#378 ‒ Women's health and performance: how training, nutrition, and hormones interact across life stages | Abbie Smith-Ryan, Ph.D.

Welcome back to The Drive. I’m Peter Attia, and today we’re turning the science of longevity into practical moves for women’s health across the lifespan. My guest is Abby Smith-Ryan from UNC, a prolific researcher and coach to women through puberty, performance, perimenopause, and beyond; we dig into training, nutrition, supplements, hormones, and real-world programming with a warm, straight-talking lens.

I ran distance in college but always loved the weight room, and I fell hard for science. Asking questions, testing ideas, and realizing how much we still don’t know keeps me here.

Let’s start at the beginning. If osteoporosis is really set up in childhood, how should we think about bone, muscle, and cardiorespiratory fitness for girls?

Movement is medicine, and it begins with play and lots of varied sports. Early, well-rounded activity builds a base that’s easier to maintain, and we need to talk openly about menstruation so girls stay in sport as their bodies and performance shift.

Any training do’s and don’ts before periods begin, especially in the weight room?

Avoid early specialization and mix movements. Total-body strength—bands, light weights, plyometrics, med balls—helps prevent injuries and builds coordination.

Intense training can delay menarche in gymnasts and runners; what else should we know about bone and development in that window?

Delayed cycles often track with low energy intake or high training loads and can harm bone. We frequently see spinal curves in jumpers and gymnasts on scans, which underscores how early loading patterns shape the skeleton and why later we focus on stabilizing what’s already set.

Is there a ceiling on VO2 max or training adaptation when you’re young?

There’s no hard ceiling; youth adapt fast, but sport demands differ. Exercise produces gains at any age, while early habits and skeletal loading leave long shadows.

Talk nutrition for active girls and teens, especially with busy mornings and GI issues.

Fuel first and use timing; pre, during, and post intake supports performance and recovery. When appetite is muted, lean on calorie-dense healthy fats you can pack—whole milk yogurt, nuts, seeds—and plan intake since exercise can blunt hunger.

Why the GI distress, and how should we think about carbs?

It’s multifactorial—stress, cycle effects, not just carb load. The low-carb trend can backfire for active females; carbohydrates are vital for training and recovery.

How should training flex around the cycle for an athlete who wants to push hard all month?

You can train any day, but many feel worse late luteal with fatigue, bloating, and slower recovery; acknowledge it and adjust expectations or recovery tactics, not commitment.

Walk us through performance and fueling by phase, starting with menses.

Early follicular is low hormone and often feels steady with higher carb use; just fuel and hydrate, and keep an eye on iron if heavy bleeding. Late follicular and ovulation often feel like a high—great time to test best efforts, though ovulation timing can be variable.

Early luteal versus the final premenstrual week?

Early luteal often feels similar to the prior week. Late luteal brings more mood, heat, water shifts, and inflammation; prep with two to three grams of omega-3, add zinc and magnesium, tighten sleep and produce, and consider creatine to pull water into muscle and caffeine for fatigue.

Creatine specifics and protein guidance here?

In studies we load twenty grams across five days, then five grams daily, though some midlife and brain data support up to ten grams. Aim for about 1.6 grams per kilogram of protein and place amino acids around training; late luteal energy needs may rise by two to three hundred calories while water retention hides it on the scale.

Should women rewrite their monthly training plan around hormones, or stick with broader periodization?

Program by goals and cycles of build and taper, and if it helps, align mesocycles with your pattern. Track symptoms and length, give yourself grace on rough days, and use the data to tweak recovery rather than skipping work.

What about running continuous oral contraception to reduce variability?

It can smooth training by reducing symptom swings and bleeding, which many find helpful; the advantage is consistency.

Perimenopause: how should women measure and act during this long transition?

Get baseline labs in your thirties and track changes; daily at-home urine tools for estrogen proxies, progesterone, FSH, and LH expose variability tied to symptoms like sleep and hot flashes. Our data show perimenopause is when metabolism, muscle size and quality, bone, and metabolic flexibility shift most, making it a prime time for lifestyle upgrades.

Clinically, a day-five FSH is a useful anchor; IUDs complicate timing, but breakthroughs help. For the busy mom who can spare only a little time, what’s the move?

Start now, even small doses; consistency beats volume when life is full. Intensity matters when time is tight, but we’ll blend it so you recover and build a base.

With limited time, we lean more on intensity; with lots of hours, volume drives more adaptation. How do you structure three hours a week?

Twice-weekly, 30-minute total-body strength at about 60 to 80 percent one-rep max, six to eight reps with short rests. For cardio, do one to two high-intensity sessions and one easy movement day; a simple template is one minute hard, one minute easy for ten hard minutes, guided by effort or fixed power.

Do you split that cardio time or keep it whole, and any extra reasons to keep HIIT?

Short sessions fit better and keep you consistent. HIIT also nudges lean mass, which helps in midlife.

How do you reframe weight loss as body comp change?

Measure fat and lean mass with DEXA or reliable impedance, then set goals by body fat percent instead of the scale. We often aim toward healthier percentiles rather than a nostalgic number.

A 5 foot 6, 150-pound, 30 percent fat woman wants to drop twenty pounds. What’s realistic and how?

Ten pounds with recomposition is often smarter; create a modest deficit while adding fiber, protein, and quality carbs, and lift to protect muscle. If she uses a GLP1, pair it with strength work and about 130 to 150 grams of protein per day, aim for roughly 30 grams per meal, and consider essential amino acids around training.

People on GLP1s need higher diet quality, not just fewer calories, and should monitor body comp. Why are we seeing bone drops?

Under-fueling produces RED-S-type effects that depress hormones and harm bone and muscle, and GLP1 appetite changes can amplify that. Time amino acids before and after workouts on these meds to protect lean mass.

