Emmenology (MENOPAUSE & PERIMENOPAUSE) Part 1 with Monica Christmas, Mary Claire Haver and Lara Durgavich

"Oh, hey, it's that band-aid floating in the public pool. Don't worry about it." "Aliward." And I have been promising you this episode for seven years. So don't say that I never gave you anything. It just took a minute. Because this one is a three-parter, technically, five guests, just an embarrassment of riches when it comes to information and also guests. So, eminology, it's a study of menstruation, apparently, and it's related disorders. And this episode, we will get to what's natural and other primates, symptoms, tests, the latest research. And this one is also for people assigned male at birth for partners and kids and coworkers of people experiencing paramedics and menopause. Because if you don't have info about it, your relationships will 100% be impacted. Also, don't call yourself an ally or like a feminist or someone who believes in gender-affirming care and then skip this one, because it's about menopause. So, I'm glad we're all here. Also, a note-up top, trans men can go through menopause, non-binary people can go through menopause. Not all women have uteruses by self-included. Many times you will hear the words female or women in terms of describing a patient and just know that refers to the majority, but not the entirety of gender identities going through this. And we have an awesome episode of Dr. Daniel Fowl, called neuroendocrinology. It talks a lot about hormones and the brain and gender will link that in the show notes too. But before we go further, let's say a quick thank you to patrons of allergies who are signed up for a dollar or more a month via patreon.com/ologies and who submit questions that help steer the show so much. Next week's part two will be wall-to-wall your questions. Also, if you do have kids, heads up, we have a spin-off podcast called Smalleges. You can find it anywhere you get podcasts, just search for SMOLOGIS, no swears and that one. 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And this week, in part one, we're covering the symptoms and the biology and the cognitive effects and hot flashes and diagnostic tests and first-hand perspectives of two OBGYNs who actually went through it. And next week, it's all about what to do about it. What do you do? Hormones, no hormones, how to do with brain fog. What do you do or what can you take for the feelings of mood swings or depression, how to get better sleep, what to put on your vagina, making whoopi with gusto again, and why you should think about your skeleton now. Like now. That's all gonna be next week. What do you do? So this week, we have one oligis, Dr. Monica Christmas. Monica Christmas, she, her. An associate professor of obstetrics and gynecology and the director of both the menopause program and the Center for Women's Integrated Health at the University of Chicago. We also have on Dr. Mary Claire Haver. Dr. Mary Claire Haver, she, her, who's a longtime healthcare provider in obstetrics and gynecology and a well-known advocate in this space she authored the New York Times best selling books, the new paramedics book and the New York Times bestseller also, the new menopause book and she hosts the podcast unpossed. And for this part one, we also have a message to you from Dr. Lara Durgavitch, who is a visiting lecturer at Boston University's Department of Anthropology and she shares why we, as a, why are bodies a bother with menopause? Why are they doing it? And how researchers study it and what we can potentially infer from orangutans, going through a change of life. So take my hand. Let's dive in with some of the most experienced ologists on this planet about this. Dr. Haver, Dr. Christmas, and Dr. Durgavitch, all of whom are excellent immunologists. (upbeat music) - You have been on our list for a really, really long time and every single week when we check in in our meeting we go, have you heard from Dr. Christmas? - Oh my gosh. - Do we hear that? And so we're all like, wow. - Yeah, we've been talking about you for months. So today's a big day for our whole team. You're a celebrity. Dr. Christmas, you get asked about that every single day, don't you? (laughing) - People ask me, what does it mean? I'm like, I don't really know it's my married name and I'm a divorced person now. (laughing) But the patients like it, especially during the holiday season. So it got me into a lot of trouble though. I had my maiden name through medical school, but I changed it onto my married name, right before residency, and it was not fair because everybody could remember Christmas. So I got called on all the time. And I would say that to my colleague, "Oh, you're exaggerating, I get called on too." And then I was out for vacation one week and one of my co-residents called and was like, "Yeah, Christmas, you're right. They are just calling on you." Because you got called on 10 times today and we kept saying she's not here. So I'm like, "I told you, I told you that I was unfairly being targeted." (laughing) - Like no one ever forgets I'm sure. - Right. I have more questions. I am. - Well, that's probably why you're so good at what you're here. So I'm almost like you got one on one tutoring so much one on one attention. And I know that you give very good attention to your patients who have a very holistic approach from what I understand. A lot of people I hear from, they're like, "My doctor doesn't even know what's going on." What was it about gynecological health and obstetrics and menopause that kind of attracted you to this? - Well, the menopause stuff kind of fell into my lap serendipitously, which is always the best way for things to come your way. That means the universe conspires for good. But my first job out of residency, I worked with two fabulous doctors. They're really great guys. And they were great obstetricians. I mean, they were gynecologists too, but they had a really big obstetrical following. Women came to them. So when I first started with them, like I didn't have any patients really, right? I mean, 'cause all of the pregnant patients saw them. So what I was left with was a lot of women that were going through this midlife transition and not gonna claim that I knew everything, but what they really loved is that, one, I had a lot of time. I had a lot of time 'cause I had many patients. So I could spend an hour or more just shooting the breeze, listening to them. And then I would call them back later that day, which they loved, like, "Oh my gosh, my doctor, she's so sweet." She called me at home and I tell them, "Well, you know, these are the options that we could try and if this doesn't work, we could do this next thing." And so before I knew it, they had told all the people at the train stop or at the water cooler at work that they met this nice, great young doctor and she's so good, she just really listened. Little did they know, like, all I had to do was listen. I had all this time. But anyways, I built this patient following and a lot of midlife women too have issues with bleeding and sometimes it was fibroid related or adnomyosis or, you know, a host of things. And so then I had a big surgical patient population too. And it turned out that I really love surgery and I really loved taking care of women or helping them traverse through this thrive. I should say thrive through the menopause transition. And my mom was also going through menopause at the same time and having a horrible time of it. But like, I'm having these issues and what does this mean? And, you know, is it my thyroid? Is it this? Is it that? Sometimes it's all of the, but that's the thing. Is that menopause happens at a time when we are aging. And