Is Menopause the Beginning of the End?: Transcript

Dr. Jen Gunter:
Let me take you back in time to 1800’s France.

After a luxurious walk along the Seine and a buttery pastry you wander into a bookshop, where you find a new book by Doctor Charles Pierre Louis De Gardanne. It’s called Of Menopause: Or the Critical Age of Women.

It’s cutting edge science, all about what happens during that mysterious time when a woman stops being fertile. He named it “menopause”

“The approach of menopause makes such an impression that her imagination creates vain chimeras, which bring a great disturbance in her being; she becomes morose, worried, taciturn…

“She has lost her charms, with no hope of recovering them! She constantly regrets pleasures that are no longer her age, and paints the future with the saddest colors.

“Grave dangers precede, accompany and follow the cessation of fertility, which is why it is called the Critical Age.”

Yikes.

It’s 2021, and science has come a long way since Dr. De Gardanne came up with the word “menopause.” But the way we look at it hasn’t.

We are still bombarded with messages about how menopause is a kind of pre-death. It’s like we become invisible once we’re unable to reproduce.

“Your best days are behind you, it’s all downhill from here.”

Give me a break!

Menopause is not an expiration date on learning, on achievements, or on pleasure, on anything!

I’m Dr. Jen Gunter. From the TED Audio Collective, this is Body Stuff.

Before we go any further-- I want to note that there is so much gender diversity, and there’s no one phrase that will capture everyone’s experience.

We want to make it clear that not all women have ovaries.

And not everyone who has ovaries is a woman. For our purposes here, when we say “woman” we’re talking about women with ovaries or women who have had ovaries.

Let’s return to Dr. De Gardenne. His work is one part of hundreds of years of stigma around menopause. And that stigma has had a big impact. I’m an OBGYN, and I often see patients who have symptoms related to menopause and a LOT of questions.

Think about it this way: there’s basic information out there about puberty and periods. You might see it mentioned in a novel, learn about it in health class, or talk about it with your pediatrician.

The quality of information may vary depending on the source but there is an acknowledgement that menstruation exists.

But when you start the menopause transition there’s no health teacher to awkwardly walk you through the changes. So many people suffer in silence.

But I want you to know that menopause is a normal biological event. And the fear isn’t innate-- it comes from a patriarchal society that says women’s only worth is related to reproduction.

So you might be thinking, “I’m not in menopause now” or “I’m not going to go through menopause, ever. So why should I care?”

We all have people in our lives who either are going through, or will go through menopause. And those people deserve good information and healthcare.

We’ve all got to tackle the stigma around menopause.

As we’ll talk about in this episode…menopause is all about the ovary brain connection. It’s a biological experience that can only happen when there are ovaries or there have been ovaries.

Before menopause the ovaries are ovulating. Think about ovulation as the process of getting into a crowded nightclub. Remember those?

The bouncer is the set of hormones who regulate this whole process.

The ovaries contain follicles, which contain oocytes, which are immature eggs, and surrounding cells. It is in the follicles where the bulk of the estrogen is made.

For our purposes we’re going to use egg when we mean follicle to make it easier for everyone to picture.

So-- Eggs are partygoers waiting to get into the club.
And the brain is like a club promoter-- sending out a news blast that it’s time to get the party started. Along the way, some eggs drop out.

Cuz there’s always a few of those friends who flake at the last minute!

Maybe four or five eggs will actually get to the door.

And the bouncer lets just one, maybe two eggs through. They’re high quality, VIP. The uterus is an exclusive venue.

And this process happens each month. When the menopause transition occurs, it’s this process that starts to change.

At the beginning of the menopause transition that bouncer (the set of hormones) might go for a break and let in a couple eggs at a time.

Or maybe those eggs might say, “to heck with it I’m not waiting in line” and they walk away. So there’s no ovulation.

For a while, it’s super chaotic.

Over time, eggs stop showing up to the party, and the estrogen levels drop

My own “hormonal chaos” started when I was 45, my period started getting a little irregular and sometimes HEAVY.

For most people, menstrual irregularity, the most common symptom of the menopause transition, will appear around the mid to late 40’s -- but really-- there is a wide range of experiences.

Think about your menstrual period-- it’s probably different from your best friend’s or sister’s.

