23: The Missing Piece for Women Who Already Work Out: Part 2

Hey, it’s Megan. Grab your coffee and let’s have a convo.

INTRO

Welcome back, I’m Megan Piffner and this is Mornings with Megan. Last week we covered the full cardio framework, interval training, cortisol, and how to find your right starting point depending on where your stress cup actually is right now. If you haven’t listened to that one yet, go back, it sets the stage for today.

Because today we are going all in on the one thing I told you was coming, the non-negotiable, the thing I talk about with almost every single client, the piece of the puzzle that I genuinely believe changes everything in perimenopause. We are talking about resistance training.

And I want to start by telling you something I say a lot. I can make a really compelling argument for every element of the perimenopause matrix. Protein matters. Sleep matters. Stress regulation matters. But if you forced me to name the one single intervention with the strongest evidence behind it for perimenopausal women, the one that touches metabolic health, blood sugar, bone density, cardiovascular disease risk, body composition, longevity, it is resistance training. It’s not even close.

So today I want to give it the full conversation that it deserves. We are going to talk about the science. We’re going to talk about why the stakes are genuinely high here. And then we’re going to talk about exactly how to start from absolutely zero.

THE STAKES: RESISTANCE TRAINING IS CARDIOVASCULAR MEDICINE

If that’s where you are today, I want to start with a number that I think about all the time that most women don’t know. Heart disease is the number one cause of death of women in the United States, not breast cancer.

And metabolic disease, which includes type 2 diabetes, insulin resistance, dyslipidemia, is one of the primary drivers. I bring this up not to scare you, but because a lot of women don’t know this. We are rightly concerned about breast cancer, osteoporosis, cognitive decline, and those things matter enormously. But cardiovascular disease is killing more women than anything else, and perimenopause is when the risk trajectory changes.

Here’s what surprises most people. When I say resistance training is cardiovascular medicine, I mean that literally. The research shows that strength training improves lipid panels, reduces visceral fat, lowers blood pressure, and improves insulin sensitivity. The exact cluster of risk factors that puts women at risk for cardiovascular events as they age.

And beyond the metabolic picture. A large systematic review and meta-analysis published in the American Journal of Preventative Medicine found that doing any amount of resistance training, any amount, was associated with a 15% reduction in all-cause mortality and a 19% reduction in cardiovascular mortality compared to doing none. A separate analysis confirmed that the optimal dose for a mortality benefit appears to be around 60 minutes per week. That’s not a lot. I’ll link all of this in the show notes.

But I want you to hear this loud and clear. Resistance training is cardiovascular medicine. It just doesn’t look like what we’ve been told cardiovascular exercise looks like.

THE MUSCLE-GLUCOSE CONNECTION: THE UNDER-MUSCLED WOMAN

Let me tell you about something I see in my practice that doesn’t get talked about enough. I see women in their 50s and 60s who are eating well. They’re lean. Some of them are quite thin. And their glucose numbers are creeping up. The hemoglobin A1C is inching towards pre-diabetic range and they cannot figure out why because they’re eating carefully, sometimes low carb, and they’re not overweight.

I don’t want you listening in your 40s to become her. If we had met sooner, we could have prevented what she’s going through. What is happening in many of these cases is that they don’t have enough muscle.

Skeletal muscle is the largest glucose clearing organ in your body. When you eat carbohydrates, your muscle is supposed to absorb and store that glucose. Think of it as a sink. When your sink is big, it drains fast. When your sink is small, and when you don’t have enough muscle mass, that glucose has nowhere to go efficiently, and it stays elevated in the blood sugar because the sink can’t drain it.

Over time, the pancreas compensates. Insulin rises and you are now on the road to insulin resistance, even though you’re eating carefully and don’t look like someone who should have blood sugar problems. This is the under-muscled woman. She is not rare. She’s often in her 40s, 50s, and 60s. She may have done cardio for years. She’s careful with her food. She looks fine from the outside, but her glucose is trending up.

Her hemoglobin A1C is climbing and her lipids, particularly triglycerides, are starting to drift. And the answer isn’t in eating fewer carbs. The answer is in building more muscle.

