Speaker 1: Hi, my name's Marika. Well, this is one of the
Speaker 1: strangest times in my life. In my late twenties to
Speaker 1: early forties, I was hyper productive, high achieving, goal oriented,
Speaker 1: and I was just able to get a lot done.
Speaker 1: I was able to be highly productive with little sleep. However, now,
Speaker 1: with brain fog and high levels of fatigue, some days
Speaker 1: it's difficult to complete a simple list of tasks. It's
Speaker 1: like living with my head in a cloud. Some days
Speaker 1: I'm so tired. The fatigue is really challenging and limits
Speaker 1: my ability to want to do things outside of my
Speaker 1: work and home responsibilities. I have also experienced a substantial
Speaker 1: weight gain of about fifty pounds, which no amount of
Speaker 1: physical activity or calorie restriction seems to address. And oh,
Speaker 1: my gosh, the heat. I used to get cold easily
Speaker 1: Now I long for those days. My first hot flow
Speaker 1: or flesh felt like a wave that started at my
Speaker 1: feet and slowly moved up my body and unfurled and
Speaker 1: unleashed its heat on me. It was wild and almost
Speaker 1: anxiety producing because it felt unlike anything I had experienced previously.
Speaker 1: Since then, I have had many more, but something I've
Speaker 1: really noticed is how hot I am most of the time. Interestingly,
Speaker 1: now I experience fewer hot flashes and instead just feel
Speaker 1: hot most of the time. I've also had really itchy
Speaker 1: in our ears, which I thought was just a strange
Speaker 1: issue I was having, but as I've read more, I
Speaker 1: found that it's a common symptom for women at my
Speaker 1: stage in life. And the darnedest thing is no matter
Speaker 1: the amount of scratching I do, which looks really pretty,
Speaker 1: but it persists what's going on. So men of PAD
Speaker 1: is defined as one year following one's last period. However,
Speaker 1: I had an dmitrial ablation in two thousand and seven
Speaker 1: and haven't had a period since then, so the monitoring
Speaker 1: aspect of where I am in the timeframe of menopause
Speaker 1: or perimenopause is based solely on my symptoms. I found
Speaker 1: it hard to find a practitioner who's truly knowledgeable about
Speaker 1: menopause and perimenopause. My OBGYN is not. My former general
Speaker 1: practitioner and integrative health professional was not, although she claimed
Speaker 1: to be. It took me years to find a North
Speaker 1: American Menopause Society or NAMS certified provider in my rural area,
Speaker 1: and in fact, it took me a long time to
Speaker 1: even find out about NAMS meeting my certified NAMS provider
Speaker 1: was a relief because all the scientific information I had
Speaker 1: read about prior to our meeting was reinforced during the meeting.
Speaker 1: This led to complicated discussions and a lot of reading
Speaker 1: about hormone replacement therapy or HRT for short. There are
Speaker 1: so much conflicting information out there. I'm an alternative medicine
Speaker 1: type of girl, and although I'm very pro vaccine, I've
Speaker 1: always prided myself on not taking a lot of meds
Speaker 1: or finding herbal remedies for many ailments. When I was
Speaker 1: in grad school in two thousand and one, the large
Speaker 1: research study called the Women's Health Initiative was grounded and
Speaker 1: halted all recommendations for HRT meds due to the cost
Speaker 1: of treatment outweighing the benefits. One of my statistic professors
Speaker 1: was in the research group for this trial and talk
Speaker 1: to us then about the problems with stopping the trials prematurely,
Speaker 1: including how the data were being misinterpreted, and little did
Speaker 1: I know how this would affect me later. It turns
Speaker 1: out the misinterpretations of the data led to misinformation and
Speaker 1: led me to being really scared to try HRT. As
Speaker 1: a result, I first chose bioidentical hormones, those that mimic
Speaker 1: the ones created by our bodies but derived from plants
Speaker 1: or in this case, sweet potatoes. When I was having
Speaker 1: little or inconsistent results, my provider gently shared the data
Speaker 1: and ideas about taking more traditional HRT. She mentioned that
Speaker 1: the traditional HRT, which has bought at a standard pharmacy,
Speaker 1: meets the standards for consistent dosing, is recommended by NAMS,
Speaker 1: and is effective when started prior to the cessation of symptoms.
Speaker 1: So now I'm six years in and while my symptoms
Speaker 1: are better across the board, they're still present. I look
Speaker 1: forward to the day when they are behind me totally.
Speaker 1: It's been so interesting to find how different people's experiences are.
Speaker 1: Some people have zero symptoms and don't know where they
Speaker 1: are if they've completed menopause or not, and others have
Speaker 1: more extreme symptoms than I do. I'm happy to have
Speaker 1: great physicians to follow, such as doctor Jen Gunter. She's
Speaker 1: an O B G y N who wrote the Menopause
Speaker 1: Manifesto and actively works to debunk myths about menopause as
Speaker 1: well as educate us about what's going on with our bodies.
Speaker 2: Thank you so much, Marika for sharing your story with us.
Speaker 2: We really appreciate it.
Speaker 3: Yeah, thank you. Hi. I'm Aaron Welsh and I'm Aaron
Speaker 3: Oman Updike.
Speaker 2: And this is this podcast will kill you.
Speaker 4: Welcome to the last episode of this season.
Speaker 2: Yeah, I hope that we've been I can't remember have
Speaker 2: we been saying that? Like we're wrapping up this episode.
Speaker 3: Of this season.
Speaker 2: Whoops, not even a little bit, so surprise, but we're
Speaker 2: making it an extra long, extra fun, extra fascinating one.
Speaker 4: Yeah, talking today about menopause.
Speaker 3: We say this a lot.
Speaker 2: This could have been a two parter, a three parter, yeah,
Speaker 2: a four part or a season.
Speaker 3: Maybe it should be maybe you do it.
Speaker 2: Yeah, but I had such a great time researching for
Speaker 2: this episode.
Speaker 3: I am super excited.
Speaker 2: I honestly, I think that I've probably annoyed so many
Speaker 2: people because I cannot stop talking about it. I've lost
Speaker 2: friendships because I will not shut up about menopause.
Speaker 4: You're probably not the first one. Arin, Oh, that's exciting.
Speaker 4: I'm really excited to hear your entire section. Like I
Speaker 4: feel like you have given me just enough of a
Speaker 4: glimpse of like the general topics that I'm like, oh.
Speaker 3: I can't wait. I hope I do it justice.
Speaker 2: But before we get to all of that, should.
Speaker 3: We is it? It's quarantine dime?
Speaker 2: Oh yeah, what are we drinking this week?
Speaker 3: We could be drinking nothing other than blood, sweat and beers.
Speaker 2: I love it, and I also I also love the
Speaker 2: recipe because it's more or less Mitchellata. It's something that
Speaker 2: we've done before, but we're spicing it up this time
Speaker 2: by adding cucumber and jalapano and limejuice.
Speaker 3: I don't know how like we know what it's going
Speaker 3: to be delicious.
Speaker 2: It is, it is, and we will post the full
Speaker 2: recipe for the quarantini and the non alcoholic placyburrita on
Speaker 2: our website This Podcast will Kill You dot Com, as.
Speaker 3: Well as on all of our social media channels.
Speaker 4: On our website This Podcast will Kill You dot Com,
Speaker 4: you can find so many things, like our bookshop dot
Speaker 4: org affiliate account. You can find our Goodreads list, you
Speaker 4: can find Bloodmobile, our music and our merch and our
Speaker 4: Patreon and transcripts from all of our episodes and our.
Speaker 3: Sources from every episode. All the list is long, so
Speaker 3: so many things. Check it out.
Speaker 2: I don't think there's any other business besides, you know,
Speaker 2: this is the last episode of the season. Either, we
Speaker 2: will not make you wait very long for the next season.
Speaker 2: Don't worry, and the next season will be jam packed
Speaker 2: full of very many fun, cool things.
Speaker 4: We have so much entirely unplanned, but so many ideas.
Speaker 4: It's gonna be a really great season.
Speaker 2: I you know what I'm I can't wait me neither.
Speaker 2: But first, maybe we should do this episode.
Speaker 3: So we should. Should we take our quick break and
Speaker 3: then get started. Yeah, we should. So.
Speaker 4: The definition of menopause, according to textbooks and doctors and
Speaker 4: all the papers, the definition of menopause is twelve months
Speaker 4: of a menorrhea or twelve months of no period, specifically
Speaker 4: as a result of the cessation of ovarian function. That
Speaker 4: is like the clinical definition, and menopause is like clinically defined.
Speaker 4: There's not like a single test that you can do
Speaker 4: to say menopause or not menopause. So, in a person
Speaker 4: who menstruates after menarc which is like the start of
Speaker 4: getting your periods some number of years later, once you
Speaker 4: then go twelve months without a period, without anything like
Speaker 4: contraceptives or IUD or pregnancy or breastfeeding or even cancer,
Speaker 4: or chemotherapy or something that's altering your hormones temporarily. Once
Speaker 4: you have twelve months with no period, because your ovaries
Speaker 4: are no longer having follicular function, we call that menopause.
Speaker 3: If you think.
Speaker 4: Of it as a reproductive life span. People with ovaries
Speaker 4: and uteruses have the beginning of their reproductive life span
Speaker 4: with menarc that's like your first period anywhere from like
Speaker 4: ten to sixteen years old. And someday we'll do an
Speaker 4: episode about menstruation, we really really need to. Feels like
Speaker 4: a missed opportunity. Could have done that one first, But
Speaker 4: we start where we start, yep. So menarch is the
Speaker 4: beginning of this reproductive life span, as it were, and
Speaker 4: then menopause is like the end of it. And so
Speaker 4: after menopause you are postmenopausal but still alive for a
Speaker 4: really long time hopefully.
Speaker 3: Okay.
Speaker 5: Question I love it already, Okay, already, okay, Like.
Speaker 2: How long do the ovaries take to stop functioning? Is
Speaker 2: menopause a before and after snapshot in time or is
Speaker 2: it a progression? Is something that happens over time?
Speaker 4: Okay, this is such a good question. So it is
Speaker 4: both a process and a single event, and it depends
Speaker 4: on what you're truly talking about, because a lot of
Speaker 4: people call menopause a whole period in which they are
Speaker 4: experiencing symptoms that they're relating to menopause, right, So we're
Speaker 4: going to talk a lot about like what is happening
Speaker 4: in your ovaries, in your brain, in your body during
Speaker 4: this whole transition.
Speaker 3: But because the clinical.
Speaker 4: Definition of menopause is this time point at which you've
Speaker 4: had twelve months with no periods, that's like the clinical
Speaker 4: in the doctor's office definition. Leading up to that period,
Speaker 4: there is a lot of hormonal changes that are happening
Speaker 4: that may or may not result in symptoms. This time
Speaker 4: period is called perimenopause or the menopausal transition, and a
Speaker 4: lot of people just call that period menopause.
Speaker 2: Yeah, I certainly, I think use the two kind of interchangeably,
Speaker 2: like menopause to mean cessation of ovarian function, but also
Speaker 2: going through menopause right as like a term yeah, yeah, yeah.
Speaker 4: And it's kind of like, you know, it's all the
Speaker 4: menopausal transition. I think that's my favorite of the terms
Speaker 4: for it. And so this in theory can happen anytime
Speaker 4: in a person who menstrates, but to be called menopause.
Speaker 4: It generally has to happen towards the end of the
Speaker 4: fortieth or beginning of the fiftieth decade of life. And
Speaker 4: the average age globally is about forty eight to fifty two,
Speaker 4: And there's some variation geographically, but not a ton of
Speaker 4: variation in this. If menopause happens between age forty and
Speaker 4: forty five, we call it early menopause, and if it
Speaker 4: happens before age forty, so if you have cessation of
Speaker 4: periods for twelve months before age forty, we don't call
Speaker 4: it menopause at all. We call it premature ovarian insufficiency, Okay,
Speaker 4: And I'm not going to get into that because it
Speaker 4: is something different. But part of the reason for that
Speaker 4: is that there's a lot of things that can cause
Speaker 4: premature ovarian insufficiency, and they're not all permanent. So sometimes
Speaker 4: ovarian function can return in the case of premature ovarian insufficiency,
Speaker 4: and sometimes it can't. Whereas with menopause, it's happening because
Speaker 4: the ovaries are done ovulating.
Speaker 2: What if you're taking some form of birth control that
Speaker 2: results in like either really light or non existing periods.
Speaker 4: Aarin, There's so much more to it than just if
Speaker 4: you're taking birth control. I'm so glad you asked though,
Speaker 4: because this criteria that we use to define menopause is
Speaker 4: entirely dependent on bleeding, right, It's dependent on menstrual bleeding.
