Once a month we answer Barbell Medicine Plus subscribers’ questions on the Direct Line. This is a free look at June’s episode. We start with GLP-1 drugs and muscle: why DEXA overstates the loss, what resistance training actually does, and whether creatine is worth taking. Then whether bulking and cutting does anything the scale can’t already tell you, how to get real benefit from one training hour a week, and what happens to your muscle, strength, tendons, and bone when you take time off, including why muscle memory brings it back faster than you built it.

What we cover:

•   GLP-1s and muscle: the DEXA problem, resistance training, and creatine

•   Bulking vs cutting vs just maintaining, and a health-first way to choose

•   Training on one hour a week: the least that still moves the needle

•   How fast you lose muscle when you stop, and why it comes back fast

The full two-hour episode and every back episode are on Barbell Medicine Plus, which can bundled with Premium. Resources and full references below.

Timestamps

0:00 Intro + GLP-1 and the DEXA muscle-loss myth

3:00 Do GLP-1s spare or waste muscle?

8:03 Does creatine help on a GLP-1?

10:45 Does bulking and cutting do anything?

13:18 Health first: when to lose fat before gaining

22:30 Training on one hour a week

36:22 How fast you lose muscle when you stop

43:19 Muscle memory: why it comes back

48:25 The full episode on Plus

Resources

• Barbell Medicine coaching and templates: https://www.barbellmedicine.com
• https://www.barbellmedicine.com/shop/subscriptions/plus-podcast-subscription/
• https://www.barbellmedicine.com/shop/subscriptions/barbell-medicine-premium/
• Signal book pre-order: https://www.barbellmedicine.com/shop/learning/signal/
• 
  

https://www.barbellmedicine.com/blog/glp-1-muscle-loss/

https://www.barbellmedicine.com/blog/creatine-on-ozempic-does-it-prevent-muscle-loss/

https://www.barbellmedicine.com/blog/novice-intermediate-advanced-strength-training/

Lundgren JR, et al. Healthy Weight Loss Maintenance with Exercise, Liraglutide, or Both Combined (S-LITE). N Engl J Med 2021;384:1719-1730. nejm.org · NEJMoa2028198

T-REX trial: tirzepatide with or without resistance training (Univ. of Western Australia). Preliminary. ANZCTR ACTRN12623001236684

Creatine + GLP-1 pilot (Univ. of Saskatchewan). Ongoing, results expected 2027. ClinicalTrials.gov NCT07625202

Momma H, et al. Muscle-strengthening activities and lower risk/mortality in major non-communicable diseases. Br J Sports Med 2022. PubMed 35228201

Wall BT, et al. 2014. Immobilization and disuse muscle atrophy (quadriceps −3.5% at 5 days, −8% at 14 days). PubMed 24168489

Gaffney CJ, et al. 2021. Grip strength loss with short-term arm immobilization. PMC8107283

Farthing JP, et al. 2009. Cross-education and preservation of the immobilized limb. PubMed 19150859

Marusic U, et al. 2021. Bed rest: strength loss outpaces size loss. PMC8325614

Yoshihara, et al. 2023. Sepsis-associated muscle wasting (−26% in a week). PMC10003568

Warren GL, et al. 2017. Strength loss and recovery after muscle injury (meta-analysis). PMC5214801

Hortobágyi T, et al. 1993. Short-term detraining in strength athletes. PubMed 8371654

Gavanda S, et al. 2020. Training cessation in previously untrained adolescents. PMC7241623

Lovell DI, et al. 2010. Detraining strength loss in older adults. PubMed 20140683

Mujika I, Padilla S. 2001. Physiology of detraining (review). PubMed 11474330

Smith K, et al. 2003. Two years of training, then detraining, in older adults. PubMed 12955872

Staron RS, et al. 1991. Detraining and muscle cross-sectional area in women. PubMed 1827108

Ivey FM, et al. 2000. Detraining across age and sex. PubMed 10795719

Taaffe DR, et al. 2009. Training and detraining in older adults. PMC2756799

Grgic J, et al. 2022. Muscle size loss with detraining (meta-analysis). PubMed 36360927

Bosquet L, et al. 2013. Detraining effects on strength and power. PubMed 23347054

Bruusgaard JC, et al. 2010. Myonuclei acquired by overload persist after detraining (muscle memory). PMC2930527

Weakley J, et al. 2017. Day-to-day variation in strength performance. PubMed 28277425

McGuigan MR, et al. 2004. Strength performance variability. PubMed 15320651

Andreoli A, et al. 2009. DEXA precision and assumptions. PMC9263164

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Is there really a “menopause-specific” way to train, eat, and supplement — or is most of it marketing? In the finale of our 4-part menopause series, Drs. Jordan Feigenbaum and Austin Baraki go straight to the evidence on building muscle and bone before, during, and after the transition.

We cover whether menopause blunts your response to lifting (the Isenmann 2023 head-to-head trial and the 2026 meta-analysis of ~4,000 women say it doesn’t), the one-index-card prescription that actually works. Then we work through the loudest claims in the space — cortisol “wrecking” your fat loss, anabolic resistance, the protein and creatine hype, hormone therapy as a cure-all, and “you need a different paradigm” — steelmanning each before we push back. We close with the strongest case in the whole space: heavy lifting for bone density (the LIFTMOR trial), the pelvic-floor evidence, your three biggest fears answered, and how to tell a good coach or clinician from a bad one.

Claims discussed are associated with Stacey Sims, Mary Claire Haver, Mindy Pelz, and the broader functional-medicine space. We push back on the claims, not the people.

Timestamps:

• 0:00 The 90-year-olds who tripled their strength
•  1:10 Why this matters: heart disease and falls, not vanity
•  2:28 Can women still build muscle after menopause? (Isenmann 2023)
•  7:31 Does menopause blunt your gains? The 2026 meta-analysis
•  8:49 Is it menopause, or just individual variation?
•  14:42 The estrogen "shield" and the mechanical override
•  18:31 Does hormone therapy replace training? (the 2021 estradiol trial)
•  22:44 What actually works: the whole prescription
•  24:18 Program details: frequency, volume & insulin sensitivity
•  30:22 Nutrition: protein and the 2026 review
•  35:06 Creatine, vitamin D & calcium
•  43:29 Anabolic resistance: mostly overstated
•  47:22 Clinical case: the supplement-stack patient
•  52:23 A short history of wrong advice for women
•  53:38 Claim 1: "Lift heavy or lose your bones" (Stacey Sims)
•  1:01:09 Claim 2: the cortisol myth
•  1:15:18 Clinical case: the cortisol-anxious patient
•  1:18:20 Claim 3: "It's all hormonal, HRT fixes it" (Mary Claire Haver)
•  1:20:45 Testosterone in women: what it does and doesn't do
•  1:21:51 Claim 4: "Menopause needs its own paradigm" & the SWAN data
•  1:24:48 Bone density done right: the LIFTMORE trial
•  1:33:07 Does heavy lifting wreck your pelvic floor?
•  1:38:59 Your three biggest fears, answered
•  1:40:44 Green flags & red flags 

Resources:

• Menopause Series Part 1 : https://www.youtube.com/watch?v=yzk0IkTy0WM
• Menopause Series Part 2 — https://www.youtube.com/watch?v=YKAlamIOiwU
•  Menopause Series Part 3 — https://www.youtube.com/watch?v=jzoNMQaBAcI 
• Hypercortisolism episode - https://open.spotify.com/episode/7tDdUi8dDFWjMYx0fRJdOz 

