00:00:00
If someone's menstrual cycle is irregular, should they be concerned? Yes. Yes. Yes. Yes. Your body is meant to
00:00:05
work like clockwork. And our monthly cycle is so much more than getting ready to have a baby,
00:00:11
especially when we're looking at exercise. And it's important to say if you don't have a period, it's very
00:00:17
harmful to long-term health, brain health, mental health, low energy, mood, and libido. And I don't want the younger
00:00:23
generations to have to go through the stuff that we've gone through. So, it's an important discussion that we need to have. We are joined by four leading
00:00:29
female health experts from very different fields to have a crucial conversation about women's health. With over 80 years
00:00:35
combined experience, they're sharing the truth about what every woman and every man needs to hear. We asked a thousand women to submit
00:00:41
their questions ahead of this conversation. And I got so many questions around fertility, understanding hormones, PCOS, birth
00:00:47
control pill, miscarriage. And I'll say this, Stephen, it's because we haven't had these discussions publicly. When we look at funding in
00:00:53
women's health, it's horrible. like less than 1% is spent on women over 40. Women are living 20% more of our lives
00:01:00
with chronic disease or mental health disorders. I mean 50% of patients with unexplained infertility have indometriosis. But yet it takes women 7
00:01:07
to 10 years to get a diagnosis after symptoms start. But also there are things that we do that will inherently
00:01:12
harm our fertility because we're not taught this and it predisposes you to many medical problems later in life.
00:01:18
And patients will say but I have a really high pain tolerance like it's a badge. And so they gaslight themselves.
00:01:25
And that's what we're all trying to fight here. But there are a lot of things we can do to deal with this. And then I want to talk about menopause.
00:01:31
So in medical school, menopause just gets shoved into a tiny box. This is a scary statistic. So Oh my god,
00:01:38
it's crazy. I just think it's insane. This is why we need to create change. This might be one of the most important conversations we ever have on the diio because women's health has long been a
00:01:50
total mystery to so many people and so many people are struggling with all of the issues that we're going to talk about today with their menstrual cycles,
00:01:56
PCOS, endometriosis, with diet, with understanding how to exercise as a woman. It's probably never going to be the case again that these four individuals that at the very top of
00:02:06
women's health in their fields will be in the same place at the same time having this conversation. We structured
00:02:13
this conversation into two parts. They cover completely different subjects, but they're fundamentally interlin. For me,
00:02:20
the understanding that I got from this conversation at this table with these four women has fundamentally changed my
00:02:26
life. It's going to change how I deal with my romantic partner, my sister, my team members that I work with every
00:02:32
single day. And funnily enough, because it's a conversation I wouldn't have clicked as a man, it turned out to be
00:02:39
the conversation that I needed the most. And I don't think I've ever said this before, but if there was ever an episode
00:02:44
to share with a loved one, then this is that episode. Please share this episode with as many women as you can, but also
00:02:51
with as many men as you can. [Music] Ladies, we should start with some introductions. Could you give me a brief introduction, Stacy, as it relates to
00:03:03
your perspective and your experience and what your sort of bias is as it comes to this debate? When I say bias, I mean
00:03:08
your your your experience and your your research that you're lending to this conversation today.
00:03:14
I come from the exercise fizz and sports med background. Um, so I'm always looking through the lens of activity and
00:03:21
nutrition and how that has a impact on our stress and our stress outcomes and how we can adapt to specific applied stressors especially when we're looking
00:03:32
at improving health span, improving mood, improving body composition, all of those things. I've worked with and still work with uh the subset of active women.
00:03:43
Um, I come from an endurance and a high-profile high performance sport background. So, that's where I've gotten
00:03:48
my chops and then brought it over into the general recreational female athlete kind of perspective. Natalie, I'm a fertility doctor and every day I help patients with IVF get pregnant
00:04:00
because I have an IVF clinic. But my big passion has always been natural fertility after I experienced my own
00:04:05
pregnancy losses. trying to understand how we interact with the world and how that changes our hormones and help women
00:04:12
understand what their hormones are, what natural fertility is, what happens as we age to our bodies, our eggs and our
00:04:19
hormones, and let them be better stewards of their own fertility and their own health decisions.
00:04:25
Mary, I have a background in general OBGYn, so I'm considered to be a women's health
00:04:31
specialist. And it wasn't until I kind of went through my own menopause that I realized that there was significant gap in my training. You know, hearing watching Dr. Sims on um I think your
00:04:44
podcast talking about how women are not little men really struck such a chord with me and made me realize I was
00:04:50
siloing women's health to the reproductive organs, the breast, the uterus, the ovaries, the vagina and that
00:04:58
if I really wanted to make a difference in a woman's whole health life, this last 30 years, 30, 40 years of her life,
00:05:04
I needed to refocus what we were thinking about women's health for the long term. So I come from
00:05:11
a background in academics. I was a professor for 20 years. I was a residency program director. Stepped away
00:05:17
from that so I could focus on the lack of my own education and knowledge in menopause care. And now I want to step
00:05:23
back into the academic world to bring everything I've learned and change the way we educate our providers. Vonda
00:05:30
I am a orthopedic sports surgeon by training and I sit at the unique juxtaposition of orthopedics and
00:05:36
performance having taken care of elite athletes most of my life aging and longevity most of my academic research I
00:05:44
too as an academic is on subjects of muscularkeeletal aging but many years ago added a third circle of the whole health of a woman and so sitting in this place it fits directly into the mantra
00:05:57
of my career which has always been I am going to change the way we age in this country and the world because the tool
00:06:04
that I bring to the table is the fact that if I save your mobility I'm going to save you from the ravages of chronic disease and so the work that I do is not
00:06:15
only educational it's uh research and it's now education of the world about these subjects explain this to me like I'm an idiot ladies why do we need to have a conversation about women's health and
00:06:27
not just health broadly. I think the statistic that people don't realize on a day-to-day basis is that
00:06:33
women are 51% of the population. We're actually not a minority. We're the majority and yet often our health, our
00:06:41
healthc care access, the research treats us as if we're a niche product, but we are the majority product. We have to have this conversation
00:06:53
because data show that of the $450 billion dollars spent on research in this country alone, less than 1% is spent on women over 40.
00:07:05
And yet we are nearly 90 million people. And we make 80% of all the health care decisions in this country for ourselves and everyone we touch. And so even
00:07:17
though when you look at the the long-term data, women are winning the longevity race here. We're living an
00:07:24
average of 6 years longer than men. But as all of us talk about all the time, women suffer longer.
00:07:30
Yeah. We're living 20% more of our lives versus our male counterparts in poor health with chronic disease or mental
00:07:38
health disorders. And so McKenzie looked at the data and it was for the Gates Foundation and what they found was yes,
00:07:45
we live longer. We've all known that. However, we have, you know, twice as high of mental health disorders. We're two times as more likely to end up in a nursing home. We are much more likely to
00:07:57
lose our long-term independence from frailty or dementia, much more than our age matched male counterparts. And
00:08:03
that's I think what we're all trying to fight here. And diseases that impact women specifically and only things like
00:08:09
PCOS, endometriosis are extensively underfunded and not researched. It takes women 7 to 10 years to get a diagnosis of endometriosis after symptoms start. And we know this is a disease that
00:08:22
impacts your entire body in addition to your fertility. But women are dismissed.
00:08:27
They're not taken seriously. and there's not research guiding what we can do in a
00:08:33
lot of these situations to try to help them the best. Why isn't the research there? Why why don't they research if women are the
00:08:41
majority of the population? Why is all the funding going to researching men? You have to think about who was in the
00:08:46
room when medicine and science first started. So if you think about back when the industrial revolution and the
00:08:53
modernization of what we know is medicine, women were pushed out because they were believed to have smaller
00:08:59
brains. thanks to Darwin and not thought to have a seat at the table. So when you're thinking about designing studies, it was pretty much designed on the male physiology on the male body and then
00:09:10
women were an afterthought. So there wasn't any real in-depth look of well women are different from birth or in
00:09:17
utero XX is different from XY. So all the research has just been generalized to women. Even things like aspirin for heart attacks and thinning blood
00:09:28
inhibitors. Yeah, all of this all of this was done on men and then just generalized to women and now that we're
00:09:34
having this global conversation on women's health, people are like, well, where is the information specific for
00:09:40
women? And there's just a very small subset. So, we're looking and trying to expand that, but we have a lot of
00:09:46
catching up to do. And that's primarily not only because of what you said, but the shocking statistic is that not until
00:09:53
1993 were women required to be represented in studies. 1993, I mean, we were all far into our our lives in research by then.
00:10:05
Isn't that a shocking? That's crazy. And there were still loopholes where people were finding ways to exclude women and then
00:10:11
right, we're still not at 50%. No, we're harder to study. You have menstrual cycle, hormonal fluctuations,
00:10:18
even menopause, pre even the animal models. It's not that we're harder to study. It just makes it presumed harder to study.
00:10:24
There's more variables at play, right? It's more of a complexity to the research, but it's not more difficult. And this is where I bring it in. It's like if a woman had a seat at the table when all the study designs were started,
00:10:36
it wouldn't be a question. It would just have been assimilated in. because we've been so drawn into we have a crossover,
00:10:43
here's one week crossover, next week because of male physiology. When you add women's hormone fluctuations and people
00:10:49
like, "Oh, it's too complex." Right? But it's not. What is it that makes, and this is a super dumb question, but an important
00:10:54
one. What is it that makes men and women different from a physiological standpoint? Because to understand why
00:11:00
research would need to be done separately, we need to understand the differences. Yeah. Well, I mean, we can look from a
00:11:06
morphological standpoint where men have more of our fast twitch fibers. Women are born with more endurance fibers, which is muscle, right? Uh when we're talking about muscle. Yeah. So, uh men have more of the
00:11:19
ability to do power and and really fast energetic type activities or women are more attuned to endurance type activities. And this affects metabolism. It affects blood glucose homeostasis.
00:11:32
And when we're looking at bone and bone density, men have stronger bones. Uh they can acquire more load. They hold on
00:11:39
to it better than women do. We see smaller lungs, smaller heart, less hemoglobin in women than men. And that's
00:11:46
an offshoot of what testosterone does. So there are just basic physiological differences between XX and XY that people don't really assimilate and
00:11:57
understand. And the way I like to say it is you go into a shop and you have a men's section and a women's section and
00:12:02
there are touch points on the external that really identify gender andor sex. But when you look intrinsically no one is identifying those touch points until now. Also when we look at how we disease
00:12:15
so in cardiovascular disease is is aththeroscerotic disease is the best example. Men tend to have their
00:12:22
blockages. So aththeroscerotic disease is basically the plaques that build up in the coronary arteries around the
00:12:27
heart. Men tend to develop their plaques very early right as those arteries exit
00:12:32
the aorta and dive into the heart muscle. So we get what we call the widowmaker. Okay? It's called that for a
00:12:37
reason because men die and they make a widow. And so that's the left anterior descending artery. Women by and large
00:12:44
tend to not have these larger artery blockages, but their blockages are diffuse and microvascular deeper into
00:12:51
the heart muscle, which is why we present with a heart attack much differently than a man does. And those
00:12:58
we're not teaching our, you know, we're not educating our clinicians as to these differences. Women are considered to
00:13:03
have atypical chest pain. Dr. Wright, 51% of the population is female. Why are why is my heart attack atypical
00:13:10
and a man's typical? But this happens not only at the organ level. It makes sense that if we have a population with XX chromosomes, a population with XY genetically and the way we express those
00:13:24
genes are differently. But I think we miss the fact that down to a cellular level, every cell from an XX is expresses these tissue changes, tissue
00:13:36
manifestations differently than an XY. Our lab used to study, we called them muscle derived stem cells so 20 years ago. Now they're called satellite cells. But when we harvested them and asked
00:13:47
them to behave and in different environments, satellite cells from XX people and XX
00:13:55
animals, women, females were better under the same circumstances experimentally at making cartilage and muscle. XY male
00:14:08
were better under the same circumstances in making bone. So down to a cellular level, we express our genes differently. It should be no mystery to us or anybody else that there are differences. And yet
00:14:22
there is the propensity just to lump us all in the same basket and almost say I almost sometimes feel as pjorative to say, oh the women are different. Of course they're different. Yeah,
00:14:34
we're genetically different down to every cell in our body. Every cell. So, it should be no surprise to anybody, but it it seems to be a
00:14:40
surprise. Seems to be a surprise all the time. Yeah. I get pushed back all the time. There's no difference. Yes, there is.
00:14:46
There is. And it's not just bad. It's just is. Yeah. There's Yeah. Because at one point that was quite a controversial thing to say, wasn't it? To point at the differences between men and women. Mhm. Outside of, you know, our different
00:14:58
organs. Yeah. You know. Yeah. And because of this research gap and the bias in medicine, um, women have
00:15:05
been misunderstood by their male counterparts in a number of ways. I remember I think it was you, Mary, that was telling me about this whiny women
00:15:11
thing that you were exposed to. When I was in training and and you all may have similar stories and I just
00:15:17
heard a new one the other day, my first patient in gynecology clinic, I'm an intern. I'm very excited. You know, we
00:15:23
have our stacks of charts. That's how old I am. We had paper charts. I pick up the chart, open it up. It's a 40-year-old woman with multiple vague
00:15:30
complaints. She's gained some weight. She's a little bit depressed. Her libido is off. Her blood pressure is a little
00:15:36
bit up. Her cholesterol is starting to rise. And she's seen family medicine. Like we're the third or fourth doctor at
00:15:41
this point. And so my upper level who happened to be male this, you know, it could have been anyone. Walks down the
00:15:47
hall in his cowboy boots cuz Texas. And um and he's like, "What you got?" And I said, "Well, I have Miss Smith,
00:15:53
whomever, you know, she's a 40-year-old woman with." And I list the complaints. And he goes, "Did you check her thyroid? Family medicine did. Did you check this,
00:15:59
you know, a few simple labs?" And he goes, "Hm, you got a WW." And I said, "What's I don't know this, you know." And he said, "Uh, don't write this in the chart, but we call that a
00:16:12
whiny woman around here." Oh my gosh. And I said, "Okay." He said, "Listen, women just tend to go through this at this age, and we're not really going to
00:16:23
be able to help her. pat her on the knee, tell her to have some wine, go on date night, you know, she'll get better,
00:16:29
but we're not going to be able to help her. And that stayed with me. Now, I was, you know, a good girl. I did what I
00:16:35
was told. You know, it took me 20 years of internalization to realize this, you know, I don't want to blame him. He's not a bad guy. This was taught to him. But this kind of thinking, I mean, I saw
00:16:47
this in the ER. I saw this in the O. I saw this in every clinic. And so I've asked other clinicians around the
00:16:52
country and I've heard whiny gyne status Hispanicus total TBD total body delore like in different regional areas there was a name for this kind of vague complaints from this middle-aged woman
00:17:05
and we couldn't quite put our finger on it and I realized this was systemic bias
00:17:10
built into the system where women and there's historical you know precedent for this the wandering uterus the
00:17:16
hysteria you know these were real medical terms just until like not even a generation ago.
00:17:22
Yeah. They used to put women into asylums. Yeah. Because of hysteria and it was hot
00:17:28
flashes, all the things that that are now known with permenopause. They used to think it was some kind of insanity
00:17:34
and put women into insane asylums to lock them down. But this is pervasive. Not just an OB.
00:17:40
You're not the only guilty. It's every medical subsp specialty has some culture of for lack of better words blowing women off it right. We're not having the
00:17:54
curiosity that defines medicine. We are supposed to be curious people. But yet when it comes to this, why do we stop at just seems to be something that happens to middle-aged women, right? it that
00:18:06
that's written in the orthopedic literature seems to happen to middle-aged. Where's the curiosity?
00:18:13
Where was it? Yeah. Well, in X-fist text, you always had the representative of him or they
00:18:18
and the vuvius man and all the angles of the male body, but there was never representation of women. The only time
00:18:26
you heard about a female athlete was all the pathophysiology. You know, the iron deficiency, the female athlete triad,
00:18:32
which we now call um relative energy deficiency in sport. And when you're looking at the
00:18:38
historical idea of sport, the only way women were actually included and accepted is when they were amenic because then they were quote more like men and then there wasn't a problem with
00:18:49
training them and then they could work as hard. But we know that that's not appropriate. That's a sign of of illness
00:18:55
and overtraining under recovery. So, it is pervasive everywhere. It's not just the medical, but it goes into when you
00:19:02
think about what it means to be successful in sport. It's the power. It's the aggression. It's the unfallibility of being human. And a
00:19:09
woman having a menstrual cycle was deemed a fallibility. So, they're trying to push it aside. This is so systemic
00:19:15
though that women downplay their own complaints. They gaslight themselves. It takes them a long time to seek care because they're afraid of the response. They are not always honest with what's
00:19:28
going on in their body. I'll say, "Do you have pain?" "Oh, no more than regular." They downplay everything. You
00:19:33
have to really ask. And it's almost the society, I don't want to be viewed as this way. I don't want to be not taken seriously. And it causes them an to have
00:19:44
an even harder time to get to a diagnosis because they don't feel comfortable sharing some of these symptoms or they've downplayed them in
00:19:50
their life so much. This is why they have to get so sick to often present to even try to get care. And they come to
00:19:58
me almost to a woman after I'm talking about whatever muscularkeeletal thing they'll say even before they want to describe it to me. They'll say, "But you know, I have a really high pain
00:20:11
tolerance." Yes. Mhm. Like it's a badge because we've been conditioned to not come for any pain.
00:20:17
But I've suffered. I've tried. That's why your arm doesn't move anymore. I've got such a high pain tolerance, but I
00:20:23
couldn't take it anymore. I didn't want to come. And I feel like why does it have to be that way?
00:20:30
So, you train treating both males and females. I I was locked in a room with women for 25 years, you know, and so
00:20:37
it's so fascinating to me to hear how men and women come in with the same complaint in your clinic, in your fellowship, all those years you spent training, and yet you were taught to
00:20:49
treat them differently, you know, and the urologists say the same thing, you know, who I don't think I was aware of it.
00:20:54
Yeah. There was just that's so much bias. Yeah. I didn't realize. I didn't either
00:21:00
because like you, until I went through my own pmenopause, I might not have paid it attention to
00:21:07
it. Yeah, I may have been less sensitive. I was a terrible menopause. I see messages all the time in the comments section that some of you didn't realize you didn't subscribe. So, if you
00:21:18
could do me a favor and double check if you're a subscriber to this channel, that would be tremendously appreciated. It's the simple, it's the free thing
00:21:25
that anybody that watches this show frequently can do to help us here to keep everything going in this show in the trajectory it's on. So, please do
00:21:31
double check if you've subscribed and uh thank you so much because it's strange where you are you're part of our history
00:21:37
and you're on this journey with us and I appreciate you for that. So, yeah, thank you. Is that in part because we know very little about hormones as well. When
00:21:44
I was speaking to our audience, we asked a thousand women to submit their questions ahead of this conversation. And one of the most asked questions, all
00:21:52
the most asked questions sort of related to understanding hormones. I think the conversation around hormones is quite a new one in society and I actually think it's been driven a lot by a heightened
00:22:03
understanding of menopause generally. I think the the conversation of hormones around outside of fertility and the
00:22:11
general menstrual cycle. I can right now draw from memory the exactly what's going to happen in a normal menstrual
00:22:16
cycle. We were taught that, you know, very very well. But when I saw maybe 3 years ago an academic paper that showed all of the locations of the G-coupled
00:22:28
estrogen receptors in the human body, what's that? I lost my mind. So basically, where are
00:22:33
the estrogen receptors in the human body? And they're everywhere. The brain, the bones, the muscle, the gut, you
00:22:39
know, the the every almost nothing. The the the endothelial, the lining of the individual blood vessels around our heart, you know, it's really radical to me to think about how all these sex
00:22:52
hormones are the progesterone, estrogen, testosterone, hormones are everywhere. What is a hormone? They're not actually sex hormones. hormones are your body's communication system, right? So, it is really how your
00:23:03
body is sending out messengers to communicate. So, a hormone is dictating an action and I think there's going to
00:23:09
be a lot of great discussion. But one thing that I think is very important to your point, Stephen, is even things that
00:23:16
we were readily taught about the menstrual cycle and estrogen, progesterone, testosterone, the public
00:23:21
is now becoming aware of because we've not done a good job at public education that this is what's really happening in
00:23:26
your body. this is what your menstrual cycle is. This is what happens when you go through menopause. This is what
00:23:32
happens when you're trying to train for a sport. We haven't had these discussions publicly that we are seeing.
00:23:39
And I think that is highlighting interest in all of this even if some of us were taught some of this. But when it
00:23:46
comes to hormones there, everybody wants really easy fast. Draw my level. Tell me
00:23:51
what to do. Give me a medicine. Fix it. And I think the most important thing to understand is that by definition, your
00:23:58
hormones are dynamic. Your body is responding to the hormonal signal it sees and determining what next signal to
00:24:06
send out. So constant fluctuation throughout the day in response to multiple stimuli. And that's how it's
00:24:13
supposed to be. If we didn't do that, we'd all be dead. It's a symphony. But that makes it really hard for somebody to understand
00:24:19
on the other end who's not in medicine who says, "Well, is it my hormones?" Because there's no one test that's going
00:24:25
to give you one answer. You have to really interpret it in context of the full body. And it makes it really hard
00:24:31
for practitioners who do not understand the hormones as well. And we see a lot of mismanagement of hormonal scenarios
00:24:37
and situations right now that are actually detrimental to patients. So, I'm glad you're having this discussion
00:24:43
because that's not a stupid question. What is a hormone? Many people don't really understand that.
00:24:48
What is the I really want to make sure that if someone for both the men that probably have less understanding but also from our conversations I've
00:24:54
realized and the feedback I've gotten a lot of women don't understand their own hormones and their own menstrual cycles.
00:25:00
What is the most basic level that we have to start at to give people an understanding that we can then build on
00:25:06
of what's going on here? I was say I want to get rid of this graph. Okay. So that leave it out. Leave it
00:25:13
out. But it it shows just a textbook of what a menstrual cycle is is, but it doesn't show the daily perturbations of estrogen and the luteinizing hormone pulses and all the things that go as
00:25:26
Natalie is saying to make it to make it work. You see two organs there, the ovary and the endometrial lining. You're not
00:25:33
seeing the muscle, the bone, the brain. All of those organs are affected by these normal monthly fluctuations.
00:25:40
Yeah. And the conversation that we're having now in research methodology is the fact that there is no real definition of normal cuz every woman's cycle is variable. So when we look at
00:25:52
this, everyone thinks that this is normal but we don't actually know if that is for the fact that a woman's
00:25:59
variation this can change cycle to cycle. This can change cycle to cycle. Sometimes we have
00:26:05
an ovulatory cycles. So until a woman can identify what her own normal is, we can't rely on this graph to actually explain to them. How does a woman know what their normal is versus, you know, because a lot of
00:26:17
women are on birth control pills since a very young age. So I think my partner Melanie, she's she was on birth control
00:26:22
for about a decade. So she like didn't have her cycle and then it came back and it was every I don't know 60 90 days.
