Women's fitness expert Dr Stephanie Estima on hormones, muscle building, and why the pursuit of skinny is harmful
Steven Bartlett interviews Dr Stephanie Estima, a chiropractor and women's fitness expert, on The Diary of a CEO.
Summary
Dr Stephanie Estima, a chiropractor with 20 years of clinical experience and author of The Betty Body, joins Steven Bartlett on The Diary of a CEO to discuss women's health, fitness, and body composition. Estima argues that women have been systematically misled into pursuing thinness at the expense of muscle, bone density, and long-term health — a pattern she experienced personally when competing in a figure competition left her at 11% body fat, without her period, and hating her body despite receiving constant compliments. She presents four female fitness archetypes — Overwhelmed Olivia, Skinny Fat Sophia, Exorcist Emily, and Dialed-In Diana — as a framework for where women are and where they need to go. The conversation covers the anatomical differences between male and female pelvises and how they affect training, the importance of sprinting and VO2 max at any age, pelvic floor health after childbirth, key supplements for women, and why long fasting protocols can disrupt the female hormonal environment. Estima also addresses PCOS, GLP-1 medications, menopause hormone therapy, and the often-neglected role of tendons, ligaments, and connective tissue in long-term fitness.
Key Takeaways
FULL TRANSCRIPT
Dr Dr Stephanie Estima's mission: undoing bad advice given to women
Steven Bartlett: Dr Dr Stephanie Estima, why is it you do what you do? What is it you're trying to change in the world? What impact are you trying to have, and who are you trying to have it for?
Dr Dr Stephanie Estima: I am on a mission to really undo the genuinely terrible advice that most women have been given as it concerns their health and their fitness. What I mean by that is, for the vast majority of health and fitness goals for women, it's all about becoming smaller. It's about becoming skinnier. It's about losing weight. It's about dropping a dress size. Steven, if I can be very honest with you, I want women to stop being losers. I want them to stop trying to lose all the time. Instead, what I would love for them to do is to shift their focus from losing and focus more on what they have to gain. How much muscle can they gain? How much bone density can they gain? How much connective tissue capacity from their joints, their tendons, their ligaments can they gain? Can they work towards building a body that they love and trust and enjoy living in?
Steven Bartlett: Why do you want that for women? Specifically this losing-gaining thing.
Dr Dr Stephanie Estima: We've been sold a lie that our worth is the number on the scale — which, by the way, when you're weighing yourself, this is really just a reflection of your relationship with gravity, no more, no less. But we are told that when we fit into a certain dress size, we are now worthy, that we will somehow have arrived. That is not the full experience of being women. Women can be strong, women can be capable, women can be competent. And you can't do that when you're starving yourself, when you're over-exercising, and you're not prioritising your recovery or treating recovery like it is something that you have to earn.
Steven Bartlett: So are you saying being skinny is a bad thing?
Dr Dr Stephanie Estima: I'm saying that the pursuit of skinny at all costs is a bad thing. Right now a lot of online dialogue is "strong is the new skinny." I don't want to pit those two things against each other, but if you are obese, you are much better off not being obese. But it is the pursuit of skinny at the sacrificial altar of everything else. If you are somebody who values being slim, the likelihood that you are going to pick up heavy weights or weights that challenge you with enough effort and intensity is going to be lower. The likelihood that your bone density is going to be sufficient over the arc of your life is going to be lower. You are going to likely under-consume calories. If you are someone who thinks they've won because they're 40 and they can fit into a size-whatever dress, but when you're 65 you have osteoporosis, you haven't won. You've been tricked.
Steven Bartlett: Tricked by who?
Dr Dr Stephanie Estima: A society that tells us that our worth is solely based on how small we are.
Steven Bartlett: And who are you? What context do I need to know about Dr. Stephanie? Because I can see you're a little bit pissed off.
Dr Dr Stephanie Estima: I am pissed off — in a loving way. I have professional experience in this and I also have personal experience in it as well. I have an undergrad in neuroscience and psychology from the University of Toronto. When I was pursuing that, I became a fitness instructor and a personal trainer. So very young, I started having my first exposure to seeing firsthand how people were setting goals for themselves and having a difficult time achieving them. I went on to the Canadian Memorial Chiropractic College in Toronto, Canada, and I've been in practice for 20 years. I've seen tens of thousands of patients over my 20-year tenure and the same pattern kept showing up over and over and over.
And then personally, just being a woman living in this society, I grew up also struggling with my weight, trying to control what I ate, trying to do lots and lots of cardio to keep my weight down into what I thought was the ideal body type. I competed in a figure competition, which was really the first moment for me where I felt like the science failed me, because I had followed everything to a T — do lots of cardio, restrict your calories, you have to earn your recovery. The day that I got up on stage, I was 11% body fat. Just for context, women have about 10 to 13% essential body fat, and if you go beneath that, you start to get into a lot of trouble. Most women, a healthy body fat percentage is something like 18 to 25%. I had lost my period for two or three months before I stepped on stage. I ended up with hormonal issues. It took a long time for that to regulate again. I gained all the weight back that I had lost, and I felt like a total failure. I felt like the science had failed me.
Steven Bartlett: And it caused you a lot of pain.
Dr Dr Stephanie Estima: I hated myself. Full stop. I looked in the mirror and hated what I saw. I would pinch, I would pick — I wish this, I wish that. The other thing I'll say is the weeks before I stepped up on that stage, people were coming up to me and showering me with compliments. People were like, "Oh my god, you look amazing. What are you doing? What's your program?" And I think it's so confusing for women. Maybe we lose the weight or we go on this health journey — which is often just code for getting smaller — and we get showered with these external compliments. At the time, I was starving. I was completely overworked. I wasn't sleeping. I didn't have my period. I was not the picture of health, but everybody was telling me how amazing I looked. So I think that's where we hitch our worth to what the outside world tells us, rather than thinking about who we need to be and how we need to show up for ourselves first.
Steven Bartlett: And for the women and all the people that have clicked to listen to this conversation right now, what are they going to leave this conversation with specifically?
Dr Dr Stephanie Estima: This is for women and the men who love them — so this is for everyone. For women, maybe you have been doing the good-girl thing like I was doing. You're doing the things you thought you should have been doing, but you still don't have the dream body or the body composition that you want. We're going to talk through some actionable strategies on how to do that. And if you're in midlife — in your 40s or 50s — and you're finding that the strategies you used to use aren't working as well as they once did, we're going to break a little bit of your paradigm in the way you're thinking about health.
Steven Bartlett: And how old are you?
Dr Dr Stephanie Estima: I'm 48.
Steven Bartlett: I think it's important context. But you're also a mother?
Dr Dr Stephanie Estima: I'm a mother of two, and I also have a stepson as well.
The four female fitness archetypes
Steven Bartlett: There are lots of things on the desk here that I'd love to go through — five fitness myths in this envelope, and these archetypes. Where do you believe the best place to start this conversation is?
Dr Dr Stephanie Estima: I think we can talk about the archetypes, because I think it sets the stage for allowing women to identify themselves in their fitness journey.
The first is Overwhelmed Olivia. This woman wants to do the right thing. She's on social media and within a couple of minutes she sees someone saying, "Plants are trying to kill you. You should never have plants." She keeps scrolling and then comes upon someone else who says, "Actually, plants are great for you. They have lots of fibre, lots of phytonutrients." So she's like, "Oh, okay, that's weird." Then she looks up some fitness stuff and the same thing happens — some people say, "You don't want to get bulky, Olivia, so you need to do light weights, high reps." And then there are other people saying, "That's not true. As long as you're bringing the muscle close to failure, you will build muscle." She's getting what I like to call infobesity — so much information that she ends up with analysis paralysis. This woman I have a soft spot for because she's so scared to start something else and fail at it, because she doesn't want that to reinforce her own perception of herself as a failure. So she doesn't do anything.