Barbell Medicine coaching and templates: https://www.barbellmedicine.com

Signal book pre-order: https://www.barbellmedicine.com/shop/learning/signal/

Isenmann (2023) https://doi.org/10.1186/s12905-023-02671-y

Isenmann (2026) https://doi.org/10.1016/j.jsams.2026.01.004

Fiatarone (1990) https://doi.org/10.1001/jama.1990.03440220053029

Fiatarone (1994) https://doi.org/10.1056/NEJM199406233302501

Dam (2021) https://doi.org/10.3389/fphys.2020.596130

Markofski (2015) https://doi.org/10.1016/j.exger.2015.02.015

Orsatti (2022) https://doi.org/10.1016/j.exger.2022.111904

Walter (2026) https://doi.org/10.1186/s40798-025-00954-2

dos Santos (2021) https://doi.org/10.3390/nu13113757

Myung (2021) https://doi.org/10.3390/nu13020368

Dote-Montero (2021) https://doi.org/10.1111/sms.13999

Ravussin (2015) https://doi.org/10.1093/gerona/glv057

Cadegiani (2016) https://doi.org/10.1186/s12902-016-0128-4

Greising (2009) https://doi.org/10.1093/gerona/glp082

Islam (2019) https://doi.org/10.1016/S2213-8587(19)30189-5

Testosterone in women review (2026) https://doi.org/10.1080/09513590.2025.2592402

NAMS nonhormone position statement (2023) https://doi.org/10.1097/GME.0000000000002200

Vasomotor exercise meta-analysis (2022) https://doi.org/10.1080/13697137.2022.2097865

Greendale (2019) https://doi.org/10.1172/jci.insight.124865

Watson, LIFTMOR (2018) https://doi.org/10.1002/jbmr.3284

Skaug (2024) https://doi.org/10.1249/MSS.0000000000003278

Skaug (2021) https://doi.org/10.1007/s00192-021-04739-5

Dumoulin (2018) https://doi.org/10.1002/14651858.CD005654.pub4

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Most women in 2026 are told menopause affects everything, the weight, the belly fat, the bones, the heart, the brain, and that the fix is hormones, supplements, and a proprietary protocol. The data tell a different story. Menopause does some of it, but not all of it.

In this episode, Dr. Jordan Feigenbaum and Dr. Austin Baraki, with OB-GYN Dr. Loraine Baraki at the clinical handoffs, put real numbers on what menopause actually changes, e.g. body composition, the cardiometabolic shift around the final menstrual period, bone, cognition and sleep — and on the single biggest modifiable lever against what actually kills postmenopausal women.

This is Episode 3 of Barbell Medicine's four-part menopause series.

Timestamps:

• 01:23 Intro 
• 02:45 Body composition & the SWAN study 
• 04:16 How much weight gain is really menopause?
•  06:55 The answer: about 1.5 kg 08:14 Subcutaneous vs visceral fat
•  11:08 Why waist beats weight (and body-fat %) 
• 17:21 Does menopause crash your metabolism? 19:02 Clinic: MHT for body composition 
• 23:51 Dr. Loraine Baraki — MHT, weight & testosterone 
• 27:29 The cardiometabolic shift: cholesterol at the FMP 
• 30:18 Insulin resistance & metabolic syndrome 
• 33:12 Blood pressure & 10-year heart risk 
• 34:54 Clinic: the "estrogen crisis" lipid panic 
• 39:13 Bone: the advice vs the data 40:34 Why DXA misses most fractures 
• 41:24 LIFTMOR: lifting heavy with low bone density 
• 44:47 The LIFTMOR results 
• 46:53 Lifting vs Pilates, and falls 
• 52:17 Clinic: "Should I be deadlifting?" 
• 56:14 Cognition & brain fog 
• 57:50 Why brain fog is mostly a sleep problem 
• 59:17 Clinic: brain fog, night sweats, broken sleep 
• 1:03:06 Depression & dementia in midlife 
• 1:05:43 Does hormone therapy protect the brain? 
• 1:08:53 Clinic: "Am I getting early dementia?" 
• 1:13:19 Dr. Loraine Baraki — the timing hypothesis & the brain
• 1:16:15 What actually kills postmenopausal women 
• 1:17:31 Fitness: the biggest mortality lever 
• 1:20:21 Strength, power & grip 
• 1:25:15 Clinic: where to start when you're overwhelmed 
• 1:30:41 The detraining problem 
• 1:32:38 Trained vs untrained: what's recoverable 
• 1:34:53 The actual plan 
• 1:39:48 Takeaways

Resources:

Subscribe to BBM Plus for the full unabridged Direct Line: https://barbellmedicine.supercast.com/

Barbell Medicine coaching and templates: https://www.barbellmedicine.com/

Signal book pre-order: https://www.barbellmedicine.com/shop/learning/signal/

Body composition & metabolism

 Greendale et al., SWAN body composition, JCI Insight 2019: https://doi.org/10.1172/jci.insight.124865

 Lovejoy et al., visceral fat across the transition, Int J Obes 2008: https://doi.org/10.1038/ijo.2008.25

 Pontzer et al., daily energy expenditure across life, Science 2021: https://doi.org/10.1126/science.abe5017

 Karppinen et al., metabolism in midlife women, Eur J Prev Cardiol 2023: https://doi.org/10.1093/eurjpc/zwad177

Cardiometabolic

Matthews et al., lipid changes & the menopause transition, JACC 2009: https://doi.org/10.1016/j.jacc.2009.10.009

Janssen et al., menopause & metabolic syndrome (SWAN), Arch Intern Med 2008: https://doi.org/10.1001/archinte.168.14.1568

 El Khoudary et al., AHA Scientific Statement on midlife women, Circulation 2020: https://doi.org/10.1161/CIR.0000000000000912

Bone

Greendale et al., SWAN bone loss across the FMP, JBMR 2012: https://doi.org/10.1002/jbmr.534

 Siris et al., undiagnosed low BMD & fractures (NORA), JAMA 2001: https://doi.org/10.1001/jama.286.22.2815

 Watson et al., LIFTMOR, JBMR 2018: https://doi.org/10.1002/jbmr.3284

Kemmler et al., EFOPS 16-year, Menopause 2017: https://doi.org/10.1097/GME.0000000000000720

Kistler-Fischbacher et al., MEDEX-OP, JBMR 2021: https://doi.org/10.1002/jbmr.4334

 Sherrington et al., exercise for preventing falls, Cochrane 2019: https://doi.org/10.1002/14651858.CD012424.pub2

ACSM Position Stand: Osteoporosis and Exercise, Med Sci Sports Exerc 1995;27(4):i–vii (no DOI)

Cognition & mood

Greendale et al., SWAN cognition, Neurology 2009: https://doi.org/10.1212/WNL.0b013e3181a71193

Kravitz et al., sleep in midlife women, Obstet Gynecol Clin North Am 2018: https://doi.org/10.1016/j.ogc.2018.07.008

Cohen et al., Harvard Study of Moods and Cycles, Arch Gen Psychiatry 2006: https://doi.org/10.1001/archpsyc.63.4.385

Bromberger & Kravitz, mood and menopause (SWAN), Obstet Gynecol Clin North Am 2011: https://doi.org/10.1016/j.ogc.2011.05.011

Livingston et al., Lancet Commission on dementia 2024: https://doi.org/10.1016/S0140-6736(24)01296-0

Shumaker et al., WHIMS (estrogen+progestin & dementia), JAMA 2003: https://doi.org/10.1001/jama.289.20.2651

 Espeland et al., WHIMS (estrogen-alone & cognition), JAMA 2004: https://doi.org/10.1001/jama.291.24.2959

Gleason et al., KEEPS-Cog, PLoS Med 2015: https://doi.org/10.1371/journal.pmed.1001833

 Henderson et al., ELITE (timing hypothesis & cognition), Neurology 2016: https://doi.org/10.1212/WNL.0000000000002980

USPSTF, hormone therapy for primary prevention, JAMA 2022: https://doi.org/10.1001/jama.2022.18625

Fitness & mortality

 Mandsager et al., cardiorespiratory fitness & mortality, JAMA Netw Open 2018: https://doi.org/10.1001/jamanetworkopen.2018.3605

Kodama et al., fitness & mortality meta-analysis, JAMA 2009: https://doi.org/10.1001/jama.2009.681

