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2. GLP-1s & Metabolic Health in Perimenopause & Menopause with Ann Konkoly, WHNP-BC
139 Plays2 months ago
Weight frustration in perimenopause isn't just about vanity—it’s about a physiological shift that changes how our bodies handle fuel. In this episode, Dr. Rachel Pope sits down with midlife health expert Ann Konkoly to demystify GLP-1 medications (like Ozempic and Zepbound), the hidden dangers of visceral fat, and why the scale is often a "shitty measurement" for your actual health.
In this episode, we discuss:
- The "Middle" Mystery: Why the "eat less, move more" mantra fails women in perimenopause and how this transition impacts weight maintenance.
- GLP-1s Beyond Weight Loss: Ann explains the metabolic benefits of these medications, including reducing neuroinflammation and protecting the heart and kidneys.
- The Hidden Danger of Visceral Fat: Why a "normal BMI" can be misleading and how internal fat affects your risk for chronic disease.
- Synergy with MHT: How optimizing cardiovascular health can create a safer "on-ramp" for starting hormone replacement therapy.
- Preserving Lean Muscle: Strategies for "muscle-centric medicine" to ensure weight loss doesn't come at the expense of your strength and bone density.
- The HOMA-IR Hack: A simple way to use fasting glucose and insulin levels to see if insulin resistance is your primary roadblock.
- Planning for your later years: Why the choices you make in your 40s and 50s determine your mobility and independence in your 80s and 90s.
The "Proactive Midlife" Lab Checklist
Ann suggests asking your provider for these specific markers to get a true picture of your metabolic health:
- Fasting Insulin & Fasting Glucose (to calculate your HOMA-IR score).
- Lipid Panel (focusing on Triglycerides).
- Lipoprotein(a) & hs-CRP (markers of inflammation and genetic heart risk).
- Body Composition Analysis (to track muscle mass vs. visceral fat).
About Ann:
Ann Konkoly is a board-certified Nurse Practitioner, Certified Nurse Midwife, and Menopause Society Certified Practitioner. She is the founder and CEO of Kultivate Women’s Health in Beachwood, Ohio, where she specializes in evidence-based hormone therapy, metabolic health, and medical weight management.
Connect with Ann:
- Website: www.kultivatewomenshealth.com/about
- Instagram: www.instagram.com/annkonkoly.np
Connect with Dr. Rachel Pope:
- Website: ourwomanity.com
Social Media: @drrachelpope
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Transcript
Struggles with Weight and Menopause
00:00:00
Speaker
Almost every day that I'm in clinic, I have at least one patient who tells me how frustrated she is with all the work she's putting in to try to maintain, not just lose weight, but maintain her weight. And especially around the middle section. And it's all since perimenopause or sometimes worsened in menopause. But regardless, it has snuck up on her and she's frustrated. And she almost always asks me what I think about GLP-1s. I really have a hard time answering this. This is not something I was trained in. This was not something I have expertise in. And so I tend to refer to people who are experts in it, like my guest today,
Guest Introduction: Anne Conkley
00:00:36
Speaker
Anne Conkley. So Anne Conkley is a board-certified nurse practitioner and certified nurse midwife specializing in midlife women's health, menopause care, and metabolic health. She's the founder and CEO of Cultivate Women's Health, a private practice in Peachwood, Ohio, that offers evidence-based hormone replacement therapy and medical weight management. Anne is a Menopause Society certified practitioner um and is passionate about providing thoughtful, personalized care, grounded and shared decision-making, and the latest clinical evidence. And as a side note, I've known Anne Conkley for many years. We go way back to labor and labor.
00:01:13
Speaker
Yeah. So, Anne, thank you so much for being
Menopause and Metabolic Health
00:01:16
Speaker
here today. and Welcome to my little platform. I love it. Thank you for having me. i happy to be here. I think these are wonderful topics and this is why our private practice exists. And when I say R, I say the NPs that work with me and you know this is like the bread and butter of a lot of what we do. And it is so frustrating and like, man, I'm in perimenopause and like, it's just frustrating. And so I get it. And so happy to talk about all the things. Yeah, so give us the good, the bad, the ugly. What do women need to consider before starting on this journey? What
Understanding GLP-1 Drugs
00:01:47
Speaker
should they be thinking about, the pros and cons? What are you seeing in your clinic?
