Dear Menopause
Are you experiencing changes to your physical, mental and emotional health you find hard to explain?
Have you tried talking to your doctor/partner/employer/best friend and been left feeling unsupported?
In this weekly show, host Sonya Lovell interviews a range of experts and shares the stories of everyday people to help you understand what the hell is going on, why and where you can find support, empowerment and most importantly, a like-minded community.
Dear Menopause
117: Weight Loss, Hormones and Metabolic Health with Dr Lucy Burns
Have you ever wondered why weight creeps on during menopause, despite your best efforts?
Dr Lucy Burns pulls back the curtain on what she calls the "metabolic triad of menopause" – a perfect storm of declining estrogen, rising cortisol, and increasing insulin resistance that creates the ideal conditions for stubborn weight gain.
As a GP who retrained in lifestyle medicine after experiencing her own health challenges, Dr. Burns offers a refreshingly honest perspective on why traditional approaches to weight management fail so many midlife women. Using the powerful analogy of a locked woodshed, she explains how high insulin levels essentially padlock your stored fat, making it impossible to access no matter how much you restrict calories or exercise.
What makes this conversation truly valuable is how Dr Burns connects the dots between hormonal changes, metabolic health, and practical lifestyle solutions. She introduces her "six S's for success" – sustenance, sleep, stress management, strength training, sunshine, and social connection – as foundational pillars for reclaiming metabolic health during menopause and beyond.
The discussion takes fascinating turns through hormone therapy considerations, the psychological aspects of food addiction, and why so many of us grew up alternating between strict dieting and giving up entirely. Throughout, Dr Burns maintains that improving metabolic health should be the primary goal, with weight loss simply being "a happy side effect" of addressing the underlying hormonal imbalances.
If you're exhausted by diet culture but still concerned about your health during menopause, this episode offers a science-based approach that works with your changing physiology rather than against it. Discover why muscle is your "metabolic organ," how stress impacts your ability to lose weight, and practical steps to break free from the metabolic challenges of midlife.
Ready to stop blaming yourself and start understanding the real science behind menopausal weight changes? Listen now and discover why it's time to focus on metabolic health, not just the number on the scale.
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The Real Health and Weight Loss Podcast
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Welcome to the Dear Menopause podcast. I'm Sonya Lovell, your host Now. I've been bringing you conversations with amazing menopause experts for over two years now. If you have missed any of those conversations, now's the time to go back and listen, and you can always share them with anyone you think needs to hear them. This way, more people can find these amazing conversations, needs to hear them. This way, more people can find these amazing conversations. Welcome to this week's episode of Dear Menopause. I am delighted to be joined today by Dr Lucy Burns.
Dr Lucy:Lucy, welcome to the show, Sonya. Thank you so much for having me. It's an absolute delight.
Sonya:It's always a pleasure to have like-minded smart women on the podcast, and I know my audience are going to love what we're going to talk about today, which is predominantly metabolic health. So, Lucy, before we do that, why don't you share a little bit about who you are and what?
Dr Lucy:you do Absolutely.
Dr Lucy:So my name's Lucy, I'm a medical doctor in Australia and I started my life off as a GP and then, interestingly, toddled off.
Dr Lucy:I worked for Defence for a long time, which sort of sounds weird, but it suited me that we live near a Defence base.
Dr Lucy:And so I stepped out of general practice and saw mainly young people, came back into general practice and saw the older population, sort of midlife and beyond beyond, and realised in the 15 years that I'd been out that this explosion of chronic disease had just taken over and that people who were 55 were not the same as they were 15 years prior, that 55 had suddenly become, you know, the new 75. It was like what? And so, on top of all of that, a zillion drugs moving into the space and us having to know everything, and I thought, oh, this can't be right, I need to go step back and sort of look at the root cause. And so I went and retrained as a lifestyle medicine doctor then, looking at the root cause of a lot of our chronic disease around insulin resistance, and so that then became my little passion and really talking about insulin resistance, the management of it with you know, yes, potentially some medications, but really how can we improve lifestyle to optimize that and prevent chronic disease so that we can live our glory years having fun yeah?
Sonya:absolutely A couple of things I want to ask you in there what year was this when you kind of dipped back into being a GP after those 15 years in defence?
Dr Lucy:Yeah, about 2018. Yes, a little while ago now. And look like lots of people, you end up in an area because it's somehow all about you. So it was, it was all about me and, interestingly, I had spent an entire lifetime, you know, dieting, going on a diet or going on a bender. So I was really good at dieting. I'm really diligent, really strict, good going to the gym, doing all of the things.
Dr Lucy:I was either all or then doing nothing, doing nothing and just eating donuts and everything, until I get to the point where I think, oh my God, I can't fit into all my clothes going back into it. And that was all fine until well, it secretly wasn't that fine, but I thought it was fine until I got to a point where it sort of wasn't really working. And then I just thought you know what I'm sick of this dieting business. I'm just going to make peace with my elastic waist and pants. You know, my husband still loves me. I'm not a bikini model, I don't need to worry. Except then I actually got pre-diabetes and fatty liver disease. Wow, this is not good.
Dr Lucy:I don't want to be a doctor with pre-diabetes and fatty liver disease and so, yeah, that was really, I guess, part of the impetus and seeing that, it wasn't just me, it was all the patients, as well, that was having this.
