Podcast Summary: The Peter Attia Drive – Episode #378

Title: Women's health and performance: how training, nutrition, and hormones interact across life stages
Guest: Abbie Smith-Ryan, Ph.D.
Date: January 5, 2026
Host: Peter Attia, MD

Overview

This episode deeply examines the science and real-world application of exercise, nutrition, and hormonal health for women across different life stages. Dr. Abbie Smith-Ryan, an expert in exercise physiology, women’s health, and metabolism, joins Dr. Attia for a practical, evidence-based discussion aimed at parents, athletes, and women of all ages. Topics include optimizing bone and muscle health in youth, tailoring training and recovery across the menstrual cycle, managing the transition to perimenopause and menopause, safe postpartum strategies, supplement use, and reconciling modern pharmacology (e.g., GLP-1 agonists, hormone therapy) with foundational lifestyle interventions.

Key Discussion Points & Insights

1. Exercise in Youth – Laying Foundations ([04:03] – [11:34])

• Bone and Muscle Health Early On:

  • Osteoporosis is a childhood disease: Bone density peaks around age 19, then declines. Early activity is a critical “bank” for lifelong health ([04:03]).
  • Emphasized unstructured play and multi-sport participation over early specialization.
  • Resistance training from a young age helps prevent injury and support musculoskeletal development.
  • Dr. Smith-Ryan: “Resistance training is the best prevention of injury. … total body exercises, whether we start with resistance bands or plyometrics or med balls, those are all really great things.” ([07:42])

• Puberty, Menstruation, and Sport Dropout:

  • Puberty often coincides with girls leaving sports, sometimes due to misinformation or lack of support about menstruation’s effects on motivation, performance, and recovery.
  • Delayed menstruation (due to high training volume/calorie deficit) negatively impacts bone health ([08:52]).

• Structural Changes in Youth Athletes:

  • High jumper and gymnast DEXA scans often reveal spinal curvature, sometimes unrecognized as acquired, closely tied to early intense, asymmetrical sport ([09:05]).

2. Peak Performance, VO2 Max, and Adaptation in Adolescence ([10:58] – [12:41])

• Youth have high adaptability to training with no strict “ceiling,” but optimal early exposure and variety matter more than intensity alone.
• Adaptive fitness (VO2 max, skill transfer across sports) best maintained through diversity and sustained engagement.

3. Nutrition for Young Female Athletes ([12:41] – [16:04])

• Fuel, Not Restriction:

  • Priority is sufficient calorie intake, especially as appetite signals are often blunted with early morning training.
  • High-calorie, nutrient-dense foods are recommended—e.g., whole milk, nuts, seeds ([14:43]).
  • Carbohydrates should not be feared, despite current trends to overemphasize protein.

• GI Distress:

  • Common around the menstrual cycle—stress, hormonal fluctuations, and not just carbohydrate intake contribute.

4. Training and Nutrition Across the Menstrual Cycle ([16:04] – [35:31])

• Overall Principles:

  • Women can train at any time during their cycle. Subjective symptoms drive most variation, not physiologic performance limits ([16:17]).
  • Luteal phase (pre-menstruation): More bloating, fatigue, and soreness; may benefit from “giving oneself grace” when training feels tougher ([35:00]).

• Detailed Cycle Strategies:

  • Follicular Phase (Menstruation and Following Week):
    • Greater carb oxidation, generally feel better ([19:01]).
    • Maintain hydration and regular iron monitoring.
  • Ovulation/Early Luteal Phase:
    • Peak perceived performance, but variability in ovulation detection.
  • Late Luteal/Pre-Menstrual:
    • Physical: Increased inflammation, water retention, disrupted sleep, heightened soreness, and sometimes reduced protein synthesis ([24:34], [28:51]).
    • Supplements/Strategies: Increase omega-3 (2–3g), magnesium, zinc; possibly pulse caffeine and creatine (5–10g) for edema relief and performance ([25:09], [27:26]).
    • Appetite often confused (may eat less due to discomfort despite raised metabolic rate ~200–300 kcal/day) ([29:12]).
    • Key quote: “The scale might suggest you’re gaining weight, but in reality you’re losing stored energy.” – Attia ([29:28])

• Protein:

  • Target: 1.6–2.0g/kg (“about 1g/lb”) throughout the cycle, especially important if vegetarian or during high protein turnover phases ([30:14], [32:20]).
  • Consistent intake and nutrient timing around workouts matter more than absolute amounts every single day.

