Women's Fertility & Lifestyle Debate: Dangers Of Not Having A Period! Fasting Can Backfire For Women

If someone's menstrual cycle is irregular, should they be concerned?

Yes,

yes.

Your body's meant to work like clockwork.

And our monthly cycle is so much more than getting ready to have a baby.

Especially when we're looking at exercise.

And it's important to say if you don't have a period, it's very harmful to long-term health, brain health, mental health, low energy, mood, and libido.

And I don't want the younger generations to have to go through the stuff that we've gone through.

So it's an important discussion that we need to have.

We are joined by four leading female health experts from very different fields to have a crucial conversation about women's health.

With over 80 years combined experience, they're sharing the truth about what every woman and every man needs to hear.

We asked a thousand women to submit their questions ahead of this conversation.

And I've got so many questions around fertility, understanding hormones, PCOS, birth control pill, and miscarriage.

And I'll say this, Stephen, it's because we haven't had these discussions publicly.

When we look at funding in women's health, it's horrible.

Like less than 1% is spent on women over 40.

And women are living 20% more of our lives with chronic disease or mental health disorders.

I mean 50% of patients with unexplained infertility have endometriosis.

But yet it takes women seven to ten years to get a diagnosis after symptoms start.

But also there are things that we do that will inherently harm our fertility because we're not taught this and it predisposes you to many medical problems later in life.

And patients will say, like, I have a really high pain tolerance.

Yes.

Like it's a badge.

So they gaslight themselves.

And that's what we're all trying to fight here.

But there are a lot of things we can do to deal with this.

And then I want to talk about menopause.

So in medical school, menopause just gets shoved into a tiny box.

This is a scary statistic.

So

it's crazy.

I just think it's insane.

This is why we need to create change.

This might be one of the most important conversations we ever have on the diet of a CEO because women's health has long been a total mystery to so many people.

And so many people are struggling with all of the issues that we're going to talk about today with their menstrual cycles, PCOS, endometriosis, with diet, with understanding how to exercise as a woman.

It's probably never going to be the case again that these four individuals that are at the very top of women's health in their fields will be in the same place at the same time having this conversation.

We structured this conversation into two parts.

They cover completely different subjects, but they're fundamentally interlinked.

For me, the understanding that I got from this conversation at this table with these four women has fundamentally changed my life.

It's going to change how I deal with my romantic partner, my sister, my team members that I work with every single day.

And funnily enough, because it's a conversation I wouldn't have clicked as a man, it turned out to be the conversation that I needed the most.

And I don't think I've ever said this before, but if there was ever an episode to share with a loved one, then this is that episode.

Please share this episode with as many women as you can, but also with as many men as you can.

Ladies, we should start with some introductions.

Could you you give me a brief introduction, Stacey, as it relates to your perspective and your experience and what your sort of bias is as it comes to this debate?

When I say bias, I mean your experience and your research that you're lending to this conversation today.

I come from the exercise, fizz, and sports med background.

So I'm always looking through the lens of activity and nutrition and how that has an impact on our stress and our stress outcomes and how we can adapt to specific applied stressors, especially when we're looking at improving health span, improving mood, improving body composition, all of those things.

I've worked with and still work with this subset of active women.

I come from an endurance and a high-profile, high-performance sport background.

So that's where I've gotten my chops and then brought it over into the general recreational female athlete kind of perspective.

Natalie?

I'm a fertility doctor, and every day I help patients with IVF get pregnant because I have an IVF clinic.

But my big passion has always been natural fertility after I experienced my own pregnancy losses, trying to understand how we interact with the world and how that changes our hormones and help women understand what their hormones are, what natural fertility is, what happens as we age to our bodies, our eggs, and our hormones, and let them be better stewards of their own fertility and their own health decisions.

Mary?

I have a background in general OBGYN, so I'm considered to be a women's health specialist.

And it wasn't until I kind of went through my own menopause that I realized that there was a significant gap in my training.

You know, hearing, watching Dr.

Sims on, I think, your podcast talking about how women are not little men really struck such a chord with me and made me realize I was siloing women's health to the reproductive organs, the breast, the uterus, the ovaries, the vagina.

And that if I really did wanted to make a difference in a woman's whole health life, this last 30 years, 30, 40 years of her life, I needed to refocus what we were thinking about women's health for the long term.

So, I come from a background in academics.

I was a professor for 20 years.

I was a residency program director, stepped away from that so I could focus on the lack of my own education and knowledge in menopause care.

And now I want to step back into the academic world to bring everything I've learned and change the way we educate our providers.

Wunde.

I am a orthopedic sports surgeon by training, and I sit at the unique juxtaposition of orthopedics and performance, having taken care of elite athletes most of my life, aging and longevity.

Most of my academic research, I too as an academic, is on subjects of musculoskeletal aging, but many years ago added a third circle of the whole health of a woman.

And so, sitting in this place, it fits directly into the mantra of my career, which has always been, I am going to change the way we age in this country and the world, because the tool that I bring to the table is the fact that if I save your mobility, I'm going to save you from the ravages of chronic disease.

And so the work that I do is not only educational, it's research, and it's now education of the world about these subjects.

Explain this to me like I'm an idiot, ladies.

Why do we need to have a conversation about women's health and not just health broadly?

I I think the statistic that people don't realize on a day-to-day basis is that women are 51% of the population.

We're actually not a minority.

We're the majority.

And yet often our health, our healthcare access, the research, treats us as if we're a niche product.

But we are the majority product.

We have to have this conversation because data show that

of the $450 billion spent on research in this country alone, less than 1% is spent on women over 40.

And yet we are nearly 90 million people.

And we make 80% of all the health care decisions in this country for ourselves and everyone we touch.

And so even though when you look at

the long-term data, women are winning the longevity race here.

We're living an average of six years longer than men.

But as all of us talk about all the time, women suffer longer.

We're living 20% more of our lives versus our male counterparts in poor health with chronic disease or mental health disorders.

And so McKinsey looked at the data and it was for the Gates Foundation.

And what they found was, yes, we live longer.

We've all known that.

However, we have, you know, twice as high of mental health disorders.

We're two times as more likely to end up in a nursing home.

We are much more likely to lose our long-term independence from frailty or dementia, much more than our age-matched male counterparts.

And that's, I think, what we're all trying to fight here.

And diseases that impact women specifically and only, things like PCOS, endometriosis, are extensively underfunded and not researched.

It takes women seven to ten years to get a diagnosis of endometriosis after symptoms start.

And we know this is a disease that impacts your entire body in addition to your fertility.

But women are dismissed, they're not taken seriously, and there's not research guiding what we can do in a lot of these situations to try to help them the best.

Aaron Powell, why isn't the research there?

Why don't they research, if women are the majority of the population, why is all the funding going to researching men?

You have to think about who was in the room when medicine and science first started.

So if you think about back when the Industrial Revolution and the modernization of what we know as medicine, women were pushed out because they were believed to have smaller brains thanks to Darwin and not thought to have a seat at the table.

So when you're thinking about designing studies, it was pretty much designed on the male physiology, on the male body, and then women were an afterthought.

So there wasn't any real in-depth look of, well, women are different from birth or in utero, XX is different from XY.

So all the research has just been generalized to women, even things like aspirin for heart attacks and thinning blood.

Blood inhibitors.

Yeah, all of this.

all of this was done on men and then just generalized to women.

And now that we're having this global conversation on women's health, people are like, well, where is the information specific for women?

And there's just a very small subset.

So we're looking and trying to expand that, but we have a lot of catching up to do.

Aaron Ross Powell, and that's primarily not only because of what you said.

But the shocking statistic is that not until 1993 were women required to be represented in studies.

1993?

I mean, we were all far into

our lives in research by then.

Isn't that a shocking?

That's crazy.

And there were still loopholes where people were finding ways to exclude women.

Right, we're still not at 50%.

No.

We're harder to study.

You have menstrual cycle, hormonal fluctuations, eventopause, pre-peven animal models.

It's not that we're harder to study.

It just makes sense.

It's assumed harder to study.

There's more variables at play.

Right.

It's more of a complexity to the research, but but it's not more difficult.

And this is where I bring it in.

It's like, if a woman had a seat at the table when all the study designs were started, it wouldn't be a question.

It would just have been assimilated in.

But because we've been so drawn into we have a crossover, here's one week crossover next week because of male physiology.

When you add women's hormone fluctuations in, people are like, oh, it's too complex.

Right.

But it's not.

What is it that makes, and this is a super dumb question, but an important one.

What is it that makes men and women different from a physiological standpoint?

Because to understand why research would need to be done separately, we need to understand the differences.

Yeah.

Well, I mean, we can look from a morphological standpoint where men have more of our fast twitch fibers.

Women are born with more endurant fibers.

Which is muscle, right?

When we're talking about muscle, yeah.

So men have more of the ability to do power and

really fast, energetic type.

activities or women are more attuned to endurant type activities.

And this affects metabolism, it affects blood glucose homeostasis.

And when we're looking at bone and bone density, men have stronger bones.

They can acquire more load.

They hold on to it better than women do.

We see smaller lungs, smaller heart, less hemoglobin in women than men, and that's an offshoot of what testosterone does.

So there are just basic physiological differences between XX and XY that people don't really assimilate and understand.

And the way I like to say it is you go into into a shop and you have a men's section and a woman's section and they're touch points on the external that really identify gender and or sex.

But when you look intrinsically, no one is identifying those touch points until now.

Also, when we look at how we disease.

So in cardiovascular diseases, atherosclerotic disease is the best example.

Men tend to have their blockages.

So atherosclerotic disease is basically the plaques that build up in the coronary arteries around the heart.

Men tend to develop their plaques very early, right as those arteries exit the aorta and dive into the heart muscle.

So we get what we call the widowmaker.

Okay, it's called that for a reason because men die and they make a widow.

And so that's the left anterior descending artery.

Women, by and large, tend to not have these larger artery blockages, but their blockages are diffuse and microvascular deeper into the heart muscle, which is why we present with a heart attack much differently than a man does.

And those, we're not teaching our, you know, we're not educating our clinicians as to these differences.

Women are considered to have atypical chest pain.

Dr.

Wright, 51% of the population is female.

Why is my heart attack atypical and a man's typical?

But this happens not only at the organ level.

It makes sense that if we have a population with XX chromosomes, a population with XY, genetically and the way we express those genes are differently.

But I think we miss the fact that down to a cellular level, every cell from an XX expresses these tissue changes, tissue manifestations, differently than an XY.

Our lab used to study, we called them muscle-derived stem cells so 20 years ago.

Now they're called satellite cells.

But when we harvested them and asked them to behave in different environments,

satellite cells from XX people and XX animals, women, females, were better under the same same circumstances experimentally at making cartilage and muscle.

XY, male, were better under the same circumstances in making bone.

So down to a cellular level, we express our genes differently.

It should be no mystery to us or anybody else that there are differences and yet

there is the propensity just to lump us all in the same basket and almost say, I almost sometimes feel as pejorative to say oh the women are different of course they're different yeah we're genetically different down to every cell in our body every cell so it should be no surprise to anybody but it it seems to be a surprise it seems to be a surprise all the time yeah i get pushed back all the time there's no difference yes there is there is and it's not just me saying

it's just is yeah yes yeah because at one point that was quite a controversial thing to say wasn't it to point at the differences between men and women

outside of you know our different organs yeah you know?

And because of this research gap and the bias in medicine, women have been misunderstood by their male counterparts in a number of ways.

I remember, I think it was you, Mary, that was telling me about this whiny women thing that you were exposed to.

When I was in training, and you all may have similar stories, and I just heard a new one the other day.

My first patient in gynecology clinic, I'm an intern.

I'm very excited.

You know, we have our stacks of charts.

That's how old I am.

We had paper charts.

I pick up the chart, open it up.

It's a 40-year-old woman with multiple vague complaints.

She's gained some weight.

She's a little bit depressed.

Her libido is off.

Her blood pressure is a little bit up.

Her cholesterol is starting to rise.

And she's seen family medicine.

Like we're the third or fourth doctor at this point.

And so my upper level, who happened to be male, this, you know, it could have been anyone, walks down the hall in his cowboy boots because Texas.

And

he's like, what you got?

And I said, well, I have Miss Smith, whomever, you know, she's a 40-year-old woman with, and I list the complaints.

And he goes, did you check her thyroid?

Family medicine did.

Did you check this?

You know, a few simple labs.

And he goes, hmm,

you got a WW.

And I said,

I don't know this, you know.

And he said,

don't write this in the chart, but we call that a whiny woman around here.

Oh, my gosh.

And I said, okay.

He said, listen, women just tend to go through this at this age.

And

we're not really going to be able to help her.

Pat her on the knee, tell her to have some wine, go on date night, you know, she'll get better, but we're not going to be able to help her.

And that stayed with me.

Now, I was, you know, a good girl.

I did what I was told.

You know, it took me 20 years of internalization to realize this, you know, so I don't want to blame him.

He's not a bad guy.

This was taught to him.

But this kind of thinking, I mean, I saw this in the ER.

I saw this in the OR.

I saw this in every clinic.

And so I've asked other clinicians around the country, and I've heard whiny gyne,

status Hispanicus, total TBD, total body delore, like in different regional areas, there was a name for this kind of vague complaints from this middle-aged woman, and we couldn't quite put our finger on it.

And I realized this was systemic bias built into the system where women, there's historical, you know, precedent for this, the wandering uterus, the hysteria.

You know, these were real medical terms just until like not even a generation ago.

Yeah, they used to put women into asylums.

Yeah.

Because of hysteria.

And it was hot flashes, all the things that are now now known with perimenopause.

They used to think it was some kind of insanity and put women into insane asylums to lock them down.

But this is pervasive, not just an OB.

You're not the only guilty person.

It's every medical subspecialty

has some

culture of, for lack of better words, blowing women off.

Right?

We're not having the curiosity that defines medicine.

We are supposed to be curious people, but yet when it comes to this,

why do we stop at just seems to be something that happens to middle-aged women, right?

That's written in the orthopedic literature.

Seems to happen to middle-aged women.

Where's the curiosity?

Where was it?

Yeah.

Well, in ex-vistext, you always had the representative of him or they and the Vesuvious man and all the angles of the male body, but there was never representation of women.

The only time you heard about a female athlete was all the pathophysiology.

You know, the iron deficiency, the female athlete triad, which we now call relative energy deficiency in sport.

And when you're looking at the historical idea of sport, the only way women were actually included and accepted is when they were amenorric.

because then they were, quote, more like men.

And then there wasn't a problem with training them.

And then they could work as hard.

But we know that that's not appropriate.

That's a sign of illness and overtraining under recovery.

So it is pervasive everywhere.

It's not just the medical, but it goes into when you think about what it means to be successful in sport.

It's the power, it's the aggression, it's the unfallibility of being human.

And a woman having a menstrual cycle was deemed a fallibility.

So they're trying to push it aside.

This is so systemic, though, that women downplay their own complaints.

They gaslight themselves.

It takes them a long time to seek care because they're afraid of the response.

They are not always honest with what's going on in their body.

I'll say, do you have pain?

Oh, no more than regular.

They downplay everything.

You have to really ask.

And it's almost the society, I don't want to be viewed as this way.

I don't want to be not taken seriously.

And it causes them to have an even harder time to get to a diagnosis because they don't feel comfortable sharing some of these symptoms, or they've downplayed them in their life so much.

This is why they have to get so sick to often present to even try to get care.

And they come to me almost to a woman after I'm talking about whatever musculoskeletal thing.

They'll say, even before they want to describe it to me, they'll say, but you know, I have a really high pain tolerance.

Yes.

Like it's a badge, because we've been conditioned to not come for any pain.

But I've suffered, I've tried, that's why your arm doesn't move anymore.

I've got such a high pain tolerance, but I couldn't take it anymore.

I didn't want to come.

And I feel like, why does it have to be that way?

So you train treating both males and females.

I do.

I was left in a room with women for 25 years, you know, and so it's so fascinating to me to hear

how man and woman come in with the same complaint in your clinic and your fellowship, all those years you spent training, and yet you were taught to treat them differently, you know, and the urologists say the same thing, you know, who treated them.

I don't think I was aware of it.

Yeah.

There was just, that's

so much bias.

Yeah.

I didn't realize.

i didn't either because like you until i went through my own perimenopause

i might not have paid attention to it yeah i might have

been less sensitive i was a terrible menopause teacher just give me 30 seconds of your time Two things I wanted to say.

The first thing is a huge thank you for listening and tuning into the show week after week.

It means the world to all of us.

And this really is a dream that we absolutely never had and couldn't have imagined getting to this place.

But secondly, it's a dream where we feel like we're only just getting started.

And if you enjoy what we do here, please join the 24% of people that listen to this podcast regularly and follow us on this app.

Here's a promise I'm going to make to you.

I'm going to do everything in my power to make this show as good as I can now and into the future.

We're going to deliver the guests that you want me to speak to, and we're going to continue to keep doing all of the things you love about this show.

Thank you.

Is that in part because we know very little about hormones as well?

When I was speaking to our audience, we asked a thousand women to submit their questions ahead of this conversation.

And one of the most asked questions,

all the most asked questions, sort of related to understanding hormones.

I think the conversation around hormones is quite a new one in society.

And I actually think it's been driven a lot by a heightened understanding of menopause generally.

I think the conversation of hormones around outside of fertility and the general menstrual cycle, I can right now draw from memory exactly what's going to happen in a normal menstrual cycle.

We were taught that, you know, very, very well.

But when I saw maybe three years ago an academic paper that showed all of the locations of the G-coupled estrogen receptors in the human body,

I lost my mind.

So basically, where are the estrogen receptors in the human body?

And they're everywhere.

The brain, the bones, the muscle, the gut, you know, the, the,

every,

almost nothing, the endothelial, the lining of the individual blood vessels around around our heart.

It's really radical to me to think about how all these sex hormones or the progesterone, estrogen, testosterone hormones are everywhere.

What is a hormone?

They're not actually sex hormones.

Hormones are your body's communication system, right?

So it is really how your body is sending out messengers to communicate.

So a hormone is dictating an action.

And I think there's going to be a lot of great discussion.

But one thing that I think is very important to your point, Stephen, is even things that we were were readily taught about, the menstrual cycle and estrogen, progesterone, testosterone, the public is now becoming aware of because we've not done a good job at public education that this is what's really happening in your body.

This is what your menstrual cycle is.

This is what happens when you go through menopause.

This is what happens when you're trying to train for a sport.

We haven't had these discussions publicly that we are seeing.

And I think that is highlighting interest in all of this, even if some of us were taught some of this.

But when it comes to hormones,

everybody wants really easy fast.

Draw my level, tell me what to do, give me a medicine, fix it.

And I think the most important thing to understand is that by definition, your hormones are dynamic.

Your body is responding to the hormonal signal it sees and determining what next signal to send out.

So constant fluctuation.

throughout the day in response to multiple stimuli.

And that's how it's supposed to be.

If we didn't do that, we'd all be dead.

It's a symphony.

But that makes it really hard for somebody to understand on the other end who's not in medicine who says, well, is it my hormones?

Because there's no one test that's going to give you one answer.

You have to really interpret it in context of the full body.

And it makes it really hard for practitioners who do not understand the hormones as well.

And we see a lot of mismanagement of hormonal scenarios and situations right now that are actually detrimental to patients.

So I'm glad you're having this discussion because that's not a stupid question.

What is a hormone?

Many Many people don't really understand that.

What is the, I really want to make sure that if someone, for both the men that probably have less understanding, but also from our conversations, I've realized in the feedback I've gotten a lot of women don't understand their own hormones and their own menstrual cycles.

What is the most basic level that we have to start at to give people an understanding that we can then build on of what's going on here?

I was going to say, I want to get rid of this scrap.

Okay, so I'll talk about that.

None of that.

No.

Leave it out.

Leave it out.

But it shows just a textbook of what a menstrual cycle is.

But it doesn't show the daily perturbations of estrogen and the luteinizing hormone pulses and all the things that go, as Natalie's saying, to

make it work.

You see two organs there, the ovary and the endometrial lining.

You're not seeing the muscle, the bone, the brain.

All of those organs are affected by these normal monthly fluctuations.

And the conversation that we're having now in research methodology is the fact that there is no real definition of normal because every woman's cycle is a variable.

So when we look at this, everyone thinks that this is normal, but we don't actually know if that is.

For the fact that a woman's variation,

this can change cycle to cycle, this can change cycle to cycle.

Sometimes we have an ovulatory cycles.

So until a woman can identify what her own normal is, we can't rely on this graph to actually explain to them.

How does a woman know what their normal is versus, you you know, because a lot of women are on birth control pills since a very young age.

So I think my partner, Melanie, she was on birth control for about a decade.

So she like didn't have her cycle.

And then it came back and it was every, I don't know, 60, 90 days.

And then she changed her diet a little bit and it kind of went down to 30 days over time.

