Better Sex & Lives in Menopause with Dr. Jen Gunter
April 28, 2022
Glennon Doyle:
Welcome back to We Can Do Hard Things. We are going to jump right in today because we are lucky enough to have Dr. Jen Gunter back to answer all of our burning, for many of us menopausal women, literal burning questions about menopause, because we are committing the feminist act of demanding to understand our own bodies. And we are also going to talk about all of, even the embarrassing things about menopause and our bodies today, because we refuse to allow the entire world to talk about women’s bodies and sit it out. Everything on earth is sold with a woman’s body. Everybody from companies, to movies, to everyone on earth, religions, to congresses, gets to talk incessantly about women’s bodies. And then for some reason, we are ashamed to take the conversation back. So, we’re not just going to let the whole world talk about the way our bodies look.
Glennon Doyle:
Today, we’re going to talk about the way our bodies function and feel. And we’re going to do that with the Dr. Jen Gunter, who is an OBGYN and pain medicine physician, and the author of The Menopause Manifesto, can’t recommend enough, also The Vagina Bible, and The Preemie Primer.
Glennon Doyle:
And Dr. Jen, I want you to understand that I have The Menopause Manifesto and The Vagina Bible on my coffee table, so that everyone who sits down can feel more comfortable with the words menopause and vagina right up in their face. Okay. She is the host of the podcast Body Stuff, TED Audio Collective, and of the streaming docuseries Jensplaining. She blogs at TheVagenda.com, and her writing can also be found in the New York Times, Glamour, Dame, and other publications. Her mission is to build a medical internet. She has been called Twitter’s gynecologist, the Internet’s OBGYN and a fierce advocate for women’s health. Dr. Jen Gunter, thank you for returning to We Can Do Hard Things.
Dr. Jen Gunter:
Thank you.
Amanda Doyle:
We’re going to talk today about the biggest, most important, most common questions that folks have about menopause, and our first one is from Lynn.
Lynn:
This is Lynn. I’m facing menopause, and if I hear one more god damn thing about a hot flash or about all this sort of surrounding things for midlife, no one is talking about orgasm. I can’t have an orgasm anymore, and I’m shouting it from the rooftops because I’m so tired of this being dismissed. I listen to so many midlife podcasts. “Oh, just rub a little essential oil.” I don’t need essential oil. I need an orgasm. Do you understand? And I know you feel me, so just please help me find a really good person that can come on your show, talk about orgasm, talk about the brain event. I just need a bunch of professionals to figure out why I can’t have an orgasm at 50. It’s not okay. Okay? I love you. I love sister. I love Abby. I love the whole thing. I guess that’s it. I think that’s enough. I’m not angry. I’m just ready to get some answers. Love you guys. Bye.
Glennon Doyle:
I love her. I love her. I don’t need essential oils. I need a god damn orgasm. Can we call this episode that?
Dr. Jen Gunter:
Obviously, I can only speak in generalizations because there are so many questions to ask an individual person, and especially when you’re talking about sex. You actually have to know what their sex life is beforehand, leading up to it. So, if we’re sort of thinking about somebody who said, “I’m really having difficulty achieving orgasm,” or, “I can’t achieve orgasm now,” there are kind of a list of things to run through.
Dr. Jen Gunter:
So, the first is probably to start treatment with vaginal estrogen, to make sure that you have enough blood flow to the tissues. So, when we go through menopause, there’s a decrease of flow of estrogen to our vaginal tissues, and that affects how well things function. And if you think about Viagra and those drugs phosphodiesterase inhibitors for men, what they do is they increase blood flow to the penis. Well, vaginal estrogen increases blood flow to the clitoris, to the vaginal tissues. It causes the tissues to just basically have more moisture and be back to how they should be. So, the number one thing for someone who’s having a sexual difficulty would, first of all, be to make sure that they’re using vaginal estrogen and they’re using enough so that the tissues are kind of at the baseline.
Dr. Jen Gunter:
Now, what can also happen sometimes with age, and sometimes even with menopause, as well, as the pelvic floor muscles get a little bit weaker, and those are the muscles that wrap around the vagina, and when you cough or sneeze, those are the muscles that hold your urine in, or if they’re a little bit weak, they let the urine out.
Amanda Doyle:
They do.
Dr. Jen Gunter:
Yeah.
Amanda Doyle:
Yeah, they sure do, they sure do.
Dr. Jen Gunter:
And so…
Glennon Doyle:
Even right now.
Dr. Jen Gunter:
Yeah, exactly. So, those muscles can actually weaken a little bit, and those are the muscles that contract when you have an orgasm. So, if those muscles have become weaker and you’re kind of not getting that same feedback to the system, a visit with a pelvic floor physical therapist might also help you to make sure that those muscles are kind of functioning how they should be. And some women actually find that working more on the kegels can actually be very helpful from a sexual satisfaction standpoint.
Dr. Jen Gunter:
The other thing is to think about sometimes with age, you need a little bit more input. So, I didn’t need glasses three years ago. Now I’m with like, I don’t know, a gajillion progressive things, and this is all age related change, right? Like, five years ago I could read pretty much anything. And so, I need glasses to help me. Some people might need to use a vibrator or a stronger vibrator than they needed to use before. They might need to just have a little bit more input into the system.
Dr. Jen Gunter:
And, then, another thing to think about is there are medications that can actually affect orgasm. and so, sometimes people associate what’s happening to them with menopause, but something else might have happened. If you were started on antidepressants, that can also have an impact. and so, I would want someone to kind of get those baseline things addressed as well, and also have a conversation with them about what their sex life was like beforehand.
