Episode 13: Reduce Menopause Symptoms By Fixing Your Gut & Vaginal Microbiome

Hello and welcome to The Better Biome Podcast where we explore the universe within. I'm your host, Dr. Nicole Beurkens, and on today's show, we are talking with Dr. Anna Cabeca about the microbiome and hormone connection for women as they age. Dr. Cabeca is a triple board certified, Emory University trained physician and hormone expert who was diagnosed with early menopause at age 38. Devastated, she set out on a personal wellness journey to reverse her menopause side effects, which resulted in her delivery of a healthy baby girl at the age of 41. After experiencing her own health successes, Dr. Cabeca began counseling others, ultimately changing the lives of thousands of women across the globe. Her new book, The Hormone Fix and other empowering transformation programs have helped women of all ages become their best selves again. She has a line of all-natural products to support various aspects of women's health, and has received several awards for innovation and clinical practice. Such a pleasure to have you on the show today. Welcome!

Thank you. Great to be here.

You have such an interesting story, both personally and professionally. I'd love to have you share a little bit with our audience about how you came to be doing the women's focused work that you are doing today.

Yeah, I really delved into it at a young age because I saw my mother with heart disease, she was 52 and requiring cardiac bypass surgery. At that time, I was 16 years old, and I already knew I wanted to be a physician. And what I recognized was the research that they were basing her care on was based on men, and early on as a women's health advocate, part of my journey is that at age 39, I was diagnosed with premature ovarian failure, early menopause, and told I would never be able to have another child, and that was at that point devastation upon devastation. In obstetrics and gynecology, when we are given a diagnosis, we are told we are in menopause, we don't think of reversing it. These are your numbers. This is what the data is showing. Your ovaries aren't existing on ultrasound. I mean, everything was in place, they're non-responsive to the highest doses of injectable fertility meds, and that for me was just devastation upon devastation, and my doctor's bag was empty. And so that led me, honestly, on a journey around the world looking for answers. I needed to find answers for myself, but also for the many women that hit dead ends, so to speak. And as a result of that I reversed menopause and became pregnant, delivered my daughter, Ava Marie at age 41. And so now I'm 53 with an almost 12 year old, and it's great You've got to stay healthy. And so menopause crept back up on me. So after reversing at age 39, it came up again at age 48: Perimenopause, brain fog, hot flashes, three hours of sleep a night, irritability, mood swings. I didn't like who I was like "This is not me." I recognized that. And then the worst thing — One of the bad things that happened, but certainly for women — I had been over 240 pounds, and I lost that weight and kept it off for nearly a decade. But what happened is something that so many women experience and would tell me, they'd say, "Doctor Anna, I'm gaining 5, 10, 20 pounds, and I'm not doing anything different" So as a young cocky doctor, I'd be like, "Sure you are not. Really?" You're not as active, you're parking closer, you are driving through for a meal or two." But then that happened to me. And it was like, legit, I am not doing anything different. What is going on? As a hormone specialist already, I dug deeper into the hormones and really understanding metabolic hormones through midlife transition. It's a special time period, and it can be an empowering time period if we are not miserable. And at that point, I was miserable. So that's where I dug into what the research showed were the best practices, and the way I was feeling as I improved my health and optimized my health. And that's where I've developed my techniques, practices and what I teach now.

I think, for so many of us, our career path intertwines with our personal journey, right? And we have our toolkit of what we learned in school, but then we encounter things for ourselves and it's like "I need some different tools. I need some different information here." I think what you said initially is so true that often, when we get these kinds of diagnoses or we are having these symptoms, especially in women, we are told, "Oh, this is normal. This is part of what happens as you age. This is just going to be an ongoing issue." The idea of reversing these things or saying maybe it is possible to be in perimenopause or menopause and not be miserable all the time. I mean, these are not things that our people are commonly told, right?