• Performance Mindset:

  • No need to micromanage training to the exact day of the cycle—consistency, flexibility, and self-tracking for context are key ([34:07]).

5. Oral Contraceptives & Performance ([36:23])

• Continuous oral contraceptives can flatten the hormonal fluctuations, indirectly benefitting athletes by reducing cycle-related symptoms and allowing more consistent training.

6. Transition to Perimenopause & Menopause ([37:17] – [46:08])

• Identifying Perimenopause:

  • Early bloodwork (FSH levels, day 5) is key to detect changes; at-home urine hormone tests offer helpful, though less precise, daily trends ([39:18]).
  • Dr. Attia: “Once FSH is hitting 10, we know she’s now entering that zone. … it rises to 25, 30, 50 (in menopause).” ([39:24])

• Metabolic Shifts:

  • Perimenopause brings significant changes to metabolism, muscle and bone quality, and metabolic flexibility ([40:51]).
  • Critical window: “Late 30s to 50s is really the time for lifestyle impact on life-long healthspan.” – Smith-Ryan ([41:54])

• Prioritizing Exercise:

  • “Intensity is more important than volume, and consistency is more important than volume.” – Smith-Ryan ([42:36])
  • Attia counters: With limited time, intensity must rise; unlimited time allows volume focus ([44:31]).
  • Sample Weekly Structure for Busy Midlife Women (3 hours/week):
    • 2 x 30min resistance training (whole body, moderate/high intensity, short rest)
    • 2 x 30min aerobic sessions (minimum 1 high-intensity interval session) ([47:59]–[49:20])

7. Resistance vs. Endurance: Programming for Different Goals ([47:25] – [54:58])

• Balance:

  • With limited time, combine high-intensity interval (HIIT) days (e.g., 10 x 1 min on/1 min off, as hard as possible) with steady-state movement ([50:04]).
  • Prioritize resistance training for muscle maintenance, especially if weight loss/recomposition is a goal.
  • “High intensity increases lean mass as well, which can be helpful for that midlife.” – Smith-Ryan ([53:33])

• Body Composition Focus:

  • “It is all about body composition … the weight doesn’t change or goes up.” – Smith-Ryan ([53:46])
  • Use DEXA or similar tools to track fat vs. lean mass.

8. Nutrition & Training With Weight Loss Medications (GLP-1 agonists) ([58:16] – [63:53])

• Many on GLP-1 agonists (e.g., semaglutide, tirzepatide) lose weight rapidly—risk losing muscle/bone.
• “If you’re on a GLP-1 … you have to create a new diet that has to be much higher in quality to compensate for the reduction in total energy.” – Attia ([61:39])
• Strategies: Intensive resistance training, daily protein target based on goal weight (e.g., 130–150g/day for a 150lb woman), protein distribution (30g per meal, consistently), amino acids peri-workout.
• Amino acid supplementation especially useful around exercise to help preserve muscle.

9. Pregnancy and Postpartum Training & Nutrition ([73:31] – [81:43])

• Pregnancy:
  • Exercise is feasible and beneficial; prioritize resistance work (e.g., squats, lats) and gradual calorie increases.
  • “Birth is one of the most athletic events you’ll do, and you should train for it.” – Smith-Ryan ([77:41])
  • Balanced, micronutrient-rich, and moderate surplus nutrition for fetal development and mom’s health.
• Postpartum:
  • Regular movement ASAP (walking within days, resistance within weeks if possible).
  • No “inevitable” set point: “If you have that consistency, it [body composition] can really help.” ([75:17])
  • Biggest mistakes: Poles of “eating whatever you want” vs. ignoring nutrition; not prioritizing movement for recovery.

