Hey, it's your friend Mel and welcome to the Mel Robbins podcast.
I am so happy you chose to listen to today's episode. It's going to make you feel completely
seen and understood because our expert is the extraordinary Dr. Jen Gunter. She is the number one
OBGYN that people turn to for trusted science back advice regarding menopause. And she is here
to bust the myths and clear through the misinformation. And it is so prevalent on the topic of
menopause. In fact, Dr. Gunter is so in demand that I've been waiting a year to have this
conversation with her. She has jumped on a plane, flown across country to be here for you
to set the record straight and to answer your questions. Are my symptoms normal? Is hormone
replacement therapy safe? What exactly are biidentical hormones and are they better than normal ones?
What are compounded hormones? How do I talk to my doctor and my family about this? Today, you are
getting the exact specific protocol you need from one of the most respected experts in women's health
on the planet. And if menopause is not impacting you personally, do not change this episode,
do not touch that dial because it is impacting someone you love. And simply listening and learning
is going to help you love them even better because today we are busting the myths and you are getting
the facts about menopause. Hey, it's Mel. I am so thrilled to bring this episode and conversation
to you today. Dr. Jen Gunter is here to tell you everything you need to know about menopause
with a very particular focus on exactly what to do in order to feel better. Now, Dr. Gunter has
been called the internet's favorite OB-GYN. She is a double-board certified fellowship trained
medical doctor and she is a fierce advocate for women's health. She is also the best-selling
author of three international bestsellers, including the menopause manifesto and her latest best
seller blood. She's known for myth-busting and no nonsense facts and you are going to love this
conversation with her today. And I want to remind you, this is not just for you, please be generous
and share this with every single woman that you know because what you're about to hear will change
her life and yours. Without further ado, please help me welcome Dr. Jen Gunter to the Mel Robbins
podcast. I am so glad to be here. So, Dr. Gunter, thank you so much for jumping on a plane flying
all the way across country to be here with us in Boston. I cannot wait to jump in and talk about
menopause, bust the myths. Have you empower us? I want to start by having you speak directly to the
person who's listening who is either about to hit menopause going through menopause or maybe they're
listening to this episode because somebody that they love has sent it to them. Could you talk to
the person listening about what they are going to experience and what they're going to learn and
how they're going to feel after they're done learning from you today? Yeah, so I want you to feel
seen if you're going through the menopause transition. I think so often women are made to feel
small and they're not important and women are uniquely affected by ageism. So you kind of have
the double whammy at this time. So I'm hoping that you'll feel that your concerns are valid and
they're important and there are lots of options to do for my health standpoint and there are many
ways to take care of yourself and I can give you some tools to reframe what's going on with your
bodies. You kind of know where you are and also give you tools to find help if you're struggling.
What do you want to say to women who are in menopause? Yeah, team menopause. I'm on it too. So I
would say that menopause is a normal part of the ovulatory cycles that we have and just like you
went through puberty which might have been challenging and had some symptoms and cause a lot of
physical change of the your body that menopause is in many ways the same thing. You can think about
it as puberty in reverse. It is not a sign that your body is going to fall apart the next day. It is
not some new experience. I know there's a lot of people out there who think that oh because women
are living longer now they're just experiencing menopause but that's not true. The ancient Greeks
knew that the average age was about 50 which is about what it is now and if we erase menopause
then we erase all the grandmothers in history. So that it is a normal experience but normal
doesn't have to mean pleasant. So just like when you went through puberty maybe you got acne
or maybe you had really heavy regular periods or pregnancy also a normal experience. Maybe you
had terrible nausea and vomiting. Maybe you had other complications. So normal things can have
complications and I would say that there are things about menopause that can be unpleasant for
people. There's things that can be very liberating. People who've had terrible painful periods who
now don't have them think it's amazing. People who've had maybe terrible PMS find that the
the study, the lack of ups and downs of hormones are liberating. So I would say that if you're
suffering there is often medical treatment for that and the best way to know how to make it
more pleasant experience or less onerous experience depending on the spectrum you're on is to get
informed and have accurate information. I've never heard anybody call it puberty in reverse.
That actually makes a lot of sense. Yeah well just like you're, it's a different physiologic
process but you know you have a winding up right. So when you go through puberty you don't start
and bang on have cycles regular. They sort of start and stop. They might be heavy. You know how
that have that sort of like flirting with it if you will. Well you have that same and kind of the
last couple of years you have the starting and stopping with the periods. You having the winding
down of ovulation and so yeah so they're like bookends a little bit different. You know maybe like
sisters not twins I don't know. What is happening to the body when you're going through metapause?
So metapause the metapause transition which is the time leading up to metapause that you know you
might also think of heard called parry metapause or pre-metapause. How long is that last? Well anywhere
kind of from sort of four to ten years depending. Just kind of like puberty right like a big range
and how long it can last. Some people seem to have these late growth spurs goes on forever. You know
some people relatively short kind of the same thing. Oh wait a minute. Okay so when you were talking
about puberty I was just thinking about getting my period. I wasn't thinking about all the other
things that happened like your breast coming in your body shape changing. The fact that you grow taller.