The menopause transition is also when some physical symptoms, such as hot flushes, insomnia and vaginal dryness may begin.

In the 1950’s and 60’s and even sadly until relatively recently, the medical establishment believed menopause was a disease to be cured. Just because troublesome symptoms exist doesn't mean something is a disease.

Think of it this way: pregnancy has troublesome symptoms like nausea and swelling. Puberty has troublesome symptoms like acne, mood swings. That doesn’t make them diseases.

But you don’t have to just put up with troublesome symptoms! Quality of life matters . So if symptoms are present and they're bothersome, they can almost always be managed. We’ll get that later in the episode.

Even after last call, when Club Ovary metaphorically closes, our party isn’t over. We keep flourishing after menopause.

And I want to tell you how incredibly unique this is in nature!

Almost every female mammal dies shortly after it stops reproducing. But there are two exceptions to this rule -- humans and toothed whales.

How did humans become so resilient that we outlive the function of our ovaries?

Turns out the answer could be grandmothers.

Dr. Kristen Hawkes:
Ancestral grandmothers in ancient Africa, uh, put us on the road to what we see in every living human population.

Dr. Jen Gunter:
That’s Anthropologist Dr. Kristen Hawkes. I think she’s a big deal.

Dr. Jen Gunter [to Dr. Hawkes] :
I do have a book coming out, um, on menopause and I have to say, I used a lot of your research in it. Um, so I feel like I'm fan girling. Cause I was like, Oh my gosh, I’m going to get to talk to her.

Dr. Kristen Hawkes:
Oh, it was so glad you're paying attention. I mean, in a way, the things that you confront and the kinds of things that I work on, boy, they, they are relevant to each other, but we're both using really different lines of evidence. So, yeah let's try to talk about it.

Dr. Jen Gunter:
Dr. Hawkes lived with the Hadza people in Tanzania, in sub-Saharan Africa. The Hadza are a hunter gatherer community that until recently resisted many aspects of modern life.

Dr. Hawkes’ research has led us to the grandmother hypothesis, a possible explanation for why we evolved to live beyond our reproductive abilities.

Dr. Kristen Hawkes:
We were studying people, modern people just like us, but special because these people are living on wild food in a part of the world where our radiation evolved in, in, uh, Savannah. Africa. And, and so they were so wonderful and let us, you know, hang out and count and measure and do all these things and to see how you do it. How do you do that? And, um, what we learned from that was initially so surprising first that these old ladies. Who are well past, their childbearing years were so economically productive

Dr. Jen Gunter:
For a long time we thought we understood the societal structure of early humans-- men hunted, women gathered food and had children... And old people were useless.

Enter the Grandmother Hypothesis.

Human babies take a long time to become self sufficient and therefore require quite a bit of work on their mother’s part.

Nursing a baby means that it’s more difficult to forage for food. And as we know, even once a child is weaned, it takes a long time before they can feed themselves.

That’s where grandmothers save the day, taking on the needs of their grandchildren.

And these old ladies were spending, they were getting the same return rates as, as women in the childbearing ages but they were spending more time at this, especially energetically expensive, uh, foraging that the little kids are just not efficient at.

So according to Dr. Hawkes grandmothers were pretty crafty at acquiring food and that could help the family unit flourish because when mothers have a little help and the right nutrition they may be more likely to have healthy children--and more children.

Dr. Jen Gunter [to Dr. Hawkes]
So grandmothers were providing the nutrition and providing the support, uh, for, you know, they were, they obviously were invested in their grand offspring, right? Like that. So it's basically genetics, the long game or survival of the fittest, the long game,

Dr. Kristen Hawkes
Absolutely, the long game.

The presence of a grandmother can have a, uh, a notable effect in a lot of contexts on the welfare of, of little kids...And that continues lifelong and those same appetites for connection and concern and interaction and being on the same page, continue to be characteristics in grandmothers and in everybody else.

Grandmother's aren't weak or as frail as you’ve been led to believe. In hunter-gatherer societies, grandmothers not only contributed calories, but also contributed to the ongoing survival of their family unit and the community in general.

Dr. Jen Gunter
Turns out it does take a village.

And there’s more data showing this--research using historical birth data from the Canada and Finland found similar patterns--when a grandmother lived close to her daughter or son, that child was more likely to have more children. If her daughter moved away, the effect was lost.