Sonya:We come from a generation of dieters, don't we? I remember when I was reading a little bit about you before we met and came together to talk, and there was something that you said that really jumped out at me because I totally resonated with it, and that was having the fat wardrobe and the thin wardrobe, which is, you know, that's what you had. You had the clothes that you wore when you had had those binge periods and you'd, you know, got so exhausted by the dieting. You know, you had your fat wardrobe and I, as much as I, have followed a similar path to you with making peace and just being so completely exhausted by dieting, not to mention unwell and not serving me any longer. But I still find that I hold onto clothes in my wardrobe for when I fit into them and I have, I catch myself now and go. No, they can go.
Dr Lucy:They can go. Yeah, yeah, yeah, yeah, absolutely. And I and I remember, you know, maybe having like going to an event, maybe a wedding or a formal function, and sort of praying that the dress will fit, and thinking, oh my god, if it doesn't fit, what am I going to do? And you know, then you'd go. So then you'd, you know, crash, start to try and squeeze into this dress and, yeah, yeah it was.
Dr Lucy:It was totally exhausting and, yeah, at the end of the day, left me in a situation that was, yeah, you know, yeah, not ideal from a health perspective no, no, and so I guess that that then became part of what I, what I started doing, which was, yeah, lifestyle medicine around managing, you know and again, I use the word weight loosely because everybody knows the phrase weight loss but I'm really talking about metabolic health, and when we improve our metabolic health, weight loss comes along for the ride as a sort of just a little side effect, but it is not the goal per se.
Sonya:Yeah, I love that, that shifting of the goal from being yes, you'll get some weight loss, you know, like you say, as a happy side effect.
Dr Lucy:But it's not our overarching goal.
Sonya:No One of the other questions that I have for you, and I'd love for you to expand on this, because it's something that I have recently become aware of and I'm really excited about. I believe that this is the future of healthcare and that is the lifestyle medicine. So can you explain for anyone listening that doesn't understand the difference between medicine and lifestyle medicine and also what was involved in that upskilling for you?
Dr Lucy:Yeah, absolutely so. I mean in general medicine, it treats disease. So we talk about preventive care, but it's really even preventative care. What we're looking at is measuring risk factors and then working out well, high blood pressure, that's a risk factor for cardiac disease. So the preventative care is to treat the blood pressure.
Dr Lucy:We are not very good at prescribing lifestyle changes within the current confines of our medical system, and there's lots of reasons for that. It's usually time-based, as one of them, but I think for a lot of doctors, they think lifestyle doesn't work and so they'll give it lip service and they go oh, yeah, yeah, lifestyle, but really what they're going to need is this blood pressure medication, or what they're going to need is you know, or what they need is weight loss, and then they won't need a blood pressure medication, whereas lifestyle medicine is a way that we can not only prevent disease but we can actually treat it. So it includes, you know, know again, moving your body, but moving it in a way that is not actually harmful, because not all movement is good for us, as we know. But so, you know, there's movement, there's nutrition. It clearly fundamental nutrition, and you know, the reduction of ultra processed foods would be the number one thing that we look at and sleep, optimizing sleep, stress. So there's a whole lot of pillars which I call we actually use the little phrase the six S's for success, so which is sort of a success successes. So the six S's, as I remember them, are sustenance and that's just because that is a good way to fit nutrition in with an S. So we do sustenance, we do sleep, we do stress management, we do strength training, we do sunshine and social connection, I know, and when we can optimise those, then we absolutely reduce our risk of further chronic disease. But we can even improve and treat chronic disease.
Dr Lucy:So for me it's really about then being able to de-prescribe, so actually take people off their medications is exciting and so, yeah, so that's sort of how that started. So, yeah, I went through there's the Australasian Lifestyle Medicine Association, I did their training and I'm now a fellow of that college. There's some and again, like everything I think there's, it was initially. Their nutrition component was initially plant-based, and I'm not plant-based and in fact I've got some thoughts around plant-based nutrition. I'm an omnivore, very proud omnivore, and so. But at the end of the day, rather than looking at the differences, I think that really we want to look at, well, where are the similarities? And it really is around that reduction of ultra processed food.
Dr Lucy:And then I guess part of then what I did was I thought, well, it's all very well to have these successes, you tell people this is what you need to do and that's all great, but then actually the implementation is where people fall down. So the knowledge is step one, but the implementation is step two. And so I went and had a look. I'd already had quite a lot of psychological medicine training as part of my general practice. Mental health was something I was really interested in. But then I did hypnotherapy course, which has been again life-changing and really exciting on many fronts, but also then a whole heap on behavioral change and understanding how our brain works, and then, I guess, being able to distill science into funny stories that then people can relate to and go yes, I can see that and I can probably do that now.
Sonya:Yeah, that's fascinating. I am really very interested in lifestyle medicine. I've got a girlfriend who's just started studying herself. She's a nurse, very highly qualified, highly experienced nurse, and she's constantly going. Oh my God, I've just learned this, sonia, this is right up our alley, and I truly do believe that this is the way of the future. Obviously, there are needs for medical interventions at different points in time, but lifestyle has to be those pillars that you talked about. You know so important, and I think, with the way I look at it is the way that our society has evolved and where we're kind of heading, they've become even more important to be reminded of.
Dr Lucy:Yeah, absolutely, because the environment that we live in is not conducive to those lifestyle pillars. They don't happen easily, so we have to, I guess, hijack our current environment to make them easier. It won't happen without some intention.
Sonya:Yeah, and it's funny, isn't it? So even the things like you talked about the sunshine being one of them, and the social connection they're things that it sounds a bit wistful, I suppose. Sometimes when you kind of go, you know these are things that our grandparents did and they didn't think about doing them, they were just a part of their life. But we do have to actually now work at making those things part of our life.