00:01:51
Speaker
It's kind of an interesting conversation because I think even so in how we frame it, because you know for many of us, we've always used weight as a measure, whether it's personally or even clinically as healthcare providers. And you know we've used weight as a measure and it's a terrible, shitty measurement you know because it really doesn't give you much understanding of what's going on. within those pounds. And so we talk about but it as a weight loss drug. And the reality is these meds, the GLP-1s and receptor agnes, including, and I'll just kind of use as an umbrella term, which are going to include your brand names of Zempic and Wrigovi, and then also Zephound and Manjaro, and then all the compounded of semaglutide and trazeptide. And it's so interesting because like these are meds that, yes, like people do lose weight with them, but they're really, really impressive in terms of improving metabolic health. decreasing visceral fat, you know improving function of how well the pancreas is working, improving you know experience around food. So changing some of the neural pathways with dopamine hits. I mean, they're fascinating. Even some of the secondary uses of these meds. So you're seeing it with decreasing major adverse cardiac event you know for the second, like the FDA approval to use these medications to decrease the risk of a second
Body Composition vs. Weight
00:03:00
Speaker
mace. And then for like the kidney improvements and, you know, and then there's a lot of emerging research on neuroinflammation and dementia. And so like the ugly is like we talk about weight and then like the good of it is like, well, we actually are looking at a med that and an intervention that is really, really impressive in terms of its effects and inflammatory response and on the brain and the heart. So I think that's kind of one thing to just consider about these, that they're really, they are impressive. It's not about weight loss. I love the way that put that.
00:03:32
Speaker
We call them weight loss meds, but it's not just about weight loss. It's not just about weight loss. And I almost wish we would just like start like changing the narrative drive around that. And I think we will get there. I mean, the next five to 10 years with these meds are going to be like fascinating to watch. It already has been fascinating to just be a part of it, but we're going to have more nuanced conversations, I think, around you know retiring weight, I would hope is the measurement that we use and moving over to something that includes body composition and starts to understand some of the shifts that many of us in perimenopause go through, which is just exactly as you said, women come into our office and they say, by and large, the same thing, which is like, I'm doing the same thing I was doing
00:04:06
Speaker
It doesn't work anymore. i don't understand what's going on. I go into a caloric deficit or I cut calories and it's not working. I'm on an 800 or 1100 or 1200 calorie diet, which is absolutely not sustainable for anyone. And it's not working. And then they say, and also it's all in my belly. Like, what is this? And then they go like this and they grab their belly and they say, it and it's all right here. You could like film it a million times. I mean, it's the exact same conversation. And that's because, you know, some of these changes that we see in perimenopause with this decrease in estrogyle, we see this decrease in our anabolic effect. Like these things make it more challenging for us to maintain weight, increase inflammation. And so I love these meds. I think they're super cool
Health Risks and Visceral Fat
00:04:47
Speaker
and interesting. I've seen, gosh the patients in our practice have lost hundreds and hundreds of pounds. I mean, we may be into like, i don't know.
00:04:56
Speaker
1,500, 2,000 pounds, like tons and tons. Again, weight, but drop in visceral fat as measured by body composition devices. And so it's been really, really impressive. The visceral fat is really dangerous, right? Like visceral fat, the higher percentages that we have, the more cardiovascular health problems we have, the more diabetes we have. Like these are things that over time sneak up on us and that we don't feel like when we grab our middle, but at the middle part is reflective yeah Yeah.
Menopause Hormone Therapy Considerations
00:05:25
Speaker
right yeah there's a more metabolically dangerous type of fat so it increases your rate for chronic disease and and it's interesting because like i even have women who come in and they're like you know you would look at them and subjectively be like oh like she' is not yeah or she's not heavy or whatever word you want to use and then we do a body composition a tool that measures by impedance and it We're looking and like, oh, well, actually your your body fat percentage is 40%, your visceral fat is 16%. And like you are in a decently like a pretty close to normal BMI, so to speak, meaning for your weight and height ratio, you know, you wouldn't necessarily be flagged. And your body composition is not good in terms of the things that you have now.
