The Perimenopause Gut and Hormone Connection with Cynthia Thurlow

The midlife hormone rollercoaster leaves many of us wondering what is happening to our bodies and how to find relief – and in what order do we need to start tackling things?! What are some actual, tactical things we can start doing right now to start feeling better?  

I had the pleasure of interviewing my friend and colleague Cynthia Thurlow, a nurse practitioner and women’s health expert whose TedX talk on intermittent fasting has garnered over 15 MILLION views. We demystify perimenopause and menopause, revealing the critical order of priorities for addressing symptoms and simple strategies that actually work. From surprising truths about intermittent fasting to the gut-hormone connection few doctors discuss, this interview offers practical wisdom for women ready to thrive through their hormonal transitions rather than merely survive them.

What I love about Cynthia is her willingness to evolve her thinking as new research emerges and as she observes the effects of different approaches in her own body and with her clients. Just as I’ve updated my own programs based on new insights, Cynthia has refined her stance on topics like intermittent fasting. Let’s dive in! 

Understanding Perimenopause vs. Menopause

Perimenopause is the 5-10 year period preceding menopause when our ovaries gradually produce fewer hormones. Our ovaries are the pacemakers of aging. We are born with a finite amount of eggs that over time, we are getting closer and closer to becoming non-fertile. During this time, which can begin in your late 30s or early 40s, you may experience:

• Declining progesterone levels (the first hormone to decrease)
• Erratic fluctuations of estrogen
• Heavier menstrual periods
• Breast tenderness
• Sleep disturbances
• Anxiety or mood changes
• Weight loss resistance
• Brain fog

Cynthia described perimenopause as “reverse puberty” – a time of hormonal chaos, which is completely personalized to your body, lifestyle, and genetics. 

In contrast, menopause officially begins after 12 consecutive months without a menstrual period. Many women actually feel better in menopause because the wild hormonal fluctuations have settled down, though symptoms like hot flashes may continue.

The Order of Priority: Where to Start When Addressing Symptoms

Cynthia’s guidance on the order of priority for addressing menopausal symptoms is as follows:

1. Sleep

Sleep is foundational. If you’re not getting 7-8 hours of uninterrupted sleep (not waking up), this needs to be your first focus.  

• Create a sleep-conducive environment (no tablets, TVs, or screens in the bedroom)
• Use blue-blocking glasses in the evening (this has been transformational for me)
• Consider targeted supplements like melatonin, myo-inositol, or even creatine
• Examine whether vaginal estrogen might help with nighttime urination (which can be taken by any one, at any age) 
• Use adaptogenic herbs to calm the nervous system

Many women who have done all the “right things” still struggle with sleep during perimenopause and menopause. This is where hormone replacement therapy (HRT) can be valuable – progesterone helps with falling asleep, while estrogen helps with staying asleep.

2. Stress Management

As we enter perimenopause, we become less stress-resilient. Our adrenal glands, which normally serve as a backup system for progesterone production, can’t keep up if we’re constantly stressed. It’s really important for us to be:

• Setting boundaries and saying “no” more often
• Finding activities that genuinely calm your nervous system
• Connecting with nature
• Practicing breath work
• Listening to 528Hz sound (you can find it on YouTube) 
• Considering adaptogenic herbs like Ashwagandha or Rhodiola

3. Nutrition

Food choices significantly impact how we feel during perimenopause and menopause. Some things you should be doing: 

• Focusing on protein-centric, nutrient-dense whole foods
• Being mindful of inflammatory triggers (gluten, dairy, processed sugars, alcohol, grains)
• Understanding your personal food tolerances
• Prioritizing protein intake (this becomes more challenging as our appetite often decreases)
• Including plant fiber and phytonutrients for gut health
• Being cautious about fasting approaches (more on that below) 

A New Perspective on Intermittent Fasting

Intermittent fasting is choosing to eat within a prescribed window of time. It could be 16 hours fasted with 8 hours of eating. It could be 12 hours eating with 12 hours not, or 4 hours eating and 20 hours not. When you are in an unfed state, and your insulin levels are low, over time your body can use different types of “stored” things in your body for energy (like fat). 

Over the years, Cynthia has evolved her thinking on intermittent fasting, especially for women in perimenopause and menopause. While she still believes fasting can be beneficial, she currently recommends:

• A 12-hour digestive rest period rather than longer fasting windows (opposed to 16:8 or 20:4)
• Prioritizing protein intake and muscle maintenance
• Being mindful that reduced appetite doesn’t mean we need less nutrition
• Finding a balance that supports both metabolic health and muscle preservation

This shift came from recognizing the importance of maintaining muscle mass as we age, which becomes more difficult during longer fasting periods. Muscle loss with aging is a real issue and as such, if you want to put on muscle, you have to eat more protein, which can require a larger eating window. 

The Gut-Hormone Connection

I know I used to dismiss the whole idea of “gut health” before I went down the rabbit hole myself and saw the benefits first hand. There is a BIG gut-hormone connection. Before starting HRT, it is suggested that you address your gut health for several reasons:

• Our gut microbiome changes during perimenopause, beginning to resemble men’s microbiomes
• The gut is responsible for the third phase of estrogen detoxification
• Constipation can lead to recirculation of estrogens that should be eliminated
• Women who start HRT without addressing gut issues are more likely to experience weight gain

Even if you don’t have digestive symptoms, your gut health could be impacting how your body processes hormones. As someone who didn’t realize the importance of gut health until I experienced serious health issues myself, I can’t emphasize this enough.

Bioidentical Hormone Replacement Therapy (HRT)

Both Cynthia and I are proponents of bioidentical hormone replacement therapy when appropriate. First thing first is to make sure your lifestyle is dialed in. Then you may want to consider: 

• Starting with the lowest effective dose to see how your body responds
• Individual needs vary – some women do well on generic options, while others need compounded formulations
• Focusing on symptom relief rather than hitting specific lab values
• Recognizing and remembering that HRT works best when the foundation (sleep, stress, nutrition, gut health) is solid

I personally use a bioidentical estrogen patch, compounded progesterone, and testosterone injections at moderate levels to manage my symptoms. Cynthia uses a similar approach but is considering switching from transdermal testosterone to injections due to unwanted hair growth.

GLP-1 (Weight Loss) Medications

GLP-1 medications (like Ozempic, Mounjaro, and Trezepetide) are increasingly being prescribed for weight management. Cynthia’s take was refreshing:

• These medications can be life-changing for people struggling with metabolic health
• The “start low, go slow” approach applies here too
• There are legitimate concerns about access and who can afford these treatments
• For many people, these may need to be long-term medications

Key Takeaways for Women in Midlife

1. Be your own health detective. What works for someone else may not work for you.
2. Address the foundations first. Sleep, stress management, nutrition, and gut health create the platform for everything else.
3. Focus on muscle maintenance. Losing muscle as we age accelerates many negative health outcomes.
4. Consider bioidentical HRT if you’re struggling. Don’t suffer unnecessarily.
5. Evolve your approach as your body changes. What worked in your 30s likely won’t work the same in your 50s.

The contents of the Midlife Conversations podcast is for educational and informational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician. Some episodes of Midlife Conversations may be sponsored by products or services discussed during the show. The host may receive compensation for such advertisements or if you purchase products through affiliate links mentioned on this podcast.