Do we shrink when we're going through metapause? Not really. I'm certainly if you develop osteoporosis
you can. But no otherwise not and it would be rare to develop osteoporosis you know in your
late 40s or early 50s that would be a really assigned and you should be something else going on
significant. But over time if you have osteoporosis you certainly can lose height and we want to
want to protect that. But yeah puberty is is a many years experience right you start to get
pubic here you start to grow you get breast buds your body shape changes. You know you you may have
mood swings you may have acne you sort of this whole experience and just like puberty might have
ended at a different time for different people. Some people stopped growing in grade seven. I was
still you know growing in grade 10 grade 11 right you have this big range it's the same thing with
the metapause transition. And so I just encourage people to think about it more that way that it is
change and these changes you know don't happen overnight. So it's it's this physiologic change and
it's related to the decrease in the number of follicles or eggs that can ovulate. And so what happens
sort of in response to the decreasing levels of estrogen that are produced you get other hormonal
changes your your brain is trying harder to get the ovaries to ovulate. It can start to get
um discordinated so you might get one ovulation right on top of each other. So some cycles you
might have higher estrogen levels than normal. Some cycles you may not have progesterone. Some cycles
might be shorter. Some you might develop estrogen not get progesterone but still men straight. So
it's basically hormonal chaos. And so it's people mistakenly think of it as sort of this gradual
smooth transition but it's more like but obviously there's variation. My best friend had regular cycles
and then her period stopped and she had one hot flash. And I'm like that's kind of the equivalent
of showing up as a unicorn. Well that's like showing up in late the hospital and you're like oh
I feel a little contractions and you're like nine centimeters and go oh the baby comes out right
like there's you know there are people who have those experiences and then there's people who have
you know 72 hour laborers right so um so yeah so it's this wide experience and there are many
things that can affect it. Dr. Gunter what are the biggest myths of menopause?
Well oh gosh the biggest myth. I would say the biggest myth is that that your life is over.
You know that that that this is the end you know once you age out of being a breeder for lack of
a better term you've lost value but I would say that um you know many women once the menopause
transition is over really described that they have a greater clarity and they feel
you they feel great and maybe it's not having the hormonal fluctuations maybe it's the fact
they just don't care anymore because they're older it's wisdom with age I don't know the answer to
that. Maybe it's the fact that all of the part of your brain that was tied up with ovulation is
now gone because your brain prunes pathways it doesn't need anymore I mean I don't know the answer
but I would say that you know for some people it can be very rocky and and for some people it isn't
and for people who it's very rocky we have treatment. That's true you know I think the biggest myth
if I'm kind of just thinking about what my friends are talking about is that you're going crazy
and it feels very liberating when a doctor tells you oh that brain fog that can be explained
by menopause oh you know frozen shoulder that can be explained by menopause and so understanding
that there's an underlying reason for all of these things suddenly coalescing for me has been
the biggest most liberating thing is to kind of understand what's going on instead of feeling like
I'm a victim to what's going on. Yeah I think education about how your body works is very liberating
so then you don't think that you're uniquely broken or uniquely crazy or something you know that
that you know what is specific you know why is my body behaving this way in no one else's and
you're like oh lots of people are behaving this way okay I don't feel so alone so sometimes
just kind of safety or comfort in numbers. What are the top three non hormone interventions that
you recommend all women do to impact their health? Well I would say the top recommendation is exercise
I would put that over hormones absolutely but in menopause in particular how come? Well exercise
touches almost every single domain that is affected by menopause so if you think that menopause
can start to change the trajectory for you know risk of osteoporosis and risk of dementia
risk of muscle loss all of these things exercise touches all of those domains so in the menopause
transition there's an increased risk of depression exercises can treat depression exercise can help
protect bone mass exercise can help build muscle strength build muscle mass exercise is great for
your heart it's great for your brain basically exercise treats almost everything in menopause except
the hot flashes and vaginal dryness I mean you know and we have great medications for those so
but so what I'm saying is is that you know going into menopause without strong foundation
and it's not just you know cardio resistance training exercise helps with your balance so you're
less likely to fall I mean the number one risk factor for breaking a bone is actually falling right so
you know so all of these things can be protected with exercise but that's not a sexy cell
you know that's true like if you would only ever do one thing for your health it would be to get
your exercise I mean and you don't want to play favorites and say well you can only do one thing
but you know you get what I mean I'm just trying to emphasize how important exercises and resistance
training and building muscle and I'm always inspired by all these women in their 50s 60s and 70s
on Instagram that are like showing like they're flexing their backs or just they're just like cut
and I'm just like oh yeah never too late yeah well I'm working on it so so yeah so I exercise eating
you know 25 grams of fiber a day trying to have you know more protein many women don't eat enough
protein and trying to have more plant-based protein in your diet and having more vegetables I
mean this not the sexy stuff but it's the stuff and then obviously not smoking I just love how you
explain this stuff what is hormone replacement therapy so menopausal hormone therapy which is what
we call it is giving hormones to treat symptoms of menopause or to prevent complications associated
with menopause like osteoporosis can you explain the different types of hormone replacement therapies
Dr. Gunter yeah so there's evidence-based FDA approved and then there are scams I would think
that's the best way to sort it out so many people get hung up on the term bioidentical which is really
a meaningless term is a medically meaningless term whether hormone is the same or similar to what
your body makes doesn't make it safe I could give you a high amount of epinephrine and and you know
cause harm to you but that's something your body makes right so I can give somebody tons of estrogen
and give them endometrial cancer so whether something's similar to what your body makes or not
doesn't make it safe what makes it safe is as it's studied is it safe is it effective and is it
something that can be we know exactly how much you're getting so one of the big problems is a lot
of people are using compounded medications or pellets and we don't know what's actually in those
things from a you know from an actual amount of hormone so if I give you an estrogen patch I know
how much is going to be absorbed I could you know this there have been studies that have been done
I know if you put it on a different body part that's going to affect absorption because all of this
has been done with compounded products none of that exists none of it I don't know how much is
getting across your skin I don't know how much you're ingesting I don't know how much is being