00:06:05
Speaker
in terms of your visceral fat and the increase in chronic disease that we see. i mean, you know we're just looking at the next five to 10 years of this very slow predictable trend, which is all of a sudden your fasting blood sugar is up, then your fasting insulin is up, then all of a sudden you're watching prediabetes and then you're watching a creeping up hemoglobin A1C into the diabetic range. And then, I mean, it's just like a vicious cycle.
00:06:25
Speaker
so It's true. And you know even speaking about cardiovascular health, one of the issues that I have with you know trying to help women with menopause and hormone therapy is we know that there are risks of starting hormone therapy if your cardiovascular health is worse off. And sometimes I get to the point where like, but I also know that I could help your cardiovascular health if I could get you the hormones. And so I think it'd be really interesting. Could we reduce people's cardiovascular health risks using medications, using other lifestyle interventions, but get them to the point where it's then at the optimized safe time to start hormone therapy for them. And then they are like preventing those health issues, the sequela of cardiovascular health risks, you know, for the next rest of their life. Yeah. And I think the sooner that you intervene on that pathway, the better. And you're right. I mean, that's a very similar, i think, conversation, what we're having in terms of HRT and what we're having with these
Personal Experiences with GLP-1s
00:07:21
Speaker
GLP-1s. Yeah, that is interesting. I mean, i will tell you, I'll be vulnerable here. My vanity is like complicated because I have thought about. Who's isn't, Rachel? Well, here, stay with me. So like I've thought about starting the medication. So I went from like having my third child being postpartum to like basically going into perimenopause. And it's right. It's like this midsection. I just want my pants to fit.
00:07:44
Speaker
And then I realized maybe that's where mom jeans came from because all of us. That's good point. Right? That's where mom jeans came from. Anyway, I just want my pants to bed. And so I have thought, could I be on something short term just to get rid of my belly fat? But then I don't want the changes that I see in some women's faces or men's too to happen because I'm too vain for that. So then I'm like, how do you address that?
00:08:08
Speaker
Because yeah we do see it, right? People call it ozempic face and they're losing the fat in their face, right? Yeah. and I mean, it is interesting. So two things I would point you to just for resources so that you know of them. Dr. Rosio Salas-Whalen just wrote Weightless, which came out the first year. It's really good. I read that. And then Dr. Alexandra Soa, they're both obesity medicine certified. And ah her book, I can't remember the name of her book, but her book is really good too. And it's maybe a couple of years old. And they're both really impressive. They are really designed for clinicians, mostly for patients, but a lot of really good information in there for us as clinicians. And one of the things that Dr. Salas Whalen talks about is this idea of, which I think coming back around as a clinician and now looking at patients, I see it. And she said,
00:08:53
Speaker
It's interesting because there are some people where they'll go through these like times where they'll gain, right? Like maybe it's you have your third baby or you move abroad. I had a patient who just came in. She moved abroad and was in somewhere in Europe for about, you know, two years. And she's like, I just gained weight. And like, you know, it it was so stressful and like a relationship ended and it was a new job and blah, blah, blah. And so she's like, I really want to get back on track. So we started her on a GLP-1 and it's really helped her. and And I'll be very curious, but in my mind, especially I think based on what Dr. Salas Whalen says, probably these are the people who, where if you put them on a med because they've had this precipitous gain, like for some sort of a reason, right? An associated event, that those are people where if you help them to lose it, to a GLP-1 to lose, they're probably in that third where they're going to be able to just maintain with good resistance training and good protein first, you know, dietary habits. And then they're probably the people where you could start it, use it, lose it, and then wean off and maybe not need
Effective Use of GLP-1s
00:09:52
Speaker
to go back on. I mean, that's one of my questions, right? Like, you have to stay on it forever?