Dr. Jen Gunter:
The other thing that I also recommend is possibly the best book on sort of libido and sex is Dr. Lori Brotto’s book, Better Sex Through Mindfulness, and it’s about cultivating desire and libido. And you also want to ask this person, “Is your orgasm problem in a background of having desire issues and libido issues, or is all that working fine, and the only thing that’s not is having an orgasm?”
Dr. Jen Gunter:
So, those would kind of be the basic level things to kind of get started with. And, then, if all of those things are in place and you’re still having trouble achieving an orgasm, then I would recommend a sex therapist and also recommend seeing a doctor who specializes in sexual medicine. This might be a situation where a low dose of testosterone might be beneficial, not something that’s applied topically to the area, but these are things that really require more of an in depth conversation, but that would be what I would get started with.
Glennon Doyle:
And bravery. They require bravery, because you got to walk into your doctor and say, here are my issues.
Dr. Jen Gunter:
Right.
Glennon Doyle:
I want to have an orgasm.
Dr. Jen Gunter:
Yeah.
Glennon Doyle:
Or, and or, I want to up my libido. Right? Cause it’s two separate things.
Dr. Jen Gunter:
Yeah. Yeah, and absolutely. If your doctor, isn’t someone that you can talk with sex about, then they’re not the right doctor to help you with this problem.
Amanda Doyle:
We were talking about taking hormones in Tuesday’s episode. Is vaginal estrogen a topical cream that you rub on, as opposed to the hormone therapy that you ingest?
Dr. Jen Gunter:
Yeah. So, when we say menopausal hormone therapy, we mean hormones that are getting into the bloodstream. And we didn’t talk about this in the last episode, but the safest way is transdermal, meaning across the skin. And that would be with a patch, with a gel, a lotion, or they even make a vaginal ring where you can deliver estrogen into the bloodstream. So, those are the safest ways. You can also take a pill, but there is a slightly higher risk of complications with that, so we recommend starting with transdermal. The vaginal estrogen, and it gets a bit complicated because one of the vaginal estrogens can get into the bloodstream, but there’s also vaginal estrogens that just stay vaginally. And those are, that’s also, there’s a ring for that as well. And there’s creams, there’s tablets, there’s suppositories, and there’s also a product that’s called DHEA, which is converted in your body into estrogen. It’s kind of like a prodrug for estrogen.
Dr. Jen Gunter:
So, there’s lots of different ways to approach it. Some people love cream. Some people love the idea of a ring that you just change every three months. It depends. But, for somebody who’s having an orgasm problem, I would recommend the cream because then you can also apply a little bit to the clitoral area as well. It’s not like a rubbing in, you do just kind of apply it and it’ll get absorbed. For people who are using transdermal estrogen, about 50% of the time they’ll get enough estrogen for their vagina, depending on the dose they use, but a lot have to augment with vaginal estrogen. So, we don’t really recommend taking it throughout your whole body just to treat your vagina, because you have to use higher doses, and you don’t need it everywhere if you only need it in your vagina. So, try to think of them as separate,
Glennon Doyle:
Right, so that topical, that helps with orgasm but not increasing libido?
Dr. Jen Gunter:
Right. It wouldn’t impact libido. Libido is very complex. And the way that we talk about libido in our society is also very sort of heteronormative, sort of cisgender male fantasy about the woman being ready at the drop of a hat. All we just need is the male gaze, and we’re ready to go, right? So…
Glennon Doyle:
It’s been my experience.
Dr. Jen Gunter:
Yeah, right? Like just twist a nipple and stick it in. I’m good.
Glennon Doyle:
Twist a nipple and stick it in. I’d also like to put that up for consideration for the title.
Dr. Jen Gunter:
A lot of conversations that I have with people are just kind of explaining that libido changes throughout our life cycle. And sometimes people are really having a change in sex drive related to menopause, but sometimes what they’re having is actually very normal and they’ve sort of assumed that it wasn’t. So, it’s, some people have a receptive libido. It doesn’t get going until the right situation is there. For some people, desire can kick in after a sexual arousal. That’s not abnormal. It’s more complicated than just being kind of like hot and horny. That’s only one very small sliver of libido.
Glennon Doyle:
And shout out to all the lesbians.
Dr. Jen Gunter:
Yes!
Glennon Doyle:
Very…
Dr. Jen Gunter:
I mean…
Glennon Doyle:
…Tricky. Menopausal, two women, libido, Netflix. It’s just all, you know, it’s all…
Amanda Doyle:
Mo’ women, mo’ problems.
Glennon Doyle:
Actually not true. This is the only area of your life where you have more problems. Rest of it is better.
Amanda Doyle:
We love you. Lynn, for orgasms is what we’re going to go for. And, there’s also a whole host of folks whose problem is even in some ways like a precursor to Lynn’s problem, which is, isn’t it very common symptom to have vaginal dryness, vaginal burnings, sandpaper-like feelings? So, there’s actually pain in penetration. So, can you talk about some of that, because that is a very common issue that people are dealing with.
Dr. Jen Gunter:
Yeah. This is very under-discussed. This idea that vaginal symptoms with menopause are very common. Over time, about 80% of people will get them. That’s pretty significant. And, one of the other medical consequences, besides sex is very medical, in my mind you deserve to have good sex, just like you deserve to have everything working with your body, but, low estrogen in the vagina can also increase your risk of getting urinary tract infections. Vaginal estrogen can actually be preventative for that.
Dr. Jen Gunter:
So, if you’re having vaginal dryness, if you’re having lubrication issues, if you’re having some discomfort and you’re in your forties, then there is a very good chance it could be related to menopause transition, menopause spectrum. There are other things that can masquerade as that. So, again, it’s important to get an exam and get checked out. But, the great thing about vaginal estrogen is it’s highly effective and it works really quite quickly. You’ll know in about six to eight weeks.