Dr Lucy:Yeah, yeah, because otherwise that won't happen. Our life is we get up, we go to work in the dark. If we even go to work, some of us work from home. You don't. You know. You can have days and days without going outside. A hundred percent agree, you know I find myself sometimes like I'll get up.
Sonya:It's now darker in the morning, so I could get up in the morning. I can still walk my dog outside, but it might be darker than it was previously. Then I go to the gym, which is inside, yes, and then I'll come home and I will work in front of my computer and I have to remind myself to get up. Go outside, you know, take a walk, get the sunshine, get the fresh air, because it is way too easy to just spend all your time inside.
Dr Lucy:Totally, totally and again. And I mean going outside is kind of something that's relatively easy, like it's not painful, there's not a lot of barriers, but we still have trouble doing it, whereas you know nutrition, moving your body, they're a bit harder, so you can imagine the barriers for that are even more intense.
Sonya:You mentioned that addressing metabolic health, and particularly through the use of lifestyle medicine, can have a huge impact on chronic disease. So can you explain what you mean by chronic disease, what some of those diseases are, and then we'll kind of dive into your recommendations around avoiding those?
Dr Lucy:Yeah, sure. So again, if we think about, the biggest chronic disease that we are facing these days is type 2 diabetes and obesity. So, again, obesity is a triggering word. I get it. It's been used as a slur, it's used as a marker that people are lazy and gluttonous, and all of that. It's nothing to do with that. It really is. It's a condition where, again, our metabolic hormones become deranged. Our body becomes very, very good at storing fat and it starts storing it in areas that it was probably never designed to store, so in particular, in and around our organs. So we can end up with things like fatty liver disease and, interestingly, fatty every other organ disease.
Dr Lucy:So yeah people hear about fatty liver, but there's fatty pancreas and fatty heart, and these also cause separate diseases in themselves, and what ends up happening then is that we really accelerate the risk of cardiovascular disease as well with some of these conditions, and so people end up having heart attacks or strokes early in life. With type 2 diabetes, they end up with neuropathies. They lose their vision. Other thing that it exacerbates really is things like arthritis, and all of that affects the way we move. So, at the end of the day, the chronic diseases affect our functional capacity, and so we can't do anything like you have to go, you need a walkie frame, you've got to go to spend your life going to doctors, to getting pills, potions, hip replacements, and I kind of think, wow, people work hard their whole life, they work really hard.
Dr Lucy:Australians are hardworking people. They want to enjoy their retirement, the glory years, as I call them and yeah, they're crippled by chronic disease of varying sorts. They're taking a lot of medications, it's expensive and that's not how it's supposed to be. Yeah, and I guess you know, and a slightly different tact, but another emerging set of conditions is autoimmune conditions, which are separate to these other ones. So these things that I was talking about are really related to insulin resistance. As the core driver, autoimmune, is separate, highly likely to be related to our lifestyle, but it is tricky to determine exactly which part of our lifestyle because it's going to be multifactorial.
Sonya:And when you're talking about autoimmune disease, can you give us a couple of examples? So thyroid, is that something that falls into?
Dr Lucy:autoimmune? Yeah, absolutely, and that was one of, again, one of my light bulb things. When our general practice and intergeneral practice, at that 15 year gap, where, again, just looking after young people in defense, young people don't, they don't have chronic disease usually yet Coming back and going, oh, my God, everybody seems to have Hashimoto's. What is going on here? So, yeah, increasing Hashimoto's, increasing celiac disease, and again, some of celiac is because we've got better at detecting it, but it's actually just more prevalent. They would be the two biggest ones that I've seen that are increasing. And then you know there's rheumatoid arthritis, but that's been around for a long time. It's just the rate at which we're getting it now. Inflammatory bowel disease would be another one, wow, okay.
Sonya:Yeah, so what I'd like to explore with you and you did touch on this very briefly how our hormones play a part in some of this metabolic health and a lot of the things that we've just talked or you've just talked about. There are things that we talk about when it comes to menopause symptoms and also the impact on our quality of life long-term post-menopause.
Dr Lucy:Yeah, absolutely so, you're right. I mean, everything I just spoke to about then applies to both men and women. And what we have as women and this is where my interest in menopause has come in to play is recognizing that pre-menopause estrogen in particular what a frigging super hormone that is, isn't it? It is it's so protective, cardioprotective, and it's got so many brilliant properties that then, when it disappears, it kind of unmasks all of these other risks into chronic disease and the thing that I guess that I see a lot of and is and I've kind of just coined this phrase, I don't think it's a real phrase, but I call it the metabolic triad of menopause. And so what happens is, as estrogen declines estrogen is really good at being insulin sensitizing. So as estrogen declines, our insulin levels will go up, our insulin resistance will go up, and as estrogen declines, interestingly, our cortisol levels will go up.
Dr Lucy:So these three have a little tribe, because another interesting thing is that as cortisol goes up, estrogen can go down as well. So again, we look at that area in the adrenals, which I know you're really well educated in, but we always think of estrogen as just being made in our ovaries and obviously that is what stops once we hit menopause. But estrogen is also made in the adrenal glands, as is cortisol, and so we have this situation where if we're making extra cortisol, for whatever reason lots of stress or a pathological process well, that will cause estrogen to go down. As estrogen goes down, cortisol goes up. So as cortisol goes up, insulin goes up. So, or a pathological process well, that will cause estrogen to go down. As estrogen goes down, cortisol goes up. So as cortisol goes up, insulin goes up.
Sonya:So there's this little triad, that kind of-. There's this real interplay going on, isn't there constantly between cortisol and estrogen.
