You’re listening to Burnt Toast! Today, my guest isMara Gordon, MD.

Dr. Mara is a family physician on the faculty of Cooper Medical School of Rowan University, as well as a writer, journalist and contributor to NPR. She also writes the newsletter Your Doctor Friend by Mara Gordon about her efforts to make medicine more fat friendly. And she was previously on the podcast last November, answering your questions on how to take a weight inclusive approach to conditions like diabetes, acid reflux, and sleep apnea.

Dr. Mara is back today to tackle all your questions about perimenopause and menopause!

Actually, half your questions—there were so many, and the answers are so detailed, we’re going to be breaking this one into a two parter. So stay tuned for the second half, coming in September! As we discussed in our recent episode with Cole Kazdin, finding menopause advice that doesn’t come with a side of diet culture is really difficult. Dr Mara is here to help, and she will not sell you a supplement sign or make you wear a weighted vest.

This episode is free but if you value this conversation, please consider supporting our work with a paid subscription. Burnt Toast is 100% reader- and listener-supported. We literally can’t do this without you.

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Episode 203 Transcript

Virginia

When I put up the call out for listener questions for this, we were immediately inundated with, like, 50 questions in an hour. People have thoughts and feelings and need information! So I’m very excited you’re here. Before we dive into the listener questions, let’s establish some big picture framing on how we are going to approach this conversation around perimenopause and menopause.

Mara

I should start just by introducing myself. I’m a family doctor and I have a very general practice, which means I take care of infants and I have a couple patients who are over 100. It’s amazing. And families, which is such an honor, to care for multiple generations of families. So, perimenopause and menopause is one chunk of my practice, but it is not all of it.

I come from the perspective of a generalist, right? Lots of my patients have questions about perimenopause and menopause. Many of my patients are women in that age group. And I have been learning a lot over the last couple of years. The science is emerging, and I think a lot of practice patterns amongst doctors have really changed, even in the time that I have been in practice, which is about 10 years. There has been a huge shift in the way we physicians think about menopause and think about perimenopause, which I think is mostly for the better, which is really exciting.

There’s an increased focus on doctors taking menopause seriously, approaching it with deep care and concern and professionalism. And that is excellent. But this menopause advocacy is taking place in a world that’s really steeped in fatphobia and diet culture. Our culture is just so susceptible to corporate influence. There are tons of influencers who call themselves menopause experts selling supplements online, just selling stuff. Sort of cashing in on this. And I will note, a lot of them are medical doctors, too, so it can be really hard to sort through.

Virginia

Your instinct is to trust, because you see the MD.

Mara

Totally. There’s a lot of diet talk wrapped up in all of it, and there’s a lot of fear-mongering, which I would argue often has fatphobia at its core. It’s a fear of fatness, a fear of aging, a fear of our bodies not being ultra thin, ultra sexualized bodies of adolescents or women in their 20s, right?

This is all to say that I think it’s really exciting that there’s an increased cultural focus on women’s health, particularly health in midlife. But we also need to be careful about the ways that diet culture sneaks into some of this talk, and who might be profiting from it. So we do have some hearty skepticism, but also some enthusiasm for the culture moving towards taking women’s concerns and midlife seriously.

Virginia

The cultural discourse around this is really tricky. Part of why I wanted you to come on to answer listener questions is because you approach healthcare from a weight inclusive lens, which is not every doctor. It is certainly not every doctor in the menopause space. And you’re not selling us a supplement line or a weighted vest, so that’s really helpful. So that’s a good objective place for us to start!

Here’s our first question, from Julie:

It’s my understanding that the body naturally puts on weight in menopause, especially around the torso, and that this fat helps to replace declining estrogen, because fat produces estrogen. I don’t know where I’ve heard this, but I think it’s true? But I would like to know a doctor’s explanation of this, just because I think it’s just more evidence that our bodies know what they’re doing and we can trust them, and that menopause and the possible related weight gain is nothing to fear or dread or fight.

