91. Better Sex & Lives in Menopause with Dr. Jen Gunter

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Welcome back to We Can Do Hard Things.

We are going to jump right in today because we are lucky enough to have Dr.

Jen Gunter back to answer all of our burning, for many of us, menopausal women, literal burning questions

about menopause because we are committing the feminist act of demanding to understand our own bodies.

And we are also going to talk about all of even the embarrassing things about menopause and our bodies today because we refuse to allow the entire world to talk about women's bodies and sit it out.

Everything on earth is sold with a woman's body.

Everybody from companies to movies to everyone on earth, religions to congresses gets to talk incessantly about women's bodies.

And then for some reason, we

are ashamed to take the conversation back.

So we're not just going to let the whole world talk about the way our bodies look.

Today, we're going to talk about the way our bodies function and feel.

And we're going to do that with the Dr.

Jen Gunter, who is an OBGYN and pain medicine physician and the author of The Menopause Manifesto.

Can't recommend enough.

Also, The Vagina Bible and the Premi Primer.

And, Dr.

Jen, I want you to understand that I have the Menopause Manifesto and the Vagina Bible on my coffee table so that everyone who sits down

can feel more comfortable with the words menopause and vagina right up in their face.

Okay.

She is the host of the podcast Body Stuff TED Audio Collective and of the streaming docuseries Jen Splaining.

She blogs at thevagenda.com and her writing can also be found in the New York Times, Glamour, Dame, and other publications.

Her mission is to build a better medical internet.

She has been called Twitter's gynecologist, the internet's OBGYN, and a fierce advocate for women's health.

Dr.

Jen Gunter, thank you for returning to We We Can Do Hard Things.

Thank you.

We're going to talk today about the

biggest, most important, most common questions that folks have about

menopause.

And our first one

is from Lynn.

This is Lynn.

I'm facing menopause.

And if I hear one more goddamn thing about a hot flash

or about all the sort of surrounding things for midlife.

No one is talking about orgasm.

I can't have an orgasm anymore.

And I'm shouting it from the rooftops because I'm so tired of this being dismissed.

I listen to so many midlife podcasts.

Oh, just rub a little essential oil.

I don't need essential oil.

I need an orgasm.

Do you understand?

And I know you feel me.

So just please help me find a really good

person that can come on your show,

talk about orgasm, talk about the brain event.

I just need a bunch of professionals to figure out why I can't have an orgasm at 50.

It's not okay.

Okay.

I love you.

I love sister.

I love Abby.

I love the whole thing.

I guess that's it.

I think that's enough.

I'm not angry.

I'm just ready to get some answers.

Love you guys.

Bye.

I love her.

I love her.

I don't need essential oils.

I need a goddamn orgasm.

Can we call this episode that?

Obviously, I can only speak in, you know, in generalizations because there are so many questions to ask an individual person.

And especially when you're talking about sex, you actually have to know what their sex life is beforehand leading up to it.

So if we're sort of thinking about somebody who said, you know, I'm really having difficulty achieving orgasm or I can't achieve orgasm now, there are kind of a list of things to run through.

So the first is probably to start treatment with vaginal estrogen to make sure that you have enough blood flow to the tissues.

So when we go through menopause, there's a decrease of flow of estrogen to our vaginal tissues, and that affects how well things function.

And if you think about Viagra and those drugs, phosphodiesterase inhibitors for men, what they do is they increase blood flow to the penis.

Well, vaginal estrogen increases blood flow to the clitoris, to the vaginal tissues.

It causes the tissues to basically have more moisture and be back to how they should be.

So the number one thing for someone who's having a sexual difficulty would first of all be to make sure that they're using vaginal estrogen and they're using enough so that the tissues are kind of at the baseline.

Now, what can also happen sometimes with age and sometimes even with menopause as well, as the pelvic floor muscles get a little bit weaker.

And those are the muscles that wrap around the vagina.

And when you cough or sneeze, those are the muscles that hold your urine in, or if they're a little bit weak, they let the urine out.

Yeah, so

right.

Yeah, sure do.

And so,

exactly.

So those muscles can actually weaken a little bit.

And those are the muscles that contract when you have an orgasm.

So if those muscles become weaker and you're kind of not getting that same feedback to the system, a visit with a pelvic floor physical therapist might also help you to make sure that those muscles are kind of functioning how they should be.

And some women actually find that working more on the kegels can actually be very helpful from a sexual satisfaction standpoint.

The other thing is to think about sometimes with age, you need a little bit more input.

So I didn't need glasses three years ago.

Now I'm like with like, I don't know, a gajillion progressive things.

And there's all age-related change, right?

Like five years ago, I could read pretty much anything.

And so I need glasses to help me.

Some people might need to use a vibrator or a stronger vibrator than they needed to use before.

They might need to just have a little bit more input into the system.

And then another thing to think about is there are medications that can actually affect orgasm.

And so

people associate what's happening to them with menopause, but something else might have happened.

If you were started on antidepressants, that can also have an impact.

And so I would want someone to kind of get those baseline things addressed as well, and also have a conversation with them about what their sex life was like beforehand.