This is why I get frustrated when resistance training gets framed as purely an aesthetic conversation. Muscle is metabolic infrastructure. It is an endocrine organ. When you contract skeletal muscle, it releases proteins called myokines, including one called irisin. They communicate with the bone, with the brain, with the pancreas, with fat tissue. Muscle literally talks to your whole body. That’s not a metaphor. That is how your body actually works.

THE PERIMENOPAUSE POWER WINDOW

Here’s the part that makes this even more urgent for where you are right now. Research published in the Journal of Menopause looked at 72 women across three groups. Pre-menopause, perimenopause, and postmenopausal, all of them generally active. And what they found was striking. The greatest changes in body composition and metabolism happened during perimenopause, not after. The perimenopausal women had significantly more fat mass and meaningfully less lean mass compared to both the pre and postmenopausal groups. They also showed reduced metabolic flexibility, the ability to shift between fat burning and carbohydrate burning.

And the women in the perimenopause group were on average lifting weights at the least of the three groups.

Dr. Stacy Sims calls this perimenopause power window. And I think that framing is exactly right. This is not the beginning of a decline. This is the moment where your choices have the highest leverage. What you do now doesn’t just help you feel better this year. It sets the trajectory for the next 30 years.

There is also something important happening at a cellular lab level. When estrogen starts to fluctuate and decline, muscle stem cells, the cells responsible for repair and regeneration lose some of their signaling. Research on this shows that removing estrogen from animal models causes muscle regenerative capacity to drop by 30 to 60 percent, and muscle biopsies in women during the menopausal transition show the same pattern.

You don’t have to lose that muscle, but you do have to give it a reason to stay. And the only signal strong enough to compensate for declining hormonal support is mechanical load, progressive resistance training.

BONE HEALTH: WHAT HAPPENS WHEN THE HORMONES STOP CYCLING

I want to pause here and talk about bone because it connects directly to this hormonal picture. And it’s something I don’t hear explained clearly very often. Most people know that estrogen is important for bone health. What’s less discussed is the role of progesterone and what happens when both of these hormones stop cycling together.

Why am I telling you this in a resistance training episode? Because mechanical load on skeleton is one of the few things we can do right now to keep stimulating bone formation as that hormonal signal weakens. Weight bearing movement keeps osteoblast active. The muscle pulling on bone during a heavy squat or a deadlift sends the signal that the skeleton needs to be maintained.

That is not a secondary benefit of resistance training. That is a central one. I can’t wait to talk about this more in episode 24. It’s going to be good one. But for now, let’s talk about load.

THE HEAVY WEIGHTS DEBATE: WHAT THE SCIENCE ACTUALLY SAYS

Now, you may have heard some debate in the fitness research space about whether you need to lift heavy to build and preserve muscle. I want to address it because I think the conversation sometimes generates more confusion than clarity.

Dr. Stacey Sims talks about lifting heavy. She’s adamant about it and she gets pushback. Sometimes from researchers who point out that you don’t actually need to lift heavy to build and preserve muscle. Both positions are supported by research and I want to explain why they’re not actually conflicting.

Dr. Lauren Colenso-Semple is a researcher at McMaster University and co-owner of Mass Research Review. She’s done some of the most rigorous work on this question. A large network meta analysis she co-authored published in the British Journal of Sports Medicine analyzed over 170 studies and found that for muscle hypertrophy, building and preserving muscle tissue, all resistance training prescriptions produced comparable results. High load, low load, moderate load. What mattered the most for hypertrophy was training close to muscular failure, working hard enough that another rep would be genuinely difficult.

The load itself was less determined for muscle building than most people assume.

Where higher or low does make a meaningful difference is in strength. Your ability produce force. Strength matters enormously for function, for bone health, for fall prevention, and for long-term independence.

So here’s how I hold both of these things. And where Dr. Sim’s recommendations make sense, her argument for heavy lifting is fundamentally about the hormonal context of perimenopause and time efficiency. When estrogen is declining, you need a stronger mechanical signal to maintain muscle stem cell activity and stimulate bone. Heavy lifting delivers that signal efficiently and in less time. Fewer reps, fewer sets, more stimulus. That matters a lot when we’re all thinking about keeping sessions short to manage cortisol. So her point isn’t that lighter loads don’t work at all. Her point is that for perimenopausal women, the limited time and cortisol picture to manage. Heavier loads are a smarter investment.