Speaker 4: By that definition, we can define menopause in a lot
Speaker 4: of people who men straight, but a.
Speaker 3: Lot of people get left out.
Speaker 4: So that includes, yes, people who are taking oral contraceptives,
Speaker 4: or people who have something like a progestin IUD who
Speaker 4: might not have any periods because they have an IUD
Speaker 4: in place. Also people who've had a hysterectomy or an
Speaker 4: endometrial ablation. They're not going to be bleeding at all.
Speaker 4: It also means it's difficult to diagnose in people with
Speaker 4: pcos who might have really variable cycles to begin with, right,
Speaker 4: or for example, trans men who might still have ovaries
Speaker 4: and even a uterus but beyond various hormones so that
Speaker 4: they're not menstruating. There are so many people that are
Speaker 4: left out by this specific definition of menopause. And yet
Speaker 4: if they have ovaries, they're still going to eventually stop
Speaker 4: functioning and therefore have gone quote unquote through menopause or
Speaker 4: through this menopausal transition, whether they realized it or not.
Speaker 4: This is also quote unquote natural menopause, which is different
Speaker 4: than surgical menopause, which is when the ovaries are removed
Speaker 4: surgically for any number of reasons. And as we'll talk about,
Speaker 4: this causes a really rapid decrease in hormones and results
Speaker 4: in menopause. But it's different than quote natural menopause. Okay,
Speaker 4: there's so much here eron, there is so much here.
Speaker 4: So because of that, there are other diagnostic criteria that
Speaker 4: we can use to help diagnose menopause.
Speaker 3: It is if someone.
Speaker 4: Is of the right age, if they are having symptoms
Speaker 4: that we correlate to menopause, then we can also check
Speaker 4: certain hormone levels and we'll get into that, and if
Speaker 4: these hormone levels have risen the way that we expect
Speaker 4: with menopause, then you can use.
Speaker 3: All of this together to say, yes, you.
Speaker 4: Have gone through menopause or maybe are in the midst
Speaker 4: of the menopausal transition.
Speaker 2: I have another question, but I'm worried that, like I'm
Speaker 2: just I've stalled us out at the very beginning of
Speaker 2: the biology. There's so much though, areas so so much
Speaker 2: so if it's like getting ahead of things, we can
Speaker 2: just wait and answer it later. Okay, why is it
Speaker 2: important to know whether someone has or has not yet
Speaker 2: gone through menopause besides something like you know, fertility.
Speaker 4: So fertility is a big one if people want to
Speaker 4: know either whether they could still have children or make
Speaker 4: sure that they can no longer have children, if they're,
Speaker 4: for example, wanting to come off of birth control or
Speaker 4: something like that. It also, as we'll talk about, risks
Speaker 4: of certain diseases do change after menopause because of these
Speaker 4: changes in hormone balance, so perhaps it would be worth
Speaker 4: knowing for that reason. But really, if someone is not
Speaker 4: experiencing symptoms related to this menopausal transition, there is not
Speaker 4: a need to do any testing necessarily to say you
Speaker 4: are or you are not menopausal or postmenopausal. It really
Speaker 4: comes down to what somebody is experiencing and what their
Speaker 4: desires are in terms of knowing what's going on or
Speaker 4: what has or hasn't happened kind of a thing. So
Speaker 4: let's talk about that, shall we Let's talk about like
Speaker 4: what is we defined menopause And now we're like, well,
Speaker 4: what the heck is that?
Speaker 3: Forty questions?
Speaker 4: Right, So let's talk about what is happening physiologically during
Speaker 4: this time, and then I will talk about the quote
Speaker 4: symptoms that can occur during this menopausal transition. But first,
Speaker 4: let's just talk about what the hormones are happening doing.
Speaker 6: Okay, yeah, to do that, let's remind ourselves briefly of
Speaker 6: what is going on hormonally in people who menstruate prior
Speaker 6: to menopause, Like, what is menstruation exactly?
Speaker 3: Okay, just the basin, just the basic.
Speaker 4: So the menstrual cycle itself, which again starts with menarch
Speaker 4: like in the teenage years, the menstrual cycle has two
Speaker 4: main phases, the follicular phase at the beginning, and the
Speaker 4: luteal phase. The follicular phase starts when you start your
Speaker 4: first day of bleeding. That's how we like define the
Speaker 4: start of a menstrual cycle. And every month ish during
Speaker 4: this follicular phase, follicles in the ovary are recruited and.
Speaker 3: Start to mature. These are basically baby eggs. Okay yeah.
Speaker 4: After a period of maturation and in response to hormone
Speaker 4: surges specifically estrogen and lutinizing hormone, one mature follicle aka
Speaker 4: one egg is released, and that is ovulation. Following ovulation,
Speaker 4: we then enter the luteal phase, which lasts about fourteen days,
Speaker 4: and at the end of that phase, if there's no
Speaker 4: embryo that gets implanted, then menstruation occurs. That is the
Speaker 4: shedding of uterine lining and vaginal bleeding cool and you've
Speaker 4: started your next cycle. During this menstrual cycle, there are
Speaker 4: a lot of hormonal fluctuations that are happening, and these
Speaker 4: hormonal fluctuations are a very complex interplay of positive and
Speaker 4: negative feedback cycles that are happening between our ovaries, which
Speaker 4: are making hormones like that you've heard of, like estrogen, progesterone, testosterone,
Speaker 4: but also a lot of lesser known but not less
Speaker 4: important hormones like anti mularian hormone and in hibben b.
Speaker 4: And these hormones travel through our bloodstream and interact with
Speaker 4: and are then affected by hormones released in our brain,
Speaker 4: specifically by this axis in our brain called the hypothalamic
Speaker 4: pituitary axis, so like two different areas in our brain,
Speaker 4: and these are hormones like gnatotropin releasing hormone, follicle stimulating
Speaker 4: hormone FSH, and lutinizing hormone or LH. We don't have
Speaker 4: to understand all of the nitty gritty of this cycle,
Speaker 4: in part because that's another episode, but also because what
Speaker 4: we just need to understand to understand menopause is.
Speaker 3: That there are are these cyclic ups.
Speaker 4: And downs of all of these hormones that are happening
Speaker 4: in communication between our ovaries and our brain, and as
Speaker 4: our ovaries start to deplete these follicles, big shifts start
Speaker 4: to happen. So, because we are born, if you're born
Speaker 4: with ovaries, you have a set number of ovarian follicles
Speaker 4: that you're born with. We don't make any more. Unlike
Speaker 4: people born with testes who are constantly just making more
Speaker 4: sperms like all the time, the ovary has a certain
Speaker 4: number of follicles and they don't make any more.
Speaker 3: So as these.
Speaker 4: Follicles are literally depleted because they are used up and
Speaker 4: either ovulated out or just half matured but then never
Speaker 4: quite ovulated, this ovary loses a number of follicles. And
Speaker 4: as this happens, hormone levels start to shift, specifically anti
Speaker 4: Mularian hormone or AMH and in hibben B, which are
Speaker 4: two hormones the ovary produces slowly starts to fall As
Speaker 4: we age, they peak at like around age twenty five,
Speaker 4: and then.
Speaker 3: Slowly, slowly, slowly start to go down over time.
Speaker 4: This has an effect on our brain of slowly increasing
Speaker 4: hormones like FSH, which is what stimulates our follicles to
Speaker 4: make an egg for ovulation, to make like a ripe
Speaker 4: egg for ovulation. And as we see these declines in
Speaker 4: the number of follicles and these hormones like AMH and
Speaker 4: in hibbin, what we see is an ovary and follicles
Speaker 4: that are less responsive, so they need higher and higher
Speaker 4: amounts of FSH to be able to respond appropriately.
Speaker 3: If that makes sense.
Speaker 4: Yeah, kind of like in our diabetes episode when we
Speaker 4: talked about like your pancreas needs, like your pancreas is
Speaker 4: making more and more insulin because your tissues just aren't responding.
Speaker 4: It's kind of like that, h But eventually you get
Speaker 4: to a point where there are so few follicles that
Speaker 4: ovulation just isn't going to happen, but you're still going
Speaker 4: to get this increase in FSH because of all these
Speaker 4: complex feedback loops. And at the same time that all
Speaker 4: of this is happening, estrogen declines pretty drastically, so by
Speaker 4: the end of menopause. What has happened is that we
Speaker 4: have depleted all of those follicles. There's no more eggs
Speaker 4: left in your ovaries to ovulate, and our hormone levels
Speaker 4: have shifted from estrogen being high, which is what it
Speaker 4: looks like during the reproductive years, and FSH being low
Speaker 4: on average, to a reverse where FSH is high and
Speaker 4: estrogen is now low. And that is the big change
Speaker 4: that occurs. By the point that you've gotten to menopause,
Speaker 4: that is twelve months without a period.
Speaker 2: If there are no more f's for FSH to act
Speaker 2: on or stimulate, then what is FSH doing?
Speaker 3: Oh great question?
Speaker 4: Not much, but it's still going to be there, right
Speaker 4: because our brain doesn't necessarily know like, hey, FSH, like
Speaker 4: you're not doing much, Like we can just.
Speaker 3: Chill out with you.
Speaker 4: It's more like we have lost the negative feedback and
Speaker 4: hibben has decreased, and so now there's no negative feedback
Speaker 4: to say, hey, we don't need this anymore.
Speaker 2: And so that's how it remains for like after menopause.
Speaker 7: Uh huh.
Speaker 2: The whole time, we're just still making yep FSH.
Speaker 3: Yeah.
Speaker 4: And it's possible that there's a point at which it
Speaker 4: like slowly starts to kind of go down from like
Speaker 4: a peak or something like that. But realistically, for the
Speaker 4: rest of your postmenopausal life, estrogen is low and FSH
Speaker 4: is high.
Speaker 2: I am okay, I don't know why that, like, I'm
Speaker 2: so hung up on Yeah, well, it's interesting, right because
Speaker 2: it's basically you've lost this what used to be cycles.
Speaker 3: You've lost it.
Speaker 4: Yeah, you've lost that cycling now during the menopausal transition.
Speaker 4: Right during this timeframe when your ovaries are still making eggs,
Speaker 4: they're still ovulating, but the number of follicles has started
Speaker 4: to decline. What we see is a lot more erratic
Speaker 4: hormone changes because your ovaries still have enough to sometimes
Speaker 4: ovulate and they're still making enough estrogen that they might
Speaker 4: sometimes cause a cycle to happen, even if it's not
Speaker 4: an ovulatory cycle.
Speaker 3: So it gets really.
Speaker 4: Complicated in that timeframe that we call perimenopause, or the
Speaker 4: time leading up to menopause, and that is a timeframe
Speaker 4: in which sometimes people might have symptoms, But it's also
Speaker 4: after that menopause transition and the years they're after, where
Speaker 4: your body is getting used to this new normal of
Speaker 4: low estrogen and high FSH and it's not just FSH
Speaker 4: and estrogen, because this alteration in hormone production, remember, is
Speaker 4: affecting our brains, our hypothalamic pituitary axis, and the hormone
Speaker 4: production alterations that happen in our hypothalamus also have direct
Speaker 4: effects on other pathways like our neurogenergic pathway, our serotonergic pathway.
Speaker 4: We can see decreases in growth factors and growth hormones
Speaker 4: and insulin. This can alter the lipid profile. There's a
Speaker 4: change in the activity of GABBA, Like this is affecting
Speaker 4: the hormonal milieu of our brain entirely, in addition to
Speaker 4: our body experiencing a very significant decline in estrogen specifically.
Speaker 4: Does that kind of make sense?
Speaker 2: Yes, there's a whole lot of stuff going on. Yeah,
Speaker 2: and it's not just estrogen. It's not just estrogen, Okay, Yeah.
Speaker 3: Aaron, I have so many questions me too.
Speaker 2: Have we been able to quantify these effects and how
Speaker 2: much variation is there, you know, from individual to individual.
Speaker 4: Oh, I don't have an answer for that except that like, yes, lots, ye.
Speaker 3: Yeah.
Speaker 4: So I think what we could start to talk about
Speaker 4: is like, what does this end up looking like? Like,
Speaker 4: what are the quote unquote symptoms of menopause or of
Speaker 4: this transition, right, And I want to take a moment
Speaker 4: here to say that we're going to spend time on
Speaker 4: what these symptoms are because they're really important. Because what
Speaker 4: I think is tricky about menopause is that these are
Speaker 4: changes that are happening hormonally in people's bodies that have
Speaker 4: ovaries always like it will always. It is an inevitability, right,
Speaker 4: and it is a natural phenomenon. Is it really is
Speaker 4: like an inevitability if you've got ovaries still.
Speaker 3: In life, it's life.
