PDF Summary:Next Level, by Stacy T. Sims

Menopause brings significant changes to your body and mind, from shifts in metabolism and muscle mass to hot flashes and brain fog. In Next Level, Stacy T. Sims explains how declining hormones affect everything from your thermoregulation and pain tolerance to your cognitive function and emotional stability. She breaks down the stages of perimenopause and menopause, showing how these transitions impact women differently based on factors like ethnicity and age.

Sims provides strategies for managing these changes through targeted training and nutrition. She covers the importance of heavy lifting for maintaining muscle and bone density, explains why protein timing matters for recovery, and discusses both hormonal and nonhormonal treatment options. This guide offers practical approaches to help you navigate menopause while maintaining your fitness, health, and quality of life.

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(Shortform note: Hepcidin is a hormone-like protein made by your liver. When inflammation triggers hepcidin, it locks iron inside storage cells, preventing it from reaching your bloodstream and bone marrow. This means less iron is available for making red blood cells, leading to anemia.)

In addition, Sims notes that hormonal decline influences brain function and emotions. Estrogen and progesterone affect the hypothalamus, which helps regulate fatigue and emotional control. Estrogen boosts serotonin, a neurotransmitter that can negatively affect the CNS, leading to psychological and bodily exhaustion. Progesterone has a calming impact on the brain, reducing anxiety and potentially boosting memory performance. It additionally boosts brain-derived neurotropic factor (BDNF), a protein

When progesterone decreases, we miss out on key advantages, potentially experiencing emotional fluctuations, forgetting things, and the muddled thinking often called "brain fog" by menopausal women. Estrogen also helps control cortisol, which is commonly known as the stress hormone. As estrogen diminishes and cortisol increases, it may seem like you're always being pursued by an invisible force, even during moments of rest.

Serotonin’s Complex Role in the CNS

Sims’s discussion of serotonin is somewhat misleading. She suggests that serotonin negatively affects the central nervous system (CNS) and leads to psychological and bodily exhaustion. However, research shows that serotonin plays a complex role in the CNS, acting as a neuromodulator that can have both excitatory and inhibitory effects depending on the context. While serotonin imbalances are associated with mood disorders and fatigue, it’s an oversimplification to portray serotonin as inherently harmful to the CNS or as a primary cause of exhaustion.

Finally, hormonal decline affects your pain tolerance. Sims explains that those hormones can reduce pain. Increased progesterone enables you to detach emotionally from pain, which prevents its amplification. They also enable you to dissociate from the intensity and discomfort of pain. When the amount of progesterone decreases, you lose these benefits. Low progesterone along with elevated cortisol—the stress hormone—leads to the most severe pain. Pain is at its peak when sex hormones are at their lowest.

(Shortform note: Sims’s assertion that pain is at its peak when sex hormones are at their lowest is controversial. In an academic paper, researchers reviewed studies on the relationship between the menstrual cycle and pain. They found that the studies didn’t consistently show that pain sensitivity was highest when estrogen and progesterone were lowest. The researchers concluded that the relationship between the menstrual cycle and pain is complex and not fully understood.)

Vasomotor Symptoms & Thermoregulation

Sims notes that menopause commonly causes symptoms such as hot flushes and nighttime sweating. Hot flashes involve an abrupt feeling of warmth in the facial area, neck, and upper body, often accompanied by flushing, sweating, and a racing heartbeat. Night sweats are hot flashes happening during the night.

Roughly 75 to 80 percent of women in North America experience hot flushes. They're triggered by decreased serotonin, which occurs when estrogen decreases. This leads your brain to believe your core temperature is elevated, prompting it to send blood to your skin's surface to cool you down. Hormonal treatments and antidepressants can help ease these symptoms.

Cognitive-Behavioural Therapy for Hot Flushes and Night Sweats

In Managing Hot Flushes and Night Sweats, Myra Hunter and Melanie Smith present cognitive-behavioural therapy (CBT) as a non-hormonal, non-drug treatment for hot flushes and night sweats. CBT is a structured, time-limited therapy that helps you understand the connection between your thoughts, feelings, and behaviours. It teaches you to identify and change unhelpful thought patterns and behaviours that can worsen symptoms. The authors explain that CBT for hot flushes and night sweats has been tested in randomised controlled trials and shown to significantly reduce how troublesome women find their symptoms, improve their sense of control, and enhance sleep and quality of life. The therapy includes education about the flush-anxiety cycle, cognitive restructuring to challenge negative thoughts, behavioural strategies like paced breathing and relaxation, and techniques to manage sleep disturbances.

