00:00 Introduction

01:47 Dr Mahananda's introduction

04:02 Dr Mahanda's career

06:28 PCOS 

11:12 Environmental toxins including BPA can cause PCOS

12:21 Heat in plastic takeaway cups linked/key factor to toxins leading to PCOS

13:12 Foundational approach to health should be diet & removing ultra-processed foods

15:50 Menstruation should be viewed as a vital sign

20:35 Endometriosis: 50% have recurrence after surgery, need to get to the root cause of the inflammation

26:05 Menopause: Estradiol helps insulin sensitivity. Women have a lower risk of T2D UNTIL they hit menopause when estrogen drops.

28:00 Make diet changes in 40s before perimenopause hits

34:00 Post-menopausal fasting has proven beneficial, cleans up cells, and 'reboots' the system

39:00 For women, low carb may not be enough. Fasting is a good tool if plateauing

42:00 Benefits of MHT (ie HRT): drop in estrogen leads to a drop in bone density. MHT prolongs bone density/health

49:00 All women should be presented with MRT as an option

49:50 Menopause treatments should include: diet, fasting, MHT, reduce environmental exposures, power of sleep, exercise

52:00 Importance of functional movements, using own body weight. Insulin sensitivity increases when lean muscle mass increases

56:00 Testosterone therapy can be useful for women too. Helps cognitive function, and energy levels

Dr Peter Brukner (00:00.526)
and welcome to this Defeat Diabetes webinar on women's health. And we're very excited that we have a very special guest tonight to tell us all about matters related to women's health and nutrition. And that's Dr. Deepa. So Deepa, lovely to have you today and welcome.

Dr Deepa Mahananda (01:47.682)
Thanks, Peter. It's really nice to be on this webinar tonight speaking about women's health.

Dr Peter Brukner (00:47.682)
Great, I've heard Deepa speak on this subject before and she's a wealth of knowledge. so let's get straight into it. Well, actually, now before we get straight into it, tell us a little bit about your career Deepa and how you finished up in the sort of the low carb space. We'd love to hear your journey.

Dr Deepa Mahananda (01:47.682)
Sure. So basically, think it basically arcs back to my desire to become a general practitioner. And that was very early on in high school. So went through medical school, graduated in 2012 and fast forward into general practice training. And then finally getting to work with patients and get hold of their preventative health. And that's really what drove me to that spot in the first place.

But I think very quickly I started to learn that in general practice, the sad reality was that instead of preventing disease, we were really just band-aiding disease and giving out a lot of prescription medication to people and unfortunately just losing sight of what I had thought general practice was all about. So that led me into the low carbohydrate medicine space and I also simultaneously had my own sort of health issues at the time, one of which was being diagnosed with stage four endometriosis just soon after I left medical school. So I think it was that culmination of using different strategies for myself and also seeing what my patients were doing and starting to learn from them as well.

And then starting to get the knowledge around low carbohydrate medicine and truly understanding what that meant. And I think the pivotal moment was when we, myself and Alex, my husband, who's also a doctor, we attended the Low Carb Down Under Conference on the Gold Coast in 2017. And that was phenomenal. It just cemented why this was a very plausible mechanism that had lots of evidence that it's and it was just evidence that I was completely unaware of. So I think once we learnt more about that, we were able to then apply that further with patients and just see absolutely fantastic results in over a range of medical conditions, not just diabetes-related, but many other things that started to improve for our patients. So that's sort of where we got to. And at that stage, we had... a desire to really make this more or to focus on this area for our career and developed a clinic which is called Sydney Low Carb Specialists. And we founded that in 2019. I call it my third child because I was pregnant at the time with my second child. And that's a multidisciplinary clinic where we... now got doctors, a dietician, a health coach and an exercise physiologist where we work in a very integrated manner with our patients to try and either set up a low carb lifestyle or to troubleshoot low carb lifestyles and apply them across either a range of chronic conditions or even just optimising general health as well. So it's been an incredibly satisfying way to practice medicine, particularly when you see your patients get better.

Dr Peter Brukner (04:02.094)
Yeah, I think that's the case. think so many doctors these days just don't get any satisfaction out of medicine. They're just writing scripts and writing certificates and so on. And those of us who have discovered the of the low-carb way of treating chronic disease, it's enormously satisfying. And I know David Unwin talks a lot about the British GP that we've had on this webinar before talks about he was all set to retire because he just stopped enjoying medicine and then he had a new lease of life. So it's true.

Let's not dilly-dally, we've got lots to talk about. There are so many topics. And some of the topics I want to get through tonight are PCOS, polycystic ovary syndrome, which is extremely common in somewhat younger women associated with infertility. So we'll talk a little bit about fertility. We'll cover endometriosis, both from your own experience and then yours with patients. And we'll do a run through gestational diabetes as well.

And then I want to spend the sort of the second half of the show really talking about menopause and post menoposal and post menopausal issues. And I think that's what a lot of our audience are concerned about. But we'll come back to that in a little while. Let's start with PCOS, I said, polycystic ovary syndrome. And to be honest, I had no idea that PCOS was as common as it is. So tell us a little bit about PCOS.