And for every decade a grandmother lived past the age of 50 and close to her children, her daughter or son had two more kids.

And the amazing thing? Killer whales--who also go through menopause-- show a supporting pattern

The Grandmother Hypothesis is just that-- a hypothesis. There’s lots of evidence for it, but not everyone is convinced. Critics argue that there are other factors that could explain how longevity extended past the menopause transition.

Some researchers point to the calories provided by men’s hunting as being as important or more important than what grandmother’s collected. But Dr. Hawkes isn’t so sure."

Dr. Kristen Hawkes:
When you're successful, Whoa, there's an enormous bonanza, which you can't hide. And your reputation as a hunter has a huge influence on how much others defer to you.

Dr. Jen Gunter:
This is important! A man’s status is a big part of how community life is structured. But for all the time the Hadza men spent hunting, Dr. Hawkes and her archeologist colleagues found that they had only about a 3% success rate.

Dr. Kristen Hawkes:
Hunting these big animals is no way to feed the kids.

The grandmother hypothesis is a very unusual feature. Of our life history that women's fertility ends at about the same age at ends and other apes. And yet we have this post-menopausal life stage that is given all of these associated things that look like they go with that is the heart says the hypothesis of what has made us human.

Dr. Jen Gunter [to Dr. Hawkes]:
So grandmothers are the heart of humanity.

Dr. Kristen Hawkes:
[laughs] There you go.

Dr. Jen Gunter [to Dr. Hawkes]:
And you know, I'm menopausal as well. I've been post-menopausal for several years and I'm, I'm in the group of people who are super flushers. So I get a lot of hot flashes. Still, even though I'm I'm on hormones. And, uh, there's actually some interesting work that says that cognitive behavioral therapy can be very helpful for hot flashes and you sort of have like a mantra to sort of deal with it. And so now whenever I get a hot flash, I think I have this because of women evolved to drive humanity. This is a sign of strength, not a sign of weakness. And then the hot flash goes away.

Dr. Kristen Hawkes:
Excellent. Excellent.

Dr. Jen Gunter:
Menopause is a marvel--not something to be ashamed of.

But let’s be honest-- the evolutionary genius of menopause can be overshadowed by some nasty symptoms: lost sleep, vaginal dryness and hot flushes. More about those, after the break.

To be honest, I think a lot of the fear and silence around menopause is just misogyny combined with the fear of aging...

Menopause isn’t a disease. That doesn’t mean it’s a party either. There can be troublesome symptoms for many people.

One thing that people have often heard about… the most infamous symptom of the menopause transition is…
[sound: match strike, fire lights] the hot flush.

No not like that.
[Sound of a warm cozy cracking fire]
No, no… hotter.
[Sound: Louder sound of heat]
Yes, hot and fast and really inconvenient!!
[Sound: Whoshing heat, electric guitar, intensity]
That sounds more like it.

I studied menopause for years before I actually experienced it. And when I got my first hot flush I thought “holy shit.”

It’s hard to understand how bothersome they are until you’ve had them.

What is going on inside our bodies when we get a hot flush?

You may not know this-- but your body has an internal thermostat, a set of nerves that lets you know when to sweat or shiver to maintain body temperature.

Hot flushes are a complex process, and we don’t yet understand all of the biology. But we do know control of body temperature or thermoregulation and reproductive hormones are connected. New research suggests that one mechanism behind hot flushes involves estrogen suppressing the nerves that tell us we are hot. So when, as part of menopause, estrogen levels decrease, those nerves get super jumpy.

Imagine if the thermostat for your house is telling you it's 80 degrees when it's really 54. Your AC is going to turn on, right?

The way your body cools off is it sends blood to your upper torso, arms and head. And that wave of heat you feel is part of the hot flush.

And you also sweat to release that heat.

But you never needed to release any of that heat in the first place. Because remember-- it’s really 54 degrees in the house.

So now you’ve dumped all that heat, AND that cold sweat produced may make you start to shiver. So now you may actually feel cold. Imagine that happening 20 times a day. It’s kind of miserable.

Dr. Lubna Pal:
If we can have these conversations, so non-medical people also have the awareness to know, okay, you know what? This is normal. And when this is too much, it's affecting me, I need to seek help.