Right. And that's so true. And feeling like my doctor's bag was empty, how is everyone else doing? The other thing is we are told to power through or this is normal, but it's not true, because there are women that go through menopause asymptomatically. Now, sometimes there's a red flag when I hear that, and if a woman has estrogen-dominance symptoms, their periods just stop, and they've not experienced hot flashes, whatever, that's estrogen dominance, and sometimes they end up with endometrial cancer because they've got those high levels of estrogen without the opposition of progesterone, so they're not cycling. They're in a kind of false early menopause or false menopause, and then their hormones will catch up with them. But if we don't correct that estrogen dominance, that imbalance, and check the uterus as a gynecologist, then we are risking that they come back with spotting, bleeding, and before we know it, it's endometrial hyperplasia or endometrial cancer. It's completely preventable. I mean, 99.9% of endometrial cancers are completely preventable with hormone management and functional medicine.

Yeah, which is such empowering information for people to have too, because especially when it comes to things like cancers, there's been this idea that, well, if it's going to happen to you, it's going to happen to you, and there's not a whole lot you can do, and you are saying no, actually, there's a lot of proactive things we can do. So I want to start delving into this idea of the various microbiomes being connected to hormone balance, hormone health, particularly as we age, because on this show we tend to focus on all the different biomes, and there's several that are intertwined with this. So how did you first become interested in or start exploring the connection between gut microbiome, vaginal microbiome and what's going on with women as they get older?

Yeah, there's two really big things that happened in kind of my career transition or awareness. The first is that as a gynecologist obstetrician, when patients come in with perimenopausal symptoms: PMS, irregular bleeding, irritability, sleeplessness, there's often a prescription for the symptoms, right? But as I learned through my journey and my experience with functional medicine and bioidentical hormones, I started having patients come in, I would detox them on a nutritional detox supporting liver function, put them on a very plant-based alkalizing diet, which supports the microbiome, their hormones would be more balanced when they came back in six weeks and they'd tell me "I'm 90% better" without me writing a prescription. I'm like, well, then I still think we need some bioidentical progesterone or whatever it may be. But that was so eye opening for me, and I knew that as we address the gut, improve the gut health, that improves hormone health. And now we know about the estrobolome, and that's really powerful.

So we need that diversity. We need healthy detoxification. We can't be constipated or have too much beta-glucuronidase, then we are increasing estrogen toxicity. It's fascinating to me. And then the second part is vaginal health. Vaginal health and the vaginal microbiome. The vagina gets short sighted. In so many ways, we neglect it. There's a microbiologist who wrote "The vagina is not merely a passageway for menstrual blood, babies and sperm. It is a huge life force." It's a life force for us. I wish I wrote that myself. But it also reminds me of the story, have you guys talked in this podcast about "Horton Hears a Who!"? Do you know that book by Dr. Seuss? Just to summarize, this beautiful elephant, he hears on this daffodil, this sound, and he's like, "No, there's life here", and he can see it because now he knows it's there and he's heard it. But everyone else is like "It's not there. Let's just wipe it out." And so he goes on this crusade to save this colony, right? And that's how we have treated our microbiome, especially the vaginal microbiome. Oh man, you got some odor? Let's just wipe out everything, here's some Flagyl. Yeast? Here's some Diflucan.

Here's some fragrant sprays and all kinds of things.

Let's just put all this stuff up there and douche. The old Listerine commercials, right? Vaginal Listerine. Ah, there's an image. You guys can Google this because there's an old Listerine vaginal douching image. Have you seen this one? There's chains on the door, husband locked in, "Don't lock me out!", and it's all for vaginal health, vaginal odor.

Right, which now we know those are the worst things that we can do. We had a really interesting researcher, Jacques Ravel was on the show talking about his research on the vaginal microbiome, and he said the number one thing that is common that women do and have been told to do is douching, and that that is absolutely the most devastating thing for the vaginal microbiome. Yeah.