Dr Lucy:Absolutely so, then we can go. Well, actually, we can help this process by again bringing back lifestyle into it. Because if we can help this process by again bringing back lifestyle into it, because if we can reduce our insulin resistance with lifestyle changes and look, a powerful driver is for us. We advocate a low carbohydrate lifestyle. This is not a no carbohydrate lifestyle. People always go how can you get rid of a whole macronutrient? It's like, well, I'm not getting rid of it, yeah, it's just reducing it. So reducing your carbohydrates really powerful driver of insulin resistance. Improving stress management Like again, I cannot underestimate the effect of chronic stress and I think what people think is that in order to have a stress-free life, they need to run away, they need to go off to a tropical island and you know, then they can't, there'll be nothing to To be stressed about.
Dr Lucy:Yeah, exactly, but you know I don't own a tropical island. I don't know many people that do.
Dr Lucy:I mean, it sounds really appealing. It does. It does, although, interestingly, if you go to a tropical island all by yourself, well then you're dealing with loneliness, which is another one of the S's that we have to measure. I think we have this expectation that the only way we could be unstressed is to not have any external stressors, and so if everything else outside of our environment was hunky dory, then we wouldn't be stressed. But again, that's not realistic. So it's really looking around the stress cycle and we need to have periods where there is some stress, because that's normal, and we also need to have periods where we rest, because that's also normal, and that's how we're supposed to be. But women in particular are not very good at that. We don't actually ever stop. We, you know rest is considered lazy, we're not being productive, we're not making good use of our time, so we fill up any periods that might where we could potentially rest with and that's conditioning, that's societal conditioning, that and you know, modeling from families as well, probably from previous generations of women within our families.
Sonya:Yeah, yeah, that's that's created. We're stuck in that cycle now aren't we Of that stress cycle?
Dr Lucy:Yeah, yeah. So again, yeah, it's, it's being so, it's so. It's chronic stress as opposed to acute stress. Acute stress just means short-term high, you know, and then resolves. Chronic stress is this low level, but chronically always on. So we're always getting stressed when we don't sleep properly. All of those things really impact again that cardiac metabolic triad. So that and part of the thing about the cortisol levels is that cortisol does increase our glucose. It's its job. One of its jobs is to increase blood glucose and that was all designed so that if we needed to run away from something, that we had enough fuel to do so.
Sonya:To do so, yeah, so what we've got then is declining estrogen, increasing cortisol, increasing glucose, so hence the insulin.
Dr Lucy:Yes, yes, so that's where that side comes from. It. Declining insulin increases. Sorry, declining estrogen automatically increases insulin anyway, because it's one of its things that it does. There's some extra components in there as well, because we know that declining estrogen, you know, affects our muscle mass. Muscle is our metabolic organ. The more muscle we have, the lower our insulin. The less muscle we have, the lower our insulin. The less muscle we have, the higher our insulin. And so there's this hugely complex interplay between estrogen and our metabolic health, which is why women got premenopausal women are protected and then go through menopause, their cardiac risk factor skyrocket. They've got no idea. No one told them that Suddenly their lipids are all over the place. They've developed hypertension, they've put on weight around their belly, they've got fatty liver disease and thinking, holy hell, what happened? Yeah, yeah.
Sonya:So then, and this is one of the areas that I find really fascinating so if we talk about hormone therapy for just for a moment I know that's not what we came on to talk about, but one of the conversations that has become very loud and it's a really strong narrative now that is used from clinicians and a lot of doctors when they're talking about the benefits of taking hormone therapy is not just that immediate symptom management side of things, but the longevity impacts, so the things that we're just talking about there, so the healthy bones and the healthy heart and the cognitive protection as well. So am I right, then, in assuming that if somebody was to use hormone therapy, so there's that hormone top-up, if you like, that that does also help protect against some of these metabolic diseases that you're talking about?
Dr Lucy:so I think the tricky bit is that initially. So we've known about this face with estrogen for a long time. That's not new news, it's not my news, it's it's old news. And then again, back in 2000, women's health initiative study we all know that. And they'll give an oral estrogen. And oral estrogen goes through the liver, which increases the clotting, which is not so great for cardiac health and increased there for the some heart disease or heart attacks in women who were already a bit older. So this wasn't women in their 50s, but women who were starting this oral estrogen in their 60s and 70s. So we know that for them that wasn't ideal.
Dr Lucy:However, transdermal estrogen my favorite thing in the world it has no effect on clotting, none above your baseline. And now we know that, particularly if it started within 10 years of menopause, that it is cardioprotective. So those women who started somewhere within that 10-year period will go on to maintain their cardiac benefits while they're taking it. So the cardiac benefits do stop once you stop. So if you're only planning to take it for a few years to manage your flushes, you're not going to get the long-term benefits from it, and we know the same is true with bone health. The same is probably or possibly going to be true for brain health, and it seems to be likely, but there's just not the data yet. But it's promising.
Sonya:But I think, coming back to what we did come on to talk about, is that, even for somebody who does choose to use hormone therapy, that these other pillars that you're talking about need to also be considered. So the two things need to go hand in hand. That you, you know. I think one of the things we need to always talk about if someone is taking hormone therapy is that it's not a silver bullet. And, yes, you do get that estrogen protectiveness back, but you must also be addressing the lifestyle factors that you're talking about as well.
Dr Lucy:Yeah, absolutely. And again, my favourite thing is it's not this or that, it's this and that, and that sometimes taking MHT or HRT can help you implement your lifestyle factors, because suddenly your joints aren't so sore.