Dr. Jen Gunter:
That’s my friend Dr. Lubna Pal. Like me, she’s an OBGYN. She teaches at Yale Medical School.

She’s an expert in the symptoms of menopause.

Because we don’t talk about menopause much, patients often don’t know what’s going on and so they suffer from symptoms like hot flushes for longer than they need to.

There are many different types of treatments for hot flushes, here are the ones with the most evidence behind them:

Cognitive behavioral therapy, or CBT. It’s a type of talk therapy that harnesses the mind-body connection.

Medications can also help, like menopausal hormone therapy, and certain antidepressants. There’s other medications too-- if you’re interested your doctor will be able to talk you through the options.

And in addition to troublesome symptoms like hot flushes, there are also medical conditions linked to menopause. Such as osteoporosis, the loss of bone mass and weakening of the structural integrity of the bone.

We’re building new bone mass until our mid-twenties. And then it starts to decline. Estrogen is an important contributor in the process of building bone.

Dr. Lubna Pal:
So our reproductive years, our ovarian function is adding to this retirement account, which is bone mass. So menopause, if we construe that from the bone perspective as retirement, right. I, I can not put any more cash in my account now that my income has gone.

Dr. Jen Gunter [to Dr. Lubna Pal]:
At what phase, when is that happening?

Dr. Lubna Pal:
So that absolute end happens when menopause, so our periods have stopped. So our skeleton starts becoming a little bit more stressed at that stage of life.

Dr. Jen Gunter:
And just to be clear-- anyone can develop osteoporosis! It’s unfortunately an all gender issue.

Here’s what you can do to prevent it: It’s beneficial for your bones to have a healthy diet with enough calcium and regular weight bearing exercise and adequate vitamin D. You can learn more about bone health in our next episode.

But some people do turn to hormone therapy to help them prevent loss of bone density

Menopausal hormone therapy can be a thorny topic--

Before we get into the controversy, let’s explain what it is!

When we say menopausal hormone therapy we mean estrogen, and sometimes the hormone progesterone or a closely related hormone.

Menopausal hormone therapy can help with troublesome symptoms like vaginal dryness, hot flushes and night sweats and even mild depression … things that can really mess with your quality of life.

Dr. Pal hears from patients who are tired of “toughing it out.”

Dr. Lubna Pal:
And the bottom line is. I cannot sleep. I cannot function. I am distracted. I can’t focus. And this has been happening for, you know, women describe when they were fine and over a course of how long their life has changed. And by the time they come to me, they've gone through a couple of physicians and they are. They just want their life back

Dr. Jen Gunter:
Menopausal hormone therapy can help with some of those symptoms.

Dr. Lubna Pal:
So hormone therapy really is to crystallize it down to it's a little bit of estrogen enough to control your symptoms, not to give you zero symptom, but to improve your quality of life to a point that it doesn't matter if I get one flush every now and then I feel so much better.

Dr. Jen Gunter:
For a long time the male dominated medical field framed it as being all about maintaining femininity.

They said that menopausal hormone therapy would keep you looking younger and hotter. It would keep your husband interested and make you look cute in your tennis skirt.

It’s the “feminine forever concept.” Brought to you by big pharma and the patriarchy!

Dr. Lubna Pal:
The feminine forever concept that your feminine identity is tied to your ovaries, which is tied to your hormones. And therefore, let's go give you back what you have lost for whose benefit? For men's benefit?

Dr. Jen Gunter:
To say the absolute least, I’m suspicious of this feminine forever framing. Our goal is not trying to fit into one demographic’s definition of sexy. It’s to make people’s lives better.

And like with any treatment, there are risks to menopausal hormone therapy. If you’re over 60 when you start, the risks typically outweigh the benefits.

Dr. Lubna Pal:
Now we are in a place where gosh, less is more. So we want to reduce the risk and enhance the benefits.

Dr. Jen Gunter:
It’s different for everyone. Some people have bothersome symptoms for example, some of us, like me, are “super flushers.” Others might not have hot flushes at all.

It’s about weighing your personal risk v. benefit.

Dr. Lubna Pal:
But we have got to choose the right tool for the right patient. So if a woman who is not a diabetic, who's not hypertensive who does not have cardiovascular disease, and who is suffering from common symptoms of. Uh, quality of life is being affected. I think hormone therapy has a great role to improve her quality of life.

