ZOE Science & Nutrition - Menopause ruins sleep and sex - here’s how to fix it | Dr. Kameelah Phillips and Prof. Sarah Berry

Episode Date: October 17, 2024

Menopause can disrupt sleep, emotions, and intimacy. Yet much of this remains taboo. Whilst every woman will go through menopause, these highly personal questions are hard to confront. Questions like: Does lack of sleep lead to problematic weight gain? And why does intimacy feel so hard to rekindle? In this episode, Dr. Kameelah Phillips joins us to bring clarity and compassion to these sensitive questions. She debunks the biggest myths around sleep, intimacy and emotional wellbeing in menopause. Her energy and positivity will empower you to thrive in this stage of life. Kameelah is joined by ZOE’S Chief Scientist Professor Sarah Berry who shares details of ZOE’s groundbreaking new menopause research. 🥑 Make smarter food choices. Become a member at zoe.com - 10% off with code PODCAST 🌱 Try our new plant based wholefood supplement - Daily 30+ *Naturally high in copper which contributes to normal energy yielding metabolism and the normal function of the immune system Follow ZOE on Instagram. Timecodes: 00:00 The silent consequences of menopause 01:40 Quickfire questions 04:06 When does menopause start? 05:08 What causes hormonal chaos? 10:20 Biggest menopause myths 12:30 ZOE’s new menopause research 19:52 Does menopause lower libido? 24:16 Sex myths in menopause 25:14 Does testosterone increase libido? 29:15 How menopause affects sleep 38:59 Does exercise impact sleep and sex? 42:08 Weight loss during menopause 43:19 Does HRT affect sleep and intimacy? Books by our ZOE Scientists: The Food For Life Cookbook Every Body Should Know This by Dr Federica Amati Food For Life by Prof. Tim Spector Mentioned in today's episode: Menopause Is a Key Factor Influencing Postprandial Metabolism, Metabolic Health and Lifestyle: The ZOE PREDICT Study (2022), published in Current Developments in Nutrition Diet may counteract menopause metabolism change, ZOE study shows (2024), published by ZOE Menopause weight gain and why you should stop dieting (2024), published by ZOE  Spotlight on the Gut Microbiome in Menopause: Current Insights (2022), published in International Journal of Women’s Health Sleep disturbances may contribute to weight gain in menopause (2021), published by Endocrine Society Have feedback or a topic you'd like us to cover? Let us know here. Episode transcripts are available here.

Welcome to ZOE Science and Nutrition, where world-leading scientists explain how their research can improve your health. Today we discuss the consequences of menopause that no one seems to talk about. I'm talking about sexual well-being, intimacy and sleep. For many women, menopause is a time of significant changes to their body. It can be hard to know what or who to ask to begin to address them. Harder still if these are changes that happen behind closed doors. That's why today my guests are talking sex and sleep, and they're not holding back. My first guest is Dr. Camila Phillips, a gynaecologist who is both experienced and compassionate.

And in today's episode, she illuminates ways to thrive during this transitional period in life. She's joined by Dr. Sarah Berry. Sarah is associate professor of nutrition at King's College London and chief scientist at ZOE and is leading some of the world's largest studies of menopause and diet. Together, they explain how menopause can be a golden opportunity for women to reclaim their health. Camila, thank you for joining me today.

Thank you. Thank you for having me. It's a pleasure. And Sarah, thank you for joining as well. Excited as always, Jonathan. And this is especially exciting because straight after this, Camila is off to deliver a baby. And there is a danger that there might be a phone call. So I know I have to be more efficient than usual in case I don't get to the end and suddenly you're off.

So Camila, we have a tradition here at Zoe where we always start with a quick-fire round of questions from our listeners. Oh gosh. And you have to give us a yes or a no, or if you absolutely have to, you can have a one-sentence answer. OK, I'm going to try and stick with Yasuna. Brilliant. Are most women properly prepared for menopause before going through it?

No. Is sexual intimacy often affected during perimenopause and menopause? Yes. Is sleep negatively affected by menopause? Yes. Sarah, can these changes lead to a change in your weight? Yes. Are there unfavorable changes in your metabolism during perimenopause and men your weight? Yes. Are there unfavorable changes in your metabolism

during perimenopause and menopause? Yes. Camila, it sounds like menopause has to be a negative experience? No. Just finally, you get a whole sentence now. I know, you see I'm holding it in. A whole sentence now. What do you think is the biggest misconception

around menopause? I think because menopause has such a bad rap, it's because we're not prepared. We didn't talk to our mom and our grandmother. The biggest misconception is that you can prepare for menopause. You can prepare your body, your mind, your family, your job, loved ones.

So I think that's the biggest misconception that we should be preparing for menopause. I love that. And also love the way that you said like your mother and your grandmother never talked about it because, you know, it's something that I always say whenever we're discussing menopause was that, you know, my mother went through it

and she never said anything about it, not a single word. And I discussed it with her afterwards. She's like, oh, well, you know, I didn't have it that badly, but she's also very British. So, you know, I'm not sure that I'd really believe this. So I don't know what to say. So I actually love that actually people are discussing it a lot more, but I do, I'm really struck. I had always assumed that like, I'm a man and that's why I never heard about it. But actually, you know, all, you know, my sister was hearing about everything about this from, you know, my mother. Like, no, nothing whatsoever.

So that is a big change. Maybe just, you know, to start at the beginning for anyone who hasn't covered, really been talking about this at all, could you just start, like, what is menopause? When does it start? And I think people are increasingly aware of this terminology, perimenopause. Could you just put that together for us? I completely can. So, the quick and dirty is that menopause is one year after your last period. Okay? It lasts for the rest of your life.

So, once you enter menopause, you don't exit menopause. Menopause is the one year after your last period. It's like Hotel California. Check in, check out. You are checked in. And I say that because sometimes people occasionally will have a period and they're just like, oh, I'm having periods again. And that's actually a red flag. You need to see your doctor. The time before that is what we call perimenopause. So that's the like five to eight years before that last period.