Yeah, it's so true. And there's an occasional reason where I will recommend a douche, like a vinegar and water douche, something like that, or even just soaking in the tub. And there's that whole post-intercourse, what do we do there? Because that's a whole other microbiome. That's a whole other DNA-RNA transmission. So what are we doing to protect the vagina? And I think that's what we really need to think about. So how do we protect the vagina? How do we maintain our health and integrity? Because as we get older, we lose glycogen, we lose those normal healthy folds and secretions which are all protective to the vagina. They are protective and they help support healthy bacteria. Our vaginal pH is acidic to kill off bacteria, to kill off sperm, which is very alkaline. Semen is very alkaline, compared to vaginal secretions which are very acidic. But as we get older, there's a natural shift there to the pH of the vagina. And that allows more bacterial vaginosis, odor, and then after intercourse, discharge, odor, irritation, discomfort, urinary tract infections, and the dryness. It's worsened by tampon trauma, using dehydrating soaps and sprays and feminine washes and things like that. We really have to protect that, so one of my crusades has been to protect the vagina, and that's why I created one of my natural products called Julva.

Well, I actually wanted to talk about that because a lot of the products that are marketed to women, particularly as they get older, when they are dealing with those kinds of issues: Vaginal dryness, painful intercourse, those kinds of things, are products that are filled with chemicals and microbiome-disrupting things that actually seem to make the problem worse, right? And you have really been on a crusade to say we can manage this in a different way. So talk about that, particularly as it relates to the vagina and the vaginal microbiome.

It's something that's not out there. As you just said, you found there's nothing out there that can support health and can address these issues that may seem like surface level issues, but to do that in a way that is safe and that actually strengthens the foundations of health of the vagina, of the entire body too, right?

And the microbiome too. Keeping the pH moving from alkaline to acidic. We know that that's creating some improvement, improving your natural secretions versus layering on a false secretion that's only temporary and can actually be causing more harm. And the other piece to this is just really about — many of us think okay, it's superficial or after menopause, we no longer have our feminine private parts, right? And it's not at all, because the number one reason caregivers — and I found this was so powerful: The number one reason caregivers put their loved ones in a nursing home is incontinence. And I have treated so many elderly women and not so elderly women with terrible incontinence issues: Prolapse, incontinence, most were surgical candidates, but some weren't. But when we use bioidentical hormone therapy to help that use vaginal probiotics or healthy probiotics, doing that health regimen that improves your microbiome, use something like my product, Julva, then we can reduce those accidental leaks, we can improve the skin integrity and the condition of the skin. And so we can do this naturally, and we won't suffer these consequences. Now I have four daughters. And let me tell you, I do not want to give them another excuse to put me away!

It won't be because of incontinence! That's such an important point, though. And this is not stuff that's talked about, I mean, people are embarrassed to even bring this stuff up. But that's a powerful statistic that that's a really common reason why people end up in nursing homes or facilities, and you are saying it doesn't have to be that way.

Let's shift to the gut microbiome a bit, because people often think, "Okay, these are problems with my female hormones, what does that have to do with my gut? What does my microbiome have to do with it?" And there's actually a lot of interconnections there. So you just mentioned some things like probiotics and gut health. What are some of the things you see as key there to supporting the gut microbiome to then help with just hormone function in general?

I talk about this a lot in my book, The Hormone Fix, and my next book coming out, which is May 2020, is called Keto-Green 16. And so the way to heal, more powerful than our reproductive hormones, more powerful than our sex steroids, so to speak, estrogen, progesterone, even testosterone, are insulin, cortisol and oxytocin. These three very powerful hormones. But how do we improve microbial diversity? And I think that's the really big thing: How do we strengthen and create a powerful microbiome that's going to resist attack? And so I call it my Keto-Green way. So the first step is intermittent fasting. To answer your question, intermittent fasting, we want to keep 13 to 16 hours between dinner and breakfast and occasionally do extended fasts. I'm all for feasting. I will say have a 10-80-10 rule. 10% of the time fasting, 80% keto-green, 10% feasting. We have to have that diversity too. That's like if you are a town that never gets attacked, your fortifications go down, right? So you need to have some good variability and that good challenge to your microbiome for sure so we don't have a lazy gut.