The other thing that I also recommend is possibly the best book on sort of libido and sex is Dr.

Lori Brado's book, Better Sex Through Mindfulness.

And it's about cultivating desire and libido.

And you also want to ask this person, you know, is your orgasm problem in a background of having desire issues and libido issues, or is all that working fine?

And the only thing that's not working is having an orgasm.

So those would kind of be the basic level things to kind of get started with.

And then if all of those things are in place and you're still having trouble achieving an orgasm, then I would recommend a sex therapist and also recommend seeing a doctor who specializes in sexual medicine.

This might be a situation where a low dose of testosterone might be beneficial,

not something that's applied topically to the area, but these are things that really require more of an in-depth conversation.

But that would be what I would get started with.

And bravery, they require bravery because you got to walk into your doctor and say, here are my issues.

I want to have an orgasm.

Yeah.

Or, and, or, I want to up my libido, right?

Because it's two separate things.

Yeah.

Yeah.

And absolutely.

If your doctor isn't someone that you can talk with sex about, then they're not the right doctor to help you with this problem.

We were talking about taking hormones in Tuesday's episode.

Is vaginal estrogen like a topical cream, like that you rub on as opposed to the hormone therapy that you ingest?

Yeah, so when we say menopausal hormone therapy, we mean hormones that are getting into the bloodstream.

And we didn't talk about this in the last episode, but the safest way is transdermal, meaning across the skin.

And that would be with a patch, with a gel, a lotion, or they even make a vaginal ring where you can deliver estrogen into the bloodstream.

So those are the safest ways.

You can also take a pill, but there is a slightly higher risk of complications with that.

So we recommend starting with transdermal.

The vaginal estrogen, and it gets a bit complicated because one of the vaginal estrogens can get into the bloodstream.

but there's also vaginal estrogens that just stay vaginally.

And those are, that's also, there's a ring for that as well.

And there's creams, there's tablets, there's suppositories, and there's also a product that's called DHEA, which is

converted in your body into estrogen.

It's kind of like a pro-drug for estrogen.

So there's lots of different ways to approach it.

Some, you know, some people love creams, some people love the idea of a ring that you just change every three months.

It depends.

But for somebody who's having an orgasm problem, I would recommend the cream because then you can also apply a little bit to the collateral area as well.

It's not like a rubbing in.

You just kind kind of apply it and it'll get absorbed.

For people who are using transdermal estrogen, about 50% of the time they'll get enough estrogen for their vagina, depending on the dose they use.

But a lot have to augment with vaginal estrogen.

So we don't really recommend taking it throughout your whole body just to treat your vagina because you have to use higher doses.

And you don't need it everywhere if you only need it in your vagina.

So try to think of them as separate.

With rats.

That helps with orgasm, but not increasing libido.

Right.

It wouldn't impact libido.

Libido is very complex.

And the way that we talk about libido in our society is also very sort of heteronormative, sort of cisgender male fantasy about the woman being ready at the drop of a hat.

All we just need is the male gaze, and then we're ready to go, right?

So

yeah, right.

Like, just twist a nipple and stick it in.

I'm good.

Twist a nipple and stick it in.

I'd also like to put that up for consideration for title.

A lot of conversations that I have with people are just kind of explaining that libido changes throughout our life cycle.

And sometimes people are really having a change in sex drive related to menopause.

But sometimes what they're having is actually very normal and they've sort of assumed that it wasn't.

So it's, you know, some people have a receptive libido.

It doesn't get going until the right situation is there.

For some people, desire can kick in after sexual arousal.

That's not abnormal.

It's more complicated than just being kind of like hot and horny.

That's only, that's only one very small sliver of libido.

And shout out to all the lesbians.

Yeah.

Scary.

I mean, tricky.

Menopausal to women, libido,

Netflix.

It's just all, you know, it's more women, more problems.

Actually, not true.

This is the only area of your life where you have more problems.

Let us admit it is better.

We love you.

Lynn for

orgasms is what we're going to go for.

And there's also a whole host of folks whose problem

is even

in some ways like a precursor to Lynn's problem, which is, isn't...

isn't it very common symptom to have vaginal dryness, vaginal burning, sandpaper-like feelings.

So there's actually pain

in penetration.

So can you talk about some of that?

Because that is a very common issue that people are dealing with.

Yeah, this is very underdiscussed.

This idea that

vaginal symptoms with menopause are very common.

Over time, about 80% of people will get them.

So that's pretty significant.

And one of the other medical consequences, besides sex is very medical.

And in my mind, you deserve to have good sex just like you deserve to have everything working with your body.

But low estrogen in the vagina can also increase your risk of getting urinary tract infections.

Vaginal estrogen can actually be preventative for that.

So if you're having vaginal dryness, if you're having lubrication issues, if you're having some discomfort and you're in your 40s, then there is a very good chance it could be related to menopause transition, menopause spectrum.

There are other things that can masquerade as that.

So again, it's important important to get an exam and get checked out.

But the great thing about vaginal estrogen is it's highly effective and it works really quite quickly.