But I don't think she knew what normal was.

Is there such thing as normal?

I mean, there is what should be normal for you.

So you should have a regular predictable period, which means that you are having a menstrual bleed at a predictable interval.

It can range person to person, but for you, really, it should be within a couple days, month to month.

I always tell patients, I should be able to give you a calendar.

You should be able to take your finger, pick when your next period is coming, and within a few days, be accurate.

Now, usually that range is somewhere between 25 and 35 days for the average person.

When it starts to get shorter or longer, it can be a warning sign that something is going on.

When it comes to the menstrual cycle, because I think we're going to talk about these hormones really well, and I talk about this every day.

Let's give a one-minute explanation.

If we think about, to Stacey's point, from the brain, the brain is sending out pulses of hormones, but FSH drives egg growth.

It's called follicle-stimulating hormone, and each egg is inside a follicle.

So you have a group of follicles inside the ovary.

FSH comes from the brain, grabs one of them, and gets it to grow, and it makes estrogen.

And this estrogen from the ovary, as the egg is growing, is called estradiol, and it's the primary type of estrogen in your body.

So it is rising, and when it gets to a peak level, and the body is so fascinating because it's 200 picograms for 50 hours.

It's a very exact amount.

Then the brain says, we must have a mature egg and it kicks out a surge of luteinizing hormone or LH.

And that is going to allow the follicle to rupture, the egg to be released, and the follicle to reform and then become a corpus luteum.

And then the brain is going to send out pulses of LH, giving you pulses of progesterone.

So Stacey's point, that's an average.

And those numbers on the little graph are nowhere near accurate because progesterone goes up and down the entire second half of the cycle, known as the luteal phase.

What's progesterone?

Progesterone is also made from the ovary.

So the two main hormones when it comes to a premenopausal female are going to be estrogen and progesterone.

Progesterone is the progestational hormone or pro-pregnancy.

It is going to change the endometrial lining and it is essential to get pregnant.

It opens and closes the implantation window within the uterus and it completely changes the physiology of your body.

And we're going to talk a lot.

That is why in the luteal phase, your body works differently when you have progesterone.

And the luteal phase is after ovulation when you have a corpus luteum.

So when LH is coming from the brain, you have a corpus luteum.

It makes progesterone.

This is the second half of the cycle known as the luteal phase.

The first half when you have estrogen only is the follicular phase.

So you have an estrogen dominant phase and then you have a phase where you have both estrogen and progesterone.

And your body is made, yes.

So we have our estrogen phase, the follicular phase, and then we have both estrogen and progesterone here in the luteal phase.

And your body is made to function differently in these because, in the progesterone side, it's preparing you for a pregnancy.

It thinks every month you might get pregnant.

And it starts to change how your body is going to work on a cellular level.

But if you don't get pregnant, that progesterone level is going to drop and the cycle starts back over.

And from like an exercise and sports point of view, when we get into this, the progesterone's job is to build this lush endometrial lining.

And it creates a lot of glycogen storage.

So we often hear about glycogen in the muscle, and that's what we're using for fuel.

It has a way of shuttling a lot of the carbohydrate away and storing it into the endometrial lining, which is why we see differences in intensity and the way that a woman can respond to exercise if she has ovulated.

So is this in preparation of a potential baby?

Yeah.

Correct.

Yeah.

In the second half of the cycle, your core body temperature increases, your resting heart rate is higher.

Your heart rate variability is lower.

You have increase in fatigue.

You have an increased appetite.

Your body is shifting function in case an embryo comes in so that it can start to divert energy and change what it is doing.

Right down to your immune system changes.

And that's roughly from day 14, roughly.

Roughly.

Yeah.

At ovulation.

It's about three days after ovulation.

If you'd like to be specific, it's about three days after ovulation until when you get your next period.

Yeah.

You all talk about how menstrual cycles can be a broader sign of whole body health.

And so if someone's menstrual cycle is irregular, should they be concerned?

Yes.

Yes.

I thought you were going to say no.

How irregular?

What's like, if I'm not getting my menstrual cycle.

Absolutely not good.

You should go see a doctor.

Yeah.

If your cycle is irregular, if the calendar trick, you're putting your finger and it's nowhere near when your cycle's coming.

Or I have women who say, oh, there's no way I could predict it.

Or I know it will come, but it'll come every four to six weeks.

Your body's meant to work like clockwork when it comes to your hormones and your menstrual cycle.

And yes, you can always have one abnormal month, always, but when you consistently are having irregularity, that is a sign that something else is going on.

It's one of the biggest red flags that we have.

for early hormonal health or systemic problems.

But to your earlier point, Stephen, we have a generation of women on contraceptive options who are not tracking their cycles.

We have women who are not taught how to track their cycles.

They don't know when ovulation occurs.

They don't know how long their luteal phase is.

If I say the first sign of ovulatory dysfunction or having a problem with your cycle is a short luteal phase, well, you only know that if you're tracking when ovulation occurs, because otherwise you could still have a regular cycle, but you don't know that something's abnormal.

And that luteal phase, again, is the last

half of your cycle.

Exactly.

But I think that the conversation that's happening now is not just at this table, but in society, that

our monthly cycle is so much more than getting ready to have a baby.

Because I think that none of us knew this.

No.

Because

at 17, I wasn't that interested in having a baby, so it didn't occur to me that I should care.

Right.

Right.

And it's the only time.

If you're thinking about it in that way that you're worried about your period is if you don't have one and pregnancy, right?

And so if we're shifting the conversation to this is physiology, this has to do with every part of female physiology,

maybe it will be easier for people to know,

right?

Yeah, I often put it with my athletes that it's a marker of health, that if you are able to take on the load of training, the load of travel, and maintain your normal menstrual cycle, then you are robust enough to be able to progress.

But if there becomes a misstep in your menstrual cycle, then we need to look at all the stressors that are in the allostylic load and pull you back and see what do we need to address?

Do you need to eat more?

Do you need to recover more?

What are the things that are missing to bring you back to normal?

I was diagnosed with polycystic ovarian syndrome in medical school.

And so like every medical student, of course, it was like gloom and doom.

And I, you know, thought I had the most extreme case ever known to mankind.

It was really just garden variety PCOS.

And I had very serious boyfriend quickly engaged, you know, looking forward to having a family with him, starting a family with him, and the terror around my infertility and what the impact was.

What was never taught to me and what I didn't understand until much later was the metabolic impact.

Like PCOS is a symptom.

There's nothing wrong with my ovaries.

They're just responding to this high insulin level I was born with.

And no one really sat me down and talked to me about my first research project was women with irregular periods and the risk of developing gestational diabetes.

And, you know, I didn't even know what insulin resistance was at the time.

And now we're coming to understand that, you know, when these young women are coming, you know, I only do menopause now, but before I left that practice, you know, when women were coming with irregular cycles and we were making these diagnoses, immediately I was launching into the discussion about her metabolic health long term and what this, you know, it's a gift to know this.

So now we can start making interventions, nutrition, diet, exercise, to give you a better system to deal with this thing that you were born with and her fertility, of course.

A huge amount of women have PCOS and I think that's

one of the top causes of having irregular menstrual cycles.

You mentioned insulin resistance and metabolic dysfunction there and you said something like

gestational diabetes.

Diabetes and pregnancy.

So someone who was non-diabetic before pregnancy and then develops diabetes.

So her blood sugars have now reached a threshold where they are higher than normal and can cause, you know, problems for her pregnancy and herself long term.

And up to 50% of those patients who develop diabetes in pregnancy will develop type 2 diabetes within 10 to 15 years after that gestation, after being pregnant.

And so what we know now is like we have warning signs of this well before pregnancy, where we can set these women up for success.

Before it's just we wait till we make the diagnosis, everybody gets their glucose test and off you go.

But now with this PCOS diagnosis, we are monitoring earlier.

We're starting her on the nutrition, you know, we're treating her like a diabetic with nutrition and exercise recommendations rather than waiting till she reaches the criteria.

Stephen, having infertility, this is a scary statistic.

It predisposes you to many medical problems later in life, including an 80% higher chance of having a heart attack, 75% higher chance of having metabolic syndrome, higher risk of cancer and early death.

Why infertility?

Well, it's not exactly that infertility is causing this, but it's that for many women, we'll use Dr.

Haver as the example, you're healthy until you get this diagnosis.

It's one of the first warning signs your body's giving you that there might be inflammation and insulin resistance or something impacting.

your hormones, your menstrual cycle, your ability to conceive that if it is not corrected now is setting you up for many problems down the road.

PCOS is an example of this because, in PCOS, you have a lot of eggs inside the ovary.

It's actually something that genetically runs in families.

Likely, there's something that happens when you're a baby inside your mom that predisposes your ovary to not lose as many eggs as it should, and it changes how they respond to insulin.

So, what happens is you end up having more eggs on an average.

Your brain doesn't know this and sends out the average signals, but that gets diluted amongst all the eggs.

And so you're not getting into these ovulatory stages of Stacey's favorite graph here.

What happens from there is that you're actually in a relatively lower estrogen phase than you should be.

You never see the progesterone.

And what happens is you start to completely shift.

The ovary itself actually becomes insulin resistant.

And what this means is that throughout your entire body, you start to develop high glucose, which is the blood, right?

That's your blood sugar.

Your blood sugar is the fuel for all your cells.

All your cells need glucose.

Well, insulin is the hormone that helps that glucose go from the bloodstream into your cells.

Well, in insulin resistance, when your body sees high glucose all the time, it starts to send out more insulin saying, hey, we need to get this into cells.

But the cells start to, oh, I'm used to insulin being here, so I'm not going to respond.

It's going to take a higher insulin signal to get the cell to open up the door and let glucose come in.

This becomes very problematic, especially in, we'll say, PCOS, because that that insulin is very inflammatory, causes you to get extra fat stored in different places.

It also just completely changes how your body, your metabolic health in general, but also your hormonal health and in your brain, because your brain sees this and says, why are we keeping glucose in our bloodstream?

What's going on?

Heightens everything.

And so this resistance to insulin actually shifts how your brain's going to respond to hormones, therefore the hormones it's sending out.

And it's a self-perpetuating cycle.

And a lot of when we talk about lifestyle mechanisms to improve hormonal health, which I know that we all will, a lot of that is targeting improving insulin resistance and combating inflammation.

Because those two players, a lot of it is controlled by the world around us and what we do to some degree.

And especially if you have an underlying diagnosis like PCOS, endometriosis, which is a chronic inflammatory disease, autoimmune disease, you're at even higher risk.

I would say your scale is already tipped in a way that's going to be really hard for you.

You have to make active steps to fight what is happening inside your body.

We'll talk about some of the ways one can reverse their PCOS, if that's even a possibility.

But again, on the causal factors, is it something...

So my girlfriend's got PCOS.

She's been very public about that.

Is it something she did?

Is it something she ate?

Is it...

Is this the way she was born?

So she was born with a predisposition of having too many eggs.

You lose most of the eggs inside your body when you're a baby inside your mother's womb.

You lose the next biggest set before you ever have your first period.

Now, if you don't lose them for some reason, you're born with more and it interferes with how your hormones are supposed to communicate, leading to this metabolic issue and this insulin resistance.

She did nothing to cause this.

Nobody with PCOS caused it.

However, what you said earlier, oh, she changed how she ate and her cycles got more regular.

You can influence the severity of the symptoms that you experience with it.

So, even if you don't cause your disease, because you did not, choices you make can make it, absolutely can make it better or worse, just like any disease.

And when you use the word insulin, I think of, or insulin resistance, I think of sugar.

Yeah, because glucose is sugar, essentially.

And many people, and I'll have patients tell me this: I don't need to worry about insulin resistance because I don't have diabetes or it's not in my family.

We've so we've ingrained this word insulin resistant or talking about glucose or checking glucose with a diabetic or pre-diabetic state.

But the world around us honestly promotes insulin resistant.

That's how our bodies

have an

obesogenic environment.

I mean, there's no doubt, at least in the U.S., you know, and most industrialized nations, our environment is what we call obesogenic, you know, and insulin resistant.

egenic.

So

you have to fight against kind of the systems that are in place now for most of us, unless we have some genetic predisposition to just be, you know, magical.

Two, because the way we process food, the way food is delivered to communities, the way, you know, our lack of exercise, you know, everyone's working from home now, just

modern life is really, you have to fight against.

One of the questions that came in from the audience was, I would like to know how best to manage my PCOS.

When it comes to managing your PCOS, targeting those two factors that we talked about earlier, insulin resistance and inflammation, are really the key.

And I'll let these two speak to a little bit of some of the exercise changes that we can try to impact.

But what I'll say is that the best way to decrease inflammation in your body is going to be to start by focusing on your gut.

Your gut health controls a lot of the inflammatory burden that your body sees.

The foods you choose to eat, they can be both helpful if they have a lot of fiber in them.

They can feed your gut microbiome, which is important in estrogen metabolism, but they can also be be very harmful if they are ultra-processed foods that are even causing more inflammation, not feeding your gut microbiome at all, and worsening.

So I always say it's like a scale.

If you think every little food I eat, it can make my insulin or it can make my inflammation better, it can make it worse.

And so how we structure the food that we put in our body is one of the biggest changes the majority of people can make that is going to make a difference.

And that's going to be a very plant-forward diet.

It doesn't mean it's plant-only, but plants have fiber.

Fruits and vegetables have fiber.

So we have to make sure we're getting fiber as a big change.

That's what we see.

I see a lot of patients with PCOS specifically being told I shouldn't eat fruit.

I shouldn't do this.

I need to avoid

keto genetics.

I need to do keto.

Yes.

So we see people avoiding certain food groups.

And I always say it's not a really sexy diet, but it's a diet we all know.

Lots of whole foods, fruits and vegetables, healthy fats, healthy sources of protein, avoiding the ultra-processed foods.

That's going to be probably the biggest change most people can make in addition to foundational changes of your day, which is going to be sleep more.

That is when your body fights inflammation, fights insulin resistance, work on decreasing chronic stress.

To Stacey's point, you're not running from the bear.

So your body is not using that challenge, but you get an email.

you get stressed and your body releases a lot of glucose so it can have sugar and fuel to run from a bear and there's no bear, right?

In previous days, that would happen.

And then you'd go run, and that glucose would go into all of your muscles, and your body would go back to normal.

But now we're chronically stressed.

So actively decreasing stress.

And then exercise.

Building and using skeletal muscle is one of the most effective ways to combat insulin resistance that exists.

And since 80% of patients with PCOS have insulin resistance, a large portion of women with infertility, even without PCOS, have insulin resistance.

That is a huge thing that people are missing, especially when it comes to the exercise discussion.

And I know you guys probably have things to add on that one.

No, but based on what you just said, I just took a phone call this morning from a patient when, and it's just such a typical conversation.

She doesn't like the way her body looks.

Her solution is not to eat.

This happens almost every day when I'm talking to people.

It's we're having coffee for breakfast.

We don't eat till midday when we do eat.

So the gut reaction, because of the way many women are raised, is that we're going to starve ourselves, which is the opposite of good when it comes to physiologic wholeness.

And then you don't have the energy to do the kind of exercise you need.

Or on the other side, the response is, I am going to work so hard every single day that you actually increase your stress.

There is overtraining.

So you're just getting behind the eight ball with starving yourself and overtraining, none of which are going to solve either the core problem due to PCOS or the core problem in any stage of a woman's life, right?

And this is where we look at the sociocultural effect of what a woman is supposed to look like.

Yeah.

And that's the thing that I'm really pushing out.

It's like,

We want to think about how strong we can be and how much muscle we can build because muscle is a a massive metabolic help,

and as well as bone, right?

And so we talk about it.

And then when I get the pushback of, oh, I'm going to do fasted training or I'm going to fast till noon.

I'm like, wait a second.

Not only are we going to interfere with our circadian rhythm and our hormone pulses, we're also acutely interfering with our appetite hormones.

Because if we're looking at acetylated garillin, which is our active form of our appetite, makes us hungry.

It's elevated with cortisol.

And so, if we're thinking about that elevation and we're not doing anything to drop it and tell our body we have food, then it goes in and directly affects our neuropeptides, which then affects our hormone, our hormone pulses.

So, when a woman's like, I'm just having coffee for breakfast, I'm going to hold my fast, it's like, okay, well, here we go.

Cortisol is going up.

Acetarillin, you're going to get hungrier, then you're going to learn not to respond to that hunger.

You're going to hold your fast.

And we see from the research that women who do that end up craving more simple carbohydrates in the afternoon, moving incidentally less, and contributing to poor sleep because they've now phase shifted.

So, when we're talking about sleep and how important sleep is, we also have to think about the circadian rhythm and how it is affected by food intake, light, darkness, and all of the things.

And we need women to understand we want to build muscle, we want to sleep well, and that requires food.

Well, and this goes back, this whole thing you just said goes back to very early in this conversation where I was talking about about sometimes we like to focus on the bright, shiny gadgets when we haven't taken our health from fine

to optimize because everything you just talked about,

it isn't a gadget.

It's basic lifestyle.

In the medical model of PCOS, when I'm talking about what we're taught and how we train our clinicians,

we go into the, you know, we aren't taught a lot about disease prevention or, and I hate to use the term root cause because I think it's been usurped by certain members of, you know, the wellness community.

Take it back.

Yeah.

We're going to take it back.

And so, especially for PCOS, I was taught to give a patient birth control pills or Clomid when she's ready to get pregnant.

And so, nothing, nothing around nutrition, exercise, lowering inflammation.

And I was a program director until 2018.

And there was nothing in the curriculum around this, which affects at least 10% of women, probably more, this condition that

how important lifestyle is.

You know, she went on for 10 minutes about all the lifestyle check, which is amazing, which is amazing.

But patients are like, I'm sitting there thinking, birth control pills, birth control pills.

I mean, that was a knee-jerk reaction.

I mean, I was treated for my own polycystic ovarian syndrome for 20 years with oral contraceptive agents.

And I learned online through chat rooms about the nutrition end of it.

Yeah, when I have athletes, because we see a higher percentage of PCOS in successful female athletes, like what do I do?

And it's looking at what kind of training they're doing.

So we're putting this more short, sharp, high-intensity to get that post-exercise response of anti-inflammatory growth hormone response, all of these things that then

bring down total body inflammation.

And then we're very careful about food intake and when we're doing it and what kinds of food so that they don't have to go down the route of oral contraceptive pills because that to them has an effect on their performance.

And we're talking about the top end.

And when we bring it back down into recreational female athletes, we can do the same thing.

It's just we have to educate and say, these are our lifestyle choices.

And then these are our medical choices.

And what's optimal for your life at this point?

It's important to say at this table, and we all talked about it last night, You need to have a period if you're not preventing a period with hormonal contraception and you're in your reproductive years.

Because very often often women with PCOS or hypothalamic amenorrhea will say, I don't have a period, but I didn't really like that anyway, so it doesn't bother me.

How many women have said, well, I didn't get my period for a year, but that was fine by me, but that's not fine by your body.

That is hypoestrogenic time.

It's low estrogen.

Yeah, very low estrogen.

It's bad for your body on so many reasons to be low estrogen during these crucial bone building years.

But for we're talking about how your hormones communicate back.

It's very harmful to long-term health to have low estrogen

at all.

Brain health.

But yeah, but especially in young years when you're still developing.

Why would a woman say that she didn't want to have a period?

I mean, this is a super naive question as a guy, but I understand it's painful.

I mean, do you want to bleed for a brain?

I mean, do you want that?

I mean, if it was a choice, no.

Actually, knowing now what I know now

and for my own young daughters, I'm like, we have got to make sure you have a period.

But when I was young, i was a dancer and an athlete i had very low body fat and i wouldn't have periods for six to nine months and i'm like yes you know what's interesting i was thinking of mel

she because of what she's been through and also because she's listened to the conversations i've had with all of you and she understands the value and importance of her period she now celebrates it it's like a celebration in our house when it arrives because because if you understand the importance that it has in sort of full body health and the role it's playing, then the pain or the downside is weighted against your understanding of the upside, which to her means she's healthy, she's fatal.

Emotional is working.

Things are great.

And that's the conversation shift that I'm hoping is going to, instead of being a detriment and a downer and talked about, she must be on whatever derogatory, yes, derogatory things are said about us that, oh my gosh, she is so healthy.

Yeah.

I remember sitting in a high performance meeting just maybe three years ago, and the leading athletics coach stood up and said, I know when my athletes are ready to perform on the world stage, when their periods stop.

And all of us went, what?

It's like, no, that's the time where

we have to really look at your athlete is getting ready to crack and be injured.

And it's still this pervasive idea.

And it's still pervasive even in the fitness industry that losing your period is okay because that means you're training harder.

They actually are very resistant to getting it back.

Yes.

Like it's it's a sign of failure of their sport or their athletic endeavor because this is so pervasive.

And I think that's why it's important to have these discussions.

