90. Menopause: What We Deserve to Know with Dr. Jen Gunter

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Welcome back to We Can Do Hard Things.

For today's introduction, I'm going to pass it over to my sister Amanda.

Sissy, go.

Thank you, Glennon.

I'm going.

I am so excited for today.

I have been banging the drum for this week's episodes since before we even aired our first podcast.

Correct.

Because this week is menopause week.

And we are demystifying menopause.

We are sharing accurate information.

We are forging solidarity over a process that will, for most of us, comprise over half of our lives.

For me, this is about menopause, but it's about so much more than menopause because menopause mirrors this cycle that is in so many aspects of women's lives.

Because with menopause, women are experiencing something deeply personal and it's near universal for women, but we do not have access to the information to know that the experiences are typical.

So we think there is something wrong with us.

And that fortifies this culture of silence and misinformation.

And that is what leads to powerlessness and shame.

I just feel like it's exactly encapsulates everything we try to do on this podcast, which is to say,

see that thing that is deeply, deeply personal to you and vital to your quality of life, that thing that we don't talk enough about.

That is the thing that we need to bring into the open

because

disempowerment disempowerment thrives in silence

and low information and loneliness in in thinking that your issues are singular and the result of your personal failings but empowerment

thrives in solidarity and shared information and in recognizing like this that the personal is the political and your personal issues are connected to this wider struggle that we can actually help walk each other through

and so i'm just so excited And I feel like it's an opportunity to see that it's not by accident that we have such little information and that we don't know what's going on.

And just so for anyone who doubts the patriarchal minimization of women as a reality, I just think it would be fruitful to have a quick comparison to start off our conversation.

Woot, woot.

Woot, woot.

About 18% of men experience erectile erectile dysfunction.

Okay, this is the inability to get and keep an erection.

You can't walk to your mailbox without being inundated by a Viagra or a Cialisad, assuring men that they do not have to live like this.

And the Super Bowl is essentially sponsored by the idea that justice requires good sex for men for the entirety of their lives.

Our Department of Defense in a four-year period spent $294 million

on erectile dysfunction drugs.

This is how strongly we believe that men's quality sex life should last until the day that they die.

Yet menopause is experienced by nearly all women and dramatically affects not only their sexual experience, but every aspect of their lives for up to 20 years.

Correct.

It's their mental health, your ability to sleep, your ability to do work.

But we don't get a Super Bowl ad.

We don't even get information.

In fact, the silence and misinformation about symptoms and treatment is so pervasive that 73% of women are never treated for their menopause symptoms.

We're told it's a natural process.

Just deal, just deal.

But guess what we don't do?

We don't tell 70-year-old men who can't get a boner that it's a natural process and they just need to deal.

That's not acceptable to us as a society.

But these debilitating systems for up to 20 years for a lot of women is an acceptable outcome for our society.

And so we are here to reject the culture that says that women's quality of life is dispensable and to reject the status quo that says women should adjust to a lower quality of life instead of insisting that information and medicine adjust to support a higher quality of life for women.

And this is why

we are very honored to have with us today the woman who wrote this.

It should not require an act of of feminism to know how your body works, but it does.

Her name is Dr.

Jen Gunter,

and she is here this week to help us understand how our bodies work in menopause.

This is an exercise that is as much an act of feminism as it is a medical act of service.

And we are so grateful.

Before I read Dr.

Jen Gunter's bio-Sissy, I just want you to know if you ever want to quit the podcast and just run for president,

I will work so hard on your campaign.

Dr.

Jen Gunter is an OBGYN and pain medicine physician and the author of The Menopause Manifesto, Have It, Love It, Read It Cover to Cover, The Vagina Bible, and The Premier Primer.

She is the host of the podcast, Body Stuff.

We listened to all of them this weekend.

all of them

TED Audio Collective and of the streaming docuseries Jensplaining.

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.

Welcome, Dr.

Jen Gunter.

Oh, thank you so much for having me.

Thank you.

This is sisters moment.

Okay, before we start, can we start with this, Dr.

Gunter?

On this podcast, trans women are always included when we are talking about women.

Always, of course.

It's clear though, though, that not all women have ovaries and not all people with ovaries are women.

So for purposes of this podcast on menopause, when you talk about what medical research tells us about women in menopause, Who are we talking about here?

For the majority of the research, we're talking about people with ovaries and people who've identified as women

because that's how the studies have been designed those are the populations that were collected and certainly we need absolutely more data to be more inclusive but that's the research that's been collected so far okay so there is there anywhere for people who want more more of us involved in this conversation to find

research about their own bodies or is it just that the research has not been done anyway?

Well, for someone who never had ovaries to begin with, menopause, as we know it won't exist because you won't have gone from the sort of cyclic changes in hormones to not having that.

However, if somebody is on estrogen for their hormone therapy and then they decide to reduce the dose or they decide to go off of it, they could absolutely experience similar symptoms.

But the long-term consequences of that, we don't actually have that data yet.

And so we absolutely need more research.

For people who are going on testosterone, who have ovaries, they may also get menopause symptoms.

They may not.