00:26:28
Mhm. And then she changed her diet a little bit and it kind of went down to 30 days over time. But I don't think she knew
00:26:34
what normal was. Is there such thing as normal? I mean there is what should be normal for you. So you should have a regular
00:26:41
predictable period which means that you are having a menstrual bleed at a predictable interval. It can range
00:26:46
person to person but for you really it should be within a couple days monthtomonth. I always tell patients I
00:26:52
should be able to give you a calendar. You should be able to take your finger pick when your next period is coming and within a few days be accurate. Now
00:27:00
usually that range is somewhere between 25 and 35 days for the average person. when it starts to get shorter or longer,
00:27:06
it can be a warning sign that something is going on. When it comes to the menstrual cycle, because I think we're
00:27:12
going to talk about these hormones really well, and I talk about this every day, let's give a one minute
00:27:18
explanation. If we think about to Stacy's point from the brain, the brain is sending out pulses of hormones, but
00:27:24
FSH drives egg growth. It's called follicle stimulating hormone, and each egg is inside a follicle. So, you have a
00:27:30
group of follicles inside the ovary. FSH comes from the brain, grabs one of them and gets it to grow and it makes
00:27:36
estrogen and this estrogen from the ovary as the egg is growing is called estradiol and it's the primary type of
00:27:42
estrogen in your body. So it is rising and when it gets to a peak level and the body is so fascinating because it's 200 pogs for 50 hours is a very exact amount. Then the brain says we must have
00:27:54
a mature egg and it kicks out a surge of luteinizing hormone or LH and that is going to allow the follicle to rupture the egg to be released and the follicle to reform and then become a corpus
00:28:06
ludium and then the brain's going to send out pulses of LH giving you pulses of progesterone. So Stacy's point
00:28:13
that's an average and those numbers on the little graph are nowhere near accurate because progesterone goes up
00:28:18
and down the entire second half of the cycle known as the ludial phase. What's progesterone? Progesterone is also made from the
00:28:24
ovary. So, the two main hormones when it comes to a premenopausal female are going to be estrogen and progesterone.
00:28:31
Progesterone is the progesterational hormone or progreg. It is going to change the endometrial lining and it is
00:28:38
essential to get pregnant. It opens and closes the implantation window within the uterus and it completely changes the
00:28:45
physiology of your body. And we're going to talk a lot that is why in the ludal phase your body works differently when
00:28:51
you have progesterone and the lutial phases after ovulation when you have a corpus ludium. So when LH is coming from the
00:28:58
brain you have a corpus ludium it makes progesterone. This is the second half of the cycle known as the ludal phase. The
00:29:04
first half when you have estrogen only is the follicular phase. So you have an estrogen dominant phase and then you
00:29:10
have a phase where you have both estrogen and progesterone. And your body is made Yes. So we have our estrogen
00:29:16
dominant phase, the follicular phase, and then we have we have both estrogen and progesterone here in the ludial phase. And your body is made to function
00:29:23
differently in these because in the progesterone side, it's preparing you for a pregnancy. It thinks every month
00:29:28
you might get pregnant and it starts to change how your body's going to work on a cellular level. But if you don't get
00:29:35
pregnant, that progesterone level is going to drop and the cycle starts back over. And from um like a exercise and sports
00:29:42
Yeah. point of view. When we get into this, the progesterone's job is to build this lush endometrial lining and it
00:29:50
creates a lot of glycogen storage. So, we often hear about glycogen in the muscle and that's what we're using for
00:29:55
fuel. It has a way of shuttling a lot of the carbohydrate away and storing it into the endometrial lining, which is why we see differences in intensity and the way that a woman can respond to
00:30:08
exercise if she has ovulated. So is this in preparation of a potential baby? Yeah, correct. Yeah. In the second half of the cycle, your core body temperature increases, your resting heart rate is
00:30:20
higher, your heart rate variability is lower, you have increase in fatigue, you have an increased appetite, your body is
00:30:27
shifting function in case an embryo comes in so that it can start to divert energy and change what it is doing right
00:30:34
down to your immune system changes. And that's roughly from day 14 roughly. Roughly. Yeah. Yeah. At ovulation, it's
00:30:40
about 3 days after whatever day. If you'd like to be specific, it's about 3 days after ovulation until when you get
00:30:45
your next period. Yeah. You all talk about how our menstrual cycles can be a broader sign of whole
00:30:51
body health. Mhm. And um so should if someone's menstrual cycle is irregular, should they be
00:30:57
concerned? Yes. Yes. I thought you were going to say no. How irregular? What's like if I'm not getting my menstrual cycle? Absolutely not good. You should go see a
00:31:07
doctor. Yeah, if your cycle is irregular, if the calendar trick, you're putting your finger and it's nowhere
00:31:13
near when your cycle's coming. Or I have women who say, "Oh, there's no way I could predict it." Or, "I know it will
00:31:18
come, but it'll come every 4 to 6 weeks." Your body's meant to work like clockwork when it comes to your your hormones and your menstrual cycle. And yes, you can always have one abnormal
00:31:28
month, always. But when you consistently are having irregularity, that is a sign
00:31:34
that something else is going on. It's one of the biggest red flags that we have for early hormonal health or
00:31:39
systemic problems. But to your earlier point, Stephen, we have a generation of women on contraceptive options who are
00:31:45
not tracking their cycles. We have women who are not taught how to track their cycles. They don't know when ovulation occurs. They don't know how long their
00:31:52
ludal phase is. If I say the first sign of ovulatory dysfunction or having a problem with your cycle is a short ludal
00:31:59
phase, well, you only know that if you're tracking when ovulation occurs because otherwise you could still have a
00:32:05
regular cycle, but you don't know that something's abnormal. And that lut your phase again is the last the last half of your your cycle.
00:32:13
Exactly. But I think that the conversation that's happening now is so not just at this table but in society
00:32:20
that our monthly cycle is so much more than getting ready to have a baby because I think that none of us knew this. No. Because at 17 I wasn't that interested
00:32:33
in having a baby. So it didn't occur to me that I should care. Right. Right. And it's the only time if you're
00:32:40
thinking about it in that way that you're worried about your period is if you don't have one and pregnancy, right?
00:32:46
And so if we're shifting the conversation to this is physiology, this is has to do with every part of female physiology, maybe it will be easier for people to
00:32:59
know, right? Yeah. I often put it with u my athletes that it's a marker of health that if you
00:33:05
are able to take on the load of training, the load of travel and maintain your normal menstrual cycle,
00:33:12
then you are robust enough to be able to progress. But if there becomes a misstep
00:33:18
in your menstrual cycle, then we need to look at all the stressors that are and the allosic load and pull you back and
00:33:25
see what do we need to address? Do you need to eat more? Do you need to recover more? what are the things that are
00:33:30
missing to bring you back to normal? I was diagnosed with polycystic ovarian syndrome in medical school and so like
00:33:37
every medical student of course it was like gloom and doom and I you know thought I had the most extreme case ever
00:33:42
known to mankind. It was really just garden variety PCOS and I had very serious boyfriend quickly engaged you
00:33:49
know looking forward to having a family with him starting a family with him and the terror around my infertility and
00:33:56
what the impact was. What was never taught to me and what I didn't understand until much later was the
00:34:02
metabolic impact. Like PCOS is a symptom. There's nothing wrong with my ovaries. They're just responding to this
00:34:08
high insulin level I was born with. And no one really sat me down and talked to me about my first research project was
00:34:15
women with irregular periods and the risk of developing gestational diabetes and and you know I didn't even know what
00:34:20
insulin resistance was at the time. And now we're coming to understand that, you
00:34:26
know, when these young women are coming, you know, I only do menopause now, but before I left that practice, you know,
00:34:32
when women were coming with the regular cycles and we were making these diagnosis, immediately I was launching into the discussion about her metabolic
00:34:38
health long term and what this, you know, it's a gift to know this. So now we can start making interventions,
00:34:44
nutrition, diet, exercise to give you a better system to deal with this thing that you were born with and her fertility. Of course, a huge amount of women have PCOS and I think that's one of the leading one of
00:34:56
the leading one of the top causes of having irregular menstrual cycles. You you mentioned insulin resistance and
00:35:04
metabolic dysfunction there. And you said something like diabet gestational diabetes, diabetes in pregnancy. So someone who
00:35:10
was non-diabetic before pregnancy and then develops diabetes. So her blood sugars have now reached a threshold where they are higher than normal and can cause you know problems for her
00:35:22
pregnancy and herself long term. And up to 50% of those patients de who develop diabetes in pregnancy will develop type 2 diabetes within 10 to 15 years after
00:35:33
that gestation after being pregnant. And so what we know now is like we have warning signs of this well before
00:35:40
pregnancy where we can set these women up for success. Before it's just we wait till we make the diagnosis, everybody
00:35:46
gets their glucose test and off you go. But now with this PCOS diagnosis, we are
00:35:52
monitoring earlier. We're starting her on the nutrition. You know, we're treating her like a diabetic with nutrition and exercise recommendations
00:35:59
rather than waiting till she she reaches the criteria. Stephen, having infertility, this is a scary statistic.
00:36:05
It predisposes you to many medical problems later in life, including an 80% higher chance of having a heart attack, 75% higher chance having metabolic syndrome, higher risk of cancer, and
00:36:17
early death. Why infertility? Well, it's not exactly that infertility is causing this, but it's that for many women,
00:36:24
we'll use Dr. Haver's example, you're healthy until you get this diagnosis. It's one of the first warning signs your body's giving you that there might be inflammation and insulin resistance or
00:36:35
something impacting your hormones, your menstrual cycle, your ability to conceive that if it is not corrected now
00:36:43
is setting you up for many problems down the road. PCOS is a example of this because in PCOS you have a lot of eggs inside the ovary. It's actually something that genetically runs in
00:36:56
families. likely there's something that happens when you're a baby inside your mom that predisposes your ovary to not
00:37:02
lose as many eggs as it should and it changes how they respond to insulin. So what happens is you end up having more
00:37:09
eggs on an average. Your brain doesn't know this and sends out the average signals but that gets diluted amongst
00:37:16
all the eggs and so you're not getting into these ovulatory stages of Stacy's favorite graph here. Well, what happens
00:37:22
from there is that you're actually in a relatively lower in estrogen phase than you should be. You never see the
00:37:28
progesterone. And what happens is you start to completely shift. The ovary itself actually becomes insulin
00:37:34
resistant. And what this means is that throughout your entire body, you start to develop high glucose, which is the blood, right? That's your blood sugar. Your blood sugar is the fuel for all
00:37:46
your cells. All your cells need glucose. Well, insulin is the hormone that helps that glucose go from the bloodstream
00:37:51
into your cells. Well, in insulin resistance, when your body sees high glucose all the time, it starts to send
00:37:57
out more insulin saying, "Hey, we need to get this into cells, but the cells start to, oh, I'm used to insulin being
00:38:03
here, so I'm not going to respond." It's going to take a higher insulin signal to get the cell to open up the door and let
00:38:10
glucose comes in. This becomes very problematic especially in we'll say PCOS because that insulin is very inflammatory causes you to get extra fat stored in different places. It also just
00:38:23
completely changes how your body your metabolic health in general but also your hormonal health and in your brain
00:38:29
because your brain sees this and says why are we keeping glucose in our in our bloodstream is what's going on heightens
00:38:35
everything. And so this resistance to insulin actually shifts how your brain's going to respond to hormones, therefore the hormones it's sending out. And it's a self-perpetuating cycle. And a lot of
00:38:47
when we talk about lifestyle mechanisms to improve hormonal health, which I know that we all will, a lot of that is
00:38:53
targeting improving insulin resistance and combating inflammation because those two players, a lot of it is controlled by the world around us and what we do to
00:39:04
some degree. And especially if you have an underlying diagnosis like PCOS, endometriosis, which is a chronic
00:39:10
inflammatory disease, autoimmune disease, you're at even higher risk. I always say your scale is already tipped
00:39:16
in a way that's going to be really hard for you. You have to make active steps to fight what is happening inside your
00:39:22
body. We'll talk about some of the ways one can reverse their PCOS, if that's even a possibility. Um, but again on the causal
00:39:30
factors, is it something So my girlfriend's got PCOS. She's been very public about that. Um, is it something
00:39:36
she did? Is it something she ate? Is it She was Is this the way she was born? So, she was born with a predisposition
00:39:43
of having too many eggs. You lose most of the eggs inside your body when you're a baby inside your mother's womb. You lose the next biggest set before you
00:39:50
ever have your first period. Now, if you don't lose them for some reason, you're born with more and it interferes with
00:39:57
how your hormones are supposed to communicate leading to this metabolic issue and this insulin resistance. She
00:40:04
did nothing to cause this. Nobody with PCOS caused it. However, what you said earlier, oh, she changed how she ate and
00:40:09
her cycles got more regular. You can influence the severity of the symptoms that you experience with it. So even if you don't cause your disease cuz you did not,
00:40:20
choices you make can make it absolutely can make it better or worse, just like any disease.
00:40:26
And when you use the word insulin, I I think of or insulin resistance, I think of sugar. Mhm. Yeah. Because glucose is sugar
00:40:32
essentially. And many people, and I'll have patients tell me this, I don't need to worry about insulin resistance
00:40:37
because I don't have diabetes or it's not in my family. And we've so we've ingrained this word insulin resistance
00:40:44
or talking about glucose or checking glucose with a diabetic or pre-diabetic state. But the world around us honestly
00:40:52
promotes insulin resistance. It's it that's how our bodies we live in this obesogenic environment. I mean there's no doubt at least in the US you know and
00:41:03
most industrialized nations our environment is what we call obesogenic insulin you know and insulin resistant
00:41:10
so it you have to fight against kind of the systems that are in place now for most of us unless we have some genetic
00:41:17
predisposition to just be you know magical um to because the way we process food the way food is delivered to communities the way you know our lack of exercise you know everyone's working
00:41:28
from home now just just modern life is is really you have to fight against. One of the questions that came in from the audience was I would like to know how best to manage my PCOS.
00:41:39
When it comes to managing your PCOS, targeting those two factors that we talked about earlier, insulin resistance
00:41:44
and inflammation are really the key. And I'll let these two speak to a little bit of some of the exercise changes that we
00:41:51
can try to impact. But what I'll say is that the best way to decrease inflammation in your body is going to be
00:41:58
to start by focusing on your gut. Your gut health controls a lot of the inflammatory burden that your body sees.
00:42:04
The foods you choose to eat, they can be both helpful if they have a lot of fiber in them. They can feed your gut
00:42:11
microbiome, which is important in estrogen metabolism, but they can also be very harmful if they are ultrarocessed foods that are even causing more inflammation, not feeding
00:42:22
your gut microbiome at all and worsening. So, I always say it's like a scale. If you think every little food I
00:42:28
eat, it can make my insulin or it can make my inflammation better, it can make it worse. And so how we structure the
00:42:35
food that we put in our body is one of the biggest changes the majority of people can make that is going to make a
00:42:41
difference. And that's going to be a very plantforward diet. Doesn't mean it's plant only, but plants have fiber.
00:42:48
Fruits and vegetables have fiber. So we have to make sure we're getting fiber as
00:42:53
a big change. That's what we see. I see a lot of patients with PCOS specifically being told I shouldn't eat fruit. I
00:42:59
shouldn't do this. I I need to avoid do the ketogenic. You need to do keto. Yes. So, we see people avoiding certain
00:43:06
food groups. And I always say it's not a really sexy diet, but it's a it's a diet we all know. Lots of whole foods, fruits and
00:43:12
vegetables, healthy fats, healthy sources of protein, avoiding the ultrarocessed foods. That's going to be
00:43:18
probably the biggest change most people can make. In addition to foundational changes of your day, which is going to
00:43:23
be sleep more, that is when your body fights inflammation, fights insulin resistance. work on decreasing chronic stress. To Stacy's point, you're not
00:43:34
running from the bear. So, your body is not using that challenge, but you get a email. You get stressed and your body releases a lot of glucose so it can have
00:43:44
sugar and fuel to run from a bear and there's no bear, right? And previous days that would happen and then you'd go
00:43:50
run and that glucose would go into all of your muscles and your body would go back to normal. But now, we're
00:43:56
chronically stressed. So, actively decreasing stress and then exercise, building and using skeletal muscle is one of the most effective ways to combat insulin resistance that exists. And
00:44:08
since 80% of patients with PCOS have insulin resistance, a large portion of women with infertility, even without PCOS, have insulin resistance, that is a
00:44:18
huge thing that people are missing, especially when it comes to the exercise discussion. And I know you guys probably
00:44:24
have things to add on that one. No, but based on what you just I just took a phone call this morning from a patient
00:44:30
when and it's just such a typical conversation. She doesn't like the way her body looks. Her solution is not to eat. It's this
00:44:41
happens almost every day when I'm talking to people. It's we're having coffee for breakfast. We don't eat till
00:44:47
midday when we do eat. So the the gut reaction because of the way many women are raised is that we're going to starve ourselves which is the opposite of good when it comes to physiologic wholeness
00:45:01
and then you don't have the energy to do the kind of exercise you need or on the other side the response is I am going to
00:45:09
work so hard every single day that you actually increase your stress there is over there is overtraining so you're just getting behind the eightball with starving yourself and
00:45:21
overtraining. None of which are going to solve either the core problem due to PCOS or the core problem in any stage of
00:45:30
a woman's life. Right. And this is where we look at the socioultural effect of what a woman is supposed to look like.
00:45:36
Yeah. And that's the thing that I really pushing out. It's like we want to think
00:45:41
about how strong we can be and how much muscle we can build because muscle is a massive metabolic help. Mhm.
00:45:49
And as as well as bone, right? So, we talk about it and then when I get the push back of, oh, I'm going to do fasted training or I'm going to fast till noon. I'm like, wait a second. Not only were
00:46:00
we going to interfere with our circadian rhythm and our hormone pulses, we're also acutely interfering with our
00:46:07
appetite hormones because if we're looking at gerolin, which is our active form of of our appetite, makes us
00:46:14
hungry. It's elevated with cortisol. And so if we're thinking about that elevation and we're not doing anything
00:46:19
to drop it and tell our body we have food, then it goes in and directly affects our neuropeptides, which then
00:46:26
affects our hormone, our hormone pulses. So when a woman's like, I'm just having coffee for breakfast and I'm going to
00:46:31
hold my fast. It's like, okay, well, here we go. Cortisol is going up. As Gary, you're going to get hungrier. Then you're going to learn not to respond to
00:46:38
that hunger. You're going to hold your fast. And we see from the research that women who do that end up craving more
00:46:44
simple carbohydrates in the afternoon moving incidentally less and contributing to poor sleep because
00:46:50
they've now phase shifted. So when we're talking about sleep and how important sleep is, we also have to think about
00:46:55
the circadian rhythm and how it is affected by food intake, light, darkness, and all of the things. And we
00:47:02
need women to understand we want to build muscle. We want to sleep well and that requires food. Well, and it this
00:47:08
goes back this whole thing you just said goes back to very early in this conversation where I was talking about sometimes we like to focus on the bright
00:47:19
shiny gadgets when we haven't taken our health from fine to optimize because everything you
00:47:27
just talked about it isn't a gadget it's basic lifestyle in the medical model of PCOS when I'm talking about what we're taught and how
00:47:39
we train our clinicians. We go into the, you know, we we aren't taught a lot about disease prevention or and I hate to use the term root cause because I think it's been usurped by
00:47:49
certain members of, you know, the wellness community. Take it back. Yeah, we're going to take it back. And so, especially for PCOS, I was taught to
00:47:57
give a patient birth control pills or Clomid when she's ready to get pregnant. And so nothing nothing around nutrition,
00:48:05
exercise, lowering inflammation and I was a program director until 2018 and there was nothing in the curriculum around this which affects at least 10% of women probably more this condition
00:48:18
that how important lifestyle is. You know, she went on for 10 minutes about all the lifestyle change, which is amazing. Which is amazing. But but patients, but I'm sitting there thinking birth
00:48:28
control pills, birth control pills. I mean, that was a knee-jerk reaction. I mean, I was treated for my own polycystic ovarian syndrome for 20 years
00:48:36
with oral contraceptive agents. And I learned online through chat rooms about the nutrition end of it. Yeah. when I have athletes because we
00:48:47
see a higher percentage of PCOS in successful female athletes. Why like what do I do? And it's looking at
00:48:54
what kind of training they're doing. So, we're putting this more short, sharp, high intensity to get that post exercise
00:49:00
response of anti-inflammatory, growth hormone response, all of these things that then bring down total body
00:49:07
inflammation. And then we're very careful about food intake and when we're doing it and what kinds of food so that
00:49:14
they don't have to go down the route of oral contraceptive pills because that to them has an effect on their performance.
00:49:20
When we're talking about the top end and when we bring it back down into recreational female athletes, we can do
00:49:26
the same thing. It's just we have to educate and say these are our lifestyle choices and then these are our medical
00:49:32
choices and what's optimal for your life at this point. Mhm. It's important to say at this table, and
00:49:37
we all talked about it last night, you need to have a period if you're not preventing a period with hormonal
00:49:43
contraception and you're in your reproductive years. Because very often women with PCOS or hypothalamic
00:49:50
amenorhea will say, I don't have a period, but I didn't really like that anyway, so it doesn't bother me, right?
00:49:56
How many women have said, well, I didn't get my period for a year, but that was fine by me. But that's not fine by your
00:50:02
body. That is hypoestrogenic time. It is low estrogen. Yeah. Very low estrogen. It's bad for
00:50:08
your body on so many reasons to be low estrogen during these crucial bone building years. But for we're talking
00:50:15
about how your hormones communicate back. It's very harmful to long-term health to have low estrogen
00:50:22
at all. Brain health. But yeah, but especially in young years when you're still developing.
00:50:28
Why would a woman say that she didn't want to have her period? I mean, this is a super naive question as a guy, but I understand it's painful. I mean, do you want to bleed from
00:50:34
Do you want that? I mean, if it was a choice now, actually knowing now what I know now
00:50:41
and for my own young daughters, I'm like, we have got to make sure you have a period. But when I was young, I was a
00:50:47
dancer and an athlete. I had very low body fat and I wouldn't have periods for 6 to9 months. And I'm like, yes.
00:50:54
Do you know what's interesting? I was thinking of Mel. She because of what she's been through
00:51:00
and also because she's listened to the conversations I've had with all of you and she understands the value and
00:51:06
importance of her period, she now celebrates it. It's like a celebration in our house when it arrives because
00:51:12
because if you understand the importance that it has in sort of full body health and the role it's playing, then the
00:51:18
pain, the downside is weighted against your understanding of the upside, which to her means she's
00:51:24
healthy, she's fat, hormonal health is working, things are great. And that's the conversation shift that I'm hoping is gonna instead of
00:51:31
being a detriment and a downer and talked about she must be on whatever derogatory yes derogatory things are
00:51:37
said about us that oh my gosh she is so healthy. Yeah. I remember sitting in a high
00:51:44
performance meeting just maybe three years ago and the leading athletics coach stood up and said I know when my
00:51:50
athletes are ready to perform on the world stage when their periods stop. And all of us went what?