The practical translation. If you’re already training and progressing well, increasing load over time is a very good strategy. If you’re brand new, coming back from injury or in a high cortisol season of life, lighter weight with genuine effort, working close to failure can absolutely build and preserve muscle. The research fully supports that. The goal either way is progressive overload over time.

PROGRESSIVE OVERLOAD: WHAT IT ACTUALLY MEANS

Now let me explain progressive overload because this phrase gets thrown around without a lot of explanation. Progressive overload simply means that you are consistently asking more of your muscles over time. When your muscles have to work harder than they’re used to, they adapt. They get stronger, they maintain and build mass, they become more metabolically active.

The way you can create progressive overload are more varied than most people think. You can increase the weight. You can increase the volume, the number of reps and sets. You can increase frequency, how often you train a given muscle group. You can even change the cadence, how slowly you move through each rep, which increases the time your muscle is under tension. There are a lot of levers, but the trade-off you always have to consider is time and energy. Heavier weights mean fewer reps needed to get the stimulus. Higher volume means more time at the gym. Slower cadence can be done with lighter weights, but takes longer.

These are choices you make based on your schedule, your cortisol level, and where you are in your training. The trend over weeks and months should be upward. You are not doing the same thing forever. That’s what drives adaptation.

WOMEN, FATIGUE, AND REST BETWEEN SETS

Here’s something that genuinely surprised me when I was looking into the research on this, and I think that it has real practical implications for how you structure your training. The data suggests that women are generally less fatigable than men during resistance exercise. Right? You did hear me, right? Women are generally less fatigable than men during resistance exercise, meaning that we can sustain effort at the same relative intensity for longer before our performance drops. This is a real physiological difference, likely related to differences in muscle fiber composition and metabolic substrate use.

What this means practically is that women may not need quite as long between sets as a standard male-based training recommendations suggest. But, and this matters, there’s a trade-off to understand here. Super setting, meaning moving directly from one exercise to the next with little to no rest is a popular time-saving strategy. You do your squats, and then instead of sitting around for two minutes, you immediately do an upper body pull. This does save time, but it also pushes you into more of a metabolic cardio adjacent space because you’re not allowing full recovery between efforts. That’s not necessarily bad. It definitely has its own benefits. But if cortisol management is a priority for you right now, and we talked about this a lot in episode 22, the rest time between sets is actually doing something important. It keeps the session from becoming a cortisol spike. It also allows you to produce better quality work in each set.

So here’s my take. If your cortisol is in check and you are genuinely time crunched, supersetting is a smart and legitimate efficiency tool. If you’re in a high stress season or still working on your recovery, prioritize the rest. This is a judgment call for you and your perimenopause. It’s not a rule. This also circles back to why Dr. Stacy Sims’ preference for heavier weights makes sense from a time efficiency standpoint.

If you’re lifting heavy and working hard, you get the stimulus and fewer total reps and sets, and you can get out of the gym faster.

HOW TO ACTUALLY START: THE PROGRESSION

Okay, I want to talk about how to actually start because I know that some of you are hearing all of this and thinking, I want to, but I don’t know where. And I also know that some of you have tried before, gotten hurt or gotten sore and couldn’t walk and then quit.

Let me tell you how I actually started. I tried running, couldn’t stick with it. I tried going to the gym, too intimidating. I tried Google Classes too much, too fast. I tried yoga. I could not get myself to go consistently. I was out of shape and I didn’t have any foundation for working out. So everything I tried felt like too much for where my body actually was.

What finally worked was embarrassingly small. Three minutes. I’m serious. Remember the seven minute workout? I couldn’t make it through that. I started with three minutes. So three minutes included jumping jacks, pushups, and mountain climbers in my living room. That was it. I built from there slowly over weeks until I was doing a seven minute circuit, then 10 minutes, and then I started adding load.

I’m not telling this to you to be cute. I’m telling you this because I think a lot of women are starting from the same place I was and they compare themselves to what they think exercise is supposed to look like. And then they opt out entirely because the gap feels too large. Three minutes done consistently is not failure. Three minutes done consistently is the beginning of everything.

Step One: Mobility and Range of Motion First

Before you add load, your joints need to be able to move through their full range of motion safely. This is not an exciting step, but it is the step to prevent injury. And injury is the number one thing that ends training habits. If you have pain in your hips, your knees, your shoulders, or your back that limits your movement, please work with a physical therapist before you add resistance.