Yeah. So that fasting piece, I think that's interesting, because the word breakfast, break-fast, is supposed to come at the end of a fasting period. But in society, we have sort of evolved to this place where we just eat all the time, or we are not thinking about the timing of our eating. And so people are grabbing dinner late, 9 or 10 at night before they go to bed, but you are saying the timing of that, like really having a good period each night of fasting, of letting the system rest is important for the microbiome.

It's hugely important. It is absolutely hugely important. And no more snacking. We were poisoned with the thought that we need to eat three to six small meals a day. Where did that even come from? Maybe you are an elite athlete that's got excellent metabolism and great muscles. Maybe. But not me who is at a desk, working and momming. Definitely not snacking. And for 99.9% of us, snacking is detrimental because it creates insulin resistance. And I think that's a really key thing I want people to understand: When we eat, glucose is going to go up, even a little bit maybe in our keto-green lifestyle, But then insulin will come up to attack that glucose and bring it into use of energy or store it in the cells. Now, it can take — we say fasting labs are 12 hours after your last meal, right? But sometimes it takes longer to get to your baseline. So what's happening? We should get close to baseline in four hours — three to four hours, it depends on how insulin-sensitive, those of us that are really insulin-sensitive, within two hours will be back down to baseline ideally, but if we are eating every three to four hours, you are just — glucose is up. Glucose is up. It's a roller coaster and you are exhausted, you feel like you need to eat more and you say "How come I have no willpower?" Willpower is physiology. It's because your blood sugar's all over the place. And that's what I want people to know, that rule of small meals, even though when I say "No more snacking", I often get told, for adrenal fatigue, patients will say, "Well, don't I need to?" You need to fast.

And it can take some time if you are used to that type of pattern of grabbing and eating all the time. It can take some time to shift towards eating at set periods and not eating all the time, right?

Absolutely. And again, so many people say "I have to eat because I get hypoglycemic" I say, well, that's very interesting. You are getting too many carbs at that meal, and that's why your blood sugar's adjusting and it's hitting that bottom, and that's why you feel like I need to eat again. So eliminate the carbs, just use your complex — the dark leafy greens, like I talked about, my alkalizing vegetables, cruciferous vegetables, dark green leafies. Beet greens are amazing, and I threw them away for decades. Beet greens are so good. Just do that. And when you have healthy fats, you are going to have much more stable blood sugar, and you will not be hypoglycemic. So in my online program, called Magic menopause, when women come in with that complaint, the rest of the women in the community, they're like, "Just wait, stick with it, follow it, you will not get hypoglycemic, do not worry, you will not get hypoglycemic."

I'm glad you addressed that, because that is a common objection to that. But it just takes some time to shift into it. You are talking about a lot of green things, keto-green. We could have a whole other conversation about the direction that the Keto world has taken and what it means to really be keto, and do that in a gut-supportive way, a healthy way. But let's talk about that focus on greens, that focus on vegetables, produce as part of this, because there really is an important microbiome connection to that, right?

There absolutely is, and in the Keto community, I think there is a turnaround now coming. You have the carnivore keto. You have the Keto dirty, which is just like eating bacon, hotdogs and velveeta. And you have keto clean, which is keto-green, and that's it. And the greens, we know just from all the research on microbiomes and all the research in preventive health, that plant-based eating increases diversity of the microbiome. So we cannot refute that. We can have amazing elitists that are exceptional that can do without greens, and they're just amazing. They're eating a lot of animal sources that have eaten a lot of greens versus fed grains. They're hopefully catching on to that. But that is not the norm. That is the exception, the 1%. So we need this diversity because we know that microbial diversity is key to life and longevity.

Right. And that diversity then, let's talk about how that impacts the hormone piece, particularly for women, as they're going through these transitions and these life changes, moving past their reproductive years. Why is that diversity important? What does that have to do with how we metabolize hormones, how all that works?