Sonya:So you're happy to go. You're sleeping better, you've got a bit more energy, yeah.
Dr Lucy:Yes and again. You know, because life's always you know all about me or whoever's talking For me. Part of my interest in menopause became again when, despite doing all my lifestyle stuff, having been the world's best sleeper and rarely stressed, I started getting hot flushes. Not hot flushes during the day, night sweats, night sweats, waking up at 3am thinking what am I doing awake. And then, interestingly, I woke in the morning with just this ridiculous anxiety in the pit of my stomach. It'd be like I'd wake up going and I think what am I worried about? What's going on? What am I worried about? Be like I'd wake up going and I think, what am I worried?
Dr Lucy:about what's going on. What am I worried where? And I'd have to do this little talk myself off the going. Well, there's nothing worrying, don't need to worry. And so I thought, oh my god, I've got menopause. Well, actually, I didn't think menopause at first. I thought, oh my god, I must be worried about. You know, I'm now a business owner. I'm worried about the business I must be worried about about something, and it was really the night sweats that I needed the treatment for. I thought I needed a treatment for. So I got treatment for that and wow, amazingly, I also started to sleep a bit better and the anxiety went away. And that's when I've gone, oh my God.
Sonya:And I find these conversations so fascinating when they're with clinicians because the amount of stories that I hear from doctors, specialists, nurses, that all had their own experience, like you, where they had all sorts of symptomology and then the menopause, and then they realize that hang on a second, yeah, and you kind of go and this is, you know. This leads us into an area that is where I'm so um prominent with my voice is like if you didn't know, yeah, how the hell were we supposed to know what's going on?
Dr Lucy:I know, I know, and again it's like you know, you feel like such a goose. I'm thinking, oh my god, I'm so, how? How could I have been so, I don't know stupid or blind, or thick. I'm thinking, oh, anyway, I'm now more like. Now. I feel like I'm thick. I'm thinking, oh anyway, I'm now more like. Now. I feel like I'm vigilant, like I'm on this menopause oh my God, you know you've got itchy skin. Oh, it's probably menopause, but yeah, the thing is that it probably is. Yeah, I think now it's.
Dr Lucy:I think back, and you know, again I've got another patient I can remember prominently about her. She came again because I'd set myself up as a weight management clinic and metabolic health clinic and she was coming to me to talk about her weight and she was just talking about her bone, her fatigue, and she said I feel so weak, I'm so tired and I just don't feel strong. And I sort of thought, oh, I've got an idea what's going on. I feel so weak, I'm so tired and I just don't feel strong. And I sort of thought, oh, I've got an idea what's going on. I don't know. Let's just keep talking about lifestyle and talking, talking, talking. She was doing, doing, doing. But she honestly just had such terrible fatigue and she told me she goes.
Dr Lucy:Oh, I went and saw a menopause doctor, Dr Ginny. This is back in 2018. And I'm thinking, oh right, and I knew nothing about menopause, dr Ginny and I go okay, that's good, she goes. Oh, she's put me on some you know testosterone. And I'm going, oh gosh, anyway, she found a million bucks. And so now I'm thinking I just didn't know, I didn't know about it then, and you don't know what you don't know.
Dr Lucy:No, no. So now I'm sort of going radio, okay. So I guess you know. So I do. I totally love estrogen. I think estrogen is fantastic.
Dr Lucy:Progesterone I have a few different ideas, perhaps to some other people around it, because progesterone unfortunately, it can cause insulin resistance. Okay, I haven't heard that before. No, well, progesterone is. So its main job is to balance the lining of the uterus and stop it becoming gigantic. And then its other job is in pregnancy. So its job is to maintain the corpus luteum, or the little cyst, the fetus, when it's first a fetus and then over time it maintains the pregnancy and it's the thing that causes women to store fat when they're pregnant. So for women that, particularly if they're genetically predisposed to insulin resistance so maybe they have polycystic ovarian syndrome or maybe their parents have type 2 diabetes they can stack on tons of weight in pregnancy.
Dr Lucy:And again, it's all about me. This happened to me in pregnancy. I was a person and I went off to my exercise. I did my bloody thing on the ball that you do Pilates all the pregnancy exercises. I'm eating well, I'm not having my moldy cheese, I'm not eating sushi. I'm doing all the right things. And you probably stopped drinking as well, yeah, oh, yeah, god, yeah, no, no alcohol, yeah, 35 kilos again in pregnancy and I was like holy hell. Interestingly, I didn't have gestational diabetes back then.
Dr Lucy:If I was having my glucose test now I would have, because the criteria has changed, yeah, so so again, it's progesterone is the thing that is the, and progesterone comes from your placenta, so it's the thing that then causes your body to store fat. It's the thing that produces a gestational diabetes. As soon as the placenta's out, everything reverts to normal. So it is one of the reasons why, when in menopause, then, women are starting to gain weight is because they're losing their estrogen, but their progesterone stays around a bit longer. It does, yeah, yeah, and for some women, the progesterone component of their MHT can still cause them to store body fat.
Sonya:Okay, but we need to weigh that obviously against the risk of uterine cancer.
Dr Lucy:Absolutely. I'm not saying don't take progesterone, Absolutely not Okay cool. So there's a couple of things that we can do, though, so, first of all, if you don't have a uterus, well then, you don't have to take progesterone for your uterus, but the other thing that we need to balance, then, though, is that, for some women, progesterone is helpful for sleep.
Sonya:It's that chill hormone as well, isn't it? So it can take the edge off anxiety. It can take that. Help with that sleep, yeah. Yeah, it can, she's a tricky little sucker then, isn't she? It is.