Sui et al., fitness & adiposity in older adults, JAMA 2007: https://doi.org/10.1001/jama.298.21.2507

Momma et al., muscle-strengthening activity & mortality, Br J Sports Med 2022: https://doi.org/10.1136/bjsports-2021-105061

Araújo et al., muscle power vs strength & mortality (CLINIMEX), Mayo Clin Proc 2025: https://doi.org/10.1016/j.mayocp.2025.02.015

Leong et al., grip strength & mortality (PURE), Lancet 2015: https://doi.org/10.1016/S0140-6736(14)62000-6

Detraining & trained-vs-untrained

Troiano et al., accelerometer-measured activity, Med Sci Sports Exerc 2008: https://doi.org/10.1249/mss.0b013e31815a51b3

Fleg et al., aerobic-capacity decline (BLSA), Circulation 2005: https://doi.org/10.1161/CIRCULATIONAHA.105.545459

Ratley et al. aerobic-capacity changes during menopause, 2025

https://pmc.ncbi.nlm.nih.gov/articles/PMC12358808/

Janssen et al., skeletal muscle mass across adulthood, J Appl Physiol 2000: https://doi.org/10.1152/jappl.2000.89.1.81

 Pollock et al., master athletes & aerobic capacity, J Appl Physiol 1987: https://doi.org/10.1152/jappl.1987.62.2.725

Latella et al., strength across ages in powerlifters, Sports Med 2024: https://doi.org/10.1007/s40279-023-01962-6

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The story goes that hard exercise is risky for women, and that the idea is ancient. Both halves fall apart on contact. In this solo episode, Dr. Jordan Feigenbaum follows the claim that physical effort harms the female body across twenty centuries, and shows that almost every version of it arrived as a verdict first, with the science bolted on afterward.

It runs from antiquity to the present: what Galen actually wrote, why Sparta trained its women on purpose, the Victorian “vital force” panic and Edward Clarke’s claim that studying would sterilize girls, the doctor who prescribed bed rest to women and the wilderness to men, and the 1928 Olympic 800m that was erased for 32 years over a collapse that never happened. Then the correction: the research that finally tested heavy training in older women and women with low bone mass, and what it found. The episode closes on 2026, where the guidelines say lift and the menopause market often says don’t.

What we cover

•    Why the “ancient Greeks” origin story for the no-hard-exercise rule doesn’t hold up.

•    How a Victorian energy-budget idea became a medical case against women lifting and studying.

•    The real story of the 1928 Olympic women’s 800m and the 32-year ban.

•    The strong women who were relabeled as freaks or exceptions instead of counted.

•    What Fiatarone’s nonagenarians and LIFTMOR actually showed about lifting heavy later in life.

•    The cortisol panic, the fasting scare, and cycle syncing, examined against the data.

•    Why the cautious messaging now comes from the market, not the medical guidelines.

Timestamps

• 00:00 The 1928 Olympic “massacre” that never happened
• 03:37 Antiquity: what the Greeks actually said
• 06:50 The Victorians and “vital force”
• 10:02 Mary Putnam Jacobi tests the claim, and is ignored
• 11:53 1928 in full: who killed the women’s 800m
• 13:53 The double standard, and Alice Milliat
• 15:39 The strong women history relabeled
• 20:26 The correction: what the evidence shows
• 22:27 LIFTMOR: lifting heavy with low bone mass
• 24:35 2026: guidelines, the market, and cortisol
• 28:34 Cycle syncing, and naming the pattern
• 30:40 What to take away

Subscribe to BBM Plus for the full unabridged Direct Line: https://barbellmedicine.supercast.com/

Barbell Medicine coaching and templates: https://www.barbellmedicine.com/

Signal book pre-order: https://www.barbellmedicine.com/shop/learning/signal/

References

Cahn S. Coming on Strong: Gender and Sexuality in Twentieth-Century Women's Sport. Harvard University Press; 1994.

Clarke EH. Sex in Education; or, A Fair Chance for the Girls. Boston: James R. Osgood and Company; 1873.

Colenso-Semple LM, McKendry J, Lim C, et al. Menstrual cycle phase does not influence muscle protein synthesis or whole-body myofibrillar proteolysis in response to resistance exercise. J Physiol. 2025. PMID: 39630025.

Daly W, Hackney AC. Is exercise cortisol response of endurance athletes similar to levels of Cushing's syndrome? J Sports Med Phys Fitness. 2019. PMID: 31371847.

Eastell R, Rosen CJ, Black DM, Cheung AM, Murad MH, Shoback D. Pharmacological management of osteoporosis in postmenopausal women: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2019;104(5):1595-1622. PMID: 30907953.

Fiatarone MA, Marks EC, Ryan ND, Meredith CN, Lipsitz LA, Evans WJ. High-intensity strength training in nonagenarians: effects on skeletal muscle. JAMA. 1990;263(22):3029-3034. PMID: 2342214.

Fiatarone MA, O'Neill EF, Ryan ND, et al. Exercise training and nutritional supplementation for physical frailty in very elderly people. N Engl J Med. 1994;330(25):1769-1775.

Galen. On the Preservation of Health (De Sanitate Tuenda). 2nd century CE. Various translations.

Jacobi MP. The Question of Rest for Women During Menstruation. New York: G.P. Putnam's Sons; 1877. (Awarded the Harvard Boylston Prize.)

Latella C, Teo WP, Spathis J, et al. Using powerlifting athletes to determine strength adaptations across ages in males and females: a longitudinal growth modelling approach. Sports Med. 2024;54(3):753-774.

Maudsley H. Sex in mind and in education. Fortnightly Review. 1874;15:466-483.

Plutarch. Life of Lycurgus. Approx. 75 CE. Various translations.

Schultz J. Qualifying Times: Points of Change in U.S. Women's Sport. Urbana: University of Illinois Press; 2014.

Sinaki M, Mikkelsen BA. Postmenopausal spinal osteoporosis: flexion versus extension exercises. Arch Phys Med Rehabil. 1984;65(10):593-596. PMID: 6487063.

Soranus of Ephesus. Gynecology. Approx. 2nd century CE. Translated by Temkin O. Baltimore: Johns Hopkins University Press; 1991.

Switzer K. Marathon Woman: Running the Race to Revolutionize Women's Sports. Cambridge, MA: Da Capo Press; 2007.

Todd J. Various publications. Iron Game History. Stark Center for Physical Culture and Sports, University of Texas at Austin.

Tunis JR. Women and the Olympic Games. Harper's Magazine. July 1929. (And contemporaneous press coverage.)

Watson SL, Weeks BK, Weis LJ, Harding AT, Horan SA, Beck BR. High-intensity resistance and impact training improves bone mineral density and physical function in postmenopausal women with osteopenia and osteoporosis: the LIFTMOR randomized controlled trial. J Bone Miner Res. 2018;33(2):211-220. PMID: 30861219.

Xenophon. Constitution of the Lacedaemonians. Approx. 4th century BCE. Various translations.

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In 1889 a French physiologist injected himself with guinea pig and dog testicle extract and published a claim of self-rejuvenation in The Lancet. That announcement kicked off a 200-year medicalization of menopause that ran through leeches and bromides, Premarin, the 2002 Women's Health Initiative, and the contemporary menopause-content space. 

In Episode 1 of our three-part menopause series, Dr. Jordan Feigenbaum and Dr. Austin Baraki walk through what menopause actually is at the hormonal level, which midlife symptoms are menopause-driven and which are not, the KNDy neuron mechanism behind hot flashes (and the new medication that blocks it), and the 24-year follow-up on the WHI that substantially revised the original conclusions. OB-GYN Dr. Loraine Baraki walks the clinical workup, the lab panel she actually orders, and how she handles patients arriving with DUTCH panels and compounded hormone protocols.

If you have heard contradictory things about menopause hormone therapy from your primary care, your menopause coach, and your sister, that is not your fault. The evidence base has been revised in significant ways since the 2002 publication, and most patient-facing summaries are out of date.