00:51:57
It's like no, that's the time where like we have to really look at your athlete is getting ready to crack and be
00:52:03
injured. And it's still this pervasive idea and it's still pervasive even in the fitness
00:52:09
industry that losing your period is okay cuz that means you're training harder. They actually are very resistant to
00:52:15
getting it back. Yes. Like it's a sign of failure of their sport or their athletic endeavor
00:52:20
because this is is so pervasive. And I think that's why it's important to have these discussions. And I love hearing
00:52:26
that Mel now says, "Yay, my period is here." Because that's a sign of hormonal health and things are working well
00:52:32
because that is how we should feel. But I think the other part of it is for women who have mayoria or heavy bleeding
00:52:39
and heavy cramping. They don't realize that they can get help with that as well. Mhm. And that's a conversation that isn't
00:52:45
followed through when we're like, "Yes, get your period, but if you're someone who suffers from really bad cramps, we also have to educate that there are
00:52:51
things that we can do to help with that. Does the size of the bleed matter?" Because she turned around to me the
00:52:57
other day and she said with her last cycle, she said that she didn't bleed much and she seemed slightly concerned.
00:53:02
Obviously, I had no idea what to say to that. It depends. Congratulations. Well done. I'm so sorry. minora. So we have definitions
00:53:09
and there are you know we don't walk around with measuring cups generally between our legs to measure how much blood's coming out each month. But
00:53:15
but women know but women know your period should not cause you with modern you know period
00:53:22
products your cycle shouldn't cause you any stress in your life. You should just
00:53:27
roll with it, right? And so that's when I'm like when is it a problem? Shouldn't bleed through your clothes. You should be able to sleep through the
00:53:32
night. You should be able to get through an athletic performance. You should be able to do X, Y, and Z. Now when we do
00:53:38
start measuring and you should not be anemic. So I'm not waiting till anemia. I am anemia is low red blood cell count
00:53:46
you know to the point where your performance is affected. Your ability to carry oxygen is effective. So the red blood cells are what carries oxygen in
00:53:56
our bodies. And women who have heavy periods however that's defined can lead to anemia. But the first thing that we notice is their feritin is dropping. That's the first sign my do my daughter
00:54:08
we just had some blood work done. She was feeling a little fatigued and her ferotin and iron saturations were really
00:54:13
low and I was like talk to me about your period. Turns out she's not eating a lot of iron rich foods. So we're dealing with that. But you know we can get so
00:54:19
far ahead of this and looking at these ferotin levels the transfer you know these iron studies before she's actually
00:54:26
anemic which is like the last thing that happens when her red blood cell count drops or they become so small and what
00:54:32
we call microitic. you know, we are we need to do a better job at recognizing these things. We're not going to walk
00:54:38
around and measure how much blood's coming out because I could maybe squeak out 200 cc's, you know, a period and you
00:54:45
could be 300 and we're both doing fine. You know, we both have great. So, I think it's really looking at, you know,
00:54:50
how much bleeding is too much. Now, how little is too much? That that's probably better in your Yeah. Is any change from what you
00:54:57
consider normal? We would all say this is a normal amount. So if it gets heavier than that or less than that and
00:55:02
it stays that way, that is concerning. You can always have a one-off. Estrogen is the driver of growing the uterine
00:55:08
lining. So if you have a lighter bleed one month, we are concerned that you did not grow as thick of a lining. Your body didn't see as much estrogen. Most the time you ovulated earlier that cycle,
00:55:19
your cycle came a little bit sooner than you're used to it coming, and it's not quite a big deal. But this can be
00:55:26
concerning if we see consistently light periods, especially if we have history of progesterone contraception, which progesterone thins out the lining and estrogen grows it. So progesterone
00:55:38
actually stabilizes it, but for the sake of the discussion, we'll say estrogen grows it, progesterone thins it. When
00:55:44
you only see progesterone, like a progesterone IUD, the progesterone shot, even continuous birth control pills,
00:55:50
because they give you a type of synthetic estrogen and progesterone every day, your uterine lining gets
00:55:57
thinner and thinner and thinner. And so we see it can take months to return to normal after coming off of hormonal contraception. You also can get damage to the endometrial lining. There's stem
00:56:09
cells in the endometrium that regenerate every month after you bleed. They regenerate so that the next group can
00:56:16
grow in response to estrogen. And this can get damaged from typically anything inside the uterus. So most commonly this
00:56:24
is post birth, you know, a traumatic birth, a retained placenta, a DNC procedure, which is sometimes used after birth or in a miscarriage or even IUDs or intrauterine surgery. and it can form
00:56:36
scar tissue in the uterus that can cause a light period. So if you said, "Oh, Mel
00:56:42
had a miscarriage and had this procedure and now her periods are lighter." I'm highly concerned.
00:56:47
Versus amen. Yeah. So that is concerning for scar tissue in the uterus. Okay. If you said, "Oh, she was on a birth
00:56:55
control pill for a while and now it's a little bit lighter." I'm less concerned that's probably going to get better. or if this period came closer together
00:57:02
or if you traveled around the world three times this last month or so one one off is no big deal but a
00:57:09
change from your baseline can be concerning in addition we should say that that graph is beautiful but you
00:57:15
know your thyroid your pituitary gland it makes prolactin prolactin also changes the endometrium so there's
00:57:21
subtle signs of other hormonal issues that your menstrual cycle is the first warning sign that something is off what about pain She 2 months ago she had like excruciating pain that I've never
00:57:32
seen before during her menstrual cycle. Well, it's not pleasant to have your uterus contract and expel its contents
00:57:40
in any form. But what if it's like way above the norm? One time way above the norm is probably
00:57:46
situational based on other things that are contributing to inflammatory burden or response. your body is also healing
00:57:53
from a the corpus ludium's a cyst on your ovary that can also feel painful and at the time of your period it is
00:57:59
also healing so there's multiple things that can cause pain to Vonda's point so many people say I
00:58:06
have a high pain tolerance this is okay because we don't talk about our own pain
00:58:11
so I don't know if my pain is normal compared to somebody else's your pain should not keep you out of your
00:58:18
activities of daily living you shouldn't call in sick to school call in sick to work, cancel dinner plans with friends
00:58:25
consistently. Again, everybody can have a one-off month where something is off. But if this happens every month, oh,
00:58:31
it's my period. I'm going to cancel that. That is a warning sign that something else could be going on.
00:58:36
Endometriosis, adnomiiosis, and uterine fibroids. You mentioned the word iron a second ago, Dr. Mary. What is iron got to do
00:58:45
with this? And what is iron? So iron is an element that is in our diets and we do tend to store quite a bit of iron in our bodies and it's an essential when we look at the structure of the red blood
00:58:55
cell and of hemoglobin specifically. So hemoglobin is the actual molecule that is inside of the red blood cell that carries the oxygen. So iron is really critical to the formation of healthy you
00:59:08
know iron carrying red blood cells and we we store iron in our bodies and so and a lot in the bone marrow and in and
00:59:16
it's stored in this particular molecule called feritin. So when we're measuring ferotin levels in the blood that is you
00:59:24
know the first sign that your iron stores are getting low is when we see these low feritin levels. Are women more
00:59:30
iron deficient than one would think? Like is the general population iron deficient or what do you tend to see
00:59:37
when you run lab tests? A menstruating woman. Yes. A menstruating woman is is often
00:59:43
iron deficient. Yes. And I we I do see it in our post post-menopausal patients as well. That's
00:59:48
usually nutritional and inflammation related. So ferotin is also something that will decrease in in times of chronic inflammation. And so you're not able to utilize the iron that's coming
00:59:59
in and store it because this inflammatory state is kind of inhibiting that. So in a menstruating patient, I'm
01:00:05
always thinking is she bleeding too much the first time, you know, and is that bleeding menstrual? Is it coming from her rectum? Is it coming from her
01:00:11
gastrointestinal tract? You know, does she have gastritis or, you know, we have to go through the, you know, the algorithm of why that might happen. In a
01:00:18
post-menopausal patient, we can remove vaginal bleeding from the issue, you know, uterine bleeding, a period, but
01:00:24
then now I'm looking at nutrition. And I'm looking at exercise. I'm looking at inflammation as causitive factors. And the global pitch here is the World
01:00:30
Health Organization estimates that roughly 30% of women aged 15 to 49 worldwide are anemic with iron
01:00:36
deficiency being the leading cause. And in some reason regions of South Asia and subsaharan Africa prevalence can be up
01:00:42
to 50% of women are anemic with iron deficiency being the leading cause. H you noticed the norms have changed. So it depends on who you read.
01:00:54
Yeah. again, you know, when you're looking at male male normative curves versus what you know, we're we're tend
01:01:00
to accept lower levels for a female. But now that we're looking at performance and, you know, looking at other factors
01:01:07
besides just what is this feritin level, um there's a lot great new research coming out that we are looking at this differently and that that we're in our clinic, we are looking for 60 to 100 for
01:01:18
a feritin level to be considered optimal. very different than, you know, the baseline for, you know, keeping you
01:01:27
out of out of a hospital versus you functioning at your absolute best. Yeah. Because the norms that often get measured for us because they tripled, right? They were
01:01:38
15 and then they went up to to 40. So now they're saying 20 and above is normal. And when I look at a lot of
01:01:45
women who are sitting 20 to 30, they can't get help. They cannot get help. And it's like,
01:01:51
whoa, it was maybe four or five years ago. If you were below 50, then we would look to get help. But now with the norms that have shifted with the sicker population,
01:02:02
we can't get women help unless they are below 20. So when we say normal, I think
01:02:07
this is important for everybody watching or listening. Normal in medicine means common, not non-pathological, okay? Not bad, you know, doesn't mean it's not
01:02:18
bad. And so norms shifting meaning we're getting sicker as a population and we're
01:02:24
willing to accept lower levels although they're not optimal for health. The lab reference range what they say when you
01:02:30
get your blood work drawn and you see the reference range is based on population averages. And so if the
01:02:36
population is more anemic this is going to accept a lower levels being normal even though they're by no means optimal. And I think that's one thing we all talk about is well how are you feeling your
01:02:50
symptomology? What do we see? And you have to interpret blood work in context of the whole person and what is
01:02:56
happening. And that is one issue we do see with getting your own blood work drawn or these online companies when
01:03:02
nobody's interpreting it or helping you interpret it on the other end. You see something that is in a normal range but
01:03:09
it's not at all optimal for you and it could be the reason why insurance. Yeah, exactly. I want to talk about
01:03:14
endometriosis. I we have a team member who's been with the Davosio since the very beginning called Liv. Yes.
01:03:20
Are you familiar with Liv? I am. So at age 13, she had her first period and she experienced agonizing pain with
01:03:25
heavy bleeding. At age 14, she was put on the pill to manage the symptoms. Between age 15 and
01:03:32
24, she continued to have severe stomach pain which resulted in multiple A&E visits. She was often dismissed as
01:03:40
having gastriisitis. Mhm. And it led to having her appendix removed. Oh my god. Why'd you say oh my god can get surgery? But she had major surgery and
01:03:54
um I' I've seen this course before and it's it's devastating cuz she's going years and years and years now of Yeah. age 25 she came off the pill to see how she felt without it but her
01:04:06
periods worsened and she fainted from the pain. So she went to accident and emergency. At age 26, she got an
01:04:11
ultrasound which suggested endometriosis, but no NHS diagnosis was given. We ultimately had a conversation with you on the podcast, Natalie, and she felt very heard and she was actually
01:04:24
there. And so afterwards, Jamaima in the team, who you you guys know, um told Liv to come and speak to me. And Liv told me
01:04:31
after you left about um the symptoms, did she speak directly to you at that time? She did. Okay. So, she came and
01:04:37
she spoke to us about her endometriosis, which is the first time I'd ever heard of it. Um, and then we offered to help
01:04:44
support her privately so she could get private support with it. Um, and she got an MRI scan privately, which confirmed stage 4 infiltrating endometriosis. Oh gosh.
01:04:55
Liv then pushed um on with her NHS appointments, the National Health Service in the UK, but the pain was so
01:05:01
much that she took me up on my offer to pay for it privately. So, we paid for it privately. Uh, and the endometriosis by
01:05:08
that point had spread to her bowels and pelvis. And I've got this picture of this four cm cyst. If you're all
01:05:14
faint-hearted, I mean, I don't know where we'll put this on the screen, but this is from her operation. Yeah. It's called an endometrioma. It's
01:05:20
huge. For anyone that can't see, it kind of looks like a tumor. Yeah. Um, next to her ovaries
01:05:28
and it had spread at that point to her bow and pis pelvis. It had become about 4 cm big. Her ovaries were stuck
01:05:34
together and attached to her womb and her bowels. She then needed to book an appointment for surgery. And before the
01:05:40
surgery, because of the scale of her endometriosis, she had her eggs frozen to protect her future fertility, which I
01:05:45
guess came from your advice. This process took her 7 years and she was in pain for 17 years because she did not get a diagnosis. Her story is unfortunately not uncommon.
01:05:58
This is a very typical story for somebody who suffers from endometriosis. Endometriosis is an inflammatory condition. And the way I like to explain it is when your body responds abnormally
01:06:11
to a normal process. You have immune dysfunction as well. So let's think of it as an autoimmune disease and a
01:06:16
chronic inflammatory disease. When you have your period, you bleed out indometrial cells in your menstrual
01:06:22
blood. We're used to that. In everybody, you also have some indometrial cells that will escape out the fallopian
01:06:27
tubes. That's not a big deal. If you take out somebody's appendix while they're on their period, you'll actually see menstrual blood in their abdominal
01:06:33
cavity. In the regular person without endo, your body says, "Oh, she's just on her period." In the person who has endometriosis, this creates a huge inflammatory response where your body
01:06:45
starts to attack indometrial cells and you get these implants throughout the what's called the peritineal cavity or
01:06:51
the abdominal cavity of indometriallike tissue that gets worse every time your body sees estrogen which because it's feeding the endometrium just like it would in the uterus and so it gets worse
01:07:04
over time. The more ovulatory cycles you have the disease gets worse. It's so inflammatory that it's not uncommon to
01:07:11
get extensive organ scarring. You get anatomical distortion. These are some of the
01:07:18
toughest surgical cases in addition to managing lifelong health but also fertility as well. Just obliterate the anatomy like because the infiltration you'll these implants will start growing into other organs
01:07:31
because they'll find new blood supply. They'll steal blood, you know, blood supply from from the bowel from because
01:07:37
all of our pelvic organs are just sitting there on top of each other, the bladder, the bowel, the c, you know, and
01:07:43
so it sounds like it's alive, like it's a cancer or something. Think of it like velcro is what I say almost these little patches of velcro
01:07:49
and they just start sticking together. And that's what inflammation and scarring does throughout your whole body. And what happens here is that
01:07:57
because the primary symptoms of endometriosis is pain. So again, back to women's pain being taken seriously. That's one of the issues and why the
01:08:07
average time to diagnosis is 7 to 10 years. Truly 17 years in this case from when she had pain.
01:08:14
But the other symptoms do include sometimes also pain with intercourse. Typically though, that is very hard to
01:08:21
ascertain from somebody, but it's usually with certain positions. Deep penetration tends to be what really
01:08:27
stimulates pain. But you also see a lot of GI manifestations that we don't talk about. So if I have somebody who has
01:08:32
painful periods and they say they have irritable bowel syndrome or a lot of vague GI complaints,
01:08:39
that is a really big red flag to me because like you said, these little indometrial implants on the bowel, the
01:08:45
intestine, this high inflammation that's happening irritates your intestine and you get this GI response as well. One of
01:08:53
the hardest things about indometriosis is that it's a surgical diagnosis only. To be honest, we can means
01:09:00
have to do surgery to fully see and diagnose that you have this. It's one of those no meat, no treat, you
01:09:06
know, in in in medicine where you can't make the diagnosis until you have a tissue sample. So meat means you go and
01:09:12
take a biopsy. Okay. See? Okay. So you can suspect it based on imaging. We're not great at this. And Dr. Crawford, why don't we have a cure? Mhm. Well, because it hasn't been
01:09:23
studied is one of is the primary answer. Uh the secondary answer is that often the the goals are tough with endo because if estrogen feeds it, we all are going to sit at this table and talk
01:09:35
about how important estrogen is for your body. And a a lot of the treatments that exist for endometriosis take estrogen
01:09:42
away to try to not feed these lesions. And that has a slew of other symptoms and long-term health implications as
01:09:48
well. Truly, we don't even give women options to try to feel better. They are given birth control pills because, hey, I'm going to stop the ovulatory cycle.
01:10:01
I'm going to you're going to have less what we call unopposed estrogen days. We do have symptomatic relief. Yeah. But we have and that's going to
01:10:07
help hopefully with some of your symptoms. And it can for some women. It doesn't reverse disease. It doesn't cure
01:10:13
it. It doesn't make anything better, but it can slow down the progression any of
01:10:18
these treatments that do halt the ovulatory process, but it severely impacts I mean beyond so many layers of
01:10:26
your your mental your emotional health, your relationships, but your fertility. Stage three or four disease, regardless
01:10:33
of your age, you're going to have a less than a 20% chance of conceiving naturally over the course of your life if you have stage three or four disease.
01:10:40
Every stage is impactful to your fertility because of the inflammation. Once you have anatomical distortion, an
01:10:45
indometrium or cyst inside the ovary, removing that cyst is going to decrease your egg count. That that's going to
01:10:52
have a major implication on your potential. That's why we froze eggs before we to cyst out so that we could get those eggs, at least some that we could out of the body before we went and
01:11:02
did something that was going to destroy part of the ovarian tissue. What you said, Stephen, is it seems like
01:11:08
indometriosis is alive. And that's a really great analogy because it does just feed into tissue and it's highly
01:11:15
destructive and if it distorts the anatomy, we need a healthy floppy fallopian tube generally that can swing around and pick up this egg that's floating around our abdominal cavity for
01:11:27
and then you need a place for the egg and sperm to meet which is generally a healthy non-inflamed fallopian tube. So
01:11:33
they're also at increased risk for infertility but ectopic pregnancies. That's where I see them, you know, is
01:11:39
when I was a hospitalist is in the O, you know, emerently from a ruptured fallopian tube from this, you know, and I go in and I'm making not only she's lost a wanted pregnancy now I and I'm
01:11:51
making the diagnosis of indometriosis at the same time and they are just devastated. I just feel sitting here not
01:11:57
being anywhere within this field thinking wait a minute because I was a cancer nurse first right before I did
01:12:02
this wait a minute there's got to be a cell surface marker that's unique to the endometrium that we could make a
01:12:09
monoconal antibbody against there's got to be a cell surface marker and I will say that there are people now
01:12:15
doing lovely and wonderful research on a cellular level of indometriosis trying to look at the endometrium itself what
01:12:22
cell markers are similar in indometrial implants Can you diagnose this on an endometrial
01:12:28
biopsy in somebody? We haven't seen it get to the point where it needs to, but at least people
01:12:34
are paying attention. So, I do think we might have emergent technology that will change the course of this for people.
01:12:41
Right now, I think awareness is key. And one thing I always say is that especially as a teenager because women
01:12:48
adjust. You accommodate to the world around you. That's one of the things that I think makes women so resilient. I
01:12:55
mean, if you have pain every single month of your life, you are going to convince yourself this is normal for a
01:13:00
degree of time because what other option do you have? Has to get so bad. But when you're a teenager, you don't know that.
01:13:07
And so, if when you are a teen, you would stay home from school, you would not go to the football game or go out to
01:13:13
dinner with friends, that to me has is a huge red flag. But it actually is a very
01:13:19
high predictive marker that you do have indometriosis. So pain out of proportion to being able
01:13:25
to complete your normal life as a teenager is a really big warning flag. I ask every patient about that when we
01:13:31
talk about their periods because 50% of patients with unexplained infertility have indometriosis.
01:13:37
It is so hard to diagnose and underdiagnosed yet impactful to our body. 26 years old. The advice given to her by the NHS was to go back on the pill to
01:13:49
solve for the the pains that she was getting. We certainly have a lot of dismissive doctors and people who don't
01:13:55
take pain seriously, but also a disease that is underfunded and not researched. We do have limited options for how you
01:14:02
can help somebody. And I think we have to acknowledge that both things can be right. Now, getting to the root cause of
01:14:08
your pain is always going to be really important versus just saying here's a birth control pill that should take care
01:14:14
of it. Some women with endometriosis love being on the birth control pill. does highly improve their symptom
01:14:20
profile and it's an important part of their treatment regimen. Other women do not find any benefit from it and it's
01:14:26
really important to have the discussion especially with indometriosis in regards to your family planning goals. Do you
01:14:32
want kids? When is that going to be? What might this look like? Because we know if you have a higher rate of
01:14:38
infertility, a higher rate of needing IVF, do we need to intervene sooner? But that's going to impact some of the treatment options we're able to give you because some of them do delay ovulation from for a prolonged period of time.
01:14:50
What I find in the patients, you know, when we made the diagnosis was they're forced into making these kind of
01:14:56
life-changing decisions about around their fertility and ability to conceive before they were ever before their peers were even thinking about it. It's pretty
01:15:06
devastating. It is. We have some pilot data looking at taking some of the nuances of
01:15:12
recovery and looking at how to dampen inflammation. So we have some pilot data that's showing when women do cold exposure that it dampens inflammation and
01:15:23
improves their symptomology. So I'm always thinking on the outside like what other things can we do to dampen
01:15:30
inflammation in a positive way to improve symptomology. How does that work? So, if we're
01:15:36
thinking about the responses to cold exposure, and we're not talking about ice, we're talking about cold water
01:15:42
exposure. It creates a cascade of immune responses that kind of protects the body. So, we're reducing inflammation, we're improving parasympathetic, which reduces stress. Mhm.
01:15:54
So, if we're timing it and they know when their period is and they can go, okay, well, for the next or the 10 to 14 days before my period starts, I'm going to have 10 minutes of cold water
01:16:06
exposure. And over the course of 3 to 4 months, that immune response becomes learned. So, it reduces symptomology. So, it becomes one of the treatment options that we have for some of our
01:16:19
athletes that have endo and interferes with their training. Mhm. So I mean the cold water exposure is
01:16:24
available there. So that's how we started the pilot study. Um trying someone wanted to do this at
01:16:30
home. 10° C. So what is that about 40? Yeah. It feels really cold but not an ice bath. Not an ice bath because ice is Ice is not good for Can you get that in the shower?
01:16:42
You you need to This is like cold submersion. Can you do that at a home tub just with turning on the spigot?
01:16:48
You could if you get really cold. Yeah. You might want to add a little bit of ice and let it melt. Okay. But um not ice baths that we see in all
01:16:55
the popular media because that is way too cold for a woman's body. It does the opposite. It's a severe stress and
01:17:02
causes a stress response rather than a parasympathetic calming response that we want.
01:17:07
Okay. Like Stacy said, decreasing inflammation in an inflammatory disease is key to controlling the factors you
01:17:13
can. And much like we talked about inflammation and PCOS, we heard the same word right here with endometriosis.
01:17:20
Chronic inflammatory diseases are the number one thing that we see across the board impacting the population but
01:17:26
especially women. And so these same strategies to work on decreasing your own inflammation
01:17:33
and for endo it's a little different because you can target it for when you expect to have that high inflammatory
01:17:40
burden. But that's really an important part that we don't talk about. I don't see that the NHS talked about an
01:17:45
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Piperive by going to piperive.com/ceo. Now, on this point of birth control, one of the questions that came in from the audience was, "How terrible is birth control to female hormones?"
01:19:03
The birth control pill shuts off the brain's desire to send the signal to the ovary to make hormones. So, it is ethanol estradiol, a synthetic estrogen, and a type of a synthetic progesterine
01:19:15
or progesterone. These work, the brain thinks that you have estrogen and progesterone present. As we said, that's the ludial phase. And so, your brain says we don't need an egg to grow.
