medication, there are people that these are
not right for, and so.
Dr. Gillian Goddard (47:02):
to popular belief.
Lisa (47:04):
Yeah, there, I've seen some videos of some people that
are like, I think in 10 yearseveryone will be on these'cause
they're good for everything.
Like, probably not, probably notgood for everything.
but who should not be considereda candidate?
Dr. Gillian Goddard (47:19):
I mean, I really think these medications
are for people who arestruggling with weight gain,
struggling with overweight andobesity.
Who and.
I would even add and arestarting to see the, have
metabolic effects that areassociated with obesity.
(47:40):
Those are the people who, whothese medicines are intended
for, and those are the peoplewho have been studied in
clinical trials with thesemedicines.
people who should not be onthese medicines are people who
are looking to lose a modestamount of weight, for.
Sort of more van vanitypurposes.
(48:02):
Look, I mean, I think there's,there's lots of us out there
who, you know, grew up in dietculture and feel like we, you
know, we could always loseanother five pounds.
These are not for that.
I also think that one of thethings that.
It really concerns me aboutpeople who are using these
(48:24):
medications inappropriately.
Women in midlife who are usingthese medications appro
inappropriately.
Is that it really?
Being too thin leads to problemslater in life too.
and so people who are thin andfrail also have health problems.
They may have different healthproblems.
(48:46):
and so I worry that people are,you know, gonna be trading one.
Like one thing for another, andwe need to recognize that
there's a point at which beingthinner is not better.
Lisa (49:06):
Yeah.
Yeah.
Perfect.
Okay.
This has been so good.
So good.
I've been delightful talking toyou.
I love, well, I just lovetalking to medical professionals
that really just know whatthey're doing.
So thank you so much for sharingyour wisdom.
So why don't you tell us moreabout, I know you have a
substack, we wanna, we'll putthe link, but tell us a little
(49:26):
bit about that, where people canfind you online.
Dr. Gillian Goddard (49:28):
Yeah, absolutely.
So, I have a substack called HotFlash.
it is not just aboutperimenopause and menopause,
it's about all women's hormonalhealth.
we talk about all differentkinds of things there.
And thatis@savvypatient.substack.com and
we'll make sure to get you thatlink.
And if you like what you readthere, stay tuned because I do
(49:50):
have a book coming out in springof 2026 where we will talk about
all things related to women'shormonal health and not just
estrogen and progesterone, butlike all the hormones.
So I think it's gonna be reallygreat.
Lisa (50:04):
Awesome.
Thank you so much.
And yes, we'll put those linksin the show notes have so thanks
again.
Dr. Gillian Goddard (50:10):
Oh, thanks so much for having me.
It's been really fun.
If this episode hit home for youand you want support working
through your perimenopause ormenopause symptoms and weight
gain, I'd love to talk with you.
I have two free resources rightnow that I know will help you
download the What to Do When YouOvereat Course.
If you find yourself overeatingtoo many times in a week to see
lasting weight loss, you'll getthe reset and recover guide and
(50:33):
figure out how to reduce yourover eats and not beat yourself
up about it.
Or you can grab my brand new GLPone Success Starter Kit.
This is for anyone already onGLP ones, or maybe you're just
GLP one Curious, but you don'thave any support or structure
around what to do.
Your doctor knows how to writethe prescription, but she isn't
equipped to support you day today, and that's what a coach
does.
You can also schedule a freeconsult session to see if my
(50:55):
one-on-one coaching programs areright for you.
All the links are in the shownotes.
Remember, it's not just aboutthe food, it's about empowering
yourself with choices that trulyserve you.
Have a great week and as always,thanks for listening and sharing
the Eat Well Think Well LiveWell podcast.
This is the Eat Well Think WellLive Well podcast.
(00:02):
I am Lisa Salisbury and this isepisode 160 Midlife Metabolism
with Dr.
Jillian Goddard.
Welcome to eat well.
Well, the podcast for busy womenwho want to lose weight without
constantly counting, tracking,or stressing over every bite.
I'm Lisa Salsbury, a certifiedhealth weight loss and life
(00:24):
coach, and most importantly, arecovered chronic dieter here.
You'll learn to listen to yourbody and uncover the reasons
you're reaching for food.
When you're not truly hungry,freeing you to focus on a
healthier, more fulfillingapproach to eating.
Lisa (00:39):
welcome back to the Eat Well Think Well Live Well
podcast.
I am so excited to be talking toDr.
Jillian Goddard.
She's an endocrinologist and anadjunct assistant professor at
Grossman School of Medicine.
Did I get all that right?
Dr. Gillian Goddard (00:51):
Mostly, yeah,
Lisa (00:52):
Mostly.
Okay.
You correct me.
Let's, let's hear from you.
Introduce yourself a little bit.
Tell us about who you are andwhat you do.
Dr. Gillian Goddard (01:02):
Sure.
Absolutely.
So as you said, I'm anendocrinologist and a professor
at NYU.
uh, write a newsletter calledHot Flash, which is all about
women's hormonal health, notjust about menopause and
perimenopause, but sort ofeverything from puberty through
menopause, and I'm so excited tobe here.
Lisa (01:24):
Great.
Okay.
Well, as a lot of my listenersare in midlife, less of us in
puberty, it's like, what dopeople call it?
Like second puberty or,
Dr. Gillian Goddard (01:33):
Something like that.
And sometimes if you yourselfare in midlife, you live with
someone in puberty, so there'slots of crossover there.
Lisa (01:42):
Yes, I'm familiar with that.
I have two, two girls, so, um,17 and 20.
So yeah, we are definitely inthat crossover time.
So obviously the main feature ofperimenopause going into
menopause is the hormonalchanges.
That's what causes all of the,problems.
(02:04):
So, let's just talk about that,like a little bit of education
on how those hormonal changes ofperimenopause, like what
happens.
generally, and then specificallywe wanna talk about how those
affect our metabolism sincethat's, you know, a lot of what
we talk about on this podcast isweight loss and, things that
affect it.
Dr. Gillian Goddard (02:25):
Absolutely.
So.