when I say everything isn't just menopause, I mean, everything isn't just due to your ovaries not making the reproductive hormones anymore. It is very difficult to sometimes disentangle which truly due to chronological aging versus what is actually due to menopause. And there's not one menopause syndrome that every single person gets. Some people have very few symptoms of any at all and then there are other people that have everything under the sun. So, you know, it's important not to unnecessarily scare people and think that this horrible thing is going to happen to you, you know, because that's not true either. And I think we are creating a sense of hysteria for people now that shouldn't happen. Histeria, Sino, comes from the Greek word meaning uterus and hysteria was a condition thought to be caused by a wandering womb that was an animal living inside your body, just sontering around and lured to and fro by pleasant smells or stomping around angry because it's lack of a child inside. You're like, okay, dude, sounds pretty solid. But interestingly enough, actually, there's a very real condition, endometriosis, caused by uterus, and like tissue that just up and grows anywhere in the body. It can grow in the bowels or the pelvis, sometimes a lung or the brain, and thousands of years after our boys and togas were contemplating an entity wandering about the cabin, we still don't have any readily available tests or good answers for this excruciatingly painful and debilitating condition of endometriosis. Much on average takes 7 to 10 years of pain to diagnose if it's ever clocked by a doctor, not to get hysterical about it. But yes, menopause. That's such a good point off the bat because I know that it looms for some people as like, when is this thing going to hit me like a specter, like a hormonal goblin waiting to pounce? And you know, I'm wondering for you personally because you started out obviously such like a young, inquisitive and hardworking doctor, I don't, you're probably not at that age yet. But as you age, are you like looking out for those types of signs? Oh no, I'm in my mid 50s and I'm menopausal. So, yeah. You don't look like it. Oh, bless your heart. No, you didn't. I thought you were much younger than I am. I happen to have gone through it in my mid 30s. I have POI, so like, didn't know what was going on. So now my friends are starting to go through it and I'm like, done that, but I'm also the friend that they're like, hormone patches. What do you use? But I'm wondering how do you, for you going through it, has it changed at all? Having experienced things firsthand? Like, do you feel like you're more keyed in to seeing these symptoms on a smaller detail? You know, it's always different when it's yourself too. You know, I started to experience menopause related symptoms really early to early earlier than the natural you mentioned, premature ovarian insufficiency. And so I remember being like, oh my goodness, waking up with night sweats and I thought I had tuberculosis. Right? Yes, I'm only whatever age. Like, I've got TB. You know, when you're a healthcare professional, you can give yourself all kinds of bad diagnosis and you go to the extreme. It doesn't necessarily make you smarter. You know, so I'm like, oh my God, I have TB. You know, who coughed on me? Yeah. I don't have TB. Yeah. But of course, you're not expecting it at a younger age, but. No, then the other funny, when you don't think it's you too, is that, so I have frozen shoulder and both my shoulders, right? And I love Pilates and yoga. And if there was ever a fountain of youth, it's actually not more month therapy. It's probably Pilates or yoga, I would say. But I think I'm in shape, you know, that's my life's favorite favor, whatever exercise. But so anyway, start having this pain initially is on the right shoulder. And it got really bad though. Like I couldn't get my arm in and out of a jacket, let alone. I wasn't wearing any dress that had a zipper in the back because I couldn't get my arm around a zip. I'd roll over a certain way and bed at her. And so I was convinced that like, again, with the TB diagnosis, I was convinced I had torn my lab room or something, you know, like I'm so dramatic. And so I went to like an ortho colleague of mine and got the million dollar work up and he comes in the room. He's much younger than me too. And he sits down and he says, "Well, you know, Dr. Christmas, women of a certain age, immediately." I was like, "All right. If that's all it is, I'm fine with it." I thought this was much worse than I thought a frozen shoulder could be. So that made me more sympathetic to the patients that came in with joint pain. And I don't have a fixed board. Frozen what? Now, yeah, frozen shoulder. You can call it also adhesive capsulitis if you want. If you're screaming, this can happen into your potting soil or your windshield right now. Yes, it can. News to me. And according to a very recent paper, frozen shoulder. A monastic treatment of adhesive capsulitis in the American Journal of Medicine. Corticosteroid injection and physical therapy can provide meaningful benefit in appropriately selected patients while surgical intervention is reserved for the tougher cases. What else can work? Why? So hormone replacement therapy could. Newer research is suggesting that estrogen is protective against inflammation and fibrosis of tissues. And the small Duke University study found that the prevalence of frozen shoulder was about half of that in the group on hormonal replacement therapy. But again, small sample size, more research is needed if they can get the funding. But Dr. Christmas afflicted and helping those afflicted sees clinically that some people will respond to hormone therapy in cases of the frozen shoulder, but the vast majority of people don't. And so people will come in and they'll say, great, my hot flashes in night sweats are gone. I'm sleeping much better, but I still have this terrible joint pain. And in my case, I still have shoulder pain. And I'm like, yeah, but I never told you it was going to fix that. No, there's only so much it can do here like Dr. Heal they self. Right. Especially when you're like, I'm an athlete. Okay. I'm an athlete. This is from yoga. Right. Speaking of athletes, we do have a whole team of experts for this three part episode. So let's meet Dr. Mary Claire Haver, author of the new menopause and the new paramedicause, globally known advocate for menopausal awareness, who communicates a lot on the topics of hormone replacement and increased research for women's health and the role that physical activity can play in staying healthy. So let's roll back a little. Let's learn more about her. From your book, I know that you were doing a lot of reproductive care, a lot of care for women and other people with uteruses. And it wasn't until you went through some hormonal changes yourself that you were like, oh, shit. What? Yeah. I wish I could tell you that, you know, I noticed the patterns from my first day of clinical practice that, you know, women after reproduction and we're getting the shaft. But no, no. I was a horrible menopause doctor for probably 15 years. And I was aging along with, so I didn't have that many menopausealish patients because when you start out, you get all the OB patients. Yeah. And I was having babies with them. So I'm aging along with my patients. So, you know, it took 10 to 15 years for me to start going, huh, I run with this woman. We've run marathons together. We do book club like, she's not lying. I know what she eats. I know how much she exercises like this weight gain stuff, her brain fog, like, this is real. Then the divorces started happening in our like friend