Overview of Decoding Women's Health (Rich Roll — guest Dr. Elizabeth Poynor)
This episode features gynecologic oncologist Dr. Elizabeth Poirier speaking with Rich Roll about midlife hormonal transitions in women (late reproductive years → perimenopause → menopause), why medicine historically under-addressed these changes, what actually works (medical and lifestyle), and how to get better care. Dr. Poirier emphasizes that many midlife symptoms are real, measurable physiologic changes — not “just aging” — and that women have agency and options to improve symptoms, metabolic and brain health, and longevity.
Major topics covered
- Timeline and physiology of ovarian aging (late reproductive years, perimenopause, menopause)
- The spectrum of symptoms and early warning signs (brain fog, mood changes, visceral fat, sleep disruption, sarcopenia)
- Hormone therapy (historic controversy, modern approaches, routes and formulations)
- Who should/shouldn’t take hormone therapy and how to decide
- Diagnostic gaps and common misdiagnoses — how to evaluate symptoms properly
- Non-hormonal medical options (new CNS drugs for hot flashes, GLP‑1s for metabolic dysfunction)
- Practical lifestyle pillars for midlife health and longevity
- Supplements with potential benefit for brain and metabolic health
- Environmental endocrine disruptors and practical avoidance
- How partners can support women during this transition
- Resources and where to find specialist care; Dr. Poirier’s new podcast, Decoding Women’s Health
Key insights and takeaways
- Midlife is a long, gradual transition (often spanning ~35–60 years of age in terms of clinical relevance). Symptoms often start subtly in the late reproductive years (mid‑30s → 40s) and become more pronounced in perimenopause.
- Many common complaints — fatigue, low libido, mood shifts, irritability, brain fog, difficulty losing fat (especially visceral fat), sleep fragmentation, early sarcopenia — are linked to hormonal changes and metabolic shifts, not merely “normal aging.”
- Hormones (estrogen, progesterone, testosterone) influence the whole body — brain, heart, bone, muscle, metabolism — and calling them only “sex hormones” is misleading.
- There are answers. Lifestyle changes are foundational, and modern menopausal hormone therapy (MHT) delivered in contemporary formulations/routes can be safely and effectively used for many women.
Medical details — hormone therapy and safety
- Historical context: The Women’s Health Initiative (WHI) used oral conjugated equine estrogen + medroxyprogesterone acetate (PremPro) in older, often long‑postmenopausal women; that formulation and route drove many of the concerns about cardiovascular and cancer risks.
- Modern approach:
- Prefer estradiol over conjugated equine estrogens; prefer transdermal (patch/gel) delivery when appropriate — transdermal estradiol is less inflammatory and has lower thrombotic risk than oral estrogen.
- Use natural progesterone (when a uterus is present) rather than older synthetic progestins, which are associated with higher breast cancer risk.
- Low systemic doses used for symptom control or physiologic support are generally much lower than doses in contraceptives.
- Benefits supported by evidence (especially when started earlier in the menopausal transition): improvement in vasomotor symptoms, sleep, mood, body composition (muscle preservation), metabolic profile, bone protection, and associations with lower dementia risk in some observational analyses.
- Contraindications/considerations:
- Current or recent estrogen‑dependent breast cancer: standard practice is cautious/avoid systemic estrogen; these cases need oncology input and individualized discussion.
- Prior stroke or unstable vascular disease: careful cardiology/stroke specialist consultation — transdermal routes may be lower risk but require individualized assessment.
- Genetics (BRCA, etc.): genetic predisposition alone is not an absolute contraindication to hormone support; nuanced discussions with specialists are necessary.
- Local (vaginal) low‑dose estrogen is generally safer for urogenital atrophy/dyspareunia and should be considered even when systemic estrogen is contraindicated, but consult oncology if cancer history is present.
Diagnostics, misdiagnosis, and data gaps
- Always do a differential diagnosis: thyroid disease, GI issues, cancer, sleep disorders, mood disorders, and other medical causes can mimic hormonal transition symptoms.
- Useful measurements:
- Cardiometabolic: blood pressure, lipid panel (including ApoB, Lp(a) if indicated), fasting glucose, HbA1c, fasting insulin or HOMA‑IR.
- Body composition: waist‑to‑hip ratio is a simple, high‑value metric (visceral fat signal). DEXA with body composition is useful for bone and muscle assessment.
- Hormone mapping: day‑3 FSH and cycle‑timed hormone measures can be informative; “snapshot” blood tests often miss dynamic changes. Home urine panels (e.g., Dutch testing) and wearables can add longitudinal context.
- Brain health biomarkers and functional imaging are being studied as surrogate endpoints; large RCTs for dementia prevention are unlikely, so surrogate markers gain importance.