Dr Deepa Mahananda (06:28.014)
Yeah, so PCOS is incredibly common. It affects up to 13 % of Australian women and that number rises in Indigenous women. Almost 20 % of those women are affected by this condition. it's rather than a disease itself, it's really just a spectrum. It's a syndrome, a cluster of different features that are all occurring in a particular woman. And they may only have one or two of those features and that's all. Where I sort of define it as mild, moderate, severe, and really crossing a whole range of conditions. Many women may know of it as affecting their menstrual cycles. So they often either get very irregular periods or they may miss periods or even just have cycles where they're not ovulating. So that's one of the big features. But other things that tend to happen are issues with herstutism, which is hair growth in unwanted spots. Acne is also a big feature of polycystic ovarian syndrome. And then there's of course the cysts themselves, which it's all a bit of a misnomer because many of the women who are actually affected by polycystic ovarian syndrome actually don't even have that feature on ultrasound. So there are also some other symptoms like hair loss that's associated with it. So it's really characterised from a chemical level, about 70 % of women who suffer from PCOS have insulin resistance. So it's quite a high number of women that have this condition who have this insulin resistance. And the problem with having high levels of insulin and also high levels of circulating blood sugars is that it affects the liver.

And the liver then actually reduces its production of a particular molecule, which is called sex hormone binding globulin. Now, when this molecule is quite low, we tend to get a rise in or an unchecked rise in what we call free androgens. And these are particularly masculinizing to a woman. So these are things like testosterone and something called DHEAS, which is a precursor to some of our sex hormones. So that's kind of where the hair growth and issues with acne as well come from. So it's that real hormonal imbalance that the results. there are a cluster of changes happening in this condition, but it's remarkable that so much of it can be related back to something like having high insulin levels and it really speaks to where we need to go to treat that condition.

Dr Peter Brukner (08:24.256)
So someone comes into your clinic and you diagnose them with PCOS. What's the first thing you'd recommend for them?

Dr Deepa Mahananda (10:26.99)
So the first thing we'd recommend and traditionally standard of care would be actually starting to reach for the prescription pad because that's sort of been the go-to thing. Things like metformin or putting someone on a neurocontroceptive pill and things like clomiphene and spironolactone to treat other things that are related like fertility, particularly with clomiphene. So getting a woman to ovulate again.

But what I do these days is I start to speak with them about this factor called insulin resistance and how we might be able to turn that around by simply choosing different foods that are not producing a large spike in insulin levels. And insulin is produced by the pancreas. And we know that if someone is already vulnerable to making large amounts of that, we can start to get cells that are becoming immune to that signal. So they're starting to get deafened by the sound of this insulin. So they're really unable to then take in extra blood sugar that is in the bloodstream and that then leads to higher levels of blood sugar as well within the bloodstream. So it's really a domino effect. So that's the first thing we would reach for is a lifestyle change. And some of the other things we speak about as well that surround that are it's one of the associated risks with PCOS is overweight and obesity. So that's also a massive area where we want to also advise women on how they can reduce some of the chemicals that may be entering their bodies as well. So we talk about these things that are called endocrine disruptors, and these are chemicals in our environment that we might ingest, inhale, or even eat, inadvertently or unknowingly and they basically enter our blood and can mimic our own hormones and unfortunately this then interferes and interrupts with our own hormone signaling which is actually a large part of what's also going on with polycystic ovarian syndrome. So we also chat about that lifestyle side of things as well, environmental exposures.

Dr Peter Brukner (12:20.564)
Right, what are some of the common environmental exposures that you've seen?

Dr Deepa Mahananda (12:20.564)
So some of the common ones are things like parabens and things like dioxins as well, which live in the environment. there are also things that people may have heard of our BPA, which is actually something that many plastic products often used to contain before they got banned. But we know that BPA has been largely eliminated from the production of plastic, but there are many, many other chemicals that actually mimic the action of these particular plastics and have been studied fairly widely in pre-clinical studies and in mice and have demonstrated all sorts of side effects which are you know not really the kind of thing that women would be wanting to be ingesting given that we just don't know and we are quite unsure about what these long-term effects are going to be. So one of the easiest and simplest ways to look at it is to start to look at what you cook your food in and move away from plastics and Teflon and use things like cast iron and store food in glass containers, don't reheat things in plastic either, and even simple things like your coffee cup. So they're often lined with chemicals that can be ingested and mimic your own hormones. So the heat applied to those particular packaging can actually trigger that issue and worsen the amount of those chemicals that transition into your coffee.

Dr Deepa Mahananda (12:20.564)
And therefore you can get this issue happening as well. The other things are perfumes and fragrances and makeup. And there are many options now on the market for low toxin products that are actually trying to reduce some of these things, such as phthalates and parabens. So I think that's really a key factor given that women disproportionately will be using some of these products and are unknowingly contributing to problems like hormonal imbalances that then can cause gynecological disorders.

Dr Peter Brukner (14:03.884)
Right, fascinating. So, but really the first step is diet, isn't it? I mean, it's just to, you know, to tackle the insulin resistance is by reducing your carbohydrate intake.