00:09:56
Speaker
Yeah. And it's about, I'd say anecdotally, you know it's a third, a third, a third. But it is also interesting too, because, and I say anecdotally, because like yeah we have a lot of good research in diabetics and we have a lot of good research in people with BMI over 30 and now BMI over 27 with a comorbidity, but like we don't have really very little data. There's one poster that was presented last year by Andrade. And I think I have it in my references and I'll send it to you, but it was this interesting, now it's observational data, so it's not RCTU. But it's something, right? And we don't have a lot of data on the perimenopausal women or like the women, I would say, who aren't BMI over 27 or over 30. They're in that like under 27 category maybe. So we're starting to see a little bit of data come out. And so in her research, it was looking more specifically at postmenopausal women, but postmenopausal women giving them HRT and then giving them turges appetite and three arms terzeptide only, HRT only, and then a combined group of HRT plus terzeptide. And patients surprisingly in the terzeptide plus HRT arm did, had something like, I think it was either 18% or 30% additional weight loss then using one intervention alone, which is pretty impressive. But it's hard. We don't have that data. So therefore, it's hard to make predictions. And I think most of us who are working in this space who are doing, this would be considered off-label prescribing if you're doing it for the purpose of helping somebody to lose this weight where they don't meet the FDA-approved criteria to use it. A lot of it's anecdotal because in case studies and maybe like an expert report here and there, but like most of the stuff is just much more anecdotal. It's just something It just seems like if you could help someone before it gets bad. yeah
00:11:32
Speaker
Right. Like then, yeah, like you said, if then you wean off of it, then that'd be great. And I never honestly never knew that that was even possible because I hear people talk about having to kind of stay on it forever. And then if people come off at the weight gain comes back. Well, that's really helpful to know. It is. And and I would just it put a like a little caveat there and just say like obesity is a chronic disease. And so the majority of people who are going to use these meds are probably people where we have some genetic component that's contributing and driving their weight and their insulin resistance. So... For those people where, you know, and these are the people who like, they come to the office and we do a pretty thorough intake on, you know, tell me the things that you've done to maintain your weight in the past and what's worked and what's not worked. And tell us why, you know, why you think in your best estimation. I mean, look, if there's one thing that that I feel like our patients and me, myself as a woman that like, I know it's like, what's the shit that's worked, what's not worked. And then, you know, what do you want to kind of do from there? Right. These are the people who are, they're just like, man, I have to do Whole30 once a year, or i have to do a keto, or I'm just so so sensitive to carbs. Like I look at a carb and I gain weight. we hear that sentence once, I hear it like a million times. And these are the women where you're just like, it's just like not normal to have to be so disciplined around food and to be so carb conscious. Carbs are a normal part, I mean, for all bodies. yes Some of us are super sensitive, which is probably driven by either some underlying insulin resistance or some sort of genetic contributing factor. And so that's the the other piece of it is like, there's going to be a third, probably but it's like a third, a third, a third, right? A third are going to be able, you'll treat them, lose the weight, they'll come off and maybe they'll be able to maintain. A third, you know, maybe it's wishy-washy. They take the weight off, but maybe they have a slow-ish regain over time. too
00:13:18
Speaker
And then there's people who they come off of it, their insulin resistance drives back up and then they are, you know, they're approaching the same place that they were when they started the med. And sometimes you don't know, but that doesn't mean we don't necessarily try it and see.
00:13:31
Speaker
Right. That's so interesting. And how do you help people when you find out from your conversation that they aren't really that aware of the proper nutrition during this time or even the exercise during this time? How do you incorporate that with starting medication? It's interesting because like, in my mind, we have these big pillars, right? You have hormone replacement and then you have, is your thyroid right? Like, do you have antibodies? Like, do you have like a well-functioning thyroid. And then there's this, do you practice this muscle-centric medicine kind of thing that Dr. Gabrielle Lyon has coined. And this idea of, I want to build up my muscle to work as a second pancreas, essentially, right? To be a glucose disposal agent and to help me maintain blood sugars, more steady blood sugars, and also protect my bones and also you know like give me great looking arms.