Dr. Jen Gunter:
I've seen patients who've tried unproven and dangerous therapies. All because they've been recommended by predatory doctors or talked up on Instagram by celebrities.

I’m thinking about things like compounded bioidentical hormones.

They’re often marketed as being “all natural” or “bespoke.” But it’s just that: marketing.

When you mess with treatments that haven’t been FDA approved, there’s a really good chance that you’re getting imprecise dosages via untested delivery systems.

As a doctor, I want all of my patients to get safe, verified treatments. Which is why I only recommend or prescribe FDA approved treatments.

Dr. Lubna Pal:
Potential for harm comes from complete lack of regulation in batch to batch variability. How much are you getting exposed to? If you're getting exposed to too much estrogen.

You can develop clots. You can develop endometrial cancer, you can have stroke, right? So you are just a setup for harm. There's no benefit from a bio-identical.

Dr. Jen Gunter [to Dr. Lubna Pal]:
Yeah. the explanation that I often give you, so for example, I'm on, I'm on MHT menopausal hormone therapy. Um, I have very, my mother died from osteoporosis in fact.

Dr. Lubna Pal:
Oh I’m so sorry.

Dr. Jen Gunter [to Dr. Lubna Pal]:
I tell people what I, I, I use pharmaceutical estrogen because I want to know exactly how much my body is getting every single day.
I want to make sure the hormone therapy I’m on is giving me enough estrogen to really help my bone density and prevent osteoporosis.

It all comes down to talking with your doctor and making some lifestyle changes.

Dr. Lubna Pal:
So to me, lifestyle is really about so much other than eat and exercise. It's about social engagement. And weight bearing exercise: good for the skeleton. aerobic exercise: good for your cardiovascular system. Mental exercise: good for your cognition. Social interactions. Good for the whole of you.

Dr. Jen Gunter:
I asked Dr. Pal what she wishes more people understood about menopause:

Dr. Lubna Pal:
There's so much positivity at that stage of life, you know, I think. You, the person are so complete at that phase of life. You lose some, you gain more, but don't focus on the loss focus on it's another phase my one message is it is normal.

Dr. Jen Gunter:
I like to think of menopause as a victory lap rather than the end of a race. We evolved to survive the rigors of childbirth but we also evolved to keep thriving after our childbearing years were over.

Vera Wang started her career as a wedding dress designer at 40.

Civil rights icon Fannie Lou Hamer began her activism at age 44.

And Kamala Harris just reached new heights at age 56.

These women are exceptional, but not because of their age. All over the world we are accomplishing feats big and small regardless of the status of our ovaries.

Hey--I started this podcast at 54 and met the love of my life at 53.

Instead of being surprised at seeing an older woman doing pretty much anything we should say, well, of course she can!

Older women have been productive, creative and intelligent since humanities earliest days.

Instead of telling them how to look and act, instead of diminishing them, we should just sit back and let them show us how amazing they really are.

Next week on Body Stuff:

[EPISODE CLIP]
My dad's mother had just the largest hunch in her back and that was used as a fear tactic...sit up straight, drink your milk.

We had people from farms that would visit our elementary school and just basically tell us about the positives of milk.

I remember advertisements when I was a kid that milk is critical for healthy mind and body strong bones, calcium, things like that. And I think there was a series of TV ads later, with celebrities showing their milk mustache.

Dr. Jen Gunter:
Do you really need to drink milk to have strong bones?

Body Stuff is a member of the TED Audio Collective. It’s hosted by me, Dr. Jen Gunter, and brought to you by TED and Transmitter Media. This episode was produced by Alice Wilder and edited by Sara Nics and Lacy Roberts. The rest of the team includes Camille Petersen, Gretta Cohn, Michelle Quint, Banban Cheng, and Roxanne Hai Lash. Alex Overington is our sound designer and mix engineer. Krystian Aparta and Neeraja Aravindan are our fact checkers.

Special thanks to Aubrey Kobayashi.

We’re back next week with more Body Stuff. Make sure you’re following Body Stuff in your favorite podcast app so you get every episode delivered straight to your device. And leave us a review! We love hearing from our listeners.

See you next week!