When we think about Overwhelmed Olivia, we don't want to get her from A to Z. We just want to give her a couple of quick wins. Get her just from A to B. We're just going to get her walking. She's going to have a goal of racking up 5,000 to 7,000 steps in a day so she feels like she's a winner in some vertical of her life. And then you start to layer in more things as she goes along.
The second one is probably my favourite — the most common woman that I see — Skinny Fat Sophia. The technical term for skinny fat is TOFI: thin on the outside, fat on the inside. This is a woman who doesn't present as obese, but her body composition shows a loss of bone and a loss of muscle because she is very afraid of heavy weights. So maybe she'll do some Pilates, some yoga, maybe she'll walk. She also calorically restricts as well. This woman is personally my favourite because when we start giving her a little bit more food and just a little bit heavier weights than the 2-lb weights she's been lifting in her Pilates class — and by the way, I don't want Pilates people to come for me, I love Pilates, I do it twice a week, it's fantastic, but it's just not the main strategy for muscle building — this woman, when she starts eating a little bit more, always says to me, "I can't believe I'm losing fat by eating more. What is this trickery? What is this magic?" I love this woman because when we get her to see the light, it's just a beautiful thing to have all her assumptions rearrange in terms of what she thought was possible for her.
Steven Bartlett: On the subject of fat — if someone comes to you and says, "Stephanie, I would love to lose some belly fat because I'm skinny fat, or I just have a bit too much weight on me," what do you say to them?
Dr Dr Stephanie Estima: You can't actually spot reduce.
Steven Bartlett: What does spot reduce mean?
Dr Dr Stephanie Estima: Someone wants to reduce their belly fat, but you can't just target belly fat. The way that you're going to reduce overall adiposity in the body is through strength training, which we've talked about, but you will probably also need some kind of caloric deficit. When we think about that very famous, somewhat oversimplified calories-in, calories-out equation, you want to think about how you're going to create a deficit — either consuming fewer calories on the calories-in side, or eating the same but having more output through more cardio, more weight lifting, more walking, something where your calories out surpass your calories in.
Steven Bartlett: Is there an easiest way to do that? Because hearing "just eat less" is not great.
Dr Dr Stephanie Estima: I hate it. And it doesn't work in the long term either. You can temporarily reduce your food, but at some point your hunger hormones and your body are just going to drive you to consume more calories. I personally find it easier for women specifically to do more on the calories-out side — so doing more exercise, more daily movement. The calories-in approach is totally doable and people do it all the time, but I find it's hard for most women to stick to long term because they have to measure and do all the things. If you can figure out what your maintenance calories are and then surpass that with maybe more walking or something that's not going to ratchet up your hunger hormones or your cortisol levels, I think that's often a healthier option. You're also making sure that you're getting in sufficient calories so that you can actually build muscle, bone density, collagen, and so on.
So that's Skinny Fat Sophia. Up next — I was this woman, and I sometimes still am this woman — Exorcist Emily. This is just a funny word to describe the intensity that this woman puts out at the gym. You have no problem getting her to the gym. She is the woman at the squat rack. What her issue is — and this was me for years — is that she still has some of the Skinny Fat Sophia attitude towards food. There's a mismatch between how much effort she's putting out with her exercise programme and how much energy is coming in with her food. She's still under-eating because she's scared of gaining weight.
I was Exorcist Emily. I had the hoodie on, the big earphones — nobody talked to me. This was for me after I was going through a divorce. I had very young children at the time — they were five and three. I was grieving that, and I was still adhering to this idea that I had to punish myself. I was going to go to the gym and crush it, and then follow that with insufficient calories afterwards, because I still had that mentality of "I can't eat a lot or I'm going to gain weight."
And then the pinnacle, if you will, is Dialed-In Diana. This is the woman who has maybe made peace with some of her demons, enjoys movement, knows that it's a way for her to tend to herself. Food is not a punishment. She doesn't restrict calories because she ate too much. She fuels to nourish her lifts, to nourish her recovery, and for pleasure — because I think a lot of women have forgotten that food is pleasure. It gives us joy and happiness. My sourdough bread in the morning gives me lots and lots of pleasure and I will not give it up for anything. This is where we want every woman to be able to get to. We want her to dial in both her exercise programme and her nutrition programme, and to give herself some grace with her recovery.
Steven Bartlett: So we're trying to get everybody to become Dialed-In Diana.
Dr Dr Stephanie Estima: Yes. And also just know — if you've been listening to these descriptions and thinking, "I've got a little bit of Exorcist Emily, I've got a little bit of that rage or grief, but then I also sometimes have analysis paralysis" — you will also oscillate through them, and that's completely normal.
Steven Bartlett: When you were talking about Exorcist Emily, that wasn't a light season of your life, was it?
Dr Dr Stephanie Estima: No, it was very dark. And it was the lifting that got me through it, truthfully. Sometimes when we think about resistance training, it's literally training your resistance. It's not a question of if something bad is going to happen — it's just a matter of when. Voluntarily putting yourself in a situation where you are making yourself uncomfortable, going to the gym and moving your muscles to failure — it's not fun, it can be quite intense, but it does train your resistance, your grit, your mental capacity to withstand terrible things.
Steven Bartlett: So by the end of this conversation, everybody listening is going to be a Dialed-In Diana.
Dr Dr Stephanie Estima: That is my dream.
Five fitness myths debunked
Steven Bartlett: Let's start with debunking some of the myths. What's in this envelope?
Dr Dr Stephanie Estima: Okay. The first one is carbs. All the ladies who are listening — we have to heal our relationship with carbohydrates. You can restrict carbs temporarily, and for certain populations that's a wonderful idea. If you're a woman who has type 2 diabetes or PCOS, a temporary clawback of carbohydrates is fantastic for improving insulin sensitivity and glucose disposal. But diets like a low-carb diet or a ketogenic diet — which I am a big fan of for certain populations and even for a temporary amount of time — I think what a lot of women did with carbs is that once they started losing weight on a keto or low-carb diet, they said, "The problem is the carbs. I'm never going back." And the problem with that is — if you were sick, you had a bacterial infection, you went to your doctor, they did a swab, it came back positive, and they said, "You have a bacterial infection. I'm going to give you a script for antibiotics. Take it for the next 10 days and then come back for a checkup." You do that, you follow the protocol, you take the medication. I don't think anybody listening is going to come to the conclusion at the end of those 10 days: "Do you know what I need to do to never get sick again? I need to continue taking antibiotics for the rest of my life." No one is going to do that. But somehow, for carbohydrates, people made the illogical conclusion that you should never have them ever again.
For women, what I noticed — and I advocate for a low-carbohydrate, higher-protein diet in my first book, The Betty Body — is that it's for a transient amount of time, until you achieve the goal of reversing metabolic issues or losing some weight or improving your period. But if you stay there too long, your thyroid starts to malfunction.
Steven Bartlett: What's the symptom of the consequence if your thyroid is malfunctioning?
Dr Dr Stephanie Estima: You're always cold — your hands are cold, you're always cold. You might have very heavy bleeding during your bleed week, that first three to seven days when you're on your period. Hair shedding — hair starts to actually fall out. Hair is not necessary at all for survival, so when you don't have sufficient calories or a sufficient balance of macros, your body is going to sacrifice the things that don't matter to your survival. A lot of women will start to notice hair shedding. The classic sign is the lateral third of the eyebrow — the outside third of the eyebrow starts to get really sparse and thin as well.