Sometimes testosterone can protect it.

Sometimes it doesn't.

It also might depend if you have your ovaries removed or not.

And so there are some permutations and combinations there that can absolutely influence things.

And so we just don't have a lot of robust data that I think also just reflects in general with menopause.

You know, we've only had a real sort of increase in good research, you know, in in the last sort of 20 years.

I think it would be great to start with just kind of menopause 101.

Technically, menopause refers to the

moment when it's been 12 months since your last period.

But there's also this very long transition over a number of years.

And I think it's for most women, it's a seven years.

Is that right?

Yeah, it can vary sort of anywhere from four to 10.

And this is part of the problem is the terminology is a little bit clunky.

And it works for us in medical studies, but that doesn't always translate into how we talk about it in public.

So that's actually one of the issues.

So medically, menopause is basically the date of your last period, but nobody knows that when they're having it, just kind of like you don't know the date you start puberty or the date you end it, right?

Postmenopause is everything that happens sort of after that.

And pre-menopause or the menopause transition is a period of time before.

But the other wrench is we can't tell you it was your last period until we're a year beyond your last period.

So you're almost tripping over yourself a bit with the terminology, which adds to the confusion.

And so it is very fair to think of sort of the whole experience from starting into the menopause transition, the time leading up to menopause, and everything that happens afterwards as menopause because symptoms are very similar and there's really only a few medical reasons why we need to know if your periods have truly stopped or not.

That's so important because we think menopause periods, but there's so much more than to it.

And you have talked about it as puberty in reverse.

Can you just walk us through kind of the basics of eggs in ovulation so that we understand all of this in the context of how our bodies work?

Not just One day we get our periods when we're younger and then one day we stop getting our periods when we're older.

Just the super basics of the the follicles, the eggs, why it's happening this way.

You bet, absolutely.

Because it's true.

You know, we do such a bad job teaching not just about puberty, but obviously if we don't teach well about puberty, we're teaching nothing about menopause.

I mean, I think kids learn more about frog biology than they do about their own biology, which, I mean, not that I want to slag on comparative animal physiology or anything.

But, you know, it would be practical to learn about your body.

It would be.

It would be, wouldn't it?

So basically, we're born with all the eggs, which medically we kind of call follicles, that you're ever going to have.

So kind of that one cool fact is when you're a fetus, all of your eggs were inside your mother, right?

So it's like this sort of like nesting doll type of thing.

So you're born with this complement of follicles.

And by the time you hit puberty, maybe you've got about 300,000 or so left, which is ample.

And over the years, you start to use your follicles up.

Every month you ovulate.

You don't just get rid of sort of one follicle there are actually many that get recruited i always sort of say it's a group effort to get the best one so everybody's on team follicle and we got to get the best one each month it's a team effort and you know you're sort of the team gets kind of you know run out of players you only have so many to pull from the bench right so that's menopause and there's genetics that might tell us some people might sort of have a thinner bench and so in their early 40s they're getting low and other people into their 50s so there's this big variation also not that i know anything about sports but i like to use sports analogies i might have them all totally wrong so just

abby would love this

in her language so can i just ask a quick question because i didn't know this so when menopause starts for you is based on how many eggs you started with That's one of the variables.

And then how fast that they're lost.

And that's related to so many other health issues, right?

So for example, if you smoke, you actually end up losing more follicles and having, you know, more follicle sort of death, if you will.

And so it happens earlier.

And so there's a lot of environmental factors, genetic factors that go into this.

And so when you get to the menopause transition, what's happening is there's fewer and fewer follicles.

So to get the amount of estrogen you need, it takes the analogy I use here is it's sort of like you've already had a bunch of people retire from work and the manager is trying to make the remaining people make up all the difference.

There's a lot of shouting that's going back and forth.

So, your brain starts cranking up the signals to tell your ovaries, like, hey, we need more estrogen.

Like, come on, get to it.

And so, it gets a little chaotic in the office when you get yelled at.

Nobody likes to be yelled at.

And so, sometimes hormone levels are high, and sometimes they're actually low because it gets chaotic.

And this is why, for many people, the menopause transition is actually the worst time for symptoms because it's people always think it's this sort of steady, slow decline, but it's not.

It's up and down and up and down.

And you may go a couple of months with higher estrogen levels and then months with shorter cycles and months with longer cycles.

And so it's really true chaos, kind of like puberty.

And so it is the estrogen levels, the fluctuating estrogen levels, which is a hormone naturally produced by people with ovaries that

results in the fluctuation because that is affecting

aspects of your daily life.

So, I wouldn't say it's the result of the fluctuation.

It's all part of the fluctuation.

So, you're getting disordered signals from the brain.

You're getting a disordered response.

It's kind of like a symphony playing out of sequence.

So, instead of getting the tune that you want, you're getting this kind of mishmash.

And then, those, because your brain and your ovaries, it's really this

feedback loop.

So, you're kind of having the wrong signaling go on, you're getting the wrong signaling back.

And so this, what was really a tightly constructed sort of orchestral sort of movement is now a little bit more chaotic.