absorbed you would want to know what you're putting into your body right so so I would say there
are FDA approved therapies and there are many good ones out there so there are you know
as there's estradiol which is the main hormone that the ovary makes and we have pharmaceutical
variations of those another big myth is that some hormones are plant-based and you know that again
as a marketing is that true well I mean petroleum's plant-based too if you want to look at it that way
right so yeah it's plant-based but it's not you know they used a starting chemical found in a plant
and converted it into estradiol that doesn't make it any better than if I made estradiol by
assembling it from different molecules it's the same thing your body can't tell the difference
we just make it from soybeans which is called a semi-synthesis because it's cheaper than making it
by synthesis which is assembling the molecules itself so it's a total marketing thing it plant-based
it means nothing nobody's grinding up yams and putting them into pills and giving them to you
how do I know that I'm doing the right thing like I I listened to you and I'm like yes yes yes I love
take it down take it down go go go doctor Gunter thank god you're out there cleaning up the internet
for us but then I'm like shit what what am I ask what am I asking my doctor like how like so
so if I'm going into my gynecologist and I'm interested in hormone replacement therapy what
is the proper thing to ask for so that I am in the land of research and in the land of things
that we can measure versus in the kind of fringe areas of right the other stuff so if you're
getting a prescription that doesn't have a package insert with it what is a package so you know
whenever you get any prescription and there's this little folded up book and you unfold and it's like
all the risks and benefits and it's like this big thing if it doesn't have that then it's not FDA
approved oh okay so all the things that you get from the compound pharmacy not FDA improved
no because they haven't like how could they be because the packaging has been through clinical
trial after clinical trial and it's had to have been tested and passed through all these hoops for
your safety and so that you as a doctor can understand right what you're actually prescribing
yeah so there's this whole sort of loophole for compounded medications and so they don't have to
have that package insert they don't have to tell you about risks of blood quads or risks of it they
don't have to tell you any of that so that's a big problem and it makes people think that they're
safer because look if I gave you two things one had a list that had said it had a black box warning
on it right and the other one didn't you're gonna automatically think the one that doesn't have
the black box warning on is safer well it doesn't have the black box warning because it wasn't
required because it's not FDA approved oh my god you know when I was going through parry menopause
I got bioidentical hormones from a compound pharmacy and I thought I was fancy I thought this is
like high-end medicine they have taken something for me I like this is how how uninformed I was
they have literally because of the word bioidentical I thought it meant oh well somehow this is
custom formulated for me to match my hormones it is bioidentical which sounds really fancy and
trustworthy and then I would get this packet from a compound pharmacy and it would have these
like tubes in it and there were all these warnings like don't expose to light don't do this do
that now that I follow those of course not was I precise in how much I would squirt on my wrist
no if I'm being honest and so I thought that I was having the better result when I can see now
what you're basically saying is that no not really you were having the inferior you were paying
more and getting less because we all think when when someone's customizing something for us that
we're getting better we're trustworthy we believe people and no menopause society recommends
compounded hormones they're not recommended by the North American or we now call them they're now
called the menopause society the national academies for a science medicine and engineering don't
recommend compounded hormones the international menopause society the British menopause society none
of them recommend compounded hormones because it takes science and research to know how to get hormones
through a skin it takes science and research to know how to get them from your gut into your blood
stream when you make hormones they just get dumped into your blood stream from your body you're not
eating them you're not absorbing them you're not rubbing them on your skin you didn't evolve to get
hormones that way now it doesn't value that we have modern medicine for reasons so you don't it doesn't
mean you shouldn't take them because we didn't evolve for that but funny thing it takes science to
figure out how to make these molecules work for us and so there are several issues with using
compounded products people may be getting more of a hormone than they think they're getting so
you might be getting more estrogen than you need which could put you at risk for endometrial cancer
you might be getting not enough progesterone which would put you at risk for endometrial cancer
or you might not be getting enough estrogen putting at risk for osteoporosis so you think that
you're you're preventing osteoporosis but you're not so this is the analogy I use using FDA approved
hormones is like going to the gas station that has the gallons on it and you can choose you know
whichever gas you want you fill your car and you have a working gas gauge and you're like I know
what's in there and that's important going to a getting these compounded formulations or pellets
is like buying gas from a dude on the side of the road who's telling you he has bespoke gas for you
and let him fill your tank and oh he's gonna flip that switch off so you don't know how much
is in there because you should trust him because he knows that's the difference I
am speechless I guess it's not very often that I don't have anything to say and
you just took a flame thrower to the entire idea of bioidentical hormones I would never ever try it
again and then I would add on top by the way you've brought the science and the research
and a very compelling analogy I'm gonna add one more as somebody who already has ADHD and has
increased brain fog due to menopause I am not that great at being consistent at storing things
the right way or using it the right way and so I'm probably over under dosing even if it was
made in a way that was clinically sound and so case closed not doing bioidentical hormones yeah
and I would say move away from using bioidentical and just call them compounded because bioidentical
doesn't mean anything so bioidentical is a marketing term used to describe hormones that are plant
based that are identical to what your body makes but estradiol that you get from an FDA approved company
you know I use an estrogen patch it's estradiol I've got it on right now the estradiol in the patch
is no different from the estradiol the compounding pharmacy is using they're both buying the raw
hormone from the same place the difference is the pharmaceutical company has studied how to give
that estradiol to you in a reliable dosing manner the compounding pharmacy has not done that work
they don't have that and because of that they're not FDA approved because you have to show to the FDA
and it's expensive you have to do all those kinds so so they they haven't submitted that data they're
just making things up so you have a precise studied formulation but the big thing is they're not
buying fancier hormones all the raw hormone comes from the same one or two plants in the world
it's like me buying Cheerios and putting them in a Cheerio box or putting them in a glass jar
with a ribbon around but they're the same product except the delivery mechanism is different
gotcha so that's why I tell people you know every every estrogen that I would prescribe you from an