So there are lots of common signs and symptoms. But we need carbohydrates — if not for the thyroid, then for our mood, our sleep, even performance at the gym. In the vein of transparency and honesty, I don't always get to eat before I train, but on the weekends when I do and I have some bread and some omelettes and I go and train, it's a fantastic performance enhancer. A lot of women are scared to consume more carbohydrates because they think it's going to make them fat. This really comes down to the carbohydrate-insulin model of obesity, which has largely been disbanded — there's not a lot of evidence to support it anymore. But there are a lot of people online who will scare you into thinking that if you have carbs, your glucose levels might spike, and that is presented as the worst thing that could ever happen to you.
Steven Bartlett: But there's such a thing as too many carbs.
Dr Dr Stephanie Estima: Correct. The problem is not that carbs were the problem — it's the overconsumption of carbs, the overconsumption of fat, the overconsumption of total calories.
Steven Bartlett: So it's defined by calories here.
Dr Dr Stephanie Estima: Yes.
Steven Bartlett: What's the next myth?
Dr Dr Stephanie Estima: This one I love. Women getting bulky. Women are still scared that if they engage in a programme of progressive overload — lifting heavy weights, doing more volume, more sets or more repetitions — they are somehow going to bulk up, as if to say they're going to start looking like a physique competitor or a bodybuilder. It is the equivalent of saying that if you drive to the store to get some groceries, you are going to be on par with Lewis Hamilton and become a Formula 1 driver. It's almost impossible. I'm going to say 97 to 98% of women don't have the hormonal environment to bulk. There are a few genetically gifted outliers who absolutely can, but for the most part, women cannot bulk. We do not have as much testosterone as men do. You have like 10 to 20 times more than I do. So even if we train the same way, I'm never going to be able to put on as much muscle mass as you.
What I will say is that some people, when they do start lifting weights initially, will start to feel a little thicker, because the muscle is a little bit more swollen. There's also a layer of fat that usually sits on top of the muscle. As you begin to lose body fat, your muscles will begin to poke through. Sometimes that's why people will say, "I started and I stopped because I was getting bulky." It's just a swelling or an inflammation of the muscle underneath.
Long fasts. I will call myself out here as well. I used to believe this was the key — when I was in my Skinny Fat Sophia era, when I was in my Exorcist Emily era — where I thought that the more you could fast, the less calories you could take in, and you could lose weight. You want to make sure that you have sufficient total calories. You don't want to over-consume, but you also don't want to under-consume. Fasting doesn't actually teach you how to eat when you are not fasting. A lot of people overly rely on long fasts — and when I say long, I mean 20 hours, 24 hours, 36, 72, these really multi-day fasts.
If I start eating a lot less calories than you do, I'm going to have, over the long term, more detrimental effects than you might.
Steven Bartlett: Why?
Dr Dr Stephanie Estima: The female body is just more sensitive to whether nutrients are coming in or not, so that we can figure out whether or not we want to direct our energy to being able to get pregnant that month. Our ovaries — when we look at the density of the mitochondria in them, it's something like 100,000 mitochondria per oocyte, per cell. They're constantly scanning the environment to see whether it's safe for a woman to get pregnant. So if you are fasting all the time, you run the risk of sending a signal that it's not safe, that these are famine conditions, and that you should not be producing an egg — because if you got pregnant, there's not enough food to feed you or the baby.
Steven Bartlett: So it shuts off your menstrual cycle as a way to stop you having a baby.
Dr Dr Stephanie Estima: Yes. You can still fast, but the way that I like to fast is to pull the food about 2 to 3 hours before you go to sleep. That's when you cut off the food. You sleep for 8 or 9 hours — that's like a 10 to 11-hour fast — and then you wake up in the morning and you eat. What often happens is women try to push that. They'll have a cup of coffee in the morning and then try to push their eating window to 11:00 or noon. That ends up making it more difficult to get in sufficient calories, sufficient protein, sufficient carbohydrates, and fats in a restricted eating window.
Okay. This is related to the bulky myth. I think a lot of women are scared of lifting heavy partly because they've never done it, so it's foreign. And I think the other reason is they're scared of getting injured, which to be fair is a valid concern. In the era of social media, which can be a blessing and sometimes a vehicle for misinformation, we hear about muscle mommies and lifting heavy. And for women in my cohort — 40s and 50s, who grew up in the 90s with the Kate Mosses of the world — asking a woman who is very comfortable with a cardio machine to now move into the free weight section of the gym, the deadlifting platforms, even the machines, can feel really intimidating.
There are lots of different ways that you can build muscle. It doesn't have to just be heavy. There are other ways that you can progressively overload the muscle — applying sufficient intensity and effort every single time, whether it's heavy weight, more volume, or increasing the density of your workout by taking less rest so you're a little bit more tired. There are a lot of different ways to make a workout harder. It doesn't always have to be heavy.
Post-workout fuelling. We used to think that you only had 15 minutes to knock back a protein shake after you've done a workout, because you need to replenish the glycogen and start muscle protein synthesis. I would say that this is largely false. Your muscle protein synthesis is not just limited to the 15 or 30 minutes immediately after the workout. Your muscles are building little protein factories over the next 10 to 72 hours in some cases, depending on how trained you are. As long as you are getting sufficient total protein over the course of the day, total calories over a 24-hour period, you're totally fine.
Pre-workout fuelling. In an ideal world, everyone would have some food before they train — a little bit of protein, a little bit of carbs, just to start raising blood sugar and have some available substrate for the workout. I don't do this most of the week. When I work out during the week, I'm typically at the gym around 6:00 in the morning, and I don't like the way it feels when I eat that early — it feels like I have a brick in my stomach. So what I typically do is fuel with ketones for my workout, and then when I get home, that's when I have my big meal.
Steven Bartlett: So you have ketones before you do a workout. Why?
Dr Dr Stephanie Estima: In the absence of food, ketones are fuel that your body already knows what to do with, especially when it's a big muscle group — if you're doing a leg day or a back day. It provides you with the neural drive to continue going, so you get into that sympathetic state.
In an ideal world, we would fuel before we work out, but the constraints I have in my life mean I just can't during the week. On the weekend, different story. I can wake up later, have a long coffee with my boys, have breakfast, head to the gym — and I always know that when I do have food, my performance is better. Always, 100% of the time.
What women should be doing in the gym
Steven Bartlett: Let's talk about what you do in the gym and why you do it. You clearly have a big focus on muscle being important. I train with lots of women. I actually trained with a colleague of mine this morning called George. She often goes off into the cardio section, and she does some resistance training as well. I go off in the other direction to the platforms — the stuff men typically gravitate towards. What do you think all women should be doing in the gym? If you think about a 7-day workout regime, what do you think is optimal?
Dr Dr Stephanie Estima: I do want to call out something you just said, and then I'll answer your question. You said, "I go to the area that typically men go to, and I do the exercises that men typically do." Just because squats and deadlifts and presses and pull-ups are typically done by men doesn't mean those are male exercises. Those are fundamental human motor patterns that both men and women can benefit from. But to your point, there is typically more men doing those things and more comfortable doing those things, versus someone who's like, "I can figure out how a stairmaster works. I'll just get on this thing for the next 35 or 40 minutes."
In terms of what I think people should be doing — if she can aim for something like three or four days a week of strength training, it would be alternating upper body and lower body, and then thinking about what muscle groups we're going to be working together. Is it a pull or a push?