It's really interesting that many symptoms are really not related to hormone levels.

And so there's many other factors that we just don't understand, but but often it's this chaos, this up and this down.

Estrogen is not the only hormone that's also in flux.

Progesterone is as well.

And there's other hormones released by your ovaries that could potentially have an effect.

And finally, the signaling from the brain, the hormone called follicle stimulating hormone.

We used to think that was sort of a passive thing that was just kind of happening, but actually, there's now data to show that that might be a driver of some symptoms.

I always like to say we don't know what we don't know.

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This whole period where you're having the chaos,

this is all, we refer to everything

pre-cessation of periods as perimenopause.

So you said there's an early stage of that and a late stage.

Can you walk through that so people can understand those phases?

Yeah.

So again, getting back to this clunky language.

So we have words like perimenopause, pre-menopause, and the menopause transition.

And perimenopause is everything leading up to menopause plus plus a year after.

Pre-menopause is everything leading up to menopause.

And the menopause transition is everything leading up to menopause.

Now, medically, we go with the menopause transition.

And I think trying to make the language sound as similar is a good idea.

But so there's an early phase and a late phase.

And the early phase can start for some people, you know, even 10 years, 12 years sometimes before their last menstrual period.

And the most common symptom is a mild sort of irregularity in menstrual periods.

So it's normal month to month to have sort of up to a seven day variation in the length of your periods.

And that's primarily due to the time it takes to remember how I said it's a group effort to ovulate.

That's sort of the time it takes to recruit the group.

There's several waves of eggs that develop.

So if the first wave is brilliant and you've got great estrogen, well, then maybe there isn't going to be a second wave, but there can be a second wave, there can be a third wave.

And so because your body is trying trying to come up with the best egg for pregnancy, right?

You always have to think, even though we were definitely not put on this earth to reproduce, you do have to think about the biology in those terms because that sort of, it's all evolved for that.

So it's all sort of the evolution to get the best egg, to get the best outcome.

So during the early phases of the menopause transition, that initial phase gets shortened because maybe there aren't as many follicles to sort of get up that ramp or sometimes they might go through that ramp faster.

And so that's the typical thing is that people actually their cycles start to get a little closer together they can also get a bit heavier because that you might be producing a little less progesterone in the second part of the cycle but you can also get heavier because we accumulate medical conditions as we age that can also make your periods a little bit heavier and some people might notice some subtle uh symptoms maybe some occasional hot flushes maybe some night sweats maybe some mild depression that can easily be triggered in the early menopause transition And so these are some of the more common symptoms.

But obviously, you know, there can be a variety of others.

I really want to talk about symptoms in depth in a second because I think that's, it's really important for people to hear those out loud to normalize them.

But I have a personal question.

How do people like me?

I have an IUD, so I don't get.

my periods.

How do people like me know that there is a signs of premenopause?

I'm going to be 43 tomorrow.

I, for example, have twice in the last year and a half gone to my OB and said, well, it's here.

Twice I've done this, Dr.

Gunther.

Well, it's here.

I am ragey.

I can't stand anyone.

I am fluctuating.

My moods are all over the place.

I am definitely premenopausal.

And then she has done a variety of tests on me twice and said, good news.

You are not.

You're just still an asshole.

you're just

somehow i am convinced i have covet every week and they're like nope you're just still lazy well

i would say that those tests are not reliable and so

yeah so we don't recommend testing people basically unless there's a very, very sort of extreme reason because it's not reliable because your hormone levels can be super high one month and they can be super low the next.

If you happen to catch you in a time where you just didn't ovulate for one month, I could erroneously tell you that it looks like you're in menopause and the next month you might be ovulating fine.

So we don't actually recommend testing kind of over the age of 40 to see where you are or to check that that's not recommended.

So the blood tests are not those.

So I really might be.

You know, so

obviously it's a possibility, but the average age of menopause is 51.

Right.

So you have to think, okay, if you're fully menopausal at 43, that's not impossible.

And so if you came into me at 43 and said, I have had crippling hot flashes for six months.

I've had terrible vaginal dryness.

43 is a little young.

And so I might check you just to see if you're not getting close, but if it looks like you could have come and gone.

If you're 45, I wouldn't, right?

So it's sort of between 40 and 45 is a little bit of a sweet spot, but to spitball and see, are you close?

Are you there?

You can't tell that.

So with an IUD, the great thing about it is you are unlikely to experience the menstrual chaos.

Yay, modern medicine, that's great, right?

I'm all for better living through chemistry.

So you're unlikely to have the menopa the menopausal menstrual fluctuations, which happens to be meaning like super heavy some and then closer together and all that stuff.

Right.

Or skipped periods, right?

Like I thought I was done.

I was on a plane.

I was flying to Europe.

I was 50.

I had a period in seven months.

The plane had just taken off.

The seatbelt light came on and super soaker, awesome, you know.

So you won't get that.

So that's amazing, but you're still ovulating with a Morena IUD, right?

So you will still get hot flashes.

You'll still get night sweats.

You'll still get those other symptoms, which about 75% of people experience.

And so it's possible that that if you're having a big mood change, it could be very early menopause transition, but it could be depression.

