Menopause: What We Deserve to Know with Dr. Jen Gunter
April 26, 2022
Glennon Doyle:
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.
Amanda Doyle:
Thank you, Glennon.
Glennon Doyle:
You’re welcome.
Amanda Doyle:
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, 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.
Amanda Doyle:
I just feel like it 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 thrives in silence, and low information, and loneliness 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 too, 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.
Glennon Doyle:
Woot woot!
Amanda Doyle:
Woot woot! About 18% of men experience erectile dysfunction. 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, ensuring 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. 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. 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.
Amanda Doyle:
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 symptoms 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 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.
Glennon Doyle:
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 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 Preemie 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 docu-series, Jensplaining. She blogs @thevajenda.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.
Dr. Jen Gunter:
Oh, thank you so much for having me. Thank you.
Glennon Doyle:
This is sister’s moment. 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 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 in menopause, who are we talking about here?
Dr. Jen Gunter:
For the majority of the research, we’re talking about people with ovaries and people who have 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.
Glennon Doyle:
So is there anywhere for people who want more of us involved in this conversation to find research about their own bodies, or is it just the research has not been done anywhere?
Dr. Jen Gunter:
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 and 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 don’t have a lot of robust data that I think also just reflects in general with menopause. We’ve only had a real sort of increase than good research in the last 20 years.
Amanda Doyle:
I think it would be great to start with just kind of menopause one-on-one. 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 for most women it’s seven years, is that right?
Dr. Jen Gunter:
Yeah. It can vary anywhere from 4-10. And this is part of the problem is the terminology’s 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 like you don’t know the date, you start puberty or the date you end it. Post-menopause is everything that happens sort of after that, and pre-menopause, or the menopause transition is a period of time before.
Dr. Jen Gunter:
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 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.
Amanda Doyle:
That’s so important because we think menopause periods, but there’s so much more to it and you have talked about it as puberty in reverse. Can you just walk us through the basics of eggs and 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 stopped getting our periods when we’re older. Just the super basics of the follicles, the eggs, why it’s happening this way.
Dr. Jen Gunter:
You bet. Absolutely. Because it’s true. 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 think kids learn more about frog biology than they do about their own biology, not that I want to sag on comparative animal physiology or anything, but it would be practical to learn about your body to say.
Glennon Doyle:
It would be, wouldn’t it?
Dr. Jen Gunter:
So basically we’re born with all the eggs, which medically we can’t call follicles that you’re ever going to have. So that one cool fact is when you’re a fetus, all of your eggs were inside your mother, so it’s like this nesting doll type of thing. So you’re born with this compliment 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 at up every month you ovulate, you don’t just get rid of one follicle. There are actually many that get recruited.
Dr. Jen Gunter:
I always say, it’s a group effort to get the best one. So everybody’s on team follicle and we already get the best one each month, it’s a team effort. And the team gets kind of run out of play as you only have so many to pull from the bench. So that’s menopause and there’s genetics that might tell us some people might have a thinner bench and so in their early forties, they’re getting low and other people into their fifties. So there’s this big variation. Also, not that I know anything about sports, but I’d like to use sports analogy. So I might have them all totally wrong.
Glennon Doyle:
Abby would love this in her language.
Glennon Doyle:
So can I just ask a quick question because I didn’t know this?
Dr. Jen Gunter:
Yeah.
Glennon Doyle:
So when menopause starts for you is based on how many eggs you started with?
Dr. Jen Gunter:
One of the variables, and then how fast that they’re lost and that’s related to so many other health issues. So for example, if you smoke, you actually end up losing more follicles and having 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 this… 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. Come on, get to it.”
Dr. Jen Gunter:
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 from many people, the menopause transition is actually the worst time for symptoms because people always think it’s this 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, like puberty.
Amanda Doyle:
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 the aspects of your daily life?
Dr. Jen Gunter:
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, so you’re getting a disordered response. It’s 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 because your brain and your ovaries, it’s really this feedback act loop. So you’re having the wrong signaling, go on, you’re getting the wrong signaling back, and so what was a really a tightly constructed orchestra sort of movement, is now a little bit more chaotic.
Dr. Jen Gunter:
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 often it’s this chaos, this up and this down. Estrogen’s 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 happening, but actually, there’s no 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.