This is from my upcoming book, actually, called Nothing to Lose — because we shouldn't be losing, we should be gaining. These are the muscle groups that I want women to be thinking about if their goal is body composition and they are trying to build a body that has curves. You can't spot reduce, but you can definitely spot build. You can put curves where they weren't before.
Starting at the top, we have the deltoid muscle group — these are your shoulders. I like to call these your bread buns. They're sitting on the side of your shoulder, the lateral delts. Below that, we have the back muscles and the lats in particular. I like to call the lats our angel wings, because they sort of create that V as the back widens, giving the appearance of a slimmer waist. Moving posteriorly, we have the glutes — there are three muscles that make up the glutes: glute maximus, gluteus medius, and gluteus minimus. Then we have the adductor group.
Steven Bartlett: Which is the insides of the legs.
Dr Dr Stephanie Estima: The inner thigh muscles, yes. And then the last one is the pelvic floor, or more broadly, the core muscles.
Steven Bartlett: For a woman thinking about building these five muscles — are there big misconceptions about how to train to build them? What do I need to know?
Dr Dr Stephanie Estima: For these muscle groups, you should probably be hitting something like 10 sets of exercises per week per muscle group.
Steven Bartlett: Okay, so if I do four hip thrusts, that is one set of four, and that's going to help my glutes. So you're saying I should be doing 10 sets a week.
Dr Dr Stephanie Estima: Per muscle group per week. Yes. And this is why I was saying before — the ladies who say, "I just have two days, that's all I can give you" — you can still have incredible results. As long as you are taking the muscle close to failure — which is to say you can no longer perform the repetition anymore — you don't have to take it all the way to failure, but as long as it's one to three repetitions from failure, that's all you need to do.
And it's simple to say that, but it's going to be very difficult to do, because you are going to start noticing your range of motion is going to be limited. You're going to start noticing the velocity of the repetition is starting to slow down. You're going to subjectively feel — even though you can see you're holding a 15-lb or 10-lb weight — like it's 20 or 25. Your subjective perception of the weight is going to be increasing. If you were to rate it out of 10, you would rate your effort like eight or nine out of 10.
How female anatomy affects training
Steven Bartlett: Men and women, because they have different anatomies, should be doing slightly different exercises?
Dr Dr Stephanie Estima: I think that's more a matter of preference and goals.
Steven Bartlett: But is my anatomy and your anatomy the same?
Dr Dr Stephanie Estima: Our anatomy is not the same. When we think about the way that we move — if you and I were to squat together or lunge together — there are going to be some differences in terms of how we look. So we'll pull up some props here. This is a female pelvis, and this is a male pelvis. When we look at the difference between them, the female pelvis is wider and more shallow. The male pelvis is more narrow. The female pelvis looks a little bit more like a heart shape, and the male pelvis looks a little bit more like an oval shape. The reason for that is to allow a baby to pass through.
Why this is so important is that it's going to shape the stressors that happen in our knees and our ankles. We have something called the Q angle. You take a measurement from the hip and draw it all the way down to the kneecap or the patella, and then take another line from the tibial tubercle and draw it upward. For the nerds listening, it's the anterior superior iliac spine all the way down to the patella, and then the tibial tubercle.
What you'll see for women — because the pelvis is wider — is that the femur has to more aggressively come in medially, more to the centre. This makes women more knock-kneed compared to men, meaning the knees are coming more together. This is going to impact literally every way we move — how we walk, how we jump, how we squat, how we lunge, how we run.
It's important for women to understand how we're different, because often the cueing and instruction that women get is based off a male pelvis. So we can run into feeling like squats are not comfortable, that lunges are not comfortable, or we start to shy away from some of these motions because we don't think they're meant for us. You just need to know how to adapt your training to support some of those shear forces as you're moving.
What ends up happening for women is that as we are lunging or squatting and the knee comes down, we start to see more shear forces being placed through the medial, or inside, part of the knee. That puts us at a greater risk for ligamentous injuries. In the knee, the big one we often worry about is the ACL. As you're getting tired, you need to be aware that you're going to have a tendency for that knee to come in. There's nothing wrong with the knee coming in as long as you have muscles that can support it.
The muscles that are going to help control the way that the hip moves are the glutes — specifically the gluteus medius, which is often called the upper shelf muscle. That's actually going to help counteract the femur being pulled inwardly.
So we do have different anatomical differences that women need to be aware of so that we can bias training that will provide mobility and stability for us. That's another reason why — yes, glutes look amazing in jeans — but they are also providing such a driving force of stability for the spine, for the knees, for the ankles, literally for the entire body.
Steven Bartlett: And so with squatting, men and women should squat differently?
Dr Dr Stephanie Estima: Not all women and men should squat differently. There are women who can squat with the traditional cueing. Can I show you?
Steven Bartlett: Sure.
Dr Dr Stephanie Estima: So the typical squat — the way we're often cued — is feet hip-width apart, toes facing forward, and then we come down. And I'm just — I can't actually get there. I'm collapsing my chest at this point. For women, what a lot of women find more comfortable and what actually allows them to get the full range of motion is taking your feet a little bit wider and then turning the feet out. Because the female femur tends to sit a little bit more internally rotated, with this external rotation we can actually get all the way down into a squat. We can hang out here — we could probably do the rest of the podcast like this if you'd like.
Steven Bartlett: I'd rather not.
Dr Dr Stephanie Estima: The other thing to think about — whether it's a squat with two feet or a lunge or a split squat with one — is that when a woman is coming down, decelerating into the lunge or the split squat, everything is going to be internally rotating. The femur is coming in, the tibia is coming in, the foot on the inside — you're actually rolling onto the inside, flattening the arch. That's called pronation, which everybody says is a bad thing, but you need it to be able to load the spring. And then for women, as we're coming down, the knee tracks a little bit inward versus staying a little bit more straight. There's nothing wrong with that. It's just a matter of whether or not you have sufficient control with your hip stabiliser muscles to make sure you're not putting excess shear forces on the knee.
Steven Bartlett: So you need to strengthen your hip stabiliser.
Dr Dr Stephanie Estima: Yep. The peach.
Steven Bartlett: I read something about the Women's World Cup — I think something like 12 women had got ACL injuries in the lead-up to the tournament.
Dr Dr Stephanie Estima: When we think about why that happens, it usually happens when the athlete is tired. If it's leading up to the World Cup, they've probably over-trained, they're not recovering, and then they take a weird step, the shear forces happen just before the ligaments and tendons are able to stabilise it, and you damage it.
Steven Bartlett: Is there a connection between your brain and your mechanics that often results in injury? I think a sleep doctor told me that when you're underslept, one of the reasons you get so many injuries is because when you jump, your brain's reaction time is slow.
Dr Dr Stephanie Estima: Yes. And you see a lot of athletes doing deceleration work before games — they're almost practising landing. It's basically a stick and land. They're jumping and holding it so that the forces are not dumped into the joints but rather absorbed into the connective tissue — the ligaments and the tendons.
Steven Bartlett: Why is deceleration important even for non-athletes?
Dr Dr Stephanie Estima: If you are not an athlete and you're just somebody who doesn't want to fall and break a hip, that's really important. If you're thinking about falling, what you need to be able to do is get the hip flexor up in front of you and then stop the fall. There are a couple of muscles involved. The hip flexor has to come up quickly to get ahead of the fall. We have the tibialis anterior — the muscle in the front of the tibia — which is involved in dorsiflexion, which is just nerd speak for toes come up. You need to be able to clear the floor. Then you need glutes to absorb and brake. And the adductors — the inner thigh muscles — will actually pull the leg back underneath you to help stabilise the fall. The abductors on the outside, the side of the glutes, are also going to help brake. So when you're falling, you've got to get the leg up, you've got to have the toe clear the floor, and if you're falling off to the side, you need the adductors and abductors to stabilise so you don't trip over yourself.