You'll know in about six to eight weeks.

Now, if some people don't want to use them, there are fantastic vaginal moisturizers.

The products that I like contain high aleuronic acid, but there's silicone-based products and water-based products.

And so some people like the feel of the moisturizers.

Touch and feels very personal.

And so what feels good to one person feels awful to another and vice versa.

So, but vaginal estrogen is highly effective.

Over time, there will be a little bit of shrinkage of the vagina with lots of estrogen.

So, the length of the vagina might shorten a little bit, the opening might tighten up a little bit.

And that's because we also lose collagen with age, and estrogen also helps with collagen.

So, you kind of have the double whammy of aging and low estrogen.

And so, you know, vaginal estrogen can really help protect against a lot of that.

It's very safe, it doesn't get in your bloodstream.

Almost every single person can use it if they need to.

It's also a great option for trans folks because a lot of times when people are on testosterone, they can get vaginal dryness from the testosterone and the vaginal estrogen can counteract that.

So for people who are suffering with vaginal dryness or they want to have vaginal sex.

So Lynn might walk into the doctor and say, because Lynn doesn't sound to me like she's having a problem with libido.

She just wants the freaking orgasm.

So she could walk into her doctor and say,

I'm having trouble with orgasm and I want to try vaginal estrogen

sure but you should have an exam first to make sure that there isn't something else going on for example there's skin conditions that can affect the clitoris and so you need to have an exam to make sure that's not going on so it does require an exam to make sure there's nothing else but i start vaginal estrogen over the phone all the time like well let's get you started and see what it's like when you come in unless somebody's got a bad itch because yeast infections can sometimes present with dryness so if someone tells me they've got a really bad itch then i might be like oh well let's just check you out first but otherwise you can start it.

You know, we don't have to worry if you have high blood pressure.

You don't have to worry if you have high cholesterol.

None of these things matter.

You can be on vaginal estrogen.

So it's a totally different bucket than the other thing we talked about Tuesday.

Absolutely.

Okay.

But there are certain things that you advise definitely not near your vagina.

So no fragrance products.

I think that you want to stay away from fragrance products.

You know, there are many reasons for that.

One, they're often irritating.

Two, they're really bad for the environment.

Everything that's made with fragrance releases a a volatile chemical, right?

And that air pollution is as much a problem from all of our personal care products that release and everything that we have, like furniture manufacturing, everything that releases sort of volatiles is as bad as cars for air pollution.

So nobody needs fragrance stuff.

Like just ditch it, man.

You don't need it.

It's not good for the environment.

It's not good for your skin.

It's not adding anything.

I see sometimes people buying menstrual pads with like that are impregnated with like essential oils and stuff, and then they get rashes.

and someone told me you don't need that.

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Okay, let's hear from Deborah.

This is Deborah.

I am coming because I am in the middle of this fresh hell called menopause.

And I was thinking it might be a really beneficial thing for you all to talk about what happens to our bodies during menopause.

It is so effing hard.

I don't mean to cry.

It's really hard.

The physical changes, the emotional changes, and there is so much that we don't know.

There is so much that nobody tells us and nobody helps to prepare us for.

And it is really like having an alien move in and take over your body.

And I know I'm not alone in feeling the things that I'm feeling.

And I bet I'm not alone in the physical things that I'm experiencing.

From night sweats to hot flashes to making choices about hormone replacement therapy to vaginal estrogen creams.

and to all of these other things that no one tells you about.

I just learned about burning mouth syndrome.

It's a thing for women in menopause and I have it.

And it sucks.

Anyway, since you all do such an amazing job talking about the female experience, what it is like to be a woman living in a patriarchal world, which I think withholds so much information from us about these things and makes us feel like we're crazy, I just thought maybe you could all talk about this.

Deborah, you are not crazy.

You're just a goddamn menopausal cheetah.

That goes back to what we were saying about, you know, spending your whole life defending yourself against this kind of caricature of what a woman is and then

feeling like you have to go somewhere to be vulnerable enough to say

this is actually my experience do you see that a lot this is deeply shaking her on an emotional level too that's the whole reason why i wrote the menopause manifesto because i hear this over and over again uh you know i would i was

do be doing interviews for my book, The Vagina Bible, and I sort of casually mentioned I was on hormones.

And then that's all the reporter wanted to talk about.

They were talking about, they all want to talk about menopause.

When I was on book tour, and it was really interesting, creating a space where it was safe enough to talk about vaginas seemed to create a space where you could talk about the last taboo.

menopause.

And once one person asked a menopause question, the whole thing, you know, became about menopause.

And so I really realized, obviously, there's this like simmering rage about why don't I know what's happening to my body?

This simmering rage about why am I being aged out of society when I'm at my most productive.

I really believe a lot of the rage is the fact that, whoa, like I'm at my peak.

I'm at my mental peak.

And now all of a sudden you're telling me that I'm not worthy, that I don't belong.

So I think there's a lot of that as well.

And you're just fed up with being dismissed.

I mean, we all have breaking points.

You're dismissed in puberty.

You're dismissed with your menstrual cramps.