Speaker 4: Yeah, yeah, So I think what's difficult about menopause is
Speaker 4: balancing the very real experience that people have and their symptoms,
Speaker 4: some of which, as we'll talk about, might be very
Speaker 4: unpleasant or distressing or significantly impacting their life, while at
Speaker 4: the same time not over pathologizing something that is a
Speaker 4: normal physiologic process, and understanding that while everyone with a
Speaker 4: uterus and ovaries will experience menopause because their ovaries will
Speaker 4: eventually stop ovulating, not everyone with the uterus and ovaries
Speaker 4: will experience it in the same way at all, and
Speaker 4: some many might never experience any quote unquote symptoms related
Speaker 4: to it, while others might have very significant symptoms during
Speaker 4: this time. So it's a very interesting phenomenon I think,
Speaker 4: and I know Erin you're going to talk more about
Speaker 4: the like cultural history of it all, but it's even
Speaker 4: biologically really interesting that the experience can be so different.
Speaker 2: Yeah, everything, Like, there are so many different components that
Speaker 2: go into this, and I feel like menopause has, at
Speaker 2: the same time been its importance has been overstated and understated.
Speaker 3: Yes, I agree, I feel like it still is. Yeah, totally.
Speaker 3: So that's why we're doing this episode.
Speaker 4: Yeah, okay, so anyways, let's talk about it. Yeah, so
Speaker 4: let's talk about these symptoms. I will say there's a
Speaker 4: lot of big like buckets of symptoms that people associate
Speaker 4: with menopause.
Speaker 3: Not all of them are.
Speaker 4: Actually clearly attributable to menopause itself. And when I'm saying menopause,
Speaker 4: I mean this hormonal transition itself, and some of them
Speaker 4: definitely are, like we know the kind of mechanics of
Speaker 4: estrogen withdrawal causing X, Y and Z. Right, So what
Speaker 4: I will try and do is at least mention all
Speaker 4: of these symptoms that are often associated and then talk
Speaker 4: about which ones have more support for truly being menopause
Speaker 4: driven versus perhaps a result of aging and happen in
Speaker 4: like a even wider population, or it might be just
Speaker 4: happening in all populations, but we're only studying it in
Speaker 4: certain populations, if that makes sense.
Speaker 3: Yeah, yeah, yeah, okay.
Speaker 4: So the most classic, the most strongly associated, and the
Speaker 4: most really is just the most classic are vasomotor symptoms.
Speaker 3: That is the hot yep I also hot flush, I've.
Speaker 4: Seen flash, hot flash, night sweats, night sweats, like it's
Speaker 4: all They're all vasomotor symptoms, is what these are all called.
Speaker 3: And these are exactly what they sound like.
Speaker 4: They're often sudden feelings of maybe like a head rush, sweating,
Speaker 4: feeling hot, and then sometimes they're after feeling cold and chills.
Speaker 4: These type of vasomotor symptoms can start as early as
Speaker 4: a couple of years before the actual final menstrual period,
Speaker 4: but they often tend to peak a year or so
Speaker 4: after that, so kind of after the true quote unquote menopause.
Speaker 3: Point, and then they can continue and in some.
Speaker 4: People for years thereafter. So in a lot of the literature,
Speaker 4: it's reported that the median time of experiencing vasomotor symptoms
Speaker 4: for people who experience these is about seven years, which
Speaker 4: is a pretty long time.
Speaker 3: That is a long time.
Speaker 4: Typically vasomotor symptoms have been attributed directly to estrogen withdrawal,
Speaker 4: but it's thought that it's actually more a manifestation of
Speaker 4: the declining sensitivity of that hypothalamic pituitary axis to estrogen,
Speaker 4: because a lot of times they start happening before that
Speaker 4: estrogen has truly declined, right during that time when menstrual
Speaker 4: cycles are maybe more erratic and estrogen is still cycling
Speaker 4: but in a perhaps different way than it used to
Speaker 4: during the.
Speaker 3: Peak reproductive years. Yeah, we still.
Speaker 4: Don't have a perfect explanation for like X, Y and
Speaker 4: Z is what causes vasomotor symptoms, but we do think
Speaker 4: that it's directly related to changes in temperature regulation.
Speaker 3: And I'll get.
Speaker 4: Into a little bit more of that in the current
Speaker 4: event section, because there's some new medicines that are not
Speaker 4: estrogen hormonal related that affect vasomotor symptoms, which are really interesting, huh.
Speaker 2: And so you get into like the like the mechanistic
Speaker 2: a little bit.
Speaker 4: It's basically like, because estrogen is affecting your brain hormones,
Speaker 4: there are other brain hormones that are related to your
Speaker 4: temperature regulation. Set points that we can also target to
Speaker 4: treat vasomotor symptoms.
Speaker 2: Okay, yeah, but also hot flashes or hot flushes are
Speaker 2: not unique to perimenopausal or postmenopausal people.
Speaker 4: Absolutely not, and they're not universal in postmenopausal or perimenopausal people.
Speaker 2: Right, So, like, have you come across studies that looked
Speaker 2: at the breakdown of like, let's say, people who are
Speaker 2: nowhere near the age of menopause or people without ovaries, Like,
Speaker 2: how who experiences Is it significantly higher in people who
Speaker 2: are going through menopause?
Speaker 3: It's a good question. I don't. I don't.
Speaker 4: I didn't look at papers that specifically look at those comparisons,
Speaker 4: and even looking like geographically, there's pretty huge variation in
Speaker 4: people reporting vasomotor symptoms across the globe, although vasomotor symptoms
Speaker 4: do tend to be one of the most commonly reported.
Speaker 4: If there are going to be symptoms associated with menopause,
Speaker 4: but I think if we think about this as menopause
Speaker 4: is a time when hormones are affecting our brain and
Speaker 4: causing changes in those hormones that could affect temperature regulation,
Speaker 4: there are lots of other states in our lives. Whether
Speaker 4: you have ovaries or you don't have ovaries that can
Speaker 4: also affect your temperature regulation because it's affecting hormones in
Speaker 4: your brain, right, So it's not that surprising that other
Speaker 4: people can also have hot flashes even if they're not menopausal,
Speaker 4: and that menopause can directly cause these vasomotor symptoms. Does
Speaker 4: that make sense?
Speaker 3: Yes?
Speaker 2: What about the geographic variation.
Speaker 4: I don't have a great explanation for that, because some
Speaker 4: thought is like, oh, is it also related to ambient temperature?
Speaker 4: But not necessarily because there's not seasonal effects. I don't know, Aaron,
Speaker 4: there's too much, too much, And I've only said one
Speaker 4: symptom so far.
Speaker 3: I know a lot more. It's gonna be a long episode.
Speaker 4: Another one that's commonly associated with menopause is sleep disturbance,
Speaker 4: and sometimes this tends to be conflated with the vasomotor symptoms.
Speaker 3: Because these hot flashes.
Speaker 4: Do often occur at night and can lead to a
Speaker 4: lot of nighttime awakenings. But other than that, this idea
Speaker 4: of menopause directly causing sleep disturbance, we don't have a
Speaker 4: lot of great data on like A what the mechanisms
Speaker 4: are or B is it truly menopause? Or is it
Speaker 4: other things that are happening that a is not directly
Speaker 4: attributable to menopause, and that is true for a lot
Speaker 4: of the symptoms like the laundry list that are often
Speaker 4: associated with menopause, Depression and anxiety in some cases are
Speaker 4: reported as higher during the menopausal transition compared to premenopause.
Speaker 4: Cognitive changes, including declines in memory and concentration, are sometimes
Speaker 4: associated with this perimenopausal time period and sometimes reported as
Speaker 4: transient during this time period. Weight changes are sometimes reported
Speaker 4: as related to menopause. That one especially, there's really not
Speaker 4: good data that menopause itself has any influence over weight gain.
Speaker 4: But all of these are things that people might experience
Speaker 4: at any point in their lives, and for some people
Speaker 4: they might experience it in association with this hormone fluctuation,
Speaker 4: and in some people they might not. But we don't
Speaker 4: have like hard data to say that menopause is causing
Speaker 4: any of those type of symptoms, especially not universally. In
Speaker 4: our migraine episode, we talked about how sometimes migraine headache
Speaker 4: can increase in frequency during perimenopause and often decrease post menopause,
Speaker 4: but again this is not universal.
Speaker 3: Yeap but there's so many.
Speaker 4: Caveats on everything I'm saying, but it is something that
Speaker 4: sometimes people might experience because we know that migraines are
Speaker 4: sometimes strongly associated with things like estrogen. So if you're
Speaker 4: having these sometimes extra fluctuations in estrogen in that menopausal
Speaker 4: transition period and then a decline and estrogen thereafter, you
Speaker 4: might see a similar effect on your migraines, with an
Speaker 4: increase in frequency and then a decline thereafter.
Speaker 3: Maybe a couple of things.
Speaker 4: That we do know are associated with the estrogen withdrawal
Speaker 4: that happens post menopause. So now I'm not talking about
Speaker 4: menopausal transition symptoms, but really post menopause, where we have
Speaker 4: this shift from high estrogen to low estrogen. Right, there
Speaker 4: are a few things that we see are strongly associated
Speaker 4: with this time period. One is an increase in risk
Speaker 4: of cardiovascular disease. This is something that we see especially
Speaker 4: in the cases of like surgical menopause, when the ovaries
Speaker 4: are removed at a potentially young age, but they're also
Speaker 4: removed entirely, where you have a very drastic decline now
Speaker 4: in estrogen, cardiovascular disease risk increases significantly, and postmenopause we
Speaker 4: see an increase in cardiovascular disease risk compared to age
Speaker 4: matched mail so people with testes controls of the same age.
Speaker 4: Does that make sense?
Speaker 3: Yeah? Why?
Speaker 2: How does what is estrogen doing or like what is
Speaker 2: its withdrawal doing.
Speaker 4: We don't fully know classic, but estrogen is kind of
Speaker 4: protective in a way where it reduces the low density
Speaker 4: lipoprotein levels. That's our LDL cholesterol, which is the most
Speaker 4: strongly associated type of cholesterol with cardiovascular risk, and estrogen
Speaker 4: helps to increase our high density lipoprotein or our good
Speaker 4: cholesterol levels, and it has benefits to our endothelial function
Speaker 4: in our vasculature, especially in our coronary arteries. So estrogen
Speaker 4: itself is protective, and we have higher levels of it
Speaker 4: during the reproductive years and then low levels of it postmenopausal.
Speaker 4: So we see an increase in risk independent of age
Speaker 4: after someone has gone through menopause, to where your risk
Speaker 4: looks more like someone with testicles than someone with ovaries
Speaker 4: that are still functioning exactly right, It's pretty similar. So
Speaker 4: that is like a known risk associated with lower estrogen levels.
Speaker 4: Another thing is eurogenital symptoms, and this can really run
Speaker 4: the gamut and is definitely not universal, but the tissues
Speaker 4: of the vagina, the bladder, and like the whole vulva
Speaker 4: are very estrogen receptor heavy, so they are very dependent
Speaker 4: on estrogen. As estrogen declines, and over time I'm talking
Speaker 4: many years postmenopause, not immediately postmenopause.
Speaker 3: Usually this lower level.
Speaker 4: Of estrogen causes changes to the tissues of the vagina
Speaker 4: and the volva and like the urethral opening. So for
Speaker 4: some people this can result in a wide variety of symptoms.
Speaker 4: It could be things like recurrent UTIs or vaginal dryness
Speaker 4: or pain with vaginal intercourse, and this could then result
Speaker 4: in sexual dysfunction for people, especially if they're having a
Speaker 4: lot of pain with intercourse. So this is more directly
Speaker 4: related to that low levels of estrogen. But again this
Speaker 4: is something that's happening usually a pretty long time postmenopause,
Speaker 4: once these tissues have significantly changed because of that low
Speaker 4: level of estrogen. And finally, though not the final symptom
Speaker 4: that people have associated with nope with menopause, but the
Speaker 4: other one that we see a really strong association with
Speaker 4: this decrease in estrogen is a decrease in bone density,
Speaker 4: so a significantly increased risk of osteopenia and osteoporosis and
Speaker 4: therefore fractures associated with that. Because estrogen has direct effects
Speaker 4: on our bone formation and remodeling, so the decline in
Speaker 4: estrogen causes a shift so that bone resorption is exceeding
Speaker 4: formation and so overall you're losing bone mass as a
Speaker 4: result of this loss of estrogen.
Speaker 3: That's not fair.
Speaker 4: I know, it really isn't, right, Like why, yeah, yeah.
Speaker 2: It's very interesting, it is, I know, And there's like
Speaker 2: so much moving parts to this, which I think is
Speaker 2: the thing that I struggle with, like how does it
Speaker 2: affect hearts and bonds?