01:19:26
Ovulation starts in the brain. Y, right? So, no FSH comes out and you're not going to get ovulation. So they're very
01:19:32
effective for prevention of ovulation which is makes it a very effective contraceptive option. But as far as hor
01:19:40
hormonal shifts, yeah, your brain's not sending out FSH and LH. Your ovaries are not going to be making estradiol or
01:19:46
progesterone or testosterone. True. And so that is how they are sometimes helpful if you have, you know, uh some
01:19:55
women get hemorrhagic cysts with ovulation. every every time you ovulate, you when you rupture that cyst, you get
01:20:00
a lot of bleeding. The birth control pill can prevent ovulation, therefore prevent some women from being in
01:20:05
terrible pain. If you have PCOS, they're often handed out like candy. One reason is because it will regulate your cycle
01:20:12
so that you don't have these prolonged irregular periods, but also will decrease testosterone levels, which is
01:20:19
sometimes a good side effect of the pill for women who have PCOS, back to a normal level.
01:20:24
Yeah. But if you don't have PCOS or the regular person, a lot of times your body's tissues are not responding to synthetic estrogen and progesterone the same way it does to natural. I think that's a very important point. So my
01:20:36
niece who competes uh at a national level and she's 14 started suffering from as she was going through her adolescence her acne got outrageous and she's a 14-year-old girl 13. start at 12
01:20:49
and a half. And of course, you know, she goes to the dermatologist and they're trying some topicals. And then finally,
01:20:55
as you go down the algorithm for how we treat acne, one of the off label uses is
01:21:00
birth control pills will lower the testosterone. Their skin can clear up. So, her father, a little concern, comes to me. Um, her mom passed away. Her
01:21:08
stepmom had passed away. So, he didn't have the mom in the house to, you know, the immediate mom to talk to. And for
01:21:14
the first time, I immediately thought of her athletic performance. Thank you, Dr. Sims and I thought she wants to go to
01:21:20
the Olympics. There's no way I'm going to let her testosterone levels drop. Like, we're going to throw everything
01:21:25
topical at this. And we finally found the right combination. Her skin looks great and she's super happy. But like, the next logical thing was to put this
01:21:32
14-year-old, you know, on a birth control pill to get her acne under control, which is the end result. But
01:21:38
what no one's thinking of is her athletic performance. How is it going to affect her
01:21:44
training years leading and her training years? Like, this is critical for her. 16 is when the next trials are up for her. So that's 2 years
01:21:50
from now. So we were able to get her acne under control, avoid the birth control pill, but that was nothing I'd
01:21:56
ever thought of before. Well, I'm sitting here from a muscularkeeletal standpoint thinking
01:22:02
about the high percentage of women who have endometriosis and PCOS and the complete soundingly imbalance of natural hormones. Plus,
01:22:16
for a lot of reasons now, girls are not cycling normally. Mhm. And I'm sitting here terrified for their bones. Yep. 100%.
01:22:27
Because we build bone from 15 to 25. And if we are so inflamed that we're producing all kinds of inflammatory cytoines IG interlucan 6 and uh C
01:22:41
reactive protein and tumor necrosis factor which halt bone development we don't have enough estrogen for whatever reason we're going to shut off our testosterone because it makes us feel
01:22:52
better and we're not exercising and we're sitting around. No wonder I have 20 and 30 year olds
01:22:59
with no bone density that are then going to go into pmenopause which we will get
01:23:04
to and lose another 20%. So I was pretty feeling pretty hopeful that the generation Xers are going to get to the millennials and get to the
01:23:16
whatever they're called after that. It is we're gonna be you're gonna see it get worse before it gets better. Exactly.
01:23:22
That's what I'm sitting here terrified like. Okay. I thought, okay, baby boomers, those women missed out. Xers,
01:23:30
we're doing the best we can. Millennials, but no, cuz now you're telling me our 15 to 25 year olds are still in the same detriment with muscle
01:23:42
and bone building. We are trying to change the narrative. That's the group we're trying to target
01:23:48
right now. And I do think by educating across the lifespan, we're going to change how those of us who have 11 and
01:23:56
12 year olds what we recommend. I I treat girls in their teen years when they come to me without their period much differently than a lot of other people do. But this is learned
01:24:07
experience. Instead of just you don't have a period, here's a birth control pill. Say you're not making estrogen and
01:24:13
this is a crucial time for you. Let's give you estrogen. Let's talk about why you're not. what can we do to change it?
01:24:20
And so this discussion is more than just disease state important like PCOS and endometriosis. It's truly important
01:24:27
across the lifespan of a woman. The choices that are being made in her early reproductive timeline is going to impact
01:24:35
her longevity. Can I ask all of you what you would have done differently for ourselves?
01:24:40
Yeah, for yourselves. Obviously, I know several of you have daughters as well, but what would you have done? I wish
01:24:46
everybody could see all of your faces. Oh yeah, I've talked about this before. I mean, I was amenoric until I was 20.
01:24:54
What's amenoric? Didn't have periods. Okay. Because of high stress, high sport, you
01:24:59
know, didn't care, didn't eat well in the whole um mindset of the, you know, ' 90s of calories in, calories out. If
01:25:07
you're thinner, then you'll run better. If you're running better, then you're going to hit different metrics. cuz I
01:25:13
was a runner in high school and then joined the crew team. Same thing. So, if I could go back and talk to my younger
01:25:19
self, I would have been like, "You need to eat, you need to recover, you need to eat, you need to recover." Instead of
01:25:24
the mantra of calories in, calories out, more cardio, lose weight, lose weight, lose weight. Because now I educate
01:25:30
people is you want to take up space, you want to be strong, you want to look at um not the idea of losing something, but
01:25:36
gaining something, gaining that power, gaining that strength, gaining that bone, gaining that muscle, gaining your
01:25:42
period. Those are the things that I'm trying to educate the younger generation cuz that was not impressed upon me as a
01:25:49
younger athlete, which then had a lot of repercussions later in life. Luckily, my
01:25:54
bone density is fine. So, were you on the contraceptive pill? No, you might. Okay.
01:26:00
I was um not an athlete, so mere mortal. And um uh but it's so you've you've you've been able to take that experience though and apply what you've learned in this this
01:26:11
high int, you know, working with these intense athletes to the to the regular, you know, to people who don't exercise
01:26:18
at that level. And you know, I completely fell under the the expectation of the aesthetics of it. When I did exercise, I exercised to look
01:26:31
a certain way. And then in my 30s, I exercised for performance. I started running half marathons. I was doing baby
01:26:38
triathlons, really short ones with my girlfriends. It was a social thing and it was super fun. You know, I was running for time. Now I'm exercising for
01:26:46
my old lady body. Yep. You know, I'm exercising to be in a bigger body cuz I know my mother and my grandmother. So,
01:26:53
my grandmother spent the last 10 years of her life in a bed incontinent with dementia and completely frail.
01:27:01
And my mother is on the same course. My mother is 88, fell and broke her hip in January. She just now is walking on a
01:27:08
walk or she's in assisted living facility for Alzheimer's. I want to change that legacy for my
01:27:13
children. I don't want that to be my path and I don't want my children to have that to be an expectation. So all of the things I would have done
01:27:24
differently was I wanted to be thin. Thin was healthy. That is what I learned in medical
01:27:30
school. The thinner you were up to starvation, you know, up to you want the lowest body mass index possible without
01:27:38
being a little bit too low, you know. And I kind of skirted that line because I stopped eating in medical school due to stress. I would have fed myself. I
01:27:44
would have lifted weights. I would have stopped doing so much cardio because knowing I was chipping away at my bone
01:27:50
density. I was chipping away. I was raising my inflammation levels. I was chipping away at my ability to resist
01:27:56
the Alzheimer's, you know, and dementia that runs in my family. And that's what I'm trying to impress. My girls are 21
01:28:03
and 25. What I'm trying trying to impress on them. But that's the mentality that we grew up
01:28:09
in, right? When you're looking at the supermodels of the '9s and Kate Moss and it was all
01:28:15
heroin chic. Yes, heroin chic, which is the worry now with the GLP1s coming back and the
01:28:21
ballerina body and all the things that we're seeing come back again. And it's it is worrisome.
01:28:27
You know, when I think about I mean, I've already told the world now about having low body fat, maybe being POS and
01:28:35
not knowing it, not ever talking about that, having no periods, but then so there was that in my youth that that I
01:28:43
would have done better, but that it didn't end in my youth. I mean, I went to college, same. I went to grad school,
01:28:52
still same. I went to medical school and in medical school and four years of medical school, seven years of residency and fellowship. Still didn't eat, still wasn't having periods.
01:29:05
I didn't sleep for about 11 years, whether between call every third night and then I had a baby and then I was
01:29:11
awake for two years cuz she slept with me. That's another discussion. But I think of all these things that I wish I knew then that I know now. I have the same goal. I have four 30-year-old
01:29:24
daughters and I have a 17-year-old and they are not going to be allowed to hit a wall like some of us may because we didn't know. And were you on the birth control pill?
01:29:37
You know, intermittently. Uh probably totally in my life about 10 years, but um not continuously. And Mary, I forgot to ask, were you on the birth control? Yeah, you were off
01:29:50
and on for 20 years. So, polycystic ovarian syndrome that was the treatment. I mean, I learned about
01:29:57
nutrition kind of on the back end. But the life that I had set up for myself between, you know, medical school, residency, and then going into the field
01:30:07
of OBGYn with limited sleep, you know, working 100hour weeks there. I didn't have a environment that would have been conducive to be able to manage that disease
01:30:19
with lifestyle and I can look back and say that honestly now um with without using the crutch of the birth control pill to manage my
01:30:30
symptoms. I was on the birth control pill for probably 15 years continuously. And you
01:30:36
know, we have to give credit where credit's due because I was able to pursue medical training and not worry
01:30:43
about what family building looked like for me, which was really important because I was not ready to have a child. So, anytime we frame a discussion around birth control, I always want to say it's
01:30:55
not ever going to fit into one bucket of all good or all bad. It's going to be, you know, different stages of life, different things are important. I didn't
01:31:01
stop it soon enough to learn to track my cycle. I didn't recognize cycle abnormalities when I had recurrent
01:31:07
miscarriages. I had a really hard time knowing is this how my cycle's supposed to be or not because I never had the
01:31:14
opportunity to just have periods and see what is my normal. I stopped it and started trying right away and got into a
01:31:22
cycle of having a pregnancy and that would last for a while and then I would lose it. So I really lost the
01:31:28
opportunity to say this is my baseline and oh there might be a problem here or to intervene. I wish id advocated more
01:31:34
when I had my own pregnancy losses. I was told over and over, there's nothing you can do. This is nothing. Just keep
01:31:40
trying. And even as somebody in the field, that felt very dismissive and is a fuel for a lot of what I do now. But
01:31:47
on a personal level, you know, 10 years after having those pregnancy losses, I was diagnosed with celiac disease
01:31:54
because I had osteopenia on a dexa scam. And so I had to explain what that is. Yeah. So celiac disease is essentially an allergic reaction to gluten. So when I was taking gluten, which is in most of
01:32:05
your carbohydrates or the good stuff like breads and pastas, when I was eating those, it was
01:32:11
causing an inflammatory reaction inside my body, making my gut unhealthy and kind of creating a baseline level of, let's say, chronic inflammation. And recurrent pregnancy loss can be one
01:32:22
of the signs and symptoms of it in addition to just some other what feel like very generalized symptoms. fatigue,
01:32:30
low energy, headaches, GI distress, WW. Yeah, I was a whiny woman. And when some
01:32:38
of these symptoms finally got to a state where they were getting worse, probably with hormonal change with age, and my
01:32:44
doctor ordered a bone scan, and it came back that I had osteopenia, which is very low density of my bones for my age
01:32:51
and especially at the time, you know, no known medical problems. And so luckily had somebody who was very committed to
01:32:57
not labeling me a WW and saying I think you're not absorbing something correctly to get on this pathway to figure out
01:33:04
that because of this autoimmune disease celiac disease I wasn't my gut was inflamed. I wasn't be able to absorb the
01:33:10
nutrients that I needed. But somebody had to be committed on the other end because these symptoms went on for so long. I just accepted them. I let
01:33:18
them be. But I also am scared because those critical bone building years I was on the PEL and I used it continuously which means every single day all the time
01:33:29
I you know I know I was chronically inflamed and so now I'm at a stage of my life at 43 saying I've got to try to
01:33:36
catch up before it's too late and that is scary and can you catch up? Yes. Yes, you can build bone. Um because you know I see all these grass wonder that
01:33:47
you know you kind of yes you go curve but yeah and then it goes down from your wherever you manage to get it
01:33:54
up to. So I'm telling all my friends at the moment thanks to you I'm telling all of them to get their muscle and their bone as high as possible because it's
01:33:59
probably going to fall with age naturally. Well everyone ages. Yeah. Age is the most natural
01:34:06
thing we do from the minute of our birth. But men and women age at different rates, especially
01:34:13
after pmenopause with the the lack of estrogen, we rate we age very differently from that point on. But your point being made is can we please
01:34:24
maximize our bone density and our muscle mass and everything else frankly in our youth when we're probably not aware, right? When we're in college and doing all the things kids do, it's the
01:34:37
last thing on our mind. And yet it's the most critical time because you want to start both your bone and your muscle
01:34:42
from the highest possible level. Now, can you through lifestyle and hormones build bone again? Yes, actually you can. But wouldn't it have been better to start out with the maximum so that the
01:34:57
natural decline doesn't take you into dangerous levels? Right. Mhm. On that point of birth control, what are
01:35:02
you saying to your daughters that wasn't said to you? Are you Because Mel regrets, my girlfriend, she's very open.
01:35:08
She regrets being on the birth control pill for 10 years because she had no idea what it what it was doing to her body. And then obviously when she came
01:35:14
off her cycle, I think she spent like you, Natalie, 2 years trying to figure out what was going on and she didn't
01:35:19
have her period for an extended period of time after she came off. What are you saying to your daughters about the birth control pill that wasn't said to you?
01:35:26
Are you recommending them to use it how you guys used it or I mean, we were started on it so young. I I do see a trend towards not starting
01:35:33
it as young as it was started in our generation and I think that that is important. I see, you know, personally,
01:35:41
my daughter is not quite at that stage yet. So, we haven't had to make these decisions as um they have had to, but I
01:35:48
do think it's cycle awareness is one of the few early signs you have of your body's health as a young woman. And so,
01:35:55
to purposefully never get to know what that is, is a detriment to saying, "I'm aware of what's healthy for me and I
01:36:02
know what's happening in my body." But you guys have had these discussions at different time periods. For my youngest
01:36:07
daughter, we I was worried about uh she was a dancer also. She was teeny tiny. So tiny
01:36:17
even though she had great muscle mass, but she like me wasn't having periods. And so the advice was to put her on
01:36:23
birth control to regulate periods. But I was always uncomfortable with that because she didn't to be a dancer. She didn't have to be quite as tiny as she was. And so what we have done now is
01:36:36
I've encouraged her to gain a little weight and get a little bit more body fat because I took her off of that. She
01:36:43
only had to gain 5 lbs. I think I said to you, maybe seven and it has more regulated her and she's having her own periods now. And so I don't know what
01:36:54
she's going to decide. She's going to be 18 soon. And but I think what we should be telling our daughters is all the
01:37:01
information so that they can make an educated decision because I just did what I was told and I'm a doctor and I and but I'm not an OB so I don't understand the nuances
01:37:13
of what the pill is that it's synthetic that this is how it works this is what it doesn't do. So I would want to give my daughters all the information so that
01:37:25
they can make an educated decision. So my oldest, the first one coming through, uh wanted it for contraception.
01:37:33
And so when we talk about contraception, it's not just most people automatically think the oral birth control pill, but I
01:37:39
did go through all of the options with her and then sent her to a trusted friend um to let her go and make her own
01:37:46
decision. and she decided to have an an IUD inserted, which I thought was a great choice for her cuz she had normal
01:37:51
regular periods before we did this. There were no issues. And she had it inserted and then within a week she
01:37:59
started having severe cramping, called me into the bathroom. And this is my daughter who has not let me see her
01:38:04
unclothed since she was 7 years old. She's just very private and she's like writhing on the floor. Bless her little
01:38:10
heart. And she had expelled the IUD on her own. She had cramped it out uterus pushed it out of her body and it was extraordinarily painful and so we basically delivered the IUD on her
01:38:22
bathroom. So do you know what an IUD is? Is not the coil is that's one form of an IUD. She had a
01:38:28
different form but she basically pushed out her own IUD her uterus uterine device. So it's birth control
01:38:34
that is placed inside the uterus and it's shaped like a tea. It is shaped like a most is shaped like
01:38:39
a tea. the UK they use the coil still quite a bit which is copper and so um there's different there's different options for the IUD some contain progesterine some contain just the
01:38:50
copper and so the way an IUD works is that it creates an inflammatory response in the uterus so that um the cervical
01:38:58
mucus thickens so that when we are fertile in our for fertility window midcycle and jump in if I mess this up
01:39:05
the mucus of the cervix thins to the point where sperm can actually get through most of the month probably 85 to
01:39:11
90% of the month the sperm cannot traverse the cervix you cannot you know so in our fertility window right at
01:39:18
ovulation the cervical mucus thins and then the sperm can transmit so the you the the presence of the IUD creates an
01:39:25
inflammatory environment that will basically is toxic to sperm and thickens the cervical mucus where it becomes a
01:39:30
plug that's how it works works very very well Katherine within a week her uterus
01:39:35
ejected it so she cramped so much that it pushed it through and so that wasn't an option for her. She wasn't willing to go through that again. So then at that point she had to go through the hormonal
01:39:46
options for for that and she decided to have the implant. So it's progesterone only implanted in her arm. Quickly we realized she needed some estrogen. So we she supplements estrogen on top of that.
01:39:59
Stephen, I think the contraceptive discussion we have to say that there are options that are highly effective at
01:40:04
preventing pregnancy and at some times in your life that is the number one most important goal and we need to choose a
01:40:10
highly effective option. However, certain some of those options included have downstream impacts that have not
01:40:17
been discussed about. The typical contraceptive discussion says here are some side effects you may have. If you
01:40:23
want to still proceed, let's go for it. We're not talking about long-term implications of these. We're just talking about how you're going to feel,
01:40:29
not exactly what is happening in your body. A lot of these contraceptive options are progesterone only. And so,
01:40:36
you know, by your new favorite graph that you don't see progesterone every single day. So, when you have
01:40:42
progesterone only, it is shifting your hormonal profile. And a lot of women, this progesterone is so high that it works by also preventing ovulation. Makes it highly effective. But if you're
01:40:53
not ovulating, you're not going to be making those high estrogen levels. And Dr. Haver and I have even talked about
01:40:58
how we wish there was a contraceptive option that had estradiol in it so that your body could still have some estradi. Estradiol. So this ethanol estradiol is
01:41:09
very different than plain estradiol. They've they've put this estester group on the end which makes it bind to the
01:41:15
estrogen receptor in the brain 300 times more powerful powerful than regular estradile. Yeah. Which is why it's so effective. you know
01:41:25
why we do it in a micro dose versus estradiol is dosed in milligrams and ethanol estradile is dosed in micrograms
01:41:32
because it is that much more potent. Um so very very different. Now in the UK and in other places in Europe there is a new form of contraception that has asteratrol which is the fetal estrogen.
01:41:45
So we have four natural estrogens in the body. The ovary produces estradile. That's the one we all know. It it it's
01:41:51
really the biggest bang for our buck. The placenta produces something called estriol. Our fat cells and in the
01:41:57
peripheral tissues, the tissues outside of the ovaries can produce something called estrone. And then we have this
01:42:03
fetal estrogen called eststeratrol, if I'm pronouncing it correctly. And so they've they've compounded they've been
01:42:09
able to formulate that. Um, so it is one of the natural estrogens and they've put it in a birth control pill that is
01:42:15
available in the UK. If you were 18, what choice would you make for contraception? No, studies have proven within a shadow of a
01:42:23
doubt that relying on natural family planning at most ages is not a reliable form of contraception. So I would not recommend that and relying on condoms. What do you mean by natur relying on
01:42:34
natural family? So you timing your intercourse. Oh okay. So cycle tracking we know that the fertile window is the 5 days before and
01:42:40
the day of ovulation 5 days before 5 days before and then the day of. Sperm can live for 5 days in the female
01:42:46
reproductive tract. The egg lives for 24 hours. So on this graph, where is Yep. So the line right is ovulation and
01:42:53
then the 5 days before. Yeah. Yeah. So in popular culture, you would call that natural family planning.
01:42:58
Okay. Fine. Avoiding intercourse. Abstaining any time in that window. But but if I if I'm trying to get male
01:43:05
pregnant, then I should really be aiming. Yeah. Those are your target days. Yeah. There apps for that you can track. Yeah.
01:43:10
Oh, I've got the app. Yeah. Okay. Oh, he knows. Remember the variability. He's made download it nine times. There's a few different ways you can do natural family planning to hijack the
01:43:20
discussion for a minute and they have different degrees of effectiveness, but one of the main issues is that they have
01:43:26
very large abstinence windows. So, it's often not very sustainable to say, "Well, we're just not going to have intercourse for 18 days out of the month
01:43:33
or some very long time period, depending on which one, because your cycle's never
01:43:38
perfect. What if you did ovulate sooner? If this is all you're relying on for your prevention of pregnancy, you have
01:43:45
to really assure that you know when that ovulation is happening, it can be an effective way to prevent pregnancy if
01:43:52
your cycles are very regular. But in my brain, I wish that's what you stop the birth control pill at least 6 months
01:43:58
before you want to get pregnant. And then you start learning how to track your cycles and you're using some natural family planning if you're not
01:44:04
quite ready then because the margin of error, oopsies, it didn't work. the acceptance of well we were going to try to get pregnant soon is usually okay. It's not an effective contraception for
01:44:16
most of the population. We have to factor in when we're looking at, you know, I was trained and taught to only
01:44:22
look at birth control through the lens of contraception, right? We know that they might have some weird bleeding and
01:44:27
maybe a few headaches. And for some a DVT, if they have, you know, deep venus thrombosis, you can have blood clots.
01:44:32
It'll increase your risk, especially if you have a pre-genetic disposition to that. But what we didn't talk about were
01:44:38
mental health, mood, and some of the long downstream libido effects. So, of of taking, right? And so then I'm looking at it through the lens of, you know, if I'm only looking at on the lens of she
01:44:50
doesn't want to be pregnant younger patient. So you're talking about 18 is less likely to remember to do
01:44:56
something every day. Correct. Okay. So then to take the impetus of remembering to take a pill every day or
01:45:03
change a patch once a week um for the patch option. Then we're looking at maybe a vaginal ring that she inserts for 3 weeks and removes for one for her period. Pick one. If I had to pick one right
01:45:15
now, if I was if it was available in the US, I think I would go with the Asteratrol. What's that option? That's the one she's saying is in the UK, a newer option that we don't have. No, it's still a pill. It's still
01:45:26
a pill. Yeah. And it's it's because it it more it looks like so far it's newer that it
01:45:34
has less of the downstream effects. So you're not having that complete suppression, you know, that complete
01:45:40
binding and it's it's, you know, may have and also probably has less risk of um DVT of blood. I'll jump on this. I do not love
01:45:51
intrauterine device for a patient who is 18 for a multitude of reasons. Now, I'm going to preface this to say it is an
01:45:59
highly effective contraceptive choice. It's one of the most effective ones that we have. And so there are certainly
01:46:04
circumstances where that is the right thing to do. We've had IUDs in practice for a really long time. For the majority
01:46:11
of this, we were only placing them in women after they had given birth at least once because of their size and
01:46:17
being able to pass them through the cervix. Now we have different options and we are offering them to women younger, which is wonderful. However,
01:46:25
when we're putting IUDs in the uterus of women who are really young, sometimes the progesterone dose in them is so high
01:46:30
that it is preventing ovulation. And we are seeing young women who are not ovulating and they are not making
01:46:36
estrogen therefore and they don't even really realize it because that's not disclosed as one of the main
01:46:44
mechanisms of a progesterone IUD because it doesn't happen in enough people to effectively prevent conception that way.