I think it's this.

nexus event.

And I think it's sort of, I'm mad as hell and I'm not going to take it anymore.

And I'm hot as hell too so that's not okay so i think that there are a lot of changes that people need to know about imagine if you were told you had to move to a new city you're just you got to move sorry and you're told nothing about that city you know you're just dumped there and you don't speak the language you got to figure everything out versus if you were told a year, two years, five years in advance, you know, five years, you're going to move to that city.

You now have five years to learn the language.

You have five years to learn the lay of the land.

You have five years to maybe start connecting with people on social media.

So when you get there, you've got friends, you already know the good restaurants, you know where there's a theater group, you know the running path you're going to use.

Totally different experience, right?

So, and it doesn't mean there won't be challenges in this new city, but you're more prepared for them.

And that's kind of what I like in that experience with menopause is you're dumped into this rebooted body and you don't have any information about it.

And for me, because I got into medical school when I was really young, I was 20 when I started.

So I knew a ton about how my body worked for almost all of my reproductive life and what a difference that has made for me.

And so that's kind of my mission to try to help people not be so in the dark.

Oh, yeah.

Deborah mentioned burning mouth syndrome.

I know on Tuesday we talked a lot about the most common symptoms, the hot flushes, decreased libido.

What are some of the

less common symptoms that we can kind of normalize for people.

So people like Deborah are not feeling so alone if they're not one of the

folks that has the most talked about symptoms.

Well, I think some of the symptoms that are not as talked about would be heart palpitations,

anxiety feelings, mild depression.

Burning mouse syndrome is pretty uncommon.

I've had a couple of people who've reported it kind of worsened around menopause.

And I just read a report that tinnitus, you know, ringing in the ears might be associated with menopause, but it's understudied.

When we're doing, you know, when you do these large population studies, you know, people sort of, there's only so many symptoms you can ask about.

And that's not really an excuse.

It's just kind of an explanation.

And we definitely need more data.

Because the thing is, is the way your hormones affect you is a very individual way.

We can sort of speak in generalities, but for everybody, for every five people who tells me their mood is worse right before their period, I'll get one person who tells me their mood is better.

You know, so

I'm always open to, huh, that's possible.

My patients who've had Burning Mouse syndrome that sort of seems to be associated with a menopause transition,

I've tried estrogen if they want to try it and see if it helps.

I mean, you know, there are other treatments as well.

And it's not surprising to me that we see a lot of these other things starting sort of in the 40s because we often see a lot of autoimmune conditions kind of starting around then too.

And so I always tell people, you want to keep an open mind that this also could be the first sign of something else.

And so again, just kind of keeping an eye on things.

But for many of these things, it's very reasonable to say, well, does semestrogen make it better?

Is it safe for me to try it?

For most people, it is.

And you see, you give yourself a six months trial.

Has that helped or not?

What I hear most from her is that dismissal.

And that's really sad because there isn't a reason that should happen.

that you should be able to come in, you should be able to talk about your symptoms.

But we also have to talk about the fact that in a lot of healthcare settings, people get 15 minutes with their doctor and that's just not acceptable.

Yeah.

Got to have a list.

You're only going to get the 10 minutes.

You got to have a list.

Yeah.

Listen to the end of Tuesday's episode where Dr.

Gunter talks about your strategy for going to talk to your doctor and the list you should have.

Another strategy I'd like to add in is the follow-up visit.

So what happens is people go in and then they kind of get whatever started and then they sort of head out into the ether.

And there isn't really any follow-up or check in to see how you're going to do.

Or you might then start to get worried that you're not going to be able to get to these other symptoms on your list.

You make your first appointment and then say, I'd like to make a Fallup appointment in eight weeks' time.

So we can see how this initial treatment is going or three months.

If you're going to start hormones, you generally want to give it about eight to 10 weeks.

So then we can check in and then I can see if the other symptoms on my list are better or not.

And then we can get to those.

And when you tell them you're coming back, no matter what, maybe they're more likely to

curious.

That's one of the things that I do that I feel is possibly the

most undervalued thing in medicine is booking the follow-up visit before you leave.

Because I think that tells people that you are interested in what happens and that you have a plan.

So if my treatment A doesn't work, I want to know about it.

I set up my follow-up visits and I explain to patients, well, I'm not going to expect this to work before four weeks or before six weeks.

So we need to set up our follow-up at the appropriate time.

And I think it helps people also feel that they're being cared for.

Yeah.

Deborah also says, I know I'm not alone in feeling the things I'm feeling and I'm not alone in the physical things.

Are there any communities that are existing now where women who are going through this can connect to other women?

Are you seeing communities that you think are valuable to let people like Deborah know they're not alone in this?

There's a lot of support groups and groups that people have started.

It's always hard to recommend one if you don't know the person because unfortunately with online stuff, there's also a ton of misinformation, right?

And

sometimes these groups are even sort of offshoots of practices that offer, you know, scammy hormones or scammy tests or other types of things.

So

a friend of mine, Amanda Theeb, is a a trainer and she wrote a great book called Menapocalypse and she has a pretty active Facebook community and she's really good at sorting through the evidence and science and really,

I think does a really great job in curating her community.