Speaker 4: And I don't know, I know, I know, it's really
Speaker 4: it's a lot.
Speaker 3: And so I think again it comes.
Speaker 4: Back to this idea that like, these are changes that
Speaker 4: are happening as a result of the natural aging process
Speaker 4: of the ovaries and at the same time can potentially
Speaker 4: cause quite a lot of symptoms and result in morbidity,
Speaker 4: like from that, right.
Speaker 2: Right, Okay, So I know we talked a little bit
Speaker 2: about hot flashes and how they are certainly not universally experienced.
Speaker 2: Is something like the cardiovascular disease risk is that more
Speaker 2: or less universal, like everyone experiences an increase in risk,
Speaker 2: and then the eurogenital symptoms, Like what what is the
Speaker 2: breakdown of the symptoms that we talked about after hot flashes?
Speaker 4: Yeah, the breakdown is I don't have numbers for you
Speaker 4: on the breakdown the increase in risk, Like, yes, everyone's
Speaker 4: cardiovascular disease risk is going to increase, but everyone's cardiovascular
Speaker 4: disease risk increases as we age period, and everyone's baseline
Speaker 4: cardiovascular disease risk is different period because of genetics, because
Speaker 4: of environment, because of so many other factors. So I
Speaker 4: can't say that like everyone's risk postmenopause increases by blank percent.
Speaker 4: It's very individual, okay. And similarly with the eurogenital changes,
Speaker 4: those tissues are likely to undergo some degree of change
Speaker 4: in most everyone, though I don't know that we have
Speaker 4: data to say like, yes, everyone experiences changes to the
Speaker 4: vaginal mucose, but because those are hormone sensitive tissues, it
Speaker 4: is likely that all of those tissues are going to
Speaker 4: undergo some version of change. That doesn't mean everyone's going
Speaker 4: to notice there's any changes, right, And that is definitely
Speaker 4: something that the data on people's reporting and experiences is
Speaker 4: all over the map. As you can imagine, especially because
Speaker 4: some of those symptoms that get associated with menopausal changes
Speaker 4: aren't actually menopausal related. Like there can be increases in
Speaker 4: urinary incontinence that happens postmenopause, but some of that is
Speaker 4: not due to the estrogen changes, but is due to
Speaker 4: a whole bunch of other things that also change as
Speaker 4: we age, or is associated with how many children someone
Speaker 4: has had, or whether they've had a hysterectomy, or like
Speaker 4: so many other things that also coincide with menopause. Like,
Speaker 4: it's just so complicated. And then when you get into
Speaker 4: like sexual function, depending on who you're talking to, people
Speaker 4: might have very different experiencess willingness to talk to researchers
Speaker 4: about their sexual function.
Speaker 3: So it's really all over the map.
Speaker 2: What are some of the factors or do we know
Speaker 2: what factors contribute to or are associated with age a
Speaker 2: menopause and likelyhood of getting experiencing these symptoms during menopause.
Speaker 3: Yeah, it's a really good question.
Speaker 4: There's a lot of things that can influence the age
Speaker 4: at menopause, and there's not at this point anything that
Speaker 4: we can do to predict at what age someone is
Speaker 4: going to go through menopause, but there are a lot
Speaker 4: of things that potentially influence it, some of which we
Speaker 4: don't understand like why or how, But things like smoking
Speaker 4: status can influence the agent menopause parody, So how many
Speaker 4: children someone has had, at what age they've had them,
Speaker 4: and how long they breastfed for There's some relation maybe
Speaker 4: between environmental factors, like how much things like soy and
Speaker 4: other things that have isoflavones in them that kind of
Speaker 4: act like estrogen in our bodies. Genetics plays a huge role,
Speaker 4: so like at what age your mom went through menopause
Speaker 4: can maybe help you predict at what age you might
Speaker 4: go through menopause. But it's not like a one to
Speaker 4: one at all. So there's a huge range of things
Speaker 4: that can affect and we don't again fully understand what
Speaker 4: is it. Is it also like the number of follicles
Speaker 4: that you happen to be born with, or is it
Speaker 4: things that are altering how quickly your follicles are being
Speaker 4: depleted and why that is. So there's a whole range.
Speaker 4: I remember going down a rabbit hole trying to figure
Speaker 4: out Okay, well, if you're on combination contraceptives, right, like
Speaker 4: an estrogen progesterone contraceptive, then you are not ovulating, so
Speaker 4: then shouldn't you have a greater reserve of ovarian follicles,
Speaker 4: So then would you have a later age of menopause.
Speaker 4: And there's people who thought maybe that that's the case,
Speaker 4: but there's not really actually data to support that when
Speaker 4: we've looked at the literature, which is so interesting. So
Speaker 4: it's very complicated, but there are definitely a lot of
Speaker 4: factors that can influence especially whether you are at higher
Speaker 4: risk of having an early menopause. And then you also ask,
Speaker 4: like what influences the risk of whether or not you
Speaker 4: have symptoms, And that is a can of worms that
Speaker 4: I don't feel qualified enough to dive into because there's
Speaker 4: a lot.
Speaker 2: Because it's also like we think this is associated with
Speaker 2: some of the symptoms that have previously been associated.
Speaker 4: But yeah, and one thing that I think is important
Speaker 4: is so we can also talk about, like how do
Speaker 4: you treat these symptoms? Like what do you do if
Speaker 4: someone is having potentially really bad symptoms that might be
Speaker 4: associated with menopause? And very often the answer is hormone
Speaker 4: replacement therapy or HRT. And there's a lot of controversy
Speaker 4: regarding like a lot of controversy regarding hormone replacement therapy,
Speaker 4: and for some people, hormone replacement therapy completely resolves their symptoms,
Speaker 4: whether or not we have data to say that this
Speaker 4: symptom is definitely associated with menopause, does it matter that much?
Speaker 4: If hormone replacement therapy resolves the symptoms, right, Right, If
Speaker 4: any of the other therapies that we use to treat
Speaker 4: menopause specifically is helping with those symptoms, then it's associated
Speaker 4: with menopause, even if it's not on a like a
Speaker 4: scientific level that we can have enough data to support it.
Speaker 2: Right, it's right, like if it's if it's menopause or
Speaker 2: if it's aging period, like, right, does it matter the
Speaker 2: I mean, I think it does matter to distinguish between
Speaker 2: the two, just because it often seems like if you're
Speaker 2: a woman and you are aging and you experience something,
Speaker 2: there's a tendency to be like, oh, it's menopause.
Speaker 4: Oh it's where a tribut eating everything to menopause, right, always, always,
Speaker 4: and then we're not treating it because it's just menopause.
Speaker 3: Uh huh.
Speaker 4: So that's an interesting that's what. Yeah, Yeah, that's all
Speaker 4: I got, Aaron. I mean, I don't know if that
Speaker 4: was enough or too much?
Speaker 2: No, totally. And are you going to talk about HRT
Speaker 2: later on? Because I am very curious.
Speaker 3: Yeah, I.
Speaker 4: Can talk about it later, I can talk about it
Speaker 4: now if you want.
Speaker 3: I mean, totally up to you. What do you want
Speaker 3: to know about HRT?
Speaker 2: Erin, I guess I want to know, okay, because when
Speaker 2: I did a little bit, and I'll talk more about
Speaker 2: this in the history section, But like coming across the
Speaker 2: HRT as the solution and then people finding out that,
Speaker 2: like we actually don't know with some of the earlier HRTs,
Speaker 2: is this working in the way that we expect? Is
Speaker 2: it working at all? And is it actually associated with
Speaker 2: an increase in risk of things like cancer?
Speaker 3: Yeah? And so when are.
Speaker 2: People advised to try HRT and when are they not?
Speaker 4: Yeah, it's a great question. So there was a time
Speaker 4: period in which hormone replacement therapy was the holy Grail
Speaker 4: and the answer for any anyone with ovaries going through
Speaker 4: menopause or the menopausal transition or anything when they were
Speaker 4: in their forties, fifties, sixties, seventies and beyond. And there
Speaker 4: was a lot of thought for a time period that
Speaker 4: part of the reason to treat with hormone replacement therapy,
Speaker 4: even if someone had no symptoms whatsoever, was to reduce
Speaker 4: the risk of osteoporosis and fractures and reduce the risk
Speaker 4: of cardiovascular disease because remember we know that those are
Speaker 4: associated with declines and estrogen. So there was this huge
Speaker 4: study in the late nineties when it was all the
Speaker 4: rage where everyone was getting hormone replacement therapy if you
Speaker 4: were above a certain age and had ovaries, and this
Speaker 4: study was trying to look at the risks and benefits
Speaker 4: and like the protective benefit if there was one of
Speaker 4: hormone replacement therapy in postmenopausal women, and they found something
Speaker 4: unexpected and that was an increase in breast cancer risk
Speaker 4: and either no change or in some cases an increase
Speaker 4: in cardiovascular risk in their study of hormone replacement therapy
Speaker 4: versus place ebo. So after that study came out in
Speaker 4: like the early two thousands, it was like, no one
Speaker 4: can have hormones, take them all away, absolutely not. Hormone
Speaker 4: replacement therapy is the worst thing ever. And as pendulums
Speaker 4: often do in medicine, it swung from one extreme to another,
Speaker 4: and I think that we have landed in a place
Speaker 4: that's much more in the middle, because as this same
Speaker 4: cohort of women that were in this study has been
Speaker 4: subsequently followed through the last paper I read was through
Speaker 4: like twenty sixteen, the data that they collected has now
Speaker 4: been stratified and reanalyzed, and with this longer term follow up,
Speaker 4: it turns out that.
Speaker 3: The results of the study.
Speaker 4: Are actually a lot more nuanced than that and not
Speaker 4: nearly as scary as they seemed in two thousand and two.
Speaker 4: So what it comes down to really is the timing
Speaker 4: of the initiation of hormone replacement therapy, and the data
Speaker 4: suggests that when people are prescribed hormone replacement therapy within
Speaker 4: that first ten years postmenopause, which means the first ten
Speaker 4: years after that final menstrual period, then it is actually
Speaker 4: protective against cardiovascular disease. We see small but significant decreases
Speaker 4: in the risk of coronary artery disease. We see decreases
Speaker 4: in the risk of hip fracture, we see decreases in
Speaker 4: all cause mortality, and when it comes to breast cancer,
Speaker 4: there are some studies that actually suggest a protective effect
Speaker 4: of hormone replacement therapy and some that suggest perhaps a
Speaker 4: slight increase in risk, and so it's thought that it's
Speaker 4: more of like a net neutral overall. Okay, but this
Speaker 4: is in people who start hormone replacement therapy early on.
Speaker 3: Gotcha.
Speaker 4: There's also nuance if you have a uterus or don't
Speaker 4: have a uterus, whether you need progesterone or not, and
Speaker 4: what type of progesterone. So there's like definitely an a
Speaker 4: lot of nuance there, but it's it is not the
Speaker 4: horrible thing that it was thought to be in the
Speaker 4: early two thousands. At the same time, there are some
Speaker 4: risks associated with it, especially if we're starting it after
Speaker 4: that ten year timeframe, and for some people they might
Speaker 4: not be candidates for estrogen, especially oral estrogen at all,
Speaker 4: because there are reasons premenopause that we don't recommend estrogen
Speaker 4: for people if they have a history of migraines with
Speaker 4: aura or a history of blood clotting disorders because estrogen,
Speaker 4: so it decreases your cardiovascular disease risk, can't increase your
Speaker 4: risk for clotting and for strokes in certain people. So
Speaker 4: again there's a lot of nuance, but it's often very
Speaker 4: effective for treating some of the vasomotor symptoms and it
Speaker 4: can be protective in these cases. So where the medical
Speaker 4: literature has landed as of now twenty twenty three is like,
Speaker 4: we don't use hormone replacement therapy as a preventative, but
Speaker 4: it's perfectly reasonable to use it if you're experiencing symptoms.
Speaker 3: Okay, does that kind of make sense? Yes? Another question?
Speaker 3: Uh huh?
Speaker 2: What about menopause or are there substantial hormone changes in
Speaker 2: people with testes?
Speaker 4: Oh, it's such a good question. I didn't do any digging.
Speaker 4: I didn't do any research on this, Erin, so I
Speaker 4: don't know, but I know it's a thing that people
Speaker 4: look at. The testes are a whole different organ then
Speaker 4: are ovaries. So we should just do an episode about
Speaker 4: aging testicles. Just old balls, old balls, because I don't
Speaker 4: want to say things that I don't know.
Speaker 3: Okay, fair enough, So Erin with.
Speaker 4: Dads, can you please tell me? I don't know what
Speaker 4: to ask Aaron. I have so many questions.