I think the best way to thinkabout perimenopause is from the
point of view of your ovaries.
Women and girls are born withall the eggs that they will ever
have, and from your first periodonward, you are maturing eggs
and ovulating approximately oncea month, barring.
(02:49):
You know, events like pregnancy,and as we get into our,
typically into our late fortiesand early fifties, the numbers
of eggs that are left in ourovaries are starting to dwindle.
In addition to that, the way ourhormonal system works is the,
the, the young healthy, likebest quality eggs get ovulated.
(03:12):
First, and so again, by the timewe're in our late forties and
early fifties, not only arethere fewer eggs, but the
quality is lower.
And the reason that's
Lisa (03:22):
Sorry, I'm gonna interrupt you.
The body just naturally choosesthose.
Dr. Gillian Goddard (03:27):
kind of.
It's more that they kind ofraise their hand,
Lisa (03:31):
That's fascinating.
I did not know that.
Which is why we're more fertilewhen we're younger because of
the quality of the egg.
Fascinating.
Okay.
Carry on.
Dr. Gillian Goddard (03:41):
So those old low quality last kids picked
for the team, eggs that are leftin our ovaries in our forties
and fifties need a lot more.
Hormonal drive to get them tomature and prepare for
ovulation.
Um, and the hormone that doesthat is called follicle
(04:03):
stimulating hormone, FSH.
And so you need much, much moreFS, H to drive those eggs to.
And FSH also tells the ovariesto make estrogen.
And so what happens inperimenopause is you get these
big spikes in estrogen and thesebig drops in estrogen.
(04:23):
And that is a lot of what drivesthe symptoms that we are having,
during perimenopause and earlymenopause.
And then As the eggs get evenfewer by the time you're down
to, you know, under a thousandeggs at that point, sometimes it
takes so long to get an eggready to go that the wires get
(04:45):
crossed and you have a periodwithout ovulating.
That's called an anovulatorycycle and sometimes you might go
many months.
Without a period because you'renot ovulating.
'cause the eggs just can't getready quickly enough and be
ready to ovulate.
and then finally you run out ofeggs essentially, and you have
(05:07):
your last menstrual period.
And the ovaries kind of start tosay they're done and start to
shut down, but.
Our estrogen levels can stilloccasionally like spike up and
drop even after our lastmenstrual period.
And it is actually not therising estrogen, but really the
dropping estrogen that tends tocreate a lot of the symptoms
(05:27):
that we have in perimenopause.
The classic ones that peoplethink of, like hot flushes,
night sweats, and sleepdisruption.
But the other thing that happensis our estrogen levels drop and
our androgen levels, those arehormones that we typically
associate with men liketestosterone.
Our androgen levels oftentimesstay about the same, and so
(05:50):
estrogen levels drop, butandrogen levels stay the same.
So the balance, the ratiobetween androgen levels and
estrogen shifts towardandrogens.
And androgens promote weightgain in our midsection around
our organs.
Estrogen promotes weight gainaround our hips, thighs, and in
(06:14):
our breasts.
and so we get this shift from asort of weight gain more in the
hips and thighs to this weightgain in the midsection.
And the, that's super importantfor everything that happens to
us metabolically after that,because it's weight gain in the
midsection that changes how wemetabolize carbohydrates.
(06:37):
That changes, you know, How wellour body is able to use
carbohydrates and how muchinsulin we need to use
carbohydrates.
it also has some effects onmuscle mass.
So, on average women lose abouta pound to two pounds of muscle
(06:59):
mass during the perimenopausaltransition.
And if you gain fat in yourmidsection and you lose muscle
mass, you pick up some insulinresistance and you lose some
basal metabolic rate, so yourmetabolism slows, you're burning
less calories at rest.
and when you consumecarbohydrates, you're needing a
(07:20):
lot of insulin to utilize them,and so they preferentially get
stored in your midsection, whichcauses more weight gain in your
midsection, and then you justend up on this vicious cycle
where you become more insulinresistant, you gain more weight
in your midsection.
On and on and on.
Un until you break the cycle.
Doesn't it sound fun?
Lisa (07:40):
Okay.
Yeah.
Oh, dear.
Okay.
so I have questions.
Dr. Gillian Goddard (07:45):
Sure.
Lisa (07:46):
First of all, and this is actually just like a curiosity
question, not really even onthis topic.
You said when you get down tounder a thousand eggs, I used to
think, and I I might be like, Iwas today years old when I
learned this.
I used to think that you had theexact, like the number of eggs
and you released one per cycle.
But I learned recently thatthat's not exactly true.
(08:07):
'cause I'm thinking a thousandeggs, that's, you still got
plenty, like that's a lot ofcycles.
But
Dr. Gillian Goddard (08:12):
That's three years or something, right?
More than,
Lisa (08:16):
more, yeah.
Way.
So how, how many eggs do youtypically release?
Because a thousand eggs seemslike still a lot left.
Dr. Gillian Goddard (08:23):
So you start, most women start life
with something in theneighborhood of.
600,000 eggs, which sounds likeyou should be able to ovulate
for like a millennium.
But what actually happens is awhole group of eggs, start down
the process of maturation.
(08:44):
So at the beginning, you mighthave 50 or a hundred eggs
starting down this process.
But over the course of thematuration process, many of them
will die off and there's achemical process that occurs
within the ovary so that some ofthose eggs spontaneously, like
(09:05):
they stop growing and they, theykind of just.
Involute and get taken care ofby the, the body's system for
cleaning up old cells so thatyou get to, you end up with a
dominant follicle, and thatdominant follicle is the
follicle that ovulates, so youonly ovulate typically one egg a
month.
(09:26):
There are exceptions to that.
Sometimes some women ovulate twoeggs per month, and that's, you
know.
Lisa (09:32):
get twins.
Dr. Gillian Goddard (09:34):
Outside of IVF?
Yes, that, that's one of thenatural ways we get twins.
but most of the time you ovulateonly one egg, but many more eggs
are starting down that process.
So a thousand eggs is, you know,enough to get you through three
to five years probably.
Lisa (09:53):
Okay.