If we don't have that diversity, what it leads to often is irritable bowel symptoms or constipation. And so now you are not eliminating and you are reabsorbing toxins and actually creating a more toxic estrogen detoxification path or powering the estrogen detoxification pathways that are unhealthy for us. And so that's one piece of it. What's really fascinating is symptomatology. So what we see, we see women who have been suffering from hot flashes, even for a decade, over a decade, we see women with continued night sweats and difficulty sleeping and feel like they're aging faster than their years and mood swings, right? Mood swings are microbiota. Hot flashes, that insulin resistance increases hot flashes. So just by going keto-green in this healthy way that I outlined in The Hormone Fix which is that part about intermittent fasting, healthy fats, healthy protein, lots of greens, right? That's very simple. No more snacking. Don't drink with your meal, drink between your meal. And we have got a great video that shows this digestion emphasis. I would go on a tangent here, but I will say that free refills are killing us. We take a piece of meat, pour acid on it, that's what our stomach is supposed to do, right? But here we are drinking with our meals, watering it down. We dilute that acid, and it doesn't break down the food. And I just did a video, like one of those tasty videos, top down. So I just had my piece of meat, my hamburger in two jars and, I poured hydrochloric acid on it, not full-strength, but hydrochloric acid, just a little bit less than a pH of three. And then I poured the same in the other bowl with a cup of water. And so what was so interesting, this turned brown immediately, hydrochloric acid broke up the hemosiderin, broke up the red blood cells, and started breaking down the meat. And this other piece just sat there. The red cells weren't broken down. So we are not even getting the nutrients out of the food. That was just a beautiful illustration. I don't know how long it's going to take to even break down the red blood cells and to get the nutrients out of the food. And that's pretty powerful.

Absolutely. And I think what a lot of people don't realize is how acidic the pH of the stomach is to break that down. And it's true as we age, that our hydrochloric acid production can start to diminish. So we naturally have that problem as we start to get older of not having enough of that acidity to break our food down well, and then if we are having a lot of water and other things on top of it, then that impacts our microbiome too, because as you are saying, pouring the water on the meat, if it's just sitting there in our stomach, not getting broken down, not doing what it needs to do, clogging up the system, that just backs everything up and doesn't allow anything to function properly.

Yeah, and especially as we get older. In my new book, Keto-Green 16, I really focused on that digestive factor too. I really wanted to make it simple and just add that digestive factor to each of the food sources that we are using in our cooking, and then doing the lifestyle, like chewing our food till it dissolves in our mouth, intermittent fasting, not drinking with our meal, those things to stimulate digestion, to stimulate the ability of our body to break down and get what we need from what we are spending our money and time on, and nourishing our bodies. And as a result, you are not as hungry, you are digesting better, you feel better, you feel healthier, all those good things. So part of the composition of the menu plans that I put together in Keto-Green 16 is fabulous because we have our healthy fats, which is needed for every meal because that's going to help with blood sugar stability, and then seasonings. Think salts and seasonings. And then third, acid to start breaking it down, whether it's apple cider vinegar, whether it's citrus or using fermented vegetables and things like that to have that combination in your meal already. That helps, when you eat it, you will start increasing your digestive enzymes, and you will be able to — not only does it taste fabulous, but you are digesting it better and have less of the bloating, the belly weight gain, the gas and the symptoms that are just terrible.

And that type of eating provides not just nutrients and prebiotic fibers and things that support our gut microbiome, but also an acidity level that's appropriate because lot of people don't realize that our gut microbiome is meant to exist in a certain of acidity, and when that gets out of whack, then pathogenic organisms can rise, and that's a whole other problem. Right?

Exactly. And there are different pH values in different areas. From the stomach to the small intestines to the large intestine and all throughout, and the need of our gallbladder to function well because it's pulling out the bile acid, right?

So when we are digesting well, when we are eating the right kinds of foods, feeding that gut microbiome, digesting our food well, that then, down the chain, as you were saying with the liver, with the detoxification, has an important role with estrogen. People hear a lot about circulating estrogen, a lot of those kinds of issues. And some people think, oh estrogen dominance, too much estrogen, it's like, really, you have got all of this recirculating stuff that your body can't use because you are not getting things out. And that's very linked to digestion.