And it gives you signals. Period starts to change, maybe your metabolism, mood, sleep, early things, which is really important to take note of and start talking to your doctor about it. But perimenopause is that five to eight years before the actual last year of no period. And then that next day you are officially in menopause for the rest of your life. And I think Jonathan a way to think about perimenopause is this state of hormonal chaos. It's not that you suddenly have this nice you know gradual decline in estrogen which is the hormone

that declines during the menopause. It's fluctuates so you know this is why some of the symptoms day to day can be so variable. So it's that hormonal chaos that's really burdensome. Mm-hmm. And it usually shows up, first of all, in your menstrual cycle. So if you start seeing changes in your menstrual cycle, that should be a clue that you want to start thinking more broadly about what's going on in your life and your health. And in this country, the United States, the average age of last period is about 51.

That can vary in other countries, vary based on like your family history. I often tell women, they ask like, when's my last period? I don't know, ask your mom, ask your aunts. That can give you a little bit of insight to what you might experience, but in this country, it's 51.

And I understand there's no really reliable test during perimenopause to really understand even necessarily whether you're in perimenopause or certainly where you are. Is that accurate? Very accurate. And that's the chaos that you're talking about. Like, at any point, we can check labs and I see a lot of commercial tests coming out. Not really that helpful. Now, I always have a discussion with patients.

They come in, they say, I want to check my labs. I want to see where I am in my perimenopause or menopause. And I think there's a lot of resistance with doctors sometimes to do that at this point in my career. I'm like, let's check them. So we can have a discussion about them, but because they fluctuate so much, you should probably expect them to probably be normal.

I want to come back to that question that we had at the beginning about, are most women educated about menopause by the time they start coming to you with symptoms? Are they educated? They've done some online research. They know something's going on, and usually what they do is they come in and they say

My periods are going away or they're crazy. I'm not sleeping well. What is up with this 20 pounds? I can't get it off and I'm like say the word say it go ahead say it and Then I finally get him to say or they come up with perimenopause Maybe a little bit of denial because they don't really want. Because they, yeah, it's, you know, it's unknown, it's foreign. It can be very distressing unless you have someone to sort of guide you through it. But eventually in saying it, I think that you take back some of the mystery and the power that gets released

when you don't really know what to expect with your body or what's going on. And it sets the stage for our future conversations and engagement. And it feels to me that although people are definitely talking about it more now than even a decade ago, it's something that more than half of the human population goes through and is sort of unavoidable. It remains incredibly taboo and under-discussed.

Why is that at a time when it feels like we sort of talk about almost everything else? Yeah, you know, I'm going to take a little responsibility for that. And by that, I mean like our medical training and our medical system. We spend so little time, first of all, in just like women specific issues that when you really start to niche down all the things that can happen in the female body, I mean, maybe residents get two to three lectures on menopause, if that. Two to three lectures in their entire time of training to be a doctor. Yeah, in their entire, like, maybe med school training, and then you have to go to residency to be an OB-GYN to get further teaching.

So if you're an orthopedist, you're not learning about menopause, but we know that it affects women's bones and their fracture risk. If you are a dermatologist, we know that there's issues with hair loss, skin changes, et cetera, but you're not getting those lectures. So I want to, for us physicians, take responsibility that we actually need to do better because we have a captive audience that then can go out and like preach the gospel of menopause health and wellness. And so that's if you're a gynecologist and such, I'm guessing that the underlying science there is also part of why there's so little

education as a doctor around this, whether it's in the States or the UK or Australia or wherever. Yeah, I think it's fair to say that the science is moving at the same pace that we're starting to talk about it. So we weren't doing any science on it. I've run 30 randomized control trials before starting the work that we've been doing at ZOE. I didn't recruit any females into these studies for various reasons because women are more complicated

to study. You have to think of their menstrual cycle. You have to think of whether they're pre-peri or post-menopausal. So women traditionally in science have been incredibly understudied, never mind whether we've even studied the menopause transition. Fortunately, there's a lot more research going on in this area. And fortunately for us, we're leading a lot of this research at ZOE. And I think we will make great leaps in this area in the next decade. But we're really behind on this. As ZOE's chief scientist, I wanted to talk about something that's not talked about. Menopause symptoms. As chief scientist, I wanted to talk about something that's not talked about.

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research analysis of menopause and nutrition in the world. In our research participants reported an overwhelming number of symptoms. 66% of perimenopausal women reported experiencing over 12 symptoms like weight gain, memory problems and fatigue. The good news is our research shows that changing our food habits may reduce the chance of having a particular menopause symptom by up to 37% for some women. The Menoscale Calculator puts our science in your hands. Go to zoe.com forward slash menoscale to get your score. The calculator is free and only takes a couple of minutes. As we scientists say, if you can't measure it, you can't change it.

All right, back to the show. It's really interesting. So what are some of the biggest misconceptions, Camila, about menopause when people come in to see you? That we don't have anything to do to help them with their symptoms. Whether it's sleep or intimacy or the weight gain, that we don't have ways to help them get through this and we do. The other misconception is that it's all hormones, hormones, hormones.

There are a lot of people who either have contraindications to hormones, family reasons, medical reasons, or just philosophically don't want to go that route and that's not necessarily the case. So this is about saying sort of estrogen replacement, HRT in the UK, that that's the only thing you can do. Is that what you're saying? So people that and you're saying that is not that is not the case. Yeah, that there are options and I think it deserves a conversation. Every person deserves a personalized, you know, assessment of what their needs are and their

risk are and we go from there. So I think the biggest thing is that you can't do anything about it. And no, menopause is inevitable. If you're lucky enough to live old enough, you will experience menopause, but it doesn't mean that it has to be a terrible experience. I think as well, it's so variable for every individual. So what your friends might be experiencing versus what you're experiencing is hugely variable. And this is why, again, I think it's something that we really struggle with because, you know, naturalist human beings,

we compare ourselves to our friends, you know, and the people around us. And we know from our ZOE PREDICT research where we looked at in many thousands of individuals at the prevalence of symptoms, the severity of symptoms. And although we see that about 80% of people have sleep disturbances, 70% of people have anxiety, brain fog, so forth, but actually the clusters of symptoms differ hugely from one person to the next and also vary from month to month as well. And actually Sarah, I'd love to talk a little bit about those studies. I know you're running some of the biggest studies on menopause in the world, which is very cool. And I know that those studies are showing

that there's more going on than just sort of women have less estrogen. From your perspective, could you maybe describe these studies a little bit and sort of what you're seeing? So from a research perspective, and it would be interesting to know from a clinical perspective,

if you also kind of categorize in this way, we think of menopause in terms of symptoms and we think of menopause in terms of the disease risk as well. So what we know is that when you go through the menopause, your estrogen declines, you have estrogen receptors all over your body. This is why these symptoms are so burdensome, so widespread. You have estrogen receptors in your brain, in your fat tissue, everywhere. And so that's why you have all of these variety symptoms. And there's about 36 different symptoms that have been classified.