Okay.
That makes, that makes a lotmore sense because I was like,
but how can you release morethan one egg?
We would have way more multiplebirths.
But it's not that you releasemore than one, it's just that,
more than that there's a bigOkay.
Ghost, you, you heard her?
I won't restate.
So that's, that's really just,that's just interesting.
I just like learning about thewomen's body.
(10:13):
So, Okay, so my next questionabout this, like estrogen versus
testosterone balance is that wehave seen a lot in, You know,
I'm sure a lot of my listenersare on Instagram and with a lot
of menopause influencers.
So there's a, a lot of push withhormonal replacement therapy,
which I am on, and I really, I'mthriving on, especially
(10:35):
progesterone at night.
I love that she's nodding.
If you're not watching video,she's nodding along so we can
talk about.
Dr. Gillian Goddard (10:42):
therapy is fantastic.
Lisa (10:44):
Okay, but why then is testosterone?
One of the things that I've beenrecommend, I, I've been on and
off of it.
I am, I'm like, I mostly becauseI'm not sure I'm seeing the
results for the cost and becausemy estrogen and progesterone are
like basically covered a hundredpercent by my insurance.
But testosterone, my doctorwon't prescribe the, the mail
(11:05):
version because that's an
Dr. Gillian Goddard (11:07):
by her insurance, even if she did.
Lisa (11:10):
Well, it's just a lot cheaper than the compounding
version that I have to chooseanyway, point being.
It's a little bit of a, of acost for me.
And so I have been kind of onand off about it and, but what
I'm kind of paranoid about, nowthat you've said this and I, I
just think people that might beon testosterone might think,
well, why would I want to be ontestosterone if that's gonna
(11:32):
cause weight gain around themiddle?
So how would that play into it?
Why would we be, you know,recommended to be on a
testosterone replacement?
Dr. Gillian Goddard (11:42):
I think this confuses a lot of people.
So I'll say a couple of thingsabout this.
Not everyone's testosteronestays the same in perimenopause.
Some people's testosteroneactually rises during the
perimenopause.
In early menopause, some womenstays approximately the same and
some women's testosteroneactually falls.
And so if your testosteronelevels are very low and you're
(12:04):
symptomatic because of that.
then adding testosterone may behelpful.
That said, the only thingtestosterone has really been
studied for in women is,hypoactive sexual desire
disorder, which put much moresimply is low desire for sex and
difficulty getting aroused.
Lisa (12:25):
Loss of libido.
Yeah.
Dr. Gillian Goddard (12:27):
Yeah.
Not really wanting to have sexand when you do not feeling all
that satisfied by it.
And that's actually the onlything that testosterone has
really been proven in theliterature to do.
but you're right, there's notestosterone that has been
approved in a formulation dosedfor women.
And so your two options arecompounded testosterone, which
(12:50):
you get at a compoundingpharmacy.
The big challenge, there's twobig challenges there.
One is cost, as you mentioned,and the other is that
compounding pharmacies vary agreat deal in their, quality
control and reliability.
They're not, the way they'relicensed is very variable.
or you can use testosteroneformulated for men and just use
(13:13):
really tiny doses of it, which
Lisa (13:15):
Yeah.
Dr. Gillian Goddard (13:16):
It's messy and, and inelegant and not, but
I have lots of patients who doit because it is quite a bit
cheaper.
there has been talk aboutgetting a product for women on
the market, but I think we're along ways away from that,
happening partly because apharmaceutical would have to get
behind it
Lisa (13:35):
yeah.
Yeah.
And a lot more studies donebecause, so.
Dr. Gillian Goddard (13:39):
studies.
Lisa (13:41):
So if someone were like, okay, but I do have, you know,
the loss of libido, it bothersme.
I can't orgasm.
I'd really like to try it.
Are they risking midsectionweight gain by using it?
Dr. Gillian Goddard (13:54):
Not if you're careful with the dosing.
So
Lisa (13:58):
Mm-hmm.
Dr. Gillian Goddard (13:59):
one, so one thing that can happen when you
take testosterone is you can getthe, make the doses very high.
So they're higher than like atypical woman's.
testosterone would be, and thereyou may get into trouble with
side effects, including someweight gain.
if you're getting, taking thelevels and you're moving them
from sort of low to, you know,more middle of the road for a
(14:22):
typical female level, you don'ttend to see weight gain issues
with that.
And the question is sort of why,right?
some of this is because there's.
Other factors at play that we'rejust starting to understand,
around FSH and the role of FSHoutside of the ovary.
(14:42):
So I told you FSH tells theovary to mature an egg and make
estrogen.
there's some.
A growing body of literature, Ithink is the way I would put it.
about FSH and FSH receptorsoutside of the ovary having
potentially being related tometabolic changes we see.
Women in perimenopause becausewhat happens to FSH in
(15:07):
perimenopause and menopause isthat it can rise very high.
and so FSH may actually beacting in other parts of our
body, including in this case,importantly the adrenal gland,
to have impacts on.
Our metabolism, our bloodpressure, our cholesterol, that
are mitigated by that hormonedirectly, and not by this
(15:28):
mismatch between estrogen andtestosterone.
Lisa (15:33):
Okay, so it's my understanding that.
Menopause hormone replacementtherapy or HRT or however you
want to call it, is not ametabolism or weight loss fix.
We don't get prescribed thesethings because we've gained
weight.
How though, could they help inweight maintenance or are they a
(15:55):
factor?
Because I've heard people sayoh, well I'm gonna get on, HRT
and try and lose some weight,and I'm like, those are two.
Separate things, and yet ourhormones are connected to our
metabolism.
So what role does that have?
Dr. Gillian Goddard (16:11):
So that's actually why people got
interested.
It in, in FSH as a potentialmitigating factor with all of
this to begin with is peopledidn't understand.
If you give women back, thereason we don't use estrogen to
help women in menopause andperimenopause lose weight is
because it doesn't work.
there's lots of data to showthat it doesn't work,
Lisa (16:32):
And it works for a lot of other things, like
Dr. Gillian Goddard (16:35):
it's great for hot licious, night sweats,
Lisa (16:38):
great.