Dr Deepa Mahananda (14:03.886)
Absolutely, and I think that's a key. It's a foundational factor in approaching this condition. So the key things that people would be looking to reduce that are very high in carbohydrates are the highly processed foods. So these are typically what you would find in the supermarket. It's packaged. They are usually from grain-based products. And then there are those things that are high in fructose, so things like soft drinks.

And then there are the chocolates and biscuits and many of these products that are basically what we'd class as those processed foods. Then the other things to look at for women to reduce would be certain starchy vegetables, which can be quite high in carbohydrate. There are certain fruits that are also quite high in carbohydrate, particularly the fructose load. And then trying to replace within their diet, higher whole foods such as proteins that are found naturally. So this could be both vegetarian-based proteins in the form of dairy products and eggs if that's tolerated in a vegetarian diet. And then also including high quality full fat meats. And those products or those foods are basically going to reduce the amount of blood sugar that is existing in the bloodstream.

In someone who's already vulnerable to having high insulin levels, this is wonderful because it just reduces their production of insulin. So the pancreas starts to take a breather and it can even start to heal as well. So there's a concept of pancreatic beta cell retrieval and even emerging evidence that there's regeneration. The sooner you can act upon the problems with overproduction of insulin by the pancreas.

Just by making a few simple changes to the diet, you can already start to see in women that many will then spontaneously start to ovulate again and get a return to their menstrual cycles. And that's quite critical when it comes to particularly the time in a woman's life when they're considering having a baby and trying to regulate and have a very predictable menstrual cycle because highly believe that the menstrual cycle is a woman's vital sign and it should be added to one of those vital signs that we should be checking when we are actually reviewing women, know, not just blood pressure and heart rate, but actually looking at how predictable is your menstrual cycle.

Dr Peter Brukner (16:19.438)
Yes, and we know that PCOS is probably the most common cause of infertility in young women, along with endometriosis, which we'll get to. I mean, what about, I'm sure you have patients and probably friends who have problems getting pregnant with the problems of their fertility, and you put them on a low carbohydrate, sort of anti-inflammatory type diet and the success rate is remarkable.

Dr Deepa Mahananda (18:09.294)
It is, it's also for people as well, couples who weren't even intending on pregnancy, which is, you know, they actually end up falling pregnant. So it can actually be something that we warn people about when they go on to a low carbohydrate diet, because you may actually get a return to ovulation and also very increase your chances of fertility, not only because you're ovulating again, but also because you're starting to consume what is a far higher nutrient dense foods in your diet. So often when people are eating a standard dietary pattern and having a lot of whole grains, what is going on is that the nutrients that are in these things are often fortified. So they're having added folate into these foods and often iodized salt and even thymine, which is fortified in the food supply in Australia. So you're getting your nutrients, but you're actually getting your nutrients in a very artificial way. And the absorption and utilization of synthetic nutrients we know is a lot, or it's more subpar than if you're actually extracting nutrients in their natural state and form, and then you're actually better able to utilize them and absorb them into the multiple pathways that are needed within cells to produce energy. So it is actually really key that when you take on a whole food dietary approach as much lower in carbohydrates, you actually find that you're starting to increase and improve the nutrient profile. And that is really important for a woman who is at the time of thinking about preconception and then hoping to carry on a pregnancy and supply adequate nutrients to their baby as well for growth and development.

Yes, I had one of my colleagues at work a few months ago came to have a chat and talked about her problems about fertility. They've been trying for some time to get pregnant. And I had a chat and gave her copy of my book. two months later, she came back in with a big smile and said, it worked. you know, we've all had lots of those situations. I mean, I'm not suggesting it's a guarantee, but it's remarkable how often people who having trouble getting pregnant get to change their diet and achieve a pregnancy. let's talk about the other sort of form of cause of infertility and problems in younger women, and that's endometriosis. And I think it's a massive problem in our society. It seems to be getting more common. I don't know whether that's your impression as well. And generally not that well treated. mean, most doctors will make the diagnosis and send you off for a surgery, for a laparoscopic surgery and so on, which may or may not help. So tell us your approach to the patient who comes in with endometriosis.

So often the person who has endometriosis and doesn't even know about it, often those key symptoms that tip me off that it could be at play, that they're complaining of pain and fairly debilitating pain at that. So that's on every menstrual cycle and maybe even in the lead up to their periods and during their periods as well. They may also be experiencing fairly heavy breathing, bleeding and pain that radiates down the back of their legs and also into all sorts of other places as well. So can be quite an uncomfortable and painful condition to the point that it can debilitate women to the point they can't even work. So it can affect their quality of life quite dramatically. And the other issue that women with endometriosis have is that they find that they, particularly if they're at the time of preconception that they may not be falling pregnant easily. And the reason for this is that the condition itself is really where the lining of the uterus is growing in spots it should not be. So you might find these spots that are called endometriomas growing in the ovaries, inside the fallopian tubes, outside of the uterus, outside the bladder, outside the colon as well. And even in

I think in the literature they found it as widespread as the diaphragm and beyond. So it can be an incredibly painful condition and these endometriomas basically grow every time the menstrual cycle repeats itself. So with women who are affected by this condition, we need to think about what are all of the... the causes or the mechanisms for why this has occurred. And there are actually a raft of reasons and a lot of research that's been done into possible mechanisms, some of which actually revolve around endocrine issues. So, you know, people who are actually experiencing overweight and obesity and having that secondary to insulin resistance, there is an association between that and the development of endometriosis.

