reNotes example:

Menopause is a natural biological process that happens to all women. It is the time in a woman's life when her ovaries stop producing eggs and she can no longer get pregnant. Menopause typically occurs around age 51, but can happen earlier or later depending on a woman's individual health and history.

There is a lot of confusion and misinformation about menopause. Many women feel like they can't talk about it or don't know where to turn for information and support. This lack of understanding and awareness can lead to feelings of powerlessness and shame.

The speaker argues that by sharing information and stories about menopause, we can help to empower women and create solidarity. The majority of medical research on menopause relates to people with ovaries who identify as women. However, there is a need for more inclusive research to better understand the experience of all people going through menopause.

The speaker discusses how menopause is defined medically, and how the terminology can be confusing. They point out that menopause is not just the date of your last period, but the entire experience leading up to and after that point.

The article explains the basics of eggs and ovulation, and how they relate to menopause. Menopause occurs when a woman's supply of eggs dwindles, and this process is affected by factors like genetics and smoking.

This content discusses the various factors that can contribute to menopause symptoms, including fluctuating hormone levels and signal disruptions from the brain. It also notes that many symptoms are not related to hormone levels, suggesting that there are other unidentified factors at play.

This person discusses the benefits of using parachute products, which are made with organic cotton and are therefore more sustainable. They love that they are doing good for the planet while also taking care of their own health and their family's health.

This content discusses some of the common symptoms of pre-menopause and how people can know if they are experiencing it. It also notes that there is no reliable test to determine if someone is in pre-menopause and that the average age of menopause is 51.

The IUD is a great option for those who want to avoid the menstrual chaos that can come with menopause. However, it is important to note that you may still experience other symptoms of menopause, such as hot flashes, night sweats, and joint pain. Depression can also be a part of menopause, so it is important to check with your doctor to rule out any other conditions.

This person is discussing hot flashes, which are sudden waves of heat that can make a person feel flushed and sweaty. They occur when the brain tells the body it is hot, even when it is not, and can be caused by a lack of estrogen.

Dr. Jennifer Gunther describes hot flashes as a sensation of heat that starts in the head and chest and can be accompanied by feelings of panic. Hot flashes can disrupt sleep and be extremely uncomfortable. Estrogen is one medication that can help alleviate hot flashes.

This content discusses how menopause affects women's careers and how corporate America does not yet have any accommodations for it. It also talks about the evolutionary reason for menopause and how it is actually beneficial for women.

Studies of hunter-gatherer societies show that women are more likely to survive into old age than men. This is because they are better able to find food and have more knowledge about survival. Grandmothers play a vital role in these societies, providing care for their daughters and grandchildren.

The Women's Health Initiative study of 2002 found that hormone therapy could cause breast cancer, leading to millions of women going off hormone therapy overnight. This had a profound impact on women's health, as hormone therapy can have many therapeutic benefits.

This content provides background on the development of hormone therapy to treat menopause, specifically discussing the Women's Health Initiative. The Initiative was a large-scale study that looked at the effects of hormone therapy on various health outcomes. The study found that hormone therapy did have some benefits, but also came with some risks, specifically an increased risk of breast cancer.

The study was stopped because it showed that there was no prevention of heart disease, and it might even worsen it. They found that starting hormones when you're older than 60 might increase the risk of heart disease and dementia. However, for those who are under 60, the risk is quite low. If you're going to take hormones, the risk of breast cancer doesn't really increase for a few years.

The risks of taking hormone therapy to relieve menopausal symptoms are very low, especially for women under 60 who are within 10 years of their last period.

Podcast: We Can Do Hard Things with Glennon Doyle
Episode: Menopause: What We Deserve to Know with Dr. Jen Gunter

Welcome back to we can do hard things, or today's introduction. I'm going to pass it over to my sister Amanda. See? No. Thank you, Brandon, you weren't 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. 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 encapsulate 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 thrives in silence, and low information and loneliness in in thinking that your issues are singular and the results 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.

About 18% of men experience 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 Cialis ad, showing men that they do not have to live like this.

And the Superbowl is essentially sponsored by the idea that justice requires good sex for men for the entirety of their lives, right. Our department events 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 it's their mental health, your ability to sleep, your ability to do work, but we don't get a Superbowl 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.

Were told it's a natural process. Just deal. Just deal. But guess what we don't do. We don't tell 70 year old man 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 now, 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 feminism to know how your body works, but it does. Her name is Dr. Jen Gunter. And she is here this week.

seek 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. Jenn Venters BIOS to see 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 OB GYN 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 premium primer. She is the host of the podcast body stuff. Listen to all of them this weekend, all of them. Ted audio collective and of the streaming Docu series Jen splaining. She blogs at the vagenda.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 OB GYN and a fierce advocate for women's health. Welcome Dr. Jen Gunter. Oh, thank you so much for having me. They view

this as sisters moment. Okay, before we start, can we start with this Dr. Gunther, on this podcast, trans women are always included when we are talking about women always. Of course. It's clear that 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 and menopause, who are we talking about here? For the majority of the research, we're talking about people with ovaries and people who have identified as women. And 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? Anyone? 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 that 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 test 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 we 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 the last sort of 20 years.