10. Sarcopenia, Resistance Training, and Aging ([81:43] – [107:00])

• Women have lower baseline muscle mass and only ~19% report regular resistance training.
• Sarcopenia (muscle loss with age) worsens in women due both to hormonal change and under-training.
• Midlife critical for robust resistance and power training—muscle “quality” (not just size) erodes, with increases in fat marbling (“ribeye vs filet”—Smith-Ryan; [84:26]).
• Exercise—especially HIIT and resistance—can restore or sustain metabolic flexibility and function ([88:06]).
• Power is pivotal: Losing explosive fibers (type IIa) is more critical than simply losing strength; “power” is the difference between stumbling and falling as you age ([103:55]).

11. Recommendations for Older & Inexperienced Women ([107:00] – [112:41])

• “You literally can do [exercise] at any time and start. If you can start sooner, that’s better, but no, you can gain strength and muscle at any age.” – Smith-Ryan ([106:35])
• Start with resistance bands or machines, focus on whole-body routines (glute activation, push/pull, deltoid/shoulder health), progress to more functional work (carries, core).
• Seek guidance from qualified trainers (referrals, credentials matter).
• Emphasize consistency and slow, progressive challenge.

12. Mental Health, Trends, and Misconceptions ([112:52] – [115:00])

• Exercise’s role in mental health (anxiety, depression, “brain fog”) is under-recognized; both aerobic and resistance training improve cognition and mood.
• Beware absolutist trends (“only do X, never Y”); the best plan is what you enjoy and do consistently.
• Don’t overcomplicate—adjust based on your unique context, goals, and stage of life.

Notable Quotes & Memorable Moments

• “Osteoporosis is a childhood disease. … They are reaching their genetic ceiling at about age 19 in terms of bone density.” – Attia ([04:03])
• “Exercise is the best medicine starting young.” – Smith-Ryan ([05:39])
• “Females will compete regardless [of the cycle], but it’s the recovery—science can help here.” – Smith-Ryan ([17:38])
• “[Luteal phase:] The scale might suggest you’re gaining weight, but in reality you’re losing stored energy.” – Attia ([29:28])
• “Creatine was able to take that extracellular fluid and bring it into the cell, so help with fluid in the right places… supported performance.” – Smith-Ryan ([25:06])
• “With limited time, intensity is more important; with unlimited time, volume matters most.” – Attia ([44:31])
• “You can gain strength and muscle at any age… If you can start sooner, that’s better, but no, the ship hasn’t sailed at 70.” – Smith-Ryan ([106:35])
• “Exercise is such a remarkable stimulus…there are far too many benefits that could ever be replaced by a pill.” – Attia ([128:02])
• “Less rules—exercise is powerful no matter how you do it.” – Smith-Ryan ([113:56])

Timestamps for Important Segments

• Adolescence & Building Potential: [04:03]–[12:41]
• Menstrual Cycle & Training: [16:04]–[35:31]
• Perimenopause & Exercise Adaptation: [37:17]–[46:08]
• Training Split for Busy Women: [47:25]–[54:58]
• GLP-1 Agonists & Muscle Preservation: [58:16]–[63:53]
• Pregnancy/Postpartum Strategies: [73:31]–[81:43]
• Sarcopenia & Menopause: [81:43]–[107:00]
• Starting Late or New to Exercise: [107:00]–[112:41]
• Mental Health & Myths: [112:52]–[115:00]

Closing Takeaways

• Start early but it’s truly never too late to build or maintain strength, bone density, and cardiorespiratory health.
• Hormones matter, but lifestyle—particularly resistance training and protein intake—can powerfully offset natural declines.
• For busy women: Consistency and intensity are the keys to thriving in limited time; aim for 2–3 strength sessions per week, HIIT, and stay moving.
• Track what matters: Body composition > weight; menstrual cycle symptoms for context, not perfection; and prioritize real recovery and self-compassion.
• Empowerment through education: Know that you can advocate for yourself, combine modern medicine (hormones or GLP-1s if needed) with strong lifestyle science, and ignore dogma in favor of what’s evidence-based and personally sustainable.

For more in-depth notes and resources, visit the episode’s show notes at peterattiamd.com.