And I love hearing that Mao now says, yay, my period is here because that's a sign of hormonal health and things are working well because that is how we should feel.

But I think the other part of it is for women who have Maharanja or heavy bleeding and heavy cramping, they don't realize that they can get help with that as well.

And that's the conversation that isn't followed through when we're like, yes, get your period.

But if you're someone who suffers from really bad cramps, we also have to educate that there are things that we can do to help with that.

Does the size of the bleed matter?

Because she turned around to me the other day and she said, with her last cycle, she said that she didn't bleed much.

And she seemed slightly concerned.

Obviously, I had no idea what to say to that.

It depends.

Congratulations.

Well done.

I'm so sorry.

Vinaraja, so we have definitions.

And there are, you know, we don't walk around with measuring cups generally between our legs to measure how much blood's coming out each month.

But women know.

But women No.

Your period should not cause you with modern, you know,

period products.

Your cycle shouldn't cause you any stress in your life.

You should just roll with it.

Right.

And so that's when I'm like, when is it a problem?

Bleed through your clothes.

You should be able to sleep through the night.

You should be able to get through an athletic performance.

You should be able to do X, Y, and Z.

Now, when we do start measuring, and you should not be anemic, so I'm not waiting till anemia.

Anemia is low red blood cell count, you know, to the point where your performance is affected, your ability to carry oxygen is affected.

So the red blood cells are what carries oxygen in our bodies.

And women who have heavy periods, however that's defined, can lead to anemia.

But the first thing that we notice is their ferritin is dropping.

That's the first time.

My daughter, we just had some blood work done.

She was feeling a little fatigued and her ferritin and iron saturations were really low.

And I was like, talk to me about your period.

It turns out she's not eating a lot of iron-rich foods.

So we're dealing with that.

But, you know, we can get so far ahead of this.

And looking at these ferritin levels, the transferrin, you know, these iron studies before she's actually anemic, which is like the last thing that happens when her red blood cell count drops or they become so small and what we call microcytic, you know, we are, we need to do a better job at recognizing these things.

We're not going to walk around and measure how much blood's coming out because I could maybe squeak out 200 cc's, you know, a period and you could be 300 and we're both doing fine you know we both have grades so i think it's really looking at you know how much bleeding is too much now how little is too much that that's probably better in your yeah

any change from what you consider normal we would all say this is a normal amount so if it gets heavier than that or less than that and it stays that way that is concerning you can always have a one-off estrogen is the driver of growing the uterine lining so if you have a lighter bleed one month we are concerned that you did not grow as thick of a lining your body didn't see as much estrogen.

Most of the time, you ovulated earlier that cycle.

Your cycle came a little bit sooner than you're used to it coming, and it's not quite a big deal.

But this can be concerning if we see consistently light periods, especially if we have a history of progesterone contraception, which progesterone thins out the lining and estrogen grows it.

So, progesterone actually stabilizes it, but for the sake of the discussion, we'll say estrogen grows it, progesterone thins it.

When you only see progesterone, like a progesterone IUD, the progesterone shot, even continuous birth control pills, because they give you a type of synthetic estrogen and progesterone every day, your uterine lining gets thinner and thinner and thinner.

And so we see it can take months to return to normal after coming off of hormonal contraception.

You also can get damage to the endometrial lining.

There's stem cells in the endometrium that regenerate every month.

After you bleed, they regenerate so that the next group can grow in in response to estrogen.

And this can get damaged from typically anything inside the uterus.

So most commonly, this is post-birth, you know, traumatic birth, a retained placenta, a DNC procedure, which is sometimes used after birth or in a miscarriage, or even IUDs or intrauterine surgery.

And it can form scar tissue in the uterus that can cause a light period.

So if you said,

oh, Mel had a miscarriage and had this procedure and now her periods are lighter, I'm highly concerned.

Versus Asherman syndrome.

Yeah, so that is concerning for scar tissue in the uterus.

If you said, oh, she was on a birth control pill for a while and now it's a little bit lighter, I'm less concerned that's probably going to get better.

Or if this period came closer together.

Or if you traveled around the world three times

last month.

So one-off is no big deal, but a change from your baseline can be concerning.

In addition, we should say that that graph is beautiful, but your thyroid, your pituitary pituitary gland, it makes prolactin.

Prolactin also changes the endometrium.

So there's subtle signs of other hormonal issues that your menstrual cycle is the first warning sign that something is off.

What about pain?

Two months ago, she had like excruciating pain that I've never seen before.

during her menstrual cycle.

Well, it's not pleasant to have your uterus contract and expel its contents in any form.

But what if it's like way above the norm?

One time, way above the norm, is probably situational based on other things that are contributing to inflammatory burden or response.

Your body is also healing from the corpus luteum's assist on your ovary.

That can also feel painful.

And at the time of your period, it is also healing.

So there's multiple things that can cause pain.

To Vonda's point, so many people say, I have a high pain tolerance.

This is okay because we don't talk about our own pain.

So I don't know if my pain is normal compared to somebody else's.

Your pain should not keep you out of your activities of daily living.

You shouldn't call in sick to school, call in sick to work, cancel dinner plans with friends consistently.

Again, everybody can have a one-off month where something is off.

But if this happens every month, oh, it's my period, I'm going to cancel that, that is a warning sign that something else could be going on.

Endometriosis, adenomyosis, and uterine fibrades.

You mentioned the word iron.

a second ago, Dr.

Mary.

What has iron got to do with this and what is iron?

So iron is an element that is in our diets, and we do tend to store quite a bit of iron in our bodies.

And it's an essential when we look at the structure of the red blood cell and of hemoglobin specifically.

So hemoglobin is the actual molecule that is inside of the red blood cell that carries the oxygen.

So iron is really critical to the formation of healthy, you know, iron-carrying red blood cells.

And we store iron in our bodies, and so in a lot in the bone marrow, and

it's stored in this particular molecule called ferritin.

So, when we're measuring ferritin levels in the blood, that is the first sign that your iron stores are getting low, is when we see these low ferritin levels.

Are women more iron deficient than one would think?

Like, is the general population iron deficient?

Or what do you tend to see when you run lab tests?

A menstruating woman, yes.

A menstruating woman is often iron deficient.

Yes, and I do see it in our post-postmenopausal patients as well.

That's usually nutritional and inflammation related.

So, ferritin is also something that will decrease in times of chronic inflammation.

So, you're not able to utilize the iron that's coming in and store it because this inflammatory state is kind of inhibiting that.

So, in a menstruating patient, I'm always thinking, is she bleeding too much the first time?

You know, and is that bleeding menstrual?

Is it coming from her rectum?

Is it coming from her gastrointestinal tract?

You know, does she have gastritis?

Or, you know, we have to go through the

algorithm of why that might happen.

In a postmenopausal patient, we can remove vaginal bleeding from the issue, you know, uterine bleeding, period.

But then now I'm looking at nutrition, I'm looking at exercise, I'm looking at inflammation as causative factors.

And the global pitch here is the World Health Organization estimates that roughly 30% of women aged 15 to 49 worldwide are anemic, with iron deficiency being the leading cause.

And in some recent regions of South Asia and sub-Saharan Africa, prevalence can be up to 50% of women are anemic, with iron deficiency being the leading cause.

Have you noticed the norms have changed?

So it depends on who you read.

Yeah.

Again, you know, when you're looking at male normative curves versus what, you know,

we tend to accept lower levels for a female, but now that we're looking at performance and, you know,

looking at other factors besides just what is this ferritin level,

There's a lot great new research coming out that we are looking at this differently and that we're in our clinic, we are looking for 60 to 100 for a ferritin level to be considered optimal very different than you know the baseline for you know keeping you out of out of a hospital versus you functioning at your absolute best yeah because the norms that often get measured for us

Because they tripled, right?

They were 15 and then they went up to 40.

So now they're saying 20 and above is normal.

And when I look at a lot of women who are sitting 20 to 30, they can't get help.

They cannot get help.

And it's like, whoa, it was maybe four or five years ago, if you were below 50, then we would look to get help.

But now with the norms that have shifted with the sicker population,

we can't get women help unless they are below 20.

So when we say normal, I think this is important for everybody watching or listening.

Normal in medicine means common,

not non-pathological.

Okay.

Not bad.

You know, it doesn't mean that's not bad.

And so norms shifting, meaning we're getting sicker as a population and we're willing to accept lower levels, although they're not optimal for health.

The lab reference range, what they say when you get your blood work drawn and you see the reference range, is based on population averages.

And so if the population is more anemic, this is going to accept

lower levels being normal, even though they're by no means optimal.

And I think that's one thing we all talk about: is, well, how are you feeling?

Your symptomology, what do we see?

And you have to interpret blood work in context of the whole person and what is happening.

And that is one issue we do see with getting your own blood work drawn or these online companies when nobody's interpreting it or helping you interpret it on the other end.

You see something that is in a normal range, but it's not at all optimal for you.

And it could be the reason why.

It's a lot of reassurance.

Yeah, exactly.

I want to talk about endometriosis.

We have a team team member who's been with a diroversia since the very beginning called Liv.

Yes.

Are you familiar with Liv?

I am.

So at age 13, she had her first period and she experienced agonizing pain with heavy bleeding.

At age 14, she was put on the pill to manage the symptoms.

Between age 15 and 24, she continued to have severe stomach pain, which resulted in multiple A and E visits.

She was often dismissed.

as having gastritis

and it led to having her appendix removed.

Oh my God.

Why do you say, oh my God,

she had surgeries.

But she had major surgery.

And

I've seen this course before, and it's devastating because she's going years and years and years now.

Yeah.

Age 25, she came off the pill to see how she felt without it, but her periods worsened and she fainted from the pain.

So she went to accident and emergency.

At age 26, she got an ultrasound which suggested endometriosis, but no NHS diagnosis was given.

We ultimately had a conversation with you on the podcast, Natalie, and she felt very heard and she was actually there.

And so afterwards, Jemima in the team, who you guys know, told Liv to come and speak to me.

And Liv told me after you left about

the symptoms.

Did she speak directly to you at that time?

She did.

Okay.

So she came and she spoke to us about her endometriosis, which is the first time I'd ever heard of it.

And then we offered to help support her privately so she could get private support with it.

And she got an MRI scan privately, which confirmed stage four infiltrating endometriosis.

My gosh.

Liv then pushed on with her NHS appointments, the National Health Service in the UK, but the pain was so much that she took me up on my offer to pay for it privately.

So we paid for it privately.

And the endometriosis by that point had spread to her bowels and pelvis.

And I've got this picture of this four-centimetre cyst.

If you're all faint-hearted, I mean, I don't know whether we'll put this on the screen, but this is from her operation.

Yeah, it's called an endometrioma.

It's huge.

For anyone that can't see, it kind of looks like a tumour

next to her ovaries.

And it had spread at that point to her bowelumpevris pelvis, it became about four centimeters big.

Her ovaries were stuck together and attached to her womb and her bowels.

She then needed to book an appointment for surgery.

And before the surgery, because of the scale of her endometriosis, she had her eggs frozen to protect her future fertility, which I guess came from your advice.

This process took her seven years, and she was in pain for 17 years because she did not get a diagnosis.

Her story is unfortunately not uncommon.

This is a very typical story for somebody who suffers from endometriosis.

Endometriosis is an inflammatory condition.

And the way I like to explain it is when your body responds abnormally to a normal process.

You have immune dysfunction as well.

So let's think of it as an autoimmune disease and a chronic inflammatory disease.

When you have your period, you bleed out endometrial cells in your menstrual blood.

We're used to that.

In everybody, you also have some endometrial cells that will escape out the fallopian tubes.

And that's not a big deal.

If you take out somebody's appendix while they're on their period, you'll actually see menstrual blood in their abdominal cavity.

In the regular person without endo,

your body says, oh, she's just on her period.

In the person who has endometriosis, this creates a huge inflammatory response where your body starts to attack endometrial cells and you get these implants throughout the, what's called the peritoneal cavity or the abdominal cavity of endometrial-like tissue that gets worse.

every time your body sees estrogen, which because it's feeding the endometrium just like it would in the uterus.

And so it gets worse over time.

The more ovulatory cycles you have, the disease gets worse.

It's so inflammatory that it's not uncommon to get extensive organ scarring.

You get anatomical distortion.

These are some of the toughest surgical cases in addition to

managing lifelong health, but also fertility.

If you just obliterate the anatomy, like because the infiltration, these implants will start growing into other organs because they'll find new blood supply.

They'll steal

blood supply from the bowel, because all of our pelvic organs are just sitting there on top of each other, the bladder, the bowel, the cult.

It sounds like it's alive, like it's a cancer or something.

Think of it like Velcro is what I say almost.

These little patches of Velcro, and they just start sticking together.

And that's what inflammation and scarring does throughout your whole body.

And what happens here is that because the primary symptoms of endometriosis is pain, so again, back to women's pain being taken more seriously.

That's one of the issues, and why the average time to diagnosis is seven to 10 years, truly 17 years in this case, from when she had pain.

But the other symptoms do include sometimes also pain with intercourse.

Typically, though, that is very hard to ascertain from somebody, but it's usually with certain positions.

Deep penetration tends to be what really stimulates pain.

But you also see a lot of GI manifestations that we don't talk about.

So if I have somebody who has painful periods and they say they have irritable bowel syndrome or a lot of vague GI complaints, That is a really big red flag to me because like you said, these little endometrial implants on the bowel, the intestine, this high inflammation that's happening irritates your intestine and you get this GI response as well.

One of the hardest things about endometriosis is that it's a surgical diagnosis only, to be honest.

We can

have to do surgery to fully see and diagnose that you have this.

It's one of those no meat, no treat, you know, in medicine where you can't make the diagnosis until you have a tissue sample.

So meat means you go and take a biopsy.

Okay, see, okay.

So you can suspect it based on imaging.

We're not great at this.

And Dr.

Crawford, why don't we have a cure?

Well, because it hasn't been studied, is one of the primary answer.

The secondary answer is that often the goals are tough with endo because if estrogen feeds it, we all are going to sit at this table and talk about how important estrogen is for your body.

And a lot of the treatments that exist for endometriosis take estrogen away to try to not feed these lesions.

And that has a slew of other symptoms and long-term health implications as well.

Truly, we don't even give women

options to try to feel better.

They are given birth control pills because, hey, I'm going to stop the ovulatory cycle.

I'm going to, you're going to have less, what we call unopposed estrogen data.

You do have symptomatic relief.

Yeah, but we have, and that's going to help hopefully with some of your symptoms.

And it can for some women.

It doesn't reverse disease, it doesn't cure it, it doesn't make anything better, but it can slow down the progression.

Any of these treatments that do halt the ovulatory process, but it severely impacts, I mean, beyond so many layers of your mental, your emotional health, your relationships, but your fertility.

Stage three or four disease,

regardless of your age, you're going to have a less than a 20% chance of conceiving naturally over the course of your life if you have stage three or four disease.

Every stage is impactful to your fertility because of the inflammation.

Once you have anatomical distortion and endometrium or cyst inside the ovary, removing that cyst is going to decrease your egg count.

That's going to have a major implication on your potential.

That's why we froze eggs before we took a cyst out, so that we could get those eggs, at least some that we could, out of the body, before we went and did something that was going to destroy part of the ovarian tissue.

What you said, Stephen, is it seems like endometriosis is alive.

And that's a really great analogy because it does just feed into tissue and it's highly destructive.

And if it distorts the anatomy, we need a healthy, floppy fallopian tube generally that can swing around and pick up this egg that's floating around our abdominal cavity.

And then you need a place for the egg and sperm to meet, which is generally a healthy, non-inflamed fallopian tube.

So they're also at increased risk for infertility, but ectopic pregnancies, that's where I see them.

you know, is when I was a hospitalist is in the OR, you know, emergently from a ruptured fallopian tube from this, you know, and I go in and I'm making, not only is she's lost a wanted pregnancy, now I, and I'm making the diagnosis of endometriosis at the same time, and they are just devastated.

I just feel sitting here, not being anywhere within this field, thinking, wait a minute, because I was a cancer nurse first, right, before I did this.

Wait a minute.

There's got to be a cell surface marker that's unique to the endometrium that we could make a monoclonal antibody against.

There's got to be a cell surface marker.

I will say there are people now doing lovely and wonderful research on a cellular level of endometriosis, trying to look at the endometrium itself, what cell markers are similar in endometrial implants.

Can you diagnose this on an endometrial biopsy in somebody?

We haven't seen it get to the point where it needs to, but at least people are paying attention.

So I do think we might have emergent technology that will change the course of this for people.

Right now, I think awareness is key.

And one thing I always say is that especially as a teenager, teenager, because women adjust.

You accommodate to the world around you.

That's one of the things that I think makes women so resilient.

I mean, if you have pain every single month of your life, you are going to convince yourself this is normal for a degree of time because what other option do you have?

It has to get so bad.

But when you're a teenager, you don't know that.

And so if when you are a teen, you would stay home from school, you would not go to the football game or go out to dinner with friends.

That to me is is a huge red flag, but it actually is a very high predictive marker that you do have endometriosis.

So, pain out of proportion to being able to complete your normal life as a teenager is a really big warning flag.

I ask every patient about that when we talk about their periods because 50% of patients with unexplained infertility have endometriosis.

It is so hard to diagnose and underdiagnose, yet impactful to our body.

26 years old, the advice given to her by the NHS was to go back on the pill

to solve for the pains that she was getting.

We certainly have a lot of dismissive doctors and people who don't take pain seriously, but also a disease that is underfunded and not researched, we do have limited options for how you can help somebody.

And I think we have to acknowledge that both things can be right.

Now, getting to the root cause of your pain is always going to be really important versus just saying, here's a birth control pill that should take care of it.

Some women with endometriosis love being on the birth control pill.

It does highly improve their symptom profile and it's an important part of their treatment regimen.

Other women do not find any benefit from it.

And it's really important to have the discussion, especially with endometriosis, in regards to your family planning goals.

Do you want kids?

When is that going to be?

What might this look like?

Because we know if you have a higher rate of infertility, higher rate of needing IVF, do we need to intervene sooner?

But that's going to impact some of the treatment options we're able to give you because some of them do delay ovulation for a prolonged period of time.

What I find in the patients, you know, when we made the diagnosis, was they're forced into making these kind of life-changing decisions around their fertility and ability to conceive before they were

ever

before their peers are even thinking about it.

It's pretty devastating.

It is.

We have some pilot data looking at taking some of the nuances of recovery and looking at how to dampen inflammation.

So we have some pilot data that's showing when women do cold exposure,

that it dampens inflammation and improves their symptomology.

So I'm always thinking on the outside like what other things can we do to dampen inflammation in a positive way to improve symptomology.

How does that work?

So if we're thinking about the responses to cold exposure, we're not talking about ice, we're talking about cold water exposure, it creates a cascade of immune responses that kind of protects the body.

So we're reducing inflammation, we're improving parasympathetic, which reduces stress.

So if we're timing it and they know when their period is and they can go, okay, well, for the next or the 10 to 14 days before my period starts, I'm going to have 10 minutes of cold water exposure.

And over the course of three to four months, that immune response becomes learned.

So it reduces symptomology.

So it becomes one of the treatment options that we have for some of our athletes that have Indo and interferes with their training.

So, I mean, the cold water exposure is available there.

So that's how we started the pilot study.

Cold like someone wanted to do this at home.

10 degrees Celsius.

So what is that?

About 40.

40.

40s.

Yeah, it feels really cold, but not a nice bath.

Not a nice bath because ice is...

Ice is not good for water.

Can you get that in the shower?

You need to.

This is like cold submerged.

Can you do that at a home tub just with turning on the spigot?

You could get back to it.

If you get really cold, yeah, you might want to add a little bit of ice and let it melt.

Okay.

But not ice baths that we see in all the popular media because that is way too cold for a woman's body.

It does the opposite.

It's a severe stress and causes a stress response rather than a parasympathetic calming.

response that we want.

Okay.

Like Stacey said, decreasing inflammation in an inflammatory disease is key to controlling the factors you can.

And much like we talked about inflammation in PCOS, we heard the same word right here with endometriosis.

Chronic inflammatory diseases are the number one thing that we see across the board impacting the population, but especially women.

And so these same strategies to work on decreasing your own inflammation.

And for Indo, it's a little different because you can target it for when you expect to have that high inflammatory burden.

But that's really an important part that we don't talk about.

I don't see that the NHS talked about an anti-inflammatory diet or getting more sleep or cold exposure.

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Now,

on this point of birth control, one of the questions that came in from the audience was, how terrible is birth control to female hormones?

The birth control pill shuts off the brain's desire to send a signal to the ovary to make hormones.

So it is ethanol estradiol, a synthetic estrogen, and a type of a synthetic progestin or progesterone.

These work, the brain thinks that you have estrogen and progesterone present.

As we said, that's the luteal phase.

And so your brain says, we don't need an egg to grow.