And we know that the most common ones, as I mentioned, are sleep disturbances, brain fog, anxiety, hot flushes, weight gain. We know that about 45% of women say that their symptoms are so severe it impacts their quality of life. And we're starting to understand a lot more about how different approaches can help attenuate, so reduce some of these symptoms. But I think something that's not talked about enough, and this is an area that we've also been doing research in at ZOE,

is the increased disease risk that happens postmenopause. And this is something everyone that I speak to, I'm late 40s, I met that perimenopausal phase, everyone's just so preoccupied with these awful burdensome symptoms that you're having at that time. But actually your risk of chronic disease goes up massively. And so what happens is, is when you transition to the postmenopausal phase,

you have an increased blood pressure, you have increased circulating blood cholesterol, you have worse insulin sensitivity, so worse blood sugar control, you have increased inflammation, you have increased body fat around your waist, which we know is particularly harmful, and you also process your food very differently, which increases your risk of disease as well. Can we talk about that for a minute, because I know that's one of the areas where, you know, this research you've been doing is just a much bigger scale than anyone has ever done before.

Yeah, so with our ZOE Predict study where we had 1,100 individuals and we focused on something called postprandial metabolism. So that simply means post-meal metabolism, so how you process your foods. And we were particularly interested in looking at how people process sugar, carbohydrates, how they process fats. And we looked particularly interested in looking at how people process sugar, carbohydrates, how they process fats. And we looked at the post-meal increases in circulating blood sugar because we know that if it's excessive, repeated, it's associated with increased risk of many chronic diseases. We also looked at circulating blood fat from the fat that you eat in a meal, again, because we know that if it's excessive, it's

associated with increased risk of many chronic diseases. And what we found was that postmenopausal women had higher levels of postmeal circulating blood sugar and postmeal circulating blood fat to a standard meal compared to premenopausal women. And we actually also looked at what about in age-matched individuals because menopause is an age-related event. And so it's really important to try and tease apart what's actually just part of the natural aging process. So for example, we know men as you age, you have an increased blood pressure, cholesterol, et cetera. And so in our study, because it was of such a scale, we were able to take a subgroup of individuals and age match them, where half of them were premenopausal, half were postmenopausal but the same age.

And we still saw these significant differences in these post-meal blood sugar levels, that the post-menopausal women were processing the blood sugar in an unfavorable way. So they were having these higher peaks in blood sugar after a meal. Camille, I mean, I think describe these women coming in who maybe not even want to identify necessarily that there's perimenopause because it's sort of tied in with all of these things that sound really bad. It also means we're getting old. Yeah.

I'm not ready for this, for aging. And actually, I was going to ask, like, what is that like and what do you say to these women? I talk to them about this being a time where they can really level set and look at their life and all the different aspects of their life and see where they can really work to be their best selves to prepare them and prepare their family for the menopausal change. We talk about how exercise, is it, or is it not a part of your life? What can we do to augment that? We talk about their food and their diet.

We talk about rest and their mental health, reducing stress, these kind of things. So I sort of frame it as this being the beginning of the rest of your life and more so in a positive way. What are the things that they're looking forward to? How can we augment their health throughout this mid and a poso transition so that they can reach their health goals

and do better as it relates to cholesterol, diabetes, that kind of thing. And so in the mid thirties, I start talking to them about it. Hey, you know, we might wanna start thinking about your diet, how's your workout? You know, things like that we know are really about consistency so they can have some tangible anticipatory guidance

about conversations that are coming in the 40s. And do you find that people are ready to embrace the fact that they are aging and they do need to think ahead to the future in their 30s? I do. I wasn't. I know, I really do. I'm still struggling. No, listen, every day I'm like, oh, what are my knees going to do today?

But I feel the same way. And I think it's because we're talking about it more. So it's no longer taboo when, you know, we bring up menopause, when we bring up intimacy. And I also presented in the office like, okay, what's sex like these days? And it just level sets that, okay, what's sex like these days? And it just level sets that, oh, this must be a regular conversation we have with people.

And so there's no mystery about it. There's no hesitancy to jump right in and start talking about it. So I do find that they're pretty receptive. One of the things that Sarah says is that science has tended not to measure anything about how people feel or sort of activities, anything that can't be like nicely measured with a really independent sort of blood test,

sort of has historically not been viewed as maybe as valid. Is this fair, Sarah, what I'm saying? Oh, absolutely. And until I started the ZOE studies, we never asked people how they felt. I mean, that's just wishy washy in science. You know, we want a biochemical marker, full stop. But what's really interesting is with all of our studies now, we're asking people, what's your energy like? What's your mood like? What's your hunger like? What's your alertness like? You know, and general stuff about just how great they're feeling. And it's lovely how we're seeing, with our own

research, this play out in many of our results. It's important, right? I see it as a measure of your quality of life. I ask questions like, are you having an orgasm? How strong are they? Are you masturbating? So like- We haven't started asking those at all yet.

Well, it's, you know, pace yourself. But it speaks to their quality of life. Yeah. And intimacy ranks really high for some people. And so during the menopausal transition, if they start to lose it, then it seeps into the relationship, you know, and how they feel overall. I was thinking, we talk directly about this, you know, it's not something you measure with biochemistry and it's something, again, that people people historically felt is very taboo to discuss. Could you actually start actually with like what kind of shifts do women experience in terms of their libido and also what might

be happening sort of physically that might affect intimacy? And then love for you to talk us through sort of how you then respond to that. So generally when I start to approach patients about intimacy, their love life relationship, a lot of our conversation, to your point Sarah, talks about how estrogen receptors are all over the body. And unlike our male counterparts, what is, in my opinion, our largest sexual organ? And it's this, I always am like pointing to the female brain. When we start to experience lower levels of estrogen,

it affects our brain, it affects our love centers, it affects our highs and lows, and it also affects our vulva and vagina. And so as we enter perimenopause menopause, I use the analogy sort of of how the vagina is like an ocean and she's just waving and flowing and that's usually what we see in adolescents, our 20s or 30s, a vagina that's well estrogenized and receptive to penetration, touch, that kind of thing.