Dr. Gillian Goddard (16:39):
brain fog, muscle aches, joint pain, your
hormone replacement will helpyou with all of that, but it
does not help women lose weight.
and so the question was, well,why doesn't it?
And, and we think that this iswhere FSH comes into play
because when you take hormonereplacement therapy, you do not
typically suppress.
(17:00):
Your FSH, so you don't typicallyget a lower FSH from taking
estrogen.
and so that may be part of theissue.
However, I do think women whoare taking hormone replacement
for other indications sometimessee that their metabolic changes
(17:21):
are less dramatic.
and so They may not lose weight,but they also may not gain as
much weight as the typical womandoes in in perimenopause.
Lisa (17:33):
Yeah.
Possible though, that that couldbe a correlation factor because
people that are pursuing HRT arealso those that are living
typically gonna be living a morehealthy lifestyle.
They're typically the ones thatare gonna going to already be
exercising and, and eating thethings and, right.
So it's, it's a confusing,
Dr. Gillian Goddard (17:55):
it is, and we don't have nearly enough.
You know, clinical trial data,like randomized clinical trial
data, around any of these issuesbecause for 20 years we didn't
do clinical trials, inperimenopausal women with
hormone replacement therapy,because of the women's health
initiative.
And so we're just starting tosee those types of clinical
(18:16):
trials really get going again.
And so all we really have areobservational studies from the
last 20 years or so, which.
You cannot sort out causationversus correlation with an
observational study.
Unfortunately,
Lisa (18:33):
So, I mean, percentage wise, really, except for from
what I, I understand the last,you know, handful of years, the
percentage of women on HRT hasbeen so low.
Dr. Gillian Goddard (18:45):
between 19 or between 20, 24, which was the
year that the Women's HealthInitiative study was paused,
and.
Basically women throughout theirHRT on, on mass, like in a
single day, because of the mediacoverage of the study.
between that,
Lisa (19:04):
20, 24 was just last year.
Dr. Gillian Goddard (19:06):
2004, sorry.
Between 2004 and 2020.
Sorry, I misspoke.
Lisa (19:12):
okay.
Dr. Gillian Goddard (19:12):
So in those, in, in those years
between when the Women's HealthInitiative study came out and
2020.
Four to 5% of women were takinghormone replacement therapy.
80% of women have hot flushesand night sweats, and four to 5%
of women were taking hormonereplacement therapy.
So when people talk about like,oh, we should be using it for
(19:35):
this and that and the other, I'mlike, how about we just start by
treating the symptoms that womenare having that we know it works
for?
Lisa (19:42):
Yeah.
Well, and another one I'm superpassionate about, like all my
friends know, I'm like, are, areyou on vaginal estrogen though?
Because everyone can be onvaginal estro.
And this is kind of off topicfrom what we're, what you and I
are trying to talk about with.
you know, metabolism and, andthese changes.
But honestly, anytime I can plugthat, like, it's so safe.
(20:03):
It's a microdose and
Dr. Gillian Goddard (20:06):
safe For women who have had estrogen
receptor positive breast cancer,it does not affect breast cancer
risk.
Lisa (20:12):
yeah, like I just want you to say that again.
Like, we have an endocrinologisthere telling us it is safe.
It
Dr. Gillian Goddard (20:22):
Vaginal, estrogen is safe for everyone.
We even now think it's safe forthe vast majority of women who
had estrogen receptor positivebreast cancer.
Lisa (20:33):
Yeah.
Okay.
And why would a person want touse vaginal estrogen?
Dr. Gillian Goddard (20:41):
because vaginal dryness is very common
and can lead to a whole host ofundesirable symptoms, when our
vaginal va vaginal lining andour vulva and the muscles that
support our vagina and vulvadon't have estrogen, they dry
out.
(21:01):
When they dry out, they thin andthey stick together.
One of my patients once saidthat her vagina felt like two
pieces of Velcro being pulledapart when she moved.
you, you can start to getatrophies.
You can actually start to getbreakdown of the tissues and not
be able to.
Insert anything in the vagina, aspeculum, a finger, a penis, if
(21:26):
that's something that you'reinterested in doing.
So sex can become veryuncomfortable.
it disrupts the The flora, thebacteria that grow in the vagina
so you can get yeast infections.
And then my all time favorite isthat the slumping down of the
vagina actually pulls the anusand the urethra closer together.
(21:48):
So it's easier to get urinarytract infections too, because
you get bacteria from the anusinto your urethra.
So.
And then your, your, I mean, Icould go on and on.
Your
Lisa (22:00):
Yeah, I know.
I.
Dr. Gillian Goddard (22:02):
press on your bladder and
Lisa (22:04):
It's, it just, it affects the entire area down there.
It's not just for vaginaldryness, although that is, I,
I've gotten to be almost sosensitive that I'm, I, because
it's just a twice a week.
And so I can tell like when it'stime, like my body will tell me
it's time.
Don't forget your dose today.
but even, you know, if,especially.
(22:25):
It's so cheap.
So if you are having troublelike with in, with intercourse
and you can't do testosterone,like start with vaginal
estrogen, that will increaseyour comfort.
To the point that you, you mightsolve your problem there.
I mean, I don't know.
You know, it depends on whatyour problem is, but if it's
just a comfort issue, start withvaginal estrogen because it's
(22:46):
dirt cheap and, will really makesuch big difference.
So anyway, I, I just lovetalking about HRT, like
sometimes I think I shouldswitch over to a menopause
podcast, but I, it's just, itjust makes such a difference
and,
Dr. Gillian Goddard (22:59):
big fan.
Lisa (23:00):
So yes, we could talk a long time, but let's, let's get
back to like the, the metabolicchanges that we wanted to
discuss.
So we've got these metabolicchanges and all of these
hormones are kind of doing whatthey do in this midlife time,
and we get that resulting changein body composition, so we get a
little bit more fat.
(23:21):
A little bit less muscle, one totwo pounds of muscle.
Doesn't sound like a whole lot,but is this happening?