Ovulation starts in the brain.

Yep.

Right.

So no FSH comes out and you're not going to get ovulation.

So they're very effective for prevention of ovulation, which makes it a very effective contraceptive option.

But as far as hormonal shifts, yeah, your brain's not sitting out FSH and LH.

Your ovaries are not going to be making estradiol or or progesterone.

Or testosterone.

True.

And so that is how they are sometimes helpful.

If you have,

you know, some women get hemorrhagic cysts with ovulation.

Every time you ovulate,

when you rupture that cyst, you get a lot of bleeding.

The birth control pill can prevent ovulation, therefore prevent some women from being in terrible pain.

If you have PCOS, they're often handed out like candy.

One reason is because it will regulate your cycle so that you don't have these prolonged irregular periods, but also also will decrease testosterone levels, which is sometimes a good side effect of the pill for women who have PCOS.

Back to a normal level.

Yeah.

But if you don't have PCOS or the regular person, a lot of times your body's tissues are not responding to synthetic estrogen and progesterone the same way it does to natural.

I think that's a very important point.

So my niece, who competes

at a national level, and she's 14, started suffering from, as she was going through her adolescence, her acne got outrageous outrageous and she's a 14 year old girl 13 it started at 12 and a half and of course you know she goes to the dermatologist and they're trying some topicals and then finally as you go down the algorithm for how we treat acne one of the off-label uses is birth control pills will lower the testosterone their skin can clear up so her father a little concern comes to me um her mom passed away her stepmom had passed away so he didn't have the mom in the house to you know the immediate mom to talk to and

for the first time i immediately thought of her athletic performance.

Thank you, Dr.

Sims.

And I thought, she wants to go to the Olympics.

There's no way I'm going to let her testosterone levels drop.

Like, we're going to throw everything topical at this.

And we finally found the right combination.

Her skin looks great.

She's super happy.

But like, the next logical thing was to put this 14-year-old, you know, on a birth control pill to get her acne under control, which is the end result.

But what no one's thinking of is her athletic performance.

How is it going to affect her?

Her training years, leading up to her.

And her training years.

Like, this is critical for her.

16 is when the next trials are up for her.

So that's two years from now.

So we were able to get her acne under control, avoid the birth control pill, but that was nothing I'd ever thought of before.

Well, I'm sitting here from a musculoskeletal standpoint thinking about the high percentage of women who have endometriosis and PCOS, and the complete, soundingly

imbalance of natural hormones.

Plus,

for a lot of reasons now,

girls are not cycling normally.

And I'm sitting here terrified for their bones.

Yep, 100%.

Because we build bone from 15 to 25.

And if we are so inflamed that we're producing all kinds of inflammatory cytokines, i.g.

interleukin-6 and C-reactive protein and tumor necrosis factor, which halt bone development.

We don't have enough estrogen for whatever reason.

We're going to shut off our testosterone because it makes us feel better.

And we're not exercising.

And we're sitting around.

No wonder I have 20 and 30 year olds with no bone density that are then going to go into perimenopause, which we will get to, and lose another 20%.

So I was feeling pretty hopeful that the Generation Xers are going to get to the millennials and get to the whatever they're called after that.

It is worse.

You're going to see it get worse before it gets better.

Exactly.

That's what I'm sitting here terrified.

Like, okay, I thought, okay, baby boomers,

those women missed out.

Xers, we're doing the best we can.

Millennials, but no.

Because now you're telling me our 15 to 25 year olds are still in the same detriment with muscle and bone building.

We are trying to change the narrative.

That's the group we're trying to target right now.

And I do think by educating across the lifespan, we're going to change how those of us who have 11 and 12-year-olds, what we recommend.

I treat girls in their teen years when they come to me without their period much differently than a lot of other people do.

But this is learned experience.

Instead of just you don't have a period, here's a birth control pill.

Say, you're not making estrogen, and this is a crucial time for you.

Let's give you estrogen.

Let's talk about why you're not.

What can we do to change it?

And so, this discussion is more than just disease-state important, like PCOS and endometriosis.

It's truly important across the lifespan of a woman, the choices that are being made in her early reproductive timeline is going to impact her longevity.

Can I ask all of you what you would have done differently?

For ourselves?

Yeah, for yourselves.

Obviously, I know several of you have daughters as well, but what would you have done?

I I wish everybody could see all of your faces.

Oh, yeah.

I've talked about this before.

I mean, I was amenorrheaic until I was 20.

What's amenorrheaic?

Didn't have periods.

Okay.

Because of high stress, high sport, you know, didn't care, didn't eat well, in the whole mindset of the 90s of...

Calories in, calories out.

If you're thinner, then you'll run better.

If you're running better, then you're going to hit different metrics.

Because I was a runner in high school and then joined the crew team, same thing.

So if I could go back and talk to my younger self, I would have been like, you need to eat, you need to recover, you need to eat, you need to recover.

Instead of the mantra of calories in, calories out, more cardio, lose weight, lose weight, lose weight.

Because now I educate people is you want to take up space, you want to be strong, you want to look at

not the idea of losing something, but gaining something, gaining that power, gaining that strength, gaining that bone, gaining that muscle, gaining your period.

Those are the things that I'm trying to educate the younger generation because that was not impressed upon me as a younger athlete, which then had a lot of repercussions later in life.

Luckily, my bone density is fine.

So were you on the contraceptive pill?

No.

You weren't.

Okay.

I was

not an athlete, so mere mortal.

And

but it's so you've you've you've been able to take that experience though and apply what you've learned in this this high intent, you know, working with these intense athletes to the to the regular, you know, to people who don't exercise at that level.

And,

you know,

I completely fell under the

expectation of the aesthetics of it.

When I did exercise, I exercised to look a certain way.

And then in my 30s, I exercised for performance.

I started running half marathons.

I was doing baby triathlons, the really short ones, with my girlfriends.

It was a social thing and it was super fun.

You know, I was running for time.

Now I'm exercising for my old lady body.

Yep.

You know, I'm exercising to be in a bigger body because I know my mother and my grandmother, so my grandmother spent the last 10 years of her life in a bed, incontinent with dementia and completely frail.

And my mother is on the same course.

My mother is 88, fell and broke her hip in January.

She just now is walking on a walker.

She's in an assisted living facility for Alzheimer's.

I want to change that legacy for my children.

I don't want that to be my path.

And and I don't want my children to have that to be an expectation.

So

all of the things I would have done differently was

I wanted to be thin.

Thin was healthy.

That is what I learned in medical school.

The thinner you were up to starvation, you know, up to you want the lowest body mass index possible without being a little bit too low, you know, and I kind of skirted that line because I stopped eating in medical school due to stress.

I would have fed myself.

I would have lifted weights.

I would have stopped doing so much cardio because knowing I was chipping away at my bone density.

I was chipping away, you know, I was raising my inflammation levels.

I was chipping away at my ability to resist the Alzheimer's, you know, and dementia that runs in my family.

And that's what I'm trying to impress.

My girls who are 21 and 25, what I'm trying, trying to impress on them.

But that's the mentality that we grew up in, right?

When you're looking at the supermodels of the 90s and Kate Moss and it was heroin chic.

Yes, heroin chic, which is the worry now with the GLP ones coming back and the ballerina body and all the things that we're seeing come back again.

And it's, it is worrisome.

You know, when I think about, I mean, I've already told the world now about having low body fat, maybe being PA SOS and not knowing it, not ever talking about that, having no periods.

But then, so there was that in my youth that

I would have done better, but it didn't end in my youth.

I mean, I went to college, same.

I went to grad school, still same.

I went to medical school and in medical school and

four years of medical school, seven years of residency and fellowship, still didn't eat, still was having periods.

I didn't sleep for about 11 years, whether between call every third night and then I had a baby and then I was awake for two years because she slept with me.

That's another discussion.

But I think of all these things that I wish I knew then that I know now I have the same goal.

I have four 30-year-old daughters and I have a 17-year-old and they are not going to be allowed to hit a wall like some of us may

because we didn't know.

And were you on the birth control pill?

You know, intermittently,

probably totally in my life about 10 years,

but

not continuously.

And Mary, I forgot to ask, were you on the birth control?

Yeah, we were often on for 20 years.

So polycystic ovarian syndrome, that was the treatment.

I mean, I learned about nutrition kind of on the back end,

but the life that I had set up for myself between, you know, medical school, residency, and then going into the field of OBGYN with limited sleep, you know, working 100-hour weeks,

there,

I didn't have an environment that would have been conducive to be able to manage that disease with lifestyle.

And I can look back and say that honestly now

without using the crutch of the birth control pill to manage my symptoms.

I was on the birth control pill for probably 15 years continuously.

And, you know, we have to give credit where credit's due because I was able to pursue medical training and not worry about

what family building looked like for me, me, which was really important

because I was not ready to have a child.

So, anytime we frame a discussion around birth control, I always want to say it's not ever going to fit into one bucket of all good or all bad.

It's going to be, you know, different stages of life, different things are important.

I didn't stop it soon enough to learn to track my cycle.

I didn't recognize psycho abnormalities.

When I had recurrent miscarriages, I had a really hard time knowing is this how my cycle is supposed to be or not?

Because I never had the opportunity to just have periods and see what is my normal.

I stopped it and started trying right away and got into a cycle of having a pregnancy, and that would last for a while, and then I would lose it.

So, I really lost the opportunity to say, This is my baseline, and oh, there might be a problem here, or to intervene.

I wish I'd advocated more when I had my own pregnancy losses.

I was told over and over, there's nothing you can do, this is nothing, just keep trying.

And even as somebody in the field, that felt very dismissive and is a fuel for a lot of what I do now.

But on a personal level, you know, 10 years after having those pregnancy losses, I was diagnosed with celiac disease because I had osteopenia on a dexascam.

And so I had to explain what that is.

Yeah.

So celiac disease is essentially an allergic reaction to gluten.

So when I was taking gluten, which is in most of your carbohydrates.

or the good stuff like breads and pastas.

When I was eating those, it was causing an inflammatory reaction inside my body, making my gut unhealthy and kind of creating a baseline level of, let's say, chronic inflammation.

And recurrent pregnancy loss can be one of the signs and symptoms of it, in addition to just some other, what feel like very generalized symptoms, fatigue, low energy, headaches, GI distress.

W, Debbie.

Yeah, I was a whiny woman.

And when some of these symptoms finally got to a state where they were getting worse, probably with hormonal change with age, and my doctor ordered a bone scan, and it came back that I had osteopenia, which is very low density of my bones for my age.

And especially at the time, you know, no known medical problems.

And so, luckily, I had somebody who was very committed to not labeling me a WW and saying, I think you're not absorbing something correctly to get on this pathway to figure out that because of this autoimmune disease, celiac disease, I wasn't, my gut was inflamed.

I wasn't able to absorb the nutrients that I needed.

But somebody had to be committed on the other end because these symptoms went on for so long.

I just accepted them.

I let them be.

But I also am scared because those critical bone-building years, I was on the Pell.

And I used it continuously, which means every single day all the time.

I, you know, I know I was chronically inflamed.

And so now I'm at a stage of my life at 43 saying, I've got to try to catch up before it's too late.

And that is scary.

And can you catch up?

Yes.

Yes, you can build bone.

Because, you know, I see all these graphs, Wonder that, you know, you kind of

then it goes down from your, wherever you manage to get it up to.

So I'm telling all my friends at the moment, thanks to you, I'm telling all of them to get their muscle and their bone as high as possible because it's probably going to fall with age naturally.

Well, everyone

ages.

Yeah.

Age is the most natural thing we do from the minute of our birth.

But men and women age at different rates, especially

after perimenopause with the lack of estrogen.

We age very differently from that point on.

But your point being made is, can we please maximize our bone density and our muscle mass and everything else, frankly,

in our youth when we're probably not aware, right?

When we're in college and doing all the things kids do, it's the last thing on our mind.

And yet it's the most critical time because you want to start both your bone and your muscle from the highest possible level.

Now, can you, through

lifestyle and hormones, build bone again?

Yes, actually, you can.

But wouldn't it have been better to start out with the maximum so that the natural decline doesn't take you into dangerous levels?

Right.

On that point of birth control, what are you saying to your daughters that wasn't said to you?

Are you because Mel regrets, my girlfriend, she's very open.

She regrets being on the birth control bill for 10 years because she had no idea what it what it was doing to her body.

And then obviously when she came off her cycle, I think she spent, like you, Natalie, two years trying to figure out what was going on.

And she didn't have a period for an extended period of time after she came off.

What are you saying to your daughters about the birth control pill that wasn't said to you?

Are you recommending them to use it how you guys used it?

Or?

I mean, we were started on it so young.

I do see a trend towards not starting it as young as it was started in our generation.

And I think that that is important.

I see...

You know, personally, my daughter is not quite at that stage yet.

So we haven't had to make these decisions as

they have had to.

But I do think it's important.

Psycho awareness is one of the few early signs you have of your body's health as a young woman.

And so, to purposefully never get to know what that is is a detriment to saying, I'm aware of what's healthy for me and I know what's happening in my body.

But you guys have had these discussions at different time periods.

For my youngest daughter,

I was worried about she was a dancer also.

She was teeny tiny, so tiny, even though she had great muscle mass, but she, like me, wasn't having periods.

And so the advice was to put her on birth control, to regulate periods.

But I was always uncomfortable with that because she didn't, to be a dancer, she didn't have to be quite as tiny as she was.

And so what we have done now is I've encouraged her to gain a little weight and get a little bit more body fat.

Because I took her off of that.

She only had to gain five pounds, I think I said to you, maybe seven.

And it has more regulated her, and she's having her own periods now.

And so I don't know what she's going to decide.

She's going to be 18 soon.

And, but I think what we should be telling our daughters is all the information so that they can make an educated decision.

Because I just did what I was told.

And I'm a doctor,

but I'm not an OB, so I don't understand the nuances of

what the pill is, that it's synthetic, that this is how it works, this is what it doesn't do.

So I would want to give my daughters all the information so that they can make an educated decision.

So my oldest, the first one coming through,

wanted it for contraception.

And so when we talk about contraception, it's not just most people automatically think the oral birth control pill.

But I did go through all of the options with her and then sent her to a trusted friend to let her go and make her own decision.

And she decided to have an IUD inserted, which I thought was a great choice for her because she had normal regular periods before we did this.

There were no issues.

And she had it inserted.

And then within a week, she started having severe cramping, called me into the bathroom.

And this is my daughter who has not let me see her unclothed since she was seven years old.

She's just very private.

And she's like writhing on the floor.

Bless her little heart.

And she had expelled the IUD on her own.

She had cramped it right out.

The uterus pushed it out of her body.

And it was extraordinarily painful.

And so we basically delivered the IUD on her back.

So do you know what an IUD is?

Is that the coil?

Ish.

That's one form of an IUD.

She had a different form, but she basically pushed out her own IUD.

It's true, uterine device.

So it's birth control that is placed inside the uterus.

And it's shaped like a T.

It is shaped like a T.

It's used to shaped like a T.

In the UK, they use the coil still quite a bit, which is copper.

And so

there's different options for the IUD.

Some contain progestin, some contain just the copper.

And so the way an IUD works is that it creates an inflammatory response in the uterus so that the cervical mucus thickens so that when we are fertile in our fertility window, mid-cycle, and jump in, if I mess this up, the mucus of the cervix thins to the point where sperm can actually get through.

Most of the month, probably 85 to 90% of the month, the sperm cannot traverse the cervix.

You cannot, you know.

So in our fertility window, right at ovulation, the cervical mucus thins and then the sperm can transmit.

So

the presence of the IUD creates an inflammatory environment that will basically is toxic to sperm and thickens the cervical mucus where it becomes a plug.

That's how it works.

Works very, very well.

Catherine, within a week, her uterus ejected it.

So she cramped so much that it pushed it through.

And so that wasn't an option for her.

She wasn't willing to go through that again.

So then at that point, she had to go through the hormonal options for that.

And she decided to have the implant, so it's progesterone only implanted into her arm.

Quickly, we realized she needed some estrogen.

So she supplements estrogen on top of that.

Stephen, I think the contraceptive discussion, we have to say that

there are options that are highly effective at preventing pregnancy.

And at some times in your life, that is the number one most important goal.

And we need to choose a highly effective option.

However, certain, some of those options included have downstream impacts that have not been discussed about.

The typical contraceptive discussion says, here are some side effects you may have.

If you want to still proceed, let's go for it.

We're not talking about long-term implications of these.

We're just talking about how you're going to feel, not exactly what is happening in your body.

A lot of these contraceptive options are progesterone only.

And so you know by your new favorite graph that you don't see progesterone every single day.

So when you have progesterone only,

it is shifting your hormonal profile.

And a lot of women, this progesterone is so high that it works by also preventing ovulation, makes it highly effective.

But if you're not ovulating, you're not going to be making those high estrogen levels.

And Dr.

Haver and I have even talked about how we wish there was a contraceptive option that had estradiol in it so that your body could still have some estradiol.

So, this ethanol estradiol is very different than plain estradiol.

They've put this ester group on the end, which makes it bind to the estrogen receptor in the brain 300 times more

powerful than regular estradiol.

Yeah,

which is why it's so effective.

You know, why we do it in a micro dose versus estradiol is dosed in milligrams and ethanol estradiol is dosed in micrograms because it is that much more potent.

So very, very different.

Now, in the UK and other places in Europe, there is a new form of contraception that has esteratrol, which is the fetal estrogen.

So we have four natural estrogens in the body.

The ovary produces estradiol.

That's the one we all know.

It's really the biggest bang for our buck.

The placenta produces something called estriol.

Our fat cells and the peripheral tissues, the tissues outside of the ovaries, can produce something called estrone.

And then we have this fetal estrogen called esteratrol, if I'm pronouncing it correctly.

And so they've compounded, they've been able to formulate that.

So it is one of the natural estrogens, and they've put it in a birth control pill that is available in the UK.

If you were 18, what choice would you make for contraception now?

Studies have proven, within the shadow of a doubt, that relying on natural family planning at most ages is not a reliable form of contraception.

So I would not recommend that.

And relying on condoms.

What do you mean by relying on natural family planning?

So timing your intercourse.

Oh, okay.

So cycle tracking, we know that the fertile window is the five days before and the day of ovulation.

Five days before.

Five days before and then the day of.

Sperm can live for five days in the female reproductive tract.

The egg lives for 24 hours.

So in this graph, where is...

Yep.

So the line, right, is ovulation, and then the five days before.

Yeah.

So in popular culture, you would call that natural family planning.

Okay, fine.

Avoiding intercourse.

Abstaining any time in that window.

But if I'm trying to get...

male pregnant, then I should really be aiming.

Those are your target days.

Yeah.

There are apps for that you can track.

Yeah.

Oh, I've got the app.

Okay.

Oh, he knows.

Remember the variability aspect then.

He's made me download it it mindset.

There's a few different ways you can do natural family planning to hijack the discussion for a minute, and they have different degrees of effectiveness.

But one of the main issues is that they have very large abstinence windows.

So it's often not very sustainable to say, we're just not going to have intercourse for 18 days out of the month or some very long time period, depending on which one, because your cycle is never perfect.

What if you did ovulate sooner?

If this is all you're relying on for your prevention of pregnancy, you have to really assure that you know when that ovulation is happening.

It can be an effective way to prevent pregnancy if your cycles are very regular.

But in my brain, I wish that's what you stop the birth control pill at least six months before you want to get pregnant.

And then you start learning how to track your cycles and you're using some natural family planning if you're not quite ready then because the margin of error, oopsies, it didn't work.

The acceptance of, well, we were going to try to get pregnant soon is usually okay.

It's not an effective contraception for most of the population.

We have to factor in when we're looking at, you know, I was trained and taught to only look at birth control through the lens of contraception, right?

We know that they might have some weird bleeding and maybe a few headaches.

And for some, a DVT, if they have, you know, deep venous thrombosis, you can have blood clots.

It'll increase your risk, especially if you have a pre-genetic disposition to that.

But what we didn't talk about were mental health, mood, and some of the long,

downstream libido effects.

So

of taking control.

Right.

And so then I'm looking at it through the lens of, you know, if I'm only looking at it on the lens of she doesn't want to be pregnant,

a younger patient, so you're talking about 18, is less likely to remember to do something every day.

Correct.

Okay.

So then to take the impetus of remembering to take a pill every day or change a patch once a week

for the patch option, then we're looking at maybe a vaginal ring that she inserts for three weeks and removes for one for her period.

Pick one.

If I had to pick one right now,

if it was available in the U.S.

I think I would go with the esteratrol what's that option that's the one she's saying is the UK a newer option that we don't have no pill it's still a pill yeah and it's it's because it it more

It looks like so far it's newer that it has less of the downstream effects.

So you're not having that complete suppression, you know, that complete binding and it's it's you know may have and also probably has less risk of

DVT of blood clots.

I'll jump on this.