I think it would be great to start with just kind of menopause one on one, technically, menopause refers to the 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, 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 day you end it, right. post menopause 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 two

it and you have talked about it as puberty in reverse? Can you just walk us through kind of the basics of eggs and ovulation so that we understand all of this in the context of, of how our bodies work, not just one day we get our periods when we're younger? And then when do we stop getting our periods when are older? Just the super basics of 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 and say, would be.

So basically, we're born with all the eggs, which medically we call follicles that you're ever going to have. So it kind of that one cool fact is when you're a fetus, all of your eggs were inside your mother, right? So it's 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. They're actually many they get recruited, I was sort of say, it's a group effort to get the best one. So everybody's on Team follicle, and we already had 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, so I have them all totally wrong. So just Abby with love this in her language.

I just asked him a question. 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 all that. 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 was 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 that results in the fluctuation because that is affecting that the 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, the 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, this feedback loop. So you're kind of having the Ron signaling go on, you're getting the Ron signaling back. And so this 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 is up in 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 an

Now data to show that that might be a driver of some symptoms. I just 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 a year after pre menopause is everything leading up to menopause. And the menopause transition is everything leading up to menopause, the medically we go with the menopause transition. And I think trying to, to make the language sound as similar is a good idea. But so there's an early phase in the 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 and 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 sort of the time it takes to recruit the group, there's several waves of 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 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 the you might be producing a little less progesterone and the second part of the cycle, 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 symptoms, maybe some occasional hot flashes, 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 and 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 science of pre menopause? I'm going to be 43 tomorrow. I for example, have twice in the last year now. I've gone to my OB and said well, it's here twice. I've done this Dr. Gunther? Well, it's here I am Rayji I can't stand anyone. I am fluctuating my moods are all over the place. I am definitely pre menopausal. And then she has done a variety of tests every twice and said good news or not. You're still an asshole. You're just

I

am convinced them COVID Every week and they're like, Nope, you're just still lazy? Well, I would say that those tests are not reliable. So Oh, 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 and a time where you just didn't ovulate for one month, I can 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's not recommended. So the blood tests are not, though. Yeah, so I really

don't you know, so.

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 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. A little bit of a sweet spot, but to spitball and see Are you close you there? You can't tell that. So with an IUD, the great thing about it is you're 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 menopause the menopausal menstrual fluctuations, which have meaning like super heavy, some and closer together and all that right or are skipped periods, right. Like I thought I was done. I was on a plane. I was flying to Europe, I was 50. And then a period in seven months, the plane had just taken off the seatbelt light came on and Supersoaker awesome, you know. So you won't get that. So that's amazing. But you're still ovulating with a Mirena 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 to 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 talk about 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 to complain in one direction or to complainy and 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, 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 other people who are super flashers, they just get them the whole time. And and I appear to be a super flashers. So yay, go be go team. So, other symptoms that that people experienced joint pain is actually quite common and we don't really understand why I mentioned depression can be a 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 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 liked the term hot flashes because of a flash is like to me it flashes 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 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? Yeah.

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, that hypothalamus as like a motherboard, 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 that tell you when you're feeling heat, and these neurons are, 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 you your your blood vessels all dilate, and all the blood rushes to your skin. And that's the redness in the flushing that you can get. And then that creates more heat because the heats coming out, right, so you feel that wave of heat. And then that's why a lot of people shiver after a feel cold afterwards, because you weren't ever 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 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 you, you literally want to rip clothes off. Like you're just like, oh my god, I gotta get this off. Sometimes it's accompanied by a bit of a feeling of a panic. And, you know, I mean, your brains 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 where you are flush or hot blue. 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 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 disrupted sleep or disordered sleep, and you're really hot. So my partner tells me all the time, he was said to be like on a roll over and you know, cuddle me in the middle of night, you'd be like, well, Whoa, it's like pizza.

Pizza, right? I mean, Dr. Gunther, it's unbelievable. Like I will wake up just so like the whole sheets, the the pillowcase there. And then I'm too lazy to do anything about 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.

It's just a good time. It's party. It's Friday. Yeah. And please call me Jen. So for me that was actually the driving reason for me to start estrogen was your 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 if I'm working with with extra 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 as shield a hat, right and you get a hot flash and you'd literally I would come out of the bar 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.