group at all around the same age. And I'm like, you see people's resilience start crumbling when you watch the lives that they built and they were managing everything, the ups and downs, the stressors and then all of a sudden they've just like hit a wall. So those were really when I was like, something is not right. And then it was happening to me too, of course. Do you feel like people's front line person for questions about menopause like more so than their own doctors? Yeah. And that's okay. I don't mind it. What kind of freaks me out is I've been doing this 10 years? And I get the same questions every day. Really? Yeah. Really? Okay. Let's launch into them. Okay. Just rattle off. Like, what are some of the most common ones that people have? I mean, I now get thousands of DMs a day and we can't answer them, right? But just the most basic stuff, like, is it okay for me to be an on hormone therapy? Is it safe? Am I in menopause if I have X, Y and Z? Just I'm like, wow. It's crazy to me that gosh, there's still women out there who aren't getting access to the basics. So for sure. So let's start with those basics to save your sanity and also your bones and your heart. So the best way I can explain it is in a pre-menopausal woman, before menopause enters the chat or perimenopause, females are born with their entire X supply. Males make their stuff fresh every day. So big difference between the testicles and the ovaries. The ovaries are just waiting for instruction. They don't actually do anything on their own. The instructions come from the brain. So we have two glands in the brain, the hypothalamus and the pituitaries. The hypothalamus is basically looking for estridial. Okay. Where is it? Where is it? It's actually in a normal cycle. It starts saying, hey, we want those estrogen levels back. Come on. So it starts sending signals from the hypothalamus to the pituitary and the pituitary pumps out FSH and LH that go and bind to the cells around the eggs. And those cells, the follicular and grainyalosis cells around the egg are where the sex hormones are made. I'm simplifying a very complicated process. So when you look at LH, FSH, Eshydrial and Pregestero, in a healthy woman who has regular cycles, right? You at 23. I'm assuming. You have this very predictable ebb and flow EKG-like month after month after month of day 12. You're going to do this. Day 14. You're going to do the outside of starvation pregnancy, heavy exercise, stress, you know, that process is meant to happen month after month after month until we reach a critical egg threshold level, which you met very young. Yeah. Something destroyed the eggs out of immune disease usually in your body before they would have run out on their own. And that's with P O I S. And so we reach this critical threshold with the signals coming from the brain, the ovaries become resistant. And then it'll work as well, okay? There's not enough eggs to respond. So the brain starts flipping out like, when? There's my estrogen starts pommeling the pituitary. Give me more, give me more. We get these much higher levels of pulsatile LH and FSH to force those few last, you know, the eggs remaining to make the ovulation happen. Sometimes we have these loop ovulations where we have two back to back with no break. So we end up getting a very sporadic, bit much higher than outside of pregnancy. So we'll get estradiol levels, sometimes three, four hundred like pregnancy levels, like early pregnancy levels. Well, then we get these crashes and the progesterone never keeps up. So what used to look like EKG predictability now becomes chaos, which is why we call it the zone of chaos. We've known this since 1996. That paper came out in 1996. I'd never heard of it. Oh, the rage, the flames all the side of my face. Flames, flames on the side of my face. Breathing, breath, heaving breaths. Until 2023. Insane. And I'm reading this paper. And I'm like, what the fuck? Like, so all of that chaos of our hormone levels, our neurotransmitters are affected, our estrogen receptors, and where they're located. We upregulate in certain areas. How we process glucose in the brain, the amygdala that controls our emotional centers, the frontal lobe where memories are consolidated. All of that takes a hit. The brain stem, how we sleep, cortisol, stress. Like it all becomes this whirling dervish. So Perry menopause is the brain. And so brain fog, mental health changes, anxiety and depression, rage, and sleep disruption. That is the beginning of Perry menopause. Not cycle, cycle disruptions are at the end for most women. Oh my god. Oh, dear Lord, there's so much to learn. Okay, so let's talk timing. Let's talk symptoms. If you're not me with a wonky early condition, Dr. Christmas lays it out. And what is natural menopause? The median age is about 51 and a half, 52. The range that 95% of people fall into is between the ages of 45 and 55. And we start to experience symptoms related to hormonal fluctuations up to four to seven years beforehand. Oh god. So it is actually true that potentially for some people in their late 30s or early 40s, you might start to have some symptoms. The first symptom is usually changes to your menstrual cycle. So if your cycles are changing by more than seven days, consistently, not a one off, but consistently, that's the early period menopause phase. And once you start skipping more than 60 days, consistently, that is the late period menopause. And then do you cross that sort of checkered flag when it's been a year since you've had a period or is there a certain amount of time where it's like, okay, it's definitely, it's jigs up. Yeah, it's a full year in its retrospective 'cause you don't know when you're having the last menstrual cycle. In fact, Mother Nature has a very cruel sense of humor and people can go many months without having a period. They give all of their protective things away and they're like, I'm here and then they'll get like a last-traumat or two. So that part of it really burns me up 'cause it's like, why don't you stop? Like why don't you have to do that? Just stop. Yeah, nobody asked for an encore. No, nobody did. It's not fair at all. Hey, heads up. Perimenopause can last between two to 14 years. And even though your egg supply might be diminishing and only takes one egg to get pregnant, folks, and when I didn't know what was happening in my 30s, my period took a little hike, took a hiatus. It's like gone fishing for a bit. And I thought, what if there's a uterus and truder in there? Is that why I don't have my period? And I was forced to go to a Walmart where I bought a diet doctor pepper and a pregnancy test. And the weird thing about buying a pregnancy test when you're in your 30s is like the cashier who was a younger woman. She gave me a really like encouraging good luck as I left. And readers, I did not want a child. But I peed on it in a nearby gas station bathroom. Surprise. It was just menopause. And it was thankfully negative. So if you're not looking to cultivate anything in your uterus at the moment, and you're like, I should be fine. I'm like having hot flashes. I'm sorry, babe. Do not be the victim of a cruel hormonal joke where the punchline has two blue lines. One of my favorite things to do during parimenopause, though, is to use either continuous hormonal birth control or put in a progestin IUD. Because it helps to kind of cheat our way through that erratic bleeding. Because even if your periods get shorter later, and they start to space out and then politely go away, it's still-- if you don't know when it's going to come, that can be extremely anxiety provoking for some people not knowing. I mean, it would be for me, so. If you think that answering a