- Clinical problem: limited, inconsistent education and sparse research on non‑fertility aspects of the late reproductive years; clinicians must listen to patient narratives and integrate multiple data sources.
Non-hormonal and adjunct medical options
- New CNS-acting drugs for hot flashes (e.g., fezolinetant / Veozah) provide options for women who cannot or prefer not to use estrogen.
- GLP‑1 receptor agonists (semaglutide, tirzepatide, etc.) are powerful tools for obesity, visceral fat reduction, and improving metabolic/inflammatory states. Pros and cons:
- Helpful when lifestyle alone can’t reverse metabolic dysfunction.
- Can reduce appetite and “food noise.”
- Must be combined with strength training and adequate protein to prevent muscle loss.
- Other pharmacologic considerations: some women benefit from birth‑control‑type regimens during perimenopause for symptom control; individualized decision‑making is critical.
Lifestyle interventions — the non‑negotiables
Three pillars Dr. Poirier stresses:
- Movement — prioritize progressive resistance (strength) training (3+ sessions/week) to prevent and reverse sarcopenia and preserve metabolic health; add aerobic activity for cardiovascular fitness.
- Sleep — prioritize scheduled, restorative sleep; poor sleep worsens insulin resistance, appetite regulation, and mood.
- Nutrition — whole foods, plant‑forward where possible, and increased emphasis on protein starting in late reproductive years (recommendation discussed: ~1 g protein per lb of ideal body weight for muscle gain, though individualized needs vary). Adjust carbohydrate to personal tolerance.
Other essentials:
- Stress management, social connectivity, sense of purpose, and mindset/happiness are central and often overlooked determinants of midlife health.
- Environmental toxin minimization: reduce exposure to phthalates, BPA, parabens, organochlorine pesticides — practical steps include avoiding plastics for food, choosing low‑fragrance and paraben‑free personal care, and using water filtration.
Supplements with supportive evidence
- Multivitamin: some trials (e.g., COSMOS‑Mind) suggested modest cognitive benefits — not a magic bullet but reasonable as part of a broad plan.
- Omega‑3 fatty acids (EPA/DHA): anti‑inflammatory and associated with better brain health outcomes.
- Creatine: evidence supporting muscle and some neuroprotective roles.
- CoQ10: consider if on statin therapy or to support mitochondrial health.
- Vitamin D, B12, folate: correct deficiencies when present.
- General caution: supplements are adjuncts, not substitutes for lifestyle or medical therapy.
Practical guidance — finding care and questions to ask
- Resources: The North American Menopause Society (NAMS) provides clinician directories and guidance. Telehealth women’s health platforms can be valuable for access and longitudinal care.
- Key questions to ask a clinician:
- “Do you prescribe menopausal hormone therapy? What is your approach?”
- “How do you evaluate midlife hormonal symptoms and differentiate other causes?”
- Ask about experience with transdermal estradiol, natural progesterone, and non‑hormonal options.
- When getting labs, request cardiometabolic markers (lipid panel, ApoB/Lp(a) if needed), HbA1c, fasting insulin if metabolic concerns exist, blood pressure monitoring, and body composition (waist‑to‑hip, DEXA when indicated).
Quick action checklist (for listeners)
- If you feel “not yourself” (low energy, mood shifts, brain fog, sleep disruption, weight gain, low libido): consider evaluation rather than accepting resignation.
- Basic first steps you can take now:
- Track sleep and symptoms; collect longitudinal data (wearables/written logs).
- Measure waist circumference and track BP.
- Ask your clinician for a cardiometabolic workup (lipids, HbA1c, fasting insulin if warranted).
- Prioritize strength training, better sleep hygiene, and protein‑forward nutrition.
- If symptoms are bothersome, consult a women’s health specialist about modern hormone therapy options and non‑hormonal choices.
- Reduce obvious endocrine disruptors in your environment (avoid heating food in plastic, choose cleaner personal care products, filter water).
Notable quotes
- “If something has changed in how you feel, that’s indicative that something’s changing in your body — and you need to get an answer to that.”
- “Hormones are not just sex hormones. They impact the entire body.”
- “You don’t have to feel like this.”
Final notes
Dr. Poirier calls for better clinician education, more research on non‑fertility aspects of ovarian aging, and pragmatic algorithms to integrate hormonal narratives with biomarkers and wearables. She also recently launched the Decoding Women’s Health podcast to make vetted, specialist‑level information accessible and actionable for women.
For listeners: the practical message is empowerment — midlife changes are often treatable; combining evidence‑based lifestyle habits with modern medical options (when indicated) can markedly improve quality of life and potentially long‑term brain and cardiometabolic health.