Speaker 2: Well, you know what, I'll just try to preempt them
Speaker 2: by getting started on my very long history section right
Speaker 2: after this break.
Speaker 7: Okay.
Speaker 2: After spending the past few weeks reading books and articles
Speaker 2: about menopause, watching videos about menopause, thinking about menopause, talking
Speaker 2: so much about menopause, and writing about menopause, I feel
Speaker 2: at the same time like much more informed about menopause
Speaker 2: and also completely totally lost, you know the saying that's like.
Speaker 3: The more you know, the more you.
Speaker 2: Know what you don't know, something like that. That's exactly
Speaker 2: how I feel. The more that I learned about the
Speaker 2: possible adaptive reasons for menopause, the more I learned about
Speaker 2: the cultural history of menopause and the variation and its
Speaker 2: perception across cultures, about the huge diversity of symptoms and
Speaker 2: the gap in clear mechanistic research on menopause, the more
Speaker 2: I came to see menopause as not one thing, but
Speaker 2: so very many things. For some people, it's a relief.
Speaker 2: It's freedom from not having to worry about pregnancy or
Speaker 2: your menstrual blood ruining your clothes. For others, it's a
Speaker 2: nightmare with distressing symptoms and a loss of feeling socially significant. Maybe,
Speaker 2: or maybe for someone else, it's the reason why humans
Speaker 2: have evolved big brains and live cooperatively, the key to
Speaker 2: what makes us human, Or perhaps it perfectly encapsulates the
Speaker 2: pathologizing of women's bodies by Western medicine over the centuries.
Speaker 2: I love it, and some people.
Speaker 3: Might find it to be a combination of all of
Speaker 3: those things, while others may not even think about menopause
Speaker 3: or have a word for it. WHOA.
Speaker 2: If I wanted to keep this history section short, I'd
Speaker 2: be tempted to leave you with just one sentence. Menopause
Speaker 2: is whatever you want it to be. For me, someone
Speaker 2: who has not yet gone through menopause, I've been thinking
Speaker 2: so much about this over the past few weeks, Like
Speaker 2: how do I feel about it? And you know, hopefully
Speaker 2: someday I will go through menopause, Like I'll be lucky
Speaker 2: enough to reach that age. Menopause is right now, a
Speaker 2: thing on the horizon, Like I feel curious about it,
Speaker 2: not really apprehensive, but like what will it be? Like
Speaker 2: will I notice it at all? So I'm one of
Speaker 2: those ones that takes birth control pills continuously, so I
Speaker 2: don't get periods, But how will I know, like when
Speaker 2: it's done? When is my last? Like did I already
Speaker 2: have my last period? Technically I'd be lying if I
Speaker 2: said I didn't struggle with getting older. You know, I
Speaker 2: blame our culture's obsession with youth for that one and
Speaker 2: my own vanity come on.
Speaker 3: But I also think I'll feel a sense of relief.
Speaker 2: I've never wanted to have kids, and so hopefully with
Speaker 2: menopause comes.
Speaker 3: An end to the what are you going to have kids?
Speaker 3: Why don't you have kids?
Speaker 2: Oh, you'll change your mind and want them someday that
Speaker 2: I do get from time to time, though not for
Speaker 2: my family thankfully. Then again, while I know I'm not
Speaker 2: going to change my mind about having kids, maybe I
Speaker 2: will feel differently about menopause when I'm in it. But
Speaker 2: one thing is for certain, I know I'll feel grateful
Speaker 2: to be going through menopause in a time when there
Speaker 2: are so many amazing resources, books, articles, documentaries, podcasts about menopause.
Speaker 2: Should I feel like I need them? When menopause has
Speaker 2: started to appear on TV as more than just like
Speaker 2: a punchline on a sitcom, and when the silence surrounding
Speaker 2: menopause has slowly started to lift, are things perfect? Of
Speaker 2: course not, but they're a heck of a lot better
Speaker 2: than they used to be. And so, speaking of which,
Speaker 2: maybe it's about time it actually got started with the
Speaker 2: history of menopause. The word menopause was coined in eighteen
Speaker 2: twenty one, but that was far from when menopause was
Speaker 2: first recognized. Ancient Greek and Chinese medical texts both describe
Speaker 2: menstruation and fertility ending around the fortieth year, but it
Speaker 2: was mostly in the context of just this is what
Speaker 2: happens in aging, rather than and here's a list of
Speaker 2: miserable symptoms you're going to experience. There were lots of
Speaker 2: ancient remedies for menstruation, but not really for the cessation
Speaker 2: of menstruation.
Speaker 3: Interesting.
Speaker 2: Yeah. In ancient Greece, life was thought to take place
Speaker 2: in seven year stages, with considerable change happening across each stage.
Speaker 2: The seventh stage of life, life happening in the forty
Speaker 2: ninth year, was called the climacteric, which eventually became synonymous
Speaker 2: with menopause.
Speaker 4: Oh my god, I saw that word written and I
Speaker 4: was like, I don't understand what this word? Why are
Speaker 4: they calling it this? That is so interesting?
Speaker 7: Yeah.
Speaker 2: I think they used it occasionally to mark like very
Speaker 2: like periods of very substantial change or meaningful change.
Speaker 3: Yeah.
Speaker 2: Yeah. And this isn't to say that menopause was just
Speaker 2: casually described as a totally normal part of life and
Speaker 2: nothing to be feared. Women's bodies in general were pathologized
Speaker 2: in ancient Greece and Rome, with women generally being seen
Speaker 2: as inferior to men and defined by their differences to men.
Speaker 2: For example, under the humoral theory of disease, the balance
Speaker 2: of the humors in men's bodies made them warm and dry,
Speaker 2: while women's bodies were considered cold and wet. To maintain
Speaker 2: that balance, men and sweated and women bled, which was
Speaker 2: used by ancient Greek physicians as a justification for menstruation
Speaker 2: as like a normal and necessary process, so it purged
Speaker 2: women's bodies of what they viewed as toxic and poisonous
Speaker 2: aka menstrual blood.
Speaker 3: Oh my god, I can't oh buckle up hun.
Speaker 2: Ok yeah. But in this way, blood letting, which was
Speaker 2: like such a popular thing to do, didn't need to
Speaker 2: be done as often for menstruating women. But as soon
Speaker 2: as menstruation ended, boom, you were told that you had
Speaker 2: lost that superpower.
Speaker 3: Okay. And so some ancient Greek physicians believed that as
Speaker 3: you got older, you got drier overall, and so women
Speaker 3: in menopause didn't need to bleed to balance their humors. Okay, yep.
Speaker 2: But others thought that bleeding continued for all of your life,
Speaker 2: and that in menopause it just stay in your body,
Speaker 2: and that it would accumulate and accumulate, and eventually that
Speaker 2: toxic build up would cause breast cancer, uterine cancer, epilepsy, consumption, dropsy.
Speaker 3: Et cetera.
Speaker 2: Okay, some physicians went even so far as to suggest
Speaker 2: that this fictional menstrual blood build up made the woman
Speaker 2: herself toxic, with one book claiming that if a woman
Speaker 2: who stopped menstruating looked at a baby in a cradle,
Speaker 2: that baby's eyes would be damaged.
Speaker 3: Like you can't even Oh, my goodness, and.
Speaker 2: It's like bending over backwards to just make make cruel
Speaker 2: things up.
Speaker 3: Yeah for like what for?
Speaker 2: What, dude's like medieval clout I have no idea. And
Speaker 2: this taboo surrounding menstrual blood, it being deemed as unclean.
Speaker 2: It's found in many cultures around the world, both historical
Speaker 2: and contemporary, and it's a theme that we've touched on before,
Speaker 2: at least in our endometriosis episode. But it's also very
Speaker 2: relevant to the history and meaning of menopause. So where
Speaker 2: this taboo is very strong, like in cultures where menstruating
Speaker 2: women are supposed to be kept separate, or forbidden to
Speaker 2: prepare food, or who must undergo ritual cleansing after menstruating.
Speaker 2: Menopause is sometimes seen as like a positive thing, as
Speaker 2: freedom from these taboos. We don't know, of course, how
Speaker 2: women in the ancient world felt about menopause, since the
Speaker 2: texts that we do have are written almost entirely by men.
Speaker 2: But I don't think it's a stretch to imagine that
Speaker 2: there was relief from this taboo in places where it existed.
Speaker 2: But from these male perspectives. In ancient Greece, menopause was
Speaker 2: not just an internal build up or a rying out
Speaker 2: of menstrual blood. To some, it signified a return to
Speaker 2: the baseline ideal state. In other words, once a woman
Speaker 2: stopped bleeding, she became more like a man quote unquote,
Speaker 2: manly hearted and less feminine in the words of Galen okay.
Speaker 2: And sometimes this was taken to mean that a woman
Speaker 2: who couldn't produce children any longer was not worthy of
Speaker 2: keeping around. She held no more relevance. But on the
Speaker 2: other hand, some priestesshoods in ancient Greece were reserved for
Speaker 2: postmenopausal women, which I think is interesting.
Speaker 3: It's all so interesting arin.
Speaker 2: But overwhelmingly menopause was described simply as a stage of life,
Speaker 2: and that continued to be the case really until the
Speaker 2: eighteenth century, which isn't to say that postmenopausal life wasn't
Speaker 2: written about as though it was like this most horrid condition.
Speaker 2: In many physicians, almost entirely men, advised that once you're
Speaker 2: past menopause, it's a quick march to decrepitude and death.
Speaker 2: And of the few voices of women from this time,
Speaker 2: there isn't really much said about menopause, but I'm sure
Speaker 2: that there was knowledge shared, probably by midwives, but also
Speaker 2: by women of any occupation or status. A quote from
Speaker 2: an early gynecological handbook from the Middle Ages in England,
Speaker 2: written by a woman says, quote, and so to assist women,
Speaker 2: I intend to write of how to help their secret maladies,
Speaker 2: so that one woman may aid another in her illness
Speaker 2: and not divulge her secrets to such discourteous men.
Speaker 3: Quote love it. I love that. Yeah.
Speaker 2: This element of fear and shame is completely understandable when
Speaker 2: you have male physicians comparing postmenopausal women to trees that
Speaker 2: no longer bore fruit and should be cut down and burned.
Speaker 2: Oh I saw somewhere. Yeah, yeah, these attitudes about menopause
Speaker 2: that were perpetuated by the predominantly male medical writers. They
Speaker 2: persisted for like really hundreds of years, and they're still
Speaker 2: around today to one degree or another, like a lingering
Speaker 2: fart and in the eighteenth century.
Speaker 3: Like a lingering fart errand I know, it's really the
Speaker 3: first thing that came to mind. I mean, it paints
Speaker 3: a picture, thank you.
Speaker 2: And in the eighteenth century they served as the backdrop
Speaker 2: to the reframing of menopause as a disease as a
Speaker 2: diseased condition. A quote from a physician in seventeen thirty
Speaker 2: nine quote, it will not be amiss to touch upon
Speaker 2: the disorders that most women labor under when being between
Speaker 2: forty and fifty years of age. Their courses begin first
Speaker 2: to dodge and at last to leave them. For then
Speaker 2: they are frequently troubled with a severe pain in the
Speaker 2: head and back and about the loins oft times, also
Speaker 2: with colic pains, gripes and looseness, at other times with
Speaker 2: vapors to a violent degree. Likewise, feverish heats, wandering, rheumatic pains,
Speaker 2: and general uneasiness.
Speaker 3: End quote.
Speaker 4: Wow, so yeah, general uneasiness. I'm feeling that right now.
Speaker 3: I mean, I feel that often.
Speaker 2: He then, of course went on to prescribe blood letting
Speaker 2: and if that didn't work, his purging pills or his
Speaker 2: uterine drops, which of course he charged, you know, a
Speaker 2: pretty penny for.
Speaker 3: I don't want to know what's any uterine drop. Let
Speaker 3: me just say that I do, I absolutely do.
Speaker 2: The reasons why menopause began to be labeled as a
Speaker 2: disease during this time are too many to count, but
Speaker 2: one of them is certainly because it made physicians indispensable
Speaker 2: to those going through menopause. It was an opportunity to
Speaker 2: expand into a new market, if you will, and something
Speaker 2: that is still happening today. I came across a New
Speaker 2: York Times article from December twenty twenty two titled Welcome
Speaker 2: to the menopause gold Rush in Yeah, and in the
Speaker 2: article it mentioned how a lot of well known quote
Speaker 2: unquote wellness companies and other startups are beginning to get
Speaker 2: into the menopause biz like selling products. I don't know,
Speaker 2: I feel anyway, I'll just keep going because I mean,
Speaker 2: it's really just reiterating what you already said, which is
Speaker 2: that some people do experience things these symptoms that can
Speaker 2: absolutely use management.