00:14:20
Speaker
But part of it is muscle. And then a part of it is diet. So many people say, like it's so true. You can't outrun a bad diet. You just, you can't. And the foundational principles of a protein heavy and a protein first diet really do make a difference. It's one of the things we talk about so much. And then there's this genetic genetictic component, right? And so there's these different buckets, I would call them. What I tell patients is like, look, If you want to try GLP-1 and we're going to do off-label prescribing and this is sheer decision making and for your body and your kind of body composition or you know your goals and desires, this makes sense. Great. And I always say like, I would give it 12 weeks and let's just see. It's very similar conversation of HRT. Give it 12 weeks, give it four weeks and let's just observe and see what happens. What went well, what didn't work, what do we need to tinker with after that? And then from there, once people get started on it, they start to have these small wins. And it's like in Atomic Habits when James Clear talks about this 1% improvement. It's like, you know, all of a sudden you're like, oh, I don't have to like watch my carbs so, so closely, or I'm not hungry all the time. And that 1% leads to like, oh, like, okay, like maybe I would be interested in like a couple more greens and like prioritizing my food and putting my protein first and then my veg and then my you know starches. And then all of a sudden they're like, oh, like maybe I could do...
00:15:39
Speaker
one salad, you know but one extra serving of greens per day. And you just keep stacking on these habits. And a part of that is getting into the gym and doing resistance training. Part of it's the protein conversation, but we just don't do it all at once. right And so it's in my mind, like in the back of it, right it's like, we're going to watch your visceral fat drop and we're going to start to see these slow, you know small changes. And we're going to get to it all eventually, but we just don't do it all the beginning. But it does take, I think, you know some of the best programs that are out there. And I would consider ours a really good, well-rounded program. you know We're just talking about like, oh, okay, so like you want a couple more ways to get more protein? like Let's get you a consult with one of our registered dietitians and sit down and talk walk through like, what does my grocery list need to be? What does meal prep look like? So there's many pieces to it. Again, we just try and try. Try not to overwhelm people because yeah it's a step to even like come in the office and have the conversation again because I think so many people are just like, they just feel so frustrated because for years they've just been told like, you just need to eat last and
Importance of Muscle Mass
00:16:40
Speaker
move more. Like get over it.
00:16:41
Speaker
Like really, you're really must be like housing the Rice Krispie treats because like... You know, no, you're so right. And, you know, the other thing I really wanted to ask you today is about how you help your patients maintain their lean muscle, because that is the thing that I hear about GLP-1s is that, okay, you're going to lose weight, but you're also going to lose your muscle. And especially for women who are perimenopausal and menopausal, we're working so hard to help them maintain and build lean muscle that I always worry about the counteraction, know, of the medication. How do you approach that?
00:17:15
Speaker
Yeah, I think it's a very good question. And interestingly, the conversation around GLP-1s has been so much around muscle, which is fascinating. And the muscle that we're losing, especially when you're in a program like ours where we're talking about getting in your protein and this protein first strategy, we're probably doing a better maintenance of muscle than we've ever done before. So if like you are a human who who says like, oh, I once did cabbage soup diet or I did popcorn diet or I did all this other shit that we've many of us have tried over the years. Remember hearing about people doing cabbage soup? I won't name any names on ah the call, but yes, I remember that. Absolutely. How about like just the plain old soup diet? Like who out there has done that? right right yeah right Yes. And to think like when we're going through that kind of a restrictive diet, we're probably watching our weight drop because our muscle mass is dropping because we're not getting adequate protein. And there's The data is pretty clear. When you lose weight, whether it's with a GLP-1 or with a caloric restriction diet or intermittent fasting, whatever it is, you're going to see a proportionate probably loss of muscle. And I actually think we're doing better now than we've ever done about being very clear about why we need protein and especially why we need protein as we age. It's harder for us to use the protein that we actually are getting into our diets. just as normal changes that happen physiologically as we age. And so i don't buy it a ton. you know like We never talk to anybody about like, oh yeah, you know eat less and move more. And like we never worried about their muscle mass at that point. But all of a sudden we're starting to... look you know But it is unappreciable. So like I was talking about this with a patient last week about how she's 35 pounds down. And I'm like, look, to think that you wouldn't lose even a small amount of muscle when you're having a size reduction is actually maybe not realistic. So we might see a small one. Our goal is to make sure that we don't have this huge dip, number one, or that when we start to with regular body composition analysis, that when we start to see your muscle mass starting to decline slowly and the trend really is downward, that then we're like, wait a minute, like,
00:19:14
Speaker
Let's do a 24-hour dietary recall.