Training, Nutrition, and Recovery During Menopause

In menopause, nutrition needs change. Sims explains that your metabolism shifts, making you more likely to experience elevated blood sugar and resistance to insulin. You also stop producing hormones that promote muscle growth. Therefore, you must consume additional protein and fewer carbohydrates than you did before menopause. Additionally, you must eat enough calories to sustain your body.

(Shortform note: While Sims claims that you stop producing hormones that promote muscle growth after menopause, this isn’t entirely accurate. In The Menopause Manifesto, Jen Gunter explains that after menopause, your body continues to produce sex hormones, but in smaller amounts and from different sources. For example, your adrenal glands produce androgens, which can be converted into estrogen in your muscle and fat tissue. So, while your hormone production changes, it doesn’t stop completely.)

In the upcoming sections, we'll examine optimizing fitness and dietary strategies, along with physiological support and considerations for medicine.

Optimizing Training & Nutrition Strategies

According to Sims, nutrient timing is crucial for optimizing your physical abilities and recuperation while experiencing menopause. This refers to when you eat in relation to your workouts and is crucial for women experiencing menopause because of the way hormonal changes affect your body’s response to exercise. You should consume food in the first half-hour after a workout to help your body recover. Sims explains that after intense exercise, women experience elevated cortisol, a stress hormone, and a catabolic condition, breaking down tissue and muscle.

(Shortform note: While Sims emphasizes the importance of eating within the first half-hour after a workout, Brad Jon Schoenfeld and Alan Albert Aragon suggest that this window may not be as critical for menopausal women who have consumed a protein-rich meal within two hours before exercising. They argue that the body’s anabolic response to protein intake can last several hours, providing a buffer that supports muscle repair and growth even if post-workout nutrition is slightly delayed. This perspective offers flexibility for women who may find it challenging to eat immediately after exercise, allowing them to focus on overall daily protein intake rather than strict timing.)

Women experiencing menopause must exit that condition quickly because they risk losing more muscle and already tend to have elevated cortisol levels, which impede insulin function. Consuming appropriate post-exercise nutrition within half an hour of a demanding workout helps your body exit the breakdown state, decreases cortisol, and initiates the repair process. This helps improve your blood sugar control and body composition. Consuming something to eat in the half hour after working out can lengthen your rapid glycogen restoration by as much as two hours. The right post-workout nutrition keeps you from entering a condition of limited energy availability and helps your gut microbiome stay healthy. Sims explains that intense workouts are taxing on the digestive system. Providing your body with proper nutrition afterward can help heal your gastrointestinal tract and maintain healthy bacterial diversity.

(Shortform note: A condition of limited energy availability is a state in which the energy you consume is insufficient to support your body’s physiological functions after accounting for the energy you expend during exercise. Margo Mountjoy et al. explain that this condition can lead to a range of health issues, including hormonal imbalances, impaired bone health, and decreased metabolic rate. When your body doesn’t have enough energy to meet its needs, it prioritizes essential functions like maintaining body temperature and supporting vital organs, while reducing energy allocation to non-essential processes such as reproductive function and bone maintenance. This can result in menstrual irregularities, decreased bone density, and increased risk of injuries.)

Prioritize protein for recovery. The best post-workout meal or beverage should contain a ratio of three to one grams of carbohydrates to protein, as protein aids in replenishing glycogen and initiating muscle repair. It's important to consume between 30 and 40 grams of protein, which includes 3 to 3.5 grams of leucine, to effectively stop muscle degradation. Continue distributing your protein intake throughout the day, consuming 30–35 grams per meal to support building muscle and keep a balanced pool of amino acids in your body.

(Shortform note: In an academic paper, researchers explain that the recommended 30–40 grams of protein, including 3–3.5 grams of leucine, is based on the amount needed to trigger muscle protein synthesis. This amount of protein and leucine is enough to temporarily increase the concentration of leucine inside muscle cells, which activates a protein complex called mTORC1. This complex acts as a sensor that links the nutrients you consume to the genetic machinery inside your muscle cells. When mTORC1 is activated, it signals the cells to start translating specific genes into proteins, which are then used to repair and build muscle tissue.)