Exercises women should never stop doing
Steven Bartlett: Are there exercises that women and people generally tend to stop doing as they age because it becomes harder, but they should definitely not stop doing?
Dr Dr Stephanie Estima: Sprinting, 100%. I think that everybody should be sprinting.
Steven Bartlett: Why?
Dr Dr Stephanie Estima: You are going to be increasing something called your VO2 max — just nerd speak for how much oxygen can you take into the lungs and distribute to the cells. We've all heard the stat that muscle declines 1% per year if you're not doing anything. VO2 max is the same. You will decline your VO2 max capacity 10% per decade if you're not actively working on it.
Steven Bartlett: I can think of family members going up the stairs or trying to get groceries into the house who are huffed and puffed. They've lost their breath from going up a flight or two of stairs.
Dr Dr Stephanie Estima: And they think that's just getting older.
Steven Bartlett: Absolutely not?
Dr Dr Stephanie Estima: Absolutely not. It's not a function of aging. It's just a loss of capacity. There are a couple of different ways that we can sprint. You can sprint on a track — I used to be a track sprinter, so that's my love. But you can also sprint on a cardio machine in the gym. In the wintertime, I live on the East Coast where I can't always sprint on the track, so I will take my sprinting indoors and do something called the Norwegian 4x4 on a bike.
Steven Bartlett: I've heard of it, but please do explain.
Dr Dr Stephanie Estima: It's a special kind of torture. I hate it up until the moment I get on the bike, and then when I'm doing it I'm like, "Okay, I'm going to do this." And when I'm finished, I'm like, "I'm so proud of myself." A Norwegian 4x4 is basically 4 minutes at 85% to 95% of your heart rate max — so you need to know the maximum heart rate you have ever achieved — at 85% of that for 4 minutes. It's a long 4 minutes. And then you take a 3-minute break. And then you do that again four times, hence the name: four minutes, four times.
There are lots of really cool studies on VO2 max capacity. There's one I'm thinking of where they looked at women with an average age of 58 — a lot of them postmenopausal — and put them on a sprinting protocol. What they found was that in a period of 8 weeks, they were able to increase their VO2 max by 10% in 2 months. Which is wild when you think about how quickly you can lose it, and you can get 10% back in 2 months. The other really cool thing about that study was they took that cohort — the older cohort — and compared it to 18 to 30-year-olds. They found that the gains in the older cohort included mitochondrial efficiency improvements of 69%, whereas the younger cohort's mitochondrial gains were 49%.
A lot of people will frame aging as "you're getting wrinkles, you're over the hill, it's past your prime." These women had a bigger gap to close, but they had so much more upside to gain. That makes me so excited because it's never, ever, ever too late. The best time to start was 10 years ago, fine, but the second best time is today. You're not behind. You can totally do it now.
Steven Bartlett: One of the top comments in your recent video was that jumping or hopping is a good way to strengthen your bones and knees, and you should not stop doing that as we age. Because a lot of people start thinking, "I can't run anymore because it's not good for my hips and my knees."
Dr Dr Stephanie Estima: The old adage of use it or lose it is really, really key here. If you stop doing it, you're going to definitely lose your ability to do it. Your body is going to prioritise the things that it does. If somebody wanted to improve their bone density, you can strap on a weighted vest, do some plyometrics, add some weight to your jump. That's going to increase the strain magnitude and strain rate on the bone, which is going to drive positive bone reformation. But if you don't jump, you're going to lose your ability to jump.
Steven Bartlett: Is there such a thing as jump training?
Dr Dr Stephanie Estima: Plyometrics? Yes. Even if it's just isometric holds. Maybe somebody can't jump, but they can stand with their heels elevated so that the Achilles tendon and the calf — the gastrocnemius — is contracting. Maybe one of the most famous tendons in the body is the Achilles. It is the extension of the calf muscles, and it wraps around the heel and attaches into the inferior part of the calcaneus, which is your heel bone. Maybe you can't quite jump yet, but you can come up on your toes, contracting the gastrocnemius — this is called an isometric hold. That tension in the muscles and in the tendon activates little mechanoreceptors that detect stretch. They will detect whether something's being contracted or stretched and say, "We need to remodel in order to meet the demand of this activity." And then you can progress to doing little hops, then jumps, and so on.
Steven Bartlett: Very easy to do. You don't need a gym or anything like that.
Dr Dr Stephanie Estima: Not at all.
Steven Bartlett: I've heard you say that deceleration is important for mobility.
Dr Dr Stephanie Estima: Deceleration is the opposite of acceleration. In order to come to a stop without dumping all of the forces into your joints, the tendons and the ligaments need to be able to absorb that kinetic energy. From a sport perspective, your ability to decelerate — coming to a complete stop and then changing direction — is actually more predictive of whether you'll go pro than your vertical jump, your acceleration speed, or beep test results. It's also really important as we age. You might trip on something on the floor, the corner of a rug, or lose your footing on the stairs. You need to be able to get your foot in front of you and then be able to stop the motion before you fall.
Simple exercises anyone can do at home
Steven Bartlett: Are there exercises that are really simple and underrated that one can do without equipment?
Dr Dr Stephanie Estima: I have so many to show you.
So the one that I love — this is almost like a diagnosis, but then the diagnosis becomes the care plan. I just call it the X plank. It's very difficult to do, but it is a test for stability and mobility of the hip. This is directly challenging the muscles on the side of the hip and whether or not you can stay stable. So you basically come into a side plank, where your wrist and your shoulder are all aligned, toes facing forward. Hand comes up, and then you lift the arm up and try to see if you can hold this for 30 seconds. It is not easy. It's testing the stability and the mobility of your hips. It's also testing the integrity of your ability to stay abducted. There's core work, there's shoulder work — it's a really whole-body workout.
Steven Bartlett: My turn. Okay, let me just — okay, I'm going to stand on my — my feet hurt.
Dr Dr Stephanie Estima: So in this case, if you're not able to do it, this becomes the thing that you train.
Steven Bartlett: I think it's actually just me being weak. Okay, so like this? And then lifting this leg up?
Dr Dr Stephanie Estima: Lifting the leg up, there you go. Now you're just going to work yourself up to 10 seconds, 15 seconds, 20 seconds, and over time you'll just be doing this at the airport.
Steven Bartlett: I think I've got more of a balancing issue, is it?
Dr Dr Stephanie Estima: It's also a really strong balance test. This is one of those exercises that literally tests almost every system in the body. I love it as a diagnostic. For a more entry-level version, instead of doing it on both feet stacked, you can do it on your knees. You stack the knees on top of each other and do it that way. You're still having to recruit the glute medius, but it's just less stress.
Steven Bartlett: Is there anything else you can show me that you think's pertinent to the conversation we just had?
Dr Dr Stephanie Estima: This one actually relates to mobility, which we did talk about. In cultures where people sit on the floor, eat on the floor, toilet on the floor, their fall risk is literally almost zero. As North Americans or Westerners, we can do more sitting on the floor. One of the big tests I use — if it's an elderly person, maybe they're sitting on a chair — is: can they stand up unassisted, without using their hands? Feet crossed, and without using your hands, using a little bit of momentum if you want, see if you can get up.
Steven Bartlett: Ooh, that was —
Dr Dr Stephanie Estima: Well done. Now let's try to cross our feet the other way. Because you always typically cross your feet one way. I don't do this one as well as I do the other one, so I'm working on it as well. Again, no hands. You can use a little bit of momentum if you want, and you're going to come all the way up.