There's also those women who are experiencing high levels of inflammation and some of the particular molecules that are implicated in that are things like TNF-alpha and IL-6, which are these inflammatory mediators that can worsen the growth of endometriosis. And we also see in women that they may have genetic effects. So they may have a mother or a sister who was affected by this condition. And they also may be consuming quite a highly inflammatory diet as well. things like seed oils, for instance, which are quite high in omega-6 comparative to omega-3. And we know that ancestrally, sort of the ratio of consumption for that has been one is to one. But these days in a standard diet, we can see the ratio of omega-6 to omega-3 being as high as 30.

So it's quite a difference in what would have been a very ideal diet for pregnancy, which is trying to consume natural fats that really don't have high omega-6 loads. And there is also some other mechanisms that are at play. But I think one of the key things with any woman who's presenting with this condition is not to sort of jump straight away to think about it purely as how do we get rid of the disease, although that is part of the treatment in terms of reducing pain. And that's where the surgeries come in because you can actually reduce the amount of endometriosis that is there and that by default reduces pain. But it's also about thinking of how you can prevent it from returning because 50 % of women actually have recurrence within five years of surgery.

And that actually is quite a high number. So what we want to try to do is get to the root of the inflammatory causes and possibly the cardio metabolic causes as well that are implicated. And that, to a degree, is likely to have some impact on the severity of the disease. I think the other key factor is that a person who is on a very low carb diet may tend to produce ketones and ketones themselves, which are basically a free fatty acids that are combined together to create a ketone. Those are really important in inducing an anti-inflammatory effect. And so they can be quite relevant in pain management. So we know that there's a lot of research around that area in terms of therapeutic ketosis. we don't, the evidence there at the moment is still quite scant. And I think that just speaks to the large lack of interest in looking at diet and particularly ketosis in endometriosis. But I think that we will be seeing more emerging evidence to that end.

Dr Peter Brukner (26:37.286)
Yes, I mean we've talked about the possibility of doing some research ourselves haven't we Deepa? So I think no one else seems to be going to do it so maybe we might have to do it do it ourselves. Look I wonder where we're racing through time here I want to really focus on the problems around the menopause, the period menopausal symptoms and post-menopausal issues. A lot of our listeners are in that sort of a stage of their life and complaining of weight gain and metabolic syndrome and type 2 diabetes and so on. Why is that, are they vulnerable in that time of their life to those sort of conditions?

Dr Deepa Mahananda (26:37.286)
Yes, it's really common. see a lot of women who walk in and tell me that they, whatever they're trying now to try and manage their body composition and it is not working anymore when they're hitting their 40s and 50s. And what used to work in the 20s and 30s just doesn't anymore. So this is often in the presentation of weight gain because that's one of the things they can see is actually visibly happening to them around this.

this time in their lives. And what is happening around menopause is actually not just a sudden drop off in hormones, but a decline over many, many years in some cases. Because average age of menopause, which is defined as not having periods for at least 12 months, happens around 50 to 51 years of age. But it can actually happen to women anywhere after the age of 40 and happen all the way up until 60. So it could happen at any time in a woman's life. And what we really see is this time of perimenopause. So a long descent into a reduction in estrogen, particularly, and then also a reduction in progesterone. And it's interesting because the type of estrogen that is dominant in premenopausal women is the estradiol or E2.

And this particular type of estrogen tends to confer increased insulin sensitivity, which is great for premenopausal women because often women are actually at far lower risk of developing type 2 diabetes in their 30s and 40s and even in their early 50s compared to men. But as soon as they start to lose this estrogen, that's when they start to see worsening insulin resistance there is a real connection between these two hormones that many women are not even aware of. So whilst they're over here sort of beating themselves up, thinking, it's what I'm eating or am I not exercising or I'm not exercising enough and thinking that it's all because of them and that they need to work harder somehow. I really want women to know that it's actually not their fault. This is a physiological change that happens to all women. And so

What we need to do is actually be conscious of that, be aware of it, and then start to understand that, then the way you eat does need to change in a way because to mitigate the risks of worsening insulin resistance, we need to then start to address what the foods that are going to cause a rise in insulin itself. So I always think that women who are heading into menopause actually should start to be making changes as early as possible, you know, in their 40s to head off some of the issues that they'll have once the insulin resistance hits.

Dr Peter Brukner (28:42.005)
So what sort of changes are you talking about?