Dr Lucy:It is a little yeah, and again, I've also seen women who start their progesterone and actually can make them anxious. So it doesn't, it's not sedating for everybody. So I think for me this, and again, this is everyone's different, but my kind of way I like to manage progesterone is to try and keep it local if possible. So again, that might be a Mirena, it might be just using Prometrium vaginally, vaginally, yep, and that will keep it local and that is less than of an effect on your insulin resistance. Balancing that up with the sleep side of things. But I think also sometimes people and again there's a little bit of chat amongst in some of the Facebook groups around the you know the benefits of progesterone and so they're using it for the sleep, potentially before the estrogen is optimized. So and again this is just looking for me personally and some of my patients are they need a bit more estrogen first. So estrogen, again, you know, probably too much information sharing here, but I've had a hysterectomy so I didn't need the progesterone.
Sonya:Progesterone yep.
Dr Lucy:So I've just plonked my estrogen up a little bit. Add a little bit of testosterone and I'll sleep like a baby again.
Sonya:Okay, yeah, testosterone can be the missing key for a lot of people and unfortunately it is a. How do we? How do we phrase this? It's a tricky area right now, with some conflicting views on whether testosterone should be prescribed or not as a part of hormone therapy, but I believe that what I've been told and what I've read is that there's a lot of anecdotal evidence and there is some research underway to show that there can actually be some benefits for women with testosterone, particularly, like you say, on the sleep and things like that and the cognitive function as well and muscle mass, because testosterone is good for muscle.
Dr Lucy:Yeah, absolutely. And so yeah again, I kind of in my head just about every post-opausal woman is hyposexual dysphoria disorder, hsdd, that's if you have that, that's your, that's the tga approved use of testosterone yeah, but you know again, as doctors we use a lot of medications off label, a lot you know for and for lots of things you know we, we will use um I'm going to give a great example there.
Sonya:I was prescribed antidepressants not because I was depressed, but because I had hot flushes as a result of my radiotherapy and chemotherapy, and that was an off-label use of the antidepressant.
Dr Lucy:Absolutely, and we will use antidepressant, a different one to those ones. We use that for bed wetting in children. Wow, I know that's a bit off-label. There's lots of things that we use off-label, but they don't come with the same controversy that testosterone comes with. So I kind of think, again, you need to understand how to use it. You need to know the guidelines, not the guidelines. You need to know the risks. You need to understand how to use it. You need to know the guidelines, not the guidelines. You need to know the risks. You need to know the benefits. You need a discussion, but it can certainly be prescribed safely.
Sonya:Yeah, hmm, yeah, most of my listeners are curious, obviously, about all the things that they can do to improve their longevity, their quality of life and, you know, symptom management from a short-term perspective as well. So, lucy, let's talk about weight loss, because I think that that is absolutely a hot topic for so many women in this space and there are a lot of options at the buffet table when it comes to weight loss. Now we have injectables that have become a new player, but also a very, very prominent player. We have the old diet regime still rearing its ugly head. You know the eat less, exercise more life deprive, deprive. As a demographic, we are absolutely hammered with options to solve our belly fat, to solve our meno belly. There's some awful marketing out there. Tell me, from your perspective, what you have found to be the and obviously I'm imagining it's very nuanced for everybody that you see as a patient but what do you find has the best results and why?
Dr Lucy:Yeah, absolutely Great question, and I think that you're right. There's not only many options at the buffet table, there's also many opinions on how you should do it. Everyone's an expert. At the end of the day, it is way more complex than we've been led to believe and that there is no simple solution. And anyone that's offering you a simple solution is just trying to sell you something, because it is a complex interplay of metabolic hormones. A complex interplay of metabolic hormones, insulin resistance and again, I love insulin.
Dr Lucy:Insulin resistance is at the heart of fat storage, and the way I like to describe it is if we imagine that our body is a bit like a house and we're trying to heat it with a fireplace. So when you're heating a fireplace, put some kindling in a little stick, some paper. You then put some logs on to keep it going. Our fuel is very much like that. So our kindling is glucose, which is short-acting carbohydrates, and that gives us energy and that's all lovely, and then we should probably put some fat on and that will. What is our long storage and that keeps us going and fuelled for hours. What happens with insulin resistance is that, you know, in our fireplace there's no actual logs available. They're in a woodshed, stored out the back and they're not neatly stored. And you know, some people have a very large woodshed and it's got lots of wood in it and so their body. You toddle out to the woodshed to try and get a log to put on your fire and the woodshed's locked and the lock big padlock, and the lock is insulin. So I didn't know this. Another thing I didn't know, god knows what I was doing in medical school. I didn't know that insulin stops fat breakdown. So if you have high blood insulin, you can't break down your fat. And it was like what? And so it's like you go to the woodshed, you go to get a log, the log's locked away, so you come back to your fireplace.
Dr Lucy:By now you're hungry, you're pretty tired, you're a bit cranky and your brain starts going oh, my God, you've got to eat, you're starving. And it starts really telling you that you need some fuel, because by now there's only a few embers. And so, honestly, you're now starting to think well, I'll get some coffee and I'll get you know, and you grab something quick, a muesli bar, a chocolate bar, whatever you can get, because your brain actually needs some fuel. And so then it goes oh, thank God, and then you're fine for again another hour. You still can't get a log. So you're constantly having to eat these six small meals a day, or snacks or whatever it is to keep your body fueled long enough all day.