Steven Bartlett: What muscles am I using there?
Dr Dr Stephanie Estima: You are recruiting mobility in your ankles, your quads to extend your knee, your glutes to extend your hip — it's the whole leg.
Steven Bartlett: Any others you love that you can do without equipment at home?
Dr Dr Stephanie Estima: Push-ups, bodyweight squats — which I think you should eventually progress to weights, but so many people have terrible technique, so you can actually have a fantastic workout with just your body weight. Glute bridges are fantastic. You can pick up a big bag of cat food or dog food and do walking lunges down your hallway.
Supplementation for women
Steven Bartlett: Let's talk about supplementation. Do you take supplements?
Dr Dr Stephanie Estima: I do. I'll pre-frame this by saying that I am a special category of nerd, so I take a lot of the foundational supplements and then there are others I take because I'm very interested in the research and the research excites me. But for the general population, for women that are listening, if they're thinking, "I've got to supplement," there are a couple of tier-one supplements to be thinking about.
Magnesium first. This is our tried-and-true bestie. I love a magnesium glycinate. There are lots of different kinds, but glycinate is just the easiest to absorb for most people. It tends to help with relaxation, helps with sleep, helps with muscle recovery. I'll usually take one 250mg at lunchtime and then another one in the evening.
Steven Bartlett: How do you remember to take them?
Dr Dr Stephanie Estima: I tend to habit stack them. I always know that when I'm preparing my lunch, I keep my magnesium right beside my salt and my pepper. As I'm salting my food, I see it and take it. And I have another bottle upstairs in my bathroom. As I'm getting ready for bed, putting up my hair, doing my skin, I'll take one there too.
Steven Bartlett: So you put it in the way of other habits.
Dr Dr Stephanie Estima: Because otherwise, if I put it in a really beautiful supplement closet, it's just going to stay there. You're already doing something else, so just put the thing next to the thing you're already doing, and your compliance and adherence is going to go up.
Omega-3s. These are so well established in the literature. They reduce inflammation, they help with cognition. Something like 2 to 4g a day.
Steven Bartlett: I didn't know you needed to keep it in the fridge. I've been keeping it in a hot cupboard for the longest time.
Dr Dr Stephanie Estima: It just helps with spoilage. You can pop them in the fridge, and then same kind of thing — habit stacking. As you're opening up the fridge, put them in front of the thing you most commonly reach for. If you go for fruits in the morning, put them right beside your fruits.
Vitamin D — D3 with a K2. 4,000 IUs minimum per day, I would say. Most people should be taking that. They call it a vitamin, but it's not really a vitamin. It's more of a prohormone. So it's really important for sex hormone and reproductive hormone production, inflammation, and cognition.
Steven Bartlett: Every day?
Dr Dr Stephanie Estima: Every day. I can't tell you how many patients I've had who live in, say, Florida, where you think you're getting a lot of sun exposure, and you run their vitamin D and it's deficient.
Creatine. I know you just had Dr. Darren Candow on the show — he was actually on my podcast as well. For women, creatine used to be this bro supplement, associated with bodybuilders. But creatine is really, really important for women. The way Dr. Candow described it to me was: lifting weights builds the cake, and creatine is like the icing on top. You're not going to enhance performance or build strength if you're just doing the creatine — you have to be pairing it with the mechanical signal of resistance training. But I think every woman can be taking 3 to 5g of this every single day.
Steven Bartlett: How much are you taking?
Dr Dr Stephanie Estima: I take five. Sometimes a little bit more than five. When you've been — and this is the little perimenopausal hack, because I am fully in the throes of it right now — there are nights where I don't sleep well. Taking a higher dose of creatine that day will help with your cognition, your awareness, and your alertness. Something like a 10g dose, because it's a little bit harder to get across the blood-brain barrier, so you need a higher dose to facilitate that.
Steven Bartlett: And what impact has it had on you?
Dr Dr Stephanie Estima: When I haven't slept well, if I take it in the morning, it definitely wakes me up. When I'm not taking it regularly, muscles look a little less full. I don't have as much energy in the tank when I'm doing a really intense workout. There's a performance degradation when I'm not on it.
And then collagen. I love this one because it gets so much hate online. A lot of the criticism for collagen comes from this idea that it's terrible because it doesn't have any leucine — or has less than 3% leucine — which is an amino acid that stimulates protein synthesis. And yes, that's true. It is a terrible driver for muscle protein. But the whole goal for women is not just muscle. We have other tissues that go to the gym alongside our muscle — our tendons, our ligaments, our joints. Collagen is a very expensive process to create from a mechanistic point of view, so taking collagen is great for what I like to call the JTL: your joints, your tendons, and your ligaments. I'll typically take something like 10 to 15g a day. I put this in my coffee sometimes, which I know the heat is an issue, but if I don't, I won't take it.
Steven Bartlett: There are so many collagen products out there at the moment. Is that all a fad? They're saying it's good for skin, it's good for nails, it's good for hair, it's good for everything.
Dr Dr Stephanie Estima: It's good for fascia. Collagen is the primary compound in joints, tendons, ligaments, fascia, skin, hair, and nails.
Steven Bartlett: What type of collagen?
Dr Dr Stephanie Estima: Hydrolysed. Hydrolysed type 1, 2, and 3.
Electrolytes. I take electrolytes not as consistently — I typically will take them on a very heavy cardio day. I've recently taken up tennis. I'm terrible at it, but being outside, in the heat, running left and right for hours on end, when you're sweating a lot, electrolytes are really great.
And with our last one — vitamin C. I actually like to take vitamin C with the collagen because it can enhance its absorption. It's also just a general antioxidant. There's no harm in taking vitamin C — it's water soluble, you take too much, you pee it out. Good as an antioxidant, good as an anti-inflammatory, and it helps with the absorption of collagen as well.
Steven Bartlett: What about protein? Do you take protein shakes or anything?
Dr Dr Stephanie Estima: I do when I'm travelling. In my day-to-day diet, I typically don't. I will if I'm falling a bit short, but most of my protein is coming from whole foods.
Cardio, PCOS, and hormonal considerations
Steven Bartlett: What about cardio? We've talked a lot about resistance training and the importance of building muscle. Where does cardiovascular exercise — running, sprinting, the stairmaster — fit into all of this?
Dr Dr Stephanie Estima: It's life. It's everything. Cardio is fantastic as well. I think about my Overwhelmed Olivia, who's online and has people saying things like, "You should only lift weights and walk." And then there are other people doing chronic cardio and not doing enough weights. We want to be thinking about cardio not as a punishment for what you ate and not because you're trying to get skinny, but because we want to have other goals around our health span and our lifespan — living a longer life and spending more of those years healthy.
Steven Bartlett: A lot of women have PCOS, including my partner. I was looking at the comments on one of your interviews, and one of the top comments from a woman was: "For women with PCOS or insulin resistance, sprint training and HIIT often backfire because it spikes cortisol and insulin. Many of us do better with strength training plus zone two until hormones stabilise. I would love to hear more tailored guidance for PCOS."
Dr Dr Stephanie Estima: The first thing I want to dismantle in that comment is the idea that cortisol spikes are bad. Context really matters. Without cortisol, you won't wake up in the morning. We need cortisol. There's something called the cortisol awakening response where it tends to peak right around the time that you wake up, and then it gradually exits the chat. Cortisol is a normal process. A cortisol spike is a normal process. Just like when you train — if she were monitoring her hormones, she would see both a glucose spike and a cortisol spike when she's training, because to be able to train with enough intensity and effort, you need to get into sympathetic drive, into stress physiology. So I want to really caution women away from being scared of normal and predicted spikes — glucose spikes, cortisol spikes.