If recomposition is the goal with three hours, would you shift the mix?

I’d likely do three short strength sessions, one HIIT, and two easy cardios, then adjust if she’s unfit or under-fueled; use whole-body or push–pull so big muscles get worked twice weekly. Think in 24-week blocks, and if using GLP1s, titrate slowly and watch lean mass before changing dose.

You’ve tracked yourself for years; what did you learn the hard way?

I racked up stress fractures when my body fat dipped near fifteen percent even with high bone density, pointing to energy and timing, not brittle bone. Repetitive inside-leg loading and long gaps without fuel taught me to prioritize protein and carbs around sessions and to swap endless volume for smart intensity.

Besides creatine, what are your go-to supplements today, and how do aminos fit in?

Whey or amino acids both work, but aminos are lighter and absorb quickly. My staples are omega-3, vitamin D, magnesium, creatine, and a multivitamin, plus a multi-strain probiotic when my gut needs it.

Walk us through body composition across your pregnancies and whether you felt stuck with a new set point.

I gained about eight percent body fat during each pregnancy without losing muscle and returned to baseline around six months postpartum. You don’t need extreme training; consistency, some intensity, and smart nutrition prevent a forced new set point.

Eight years after your second child, is your body composition essentially the same as pre‑kids?

It’s very similar, with planned phases where I’m a bit leaner or more muscular based on training. I often get leaner by eating more frequently and prioritizing whole foods and protein, whereas less attention leads to gradual fat gain.

That sounds counterintuitive. What do you mean by eating more?

More frequent meals, roughly thirty grams of protein with fiber and vegetables spaced across the day. Chronic time restriction in many women can depress metabolic rate, blunt protein synthesis, increase hunger, and cost muscle, especially in midlife.

Were you breastfeeding while getting back to baseline, and what did training look like late in pregnancy and after?

Yes, and I treated birth like an athletic event with steady exercise and a modest calorie surplus, then returned to balance postpartum. I walked within days and did light resistance within weeks; early on I craved plant proteins and even donuts, had some GI issues so I relied on liquid foods, then reintroduced shakes, omega‑3, and creatine for convenience.

Biggest nutrition and training mistakes during and after pregnancy?

Either using pregnancy to eat anything or ignoring nutrition altogether. Prioritize nutrient density for mom and baby, keep both resistance and aerobic work, and postpartum manage nursing, hydration, and sleep while using movement to boost blood flow and mood.

How many women are actually resistance training, and what changes with menopause biology?

Only about one in five women lift and often just once a week. Even with more athletic cohorts aging, hormone changes still degrade muscle quality via inflammation, oxidative stress, and vascular shifts that affect nutrient delivery.

Should training change in menopause, and what happens to muscle quality?

Perimenopause is when muscle quality declines most even if size holds, likely with neuromuscular changes. We measure metabolic flexibility with indirect calorimetry and microdialysis; women show reduced flexibility at moderate efforts that improves with exercise, and high‑intensity intervals are potent, while protein near those sessions seems to aid blood flow and insulin response without blunting gains.

How do you quantify flexibility?

We track RER across increasing workloads with modeling, break it into heart‑rate‑based intensities, and pair it with interstitial fatty acid data to map fat versus carb use.

What drives the loss of flexibility with age, and where does hormone therapy fit?

It’s a mix of age, lifestyle, and hormone shifts. We’re now including women on and off therapy to tease it apart, but training remains the biggest lever, and protein timing likely matters even more in midlife.

Let’s zoom out to GLP‑1s, tendon risk, and time‑efficient training—what moves the needle most?

Ditch absolutes like you must lift heavy or only do HIIT; first, do something consistently, then tailor proven S&C principles to women with smart adjustments for recovery and joints. Women gain strength and muscle, though absolute gains differ and fiber‑type and motor‑unit aging might vary.

Power seems crucial for not falling when you stumble off a curb; should women double down on it?

Absolutely—power protects day‑to‑day function. Midlife joint pain, poor sleep, and brain fog can complicate jumping, so we need lower‑impact options to train speed safely.

Is it too late at seventy, and how should a true novice start?

It’s never too late; start with full‑body machines, glute activation, hamstrings, calves, and shoulder work. Lift three days a week and move most days, add light carries and sub‑max holds, and progress; older adults can gain a lot in about six months.

Any injuries you see more in women?

We’re seeing more midlife ACLs, likely from higher activity plus tendon‑stiffness changes with age and hormones; high‑sensitivity CRP tends to run higher in perimenopause, but hormone therapy’s effect there is unclear.

What popular advice is most misleading?

Rigid rules—only this, never that—do harm; keep it individual and plan for injury and recovery. Creatine helps but isn’t magic or my first lever, and we need better ways to help women advocate for appropriate hormones alongside lifestyle.

I think medicine failed women on hormones for decades; don’t accept no—find competent care. Hormones help on their own and likely help more when combined with training.

Do drugs end up crowding out lifestyle changes?

Drugs can make change easier, and hormones have independent benefits; doing both almost surely beats either alone. With limited time, intensity matters—if you only have two short lifts, push near failure; same idea for cardio, and set clear targets since many confuse easy work for zone two.

Maintenance phases are real; teach what good pain feels like so people train hard enough without breaking. Train earlier to buy freedom later, and remember no pill replaces exercise.

Thanks again. I’m encouraged that more women now recognize the value of resistance training than twenty years ago.

It’s a great moment to empower women to make space for strength, not just cardio. Thank you.

Thanks for listening to this episode of The Drive. Check the show notes for more, find me on YouTube and social, and remember this is educational content, not medical advice—please speak with your health care professional about your own care.