FDA approved source with the exception of Premren is bioidentical and so bio it so everything is
the same forget that we just forget that word okay yeah because the s so when people use the word
bioidentical it tells me that they think women are dumb well clearly I am in the area well no
seriously I I can own it because here's the thing it is confusing as hell my and there's so much
misinformation right and when you walk into the doctor's office and you are simultaneously
erupting at your family because you're all over the place with your emotions I'm speaking for
myself here and then next thing you know you're sweating like Niagara Falls and then next thing you
know your vagina feels like the Sahara Desert and next thing you know you can't remember where your
car keys are or where you put your dog because you can't remember like and you are losing your mind
and somebody says to you oh bioidentical and I can send you out you're like thank you I'll take it
whatever and so I had no idea yeah and I used it for three years and I thought I had the fancy
thing and so I want to be very clear about something and you listen keenly to me doctor
gonter to make sure I have this correct because I'm putting my lawyer head on and I'm feeling the
association of compounding pharmacists writing us a seats and a cis letter and so I want to be very
clear about what she said number one it is a fact that the menopause society does not recommend
that you use a compound delivery formula for any kind of hormone replacement therapy because
it is not gone through FDA approval and number two the distinction that we're talking about is
not the actual hormone okay so they're using the same stuff the reason why it is important that
you understand this is because the delivery mechanism of the pharmaceutical product like estr-del
has gone through FDA approval which means the researchers and scientists and doctors know how
your body is going to observe it they know the rate of delivery they know that it has been tested
and so it is what the menopause society is recommending if you are going to do hormone replacement
therapy did I get that right yeah and so you know there are the other important thing is when you
have an FDA approved medication they're batch tested so what that means is whatever however
many one bottle in 50 one bottle and I don't know what it is is tested to make sure it has what it
claims but when you're mixing up product after product one at a time there's no batch testing that
can be done right so the quality you're talking about a whole different thing in quality control
right so the only time we ever recommend a compound of product is if there is a true allergy you know
there's no pharmaceutical option because of a true allergy and that's where we you know rely on
compounding pharmacies for that situation so you know one example might be pro metrium
with oral progesterone the brand in the United States is made with peanut oil so if you have a
peanut allergy you can't take that product so the options are then to take a different pharmaceutical
or to get progesterone compounded by a compounding pharmacy without peanut oil that makes sense
so in that instance where you have a real allergy you might recommend a compound pharmacy but otherwise
100% as literally the number one gynecologist myth busting you are out there setting the medical
fact straight the menopause society and your medical recommendation is to absolutely not be using
the compounding formulas but to be using the FDA approved delivery mechanisms that are prescribed
by your OB-GYN right I am learning so much and I know you are too and we need to take a quick break
to hear a word from our sponsors and while you listen to the amazing sponsors would you please
share this episode with someone who needs to hear it which is basically every single woman in your
life and don't you dare go anywhere because when we come back we're going to keep talking about
exactly what you can do to relieve the symptoms of menopause we have so much more to learn from the
amazing doctor Jen Gunter and later on we're going to talk about exactly how you can talk to your
doctor in order to get the care that you need all right stay with us we'll be right back
welcome back it's your friend Mel Robbins and I am here with the incredible myth busting
and unbelievably empowering doctor Jen Gunter she is telling you everything that you need to know
about menopause so doctor Gunter how do I know that I'm doing the right thing what people need to
remember to the takeaway is there's really very few things you need to know about hormones
the the two main estrogens that we recommend are either estradiol and if you're stuck on the term
bioidentical that is bioidentical now I'd like people to throw that term away but sometimes it's hard
so the estradiol that I would give you in a patch or a pill from a pharmaceutical company that is
bioidentical right so you have that so you want to learn estradiol and then you want to learn
preembran which is conjugated equine estrogens and that's only actual natural estrogens because it
comes from horse urine so natural natural natural means the substance exists in nature and it's
being used unchanged so how the hell they figure out that a horse urine is something that yeah horse
urine's got all kinds of estrogens in it it's a crazy thing so those are the two things you need to
learn you need to learn estradiol and you need to learn preembran which is the trade name for
conjugated equine estrogens and then you then you need to learn oral or transvaginal or transdermal
so against the skin through the vagina or by mouth guy and we recommend the number one starting
treatment we generally recommend is transdermal estradiol here I'll show you I'm going to show you
mine right now because I'm probably due to take it off I have to do it like every four days
oh look I work black under it let me get down here okay you guys will never watch YouTube again
okay here it is so this is and look my dead skin is on it that's yeah so I have a patch my hold it
up right there yeah I have to replace it every four days change my life and so I can trust knowing
that if I put this on every four days and this is considered transdermal that's transdermal it
goes through the skin so if you're like I wouldn't put it here obviously but you don't stick it to
yourself yeah but you only want to put it in the place that the package insert says yeah because
it's been studied they've studied it in different locations that the absorption can change so if you
put it on your belly versus putting it on your thigh or putting on your butt you might get a different
absorption of the amount of estrogen and you don't want that you want to know what you're getting
right that's right and you know I I've also learned because I had no idea that you could also
insert something into the vagina for hormone replacement therapy yeah I should probably
button my pants to finish the interview yeah so there's a transvaginal ring that also has
estrogen and can be absorbed that way into this into the body and there's also a ring where the
estrogen just stays in the vagina and if you're having vaginal trinus you have you're not
very tracked infections pain was sex vaginal estrogen can be very effective for that and so some
people who have no other symptoms of metapause feel great they feel fine but they have vaginal
dynast they don't want to take a medication that goes throughout their body they want to just use
a vaginal estrogen so we have that that's a great option when you're using estrogen that goes
through your body about 50% of people will get a good level in their vagina but some people won't
but from a take home standpoint there is absorbing through the skin or through the vagina and there
is taking it by mouth and we believe that absorbing it through the skin has the lower risk of blood
clots so that's why what people need to learn is the first line therapy for metapause is transdermal
estradiol you mentioned pellets a couple times what are those so pellets are implants that you go to
a medical doctor or a nurse practitioner and I think maybe even in some places there's naturopaths