It could be everything that's going on in the world.

And you want to check and make sure it's not your thyroid because thyroid disorders are more common among women as they age.

And so a really important thing, not only do we miss a lot of menopause, but we also blame everything on menopause and then miss other conditions.

So you

have to look at that.

That is huge.

Can you talk more about that?

Well, I mean, it's just part of the whole general dismissal of women and people with ovaries in general.

You're either hysterical or you're not sucking it up enough.

It's like we're always on the edge of a knife.

You're either too complaining in one direction or too complainy in the other.

I don't mean to laugh about it, but it's awful.

And that's medicine in many ways is just a reflection of our society.

That's how our society is treating people.

That's what we see a lot of times in the office.

So symptoms are very common.

The main one is menstrual regularity.

And that's the one symptom that will go away when you're menopausal.

Other ones, hot flashes, are experienced by about 75% of people.

And there's about four different ways people can get them.

Some people get them early in their menopause transition and then they go away.

Some people get them later.

Some people don't even really get them until they're menopausal.

And then there are people who are super flashers.

They just get them the whole time.

And

I appear to be a super flasher.

So yay, go me, go team.

Other symptoms that people experience, joint pain, is actually quite common, and we don't really understand why.

I've mentioned depression can be part of it.

People can notice a feeling of anxiety, chest palpitations, heart palpitations are actually quite a common symptom, and vaginal dryness.

So these are some of the things that can be experienced.

And it doesn't mean that you're going to get all of them, low libido for some.

I also hear people tell me the opposite.

I mean, some people tell me now they don't have to worry about getting pregnant.

I'm like, all for it.

Can you talk about hot flashes?

Because like just.

Say what they are because I feel like that's the one buzzword that people know about, but I don't think

until I read your book, I didn't really understand

what they were, how they showed up in your body.

And also, are they hot flashes or hot flushes?

Well, I personally like the term hot flushes because a flash is like to me, a flash is instantaneous, right?

Oh, it's a flash of light, but it's not a flash, it stays for quite some time, usually a couple of minutes.

I personally prefer the older term from the 1700s, hot blooms, because it really does feel like the heat is blooming out of your head.

And every time I use that term in the office, people who have them, they're like, oh, that's way better.

It's like a flower.

It's like, yeah, you're blooming.

It's something.

It's an incredible experience.

You're just like, I feel like it's a...

the gynecological version of, you remember that old horror movie, that call is coming from inside the house.

It's really like that.

You're like, how is this happening?

It's very complex.

And we've only been able to even get a basic understanding of it since MRIs and that type of imaging became available, right?

Because it's not as if you can put an electrode in someone's brain and monitor it.

So basically the signaling, reproduction and temperature control are tightly linked.

That's why during the second half in your cycle, your temperature goes up because that's optimal for implantation.

So if you think about an area of your brain, the hypothalamus, as like a motherboard, it's It's got reproduction wired in.

It's got temperature control wired in.

It's got all kinds of things wired in.

So the problem is if one thing kind of isn't working well, it can affect the other.

That would be the best way to explain it.

And so there are neurons that tell you when you're feeling heat.

And these neurons are suppressed by estrogen.

And so without estrogen, your brain starts to tell you you're hot when you're not.

So,

every feeling you have is there because your brain tells you it's there, right?

So, your brain is telling you you're hot and you're not really.

It's sort of like fire in the hole.

So, what do you do when you're hot?

You try to dump heat.

So,

your blood vessels all dilate and all the blood rushes to your skin.

And that's the redness and the flushing that you can get.

And then that creates more heat because the heat's coming out, right?

So, you feel that wave of heat.

And then that's why a lot of people shiver after, feel cold afterwards, because you were never hot to begin with, but now you've sweated and flushed and got rid of all this heat.

So you've actually lowered your temperature.

So you're just sitting hanging out with your people or whatever.

And what does it feel like to begin to bloom?

Oh, well, you're thinking, what?

Wait, what, why am I hot?

And then all of a sudden, it's for me, it starts kind of like in my head and upper chest.

And that's where most people describe it.

It's really fascinating that people don't really describe it from the waist down.

And it really feels like the inside of your head is getting hot and it's just like coming out.

And it's so awful.

You can't get away from it.

You literally want to rip clothes off.

Like you're just like, oh my God, I got to get this off.

Sometimes it's accompanied by a bit of a feeling of a panic.

And, you know, I mean, your brain's doing things like you didn't tell it to do.

It's like, wait a minute.

what's going on?

And that's why a lot of people have, you know, in the past were labeled as being, you know, having panic attacks or hysteria.

And, you know, part of the problem is, is a panic attack can feel a little bit like that, right?

You can get your heart racing when you're having a hot flash with euchre flush or hot bloom.

And you can have obviously those same symptoms when you have a panic attack as well.

So when people talk about night sweats as a symptom, is that having a hot flush at night?

Is that just like while you're sleeping and that's you're soaking their sheets and stuff?

Yeah.

And so what happens is it often wakes you up, but not all the way, right?