Speaker 3: And those are completely valid.
Speaker 2: But at the same time, I really don't like the
Speaker 2: predatory nature of some of these things that can reinforce
Speaker 2: or act as like self fulfilling prophecy through corporation and marketing.
Speaker 2: I guess, I don't know.
Speaker 4: It is a really really interesting interplay and balance, I
Speaker 4: think when it comes to menopause specifically.
Speaker 3: Yeah.
Speaker 2: Also, I don't know if I've said this yet, but
Speaker 2: if I have, it bears repeating anyway, that the vast
Speaker 2: majority of the cultural and social history of menopause that
Speaker 2: I'm covering is from the quote unquote Western World, aka
Speaker 2: mostly like Europe and North America. And part of that
Speaker 2: is because the focus of most sources is the history
Speaker 2: of menopause in the Western world. But part of it
Speaker 2: is also that menopause in many other places wasn't really
Speaker 2: considered a major change warranting medical attention. And there's at
Speaker 2: least one culture I read about that didn't have a
Speaker 2: word for it, or it was like not really recognized
Speaker 2: as a constellation of symptoms. And but what's really interesting too,
Speaker 2: and I I don't really talk about this, but in
Speaker 2: the mid twentieth century, with sort of the spread of
Speaker 2: Western medicine, places that previously had never treated for menopause
Speaker 2: symptoms associated with menopause began to do that or began
Speaker 2: to include it in textbooks anyway.
Speaker 3: Interesting, Oh, it's so interesting here, because then it is it.
Speaker 4: Like that people were actually suffering with symptoms but just
Speaker 4: didn't have.
Speaker 3: Words for it or like right, because that's.
Speaker 4: The thing too of just like not you know, ignoring
Speaker 4: things and then just not having any kind of access
Speaker 4: to treatment for it because it's just like, oh, well,
Speaker 4: this is just life, but I am actually miserable, but
Speaker 4: I just.
Speaker 3: Didn't like it is just life. So ah, it's so much,
Speaker 3: it's so much.
Speaker 2: And so I know that there has been some work
Speaker 2: done on that about people who have done work on
Speaker 2: like contemporary foraging societies or contemporary societies who don't have
Speaker 2: a lot of exposure to like Western medicine, and it
Speaker 2: does seem to be kind of a mixed bag where
Speaker 2: some of those people do experience symptoms of menopause that
Speaker 2: are symptoms that we traditionally associate with menopause, and others
Speaker 2: don't seem to. And so how much of it too
Speaker 2: is like the biases of the researchers themselves asking these questions,
Speaker 2: expecting that like, oh, you seem to be around this age,
Speaker 2: do you experience these things instead of what changes have
Speaker 2: you experienced?
Speaker 4: If any Yeah, well, and I read it. I read
Speaker 4: a paper that I know, I'm interrupting you so much, FRO.
Speaker 4: I read a paper that was looking at like the
Speaker 4: the biological and cultural differences that was also like, that's
Speaker 4: also really difficult to disentangle because then if you have
Speaker 4: differences in environmental exposure and in diet, then do you
Speaker 4: have differences in what your symptoms may or may not
Speaker 4: be because of differences like that are now biological?
Speaker 1: Right?
Speaker 4: Like how much is it biological differences versus perception differences
Speaker 4: versus culture differences?
Speaker 3: What is culture?
Speaker 2: Ah?
Speaker 3: And then throwing aging into the mix, like how many
Speaker 3: of those things can you attribute to aging versus menopause
Speaker 3: versus diet culture, like all of these things? Yeah, why
Speaker 3: are we doing this? It's too much? I love it?
Speaker 3: Please keep going.
Speaker 2: I know not but yeah, so anyway. The inclusion of
Speaker 2: menopause as an official medical entry in the eighteenth century
Speaker 2: marked a new era, one where medical intervention was seen
Speaker 2: as necessary to help women survive what had previously mostly
Speaker 2: been considered just a natural progression of life. It also
Speaker 2: provided ample opportunities for physicians to express their hateful contempt
Speaker 2: of women, which was thinly veil as medical observation. Okay,
Speaker 2: I know, I'm just brace yourself. From the eighteenth century quote,
Speaker 2: with the shrinking of the ovaria, there is a corresponding
Speaker 2: change in the outer form. The form becomes angular, the
Speaker 2: body lean, the skin wrinkled, The hair changes in color
Speaker 2: and loses its luxuriancy. The skin is less transparent and soft,
Speaker 2: and the chin and upper lip become downy. With this
Speaker 2: change in the person, there is an analogous change in
Speaker 2: the mind, temper, and feelings. The woman approximates in fact
Speaker 2: to a man. This unwomanly condition undoubtedly renders her repulsive
Speaker 2: to man, while her envious, overbearing temper renders her offensive
Speaker 2: to her own sex.
Speaker 7: And like.
Speaker 3: Medical description, I should not be as shocked as I am.
Speaker 3: I know it, Just wow, I know well.
Speaker 2: Things didn't get much better in the nineteenth century, okay.
Speaker 2: In eighteen seventy, Augustus Gardner wrote quote, the body itself
Speaker 2: does not long delay entering into decrepitude, and soon we
Speaker 2: see the woman, once so favored by nature, when she
Speaker 2: was charged with the duty of reproducing, the species degraded
Speaker 2: to the level of a being who has no further
Speaker 2: duty to.
Speaker 3: Perform in the world. End quote. Just like, tell us
Speaker 3: what you really think.
Speaker 4: I feel like that's also something we didn't even get
Speaker 4: into yet of Just like, if your role is only reproduction,
Speaker 4: now you are useless.
Speaker 3: Uh huh oh ooh.
Speaker 2: Feelings, Yeah, feelings, feelings, we can talk about it. Yeah, symptoms,
Speaker 2: but symptoms. So menopause has been blamed for a long,
Speaker 2: long list of symptoms. I found this list. Quote hot flushes,
Speaker 2: cold sweats, night sweats, weight gain, backache, tingling, fatigue, headaches, palpitations, arthralgia,
Speaker 2: dizzy spells, irritability, nervousness, anxiety, apathy, depression, early wakening, emotional instability, fears,
Speaker 2: feelings of suffocation, forgetfulness, insomnia, lack of concentration, lightheadedness, loss
Speaker 2: of interest, loss of self worth, feelings of panic, sadness, tenseness, osteoporosis, depression, dysuria, dysperunia, paresthesia,
Speaker 2: chest pains, breast pains, constipation, diarrhea, facial hair, vaginal dryness,
Speaker 2: changes in libido, in skin and hair and worry about
Speaker 2: the body.
Speaker 3: End quote sounds about right. I also saw rabies mentioned once.
Speaker 3: I'm sorry, I'm gonna veto that one.
Speaker 2: Just say no, that's you get one veto.
Speaker 3: That's my Vito.
Speaker 2: And Edward Tilt in the nineteenth century considered quote melancholia, mania, alcoholism,
Speaker 2: uncontrollable murderous instincts, and other types of mental derangement typical
Speaker 2: of menopause. I like, you could use menopause as a
Speaker 2: defense against murder, a legal defense based on Edward Tilt,
Speaker 2: have him on the witness stand. I also came across
Speaker 2: an example I'm just gonna keep going from the nineteen
Speaker 2: twenties where a physician met with a woman who was
Speaker 2: coughing up blood and told him I think I have tuberculosis,
Speaker 2: and he was like, no, han, you're just menopausal. This
Speaker 2: is your body's way of getting rid of the extra blood.
Speaker 3: You just said the nineteen twenties. Nineteen twenties, Yeah, nineteen.
Speaker 4: Twenties, like when my grandparents were born. Yeah, okay, cool, Yeah, great,
Speaker 4: you're just coughing up your menstrual blood.
Speaker 7: Yep.
Speaker 4: Hey, like we know from our endometriosis episode that technically
Speaker 4: in theory, you could have endemetrilian plants and your lungs,
Speaker 4: but that's not what's happening.
Speaker 3: No, yeah, wow, okay, great.
Speaker 2: And if it wasn't enough that menopause was responsible for
Speaker 2: all kinds of horrible things, women were also told that
Speaker 2: they were responsible, their diet, their temperament, whatever, for when
Speaker 2: menopause happened and how bad it was. To be clear,
Speaker 2: the eighteenth and nineteenth centuries were a time of enormous
Speaker 2: growth in the medical and surgical fields, in the rise
Speaker 2: of patent medicines, and in the pathologization of bodies. Overall,
Speaker 2: menopause was not the only thing targeted or impacted.
Speaker 3: See our tonsils episode.
Speaker 2: Exactly, but this new framing of menopause as a disease
Speaker 2: cemented it for centuries up through today as something to
Speaker 2: be feared, survived, battled against. And my intention is absolutely
Speaker 2: not to dismiss anyone's experiences or feelings about menopause or
Speaker 2: say that menopausal symptoms are made up or no big deal,
Speaker 2: especially as someone who hasn't had menopause. My intention is
Speaker 2: simply to try to understand how the male dominated medical
Speaker 2: community in the Western world has over the centuries constructed
Speaker 2: and pushed a concept of menopause that may not be
Speaker 2: representative of the huge variety of experiences that people may
Speaker 2: actually have.
Speaker 1: Yes.
Speaker 2: And while some physicians like John father Gill in the
Speaker 2: late seventeen hundreds maintained that menopause was not dangerous or
Speaker 2: not associated with any change in health, but just in case,
Speaker 2: he sold father Gill's pill to help other their physicians
Speaker 2: saw it as a drastic transformation, regardless of whether it
Speaker 2: was quote unquote like natural menopause or if it was
Speaker 2: menopause after surgical removal of ovaries. So Virtuo, who's the
Speaker 2: famous surgeon, was referring to the surgical removal of ovaries
Speaker 2: and wrote this in the nineteenth century quote, to remove
Speaker 2: the ovary means we shall have before us a masculine woman,
Speaker 2: ugly half form, with the coarse and harsh features, the
Speaker 2: heavy bone formation, the mustache, the rough voice, the flat chest,
Speaker 2: the sour and egotistic mentality, and the distorted outlook. All
Speaker 2: that we admire and respect in woman as womanly is
Speaker 2: merely dependent on her ovaries.
Speaker 3: End quote.
Speaker 4: Oh wow, erin, Yeah, that is a quote.
Speaker 2: Isn't that a quote?
Speaker 4: All that we admire and respect that is womanly can
Speaker 4: be attributed to the ovaries. Also, who are you admiring
Speaker 4: and respecting?
Speaker 8: Because like, I like, I wish that I could better
Speaker 8: articulate the way that I feel about this same same same.
Speaker 2: Because all I it's just there's so much feeling of
Speaker 2: like what, Yeah, I don't know, Okay, I'll keep I
Speaker 2: feel like we're just gonna rage the whole time.
Speaker 3: I should keep going, let's keep going. I love it.
Speaker 2: Because then we have the expectations around how a postman
Speaker 2: apausal woman should act, which are utterly ridiculous. Essentially, the
Speaker 2: expectation was to was for you to fade into the background,
Speaker 2: to no longer feel desire or feel capable of having
Speaker 2: a sex life, to act sweet and polite and just
Speaker 2: wait peacefully until death takes you.
Speaker 3: I'm sorry if, oh gosh.
Speaker 2: If a postmenopausal person expressed sexual desire or war form
Speaker 2: fitting clothes, if they flirted, drank alcohol, spoke their mind,
Speaker 2: or just acted like a human being, that could be
Speaker 2: grounds for a diagnosis of hysteria at a minimum, or
Speaker 2: just grounds to have you locked up in an asylum,
Speaker 2: which did happen.
Speaker 4: Okay, cool, cool, I mean it not that different as
Speaker 4: pre menopause.
Speaker 2: Yeah, I mean that's the thing that was like hysteria.
Speaker 2: People were just like handing out hysteria diagnosis diagnoses all
Speaker 2: over the place. Yea, and menopause was sometimes thought to
Speaker 2: trigger hysteria, which we all know is fake diagnosis. Check
Speaker 2: out our and demetriosis episode.
Speaker 3: It's a good one.
Speaker 2: So some of this extreme blaming of menopause for everything
Speaker 2: began to be rained in as the twentieth century began.