01:46:51
It works through the inflammation, the cervical mucus changes. And why does that matter? Because if you
01:46:56
are not ovulating and you're not making estrogen, you are going to have low libido, low energy, you're not going to
01:47:02
build your bones during critical years. Let's say let's say the IUD lasts 5 to seven years. You're 18 to 25. These are
01:47:09
some of the most critical years in your mental health, your bone health, your cardiac health. And being low estrogen
01:47:16
during that time is going to set you up on a different risk trajectory for your entire life.
01:47:22
And the worst thing here about the progesterone IUD is that because of the progesterone, which will thin the
01:47:29
lining, many women just say, "I don't have my period because my lining is so thin." And that's a side effect of the IUD. If that same woman was not
01:47:39
ovulating, and came to me and said, "I haven't had a period in 7 years, and I knew she was low estrogen and not
01:47:45
ovulating." We're highly concerned about her health. But because she has an IUD,
01:47:50
what happens? Well, that's a side effect of IUD. No big deal. So, we're missing the moment to
01:47:56
understand where are some of these symptoms just side effect of the IUD or are they having a much bigger role in what's going to happen to that woman's long-term trajectory for being low
01:48:08
estrogen during crucial years? And I'll say this, Stephen, I'm very biased, right? I'm a fertility doctor. I see
01:48:14
patients who have trouble getting pregnant. That is a narrow subset. That is not the majority of women who have
01:48:20
IUDs. So, what would you suggest if you had to pick one contraceptive? Vasectomy.
01:48:27
Yeah, I would still do I would still do the pill right now. The pill or the vaginal ring? You know, I think they are both depending on somebody's personal
01:48:33
preference. I just think that it's really important if you're using the birth control pill. I do think it's
01:48:39
important to give your brain a break from the pill at times and even if you're cycling it monthly, you there's
01:48:44
options now. I took the pill, an active pill. every single day for for years, a decade probably, meaning suppressed my brain completely for that long. Now,
01:48:59
your brain sends out hormone signals that impact your entire body, right? So, we already talked about the hormones and
01:49:04
how it's this beautifully conducted symphony. But if you even if you're going to take the pill at that young
01:49:10
age, I would say take it so that you have the seven days of not t not taking a pill. let your brain have a moment of
01:49:17
release from the suppression and then take it again. That's still a very effective way to use the pill. But
01:49:22
because women don't love having periods, we've offered these other options which are not wrong, but they just have a
01:49:29
bigger consequence downstream than we're talking about. But the pill is very short acting. It only has a
01:49:36
halfife of 28 hours, meaning it is out of your body very quickly. So, you do want to stop the pill and see what is
01:49:42
happening and track your cycles. That is something nice about it versus an implant or an IUD. That is
01:49:48
fit and forget. The fit and forgets that people like set it and forget. Yeah. Yeah. The question that came in from the
01:49:54
10,00 women we spoke to in the diarrhea audience was, is there any way to control hormonal mood swings during the
01:50:00
luil phase of the menstrual cycle, which I now know is the second phase of the menstrual cycle. Stephen, you've learned so much. Yes,
01:50:07
that's great. I love that. In the ludal phase, we do tend to see more mood changes and physical changes. And a lot
01:50:13
of this is because we have an increase in estrogen and progesterone and then a decrease in both of these hormones. And what we find is that some women are simply more sensitive to these changes.
01:50:25
They feel them quite profoundly. And there's even something called PMDD, premenstrual dysphoric disorder, which
01:50:30
is when those hormones are dropping. You get these terrible mood swings, this terrible depression and anxiety in
01:50:36
addition to physical changes with terrible fatigue. You just feel like you can't accomplish any of your tasks,
01:50:42
insomnia, quite similar to a lot of the things that we talk about anytime we talk about a low estrogen state,
01:50:48
right? Like po we see it in um postpartum depression. It's a very similar and in the permenopause
01:50:55
transition, we have a 40% increase in mental health changes. And we know this because women tell us and we believe them. But what's happening is that our neurotransmitters, especially GABA,
01:51:07
serotonin, and dopamine levels are highly tied to what our hormone levels are doing.
01:51:13
Yeah. So is this is the mood swing or is the is the what's the right term to describe a mood when someone doesn't feel great? Dysphoria. Dysphoria
01:51:25
is the deoria mood after the period or before it. It's often it's before. So the estrogen
01:51:31
is dropping before and it stays low through. So what happens is about the week before your period and then the
01:51:37
week we'll say of your period you are estrogen low. The rise of estrogen from that next egg being recruited is
01:51:43
actually what stops you from bleeding and helps you start to feel better. Because of this, a lot of people will
01:51:48
throw a birth control pill at this situation because they will say, "I will give you constant hormone levels every
01:51:54
day and now you will not have these PMDD symptoms anymore." However, a lot of women don't want to be on the pill for a variety of the different reasons we've talked about. They just feel bad, let's say, this week or this 7 to 10 day
01:52:06
interval. They don't want to suppress ovulation. I find that a lowd dose estrogen in the ludial phase can be very
01:52:12
effective in targeting after ovulation. I'm going to take some estrogen helping alleviate these symptoms without
01:52:19
interfering with ovulatory function. But I was trained to give them an SSRI for those 7 to 10 days. An anti-depressant pill. Yes, an anti-depressant only for those two weeks. Saraphim was that the brand
01:52:30
name of it. And it does tend to help. But what no one taught me and what clinical experience has taught me and
01:52:37
talking to all these other smart people is a lowd dose estrogen like treating the root cause treating the root cause. Just just give her estrogen back during that time period and she gets remarkably better.
01:52:49
In some of the nutrition research finding that low iron and low vitamin D are huge contributors to it. So there's
01:52:57
that research to investigate too, which is interesting because there are some women also who don't want to go on SSRI
01:53:04
or estradile. So, you know, the endocrine society does not recommend routine testing of vitamin
01:53:10
D. It's crazy. I I just think it's insane. Yeah. With my partner, I should anticipate that her mood might drop in the leadup
01:53:16
to her having her period. Mhm. It's very common. And then after her period, it would might recover. And whether or not that
01:53:23
becomes clinically significant, whether or not it's life disruptive for her rather than she just has a little bit of a low mood, most women can tolerate
01:53:29
that. But for those who can't and that it is disrupting their day-to-day activities and how they feel about the
01:53:36
world, we have options. Yeah. Cuz I'm trying to understand I want to understand her better. So I'm looking at
01:53:42
this little graph here which says the brain during the menstrual cycle. So the menstrual cycle starts when her period
01:53:49
starts by convention. Yes. That's what we say. Day one is the first day you start bleeding. Okay. And so what is she going to go
01:53:55
through for the next 29 days? And how might I support her better through that journey? Like I want to understand what's going
01:54:01
on in her brain. Her brain starts by s from a reproductive hormone level. The brain starts by sending out FSH, follical
01:54:08
stimulating hormone, which is going to get her ovary to start growing an egg which lives inside a follicle and making
01:54:15
estrogen. And that rise in estrogen as it's growing will stop her from bleeding. So the beginning that cycle
01:54:20
day one, the bleeding that she's experiencing or her period is because she didn't get pregnant in the month
01:54:26
before. So it's getting rid of that indometrial lining, cleaning the slate. She's estrogen and progesterone low
01:54:32
during that time period. And then once her bleeding stops, it's because an egg has been chosen. Estrogen is then going
01:54:38
to rise until it gets to that peak level. During that time, she's going to feel her best for most women.
01:54:44
So is that the first 14 days? So the week by convention if you had a 28 day cycle which only about 13% of women
01:54:51
actually do but all of these graphs if you look at usually use 28 days because it's easy to go week by week
01:54:57
and that's the lunar calendar. Yeah 28 days. We see that but we have to acknowledge that most women don't have a 28 day
01:55:03
cycle. So but it is roughly the first two weeks for most women to get up to that ovulatory time period. So the time from I have started bleeding until I am now ovulating, that is all considered
01:55:15
the follicular phase. And on this little image that I have in front of me here, it says in those first
01:55:20
14 days, she's going to have better spatial skills and be more anxious. So once you get to your estrogen
01:55:26
dominant, so you have a lot of estrogen and you don't have progesterone, most women can are have increased
01:55:32
concentration. They have more focus. They actually can sleep better. They have higher libido. you feel like your
01:55:38
performance even for athletes performance tends to be improved aggression concentration more yeah
01:55:43
during what we call the late follicular phase so that means the time period when you're really making that estrogen let's
01:55:48
call it days 7 to 14 for ease so I'm now done bleeding a follicle is growing meaning an egg is making enough estrogen to stop that bleeding I've not yet ovulated and seen progesterone this is
01:56:00
where we typically have our best performance overall from how our body is functioning
01:56:06
and then From day 14 onwards, I'm she's going to be calmer. Well, progesterone slows your body's metabolism down. It It's preparing you for that pregnancy. Calmer is a nice way
01:56:18
to put it, but essentially, your metabolic rate is going to change. Your body's going to shift how it functions.
01:56:23
Many women actually have fatigue. They're hungry. Specifically in the brain, progesterone levels as they rise,
01:56:31
we see an increase in GABA, which is a neurotransmitter, one of our brain hormone, one of our brain, you know,
01:56:36
hormones that talks, you know, jumps between one one neuron to the other. And that is more of a calming hormone. So
01:56:43
women tend to we see sleep changes more. You see deeper sleep, longer sleep in that ludial phase. She's and on this it says she's going to have she's going to be horny for day 14.
01:56:54
I don't know how else to say it. Because she has an egg available because that's that peak estrogen. That estrogen level of 200 pograms is
01:57:01
heightening everything. To have peak libido when an egg is released, the body is made that way on purpose.
01:57:06
This is a bit off script, but my girlfriend always talks about her HRV being very different. And so she she has really great HRV scores and then once
01:57:18
every month for a period of time they're terrible and she can't explain it. So this is where wearables come into play. Yeah. So wearables are not designed to capture women's physiology. So what happens
01:57:30
after ovulation is your respiratory rate goes up, your resting heart rate goes up, and your HRV plummets. So on the
01:57:37
wearables, most women about 5 days before their periods start will never be in the clear, so to speak. They will never look recovered. They will never look like they can take on a lot of
01:57:48
stress. They're not stress resilient because of the way the algorithms are reading this change that is natural that
01:57:55
is produced by progesterone to alter our respiratory rate and our heart rate. It
01:58:01
doesn't mean that she's not stress resilient is what the wearable is saying. Ah cuz she came downstairs and she said,
01:58:08
"Oh god, my recovery is so bad." And then I think a couple of days later, a little while later, she had a period. I'm not sure. I can't remember the time frames, but she came downstairs and she was like shocked that she had done
01:58:19
everything right, but her recovery on on her wearable said that she was in terrible state.
01:58:25
This is why we do not let athletes use wearables leading up to a peak event because they feed into what the wearable respond or telling them and it's not
01:58:36
true data with regards to how their body can actually perform. So wearables data
01:58:43
masters then need to segate segregate populations and make new norms for women and maybe new norms for different fitness levels of women. Exactly. I've always been pushing for
01:58:55
the past five or six years interacting with wearable companies is like if you want to capture it well then you need to
01:59:02
be able to compare follicular to follicular and ludial to ludal. What does that mean? So comparing
01:59:08
like we know your HIV is going to be different in your follicular phase. This is not a bad thing.
01:59:14
People could could theoretically do that on their wearables and look at the previous month and see the the level you're at then theoretically. Obviously
01:59:20
the wearable companies could do a lot more here to to definitely helpful but no you then it comes back again on the woman trying to
01:59:27
understand and interpret the data herself which can be a little bit problematic because there's so many
01:59:34
women out there like my wearable told me that I'm in the red I can't do anything today when in fact physically and
01:59:42
psychologically they can do what they set out to do. It's just now they have this little seed saying that no, you
01:59:49
can't do it because of an improper algorithm on their wearable. Probably a good time to disclose that I'm an investor in push. Okay.
02:00:00
Yeah, I will send this to them. Please. Yeah. You wear Do you wear any devices to track your health data?
02:00:08
I wear I wear a CGM and a Whoop. Just give me a minute of your time and I'll tell you about a device that my team's been using that they won't seem to shut up about. It's called the Note
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that conversation was when I talked about this product. These are what I call barefoot shoes by Vivo Barefoot,
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02:02:11
close off on the subject of fertility because it was um heavily asked by our audience and I I guess I'm well placed
02:02:18
to ask some of these questions because I'm in that journey myself of trying to have a child at the moment. Natalie, you
02:02:23
have five fertility non-negotiables that you talk about. I do and I think it's really important
02:02:28
to think about for too long we've been told, you know, your fertility is luck. It's good luck
02:02:34
if you get pregnant. It's bad luck if it's not. And that's this narrative that gets propagated. And fertility is
02:02:40
certainly not fair. Meaning people will have infertility and do everything right. But there are things that we do
02:02:46
that will inherently also harm our fertility and our hormonal health and make it harder to get pregnant. And
02:02:52
that's even when we are doing treatments. So a lot of times people say, "I'm doing IVF so I don't need to
02:02:58
worry about these non-negotiables." And that's also not true. meaning things that we need to do. We need to, as we've
02:03:05
all said, get more sleep. That's going to be number one. We need to actively work to decrease stress. That is not a
02:03:12
I'm just going to live a stress-free life. But all these things I'm going to not take call. I'm going to set some boundaries and not have late meetings.
02:03:18
I'm going to see morning light. I'm going to take a walk outside. We live in a stressful world and chronic stress
02:03:23
itself can impact your fertility, your natural fertility, and IVF success rates. We're going to work on exercise
02:03:30
to build muscle and try to improve our muscular health since it's part of our metabolism. We're going to eat an anti-inflammatory diet. That's definitely key, high in fiber. And we're
02:03:41
going to look at the world around us and work on pulling toxins out of our world that we know we haven't even entered the
02:03:47
discussion about how environmental toxins is harming our body, our hormonal health, our fertility, our ovaries, our
02:03:53
organs. And so these are all things that we make active choices on that we have to start paying attention to and kind of
02:03:59
changing. We'll go into detail in the lifestyle factors and the environmental toxins um
02:04:05
in our second episode together. I I've always been quite shocked by this graph because it's quite um quite significant. This is just showing
02:04:11
the um egg count by age. Slide that into that direction. um what do men and women
02:04:19
need to understand about egg counts in order to make better family planning and fertility decisions? Okay. Well, I've asked you this last
02:04:25
time. So, Stephen, how many sperm do you make a second? Millions. You make 1500 a second. You mean you make millions every day? Is okay. But
02:04:36
still, you still you make a ton of sperm. You make sperm every single day. You have germ cells that create sperm. Women are born with all the eggs you're
02:04:43
ever going to have. And yes, my favorite vault analogy. So, I like to imagine that this is a vault inside your ovary
02:04:49
that is storing all of your eggs. And so, we'll use this cup with all of the beads as that analogy. And every single
02:04:56
month, since before you are born, eggs come out of this vault. And what happens is that when the vault is more full,
02:05:02
more eggs come out every month. And as the vault starts to get emptier, fewer come out. And this means that we lose
02:05:09
the majority of our eggs, you can see the line, well before our reproductive years even start. So you lose the most
02:05:15
before you're born. So from being a 5-month baby to birth, your egg count goes from 6 to 7 million to 1 to 2
02:05:20
million. Millions of eggs lost before you're even born. From birth to puberty, let's say
02:05:26
you go from 1 to 2 million to half a million to simplify numbers. So, the second biggest drop before you're ever
02:05:32
ovulating, before you ever have a chance to get pregnant, and then you only ovulate around 400 eggs over the course
02:05:37
of your reproductive lifespan, as that egg count starts to drop over time, the other really, really big important factor is that our eggs have been in our body our whole life. Two different
02:05:48
things are happening at the same time. One is that our chromosomes start to leave their perfect position. They
02:05:54
absorb the wear and tear of years. So we see more chromosome abnormalities as we get older. It's why it's harder to get
02:06:01
pregnant and why we see an increase in miscarriage as we age. But also concurrently our metabolic health is
02:06:07
poor as we are older too. And mitochondrial function in eggs. The metabolic capacity becomes less capable.
02:06:14
And so we see that it's harder to get pregnant not because women are running out of eggs but because the quality of
02:06:19
the eggs declines. But everybody will run out of eggs. You'll have a period of time where you have a very low egg
02:06:25
count. We call it diminished ovarian reserve in the fertility world. We call it perry menopause more globally. And
02:06:31
this this is two words to describe the same thing. As your egg count starts to get very low, you start to have an
02:06:36
unpredictable response to your ovary and your brain is trying to compensate for that. And so you see various hormone
02:06:44
changes, but these start before you might recognize even menstrual cycle changes. But everybody will run out of
02:06:50
eggs. Every woman will. your ovaries will go into what we call ovarian failure and no longer respond to
02:06:55
hormonal signals from the brain or artificial signals that we give. Meaning, I will see older women come in
02:07:01
and think that I have magic medicines with IVF that can still help them get pregnant, but I can only get the eggs
02:07:07
outside the vault to grow in IVF. And so, shouldn't we then be freezing our eggs?
02:07:12
You're right. As a society, if we are purposely delaying childbearing, we know that it gets harder to get pregnant with
02:07:18
age. And if having kids is a life goal, putting eggs into the freezer earlier is
02:07:23
a way to save that opportunity. It's not an insurance plan. It's not a guarantee,
02:07:29
but it is a smart game plan, especially as we are waiting longer. Because even with IVF, we can't always overcome age related infertility if we have fewer eggs and more genetic abnormalities. The
02:07:42
technology helps us identify healthy eggs, helps us have more eggs, able to grow in a certain month and take them
02:07:48
out and test embryos in a lab, but I'm working with the eggs and sperm that you're giving me. Meaning, if there's
02:07:53
not many of them, if there's a lot of chromosomeal damage, if there's a lot of mitochondrial dysfunction, if the sperm
02:07:59
quality is not great, that doesn't mean we're going to be able to have success. So, what you're doing on a daily basis
02:08:04
to impact egg and sperm quality is still crucial. But egg freezing has gotten a lot of bad rap. It's still a new technology. It's only been around about 10 years off experimental purposes.
02:08:16
Meaning that women who froze their egg 10 years ago, you know, they have much poorer egg survival rates. They were
02:08:22
older at the time. Their experience is very different than the modern woman who is freezing her eggs now, maybe in her
02:08:29
upper 20s or early 30s. What is the optimal age? If you are want to have a child as a life goal and
02:08:34
you're not ready to conceive by age 32, that is when there's a clear delineation
02:08:39
that it makes smarter financial sense as well as likelihood sense. The short answer like my daughter will freeze her eggs in her 20s. The younger you are, the more eggs that you have. If she
02:08:50
says, "I want to have kids as a life goal," then that will be something that we will do in order to help her keep
02:08:57
that because there's so many other variables which impact your ability to get pregnant or your egg count.
02:09:03
Endometriosis decreases your egg count, right? People will develop an ovarian cyst and they'll have
02:09:08
surgery, surgery, they'll have a twisting of their ovary and maybe they'll lose an ovary, smoking, chemo, radiation,
02:09:14
smoking, marijuana, any abdominal surgery. So many things can impact your your eggs because you only have this
02:09:19
group. You're born with them. So we we plan for life goals differently. And we've never really talked about our fertility life goals until more recently. Meaning when we went
02:09:30
professional career, right? We knew what we had to do to get into medical school, to get into residency, to get your PhD, you had this list of things and you set
02:09:36
goals and you worked to achieve them. But I always wanted to be a mom. Yet, I already told you I took a birth control
02:09:42
pill every single day and I didn't even think about it until that moment was in front of me. And that's the part of the
02:09:48
discussion that we do have to start to have earlier is if this is a life goal for you, what do we need to do?
02:09:54
Understand our body better, our fertility better, and maybe that does include freezing eggs because it does give many women an opportunity that time
02:10:02
would eliminate. I had a conversation with you Natalie on the podcast but then many other women over the course of the last two to three years and one of the things that I learned from that was that we as you say
02:10:14
we don't family plan and then we have to deal with the consequences of not family planning. So, as an interviewer, when I do life story episodes, I go through a
02:10:20
woman's life story. And obviously, the women that's sitting in front of me are typically high performers, high achievers in some capacity. And then we
02:10:26
arrive at the end of the conversation when we talk about family and kids and all those kinds of things. And there's
02:10:32
often a lot of tears. And it was in those conversations sitting here with several women that were on the show.