Analyzing Body Composition
00:19:16
Speaker
Let's get in for a consult with a registered dietitian. Like how much protein are mean, that's just it. You're tracking it. Yes. Right? Yes. and I think that I don't know of a lot of people who are doing that, or maybe that's what they're, maybe that's what I'm just not aware of. i I'm aware of like the online. platforms that exist. I don't think they're doing any kind of tracking like that. Yeah. And I think it's always so good. And I love these tracking devices too. Like the gold standard, if you were going to have one, would be to do a DEXA scan that that's looking at visceral fat. They're really good. They're just a little bit more expensive. So we have a device in our office where you come in and you stand on it. And so it's probably not perfect, but it gives you consistent measurement and some changes and the technology is decent on it. right And so what I love is when people come in and they're like, Like I just had a patient, it was probably maybe a week or two ago. And she was like, I'm up two pounds. And I was like, well, let's like, number one, who cares? Because like, what does weight really mean? So like, let's do a body scan. So she gets on, we do a body scan. And you see this, there's this interesting, like when you look at some of the results, you'll watch and see when people start to see a decrease in fat and an increase in muscle, it's exciting. And so sure enough, she was up like two and a half pounds of muscle from the holidays. And she was down about 2% body fat. And i was like, this is incredible.
00:20:24
Speaker
edible. It's like you're metabolically so much. Yeah. Because I don't know how this happened. like I totally had some cookies over the holiday season. was like, okay, who didn't have it? I had my fair share too. But she was just mind blown around, here I was thinking I've done wrong. I didn't do it right. It's not working. I'm never going to get to where I want to be. And then she got on and I was like, you're metabolically better off than you were, which is really, really good for your lifetime cardiovascular health and your chronic disease health. And that's the part where I get really excited. Like I know it's a weight game and stuff and like we're looking at visceral fat and all that, but I get really excited even when, you know, if people just have this win where they come and they stand on the scale and then they realize like, oh, weight's just an objective number. It doesn't have to mean anything about me, number
Affording GLP-1 Treatments
00:21:09
Speaker
one and number two. Like it doesn't give me any sense of what my body is capable of or like how well it's doing internally, right? So that's kind of one of the fun parts about this work.
00:21:21
Speaker
Okay, so I do have a lot of patients who ask me if I could prescribe for them or if I can try prescribing because they couldn't get it covered or they're trying to figure out how to make it affordable and trying to kind of get through that process, whether they are considering spending the money for it.
00:21:35
Speaker
Do you have any suggestions or advice about that? Yeah. So one of the easy ones is, Mary Claire Haver has actually a good post where she talks about these, like I think, five lab tests that she wants every patient to you know ask his or their provider for. There's two that I would focus on mostly. Number one, i mean, the lipid panel is always good. You're going to get your triglycerides and see you know kind of what's going on in terms of your disposal of sugar, number one. but number two, what I think is really useful is ask for a, you can either do a comprehensive metabolic panel or a basic metabolic panel. And you're going to get in there a fasting glucose. And you have to these labs fasting and then to do a fasting insulin level. And ideally you're fasting for eight hours. Maybe you can do 12 hours, whatever you can do. But a fasting insulin and a fasting glucose, once you have those, you can go online and just go into Google and type in HOMA, H-O-M-A-P-E-S-I-R.