Like every year we're losing oneto two pounds of muscle or every
decade.
Like, and what can we do aboutthat?
Dr. Gillian Goddard (23:33):
So the best data that we have around around.
Body composition changes inperimenopause really
specifically looks at the fiveyears before the last menstrual
period and the five years afterthe last menstrual period.
So a 10 year time with yourperiod, your last period, is
that the midpoint of that time.
(23:55):
And so that one to two pounds ofmuscle is, over that 10 year
period.
People do tend to lose muscle asthey age too.
So men lose muscle as they age.
Also, not just women, it tendsto be more gradual.
but you, it, it only gets harderand harder to maintain muscle
(24:19):
mass as we age because itbecomes such a, again, like so
many of these things, it becomessuch a cycle because then.
If it's hard to use yourmuscles, then you don't use
them.
And the less you use them, theless you will have.
So this is where, and I knoweveryone's talking about this
right now, but this is wherestrength training is so very
(24:39):
important, for women in midlifebecause the best way to keep the
muscle that you have and to.
Keep the metabolic benefit ofthat muscle is to actively do
things, to use it and build it.
the recommendation is at leasttwo non-consecutive days a week,
(25:00):
doing 30 to 60 minutes ofstrength training.
that can look like a lot ofdifferent things.
It does not have to look likeyou in the gym.
Pumping iron, although if youenjoy that, like it, it
definitely works.
my, I, I use Pilates as mystrength training and my
(25:20):
instructor knows that my goalis.
Is to use it as my strengthtraining.
you, there's lots of differentways you can do it.
You can use body weight, you canuse exercise bands.
You just have to be using thosemuscles.
one of the things that's gottenvery popular, is weighted vests.
There's zero data for that.
(25:42):
I wish, I wish it was so easythat you could just strap your
weight and fast on and go for awalk.
there's no data that it actuallyworks and it actually misses a
really important muscle group,which is like your upper core
and your, and your arms.
and.
I can't tell you how many littleold ladies I've seen who slip
(26:03):
and fall on the ice on theiroutstretched hand and they break
their wrist or they break theirhumerus or they break their
shoulder, or, and awaited vestisn't gonna help you with that.
So,
Lisa (26:13):
Because you're not using
Dr. Gillian Goddard (26:15):
'cause you're not using, you're right,
you're not carrying the weightwith your arms
Lisa (26:20):
I,
Dr. Gillian Goddard (26:21):
upper
Lisa (26:22):
so if anybody in my own neighborhood listens to this
podcast, they're gonna be like,but wait, we've seen you.
I do use a weighted vest for aparticular reason.
And it is because I sometimesjust wanna go for a long walk
and be out in nature because Ienjoy that and because, well,
it's good for my dog and I can'tget my heart rate up to the
(26:45):
point that I want it to be at orthe amount of time I'm spending.
I don't wanna just go for aleisurely walk and then have to
also work out later.
Like I want it to be my cardiofor the day.
And so I use a weighted vest toincrease my, my heart rate.
And so I just kind of wanna like
Dr. Gillian Goddard (27:01):
for that,
Lisa (27:02):
Like a post-it note.
what,
Dr. Gillian Goddard (27:05):
You're like, I'm don't think I'm
strength training.
Lisa (27:07):
yeah.
I, I have done, like, there's anold episode on my podcast, about
rocking, which is kind of like alittle bit more like a, like a
lot more weight.
I, I feel like that's probably alittle bit different category
than a, you know, a five oreight
Dr. Gillian Goddard (27:23):
Than what you usually see people out like
on your
Lisa (27:26):
Yes.
So.
Dr. Gillian Goddard (27:28):
trail?
Lisa (27:28):
Right.
So if you are using a weightedvest to increase your heart
rate, go for it.
Do it,
Dr. Gillian Goddard (27:36):
we know that increasing your heart rate
is important, but it does notreplace your strength training.
Lisa (27:42):
Yeah.
And also you don't wear yourweighted vest to do deadlifts.
Like it's not doing any good.
Like, don't do that.
It's not, there's no use for it.
Just, just lift heavier if youneed more of a challenge.
Dr. Gillian Goddard (27:55):
Yep.
Agreed.
Lisa (27:57):
Okay.
All right.
So the other thing I thinkthat's confusing about these
guidelines, is when I am in thegym lifting, I take the rest
periods, right?
It's like my program, it's like,do these lifts and rest two
minutes, but then I'm in therefor, you know, 45 minutes.
All of those 45 minutes counttowards this 30 to 60 minute
(28:18):
recommendation.
Even though some of thoseminutes I'm standing around.
Dr. Gillian Goddard (28:22):
Yes, I know it feels really weird to be
like.
To be like I, it's a 45 minuteworkout and I didn't exercise
for all of those 45 minutes.
I think there's a certain likesubset of us who are like rule
followers and wanna like get thegold star that we're like, that
doesn't feel quite right.
(28:42):
It is, it is.
The guideline does not say youdon't get to rest.
Lisa (28:47):
Okay.
Yeah.
Well, and I think too, a lot ofus come from the, little bit,
you know, cardio bunny, steparo.
I mean, I started working outfor like, my first experience
with like regular working outwas like step aerobics.
Dr. Gillian Goddard (29:03):
Right,
Lisa (29:03):
And so, you know, it's like you're working out the
whole time, and so strengthtraining feels really strange
when you've been doing that fora long, long, long time.
Dr. Gillian Goddard (29:14):
Yeah.
Yeah.
And I think, I think some ofthat is generational.
I think you and I are of thegeneration that was like cardio,
cardio, cardio, cardio.
And then like a year ago we werelike, oh, maybe we should
strength train.
Lisa (29:28):
Yeah.
Yes.
So, okay, good.
So yes, it feels like we know,we know everyone's talking about
this, but it's, it's because itreally is clear in the research,
like it's really clear for, formidlife women strength training
is key.
And, and what's sad is you can'tlike, not do your cardio though.
(29:51):
Like, I'm still, like, I'm stilldoing those long walks.
I'm still like in the pool, I swstill swim laps like.
So we just need to balance ourcardio with some strength
training.