Because we have all these different phases of sleep, and so sometimes it's not like you're waking all the way up, but it's taking you close to waking.

So, you're having some disrupted sleep or disordered sleep, and you are really hot.

So, my partner tells me all the time, he was sort of be like, going to roll over and you know, cobble me in the middle of the night.

He'd be like, Whoa, it's like a pizza.

It's a pizza.

I, I mean, Dr.

Gunter, it's unbelievable.

Like, I will wake up just soak it, like, the whole sheets, the pillowcase, the, and then I'm too lazy to do anything about it.

I have friends that like get up and change.

And I'm like, no, I just sleep in it.

I just sleep in it.

And then I wake up freezing cold.

Yeah.

It's just a good time.

It's party.

It's party.

Yeah.

And please call me Jen.

So for me, that was actually the driving reason for me to start estrogen was one of the driving reasons was the degree of hot flashes.

It was just getting a bit too much and you're scrubbed in the operating room and you're wearing that.

And I do procedures where I have to wear a lead apron because I'm working with x-ray equipment.

So I've got, you know, this unbreathable surgical gown.

I'm wearing an apron made of lead,

right?

I've got a mask on, a shield, a hat, right?

And you get a hot flash.

And you literally, I would come out of the OR and my clothes would be soaked underneath.

And they can't turn the temperature down because it's not good for patients to get cold during surgery.

So you're screwed.

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It's like we're talking about, to me, sister, about how women reach the pinnacle of their careers or their lives, and then this shit starts happening.

I was reading a study that I think it said 30% of women report that their menopause symptoms pretty dramatically affect their work.

And it just seemed like

getting to this place where you're at the age where you've built up this point in your career, imagining you doing surgery.

And that it's certain extremes.

You have to either not continue your work or have some kind of accommodation for it.

We don't have in our corporate structures any accommodation for this yet.

It seems like UK is doing a better job of highlighting this a little bit, but

it's just deal with it.

That's a personal problem.

Well, I mean, I think that's a big problem with corporate America in general.

What's really important is, you know, to say, well, hey, we're at the peak of our capabilities and this is happening.

And I always like to say, you know,

there's almost a reason for that.

And I'm not talking about like the awful workplace, but people need to know about what's called the grandmother hypothesis or the wise woman hypothesis.

It's sort of not an accident that you're super capable right at this time and the most useful to society.

So, evolutionarily speaking, you have to think, well, what's the point of ovaries that aren't functional, right?

Aren't we all here to reproduce?

Because most animals die

basically once they're done reproducing.

And humans, killer whales, and a couple of other whales live beyond their reproductive capacity.

And

that's strange.

Yeah.

Women and killer whales.

Yeah.

That was my favorite part of anything I've read or listened to with you.

Women and killer whales.

Yeah, usually the orcas.

Yes.

And I think some other tooth whales too, but orcas are most well studied.

And they also have very intricate social structures.

And if you compare us to chimps, they're our most closely related sort of animal ancestor.

They they ovulate like us, they go through puberty like us, and then their ovaries stop functioning and then they die.

We keep on living.

And the big thing that the patriarchy has done is has sort of erased all these women in history that have kept on living.

I think we've all heard this myth that, oh, menopause wasn't meant to exist because you were going to die early and, you know, that it's a sign of weakness or ovarian failure.

And actually, apart from childhood mortality, which was astronomically high, if you were in the 15s, 16, 1700s and you got to be the age of 15 or 16, you had a good chance of living to be in your 60s.

And if you look at people who live in traditional hunter-gatherer societies who have resisted modern lifestyle, industrial lifestyle, they don't all die in their 40s.

They're living into their 60s and early 70s and mid-70s very healthily.

So this idea that women dropped dead and men somehow didn't, which I always find fascinating, again, patriarchy.

If you think about how difficult it is for us to reproduce, pregnancy is nine months.

You have breastfeeding.

And think about our ancestors tens of thousands of years ago needing shelter, needing enough calories, having other children to care for at the same time, right?

Wouldn't it be useful to have another pair of hands?

And wouldn't it be useful to have another pair of hands who wasn't burdened with those tasks themselves, right?

And so it really gets back to it takes a village.

And when we look at studies in hunter-gatherer communities, grandmothers are foraging for food when their daughters are pregnant 37 hours a week.

That's a lot of work.

So if you think about it, how can you be the most useful?

You can be the most useful if you know where to find food, if you've remembered during a time of drought how to get this, if you've got all this knowledge that you've accumulated.

And sometimes I wonder if the reason why we are all so fascinated with stories is that's all part of our memory gatherings.

So we can basically be these, you know, sort of logbooks of our society, you know, and be helpful.

And so I think that looking at how capable we are, how many hard things we can do in menopause is because this is what we evolved to do.

Oh, I heard you say grandmothers are the heart of humanity.

That's the through line here.

And that we all say, oh, hunters, gatherers, the men were out there.

But hunting, I heard you say that only 3% of all the food came from the hunting, that really it was the gathering that

grandmothers were able to do while their daughters were taking care of the babies that was crucial to the survival of the tribe.

Right.