I do not love intrauterine device for a patient who is 18 for a multitude of reasons.

Now I'm going to preface this to say it is a highly effective contraceptive choice.

It's one of the most effective ones that we have.

And so there are certainly circumstances where that is the right thing to do.

We've had IUDs in practice for a really long time.

For the majority of this, we were only placing them in women after they had given birth at least once because of their size and being able to pass them through the cervix.

Now we have different options and we are offering them to women younger, which is wonderful.

However,

when we're putting IUDs in the uterus of women who are really young, sometimes the progesterone dose in them is so high that it is preventing ovulation.

And we are seeing young women who are not ovulating and they are not making estrogen, therefore, and they don't even really realize it because

that's not disclosed as one of the main mechanisms of a progesterone IUD because it doesn't happen in enough people to effectively prevent conception that way.

It works through the inflammation, the cervical mucus changes.

And why does that matter?

Because if you are not ovulating and you're not making estrogen, you are going to have low libido, low energy, you're not going to build your bones during critical years.

Let's say the IUD lasts five to seven years.

You're 18 to 25.

These are some of the most critical years in your mental health, your bone health, your cardiac health.

And being low estrogen during that time is going to set you up on a different risk trajectory for your entire life.

And the worst thing here about the progesterone IUD is that because of the progesterone, which will thin the lining, many women just say, I don't have my period because my lining is so thin, and that's a side effect of the IUD.

If that same woman was not ovulating and came to me and said, I haven't had a period in seven years, and I knew she was low estrogen and not ovulating, were highly concerned about her health.

But because she has an IUD, what happens?

Well, that's a side effect of the IUD.

No big deal.

So we're missing the moment to understand where are some of these symptoms just side effect of the IUD or are they having a much bigger role?

in what's going to happen to that woman's long-term trajectory for being low estrogen during crucial years.

And I'll say this, Stephen, I'm very biased, right?

I'm a fertility doctor.

I see patients who have trouble getting pregnant.

That is a narrow subset.

That is not the majority of women who have IUDs.

So, what would you suggest if you had to pick one contraceptive?

Vasectomy.

Yeah, I would still do, I would still do the pill right now, the pill or the vaginal ring.

You know, I think they are both depending on somebody's personal preference.

I just think that it's really important if you're using the birth control pill.

I do think it's important to give your brain a break from the pill at times.

And even if you're cycling it monthly, there's options now.

I took the pill, an active pill

every single day for for years

a decade probably meaning suppressed my brain completely for that long now

your brain sends out hormone signals that impact your entire body right so we already talked about the hormones and how it's this beautifully conducted symphony But if you even, if you're going to take the pill at that young age, I would say take it so that you have the seven days of not taking a pill, let your brain have have a moment of release from the suppression, and then take it again.

That's still a very effective way to use the pill.

But because women don't love having periods, we've offered these other options, which are not wrong, but they just have a bigger consequence downstream than we're talking about.

But the pill is very short-acting.

It only has a half-life of 28 hours, meaning it is out of your body very quickly.

So you do want to stop the pill and see what is happening and track your cycles.

That is something nice about it versus an implant or an IUD that is.

Fit and forget.

The fit and forget people like fit and forget.

Yeah.

Yeah.

The question that came in from the 1,000 women we spoke to in the diarrhea audience was, is there any way to control hormonal mood swings during the luteal phase of the menstrual cycle, which I now know is the second phase of the menstrual cycle.

Stephen, you've learned so much.

Yes.

That's great.

Yes.

I love that.

In the luteal phase, we do tend to see more mood changes and physical changes.

And a lot of this is because we have an increase in estrogen and progesterone, and then a decrease in both of these hormones.

And what we find is that some women are simply more sensitive to these changes.

They feel them quite profoundly.

And there's even something called PMDD, pre-menstrual dysphoric disorder, which is when those hormones are dropping, you get these terrible mood swings, this terrible depression and anxiety, in addition to physical changes with terrible fatigue.

You just feel like you can't accomplish any of your tasks, insomnia, quite similar to a lot of the things that we talk about anytime we talk about a low estrogen state.

Right.

Like we see it in postpartum depression.

It's a very similar.

And in the perimenopause transition, we have a 40% increase in mental health changes.

And we know this

because women tell us and we believe them.

But what's happening is that our neurotransmitters, especially GABA, serotonin, and dopamine levels, are highly tied to what our hormone levels are doing.

So is this

the mood swing, or is the is the

what's the right term to describe a mood when someone doesn't feel great?

Dysphoria.

Dysphoria.

Is the dysphoria mood after the period or before it?

It's before.

So, the estrogen is dropping before and it stays low through.

So, what happens is about the week before your period, and then the week we'll say of your period, you are estrogen low.

The rise of estrogen from that next egg being recruited is actually what stops you from bleeding and helps you start to feel better.

Because of this, a lot of people will throw a birth control pill at this situation because they will say, I will give you constant hormone levels every day, and now you will not have these PMDD symptoms anymore.

However, a lot of women don't want to be on the pill for a variety of the different reasons we've talked about.

They just feel bad, let's say this week or this seven to 10-day interval.

They don't want to suppress ovulation.

I find that a low-dose estrogen in the luteal phase can be very effective in targeting after ovulation.

I'm going to take some estrogen, helping alleviate these symptoms without interfering with ovulatory function.

But I was trained to give them an SSRI for those seven to 10 days.

An antidepressant pool.

Yes, an antidepressant.

Only for those two weeks.

Seraphim, was that the brand name of it?

And it does tend to help.

But what no one taught me and what clinical experience has taught me and talking to all these other smart people is a low-dose estrogen, like treating the root cause.

Treating the root cause.

Just give her estrogen back during that time period and she gets remarkably better.

And some of the nutrition research finding that low iron and low vitamin D are huge contributors to it.

So there's that research to investigate too, which is interesting because there are some women also who don't want to go on SSRI or estradiol.

So a lot of that.

You know, the Endocrine Society does not recommend routine testing of vitamin D.

It's crazy.

I just think it's insane.

With my partner, I should anticipate that her mood might drop in the lead lead-up to her having her period.

It's very common.

And then after her period, it would might recover.

And whether or not that becomes clinically significant, whether or not it's life-disruptive for her, rather than she just has a little bit of a low mood.

Most women can tolerate that.

But for those who can't, and that it is disrupting their day-to-day activities and how they feel about the world, we have options.

Yeah.

Because I'm trying to understand, I want to understand her better.

So I'm looking at this little graph here, which says the brain during the menstrual cycle.

So the menstrual cycle starts when her period starts.

By convention, yes.

That's what we say.

Day one is the first day you start bleeding.

Okay.

And so what is she going to go through for the next 29 days?

And how might I support her better through that journey?

Like, I want to understand what's going on in her brain.

Her brain starts by

from a reproductive hormone level.

The brain starts by sending out FSH, follicle-stimulating hormone, which is going to get her ovary to start growing an egg, which lives inside a follicle, and making estrogen.

And that rise in estrogen as it's growing will stop her from bleeding.

So the beginning, that cycle day one, the bleeding that she's experiencing or her period is because she didn't get pregnant in the month before.

So it's getting rid of that endometrial lining, cleaning the slate.

She's estrogen and progesterone low during that time period.

And then once her bleeding stops, it's because an egg has been chosen.

Estrogen is then going to rise until it gets to that peak level.

During that time, she's going to feel her best for most women.

So is that the first 14 days?

So by convention if you had a 28 day cycle, which only about 13% of women actually do, but all of these graphs, if you look at, usually use 28 days because it's easy to go week by week.

And that's the lunar calendar.

Yeah.

So 28 days.

We see that, but we have to acknowledge that most women don't have a 28-day cycle.

So, but it is roughly the first two weeks for most women to get up to that ovulatory time period.

So the time from I have started bleeding until I am now ovulating, that is all considered the follicular phase.

And on this little image that I have in front of me here, it says in those first 14 days, she's going to have better spatial skills and be more anxious.

So once you get to your estrogen dominant, so you have a lot of estrogen and you don't have progesterone, most women have increased concentration.

They have more focus.

They actually can sleep better.

They have higher libido.

You feel like your performance, even for athletes, performance tends to be more aggression.

Concentration more.

Yeah.

During what we call the late follicular phase.

So that means the time period when you're really making that estrogen.

Let's call it days seven to 14 for ease.

So I'm now done bleeding.

A follicle is growing, meaning an egg is making enough estrogen to stop that bleeding.

I've not yet ovulated and seen progesterone.

This is where we typically have our best performance overall from how our body is functioning.

And then from day 14 onwards,

she's going to be calmer?

Well, progesterone slows your body's metabolism down.

It's preparing you for that pregnancy.

Calmer is a nice way to put it, but essentially, your metabolic rate is going to change.

Your body's going to shift how it functions.

Many women actually have fatigue.

They're hungry.

Specifically in the brain, progesterone levels, as they rise, we see an increasing GABA, which is a neurotransmitter,

one of our brain

hormones that talks, you know, jumps between one neuron to the other.

And that is more of a calming hormone.

So women tend to see, we see sleep changes.

You see deeper sleep, longer sleep in that luteal phase.

And on this, it says she's going to have, she's going to be horny at day 14.

I don't know how else to say it.

Because she has an egg available.

Because that's that peak estrogen.

That estrogen level of 200 picograms is heightening everything to have peak libido when an egg is released.

The body is made that way on purpose.

This is a

bit off script, but my girlfriend always talks about her HRV being very different.

And so she has really great HRV scores.

And then once every month

for a period of time, they're terrible and she can't explain it.

So this is where wearables come into play.

Yeah.

So wearables are not designed to capture women's physiology.

So what happens after ovulation is your respiratory rate goes up, your resting heart rate goes up, and your HRV plummets.

So on the wearables, most women, about five days before their periods start, will never be in the clear, so to speak.

They will never look recovered.

They will never look like they can take on a lot of stress.

They're not stress-resilient because of the way the algorithms are reading this change that is natural that is produced by progesterone to alter our respiratory rate and our heart rate.

It doesn't mean that she's not stress-resilient, is what the wearable is saying.

Ah, because she came downstairs and she said, Oh, God, my recovery is so bad.

And then I think a couple of days later,

a little while later, she had a period.

I'm not sure.

I can't remember remember the time frames, but she came downstairs and she was like shocked that she'd done everything right.

But her recovery on her wearable said that she was in terrible state.

This is why we do not let athletes use wearables leading up to a peak event because they feed into what the wearables respond or telling them.

And it's not true data with regards to how their body can actually perform.

So wearables data masters then need to

segregate populations and make new norms for women and maybe new norms for different fitness levels of women.

Exactly.

I've always been pushing for the past five or six years interacting with wearable companies.

It's like, if you want to capture it well, then you need to be able to compare follicular to follicular and luteal to luteal.

What does that mean?

So comparing.

Like we know your HIV is going to be different in your follicular phase.

That's expected.

This is not a bad thing.

People could theoretically do that on their wearables and look at the previous month and see the level you're at then theoretically.

Obviously, the wearable companies could do a lot more here to make that.

That's definitely helpful, but no.

Then it comes back again on the woman trying to understand and interpret the data herself,

which can be a little bit problematic because there's so many women out there.

Like, my wearable told me that

I'm in the red.

I can't do anything today.

When in fact, physically and psychologically, they can do what they set out to do.

It's just now they have this little seed saying that, no, you can't do it because of an improper algorithm on their

wearable.

Probably a good time to disclose that I'm an investor in whoop.

No, thanks to push.

Okay.

Yeah.

I'll send this to them.

Please.

You wear whoops.

I wear whoops.

Do you wear any devices to track your health data?

I haven't wear many.

I wear a CTM and a whoop.

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I want to close off on the subject of fertility because it was heavily asked by our audience.

And I guess I'm well placed to ask some of these questions because I'm in that journey myself of trying to have a child at the moment.

Natalie, you have five fertility non-negotiables that you talk about.

I do and I think it's really important to think about

For too long, we've been told, you know, your fertility is luck.

It's good luck if you get pregnant.

It's bad luck if it's not.

And that's this narrative that gets propagated.

And fertility is certainly not fair, meaning people will have infertility and do everything right.

But there are things that we do that will inherently also harm our fertility and our hormonal health and make it harder to get pregnant.

And that's even when we are doing treatments.

So a lot of times people will say, I'm doing IVF, so I don't need to worry about these non-negotiables.

And that's also not true.

Meaning things that we need to do.

We need to, as we've all said, get more sleep.

That's going to be number one.

We need to actively work to decrease stress.

That is not a, I'm just going to live a stress-free life, but all these things.

I'm going to not take call.

I'm going to set some boundaries and not have late meetings.

I'm going to see morning light.

I'm gonna take a walk outside.

We live in a stressful world and chronic stress itself can impact your fertility, your natural fertility, and IVF success rates.

We're going to work on exercise to build muscle and try to improve our muscular health since it's part of our metabolism.

We're going to eat an anti-inflammatory diet.

That's definitely key, high in fiber.

And we're going to look at the world around us and work on pulling toxins out of our world that we know.

We haven't even entered the discussion about how environmental toxins is harming our body, our hormonal health, our fertility, our ovaries, our organs.

And so these are all things that we make active choices on that we have to start paying attention to and kind of changing.

We'll go into deep detail in the lifestyle factors and the environmental toxins in our second episode together.

I've always been quite shocked by this graph because it's

quite significant.

This is just showing the

egg count by age.

Slide that in that direction.

Between us, we love that.

What do men and women need to understand about egg counts in order to make better family planning and fertility decisions?

Okay, well, I've asked you this last time.

So, Stephen, how many sperm do you make a second?

Millions.

You make 1,500 a second.

You mean you make millions every day.

Okay, but still, still, you still, you make a ton of sperm.

You make sperm every single day.

You have germ cells that create sperm.

Women are born with all the eggs you're ever going to have.

And yes, my favorite vault analogy.

So I like to imagine that this is a vault inside your ovary that is storing all of your eggs.

And so we'll use this cup with all of the beads as that analogy.

And every single month, since before you are born, eggs come out of this vault.

And what happens is that when the vault is more full, more eggs come out every month.

And as the vault starts to get emptier, fewer come out.

And this means that we lose the majority of our eggs.

You can see the line, well before our reproductive years even start.

So you lose the most before you're born.

So from being a five-month baby to birth, your egg count goes from six to seven million to one to two million.

Millions of eggs lost before you're even born.

From birth to puberty, let's say you go from one to two million to half a million, to simplify numbers.

So the second biggest drop, before you're ever ovulating, before you ever have a chance to get pregnant.

And then you only ovulate around 400 eggs over the course of your reproductive lifespan.

As that egg count starts to drop over time, the other really, really big important factor is that our eggs have been in our body our whole life.

Two different things are happening at the same time.

One is that our chromosomes start to leave their perfect position.

They absorb the wear and tear of years.

So we see more chromosome abnormalities as we get older.

It's why it's harder to get pregnant and why we see an increase in miscarriage as we age.

But also, concurrently, our metabolic health is poor as we are older too.

And mitochondrial function in eggs, the metabolic capacity becomes less capable.

And so we see that it's harder to get pregnant, not because women are running out of eggs, but because the quality of the eggs declines.

But everybody will run out of eggs.

You'll have a period of time where you have a very low egg count.

We call it diminished ovarian reserve in the fertility world.

We call it perimenopause more globally.

And this is two words to describe the same thing.

As your egg count starts to get very low, you start to have an unpredictable response to your ovary.

And your brain is trying to compensate for that.

And so you see various hormone changes, but these start before you might recognize even menstrual cycle changes.

But everybody will run out of eggs.

Every woman will.

Your ovaries will go into what we call ovarian failure and no longer respond to hormonal signals from the brain or artificial signals that we give.

Meaning, I will see older women come in and think that I have magic medicines with IVF that can still help them get pregnant, but I can only get the eggs outside the vault to grow in IVF.

So shouldn't we then be freezing our eggs?

You're right.

As a society, if we are purposely delaying childbearing, we know that it gets harder to get pregnant with age.

And if having kids is a life goal, putting eggs into the freezer earlier is a way to save that opportunity.

It's not an insurance plan.

It's not a guarantee, but it is a smart game plan, especially as we are waiting longer.

Because even with IVF, we can't always overcome age-related infertility if we have fewer eggs and more genetic abnormalities.

The technology helps us identify healthy eggs, helps us have more eggs able to grow in a certain month and take them out and test embryos in a lab.

But I'm working with the eggs and sperm that you're giving me, meaning if there's not many of them, if there's a lot of chromosomal damage, if there's a lot of mitochondrial dysfunction, if the sperm quality is not great, that doesn't mean we're going to be able to have success.

So what you're doing on a daily basis to impact egg and sperm quality is still crucial.

But egg freezing...

has gotten a lot of bad rap.

It's still a new technology.

It's only been around about 10 years off experimental purposes, meaning that women who froze their egg 10 years ago,

you know, they have much poor egg survival rates.

They were older at the time.

Their experience is very different than the modern woman who is freezing her eggs now, maybe in her upper 20s or early 30s.

What is the optimal age?

If you want to have a child as a life goal and you're not ready to conceive by age 32, that is when there's a clear delineation that it makes smarter financial sense as well as likelihood sense.

The short answer, like, my daughter will freeze her eggs in her 20s.

The younger you are, the more eggs that you have.

If she says, I want to have kids as a life goal, then that will be something that we will do in order to help her keep that because there's so many other variables which impact your ability to get pregnant or your egg count.

Endometriosis decreases your egg count, right?

People will develop an ovarian cyst and they'll have surgery.

Surgery, they'll have a twisting of their ovary and maybe they'll lose an ovary.

Smoking, chemo, radiation, smoking, marijuana, any abdominal surgery.

So many things can impact your eggs because you only have this group.

You're born with them.

So

we plan for life goals differently, and we've never really talked about our fertility life goals until more recently.

Meaning when we went professional career, right?

We knew what we had to do to get into medical school, to get into residency, to get your PhD.

You had this list of things and you set goals and you worked to achieve them.

But I always wanted to be a mom.

Yet I already told you, I took a birth control pill every single day and I didn't even think about it until that moment was in front of me.

And that's the part of the discussion that we do have to start to have earlier is if this is a life goal for you, what do we need to do, understand our body better, our fertility better?

And maybe that does include freezing eggs because it does give many women an opportunity that time would eliminate.

I had a conversation with you, Natalie, in the podcast, but then many other women over the course of the last two to three years.

And one of the things that I learned from that was that we, as you say, we don't family plan and then we have to deal with the the consequences of not family planning.

So, as an interviewer, when I do life story episodes, I go through a woman's life story, and obviously, the women that sit in front of me are typically high performers, high achievers, and some capacity.

And then we arrive at the end of the conversation when we talk about family and kids and all those kinds of things, and there's often a lot of tears.

And it was in those conversations, sitting here with several women that were on the show.

What was the straw that broke the camel's back?

It was the UFC fighter Rhonda Rousey.

It just so happened that when I interviewed her, she had

just found out that her seventh round of IVF had failed.

And so she was very, very emotional.

I left that interview and had a conversation with my girlfriend.

I was like, listen, I've seen

too many women over the age of 35,

maybe sort of under the age of 50, but really under the age of 45, in tears in front of me.

I think we should have a conversation about this.

Should we freeze our eggs?

I mean, me and my partner are both 33 now.

And

at first, first,

I don't know, maybe it was the way I worded it.

He was offended.

She was like, You don't want to have a baby with me?

It was like, yeah, it was like, you don't have sex with me?

Like,

I like didn't word it well.

Like, I didn't, I didn't really think, I didn't really think about the emotions surrounding it.

I think that was really what it was.

You were trying to make a pragmatic decision.

Yeah, I was, as men often do.

Like, I was just like, we should freeze.

But I didn't think about what that meant.

And there's this prevailing narrative in society that if something's not quote unquote natural, then it's not good.

And that IVF or egg freezing is not natural.

And that like torments people's brains because they want to live a natural life, even though they're in like fucking planes and on iPhones.

We want this one area of our life to be natural.

And after honestly five minutes of that conversation,

I think the framing that

flipped her mood was that wouldn't we want to give ourselves the option?

Right.

And it's actually about having options.

But I wanted to throw that out there because I don't think people family plan.

I think, as you said, we focus on our careers, then we pop up at 35, 36, 37, and assume that we can.

But that is not the case.

Yeah, especially if you live a healthy life.

You think, oh, this will be easy for me.

Or if you're a high achiever and you've achieved other things, many women are really taken aback by not being able to achieve this or not having control over infertility.

And what is a natural process to run out of eggs and to go into menopause?

If you are lucky to live long enough, this is going to happen.

I got my diagnosis of PCOS in medical school before I was ready to start

family planning.

And

I knew I was probably going to struggle.

And

so it took us about three years to successfully conceive the first time.

You can't, even though I'm working in the business, you know, I'm running between patients to go and have another ultrasound or go get a shot or go go do all the things that it took.