02:10:38
What was the straw that broke the camel's back? It was the UFC fighter Ronda Rousey. It just so happened that
02:10:45
when I interviewed her, she had just found out that her seventh round of IVF had failed. And so she was very, very emotional. I left that interview and had a conversation with my girlfriend. I was
02:10:56
like, "Listen, I've I've seen too many of um too many women over the age of 35, maybe sort of under the age of 50, but really under the age of 45 in tears in front of me. I think we should have a
02:11:09
conversation about this. Should we freeze our eggs?" I mean, me and my partner are both 33 now. And um at first
02:11:18
I don't know, maybe it was the way I worded it. She was offended. She was like, "You don't want to have a baby with me?" It was like Yeah. It was like, "You don't want to have sex with me?" Like I
02:11:29
like didn't word it well. Like I didn't I didn't really think I didn't really think about the emotions surrounding it. I think that was really what it You were trying to make a pragmatic
02:11:35
decision. Yeah. I was as men often do. Like I was just like we should free but I didn't think about what that meant. And there's this this prevailing narrative in
02:11:42
society that if something's not quote unquote natural, then it's not good. And that IVF or egg freezing is not natural. And that like torments people's brains
02:11:53
because they want to live a natural life even though they're in like [ __ ] planes and on on iPhones. We want this one area of our life to be
02:11:59
natural. And after honestly five minutes of that conversation, I think the framing that m flipped her mood was that wouldn't we want to give ourselves the option,
02:12:11
right? And it's actually about having options. But I wanted to throw that out there because, you know, I don't think people family plan. I think as you said, we
02:12:18
focus on our careers, then we pop up at 35, 36, 37 and assume that we can. Mhm. But that is not the case. Yeah. Especially if you live a healthy life, you you think, "Oh, this will be easy for me." or if you're a high
02:12:29
achiever and you've achieved other things, many women are really taken aback by not being able to achieve this or not having control over infertility
02:12:41
and what is a natural process to run out of eggs and to go into menopause. If you
02:12:47
are lucky to live long enough, this is going to happen. I got my diagnosis of PCOS in medical school before I was ready to start, you know, family planning. And I knew I was probably
02:13:00
going to struggle. And so it took us about 3 years to successfully conceive the first time. And you can't even though I'm working in the business, you know, I'm running between
02:13:13
patients to go and have another ultrasound or go get a shot or go do all the things that it took, you know, you
02:13:19
you can't remove the emotion from it. And I can't tell you how many times I cried. And of course, all of my
02:13:25
co-residents, my four best friends, all got pregnant in succession, our poor chief residents, and with no trouble,
02:13:32
you know, and even like crying to my mother about the struggles I was having, she's like, I just I got pregnant eight
02:13:38
times with no trouble, you know, and then my first pregnancy resulted in a miscarriage and, you know, in the middle
02:13:44
of work and all my friends were there and they were cheering. They were so excited I was finally pregnant and then we lost the baby and you know and having
02:13:51
to like push through and work through it's like it was yesterday like you know I have two healthy kids thank God and
02:13:56
you know we were never after those two we tried again we were never able to get pregnant again which you know I had two kids and put a bow on it and we're done
02:14:03
but it is impossible to remove the emotion because you because in the mindset it's luck or it's something we did
02:14:14
we caused this and it's I you know as a high performing you know someone who's like you check all the boxes and you make all the good grades and you do everything right and this is the one
02:14:25
thing that suddenly you didn't think much about and then it becomes everything when that ch that that becomes hard or it's taken away from you but I think women assume that it's our burden
02:14:39
because we assume that if we can't conceive it's just us or something But I think I heard you say this, the the it's a two-way street and and the issue is
02:14:50
not always the woman. A high percentage of the time it's her partner. And so I don't think we absorb that information
02:14:57
upfront either until we start investigating it. But I'm in awe of this story that four of your residents got
02:15:04
pregnant immediately because in orthopedics that does not happen. Mhm. Every orthopedic surgeon in my
02:15:10
generation that I know if we got pregnant we miscarried and maybe that was lifestyle and maybe that was not eating for 40 hours. Maybe it's all the radiation that we undertake. I think
02:15:22
it's better now for the younger generation and we as the I'm not that old but I am older than the current
02:15:28
residents. Um, we encourage all of them. If you are not partnered and wanting to
02:15:33
have a child now, then please consider freezing your eggs if that's a goal because we can't predict our futures and
02:15:39
our residencies extend into our 40s. Well, I love that you're helping facilitate that discussion because that
02:15:45
certainly wasn't the culture back when we were in training. I am one of the ones who sat here and cried in front of Steven myself when talking about my own
02:15:53
pregnancy loss journey just because you know I see it every day you know and I tell patients every day news that they
02:16:00
do not want to hear 50% of infertility is due to male factor 50% is due to female factors one of the
02:16:08
most important things I want to convey when we on this topic is that IVF is an amazing technology that has helped 13
02:16:16
million babies be born. It has been life-changing and world changing. And things don't have to be natural. Sometimes the natural progression of disease is death. So we have technology
02:16:29
and science that exists to optimize and improve life and to help life exist. And
02:16:34
that's part of what IVF is. And I think that's important because we do see a narrative right now that IVF is
02:16:39
inherently bad and natural fertility approaches are inherently good. And we truly need to say both things are good.
02:16:46
Do women need to learn about their bodies earlier? Talk about cycle tracking, take better care of themselves, get an earlier investigation
02:16:53
when things aren't going well? Absolutely true. But also, needing to have fertility treatments is not a
02:17:00
failure. Needing to see a fertility doctor is not a failure. If you need IVF, that is okay. All the other stuff
02:17:06
is still really important to the outcome of your journey. But this narrative of IVF isn't natural, so it's bad, or egg
02:17:13
freezing isn't natural, so we shouldn't do it. That's harmful to society and to women who do carry the burden, whether they need to or not, women do carry the burden of family planning for the
02:17:25
future. Hearing you talk about that is very interesting to me because in other parts
02:17:30
of medicine, in my own medicine, right, we were talking outside about how I I now do knee surgery through needles. It's an advancement of technology. We celebrate that. We like better things
02:17:43
for people. It's not natural. Live with your thing, right? But I'm capable of helping you live a better life.
02:17:50
Right. So, it's interesting to me. It's the stigma of women's health and work. That's right. This has because this is women's health. We're going to control it. We're going to protect these gals.
02:18:01
We're not going to apply the vast knowledge. I'm a little offended by it actually. If you want to know the truth,
02:18:07
why can I be so encouraged and and be considered top of my field when I adopt new technologies? But in your field, 13 million parents or
02:18:21
26 million parents would be told that technology is not okay. I agree. It's a terrible narrative that is happening right now in the political
02:18:31
landscape. And I think it's important to say scientific advancement is good and it changes the lives for so many people.
02:18:39
And I think it's just highlighting this idea about natural doesn't always mean better. I think as you know scientists and people in medicine there's also been
02:18:50
a disservice to not trying to get to the root cause and not working on preventive medicine and so going towards treatments
02:18:56
and technology which has made the lay person feel like half of the picture wasn't discovered or talked about and so we can do better on both ends of it and that comes to women's health more
02:19:07
than anything because there is stigma when it comes to isolation there's in I mean when it comes to infertility there's isolation
02:19:14
you know being left behind your peer group. Questioning a life goal will make you question who you are, your life
02:19:21
meaning, your purpose. And that is an extremely stressful and challenging state for somebody to go through. And we
02:19:28
should be giving more support to that. We should be saying freeze your eggs. You're at a stressful lifetime instead
02:19:33
of the narrative that we are seeing right now. So would the message be to young men and women that want to have
02:19:40
kids at some point in their life to freeze their eggs in their 20s? Is that what you would advise? You know, most people in their 20s maybe don't have good awareness of these goals, but certainly your, you know,
02:19:53
later 20s, your early 30s are the prime opportunity where you still, for the average person, you're going to have a
02:20:00
high number of eggs. You're still high on the graph and your egg quality is still going to be high. meaning it's
02:20:05
going to be easier to get the outcome that you want. Certainly in your 20s would be ideal if you but it's
02:20:11
expensive. A lot of people don't have the financial resources to freeze their eggs and their 20s they're in training
02:20:17
or they're starting their career. So to have an extra $10,000 lying around isn't always realistic.
02:20:23
And I think that's why people are often waiting because that feels, you know, elective, you know, like, oh, that's
02:20:30
extra money. I don't know that I have that right now. when we see insurance that starts to cover egg freezing as an
02:20:36
option, we see huge uptake in women going to freeze their eggs. So you will see at companies where almost less than 5% of women would freeze their eggs before age 35. And then they introduced
02:20:48
a health plan that would cover egg freezing and up to 50% of them would. So you can see that both financially and
02:20:57
access and awareness, they all go hand in hand. But that's a big player in being able to do that because it is an
02:21:03
expensive process. So Dr. Crawford, I think what most people don't understand, what is the spontaneous fertility rate by age in
02:21:10
general? Yeah. So if you are 30, your odds of getting pregnant monthly. We we use a monthly rate called fundability. It's
02:21:16
going to be at best 20% per month. When you're in your 20s, it's a little bit higher. Can get up to 25% per month
02:21:23
if you're having sex monthly and regular periods. So if you're having unprotected intercourse
02:21:29
and you have regular cycles, your best odds in a given month are going to be about 20% at age 30.
02:21:35
How much sex do you have to be having? Well, really just have to have it in that fertile window. The what? Just once or
02:21:40
really just once? Yeah, sex solely on the day of ovulation would be the ideal time, but you just need to have at least
02:21:47
intercourse at least once in that fertile window. But that number drops quite significantly to what Dr. Caver is saying. So, at age 35, if you're trying
02:21:55
to get pregnant, it's going to be 10 to 12% per month odds of getting pregnant. At age 38, it's going to be 5% per
02:22:03
month. At age 40, it's going to be 3%. This if you're trying for the first time, they're a little bit higher if
02:22:08
you've had a child already because there's some proven fertility factors. But if we look at that, you say, "I'm
02:22:14
chasing these dreams. I'm going to try to have my first baby at age 38." You have a 5% chance per month. That's not
02:22:20
zero, but that means the greatest probability is that by 6 months time frame, you won't be pregnant. And then you're going to start a pathway of trying to investigate why that is happening. And if you do need
02:22:33
intervention, you're further down this graph, too. You're going to have less eggs to work with, and their quality is
02:22:38
going to be less good. That's why those numbers drop rapidly. Natural fertility rates are not about being out of eggs
02:22:45
because you ovulate just one egg at a time. It doesn't matter if you have 20 eggs outside that vault or five eggs.
02:22:52
You're ovulating one egg at a time. So natural fertility is all about egg and sperm quality. So the this huge drop we
02:22:59
see from 20% to 5% is because of the change of our egg quality as we get older during our 30s which most of us feel like is really young. And what can I do to because I know
02:23:09
weight has a role in egg quality right? If you're underweight or overweight, is there anything else that has a a really
02:23:14
pertinent impact on the quality of my eggs? Yes. So, we have two factors. We'll say
02:23:20
age, which you can't control to an extent, right? Chromosome damage is going to happen even if you are exceptionally healthy because tincture
02:23:26
of time. They've been sitting inside your body. Chromosome damage builds up. But the variables that you can is
02:23:32
everything that impacts cellular health. So chronic inflammation and insulin resistance are the two things that are
02:23:37
going to most dramatically harm your eggs metabolic function. It's going to harm your mitochondria. You're going to
02:23:42
get mitochondrial damage. We know that when we start looking at older women, they have more dysfunctional
02:23:48
mitochondria. They're shaped abnormally. The products inside their follicular fluid show higher levels of inflammation
02:23:54
just based on age that happens, but also if they start having infertility versus not having infertility. So we know that
02:24:01
inflammation and insulin resistance are key players even in patients without known PCOS or endometriosis but they
02:24:09
play a role in aging and specifically your egg health as you age. So if you say getting pregnant is a life goal. I'm
02:24:16
tracking my cycles. I don't want to freeze my eggs right now, but what should I do? All these things that we
02:24:22
talk about and we're going to talk more about to decrease inflammation inside our body. That's it. and from a young
02:24:28
age because these changes build up over time. And if I have PCOS, how does that even more important because you're at a higher predisposition to have insulin resistance? Your cells are more
02:24:39
sensitive to how they're going to respond. But do I have less eggs if I have PCOS? So, you're going to run out of eggs around the same time. You're born with a
02:24:46
little bit more, but because you lose eggs based on how many you have, essentially, you're going to catch up.
02:24:51
So during your reproductive years, you tend to have more eggs out of the vault, which interferes with normal hormonal
02:24:56
signaling, making all of the hormonal metabolic changes worse. Very interesting thing, as women with PCOS
02:25:04
tend to get older, and their egg count starts to drop, and they have fewer eggs coming out of the vault, they'll often
02:25:09
start naturally ovulating, even if they didn't earlier. And so I'm always a little concerned when somebody said, "I
02:25:16
used to never have periods, but now I do. Did I cure my PCOS? Maybe they did make some good lifestyle
02:25:22
changes along the way, but honestly, that's a red flag for me that she's now more rapidly declining in her egg count,
02:25:29
approaching what will be penmenopause for her because her egg count is low enough to then respond to the brain
02:25:35
signals. Like nodding your head over here. And as a man, is there anything I can do to increase the odds that I'm going to
02:25:41
impregnate? Mel, you can stop using um cannabis and smoking cigarettes, um drinking alcohol.
02:25:48
We need to avoid heat. So the testicles are outside the body for a reason. They need to be at a lower body temperature
02:25:53
in order to adequately make normally functioning sperm. So hot tubs, saunas, those should be off limits if you're wanting to get pregnant. Same with highintensity exercise and compression
02:26:04
of the testicles. So this is notably cycling for long periods of time. So an hour on the bike or more routinely can
02:26:11
actually compress the testicles and increase their heat. What about sitting in a chair for 5 hours? choose. She'll be fine. I want to
02:26:17
Same thing. Sitting in a chair, boxers breathe, being in a room that's hot. Those things aren't quite enough to
02:26:22
truly raise that core testicular temperature quite like some of these other things. We also see diet playing a
02:26:28
big role. The great thing about men, you're making sperm every single second. The sperm lifespan is 90 days, 72 days
02:26:36
to make a sperm, 18 days to get out the ejaculatory system. But that means you could make a singular change in your
02:26:42
health and see a different outcome in your sperm. that is so rare that doesn't exist in women's health that one
02:26:48
variable can move the needle so much. Marijuana is a huge one. Marijuana use works at the brain to prevent those FSH
02:26:55
and LH signals which are crucial to tell your testicles to make sperm and they also impact inflammatory environment. So
02:27:02
sperm are not as modal. They are not shaped as well. The DNA inside their heads is more fragmented. In fact, men
02:27:09
who use marijuana, their partners have a higher rate of pregnancy loss, even if their partners are not around it at all.
02:27:16
You're using the word pregnancy loss versus the word that we're aware of in the UK called miscarriage. Is that is that intentional?
02:27:22
Miscarriage can mean, you know, a to a lot of different things to people and a pregnancy loss, an unsuccessful
02:27:29
pregnancy depending on when you medically lose a pregnancy or if a pregnancy is in the fallopian tube and
02:27:34
it's an ectopic pregnancy, that's still a pregnancy loss. meaning you had a positive pregnancy test that did not end
02:27:40
up in a baby. So, it's a little more inclusive for a variety of different stages of when and how loss can occur.
02:27:47
Miscarriage kind of infers when we say it, you know, on my end is that the pregnancy was in the uterus and now it's
02:27:52
it's we we either have to evacuate it or it's it's self evacuating. And you were saying a second ago, Vonda,
02:27:58
that it from your experience, pregnancy loss, miscarriage is much higher with women who have high stress careers and
02:28:06
jobs. Well, I don't know the real statistics, but my I'm sure they exist. But in my experience as a high capacity, high stress, not sleeping for 11 or 22
02:28:17
years, I have seen it a lot and it happened to me. Yeah, chronic stress is associated with a higher rate of pregnancy loss. Is there anything else that people
02:28:28
misunderstand about pregnancy loss in miscarriage that is worth talking about? Well, it's not talked about, I think. Yeah. That's one of the things that people still think it's it's taboo and
02:28:40
rare, but I think all of us around the table had pregnancy loss. Yep. Two, at least two.
02:28:45
And when I had mine, I was in training and uh a I didn't want to call my attending and tell them cuz he was a man. And I didn't want to I didn't think I
02:28:56
could take any time off. Same. I went back the next day. I would have gone back the same day, but I could barely move.
02:29:02
I was running labor and delivery like at night. I got discharged. Ivy pulled out in my hand and went back on the war.
02:29:07
Yeah. Like so I think hopefully part of this international conversation about women's health not just gynecological health but health in general will give women grace because
02:29:24
there's no way that I should have been expected to go back to an orthopedic surgery residency the day after I lost a child or frankly I don't know what your
02:29:35
experiences were but in my generation of doctors and I'm sure it happens everywhere. I went back to work less
02:29:43
than five weeks after delivering a child and I think other European countries have it right.
02:29:48
Oh yeah, New Zealand is a year time. I I weeks. Six weeks. I six weeks with one and three weeks with the other because if I wanted to
02:29:59
leave my fellowship on time, that's right. I wanted to graduate on time, I couldn't exceed the total vacation. So these
02:30:05
internships and fellowships and I'm I'm sure that built into these programs we sign up for, they were all developed for
02:30:11
men who had had they had a family, had a wife, you had someone at home to like take care of that business. Yeah. And we're have, you know, we're all in
02:30:23
supportive relationships and, you know, that wasn't the issue, but like I went back before my body was ready. Yeah. because I would before that baby was ready to to unlatch
02:30:33
and my milk supply dropped immediately the minute why I went back to work and I tried to pump but you get called
02:30:39
for a crash C-section or emergency surgery and you're like pulling the pump off the breast and I'm running down the hall hooking my nursing bra back on
02:30:46
trying to get to the O and you know all that cortisol just my milk you know so I was able to breastfeed while I was home
02:30:52
with the baby and but like once I went back to work my my milk production just shattered a picture of day in the hospital and it was a day after I gave birth. My laptop is open. I'm trying to
02:31:05
breastfeed because we launched a company the month before I gave birth and instead of my male co-workers going,
02:31:13
"Okay, we'll give you some grace." No, I had a week and then they were at my house having meetings. There's such a
02:31:19
different discussion about miscarriage now than when I went through it. I told nobody. I didn't either.
02:31:24
I mean, it was so secretive. I didn't feel like I could. And we are seeing a different generation where I do think talking about women's health and Stephen you having these discussions on a bigger
02:31:35
stage are lessening the stigma for what is something that people go through. One
02:31:41
out of four pregnancies will end in a pregnancy loss. That is not a low percentage of people. In the same
02:31:46
breath, most people should not have two in a row. And if you do, you should go get an evaluation because there are
02:31:53
medical things that can contribute to pregnancy loss that we would love to identify a lot earlier and see if
02:31:59
there's something we can do to make that different. What do I need to understand about what a woman goes through either
02:32:05
in the wake of pregnancy loss or in the wake of a pregnancy and uh a birth physiologically, psychologically as an employer to be able to create a better environment for the women that are going
02:32:19
through either of those two things? Like what's what's going on inside the body? Cuz I I wouldn't know, right? So,
02:32:25
one of the, you know, simplest things to say that's going on is that pregnancy is one of the most hormone robust times you
02:32:32
have, even just momentarily pregnant. If you have a placenta starting to implant, you are now making levels of estrogen
02:32:38
and progesterone that you will not ever make at any other time period of your life. When that doesn't when you lose
02:32:45
that pregnancy or when you're postpartum, let's say you're having this huge hormone crash. Suddenly you go from
02:32:51
this very high level of these hormones dropping off immediately. And in addition to all the physical changes,
02:32:57
the emotional changes that has a huge impact, you've heard us talk a lot about low estrogen and how that feels. The
02:33:04
very interesting thing most studies about estrogen show is that the hardest time for women is when estrogen is
02:33:09
changing. So going from high to low is actually when your body is having your brain can't keep up. Can't keep up. Doesn't know what's happening. And the higher you were and the faster you come down, we'll use this
02:33:22
analogy too. Even in IVF, when we go do an egg retrieval and somebody had many eggs, they have a much higher estrogen
02:33:28
they naturally would. I go and put a needle in each one and drain the eggs out and destroy those cells and their
02:33:33
estrogen plummets and they expect to go the next day and feel normal or they expect to feel worse during the
02:33:39
stimulation process when they're using hormone shots. And I always say, you're actually going to feel worse when I'm
02:33:45
done with you. It's going to be that week after the egg retrieval where your hormones go from the highest they've ever been very quickly down low. It's
02:33:52
that delta, that change. And that happens anytime you have that. But pregnancy and loss and postpartum are
02:33:59
some of the most profound times that you experience this. And one of the other things is the identity shift. So if you're working,
02:34:07
you know, we are all very highly motivated and became parents. But it's that whole identity shift of now how do
02:34:13
I interact in my life and how do I interact with my peers? I'm a mom. How am I being identified? What are the
02:34:19
implications? So there's a complete identity shift that also isn't discussed and that can also perpetuate some of the
02:34:26
postpartum that we see as well. Mhm. And anxiety and lack of control, right? Because you don't know what you're
02:34:31
supposed to do, especially if you're a mother for the first time. that is can be very anxietyprovoking in addition to
02:34:38
hormone changes and not getting sleep. But lack of control, you don't control your schedule. You don't control when
02:34:43
you sleep. You don't control if your child gets sick. And so I would say from an employer standpoint,
02:34:49
grace, support, and flexibility. You know, if I had had better support structures to say when your child is
02:34:56
sick, it's not the end of the world if you are not here physically at the office. That didn't exist. meaning that
02:35:02
my child getting sick became this extremely stressful situation. God, but for the average woman working a 9 toive job, whether it's in medicine or other fields, if you could design their
02:35:15
working month around their menstrual cycle around, I don't know, potentially a pregnancy, whatever. How would you design redesign their month? Because we we have inherited this sort of I think
02:35:26
it's like from the industrial revolution, this like 9 to5 working hours. We don't work Saturday and Sunday. We do that four times across a
02:35:34
month. What would you change? What should women change? Because I've heard some countries or systems are are trying
02:35:39
to give women time off around certain parts of their cycle, for example. Would any of you change anything? Well, there
02:35:45
are a couple of companies in New Zealand who are pretty flexible, especially after the pandemic, where they have
02:35:51
allocated certain hours that are free to work at home. You just have to get the work done
02:35:57
to the point where they have 4 day working weeks. And then they're also putting into the annual leave what they
02:36:04
call menstrual leave or menopause leave. And it's you just say, you know, I can't come today. Some people are using it for
02:36:11
child care. Some people are using it for really bad cramping days. Other people are using it for mental health days. But it's a it's there to be used for
02:36:18
however. And you don't have to identify it as being menstrual cycle day or menopause. It's just extra leave. And
02:36:24
people don't care as long as you get the work done. And I think that having that flexibility across, you know, if you
02:36:31
have that ability to have more flex hours or shared time space or something like that greatly benefits productivity
02:36:39
as well as the feeling of empowerment and inclusivity, which then feeds forward to better productivity. If I've got an extremely high stress job, is there any part of the cycle
02:36:49
where I should theoretically be avoiding stress? Well, that's an individual thing. It's
02:36:55
how because you know we hear all the stuff about cycle tracking and it's about understanding your own responses
02:37:01
to your own hormone flux because Mel partner says to me that she needs to not do work. there's like a
02:37:08
couple of days a month where she's like, I'm just gonna nest all those. That could be her her responses and
02:37:13
she's like, I just don't have the stress tolerance to be able to do XYZ and understanding that in her own cycle is great because then she can allocate tasks that take more stress for other
02:37:25
days. For most people, it's peak ludal. Also when your progesterone is the highest tends to be when people have a
02:37:31
harder time focusing and concentrating or getting tasks done now which is where on which is going to be the middle of the ludal phase at the middle of this second
02:37:38
half of the cycle when you have that oneish. So when you have that progesterone you
02:37:44
know really high your body might be ready to implant an embryo if there was one that tends to be when people say
02:37:50
they feel more fatigue and less energy and less focus and concentration. So if you are looking at your month and you might notice that it is and you have the flexibility to say okay I'm going to try
02:38:02
to write this paper get this study done do these tasks that call these tasks that call for an increased focus in my follicular phase when I'm estrogen dominant have high estrogen and no
02:38:13
progesterone for the average person that is typically when they're easier have an
02:38:19
easier time achieving those tests which is the first 14 yeah the first couple weeks the time
02:38:25
period before ovulation, but there is an individual response and I definitely will see some people who they feel
02:38:31
immensely better when progesterone's present and not so great the other time. So, I think we use generalizations just
02:38:38
as a rule of thumb because that's what it is for most people, but hormones specifically, there's always an
02:38:43
individualized response and learning to listen to your own body is key and knowing what you need to do. I want to
02:38:48
close off on this point about just how employers and you know the way that we work can be better suited to a woman's
02:38:55
health. Is there anything else we missed there? Flexibility. I think we mentioned before
02:39:00
the ability to make a decision for yourself. This is a day that I can do these, you know, tasks. I think every
02:39:06
woman wants to do a really good job and she is going to frontload those tasks on
02:39:12
a time that she feels better and offload in a time where she's not feeling as well, but she's going to get it done for sure. And so giving her the flexibility is going to allow her to be
02:39:23
her most productive rather than demanding she have x amount every single day. And I think support can come in a
02:39:30
lot of ways, but the um financial burden to a large corporation of having a stop
02:39:37
gap child care at work. So maybe if you're not going to offer full child care because you're getting a lot of productivity out of women if they know their children are on campus and can go
02:39:48
at lunchtime. But if you're not willing to do that, if you have a stop gap where
02:39:53
instead of calling your attending or one day my nanny didn't show up and I had to find some way
02:40:00
just for those emergencies within the corporation that breeds loyalty that will increase productivity and so I think it's money well spent. Talk about having a competitive woman.