So for the individual family unit, hunting didn't provide that many calories.

But what happens is

coming in with a big kill raises your social status in the community because you're feeding other people, right?

So humans have such complex social structures that you can't just look at, well, what is that doing for my little unit?

How is that moving you up in the social standing?

How is that contributing, right?

Because, gosh, if your partner happens to be the best hunter, then if something awful is happening, well, maybe people are going to share their food with you because they want to preserve the best hunter, right?

So you start thinking about it in those terms.

And Dr.

Kristen Hawks, who is one of the anthropologists who came up with the grandmother hypothesis, her and her team, you know, she told me in an interview that one of the theories behind babies making such cute little faces isn't so mothers and fathers get attached.

It's so grandparents get attached and will help look after them.

Wow.

Wow.

Sneaky little babies.

So it's fascinating to think about it.

And obviously these are theories.

And I always like to point out, that doesn't mean that your only worth is being a grandparent.

But what it tells us is that we're all very useful.

And it's really interesting in the hunter-gatherer communities,

older women who don't have daughters or grandchildren and

families that don't have grandmothers often end up pairing up together.

So, or they end up helping each other out again.

It sort of takes a village, I guess, is really.

is really the motto.

But now we have our big brains that we can do things that we want to or not want to.

And that's also part of evolution.

I like the fact that we're trying to change the terminology to sort of more like sort of wise person, wise older.

Yes.

I like that too, because I don't think of the grandmother as literal.

like, I think of grandmothering, like, I think of as the word mothering, which I don't feel like has anything to do with whether you have babies.

Mothering is a verb, just like the grandmothering idea being the older woman

is crucial to is the heart of humanity.

Exactly.

Yeah.

Maybe there really is a mother earth.

Our Western model of sort of shunting people off and saying you don't really have anything to contribute as you age doesn't seem to be reflected in how we've evolved as a species.

I heard you say that when you started experiencing your

hot flushes is when you started your hormone therapy.

And I would really, really love to talk about that for a few minutes because

every time someone dares to whisper hormone therapy, you know, the reflexive response is, but it causes breast cancer.

And So can we please just really drill down on the Women's Health Initiative study of 2002 and how the premature release of that early data and the media frenzy caused millions of women to go off hormone therapy overnight and really, to my mind, robbed a generation of women from the therapeutic benefit of hormone therapy.

So can you just walk us through how that all went down and how that kind of changed in 2000, close to 40% of women between 50 and 59 were on hormone therapy.

And then in

by 2010, it had plummeted to less than 7%?

Yeah, so the Women's Health Initiative did cause a lot of problems.

And I think, though, it's really important to sort of say

there's a lot of things that are causing a lot of problems.

And so I want to take us back just a little bit before the Women's Health Initiative.

So if you look at the 1960s and the 1970s, basically

big pharma was the drive behind this sort of feminine feminine forever hypothesis that the worst thing that could happen to you as as a woman was to get unattractive to the eyes of a man that was basically it right that's a worst thing the worst thing that could ever ever happen you can't believe they believed that in the 70s that's such a crazy idea There was a book called Feminine Forever, which I have a copy of it.

I bought it.

So I found it.

You can find anything on Etsy.

It advanced all these theories.

And it was written by this guy called Dr.

Wilson.

And he was, of course, funded by Pharma, but it got picked up by Vogue and by Time and all this stuff and it goes to show that if you're the only person talking about something people want to hear about your message gets out right so

then big pharma sort of turned menopause into a disease to be managed right a disease to be cured and then we started to collect data to tell us that boy look people on estrogen actually look like they're living longer and they might have less dementia and they have have have better hearts and so this we went from treating menopause as a disease to estrogen kind of being preventative therapy that everybody should be on.

But obviously there's sort of still that background of, well, there must be something wrong with menopause.

That's why we need to treat it.

So then we had all this

what we would call sort of observational data, where we'd said, oh, these women decided to go on hormones.

And then and then look, they're doing better.

But you also have to remember that people who decided to go on hormones were more likely to have education, education, more likely to have access to health insurance, maybe higher socioeconomic status.

All of these things are associated with a lower level of dementia, a lower level of heart disease, lower level of osteoporosis, there are other reasons.

So that was the Women's Health Initiative.

And it was possibly the largest randomized double-blinded placebo control trial where women started on estrogen.

There was a placebo arm.

There was also a taking calcium arm and a placebo arm.

So they were looking at a diet.

They looked at all different kinds of things.

But we'll talk about the hormone arm.

And

built into the study, as every study is, is a, we're going to stop if this bad thing happens, right?

So we knew that hormones were associated with slightly increased risk of breast cancer.

This was not news.

When I prescribed estrogen back in the 1980s and the 1990s, I would say, look, we believe it prevents heart disease and prevents osteoporosis.

That's a trade-off for a low increased risk of breast cancer.

We're trying to weigh the risks and benefits for the average person because the number one killer of women is heart disease.

The study was stopped when they did an interim analysis that showed that we'd hit that level of risk with breast cancer, the risk that we knew about, right?

And that it didn't look like there was any prevention of heart disease.