You know, you, you can't remove the emotion from it.

And I can't tell you how many times I cried.

And of course, all of my co-residents, my four best friends, all got pregnant in succession, our poor chief residents, and with no trouble, you know, and even like crying to my mother.

about the struggles I was having.

She's like,

I got pregnant eight times with no trouble.

You know, and then my first pregnancy resulted in a miscarriage.

And, you know, in the middle of work, and all my friends were there and they were cheering me.

They were so excited.

I was finally pregnant, and then we lost the baby.

And, you know, and having to like push through and work through, it's like it was yesterday.

Like, you know, I have two healthy kids, thank God.

And, you know, we were never after those two, we tried again, we were never able to get pregnant again, which, you know, I had two kids and put a bow on it and we're done.

But

it is impossible to remove the emotion because

you, because in the mindset, it's luck or it's something we did.

We caused this.

And

it's,

you know, as a high-performing, you know, someone who's like, you check all the boxes and you make all the good grades and you do everything right.

And this is the one thing that suddenly you didn't think much about.

And then it becomes everything

when

that becomes hard or it's taken away from you.

But I think women assume that it's our burden

because we assume that if we can't conceive, it's just us or something.

But I think I heard you say this,

it's a two-way street and the issue is not always the woman.

A high percentage of the time it's her partner.

And so I don't think we absorb that information up front either until we start investigating it.

But I'm in awe of this story that four of your residents got pregnant immediately because in orthopedics that does not happen.

Every orthopedic surgeon in medicineration that I know, if we got pregnant, we miscarried.

And maybe that was lifestyle.

And maybe that was not eating for 40 hours.

Maybe it's all the radiation that we undertake.

I think it's better now for the younger generation.

And we, as the, I'm not that old, but I am older than the current residents.

We encourage all of them.

If you are not partnered and wanting to have a child now, then please consider freezing your eggs if that's a goal.

Because we can't predict our futures and our residencies extend into our 40s.

Well, I love that you're helping facilitate that discussion because that certainly wasn't the culture back when we were in training.

I am one of the ones who sat here and cried in front of Stephen myself when talking about my own pregnancy loss journey just because, you know, I see it every day, you know, and I tell patients every day news that they do not want to hear.

50% of infertility is due to male factor.

50% is due to female factors.

One of the most important things I want to convey when we are on this topic is that IVF is an amazing technology that has helped 13 million babies be born.

It has been life-changing and world-changing.

And things don't have to be natural.

Sometimes the natural progression of disease is death.

So we have technology and science that exists to optimize and improve life and to help life exist.

And that's part of what IVF is.

And I think that's important because we do see a narrative right now that IVF is inherently bad and natural fertility approaches are inherently good.

And we truly need to say both things are good.

Do women need to learn about their bodies earlier, talk about cycle tracking, take better care of themselves, get an earlier investigation when things aren't going well?

Absolutely true.

But also needing to have fertility treatments is not a failure.

Needing to see a fertility doctor is not a failure.

If you need IVF, that is okay.

All the other stuff is still really important to the outcome of your journey.

But this narrative of IVF isn't natural, so it's bad, or egg freezing isn't natural, so we shouldn't do it, That's harmful to society and to women who do carry the burden, whether they need to or not.

Women do carry the burden of family planning for the future.

Hearing you talk about that is very interesting to me because in other parts of medicine,

In my own medicine, right, we were talking outside about how I now do knee surgery through needles.

It's an advancement of technology.

We celebrate that.

We like better things

for people.

It's not natural.

Live with your thing, thing, right?

But I'm capable of helping you live a better life.

Right.

So it's interesting to me.

It's the stigma of women's health and organisms.

That's right.

This has, because this is women's health, we're going to control it.

We're going to protect these gals.

We're not going to apply the vast knowledge.

I'm a little offended by it, actually.

If you want to know the truth, why can I be so encouraged and be considered top of my field when I adopt new technologies?

But in in your field, 13 million parents or 26 million parents

would be told that technology is not okay.

I agree.

It's a terrible narrative that is happening right now in the political landscape.

And I think it's important to say scientific advancement is good and it changes the lives for so many people.

And I think it's just highlighting this idea about natural doesn't always mean better.

I think as

scientists and people in medicine, there's also been a disservice to not trying to get to the root cause and not working on preventive medicine.

And so, going towards treatments and technology, which has made the lay person

feel like half of the picture wasn't discovered or talked about.

And so, we can do better on both ends of it.

And that comes to women's health more than anything because there is stigma.

When it comes to isolation, there's, I mean, when it comes to infertility, there's isolation,

you know, being left behind, your peer group, questioning a life goal will make you question who you are, your life meaning, your purpose.

And that is an extremely stressful and challenging state for somebody to go through.

And we should be giving more support to that.

We should be saying, freeze your eggs.

You're at a stressful lifetime instead of the narrative that we are seeing right now.

So would the message be to young men and women that want to have kids?

at some point in their life to freeze their eggs in their 20s?

Is that what you would advise?

You know, most people in their 20s maybe don't have good awareness of these goals, but certainly your later 20s, your early 30s are the prime opportunity where you still, for the average person, you're going to have a high number of eggs.

You're still high on the graph and your egg quality is still going to be high, meaning it's going to be easier to get the outcome that you want.

Certainly in your 20s would be ideal if you, but it's expensive.

A lot of people don't have the financial resources to freeze their eggs.

In their 20s, they're in training, or they're starting their career.

So to have an extra $10,000 lying around isn't always realistic.

And I think that's why people are often waiting because that feels, you know, elective, you know, like, oh, that's extra money.

I don't know that I have that right now.

When we see insurance that starts to cover egg freezing as an option, we see huge uptake in women going to freeze their eggs.

So you will see at companies where almost less than 5% of women would freeze their eggs before before age 35.

And then they introduced a health plan that would cover egg freezing and up to 50% of them would.

So you can see that both financially and access and awareness, they all go hand in hand.

But that's a big player in being able to do that because it is an expensive process.

So Dr.

Crawford, I think what most people don't understand, what is the spontaneous fertility rate by age in general?

Yeah, so if you are 30, your odds of getting pregnant monthly, we use a monthly rate called fecundibility.

It's going to be at best 20% per month.

When you're in your 20s, it's a little bit higher.

It can get up to 25% per month.

If you're having sex.

Monthly and regular periods.

So if you're having unprotected intercourse and you have regular cycles, your best odds in a given month are going to be about 20% at age 30.

How much sex do you have to be having?

Well, really, you just have to have it in that fertile window.

What, just once?

Really, just once.

Yeah, sex solely on the day of ovulation would be the ideal time.

But you just need to have at least intercourse at least once in that fertile window.

But that number drops quite significantly to what Dr.

Caver is saying.

So at age 35, if you're trying to get pregnant, it's going to be 10 to 12% per month odds of getting pregnant.

At age 38, it's going to be 5% per month.

At age 40, it's going to be 3%.

Let's say if you're trying for the first time, they're a little bit higher if you've had a child already because there's some proven fertility factors.

But if we look at that, you say, I'm chasing these dreams.

I'm going to try to have my first baby at age age 38.

You have a 5% chance per month.

That's not zero, but that means the greatest probability is that by six months timeframe, you won't be pregnant.

And then you're going to start a pathway of trying to investigate why that is happening.

And if you do need intervention, you're further down this graph too.

You're going to have less eggs to work with and their quality is going to be less good.

That's why those numbers drop rapidly.

Natural fertility rates are not about being out of eggs because you ovulate just one egg at a time.

It doesn't matter if you have 20 eggs outside that vault or five eggs.

You're ovulating one egg at a time.

So natural fertility is all about egg and sperm quality.

So this huge drop we see from 20% to 5% is because of the change of our egg quality as we get older during our 30s, which most of us feel like is really young.

And what can I do to, because I know weight has a role in egg quality, right?

If you're underweight or overweight.

Is there anything else that has a really pertinent impact on the quality of my eggs?

Yes.

So we have two factors.

We'll say age, which you can't control to an extent, right?

Chromosome damage is going to happen even if you are exceptionally healthy because tincture of time.

They've been sitting inside your body, chromosome damage builds up.

But the variables that you can is everything that impacts cellular health.

So chronic inflammation and insulin resistance are the two things that are going to most dramatically harm your eggs' metabolic function.

It's going to harm your mitochondria.

You're going to get mitochondrial damage.

We know that when we start looking at older women, they have more dysfunctional mitochondria, they're shaped abnormally.

The products inside their follicular fluid show higher levels of inflammation just based on age that happens, but also if they start having infertility versus not having infertility.

So, we know that inflammation and insulin resistance are key players, even in patients without known PCOS or endometriosis, but they play a role in aging and specifically your egg health as you age.

So, if you say, getting pregnant is a life goal, I'm tracking my cycles, I don't want to freeze my eggs right now, but what should I do?

All these things that we talk about and we're going to talk more about to decrease inflammation inside our body, that's it.

And from a young age, because these changes build up over time.

And if I have PCOS, How does that?

Even more important, because you're at a higher predisposition to have insulin resistance.

Your cells are more sensitive to how they're going to respond.

But do I have less eggs if I have PCOS or something?

So you're going to run out of eggs around the same time.

You're born with a little bit more, but because you lose eggs based on how many you have, essentially you're going to catch up.

So during your reproductive years, you tend to have more eggs out of the vault, which interferes with normal hormonal signaling, making all of the hormonal metabolic changes worse.

Very interesting thing.

As women with PCOS tend to get older and their egg count starts to drop and they have fewer eggs coming out of the vault, they'll often start naturally ovulating, even if they didn't earlier.

And so I'm always a little concerned when somebody said, I used to never have periods, but now I do.

Did I cure my PCOS?

Maybe they did make some good lifestyle changes along the way, but honestly, that's a red flag for me that she's now more rapidly declining in her egg count, approaching what will be perimenopause for her, because her egg count is low enough to then respond to the brain signals.

Nodding your head over here.

And as a man, is there anything I can do to increase the odds that I'm going to impregnate Mel?

You can stop using cannabis and smoking cigarettes, drinking alcohol.

We need to avoid heat.

So the testicles are outside the body for a reason.

They need to be at a lower body temperature in order to adequately make normally functioning sperm.

So hot tubs, saunas, those should be off-limits if you're wanting to get pregnant.

Same with high-intensity exercise and compression of the testicles.

So this is notably cycling for long periods of time.

So an hour on the bike or more routinely can actually compress the testicles and increase their heat.

What about sitting in a chair for five hours?

You should be fine.

Same thing.

Sitting in a chair, boxers breathe, being in a room that's hot, those things aren't quite enough to truly raise that core testicular temperature, quite like some of these other things.

We also see diet playing a big role.

The great thing about men, you're making sperm every single second.

The sperm lifespan is 90 days, 72 days to make a sperm, 18 days to get out the ejaculatory system.

But that means you could make a singular change in your health and see a different outcome in your sperm.

That is so rare.

That doesn't exist in women's health, that one variable can move the needle so much.

Marijuana is a huge one.

Marijuana use works at the brain to prevent those FSH and LH signals, which are crucial to tell your testicles to make sperm.

They also impact inflammatory environment.

So sperm are not as modal.

They are not shaped as well.

The DNA inside their heads is more fragmented.

In fact, men who use marijuana, their partners have a higher rate of pregnancy loss, even if their partners are not around it at all.

You're using the word pregnancy loss versus the word that we're aware of in the UK called miscarriage.

Is that intentional?

Miscarriage can mean

to a lot of different things to people.

And a pregnancy loss, an unsuccessful pregnancy, depending on when you medically lose a pregnancy or if a pregnancy is in the fallopian tube and it's an ectopic pregnancy, that's still a pregnancy loss, meaning you had a positive pregnancy test that did not end up in a baby.

So it's a little more inclusive for a variety of different stages of when and how loss loss can occur.

Miscarriage kind of infers when we say it, you know, on my end, is that the pregnancy was in the uterus and now

we either have to evacuate it or it's it's self-evacuating.

And you were saying a second ago, Vonda, that it's from your experience, pregnancy loss miscarriage is much higher with women who have high-stress careers and jobs.

Well, I don't know the real statistics, but I'm sure they exist.

But in my experience, as a high-capacity, high-stress, not sleeping for 11 or 22 years,

I have seen it a lot.

And it happened to me.

Yeah, chronic stress is associated with a higher rate of pregnancy loss.

Is there anything else that people misunderstand about pregnancy loss and miscarriage that is worth talking about?

Well, it's not talked about, I think.

It's one of the things, and people still think it's

taboo and rare.

all of us around the table had pregnancy loss.

Yep, to at least two.

And when I had mine, I was in training and

A, I didn't want to call my attending and tell them because he was a man and I didn't want to, I didn't think I could take any time off.

Same.

I went back the next day.

I would have gone back the same day, but I could barely move.

I was running labor and delivery like at night.

I got discharged, IV pulled out of my hand and went back on the ward.

Yeah.

Like.

So I think

hopefully part of this international conversation about women's health, not just

gynecological health, but health in general, will give women grace.

Because there's no way that I should have been expected to go back to an orthopedic surgery residency the day after I lost a child.

Or, frankly, I don't know what your experiences were, but in my generation of doctors, and I'm sure it happens everywhere, I went back to work less than five weeks after delivering a child.

And I think other European countries have it right.

Oh, yeah.

Oh, yeah.

New Zealand is a year.

Weeks.

Six weeks.

I had six weeks with one and three weeks with the other.

Because if I wanted to

leave my fellowship on time,

I wanted to graduate on time.

I couldn't exceed the total vacation.

So these internships and fellowships, and I'm sure built into these programs we sign up for, they were all developed for men who had, had they had a family, had a wife, you know, had someone at home to like take care of that business.

And we're have, you know, we're all in supportive relationships.

And, you know, that wasn't the issue, but like I went back before my body was ready.

Yeah.

Because I was before that baby was ready to unlatch.

And my milk supply dropped immediately the minute I went back to work.

And I tried to pump, but you get called for a crash C-section or emergency surgery and you're like pulling the pump off the breast.

And I'm running down the hall, hooking my nursing bra back on, trying to get to the OR.

And, you know, all that cortisol, just my milk, you know, so I was able to breastfeed while I was home with the baby.

And, but like once I went back to work, my, my milk production just stepped in.

But I took a picture of me in the hospital, and it was a day after I gave birth.

My laptop is open.

I'm trying to breastfeed because we launched a company the month before I gave birth.

And instead of my male coworkers going, okay, we'll give you some grace.

No, I had a week and and then they are at my house having meetings.

There's such a different discussion about miscarriage now than when I went through it.

I told nobody.

I didn't neither.

I mean, it was so secretive.

I didn't feel like I could.

And we are seeing a different generation where I do think talking about women's health and Stephen, you having these discussions on a bigger stage are lessening the stigma for what is something that people go through.

One out of four pregnancies will end in a pregnancy loss.

That is not a low percentage of people.

In the same breath, most people should not have two in a row.

And if you do, you should go get an evaluation because there are medical things that can contribute to pregnancy loss that we would love to identify a lot earlier and see if there's something we can do to make that different.

What do I need to understand about what a woman goes through, either in the wake of pregnancy loss or in the wake of a pregnancy and a birth

physiologically, psychologically, as an employer to be able to create a better environment for the women that are going through either of those two things.

Like, what's going on inside the body?

Because I wouldn't know, right?

So, one of the simplest things to say that's going on is that pregnancy is one of the most hormone-robust times you have, even just momentarily pregnant.

If you have a placenta starting to implant, you are now making levels of estrogen and progesterone that you will not ever make at any other time period of your life.

When that doesn't, when you lose that pregnancy or when you're postpartum, let's say you're having this huge hormone crash.

Suddenly, you go from this very high level of these hormones, dropping off immediately.

And in addition to all the physical changes, the emotional changes, that has a huge impact.

You've heard us talk a lot about low estrogen and how that feels.

The very interesting thing most studies about estrogen show is that the hardest time for women is when estrogen is changing.

So going from high to low is actually when

your body is having

can't keep up.

up can't keep up doesn't know what's happening and the higher you were and the faster you come down and we'll use this analogy too even in ivf when we go do an egg retrieval and somebody had many eggs they have a much higher estrogen they naturally would i go and put a needle in each one and drain the eggs out and destroy those cells and their estrogen plummets and they expect to go the next day and feel normal or they expect to feel worse during the stimulation process when they're using hormone shots.

And I always say, you're actually going to feel worse when I'm done with you.

It's going to be that week after the egg retrieval where your hormones go from the highest they've ever been very quickly down low.

It's that delta, that change.

And that happens anytime you have that.

But pregnancy and loss and postpartum are some of the most profound times that you experience this.

And one of the other things is the identity shift.

So if you're working, you know, we are all very highly motivated and became parents, but it's that whole identity shift of now, how do I interact in my life?

And how do I interact with my peers?

I'm a mom.

How am I being identified?

What are the implications?

So there's a complete identity shift that also isn't discussed and that can also perpetuate some of the postpartum that we see as well.

And anxiety and lack of control, right?

Because you don't know what you're supposed to do, especially if you're a mother for the first time.

That can be very anxiety-provoking in addition to hormone changes and not getting sleep.

But lack of control, you don't control your schedule.

You don't control when you sleep.

You don't control if your child gets sick.

And so I would say, from an employer standpoint, grace, support, and flexibility.

You know, if I had had better support structures to say when your child is sick, it's not the end of the world.

If you are not here physically at the office, that didn't exist, meaning that my child getting sick became this extremely stressful situation.

But for the average woman working a nine-to-five job, whether it's in medicine or other fields, if you could design their working month around the menstrual cycle, around, I don't know, potentially a pregnancy, whatever, how would you design, redesign their month?

Because we have inherited this sort of, I think it's like from the Industrial Revolution, this like nine to five working hours.

We don't work Saturday and Sunday.

We do that four times across a month.

What would you change?

What should women change?

Because I've had some countries or systems are trying to give women time off around certain parts of their cycle, for example.

Would any of you change anything?

Well, there are a couple of companies in New Zealand who are pretty flexible, especially after the pandemic, where they have allocated certain hours that are free to work at home and just have to get the work done to the point where they have four-day working weeks.

And then they're also putting into the annual leave, what they call menstrual leave or menopause leave.

And it's, you just say, you know, I can't come today.

Some people are using it for child care.

Some people are using it for really bad cramping days.

Other people are using it for mental health days.

But it's there to be used for however.

And you don't have to identify it as being menstrual cycle day or menopause.

It's just extra leave.

And people don't care as long as you get the work done.

And I think that having that flexibility across, you know, if you have that ability to have more flex hours or shared time space or something like that, greatly benefits productivity as well as the feeling of empowerment and inclusivity, which then feeds forward to better productivity.

If I've got an extremely high-stress job, is there any part of this cycle where I should theoretically be avoiding stress?

Well, that's an individual thing.

It's how,

because we hear all the stuff about cycle tracking, and it's about understanding your own responses to your own hormone flux.

Because

my partner says to me that she needs to not do work.

There's like a couple of days a month where she's like, I'm just going to nest or work.

That could be her responses.

And she's like, I just don't have the stress tolerance to be able to do XYZ.

And understanding that in her own cycle is great because then she can allocate tasks that take more stress for other days.

For most people, it's peak luteal.

So when your progesterone is the highest, tends to be when people have a harder time focusing and concentrating or getting tasks done.

Now,

which is going to be the middle of the luteal phase, so the middle of this second half of the cycle when you have that.

3.1-ish.

So when you have that progesterone, you know, really high, your body might be ready to implant an embryo if there was one.

That tends to be when people say they feel more fatigue and less energy and less focus and concentration.

So if you are looking at your month and you might notice that,

and you have the flexibility to say, okay, I'm going to try to write this paper, get this study done, do these tasks that call these tasks that call for an increased focus in my follicular phase when I'm estrogen dominant, have high estrogen and no progesterone.

For the average person, that is typically when they're easier, have an easier time achieving those tests.

Which is the first

14

weeks, the time period before ovulation.

But there is an individual response.

And I definitely will see some people who they feel immensely better when progesterone is present and not so great the other time.

So I think we use generalizations just as a rule of thumb because that's what it is for most people.

But hormones specifically, there's always an individualized response.

And learning to listen to your own body is is key in knowing what you need to do.

I want to close off on this point about just how employers and the way that we work can be better suited to a woman's health.

Is there anything else we missed there?

Flexibility, I think.

Absolutely.

And she is going to front load those tasks on a time that she feels better and offload in a time time where she's not feeling as well, but she's going to get it done for sure.

And so giving her the flexibility is going to allow her to be her most productive rather than demanding she have X amount every single day.

And I think support can come in a lot of ways, but

the

financial burden to a large corporation of having a stop gap child care at work.

So maybe if you're not going to offer full child care, because you're getting a lot of productivity out of women if they know their children are on campus and can go at lunchtime.