Mara

Oof, okay, so we are just diving right in. Thank you so much for this question. It’s one I get from many of my patients, too.

So I looked into some of the literature on this, and it is thought that declining estrogen—which happens in the menopausal transition—does contribute to what we call visceral adiposity, which is basically fatty tissue around the internal organs. And in clinical practice, we approximate this by assessing waist circumference. This is really spotty! But we tend to think of it as “belly fat,” which is a fatphobic term. I prefer the term “visceral adiposity” even though it sounds really medical, it gets more specifically at what the issue is, which is that this particular adipose tissue around internal organs can be pathologic. It can be associated with insulin resistance, increasing risk of cardiovascular disease, and risk of what we call metabolic—here’s a mouthful—metabolic dysfunction associated steatotic liver disease, which is what fatty liver disease has been renamed.

So I don’t think we totally understand why this happens in the menopausal transition. There is a hypothesis that torso fatty tissue does help increase estrogen, and it’s the body’s response to declining estrogen and attempts to preserve estrogen. But in our modern lives, where people live much longer than midlife, it can create pathology.

Virginia

I just want to pause there to make sure folks get it. So it could be that this extra fat in our torsos develops for a protective reason —possibly replacing estrogen levels—but because we now live longer, there’s a scenario where it doesn’t stay protective, or it has other impacts besides its initial protective purpose.

Mara

Right? And this is just a theory. It’s kind of impossible to prove something like that, but many menopause researchers have this working theory about, quote—we’ve got to find a better term for it—belly fat. What should we call it, Virginia?

Virginia.

I mean, or can we reclaim belly fat? But that’s like a whole project. There is a lot of great work reclaiming bellies, but we’ll go with visceral adiposity right now.

Mara

Anyway, this is an active area of menopause research, and I’m not sure we totally understand the phenomenon. That being said, Julie asks, “Should we just trust our bodies?” Do our bodies know what they’re doing? And I think that’s a really philosophical question, and that is the heart of what you’re asking, Julie, rather than what’s the state of the research on visceral adiposity in the menopause transition.

It’s how much do we trust our bodies versus how much do we use modern medicine to intervene, to try to change the natural course of our bodies? And it’s a question about the role that modern medicine plays in our lives. So obviously, I’m a fan of modern medicine, right? I’m a medical doctor. But I also have a lot of skepticism about it. I can see firsthand that we pathologize a lot of normal physiologic processes, and I see the way that our healthcare system profits off of this pathology.

So this is all to say: Most people do tend to gain weight over time. That’s been well-described in the literature. Both men and women gain weight with age, and women tend to gain mid-section weight specifically during the menopausal transition, which seems to be independent of age. So people who go through menopause earlier might see this happen earlier.

This weight gain is happening in unique ways that are affected by the hormone changes in the menopausal transition, and I think it can be totally reasonable to want to prevent insulin resistance or prevent metabolic dysfunction in the liver using medications. Or can you decide that you don’t want to use medications to do that; diet and exercise also absolutely play a role. But I think it’s a deep question. I don’t know, what do you think? Virginia, what’s your take?

Virginia

I think it can be a both/and. If everybody gains weight as we age, and particularly as we go through menopause transition, then we shouldn’t be pathologizing that at baseline. Because if everybody does it, then it’s a normal fact of having a human body. And why are we making that into something that we’re so terrified of?

And I think this is what we’re going to get more into with these questions: It’s also possible to say, can we improve quality of life? Can we extend life? Can we use medicine to help with those things in a way that makes it not about the weight gain, but about managing the symptoms that may or may not be caused by the weight gain? If the weight gain correlates with insulin resistance, of course you’re going to treat the insulin resistance, because the insulin resistance is the concern. Does that mean weight loss is the thing we have to do? Not necessarily.

Mara

Totally. I define size inclusive medicine—which is the way that I practice medicine—as basically not yelling at my patients to lose weight. And it’s quite revolutionary, even though it shouldn’t be. I typically don’t initiate conversations about weight loss with my patients. If my patients have evidence of metabolic dysfunction in the liver, if they have evidence of diabetes or pre-diabetes, if they have high blood pressure, we absolutely tackle those issues. There’s good medications and non-medication treatments for those conditions.