Dr. Jen Gunter:
Now, if some people don’t want to use them, there are fantastic vaginal moisturizers. The products that I like contain hyaluronic acid, but there’s silicon based products and water based products, and so some people like the feel of the moisturizers. Touch and feel is very personal, and so, what feels good to one person, feels awful to another, and vice versa. So, the vaginal estrogen is highly effective. Over time, there will be a little bit of shrinkage of the vagina with lots of estrogen. So, the length of the vagina might shorten a little bit, the opening might tighten up a little bit, and that’s because we also lose collagen with age and estrogen also helps with collagen.
Dr. Jen Gunter:
So, you kind of have the double whammy of aging and low estrogen. And so, vaginal estrogen can really help protect against a lot of that. It’s very safe. It doesn’t get in your bloodstream. Almost every single person can use it if they need to. It’s also a great option for trans folks because a lot of times when people are on testosterone, they can get vaginal dryness from the testosterone, and the vaginal estrogen can counteract. So, for people who are suffering with vaginal dryness, or they want to have vaginal sex.
Glennon Doyle:
So Lynn might walk into the doctor and say, cause Lynn doesn’t sound to me like she’s having a problem with libido. She just wants the freaking orgasm. So, she could walk into her doctor and say, “I’m having trouble with orgasm. And I want to try vaginal estrogen.”
Dr. Jen Gunter:
Sure, but she should have an exam first to make sure that there isn’t something else going on. For example, there’s skin conditions that can affect the clitoris. and so, you need to have an exam to make sure that’s not going on. So, it does require an exam to make sure there’s nothing else, but I start vaginal estrogen over the phone all the time. Like, “Well, let’s get you started and see what it’s like when you come in.” Unless somebody’s got a bad itch, because yeast infections can sometimes present with dryness. So, if someone tells me they’ve got a really bad itch, then I might be like, “Oh, well let’s just check you out first.” But, otherwise you can start it. We don’t have to worry if you have high blood pressure. You don’t have to worry if you have high cholesterol. None of these things matter. You can be on vaginal estrogen.
Amanda Doyle:
So it’s a totally different bucket than the other thing we talked about Tuesday, which is that-
Dr. Jen Gunter:
Yes, absolutely.
Amanda Doyle:
Okay. But, there are certain things that you advise, definitely not near your vagina. So, no fragrance products.
Dr. Jen Gunter:
I think that you want to stay away from fragrance products. You know, there are many reasons for that. One, they’re often irritating. Two, they’re really bad for the environment. Everything that’s made with fragrance releases out a volatile chemical, right? And that air pollution is as much a problem from all of our personal care products that release, and everything that we have, like furniture manufacturing, everything that releases sort of volatiles is as bad as cars for air pollution.
Glennon Doyle:
Whoa, whoa.
Dr. Jen Gunter:
So nobody needs fragrance stuff. Like, just ditch it, man. You don’t need it. It’s not good for the environment. It’s not good for your skin. It’s not adding anything. I see some of these people buying menstrual pads that are impregnated with essential oils and stuff, and then they get rashes and someone told me, you don’t need that.
Amanda Doyle:
Okay, let’s hear from Deborah.
Deborah:
This is Deborah. I am calling because I am in the middle of this fresh hell called menopause. And I was thinking it might be a really beneficial thing for you all to talk about what happens to our bodies during menopause. It is so effing hard. I don’t mean to cry. It’s really hard. The physical changes, the emotional changes, and there is so much that we don’t know. There’s so much that nobody tells us and nobody helps to prepare us for, and it is really like having an alien move in and take over your body.
Deborah:
And I know I’m not alone in feeling the things that I’m feeling. And I bet I’m not alone in the physical things that I’m experiencing from night sweats to hot flashes, to making choices about hormone replacement therapy, to vaginal estrogen creams, and to all of these other things that no one tells you about. I just learned about Burning Mouth Syndrome. It’s a thing for women in menopause, and I have it, and it sucks. Anyway, since you all do such an amazing job talking about the female experience, what it is like to be a woman living in a patriarchal world, which I think withhold so much information from us about these things and makes us feel like we’re crazy, I just thought maybe you could all talk about this.
Glennon Doyle:
Deborah, you are not crazy. You’re just a god damn menopausal cheetah.
Amanda Doyle:
That goes back to what we were saying about spending your whole life defending yourself against this kind of caricature of what a woman is, and then feeling like you have to go somewhere to be vulnerable enough to say, “This is actually my experience.” Do you see that a lot? This is deeply shaking her on an emotional level too.
Dr. Jen Gunter:
That’s the whole reason why I wrote The Menopause Manifesto, because I hear this over and over again. I was doing interviews for my book, The Vagina Bible, and I’d sort of casually mention I was on hormones and then that’s all the reporter wanted to talk about. They all wanted to talk about menopause when I was on book tour. And it was really interesting creating a space where it was safe enough to talk about vaginas, seemed to create a space where you could talk about the last taboo, menopause. And once one person asked a menopause question, the whole thing became about menopause. and so, I really realized, obviously there’s this simmering rage about, “Why don’t I know what’s happening to my body?” This simmering rage about, “Why am I being aged out of society when I’m at my most productive?”
Dr. Jen Gunter:
I really believe a lot of the rage is the fact that, “Whoa, I’m at my peak. I’m at my mental peak, and now all of a sudden you’re telling me that I’m not worthy, that I don’t belong?” So, I think there’s a lot of that as well. And you’re just fed up with being dismissed. We all have breaking points. You’re dismissed in puberty. You’re dismissed with your menstrual cramps. I think it’s this nexus event. And I think it’s sort of, “I’m mad as hell and I’m not going to take it anymore ,and I’m hot as hell too!” So, that’s not okay.