who in certain I don't really know because I'm not really involved with it maybe they don't I'm not
sure and they they can either have estrogen they can have estrogen and testosterone maybe they
have other hormones and that really no and they're made in compounding pharmacies and they're implanted
they're not batch tested so you don't know how much hormone you're getting and it's my understanding
of it is it's based on a proprietary system so you get your blood drawn they follow your hormone
levels and then they decide when you get the next pellet based on that but we don't recommend
hormone levels for for you know for giving hormone therapy it's not based on levels it's based
on symptoms I don't need to know what your estrogen level is if you're 47 and starting it I don't
even need to know what your estrogen level is when you're 42 I only need to know that if I'm worried
that you have premature manopause right so the sort of system and it's just it's not recommended
there've also been issues with pellets with with complications and side effects not being reported
to the FDA which is also another you know another concern so we don't actually know how many people
have problems versus you know pharmaceutical companies when they get adverse events reported
those are you know passed on to the FDA because there's big penalties my understanding for not
doing that so so is the pellet a delivery mechanism yeah so it's a it's an implant that you know that
sits in the body I because I don't do it I'm really not much about it because it's not recommended
right you know I don't know that much about it but it can what it can happen is it can produce
very very high levels of hormones and then it drops off and in some cases you know you can be
exposed to the levels of testosterone that you know we might give someone if they're transitioning
right so the kind that can you know cause you to develop and enlarge clitoris the kind that you
know can cause you to develop you know these changes from having too high of a testosterone
we don't know when you're using those hormones then how much progesterone to give you to protect
your uterus so there's all different kinds of issues associated with them and they're very expensive
as well so you know they're they're just not recommended do you have to have your blood drawn to have
this assessed no effectively no and if anybody if you're 45 years or older you do not need a blood
test to get started on menopausal hormone therapy you know if you're 11 and having a gross spurt
no one's like oh why are you having a gross spurt we should check your blood we would expect you
to have a gross spurt at age 11 if you had a gross spurt at age 3 that would be different and that's
the same thing for menopause so if you're 45 or older and you're having hot flashes you're having
vaginal dryness you're having your regular periods it's not a mystery we're expecting it to happen
the average age of menopause is 51 right however it's happening to you when you're 39 well that's
different we need to know is this an earlier menopause or is this happening for another reason
and so if you're under the age of 45 you need the blood work because you need to make sure that you
understand why your periods have stopped now if you're just having a hot flashes that's a different
story so the blood work is really if you skipped periods so say you're 42 you haven't had a period
in three months you need to have blood work because we should figure out why that's happened yeah
but if you're 45 and you're having bad hot flashes and you've had a couple of irregular periods
that's no mystery you're starting in the menopause transition and right if the the average age of
onset for the menopause transition is 45 well you know what 50% of people are going to be younger than
45 and 50% of people are going to be older so yeah so it has to be put in context and so that's
the internet wants to absolutes the internet wants test my hormones don't test my hormones the
internet wants you know this or that but medicine is more nuanced than that and so the only absolute
I can say is if you're younger than 45 and you've skipped more than two periods then you need to
have blood work done because we need to know why is it an earlier menopause is it another condition
that's caused your periods to stop if you're 45 or older it's not a mystery why you've gotten two
months without a period and one thing that we didn't talk about is one of the contraindications
for starting estrogen is being more than 10 years from your last period or over the age of 60
and so in general that is associated with an increased risk of dementia and an increased risk
of cardiovascular disease so we sort of want to avoid starting it with people are older now
it doesn't mean like you know age 60 if you're 60 years on one day that that's like you know a hard
stop but I think it's just important for people to understand that that there's kind of a timing
and so you know so if somebody for example their last period was 55 we might not cut them off at 60
so there might be a bit of wiggle room there but in general we recommend you know if people are
going to start hormones that is going to be within 10 years under the age of 60 that's kind of the
ideal situation and the lowest risk situation. I can't believe how much I'm learning from you today
I thought I knew a lot about this topic but you're just constantly amazing me with new information
and I know as you listen you're thinking the same thing and we also need to take a quick break to
hear a word from our sponsors because they allow me to bring you world class expert advice from
the amazing doctor Jen Gunter so do me a favor listen to our sponsors and please take a minute
and share this episode with someone who needs to hear this this could truly change their life
and don't you dare go anywhere because when we come back I'm going to be waiting here with Dr. Gunter
and you're going to hear more on how to deal with your symptoms plus how to talk to your loved ones
so that they better understand what you're going through and how to talk to your doctor so you get
the care that you deserve stay with us. Welcome back it's your friend Mel Robbins I am here with
Dr. Jen Gunter so Dr. Jen Gunter one of the things that I'm sitting here thinking about is the
fact that my friends and I all talk about Manipause right because we're all in the thick of it
but more than half of the women that I know are scared of HRT and I know it's because of the fact
that I think it was 1991 when there was a huge study that was released I think it was the women's
health initiative that cast HRT in a negative light and I understand that the study has been
harshly criticized it's now 30 years later but it's very clear to me that the fear that it created
it's still lingering and it's keeping a lot of women from even exploring hormone replacement
therapy as a safe option for them can you tell us more about this study and how you think about it
as a medical doctor well the women's health initiative was the largest clinical trial I think
that's ever been done it was designed to tell whether hormone therapy Manipause and hormone therapy
was going to actually reduce the risk of heart disease without increasing the risk of breast cancer
and it was also there were other arms that looked at exercise that looked at calcium so the
calcium replacement so quite a quite a few different arms of the women's health initiative
and the arm with estrogen plus so when that was permanent that was used permanent plus of
progestin that was stopped early because they reached the threshold of concern about breast cancer
now going into the women's health initiative we we knew that there was a very low risk of breast
cancer associated with menopausal hormone therapy so this wasn't like a surprise it's kind of the
threshold that was reached and it was communicated to the public you know in a way that is typically not
done you know usually there aren't press releases want to want to study as halted usually we wait