As we get into perimenopause and menopause, those waves start to become more shallow. The vaginal walls literally, under a microscope, literally become thinner and by that effect, inflamed and so touch, penetration can become extremely painful. This is a consequence of the drop in estrogen? Estrogen, exactly, yes. And this has a huge effect on women and it is because if you begin to set up a tract in your brain and body that sex is painful, it makes a signal to your brain that like, yeah, why am I doing that? This isn't fun. And then so you begin to avoid it more.

And the vagina is an important, it's a muscle. I tell my patients, we got to exercise it, use it, or lose it. And so having regular touch, orgasm, blood flow to the area is important in maintaining vaginal health. Even like using toys, vibration is exquisitely important for women, especially in the clitoral area because our nerves, as they change, respond to vibration. So these are really important topics, specifically about intimacy and menopause that I have with patients.

Is there a huge impact as well by the fact that our body shape is changing, the fact that us women, we're tired because we're not sleeping, so all of those other things. Oh, girl, yeah. The fact that we're feeling more anxious. So even if you weren't having those direct effects,

then a lot of women are just feeling rubbish about themselves and in themselves as well. I mean, preach. This is 100% a part of the conversation because, again, our sexual organ is our brain. And so for many women, and I'm not going to generalize this all, right? But if we come home from a full day's work,

we have children to feed, we have parents to care for, we have bills to pay, the desire just goes down, down, down, down, down. And so when we're talking about a woman, to a woman about her intimacy, I often invite her partner to come because this is not just an issue of decreased estrogen per se,

it really is a psychological, social, economic, cultural conversation that needs to happen with women in terms of tackling libido. Yeah, I mean, I hear lots of people around my age saying, well, I'm just all I want to sleep. I just want to get into bed and I want to go to sleep. And it becomes such a focus, I think, for a lot of perimenopausal women, you know, when I said eight out of 10 people who are not sleeping properly, that becomes all consuming. All consuming, because it affects literally your entire day. And when you combine that with like brain fog

or heaviness, weight gain, like it really becomes a time in your life that has the potential to really bring you down. And so that's why the anticipatory guidance early on helps us target some of these issues before they come become problems Are there myths around intimacy for women through this that actually you would like to make sure we? Dispel and then I'd love to talk about so what does that mean? What should women do? What might their partners be thinking about like what are you recommending to your patients as a result?

So I think the big myth is that sex has to hurt. It doesn't. I think also another myth, and this is a little tricky because some women don't mind their decreased libido. They don't mind. It's a problem for their partner, not a problem for them. And then at that point, I just have to throw my hands up because if it's not a problem for her,

then it's kind of not a problem. But to the people who are having painful intercourse or want to do something about their libido, we absolutely can. There are probably two, maybe three, I won't mention any names, medications for women for libido. There's like 26 products for men.

So there are things, both on label, off label, that I encourage people to talk about with their healthcare providers because sex does not have to be painful. It can be very enjoyable, but it's just catching symptoms before they really get cared for. Camila, in the UK, there's quite a lot of talk on social media about taking testosterone in order to improve libido.

I don't think it's something that's encouraged at the moment by doctors in the UK. And I don't know what the perspective here is in the US and what you think about that. Is there evidence to support this? There actually is evidence to support it. And the Menopause Society and some of our larger societies have come out with papers supporting the safe use of testosterone. These are topical forms that are about a tenth of the one percent male dose, because, again, we have all these options for men, very few for women.

So we've had to adapt to the female body. There are protocols that allow us to use testosterone safely without the perceived negative side effects. We don't want your voice to change. We're not going to give you all these. So we can, yes, use it safely, but we are leaning away from methods that can give you super therapeutic levels of testosterone.

For example, injections, pellets, that's not where we are, but there are testosterone options. Is there anything else other than sort of medical treatment that you end up discussing when you're talking about these questions around intimacy? Intimacy, mm-hmm. I often give people a literal prescription to go to a sexual health store. And that is a time, there are several in the city, hopefully people can find one near them.

These are well lit, clean stores, highly educated people who can coach you about toys and lubrications and fantasy, that type of thing that often resonates with female patients because, again, we're using our brain to drive our libido and sexuality. So it's not a light switch on and off. And so I have many of my patients go to adult stores and explore what fantasy that they haven't otherwise explored with their partner and

then introduce it. And that's not like, oh, but it's during menopause, so that's all imposter. Because I think part of what I'm hearing from this is like, well, that's not going to work because of this whole story that you're describing. Feels a bit, you know, can feel a bit doom and gloom, Camila. But you're saying actually, it's not as bad that there's actually, you know, the brain is strong in this sense. The brain is strong.

The brain is strong, the vagina is stronger, and relationships are resilient. So if you really target sort of like the trifecta, people can have very happy, fulfilling, loving sexual relationships into their menopause. I can imagine a lot of listeners are listening to this and they're like, OK, I never thought about any of this. What are the questions that you'd suggest they should be sort of asking themselves

to be sort of curious about, I guess, like their own needs and their own situation that might help them to understand what they want to do next? I always ask patients first and foremost, does this bother you? Because if it doesn't bother you, then I don't really have anywhere to go. You know, it has to be a problem for you. That's actually part of the diagnosis of, you know, our hypoactive sexual disorders. It has to be a problem for the patient. And if it is to really take stock on the different cultural, psychosocial, emotional triggers that are precluding her from wanting to move forward with intimacy with her partner.

You have to be very sort of honest about that. Because sometimes it requires an investment in counseling. It requires an investment in your body. It requires an investment to do some really serious inter-partner work in order to make sex and intimacy exciting again. Thank you so much, Camila. I think that's really powerful and I'm going to make Sarah relieved by moving on now to talk about sleep.