Animal-derived protein such as whey is generally the optimal source of essential amino acids (EAAs) that promote muscle creation. Sims explains that animal protein closely resembles what muscles require. Menopausal women frequently choose soy due to its plant estrogens, which they hope will alleviate menopause-related symptoms such as hot flashes. The problem is that soy must be consumed in double the amount to deliver the same muscle recovery benefits as animal-derived proteins such as whey. Whey is a great leucine source. There are 2.5 grams of leucine in every 25 grams. In contrast, you'd require 40 to 50 grams of soy protein to get a similar leucine content. If you follow a plant-based diet and avoid animal proteins, try combining options like quinoa, hemp, and pea to achieve an amino acid profile comparable to whey.

Leucine Content in Soy and Whey Protein

While Sims claims that you need to consume double the amount of soy protein to get the same muscle recovery benefits as animal-derived proteins, researchers have found that soy protein contains only slightly less leucine than whey protein. In a research article, scientists compared the protein content and amino acid composition of various plant-based protein isolates, including soy, pea, and rice, with animal-based proteins like whey and casein. They found that soy protein isolate contains about 8.0% leucine, while whey protein isolate contains about 10.9% leucine. This means that while soy protein has slightly less leucine than whey, the difference is not as significant as previously thought. The researchers suggest that plant-based proteins like soy can still be effective for muscle recovery and growth, especially when consumed in slightly higher amounts to compensate for the lower leucine content.

In the upcoming sections, we’ll discuss training intensity and modalities, along with fueling, recovery, and physiological restoration.

Training Intensity & Modalities

Sims explains that lifting heavy weights is beneficial for women, particularly while they're experiencing menopause. It involves lifting the heaviest load you can manage for a maximum of six reps. This type of training helps maintain lean muscle, reduces fat gain, enhances bone strength, cardiovascular health, and immunity. It also strengthens the muscles that stabilize your spine, improving posture and stability. Additionally, it enhances blood pressure control, circulation to your skin and muscles, lowers inflammation, and strengthens your immune system.

(Shortform note: Bente Klarlund Pedersen and Mark A. Febbraio explain that when you lift heavy weights, your muscles release myokines, which are hormone-like signals that communicate with your immune system. These myokines help regulate immune cell activity, reducing chronic inflammation and enhancing your body's ability to fight off infections. This process not only strengthens your immune defenses but also helps prevent the development of autoimmune diseases by keeping your immune response balanced.)

However, beginners at resistance training shouldn't immediately start heavy lifting. Start with moderate weights, doing 2–3 sets of 8–15 reps to develop a base and muscle stamina. Once you reach the four- to six-week mark, increase the load and lower the reps until you do five repetitions for each of five sets. When you feel ready, your goal can be to complete 3–5 repetitions across 4–6 sets.

(Shortform note: Nicholas A. Ratamess et al. and the American College of Sports Medicine (ACSM) recommend that beginners start with 2–3 sets of 8–12 reps, and that they only increase the load and lower the reps after several weeks. However, they don’t specify how many reps you should do when you increase the load. This is an important omission, as the risk of injury increases with heavier loads. This is especially true for beginners, whose tendons and joints may not be able to handle the stress of heavy lifting.)

Fueling, Recovery & Physiological Restoration

Protein and carbs are crucial for recovering muscles and replenishing energy. Sims explains that after a workout, your body enters a catabolic phase, degrading muscle tissue. Consuming protein and carbs in the half hour following exercise helps counteract this, lowers cortisol levels, and stimulates muscle repair. Protein helps restock glycogen and kick-start muscle repair, while carbohydrates help replenish glycogen stores in the liver and muscles.

(Shortform note: If you’ve eaten a meal within two hours of your workout, you may not need to worry about the 30-minute window for protein and carbohydrate intake. This is because the amino acids from your meal will still be circulating in your bloodstream for several hours, providing your muscles with the building blocks they need for repair and growth. However, if you haven’t eaten in several hours, your muscles may be more receptive to nutrients immediately after exercise.)