Dr Deepa Mahananda (30:37.4)
Yeah, so those changes are focusing on, again, reducing those ultra-processed foods, reducing the amount of seed oil consumption, looking at lowering fructose and glucose as much as possible in the foods they consume, and really starting to focus on a whole food approach. As well as, I think, the other key thing for women is to note that they'll get a redistribution in fat. And unfortunately, that is due to then this transition of reducing all, you most of your estradiol, which is that E2 type estrogen. And you do actually still make some kind, you do make an estrogen after menopause, which is actually called estrone, and that's E1. So estrone does work against women because it basically redistributes the, or basically that is produced in fat cells and the fat tends to get redistributed from being underneath the skin, which is a subcutaneous fat, to being fat that's around the abdominal area, particularly around organs and even within organs if the person heading into menopause has already got a problem with metabolic health. So this astrone that gets produced is actually made from those masculinizing androgens. So that DHEAS we spoke about earlier in regards to polycystic ovarian syndrome then starts to turn itself within fat cells into estrone. And estrone is quite inflammatory and then it kind of worsens this whole issue with putting on like fat tissue around the abdomen basically. So the key factors with that are that with lowering your glucose intake from your food, you're not really worsening a insulin response and you aren't actually adding to that whole mixture with a whole lot of triglycerides that get produced by the liver.

So you're trying to take away some of the brunt that's already happening with this production of estrone. So the other very useful strategy for women around perimenopause and going into the postmenopausal phase is that fasting can be incredibly useful. So starting to look at your eating window and potentially considering moving your three meals a day down to two meals a day, and even in some circumstances, one meal a day where you can start to feel intuitive hunger and fullness and understand the difference between the two can be really useful. And I actually think women in postmenopause, particularly the women I see in my clinic, they are probably some of the best fastest I've ever met because it suddenly becomes a lot easier to fast when you don't have menstrual cycle. And fasting when you've got a menstrual cycle or you've somewhat got a little bit of a period and then it disappears for a few months and at that time a perimenopause can be quite tricky because we know that the menstrual cycle is sort of divided up into two phases.

And the first phase, is when it is easier to fast, that's the first 14 days. And the second phase, which leads up to the time of the period, is a lot more difficult. And that's just because it's more progesterone dominated and it often leads women to crave foods. And that's really a call out from the body for some extra glucose to assist in progesterone production. So what I advise with fasting is if you've still got a cycle, or somewhat of a cycle, a semblance of a cycle, then it's really key to try and fast with the rhythm of the menstrual cycle. And then if you actually have no menstrual cycle whatsoever, then you can really launch into a fasting routine and even ensure there's some variation to that fast as well so that the body doesn't become too predictable in what's given. Because a slight... stressor to the body is a good thing every now and then. They call those things the hormetic stressors that can be quite beneficial.

Dr Peter Brukner (34:32.118)
So you talk about fasting being this time restricted eating that they refer to. So you'll have to do all your eating within a, say a six hour window. So you might have your two meals at midday and 6 PM or something like that, or even just as you mentioned, one meal a day. What about longer fasts? There are some people who advocate, you know, 24, 48, even 72 hour fasts as a sort of a circuit breaker and so on. And I know of people who do that monthly and swear by it. What's your advice or what you experience with that type of fasting?

Dr Deepa Mahananda (34:32.118)
So that type of fasting, particularly at the postmenopausal phase, is actually quite useful. So if you take a fast beyond 36 hours, you start to enter into a process which is called autophagy. And you get a cleanup, essentially, of debris within and around cells. And it's almost a reboot to the headquarters of your cells, what we call the mitochondria.

This particular type of fasting can be wonderful in terms of prevention of certain diseases, things like mild cognitive impairment that can then lead into Alzheimer's dementia. We know that if we can start to reduce some of the glucose load, which is what fasting does, it really brings down your blood sugar level to a very reasonably well controlled number that we can see improvement in your cognition and mental clarity during the fast. And the cells tend to work better after the fast is broken. it's a one, it is actually a great circuit breaker in a way. So a wonderful way to clean up some of these cells that were already on their way out, but actually just starting to accumulate. that these...the other way in which this is quite useful and there's been some literature to this end is in cancer prevention as well. So we often think about cancer cells actually being in everybody. We all have them. It's just that our body is very good at cleaning them up and recognising them and stopping their ongoing production. So these are these pre-cancerous cells that we really want to try and clean up as much as possible. And there's been great evidence to show that using some form of time restricted eating, whether that be one or two meals a day or even these longer fasts that people enter into, that can actually help to give a cumulative effect to reducing some of these damage cells, which is excellent.

Dr Peter Brukner (36:24.718)
So, and I can hear our listeners saying right now, but you know, it's so hard. How can you possibly fast for that long? I just get too hungry. But it's not the case, is it?

Dr Deepa Mahananda (36:24.718)
No, so interestingly, people when they're initially given the idea of fasting can find that that's quite a mountainous task to overcome. And I think the key for many patients and people that we see is that they should start to adapt their metabolism to be able to use another form of fuel. So generally speaking, if someone's eating a fairly standard diet, they are mostly functioning on sugars, blood sugar and glucose. And when you start to go on a lower carbohydrate approach, you become better at using and releasing from your fat stores some energy. And this is in the form of fatty acids, and then you can make ketones from the liver. So the ability to use ketones and glucose is actually a... it's a superhuman power. It's a power that we all have and we were all born in ketosis essentially. So we all can do this. It's just that we have been so in terms of modernized diet have actually kind of dampened our ability to use those ketones because most of the time we're not able to even get rid of this excessive blood sugar that's around. So the ketones themselves, once you're able to utilize them, you start to also signal fullness. So there is this dampening of a hunger signal that goes to a control center in the brain, which is the hypothalamus. And a lot of people start to report they're just not as hungry anymore when they've got the presence of even a few of these ketones circulating. So as that metabolic adaptation occurs, which usually takes about three months for elite athletes, so for you and I, it's going to take a lot longer to get there. But it does happen and it drives over a number of months. You start to be able to then enter into fasts without even needing to think about food, getting cravings for food and feeling any hunger that comes in. And if there is hunger, it's often transient and there are often many ways to get around that transient hunger. It's usually from boredom or even just habituation with the need to have two or three meals a day.