Amanda Doyle:
This whole period where you’re having the chaos, 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?
Dr. Jen Gunter:
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. Then 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 even 10 years, 12 years sometimes before their last menstrual period. And the most common symptom is a mild irregularity and menstrual period. So it’s normal month to month to have 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.
Dr. Jen Gunter:
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 to come up with the best egg for pregnancy, 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 it’s all evolved for that. So it’s all 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 get up that ramp or sometimes they might go through that ramp faster.
Dr. Jen Gunter:
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 you might be producing a little less progesterone in 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 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 there can be a variety of others.
Amanda Doyle:
I really want to talk about symptoms in depth in a second, because I think it’s really important for people to hear those out loud, 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 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. Gunter, “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 pre-menopausal. And then she has done a variety of tests on me twice and said, “Good news, you’re not.”
Glennon Doyle:
You’re just still an ass hole.
Amanda Doyle:
You’re just an ass hole.
Glennon Doyle:
I’m convinced of COVID every week. And they’re like, “Nope, you’re just still lazy.”
Dr. Jen Gunter:
Well, I would say that those tests are not reliable. And 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 over the age of 40 to see where you are or to check, that’s not recommended.
Amanda Doyle:
So the blood tests are not-
Dr. Jen Gunter:
No.
Amanda Doyle:
Oh my gosh! So I really might be. Maybe I’m not an ass hole.
Dr. Jen Gunter:
So obviously it’s a possibility, but the average age of menopause is 51. 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. So it sort of between 40 and 45, it’s a little bit of a sweet spot, but to spitball and see, are you close, you’re 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. I’m all for better living through chemistry. So you’re unlikely to have the menopausal menstrual fluctuations which happen
Amanda Doyle:
Meaning like super heavy some, and then closer together and all that stuff?
Dr. Jen Gunter:
Right, or skipped periods. Like I thought I was done, I was on a plane, I was flying to Europe, I was 50, I hadn’t had a period in seven months, the plane had just taken off, the seatbelt light came on and puff! Super soaker. Awesome, so you won’t get that. So that’s amazing. But you’re still ovulating with a Mirena IUD. So you will still get hot flashes, you’ll still get night sweats. You’ll still get those other symptoms, which about 70% of people experience. And so it’s possible 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 the really important thing, not only do we miss a lot of menopause, but we also blame everything on menopause and then miss other conditions.
Amanda Doyle:
Yes! Talk about that. That is huge. Can you talk more about that.
Dr. Jen Gunter:
Well, 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 complainy 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.
Dr. Jen Gunter:
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 flash, they just get them the whole time. And I appear to be a super flasher, so yay, go team! So other symptoms that people experience joint pain is actually quite common, and we don’t really understand why. I mentioned depression can be part of it. People 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.”
Amanda Doyle:
Can you talk about hot flashes? Just say what they are because I feel like that’s the one buzzword that people know about, but until I read your book, I didn’t really understand what they were, how they showed up in your body.
Glennon Doyle:
And also, are they hot flashes or flushes?
Dr. Jen Gunter:
Well, I personally like the term hot flushes because to me, a flash is instantaneous, ooh, 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 17 hundreds, 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.”
Glennon Doyle:
So it’s like a flower. It’s like-
Dr. Jen Gunter:
Yeah, you’re blooming. It’s an incredible experience. I feel like it’s the gynecological version of… Remember that old horror movie, “That call is coming from inside the house.”
Dr. Jen Gunter:
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. 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 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 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.
Dr. Jen Gunter:
And so without estrogen, your brain starts to tell you’re hot when you’re not. So every feeling you have is there because your brain tells you it’s there. So your brain is telling you you’re hot and you’re not really, it’s 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. So you feel that wave of heat, and then that’s why a lot of people shiver after or 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.
Glennon Doyle:
So you’re just sitting, hanging out with your people or whatever, and what does it feel like to begin to bloom?
Dr. Jen Gunter:
Oh wow! You’re thinking, “Wait, what? Why am I hot?” And then all of a sudden for me, it starts 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 coming out and it’s so awful. You can’t get away from it, you literally want to rip clothes off. You’re just like, “Oh my God, I got to get this off.”