What's the lived experience of patients coming in to you and their experience around sleep and how it's affecting them? Usually, I see issues with sleep as it relates to vasomotor symptoms, aka hot flashes or flushes, waking them up at night. You know, they're sleeping soundly and then they get this wave of heat followed by chills and it keeps them up for the rest of the night. It disturbs their sleep and so they're just up.

I get patients who just have a hard time falling to sleep in the first place. And so for me, that also begs questions about their partners who may or may not have sleep apnea and snore and that interrupts their sleep. But the vasomotor flushes are probably the primary thing that wake women up at night. And what are the biggest sort of myths around sleep at this time?

People are often afraid to advocate for their partner to fix something. Again, sleeping with a partner who tosses and turns or has sleep apnea, it's not fair that my sleep suffers because you have sleep apnea and refuse to see the doctor or get on a machine. You know, that is a big thing. The other thing is weight gain. One of the misconceptions is that weight gain can actually affect your sleep. So it's important to recognize that even a 10, 15, even more can cause you yourself to

have sleep apnea. It can cause changes in your throat. Lower estrogen can also cause changes in your throat for some people. And that affects sleep as well. So those are the big... You mentioned the word sleep apnea a few times. Could you just explain what that is? Sleep apnea is basically when there are intermittent disruptions

to your sleep flow, your breathing. And often people can stop breathing in the middle of the night. We see this a lot of people who have that like, ah, a really deep snore. And so the apnic part is when you literally stop breathing. That can affect your health. It leads to hypertension, cardiovascular disease.

So these are important things to know about. And that might get worse through can get worse. Metabors. And Sarah, I know that in your studies, like sleep has been one of the things that you've been measuring in these very large populations. What do you see? So firstly, we see sleep, as Kamila said, is a huge problem during the perimenopause transition and also post-menopausal. But interestingly, we know that sleep is related not just to the fact that,

oh my God, I feel knackered the next day. It actually controls a lot to do with... That means tired for the Americans. Knackered? Yeah. Knackered. But if we're sleep deprived, not only do we feel absolutely exhausted the next day, but it also impacts our choices.

It impacts our brain. It impacts also how we process food. And we've seen this from our own ZeriPredict research. So what we know is that if you've had a poor night's sleep versus when you have a good night's sleep, how you metabolise the food is different. So for example, we see that if you have a high carbohydrate breakfast, if you've had a poor night's sleep, you have a really unfavourable blood sugar response compared to if you've had a good night's sleep.

What we also know is if you've had a poor night's sleep, it also heightens the reward centers in your brain. And so these reward centers are seeking out quick fixes. And so instead of if you've got your very healthy breakfast in front of you, so your style breakfast versus the less healthy breakfast, you know, like a croissant or whatever, the reward centers need that quick fix. They want that carbohydrate fix. They want to suddenly feel great. So you're waking up exhausted. You're selecting bad food or you're having to fight against the desire for the bad

food. And then you're having these worse blood sugar responses. Hi, I have a small favor to ask. We want this podcast to reach as many people as possible as we continue our mission to improve the health of millions. And watching this show grow is what motivates the whole team at Zoey to keep up the really hard work of creating new episodes each week. So right now, if you could share a link to the show with one friend who would benefit from today's information, it would mean a great deal to me. Thank you. benefit from today's information, it would mean a great deal to me. Thank you. That's quite a bad cycle then. So the bad sleep means that you're sort of being pushed towards the worst food, which is going to make your health worth and

probably affect your bad sleep. And so I think your data there also talks about the way that your diet itself can affect how strong these symptoms are. Is that right? In terms of the menopause symptoms, yeah, absolutely. So we've looked cross-sectionally, so we've looked at one point in time from our ZOE health studies in tens and thousands of individuals at their diet quality. So we've used a tool called a food frequency questionnaire where we ask them questions about all different types of foods that they eat, and then we've looked at how many symptoms they have and how severe these symptoms are.

And what we find is people that have a higher diet quality have a significant reduction in the prevalence of the symptoms. So for example, up to 20 to 30% less people report sleep disturbances, hot flushes, et cetera Now it's really important Jonathan at this point to say that is for an overall healthier diet. There is no silver bullet out there though, dietary silver bullet that's going to stop symptoms or really significantly reduce symptoms. And in the UK there's a real problem with what we call Menno washing. I don't know if you have this here where you get a supplement, you stick Menno in front of it, you get a skin care product, you stick Menno in front of it, you get a hair shampoo, you stick Menno in front of it. You can double

the price that you're charging and then you make all of these promises that it will cure that hair loss, it will make your skin, you'll look 20 years younger and take this supplement and you'll sleep better, you won't have a hot flush, etc. Unfortunately, there's no evidence to support any of these claims. And it's a billion-dollar industry, and it's increasing exponentially each year, this industry. And that's what's quite worrying, where actually a basic, healthy, balanced diet

will help to a certain extent. It's not going to stop the symptoms, but can help reduce some of these symptoms. I was just going to say, like, I'm so excited sitting here right now. And I think that's what's so fascinating about menopause is it is so multifactorial and complicated that it's just really a magnificent area of life to study. And I will say from a clinical perspective, when women come in and they hear the words that you just spoke,

I give to them, we gotta clean up this, this and this, and they do it, when they really invest in themselves and do it, oh my gosh, doc, I'm sleeping. Oh my gosh, this weight is coming off. It is just really exciting to me that we were talking earlier about how we have all these intangibles, subjective, horty-torty kind of ways that science doesn't respect. Now you have the objective clinical data to support what we're seeing. And I think what's also really relevant here is the point you said is also interrelated.

One thing affects the other. The sleep also makes us feel tired so we don't exercise, so we're not getting the physical activity. So we're also maybe not improving our bone health. We're not improving our maintenance of a healthy weight, etc. It's like this kind of domino effect. And that's what makes it so challenging because you get in this vicious circle of, well, I've put the weight on, what can I do about it? Oh, what's the point then of doing this, this and this, et cetera? But you can always change. You can always pivot. So I'd actually love to switch to that, you know, at the back end of the podcast,

we always like to sort of switch to talking about the actionable advice that people can take. And I do think that, you know, talking about menopause can often seem quite depressing. Like it's a sort of freight train bearing down on half the population that you can't avoid, right? You're like stuck on the tracks. Like when you think about reclaiming your health, what are the things that you have in mind?