And if my patients want to talk about weight loss, I’m always willing to engage in those conversations. I do not practice from a framework of refusing to talk with my patients about weight loss because I feel that’s not centering my patients’ bodily autonomy. So let’s talk about these more objective and less stigmatized medical conditions that we can quantify. Let’s target those. And weight loss may be a side effect of targeting those. Weight loss may not be a side effect of targeting those. And there are ways to target those conditions that often don’t result in dramatic or clinically significant weight loss, and that’s okay.

One other thing I’ll note that it’s not totally clear that menopausal weight gain is causing those sort of metabolic dysfunctions. This is a really interesting area of research. Again, I’m not a researcher, but I follow it with interest, because as a size-inclusive doctor, this is important to the way that I practice.

So there’s some school of thought that the metabolic dysfunction causes the weight gain, rather than the weight gain causing the metabolic dysfunction. And this is important because of the way we blame people for weight gain. We think if you gain weight, you’ve caused diabetes or whatever. This flips thta narrative on its head. Diabetes is a really complex disease with many, many factors affecting it. It’s possible that having a genetic predisposition to cardiometabolic disease may end up causing weight gain, and specifically this visceral adiposity. So this is all to say there’s a lot we don’t understand. And I think at the core is trying to center my patients values, and de-stigmatize all of these conversations.

Virginia

I love how Julie phrased it: “The possible related weight gain in menopause is maybe nothing to fear, dread, or fight.” I think anytime we can approach health without a mindset of fear and dread and not be fighting our bodies, that seems like it’s going to be more health promoting than if we’re going in like, “Oh my God, this is happening. It’s terrible. I have to stop it.”

And this is every life stage we go through, especially as women. Our bodies change, and usually our bodies get bigger. And we’re always told we have to fight through puberty. You have a baby, you have to get your body back as quickly as possible. I do think there’s something really powerful in saying: “I am going through a big life change right now so my body is supposed to change. I can focus on managing the health conditions that might come along with that, and I can also let my body do what it needs to do.” I think we can have both.

Mara

Yeah, that’s so beautifully said. And Julie, thank you for saying it that way.

Virginia

Okay, so now let’s get into some related weight questions.

I was just told by my OB/GYN that excess abdominal weight can contribute to urinary incontinence in menopause. How true is this, and how much of a factor do you think weight is in this situation? And I think the you know, the unsaid question in this and in so many of these questions, is, so do I have to lose weight to solve this issue?

Mara

Yes. So this is a very common refrain I hear from patients about the relationship between BMI and sort of different processes in the body, right? I think what the listeners’ OB/GYN is getting at is the idea that mass in the abdomen and torso might put pressure on the pelvic floor. And more mass in the torso, more pressure on the pelvic floor.

But urinary incontinence is extremely complicated and it can be caused by lots of different things. So I think what the OB/GYN is alluding to is pelvic floor weakness, which is one common cause. The muscles in the pelvic floor, which is all those muscles that basically hold up your uterus, your bladder, your rectum—all of those muscles can get weak over time. But other things can cause urinary incontinence, too. Neurological changes, hormonal changes in menopause, can contribute.

Part of my size inclusive approach to primary care is I often ask myself: How would I treat a thin person with this condition? Because we always have other treatment options other than weight loss, and thin people have urinary incontinence all the time.

Virginia

A lot of skinny grandmas are buying Depends. No shame!

Mara

Totally, right? And so we have treatments for urinary incontinence. And urinary incontinence often requires a multifactorial treatment approach.

I will often recommend my patients do pelvic floor physical therapy. What that does is strengthen the pelvic floor muscles particularly if the person has been pregnant and had a vaginal delivery, those muscles can really weaken, and people might be having what we call genitourinary symptoms of menopause. Basically, as estrogen declines in the tissue of the vulva, it can make the tissue what we call friable.