Dr. Jen Gunter:
Sometimes it’s accompanied by a bit of a feeling of a panic. 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 in the past were labeled as being having panic attacks or hysteria. And part of the problem is a panic attack can feel a little bit like that. You can get your heart racing when you’re having a hot flash where you go flush or hot bloom. And you can have obviously those same symptoms when you have a panic attack as well.
Amanda Doyle:
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 when they’re soaking their sheets and stuff?
Dr. Jen Gunter:
Yeah. And so what happens is it often wakes you up, but not all the way. 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 would be like, roll over and cuddle me in the middle of the night. You’d be like, “Whoa, it’s like pizza.”
Glennon Doyle:
Dr. Gunter, it’s unbelievable. I will wake up, just soak it, like the whole sheets, the pillowcase, and then I’m too lazy to do anything about it. I have friends that 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.
Dr. Jen Gunter:
Yeah.
Glennon Doyle:
It’s just a good time
Dr. Jen Gunter:
It’s party. And please call me Jen. So for me, that was actually the driving reason for me to start estrogen, or 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, with x-ray equipment. So I’ve got this unreadable surgical gown, I’m wearing an apron made of lead, 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.
Glennon Doyle:
It’s like we’re talking, to me sister, about how women reach the pinnacle of their careers or their lives, and then this shit starts happening.
Amanda Doyle:
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, I’m 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 at highlighting this a little bit, but it’s just deal with it, that’s a personal problem.
Dr. Jen Gunter:
Well, I think that’s a big problem with corporate America in general. What’s really important is to say, “Well, hey, we’re at the peak of our capabilities and this is happening.” And I always like to say there’s almost a reason for that. And I’m not talking about the awful workplace. But people need to know about what’s called the grandmother hypothesis or the wise woman hypothesis. It’s not an accident that you’re super capable 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? 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.
Glennon Doyle:
Can we just stop there.
Dr. Jen Gunter:
Yeah.
Glennon Doyle:
Women and killer whales. That was my favorite part of anything I’ve read or listened to with you, women and killer whales.
Glennon Doyle:
Yeah. Us and the Orcas.
Dr. Jen Gunter:
And I think some other tooth whales too, but Orcas are most well studied. They also have very intricate social structures. And if you compare us to chimps, there are most closely related animal ancestor, 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 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 15, 16, 17 hundreds, and you got to be the age of 15 or 16, you’re at a good chance of living to be in your sixties.
Dr. Jen Gunter:
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 forties, they’re living into their sixties and early seventies and mid seventies very healthly. 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, 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? And so it really gets back to, it takes a village.
Dr. Jen Gunter:
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 we can basically be these log books of our society 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.
Glennon Doyle:
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. 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 grandmothers were able to do, while their daughters were taking care of the babies that was crucial to the survival of the child.
Dr. Jen Gunter:
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. 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? 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. So you start thinking about it on those terms. And Dr. Kristen Hawks, who is one of the anthropologists who came up with the grandmother hypothesis, her and her team, 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.
Amanda Doyle:
Wow!
Glennon Doyle:
Wow!
Glennon Doyle:
Sneaky little babies.
Dr. Jen Gunter:
So it’s fascinating to think about, 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 or they end up helping each other out, again, it takes a village, I guess 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 more like wise person, wise older because-
Glennon Doyle:
I like that too because I don’t think of the grandmother as literal. I think of grandmothering 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, is the heart of humanity.
Dr. Jen Gunter:
Exactly. Maybe there really is a mother. Our Western model 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.
Amanda Doyle:
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, the reflective 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 by 2010, it had plummeted to less than 7%?
Dr. Jen Gunter:
Yeah. So the women’s health initiative did cause a lot of problems. And I think though it’s really important to 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 initiatives. So if you look at the 1960s and the 1970s, basically Big Pharma was the drive behind this sort of feminine forever hypothesis that the worst thing that could happen to you as a woman was to get unattractive to the eyes of a man that was basically it. That’s the worst thing that could ever, ever happen.
Amanda Doyle:
I can’t believe they believed that in the seventies. That’s such a crazy idea.
Dr. Jen Gunter:
There’s a book called Feminine Forever, which I have a copy of it. I bought it, I found it out. You can find anything on Etsy, and advanced all these theories and was 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. So then Big Pharma turned menopause into a disease to be managed, 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 better hearts. And so we went from treating menopause as a disease to estrogen being preventative therapy that everybody on.