Dr. Gillian Goddard (30:03):
That's correct.
We need cardio because we, Imean, it's really important for
your cardiovascular health, foryour blood pressure, and you
know, your heart.
It's, it's really important.
And so yes, we're askingeverybody to fit in an extra
Lisa (30:18):
Yeah.
Dr. Gillian Goddard (30:19):
more stuff.
Lisa (30:20):
Yeah.
okay.
So we're hoping that this sortof mitigates the weight, the
weight gain, but it doesn'treally work for everyone as far
as some of us are still gonnasee some weight gain around this
time.
I can't tell you how many timesI have seen a client who tells
me like.
Well, I guess I would say I'mabout half and half.
(30:41):
Some of my clients come to meand say they struggled with
their weight their whole lives,and other clients come to me and
say, I've never struggled withmy weight until I turned 40,
until I turned, you know, 38,45, all of just right in this
mid range.
And so despite feeling likewe're doing everything right,
we're eating the fiber andwe're, you know, counting the
(31:03):
protein grams and all of that,sometimes.
It feels like we're stillgaining weight, so what are the
options at that point?
What are we doing wrong?
And, you know, in the, like,what else can be done and, and
what would you recommend?
Dr. Gillian Goddard (31:19):
Yeah, I mean, I think one of the things
that's really tricky here is alot of the patients that I see
in my office, They're prettywell educated about their diet.
There may be some, some changesthat they can make, but There's
not any low hanging fruit.
They are really doing the work.
And for a long time we weretaught, this is literally a
(31:43):
board question on the endocrineboards, that if a patient is not
losing weight, if they create acaloric deficit.
It means that they'remiscalculating their calories or
lying or eating more than theythink they are.
And in my experience, thatanswer should be wrong.
(32:06):
It's not.
That's the, that's supposedlythe correct answer, but.
There's so much more going onthat we don't understand about
weight that isn't calories inand calories out.
and, genetics are a hugecomponent.
and, and metabolic syndrome.
And you know, we used to say,well, weight gain causes
(32:26):
metabolic syndrome.
It's becoming more and moreclear that weight gain and
metabolic syndrome are caused bythe same thing.
That is probably an interactionof our genes with our
environment.
and so I think.
You know, sure.
If, if you're eating poorly,then, then changing your diet
(32:46):
can be really helpful.
And I do think sometimes peopleare eating a lot more starch and
carbs than they realize theyare.
And a lot less protein and fiberthan they realize they are.
and so making that shift can behelpful.
Lisa (33:02):
And starting a food, I mean a food journal.
This is like, I preach on thisall the time, like just start
writing it down.
Like you don't even have to havean app.
You don't have to be enteringand, and calculate, like
weighing and measuringeverything.
Just write down what you'reeating.
It'll give you a really clearpicture of like.
Oh yeah.
I really didn't eat a vegetabletoday.
You don't need to weigh andmeasure all of your bread to
(33:22):
notice that there wasn'tanything green.
Dr. Gillian Goddard (33:25):
Yeah, I, I agree with you.
I actually track my intake dailyin a very casual way.
It's just, you know, I had.
I don't know.
I can't even think I had a saladwith chicken for lunch with the,
that's it.
Like, that's the whole entrysalad with chicken.
Lisa (33:42):
Mm-hmm.
Mm-hmm.
Dr. Gillian Goddard (33:44):
complex than that.
but it does, you look back on itand it makes you think like, oh
gosh, like I am really missingprotein today.
I should really focus on gettingsome protein in on my next, my
snack or my dinner or what haveyou.
it does raise your awarenessIt's not judging, like it's just
(34:04):
information.
It's not, I think sometimespeople feel like that you're
being very like punitive aboutit.
It's really, it's just data tohelp you make good decisions.
Lisa (34:16):
Yeah, we can't, we can't make any changes until we see
what's happening currently.
We can't possibly know what todo if we don't know what's
currently going on.
So, yeah.
So that's for starters, butcarry on with some of your other
ideas.
Dr. Gillian Goddard (34:31):
so there's a couple of different things
that people have done over theyears.
I think that, Medications ingeneral have been underutilized,
although I think that pendulumhas really swung in the last few
years.
Now, I would argue medicationsare probably overutilized, but
if you are someone who isfollowing a healthy diet.
(34:58):
And a, what is a healthy diet?
A diet that is low in refinedcarbohydrates and simple sugars,
high in fruit, vegetables,fiber, and lean proteins and
healthy fats.
It, it doesn't have to be morecomplicated than that either.
there's no like right diet, it'smore of a concept.
(35:20):
but if you're doing that andyou're exercising and nothing is
happening, or perhaps you'reeven gaining weight and you're
getting told that you have highblood pressure or you're
pre-diabetic, or yourcholesterol is rising, or you
have fatty liver, which are, Imean, all of these metabolic
changes that can come withmidlife.
(35:40):
This is really where I start tothink about medications.
and until fairly recently, wedidn't have a lot of great
options, but in the last 10years we've had GLP one receptor
agonists.
So, I mean these are, this isOzempic and Wegovy and Mojarro
(36:03):
and UND are slightly different,but kind of fall under the same
umbrella.
and the newer ones, the Ozempic,wegovy, mounjaro, Zep Bound are
much more effective than theolder ones.
But the concept of using thesemedicines for weight loss is, is
actually not new.
(36:25):
it really didn't start with KimKardashian.
Lisa (36:28):
Right.
Dr. Gillian Goddard (36:30):
have been using, have been using these
medicines for weight loss.
for more than a decade andoff-label for probably close to
two decades.
Lisa (36:40):
Yeah.
Well, GLP ones as a class wereinvented, I think 20 some years
ago.
Dr. Gillian Goddard (36:45):
first GLP one was approved in 2005.
It was called Byta.
It didn't do much for weightloss.
it was a diabetes medicine andthe reason you don't hear a lot
about it is'cause it was a twicea day injection, so it was hard
to even get diabetics to use it.
Lisa (37:00):
Yeah.
Goodness.
Dr. Gillian Goddard (37:02):
But not long after that.