Virginia

I don’t want a friable vulva! All of the language is bad.

Mara

I know, isn’t it? I just get so used to it. And then when I talk to non-medical people, I’m like, whoa. Where did we come up with this term? It just means sort of like irritable.

Virginia

Ok, I’m fine having an irritable vulva. I’m frequently irritable.

Mara

And so that can cause a sensation of having to pee all the time. And that we can treat with topical estrogen, which is an estrogen cream that goes inside the vagina and is an amazing, underutilized treatment that is extremely low risk. I just prescribe it with glee and abandon to all of my patients, because it can really help with urinary symptoms. It can help with discomfort during sex in the menopausal transition. It is great treatment.

Virginia

Itchiness, dryness…

Mara

Exactly, yeah! So I was doing a list of causes of urinary incontinence: Another one is overactive bladder, which we often use oral medications to treat. That helps decrease bladder spasticity.

So this is all to say that it’s multifactorial. It’s rare that there’s sort of one specific issue. And it is possible that for some people, weight loss might help decrease symptoms. If somebody loses weight in their abdomen, it might put less pressure on the pelvic floor, and that might ease up. But it’s not the only treatment. So since we know that weight loss can be really challenging to maintain over time for many, many reasons, I think it’s important to offer our patients other treatment options. But I don’t want to discount the idea that it’s inherently unrelated. It’s possible that it’s one factor of many that contributes to urinary incontinence.

Virginia

This is, like, the drumbeat I want us to keep coming back to with all these issues. As you said, how would I treat this in a thin person? It is much easier to start using an estrogen cream—like you said, low risk, easy to use—and see if that helps, before you put yourself through some draconian diet plan to try to lose weight.

So for the doctor to start from this place of, “well, you’ve got excess abdominal fat, and that’s why you’re having this problem,” that’s such a shaming place to start when that’s very unlikely to be the full story or the full solution.

Mara

Totally. And pelvic PT is also underutilized and amazing. Everyone should get it after childbirth, but many people who’ve never had children might benefit from it, too.

Virginia

Okay, another weight related question. This is from Ellen, who wrote in our thread in response to Julie’s question. So in related to Julie’s question about the role of declining estrogen in gaining abdominal fat:

If that’s the case, why does hormone replacement therapy not mitigate that weight gain? I take estrogen largely to support my bone health due to having a genetic disorder leading to fragile bones, but to be honest I had hoped that the estrogen would also help address the weight I’ve put on over the past five years despite stable eating and exercise habits.

That hasn’t happened, and I understand that it generally doesn’t happen with HRT, but I don’t understand why. I guess I’d just like to understand better why we tend to gain abdominal fat in menopause and what if anything can help mitigate that weight gain. I’m working on self acceptance for the body I have now, and I get frustrated when clothes I love no longer fit, or when my doctor tells me one minute to watch portion sizes to avoid weight gain, and the next tells me to ingest 1000 milligrams of calcium per day, which would account for about half of the calories I’m supposed to eat daily in order to lose weight or not gain more weight.

It just feels like a lot of competing messages! Eat more protein and calcium, but have a calorie deficit. And it’s all about your changing hormones, but hormone replacement therapy won’t change anything.

Ellen, relatable. So many mixed messages.

Dr. Mara, you spoke to what we do and don’t know about the abdominal fat piece a little bit already in Julie’s question, so I think we can set that aside. But yes, if estrogen is playing a role, why does hormone replacement therapy not necessarily impact weight?

And what do we do with the protein of it all? Because, let me tell you, we got like 50 other questions about protein.

Mara

I will answer the first part first: I don’t think we know why menopausal hormone therapy does not affect abdominal fat. You’re totally right. It makes intuitive sense, but that’s not what we see clinically. There’s some evidence that menopausal hormone therapy can decrease the rate of muscle mass loss. But we consider it a weight neutral treatment. Lots of researchers are studying these questions. But I don’t think anybody knows.