And I always think that fasting is probably something that shouldn't be thrown in straight away into the mix if someone is going low carb. I think it's something that should gradually come with time. Particularly these longer fasts, I don't think are easy to achieve when you're at the beginning, but there's certainly something that you can do once you've been eating in a low carb way for several months.

Dr Peter Brukner (38:40.472)
Yes, and look, we're coming up with a lot of the questions too about women who go low carb and unlike their male counterpart who weight just falls off them when they go low carb, there are many perimenopausal and menopausal women who might only lose one or two kilograms compared to their husband who's just lost 10 kilograms on exactly the same diet happened to my wife and I had to stop telling her how much weight I was losing because she was getting more more pissed off. you know, it's a fact, you know, isn't it? That for many, not all, but for many women, simply just going low carb is not enough. And I think you've explained it very well that maybe the next step after they try their, you know, get onto the low carb diet for a few months is to try both the time restricted eating and some prolonged fasts. Is that your approach to someone who comes in with you know a tale of a big low carb for three months I've lost you know one kilogram and it's plateaued and I can't lose anymore?

Dr Deepa Mahananda (40:39.124)
Yes, it's certainly the approach that we take is to look at diet first and then apply these strategies like fasting as well. But it is also often the case that there's a lot of women that this doesn't tend to provide success for and it's really achieving weight stagnation in a sense because often it is about the weight gain that they've had. But so they'll report to us that, OK, well, they now feel stable. They're not gaining weight anymore, which is excellent. And they might have had a slight reduction. But the next step also is to look at how they're, whether they're still experiencing any other symptoms that are associated with menopause. So some of those hallmark features are these group of symptoms called vasomotor changes, which are things like hot flushes and night sweats. And these can be quite severe, particularly at night time. And that causes a lot of sleep disturbance for women. And when you're under-slept, you have higher levels of cortisol. And the cortisol basically competes with your production of DHEAS in the adrenal gland. And we need that DHEAS to produce some of our remaining estrone, or the only estrogen that we'll have after menopause.

That also, the high cortisol levels forces our livers to produce glucose through a process we call gluconeogenesis. And so kind of from two different angles are getting bombarded within your body with these higher levels of glucose. And that's actually, you know, despite your lovely dietary changes that you've already applied. So that's when I would start to suggest whether or not it's worth treating the symptoms of menopause because we have some therapies, particularly with hormone replacement therapies, that can be really quite powerful and impactful for women who are at this time in their lives, particularly within the first 10 years of menopause, to try and alleviate some of the symptoms that can actually be the problem for why a woman is not actually losing the weight. So there are also some major benefits as well that women can consider when they think about hormone replacement therapy or it was formerly known as hormone replacement therapy. It's now been renamed to menopause replacement therapy. So the benefits that some women can have is that when we get a reduction in estrogen at menopause, our ability to synthesize new bone or what they call it bone mineralization disappears.

And what we're left with then is this dramatic decline in our bone density, which will be ongoing for the rest of a woman's life. And one of the major benefits that has appeared with the use of hormone replacement therapy or menopause replacement therapy is the ability to prolong not only your bone density, but the ability to keep continuous remineralization of your bones. So instead of really approaching osteoporosis in your 50s, you're really delaying that into your well into the 80s or 90s, which is a wonderful thing for women in terms of bone health. And it can also help with muscle strength as well. So these are some side benefits that come with the use of such therapies. And often, I think it's really worth addressing in women, what are the other issues that are happening around the time of menopause? Because there are often quite a lot of stresses involved at this time, not only from the symptoms that they're experiencing, but also from the mere fact that women are often caught in between multiple generations. They might be caring for older, for their parents, and they have younger children, and they're in a busy work schedule. So there is also an emphasis on how can a woman slow down and still engage and really... beneficial activities that are good for the mind and the body and in reduction of stress. And so yes, improving sleep, reducing stress, addressing alcohol intake. And many of these aspects are also really important around the time of menopause to then trigger further weight loss if that's what they're also looking for.

Dr Peter Brukner (45:10.518)
So HRT, or MRT as it's called now, has had a bit of a bad rap over the years. mean, concerns about links to various medical issues, cancer, and so on. mean, what do you say to people who say, well, my previous doctor told me not to take HRT.