we get the data the the article is published so you know it's peer reviewed and we have all of that
and that didn't happen and that created this big hoop law where lots of things got taken out of context
lots of things sort of accelerated in ways that you know we're uncontrollable because fear sells
right so it I don't know how many major news stories were dedicated to the WHO but it was really
out of proportion right and then when when more information came out and when there were more
studies that came out you know that never gets the same attention yes so we know that estrogen
plus a progestin is associated with an increased risk of breast cancer but those aren't the hormones
that we typically prescribe now so that's kind of the difference you know we we believe that the
progestins which are slightly different molecules and progesterone carry the higher breast cancer
risk it's still acceptable and in the safe range to take that the hormone progesterone is lower risk
and that if you don't need a progesterone or a progestin that that risk is the lowest so I would say to
people you know if you're taking a trans dermal estrogen and oral progesterone which is our
standard starting therapy we believe that the risk of breast cancer is very low you know we it's not
probably zero but that it is very very low we believe that if you're taking estrogen alone that
risk is even lower some people believe it's zero other people believe it may be a little bit higher
so this and again it depends how you look at the data but I would say for the majority of people
who are suffering with symptoms related to menopause who have things that hormone therapy can treat
that menopausal hormone therapy appears to be a very very safe option and you just have to look
at it in context if you're somebody who has a higher risk for cardiovascular disease but not super high
risk then trans dermal is probably okay but oral isn't because there's a higher risk of blood
clots associated with a girl so you just have to look at what is it going to do for you so I'm very
high risk for osteoporosis my mother died from osteoporosis I have quite a high fracks score which
is a risk calculator and so that's the main reason that I'm on menopausal hormone therapy because
my risk of osteoporosis is pretty significant and I'm already kind of you know getting closer
and closer to osteoporosis at osteopenia so and you know it's you know it's a concern for me
from a health standpoint so so that's why I'm taking it and so you know people always want us to
say like a zero risk for this and and you know getting at a car has a risk so so I always like to sort
of not talk in those kinds of absolutes and say say what's the reason you're on it and what is the
risk benefit ratio for you and for the majority of people the risk benefit ratio is absolutely
going to be in the favor of benefit but there are some situations where it might not be so for
example you know somebody at very high risk for cardiovascular disease someone who's previously
had a blood clot someone's previously had a heart attack so you have to put it in perspective thank
you for that because Dr. Gunter I've been really surprised by the number of my friends who are
suffering through menopause and parimenopause and just completely the quality of their life is
impacted who have been afraid to try hormone replacement therapy or even talk to their doctor
about it because somewhere in the back of their head there they think it causes breast cancer and
that's why they're not even considering it and so I appreciate you just kind of clearing the air
a little bit so that people know that you should at least go talk to your doctor about it.
Yeah and there are calculators that can help you determine your breast cancer risk right so I would
recommend we I think we heard it was Olivia Munn who was talking about I believe that's who it
was recently talked about she you know had a breast cancer risk assessment which led to her having
MRI which led to an early diagnosis of a breast cancer and so there's all kinds of sort of there's
several easy tools that we can do to help explain things more in context for you so if somebody comes
to me and and they have something that menopausal hormone therapy can help while I do something called
an AACVD score at Calculates your cardiovascular risk and you know we need your lipids and we need
to know your blood sugar and your blood pressure a few other things and so we can calculate that.
I need to see a mammogram and I need to ask you some questions about your breast cancer history
risk and that's important because at a certain level when your breast cancer risk is higher based
on other factors there's also a conversation to be had about medications that lower your risk
of breast cancer so you know there's so there's bigger discussions to have but so you you can do
these risk calculators and you say look well I'm somebody who's got hot flashes.
Menopausal hormone therapy is a gold standard. I have low risk for these other reasons so there
would be no reason not to go on it but again everybody weighs risks differently right and so you know
versus your somebody you've you've got a pretty high cardiovascular risk so can we talk about one of
these other treatments for your hot flashes or your somebody who's got a history of breast cancer so
can we talk about one of these other medications for hot flashes. I want to ask a couple more
questions about HRT so someone listens to this episode they feel very seen and validated. They
go into their OB-GYN they you know kind of say I want to I want to assess the risks and let's just
say you try it okay you make the personal decision with the recommendation of your doctor to go
on the standard protocol. How do you know if it's working? Well so are you sometimes improving?
So it's really you know except except for and how long does it take? Pretty quick so so unless
you're someone like me taking it for osteoporosis prevention because I don't feel any different right?
So you know and that's again a really important reason to take an FDA approved medication because
I wanted to protect my bones I need to know what I'm absorbing right so so if you're have hot flashes
most people see pretty significant improvement within four weeks. You know depending on how how
much better people feel sometimes we might you know give an eight week try before switching doses
and it just depends on how people feel on the medications so yeah so you know usually with
something like hot flashes you know you're going to see an improvement pretty quickly with depression
usually within a couple of months as well and you know they're also so I was like to talk about
with menopausal hormone therapy there's sort of green light indications meaning these are like the
FDA approved you know solid reasons hot flashes night sweats gold standard osteoporosis prevention
FDA approved and we didn't talk about this but if you have menopause before the age of 45 we do
recommend everybody take hormones regardless of symptoms until at least the average age of menopause
and then at that average age you can decide if you want to stay or not like everybody else.
What is the average age of menopause 51 so but so say you're starting it for so you've got
these green light indications great everybody believes that the you know the the benefits outweigh
the risks as long as you're in the you know the right category for that then there are sort of more
yellow light indications things where it hasn't broached where it's recommended in the guidelines but
there's pretty good data to support it so for example depression in the menopause transition
can be very helpful for that many of us would try it if somebody's got a sleep disturbance
even if they don't think they're waking up with hot flashes because sometimes people don't wake up
but what it's doing is it's disrupting your sleep architecture and then you're so you don't have
as much deep sleep so it might be worth a try to see like for example I still get the occasional
hot flash but even when I was like I don't wake up but I'm so hot I wake my partner up.