Isoleucine is especially vital for building muscle. Changes from menopause, intense physical activity, and recovering after a workout boost leucine metabolism and might lead to a catabolic state. Consuming leucine stops the catabolism. The greater your leucine intake, the more quickly your muscles are saturated with it, which signals them to heal and grow faster. Sims suggests consuming 30–35 grams of protein in each meal and 15–20 grams in snacks. Time it so that you get your biggest protein hit—about 30 to 40 grams—after your daily workout, when your body is primed to use it.

(Shortform note: A catabolic state is when your body breaks down muscle proteins faster than it can build them. This happens when the systems that degrade proteins, like the ubiquitin–proteasome and autophagy–lysosome pathways, are more active than the systems that build proteins. When these protein-degrading systems work faster than the protein-building processes, you lose muscle proteins over time.)

Physiological Support & Medical Considerations

Hormonal treatment for menopause can help manage symptoms and is considered safe for many women. Sims explains that MHT is like using an oral contraceptive pill, which is a synthetic hormone that acts similarly to your body's natural hormones. It's highly successful in easing hot flashes and night sweats, which are among the most significant issues for women experiencing menopause. It also might help with vaginal dryness, mood changes, mental cloudiness, anxiety, depression, anger, and sleep issues, though studies are ongoing. MHT may assist in maintaining bone density. It might reduce abdominal fat gain in some individuals, though it doesn't work for those who are very physically fit or highly active. However, MHT does carry risks.

(Shortform note: The conflicted opinions about MHT in the medical community and the media can be traced back to the publication of the Women’s Health Initiative (WHI) trial in 2002. The WHI was a large-scale study that aimed to assess the risks and benefits of MHT in postmenopausal women. The initial results of the WHI suggested that MHT was associated with an increased risk of breast cancer, heart disease, stroke, and blood clots. These findings were widely publicized and led to a dramatic decline in the use of MHT. However, subsequent analyses of the WHI data have shown that the risks of MHT were overstated, particularly for women who start treatment near the onset of menopause. The absolute risks of adverse events are small, and the benefits of MHT in relieving menopausal symptoms and preventing osteoporosis are significant for many women. The initial alarm caused by the WHI results created a lasting anxiety among both physicians and patients, making it difficult to have nuanced discussions about the risks and benefits of MHT.)

If you're over 60 or at least ten years past menopause, some evidence suggests it could raise your chances of developing Alzheimer's disease and dementia. There's a low chance of developing breast cancer, but it could rise depending on the formulation and how long you use it. The tablet version of MHT elevates the risk of developing blood clots in the legs and lungs. The risk of stroke is slightly elevated with MHT, depending on the type, how it's administered, and the dosage.

(Shortform note: In addition to the risks Sims lists, medical researchers have found that MHT increases the risk of gallbladder disease, which can lead to gallbladder removal. An epidemiological study found that women who took MHT in tablet form were more likely to develop gallbladder disease than women who took MHT in patch or gel form. The researchers concluded that women who take MHT in patch or gel form are less likely to develop gallbladder disease than women who take MHT in tablet form.)

Sims recommends collaborating with your doctor to identify which kinds and forms of MHT are most effective for you. This relies on several considerations: your personal risk factors, any existing conditions, if you've undergone a hysterectomy, if you have certain clotting factors, your risk factors for cardiovascular disease, your age, and how near you are to menopause. Your physician can monitor your risk factors for diseases of the metabolism and cardiovascular system to ensure they aren't rising. Additionally, your doctor can help you gradually stop MHT when it's necessary.

The Shared Decision-Making Model of Medical Care

Sims’s recommendation to collaborate with your doctor to choose the kind and form of MHT that’s best for you is an example of the “shared decision-making” model of medical care. This model is based on the idea that the patient and the doctor are partners in the decision-making process. The doctor provides the patient with information about the treatment options, and the patient shares their preferences and values. Together, they make a decision that is best for the patient. This model is based on the idea that the patient is the expert on their own life, and the doctor is the expert on medicine.

Nonhormone interventions can additionally assist in managing menopausal symptoms. Sims notes that antidepressants can effectively alleviate mental health conditions like anxiety, depressive feelings, and mental cloudiness during menopause, as hormonal changes disrupt serotonin and norepinephrine levels in the brain. These neurotransmitters are also connected to depression. Norepinephrine contributes to how hot flashes occur, which means antidepressants like serotonin and norepinephrine reuptake inhibitors (such as Venlafaxine) can also help reduce these symptoms. Lofexidine, traditionally used for hypertension treatment, may lower the occurrence of hot flashes by as much as 65 percent. It operates by adjusting and regulating serotonin and norepinephrine levels, which subsequently helps balance how your brain responds to your body's core heat.