Timestamps

• 00:00 Cold open: 200 years of menopause medicine
• 03:23 Welcome and roadmap
• 04:20 The HPG axis, follicles, and the FSH lag
• 09:11 STRAW+10 staging and the timing of perimenopause
• 13:47 Austin: the 49-year-old with a hormone panel
• 20:00 Loraine: the OB-GYN workup
• 28:00 Symptom attribution: what menopause actually causes
• 33:46 Austin: the all-estrogen patient
• 37:58 VMS duration and the KNDy mechanism (Avis, SKYLIGHT)
• 43:53 Austin: who actually gets fezolinetant
• 47:22 The WHI 24-year correction (Manson, Chlebowski, Boardman)
• 01:00:15 Modern prescribing today
• 01:06:52 Where the menopause-content space gets it right and wrong
• 01:11:50 Testosterone, compounded bioidenticals, and DUTCH panels
• 01:24:13 Takeaways

What we cover

• The HPG axis and the estrogen shield: what is happening across the 35-year reproductive era and what changes at perimenopause.
• STRAW+10 staging: how long perimenopause actually lasts and where most women fall in the timeline.
•  Symptom attribution: hot flashes and genitourinary syndrome are menopause. Weight gain, sleep, and joint pain are mostly other things.
• The KNDy neuron mechanism behind hot flashes and the new pharmacology that blocks it (fezolinetant, elinzanetant).
• The Women's Health Initiative: what the trial actually tested, what the 2002 result said, and what 24 years of follow-up have shown since then. The estrogen-alone arm reduced breast cancer incidence by 22% and mortality by 40% over 20 years.
• The timing hypothesis: hormone therapy started within 10 years of the final menstrual period vs more than 10 years out.
• Modern prescribing today: transdermal estradiol plus micronized progesterone, and why the formulations matter.
• Where the contemporary menopause-content space gets it right and wrong: the undertreatment problem, the zone-of-chaos framing, and the testosterone-for-everything marketing.
• Testosterone in women: one guideline-supported indication.
• Compounded bioidenticals and DUTCH panels.

Resources

• Subscribe to BBM Plus for the full unabridged Direct Line: https://barbellmedicine.supercast.com/
• Barbell Medicine coaching and templates: https://www.barbellmedicine.com/
• Signal book pre-order: https://www.barbellmedicine.com/shop/learning/signal
• Manson JE et al. 18-year mortality from the WHI. JAMA, 2017. https://pubmed.ncbi.nlm.nih.gov/28898378/
• Chlebowski RT et al. WHI estrogen-alone arm at 20 years. JAMA, 2020. https://pubmed.ncbi.nlm.nih.gov/32706854/
•  Boardman HMP et al. Hormone therapy for cardiovascular prevention. Cochrane, 2015. https://pubmed.ncbi.nlm.nih.gov/25754617/
• Avis NE et al. Duration of VMS in the SWAN cohort. JAMA Intern Med, 2015. https://pubmed.ncbi.nlm.nih.gov/25686030/
• Lederman S et al. SKYLIGHT 1, fezolinetant. The Lancet, 2023. https://pubmed.ncbi.nlm.nih.gov/36924778/
• Johnson KA et al. SKYLIGHT 2, fezolinetant. JCEM, 2023. https://pubmed.ncbi.nlm.nih.gov/37410020/
• USPSTF. Hormone therapy for primary prevention. JAMA, 2022. https://pubmed.ncbi.nlm.nih.gov/36318127/
• Davis SR et al. Global Consensus on testosterone in women. JCEM, 2019. https://pubmed.ncbi.nlm.nih.gov/31498871/

Our Sponsors:
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Advertising Inquiries: https://redcircle.com/brands

This is the free preview of the May 2026 Direct Line, our monthly AMA for Barbell Medicine Plus subscribers. Three reader questions answered in full.

We open with a mid-30s woman with bilateral shin pain and exertional foot numbness who started creatine a month ago and is asking whether the supplement is the cause. We walk through the compartment syndrome literature, the 2025 case report being passed around online and misinterpreted, what creatine actually does to total body water (and what it doesn’t), the four compartment pressure studies that exist, the Waterman 2013 demographic data on who actually gets chronic exertional compartment syndrome, and the workup we would actually run if this person walked into clinic.

Next, whether splitting your resistance training across the day affects strength and hypertrophy. We cover BBM’s general heuristic on frequency as a distribution tool for training load, the Schoenfeld meta-analyses on frequency (2016 and 2019), the wrinkle on cardiorespiratory fitness and exercise snacks, and where we go off the reservation compared to a strict evidence-based read.

We close with endometriosis for the lifter, including the seven-year average diagnostic delay, the 2022 ESHRE guideline shift away from required laparoscopy, what the menstrual cycle and performance literature actually says (McNulty 2020), why the anti-inflammatory diet narrative is mostly noise, the iron and protein levers that matter, post-operative return-to-lifting timelines, the meet-timing question, and Austin’s clinical case walk on supplement stacks and GLP-1 anti-inflammatory effects. A dedicated full episode on endometriosis is coming this summer.

The full unabridged Direct Line covers ten more questions, including where the GLP-1 strength trials actually are, why DEXA misleads on muscle mass loss, how we arrived at the Vital 5 weightings, the salt sermon for strongman, running shoes for casual runners, hernias and crunches in older lifters, the Bristol Stool Chart, Austin on coaching his residents, and a fresh reading list. Full episode on BBM Plus.

Timestamps:

Question 1 · Creatine and shin pain01:2713:21

Question 2 · Splitting your workout across the day13:2120:29

Question 3 · Endometriosis for the lifter20:29

What we cover:

The clinical workup for chronic exertional compartment syndrome and why creatine is rarely the culprit. The Schoenfeld frequency literature and why training load matters more than the day it’s distributed across. Endometriosis basics including diagnostic delay, prevalence, and the 2022 ESHRE guideline change. Why most endometriosis “diets” don’t have evidence behind them, and which nutrition levers actually matter (iron, protein, energy availability). Post-operative return to training, meet-timing options, supplement stacks, and the role of GLP-1 receptor agonists in chronic anti-inflammatory effects.

Resources:

Subscribe to BBM Plus for the full unabridged Direct Line: https://barbellmedicine.supercast.com/

Barbell Medicine coaching and templates: https://www.barbellmedicine.com/

Signal book pre-order: https://www.barbellmedicine.com/shop/learning/signal/

Waterman B.R. et al. 2013. Risk factors for chronic exertional compartment syndrome in a physically active military population. Am J Sports Med 41(11):2545-2552.

https://pubmed.ncbi.nlm.nih.gov/24036570/

Powers M.E. et al. 2003. Creatine supplementation increases total body water without altering fluid distribution. J Athl Train 38(1):44-50.

https://pubmed.ncbi.nlm.nih.gov/12937471/

Antonio J. et al. 2021. Common questions and misconceptions about creatine supplementation (ISSN position). J Int Soc Sports Nutr 18(1):13.

https://pubmed.ncbi.nlm.nih.gov/33557850/

Bruneau A. et al. 2025. Creatine supplementation associated with chronic exertional compartment syndrome: case report. [TO ADD: PMID once indexed]

Schoenfeld B.J. et al. 2016. Effects of resistance training frequency on measures of muscle hypertrophy: a systematic review and meta-analysis. Sports Med 46(11):1689-1697.

https://pubmed.ncbi.nlm.nih.gov/27102172/

Schoenfeld B.J. et al. 2019. How many times per week should a muscle be trained to maximize hypertrophy? J Sports Sci 37(11):1286-1295.

https://pubmed.ncbi.nlm.nih.gov/30558493/

ESHRE Endometriosis Guideline Development Group. 2022. ESHRE guideline: endometriosis. Hum Reprod Open 2022(2):hoac009.

https://pubmed.ncbi.nlm.nih.gov/35350465/

McNulty K.L. et al. 2020. The effects of menstrual cycle phase on exercise performance in eumenorrheic women: systematic review and meta-analysis. Sports Med 50(10):1813-1827.

https://pubmed.ncbi.nlm.nih.gov/32661839/

Our Sponsors:
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Most cases of low testosterone in modern men are not a problem with the testes. The number is downstream of body composition, sleep, and energy availability. The wellness-clinic algorithm walks past every one of them.