Apart from that, I think you got to ask your friends, you know, ask what kind of information might be out there.

And also different people jive with different communities, right?

So, you know, what's a welcoming place for one person might not feel like a place for others.

So I think that unfortunately with a lot of

online communities, you kind of have to suss them out and see what might work for you.

And eventually, hopefully every group where women are gathered will become that.

I mean, right now, I was at a recovery meeting last night and the woman next to you is talking about ringing her ears.

Nobody was like, maybe that's menopause.

Like just knowing this now, she's 50.

I would have said that could be menopause.

Like the more we know, the more we can just bring it into every group we're in, because there shouldn't even have to be a separate group where we're right.

I mean, really, there shouldn't be.

It should really just be like everywhere.

You know, it should, this should be really readily accessible information.

And that's why it's fantastic you guys are

dedicating two podcasts to this.

And then people are really starting to spread the word that, hey, this is a normal event, but it's also a normal event that can have problems.

And we should know about all of those.

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Let's hear from Shelly.

I was listening to the episode from what you were talking about in terms of age ranges and

when we sort of level up and go to level one, level two, level three, and it correlates a lot to a book that I just read about perimenopause and the regulation of hormones and the beginning of going through your second puberty and how oftentimes a lot of women describe feeling more settled and feeling like themselves after they go through menopause.

And I have to wonder whether or not some of what you were talking about in terms of happiness

and ages of women who are the happiest and how that relates to what is actually happening physiologically in our body.

So, just a thought that I would share.

My name is Shelly.

Okay, I was so excited about this question because

all the hard stuff, yes, all the symptoms, all the physical stuff.

But is there a correlation between what we describe in the culture as like running out of fucks to give?

Because

I just feel

like

spiritually and intellectually,

I am entering the most powerful, free, amazing time of my life.

Is running out of estrogen correlated to running out of fucks?

Running out of follicles and running out of fucks.

Another title option.

Right.

Our follicles are fucks is what I'm asking you, Dr.

Jen Gunchuk.

I would say running out of the estrogen that you need for reproduction might be correlated with that because we still have estrogen made by our brains and our bones and our muscles.

So we do have some.

But yeah, I think that it's probably a combination of, and I'm really glad that the listener brought this up because there are really wonderful things associated with menopause as well.

The menopause transition is kind of like the rapids.

This is sort of a difficult time for a lot of people, not for everybody.

But a lot of women describe a sort of a clarity.

when they're through the menopause transition that you sort of run the gauntlet and then you're like ah

and like the heavens open up.

And, you know, whether it's because you've just accumulated all this life experience, and this is nothing to do with hormones, whether it's the fact that you've all that chaos is gone, so you're super happy, or is it due to the fact, and there's some really fascinating research at the brain changes with menopause.

So when we go through the menopause transition, people often have this mild depression or they have brain fog.

Some people do, where it feels like things aren't working quite right.

And there's actually a lot of changes that are happening in the brain.

Some areas are shrinking.

And people are like, oh, well, does that, is that bad?

I mean, we don't want your brain to shrink.

But some areas are growing and parts of your brain that are using high energy sort of shifts.

And you could say, well, we're losing areas, but because brain fog is temporary and it goes away, it can't be a loss.

And one of the theories is that your brain is remodeling itself now without estrogen because it doesn't need all the connections that were used for reproduction.

Do you remember how you're reallocating resources?

Yes.

Right.

So think about how I said, remember all these things, reproduction is linked to temperature.

It's linked to all these things.

Every month, every cycle, your body's like.

Pregnancy, yes, pregnancy no.

Am I?

Okay.

Okay.

Because it's just waiting to like, I got to retrofit.

I got to get everything going.

Right.

But when you don't have that anymore, when your body doesn't have to have that kind of vigilance, when your brain doesn't have have to be doing that switchboard back and forth.

Well, you know what your brain does?

It prunes pathways that aren't needed anymore.

I do sometimes wonder, instead of causing it a brain fog, why don't we call it a brain reboot?

Because, you know, operating systems can be a bit glitchy when you get going, but once you get going, you're like, oh, my new computer is working great now.

So there are a lot of people describe a clarity afterwards.

It hasn't been well studied, but you know, now that we have some of this really

interesting data, like I hear it from lots of women.

Oh, it's and it goes with all of my beliefs about the metaphors.

There's chaos first, there's destruction first, and then there's new construction.

There's just something to it.

There's something to this idea that those

pathways don't have to be used anymore because of reproduction.

But also, our brains are adjusting to not being prey all the time, to not being looked at by the patriarchy as an object.

There's a lot of

upsetness about becoming invisible.

And I'm always thinking, dear God, let me be invisible to the patriarchy.

Like, if I got this much done while they were watching me, what can I do when they're not watching me?

Like, invisibility is a superpower.

Imagine the trouble we could cause if we were invisible to the patriarchy.

To me, it's fascinating that perhaps there is this

well, pruning of things we had to care about that we don't have to care about anymore.