02:40:12
She would probably want to work for you. Yeah. you know, and offering those things to make her mothering easier while she's trying to work. I think you would have the most competitive
02:40:24
workforce. And what does that mean? So that would mean having a n is that having a nanny on site or is that take care on site? Take care on site. on
02:40:30
site again, whether it's full-time, like bring your children full-time there, or
02:40:35
that's a that's a big corporate, but but a a smaller corporate commitment would be this emergency child care so that your kids's not there all the time, but
02:40:47
maybe they're sick or maybe somebody didn't show up and then you have days have a licensed childare provider available, you know, who could which is a fault of the US system
02:40:58
because Yeah. What happens in New Zealand? You have 20 hours free daycare a week.
02:41:03
A week? Yeah. So, it's um Yeah. 20 hours funded. Uh and then it's a very small nominal fee
02:41:10
for hours over that for up to year five or when they're 5 years old cuz then they start school
02:41:16
on the first day that they turn five. It's like you turn five, happy birthday. But it does help significantly
02:41:24
um kind of keep productivity and a little bit of the worry off. What am I going to do with my child?
02:41:30
Amazing. Yeah. What does this um conversation around eggs and fertility dove tail into
02:41:37
menopause and specifically permenopause? I guess that's the next you can't have one without the other, right? So per menopause is basically in
02:41:46
this fertility decline area. Okay. So you don't fertility is not an issue. You don't want to ever have a baby. You're
02:41:51
still going to go through pmenopause. And so per menopause is defined medically in the worst way as the transition from normal menstrual cycles to no menstrual cycle ever again. Okay.
02:42:05
So when we look at definitions, menopause is defined as one year after the final menstrual period. What it
02:42:11
really means is ovarian failure. And that offends people, but that's actually medically what it is. You have run out
02:42:18
of eggs and you run out of the ability of the ovary to produce hormones. And so per menopause begins medically at the straw staging is the
02:42:29
very complicated um methodology to define the stages of pmenopause and a lot of it is based on menstrual cycle irregularity but hormonally what's
02:42:41
happening starts well before our periods become irregular. So as those egg levels
02:42:47
decline and and the ability to respond to the stimulus coming from the brain, remember ovulation starts in the brain.
02:42:54
So when estrogen levels normally get low during the cycle, the brain doesn't like it. The hypothalamus, so the gland in
02:42:59
our brain starts looking for estrogen. It likes estrogen. And then when the estrogen levels are high, it's happy.
02:43:05
And so when estrogen levels decline naturally in a cycle, it says, "Whoop, where's my where's my estrogen?" And it
02:43:10
sends a signal to a second gland in the brain called the pituitary. And that makes the LH and the FSH. So I'm trying to figure out what causes
02:43:17
menop per pmenopause. What causes menopause? Lack of eggs. So it's the loss of eggs and the loss of
02:43:24
the the group of eggs to respond to these signals. So here we go. We're beginning pmenopause. We've reached a
02:43:29
critical threshold level where our ovaries cannot respond. And that might be I don't know millionaire.
02:43:36
So when you're not out of eggs but just the count is low, right? Let's if you're a jar. Yeah. Yeah. So if menopause is
02:43:41
going to be for simplicity, the jar is empty. When the jar gets like this, so we'll say if you had full, the jar is not empty, but it's it's gotten lower. And what is happening is the ovary
02:43:52
doesn't want to be out of eggs. So what Dr. Haver is saying is the brain is working harder to get an egg to grow
02:43:59
because the ovary becomes more stubborn. It wants to hold on to them. It doesn't want to lose them. The brain has to send out stronger signals to get an egg to
02:44:05
grow. Because there's not as many, we don't lose as many per month. So that's great, but that means we have years of
02:44:12
being at this low unreliable ovary stage where the brain is working really hard.
02:44:17
There's not as many eggs that are here. They will still ovulate, but it starts to happen at a less predictable rate. But so is that permenopause when there's Yes. And there's not a definition I
02:44:28
think that which makes it the hardest of say your point what number of eggs equals per menopause. There is a unique
02:44:35
response to each person at what level your ovary gets to where it will start to respond dysfunctionally. But what
02:44:41
happens is that the hormone changes start shifting in the brain. The ovarian response starts shifting and before you
02:44:47
have irregular cycles, you will first see a shortening of your cycles very predictably. The brain will send out a
02:44:54
stronger signal. An egg will ovulate faster. You'll start to get shorter cycles. And then there's hormone fluctuations,
02:45:00
but they're still regular. And so what will happen is a woman will start to feel these hormone shifts. It's less
02:45:05
predictable. She is having some change, but it's still a regular cycle. And so she is often told, "Your hormones are
02:45:12
fine. You have a regular cycle." So, and in the brain, as we talked about those neurotransmitters, there are not only is
02:45:20
estrogen changing and the amount that we're producing, actually in permenopause, quite often we'll have much higher estradile levels than we did
02:45:27
in our premenopausal years where we had that kind of predictable eb and flow of our our monthly monthly hormones.
02:45:34
There's also independent FSH receptors outside of so these hormones that are pumping out to talk to the ovaries are also back talking to different parts of the brain. So the first symptoms that
02:45:47
patients feel and they've done a great study on this is I don't feel like myself.
02:45:54
I don't feel like myself. And they even call it IDFM. And so you can't put your finger on it. periods are regular, but your environment hasn't changed. Your
02:46:04
normal stressors haven't changed. The life you built that you could manage, you're suddenly losing resilience.
02:46:10
And that's because of a hormone fluctuation that is hard to So, we see sleep disruptions, mental
02:46:15
health challenges increase, 40% increase across pmenopause transition and the cognitive changes and that is what really scares my patients the most. And they come in and most of them are, you
02:46:27
know, we're all high functioning in some degree. Some of us in academia, some of us in the O, some of us, but you know, most women are high functioning because
02:46:33
they're juggling so many jobs. So even if she didn't choose to go the routes that we've chosen, she is managing
02:46:39
children, you know, school drop offs, you know, all the things that women tend to put on their plates. And suddenly
02:46:46
she can't remember all the things she used to remember. Where are her keys? You know, word salad. you're you're
02:46:51
struggling to find I can't tell you how many times I am like I I see people and like I cannot remember their names or I
02:46:58
can't remember I get in the car and I can't remember where I'm going or what my purpose of getting in the vehicle
02:47:04
was. You have to think for a second. And so all of that is related to the hormonal changes. At what age? Well, I think that there's a tendency in medicine to want to have definitions.
02:47:16
Yes. So, I personally, and I know a lot of us who talk all the time, think that this random 366 days after your last
02:47:25
period, that's your menopause day. I think that's pretty random. And I don't know who made that up, but when I have
02:47:32
because I'm not an OB, but when I have patients come in to me for their muscularkeeletal things and they're of a
02:47:38
certain age and I don't just focus on whatever the muscularkeeletal body part is, but we start talking about their
02:47:44
whole health and they start talking about these things, I am often the first one to say to them, you know what, you
02:47:51
are probably in pmenopause. And they're like, but my cycles are regular. I'm like, but you are beginning this
02:47:58
transition which I call meolescence, but it's this right. I would propose that most people don't seek out a lot of help earlier. But they should just assume
02:48:10
that they're permenopausal anytime after 35 they don't feel like themselves and start down a road of learning or
02:48:17
investigating or let's feel better and what do I need to do about it? You know, it's frustrating to us all of
02:48:24
us. We talked a little bit about this last night is the people who kind of make the rules, the institutions that make the guidelines and and the academic
02:48:31
kind of ivory tower, you know, they are like, whoa, back off, slow down. We shouldn't be blaming everything on menopause, you
02:48:43
know, like. And I don't think that's what we're saying. We're not trying but completely dismissing the female
02:48:50
experience and not at all like including this cataclysmic hormonal change is hurting women. So the average age of menopause is 51 to 52. And so let's say that is when your ovaries are in
02:49:03
failure. They will no longer make eggs, make hormones or respond to brain signals. So all the eggs, all the little marbles
02:49:09
are out all the way gone at 51 52. For most women about 7 to 10 years before that
02:49:15
they will start to enter into what we will call pmenopause or the unpredictable response of the ovary and
02:49:21
the brain. I say their communication system their best friends who aren't communicating well. Their signals are
02:49:27
getting interfered. They're not responding appropriately. The ovary is getting more stubborn. The brain is
02:49:32
trying to work harder. You get these higher peaks, these lower troughs. And essentially that is the time period. So it is unique to an individual because everybody's born with a different number. They lose them at a different
02:49:44
rate. Some factors that we control impact that rate, but some things that we do not. Your mom's age of menopause
02:49:51
is a predictive factor. If you're had a first-degree relative go through menopause at 46 or sooner, you have a
02:49:58
six times likelihood of going into early menopause. So knowing having this conversation,
02:50:04
almost every patient I ask, what age did your mom go through menopause? They do not know the answer. because the moms
02:50:10
haven't talked about it. Moms haven't talked about it. There's so much stigma about reproductive health. So, knowing that information is really
02:50:15
important if you have mom or older sisters, what age is normal for your family so that you can be a little more
02:50:21
in tune if there's some genetic predisposition for you? The general idea of what Dr. Haver is saying is that in
02:50:26
these last 7 to 10 years of ovarian lifespan, it becomes more stubborn and less predictable and it does cause
02:50:33
hormonal shifts that most women can't detect with their cycles. We do know that if you are actively tracking
02:50:39
actually when ovulation's happening and looking at your follicular and ludial phase and you know what's normal for
02:50:45
you, you will most likely be able to detect these hormone shifts in that time period. But that's not what women are
02:50:51
taught. Their tracking is just that it's coming regular. And we do have a generation of women that were on
02:50:58
contraception and then went through childbearing and then on contraception again until now they're suddenly
02:51:04
entering this transitional period and they don't know what their own normal is making it even worse.
02:51:09
Correct. So like she said the average age of menopause if we look at the math uh is
02:51:15
is 51 but under that 90th percentile curve you know with 5% on each end it's about 45 to 55. That's menopause, right? That's full menopause. Now, now let's
02:51:27
just do math and back it up 7 to 10 years. So, we're looking at the mid to late 30s to 40. So, when I have a 46,
02:51:34
47, 48y old patient come in who's still cycling, she has almost 100% chance of being in pmenopause just based on her age alone, knowing the statistics around that. Yep.
02:51:45
Okay. So with my partner between the age of sort of 35 to 45 is when I can expect
02:51:50
her to go through permenopause where there's very little marbles left in the jar. Um and her hormones might be
02:51:57
disabled less predictable and one of the questions we had in from the audience was how can I manage the
02:52:03
symptoms of permenopause and they use the word naturally well we don't have a single largecale
02:52:10
study done on the treatment of per menopause. So, so let me break it down for you. When we look at funding in women's health, it's horrible. Okay? But if we, if I go into PubMed, which is
02:52:21
the, you know, database that I go to look up metal medical journal articles, and I type in the word pregnancy, I will
02:52:28
get today 1.2ish million articles for pregnancy. Amazing. So important. We need healthy pregnancies. If I type in the word menopause right now, I think it's about 99,000.
02:52:40
So those numbers represent time, brain power, funding, what what what is important in women's health. Okay. If I type in the word perry menopause, we are about at 8,000.
02:52:55
Yep. Very very very very small. Your name's on a couple of Thanks. So is the last third of my life from an academic standpoint, from funding, from
02:53:10
brain power, from where we focus not as important than when I had the ability to be pregnant. More women will go through pmenopause than menopause because we're going to lose a few to accidents and
02:53:21
cancers and, you know, early deaths. More women will go through pmenopause then get pregnant. Yet in my training,
02:53:29
so in medical school, I got one hour one one-hour lecture on menopause, nothing on Perry. And in my OB/GYN training, and
02:53:37
I'd love to hear what you have to say, as part of our reproductive endocrinology blocks, I had one block of
02:53:42
that my second year. In those six weeks, I got one one-hour lecture each week. No
02:53:47
clinics, no focus, nothing. And then as a program director where I was in charge
02:53:52
of the education of residents of over 100 residents over about 10 years, I knew exactly what the curriculum required and menopause just gets shoved into a tiny box.
02:54:04
And then what happens when we run out of marbles in the the glass there? What's really interesting and one thing we've said a couple times is this happens. This is ovarian failure. you're
02:54:15
going to go into a state of low estrogen because the ovaries no longer have the ability to make eggs. Therefore, they
02:54:21
are not going to make estrogen or progesterone. And just to be clear there, the eggs were sending a signal up to the brain to
02:54:27
make estrogen. And the eggs well the low the eggs in the brain communicate. Yes. When you
02:54:32
didn't have an egg ovulating, your estrogen would be low and that typically is the brain signal to send out more
02:54:37
FSH. That's still happening. Meaning estrogen is low, but the brain is sending out all the FSH it has. FSH is very high in menopause and the ovary
02:54:49
cannot respond because there's no more eggs. There's nothing left to respond. I need to explain that that explained
02:54:54
again. So, I'm trying to understand why estrogen drops when the eggs disappear. The estrogen is made from the cells that
02:54:59
surround each egg. So, when there's no more eggs, there's no more cells that make estrogen. Follicle goes away, too.
02:55:05
Okay. Okay. So, estrogen is made in the ovaries. So the estrogen is made in the ovaries and the primary type of estrogen that we're talking about and it's made from the cells that surround each follicle called the granulosa
02:55:17
cells. And as the follicle gets bigger, as the egg matures, more of those cells become more active and you make more
02:55:23
estrogen. So even when you have a little bit left when you're on your period, we'll say,
02:55:30
but you're some eggs here, you're still making some estrogen. It's not as high as when you're ovulating, but these
02:55:36
little eggs will each make a little bit. Do I make estrogen at times? You do, but I just make it somewhere else.
02:55:41
Yeah. It gets converted over to testosterone. Okay. So, we have enzymes in our body that
02:55:46
convert estrogen and testosterone back and forth. So, there's no more eggs. So, this is menopause.
02:55:52
So, this is men. Well, in my world, yes, ov this is ovarian failure. And we're calling it ovarian failure on purpose
02:55:57
because at this moment, you're not going to make estrogen. The brain is sending out all the signals it can. Very high
02:56:03
FSH trying to get estrogen to be made. There's no eggs, so there is no estrogen. What Dr. Haver has said, which
02:56:09
is correct, our our friends in the medical world do not define this moment as menopause. They make you sit here and be estrogen low for a year and have no
02:56:20
period for a year before they will say you're in menopause. If they even decide to treat
02:56:25
or offer treatment, you know, or even begin the discussion because of our training, you must thou shalt go without
02:56:32
one year. So, we're absolutely sure that the ovaries have have moved on before we
02:56:38
would even consider. But what is the point of that? We've made estrogen our entire lives.
02:56:43
It's a fabulous question. That's a great question. Starving our brains, our hearts, our bones, our muscles. They didn't think they were doing that.
02:56:50
I don't think that people, you know, the medical community has recognized estrogen's effects outside of reproduction until very recently. I think there's been isolated pockets, but
02:57:01
there's no no one owns menopause. Like no one you think it would be OBGYn, but there's no one in charge of women's health after reproduction ends. Like there's there's no zar.
02:57:12
So what's the harm of waiting a year before people take it seriously? What happens? Suicide, mental health changes, rapidly
02:57:19
declining bone density. I mean, you can be healthy without estrogen. Wants estrogen.
02:57:24
All vaginas need estrogen. So your brain, your bones, your heart, your blood vessels, your vagina,
02:57:30
your body has estrogen receptors everywhere that we've already established. And suddenly you've lost
02:57:36
the ability to make your primary source of estrogen. And what happens is that, you know, medicine has a lot of definitions that we use that are very antiquated. Even how we date pregnancies, right? When we talk about
02:57:48
how far along you are in a pregnancy, we date back to the last period you had, which meant 2 weeks of pregnancy or
02:57:55
before you ever ovulated an egg, before you 3 weeks before you ever implanted an embryo. Yet, we still use this pregnancy
02:58:03
timeline based on when your last period was, even though we know two weeks of that you weren't in fact pregnant at all. Now, menopause, in my opinion, is the exact same way. We're using an
02:58:14
antiquated definition saying you have to prove to me you're an ovarian failure by
02:58:19
lack of your period for 12 months because it represents a time period where we didn't fully understand what
02:58:24
was happening in the ovary or didn't have the ability to test and know what we know now. We are making women suffer
02:58:30
to get that diagnosis. If I believe I shouldn't treat you until you have menopause, you have to prove that you're
02:58:37
in it. I don't think it's where we're going. I don't think it's what's right for women. And that being this low
02:58:42
estrogen is hugely impactful at your life at any age. The female body needs estrogen to function normally. I mean, I'm looking at this chart here about suicidation. Yeah. Suicide.
02:58:54
So, the most likely time for a woman to commit suicide is between the ages of 45 and 55.
02:59:01
And do you is do you think that's linked to 100% menopause? Right. So we know that mental health
02:59:10
we have an increase in mental health disorders either pre-existing getting worse or new onset of about 40% across
02:59:17
the transition. And we look at um SSRI prescriptions which are anti-depressants. They double across the
02:59:23
menopause transition. Now there's a couple reasons for that. One is we weren't treating menopause with hormones. So they just SSRIs can
02:59:30
actually help a hot flash. Uh certain types. So, you know, Paxel is one of the ones that has been proven to decrease
02:59:36
hot flashes some. It's not great, but it works a little bit. And with all of the mental health changes, a lot of women
02:59:41
are ending up on these anti-depressant medications. So, we don't want to go a year without
02:59:47
estrogen. So, we know that some of the new data coming out when I was researching for the new pmenopause,
02:59:53
there's a really great window of using hormones to treat mental health disorders um and seeing improvement in
03:00:01
mood and also some in cognition by giving estrogen or estrogen plus the progesterine early in pmenopause before
03:00:08
the periods actually stop ra and that actually works better than an SSRI. So, say she's on an on an SSRI and has done
03:00:15
well. She's had a long history of depression. Suddenly, she's not controlled. Suddenly, her symptoms are
03:00:20
back and she's on the same medication. Rather than doubling or adding a second agent,
03:00:25
we really should be giving these women a hormonal therapy. Now, that doesn't hold postmenopause. So, this is really a pmenopausal kind of window of opportunity.
03:00:37
In postmenopause, they aren't responding as well and probably because the estrogen labels have stabilized. So when
03:00:43
we give a woman back adapts yeah you'll adapt. So postmenopause the menopause um that's
03:00:49
why the suicide rates kind of peak in this key per menopause area and we think and so in postmenopause they the hormone levels stabilize so
03:00:59
women tend to get better and so they do respond better to the SSRIs for for new onset anxiety and depression in those
03:01:05
patients. And I want to do a randomized control trial where we add some creatine. Oh that would be amazing. 20 g of
03:01:14
Well, no, it's 38 per kilogram of body gram. Yes. So, you're saying if I'm a 45year-old
03:01:19
woman and I'm I've still got my menstrual cycle Mhm. at that time before I've hit menopause,
03:01:26
I should be considering some type of hormonal therapy. So when we give someone menopausal dosed menopause
03:01:31
hormone therapy in the form of estradile usually in a patch because you have that nice steady state it is enough to feed
03:01:37
back to the hypo to that brain to calm down but not enough to suppress ovulation. So she's often giving
03:01:43
estrogen support in very low doses and menopause hormone therapy is basically micro doing compared to what we do
03:01:49
naturally. And so we're giving enough to calm the brain down and stabilize what's
03:01:54
happening in the brain without suppressing her natural ovulation. giving enough what?
03:01:59
To raise you back to maybe what that baseline would be. Giving enough estrogen. Correct. Giving
03:02:05
enough estrogen to raise the baseline level so it's not as low. It's not so high that it's preventing ovulation, but it's going to alleviate some of these drastic highs and lows that you're
03:02:16
having and it's going to create a more stable hormone environment. It's the delta that we were talking about post pregnancy. The delta
03:02:25
chaos. The space is what bothers us, not the high nor the low eventually. So, I have uh I run out of eggs and then I'm
03:02:36
by definition menopausal at this stage and my body adapts. So, there's going to be a drop and then there's going to be a
03:02:46
We're specifically talking about mental health because you brought up the suicide chart. Uh and so postmenopause
03:02:53
like once everything calms down and you're fully menopausal you're out of the zone of chaos. The hormones have just your bones continue to deteriorate
03:03:01
a lot of other things are happening but our cognit our mental our brain tends to calm down and things get better in the
03:03:06
brain. When do I become postmenopausal instead of menopausal? Oh go menopause is a day right medically
03:03:14
menopause is one day in your life. one day exactly after your final menstrual period. That's the point of that random agree, right? Because what if what if it's leap year? Do we go 366 days? What if it's
03:03:26
what if you've had an IUD? What if you've had all these things? It's like it's really a antiquated definition and we really need to modernize.
03:03:32
So, it's really you're permenopausal, then you're postmenopausal. Correct. Right. Okay. And when I'm postmenopausal
03:03:38
forever, forever. That's your new biological state. That's right. for now. I'm sure someone's working on something to change
03:03:45
something. I do wonder that. I do wonder if they're they're going to figure out a way to extend fertility. I mean, they're
03:03:51
trying. They're trying. But then I think about it as if you're a 60-year-old woman, would you still want
03:03:58
to be worried about worried about that? So, what they're doing is looking at is there a way to extend
03:04:03
we'll say ovarian function. ovarian function with lowle baseline enough to keep you out of osteop you
03:04:09
know enough to slow that down and heart disease protect your heart without pregnancy
03:04:14
I'm now post menopausal lots of things change in my body I'm guessing because I I no longer have the same levels of
03:04:20
estrogen did the levels of estrogen ever go up again naturally or do I then need to start considering
03:04:26
outside of a tumor no I mean so do I need to consider hormone replacement therapies and things like that to
03:04:31
you might and that will help me fend off what the sleep issues, the it'll slow the rate of change, okay? But it doesn't stop it. You still have to put in your lifestyle modifications
03:04:43
to improve andor stop the circenia and the bone density loss and all the things that people associate with postmenopause. And did any of you have menopause hormone therapy?
03:04:54
Yes. Yeah. Mhm. And what was the decision and what what impact has it had? So, I think what
03:04:59
Stacy just said in framing where we're going with this conversation is so now we're permenopausal. It's a new
03:05:07
physiology. What used to work for all of our exercising if we even did because we
03:05:12
know it at least in this country that 60 to 80% of people aren't intentional with
03:05:18
their lifestyle. So to frame this next part of the conversation, I'm sure we're going to talk a lot about hormones, and
03:05:24
I'll tell you my hormone decision-m, but uh I think it's important to all of us.