00:22:27
Speaker
And it's a calculator that's online that we use in our clinical practice. And it just requires that you have this fasting glucose level and a fasting insulin. And then it will spit out a number and tell you you are insulin resistant. And that's a really useful, super quick, easy thing to do. Now, if your provider will not order these labs, which sometimes they don't want to do it because they're too busy or whatever, or they just don't know how to interpret them. And then they're like, ah what do i do? Right. So whatever, we don't fault them for that. But the next step to do would to be to go to like a quest or or a direct a consumer lab. platform like Rupa or Quest, where you can just purchase the labs, they'd probably run you, i don't know, maybe 50 bucks or something. and you know If we're ordering through the clinic for cash pay patients, they're much more affordable, but get those two and just see because it'll pull up. If your insulin is over time, probably going to be insulin resistant. And when you are insulin resistant, it makes it very, very challenging to maintain and or lose weight. like It's near
00:23:22
Speaker
impossible. And so that can be a reason where you can be like, oh, number one, for your own self-satisfaction, like this is why it's so hard for me. And number two, then sometimes we'll use that, whether it's a part of our diagnosis of metabolic syndrome, or we can use that in our ICD-10 coding or insurance coding, maybe get it
Proactive Health in Midlife
00:23:39
Speaker
approved. you know Right, for insulin resistance.
00:23:42
Speaker
That is so helpful. I learned something new today, too. Honestly, I'm very research minded. And I think, oh, my gosh, we should be looking at this for research reasons, too. Right. If we're trying to help people, you know, we talked about earlier about trying to help people get to the point where they are at their healthiest to start hormone therapy so that they can continue this like trajectory of being as healthy as possible.
00:24:06
Speaker
mean, that's a perfect way to kind of help determine their level of insulin sensitivity. And I think too, this is where it really helps have somebody who's nuanced in midlife care for women. And so like what we do in our practice is I would say it's much more of a more focused conversation around like good midlife health and starting to think about, we want to make sure that the heart disease that is the number one killer of adult men and women that we're doing things today to avoid that risk. down the road and the hip fractures and the fragility fractures. And like, those are the things we want to avoid, right? And the Alzheimer's dementia. And so the provider that I would encourage you to seek out in your communities is the one who says, oh, well, let's just look and let's go have you do a coronary artery calcium CT and let's have you do a lipoprotein little a. Let's make sure your triglycerides are in good range. Let's make sure you've got a CRP on file. Like somebody who's looking at it more from a standpoint of, we're not just trying to make sure you don't have diabetes.
00:25:00
Speaker
We're actually trying to think through, what are the things we need to address today that are going to help you get into your, as Peter Atiyah calls it, terminal decade? And not only to get there, but to have a good last decade of life, right? Like where you're able to move and you're not wheelchair bound or osteoporotic and you know worried to go out weather like this, where it's snoring in Northeast Ohio, afraid that you'll break your hip and then yeah you know it's downhill from there. So that's where I think we have a really good opportunity to be more better in women's midlife health. And those are a big piece of it. But if you can't get all that, just at least ask for a fasting glucose, fasting insulin, and start there. And then from there, you'll find out a little bit more. And I think that's always kind of like more pieces to the puzzle and all useful.
00:25:44
Speaker
so Exactly. I love it. Well, I think this is so interesting and being proactive is where it really is for women in their midlives because it's like carpe diem. You got to seize the day today because tomorrow you might not be able to get up out of your chair. Okay. It's not so grim, but you know, like yeah decades, like these decades, forties and fifties, if you're in it now and you're not like on top of your health, it's only going to get harder in our sixties. If you're already in your sixties and your seventies and you're listening, I'm not trying to tell you that it's too late or there's no hope. There definitely is, but it just might be harder.
00:26:17
Speaker
Yeah, we're not getting any younger. And another piece of this is like, no one's responsible for your health. And like, even if you have the luxury of children around you now, like what kind of life do you want to experience, you know, in your last decade, in your 70s, in your 80s, in your 90s? And that's actually a really good question to ask yourself, because when you start to look at around and you're like, man, Some of these old gals are like, man, they're frail. And you see somebody walking out and somebody falls and it just happens way too commonly. And that's where I think we have a lot of opportunity now to really make a good, decent shot at you know having a really good continued health through our midlife and beyond and preparing for that last decade and making sure that we're you know able to
Microdosing GLP-1s
00:26:57
Speaker
enjoy it. Exactly.
00:26:58
Speaker
i love that. Okay, I have one last question for you. If you don't mind. Wait, what's the deal with microdosing? Is it a thing? it work? Yeah. It does. I do microdosing. So I'm on some glutide on a very small, it's like probably 0.1 milligram. And most people would say, oh, that's not a therapeutic dose, to which I would say like, I can't go much higher because I you know feel the side effects of it.