And then we get to decide what to care about for the rest of our lives.

I think that many of us carry this weight of the patriarchy telling us that we have an expiration date and making us feel that it's over, you're done, you have no value, you're not a breeder anymore.

You're not attractive to the male gaze.

You don't look like you're 20.

And I think that many of us, I've fallen, I've fell victim to that.

It's hard not to.

It's everywhere.

It's, you know,

I dated loser dudes because of that.

I did all kinds of bad decisions that I wish now I hadn't made.

But, you know, they've made me who I am.

You just have to kind of take the good with the bad.

But yeah, I think that you have this combination of this cumulative knowledge.

And, you know, maybe we have a better operating system.

But I think that we've only been taught to fear menopause because it's been something that a patriarchal society has impressed upon us.

Yeah.

But really, we should be excited about anything that patriarchy fears.

That means we're onto something.

It's also important.

You know, know, I don't want people who have symptoms to feel, well, I've, how can this be normal?

I have horrible symptoms.

Well, you know what?

Lots of people have horrible symptoms in pregnancy and lots of people have horrible symptoms in puberty.

And we have modern medicine.

We can manage a lot of that.

We just need to keep talking about it and keep normalizing it and keep letting people know the options that are available.

Wonderful.

Speaking of normalizing, some people don't have any symptoms.

Is that correct?

Yeah.

Absolutely.

Is that a small chunk of people?

So about 25% of people don't don't have any menstrual shenanigans.

They kind of just like, you know, maybe skip one or two periods and they're done.

So 25%.

I mean, obviously that's not most, but yeah, with hot flushes, 25% of people really aren't bothered.

My best friend had like two.

She's like, what are you talking about?

About 25% of people have hot flushes for shorter periods of time, but about 50% of people are going to be bothered by them.

I didn't have any brain fog.

I just, I just had hot flushes.

I'm a super deep sleeper, so I don't think my, I probably, I woke my partner up because of my heat more than I woke myself up.

Good for you.

That's awesome.

See, menopause affects everyone.

Yeah.

It does.

It does.

And the transition, you said once you're through the transition, it's temporary.

Once you're through the transition, people have clarity.

So we're pre-menopausal, we're perimenopausal.

Then our period stops.

When are we through that transition?

Are you talking about when our period stops?

So where we don't really know you're sort of through the menopause transition until you're a year past your last period.

So, you know, so it's kind of like the great period wait.

You're just kind of like waiting to see what happens.

Some people, absolutely, you know, 25% of people, their hot flashes will last for a very long time.

I mean, the average duration of hot flashes is like seven to eight years.

So, I mean, this isn't like a minor thing.

This goes on for a long time for people who have them.

For some people, you know, they do persist for a long period of time.

But that sort of feeling off balance, I think is what people associate with the menopause transition.

Daginal dryness isn't going to go away.

If you're having persistent hot flashes, those might stay.

But that sort of,

I don't feel myself, that sort of my body is cantilevering all over the place.

That's typically much more associated with the menopause transition.

Now, you know, obviously everybody's different, but that's typical.

And so what happens is a lot of people might start hormones in their menopause transition, and then they become terrified to stop them maybe five or six years later.

And you don't necessarily have to stop them, but some people do.

Some people want to say, well, maybe I'm through my chaos and I don't really need it anymore.

Everybody's different.

And so we think it's safe to stay on, but we also think it's reasonable for people to say, I might want to go off of it.

And the one thing I would like to sort of impress upon people is.

If you feel really badly during the menopause transition, that doesn't mean that that's how you're going to feel for the rest of your life.

That may just be these really bad rapids.

It doesn't mean there won't be some symptoms when everything settles out.

But to kind of keep that in mind.

When you say that people who go through menopause notice that they feel off.

So to me, that implies that there's been a long time when they've felt on, right?

When they like, there's a steadiness of people.

And then they lose their steadiness during menopause.

But for people who

struggle with mental health like for me

i don't know a long period where i've felt steady where then i will suddenly feel unsteady like my life is often a balance of the unsteadiness back to steadiness constantly since i was 10.

and for me to be really honest

I'm doing this podcast.

I'm listening to everything you say.

And it all makes sense to me for someone who has a regular mental health life.

But for me, I wouldn't know what the hell to say to a doctor.

I I wouldn't know what was my mental health issues and what was menopause, unless it was totally physical, right?

Unless it was periods, vaginal dryness, but all the other things, depression, anxiety,

libido, you know, crankiness, all of those things to me, brain fog, those have always been part of my life.

I haven't been in menopause since I was 10.

So

how do people with mental health sort out what is our brains?

What is menopause?

What do we ask for for health?

How do we know what's what?

So that can be a big challenge.

And when I say feeling off, I mean sort of off for you.

You sort of have to always compare yourself to your normal, right?

So

in your normal, maybe

a wild fluctuations all the time.

Somebody else's normal might be steady.

Someone else is in between.

So it can be very challenging.

If somebody's having a change in your mental health status in your mid-40s, how do you know it's menopause?

How do you know it's not a change in your depression?

How do you know it's not something else?

There aren't tests to tell us that.