In fact, it looked like it might worsen it.

So it was stopped early.

And instead of then beautiful papers being written from it and people trying to tease it apart and figure out what happened, there was a press a press conference and they because they wanted to to make a splash and i'm a firm believer in medicine not happening by press conferences i mean that's what andrew wakefield did right and look what happened there so then it was all over on all the front pages because nothing gets more press than scaring women about something to do with a reproductive tract like nobody wants to scare women about like eye disease nobody wants to scare women about like foot disease they want to scare women about the reproductive tract because that gets press

and so then what happened over the next year or two as people started to scramble and take apart the study, they found that the majority of people who were in this study were actually older than most people who get started on hormones.

Because remember, we said earlier that the worst symptoms are in the menopause transition.

So, is starting hormones when you're 47 the same as starting it when you're 63?

It may well not be at all.

And so, once the data was kind of teased apart, we found that over the age of 60, there seems to be a definite increase in risk of heart disease and dementia for starting hormones.

So if you go 10 years without a period and then you say, I can't take it anymore, I want to start hormones, your risks with hormones might be greater than your risks without them.

Okay.

But if you are in the earlier group, if you are within 10 years of your last menstrual period or under the age of 60, then that risk doesn't seem to be there.

That the impact on heart disease appears to be neutral.

There is a benefit for bones for prevention of osteoporosis, and you can treat a lot of other symptoms.

We don't have good data to tell us that starting hormones early prevents against Alzheimer's disease or dementia.

So we don't recommend people start for that reason.

There's still more data coming in that area.

But so we know that for people who are within that category, the risk is quite low.

If you're going to take hormones, and I'm talking about pharmaceutical hormones, not compounded stuff, because that's unsafe.

If you're going to take pharmaceutical hormones, we don't believe that the risk of breast cancer even really starts to increase for a few years.

So if somebody is saying, look, I just want to take this for two or three years just to get rid of some terrible symptoms and then see how I feel, you're basically accumulating as low risk as possible.

But for those who decide to stay on it, you're looking at a risk of breast cancer that's about equivalent to a glass of wine a day.

And so, you know, it's a pretty low risk.

We're talking, you know, like one in 5,000 kind of thing, you know, per year.

It depends depends a little bit if you have to take a hormone progesterone to balance out the effect of the estrogen on your uterus.

And so when you're taking estrogen alone, that risk might even be a little bit lower.

So the risk is there, but it's very, very low.

I believe that people are intelligent enough to decide what is this doing for me.

No medication is without side effects.

And to say that it is would be incorrect.

But the risks are very, very, very low.

And if people are suffering, there's no reason that that is a risk that should hold them back.

So to summarize that, if you are a person who is under 60 and within 10 years of your period stopping, and you are interested in

getting some relief from your symptoms, that

if you were to consult your doctor and say, I would like to learn about hormone therapy to address my symptoms, And they were to say that causes cancer.

You would need to ask more questions about that because

at least for taking it for a two to three year period, that is actually not true.

If you are in that period of time where you're within 10 years of

your last period.

Yeah, I mean, I would recommend that somebody see someone who's certified by the North American Menopause Society.

If they're hearing, don't take that because that causes cancer.

Now, there are some caveats.

If you're somebody with a personal history of breast cancer, that's a far more complicated conversation.

And the data that we do have is if you yourself have had an estrogen receptor or a progesterone receptor positive breast cancer, then your risk of recurrence may well be higher taking hormones.

If you are somebody who has a very high risk of heart disease, so you maybe have uncontrolled blood pressure or difficult to control blood pressure or you have very high cholesterol and they calculate your risk of having a major cardiovascular event we have a calculator for that if you're very high on that scale then then there are different conversations to have about hormones so when we're talking about for the general population we're talking about people who you know if they have a cardiac risk factor they they only have one we're talking about people that are that otherwise aren't falling into these other categories because you have to remember you know when these big trials when they enroll people they largely enroll people who they think are the lowest risk of having problems so there are some caveats there but the risk of breast cancer in quotation marks for someone who doesn't themselves have a personal history of breast cancer is if someone's saying that, then they don't really know enough about hormones in my mind to have a conversation with you.

Got it.

What is it called that we need certified doctors from where?

Yeah, so the North American Menopause Society, NAMS, is a great resource.

And I tell people, instead of just Googling your symptoms, you know, going to like Dr.

Google, if you put in your symptoms and put NAMS afterwards, North American Menopause Society, it will bring things that have NAMS stuff in it to the top.

So you'll be able to give yourself basically a filter to get better content.

The North American Menopause Society that has doctors like me, we've done an exam to get certified.

We have a greater interest in this and we're more aware of the literature.

And so the cancer risk is just, you know, something that we wouldn't recommend.

holding back offering estrogen for.

But everybody perceives risk as being different, right?

So some people might say, well, for me, I don't want to do that.

And that's okay.

That's part of informed consent.

Informed.

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Women, I think, are

hesitant to even talk to doctors sometimes because we are so used to our symptoms being dismissed.