In 2010, liraglutide wasapproved.
That's Victoza and Saxenda.
It was approved for diabetes in2010.
People were using it for weightloss basically from the minute
it was approved, and it actuallygot a weight loss indication in
2014.
So this idea is, is not new.
(37:24):
it's just been very widelyadopted.
Lisa (37:26):
Yes.
Which leads us to yes, they areexcellent.
Very useful in midlife.
lot of combinations that we'reseeing, like you're on hormone
replacement therapy and you'reon a GLP one can be very helpful
for midlife weight gain.
As opposed to someone who,suffers with a disease of
obesity who will likely be on aGLP one for their entire life.
(37:50):
It's my understanding that thosethat struggle with just some
midlife, like just in the lastcouple years, might be able to
use it more short term.
Dr. Gillian Goddard (37:59):
Yeah, that's my experience too.
I find that.
You know, the, the people whoreally got some midlife weight
gain and maybe it crept on andthey kind of, I feel like I, I
see this woman a lot.
She comes in, she's maybe earlyfifties, and she almost didn't
(38:19):
notice at first that because itwas, it's so insidious.
It's like a couple pounds, acouple pounds, a couple pounds
until you've gained 20 pounds.
and.
And oftentimes those women.
Have healthy habits or by thetime they get to me, they have
healthy habits.
They've already seen, someone tohelp them with their diet.
(38:43):
those people tend, those womenin particular tend to do quite
well with GLP ones and I oftenhave my patients come off of
them.
the one exception to that iswomen who.
had gestational diabetes andthen have started to develop
some blood sugar changes inmidlife.
a lot of those women tend toneed to stay on GLP one's longer
(39:06):
term, not for weight, but forblood sugar management to avoid
getting diabetes.
And they have been proven tosignificantly reduce your risk
of getting diabetes if you'repre-diabetic.
Lisa (39:19):
So, and that's an interesting feature about GLP
ones.
It's not just, they don't justwork by suppressing your
appetite.
There's, there's other o otherthings as, as the layman and me,
it's going to, she'll tell uswhat the other things are, but
there's other things that theydo to help with the metabolism.
Is that correct?
Dr. Gillian Goddard (39:39):
Absolutely.
So I actually think that theappetite suppressant effects are
some of the least importantthings that they do, especially
for people who are alreadyfollowing a fairly, a fairly
healthy diet.
They, they will reduce intake,particularly at first because
you just feel full faster andyou stay feeling full longer.
(40:01):
but they also, they.
They make your body moresensitive to insulin.
And insulin as a hormone doesn'tjust so it's main thing that
everybody thinks of it for isthat it helps your cells take up
sugar from your blood, so ithelps keep your blood sugar
normal and it helps your fatcells and muscle cells take up
sugar.
And your lip.
(40:22):
but insulin has signaling inyour brain, in your satiety
centers, insulin tells yourbody, tells your brain that
you're hungry and that you wantcarbohydrates.
And so if you can reduce insulinresistance, you actually see.
Your central drive for hungerand cravings reduced.
(40:45):
It also changes what you do withsugar when you do consume it.
So when your insulin levels arehigh, you preferentially take up
sugar and store it in yourmidsection is fat, which we've
already talked about isparticularly bad for us from an
overall health perspective.
and instead you're able toutilize that carbohydrate for,
(41:09):
for, ener like physical activityfor your brain.
and so you're not needing toconsume carbohydrates.
You're not on this rollercoaster of eat carbohydrates.
They all get taken up by mymidsection and turned into fat,
and my blood sugar drops, andthen I feel.
Hungry and I crave carbs andthen I get back on the
(41:30):
rollercoaster.
So it really helps you even outthose blood sugars so that
you're not constantly feelingthe need to consume those carbs
just to kind of maintain, tokeep yourself feeling okay.
and the rollercoaster feelscrummy.
So a lot of times people saythey feel so much better when
they're on these medicines'causethey didn't even realize that
(41:53):
they were on that sort of.
Rollercoaster ride from the, youknow, the minute they started
eating when they got up in themorning.
So, it also slows gut transittimes, not just out of your
stomach, but into your gut andhow carbohydrates get absorbed
from your gut into yourbloodstream.
And all of those things havesignificant impacts on why they
(42:15):
work.
They've actually done somestudies.
I actually think these are,nobody ever talks about these
studies, but I really like them.
So anytime you make a drug thatblocks a receptor or, or turns
on a receptor, so in this casethese drugs turn on a receptor.
They act like the hormone GLPone, which is a hormone we all
have in our bodies.
they act like that hormone andthey bind to these receptors.
(42:39):
Anytime you make a drug thatworks that way, one of the
potential downsides is that thecells just start making more of
those receptors.
And so they've actually lookedat the body and looked at
different tissue types to seehow they respond to GLP ones.
And our gut does upregulate ourreceptors.
So when you start taking a GLPone, you might feel really
(43:01):
nauseated.
You might get really constipateconstipated.
then the receptors upregulate,so there's more GLP one
receptors and those side effectsgo away.
That's also why sometimespeople.
Panic because they aren'tgetting that real big sense of
fullness anymore.
but the other thing, but thenwhen they look at the brain and
(43:22):
our brains, the receptors don'tchange.
And so all the effects aroundsatiety in the brain and
cravings in the brain are notchanging,
Lisa (43:31):
and the food noise
Dr. Gillian Goddard (43:32):
Yeah, the food noise is amazing.
Yeah.
Lisa (43:35):
Yeah.
So that's why, the protocol isto continue to go up in dose
because the receptors increase.
Dr. Gillian Goddard (43:42):
protocol is to continue to go up in dose
because when you do, I'm not abig fan of the protocol.
when you do a clinical trial,your goal is to show that the
medication is as effective asyou possibly can in the shortest
possible time, because your goalis to have the data that you
need to go to the FDA and say.
(44:04):
Look, our drug works approve usso that we can start selling it
and making back our money.
pharmaceutical companies are.
businesses, there's no doubtabout that.
and so when they did thesetrials for, with both wiggle Ovy
and Zeep, they had very strictprotocols around, up, up,
titrating the dose.