And so that takes, I think, a good working relationship with your physician and probably with a couple of physicians, because most psychiatrists aren't sort of up on menopause.

I mean, a few are.

If I have a patient who's got complex mental health issues, I'm not managing that.

So I need to be in communication.

The team needs to work together.

The thing is, is what we can say is it's relatively low risk if people want to try a low dose of hormones to see if that makes a difference.

So you can say, oh, wow, better yes, better no.

And to see, and even if it's better no, that still doesn't mean it's not menopause.

And so unfortunately, what we have are sort of the list of treatments that we can try.

And then we can say, well, does this help you?

Yes, or does this help you no?

And that's one of the really hard things about menopause is sometimes people don't know in retrospect that that's what it was because a lot of things can happen at the same time.

I mean, when people are in their 40s, they often have a lot of life changes and those can cause symptoms.

I still remember, you know,

watching something where someone was trying to blame everything on their menopause.

And they had just spoken before about saying how they were neglecting what they were eating because they were too busy taking their kids around.

And they were really sad they'd just driven their kid to school.

And like, well, okay, but there's other things going on too.

So menopause doesn't happen in a vacuum.

And I think that's what makes it really challenging because the more variables you have, the more you have to juggle all these things.

And so the best advice that I have is to sort of say, well, if I'm going to try something new, to think about what's the length of time in which I should see a desired effect?

And is it possible for me to stick it out on that new treatment so I can say, you know, better yes, better no.

And can we stay on our antidepressants with hormones?

Do they

have other significant things?

Yes.

Yeah.

And many of them actually might even help with menopause.

So some of them, like Venlafaccine, can help with hot flashes.

So some of them might be beneficial.

Now, it's also important to point out that some people who have mental health issues actually do not like how they feel on hormones.

They have the sensitivity and that very low doses just are bad for them.

And high dose, like they just can't do it.

And that's, we have non-hormonal options as well.

I have a lot of success with gabapentin for hot flashes and night sweats and sleep disturbances.

So there are other things that can be helpful as well.

Cognitive behavioral therapy is actually really effective for hot flashes too.

So there are these other options to also think about.

But yeah, it's the more you throw into the mix with any medical condition or with any health issue, and menopause is certainly part of it, the harder it is.

And the more your team needs to communicate to help you.

Tell us your mantra.

Don't do you what you did cognitive behavior.

Oh, yeah, yeah.

Mantra for your hot flashes.

Oh,

I, oh, I have a whole bunch of different mantras for my hot flashes.

I can swear.

Can I swear?

Yes.

Please.

Okay.

You know, so I'm just like, you're Dr.

Jen fucking gunter.

You could fucking get through this.

This is two fucking minutes.

You've had bad sex that's lasted this long.

You can fuck it up.

There's going to be millions of women looking in their mirror going you're doctored jen gun chick you know

i'll

i'll tell you something funny so a few years ago i took one of my sons to new zealand and i had to drive on the other side of the road which is like one of those things that stresses me out beyond belief i'm so stressed and so we're in the car and like the whatever the car rental place and we're because we have to we're going to do i want to drive this is like a trip i'd planned for him and we're in the parking lot and i have this like moment of panic and i just like i i'm like how am i gonna do this and my son he must have been like 13 or 14 he put his hand on my on my hand and he said mom you're dr jen gunter you can do this

best thing i've ever heard mama good work mama god oh i love it

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You have been so kind to answer our three pod squatter questions.

Knowing you've done this forever, what questions does the rest of our pod squad listening have

that we haven't yet answered right now?

Yeah.

One thing which I would like to say is that if you have bleeding after menopause, don't dismiss it as one sort of last raw or one last rodeo with your period.

It can be a sign of cancer and you don't want to dismiss it and you want to get it evaluated.

And And that's like one really important thing.

So, don't ever dismiss that.

I think another big question we sort of talked about earlier is brain fog.

People have a lot of questions about that.

Estrogen therapy doesn't help brain fog.

Going on hormones doesn't make a difference.

If you have a concern that you feel that your cognitive function is deteriorating, you should be evaluated.

And your doctor can do evaluations to make sure that there's no cognitive decline.

There was a study that compared women with brain fog to men of the same age, and the women still outperformed the men.

Shocked, I tell you.

I'm shocked.

Yeah.

So it's a brain bloom is what it is.

It's one of those things that feels worrying, but isn't medically worrisome.

Kind of like if you've ever been pregnant, those contractions, the false labor contractions, they're worrying, but they don't do anything.

Those are kind of two of the biggest ones.

I would say be very, very, very wary of people who are selling you compounded products and stay away from pellets.

These things are not recommended.

It turns out it's making hormones is complex.

And having pharmaceutical people who make these in labs that are followed by the FDA so you know exactly what you were getting.

Because if you get too much of estrogen or you don't get enough progesterone, you can get cancer.

You can get cancer of the uterus.

We haven't talked about that.

If I just gave somebody estrogen and they have a uterus and I didn't give them a hormone progesterone or gave them an IUD that has a very similar hormone in it, they would eventually over time get cancer of the uterus.