call from an unknown number is daunting, I invite you to wear an outfit you like and then just roll the dice on spotting blood. I've always said that death is like wearing white jeans when your period is about to start. Just non-exiety. A reminder that to be alive is to lack control. When it comes to those symptoms, what are some hallmarks to look for? Let's go through the physical symptoms that your patients come in with that you're like. Obviously, hot flashes. Do those last like 10 minutes? Do they have it at night more? Dr. Christmas explains. So let's look up the history of pariamenapause. Because that's not typically something that people have always talked about. You talk about the menapause. So anyways, I found this stuff, this doctor in 1867. He kept a diary or chronological notes of all of his pariamenapauseal women. And so to answer your question, I was trying to find it because I was going to rattle off the 22 symptoms that they dig. And I love how they describe some of them too. So that's why I was looking for the little favor. And of course, as I'm sure you know, this was the 1857 paper of Dr. Edward John Tilt titled, "A Clinical Treatise on the Diseases of the Ginglionic Nervous System, Incidental to Women at the Decline of Life." And he comes in hot in paragraph one, stating that some German doctors call this quote, "The period of sexual evolution." And he only slightly more softly notes that his female patients have called pariamenapause the dodging time. Now the table of contents in this book includes some real whoppers of anachronisms as he describes patients who have experienced delirium caused by cessation. Insanity occurring at the change of life fits and eruptions of the face caused by the change of life. Successive fits of coma at the menstrual periods. Historia caused by cessation. Short and sudden fits of the impossibility of speaking after sensation and plainly melancholia. But considering the period, if you will, he seemed to at least be a doctor who gave a shit. 'Cause in chapter two, he writes, "The ovarian influence reaches the Ginglionic center, which is in constant communication with the brain. So at the change of life, its undue influence is shown by distressing headaches, continued fretfulness, pivishness and capriciousness called temper by a temporary perversion of moral feeling or by moral insanity. The disturbance is on the mental faculties, which are for a time in a state of misty haziness. The brain feels muddled, memory is faithless and there is an incomparable desire to sleep during the day. Even when the night has been passed in repose, he concludes having thus briefly sketched the varied phenomena, I am able to open the investigation of its terminal crisis. So yes, a person can feel like our bitch in so many ways and we've known that for years, but society at large has neglected to care." - At any rate, about 80% of people will have like some sort of vasomotor symptoms, hot flashes, nights, wets, some people will say, "I don't necessarily feel hot, but I get these cold like feelings too." So however you describe it, but it's usually kind of feeling like you're on fire from the nipple line up and then it's quickly as you feel warm and it can come out of nowhere. You start to cool off and then people sweat and then you feel really cold and shivering after that because you're wet from the sweat. - So these are called the phasomotor symptoms and according to the JAMA article, duration of menopausal vasomotor symptoms over the menopause transition, they usually last between a minute to five minutes at a time and up to 80% of people going through paramedicause have them. - Those are pretty high odds. - What else do you look for? Dr. Christmas continues. - The mood symptoms and they can swing from having depressed mood to anxiety, to anodonia that not having the energy or just the motivation to do things that were much easier for you to do. People will talk about sexual dysfunction, decreased libido. Sometimes it's tied to vaginal dryness that could contribute to pain within our course, but sometimes people are like, no, I don't have any pain, I'm not dry. I just don't have desire for sex and it happened pretty abruptly for me. The joint pain that I already talked about, me and my frozen shoulders, skin changes here, thinning, maybe having acne when you never had acne issues before. A big one, huge one. I should have put this right underneath vasomotor symptoms and maybe for some people it should have been above that is weight gain. And it can seem like it happened overnight, like I woke up and I was 20 pounds heavier. It's probably not necessarily a menopause related thing but an aging thing, but we do notice it. It can be pretty pronounced like the couple of years before the last menstrual period and a couple of years, after the menstrual period. So there's about a five year window where people notice this like, if you're not doing something about it, even 20 to 30 pound weight gain, that can be extremely distrustful. And people, I'm not eating any differently, I'm not changing anything with my exercise habits, and I say I get it, but we have to. We have to put in a little bit more effort because as we get older, we're losing muscle. That muscle is replaced by fatty tissue. Much of that fat deposits in the midsection from a vanity perspective that's a horrible place for it to go from a health perspective it is too. So really counseling people about the importance of regular exercise, including weight-bearing exercise is really important. - So this, again, this was news to me, but if it seems like your body composition is changing, but your diet hasn't, there are a few factors. So without enough regular physical activity, especially weight-bearing exercise, women tend to lose up to 8% of their muscle mass per decade. That's a lot. Unless muscle mass means a lower resting metabolic rate, which leads to increased fat stores on the same diet. So low estrogen also directs that adipose tissue to just hang out and just kick it in the midsection, which can also lead to heart disease and further metabolic disruptions. So muscle mass really matters here. Also good for the bones, we'll talk about that later. But if your sleep sucks also or your stress levels are high, that can contribute to changes in your metabolic rates and eating patterns and thus body composition. And again, in part two next week, we're gonna go over how that impacts your skeleton, why that should matter a lot to you, your risks later in life. And we talked to a researcher from Smith College, Dr. Sarah Winkowski, all about the overlooked risks to heart health and menopause. And she will inspire you to just go out into the guard and start lifting logs while screaming at the sky. You gotta wear gloves though, no splinters. Overall some people just, I just don't feel like myself. I don't know how to put my finger on it, but I just don't, I don't feel as confident. I've got this brain fog. Does that mean I'm gonna have dementia? It does not mean you're gonna have dementia. I just have difficulty recalling things. I just don't think that I'm functioning like I normally do. And in my work setting, I just don't feel like I'm doing it as well. So I don't think I forgot anything. That was a lot, right? - No, yeah, I mean, there's, I'm sure so many more. The brain fog stuff is really interesting and we had so many listeners ask about that. And I remember when I was going through, you know, my ovarian failure, I also thought I had early, early onset dementia. I like wrote down my address wrong. I remember I was in a family reunion and I could not remember my cousin's name. I was introducing her to my husband and I was like, I'm