And then together, I'd love to explore some of the practical things that you could be talking about doing. Yeah. So I, again, this is a generalization, but I love menopause and the perimenopausal transition because for many women, not all, but many women have completed their childbearing.

Their kids hopefully are old enough to be a little self-sufficient. This is a time where I'm like, girlfriend, let's get selfish. Let's take back time when we come home from work to invest in ourselves. Let's, you know, have the kids do something and you take 10 minutes for yourself, 15, 20,

and then you slowly build up to workout. You don't have to leave the house, you don't have to do anything crazy, but just use that time to invest in yourself, whatever it is. Is it a workout? Is it a longer bath time? Is it reading a book at night?

Whatever it is, I usually encourage women to use this time to be selfish and self-caring. And I know that word gets, it's like so overused, but when you really take it to heart and start to manifest, just like the menopause could be a freight train, so can this self-love and indulgence be a freight train in your life so that you can start to get back on track. So we talk about tangible things. Cook your own dinner, make your own salad. What is it at any moment of the day that you can do to make the best decision for yourself? We don't have to go from nothing to everything.

And I think this is something that we often make the mistake of thinking that I've got to do half an hour exercise every day. I've got to totally eliminate ultra-processed food and all refined carbohydrates. Actually, just a tiny change can have a big impact. It's about building that habit. And there's a term that is used a lot now

called exercise snacking, and I love this term. And it's about just ask them when you can fit it in, do an exercise snack. So that could be just, when the kettle's boiling, just do 10 squats while the kettle's boiling, just do 10 squats while the kettle's boiling, while your Zoom meeting is loading, you know, again, do a few squats or wall pushers. You can fit in however busy you are. And it's just getting that as part of your daily habit.

Does that matter? Does exercise have any impact on the things we're talking about today? Oh, absolutely. Oh, thanks. Thanks, I know. Absolutely. And you taught me that term last night, which I love. Most of us can't jump in. When I started working out, I have three kids, when I lost 45 pounds, when I jumped back into working out, I thought I was going to die. There was just no way I could complete a 40-minute workout.

And I did. I had to start really slow and people kind of chuckled at the old lady in the back of the class. But it just took time, consistency, and just little steps. And it absolutely makes you feel better. The weight starts to come off. And again, you don't have to go from zero to 100. 10 is enough.

So this can make a significant... Because we talk about exercise a lot to do with sort of long-term health. Oh, weight-bearing. But it can really make a difference to the way that you're experienced this menopause change. Building muscle, your bone health is critically important.

Weight-bearing exercises, strength training, checking in on your posture and balance is absolutely critical for women as they start to age. We see increased risk of osteoporosis, osteopenia, which is a weak bone, and then fall risk. Fall risk is huge when we aren't doing weight-bearing exercises and balance, so absolutely. And I think the peripostmenopausal transition phase is the particularly most important time to be doing these weight-bearing exercises.

And you can do little things like you're standing in a queue at the supermarket, balance on one leg. That's using your muscles. Can I just clarify, because I think you were saying very strongly it's going to make a huge difference, your risk of breaking bones and things when you're older. When you're older.

What about the, actually the sort of symptoms we've been talking about today, whether that's sleep or intimacy, can exercise actually affect how you're feeling or is this really about reducing these very serious longer term risks? It's both because depending on who you are and when you exercise, aerobic exercise can help with your sleep. So it's usually recommended that you exercise more in the morning as opposed to the evening, which may activate you and make sleeping more challenging. But aerobic exercise in the morning has been associated with better

sleep. And also we know that physical activity improves mental health. There's so much evidence around that. We also know that physical activity helps with weight maintenance. Whilst it might not be the most effective way to lose weight, we know it's really important in maintaining a healthy weight. We know that during the menopause transition, that's a really difficult time for women to maintain weight. Suddenly their weight changes where their weight is on their body. They change from being what we call an apple shape, you know, around their hips. It's then distributed around your tummy, which we know is particularly

unfavorable in terms of long-term health. By exercising, that's enabling you to a certain extent, obviously you have to balance that with diet as well, to maintain your weight as well. And so the exercise is going to help to reduce the extent to which the weight is sort of moving from sort of the periphery to around your belly or did I mishear that? So a couple of things happen in terms of our body weight during the menopause transition. So estrogen is involved in where we deposit fat and how much fat we deposit. Estrogen very simply directs fat around your hips in women. When you lose estrogen, then it's directed then around your abdominal, your tummy area,

which we know is very kind of metabolically active. Yes, remember we did a podcast with a scientist just focusing on this topic. Yes, hence why it's particularly unfavorable for health. Now it's not going to change that because you've lost estrogen or you're losing estrogen, but what also happens is you're more inclined to deposit fat full stop. And so what we know is that by maintaining physical activity levels, you can maintain a healthy weight, if you're balancing that with a good diet as well.

Now, I know that talking about East Children replacement is a very large topic, but I feel that we can't have this conversation without touching on it a little bit, because it feels like it's clearly one of those conversations that everybody has that's going through it. How can that affect both intimacy and sleep that we've been discussing, and I'm sure this is a conversation you must be having with your patients all the time. Yes, and I'm going to try and keep it short and sweet, because it's important that people understand the difference.

So when we think about hormone replacement therapy, it depends on a few things. If you're a candidate, meaning age, risk factors such as smoking, heart disease, diabetes, et cetera. Hormone replacement therapy, traditionally we're talking about estrogen, and if you have a uterus, also progesterone. Hormone replacement therapy, typically our party line is that we're using it for the hot flashes, hot flashes, basal motor symptoms. We want to use the lowest dose for the least amount of time,

understanding that everyone is an individual and sometimes we have to make exceptions and people are on it for longer or shorter amounts of time. What I would say in relation to intimacy is hormone replacement therapy is not the same as when we use estrogen in the vagina, which is specifically for vaginal dryness or we call that vaginal atrophy, which helps with the pain associated with sex. So those are different things, but in general, hormone replacement therapy can help the hot flashes, which then help people sleep, mental clarity, and they're more productive. And we also see in our own research, women taking HRT,

and this is transdermal HRT in the UK, so this is the patches or the gel, which is the main form of HRT that we prescribe in the UK, that from our own research, those taking HRT versus not taking HRT tend to have a lower blood pressure, they tend to have lower blood cholesterol, better insulin sensitivity and lower inflammation as well. So there is some suggestion that taking HRT may reduce your risk of cardiovascular disease,

but we've only just started transitioning to this transdermal, this skin form of HRT. So we need to see if this actually plays out in the long term as a real beneficial effect. So many people came off of HRT after the Women's Health Initiative. We were all scared of hormones and now we know that that was a mistake. And so here and probably other places, we start initially with like oral medication, hormone replacement therapy, and then around 51 is usually our standard that we do transfer to this transdermal.