But if you're not willing to do that, if you have a stop gap where instead of calling you're attending or one day my nanny didn't show up and I had to find some way,

just for those emergencies within the corporation, that breeds loyalty.

That will increase productivity.

And so I think it's money well spent.

Talk about having a competitive woman.

She would probably just want to work for you.

Yeah.

You know, And offering those things to make her mothering easier while she's trying to work, I think you would have the most competitive workforce.

And what does that mean?

So that would mean having a nanny.

Is that having a nanny on site or is that

on site?

Whether it's full-time, like bring your children full-time there, or

that's a big corporate,

but a smaller corporate commitment would be this emergency childcare so that your kid's not there all the time, but maybe they're sick or maybe somebody didn't show up and then you have daycare.

You have a licensed child care provider available

who could,

which is a fault of the U.S.

system.

Yeah, what happens in New Zealand?

You have 20 hours free daycare.

A week.

A week?

Yeah.

So it's

20 hours funded.

And then it's a very small nominal fee for hours over that for up to year five or when they're five years old because then they start school on the first day that they turn five.

It's like, you turn five, happy birthday.

But it does help significantly kind of keep productivity and a little bit of the worry off.

What am I going to do with my child?

Amazing.

Yeah.

What is this

conversation around eggs and fertility dovetail into menopause and specifically perimenopause?

You can't have one without the other.

Right.

So perimenopause is basically in this fertility decline area.

Okay.

So you don't, fertility is not an issue.

You don't want to ever have a baby.

You're still going to go through perimenopause.

And so

perimenopause is defined medically in the worst way as the transition from normal menstrual cycles to no menstrual cycle ever again.

Okay.

So when we look at definitions, menopause is defined as one year after the final menstrual period.

What it really means is ovarian failure.

And that offends people, but that's actually medically what it is.

You have run out of eggs and you run out of the ability of the ovary to produce hormones.

And so perimenopause begins

medically at the straw staging is the very complicated

methodology to define the stages of perimenopause.

And a lot of it is based on menstrual cycle irregularity.

But hormonally, what's happening starts well before our periods become irregular.

So as those egg levels decline and the ability to respond to the stimulus coming from the brain, remember ovulation starts in the brain.

So when estrogen levels normally get low during the cycle, the brain doesn't like it.

The hypothalamus, so the gland in our brain starts looking for estrogen.

It likes estrogen.

And then when the estrogen levels are high, it's happy.

And so when estrogen levels decline naturally in a cycle, it says,

where's my estrogen?

And it sends a signal to a second gland in the brain called the pituitary, and that makes the LH and the FSH.

So I'm trying to figure out what causes

perimenopause.

What causes menopause?

Lack of eggs.

So, it's the loss of eggs and the loss of the group of eggs to respond to these signals.

So, here we go.

We're beginning perimenopause.

We've reached a critical threshold level where our ovaries cannot respond.

And that might be, I don't know, millionaires.

So, when you're not out of eggs, but just the count is low, right?

Let's see if you're in a jar.

Yeah.

So, if menopause is going to be, for simplicity, the jar is empty.

When the jar gets like this, so we'll say if you had full, the jar is not empty, but it's gotten lower.

And what is happening is the ovary doesn't want to be out of eggs.

So, what Dr.

Haver is saying is the brain is working harder to get an egg to grow because the ovary becomes more stubborn.

It wants to hold on to them, it doesn't want to lose them.

The brain has to send out stronger signals to get an egg to grow.

Because there's not as many, we don't lose as many per month, so that's great, but that means we have years of being at this low, unreliable ovary stage where the brain is working really hard.

There's not as many eggs that are here.

They will still ovulate, but it starts to happen at a less predictable rate.

But each.

So is that perimenopause when there's.

Yes, and there's not a definition, I think that which makes it the hardest to say, your point, what number of eggs equals perimenopause?

Different.

There is a unique response to each person at what level your ovary gets to, where it will start to respond dysfunctionally.

But what happens is that the hormone changes start shifting in the brain, the ovarian response starts shifting, and before you have irregular cycles, you will first see a shortening of your cycles very predictably.

The brain will send out a stronger signal, an egg will ovulate faster, you'll start to get shorter cycles, and

there's hormone fluctuations, but they're still regular.

And so, what will happen is a woman will start to feel these hormone shifts.

It's less predictable.

She is having some change, but it's still a regular cycle.

And so, she is often told, your hormones are fine, you have a regular cycle.

So, and in the brain, as we talked about those neurotransmitters, there are not only is estrogen changing and the amount that we're producing, actually in perimenopause quite often, we'll have much higher estradiol levels than we did in our premenopausal years where we had that kind of predictable ebb and flow of our

monthly hormones.

There's also independent FSH receptors outside of, so these hormones that are pumping out to talk to the ovaries are also back talking to different parts of the brain.

So the first symptoms symptoms patients feel, and they've done a great study on this, is I don't feel like myself.

I don't feel like myself.

And they even call it IDFLM.

And so you can't put your finger on it.

Periods are regular, but your environment hasn't changed.

Your normal stressors haven't changed.

The life you built that you could manage, you're suddenly losing resilience.

And that's because of a hormone fluctuation that is hard to explain.

So we see sleep disruptions, mental health challenges increase, 40% increase across perimenopause transition, and the cognitive changes.

And that is what really scares my patients the most.

And they come in and most of them are, you know, we're all high functioning in some degree, some of us in academia, some of us in the OR, some of us, but, you know, most women are high functioning because they're juggling so many jobs.

So even if she didn't choose to go the routes that we've chosen, she is managing children, you know, school drop-offs, you know, all the things that women tend to put on their plates.

And suddenly, she can't remember all the things she used to remember.

Where are her keys?

You know, word salad.

You're struggling to find, I can't tell you how many times I am like, I see people and like I cannot remember their names or I can't remember.

I get in the car

and I can't remember where I'm going or what my purpose of getting in the vehicle was.

You have to think for a second.

And so all of that is related to.

the hormonal changes.

At what age?

Well, I think that there's a tendency in medicine to want to have definitions.

Yes.

So I personally, and I know a lot of us who talk all the time, think that this random 366 days after your last period, that's your menopause day.

I think that's pretty random, and I don't know who made that up.

But when I have, because I'm not an OB, but when I have patients come into me for their musculoskeletal things, and they're of a certain age, and I don't just focus on whatever the musculoskeletal body part is, but we start talking about their whole health, and they start talking about these things.

I am often the first one to say to them, you know what, you are probably in perimenopause.

And they're like, but my cycles are regular.

I'm like, but you are beginning this transition, which I call menolescence, but it's this, right?

I would propose that most people don't seek out a lot of help earlier, but they should just assume.

that they're perimenopausal anytime after 35 they don't feel like themselves and start down a road of learning or investigating or let's feel better and what do I need to do about it.

You know, it's frustrating to us,

all of us, and we talked a little bit about this last night, is the people who kind of make the rules, the institutions that make the guidelines and the academic kind of

Ivory Tower, you know, they are like, whoa,

back off.

Slow down.

We shouldn't be blaming everything on menopause.

You know, like, and I don't think that's what we're saying.

We're not.

Completely dismissing the female experience and not at all like including this cataclysmic hormonal change

is hurting women.

So the average age of menopause is 51 to 52.

And so let's say that is when your ovaries are in failure.

They will no longer make eggs, make hormones, or respond to brain signals.

So all the eggs, all the little marbles are out.

All the way gone at 51, 52.

For most women, about seven to ten years before that, they will start to enter into what we will call perimenopause or the unpredictable response of the ovary and the brain.

I say their communication system, their best friends who aren't communicating well.

Their signals are getting interfered.

They're not responding appropriately.

The ovary is getting more stubborn.

The brain is trying to work harder.

You get these higher.

peaks, these lower troughs.

And essentially, that is the time period.

So it is unique to an individual because everybody's born with a different number.

They lose them at a different rate.

Some factors that we control impact that rate, but some things that we do not.

Your mom's age of menopause is a predictive factor.

If you've had a first-degree relative go through menopause at 46 or sooner, you have a six times likelihood of going into early menopause.

So knowing, having this conversation, almost every patient I ask, what age did your mom go through menopause, they do not know the answer.

Because the moms haven't talked about it.

Moms haven't talked about it.

There's so much stigma about reproductive health.

So knowing that information is really important.

If you have mom or older sisters, what age is normal for your family so that you can be a little more in tune if there's some genetic predisposition for you.

The general idea of what Dr.

Haver is saying is that in these last seven to 10 years of ovarian lifespan, it becomes more stubborn and less predictable.

And it does cause hormonal shifts that most women can't detect with their cycles.

We do know that if you are actively tracking actually when ovulation is happening and looking at your follicular and luteal phase and you know what's normal for you, you will most likely be able to detect these hormone shifts in that time period.

But that's not what women are taught.

Their tracking is just that it's coming regular.

And we do have a generation of women that were on contraception and then went through childbearing and then on contraception again until now they're suddenly entering this transitional period and they don't know what their own normal is, making it even worse.

Correct.

So, like she said, the average age of menopause, if we look at the math, is 51, but under that 90th percentile curve, you know, with 5% on each end, it's about 45 to 55.

That's menopause, right?

That's full menopause.

Now, let's just do math and back it up seven to 10 years.

So we're looking at the mid to late 30s to 40.

So when I have a 46, 47, 48-year-old patient come in who's still cycling, She has almost 100% chance of being in perimenopause just based on her age alone, knowing the statistics around that.

Yeah.

Okay.

So with my partner, between the age of sort of 35 to 45 is when I can expect her to go through perimenopause where there's very little marbles left in the jar

and her hormones might be displayed.

Less predictable.

Less predictable.

And one of the questions we had in from the audience was, how can I manage the symptoms of perimenopause?

And they use the word naturally.

Well, we don't have a single large-scale study.

done

on the treatment of perimenopause.

So let me break it down for you.

When we look at funding in women's health, it's horrible.

Okay.

But

if I go into PubMed, which is the

database that I go to look up medical journal articles, and I type in the word pregnancy, I will get today 1.2-ish million articles for pregnancy.

Amazing.

So important.

We need healthy pregnancies.

If I type in the word menopause right now, I think it's about 99,000.

So those

numbers represent time, brainpower, funding.

What is important in women's health?

Okay, if I type in the word perimenopause, we are about at 8,000.

Yep.

Very, very, very, very small.

Your name's on a couple of them.

Thanks.

So is the last third of my life, from an academic standpoint, from funding, from brain power, from where we focus, not as important

than when I had the ability to be pregnant.

More women will go through perimenopause than menopause because we're going to lose a few to accidents and cancers and, you know, early deaths.

More women will go through perimenopause than get pregnant.

Yet, in my training, so in medical school, I got one hour, one one hour lecture on menopause, nothing on peri.

And in my OBGYN training, and I'd love to hear what you have to say, as part of our reproductive endocrinology blocks, I had one block of that my second year.

In those six weeks, I got one one-hour lecture each week.

No clinics, no focus, nothing.

And then as a program director where I was in charge of the education of residents of over 100 residents over about 10 years, I know exactly what the curriculum required.

And menopause just gets shoved into a tiny box.

And then what happens when we run out of marbles in the glass there?

What's really interesting and one thing we've said a couple times is this happens.

This is ovarian failure.

You're going to go into a state state of low estrogen because the ovaries no longer have the ability to make eggs, therefore, they are not going to make estrogen or progesterone.

And just to be clear, the eggs were sending a signal up to the brain to make estrogen.

And the eggs, well, the low,

the eggs in the brain communicate, yes.

When you didn't have an egg ovulating, your estrogen would be low, and that typically is the brain signal to send out more FSH.

That's still happening, meaning estrogen is low,

but the brain is sending out all the FSH it has.

FSH is very high in menopause, and the ovary cannot respond because there's no more eggs.

There's nothing left to respond.

I need to explain that explained again.

So I'm trying to understand why estrogen drops when the eggs disappear.

The estrogen is made from the cells that surround each egg.

So when there's no more eggs, there's no more cells that make estrogen.

The follicle goes away, too.

Okay, okay.

So estrogen is made in

the ovaries.

So the estrogen is made in the ovaries, and the primary type of estrogen that we're talking about, and it's made from the cells that surround each follicle, called the granulosa cells.

And as the follicle gets bigger, as the egg matures, more of those cells become more active, and you make more estrogen.

So even when you have a little bit left,

when you're on your period, we'll say, but you're some eggs here, you're still making some estrogen.

It's not as high as when you're ovulating, but these little eggs will each make a little bit.

Do I make estrogen?

You do.

But I just make it somewhere else.

You do.

It gets converted over to testosterone.

Okay.

So we have enzymes in our body that convert convert estrogen and testosterone back and forth.

So there's no more eggs, so this is menopause?

So this is menopause.

Well, in my world, yes, this is ovarian failure.

And we're calling it ovarian failure on purpose because at this moment, you're not going to make estrogen.

The brain is sending out all the signals it can, very high FSH, trying to get estrogen to be made.

There's no eggs, so there is no estrogen.

What Dr.

Haver has said, which is correct,

our friends in the medical world do not define this moment as menopause.

They make you sit here and be estrogen low for a year and have no period for a year before they will say you're in menopause.

If they even decide to treat or offer treatment, you know, or even begin the discussion because of our training, you must, thou shalt go without one year.

So we're absolutely sure that the ovaries have moved on before we would even consider.

But what is the point of that?

We've made estrogen our entire lives.

It's a fabulous question.

What is the point of starving our brains, our hearts, our bones, our muscles?

They didn't think they were doing that.

I don't think that people, you know, the medical community has recognized estrogen's effects outside of reproduction until very recently.

I think there's been isolated pockets, but there's no, no one owns menopause.

Like no one, you think it would be OBGYN, but there's no one in charge of women's health after reproduction ends.

Like there's, there's no czar.

So what's the harm of waiting a year before people take it seriously?

What happens?

Suicide, mental health changes, rapidly declining bone density.

I mean, you can be healthy without estrogen.

All vaginas need estrogen.

So your brain, your bones, your heart, your blood vessels, your vagina,

your body has estrogen receptors everywhere that we've already established.

And suddenly, you've lost the ability to make your primary source of estrogen.

And what happens is that, you know, medicine has a lot of definitions that we use that are very antiquated, even how we date pregnancies, right?

When we talk about how far along you are in a pregnancy, we date back to the last period you had, which meant two weeks of pregnancy are before you ever ovulated an egg,

three weeks before you ever implanted an embryo.

Yet we still use this pregnancy timeline based on when your last period was, even though we know two weeks of that, you weren't in fact pregnant at all.

Now, menopause, in my opinion, is the exact same way.

We're using an antiquated definition saying you have to prove to me you're in ovarian failure by lack of your period for 12 months because it represents a time period where we didn't fully understand what was happening in the ovary or didn't have the ability to test and know what we know now.

We are making women suffer to get that diagnosis.

If I believe I shouldn't treat you until you have menopause, you have to prove that you're in it.

I don't think it's where we're going.

I don't think it's what's right for women.

And that being this low estrogen is hugely impactful at your life at any age.

The female body needs estrogen to function normally.

I mean, I'm looking at this chart here about suicidation.

Yeah.

So the most likely time for a woman to commit suicide is between the ages of 45 and 55.

And do you think that's linked to

100%?

Right.

So we know that mental health.

We have an increase in mental health disorders, either pre-existing, getting worse, or new onset of about 40% across the transition.

And we look at SSRI prescriptions, which are antidepressants, they double across the menopause transition.

Now, there's a couple of reasons for that.

One is we weren't treating menopause with hormones, so they just SSRIs can actually help a hot flash.

Certain types, so you know, Paxil is one of the ones that has been proven to decrease hot flashes.

Some it's not great, but it works a little bit.

And with all of the mental health changes, a lot of women are ending up on these antidepressant medications.

So we don't want to to go a year without estrogen.

So we know that some of the new data coming out when I was researching for the new perimenopause, there's a really great window of using hormones to treat mental health disorders

and seeing improvement in mood and also some in cognition by giving estrogen or estrogen plus aprogestin early in perimenopause before the periods actually stop.

And it actually works better than an SSRI.

So say she's on an SSRI and has done well.

She's had a long history of depression.

Suddenly she's not controlled.

Suddenly her symptoms are back and she's on the same medication.

Rather than doubling or adding a second agent, we really should be giving these women a

hormonal therapy.

Now that doesn't hold post-menopause.

So this is really a perimenopausal kind of window of opportunity.

In post-menopause, they aren't responding as well.

And probably because the estrogen labels have stabilized.

So when we give a woman back.

She adapts.

Yeah.

You'll adapt.

So postmenopause, the menopause, that's why the suicide rates kind of peak in this key perimenopause area.

And we think.

And so in postmenopause,

that hormone levels stabilize.

So women tend to get better.

And so they do respond better to the SSRIs for new onset anxiety and depression in those patients.

And I want to do a randomized controlled trial where we add some creatine.

Oh, that would be amazing.

20 grams?

Yeah.

Well, no, it's 0.38 per kilogram of 20 gram, grams, yes.

So you're saying if I'm a 45-year-old woman and I've still got my menstrual cycle,

at that time, before I've hit menopause, I should be considering some type of hormonal therapy.

So when we give someone menopausal-dosed menopause hormone therapy in the form of estradiol, usually in a patch because you have that nice steady state, it is enough to feed back to

that brain to calm down, but not enough to suppress ovulation.

So she's often giving estrogen support in very low doses.

And menopause hormone therapy is basically micro-dosing compared to what we do naturally.

And so we're giving enough to calm the brain down and stabilize what's happening in the brain without suppressing her natural ovulation.

Giving enough what?

To raise you back to maybe what that baseline would be.

Giving enough estrogen.

Yeah, correct.

Giving enough estrogen to raise the baseline level so it's not as low.

It's not so high that it's preventing ovulation, but it's going to alleviate some of these drastic highs and lows that you're having, and it's going to create a more stable hormone environment.

It's the delta that we were talking about post-presentation.

Exactly.

The delta chaos.

The highest chaos.

The space is what bothers us, not the high nor the low, eventually.

So

I have,

I run out of eggs, and then I'm by definition menopausal at this stage.

And

my body adapts.

So there's going to be a drop, and then there's going to be a.

we're specifically talking about mental health because you brought up the suicide chart.

And so post menopause, like once everything calms down and you're fully menopausal, you're out of the zone of chaos.

The hormones have just

low.

Your bones continue to deteriorate.

A lot of other things are happening, but our cognitive, our mental, our brain tends to calm down and things get better in the brain.

When do I become post-menopausal instead of menopausal?

Oh,

go for it.

Menopause is a day, right?

Oh, menopause is a day.

Medically, menopause is one day in your life, one day exactly after your

final menstrual period.

That's the point of that, right?

What's the diet?

We agree, right?

Because what if it's leapier?

Do we go 366 days?

What if it's what if you've had an IUD?

What if you've had all these things?

It's like, it's really an antiquated definition, and we really need to modernize.

So it's really your perimenopausal, then you're post-menopausal.

Correct.

Right.

Okay.

And when I'm post-menopausal, forever.

Forever.

That's your new biological state.

That's right.

For now.

I'm sure someone's working on something to change something.

I do wonder that.

I do wonder if they're going to figure out a way to...

Extend fertility.

I mean, they're trying.

They're trying.

But then I think about it as if you're a 60-year-old woman, would you still want to be

worried about that?

So what they're doing is looking at, is there a way to extend

ovarian function with low-level baseline,

enough to keep you out of osteoporosis, enough to slow that down and heart disease, protect your heart without pregnancy?

I'm now post-menopausal.

Lots of things change in my body, I'm guessing, because I no longer have the same levels of estrogen.

Did the levels of estrogen ever go up again, actually?

Or do I then need to start considering?

Outside of a tumor, no.

So do I need to consider hormone replacement therapies and things like that?

You might.

And that'll help me fend off what?

The sleep issues?

It'll slow the rate of change, but it doesn't stop it.

You still have to put in your lifestyle modifications to improve and or stop the sarcopenia and the bone density loss and all the things that people associate with postmenopause.

And did any of you have menopause hormone therapy?

Yes.

Yeah.

And what was the decision and what impact has it had?

So I think what Stacey just said in framing where we're going with this conversation is, so now we're perimenopausal.

It's a new physiology.

What used to work for all of our exercising, if we even did, because we know it, at least in this country, that 60 to 80% percent of people aren't intentional with their lifestyle.

So, to frame this next part of the conversation, I'm sure we're going to talk a lot about hormones, and I'll tell you my hormone decision-making,

but

I think it's important to all of us.

It's only one

of the building blocks to rebuilding a great life, right?

It's interesting that the five steps of fertility that you went over are actually

the same.

It's curious, isn't it?

It is.

It's great protein and anti-inflammatory nutrition.

It's a cardiovascular fitness life.

It's a lifting life.