(44:24):
And if you couldn't tolerate theup titration, they, you were out
of the trial essentially.
and it was because they wantedto get the biggest effect
possible in a reasonable amountof time.
I actually think.
People.
Can titrate up the dose muchmore slowly, and we would see a
lot fewer complications withthese medications if people did.
(44:47):
I usually only increase the doseif people aren't losing about a
pound a week.
Depending on patient's sideeffects profile.
So if someone's losing moreslowly than a pound a week or
they're having a lot of sideeffects, we may decide to
increase or, or not increase thedose based on that.
and so I have patients who areon very middling doses who have
(45:10):
done incredibly well withoutgoing on a very high dose.
I think it.
Lisa (45:14):
another feature of pharmaceuticals, which is to use
the lowest possible dose to getthe effect that you want, which
really, although that doesn'tmake the money.
And get it to the DA veryquickly.
It, it is the safest route.
Yeah.
Dr. Gillian Goddard (45:29):
Yeah, I mean, I just think that there's,
if you are getting the desiredeffect,
Lisa (45:35):
Mm-hmm.
Dr. Gillian Goddard (45:35):
why would you increase the dose?
It just doesn't make any senseto me.
You're all you're gonna do isget more side effects.
You're not necessarily going toget a bigger effect.
And in, in real life, we are notlimited to the 72 weeks or
whatever it was that most ofthese trials were.
(45:56):
You can be on these medicinesfor an unlimited period of time
for as long as you need'em.
And so, you know, I always.
You read about all the horribleside effects that people are
having, especially vomiting.
I always tell my patients, ifyou're vomiting, I wanna know
about it.
You should not.
You can be nauseated.
You should not be vomitingbecause that is a sign that
(46:17):
you're increasing the dose tooquickly.
Lisa (46:19):
I, I had a client that w finally quit because of the
vomiting.
And I was, I just felt so badbecause there I couldn't do
anything'cause I'm not thedoctor, you know?
And I'm like, okay, but youshouldn't be vomiting.
Like, don't do that.
We gotta do, and finally theyjust quit the
Dr. Gillian Goddard (46:35):
I know.
I mean, that's what I worryabout.
Yeah.
I feel like the patients who arereally sensitive to these
medicines honestly often doreally, really well because
they're very sensitive to themand we don't need to ratchet up
the dose for them to get thedesire result, so
Lisa (46:56):
So as with any medication, there are people that these are
not right for, and so.
Dr. Gillian Goddard (47:02):
to popular belief.
Lisa (47:04):
Yeah, there, I've seen some videos of some people that
are like, I think in 10 yearseveryone will be on these'cause
they're good for everything.
Like, probably not, probably notgood for everything.
but who should not be considereda candidate?
Dr. Gillian Goddard (47:19):
I mean, I really think these medications
are for people who arestruggling with weight gain,
struggling with overweight andobesity.
Who and.
I would even add and arestarting to see the, have
metabolic effects that areassociated with obesity.
(47:40):
Those are the people who, whothese medicines are intended
for, and those are the peoplewho have been studied in
clinical trials with thesemedicines.
people who should not be onthese medicines are people who
are looking to lose a modestamount of weight, for.
Sort of more van vanitypurposes.
(48:02):
Look, I mean, I think there's,there's lots of us out there
who, you know, grew up in dietculture and feel like we, you
know, we could always loseanother five pounds.
These are not for that.
I also think that one of thethings that.
It really concerns me aboutpeople who are using these
(48:24):
medications inappropriately.
Women in midlife who are usingthese medications appro
inappropriately.
Is that it really?
Being too thin leads to problemslater in life too.
and so people who are thin andfrail also have health problems.
They may have different healthproblems.
(48:46):
and so I worry that people are,you know, gonna be trading one.
Like one thing for another, andwe need to recognize that
there's a point at which beingthinner is not better.
Lisa (49:06):
Yeah.
Yeah.
Perfect.
Okay.
This has been so good.
So good.
I've been delightful talking toyou.
I love, well, I just lovetalking to medical professionals
that really just know whatthey're doing.
So thank you so much for sharingyour wisdom.
So why don't you tell us moreabout, I know you have a
substack, we wanna, we'll putthe link, but tell us a little
(49:26):
bit about that, where people canfind you online.
Dr. Gillian Goddard (49:28):
Yeah, absolutely.
So, I have a substack called HotFlash.
it is not just aboutperimenopause and menopause,
it's about all women's hormonalhealth.
we talk about all differentkinds of things there.
And thatis@savvypatient.substack.com and
we'll make sure to get you thatlink.
And if you like what you readthere, stay tuned because I do
(49:50):
have a book coming out in springof 2026 where we will talk about
all things related to women'shormonal health and not just
estrogen and progesterone, butlike all the hormones.
So I think it's gonna be reallygreat.
Lisa (50:04):
Awesome.
Thank you so much.
And yes, we'll put those linksin the show notes have so thanks
again.
Dr. Gillian Goddard (50:10):
Oh, thanks so much for having me.
It's been really fun.
If this episode hit home for youand you want support working
through your perimenopause ormenopause symptoms and weight
gain, I'd love to talk with you.
I have two free resources rightnow that I know will help you
download the What to Do When YouOvereat Course.
If you find yourself overeatingtoo many times in a week to see
lasting weight loss, you'll getthe reset and recover guide and
(50:33):
figure out how to reduce yourover eats and not beat yourself
up about it.
Or you can grab my brand new GLPone Success Starter Kit.
This is for anyone already onGLP ones, or maybe you're just
GLP one Curious, but you don'thave any support or structure
around what to do.
Your doctor knows how to writethe prescription, but she isn't
equipped to support you day today, and that's what a coach
does.
You can also schedule a freeconsult session to see if my
(50:55):
one-on-one coaching programs areright for you.
All the links are in the shownotes.
Remember, it's not just aboutthe food, it's about empowering
yourself with choices that trulyserve you.
Have a great week and as always,thanks for listening and sharing
the Eat Well Think Well LiveWell podcast.
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