It is primarily because it has a safer cardiovascular profile as relates to causing like pulmonary embolism or heart attack. And so women should talk to their doctor about it, but I don't worry about it. And I find that the lifestyle and the life quality improvement is great. I think we're going to see that translate into our studies. But I think anyone having a discussion with their doctor,

and it's really important to say, I have not clinically qualified, that there is reasonable evidence showing the difference in the impact on health of the oral, so that's taking a tablet versus the transdermal, the skin. And I think there is certainly better evidence for a more favorable impact from the transdermal than the oral. So can we switch maybe to talking about diet now? Because I think I was really shocked to hear that diet could have any impact on menopause symptoms.

Like it seemed a bit, you know, magical thinking. But Sarah, you have this really big study and some real data, and this is all a bit sort of fresh off the press. Could you share what your research shows? Yeah, so as well as the cross-sectional data that I talked about earlier, so that data where we asked at one point in time, what are your symptoms, what's your diet? We've recently completed some analysis at Zoey where we asked people before they started the Zoey program and then after they had gone on the Zoey program, which is all about healthy

eating, plant diversity, eating according to your individual biology as well. We asked them, what's your symptoms like before, what are your symptoms like after? And what we found was that those who following the ZOE program had a significant improvement in many symptoms after they'd followed the ZOE program, after they had improved their diet. And I think that was really encouraging to see, not just that point in time, because obviously when we collect any information about someone's diet at one point in time,

there's lots of what we call confounders, is it that there's less smokers, is it that they're more physically active that might be impacting results? But having this, what we call longitudinal data, where we followed them up and seeing an improvement was really encouraging. Again, this is about overall healthy dietary patterns.

Again, it's not about one single silver bullet. And we don't actually understand all of the mechanisms behind this. And I think this goes back to the point you said, Camila, earlier, that it's so multifactorial. Is it that the diet's helping with sleep? Is it that having the better diets impacting your mental health? We don't know. And this is something we hope to really start to unravel with all of the data we're collecting at ZOE as well. I think it's incredibly exciting, right?

Because there's a lot of people coming to ZOE, coming to be members because going through perimenopause and menopause is like this big shock. Everything changes, their body changes. They feel like they're eating the same food, but all of this stuff is different from before. And we know from these studies, right, Sarah, that it's true, like women's bodies really are changing a lot in terms of how they respond to food. But this this new data about how it's changing your diet through ZOE is actually having an impact on symptoms is really exciting. Yeah. Not something we expected at all five years

ago, right? Absolutely not. And I think there's going to be even more exciting stuff, I think, that we're going to start to unravel. We're already seeing hints that maybe time-restricted eating will improve some menopause symptoms. There's so many other areas that we're looking at. And I think it's really exciting because hopefully, as we unravel this further, there's so many tools in the toolbox that people can choose

what works best for them. There are a lot of questions to do with heart health, sort of cardiovascular risks, because it's the leading cause of death for women in the US. And I think there's evidence that there are links, Sarah, between sort of this gain in weight around the belly and links to this. Like, what's going on and is there anything specifically, again, that women should be thinking about through this period? So, I think it's really clear from our research and other published research

that there's loads of different, what we call, intermediary risk factors that change during the menopause. So, your blood pressure, your underlying levels of inflammatory markers, which we know underpin many chronic diseases, your insulin sensitivity, so your glucose control, your blood cholesterol, where you deposit the fat. And there's quite nice data that's come out recently looking in age-matched individuals,

whether you're pre- or post-menopause or what your overall risk of cardiovascular disease is, and then also following people up over a period of time and looking at how likely it was for you to have some sort of cardiovascular event like a heart attack or a stroke. And even if you're age matched, if you're postmenopausal, because of all of these changes that have occurred in your body, you're about 20 to up to 40% higher risk. 20 to 40% higher.

Higher risk. So it's a huge increase. In terms of cardiovascular disease, yeah. And from a clinical perspective, I start talking to patients about this very early because it's, again, a slow change. Behavior change is slow. And so I like to talk about it early so that they understand that menopause is exactly what you mentioned.

It's a shift in your metabolism, a shift in your weight distribution. So we need to start attacking these issues now. Even when we talk about hormone replacement therapy that we don't use for the treatment of cardiovascular disease, but we are starting to see that there are benefits related to especially transdermal that can help women long term. So again, with this just being so multifactorial, we would be remiss to not really acknowledge that when women come to the GYN, they're worried about their cervical cancer risk, their breast cancer risk.

But I remind them the number one thing in this country and other places that's going to get you is heart disease. And so it's critical that we are doing everything we can to prevent death from heart disease. And we had some interesting data, Jonathan, from the ZOE Predict study where we looked at men and we looked at women across different ages. And what you saw with men in terms of lots of these

intermediary risk factors such as blood pressure, such as cholesterol, such as inflammation, they have just a steady increase. Each year they age, they have quite a steady increase. With women, we saw that pre-menopausal, they were sitting a lot below men in terms of many of these risk factors. So much lower risk than men. Much lower risk, whether it be blood pressure, cholesterol, etc. And they were gradually increasing with age.

And then they get to the menopause and suddenly they shoot up. They catch up with men. And in some of these, they actually overtake men. And it's interesting, we published a paper on this and it's a really nice one. You see it visually. It's like, wow, you've suddenly got this kink in the curve. And that's why it's just such an exciting time and such an exciting life event because you realize the power of estrogen and how it affects all of your body systems.