Women with PCOS — it used to be known as PCOS, now it's polyendocrine metabolic ovarian syndrome, or PMOS. Her body typically behaves more like someone who is type 2 diabetic, where she has issues with glucose disposal and insulin sensitivity. Specific recommendations for someone who has PCOS: she absolutely should be training, because every time she's contracting her muscles, she's actually helping — whether insulin is present or not — to pull that glucose into the muscle cell and make energy. That's really fantastic.
Whether you have PCOS or you're type 2 diabetic, I think zone 2 cardio is fantastic for endurance. But you can also benefit from very high intensity cardio — what might be categorised as high intensity interval training, or HIIT, or sprint interval training, sometimes called SIT. SIT is basically 10 to 20 seconds all out, 100% effort, and then you recover and do that four, five, or six times. That stress, that cortisol spike, and all the physiological cascade that happens from it is going to make you stronger and a better glucose disposal agent over the long term — which is what she wants if she has PCOS.
Pelvic floor health and mothers
Steven Bartlett: One of the top comments in your recent video also talked about the specific issues mothers face after they have a child. I saw comments about prolapse and pelvic floors. You've had two children and you speak to many mothers. What are the specific issues that mothers face as it relates to fitness, workout regimes, resistance training, that I wouldn't be aware of as someone who hasn't given birth?
Dr Dr Stephanie Estima: We talked about how the hips are different for men and women. The pelvic floor is also very different. The pelvic floor is like a hammock of muscles that goes from the pubic bone — and it's like a sling of muscles that come around and attach to the coccyx, or the tailbone. These are called the pubococcygeal muscles, or PC muscles. They're different from, say, your quadriceps or your glutes, because they are literally working all the time. They are working to keep your organs in the pelvis so that they don't just fall out.
For women, this is another area where we are different, because we have more openings. If you think about the sling of muscles for a woman, you're going to have a hole at the urethra, at the opening of the vulva into the vagina, and then also the anus. So there are three holes, and you already have less surface area for those muscles to be able to contract and support. Versus a male, those PC muscles just have to deal with one. So it's mechanically much simpler for a man.
And then you layer on hormonal fluctuations over the course of a woman's life as she's menstruating — if she becomes pregnant, under the influence of different hormones like relaxin, the weight of the baby constantly pushing down, and then birth. These can significantly alter the strength and the ability of the PC muscles to absorb load appropriately.
For women who've had babies, first you obviously have to be working with your OB-GYN or your midwife or whoever is managing your care plan to be cleared for exercise. And once they do clear you, you don't want to necessarily go back to extremely heavy loads with lots of intensity right away, because you haven't necessarily completely healed yet.
This is where we get into thinking about how we can connect with the pelvic floor. The famous exercise that everybody's probably heard of is Kegels. Those are wonderful if you're someone who has a weak pelvic floor — not so much if you have a tight one.
Steven Bartlett: You just sit and contract?
Dr Dr Stephanie Estima: The way I've often cued men is: imagine you're zipping up a zipper. You're just coming up and holding it and then relaxing. You don't necessarily have to move and jump. You're literally just connecting as much as you can. It's hard because our neuromuscular connection to the pelvic floor sometimes isn't really strong, but often just closing your eyes and coming up, holding, and then coming down is enough. You can do these all day long — no one's going to know you're doing it. If you have a weak pelvic floor, that would be something to explore. A pelvic floor physiotherapist would be someone who could diagnose that and give you more counsel. But if you have a tight pelvic floor where you actually have trouble relaxing, Kegels can actually make things a little bit worse for you.
Women's sexuality and the Betty Body
Steven Bartlett: On your book The Betty Body, the last word in the subtitle is "sex" — "A Geeky Goddess Guide to Intuitive Eating, Balanced Hormones, and Transformative Sex." Why did you include transformative sex?
Dr Dr Stephanie Estima: I included it because I think, just like all of the myths we've been talking about today, the other thing that has been really taboo for women is women who enjoy their sex life. I was hoping in that first book to give women permission to want it, to desire it, to figure out if there was low desire or low libido — what maybe some of those causes were, and what are some of the ways that we can learn more about ourselves.
I'm thinking of one patient who was actually part of the reason why I included it in this first book. She came in for low back pain — the most typical mechanical low back pain. We were giving her adjustments, strengthening exercises, doing the rehab, all the things. Nothing out of the ordinary. At her re-evaluation appointment, she said, "Dr. Stef, I want to talk to you privately." We went into a room, closed the door. She said, "Do you know the real reason why I came in to see you?" I said, "Yes, it was mechanical low back pain." She said, "No. It's because when I was with my husband, getting on top of him while we were being intimate, it was really hurting me. My back was killing me, my pelvis was killing me, my joints felt like they were rubbing on top of each other." I was lucky enough that this patient trusted me enough and we had enough rapport for her to basically say, "I want to ride my husband and I can't. I couldn't before, and now I can." So I think there is a quiet taboo around women not enjoying sex, and I want to give women permission to.
GLP-1s, hormone therapy, and recovery protocols
Steven Bartlett: Stephanie, what's the most important thing we haven't talked about that we should have talked about? Well, we didn't talk about GLP-1s. That's all the new rage at the moment.
Dr Dr Stephanie Estima: GLP-1s are interesting, for sure. I do think with all medications — and I am including hormone therapy in here as well — we often marry ourselves to what we feel the benefits might be and we will divorce ourselves from the possible side effects. Hormones are going to help with your sleep, your mood. If you're experiencing some of the thermoregulatory problems — the night sweats, the hot flashes, all the things — but it's not going to go to the gym and lift weights with you. It's not going to build a healthy plate. It's not going to set boundaries with your boss. Those things you have to do yourself. So there's this beautiful opportunity where we see more women taking MHT — menopause hormone therapy — to blend that with lifestyle medicine. There's no easy button here. You have to also put in the work.
Steven Bartlett: And lifestyle medicine meaning?
Dr Dr Stephanie Estima: Training, managing your stress, recovering, doing the cardio that we've been talking about.
Steven Bartlett: On that recovery point — what are the recovery protocols that you think all women should be doing?
Dr Dr Stephanie Estima: The best one I can tell you is sleep, which can be a challenge in perimenopause, I understand. But that is where growth hormone and IGF-1 tend to surge, muscles grow when you're sleeping, and the brain cleans itself out. Sleep is the number one thing that everybody should be prioritising. That's tier one — if there's an S tier, sleep is an S tier.
Under that, if you have access to something like a sauna, that might be something you can think of for recovery, whether that's an infrared sauna or a traditional Finnish sauna. I often call it lazy cardio. If you don't feel like doing a really intense cardio session, get yourself into a sauna if you have access to one. Not necessary, but there are a lot of really cool studies that have come out of Finland — and by the way, "sauna" is the only word in English that we've borrowed from Finnish, just a little fun tidbit. And electrolytes — if you are really pushing yourself and sweating a lot, helping to recover and replenish those is important. As we lose estrogen in midlife, our ability to regulate salt also starts to decline as well.
Connective tissue: the forgotten foundation
Steven Bartlett: What should we have talked about that we didn't talk about, as it relates to the most pressing questions you get asked by the people that consume your content?