Jordan and Austin walk through what actually drives men’s testosterone down, the mechanisms behind it, and the modifiable levers that bring it back up. MOSH, the leptin and Kisspeptin pathway, the aromatase loop, the sleep apnea picture most clinics never ask about, the GLP-1 and weight-loss data on testosterone recovery, the low energy availability case that hits high-volume lifters harder than they realize, and the closing question of when a standard-dose TRT prescription actually functions as a PED.

This is Episode 3 of our four-part Signal book launch series. Mark, the patient we have been threading from Episode 1, finally gets his diagnosis revealed.

Timestamps

• 00:00 The 9x stat and Mark's diagnosis revealed
•  02:10 How body fat suppresses testosterone (MOSH)
•  07:26 Primary vs secondary causes, and Klinefelter
•  11:35 Leptin and the Kisspeptin pathway
•  14:38 Mark: the body-composition picture
•  16:10 The 40-inch-waist case
•  20:01 Weight loss, GLP-1s, and does Ozempic raise testosterone?
•  24:21 T4DM: adding testosterone to lifestyle
•  28:35 Sleep, OSA, and Mark's diagnosis
•  38:39 TRT in untreated sleep apnea
•  41:47 Can you train your testosterone down? (LEA / EHMC)
•  50:12 Replacement dose vs PED
•  55:47 Four takeaways
•  57:46 Episode 4 preview and book pre-order

What we cover:

•         How body fat suppresses testosterone at two different points in the HPG axis, and why the loop is self-reinforcing

•         The leptin and Kisspeptin pathway most clinics never address

•         Mark’s case: a 45-year-old with a 240 ng/dL afternoon draw, no workup, and an immediate prescription

•         Primary versus secondary causes, and why Klinefelter syndrome is the under-recognized one to not miss

•         Weight loss dose-response: how much testosterone climbs on lifestyle alone, with GLP-1 agonists, and after bariatric surgery

•         T4DM: why adding testosterone to a structured weight-loss program produced no extra quality-of-life benefit over placebo

•         One week of sleep restriction drops testosterone by about 15 percent in healthy young men; eight days of military field exercises drop it by 50 percent

•         Why CPAP for obstructive sleep apnea reliably improves symptoms but does not always move the lab number

•         The opposite extreme: low energy availability, relative energy deficiency in sport, and the exercise-hypogonadal male condition

•         The lifter calculus: when a textbook replacement dose is functionally a PED in a chronically underfueled trainee

Resources mentioned:

• Signal book pre-order: https://barbellmedicine.com/signal
•  Training Plateau Action Plan (free): https://www.barbellmedicine.com/training-plateau-action-plan/
•  Barbell Medicine programs and coaching: https://www.barbellmedicine.com/
•  Episode 1 (Is the Testosterone Crisis Real?)
•  Episode 2 (Is Your Testosterone Actually Low?
• 
  

Referenced studies:

Wu F.C.W. et al. 2010. Identification of late-onset hypogonadism in middle-aged and elderly men (EMAS). N Engl J Med 363(2):123-135.

 https://pubmed.ncbi.nlm.nih.gov/20554979/

 

 Travison T.G. et al. 2011. The natural history of symptomatic androgen deficiency in men. J Am Geriatr Soc.

 https://pubmed.ncbi.nlm.nih.gov/18454751/

 

 Corona G. et al. 2013. Body weight loss reverts obesity-associated hypogonadotropic hypogonadism: systematic review and meta-analysis. Eur J Endocrinol 168(6):829-843.

 https://pubmed.ncbi.nlm.nih.gov/23482592/

 

 Kounatidis D. et al. 2025. The impact of GLP-1 receptor agonists on erectile function. Biomolecules 15(9):1284.

 https://doi.org/10.3390/biom15091284

 

 Grossmann M. et al. 2024. Testosterone treatment, weight loss, and health-related quality of life and psychosocial function in men: 2-year RCT (T4DM QoL arm). J Clin Endocrinol Metab 109(8):2019-2028.

 https://pubmed.ncbi.nlm.nih.gov/38311835/

 

 Leproult R., Van Cauter E. 2011. Effect of 1 week of sleep restriction on testosterone levels in young healthy men. JAMA 305(21):2173-2174.

 https://pubmed.ncbi.nlm.nih.gov/21632481/

 

 Penev P.D. 2007. Association between sleep and morning testosterone levels in older men. Sleep 30(4):427-432.

 https://pubmed.ncbi.nlm.nih.gov/17520785/

 

 Wittert G. 2014. The relationship between sleep disorders and testosterone in men. Asian J Androl 16(2):262-265.

 https://pubmed.ncbi.nlm.nih.gov/24435056/

 

 Alemany J.A. et al. 2008. Effects of dietary protein content on IGF-I, testosterone, and body composition during 8 days of severe energy deficit and arduous physical activity. J Appl Physiol 105(1):58-64.

 https://pubmed.ncbi.nlm.nih.gov/18450989/

 

 Mountjoy M., Sundgot-Borgen J.K., Burke L.M. et al. 2018. IOC consensus statement on relative energy deficiency in sport (RED-S): 2018 update. Br J Sports Med 52:687-697.

 https://pubmed.ncbi.nlm.nih.gov/29773536/

 

 Areta J.L. et al. 2021. Low energy availability: history, definition and evidence of its endocrine, metabolic and physiological effects in prospective studies in females and males. Eur J Appl Physiol 121(1):1-21.

 https://pubmed.ncbi.nlm.nih.gov/33095376/

 

 Mäestu J. et al. 2010. Anabolic and catabolic hormones and energy balance of the male bodybuilders during the preparation for the competition. J Strength Cond Res 24(4):1074-1081.

 https://pubmed.ncbi.nlm.nih.gov/20300023/

 

 Hooper D.R. et al. 2018. Treating exercise-associated low testosterone (EHMC). Phys Sportsmed 46(4):427-434.

 https://pubmed.ncbi.nlm.nih.gov/30074435/

 

 Hackney A.C. 2020. Hypogonadism in exercising males: dysfunction or adaptive-regulatory adjustment? Front Endocrinol 11:11.

 https://pubmed.ncbi.nlm.nih.gov/32082252/

Our Sponsors:
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Three weeks of stalled squats. The conventional answer is to switch programs because you've crossed into intermediate territory. The data says something else. In Part 3 of the Progressive Loading series, Dr. Jordan Feigenbaum and Dr. Austin Baraki walk through why the standard novice / intermediate / advanced framework runs into trouble in real training, what the four adaptive systems are actually doing across a training career, and why most of what gets called a stall is impatience with the noise floor at your current strength level.

This is Part 3 of the Progressive Loading series. Part 1 covered why loading should react to demonstrated adaptation. Part 2 covered RPE-based autoregulation and the artificial-momentum approach. Today is the mechanism layer.