Dr. Jen Gunter:
So, I think that there are a lot of changes that people need to know about. Imagine if you were told you had to move to a new city, you just, you got to move, sorry. And you’re told nothing about that city. You’re just dumped there and you don’t have speak the language and you got to figure everything out. Versus, if you were told a year, two years, five years in advance, you know, five years, you’re going to move to that city. Now, five years to learn the language. You have five years to learn the lay of the land. You have five years to maybe start connecting with people on social media. So when you get there, you’ve got friends. You already know the good restaurants. You know where there’s a theater group. You know the running path you’re going to use. Totally different experience, right? So, and it doesn’t mean there won’t be challenges in this new city, but you’re more prepared for them.
Dr. Jen Gunter:
And that’s kind of what I liken that experience with menopause is you’re dumped into this rebooted body and you don’t have any information about it. And for me, because I got into medical school when I was really young, I was 20 when I started, so I knew a ton about how my body worked for almost all of my reproductive life, and what a difference that has made for me. and so, that’s kind of my mission to try to help people not be so in the dark.
Amanda Doyle:
Oh yeah. Deborah mentioned burning mouth syndrome. I know on Tuesday we talked a lot about the most common symptoms, the hot flushes, decreased libido. What are some of the less common symptoms that we can kind of normalize for people? So people like Deborah are not feeling so alone. If they’re not one of the folks that has the most talked about symptoms.
Dr. Jen Gunter:
Well, I think some of the symptoms that are not as talked about would be heart palpitations, anxiety feelings, mild depression. Burning Mouth Syndrome’s pretty uncommon. I’ve had a couple of people who’ve reported it kind of worsened around menopause. And I just read a report that tinnitus, ringing in the ears, might be associated with menopause, but it’s under-studied. When we’re doing these large population studies, there’s only so many symptoms you can ask about, and that’s not really an excuse, it’s just kind of an explanation, and we definitely need more data. Because, the thing is, is the way your hormones affect you is a very individual way. We can sort of speak in generalities, but for everybody, for every five people who tells me their mood is worse right before their period, I’ll get one person who tells me their mood is better.
Dr. Jen Gunter:
So, I’m always open to, “Huh. That’s possible.” My patients who’ve had Burning Mouth Syndrome that sort of seems to be associated with a menopause transition, I’ve tried estrogen if they want to try it and see if it helps. I mean, there are other treatments as well, and it’s not surprising to me that we see a lot of these other things starting sort of in the forties because we often see a lot of autoimmune conditions kind of starting around then too. and so, I always tell people, we want to keep an open mind that this also could be the first sign of something else. And, so again, just kind of keeping an eye on things, but for many of these things, it’s very reasonable to say, “Well, does some estrogen make it better? Is it safe for me to try it?” For most people, it is. And, you see. You give yourself a six months trial. Has that helped or not?
Dr. Jen Gunter:
What I hear most from her is that dismissal and that’s really sad because there isn’t a reason that should happen, that you should be able to come in, you should be able to talk about your symptoms. But, we also have to talk about the fact that in a lot of healthcare settings, people get 15 minutes with their doctor and that’s just not acceptable.
Glennon Doyle:
Yeah. Got to have a list. You’re only going to get the 10 minutes. Got to have a list.
Amanda Doyle:
Yeah, listen to the end of Tuesday’s episode, where Dr. Gunter talks your strategy for going to talk to your doctor and the list you should have.
Dr. Jen Gunter:
Another strategy I’d like to add in is the follow up visit. So, what happens is people go in and then they kind of get whatever started, and then they sort of head out into the ether. And there isn’t really any follow up or check in to see how you’re going to do. Or you might then start to get worried that you’re not going to be able to get to these other symptoms on your list. You make your first appointment and then say, “I’d like to make a follow up appointment in eight weeks time, so we can see how this initial treatment is going, or three months.” If you’re going to start a hormone, you generally want to give it about eight to 10 weeks. “So, then we can check in and then I can see if the other symptoms on my list are better or not. And then we can get to those.”
Glennon Doyle:
And, when you tell them you’re coming back, no matter what, maybe they’re more likely to.
Dr. Jen Gunter:
But, that’s one of the things that I do that I feel is possibly the most undervalued thing in medicine, is booking the follow up visit before you leave. Because I think that tells people that you are interested in what happens and that you have a plan. So, if my treatment A doesn’t work, I want to know about it. I set up my follow up visits and I explain to patients, “Well, I’m not going to expect to work before four weeks or before six weeks, so we need to set up our follow up at the appropriate time.” And, I think it helps people also feel that they’re being cared for.
Glennon Doyle:
Yeah.
Amanda Doyle:
Deborah also says, “I know I’m not alone in feeling the things I’m feeling, and I’m not alone in the physical things.” Are there any communities that are existing now where women who are going through this can connect to other women? Are you seeing communities that you think are valuable to let people like Deborah know they’re not alone in this?
Dr. Jen Gunter:
There’s a lot of support groups and groups that people have started. It’s always hard to recommend when, if you don’t know the person, because unfortunately with online stuff, there’s also a ton of misinformation, right? And sometimes these groups are even sort of offshoots of practices that offer scammy hormones, or scammy tests, or other types of things. So, a friend of mine, Amanda Thebe, is a trainer and she wrote a great book called Menopocalypse, and she has a pretty active Facebook community. And, she’s really good at sorting through the evidence and science and really, I think does a really great job in curating her community.
Dr. Jen Gunter:
Apart from that, I think you got to ask your friends, ask what kind of information might be out there, and also different people jive with different communities, right? So, what’s a welcoming place for one person, might not feel like a place for others. So, I think that unfortunately with a lot of online communities, you kind of have to suss them out and see what might work for you.