This is not an obstacle to starting. It is starting. A physical therapist can identify what’s going on, help you build the foundation, and most of the time the mobility work itself makes you feel better in daily life, not just in the gym. If you don’t have significant pain, but you’re stiff and haven’t moved much, begin with a five to 10 minutes of dynamic mobility before each session.

Hip circles, bodyweight squats without load, shoulder rolls, cat-cows, a few hip hinges to feel where your body is. You are teaching your body the patterns before asking it to perform them under load.

Step Two: Bodyweight First

The basic movement patterns to learn are the squat, hip hinge, the push, the pull, and the carry. Those five patterns done with just your body weight in reasonable form build the foundational strength and neuromuscular coordination that you need before adding external load.

If you’re not sure about form, a few sessions with a trainer, just even two or three, to learn the movement is worth the investment. Trainers are amazing. They understand this. They know how bodies are supposed to move and they can teach you the proper form so that you don’t set yourself for injury when you start adding load.

Step Three: Adding Load

Once you’re moving well and consistently, you start adding external resistance. This can be resistance bands, dumbbells, barbells, kettlebells, or machines. It doesn’t really matter. What matters is this principle. You are progressively making the work harder over time.

For most women starting out, two to three full body sessions per week is the target. You don’t need to split upper and lower body. That’s more advanced programming. Full body, two or three times a week, hitting your major muscle groups, legs, hips, back, chest, shoulders, and core.

A basic starting structure might look like two to three sets per exercise, eight to 15 repetitions, working close to the point of where another rep would be really difficult. You have more flexibility on the rep range than you think. Remember, the research shows that higher rep ranges can produce equivalent hypertrophy to lower rep ranges as long as you’re getting close to muscular failure.

So if lighter weights for 12 to 15 reps is where you start, that’s a legitimate training stimulus. Rest between sets matters. Two to three minutes between sets are near failure, allow your muscles to recover enough to do the next set well. This is not wasted time. This is part of the training. As you get stronger over weeks and months, you increase the demand. More weight or more reps or more sessions. The trend over time should be upward.

A NOTE ON PROTEIN

You cannot talk about resistance training without talking about protein. They are inseparable, my friends. The research on protein for active women, particularly during the menopause transition, generally lands somewhere between 1.6 and 2 grams per kilogram of body weight per day. Most experts I respect for this population recommend staying towards the higher end of that range. I want to be specific here. The higher protein target is driven by both the hormonal context and the activity demands of resistance and interval training together. Your muscles need the raw material to respond to the work that you’re putting in.

Distribution matters as much as total amount. Getting 30 to 40 grams of protein at each meal spread across the day keeps your muscles in a positive protein balance consistently. If you’re lifting and under-eating protein, you’re leaving most of that training return on the table.

Protein is going to get its very own episode, but I really wanted to call it out here because the two are truly inseparable.

OUTRO

Okay, here’s what I want you to take from today. Resistance training is not optional in perimenopause. It is one of the most powerful tools that you have for metabolic health, blood sugar regulation, bone density, cardiovascular protection, and longevity. The research is not ambiguous on this.

The question is not whether to do it. The question is where you start. And if you’re starting from zero, start here. Three minutes is not failure. Bodyweight squats in your living room are not failure. Seeing a physical therapist for your hips before you even pick up weights is not failure. That is you getting started. Build the patterns. Build the consistency. Add load. Keep going.

Episode 24 is jump training and bone health, and I’m genuinely excited for that one. We’re going to talk about one of the most underutilized tools in perimenopause exercise and why it has some of the most specific evidence for bone hip density. I’m Megan Piffner and I’ll see you next week.

Legal Bit

Can you do me a favor? If this was helpful, share it with one person who might need to hear it today. Our bodies didn’t come with a user manual and this perimenopause thing can feel confusing and lonely, but you’re not alone. You’re not crazy and you’re definitely not broken. And maybe someone in your life needs that reminder too. Let’s spread the word and be kind to each other and ourselves.

Now the legal bit. I’m a nutritionist, but I’m not your nutritionist. This podcast is for information and education only. No client relationship was formed. Always seek medical advice when necessary. I’ll see you next Wednesday morning.