Pre-order our book, Signal: barbellmedicine.com/signal

Timestamps

• 0:00 - Why your lifts aren't moving
• 1:52 - The novice / intermediate / advanced framework, three claims to test
• 13:23 - What 17 years of powerlifting data show about how long you keep getting stronger
• 32:28 - How getting stronger actually works (four systems on four clocks)
• 38:00 - What early growth is actually made of (the Damas 2016 deuterium study)
• 50:33 - The connective tissue lag and why early-training injuries happen
• 58:32 - Why heavy lifting works for bone density (and why "walk on a treadmill" advice misses)
• 1:05:10 - Why new lifters get hurt 3 to 10 times more than experienced lifters
• 1:12:56 - Fatigue is at least four different things (and most coaches treat it as one)
• 1:26:19 - The CNS fatigue myth (and what the data actually says)
• 1:33:52 - When the bar isn't moving: how to actually diagnose a stall
• 1:45:51 - Takeaways and next week's tease: leptin and low testosterone

What we cover 

- The novice / intermediate / advanced framework: three claims and why each one fails the data test

- The 17-year IPF strength curve and what the no-kink finding does and does not establish (Latella 2024)

- The four adaptive systems and their separate timescales (neural, muscle, connective tissue, bone)

- What early growth actually is, including the deuterium-oxide finding that most week-3 size is fluid (Damas 2016)

- Why connective tissue lags muscle by six to eight weeks, and why that produces patellar tendinopathy four months in

- The 9.5 vs 0.74 to 3.3 injury rate gap between novice and experienced CrossFit participants

- The CNS fatigue myth and the Skarabot 2018 finding that locates the fatigue in the muscle, not the brain

- Why the LIFTMOR trial result (heavy lifting for bone density in women in their 60s and 70s) is being missed by primary care

- A practical decision tree for stalls: environment first, then load, then program

- Tease for next week: leptin, the HPG axis, and the metabolic driver of low testosterone almost nobody connects

Resources 

Training Plateau Action Plan (free): https://www.barbellmedicine.com/training-plateau-action-plan/

Progressive Loading article series: https://www.barbellmedicine.com/blog/progressive-loading/

Beyond Progressive Overload (Part 2 article): https://www.barbellmedicine.com/blog/beyond-progressive-overload/

BBM Programs and Coaching: https://www.barbellmedicine.com/

Support our work on barbellmedicine.supercast.com

Latella C et al. Using powerlifting athletes to determine strength adaptations across ages in males and females. Sports Med. 2024. https://pubmed.ncbi.nlm.nih.gov/

Del Vecchio A et al. The increase in muscle force after 4 weeks of strength training is mediated by adaptations in motor unit recruitment and rate coding. J Physiol. 2019. https://pubmed.ncbi.nlm.nih.gov/30644584/

Lecce E et al. Resistance training-induced adaptations in the neuromuscular system. J Physiol. 2025.

Balshaw TG et al. Neural adaptations after 4 years vs 12 weeks of resistance training. Scand J Med Sci Sports. 2019. https://pubmed.ncbi.nlm.nih.gov/30474171/

Skarabot J et al. Voluntary activation and agonist EMG amplitude in resistance-trained men. J Appl Physiol. 2021.

Roberts MD et al. Mechanisms of mechanical overload-induced skeletal muscle hypertrophy. Physiol Rev. 2023.

Damas F et al. Resistance training-induced changes in integrated myofibrillar protein synthesis are related to hypertrophy only after attenuation of muscle damage. J Physiol. 2016. https://pubmed.ncbi.nlm.nih.gov/27219125/

Damas F et al. Early resistance training-induced increases in muscle cross-sectional area are concomitant with edema-induced muscle swelling. Eur J Appl Physiol. 2016. https://pubmed.ncbi.nlm.nih.gov/26280652/

Lazarczuk SL et al. Mechanical, material and morphological adaptations of healthy lower limb tendons. Sports Med. 2022. https://pubmed.ncbi.nlm.nih.gov/35657492/

Kubo K et al. Time course of changes in the human Achilles tendon properties. Eur J Appl Physiol. 2012. https://pubmed.ncbi.nlm.nih.gov/22105708/

Watson SL et al. High-intensity resistance and impact training improves bone mineral density in postmenopausal women: the LIFTMOR randomized controlled trial. J Bone Miner Res. 2018. https://pubmed.ncbi.nlm.nih.gov/28975661/

Aasa U et al. Injuries among weightlifters and powerlifters: a systematic review. Br J Sports Med. 2017. https://pubmed.ncbi.nlm.nih.gov/27445362/

Prieto-Gonzalez P et al. Injuries in novice participants during an eight-week start-up CrossFit program. Int J Environ Res Public Health. 2020. https://pubmed.ncbi.nlm.nih.gov/32155747/

Kanayama G et al. Tendon rupture in body builders. Sports Med. 2015.

Enoka RM, Duchateau J. Translating fatigue to human performance. Med Sci Sports Exerc. 2016. https://pubmed.ncbi.nlm.nih.gov/27015386/

Behrens M et al. Fatigue and human performance: an updated framework. Sports Med. 2023. https://pubmed.ncbi.nlm.nih.gov/

Halperin I et al. Accuracy in predicting repetitions to task failure: scoping review. Sports Med. 2022. https://pubmed.ncbi.nlm.nih.gov/

Skarabot J et al. Neuromuscular fatigue and recovery after heavy resistance, jump, and sprint training. Eur J Appl Physiol. 2018.

Garcia-Ramos A et al. Greater neuromuscular and perceptual fatigue after low-load to failure than heavy-load to failure. 2024.

Minor, Brian MS, CSCS1; Helms, Eric PhD, CSCS2; Schepis, Jacob3. RE: Mesocycle Progression in Hypertrophy: Volume Versus Intensity. Strength and Conditioning Journal 42(5):p 121-124, October 2020. | DOI: 10.1519/SSC.0000000000000581

Our Sponsors:
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Out of 32 symptoms commonly attributed to low testosterone, only 3 actually correlate with it. All three are sexual. The other 29 — fatigue, brain fog, low mood, weight you can't lose, feeling not quite like yourself — are real, but they are produced by something else, and the wellness-clinic funnel runs on getting that wrong.

 

Episode 2 of our Signal book launch series. Dr. Jordan Feigenbaum and Dr. Austin Baraki cover how testosterone actually works, what the number on your lab report is really measuring, and what a real evaluation of low T looks like.

Pre-order our book, Signal: barbellmedicine.com/signal

Timestamps:

00:00 Mark, revisited (cold open)

02:00 How testosterone actually works (HPG axis)

06:14 Why "in range" can still be abnormal

09:24 What your lab number actually measures

12:25 Case: total 230, low SHBG — does this guy need TRT?

17:04 The saturation model — why higher isn't better

21:11 A patient at 480 wants 900: how the conversation goes

28:57 What "in range" actually means (and why 264 is the cutoff)

34:41 The 3 symptoms that matter (out of 32)

37:16 Walking back a 10-symptom checklist

42:31 How a real testosterone workup gets done

46:42 Chasland trial — TRT vs. exercise at low-normal T

49:31 A warning for hard-training men

58:48 Takeaways, tease, and what's coming next 

What we cover:

The HPG axis explained — and why one low total testosterone reading tells you almost nothing about where the problem actually sits.

The difference between total, free, and bioavailable testosterone — and why SHBG, the binding protein the wellness-clinic workup almost always ignores, is what determines whether the number on your lab report is misleading you in either direction.

The saturation model: above roughly 250 ng/dL, the prostate androgen receptor is saturated. Libido follows the same plateau. Pushing a normal man from 500 to 900 isn't doing what the marketing implies.

The EMAS study finding: of 32 symptoms men commonly attribute to low testosterone, only 3 actually correlate. Every other symptom needs a different workup.

How a real testosterone workup gets done — morning sample, fasted, repeat draw, LH/FSH/SHBG to localize and contextualize.

The Chasland 2021 trial: when standard TRT is prescribed properly to middle-aged men with low-normal levels, does it beat exercise? The answer is what most of the wellness-clinic industry is built on getting wrong.

A note for hard-training men: the exercise-hypogonadal-male pattern, what "low-normal" means in someone whose levels are an adaptation to training load rather than a baseline deficit, and why a textbook TRT dose in that man may functionally act as a performance enhancer.

If you have a lab report on your kitchen counter right now, this is what we wrote for you. Signal, the book, drops in May. Pre-order available soon at barbellmedicine.com.