It's a stress detox, whether it's environmental or relational.

And

sleep.

Sleep.

And then, yes, hormones are really a critical building block.

But as we enter the conversation,

women are sentient beings, and we get to decide.

And we get to make the changes because we have agency.

So what we're going to describe is not a one-size-fits-all.

It is

the tools on the table.

So, I choose, if I'm going to work my proverbial rear end off to be the best I can be for the rest of my life, I choose to use all the tools.

Not everybody does that, but to choose one tool and think that's going to be enough, it never is.

Never.

Right?

So, when I decided to, and I've been pretty public about my journey in this, because you think I would have known after 22 years of formal education and all this

and being an aging a musculoskeletal aging researcher you would have think thought I would have known but I honestly looking back maybe thought I was never going to age because I was so healthy right

so I have a baby at 40 I breastfeed till almost 41 and a half 42

and then I'm back at my very quickly five weeks my high power high capacity to career

But things were getting really different about 45 for me.

And I think I went right from post-pardom to perimenopause with very little downtime.

So chaotic hormones to almost...

And so

I suffered for a while.

At 47,

I talk about it like I went from this really high capacity to thinking I was going to die, not only because of night sweats, brain fog, the thing that lots of women have

but i started having heart palpitations and i call my cardiology friend because i worked at a university i'm like ricky ricky i think i'm dying so he did put me on a stress test and my heart was perfect right at that point and then i had

arthralgia, which is total body pain.

It's part of the inflammatory response of not having estrogen.

It's part of the musculoskeletal syndrome of menopause

assembly of symptoms.

So much that I go from training to almost not being able to get out of bed and these my experience of not knowing what was coming and hitting a wall is not uncommon right and so I started educating myself and being

an acquired expert I read what I consider the world's data on safety of

hormone optimization, as I like to call it.

And I made the decision that I was going to do all the tools I was going to learn to lift heavy again which I hadn't done since high school because I was a runner and I changed the way I do my cardio and I changed my diet and I am so committed to sleep do not call me after 930 at night because I am going to be in bed and just the the quiet times of de-stress but I also decided to

augment or to optimize my hormones with estradiol, with progesterone because I have a uterus, and after I felt comfortable with those, with very small doses of testosterone.

And that makes me feel like myself again.

Not just one, because I think sometimes people think that you can just make a hormone decision and feel like yourself again.

It takes lifestyle plus or minus this decision.

Is there a stigma associated with that decision?

Taking hormones?

Taking the hormones, but also, I guess, just more broadly with entering

menopause.

Yeah.

I think there is.

There is, absolutely.

I mean, you can just look at popular media.

You can look at their representation.

The memes go right now and give me an image.

It's decreasing because of you, though.

Like, we have to acknowledge you are decreasing the stigma.

True.

And you're sitting at the table with us.

I say that, I think, because there's a woman in my life who was telling me about her decision to start taking menopause hormone therapy.

And she described the moment with her husband when she was looking at the box

and she was staring at the box and staring at the box and staring at the box and mulling it.

And there was clearly something emotional going on there that this decision to take this marks something.

Which is interesting because no one really questions OCs.

Exactly.

Oral contraceptive

birth control.

And I treat both men and women.

And when a man comes into my clinic with low energy, popping all the tendons all over his body, everything hurts, we very quickly test his testosterone and send him with no judgment because he's trying to be virile.

And I think it goes with the general

conversation about aging women.

When men talk about living longer, it's called longevity.

And we celebrate that.

And we take pictures of movie stars in the South of Western.

They are very

distinguished with their grain temples.

When we talk about women living longer until right now, because we're all screaming about it, it's under the guise of anti-aging,

a superficial like oh my god don't let her age

so i think part of that is the stigma of menopause somehow because we're no longer able to have a child there's not

we've aged out of the game which hopefully we're pivoting this narrative because as i said earlier women are winning the longevity battle we already live longer but it's how we're living that we're trying to course correct yeah and it's not just humans that go through through this.

Like, I like using the whale analogy because whales go through it, and then the whales that are no longer reproductive become like the senior, everyone, all the other little whales listen to them.

It's like, I want to be like a whale where you have this seniority and respect, the wisdom,

wisdom keeping.

Exactly.

Yeah.

Exactly.

I love this part of my life.

You love this part of your life?

Yes.

Why?

I

have never felt like I've

been in exactly where I'm supposed to be.

In this moment, I feel like I'm helping more people.

I have better relationships.

I'm having better sex.

I'm having better, you know, everything in my life pretty much is better.

And I don't know if like menopause and

life circumstances have just given me permission to like, cut out the crap and focus on what's really important and,

you know, don't sweat the small stuff.

You know, it's like something kind of switches in our brain.

No filters.

It's amazing.

And I don't think I could have done this 10 years ago.

I was too worried about what people thought.

I was too worried about being a good girl and following the rules and checking the boxes and never stepping outside of the guidelines.

But until I realized that I wasn't really serving the population that I trained for X amount of years to

that, you know, and they were being left behind

is really what allowed me to like be where I am today.

I think most of us describe this as the most authentic.

We're actually who we were made to be.

And the confidence we feel comes from our memories of success.

I think that's where confidence comes from.

We remember everything that we have learned to fix over time.

Probably we could figure anything out.

And so that comes with experience.

And frankly, it comes with aging.

The price of aging or the price of having wisdom and experience is aging, right?

And so the reps.

And so you get to this place and you're like, I'm going to figure this out.

We're going to figure this out.

And I don't want the younger generations to have to go through the stuff that we've gone through.

So if I can share my experiences to help them navigate, then that is a good thing.

Yeah.

I'm in perimenopause.

So I'm a slightly different stage.

And I know this because

my cycles are shorter, but they're still very regular.

Used to be 28, 29 days.

Now they're 25, 26.

I know that means I have less eggs coming out of my vault every month, and that's why I'm ovulating sooner, but I can feel all the hormonal shifts much more profoundly than before.

Now, as a reproductive endocrinologist, what we call a fertility doctor, most fertility doctors now do IVF day in and day out.

And there's a lot of corporate reasons why that is, but we're also trained in puberty, premature ovarian failure, and hormones.

So I'm more of a cowboy and quite cavalier at giving estrogen.

I even told these ladies last night, oh,

because I see it.

I see people who are low estrogen states and

every single day, how it impacts their life.

So I am on low-dose estrogen right now, even though I'm still cycling.

I'm still making my own progesterone.

So I don't have to take a progesterone right now.

But it clearly makes a difference in my day-to-day function and how I feel.

And

most REIs like I am will jokingly say, like, you'll put me in the ground on estrogen because it has such a profound impact on your ability, how you can function.

And specifically, if we're not forcing you to go through this empty glass period for years and years and years of your life, there's more opportunity on how you can slow down part of the process that we all know is going to happen with aging, but to live, I think, Fond, do you always say, you know, healthier, your health span.

How are you going to live healthy longer, not just live longer?

Well, and I think your approach, that I think it's part of the decision-making, is critical because

35 to 45 and early perimenopause are prime times for prevention.

It's to get our standards set.

You don't have to lose your bone like you're going to get.

But it's hard for women to get care.

And we also have to acknowledge that if you go into...

Right, if you, what you're recommending, and I also do the same thing for my patients.

It's very hard for somebody to get careful.

This is not happening in 99%

of doctors' offices.

There is no four birth control pill or nothing, which is all they were taught.

Given that even in menopause, only 4% of women have chosen or have been educated the pros and cons of hormone optimization.

And then to ex that's without, that's an empty jar person.

Yeah.

So 4%, Stephen.

Is that how many women that have?

In 2023, they did a study in the U.S., I'm not sure in other countries, and on FDA approved.

So when we add in compounding, it's maybe a little bit higher.

But when you look at FDA prescriptions, only 4% of eligible women, meaning no risk factors, right age, are

utilizing, are going to get their prescriptions filled.

Evidently, this is going to change, right?

With the education that you guys have.

We hope at least they're being offered it and having a discussion so that each one of them

do it.

And that's their right.

Side effects.

Are there side effects worth noting?

I know a lot of people are quite scared of taking certain hormones.

So, there's risks and then there's side effects.

So, when we look at the side effect profile, anytime we give a woman estrogen, progesterone, and we'll have to look at them individually.

But estrogen, you can have headaches, you can have irregular bleeding.

About 50% of patients are more on the patch than on oral.

There's a patch and there's oral.

Vonda, you take the patch, right?

I do.

And that's on your stomach?

Yeah, it's right here, actually.

And how often do you have to replace that?

Twice a week.

Okay, fine.

Yeah, so when we look at menopause hormone therapy, we have estrogen, we have progestogens, and then we have testosterone, basically.

And there's different ways to get it into your body.

There's oral and non-oral, roughly.

So in oral, it's pill.

You take it.

In non-oral, we're looking at through the skin or through the mucosa.

So mucosa could be under the tongue.

It could be in the vagina.

So mucosa is like the gastrointestinal tract is lined with mucosa and it's a nice way to absorb and in the rectum to absorb medication.

We don't have have a rectal form of estrogen yet.

And so

and then there's also injectables you can inject it straight into the muscle or subcutaneous tissue.

So most commercially available like FDA approved.

We're looking at a ring for the mucosa.

We're looking at a patch for transdermal or we're looking at pills for oral.

And what do you take?

Yes, so I am on a patch

and I've just, I'm not a great absorber through my skin.

And I couldn't get my estradiol levels high enough where studies are looking like the best bone protection is.

So I've added about a half milligram of oral estradiol at night.

I'm on oral micronized progesterone, which is probably the best way to get it into our system.

And I tolerate progesterone very well.

And testosterone, I am on a gel that is FDA approved.

I'm borrowing the men's version because we don't have an FDA-approved version

in this country for women.

So I have to do it.

I don't think anywhere.

Borrow my husband's.

Australia.

Australia.

And I think the UK just has approved one.

This is news.

Some news.

Like in the last month.

Yeah.

So, okay, so I'm, okay, so it's broadly advisable after doctor's consultation to take some form of hormone therapy.

Definitely if you're symptomatic.

If you have the classic vasomotor symptoms, it's absolutely the gold standard.

But can I comment on that?

Women say to me all the time,

either, I don't have, I don't feel that bad,

or they say, I want to do this naturally.

And those are the things that say, okay, fine, do it naturally.

But

brain fog, night sweats,

and hot flashes are not the only thing going on.

And so if you're making this decision fully informed, well, you're a sentient being.

Make the incision.

But you cannot feel your bones crumbling.

until they're broken.

You cannot feel that.

You cannot feel your muscle going away.

You cannot feel your brain starving.

You can't detect microvascular disease of your heart.

So you may think you're getting away with something.

And maybe you don't have night sweats brain fog.

But it doesn't mean you're not having a different physiology.

And if you are fully aware of that and make a decision that you don't want to optimize your hormones, that's your decision.

And I'm fine with that.

But what I'm not fine with is people thinking they're getting away with something when they're not.

True.

You're making the decision based on fear and not facts.

Correct.

I'll ask questions about love and sex and menopause.

You said you're having the best sex of your life, Mary.

And I've also heard you talk about how several people in this season of life end up getting divorces.

You said they throw the trash out.

So we talk about, you know, menopause can...

spur, you know, for some women, it's this moment of empowerment.

They realize they have to circle the wagons because the only way they're going to survive through this cataclysmic, you know, upheaval for so many women is to get rid of relationships that aren't working, put up boundaries.

And sometimes that's going to be the end of a marriage.

Other times it's going to strengthen a relationship because you're kind of cutting out things that were getting in the way of your so I see many marriages or many relationships really improve through the transition, but it does take two.

You know, sex is biopsychosocial.

So like when I look at sex, it's not, I think of the entire experience, you know.

And one, as far as my desire for the frequency, testosterone does seem to have given that an uptick.

So it is approved, you know, we have lots of studies done on libido for women, which is in medicine, we say hypoactive sexual desire disorder.

And it has to bother you.

So a lot of women are like, I don't want to have sex ever again.

And I don't care.

There's nothing wrong with that.

right?

Unless it affects your relationship and it has to bother you.

But I have a lot of patients who come in and say,

I love him.

I used to want to to do it.

We used to have a really great frequency and everybody was happy about it.

And it was something I looked forward to and enjoy it.

And now there's nothing.

I have nothing.

And for those patients, testosterone can be helpful, not for everyone, right?

And so

there's other emerging data on looking at the musculoskeletal system.

I am naturally thin.

I was not an athlete growing up.

At best, I was a dancer, you know, and I didn't do anything to protect my muscles and bones as I was coming up through the ranks.

And so here I am in my 50s, just getting out of endurance, you know, you know, recreational endurance training and thinking, what have I done to my bones and muscles?

I laid on that DEXA scan as nervous as I've ever been in my life, like getting my board scores nervous.

Like, what have I done?

And

it wasn't bad, okay?

But I'm like, but I like to be perfect.

So I'm like, what can I do to,

you know, I'm doing the, I'm eating the protein, I'm lifting the weights, I'm starting to do all these things.

And we know that women who have naturally higher testosterone levels from genetics or whatever have less frailty as they age because that's my focus.

If I run the cancer gauntlet, which probably 80% of my aunts and uncles have died of cancer.

And so if I run that gauntlet and I'm doing everything lifestyle and preventative screening to do that, and then the women end up with dementia and frailty like my mother and grandmother.

I'm like, okay, I want to have as much bone and muscle strength as I can.

So I'm going to add some testosterone and see what happens.

I at the time would not have said I had any sexual dysfunction.

I did not qualify medically for HSDD.

I go on testosterone and there's definitely an uptick in the area and everyone is happier.

Like my interest is improved.

My initiation has improved and that had kind of waned time and stress and kids and whatever.

The other thing, we were empty nesting at the same time so that probably no more kids busting in our door at two in the morning, letting us know they're home from, you know, whatever experience.

And you guys will go through this later, but also our communication is better.

You know, my husband's retired from Chevron and we are building this company together, you know, our menopause company.

And so our relationship has actually improved through all of that.

So all of the things that feed into

what we know is female desire and has is just better all the way around.

And I think testosterone had a little bit to do with it.

My ability to like focus and my ability to prioritize and put up the right boundaries has really helped with that.

And we're just having a lot of more fun with it.

But I think that we would be remiss in this part of the conversation.

And I'll say it, I'm the orth pod, but I'm going to say it anyway.

Many men, I just talked to my husband publicly about this because we're trying to educate men, is that most men don't realize that in perimenopause, as estrogen wanes, it affects all tissues.

And there is an entity called the genitouurinary syndrome of menopause, where the vagina will actually atrophy and all the external soft tissues that are usually used to engorging will become dry like a desert.

And Stephen, sex can feel like razor blades.

And men don't know that and women are afraid to tell their partners.

So the men feel rejected, like why doesn't she love me or desire me anymore?

And it may be that, but it's probably not that.

It hurts and I bleed.

And women don't know that this is normal when your estrogen is in,

that it's okay to tell you.

It shouldn't be normal, but when you're in a low estrogen state, regard menopause, birth control pills can do it.

Postpartum, breastfeeding, even progesterone IUD, these can all cause time periods where your estrogen levels are low enough that the vaginal tissue is not having the right collagen and elasticity that it should.

So, what's the solution?

Estrogen.

Not lubricant.

Lubricant can sometimes aid, but that's not a root cause, right?

It'll It'll help with lubricants.

I really help with lubricants with symptoms, right?

But if your part of the problem is that the tissue can't respond as it should, that it's frail, that it's a problem.

It's delayed orgasm,

then we really want to get to the root cause, which is estrogen is crucial for skin elasticity.

It's like men going on testosterone, right?

If he's not having an erection, there are 29 solutions for that right now.

Primarily funded solutions as well.

Oh, well, solutions.

But for women, it's not just desire, it's physiologic.

And so

putting something on

your vagina.

And what you put in your vagina is that.

So there's several options.

We have creams, we have pills.

There's a ring specifically designed just for that.

So we have different methods of getting the

estrogen into the vagina.

There's also

something called prosterone, which is DHEA, basically, which is a pre-hormone that the vagina miraculously will convert to estrogen and testosterone.

So, but it's expensive.

It tends to not be covered by insurance.

But for our, like our sex med friends, sexual medicine friends who specialize in this female sexual function, they love it because you're not only getting a boost of estrogen to the vagina, you're also getting testosterone.

And there are testosterone receptors in the vulva, you know, in the lower vagina and around the skin around the vagina as well.

But here's the bonus:

all of this, plus vaginal estrogen will help prevent

chronic UTIs, which kill old ladies.

And it will help support the pelvic floor and the uterus from prolapsing.

And so it has all these added benefits.

And here's another bonus.

It is such low dose,

it is not systemic.

So any risk that you could think of that...

you might not want to do systemic estrogen including breast cancer is unaffected by vaginal estrogen and so it is a huge solution and there's no age that a woman can't go on it.

She'll kill me.

She'll never know this.

But I put my 86-year-old mother on it so that we could prevent UTIs and failure of tissue so she didn't get sores and infections, right?

Isn't that a miracle?

I know Stephen's like, hmm.

Yeah, and we should say that vaginal estrogen in preparations made for vaginal estrogen, there are low-dose estrogen preparations.

You can give oral estradiol vaginally, and it will be systemically absorbed because the vagina is highly absorptive.

So, I don't want somebody to hear this and think for that,

but just saying we often prescribe or recommend a local treatment of vaginal estrogen products, which are in very low dose, and they really impact the local tissues of, we'll say, the pelvic floor, the urinary system, the vulva, the vagina, and they improve your well-being and your health without some of the risk that might come from systemic hormones in somebody who may not want to take them.

I am all out of questions.

So, I wanted to conclude this segment just by asking you what the most important thing that I have missed on the subjects we've talked about, menstrual cycles, menopause, everything in between.

What is the most important subject you think we might have missed?

I think we covered it,

but to stay that you control a large part, we've said over and over, inflammation and insulin resistance.

We touched on different lifestyle factors that impact this because when your body is having hormone change, there's a lot of the external world around you or the choices you're making that can make some of that better or worse or influence what is happening.

And I know we're going to go over more of this, but I think this idea that I have no control over what's happening to me isn't 100% true.

I mean, you don't have control over when some of this stuff happens, but you can.

take control of a situation by understanding your body, knowing what's happening, knowing how to advocate for yourself, and making active decisions to live a healthier, better life.

That's the goal is to empower women to understand, to ask the questions so they don't feel like something is happening to them and they don't have control or options, which is what our mother's generation had.

They were always gaslit, told, you know, it's all in your head.

There's nothing we can do.

So my mother was put on butalbitol.

It was called buta sol.

It's basically a sedative.

And it was Mother's Little Helper.

And I found an old magazine article with a, if you look at the magazine articles from the 50s and 60s on these medications, mostly sedatives that were given to women, it's like, now she can do the laundry again.

Now she's flipping a pancake in the ad and the apron in the 1950s, you know, like, get your mom back, get your wife back.

And it was a combination of estrogen plus a sedative.

And I was just

absolutely floored.

And I remember mom's little bottle and it was called buta sol.

And

it would sit on her counter and she would talk about it like it was her talisman, like it was her.

And I always thought of it as mommy's little helper, you know, like, oh, I need my butaca.

Oh, this happened.

Where's my buta sol?

Where's my buta sol?

And when I was researching and writing and reading about these sedatives that were given to women, I was like, wait, mama, I remember the bottle.

I remember what it was called because she talked about it all the time.

I went and looked it up, and it's a derivative of phenobarbital.

Oh, my God.

And it was heavily prescribed to women.

Barbituate, it's a drug.

It's a class of drug that is basically a sedative.

We use it in surgery.

We use it for seizures.

And they were sedating my mother on the daily

through her perimenopause.

Now, she had eight kids.

She was running a restaurant.

You know, she was very high-functioning.

And I just refused for that to be, that was her reality.

And here she lies in a bed with alzheimer's and a fractured hip and she hasn't walked in eight months you know she's she's just now getting on a walker eight months after her hip fracture and from osteoporosis who's never had a bone density scan in her life and like our children deserve better it's not going to be my future because i have the you know i have the means i have access but like i i want every young girl all of our children to have it have a better future than what was offered to our mothers.

Exactly.

I think ending this, I would want every woman to approach her midlife

life, her new life, with the same vigor and the same curiosity and the same demanding of care that she would do for one of her children.

If her child is sick, she's not going to take no.

She's not going to take being blown off.

She's going to keep searching till the end of the earth until she finds an answer.

And that's what, that is the same kind of taking control that I want women to do about this time in their their lives.

Thank you so much.

We're going to record, we're going to continue this conversation for the viewers that are listening at home.

I've been through all of these wonderful books that I have in front of me, and there are so many lifestyle, nutrition, exercise-related solutions to many of the things we've talked about today to be a truly optimized, hormone-healthy, menstrual cycle-healthy woman, which I want to talk about in our part two of this conversation.

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