Glennon Doyle:
And eventually, hopefully every group where women are gathered will become that. I mean, right now I’m thinking, I was at a recovery meeting last night, and the woman next to you was talking about ringing in her ears. Nobody was like, maybe that’s menopause. Like just knowing this now, she’s 50. I would have said, “That could be menopause.” Like the more we know, the more we can just bring it into every group we’re in, because there shouldn’t even have to be a separate group.
Dr. Jen Gunter:
Right. Really there shouldn’t be, it should really just be everywhere.
Glennon Doyle:
Yeah.
Dr. Jen Gunter:
This should be really readily accessible information. And that’s why it’s fantastic you guys are dedicating two podcasts to this. And that people are really starting to spread the word that, “Hey, this is a normal event, but it’s also a normal event that can have problems. And we should know about all of those.”
Glennon Doyle:
Absolutely.
Amanda Doyle:
Let’s hear from Shelly.
Shelly:
I was listening to the episode from what you were talking about in terms of age ranges and when we sort of level up and go to level one, level two, level three, and it correlates a lot to a book that I just read about perimenopause, and the regulation of hormones, and the beginning of going through your second puberty, and how oftentimes a lot of women describe feeling more settled and feeling like themselves after they go through menopause. And, I have to wonder whether or not some of what you are talking about in terms of happiness and ages of women who are the happiest, and how that relates to what is actually happening physiologically in our body? Just a thought that I would share. My name is Shelly.
Glennon Doyle:
Okay. I was so excited about this question because all the hard stuff, yes. All the symptoms, all the physical stuff, but is there a correlation between what we describe in the culture as like running out of fucks to give? Because I just feel like spiritually and intellectually, I am entering the most powerful, free, amazing time of my life. Is running out of estrogen, correlated to running out of fucks?
Amanda Doyle:
Running out of follicles and running out of fucks. Another title for the episode.
Glennon Doyle:
Right? Running out of follicles or running out of fucks is what I’m asking you Dr. Jen Gunter.
Dr. Jen Gunter:
I would say running out of the estrogen that you need for reproduction might be correlated with that. Cause we still have estrogen made by our brains and our bones and our muscles, so we do have some, but yeah, I think that it’s probably a combination of, and I’m really glad that the listener brought this up because there are really wonderful things associated with menopause, as well. The menopause transition is kind of like the rapids. This is sort of a difficult time for a lot of people, not for everybody, but a lot of women describe a sort of a clarity when they’re through the menopause transition, that you sort of run the gauntlet and then you’re like, “Ahh,” and like the heavens open up, and whether it’s because you’ve just accumulated all this life experience, and so it’s nothing to do with hormones, whether it’s the fact that you’ve, all that chaos is gone, so you’re super happy, or is it due to the fact, and there’s some really fascinating research at the brain changes with menopause.
Dr. Jen Gunter:
So, when we go through the menopause transition, people often have this mild depression, or they have brain fog. Some people do, where it feels like things aren’t working quite right. And there’s actually a lot of changes that are happening in the brain. Some areas are shrinking and people are like, “Oh, well, does that, is that bad?” I mean, we don’t want your brain to shrink, but some areas are growing, and parts of your brain that are using high energy sort of shifts. And, you could say, “Well, we’re losing areas,” but because brain fog’s temporary and it goes away, it can’t be a loss. And one of the theories is that your brain is remodeling itself now without estrogen, because it doesn’t need all the connections that were used for reproduction. So, you remember how I mentioned-
Amanda Doyle:
You’re reallocating resources?
Dr. Jen Gunter:
Yes. Right? So, think about how I said, remember all these things, reproduction’s linked to temperature. It’s linked to all these things every month. Every cycle, your body’s like, “Pregnancy, yes. Pregnancy, no. Oh, okay, okay.” Because it’s just waiting to, like, “I got to retrofit, I got to get everything going.”
Dr. Jen Gunter:
Right? But, when you don’t have that anymore, when your body doesn’t have to have that kind of vigilance, when your brain doesn’t have to be doing that switchboard back and forth, well, you know what your brain does? It prunes pathways that aren’t needed anymore. I do sometimes wonder, instead of causing it a brain and fog, why don’t we call it a brain reboot? Because operating systems can be a bit glitchy when you get going, but once you get going, you’re like, “Oh, my new computer is working great now.” So, a lot of people describe a clarity afterwards. It hasn’t been well studied. But you know now that we have some of this really…yeah, interesting data, I hear it from lots of women.
Glennon Doyle:
Ugh. It’s, and it goes with all of my beliefs about the metaphors, there’s chaos first, there’s destruction first, and then there’s new construction. There’s just something to it. There’s something to this idea that those pathways don’t have to be used anymore because of reproduction. But also our brains are adjusting to not being prey all the time, to not being looked at by the patriarchy as an object. There’s a lot of upsetness about becoming invisible. And I’m always thinking, “Dear God, let me be invisible to the patriarchy.” Like if I got this much done while they were watching me, what can I do when they’re not watching me? Like invisibility is a super power. Imagine the trouble we could cause if we were invisible to the patriarchy. To me, it’s fascinating that perhaps there is this, well, pruning of things we had to care about that we don’t have to care about anymore. And then we get to decide what to care about for the rest of our lives.
Dr. Jen Gunter:
I think that many of us carry this weight of the patriarchy telling us that we have an expiration date and making us feel that it’s over, you’re done. You have no value. You’re not a breeder anymore. You’re not attractive to the male gaze. You don’t look like you’re 20. And, I think that many of us, I’ve fallen, I’ve fell victim to that. It’s hard not to. It’s everywhere. I dated loser dudes because of that. I did all kinds of bad decisions that I wish now I hadn’t made, but they’ve made me who I am. You just have to kind of take the good with the bad. But yeah, I think that you have this combination of this cumulative knowledge and maybe we have a better operating system, but I think that we’ve only been taught to fear menopause because it’s been something that patriarchal society has impressed upon us.