So those messages feel like they’re competing because they are competing. And I don’t think we understand why all these things go on in the human body and how to approach them. So maybe I’ll turn the question back to you, Virginia. How do you think about it when you are seeking expertise and you get not a clear answer?

Virginia

I mean, I’m an irritable vulva when it happens, that’s for sure. My vulva and I are very irritated by conflicting messages. And I think we’re right to be. I think Ellen is articulating a real frustration point.

The other thing Ellen is articulating is how vulnerable we are in these moments. Because, as she’s saying, she’s working on self-acceptance for the body she has. And I think a lot of us are like, “We don’t want weight loss to be the prescription. We don’t want to feel pressured to go in that direction.” And then the doctor comes in and says, “1000 milligrams of calcium a day, an infinity number of protein grams a day. Also lose weight.” And then you do find yourself on that roller coaster or hamster wheel—choose your metaphor. Again, because we’re so programmed to think “well, the only option I have is to try to control my weight, control my weight, control my weight.” And you get back in that space.

What I usually try to do is phone a friend, have a plan to step myself out of that. Whether it’s texting my best friend or texting Corinne, so they can be that voice of reason. And I would do this for them, too! You need help remembering: You don’t want to pursue intentional weight loss. You’re doing all this work on self-acceptance. Dieting is not going to be helpful. So what can you take from this advice that does feel doable and useful? And maybe it’s not 1000 milligrams of calcium a day, but maybe it’s like, a little more yogurt in your week.

Is there a way you can translate this to your life that feels manageable? I think it’s what you do a great job of. But I think in general, doctors don’t do a great job with that part.

Mara

Yeah, I bet you Ellen’s doctor had 15 minutes with her. And was like, “Well, eat all this calcium and definitely try to lose weight,” right? And then was rushing out the door because she has 30 other patients to see that day.

I think doctors are trying to offer what maybe they think patients want to hear, which is certainty and one correct answer. And it can feel hard to find the space to sort of sit in the uncertainty of medicine and health and the uncertainty of like our bodies. And corporate medicine is not conducive to that, let’s put it that way.

Virginia

But so how much protein do we need to be eating?

Mara

I have no idea. Virginia, I don’t think anybody knows.

I think exercise is good for you. It’s not good for every single body at every single moment in time. If you just broke your foot, running is not a healthy activity, right? If you’re recovering from a disordered relationship with exercise, it’s not healthy.

But, movement in general prolongs our health span. And I’m reluctant to even say this, but, the Mediterranean diet—I hate even calling it a diet, right? But vegetables, protein—I don’t even want to call them healthy fats, it’s just so ambiguous what that means. But olive oil. All those things seem to be good for you. With the caveat that it’s really hard to study the effects of diet. And this is general diet, not meaning a restrictive diet, but your diet over time. But I don’t think we know how much, how much protein one needs to eat. It is unknowable.

Virginia

And that’s why, I think what we’ve been saying about figure out how to translate this into something that feels doable in your life. It’s not like, Oh, olive oil forever. Never butter again.

Mara

Of course not. I love butter. Oh, my God. Extra butter!

Virginia

Right. Butter is core to the Burnt Toast philosophy. I know you wouldn’t be coming here with an anti-butter agenda.

Mara

Oh, of course not. Kerry Gold forever.

Virginia

But it’s, how can you take this and think about what makes sense in your life and would add value and not feel restrictive? And that’s hard to do that when you’re feeling vulnerable and worried and menopause feels like this big, scary unknown. But you still have the right to do that, because it’s still your body.

Mara

Beautifully said.

Butter

Virginia

Well, this has all been incredibly helpful. Let’s chat about things that are bringing us joy. Dr Mara, do you have some Butter for us?

Mara

I had to think about this a lot. The Butter question is obviously the most important question of the whole conversation.

We have been in a heat wave in Philly, where I live, and it’s really, really hot, and we have a public pool that is four blocks from our house. Philly actually has tons of public pools. Don’t quote me on this, but I’ve heard through the grapevine—I have not fact-checked this—that it is one of the highest per capita free public pools in the country. I don’t know where I heard that from. I know I should probably look that up, but anyway, we’ve got a lot of pools in Philly. And there’s one four blocks from my house.