Speaker 2: But around that same time, menopause was about to undergo
Speaker 2: another major transformation. And this transformation would simultaneously shed much
Speaker 2: more light on the mechanisms of menopause and in understanding
Speaker 2: what's actually happening to our bodies, but it would also
Speaker 2: solidify its status in some ways as a disease. So
Speaker 2: one of the areas that was very much booming in
Speaker 2: research developments in the early nineteen hundreds was the field
Speaker 2: of endochronology hormones. And so maybe someday I'll tell this
Speaker 2: part of the story in more detail, But long story short,
Speaker 2: the discovery of estrogen redefined menopause as a problem of hormones,
Speaker 2: as a disease of deficiency. This meant that all of
Speaker 2: the things people might experience during menopause were sometimes reduced
Speaker 2: to just a lack of estrogen. It became about biology,
Speaker 2: not about the individual and their experiences. So even if
Speaker 2: physicians couldn't make a mechanistic link between say like estrogen
Speaker 2: and depression, or weren't able to immediately, they would just
Speaker 2: point towards estrogen levels and go, yep, there's your problem.
Speaker 3: Right.
Speaker 2: There couldn't possibly be our society's dismissal of women over
Speaker 2: the age of fifty, you know, and maybe it's not that.
Speaker 2: Maybe it is estrogen, but like there wasn't sufficient research
Speaker 2: then or now to make those distinctions and also acknowledging
Speaker 2: individual differences. For one person, it could be biology. For
Speaker 2: somebody else, it could be what their life is at
Speaker 2: that moment, or a combination of both, Like menopause is
Speaker 2: whatever you want it to be. And this also especially
Speaker 2: played into this idea of mood swings in menopause. If
Speaker 2: you're experiencing mood swings, ugh, she's just hormonal. Couldn't possibly
Speaker 2: be the microaggressions and condescension that you're faced with like
Speaker 2: every day at work or even at home. Right, And
Speaker 2: while it was great that the discovery of estrogen promised
Speaker 2: potential symptom relief to those who wanted to explore that.
Speaker 2: It also told women to feel inferior in some ways,
Speaker 2: to view menopause as a time of loss. Early hormone
Speaker 2: replacement therapies were advertised as quote unquote restoring femininity as
Speaker 2: essential if you didn't want to drive your husband away
Speaker 2: with your erratic mood swings and changing libido, which, by
Speaker 2: the way, as we talked about, there has not been
Speaker 2: shown any universal effect of menopause on libido. And I
Speaker 2: also think it's fascinating that, as the author of one
Speaker 2: of the books I read pointed out, the focus shifted
Speaker 2: to be on sexual symptoms of menopause in the mid
Speaker 2: twentieth century as marriage became more an institution based on
Speaker 2: love and sex. I don't know, that's just something I
Speaker 2: don't know the research in that, but I thought that's interesting.
Speaker 2: But overall, physicians in the twentieth century seemed dead set
Speaker 2: on establishing menopause as a major shift in health and identity.
Speaker 2: In the nineteen sixty six book Feminine Forever, author Robert
Speaker 2: Wilson wrote, quote, no woman can be sure of escaping
Speaker 2: the horror of this living decay. Every woman faces the
Speaker 2: threat of extreme suffering and incapacity.
Speaker 3: Holy guacamole, I know.
Speaker 2: A few years later, in the nineteen sixty nine book
Speaker 2: Everything You Always Wanted To Know About Sex, author David
Speaker 2: Rubin Wrights quote, as estrogen is shut off, a woman
Speaker 2: becomes as close as she can to being a man.
Speaker 2: Having outlived their ovaries, they have outlived their usefulness as
Speaker 2: human beings.
Speaker 3: And whoa, whoa, whoa whoa whoa whoa whoa, whoa whoa
Speaker 3: nineteen sixty nine. We have outlived our usefulness as human beings.
Speaker 2: I mean, I feel like I've heard certain people on
Speaker 2: the Internet say that today, Oh but yeohvoa whoa. And
Speaker 2: it wasn't only men doing the fear mongering and perpetuating
Speaker 2: these these stereotypes, this concept of menopause. Some women were
Speaker 2: also guilty, like Helene Deutsch, colleague of Freud, who wrote
Speaker 2: in the nineteen forties that quote, the changes that take
Speaker 2: place in the body of a menopausal woman have the
Speaker 2: character not only the cessation of physiologic production, but of
Speaker 2: general dissolution. Women's biological fate manifests itself in the disappearance
Speaker 2: of her individual feminine qualities at the same time that
Speaker 2: her service to the species ceases. With the lapse of
Speaker 2: her reproductive service, her beauty vanishes, and usually the warm,
Speaker 2: vital flow of feminine emotional life as well. End quote.
Speaker 4: This is so much more than I even like I
Speaker 4: knew that this was going to be a lot Aaron,
Speaker 4: but I.
Speaker 2: Wow, wow, I yep, yeah, wow, indeed, I mean, with
Speaker 2: all of this, is it any wonder that hormone replacement
Speaker 2: therapy became so hugely popular and widespread throughout the early
Speaker 2: twentieth century, even before proper testing.
Speaker 4: That's not surprising at all. You must remain vital.
Speaker 3: To your species, and I know that.
Speaker 2: You know, we talked a bit about how the hormone
Speaker 2: replacement therapy used today has gone through a lot of changes,
Speaker 2: and there's been a lot more better research or more
Speaker 2: like through our research on them. But my point is
Speaker 2: that the construct of menopause as a disease was so
Speaker 2: strong that medical intervention was seen as necessary, even if
Speaker 2: physicians weren't sure whether the cure aka these early, before
Speaker 2: being well tested hormone replacement therapies would be worse than
Speaker 2: the quote unquote disease.
Speaker 3: Wow.
Speaker 2: Yeah, there was a nineteen seventy five ad in jama
Speaker 2: from a pharmaceutical company in jama in Jamma, and this
Speaker 2: company made HRT, and the ad stated, quote, I can't okay,
Speaker 2: almost any tranquilizer might ca her down, but at her age,
Speaker 2: estrogen might be what she really needs.
Speaker 3: End quote.
Speaker 2: So this is advertising to medical professionals.
Speaker 3: Right like, oh my god, erin, I can't.
Speaker 2: I'm sweating so much right now with anger, and just
Speaker 2: like I laugh because otherwise I'd cry. Right Okay, there's
Speaker 2: more because another company advertised its estrogen pills, and I
Speaker 2: think this advertisement was more widely, not just in jama
Speaker 2: but it advertised its estrogen pills quote for the menopausal
Speaker 2: symptoms that bother him most and.
Speaker 3: Quote I'm okay, please keep going. Uh.
Speaker 2: But HRT was not without controversy is not without controversy,
Speaker 2: and many researchers over the decades advocated for a closer
Speaker 2: examination of what HRT actually did, what side effects were
Speaker 2: associated with long term use, whether there was any clear benefit,
Speaker 2: and how to use it safely. And so we're in
Speaker 2: a much better place than we used to be. And
Speaker 2: starting in the twentieth century, also, women began to share
Speaker 2: their experiences of menopause more openly in books on radio programs,
Speaker 2: and one of the themes that began to emerge was that
Speaker 2: women who had not yet gone through menopause tended to
Speaker 2: have a much more negative perception of it than those
Speaker 2: who had. The fear of menopause was worse than menopause itself.
Speaker 2: And granted, this increased attention on menopause didn't always lessen
Speaker 2: the stigma or shame surrounding it. Books intending to be
Speaker 2: guides for quote unquote surviving or dealing with menopause in
Speaker 2: some ways continued to perpetuate the idea that menopause was
Speaker 2: inherently a struggle for everyone who experienced it, something to
Speaker 2: be dreaded, and that was something that more research was
Speaker 2: finding to not necessarily be the case. In fact, researchers
Speaker 2: were finding that in some cultures there appeared to be
Speaker 2: no word for hot flushes. And I think I mentioned earlier,
Speaker 2: but I read about at least one traditional foraging society
Speaker 2: that does not appear to have a word for menopause,
Speaker 2: as in the menopause that we think of with its
Speaker 2: collection of science and symptoms. People of course did recognize
Speaker 2: that their period stopped, but there didn't seem to be
Speaker 2: this concept of the period during which that happened and
Speaker 2: an increase in certain symptoms. And this research on menopause
Speaker 2: across cultures revealed that there is no standard definition of
Speaker 2: menopause as a quote unquote syndrome or collection of syndromes,
Speaker 2: nor is there one universal attitude towards menopause dread, shame, anticipation, relief,
Speaker 2: feeling more respected, not feeling any particular way at all.
Speaker 2: Like these and so many other attitudes or feelings are
Speaker 2: real and valid. And as researchers began to ask these
Speaker 2: questions about how people feel about menopause, when menopause happens,
Speaker 2: what symptoms can be tied directly to the hormonal changes
Speaker 2: experience during menopause, they also began to set their sites
Speaker 2: on another big unanswered question.
Speaker 4: Why, yes, oh.
Speaker 2: Why does menopause exist?
Speaker 4: We don't know, Aaron, I, I can't tell you how
Speaker 4: excited I am for this question, because it's so This
Speaker 4: is the part where I am like, it is so
Speaker 4: cool that human's menopause.
Speaker 3: I know.
Speaker 2: Okay, So there is so much literature on this subject,
Speaker 2: more than I could ever hope to cover, Like I
Speaker 2: would have to go back into a PhD, and then
Speaker 2: another one, and then by the time I finished that PhD,
Speaker 2: all the literature would have been updated all of that,
Speaker 2: and then if I came back here and we did
Speaker 2: an episode, it would be like a fifteen hour episode minimum.
Speaker 3: Yeah, So what.
Speaker 2: I'm going to do here is just give a short
Speaker 2: overview of some of the ideas that are out there,
Speaker 2: just enough of a taste so that you end up
Speaker 2: really curious and excited and bringing with questions. And then
Speaker 2: I can be like, go to our website. You can
Speaker 2: read more in our sources. But before we get into
Speaker 2: these various hypotheses, let's first consider why someone would ask
Speaker 2: this question of why menopause exists.
Speaker 3: Yeah. Yeah, menopause is.
Speaker 2: Actually very rare in the animal kingdom. More precisely, humans
Speaker 2: are one of a handful of species where females experience
Speaker 2: a significant part of their life after their reproductive lifespan
Speaker 2: ends not just a decline in fertility, but sterility, and
Speaker 2: not just a few years, but often, in the case
Speaker 2: of humans, decades.
Speaker 3: Right, like more than half our life potentially.
Speaker 8: Yeah.
Speaker 2: Studying whether menopause exists in wild animals is really challenging
Speaker 2: because you need to collect accurate data on lifespan fertility
Speaker 2: over lifespan, and then determine whether it's a decline in
Speaker 2: fertility that you're observing or true sterility for long lived animals.
Speaker 2: That's incredibly difficult to do both logistically and then like
Speaker 2: where you're going to get the funding for that. And
Speaker 2: so while several animal species have been proposed to live
Speaker 2: a significant portion of their lives after their reproductive lifespan ends,
Speaker 2: and so to make things easier, I'm just going to
Speaker 2: call that menopause for the rest.
Speaker 3: Of the section.
Speaker 2: Only a few species are widely considered to have or
Speaker 2: experience menopause, humans of course, Orca whales and short finned
Speaker 2: pilot whales. There are a few more out there that
Speaker 2: sometimes get mentioned. And there's a recent science paper about
Speaker 2: menopause in a chimpanzee population that we could probably spend
Speaker 2: an entire episode talking about, but I'll link to it
Speaker 2: on our site. Very interesting, hard to say what's going
Speaker 2: on there. There's no grandmother ing in this population in chimpanzees,
Speaker 2: I should say so. Like anyway, so that rarity of
Speaker 2: menopause is in itself interesting and invites the questions why
Speaker 2: so few species and why these species?
Speaker 4: Yeah, yeah, oh erin it's also so interesting and this
Speaker 4: is something.
Speaker 3: We we'll have to talk about.
Speaker 4: More in our menstruation episode. But like, because humans are
Speaker 4: also one of only a few species who men straight,
Speaker 4: uh huh. But the group of species who men straight
Speaker 4: is not the same as the group of species who
Speaker 4: undergo menopause, with the exception of humans. So it's like, what,
Speaker 4: why do we do these two things that are kind
Speaker 4: of weird in the whole animal kingdom?
Speaker 3: Like what, it's fascinating, It.
Speaker 2: Is so interesting, There is so much here, Like, honestly,
Speaker 2: I it is. It's overwhelmingly cool, it really is. Yeah,
Speaker 2: And so the possible answers to the questions of why
Speaker 2: so few species and why these species? It depends on
Speaker 2: whether or not menopause was selected for, as in, whether
Speaker 2: menopause provides an evolutionary advantage to those species or whether
Speaker 2: it is just like a byproduct of something like the
Speaker 2: evolution of longevity and a natural expiration date to eggs,
Speaker 2: because as you mentioned, we are born with all of
Speaker 2: the eggs that we will ever produce, so we can't
Speaker 2: make more. Is it just like those expire fifty years
Speaker 2: from now? Is menopause an accident or is it intentional. Essentially,
Speaker 2: menopause must come with some cost because it limits the
Speaker 2: total reproductive output.