Dr Deepa Mahananda (45:10.518)
Yes, it's really sad the reputation that MHT has these days. And I think some of that is starting to be unwound, which is good. So what it all arcs back to is the original studies around MHT was the nurses health study and that was in the 80s and 90s. And that's actually at a time when many, many women were on hormone therapy. And we had the observation that the women who were taking that actually had reduced cardiovascular disease and outcomes that were a sequela of that. then the Women's Health Initiative was developed, which was actually two types of randomized controlled trials where they were comparing women who were on oestrogen only therapy with a placebo. And then the other trial was oestrogen plus progesterone therapy versus a placebo. And looking at what happened impacts that had primarily on cardiovascular disease. Now this study is one of the longest running studies for any women, of women, and it studied I think more than 27,000 women as well through quite a long running time. I it was about 10 to 15 years that it ran for. But it got halted in 2002 when they saw there was a slightly increased risk of breast cancer.

And unfortunately, that's where this bad reputation comes back to, which is the interpretation of this data. So what we did see was that there was what was reported, or at least in the news, was that there was a 24 to 25 % increased risk of breast cancer for the women who were taking both the estrogen and progesterone in that particular study. So when you go back and look at the data, that was actually the reporting of the relative risk. And so it sounded quite alarming. But what it actually was in the absolute risk was really just a 0.1 % increase. So to put that into practical numbers, that was looking at a woman who had four in 1,000, or four women out of 1,000 women in a year would develop breast cancer in the placebo arm versus the five out of a thousand women in the arm on HRT. that was, when you present those facts to a woman and who is really debilitated by the symptoms of menopause, it suddenly starts to look like it's actually not that much more of a risk. mean, we commit to surgeries or, a day procedures like a colonoscopy where there's a one in a thousand risk of bowel perforation without even reading the consent form properly to say that there is that risk. So we know that what really improves the quality of life of women around this time and addresses their menopause symptoms can change their happiness and their ability to thrive versus this sort of risk that's quite small. And it was unfortunately overblown and really scared away a lot of women and left a generation of women without access to this type of therapy, leading to a whole host of other issues for those women, particularly around osteoporosis. So I think we now know a lot better. We also have very different preparations in terms of what hormones we choose to use. The ones that were used back then in the Women's Health Initiative are aware of pregnant mare urine, which is conjugated equine estrogen. And that's actually a form of that, or half of that is a form of estrone, that type of estrogen that we really don't like so much because it does lead to the visceral fat formation. And the progesterone used was a synthetic progesterone that we now no longer use. So in some ways, the findings of that study, they're now well outdated and we're very unlikely to have another study of that scale done for the modern day preparations that we have for replacement of hormones. But we do know that from the observational studies of these newer hormones that they have a much safer profile, much, much safer profile across the board. So I feel like all women should be presented with this as an option because it's something that we need an informed decision about. And I think if women knew the true risks associated with it that are not sensationalized by the media, then they would be able to make a really good decision for themselves.

Dr Peter Brukner (49:35.246)
Great. Okay, so if I could just summarize, you know, the issues around menopausal and perimenopausal symptoms, we're looking at diet, so reducing the carbohydrate and the inflammatory content of the diet, introducing fasting, whether that be time restricted eating or some prolonged fasts, and the potential for MHT, menopausal hormone treatment. So they're really our three sort of options if you like to tackle these problems that seem to be so widespread in our community. that a fair summary?

Dr Deepa Mahananda (51:22.872)
Yes, it's a first summary and there's of course the additions of factoring in your environment as well and in your environmental exposures and also not forgetting sleep and the power of sleep and how much that can be improved and prioritised around the time of menopause.

Exactly, sure. But it's a bit of a catch-22, isn't it? you know, some of these other things improve sleep and then sleep improves your health and so on. sleep and we shouldn't ignore exercise as well. You know, as a sports physician, have to keep recommending exercise, which as we know, it's not necessarily that good for weight loss, but very beneficial for many other, you know, cardiovascular and other areas.

Absolutely. Yeah, we didn't get much time to talk about that, but it's a very important thing, particularly for women around that time, because if they aren't going on to MHT, they have to be aware that the bone density you have at the time you cross over into menopause is what you're left with. And the only way to maintain that is by strengthening your muscles and improving your muscle mass. So that's actually a very important aspect, particularly the focus, not just on walking and running and jogging, but on resistance exercise. So there's push, pull, lifting movements.

Dr Peter Brukner
Yeah, really important, think, both males and females in older age. you tend to lose muscle strength with age and you need to counter that by doing resistance exercise. Now, the problem is that, you know, women think of resistance exercise as, you know, going to a gym and, you know, pumping iron and, you know, loud music and all that sort of things that put you off going to gyms and so on. Whereas really, just things around the house, carrying your shopping, all sorts of, you know, things you can do to retain muscle mass just with everyday activities.

Dr Deepa Mahananda
Absolutely, I think it's the functional movements that are most important. You want to be that person who can get out of a chair without going on to everything to get out. And it's really about using your own body weight. So you don't even necessarily need to have all those fancy extra weights to achieve these things. And I think the insulin sensitivity that this increases when you have increase in your lean muscle mass and the ability for your muscle cells to take on stored glucose. So this is the glycogen increases as well. So it's a great reservoir or a sponge if you like for blood sugar.

Dr Peter Brukner (52:46.894)
Great, terrific. So we've got diet, we've got fasting, we've got hormones, we've got sleep, we've got exercise. And that's the pillars of really tackling these sort of issues. And I hope that answers a lot of the questions. We've just got a few minutes left and a ton of questions here. I don't really know where to start. As always, we have a couple of questions about lipids, about cholesterol and HGL.