Dr Dr Stephanie Estima: The only other thing I would say is the joints, tendons, and ligaments — the connective tissue capacity. We've talked a lot about muscle. I love muscle. I train muscle. Muscle is like the popular girl at the party. She gets a lot of attention. If you think about a superstar like Beyoncé — she's beautiful to look at, the pump is great, all of that. But if you put Beyoncé on a rotting stage, or a stage that can't handle her, she's just going to fall right through it. And then you have no concert. The forgotten tendons and ligaments and joints — we have to be thinking about those as we age, because you can't squat if you don't have good knees.
Steven Bartlett: How do I get great ligaments and tendons?
Dr Dr Stephanie Estima: The way that you encourage them to become stronger over time is how you train in the gym. There are a couple of different ways that you can bias for more tendon strength and more ligament strength. One of them is when you are lifting, you can bias what's called the eccentric portion of the lift. Concentric — muscle gets shorter, bones come together. Eccentric is stretch. When you start stretching the tendon, the tendon says, "I'm being stretched. Okay, we have to now create more tensile strength to be able to meet that demand."
Steven Bartlett: Okay, so stretching under load.
Dr Dr Stephanie Estima: Stretching under load. Not just stretching.
Steven Bartlett: You've got a bee in your bonnet about Pilates. You really don't like Pilates.
Dr Dr Stephanie Estima: No, no, no. It's not that. People confuse muscle endurance with muscle building. In Pilates you often have very high reps, the muscle burns — it's fantastic for the pelvic floor, phenomenal for women's health, for posture.
Steven Bartlett: But you're saying Pilates isn't enough to build sufficient muscle mass.
Dr Dr Stephanie Estima: That's the main point. And I think people are like, "How dare you talk about this? I love Pilates. I do Pilates." However, I also train four or five times a week. I'm also sprinting, sometimes two but mostly one time a week. I'm doing tennis. I'm doing all of these other things, and Pilates brings me a lot of joy. I always say I feel so happy after Pilates. But if you are just doing Pilates, that's where I fear that you're not loading your bones appropriately, you're not building sufficient muscle, your tendons and your ligaments are weak, and you're going to end up with bone disease or a loss of load capacity when you're older.
Skincare, ageing, and closing reflections
Steven Bartlett: What's the most popular question that women message you with on Instagram?
Dr Dr Stephanie Estima: Usually it's "Tell me about your skin care." Tell me about what you do with your hair, what your workout outfit is. All those little questions. But the big one is: how do I gain muscle and lose fat?
Steven Bartlett: So tell me about your skin care routine then.
Dr Dr Stephanie Estima: It's pretty basic. I learned this from my dermatology friends. Some vitamin C in the morning, some SPF, and in the evening some kind of vitamin A. I actually really like NAD. I use a company that has something called urolithin A in it, which is supposed to help get rid of senescent cells in the body.
Steven Bartlett: Which are like dead cells, right?
Dr Dr Stephanie Estima: They're like zombie cells that hang around and just create inflammation everywhere.
Steven Bartlett: You're almost 50?
Dr Dr Stephanie Estima: I'm almost 50, yeah.
Steven Bartlett: Feeling good?
Dr Dr Stephanie Estima: I feel great. I feel like I inhabit my body now in a way I wish I did in my 20s. I was so punitive and so terrible to myself. Things I would say to myself and call myself when I was 20, 30 — I would never say that out loud to anybody else. And now I feel really proud of myself. I got into weight training just like a lot of women who are watching — they want to look better, build muscle, lose fat. That's why I got into it as well. But I stayed with it because it provided me a way back home. It taught me how to love myself. It taught me how to be patient with myself. It taught me how to forgive myself when I felt like I had failed. It re-imagines your relationship with failure, which I think is a really big thing for women.
Closing question: Do you believe in God?
Steven Bartlett: Dr. Stephanie, we have a closing tradition on this podcast where the last guest leaves a question for the next, not knowing who they're leaving it for. The question left for you is: do you believe in God, and why or why not?
Dr Dr Stephanie Estima: I do believe in God. I believe that there is a force greater than us — greater than we will ever be able to explain — that protects us, that gives us the lessons that we need to learn, and that will continue to present the same lessons to us over and over and over again until we are willing to surrender to learning the lesson.
Steven Bartlett: When you're on your last day and you look back at your life and go, "You know what? I did it." What would warrant you being able to say that?
Dr Dr Stephanie Estima: That my family is around. I see my grandchildren, maybe even my great-grandchildren. That they are all around my bed telling me — you're going to make me cry, Steven — all the ways, all the things that they have learned from me and that they're going to take on to future generations in my lineage.
Steven Bartlett: Why is that so important for you?
Dr Dr Stephanie Estima: All the reasons why I do what I do — it's for my kids. I want my kids to have a better life. I want to shortcut some of the learnings for them that I had to learn the hard way. And that's not to say I want to deny them of their own learning opportunities, but I want to be able to pass on what I feel are important values that I think make the world a better place. I just want to leave the world better than how I found it. And the way I want to do that is through my family and the work that I do here.
Steven Bartlett: Thank you. Thank you for doing all that you do. I think it's incredibly important for so many reasons. It says on the back of your book, The Betty Body: "Women are not little men, but that's how we treat our bodies." And it's great to have voices like you that are so backed by science, so eloquent, that are out there demystifying what is an incredibly complicated world of health information and conflicting information. My audience will often say they relate to all of the personas you highlighted — I get a lot of Overwhelmed Olivia. Where do I start, because I don't want to fail again.
Dr Dr Stephanie Estima: So many Overwhelmed Olivias. In part because one of the upsides of there being so much information out there now is that people don't have to go to some expensive doctor — they can go on an AI, they can go on a podcast. But with science evolving over time and with lots of different voices, people are often feeling more overwhelmed than ever with what they consider to be conflicting information.
Steven Bartlett: Because it's nuanced, it's very human, it comes from lived experience, and as you said, you've sat with tens of thousands of patients through your career in practice. Things aren't always as simple as they are easy to sell, and things that sell are often simple and reductive.
Dr Dr Stephanie Estima: Yeah. And the truth doesn't always exist in a lab. You can't always replicate it in a lab.
Steven Bartlett: And one of the things I learned from your work is that it changes through time. What's true for me now at 33 years old as a man, at this stage of my life with the hormone complexion I have and the goals that I have — one thing can be true. But maybe when I'm 55, a different set of things are going to be true. And I think that nuance is super important. If people want more of your work, you've got a book coming out at the top of next year called Nothing to Lose: Build the Dream Body You Want Today, Gain the Strength and Mobility You'll Need Tomorrow. And you've got this current book here called The Betty Body — subtitled A Geeky Goddess Guide to Intuitive Eating, Balanced Hormones, and Transformative Sex. You use the word "geeky" a lot, and "nerd."
Dr Dr Stephanie Estima: It used to be a terrible word to use. I'm like, no, I'm a total nerd. Special category of nerd.
Steven Bartlett: Where else do people find you if they want to learn more or message you or get in touch?
Dr Dr Stephanie Estima: My podcast — not quite the reach that Diary of a CEO has, but I have a podcast called Better with Dr. Stephanie. I do solo episodes there where I go on my little tangents about tendons and ligaments and all the things, and then I also interview what I would qualify as the world's thought leaders in science and health, and we try to distil what it means to have a well-lived life. Podcasts are free, probably where you're listening to this, YouTube and all the places. And then you can head over to my website, drstephanieestima.com.
Steven Bartlett: Anything else you wanted to say?
Dr Dr Stephanie Estima: I would say for the woman listening — my Overwhelmed Olivias who are feeling they don't know where to start, my Skinny Fat Sophias who are scared of lifting weights and eating like a bird, my Exorcist Emilys who are still exercising their demons — you're not behind. You are absolutely enough. Don't be so hard on yourself.