(Shortform note: While antidepressants and lofexidine can help manage menopausal symptoms, they can also cause a discontinuation syndrome if stopped abruptly. This syndrome can cause symptoms like mood swings, insomnia, and even a rebound of hot flashes, which can be more severe than the original symptoms. Haddad explains that these drugs work by altering the brain's stress response pathways, and when they're suddenly removed, the brain struggles to readjust, leading to a temporary but intense resurgence of symptoms. This highlights the importance of tapering off these medications gradually under medical supervision to avoid these potentially distressing effects.)

Clonidine, which is also used for blood pressure, might also alleviate hot flashes. Fezolinetant, an oral nonhormonal therapy being clinically developed, shows promise in addressing sex hormone–related disorders and vasomotor symptoms such as hot flashes. Research featured in Menopause involved over 350 women and revealed that over 80% of participants using fezolinetant experienced a notable decrease in symptoms; in over half of the women receiving the treatment, symptoms decreased by 90% or more. Gabapentin, a seizure medication frequently given for epilepsy, may reduce how often and how severely hot flashes occur, and it appears to enhance sleep quality.

(Shortform note: A potential downside of these medications is that they can cause significant side effects, such as sedation, dizziness, or a sudden drop in vascular pressure. Therefore, using them to treat sudden heat episodes often requires careful monitoring and individualized dosing by a qualified healthcare provider. This ensures that the benefits of symptom relief are balanced against the potential risks associated with these medications.)

Sims explains that adaptogens are plant substances that help your body resist stress. They work by influencing the HPA (hypothalamic-pituitary-adrenal) axis, which is a neuroendocrine system managing your stress response and overseeing different bodily functions like digestion, mood, temperature regulation, and immunity. Using adaptogens leads to a gradual accumulation in your system, inhibiting part of your cortisol reaction, which reduces stress. Adaptogens can have stimulating or calming effects on your nervous system based on the type. They provide major relief for vasomotor symptoms, fatigue, anxiety, and cognition issues.

(Shortform note: The concept of adaptogens originated in the Soviet Union in the 1940s and 1950s, when researchers were looking for substances that could help soldiers, factory workers, and cosmonauts cope with extreme physical and mental stress. The term “adaptogen” was first coined by Soviet toxicologist Nikolai Lazarev in 1947, who defined it as a substance that could increase the body’s resistance to stressors. This idea was based on the work of Hans Selye, who proposed the concept of the “general adaptation syndrome” in 1936, suggesting that the body responds to various stressors in a similar way. The concept of adaptogens has evolved over time, with researchers proposing different criteria for what constitutes an adaptogen.)

Schisandra contains phytoestrogens, which means it functions as a mild type of estrogen in the body. This means it aids in regulating the estrogen fluctuations typical throughout menopause. Therefore, it's a useful adaptogen for reducing how often and how intensely hot flashes occur. Maca root modulates hormones, acts as a potent anti-inflammatory, helps regulate adrenal and thyroid function, and serves as a steroid hormone. Maca can enhance mood and boost energy, relieve mental fog, and significantly reduce anxiety and depression, which are typical during menopause. Research shows that using maca early in perimenopause can be just as helpful as MHT in reducing vasomotor symptoms such as night sweats and hot flashes. It enhances energy and combats fatigue by assisting in the regulation of thyroid and adrenal function.

NAMS’s Perspective on Botanical Supplements for Menopause Symptoms

The North American Menopause Society (NAMS) takes a more cautious approach to the use of botanical supplements for menopause symptoms. NAMS states that, in its evidence-based clinical statement on nonhormonal management of menopause-related symptoms, the evidence is insufficient to support recommending dietary supplements, herbal or botanical preparations, or other over-the-counter natural products for the treatment of menopause-associated vasomotor complaints, and these agents should not be considered or promoted as substitutes for hormone therapy. The Society emphasizes that while some women may find relief from certain supplements, the overall quality and consistency of evidence are lacking, and these products should not be considered replacements for established hormone therapies.