Glennon Doyle:
Yeah. Really, we should be excited about anything that patriarchy fears. That means we’re onto something.
Dr. Jen Gunter:
It’s also important, I don’t want people who have symptoms to feel, “Well, I’ve, how can this be normal? I have horrible symptoms.” Well, you know what? Lots of people have horrible symptoms in pregnancy, and lots of people have horrible symptoms in puberty, and we have modern medicine. We can manage a lot of that. We just need to keep talking about it and keep normalizing it and keep letting people know the options that are available.
Glennon Doyle:
Wonderful.
Amanda Doyle:
Speaking of normalizing, some people don’t have any symptoms, is that correct?
Dr. Jen Gunter:
Yeah, absolutely.
Amanda Doyle:
Is that a small chunk of people?
Dr. Jen Gunter:
So, about 25% of people don’t have any menstrual shenanigans, they kind of just like maybe skip one or two periods, then they’re done. And so, 25%, obviously that’s not most, but yeah. With hot flushes, 25% of people really aren’t bothered. My best friend had like two. She’s like, “What are you talking about?” About 25% of people have hot flashes for shorter periods of time. But about 50% of people are going to be bothered by them. I didn’t have any brain fog. I just had hot flashes. I’m a super deep sleeper. So I don’t think my, I probably, I woke my partner up because of my heat more than I woke myself up.
Amanda Doyle:
Good for you. That’s awesome.
Glennon Doyle:
See? Menopause affects everyone.
Amanda Doyle:
Yeah, it does. It does. And the transition, you said, once you’re through the transition, it’s temporary, once you’re through the transition and people have clarity. So we’re premenopausal, we’re perimenopausal, then our period stops. When are we through that transition? Are you talking about when our period stops?
Dr. Jen Gunter:
So, we don’t really know you’re sort of through the menopause transition until you’re a year past your last period.
Amanda Doyle:
Okay.
Dr. Jen Gunter:
So, it’s kind of like the great period wait. You’re just kind of like waiting to see what happens. Some people, absolutely. There are 25% of people, their hot flashes will last for a very long time. The average duration of hot flashes is like seven to eight years. So, this isn’t like a minor thing. This goes on for a long time for people who have them. For some people, they do persist for a long period of time. But, that sort of feeling off balance, I think is what people associate with the menopause transition. Vaginal dryness isn’t going to go away. If you’re having persistent hot flashes, those might stay.
Dr. Jen Gunter:
But that sort of, “I don’t feel myself,” that sort of my body is cantilevering all over the place. That’s typically much more associated with the menopause transition. Now, obviously everybody’s different, but that’s typical. And so, what happens is, a lot of people might start hormones in their menopause transition, and then they become terrified to stop them maybe five or six years later. And you don’t necessarily have to stop them, but some people do, some people want to say, “Well, maybe I’m through my chaos and I don’t really need it anymore.” Everybody’s different.
Dr. Jen Gunter:
and so, we think it’s safe to stay on, but we also think it’s reasonable for people to say, “I might want to go off of it.” And the one thing I would like to sort of impress upon people is if you feel really badly during the menopause transition, that doesn’t mean that’s how you’re going to feel for the rest of your life. That may just be these really bad rapids. Doesn’t mean there won’t be some symptoms when everything settles out, but to kind of keep that in mind.
Glennon Doyle:
When you say that people who go through menopause notice that they feel off, so to me, that implies that there’s been a long time when they’ve felt on, right? When there’s a steadiness of people and then they lose their steadiness during menopause. But, for people who struggle with mental health, like for me, I don’t know a long period where I’ve felt steady, where then I will suddenly feel unsteady. My life is often a balance of the unsteadiness back to steadiness constantly since I was 10.
Glennon Doyle:
And, for me, to be really honest, I’m doing this podcast, I’m listening to everything you say and it all makes sense to me, for someone who has a regular mental health life. But for me, I wouldn’t know what the hell to say to a doctor. I wouldn’t know what was my mental health issues and what was menopause, unless it was totally physical, right? Unless it was periods, vaginal dryness, but all the other things, depression, anxiety, libido, crankiness, all of those things to me, brain fog, those have always been part of my life. I haven’t been in menopause since I was 10. So, how do people with mental health sort out, what is our brains? What is menopause? What do we ask for, for health? How do we know what’s what?
Dr. Jen Gunter:
So, that can be a big challenge. And when I say feeling off, I mean sort of off for you. You sort of have to always compare yourself to your normal, right? So, where in your normal may be a wild fluctuations all the time, somebody else’s normal might be steady, someone else’s in between. So, it can be very challenging. If somebody’s having a change in your mental health status in your mid forties, how do you know it’s menopause? How do you know it’s not a change in your depression? How do you know it’s not something else?
Dr. Jen Gunter:
There aren’t tests to tell us that. And so, that takes, I think, a good working relationship with your physician and probably with a couple of physicians, because most psychiatrists aren’t sort of up on menopause. A few are. If I have a patient who’s got complex mental health issues, I’m not managing that. So, I need to be in communication. The team needs to work together.
Dr. Jen Gunter:
The thing is, what we can say is it’s relatively low risk if people want to try a low dose of hormones to see if that makes a difference. So, you can say, “Oh wow. Better, yes. Better, no.” And to see, and even if it’s “Better, no,” that still doesn’t mean it’s not menopause. And so, unfortunately what we have are sort of the list of treatments that we can try and then we can say, “Well, does this help you, yes? Or does this help you, no?” And that’s one of the really hard things about menopause, is sometimes people don’t know in retrospect that that’s what it was, because a lot of things can happen at the same time. When people are in their forties, they often have a lot of life changes and those can cause symptoms.