Dr Lucy:And so it wasn't until, honestly, I just thought, really so it wasn't until I realized that you actually need your insulin levels to get to a certain low point in order for your body to be able to access that woodchip, the stored fat, to burn it. So we really need to have low enough insulin to access your fat. So how do we do that? Well, again, insulin is raised in response to glucose. So if we can lower the amount of blood glucose we use, so lower the amount of kindling essentially which sounds weird. You're thinking, why would you do that? And this is where you start increasing your dietary fats.
Dr Lucy:So again, as an ex-dieter, I was always scared of fat. I had years of Vegemite, yeah, yeah. Or even dry toast with Vegemite, because that was low calorie and low fat. Yeah, yeah, yeah. And those horrible diet yogurts that were somehow lemon cheesecake flavored but made with chemicals. All of that, no fat in any of that. So again, no, no fuel. Whereas now you go okay, well, you can add, add some fat back in, add some fuel back in, and then, over time, what happens is your blood insulin levels will lower and you suddenly have access to your own stored body fat and this miraculous thing happens where you're not actually hungry that's like, really I'm not hungry, what and it's because suddenly your body has access to its own fuel again and it will start using it and you go oh, thank God. And so really, that reducing insulin is the number one thing that needs to be done for people that are insulin resistant or have hyperinsulinemia, which for people that are overweight, that's the majority of us.
Sonya:Okay, and is that identified through a blood test?
Dr Lucy:Yeah, you can certainly have a blood test, but there are a few kind of hallmarks that might come in. So if you have lots of skin tags, so skin tags under your arm, under your boobs, around your neck, again, everyone might have a couple. So one or two is no big deal, but if you have a lot, that's usually a sign of insulin resistance. Yeah, if you have ever had gestational diabetes or polycystic ovarian syndrome, you will have had insulin resistance. If you store the majority of your fat around your belly, then that is usually insulin resistance. And then there's this slightly unusual, more advanced sign, which is something called acanthosis nigricans, which is patches of pigment that happen under your arms or in your groin. So you'll be, you'll have these sort of dark patches under your arms groin, sometimes around your neck, some people on their forehead or forearms. So they're all signs of insulin resistance. And then you know pre-diabetes, type 2 diabetes. They're all diseases of insulin resistance.
Sonya:Wow, my brain is firing off in all sorts of different directions because I'm seeing all these connections between so we talked right at the very start about decreasing estrogen, increasing cortisol and then that increasing your glucose, which is obviously going to play into that insulin, insulin yes lock on the on the firewood door.
Sonya:Yeah, and you know, and so we know then, and you know, and also that shifting of weight being stored in the body to around the belly. You know, if we just look at that, so cortisol stress shifting weight to the belly very much. We just look at that, so cortisol stress shifting weight to the belly very much. Menopause symptoms.
Dr Lucy:Yeah, absolutely Absolutely. And when people go, I don't know if that's true. All we have to do is look at, if I prescribe cortisone to somebody for their asthma or measuring something, if they're not long enough, what do they get? Belly fat and type 2 diabetes and, interestingly, osteoporosis. So a whole heap of things related to their cortisol and cortisone. They're the same thing. If we give insulin to somebody who has type 2 diabetes, they gain weight. And doctor's advice my advice used to be it was so embarrassing again oh, make sure you don't gain weight. It's like what? Like that was it. Make sure you don't put on too much weight.
Sonya:I got told that at my cancer diagnosis it was between being diagnosed and my treatment starting I went and saw a nurse at the centre where I was going to be having my chemo. It was at the private hospital where I was treated, so it was this cancer center, I guess, and I don't remember a lot about the appointment, but I do remember her saying to me whatever you do, don't put on any more weight. And at the time I was like, well, I'm totally screwed, because I've, since getting my diagnosis, I've eaten a block of chocolate and drunk a bottle of wine pretty much every day, and you know, I know that I've put on weight just through stress. So that was horrifying and it has stuck with me as one of the pieces of advice that I was given at such a traumatic time in my life.
Dr Lucy:Yeah, absolutely. And I mean, you know, I think, to break that down, there's multiple reasons why people will put on weight. So one, you know one might be yeah, well, you're eating. You're eating chocolate and alcohol. There is no point saying to somebody who is distressed just don't do that, like that's, that's unhelpful, that's a coping mechanism. Half the time, yeah, so you're basically pulling out their coping mechanism and not necessarily giving them any others. Second thing, of course, of course, is we know that and again, I don't know what treatment you have, but lots of people have dexamethasone as part of their chemotherapy. Wow, that's cortisone.
Sonya:So lots of people will gain weight on top of all of that, and I took steroids as well, prior to my each chemo treatment. I mean, I have photos of myself with this massive moon face. Honestly, my face was like that proverbial full moon, and it was the steroids.
Dr Lucy:Yeah. And the cortisol is a steroid. Yeah, so I think. And then, on top of that you know, suddenly your estrogen's gone, like all the reasons why your body is going to start storing extra fat, but the?
Sonya:advice is Don't put on any more weight.
Dr Lucy:It's like saying to you don't breathe, don't breathe. So yeah, I know I'm slightly modified to have given rubbish advice like that too, but again, I think you know it's what, what, what people do like what, what people eat, how they sleep, all of that's really important. But but if, again, if they can't implement or don't know how to implement it consistently, again people don't have skills. They often think the reason they can't do it is they're weak, they haven't got any willpower. You know they're not disciplined.