Dr. Jen Gunter:
But obviously there’s 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 observational data, where we’d said all these women decided to go on hormones 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, to be 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 for 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 taking calcium arm and a placebo arm, so they were looking at diet.
Dr. Jen Gunter:
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, we’re going to stop if this bad thing happens. 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, 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.
Dr. Jen Gunter:
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 conference because they wanted to make a splash. And I’m a firm believer in medicine not happening by press conferences, that’s what Andrew Wakefield did 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. Nobody wants to scare women about eye disease, nobody wants to scare women about foot disease, they want to scare women about the reproductive tract because that gets pressed. 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 people who were in this study were actually older than most people who get started on hormones.
Dr. Jen Gunter:
Because remember we said earlier that the worst symptoms were in the menopause transition. So is starting hormones when you’re 47, the same is starting when you’re 63, it may well not be at all. And so once the data was 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. 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 disease appears to be neutral, there is a benefit for bones, for prevention of osteoporosis and you can treat a lot of other symptoms.
Dr. Jen Gunter:
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.
Dr. Jen Gunter:
And so it’s a pretty a low risk, we’re talking like one in 5,000 kind of thing per year. It 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.
Amanda Doyle:
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.
Dr. Jen Gunter:
Yeah. 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 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 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 there are different conversations to have about hormones.
Dr. Jen Gunter:
So when we’re talking about what are the general population, we’re talking about people who if they have a cardiac risk, they only have one. We’re talking about people that that otherwise aren’t falling into these other categories. Because you have to remember 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.
Amanda Doyle:
Got it. What is it called that we need certified doctors from where?
Dr. Jen Gunter:
So the North American Menopause Society, N-A-M-S, is a great resource. And I tell people, instead of just Googling your symptoms, going to 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 something that we wouldn’t recommend holding back, offering estrogen for, but everybody perceives risk as being different. 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
Glennon Doyle:
Informed. 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 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 ahead 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.
Amanda Doyle:
You’re hypochondriac, you’re irrational, you’re crazy, all the things.
Glennon Doyle:
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, 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?
Dr. Jen Gunter:
So the first thing that I would say, I absolutely agree with everything that you said. That’s why I write my books so people can go into the office and say, 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 don’t say what’s really important to you what you’ve been thinking about, you’re so upset 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 advocate for what I want.
Dr. Jen Gunter:
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 just so, and make a list of the things that are 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 can walk into the office and say, “What are my top two needs?” And then you’re going to start working down the list. 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 just keeps upping the dose when they actually needed to look for something else.
Dr. Jen Gunter:
And then you want to ask for the screening test 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 talking about.”
Dr. Jen Gunter:
So we need to rule that out. So just be open to… That’s why you should have give the whole list because what you might brush off is not being important. Your doctor might be like, “Ooh, 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 the biggest two, and that doesn’t mean that you can’t address the others, but it’s hard to address multiple things at once and then get your screening test done and then make a decision based on that.
Glennon Doyle:
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.
Dr. Jen Gunter:
Well, so what I would say is, 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 decided what’s the right thing that we can tell people with the information we have. So I would say that if your doctor’s like, “Oh, oh, gosh!” Someone probably shouldn’t be managing your menopause if they’re completely unaware of the guidelines. But that would be the thing, knowing what the guidelines are from the North American Menopause Society or the American college of OBGYN, or if you’re in Canada, the Society of Obstetricians and Gynecologists of Canada.
Glennon Doyle:
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. It’s 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 Medi… What the hell!
Dr. Jen Gunter:
North American Menopause Society.
Glennon Doyle:
Yes. So know what it is because you need to sound better than I just did. That’s a great plan. I like that. Okay. Excellent.
Amanda Doyle:
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 be ashamed of, including… Jen, something we’re going to talk about 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.
Glennon Doyle:
Great. Sex on the list.
Amanda Doyle:
Come back for menopause, sex and rock and roll on Thursday everyone.
Glennon Doyle:
We will catch you back here for our radical acts of feminism, which are just understanding our own bodies. Okay. See you back here.
Glennon Doyle:
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