Dr. Jen Gunter:
I still remember watching something where someone was trying to blame everything on their menopause. And they had just spoken before about saying how they were neglecting what they were eating because they were too busy taking their kids around. And they were really sad they had just driven their kid to school. And like, “Well, okay. But there’s other things going on too.” So, menopause doesn’t happen in a vacuum.
Dr. Jen Gunter:
And I think that’s what makes it really challenging because the more variables you have, the more you have to juggle all these things. And so, the best advice that I have is to sort of say, “Well, if I’m going to try something new,” to think about, “What’s the length of time in which I should see a desired effect? And is it possible for me to stick it out on that new treatment? So I can say better, yes, better, no.
Glennon Doyle:
And can we stay on our antidepressants with hormones? Do they…
Dr. Jen Gunter:
Sure, yes!
Glennon Doyle:
Okay.
Dr. Jen Gunter:
Yeah, and many of them actually might even help with menopause. So, some of them like venlafaxine can help with hot flashes. So, some of them might be beneficial. Now, it’s also important to point out that some people who have mental health issues actually do not like how they feel on hormones. They have the sensitivity and that very low doses just are bad for them, and high dose, like they just can’t do it. And that’s, we have non-hormonal options as well. I have a lot of success with gabapentin, for hot flashes, and night sweats, and sleep disturbances. So, there are other things that can be helpful as well.
Dr. Jen Gunter:
Cognitive behavioral therapy’s actually really effective for hot flashes too. So, there are these other options to also think about. But yeah, the more you throw into the mix with any medical condition or with any health issue, and menopause is certainly part of it, the harder it is and the more your team needs to communicate to help you.
Glennon Doyle:
Tell us your mantra. Don’t you, you did cognitive behavioral-
Dr. Jen Gunter:
Oh yeah, yeah.
Glennon Doyle:
You have a mantra for your hot flushes?
Dr. Jen Gunter:
Oh, I have a whole bunch of different mantras for my hot flashes. I can swear? Can I swear?
Glennon Doyle:
Yes.
Dr. Jen Gunter:
Please? Okay. I’m just like, “You’re Dr. Jen fucking Gunter. You can fucking get through this. This is two fucking minutes. You’ve had bad sex that’s lasted this long. You can suck it up.”
Glennon Doyle:
There’s going to be millions of women looking in their mirror going, “You’re doctor fucking Jen Gunter.”
Dr. Jen Gunter:
I’ll tell you something funny. So, a few years ago I took one of my sons to New Zealand and I had to drive on the other side of the road, which is like one of those things that stresses me out beyond belief. I’m so stressed. And so, we’re in the car at the car rental place. And I want to drive. This is a trip I planned for him and we’re in the parking lot. And I have this like moment of panic. And I’m like, “How am I going to do this?” And my son, he must have been like 13 or 14, he put his hand on my hand, and he said, “Mom, you’re Dr. Jen fucking Gunter. You can do this.”
Glennon Doyle:
Best thing. I’ve ever heard.
Amanda Doyle:
Mama, good work, mama.
Amanda Doyle:
God. Oh, I love it.
Amanda Doyle:
You have been so kind to answer our three pod squader questions. Knowing you’ve done this forever, what questions does the rest of our pod squad listening have that we haven’t yet answered right now?
Glennon Doyle:
Yeah.
Dr. Jen Gunter:
One thing which I would like to say is that if you have bleeding after menopause, don’t dismiss it as one sort of last hurrah or one last rodeo with your period. It can be a sign of cancer and you don’t want to dismiss it and you want to get it evaluated. And that’s like one really important thing. So don’t ever dismiss that.
Dr. Jen Gunter:
I think another big question we sort of talked about earlier is brain fog. People have a lot of questions about that. Estrogen therapy doesn’t help brain fog. Going on hormones doesn’t make a difference. If you have a concern that you feel that your cognitive function is deteriorating, you should be evaluated, and your doctor can do evaluations to make sure that there’s no cognitive decline. There was this study that compared women with brain fog to men of the same age and the women still outperformed the men.
Glennon Doyle:
Shock, I tell you. I’m in shock.
Dr. Jen Gunter:
Yeah, so…
Glennon Doyle:
It’s a brain bloom, is what it is.
Dr. Jen Gunter:
It’s one of those things that feels worrying, but isn’t medically worrisome. Kind of like if you’ve ever been pregnant, those contractions of false labor contractions they’re worrying, but they don’t do anything. Those are kind of two of the biggest ones. I would say, be very, very, very wary of people who are selling you compounded products and stay away from pellets. These things are not recommended. It turns out it’s making hormones is complex, and having pharmaceutical people who make these in labs that are followed by the FDAs, you know exactly what you are getting. Because if you get too much of estrogen, or you don’t get enough progesterone, you can get cancer. You can get cancer of the uterus. We haven’t talked about that. If I just gave somebody estrogen and they have a uterus, and I didn’t give them a hormone progesterone, or gave them an IUD that has a very similar hormone in it, they would eventually over time get cancer of the uterus.
Dr. Jen Gunter:
So, it does matter. You have to have those with the right combination of these two hormones together. We do not recommend compounded products. We do not recommend the pellets. They do make a lot of money for a lot of providers because they can order tests to sort of check your levels, and follow you, and do all the special stuff. And it’s very hard because if you search for information about hormones, almost always these sort of cash practices float to the top of your search. So, they’re very good at search engine optimization. So, that’s why I really recommend looking at the guidelines from medical societies. If these other medications were evaluated, we’d tell you. It doesn’t to me which hormone you take, but it matters to me because I want you to have the safest one and the right one.