like just blank where you're like Swiss cheese. Some people ask to their ADHD seems to get a lot worse with a drop in estrogen. So any idea why that brain fog and how those cognitive effects happen? - Yeah, Dr. Polly Mackey has done a lot of work in that area. There does seem to be some brain changes, especially in our white matter densities with decrease in estrogen. But that doesn't necessarily mean that you're going to have dementia either. And it's hard to say if that's what causes kind of the concentration focus issues and the brain fog name recall. Interestingly, if your night sweats are keeping you up at night and you didn't sleep as well because you keep waking up frequently with the night sweats, if I give you hormone therapy or any of the other non-hormone therapy modalities and there's some good ones to get rid of your night sweats, you'll sleep better than you'll probably feel more energetic, you may think better. So it's not necessarily that the treatment directly impacted the brain fog, but it might have gotten better because we manage these other things that might be contributing. You know, I have to remind people a lot to be kind and gentle with themselves too. Like at this stage too, we've got a lot that we're doing. You know, they don't call it the sandwich generation for nothing. - So as frustrating as it is to have paramanopause dismissed as like, it's just stress that's in your head. It's also not helpful to consider that all of your stress is just caused by hormonal shifts. Sometimes it really is just because things are hard, but if you have sudden pains, like in your lower right abdomen, that could straight up be appendicitis and non-hormones. Chest pain, keep an eye out for cardiac symptoms. And if you've been feeling depressed or especially anxious, no matter what the cause could be, talk to a doctor and see if medication might be helpful. Paroxytene is an antidepressant that the FDA approved to treat face omotor symptoms and menopause. Some clinicians also prescribe SNRIs or other SSRIs for physical and the psychological effects of hormone changes. And Dr. Christmas mentioned Dr. Pauline Mackie's work. And in a 2022 paper titled Brain Fog and Menopause, a healthcare professionals guide for decision making and counseling on cognition. It kicked down a definition for us on brain fog, giving that the topic itself is murky and ephemeral. And the paper says that brain fog most frequently manifests in memory and attention difficulties. And it involves such symptoms as difficulty in coding and recalling words, names, stories or numbers, difficulty maintaining a train of thought, distractibility, forgetting intentions, like the reason for coming into a specific room and difficulty switching between tasks. And if that sounds like, oh wait, I've had ADHD on my life, welcome. There's a lot of you. According to the 2024 Frontiers in Neuroscience paper, the impact of estradiol on serotonin, glutamate and dopamine systems. Estradiol functions as a neuroactive steroid and it plays a crucial role. It says in modulating neurotransmitter systems, namely those involving serotonin and dopamine and glutamate that affects learning and memory, reward and sexual behaviors, but researchers stress it's not all causal. Estrogen, remember, it affects vasomotor symptoms that interfere with sleep, which can cause brain fog and not getting enough regular exercise or adding in more habits to reduce mid-life stress can also muddle your mind. So you might have to think more holistically, like zoom out a little bit more and think of ways that you could support your overall health and mental health. And there have been anecdotal reports that adequate omega-3s and magnesium glycinate supplements can help as well. But again, talk to a doctor. Now, a 2025 journal of the International Society of Sports Nutrition titled "Creatine and Women's Health, "Bridgeing the Gap from Menseration through pregnancy "to menopause notes that creatine supplementation "has shown positive effects on muscle strength, "exercise performance and body composition, "particularly when combined with resistance training." And it says, "Editially creatine may improve mood "and cognitive function, potentially alleviating symptoms "of depression, but surprising "no one, it does conclude that data "on parry menopausal women remains limited." So take that with a big grain of creatine once again. Talk to your doctor, I'm not them. So on that executive function topic, Dr. Haver explains. - So BrainFog does tend to get better postmenopausal. It's worse in parry menopause. - Oof. - And I talked to Dr. Russell Barkley, who's an ADHD expert and he mentioned that you do need estrogen to make dopamine and a lot of people who weren't diagnosed with ADHD or had mild cases, it flares. - It was masked. - Yes, it was masked by high performance and a lot of internal anxiety, which is so many women go through. But are those levels of estrogen also executive function is impacted by dopamine? - Yes, so when we look at 20% of women in the UK quit their jobs in parry menopause and menopause. - Wow. - Not because they hate their job. Like, if you hate your job, you need to go. But because they feel like they can't function. And the problem with BrainFog is we don't measure BrainFog. We measure for dementia, okay? Big difference. BrainFog is I can't find my keys. Dimension is, I don't know what my keys are for. Dimension is severe cognitive, like inability to function. And BrainFog is, I can't function at my executive level. That I was functioning out before. - Yeah. - Like, the happening's not happening. And we have a really hard time measuring that. It's called subjective cognitive decline. So it's really like you tell me it's subjective. I'm not able to do the math at work or I'm not able to juggle all the balls or do the things. - And I know that for your personal experience, a lot of it was masked by you were going through a difficult time caring for a family member who was very ill and they call the generation, the sandwich generation where you're still taking care of kids and also you're, say your relatives, your parents are getting older. So is a lot of that kind of mixed in the soup of just incredibly high stress and high demand. And then on top of that, you're like, I don't know what's going on below my neck. - Yeah. - I got a lot of shit going on. - So it's like everything hits at once, right? For a lot of us. And so forever everybody's just blamed, oh, you're just stressed out, your parents, your kids, and like these women are coming in my office going no bitch. I built this life. - Yeah. - And I had it managed. I knew this was coming. You know, like this is different. We can't just blame stress on this. They're like, I had this managed two months ago and now we're not managing. - So how do you know if it's parrymenopause? As you age, you know that the egg supply you're born with is diminishing. That's just life, just marching toward the shorter end of it. I'm sorry, but can we get some numbers on this? Is there a test? Dr. - And then once we really hit this pivotal point, you would think that the ovaries would slow down, but they almost rev up a little bit. and you start losing, we call it atreja. You start losing more. exe even at a faster rate. And so that is why during that parimenopause transition, especially, it's actually not very useful to get lab values because oftentimes women will have actually higher estrogen levels than you would expect. That's where those loop cycles come in or people will say, "I'm glad for 30 days or more." Or, "I'll get my period, it'll go away, and then a week later I started to bleed again." It is because of those spikes in hormone levels