Sonya:Especially for a generation that does come from the diet culture yeah, where that's pretty much what you've been led to believe. They're like you diet which is never good for you, and yet then you fail and leave. They're like you diet which is never good for you, and yet then you fail, and then that's like, well, it's your fault, you didn't stick to the diet, or you obviously ate too much or you didn't do enough exercise.
Dr Lucy:Totally. I mean and again, we got sold this you will lose one kilo a week and you will do this terribly hard thing for 12 weeks. You'll lose your 12 kilos or your 10 kilos or whatever you get, you'll get to goal. Then you'll go to maintenance, and the maintenance, the promise of maintenance, was more food. Yay, and honestly, it's just, it's just garbage. It's so not how it should work, but to to be honest, there are some people who do have trouble implementing a lower carb lifestyle, and it's not the only way to reduce your insulin resistance by any stretch. I'm not the the. I recognize there's a number of ways to do it, but I think taking, looking at processed food and the way processed food is marketed to us, uh, the way it is produced, the way it is sold to us, the way we have consumed it, and understanding that there is quite an addictive component to that is really important as well. And again, you, you know, for some people I have this we talk often about the three bucket theory of addiction. The three buckets are there's the first bucket of the people who don't really care about the substance. So they'll be the people that you know have one glass of wine once a year. Or a glass of champagne at a wedding. They might put a raffle ticket on, they might have cake, you know, once in a blue moon. They really don't care about it. They take it or leave it.
Dr Lucy:The next bucket are the people of the heavy users. So they're people that might, you know again, they might be drinking three or four nights a week. They don't realize it's potentially a problem, it's not impacting them that much, but it's probably more than ideal. It's the same with, you know, the gambling. These are my like, particularly young men these days, who are all encouraged to bet with mates and, you know, they're spending a significant amount, part of their income, on gambling. And it might be people who are, you know, eating. Every time they get stressed they eat, or every time they're bored they eat. So they're probably overeating.
Dr Lucy:And then you've got the third bucket, which is actually probably the really intense sort of addiction. So people who, even with gambling, they've lost their house, alcohol, their marriage has declined. They still can't do it. And I see it. People with type 2 diabetes or significant health complications who still can't stop their chocolate addiction or just for whatever reason. Well, lots of underlying reasons can't quite change, and so what happens is that again, people, the processed food company in particular, it's giving people who are in the third bucket. It tells them all the reasons why they should have this. You know, have this a Sn the set. You're not yourself without a snickers, you know it's a party, it's a celebration.
Dr Lucy:You must have chocolate yes, if you're lonely, if you're crying on the bus, some little boy will give you chocolate.
Dr Lucy:That's the current cabri's ad.
Dr Lucy:You know it's all about, um, emotions and feelings and they play to that and and then they say, oh no, we didn't tell you to eat a block a day, like you know you don't.
Dr Lucy:You shouldn't be that, you should be like the other person who just does it once a year, like that's not our fault, and so they take zero responsibility in the problem that they've created. And so I guess the thing that certainly when I started, was I was a little bit naive, like lots of us, but maybe when we start and then over time, with more and more experience, I realized there is actually a really narrow little minefield that you have to navigate between diet culture and you know many of us feeling shame and guilt for not being able to implement some of the things, or you know, the whole falling off the wagon or any of that versus this real phenomenon that the processed food industry is absolutely trying to get you stuck into their food hook line and sinker and anyone who says that you can eat that in moderation. Not everyone can, and so it's about working out in there all the other things.
Sonya:I think what you've really wrapped up today is that metabolic health, weight gain versus weight loss it's very complicated, it's very nuanced, it's psychological, it's physiological. I think what you've done has proven exactly why there can't be one fix that's going to work for everyone.
Dr Lucy:And we haven't even talked about the GLP-1s and where they fit into it. They absolutely have a role. They absolutely do. However, I think that there is this phrase and I really loved it. I saw it somewhere on LinkedIn. It's not my phrase, but I'm going to borrow it called careless prescribing, which is where people have prescribed this, but without the whole uh, they're not given full knowledge of their side effects. They're not given had a discussion around how, how long you need to take it for how, how do you come off them? What happens if you come off them? How, what dose you know? Like none of that. And then, on top of that, again a bit like we mentioned earlier with mht and hrt, it's not in. It's not in isolation. If you just do this in isolation, then the the problem is is certainly not fixed. It's just another piece, another tool yeah.
Sonya:So uh say it's a very large buffet, yeah, with um. You know a lot of people at the party that are trying to tell you why you should eat their dish that they made that's on the buffet table, yeah. But yeah, take it all with a grain of salt and understand that there is a lot at play here from a hormone perspective. You know, like you say, what's happening with your insulin, what's your stress levels, what's causing all of that? Yeah, it is a very big picture and it's not a simple one-stop fix. Lucy, if anybody wants to understand more about what you do, how you work with women, in particular in this midlife phase of life, how do you help people?
Dr Lucy:Yeah, yeah, thank you. I run a company called Real Life Medicine with my beautiful colleague, dr Mary, and with that we have online membership and programs really around the physiology and the psychology of weight management and lovely, beautiful, supportive community, very safe and trauma-informed care and all the things I think that are lovely. And then again recognizing that some people need some more nuanced and individual care, and so I run a telehealth platform as well and that's called RLM Telehealth, so they can find us on all the socials at Real Life Medicine, or our website is rlmedicinecom.
Sonya:Beautiful, and I will link through in the show notes to all of those wonderful places where people can get in contact with you. Lucy, it's been such a pleasure. Thank you so much for sharing so much of your wisdom with us. There's a lot to take away from today's episode.
Dr Lucy:Well, thank you very much for having me. It's been delightful.