It's like we're talking about to me sister about how women reached 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 of your career imagining you doing surgery, and that it's certain extremes you, 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 the 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 that aren't functional? Right? Aren't we all here to reproduce, because most animals die is basically once they're done reproducing. And humans, killer whales, and a couple of other whales live beyond their reproductive capacity. We just stopped. 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, 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 stopped functioning, and then they die. We keep on living. And the big thing that the patriarchy has done is it 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 a varying failure. And actually, apart from childhood mortality, which was astronomically high. If you were in the 1516 1700s. And you got to be the age of 15, or 16, you had a good chance of, 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 the 40s. So they're living into their 60s and early 70s and mid 70s. very healthily. So. So this idea that 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 10s of 1000s of years ago, needing shelter needing enough calories, but 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 gathering so 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 the the grandmothers were able to do

Well, yeah, their daughters are were taking care of the babies that was crucial to the survival of the child. 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 that social standing? How is that contributing? Right? Because, gosh, if if your partner happens to be the best hunter than 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 that 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.

Sneaky little babies.

So it's fascinating to think about it. Obviously, these are theories. And I would like to point out, that doesn't mean that your only worth is being your grandparent, but what it tells us is that 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, and families that don't have grandmothers often end up pairing up together. So where they end up, you know, helping each other out again, it sort of takes a village, I guess, is, is really is really the motto, but now we have our big brains that 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 wise person wise, older, because, you know, I don't think of the grandmother as literal like I think Graham mothering 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 is a verb, just like the Grim mothering idea, being the older woman, right, is crucial to is the heart of humanity. Exactly. Yeah, maybe there really is a Mother Earth, or western model of sort of shutting 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 you when you started experiencing your hot flashes, 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 so it's really important to sort of say there's, 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 in the 1970s, basically, Big Pharma was the drive behind the sort of feminine forever hypothesis that the worst thing that can happen to you as as a woman was to get unattractive to the eyes of a man. And that was basically it, right? That's a worst thing, the worst thing that can ever ever happen. Do you believe they believe that in the 70s crazy idea, there was a book called feminine forever, which I have a copy of it, I bought it. So I found that you can find anything on Etsy and advanced all these theories and written by this guy called Dr. Wilson and he was of course funded by pharma, but he 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 better hearts. And so there's we went from treating menopause as a

Z's to estrogen kind of being preventative therapy that everybody should be on. But obviously, there was 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, all 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 more likely have access to health insurance would be higher socioeconomic status. All of these things are associated with a lower level of dementia, 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 controlled trial where, where women started on estrogen, there was a placebo arm, there was also taking calcium arm and a placebo arm. So they were looking at diet, they looked at all different kinds of things. We'll talk about the hormone arm, and built into the study, as every study is, is a we're gonna stop if this bad thing happens, right? So we knew that 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. This study was stopped when they did an interim analysis that showed that we'd hit that level of risk with breast cancer, the risks 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 try to tease it apart and figure out what happened, there was a press, a press conference. And they because they wanted 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 their reproductive tract, because that gets pressed. And so then what happened over you know, the next year or two, as people started to scramble and take apart this study, they found that the majority people who were in this direction older than most people 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 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 in this car, 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 it's a pretty low risk, we're talking, you know, like one in 5000 kind of thing, you know, per year, it depends a little bit if you have to take a hormone, progesterone to balance out the effects 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 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,

As 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, I mean, I would recommend that somebody sees someone who's certified by the North American menopause society, if they're hearing don't take that because it 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 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, 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 only have one, we're talking about people that are that otherwise aren't falling into these other categories. So 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, I 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 and a MS 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 n a m s, afterwards, North American menopause society, it will bring things that have an AMS 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, you know, might say, Well, for me, I don't want to do that. And that's okay. That's part of informed consent. Informed.

Women, I think, are, are hesitant to even talk to Doctor 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, or crazy, or 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's say to her doctor

to actually get the help she needs, right and avoid being dismissed. So the first thing that I would say, I mean, I obviously 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 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 or even thinking about, you're just you're just so you're so upset, it's and I've been there I've 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 planned 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 too so, 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, 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 hormones, and then you're not feeling good on the hormones, and somebody keeps 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 check for thyroid disease, 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, I don't really care about that I care about the hot flashes, but your doctor is like, wait a minute, that's actually a sign of cancer, what you're telling me is we need to rule that out. So just kind of be open to that's why you should give the whole list because what you might brush off is not being important. Your doctor might be like, oh, I want a little bit more about that. Get informed before you go in.

Make a list of your symptoms of your bother factor, what would you like to go away and try to focus on them the biggest two? And then 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 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 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 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 so I would say that, you know, if if your doctor says, oh, gosh, okay, well, I mean, and there's someone probably shouldn't be managing your menopause if they're completely unaware of the guidelines. But you know, that would be the thing, knowing what the guidelines are from the North American menopause society or the American College of OB GYN or if you're in Canada, the Society of Obstetricians and Gynaecologists 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 is like, 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 medic wonder Hill.

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 on Thursday's episode because we've gotten 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. That's on the list. Come back for menopause, sex, and rock'n'roll on Thursday everyone.

We will catch you back here for our radical acts of feminism, which are just understood

doing our own goddamn bugs. Okay see you back here

I give you Tish Melton and brandy Carlisle

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