So I used to think of pool time as a full day, like a Saturday activity. Like you bring snacks, you bring a book, you lounge for hours. But our city pool is very bare bones. There’s no shade. And so, I have come to approach it as an after work palate cleanser. We rush there after I get my kid from daycare, and just pop in, pop out. It’s so nice. And pools are so democratic. Everybody is there cooling off. There’s no body shame. I mean, I feel like it’s actually been quite freeing for my experience of a body shame in a bathing suit, because there’s no opportunity to even contemplate it. Like you have to hustle in there to get there before it closes. There’s no place to put your stuff. So you can’t do all those body shielding techniques. You have to leave your stuff outside of the pool. So you have to go in in a bathing suit. And it’s just like, all shapes and sizes there. I love it. So public pools are my Butter.

Virginia

We don’t have a good public pool in my area, and I wish we did. I’m so jealous. That’s magical.

Since we’re talking about being in midlife, I’m going to recommend the memoir, Actress of a Certain Age: My Twenty-Year Trail to Overnight Success by Jeff Hiller, which I just listened to on audiobook. Definitely listen to it on audiobook.

Obviously, Jeff Hiller is a man and not in menopause, but he is in his late 40s, possibly turned 50. He’s an actress of a certain age, as he says. If you watched “Somebody Somewhere” with Bridget Everett, he plays her best friend Joel. And the show was wonderful. Everyone needs to watch that.

But Jeff Hiller is someone who had his big breakout role on an HBO show at the age of, like, 47 or something. And so it’s his memoir of growing up as a closeted gay kid in Texas, in the church, and then moving to New York and pursuing acting and all that. It’s hilarious. It’s really moving. It made me teary several times. He is a beautiful writer, and it just makes you realize the potential of this life stage. And one of his frequent refrains in the book, and it’s a quote from Bridget Everett, is Dreams Don’t have Deadlines, and realizing what potential there is in the second half of our lives, or however you want to define it. Oh my gosh, I loved it so much.

There’s also a great, great interview with Jeff on Sam Sanders podcast that I’ll link to as well. That’s just like a great entry point, and it will definitely make you want to go listen to the whole book.

Mara

I love it.

I will briefly say one thing I’ve been thinking about during this whole conversation is a piece by the amazing Anne Helen Petersen who writes Culture Study, which is one of my favorites of course, in addition to Burnt Toast. She wrote a piece about going through the portal. That was what she calls it. And she writes about how she’s talking with her mom, I think, who says, “Oh, you’re starting to portal!” to Anne. And I just love it.

What she’s getting at is this sort of surge of creativity and self confidence and self actualization that happens in midlife for women in particular. And I just love that image. Whenever I think of doing something that would have scared me a few years ago, or acting confident, appropriately confident in situations. I’m like, I’m going into the portal. I just, I love it, it’s so powerful, and I think about it all the time.

Virginia

Well, thank you so much for doing this. This was really wonderful. Tell folks where they can find you and how we can support your work.

Mara

Thank you so much, Virginia. I’m such a fan of your work. It has been so meaningful, meaningful to me, both personally and professionally. So it’s such an honor to be here again.

You can find me on Substack. I write Your Doctor Friend by Mara Gordon . And I’m on Instagram at Mara Gordon MD, too. And you can find a lot of my writing on NPR as well. And I’m writing a book called, tentatively, How to Take Up Space, and it’s about body shame and health care and the pursuit of health and wellness. So lots of issues like we touched on today, and hopefully that will be coming into the world in a couple of years. But yeah, thanks so much for having me, Virginia.

The Burnt Toast Podcast is produced and hosted by Virginia Sole-Smith (follow me on Instagram) and Corinne Fay, who runs @SellTradePlus, and Big Undies.

The Burnt Toast logo is by Deanna Lowe.

Our theme music is by Farideh.

Tommy Harron is our audio engineer.

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