too. It's often the fluctuations during the menopause transition that really contribute to a lot of the tumultuous symptoms that people experience, especially the mood-related symptoms. Once your end menopause and your ovaries aren't baking and anymore at all, it's zilch zero, a lot of people feel better. It's not the roller coaster. And so when is it helpful? It's helpful if I have a 25-year-old or a 35-year-old that comes in and they haven't gotten their period and/or their experiencing symptoms that we would typically relate to menopause? Then I want to know, because that's unusual. Why are you at 35 not getting a period? So I am going to get a whole battery of labs because I want to understand, is this premature menopause? Is this polycystic ovarian disease? Is it some other endocrinabinormality? And so that's actually very useful information. If I have somebody that's of the natural age range and they are doing exactly what I expect them to do, then the lab value is really not helpful. It's helpful that they're having symptoms because I want to help them have a better quality of life. But what the value is doesn't matter. And just to fun, this is good news, side note. Since we chatted just a few weeks back, the journal Lancet published a huge paper titled "Polly Endocrin Metabolic Ovarian Syndrome," the new name for polycystic ovary syndrome, a multi-step global consensus process. So PCOS, the big news is finally has a rebrand to PMOS. And this study, which was co-authored by over a dozen top experts in the world, acknowledges that PMOS affects one in eight women and that the term PCOS is inaccurate because it implies pathological ovarian cysts while it says obscuring the multi-system pathophysiology. So it's like, you got some cysts on your ovaries. Well, really it's like it's way more than that. It's caused by different stuff. And it says it's not simply a gynecological or ovarian disorder. It's actually underpinned by endocrin disturbances in insulin, androgens, and neuroendocrin and ovarian hormones. It's the whole system. But getting back into Metapos, hormones are fluctuating a lot. Your ovaries are not, they're not quiet quitting. They make themselves known as they pack up their stuff. They're slamming some drawers, they're taking time to sleep, between taping up their boxes, they're hiding their deskplants in the break room fridge. They're letting the entire department know they are out the door. Now mine left early and unbeknownst to me and like at least seven doctors. My symptoms in my early 30s were in fact my bewildered ovaries regrettably giving notice early. What I thought, I thought they were like fevers. Those were just hot flashes arriving a decade early. I had no clue. My had weird cycles. They were getting longer in between. And then the doctors were like it's simply stress. All these weird totally menopausal symptoms I was told were just stress. And couldn't I quit my job in TV and find a rich man to marry one elderly physician asked me without even proposing to me. I had mood swings. I had crying jags. I forgot my own address. And when a female doctor finally did a hormone panel four years into this mystery agony, it revealed that my follicle stimulating hormone was jacked through the roof. And this is important. So what that number represents? FSH follicle stimulating hormone is inverse to your ovarian function. So if it's high, your brain is flooring the gas pedal to get the car to move. It's saying like ovaries. Hey, hey, where are you? But your ovaries are like my motor's not going anywhere. So premenopause, your FSH varies by day, but it's usually between the numbers four and 21. Now, once it's up around 30, it's pretty high. Your endocrine system is mashing that gas pedal with FSH to wake your ovaries up, but they are sleeping perhaps forever. So any FSH over 30 is typically like a yes for menopause. So knowing my FSH was helpful, but I didn't have a normal timeline. Because again, in my early 30s, I had what doctors called primary ovarian insufficiency. My ovaries, they took that personally. And what kind of tests are people requesting versus which are effective? I know for me with P O I, they tested my FSH and it was like 130 or something. God bless your heart. I was like, I don't, yeah. I mean, we know how to diagnose P O I fairly well. But like for paray menopause, we don't have a blood test. We don't have urine, a saliva test, save your money. Okay. We can diagnose postmenopause. So like your FSH is above 50 consistently, your postmenopausal. That's it. Okay. Above 100 foe show. Yeah. I know. Like ovaries have left the building. Eggs have left the building. So because of the chaos, these hormone tests are rarely, rarely diagnostic. So we diagnose paray menopause by guess what? Listening to the patient, oh, believing her, doing blood work to rule out other things like auto-immune disease, hypothyroidism, inflammation, nutritional deficiencies, etc. We do a lot of blood work in our clinic. But we're not like chasing hormones in paray menopause because tomorrow they could be something totally different. We're going to continue just a second. But first, we're going to donate to a cause of theologist choosing in this week. We are splitting it between Dr. Christmas's pick of Center for Food and Equity Medicine. An excellent organization that helps lift the burden of food and security off of cancer patients and their care providers. They note that in addition to soaring treatment costs, there's also just a high cost of being present during the hospitalization of a loved one. There's parking. You have to bring your own food or buy your own food. There's lost wages. I can add up quickly. So the Center for Food and Equity Medicine helps out with those costs as a fresh food pantry. They distribute meals to immunocompromised people via their grocery brigade. They do much more. Dr. Haver selected St. Jude's Children's Hospital, which works to advance cures and means of prevention for pediatric catastrophic diseases through research and treatment. They say consistent with the vision of their founder, Danny Thomas. No child is denied treatment based on race, religion, or family's ability to pay. An actor Danny Thomas, to side note, was born Amos Mousiagia Kubka Rus in Michigan, to Lebanese Catholic parents and established St. Jude with money that he made as an actor and a singer. I never knew that, but it's pretty cool. Okay, so those donations were made possible by sponsors of allergies. Let's get back to it with Dr. Haver and why learning about this is important for all genders. And in the last 10, 15 years, with social media, have you just seen people who are much more tuned in? Totally. Yeah. Yeah. So I really feel like social media has become the female water cooler. And it is a way for us to share stories and to realize that we have commonalities where we never talked about it before because we didn't have the opportunity. And so someone mentions, you know, her frozen shoulder and that it's in menopause. And like 10,000 people ask me, could my frozen shoulder be related to menopause? I go dig through the data. I find correlations. I find Jocelyn Whitstein's work in Vonda Wright. And then that video goes viral, you know, millions of views. So with tens of thousands of women in the comments going, oh my god, this happened to me and no one mentioned it. Where is the research ads? You know, I know you're digging through research, but how well funded is it? How up to date is it? Before or after this administration. So no, let me be clear. Nobody was doing menopause well. It was a bastard stepchild in the research world. So after the WHO, no one was doing this amazing. Okay. So when we look at women's health, so in 2023, McKenzie came in, the Gates Foundation hired the McKenzie group to look at women's health and funding and spending. The total NIH budget was 43 billion. I may not get the numbers exactly right. So women's health got 10 to 15% of that. Okay. So 85% did not go to women's health. 