00:27:19
Speaker
So I think it's therapeutic for me and it is useful for me. There's not consensus on what microdosing is. So it's a good thing for your listeners to know. When somebody talks about microdosing, the question is, are they talking about using the medication at less than full dose, right? Which would be above two milligrams, I would consider full dose and semaglutide and then maybe 15 milligrams of trisepatide.
00:27:38
Speaker
And so are they using it less than full dose, number one? Number two, are they using less than the lowest commercially available dose? So for semaglutide, that's 0.25 milligrams. For trisepatide, it's 2.5 milligrams. So are they using it less? Some people call that microdosing.
00:27:52
Speaker
Some people say, well, like I had a patient come in last week and she said she's been working with her endocrinologist and she's lost probably 85 pounds at this point. And she's like, I do 10 milligrams of trizapatide once a month.
00:28:04
Speaker
That would be what I would consider a microdosing protocol. It's a therapeutic dose, but she's using it you know once every four weeks. And she's like, I've been able to maintain my weight within maybe a couple pounds over the past year. Amazing, right? That's so amazing.
00:28:17
Speaker
yeah So microdosing is little different, you know, kind of things to different people. but That's why I've been confused. I mean, partially. Yeah, no, but I would say our thought about it in our practice is like, you know, you're probably, we're not getting up to full dose. I mean, most of the people that come in, you know, we're never, not as often using full dose. We're very rarely going up in the commercially available dosing guidelines and FDA approved dosing guidelines just to avoid side effects and really give people a little bit more of a gentle on-ramp to it, which seems to work really well. so But microdosing has a different connotation based on who's using it. But I do think it's a decent strategy.
00:28:53
Speaker
We've got a lot of people who are doing it. and it's hard to say because, again, we don't have any data, like any randomized controlled trial data. So we're a little, you know, kind of like blind on that. However, I hope in the next couple of years we do see some RCT data on it. Although I don't know that we will because reality is the drug manufacturers have no reason to...
Trial and Error with Medications
00:29:13
Speaker
No reason to give a smaller dose. No reason to give a smaller dose. And they're like, whatever. Like, we don't actually want you to use a smaller dose because we want you to buy the vials and, you know, at at our lowest dose. So we'll see. Yeah. Well, this has been super educational and interesting. i made a post earlier today that I'm kind of like agnostic on the whole thing just because i'm like, I don't know.
00:29:32
Speaker
I don't know that much about It's not my area of expertise, but you have educated me and I really appreciate it. I think it's really great to make people healthy. So thank you so much. You're welcome. And the only last thing I would say is like, I think, again, it's kind of like this conversation about HRT and we get so many patients who come in and they're like, I don't know. What do you think? Do you think I should try it? Like, should I do it? Even if they're not acutely symptomatic, right? And we have a lot of conversations about the long-term benefits of hormone replacement. And this is another one where i think it's really appropriate for all of us to do these things that if we're drawn to something, to do a trial of it and then to see like what worked, what didn't work and what do I want to do differently for the next 30, 60 or 90 days. And these medicines fall in that category for a lot of people because there's so much chatter and fodder and, you know, it's like IUDs.
00:30:17
Speaker
Yes. It's the same conversation about IUDs. It's like, I heard X, Y, and Z from my whoever that the baby was going to come out holding it in its hand. I love that one.
00:30:28
Speaker
I know. You're like, but in so many years of clinical practice, like I think I'm coming up short of 20 years of clinical practice. I've never seen that happen. And that's like kind of the piece that i just keep in the back of my mind, which is if you are in a place where you can afford it and it's something that you think could be useful to you, you might be right. And so like a trial could give you a lot more data on whether or not it is a good thing for you. And that's, I think, good reason to use it. So. It's a great way to put it. And for so many of these decisions, like you said, it's not like you're marrying them or, you know, even if people get married, they get divorced, right? But you're not even getting into such like a long-term commitment. You can try something and see how it works for you. it works Yep. That's exactly it. So thank you for having me. Thank you so much for your time. I really appreciate it.