Dr Deepa Mahananda (54:43.66)
You know, one listener asking, saying that no matter what she does, low carb, she can't get her HDL any higher than one. And it's frustrated with that because her triglyceride HDL ratio is not improving that much. So any sort of comments on the impact of diet on HDL, which for those who not aware, it's traditionally been called the good cholesterol. That's a horrible term, but it's what people sort of identify with the higher the, so one thing that's the higher the better.

I mean, there's multiple factors that you'd have to consider there. mean, one is are the triglycerides still very elevated? So that would still need to be addressed by maintaining as much as possible a very low carbohydrate approach, because we know that when you're consuming a lot of glucose, that's going to convert over into the triglycerides and therefore use up a lot of your HDL because you need to actually donate a HDL molecule to your triglycerides to clear it. So to clear it from the bloodstream and for it to be eliminated. The other thing is that there are certain medications such as diuretics and beta blockers that can contribute to low HDLs. And so this could be a discussion that you can have with your doctor about whether there are any medications that you're on that are potentially suppressing the HDL production. And I think beyond that, you know, there are some some rare genetic issues which you'd normally be aware of by now but that could be affecting particularly in that person's case. And I think the other thing to say is that clinically I see that HDL tends to drop, sorry, tends to rise slower when someone is on a low carbohydrate diet as opposed to triglycerides which tend to drop very, very, very quickly. And so that's just the other thing about, depends on how long you've been low carb, you might want to hang in there, persist. And we always have to be, keep an open mind that one singular parameter doesn't mean everything. It's also about the whole person and how you're feeling with this approach and how your general health and health is going. Because if you feel well, that's a very, very important thing that can't be undermined. And we can get very fixated on cholesterol profiles alone and treating them somewhat in silos. So I think we need to still be cognizant that there could be all these other amazing changes happening in this person, but just for some reason, this HDL is still not budging and that could just be time.

Dr Peter Brukner
Right, there are a couple more questions on menopause, so let's just get back to that. Petra wanted to know, as women need testosterone as well as the issue of progesterone, can we get testosterone on prescription in Australia as well as the other two as part of menopause therapy? What's your view on testosterone for women?

Dr Deepa Mahananda (56:47.118)
Yeah, so testosterone replacement therapy is available for women and it's at the moment only got approval in the context of low libido or no libido. So it's that hyper sexual function that's affected. And there is an increasing and emerging evidence that actually testosterone is very useful in replacement for women for other aspects such as cognitive health and energy levels. And anecdotally, I these are just things I've seen in my clinic, the women who happen to be taking testosterone replacement therapy report wonderful general health, but importantly, the one thing that they tend to come back to is that they just feel more energetic and they have greater energy. So it seems to be that response to testosterone that comes across from the women who are taking it. It does need to be done carefully and guided by a doctor who understands how to dose the testosterone therapy and also recognizing that women don't need very high amounts of it. So it's a very, very minute amounts that are required in women. And yes, it is actually something that women do have. So it's not an exclusively male hormone.

Dr Peter Brukner
Okay, we've got one minute left. Quickie. Liz, 61-year-old, type 2 diabetic, having a total hysterectomy soon. Sounds like MRT is the way to go, correct?

Dr Deepa Mahananda
Depends on what type of hysterectomy. mean, these days, if the hysterectomy is sparing the ovaries, and I think you said there's 61. Okay. So, I mean, presumably this person has either gone through menopause or they're probably very late in the perimenopause sort of scene. But I think if you're having a hysterectomy, in some ways, that means if you do transition to 61. Yeah, hormone replacement therapy, you won't actually need to replace progesterone. So progesterone really in all the combinations for hormone replacement is only required to protect the uterus from unregulated growth of the lining. so, yeah, so really you're only just needing estrogen. And actually, in fact, in all the women's health initiative trials, all cause mortality was tracked for women who were commencing their hormone replacement within 10 years of menopause. And they found that those women who were on the estrogen only part of the trial actually tended to do better. So across the board for all cause mortality. it's the kind of, I would say, you know, if someone is only needing to use estrogen, it really reduces some of the noise from what what is required in the body. you just don't hear that it's actually nice to be on less, to be on less than having to be on both the combined treatments.

Dr Peter Brukner
Fantastic. We're out of time, Deepa. Thank you very much. I've learned a lot myself and I hope, I'm sure our listeners have learned a lot as well. We're going to keep working on the Defeat Diabetes Program, which we really believe in and it's going to address a lot of the issues that you've talked about tonight with low-carb and anti-inflammatory sort of food. So I couldn't recommend more to adopting the Defeat Diabetes Program. So if you're interested, you're not already a member and go to defeatdiabetes.com.au and you can read all about it. It can make a big difference to you. But Deepa, so that was fantastic. We'd love to get you back on at some stage. I think there's lots more to talk about with Women's Health. But for this time, thank you again and thank you everyone for listening. Goodbye.

Dr Deepa Mahananda (01:00:23.746)
Thank you. Bye.