47 billion, but that's close enough. So yes, roughly 10% of funding goes toward women's health. But hey, did you know that before 1993, you didn't even have to include a woman, a woman, a woman in your clinical trials? So this 1993 change was called the Revitalization Act. And before it, pharma companies just didn't have to include women while testing for drugs and vaccines and stuff. Too complex, they said, those bodies, we can't figure them out. So it's fine. Again, this was until 1993. And it wasn't mandatory for the US to test automotive safety with crash test dummies with typically female proportions until, do you want to guess what year? Ever. It's still not mandatory. Crash tests, car safety, tailor toward taller, heavier male bodies. And as a result, as reported in the recent federal report, sex-based differences in odds of motor vehicle crash. injury outcomes. "Females had significantly higher odds of injury than males. Males did not have significantly higher injury odds in any crash models, so women get in the shaft from so many angles. Liver die, eh, don't worry about it. And so many medical trials still are skewed disproportionately toward white people. In the United States, Native American and Black women are two to three times more likely to die from a pregnancy-related cause than white people. And according to this 2024 McKinsey report, closing the women's health gap, a $1 trillion opportunity to improve lives and economies. Menopause is an area of highly unmet needs globally. It says it's estimated that more than 450 million women worldwide have menopause or perimenopause symptoms. And based on the prevalence, this report says, the estimated market potential for medication is up to $230 billion globally. The paper notes, investments addressing the women's health gap could add years to life and life to years, and potentially boost the global economy by one trillion annually. So, hey, we should figure that out. America, because that's a lot of money to be made from menopause. Very uterus matters because your wallet does. The lion's share of that women's health bucket went to pregnancy, pregnancy is important, and then breast and ovarian cancer. Okay. When we talk about autoimmune disease that 80% of women have, when we talk about intubitriosis, polis, scovarian, diseases that specifically affect menopause, it was like dust, like pixie dust. So how does that translate? So if you go to the NIH website to look up research articles, so that's PubMed in the US, or, well, why we can do it worldwide. And I type in the word pregnancy, okay. Right now it's around 1.2 million articles. Now those articles represent brain power, academics, research funding, you know, think of everything it takes to like create a research article and all the money and preparation that goes into that. Okay. Now I'm going to type in the word menopause. We're about 99,000, maybe close to a million now. That is 12 to 1, okay. Now I'm going to type in the word perimenopause. And we are at 9,000. Dude. And perimenopause can last like 10 years, right? Yeah. So just to give you an idea of this much funding, so 85% is taken away. Now we're going to most of it's going to pregnancy and that, you know, so here's the dust in the crumbles and the cobwebs that women's health after reproduction ends, which affects more women than it will bear children. Yeah. So that's kind of like my inspiration. Are you constantly having to refresh and see what papers are coming out and get abstracts? Yeah. So the coolest thing about PubMed is that they let you put alerts in. So I have an alert for the word menopause and I have an alert for the word perimenopause. And every morning I get my coffee, I get back in my bed, I flip over my lap. Top and I review every single article and there's not that many, Shabby. That comes out. So every day I see what has been published with the word menopause or perimenopause in it. That's so baller. And it's awesome. And I'm like, okay, and I read every abstract. There's still a lot on cancer and menopause. So that's fine, you know, but like really clinically relevant stuff, we have a long way to go. Women are of centuries of research here. Yeah. Oh, a thousand percent. So who is doing that research? We're going to link to so many studies on our website, which is linked in the show notes, or you can just go to alleywear.com/alogies/menopause. Well, do animals deal with this shit? I reached out to biological anthropologist Dr. Laura Durkovich, who you may remember from our episode on the sex lives of apes other than ourselves. And she studies menopause in orangutans. So at least someone's health is funded for that. Hello, Ms. Allie. Thank you again for inviting me to comment on this stuff. I'm very excited to be back on the show. And my research focus is on the life cycle of female orangutans, and specifically how they're reproductive hormones and their menstrual cycles, which are pretty much the same as ours, change across their lifespan. And if or how those hormones impact the female's motivation of mate or the male's interest in mating with them. Hello, ladies. But the other thing I want to know a lot about is whether parry menopause and menopause are a standard part of the female life cycle. And if so, how long they tend to live afterward. Okay. Awesome. Menopause is definitely rare in the animal kingdom. From an evolutionary perspective, the more offspring you have, the more copies of your genes you pass on to the next generation, and the more you are winning, so to speak, at the game of evolution. So it's super puzzling to see a life cycle evolve where individuals stop reproducing long before the end of their lifespan. There is evidence that some female orangutans, gorillas, and chimpanzees reach menopause, and also some species of toothed whales like workers and narwhals. Well I asked her how long are humans supposed to live? Are we even supposed to go through menopause or should we be dead by then? Humans had actually had a longer lifespan for longer than most people appreciate. I think a lot of people think that the only reason we have a long post-reproductive lifespan today is because of modern medicine, that otherwise we'd typically be dead by 50. But actually in the past, a lower life expectancy was skewed by high rates of death at young ages. So if they survived childhood, it wouldn't have been unusual in ancient times for a person to live to something like 70, which for a woman means two solid decades of life post-menopause. I mean organic foods, lots of exercise, healthy social environment, living in villages, weight bearing activity, from carrying water and other people's babies and rocks, you're hanging out in your campfires, but you're skipping the vape and bottomless mimosas of our current epic. That all kind of checks out. But why shut things down before the party's over? What is the advantage of menopause? This one is a million dollar question within evolutionary biology, and it is one that we still don't have a definitive answer for. In mammals, females are born with all the eggs they'll ever have already in their ovaries, and the physiological changes of parimenopause and menopause are the result of that number of eggs declining with age. This is called follicular depletion. The focus in evolutionary biology has shifted, and the question being asked isn't so much why do we have menopause, but rather