Resources & links

Signal — Feigenbaum & Baraki (Barbell Medicine, 2026): coming soon

Episode 1 (Is the Testosterone Crisis Real?): https://stream.redcircle.com/episodes/b25a8006-57e5-4dc3-b74c-203f6fbcebc1/stream.mp3

Training Plateau Action Plan (free): barbellmedicine.com/training-plateau-action-plan

Barbell Medicine programs and consultations: barbellmedicine.com

To support us and get ad free listening, plus special product discounts, and exclusive content, go to supercast.barbellmedicine.com

Referenced studies

Wu FCW et al. 2010 - Identification of late-onset hypogonadism in middle-aged and elderly men. NEJM 363(2):123-135. [The EMAS 3-of-32 finding]

https://pubmed.ncbi.nlm.nih.gov/20554979/

Bhasin S et al. 2018 - Testosterone Therapy in Men With Hypogonadism: An Endocrine Society Clinical Practice Guideline. JCEM 103(5):1715-1744. [264 ng/dL threshold; first-draw protocol]

https://pubmed.ncbi.nlm.nih.gov/29562364/

Travison TG et al. 2008 - The natural history of symptomatic androgen deficiency in men. JAGS 56(5):831-839. [MMAS: ~50% of initially low values normalize on repeat]

https://pubmed.ncbi.nlm.nih.gov/18308002/

Travison TG et al. 2006 - The relationship between libido and testosterone levels in aging men. JCEM 91(7):2509-2513. [Libido plateau data, Framingham + HIM]

https://pubmed.ncbi.nlm.nih.gov/16670164/

Brambilla DJ et al. 2009 - The effect of diurnal variation on clinical measurement of serum testosterone. JCEM 94(3):907-913. [Why morning, fasted matters]

https://pubmed.ncbi.nlm.nih.gov/19112025/

Morgentaler A & Traish AM. 2009 - Shifting the paradigm of testosterone and prostate cancer: the saturation model and the limits of androgen-dependent growth. Eur Urol 55(2):310-320. [The saturation model]

https://pubmed.ncbi.nlm.nih.gov/18838208/

Trost LW & Mulhall JP. 2016 - Challenges in Testosterone Measurement, Data Interpretation, and Methodological Appraisal of Interventional Trials. J Sex Med 13(7):1029-1046. [Free T unreliability at the low end; equilibrium dialysis as the reference method]

https://pubmed.ncbi.nlm.nih.gov/27210182/

Vermeulen A et al. 1999 - A critical evaluation of simple methods for the estimation of free testosterone in serum. JCEM 84(10):3666-3672. [Calculated free T methodology]

https://pubmed.ncbi.nlm.nih.gov/10523012/

Chasland LC et al. 2021 - Testosterone and exercise: effects on fitness, body composition, and strength in middle-to-older aged men with low-normal serum testosterone levels. Am J Physiol Heart Circ Physiol 320(5):H1985-H1998. [The 12-week trial]

https://pubmed.ncbi.nlm.nih.gov/33739153/

Arun AS et al. 2025 - Reevaluating the Threshold for Low Total Testosterone. Clin Chem 71(5):609-611. [2025 NHANES strength-dissociation reference]

https://pubmed.ncbi.nlm.nih.gov/40066943/

Baillargeon J et al. 2015 - Trends in Androgen Prescribing in the United States, 2001-2011. JAMA Intern Med 175(8):1413-1415. [25% no preceding lab; the 50% no follow-up monitoring gap - referenced from Episode 1]

https://pubmed.ncbi.nlm.nih.gov/26075486/

Our Sponsors:
* Check out Chilipad and use my code BBM for a great deal: https://sleep.me
* Check out Chilipad and use my code sleep.me/BBM for a great deal: https://sleep.me
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Advertising Inquiries: https://redcircle.com/brands

Stop a GLP-1 and about two thirds of the weight loss comes back within a year. Three randomized withdrawal trials (SURMOUNT-4, STEP 1 extension, STEP 4) and a new BMJ 2026 systematic review of 37 RCTs and nearly 10,000 adults all land on the same signal. The cardiometabolic benefits, blood pressure, fasting glucose, lipids, drift back in parallel with the weight. The framing that actually fits the data: GLP-1s behave like a statin. There is a cumulative benefit during exposure, but this does not extend indefinitely,

This month's Direct Line covers two subscriber questions. The first asks what the new BMJ paper on GLP-1 cardiovascular protection after cessation actually shows, and how GLP-1 durability compares to lifestyle-only interventions. The second asks how a postmenopausal woman newly diagnosed with osteopenia should structure her lifting.

Studies referenced: SURMOUNT-4 (Jastreboff, JAMA 2024), STEP 1 extension (Wilding, Diabetes Obes Metab 2022), STEP 4 (Rubino, JAMA 2021), West et al. BMJ 2026 systematic review, Budini 2026 eClinicalMedicine regain meta-analysis, SELECT cardiovascular outcomes, FLOW renal outcomes, the Diabetes Prevention Program, Look AHEAD, POUNDS Lost, and LIFTMOR (Watson, JBMR 2018).

Full episode on BBM+ covers 8 additional subscriber questions. Join at https://barbellmedicine.supercast.com/

Timestamps

• 0:00 Intro
• 1:52 Q1: What happens when you stop a GLP-1
• 5:33 Lifestyle-only comparators: DPP, Look AHEAD, POUNDS Lost
• 8:15 Austin on the cessation conversation 1
• 2:41 BMJ 2026: weight and cardiometabolic regression
• 17:59 The statin framing
• 23:41 Austin: first 6 months off GLP-1
• 28:07 Q2: Osteopenia and heavy lifting
• 35:28 LIFTMOR protocol
• 38:00 Outro

Next Steps

• For evidence-based resistance training programs: barbellmedicine.com/training-programs
• For individualized training consultation: barbellmedicine.com/coaching
• Explore our full library of articles on health and performance: barbellmedicine.com/resources
• To consult with Drs. Baraki or Feigenbaum email us at [email protected]
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Resources

Aronne, Louis J., et al. "Continued Treatment With Tirzepatide for Maintenance of Weight Reduction in Adults With Obesity: The SURMOUNT-4 Randomized Clinical Trial." JAMA, vol. 331, no. 1, 2024, pp. 38–48. https://jamanetwork.com/journals/jama/fullarticle/2812936

Wilding, John P. H., et al. "Weight Regain and Cardiometabolic Effects After Withdrawal of Semaglutide: The STEP 1 Trial Extension." Diabetes, Obesity and Metabolism, vol. 24, no. 8, Aug. 2022, pp. 1553–1564. https://dom-pubs.onlinelibrary.wiley.com/doi/10.1111/dom.14725

Rubino, Domenica, et al. "Effect of Continued Weekly Subcutaneous Semaglutide vs Placebo on Weight Loss Maintenance in Adults With Overweight or Obesity: The STEP 4 Randomized Clinical Trial." JAMA, vol. 325, no. 14, 2021, pp. 1414–1425. https://jamanetwork.com/journals/jama/fullarticle/2777886

West, Sam, et al. "Weight Regain After Cessation of Medication for Weight Management: Systematic Review and Meta-Analysis." BMJ, vol. 392, 7 Jan. 2026, article e085304. https://www.bmj.com/content/392/bmj-2025-085304

Budini, Brajan, et al. "Trajectory of Weight Regain After Cessation of GLP-1 Receptor Agonists: A Systematic Review and Nonlinear Meta-Regression." eClinicalMedicine, vol. 93, 4 Mar. 2026, article 103796. https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(26)00043-X/fulltext

Lincoff, A. Michael, et al. "Semaglutide and Cardiovascular Outcomes in Obesity Without Diabetes." New England Journal of Medicine, vol. 389, no. 24, 11 Nov. 2023, pp. 2221–2232. https://www.nejm.org/doi/full/10.1056/NEJMoa2307563

Perkovic, Vlado, et al. "Effects of Semaglutide on Chronic Kidney Disease in Patients with Type 2 Diabetes." New England Journal of Medicine, vol. 391, no. 2, 24 May 2024, pp. 109–121. https://www.nejm.org/doi/full/10.1056/NEJMoa2403347