03:05:30
It's only one of the building blocks to rebuilding a great life, right? It's interesting that the five steps of fertility that you went over are actually exactly the same.
03:05:43
Curious, isn't it? It is. It's it's great protein and anti-inflammatory nutrition. It's a cardiovascular fitness life. It's a lifting life. It's a stress
03:05:54
detox whether it's environmental or relational. And sleep, sleep, sleep. And then yes, hormones are really uh a critical building block. But as we enter
03:06:05
the conversation, women are sentient beings and we get to decide and we get to make the changes because we have agency. So what we're going to
03:06:16
describe is not a one-sizefits-all. It is it's all the tools on the tools. Put the tools on the table. So I choose if I'm going to work my proverbial rear end off to be the best I
03:06:28
can be for the rest of my life. I choose to use all the tools. Not everybody does that. But to choose one tool and think
03:06:35
that's going to be enough, it never is. Right. So when I decided to and I've been pretty public about my journey in this because you think I would have
03:06:46
known after 22 years of formal education and all this and being an aging a muscularkeeletal aging researcher, you would have think thought I would have known. But I honestly looking back maybe
03:06:57
thought I was never going to age because I was so healthy, right? So I have a baby at 40. I breastfeed
03:07:05
till almost 41 and a half, 42. And then I'm back at my very quickly 5 weeks, my high power, high capacity to career. But things were getting really different
03:07:18
about 45 for me and I think I went right from postpartum to perry menopause with very little downtime. So chaotic hormones to almost
03:07:32
and so I suffered for a while at 47. Uh I I talk about it like I I went from this really high capacity to thinking I was going to die not only because of night
03:07:44
sweats, brain fog, the thing that lots of women have. But I started having heart palpitations. And I call my cardiology friend because I worked at a university. I'm like Ricky Ricky I think
03:07:55
I'm dying. So he did put me on a stress test and my heart was perfect right at that point. And then I had arthralgia
03:08:04
which is total body pain. It's part of the inflammatory response of not having estrogen. It's part of the muscularkeeletal syndrome of menopause uh assembly of symptoms. so much that I
03:08:17
go from training to almost not being able to get out of bed and these my experience of not
03:08:24
knowing what was coming and hitting a wall is not uncommon, right? And so I started educating myself
03:08:32
and being an acquired expert. I read what I consider the world's data on safety of hormone optimization as I like to call it and I made the decision that
03:08:46
I was going to do all the tools. I was going to learn to lift heavy again which I hadn't done since high school cuz I
03:08:51
was a runner and I changed the way I do my cardio and I changed my diet and I am
03:08:57
so committed to sleep. do not call me after 9:30 at night because I am going to be in bed and just the
03:09:04
the quiet times of d-stress. But I also decided to um augment or to optimize my hormones with estradiol, with progesterone because I have a uterus and after I felt comfortable with
03:09:18
those with very small doses of testosterone and that makes me feel like myself again, not just one because I think sometimes people think that you can just make a hormone decision and
03:09:31
feel like yourself again. It takes lifestyle plus or minus this decision. Is there a stigma associated with that decision? Um taking hormones. Taking the hormones, but also I guess
03:09:42
just more broadly with entering menopause. Yeah. Um I think there is there is absolutely
03:09:50
I mean you can just look at popular media. You can look at their representation. Go right now and give me an image.
03:09:56
It's decreasing because of you though. Like we have to acknowledge you are decreasing the stigma. True. and you're sitting at the table
03:10:02
with us. I say that I think because there's a woman in my life who was telling me about her decision to start taking
03:10:07
menopause hormone therapy and she described the moment with her husband when she was looking at the box.
03:10:13
Mhm. And she was staring at the box and staring at the box and staring at the box and mulling it and there was clearly
03:10:20
something emotional going on there that this decision to take this marks something
03:10:25
which is interesting because no one really questions OC's. Exactly. Oral contraceptive birth
03:10:31
control birth control and I treat both men and women and when a man comes into my clinic with low
03:10:37
energy popping all the tendons all over his body everything hurts we very quickly test his testosterone and send him with no judgment because he's trying to be viral and I think it goes with the
03:10:50
general composa conversation about aging women when men talk about living longer
03:10:57
it's called longevity and we celebrate that and we take pictures of movie stars in the south of France very distinguished distinguished with their grain temples when women when we talk
03:11:07
about women living longer until right now cuz we're all screaming about it it's under the guise of
03:11:15
anti-aging a superficial like oh my god don't let her age so I think part of that is the
03:11:24
stigma of menopause somehow because we're no longer able to have a there's not a value. We've aged out of the game, which hopefully we're pivoting this
03:11:35
narrative because as I said earlier, women are winning the longevity battle. We already live longer, but it's how
03:11:42
we're living that we're trying to course correct. Yeah. And it's not just humans that go through this. Like I like using the
03:11:48
whale analogy cuz whales go through it and then the whales that are no longer reproductive become like
03:11:54
the senior everyone all the other little whales listen to them. is like I want to
03:11:59
be like a whale where you have this seniority and and respect the wisdom wisdom keepers. Yeah, exactly. I love this part of my life. You love this part of your life?
03:12:10
Yes. Why? I have never felt like I've been in exactly where I'm supposed to be. In this moment, I feel like I'm helping more people. I have better
03:12:24
relationships. I'm having better sex. I'm having better, you know, everything in my life pretty much is better. And I I don't know if like menopause and and
03:12:36
life circumstances have just given me permission to like cut out the crap and focus on what's really important and, you know, don't sweat the small stuff,
03:12:49
you know, it's like like something kind of switches in our brain. No filters. It's amazing. And I don't
03:12:55
think I could have done this 10 years ago. I was too worried about what people thought. I was too worried about being a good girl and following the rules and
03:13:02
checking the boxes and never stepping outside of the guidelines. But until I realized that I wasn't really serving
03:13:08
the population that I trained for x amount of years to that, you know, and they were being left behind is really what allowed me to like be
03:13:18
where I am today. I think most of us describe this as the most authentic. We're actually who we
03:13:24
were made to be. And the confidence we feel comes from our memories of success. I think that's where confidence come from. We remember everything that we have learned to fix over time. Probably
03:13:36
we could figure anything out. And so that comes with experience and frankly it comes with aging. The price of aging or the pre the price of having wisdom
03:13:47
and experience is aging, right? And so the the reps and so you get to this place and you're like, I'm going to figure this out. We're going to figure this out. And I don't want the younger generations
03:13:58
to have to go through the stuff that we've gone through. So if I can share my experiences to help them navigate, then
03:14:05
that is a good thing. Yeah, I'm in pmenopause, so I'm a slightly different stage. And I know
03:14:11
this because my cycles are shorter, but they're still very regular. Used to be 28 29 days. Now they're 25 26. I know that means I have less eggs coming out
03:14:22
of my vault every month and that's why I'm ovulating sooner. But I can feel all the hormonal shifts much more profoundly
03:14:29
than before. Now, as a reproductive endocrinologist, what we call a fertility doctor, most fertility doctors
03:14:35
now do IVF day in and day out. And there's a lot of corporate reasons why that is. But we're also trained in
03:14:42
puberty, premature ovarian failure, and hormones. So, I'm more of a cowboy and quite cavalier at giving estrogen. We
03:14:48
even told these ladies last night, oh, because I see it. I see people who are low estrogen states and you know, every
03:14:56
single day, how it impacts their life. So, I am on lowd dose estrogen right now, even though I'm still cycling. I'm
03:15:02
still making my own progesterone, so I don't have to take a progesterone right now. But, it clearly makes a difference
03:15:10
in my day-to-day function and how I feel. And most REI like I am will jokingly say like you'll put me in the ground on estrogen because it has such a profound impact on you're able how you
03:15:24
can function and specifically if we're not forcing you to go through this empty glass period for years and years and years of your life there's more opportunity on how you can
03:15:37
slow down part of the process that we all know is going to happen with aging but to live I think pond do is it you
03:15:43
know healthier your health span how are you going to live healthy longer not just live longer
03:15:48
well and I think your approach that I think it's part of the decision making is critical because
03:15:56
uh 35 to 45 and early pmenopause are prime times for prevention right it's to get our standards set you don't have to lose your bone like
03:16:08
you're going to get but it's hard for women to get care and we also have to acknowledge that if you go into
03:16:13
right if you what you're recommending and I also do the same thing for my patients very hard for somebody to get care for
03:16:18
this is not happening in 99% of doctor's offices like there is no birth control pill or nothing which is all they were taught given that even in menopause only 4% of
03:16:29
women have chosen or have been educated the pros and cons of hormone optimization and then to ex that's without that's an empty jar person
03:16:39
so 4% Stephen is that How many women that have said 2023 they did a study in the US.
03:16:45
I'm not sure in other countries and on FDA approved. So when we add in compounding it's maybe a little bit higher but when you look at FDA
03:16:53
prescriptions only 4% of eligible women meaning no risk factors right age are are utilizing are going to get their prescriptions filled. Evidently this is going to change right with the education
03:17:06
that you guys we hope at least they're being offered it and having a discussion so that each one they may choose not to the right and
03:17:13
that's their right but side effects are there side effects worth noting I know a lot of people are quite scared of taking sen hormones
03:17:20
so there's risks and then there's side effects so when we look at the side effect profile anytime we give a woman
03:17:25
estrogen progesterone and we'll have to like look at them individually but estrogen you can have headaches you can
03:17:32
have irregular bleeding about 50% of patients and more on the patch than on oral. There's a patch and there's oral. Vonda,
03:17:38
you take the patch, right? I do. And that's on your stomach. Yeah, it's right here actually. And how often do you have to replace that?
03:17:44
Twice a week. Okay, fine. And yeah. So, so when we look at menopause hormone therapy, we have estrogen, we
03:17:51
have progesterrogens, and then we have testosterone basically. And there's different ways to get it into your body.
03:17:57
There's oral and non-oral roughly. So, in oral it's pill, you take it. In non-oral, we're looking at through the
03:18:03
skin or through the mucosa. So mucosa could be under the tongue. It could be in the vagina. So mucosa is like the
03:18:10
gastrointestinal tract is lined with mucosa and it's a nice way to absorb and in the rectum to absorb medication. We
03:18:16
don't have a rectal form of estrogen yet. And so um so and then there's also injectables so you can inject it straight into the muscle or subcutaneous tissues. So most commercially available
03:18:27
like FDA approved. We're looking at a ring for the mucosa. We're looking at a patch for transdermal or we're looking
03:18:33
at pills for oral. And what do you take? Yes. So, I am on a patch. Um, and I've just been I'm not a great absorber through my skin. Um, and I couldn't get my estradile levels high enough where
03:18:45
studies are looking like the best bone protection is. So, I've added about a half milligram of oral estradile at
03:18:51
night. I'm on oral micronized progesterone, which is probably the best way to get it into our system. And I
03:18:57
tolerate progesterone very well. And testosterone. And I am on a gel that is FDA approved. We I'm borrowing the men's version because we don't have an FDA approved version for women
03:19:07
in this country for women. So I don't think anywhere is borrow my husband. Australia. Australia.
03:19:13
And I think the UK just has approved one. This is new some news like in the last month.
03:19:19
Yeah. So okay. So um okay. So, so it's it's broadly advisable after doctor's consultation to take some form of hormone therapy. Definitely if you're symptomatic, if you
03:19:32
have the classic visual motor symptoms, it's absolutely the gold standard. But can I comment on that?
03:19:37
Women say to me all the time either, I don't have I don't feel that bad or they say I want to do this naturally. And those are the things that say okay
03:19:50
fine, do it naturally. But brain fog, night sweats in the V and hot flashes are not the only thing going on. And so if you're making this decision
03:20:01
fully informed, well, you're a sentient being. Make the incision. But you cannot
03:20:07
feel your bones crumbling until they're broken. You cannot feel that. You cannot feel your muscle going away. You cannot
03:20:14
feel your brain starving. You can't detect microvascular disease of your heart. So, you may think you're getting
03:20:21
away with something and maybe you don't have night sweats, brain fog, but it doesn't mean you're not having a different physiology. And if you are fully aware of that and make a decision
03:20:33
that you don't want to optimize your hormones, that's your decision. And I'm fine with that. But what I'm not fine
03:20:38
with is people thinking they're getting away with something when they're not. True. I
03:20:44
You're making the decision based on fear and not facts. Correct. My last question is about love and sex in and menopause. You said you're having
03:20:50
the best ex of your life, Mary. And um I've also heard you talk about how several people in this season of life
03:20:56
end up getting divorces. You said they throw the the trash out. So when I So when we talk about, you know, menopause can spur, you know, for some women it's it's
03:21:10
this mo moment of empowerment. They realize they have to circle the wagons cuz the only way they're going to survive through this cataclysmic, you
03:21:16
know, upheaval for so many women is to get rid of relationships that aren't working. Put up boundaries and sometimes
03:21:23
that's going to be the end of a marriage. Other times it's going to strengthen a relationship because you're
03:21:28
you're kind of cutting out things that were getting in the way of your so I see many marriages or many relationships
03:21:34
really improve through the transition. But it it does take two. You know, sex is biocschosocial. So like when I I look
03:21:41
at sex it's not I think of the entire experience you know and one as far as my desire for the frequency testosterone does seem to have given that an uptick.
03:21:53
So it is approved you know we have lots of studies done on libido for women which is in medicine we say hypoactive
03:22:00
sexual desire disorder and it has to bother you. So a lot of women are like I don't want to have sex ever again I
03:22:05
don't care. There's nothing wrong with that, right? Unless it affects your relationship and it it bo it has to bother you. But I have a lot of patients
03:22:12
who come in and say, "I love him. I used to want to do it. We used to have a really great frequency and everybody was happy about it. It was something I look forward to, enjoy it, and now there's nothing. I have nothing." And for those
03:22:25
patients, testosterone can be helpful. Not for everyone, right? And so there's other emerging data on looking at the muscular skeletal system. I am naturally thin. I was not an athlete growing up.
03:22:36
At best, I was a dancer, you know, and I didn't do anything to protect my muscles and bones as as I was coming up through
03:22:43
the ranks. And so, here I am in my 50s just getting out of endurance, you know, you know, recreational endurance
03:22:50
training and thinking, what have I done to my bones and muscles? I laid on that DEXA scan as nervous as I've ever been
03:22:56
in my life, like getting my board scores, nervous, like, what have I done? And and it wasn't bad, okay? But I'm
03:23:02
like, but I like to be perfect. So, I'm like, what can I do to, you know, I'm doing the I'm eating the protein, I'm lifting the weights, I'm starting to do all these things. And we know that women who have naturally higher testosterone
03:23:14
levels from genetics or whatever, have less frailty as they age cuz that's my focus. If I run the cancer gauntlet,
03:23:21
which probably 80% of my aunts and uncles have died of cancer. And so if I run that gauntlet and I'm doing
03:23:27
everything lifestyle and preventative screening to do that and then the women end up with dementia frailty like my
03:23:32
mother and grandmother. So I'm like, "Okay, I want to have as much bone and muscle strength as I can. So I'm going to add some testosterone and see what happens." I I at the time would not have
03:23:44
said I had any sexual dysfunction. I did not qualify medically for HSDD. I go on testosterone and there's definitely an uptick in the area and everyone is happier like my interest has
03:23:57
improved my initiation has improved and that had kind of waned time and stress and kids and whatever the other thing we were empty nesting at the same time so that probably no more kids busting in
03:24:07
our door at 2 in the morning letting us know they're home from you know whatever experience and you guys will go through
03:24:12
this later but also our communication is better you know my husband's retired from Chevron and we are building this
03:24:20
this company together, you know, our menopause company. And so our relationship has actually improved
03:24:25
through all of that. So all of the things that feed into what we know is female desire and has is
03:24:32
just better all the way around and and I think testosterone had a little bit to do with it. My ability to like focus and
03:24:39
my ability to prioritize and put up the right boundaries has really helped with that. And we're just having a lot of
03:24:45
more fun with it. But I think that we would be remiss in this part of the conversation, and I'll say it. I'm the
03:24:51
orthod, but I'm gonna say it anyway. Many men, I just talked to my husband publicly about this because we're trying to educate men, is that most men don't realize that in pmenopause, as estrogen
03:25:04
waines, it affects all tissues. And there is an entity called the genital urinary syndrome of menopause where the
03:25:11
vagina will actually atrophy and all the external soft uh tissues that are usually used to engorging will become dry like a desert and Stephen sex can
03:25:24
feel like razor blades and men don't know that and women are afraid to tell their partners. So the
03:25:30
men feel rejected like why doesn't she love me or desire me anymore and it may be that but it's probably not that it's it hurts and I bleed and women don't know that this is normal
03:25:43
when you're estrogen is in not that it's okay to it shouldn't be it shouldn't be normal
03:25:48
but when you're in a low estrogen state regard menopause birth control pills can
03:25:53
do it postpartum breastfeeding even you know progesterone IUD these can all cause time periods where your estrogen levels are low enough that the vaginal
03:26:05
tissue is not having the right collagen and elasticity that it should. So, what's the solution?
03:26:11
Not lubricant. Lubricant can sometimes aid, but that's not a root cause, right? It'll help with
03:26:18
I I help with symptoms, right? But if your part of the problem is that the tissue can't respond as it should, that
03:26:25
it's frail, that delay orgasm, then we really want to get to the root cause, which is estrogen is crucial for skin
03:26:31
elasticity. It's like men going on testosterone, right? If he's not having an erection,
03:26:37
there are 29 solutions for that right now, but primarily funded solutions as well.
03:26:42
Solutions. But for women, it's not just desire, it's physiologic. And so vaginal estrogen put putting something up putting in your vagina and what you put in your vagina is so there's there's several options. We
03:26:55
have creams, we have pills, there's a ring specifically designed just for that. So we have different methods of
03:27:01
getting the vag you know estrogen into the vagina. There's also um uh something called prosterone which is DHEA basically which is a pre hormone that the vagina miraculously will convert to
03:27:13
estrogen and testosterone. So but it's expensive. It tends to not be covered by insurance. But for our like our sex med
03:27:20
friends, sexual medicine friends who specialize in this female sexual function, they love it because you're
03:27:26
not only getting a boost of estrogen to the vagina, you're also getting testosterone and there are testosterone,
03:27:31
you know, receptors in the vulva, you know, in the lower vagina and around the skin around the vagina as well.
03:27:38
But here's the bonus. All of this plus vaginal estrogen will help prevent chronic UTI which kill old ladies and it will help support the
03:27:50
pelvic floor and the uh uterus from prolapsing and so it has all these added benefits and here's another bonus it is such low dose it is not systemic so any risk that you
03:28:06
could think of that you might not want to do systemic estrogen including breast cancer
03:28:11
is unaffected by vaginal estrogen and so it is a huge solution. And there's no age that a woman can't go on it. She'll kill me. She'll never know this. But I put my 86-year-old mother on it so that
03:28:23
we could prevent UTI and failure of tissue so she didn't get sores and infections, right? Isn't that a miracle? I know Stephen's like, "Yeah, and we should say that vaginal
03:28:36
estrogen in preparations made for vaginal estrogen or lowd dose estrogen preparations. You can give oral
03:28:42
estradiol vaginally and it will be systemically absorbed because the vagina is highly absorptive. So I don't want
03:28:48
somebody to hear this and think that but just saying we often prescribe or recommend
03:28:54
a local treatment of vaginal estrogen products which are in very low dose and they really impact the local tissues of
03:29:01
we'll say the pelvic floor, the urinary system, the vulva, the vagina and they improve your well-being and your health
03:29:08
without some of the risk that might come from systemic hormones in somebody who may not want to take them.
03:29:14
I am all out of questions. So I wanted to conclude this segment just by asking you what the most important thing that I
03:29:20
have missed on the subjects we've talked about menstrual cycles, menopause, everything in between. What is the most
03:29:27
important subject you think we might have missed? I think we covered it but but to stay
03:29:33
that you control a large part. We said over and over inflammation and insulin resistance. We we touched on different lifestyle factors that impact this because
03:29:46
when your body is having hormone change, there's a lot of the external world around you or the choices you're making
03:29:51
that can make some of that better or worse or influence what is happening. And I know we're going to go over more
03:29:57
of this, but I think this idea that I have no control over what's happening to me isn't 100% true. I mean, you don't
03:30:04
have control over when some of this stuff happens, but you can take control of a situation by understanding your
03:30:10
body, knowing what's happening, knowing how to advocate for yourself, and making active decisions to live a healthier,
03:30:18
better life. Yes, that's the goal is to empower women to understand, to ask the questions so
03:30:24
they don't feel like something is happening to them and they don't have control or options,
03:30:29
which is what our mother's generation had. They were always gas lit, told, you know, it's all in your head.
03:30:36
There's nothing we can do. So, my mother was put on but it was called butol. Um, it's basically a sedative and it was mother's little helper. And I found an
03:30:49
old magazine article where they if you look at the magazine articles from the 50s and 60s on these medications, mostly sedatives that were given to women. It's
03:30:59
like now she can do the laundry again. Now she she's flipping a pancake in the ad in the apron in the 1950s, you know,
03:31:07
like get your mom back, get your wife back. And it was a combination of estrogen plus a seditive. And I was just
03:31:16
absolutely floored. And I remember mom's little bottle and it was called butol and I it would sit on her counter and she would talk about it like it was her talisman like it was her and I always
03:31:29
thought of it as mommy's little helper you know like oh I need my butol oh this happened where's my butol where's my
03:31:35
butol and when I was researching and writing and reading about these sedatives that were given in women I was
03:31:41
like wait mama I remember the bottle I remember what it was called cuz she talked about it all the time I went and
03:31:47
looked it up and it's a derivative of pheninoarbatl. Oh my gosh. And it was heavily prescribed to women.
03:31:52
So barbbituate. It's a a drug. It's a class of drug that is basically a sedative. We use it in surgery. We use
03:31:58
it for seizures. And they were sedating my mother on the daily. Yep. Through her pmenopause. Mhm. Now she had eight kids. She was running a restaurant. You know, she was very
03:32:10
high functioning. And I just refused for that to be that was her reality. Yeah. And here she lies in a bed with
03:32:17
Alzheimer's and a fractured hip and she hasn't walked in 8 months. You know, she's she's just now getting on a walker
03:32:24
8 months after her hip fracture and from osteoporosis who's never had a bone density scan in her life. And like our
03:32:31
our children deserve better. It's not going to be my future cuz I have the, you know, I have the means. I have access. But like I I want every young
03:32:38
girl, all of our children to have a better future than what was offered to our mothers.
03:32:44
Exactly. I think ending this, I would want every woman to approach her midlife life, her new life with the same vigor and the same curiosity and the same
03:32:57
demanding of care that she would do for one of her children if her child is sick. She's not going to take no. She's
03:33:04
not going to take being blown off. She's going to keep searching till the end of the earth until she finds an answer. And
03:33:10
that's what that is the same kind of taking control that I want women to do about this time in their lives.
03:33:18
Thank you so much. We're going to record we're going to continue this conversation for the viewers that are
03:33:23
listening at home. Um, I've been through all of these wonderful books that I have in front of me and there's so many
03:33:29
lifestyle, nutrition, exercise related solutions to many of the things we've talked about today to be an truly
03:33:35
optimized um, hormone healthy menstrual cycle healthy woman, which I want to talk about in our part two of this conversation.
03:33:46
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