We see it a little bit in pregnancy, how estrogen affects women and preeclampsia, et cetera. But now to see that shift in menopause and just really recognize how important this hormone is, it's fascinating work. But I think, Jonathan, you wanted me to be positive today, and I will be positive. What's really great is cardiovascular disease is primarily underpinned by diet. So yes, oestrogen plays a role. Yes, we know there might be some genetic component, etc. But actually, we know that we can contribute to the reduction of cardiovascular disease

risk hugely by modifying our diet. So by eating healthy types of fat, reducing many animal-based saturated fat, by having a diversity of plant-based foods, by including kind of polyphenol-rich foods, by including fermented foods in our diet, by reducing our intake of refined carbohydrates, adding other healthy oils into our diet. There is so much we can actually do through diet to reduce risk. And so again, I think it's a really good point in time to think, well, am I doing enough? What else can I do, you know,

to mitigate this reduction in estrogen? I love all of that. I mean, one final thing which I would like to spend a long time on, and maybe Camila can come up on a whole other podcast, but you've spoken about how factors like race and ethnicity create different levels of risk, I think particularly around bone health, I've heard you say, but elsewhere. What should our listeners know about that as they're considering sort of prevention and treatment?

In this country, at least, we see that race and ethnicity and access affects us on every level of our life. And so when I'm thinking about a patient as an individual and what her risks are, it's important that I actually incorporate race and her socioeconomic status and her experience as we develop health plans for her. So with my white Caucasian patients, we talk about their increased risk for bone health, bone disease, osteopenia, osteoporosis.

My African American patients, we talk about the lifestyle changes that need to be made in terms of mitigating the risk of diabetes, hypertension, food choices. And so I think that rather than running away from these questions of race and ethnicity, that they actually can be a fabulous tool for us as doctors to individualize care for patients within their own cultural context. So it's important that we have a degree

of cultural sensitivity and understanding and discussion, because when we're looking at every level of impacting a person's life, their melanin informs that. And also, I think symptoms are different. We know, for example, that East Asian populations tend to have significantly less hot flushes or hot flushes. And we actually are starting to understand why. And it's really fascinating because the East Asian populations have particular microbes

in their microbiome that can convert particular food chemicals into a very active chemical that binds to estrogen receptors. And so in the UK, in the US, only about 20% of people can produce this kind of byproduct, which is called Equal. Yeah, in East Asian populations, about 50% of the population have these microbes that can produce Equal. And as a result, fewer of them are having these symptoms. And have significantly lower hot flushes and flushes. It's amazing. Another example of how those bacteria really make a difference to our health.

I'm guessing that everyone now wants that bacteria. Yeah, and we're only just at the stage of working all of this out. Amazing. I would just like to do a quick summary. We start off by saying that one way to look about menopause might be like it's a freight train, but another way is to say that actually this is an opportunity to revisit your life. Maybe your kids are a bit older, like your situation's a bit different, there's a set of things that maybe you can do now that were hard, so you can think about that positively.

There were two particular areas we talked about. The first was around intimacy, and I think what you explained is like, estrogen is everywhere, and so it affects everything from the brain, which you described, I think, as sort of a woman's biggest sexual organ through to your vagina and everywhere else. And so there are real changes that can happen to a woman's body going through menopause. This drop in estrogen can make sex painful. That's clearly obviously gonna have a big impact

on whether a woman wants to have sex. And then there's all these other changes that are going on about how you feel, I think Sarah was talking about, which is also likely to affect, you know, how you could consider intimacy. So there's a lot of things that are sort of lining up to make intimacy less appealing. I think you said it's only relevant

if the woman actually wants to have more intimacy. So starting with that point, if you do, I think there's very positive message, there's actually quite a lot you can do. And that includes that you said there are medical treatments that you've seen work, but also there's a lot of things that you can do, going back to this idea that your brain is sort of the biggest source of this intimacy, where you can change that. So again, it's not a sort of one-way terrible story.

There's a lot of positivity and it looks to me, you know, you're sort of suggesting you've had a lot of success with people coming into your clinic. And the second thing we talked about is sleep, which is above all disturbed because of these hot flashes that are happening because of this absence of estrogen that then wakes you up. You can't then go back to sleep. There's then this horrible chain of effect that Sarah was explaining about everything from you wake up and you want to eat more of the food that's worse for you, you then metabolize it worse. it hits you worse, you put on more weight and

then it makes you sleep worse. Again, like sort of not very cheering circle. And then Sarah, I think you explained that diet can really make a difference here, um, both in terms of reducing these symptoms, including hot flashes, but sort of across the board and they can improve how you're feeling now as well as your long-term risk. And so for you, one of the things you can do, you know, seeing with this data now, which is sort of quite surprising, is you can really make a difference to not just your long-term health, which I think everybody knows, but really make a difference to your menopause

symptoms by tailoring this diet towards something that's better for you. We've of course talked about hormone replacement therapy. You know, historically there's been a lot of people concerned about it, but that this can help with a lot of these symptoms and that's a conversation you'll have with your doctor. That exercise isn't just about like long-term health, which is obviously very important,

including things like bone density, but actually, again, it can make a difference to these symptoms through menopause, including the sleep. So there's something you can really do. And then I think we talked a little bit at the end about how understanding sort of ethnicity and race is also something important to understand.

How do you tailor this to an individual with, I guess, the final summary that there is actually this opportunity to step back and rather think about this as, you know, it's all terrible as, okay, what are things that I can maybe now take on board that might have been very difficult for me 10 years earlier that can actually push my life in a sort of healthier direction? I think that's the positivity Camila that you were talking about at the beginning and the end.

That was much more articulate than myself, but thank you. Jonathan does great summaries. That was great. Well, I just play back after listening to what you said. He's a good listener. Yeah, that's what I said. Thank you so much. I love the fact that you're about to go and bring somebody new into the world.

We need an update to put on the show notes for the podcast, please. I'd like to hear how it all went. I love it. And really enjoyed that. And I hope that you'll come back and talk to us again in the future. Thank you. I appreciate this. I learned so much.

So thank you for having me. We did. Thank you. It's a pleasure. Thank you. I hope you learned something today and enjoyed the episode. If you listen to the show regularly, you probably already believe that you can transform your health by changing what you eat.

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