Knowler, William C., et al. "Reduction in the Incidence of Type 2 Diabetes with Lifestyle Intervention or Metformin." New England Journal of Medicine, vol. 346, no. 6, 7 Feb. 2002, pp. 393–403. https://www.nejm.org/doi/full/10.1056/NEJMoa012512

Look AHEAD Research Group. "Cardiovascular Effects of Intensive Lifestyle Intervention in Type 2 Diabetes." New England Journal of Medicine, vol. 369, no. 2, 11 July 2013, pp. 145–154. https://www.nejm.org/doi/full/10.1056/NEJMoa1212914

Sacks, Frank M., et al. "Comparison of Weight-Loss Diets with Different Compositions of Fat, Protein, and Carbohydrates." New England Journal of Medicine, vol. 360, no. 9, 26 Feb. 2009, pp. 859–873. https://www.nejm.org/doi/full/10.1056/NEJMoa0804748

Watson, Shelley L., et al. "High-Intensity Resistance and Impact Training Improves Bone Mineral Density and Physical Function in Postmenopausal Women With Osteopenia and Osteoporosis: The LIFTMOR Randomized Controlled Trial." Journal of Bone and Mineral Research, vol. 33, no. 2, 2018, pp. 211–220. https://onlinelibrary.wiley.com/doi/10.1002/jbmr.3284

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Every week there's a new headline saying men are losing testosterone. A quarter of men now start testosterone replacement therapy without ever getting their blood tested. The supplement aisle is full of boosters that either do nothing or contain undisclosed steroids. And the lab test that gets everybody to the pharmacy? Half of low results normalize on their own.

In Episode 1 of the Signal launch series, Dr. Jordan Feigenbaum and Dr. Austin Baraki (both MDs and strength coaches) walk through the three-layer problem with how testosterone gets diagnosed and treated in 2026, then take apart the "testosterone is crashing" headline with the most current data available, including a 2025 meta-analysis of more than one million men.

Pre-order our book, Signal: barbellmedicine.com/signal

Timestamps

• 0:00 Mark's story: treating the number, not the patient
• 1:18 Welcome to the Barbell Medicine Podcast
• 1:41 Problem 1: A quarter of men start TRT with no lab work
• 3:36 Problem 2: Why testosterone boosters do not work (and what is in them)
• 13:40 Problem 3: Why one low testosterone lab is not a diagnosis
• 19:19 Setup: Is the testosterone crisis headline real?
• 20:04 The MMAS data and the 1%-per-year number
• 20:52 The 2025 meta-analysis of over 1 million men
• 22:02 Why the headline is inflated: three causes
• 22:27 Cause 1: The testing method changed (immunoassay to mass spec)
• 25:58 Cause 2: BMI cannot see visceral fat
• 29:37 The Nyante study: when you fix both problems, the decline vanishes
• 33:58 What this actually means for you
• 37:05 The broken testosterone system, summarized
• 38:24 Five takeaways from this episode
• 39:14 Next week: How testosterone actually works
• 39:39 About Signal and credits
• 
  

What you'll learn in this episode:

•  Why 25% of new TRT prescriptions are written without any pre-treatment lab work (JAMA, 2015)
• What actually happens when researchers test 50+ "testosterone booster" supplements (spoiler: 12% are contaminated with undisclosed steroids)
• Why a single low testosterone reading is not a diagnosis, and the Massachusetts Male Aging Study data that proves it
• The real size of the population-level testosterone decline (much smaller than 1% per year)
• Why BMI cannot see the visceral fat that is driving most of the genuine decline
• The Nyante study that shows the decline essentially vanishes when you use an accurate test and measure waist circumference
• Five practical takeaways you can apply before your next lab draw

This is Episode 1 of a four-part series built around our upcoming book, Signal. Over the next four weeks we cover what testosterone actually is, how to tell when it is genuinely low, what is really driving population-level changes, and what the evidence says you can do about it.

Next Steps

• Check out our new book, Signal (coming soon)
• For evidence-based resistance training programs: barbellmedicine.com/training-programs
• For individualized training consultation: barbellmedicine.com/coaching
• Explore our full library of articles on health and performance: barbellmedicine.com/resources
• To consult with Drs. Baraki or Feigenbaum email us at [email protected]
• To support us and get ad free listening, plus special product discounts, and exclusive content, go to supercast.barbellmedicine.com

Resources

Baillargeon, J., et al. (2015). Trends in Androgen Prescribing in the United States, 2001–2011. JAMA Intern Med, 175(8), 1413–1415. — 25% no preceding lab; post-prescription monitoring gap.

Rao, P.K., et al. (2017). Trends in Testosterone Replacement Therapy Use from 2003 to 2013 among Reproductive-Age Men in the United States. J Urol, 197(4), 1121–1126. — Prescription volume growth.

Selinger, S., & Thallapureddy, A. (2024). Cross-sectional analysis of national testosterone prescribing through prescription drug monitoring programs, 2018–2022. PLoS One, 19(8), e0309160. — Recent prescribing data, 3-4 million estimate.

Vesper, H.W., et al. (2015). Serum Total Testosterone Concentrations in the US Household Population from the NHANES 2011–2012 Study Population. Clin Chem, 61(12), 1495–1504. — Population testosterone levels, NHANES data.

Clemesha, C.G., et al. (2020). "Testosterone Boosting" Supplements Composition and Claims Are Not Supported by the Academic Literature. World J Men's Health, 38(1), 115–122. — 62% no published data, 10% decreased T.

Tucker, J., et al. (2018). Unapproved Pharmaceutical Ingredients Included in Dietary Supplements Associated With US FDA Warnings. JAMA Network Open, 1(6), e183337. — 12% adulterated with undisclosed steroids.

Trost, L.W., & Mulhall, J.P. (2016). Challenges in Testosterone Measurement, Data Interpretation, and Methodological Appraisal of Interventional Trials. J Sex Med, 13(7), 1029–1046. — Half of low results normalize on repeat.

Travison, T.G., et al. (2008). The Natural History of Symptomatic Androgen Deficiency in Men: Onset, Progression, and Spontaneous Remission. JCEM. MMAS data — 50%+ spontaneous normalization.

Travison, T.G., et al. (2007). A Population-Level Decline in Serum Testosterone Levels in American Men. JCEM, 92(1), 196–202. — Original MMAS secular decline, 15–20% lower across cohorts.

Santi, D., et al. (2025). Meta-analysis of secular trend in total testosterone levels, 1971–2024. 1,256 studies, N > 1,000,000. — 0.56%/year adjusted; LH parallel decline; mass spec subgroup no significant decline.

 Methods note on the ~0.56% per year figure cited in this episode: the Santi paper does not report a single percentage rate. The headline adjusted meta-regression coefficient (−0.6 nmol/L/year) is inflated by the random-effects weighting scheme and is not a biological rate. The 0.5–0.6% per year approximation comes from the pre-2000 stratified subgroup (Fig. 5, coefficient −0.1 nmol/L/year) divided by the dataset mean of 18.5 nmol/L. The post-2000 stratum runs larger (~1.1%), and the age-stratified coefficients in Table 5 cluster in the 0.4–0.9% range. The mass spectrometry subgroup (Table 3, Group 4) showed no significant trend (p = 0.845). The episode uses the conservative end of this range as the most defensible estimate of the real population-level rate after accounting for assay drift.

Nyante, S.J., Graubard, B.I., Li, Y., McQuillan, G.M., Platz, E.A., Rohrmann, S., Bradwin, G., & McGlynn, K.A. (2012). Trends in sex hormone concentrations in US males: 1988–1991 to 1999–2004. Int J Androl, 35(3), 456–466. doi: 10.1111/j.1365-2605.2011.01230.x. — Archived NHANES samples, same platform, waist circumference added; no significant decline in total or free testosterone.

Our Sponsors:
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* Check out Quince and use my code quince.com/bbm for a great deal: https://www.quince.com
* Check out Quince and use my code quince.com/bbm for a great deal: https://www.quince.com


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