Glennon Doyle:
Is there a link? Is there, can we get that information? Because we talked about bringing the information about the Menopause Society into our doctor’s office. Is there a place we can go to find the information you just said to make sure it’s FDA approved?
Dr. Jen Gunter:
Yeah, so, if you go to the North American Menopause Society, and you put in search terms on their site, a lot of that information will come up. Just remember, if people are overselling something. When I tell people, when I put people on estrogen, I don’t tell them, “This is 100% going to cure you. This is going to make your life perfect.” I say, “You know, this is probably going to help your hot flashes a lot, but it’s not going to make it can go away. You might go from maybe having 10 day to two a day. It’s going to improve your quality of life.” So, if people are selling cures, I always say, except vaginal estrogen. That’s like…
Amanda Doyle:
That’s an actual cure.
Dr. Jen Gunter:
Medicine. Yeah. Well, that’s a problem in medicine. There’s always exceptions to every rule.
Amanda Doyle:
Right, right. Well, we know that we are not having a compounded product if we are going to our doctor and getting prescribed something? Or do we have to advocate even if we get a product, to search and make sure what’s prescribed to us is not compounded?
Dr. Jen Gunter:
Well, if they’re sending you to a compounding pharmacy, you’re getting a compounded product.
Amanda Doyle:
What’s a compounding pharmacy?
Dr. Jen Gunter:
They’re pharmacies that will make up the hormones for you. So, they’ll go in the back room, they’ll put a little bit of this in, a little bit of that in, and mix it all up. Oh, they might say, “Oh, we’re going to put it in this cream, we’re going to put it in this gel.” But the problem is everything that it’s in makes a difference as to how it’s absorbed.
Amanda Doyle:
Got it.
Dr. Jen Gunter:
You need studies. So you can say, so if I’m on a patch, I know I can open up the package and it tells me day two after putting the patch on, day three after putting the patch on, what my whole hormone levels would be, right? It’s all been studied. So, it should come in a package like your bottle of Tylenol, like your…
Glennon Doyle:
Okay.
Dr. Jen Gunter:
It should look like it came from a pharmaceutical company. You should say to your doctor, am I getting an FDA approved medication?
Glennon Doyle:
Okay.
Dr. Jen Gunter:
That’s what you should say. I want an FDA approved medication because that’s the safest.
Glennon Doyle:
Wonderful. So much of this advice is about and applies to people who have doctors that they can go to, whose insurance is working, who a million different things have to fall into line right now for women to actually get to doctors. What the hell do people who have uteruses do, who are going through menopause and do not have the access to doctors and prescriptions?
Dr. Jen Gunter:
If you have a uterus, and ovaries, and a vagina, it’s basically a preexisting condition in the way our medical system and our insurance system is structured. And, the lack of access to free healthcare, or nevermind affordable. Everybody should have access to, in my mind, affordable, hopefully free healthcare, but it’s true. People who have less access are definitely going to struggle. We used to have more county health departments where people could go and get care. And, we have less of those. We don’t invest in public health. We don’t invest in community health in the way that we should.
Dr. Jen Gunter:
And I wish I had a great answer, except you can do a lot of work yourself. My book’s available at most libraries. You can get the book out for free. You can read it, try to start getting some information, that way, many primary care providers, if you have availability to get access through Obamacare, you might be able to get it, get some basic help there. But, these are real areas that we struggle. And, even for people with insurance, vaginal estrogen is sometimes $300.
Amanda Doyle:
Oh my gosh.
Dr. Jen Gunter:
It’s ridiculous.
Glennon Doyle:
Wow.
Dr. Jen Gunter:
It’s ridiculous. You can go to another country and it’s free. So, the barriers that we put up, that you get your Viagra with your $5 co-payment. So, there’s a lot of issues.
Glennon Doyle:
Unacceptable. I like to circle back to where we started with being pissed off. So, thank you for that. Before this two hours with you, and before reading your book, I’ve always felt about menopause, kind of like I feel about geography. Like I missed everything. I don’t know anything, and so I’m scared to talk about it at all, because I don’t know. And so, I will say that the book really helped me. Go get the book, buy it, get it from your library. It just is a place to start where you feel like you have a little bit more power to begin with, which is knowledge. And, I also think that social media, I know that following you on social media helps me. Dr. Jen, thank you so much. We can’t imagine more important work. We are just very deeply grateful for what you’ve dedicated your life to.
Dr. Jen Gunter:
Oh, thank you so much for having me and thank you so much for having these conversations and really helping to heal people. You’re such a positive force. You guys really do so much. You bring a lot of light into people’s lives. So, thank you.
Glennon Doyle:
Ah, thank you, Dr. Jen. Thank you. You are Dr. fucking Jen Gunter. You go carry on. We’ll see the rest of you next time on We Can Do Hard Things. Bye-bye.
Glennon Doyle:
And talk to your friends about menopause.
Amanda Doyle:
Yes, yes!
Glennon Doyle:
Just talk it. Normalize it.
Amanda Doyle:
Send this to your friends. Talk about it. Normalize it.
Dr. Jen Gunter:
Have a menopause party. Have a party.
Amanda Doyle:
Ain’t no party like a meno party, because a meno party don’t stop.
Glennon Doyle:
Yes it does. It stops at 8:30 because we’re all so effing tired.
Amanda Doyle:
It stops, on average, at 51.
Dr. Jen Gunter:
Okay. Bye-bye.
Glennon Doyle:
Bye.
Glennon Doyle:
We Can Do Hard Things is produced in partnership with Cadence13 Studios. Be sure to rate, review, and follow the show on Apple Podcasts, Odyssey, or wherever you get your podcasts. Especially be sure to rate and review the podcast if you really liked it. If you didn’t, don’t worry about it. It’s fine.