I'm just a super deep sleeper right but I still had disrupted sleep so you might not realize that
so it might be worth a try to see the data for joint pain it's not really that great I mean maybe
it's going to help 20% of people with joint pain so it wouldn't mean it would be wrong to try you
know if it doesn't work you're not going to keep like pushing the dose higher and higher and higher
because you're like well you know it was a chance and you know maybe it's going to work maybe it's not
there's some evidence to show that it may reduce your risk of type 2 diabetes so again if you're
somebody at very very high risk that might be a conversation to have so those are kind of like
these yellow light indications and then you know there are you know if you have brain fog so
brain fog specifically there aren't studies to tell us that estrogen treats brain fog and in fact
people perform better than they think when they have brain fog so on cognitive testing so it's
kind of this symptom that don't we don't really understand so you could certainly have brain fog
from depression right you could have brain fog because you're not sleeping well you could have
you know so all of these other things could come into play so so but if you're only symptom
or brain fog then I might be like you know it's less clear you're going to get a benefit from that
and you know maybe there's a discussion to have about what might be the other factors but
if you've also you know we've done a depression questionnaire you're scoring higher for depression
or brain fog is symptom of depression too right so let's get that treated and let's see
and then let's also work on the other foundations like exercise needing healthy
because there is one study that looks at you know the healthy things you're supposed to do in
Madapal's get your right exercise Eda you know a fiber rich healthy diet and not smoke and I think
it was only 8% of women did all three wow um he wrote this unbelievable article that went crazy viral
um and Dr. Gunter you say don't use menopause to excuse mediocre men what does that mean I think
everybody does exactly what I mean but yeah um so there's this edge of a knife I think
when you're a woman right so you know we like to women are too hormonal to this to that but you
can also have symptoms related to that so it's just really important to make sure that because of this
history of causing what calling women hysterical calling them you know the mad woman in the
attic all of that kind of stuff because of that history I think it's super important to be
accurate when we're assigning fault as to what the fault is so yeah there was this advice column
in in the guardian and this woman had written in and I can't remember the specifics now but
her and her husband had had a contract or you know a verbal agreement about how they would be
raising their children and he was clearly not living up to what they'd agreed upon and he was
basically whatever her third child and I think a lot of women out there know exactly what I'm talking
anyway he was her third child and she wanted to leave them because she was like like I don't
I don't want to be a mother to him and this I hear this from a lot of women and she was writing
in for advice and because he wasn't vacuuming it was not even doing any of this stuff she was
basically doing it all and the answer was maybe it's menopause maybe you're intolerant because of
your hormones. Really? Yeah maybe she's gone hormone therapy. She didn't say she'd have
a lot flashes she didn't say was sleeping poorly at night she clearly laid out that they had
agreed to be equal partners and here she was now in this relationship where she was doing all the
grunt work all the nasty stuff and yo you know he was out at the pub like it was it was sort of the
most obvious like pull the plug get divorced save yourself run don't look back run and know maybe
it was your hormones because I know that you know when I was going through menopause you know I had
had a shorter temper so I think it's really important that we are not
excusing the bad ways that society treats women and saying that oh if you just took hormones it
would be better right because the answer to being mistreated is not taking hormones the answer to
being mistreated is to be treated correctly and so I just think that it's really important that
we're clear about these things now somebody comes to me and says oh my god like I had the perfect
relationship on my husband does everything and now that I'm not sleeping at night and I'm
soaked and sweat all the time I've got a super short temper yeah yeah your hormones might be
having something to do with that you know maybe if you actually had a good night's sleep
this would be better I think most people can agree with that right but that wasn't the situation
that was being presented so I just think that you know it's really important especially like in the
workplace too right you know that many women in the workplace are treated terribly especially
as they age that there's so many glass ceilings right and while it's super important that work
places accommodate menopause we also don't want to use that as kind of lip service so then we can
excuse all the bad policies that are keeping women from advancing right oh look you know we're
we're letting you control the temperature when really there's also a massive glass ceiling so I
just think accuracy in all things hmm well said can you speak directly to the woman who's listening
to you right now Dr. Gunter and especially if she's not getting the support from her family or her
partner and she's going through menopause or parimenopause right now I would say that's a pretty
awful place to be if you don't feel supported and I think whether it's menopause or pregnancy or
you've got any other health condition you want the person who loves you to support you so I would say
that that's an awful place to be and to maybe have a conversation if you feel safe having that
you know explaining what's going on and you know maybe saying hey here are some things that you
could read so you have a better understanding about where I'm at well a lot of women are going to
forward this episode to their family members and to their partners and so I would love to have you
speak directly to the partner the children the family members of a woman that's going through
menopause and what they could do to be more supportive yeah if you've got a family member you know
your mother your sister you know I'll have one who is going through menopause learn about it
and also think about what you can do around the house to make it easier you know I would you know
everybody needs a little bit of help in in many heterosexual households women are doing the burden
of the labor around the house there's a study that shows even when hour per hour it's the same
women do more of the less fun work right I know it's not going to surprise it doesn't surprise you
surprise anybody so if you take hour per hour well the man is more likely to be out in the yard
playing with the kids and the woman's more likely to be doing the laundry so four hours four hours
right so you know how can you think about having a more equitable division of labor in your house
right and how if you have a family member who's struggling wouldn't you want to carry some extra
load to make it easier for them like that's just being a human yeah and I would imagine any kind
of support that also lowers the stress level that you feel makes you feel better too yeah
health standpoint absolutely and and you know ask it can I go with you to a doctor's appointment can I
you know can I be your scribe you know by the manifesto you know my book you know think about
how you can how you can do some little things to help you know just if you're not someone who's
look at the chores that you're doing in the house think about how you can pick up more think about
how you can listen just sit and listen as well you know not everybody wants an answer sometimes
people just want to talk you know there's a a great episode of parks and rec where I don't know
if you've seen the show but where Anne is pregnant and her her spouses I can't remember his name
but he's played by Rob Lowe and she's pregnant and she's just very uncomfortable and she's
talking about her aches and pains and this and that and he just wants to solve everything let me
get you this let me get you this let me get you this and she just wants him to sit and listen right so