Exactly. We have to detox them on a regular basis, and that's a key part of it. A couple things that we can do on a regular basis is sleep well, of course, have daily bowel movements, healthy good clean, bowel movements. And it's so interesting, because as a gynecologist, one of my questionnaires was "Are you constipated?" And many women would say no. And as I inquire "Well, how many bowel movements you have a day?" "Well, I have one a week", I'm like "You are constipated! If you don't have a bowel movement every day, you are constipated", you have to have regular bowel movements. And people say, "I've been this way for 30 years."

"My mom was this way, everybody was that way". I find that too, because I ask about that in my work with patients too. And first of all, they go, "Why is the psychologist asking about my bowel movements?" And so that's a whole other thing. It's so important because it tells us so much about how their body is functioning, and therefore how their brain is functioning. But people will say that, they'll say, "Oh, no, I don't have a problem with constipation." I've learned to ask "How often do you have a bowel movement?" Because people say they're not constipated? "Oh, once a week", but that's their experience of normal, and they don't realize that no, actually, that's a real problem.

Yeah. And I will tell you a fault of mine as a gynecologist in my medical practice early on, was that before I learned all of this, clients would come in with rectal prolapse, right? They would have trouble or they would be constipated. And I would ask, "Do you have to put two fingers in the vagina to help you have a bowel movement?" And they'd say "Yes", I'm like, "So let's, let's tighten up this fascia here" before I knew, "Okay, you need stool softeners" or whatever was the routine course, versus fixing the entire gut, fixing the microbiome, and those problems go away. And lo and behold, a little vaginal hormone or a little topical hormone. What a difference right? That can be helped non-surgically, all the mesh erosions out there are unnecessary. We can so prevent every single one of those, and I've actually seen them heal with non-surgical intervention through taking a functional approach and using bioidentical hormones. That is life-changing for women. If there's anyone out there listening who has ever had a yeast infection as I have, you know that it is life-altering. It is not comfortable. And so, it's the same with prolapse, pelvic pressure at the end of the day, and I just think, "Okay, well, I need to operate on this." As I got better and better with what I do with hormones, and especially for incontinence symptoms. I would pre-op a patient with the hormone therapy that I recommended and the detox, and they come back for their pre-op of surgery, and they'd be asymptomatic. And I'm like, that's an upgrade.

That's right. You don't need that.

And they'd be like, "What? Really?". I'm like "Yeah, you no longer have the symptoms." And that's beautiful. That was so eye opening to me because I wasn't taught that way.

So beautiful, and so much reason for hope there for people listening who really have been told, "We don't have any other options for you", or there's people who maybe have had those kinds of procedures and it hasn't resolved it, and they're going "Well, there's nothing else for me now, I got to the end of the line and this is what I have to live with", and you are saying absolutely not. There are all these approaches that can be so helpful.

And sometimes we still have to do surgery, right? But I tell you, I went from doing two to three surgeries a week to two to three a year.

Wow. Wow. Incredible. And such a testament to your willingness as a physician to examine what you were taught, versus new information coming out and to say "You know what? I did the best I could with what I knew at the time. And now I know better and I'm doing better by these things", and to be willing to continue to evolve in your understanding and say there's new information coming out all the time, and we need to be open to that, right?

Well, I say God makes me humble. I have to.

Well, when you practice with people, that's the thing. to stay humble with that, and to say, "Boy, we only know what we know, what else is out there to explore?" And I think you are a great testament to that. So grateful to you for coming on the show today, for giving these really practical suggestions for people, and I'm excited about your new book that's out, and The Hormone Fix that has been out and is such a great resource. Thank you for spending the time with us.

Thank you for having me.

And thanks to all of you for joining us for today's episode of The Better Biome Podcast. Tune in next week to continue with us as we journey through the universe within.