We're so used to, you know, in a million different ways, walking into a doctor's office and having them minimize or even shame in insidious ways for even having needs or the symptoms of menopause can bring to a head everything we've been shamed to be our entire lives.

You're just too emotional, you're just too fragile, you're just too needy, you're just difficult, all of these things.

You're a hypochondriac, you're irrational, you're crazy, all the things.

Whatever the newest words for hysterical are, whatever the culturally appropriate word for that is, passing.

So, I would love for you.

I know that there's no script, right?

But what should a woman do who feels like she is having symptoms of menopause?

They are

affecting her quality of life.

What might a woman say to her doctor

to actually get

the help she needs and avoid being dismissed?

So, the first thing that I would say, I mean, I absolutely agree with everything that you said.

That's why I write my books.

So, people can go into the office and say, you know, I love it when people say, well, Dr.

Jen Gunter says this.

So, I think the first thing is to get educated.

The other thing that I would say is to make a list of the things that are bothering you.

Because sometimes what happens is when you go to the doctor and you have all that simmering rage from the patriarchy and all that simmering rage of how you feel, and then you're in that stressful power imbalance.

Sometimes you kind of don't say what's really important to you, what you've been thinking about.

You're just, you're just so, you're so upset.

It's, and I've been there.

I have children that have very complex medical issues.

And I've been there in the office and all of a sudden I'm a doctor not being able to like advocate for what I want.

So like any big thing plan for it in advance so i tell people to make a list of the things that are bothering them sit down and think about it if you're having hot flashes pay attention to how often they're happening if your sleep is disturbed and make a list of the things that are sort of in order of importance because we don't have magic wands we're not going to be able to make all those symptoms go away so if you walk into the office and say like what are my top two needs and then you're going to start working down the list right but you also want to ask your doctor what else could be these symptoms?

Because as we talked about, you don't want to be, oh yeah, it's menopause, here's the hormones.

And then you're not feeling good on the hormones and somebody just keeps upping the dose when they actually needed to look for something else.

So that.

And then you want to ask for the screening tests that are age appropriate so you can make a decision if you want to go on hormones or not.

So you want to make sure that you get your cholesterol done and that you've got your mammogram done and that you've been checked for diabetes and checked for thyroid disease.

So you want to have those basic health screenings done.

So then you can make an educated decision with that information and present your symptoms.

Now, I always say, let the doctor also ask you some questions because sometimes the symptom that's bothering you is actually not the symptom that's really bothering your doctor.

What I mean by that is maybe your bleeding is actually really quite catastrophic, but you're like, eh, I don't really care about that.

I care about the hot flashes.

But your doctor's like, wait a minute, that's actually a sign of cancer, what you're telling about.

So we need to rule that out.

So just kind of be open to, that's why you should have given the whole list because what you might brush off is not being important your doctor might be like oh i i wanted a little bit more about that get informed before you go in um

make a list of your symptoms of your bother factor what would you like to go away and try to focus on the the biggest two uh and then and that doesn't mean that you can't address the others but you know it's hard to address multiple things at once and and then um get your screening tests done and then and then make a decision based on that and then can you give me a line like if the doctor says something dismissive after all of that,

what is an empowering, assertive way to just let a doctor know that we won't be dismissed and we're going to redirect, we're not going to walk out of this place without a plan?

Well, so what I would say is, well, I have a copy of the North American Menopause Society guidelines with me right here.

And they say this.

The North American Menopause Society has their guidelines for physicians.

What experts have told us to do, everything I've told you about hormones is from that.

So if you have a doctor who is not willing to follow those guidelines, then you need another doctor.

All the studies have been hashed upon and we've sort of decided what's the right thing that we can tell people with the information we have.

So I would say that, you know, if your doctor says, oh, oh, oh, gosh, okay, well, I mean,

someone probably shouldn't be managing your menopause if they're completely unaware of the guidelines.

But, you know, that would be the the thing, knowing what the guidelines are from the North American Menopause Society or the American College of Obi GWAN, or if you're in Canada, the Society of Obstetricians and Gynecologists of Canada.

I love this.

We're going to think first.

We're going to make our list.

This reminds me of how I deal with my mental health doctors:

go in with the list,

with the list of symptoms and problems and wishes.

Sit down,

explain them all, but also allow questions, be open to what the doctor is saying.

And then if we feel dismissed still,

bringing out our

National American Meda, what the hell?

North American Menopause Society.

Yes.

So know what it is because you need to sound better than I just did.

Okay.

That's a great plan.

I like that.

Okay.

Excellent.

And we're going to include everything on that list that even the things that we have been socialized to think are private and personal and embarrassing because many of the things on that are going to be on this list overlap with those things that we're trained to to be ashamed of including

Jen something we're going to talk about um on Thursday's episode because we got a lot of questions about this including the way that menopause symptoms intersect with sex

that's a big one and that might need to be on your list great

second on the list.

Come back for menopause, sex, and rock and roll on Thursday, everyone.

We will catch you back here for our radical acts of feminism, which are just understanding our own goddamn bodies.

Okay, see you back here.

I give you Tish Melton and Brandy Carlisle.

I walked through fire, I came out the other side

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