I think a lot of people just want you to sit and listen to I think I speak on behalf of the person
listening and I know myself when I say can you be my gynecologist I mean I want somebody as informed
as you so can you offer up any scripts or advice for how we can have better conversations with our
OB-GYNs or how we can find somebody that is really in tune with all the research and with the
recommendations of the menopause society yeah so the menopause society does have certified you know
menopause providers and you can certainly you know look for someone who is a certified
menopause provider that's not necessarily a guarantee that you know that they're going to give you
evidence-based care or I understand there's some who also implant pellets but in general I think
that's a good place to start if you ask your doctor about menopause and they don't like
clam up you know if they're if they can have a conversation about it there's lots of great people
who know how to care for menopause who you know haven't done the test in our members of the
menopause society right so you know the other thing that I recommend people do is you can google the
the 2020 North American menopause society guidelines for hormone therapy and you can download it
it will link it and they show notes it's you know it's a PDF now there's a lot of you know
um you know semi-interesting things and they're talking about risk you know complex studies and
things like that but at the end of every section they have a kind of a general good plain language
summary and I think that many many people would find that quite illuminating and you know to read
that and you could even take it with you so you know if you're or you could read it and say oh
I'm asking for something and it isn't even mentioned in here maybe I'm asking for something that's
a little bit out of spec and so I'll ask you know do a word search you know do what is it control
after whatever you have to do you know if you've got a specific word search the document for it
and see what shows up in there so that's a it's a good place to kind of get some basic information
that's evidence-based they have some information on their website too and you know I would just say
that that for the majority of people who want to try menopausal hormone therapy a six-month to a
year trial is as low risk as anything can be you know when we look at the risks of of breast cancer
if you assume that the studies that show risk are correct again we've had the spectrum of some
study showing one thing others are showing nothing there's no risk with a couple of years like
like if that risk doesn't accumulate for a while so if you're really scared there's essentially
and you're a good candidate cardiovascular trying it for six months is about as low risk
a therapy as there could be and if you try it you're like well this hasn't improved my quality of
life you know there's your answer and if you're on it you're like wow my quality of life has changed
a lot then there's your answer because you know there's lots of things that haven't been studied you
know there's you know others sort of symptoms like many women talk but they just don't feel like
themselves we don't have a scoring system for that I don't know what that means and you know what
you're not feeling like yourself and me not feeling myself I mean two completely different things
would be completely different biological phenomena but we're using the same words to describe it
so because it's such a low risk thing if you're using the FDA approved therapies and you're in
you know a low cardiovascular risk there's very little downside for saying you know is an
appropriate dose improving things the one word of caution I would give to people is you want to
if you're not improving to be very careful about dose escalation right so if you think about an
estrogen patch that has a hundred micrograms of of estradiol that is about equivalent if you
even it out through a whole month to the amount of estrogen you make when you're ovulating
so if you're needing more than that I would say and you're over the age of 45
they probably need to be a bit more reflection because why would you need on average more estrogen
than your body was making so you know so you just want to say like if you know if you're needing more
than that then that might be a time for sort of like a you know a reassessment of things and it might
you might be on the right track but you know I would say that that's a time to reassess
Dr. Gunter if you could just speak to the person listening and if there was one or two things
that are the most important takeaways from everything that you shared today what are the things that
you would want the person listening to focus on well I would want to say that accurate evidence
based information is really the best way through any medical situation and we don't always have
all the answers and women's health has been underfunded but having the information that we have is
is a lot better than just wild guesses right so to just keep that in mind that we do have quite a
lot of information that if you're not being heard by your physician then it I know it's hard
and that shouldn't be that way but get a second opinion and you know just be mindful of people
that are selling product because you know there's a lot of incentivization that's not even a word
is there it's a lot of incentive I make sense to me there's a lot of incentive or there can be
or there can be bias right so you just need to be mindful about that you know I get paid the same
I'm on salary I get paid the same whether I talk to somebody about exercise whether I give them
hormones you know I don't have you know any kind of you know deal with a specific company I don't
take any money from any pharmaceutical company you can look me up so you know that bias can come
in all different kinds of ways as well and you know I so I just think it's important that if you're on
social media and someone's also selling a product to just be really a wary of the message
that's all I just love how you explain this stuff thank you thank you so much for having me it's
been great I feel so empowered and I am also happy that I got to reveal to you how much I did not know
and how much I was doing wrong because if I can save you the headache or the time or the heart
ache that I caused myself because I just didn't know if that's what you get out of this you learn
from my mistakes holy smokes that's absolutely incredible so thank you for spending time listening
to something that could change your life thank you for sharing this episode with women in your life
because you know anybody that you share this with it's going to help them and it's going to help them
take control of their health and in case no one else tells you today I wanted to be sure to tell you
that I love you I believe in you and I believe in your ability to create a better life and after
today's conversation learning from Dr. Jen Gunter I know that you have the research back facts
and the medical advice that you need in order to be more empowered and informed about your health
and that is one of the best things that you could do to create a better life already I'll talk to you
in a few days
so Dr. Gunter thank you for jumping on a plane and flying across comfort I can't even speak
at that okay oh sorry okay what's he knew you were just warming up it's okay getting out of that
three two one audio recording can I also I just realized I should probably clean my glasses
yeah I just took off a layer of street grime from mine and now I can I'm like oh wow my god I can
actually see it's amazing do you like that yeah I'm gonna do one more I'll learn a second
okay great great great okay gotcha we go up a little let me do it one more time
okay what was that whatever it's called you know Dr. Gunter you know you're gonna do that right
now no problem I'll do it okay um go Tris it go thank you thank you for letting me talk so much
I'll thank god you did too you were awesome
oh and one more thing and no this is not a blooper this is the legal language you know what the
lawyers write and what I need to read to you this podcast is presented solely for educational
and entertainment purposes I'm just your friend I am not a licensed therapist and this podcast
is not intended as a substitute for the advice of a physician professional coach psychotherapist
or other qualified professional got it good I'll see you in the next episode
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