So it does matter.

You have to have those sort of the right combination of these two hormones together.

We do not recommend compounded products.

We do not recommend the pellets.

They do make a lot of money for a lot of providers because they can order tests to sort of check your levels and follow you do all this special stuff.

And it's very hard because if you search for information about hormones, almost always these sort of cash practices float to the top of your search.

So they're very very good at search engine optimization.

So that's why I really recommend looking at the guidelines from medical societies.

If these other medications were of value, we'd tell you.

It doesn't matter to me, like which hormone you take, but it matters to me because I want you to have the safest one and the right one.

So is there a link?

Like, is there, can we get that information?

Because we have, we talked about bringing the information about the menopause society into our doctor's office.

Is there a place we can go to to find the information you just said to make sure it's FDA?

Yeah.

So if you go to the North American Menopause Society and you put in search terms on their site, a lot of that information will come up.

Just remember, if people are overselling something, when I tell people,

when I put people on estrogen, I don't tell them, this is 100% going to cure you.

This is going to make your life perfect.

I say, you know, this is probably going to help your hot flashes a lot, but it's.

not going to make them go away.

You might go from, you know, maybe having 10 a day to two a day.

It's going to improve your quality of life.

So if people are selling cures,

I always say, except fashion estrogen.

That's like, you know, that's an actual medicine.

Yeah.

Well, that's the problem in medicine.

There's always exceptions to every rule.

Right, right.

Well, we know that we're not having a compounded product if we are going to our doctor and getting prescribed something, or do we have to advocate even if we get a product to search and make sure what's prescribed to us is not compounded?

Well, if they're sending you a compounding pharmacy, you're getting a compounded product.

So

compounding pharmacy.

There are pharmacies that will make up the hormones hormones for you.

So they'll go in the back room, they'll put a little bit of this in, a little bit of that in and mix it all up.

Oh, they might say, oh, we're going to put it in this cream.

We're going to put it in this gel.

But the problem is, is everything that it's in makes a difference as to how it's absorbed.

Got it.

Got it.

You need studies.

So you can say, so if I'm on a patch, I know I can open up the package and it tells me day two after putting the patch on, day three after putting the patch on, what my hormone levels will be, right?

It's all been studied.

So it should come in a package like your bottle of Tylenol, like your, you know it should look like it came from a pharmaceutical company you should say to your doctor am i getting an fda approved medication okay that's what you should say i want an fda approved medication because that's the safest wonderful so much of this advice is about

and applies to people who have doctors that they can go to whose insurance is working who

A million different things have to fall into line right now for women to actually get to doctors.

What the hell do people who have uteruses do who are going through menopause and do not have the access to doctors and prescriptions?

If you have a uterus and ovaries and a vagina, it's basically a pre-existing condition.

And the way our medical system and our insurance system is structured and the lack of access to, you know, to free health care, or never mind affordable, everybody should have access to, in my mind, you know, affordable, hopefully free health care.

But it's true, people who have less access are definitely going to struggle.

We used to have more county health departments where people could go and get care, and we have less of those.

We don't invest in public health.

We don't invest in community health in the way that we should.

And I wish I had an a great answer, except you can do a lot of work yourself.

My book's available at the library, most libraries.

You can get the book out for free.

You can read it.

Try to start getting some information that way.

Many primary care providers, if you have availability to get access through Obamacare, you might be able to get some basic help there.

But these are real areas that we struggle.

And even for people with insurance, vaginal estrogen is sometimes $300.

It's ridiculous.

It's ridiculous.

You can go to another country and it's free.

So the barriers that we put up, you know, that you get your Viagra with your $5 co-payment.

You know, there's a lot of issues.

Unacceptable.

I like to circle back to where we started with being pissed off.

So thank you for that.

Before this two hours with you and before reading your book, I've always felt about menopause kind of like I feel about geography.

Like I missed everything.

I don't know anything.

And so I'm scared to talk about it at all because I don't know.

And so I will say that the book really helped me.

Go get the book, buy it, get it from your library.

It just is a place to start where you feel a little, feel like you have a little bit more power to begin with, which is knowledge.

And I also think that social media, I know social, following you on social media helps me.

Dr.

Jen, thank you so much.

We can't imagine more important work.

We are just very deeply grateful for what you've dedicated your life to.

Oh, thank you so much for having me.

And thank you so much for having these conversations and

really helping to heal people.

You're such a positive force.

You guys really do so much.

You bring a lot of light into people's lives.

So thank you.

Thank you, Dr.

Jen.

Thank you.

You are Dr.

Fucking Jen Gunter.

You go carry on.

And we'll see the rest of you next time when we can do hard things.

Bye-bye.

And talk to your friends about menopause.

Yes.

Talk.

Just talk about all this.

Talk.

Normalize it.

Send this to your friends.

Talk about it.

Normalize it.

Have a menopause party.

Have a party.

Ain't no party like a meno party because a meno party don't stop.

Yes, it does.

It stops at 8.30 because we're also acting five.

It stops on average at 51.

Okay.

Bye-bye.

Bye.

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