why did natural selection favor an extension of the human lifespan beyond the age where we, or women at least, stop being capable of reproducing? The most common explanation is something called the grandmother hypothesis, which was popularized by a woman named Kristen Hawks. And the idea here is that grandmothers can be particularly valuable in helping increase the reproductive success of their own offspring by helping to both provision and care for their grandchildren. By boosting their grandchildren's survival chances and possibly even helping their daughters have another baby more quickly, grandmothers are able to boost their genetic legacy indirectly through what's called inclusive fitness in evolutionary biology. Thanks, Rella. I know there was a well-studied female organ named Granny that was fit into this mold. For more on that, yes, we need an orca episode and I'm working on it. I know feelings are mixed on calling them killer whales, but I do feel like killer whales would be great for a spooktober. So put a pin in that. But meanwhile, you can see the 2017 current biology paper titled Reproductive Conflict and the Evolution of Menopause in Killer Whales, which explains that the reproductive conflict hypothesis predicts that older females in a pod, ceasing fertility, is a benefit to the younger females since males don't disperse from the pod so that avoids more interrelated breeding. But the 2019 piece in science.org titled Granny Killer Whales, Pass Along Wisdom and Extra Fish to Their Grand Children, touched on some new research showing the first non-human grandmother hypothesis in whales, noting that as wise grannies, they can help provide fish and knowledge of where to find them to the younger whales and that greatly increases the survival rates of that young generation. Another effect, this has not been studied, but it's my hypothesis is fashion because in 2024, young whales off the northwestern coast of North America, they were cruising around balancing dead fish on their head. No one really knows why, except that in 1987, this was also a fat. It disappeared for decades and then boom, whales started balancing fish maybe to amuse each other. So I think perhaps a young whale was like leaving through a photo album, was like grandma looked hot, put a dead salmon on like a pair of grandma's acid wash jeans, just like throwback, looks good, nature, it's a mystery. Orcas can go through the dodging event around their mid-40s, even though they can live into their 80s and 90s some even passed 100. What about the less wet mammals? I have a colleague who was a veterinarian at a zoo in Jersey and he published a paper last year where they used hormone data and ultrasound data and histology. to document menopause in a 49-year-old female orangutan. But we also know that female apes can continue to reproduce at ages that would be considered pretty late in humans. There was a female orangutan at the St. Louis Zoo who gave birth at 45. There was also a chimp named Suzie at a zoo in Kansas who gave birth when she was 56. And as for Suzie, she was taken off birth control. 'Cause that's right, apes and captivity, they're given regular old human birth control in a cup of juice every morning. We learned that in our Primatology episode. But yeah, they took Suzie off birth control for some other health concerns and quote, "Zoo officials didn't think she would get pregnant at her age, but surprise, suckers. Suzie was still freaky and she had a kid of 56 and then she lived until the age of 71 and she just passed away in the fall of 2025. So RIP allegend." - But we need more data to say whether the slope of the line is the same for hormone decline in humans and in other apes. As far as I know, there's no evidence that they experience things like hot flashes or mood swings, but obviously we cannot ask them. I wish we could. - What about in Convose with your human friends? Has research helped you or your friends and relatives in terms of their perspectives on the experience? And here, - I have to say sadly, no. I'm not there yet myself, but I think this is one of those things where understanding it better does not make it any easier to go through. - You know what else makes it easier to go through though is part two. Next week, we're gonna move on from these basics and symptoms and tell you what you can do about all this. There's hormone options. We talk flim flam, busting, specific things to ask your doctor, alternatives, latest research, why you wanna make sure your hips stay intact, vagina creams, libido, so much more. Meanwhile, Dr. Mary Claire Haver has the podcast un-possed and wrote the books, The New Menopause Book and The New Perry Menopause Book. Dr. Monica Christmas is on Instagram at Dr. Monica Christmas. We'll also link her research gate as well as Dr. Lara Durgavitches. And of course, so, so many links will be up at alleware.com/ology/menopause. And again, we're back next week with all the stuff you need to know what you can do for yourself and/or the people in your life who are going through this. It's very important. Now, we are at AlleyGee's on BlusKind Instagram. I'm at AlleyWord on both. Alley has just one L. We also have kid-friendly episodes in their own feed that shows called Smalleges. It's wherever you get podcasts, SM-O-L-O-G-I-E-S. If your kids ever watch the show Brainchild on Netflix, that's me. I was their science friend on that. So there's a fun new podcast for them if they need one. Thanks again to Patrons of AlleyGee's next week. It's all your questions, wall to wall. And thank you Aaron Talbert, who adminz the AlleyGee's Podcast Facebook group. Avaline Malik makes our professional transcripts. Kelly R. Dwyer does a website, Noel Dilworth, tracks our weeks as our scheduling producer, slamming down on my gas pedal to get the episode out on time is managing director Susan Hale, who also did an amount of research on this episode that is staggering. Just give her a PhD for this. Susan, I may not have ovaries or a uterus anymore, but I could not survive without you. And editing so wonderfully that I do not have to quit my job to marry my endocrinologist, or Jake Chafee. And lead editor, Mercedes-Mateland, of Mateland Audio, Nick Thorburn, whimpered the theme music, and if you stick around until the very end, you know I may tell you a secret. This week it's something I think I mentioned in the All Secrets episode recently, but it's that I bought one of those little sticks with a grabber on the end, like a claw grabber on the end to pick up trash on my street. And it all started with these PE bottles that kept appearing in the bushes because multi-billion dollar corporations don't let their delivery drivers take breaks. So into the bottle it goes into our bushes. I can't blame them, but I take this little trash picker on walks with Grammy and Jarrett down the street. And I just pick up trash. Honestly, here's the problem. Here's my thing. If I just took myself on walks around the neighborhood with this trash grabber, I would get so many steps. It just keeps your brain kind of searching for litter in a way that really feels like Pokemon Go, but with like hamburger wrappers and cigarette butts. But I know if I start doing that, which again, I like really want to, but I'll become that lady in the big hat with a garbage grabber. And I don't know if I'm ready to be that iconic and take on that kind of neighborhood lore right now. So if anyone else does that in your own neighborhood and just becomes it, just let me know how it goes. I'm tempted. Okay, next week we'll actually materially change your life so much information. Okay, talk to you then, bye. (upbeat music) Well, I tell you, menopause was wonderful for me.