Speaker 3: But is that cost.
Speaker 2: Outweighed by the benefits of menopause, and if so, what
Speaker 2: could those benefits be? Or is the cost of menopause
Speaker 2: not very big or is it just really difficult for
Speaker 2: evolution to act on increasing reproductive lifespan. I don't know.
Speaker 2: So the hypotheses of why menopause exists fall into two
Speaker 2: general groups, adaptive hypotheses where menopause provides a benefit, and
Speaker 2: non adaptive hypotheses, where menopause is more like an artifact
Speaker 2: of aging. So let's get into a few of the
Speaker 2: adaptive hypotheses first, starting with the mother effect. So, this
Speaker 2: is this idea that in species where offspring are dependent
Speaker 2: on parents for longer than a typical time between births,
Speaker 2: so you can have a child and then become pregnant
Speaker 2: again and have that child, and your first child is
Speaker 2: still dependent on you for like survival and.
Speaker 4: Everything, Like you could have another baby in nine months,
Speaker 4: but your nine month old is still breastfeeding and et cetera.
Speaker 2: And yeah, yeah, so in those species, at a certain point,
Speaker 2: it's beneficial for the mother to stop reproducing because otherwise
Speaker 2: she'll have more offspring than she can care for and
Speaker 2: they will all.
Speaker 3: Struggle as a result. Okay.
Speaker 2: On top of that, this is still within the mother effect.
Speaker 2: Pregnancy becomes riskier with age, both for the pregnant person
Speaker 2: and the fetus, and so not being able to get
Speaker 2: pregnant after a certain age could be protective to the
Speaker 2: existing offspring because if the mom died, that could hurt
Speaker 2: the chances of survival for her existing offspring.
Speaker 3: Cool.
Speaker 2: There's not much evidence in support of this. Also, if
Speaker 2: the species is social and works in a cooperative group,
Speaker 2: like humans, the death of a mother may be offset
Speaker 2: by care from the rest of the community. Okay, so
Speaker 2: then there's the grandmother effect. Under this hypothesis, longer life
Speaker 2: spans and women were selected for because I'm just going
Speaker 2: to found a great quote in this book called the
Speaker 2: Slow Moon Climbs by Susan Matttern quote. Post reproductive women
Speaker 2: helped their daughters, daughters in law, younger sisters, nieces, and
Speaker 2: granddaughters to feed and care for their infants and young children.
Speaker 2: This allowed the younger women to have more babies closer together,
Speaker 2: which in turn increased the inclusive fitness of the older
Speaker 2: women end quote. So essentially, grandchildren who had grandmothers providing
Speaker 2: care were more likely to survive to reproduce, and so
Speaker 2: then they tend to have Yeah, that's how sort of
Speaker 2: it's like this indirect evolution of grandmothering.
Speaker 4: I don't know, because you're still passing, those are still
Speaker 4: your genes, and so that that longevity is then being
Speaker 4: selected for in those genes and that are surviving.
Speaker 2: Yeah, and there is there's mixed evidence for this. By mixed,
Speaker 2: I mean like not very strong and sometimes opposite. But
Speaker 2: it also varies too based on like paternal and maternal
Speaker 2: grandmother and social structure, so like do daughters stay with
Speaker 2: the mothers or do they go with their mates, family
Speaker 2: and stuff like that. Like there's there's a lot here,
Speaker 2: and and why would it just be post reproductive longevity
Speaker 2: that evolved because of grandmother ing, not reproductive longevity as well.
Speaker 2: So a third adaptive hypothesis actually tries to answer that
Speaker 2: in a way. So this is the reproductive conflict hypothesis.
Speaker 2: It's a killer whale one, the killer whale one. Yeah,
Speaker 2: So basically, by stopping reproduction, there's less competition between mothers
Speaker 2: and their offspring over resources.
Speaker 3: So if if you.
Speaker 2: And your daughter are both able to reproduce at the
Speaker 2: same time, there has been some work done on orcas
Speaker 2: that seems to suggest that the offspring from the grandmother
Speaker 2: is less likely to survive than the offspring from the
Speaker 2: daughter than like the grandchild. It's very I said that
Speaker 2: very confusingly, and I think I got that right.
Speaker 4: But yeah, no, that makes sense though, because and then
Speaker 4: what they're saying is that, like, then that's why it
Speaker 4: would be selected for that you at some point would
Speaker 4: stop reproducing, so then your grandchildren can survive, even though
Speaker 4: it means that you have less children, but your children
Speaker 4: wouldn't have survived because they'd be competing with your other children.
Speaker 3: Et cetera.
Speaker 4: Yeah, exactly, and your other children's your grandchildren. Yeah, yeah,
Speaker 4: but yeah. There are also many other adaptive hypotheses of menopause,
Speaker 4: like one that where it evolved to protect against certain cancers.
Speaker 4: But those seem to be the big three that I
Speaker 4: kept encountering mother effect, grandmother effect, and reproductive conflict hypothesis.
Speaker 4: And then there are the non adaptive hypotheses where menopause
Speaker 4: is kind of like a byproduct, so one idea is
Speaker 4: called the patriarch hypothesis, where longer life spans in males
Speaker 4: were selected for and then that led to like an
Speaker 4: overall increase in lifespan for both males and females because
Speaker 4: like the longevity genes would be on autosomal chromosomes. I
Speaker 4: don't know, but extending reproduction in women wouldn't have led
Speaker 4: to much benefit, and so instead women who lived past
Speaker 4: reproductive age would have helped by sharing knowledge and helping
Speaker 4: with foraging. I don't like, I'm not super I don't
Speaker 4: feel super familiar with this hypothesis, and so maybe that's
Speaker 4: like my poor presentation of it, but I'm like, I
Speaker 4: don't quite get how.
Speaker 3: Menopause fits into that.
Speaker 2: Yeah, But then there's this idea that eggs, that mammalian
Speaker 2: eggs have a shelf life, and that we are just
Speaker 2: living beyond the shelf life. And it's true that a
Speaker 2: drop infertility is observed in many captive populations of animals,
Speaker 2: where their lifespans tend to be much longer compared to
Speaker 2: in the wild, where you know, in the wild they
Speaker 2: have to worry about like resource availability and predators, and
Speaker 2: so you can see sort of that decline infertility that
Speaker 2: may normally be experienced if they didn't have to worry
Speaker 2: about predators in so long, right, if.
Speaker 3: They didn't just die yeah in the wild.
Speaker 2: Yeah, But humans have at least as far as we
Speaker 2: can tell, lived beyond their reproductive lifespan, as in, lived
Speaker 2: beyond you know, the last egg for a very long time.
Speaker 2: This notion that life expectancy was forty in the Middle
Speaker 2: Ages is totally wrong. Right, That life expectancy number is
Speaker 2: so low because of high childhood and infant mortality in
Speaker 2: foraging societies that today that don't have access to modern healthcare,
Speaker 2: public sanitation, vaccinations, or reliable food supply. About a quarter
Speaker 2: is expected to live as grandparents for fifteen to twenty
Speaker 2: years and longevity. This longevity is estimated to have evolved
Speaker 2: at least one hundred and thirty thousand years ago. While
Speaker 2: most mammals do seem to have an average upper limit
Speaker 2: on fertility at around like forty to fifty years, there
Speaker 2: are a few species like the fin whale, which reaches
Speaker 2: sexual maturity around six or seven and continues to reproduce
Speaker 2: until beyond seventy Maximum life spans over one hundred. So
Speaker 2: maybe there's a shelf life, or maybe there isn't. And
Speaker 2: maybe part of the reason why we have no single
Speaker 2: leading hypothesis or no single convincing or satisfying hypothesis for
Speaker 2: why menopause exists is that we don't really know when
Speaker 2: it evolved or the context in which it evolved. It's
Speaker 2: also possible that menopause evolved for different reasons in those
Speaker 2: species that experience it, maybe not, you know, like orcas
Speaker 2: are social, they live in social groups. Actually don't know
Speaker 2: anything about the short fin pilot whale. But so I
Speaker 2: think it's really challenging to try to disentangle this, particularly
Speaker 2: when you're talking about something that happened on the order
Speaker 2: potentially of millions or hundreds of thousands of years ago.
Speaker 2: How do we understand what social groups were like then,
Speaker 2: I don't know, and also how variable they were. It's so, yeah,
Speaker 2: we don't know why menopause exists, and we may never know.
Speaker 3: Yeah.
Speaker 2: And while I don't necessarily agree with the grandmother hypothesis
Speaker 2: or think it's the answer the sole answer, I do
Speaker 2: appreciate this sentiment that it inspires, particularly in our society today.
Speaker 2: And so I'll leave you with this quote from The
Speaker 2: Slow Moon Climbs by Susan Mattern.
Speaker 3: Quote.
Speaker 2: Midlife is and always has been about relationships, about the
Speaker 2: roles we play in the community and in the family,
Speaker 2: the sacrifices we make, the experience we bring to bear.
Speaker 2: We become non reproductive so that we can do other things.
Speaker 2: The transition is important, but not because of the symptoms.
Speaker 2: It may or may not cause us to suffer. It
Speaker 2: is important on a much larger scale, and to reduce
Speaker 2: it to a medical condition is to trivialize it. The
Speaker 2: apprehension about menopause, the embarrassment, the tiresome jokes, the judgment
Speaker 2: and hostility aimed at older women in Western culture and
Speaker 2: in other cultures today and in the past, are all unnecessary.
Speaker 2: But menopause is necessary. Humans have menopause because.
Speaker 3: We need it.
Speaker 2: The contributions of post reproductive women have brought us this
Speaker 2: far and will lead us into whatever future we have.
Speaker 3: End quote.
Speaker 2: I like that, I do too, And with that over
Speaker 2: to you eron, okay, no presh, no fresh.
Speaker 3: We will talk about where we stand with menopause today
Speaker 3: right after this break. In terms of the epidemiology.
Speaker 4: Of a quote menopause at this point, yeah, like everyone
Speaker 4: with functional ovaries will go through menopause.
Speaker 3: So I don't have numbers. I mean, like they know,
Speaker 3: I don't even know what to ask, right, there's nothing,
Speaker 3: there's nothing.
Speaker 4: Thousands of people will reach the point of their ovaries
Speaker 4: ceasing to function on any giving day. And in an
Speaker 4: aging population, of course, more and more people are living
Speaker 4: well and well and well past the age of menopause.
Speaker 4: And like you beautifully talked about, Aaron, there have been
Speaker 4: so many differences historically, even just in like Europe and
Speaker 4: North America and the quote unquote Western World in the
Speaker 4: reporting and the perception of menopause and menopausal symptoms and
Speaker 4: the literature is really difficult to try and understand. Beyond
Speaker 4: the perception of menopause in the Western world, there are
Speaker 4: some studies that report that there's like geographic variation in
Speaker 4: the reporting of symptoms. And I mentioned that one paper
Speaker 4: which I'll mention again at the end that really tried
Speaker 4: to dive into the cultural and bio biological and cultural
Speaker 4: and biocultural differences in menopause, both the perception and the
Speaker 4: symptoms and everything, and it's just really difficult to try
Speaker 4: and assess. So I don't have for you today like
Speaker 4: numbers like eighty percent of people will experience vasomotor symptoms
Speaker 4: like that's true in some studies and it's not true
Speaker 4: in other studies. There is a study that looked in
Speaker 4: the United States called the Swan Study that really did
Speaker 4: try and specif zifically recruit across a wide range of
Speaker 4: racial and ethnic groups to see if there are differences
Speaker 4: in the experience of menopause across these groups in the
Speaker 4: United States. And in the papers from the Swan Study
Speaker 4: there are differences that they reported in symptoms across different
Speaker 4: racial and ethnic groups. But even that is still very
Speaker 4: limited because this is still people living in America. And
Speaker 4: as one example that this other paper that I mentioned
Speaker 4: will give living in the United States. As for example,
Speaker 4: a Japanese American is not the same as a Japanese
Speaker 4: person who has lived their entire life in Japan, both
Speaker 4: in terms of cultural as well as environmental exposures. And
Speaker 4: so again I don't have numbers for like the symptoms
Speaker 4: of menopause. Even the age of menopause, which does vary
Speaker 4: a little bit geographically and in some areas, seems to
Speaker 4: be declining, but I don't know that again, we have
Speaker 4: enough data to say for sure that that's happening globally.
Speaker 3: Some papers will report.
Speaker 4: That on an international level, whatever that means, twenty percent
Speaker 4: of women perceive menopause as a disease. So that's like
Speaker 4: a number that's cited. I don't know exactly how that
Speaker 4: number came about and how many papers really gathered what
Speaker 4: kind of data to answer that question. So it's complicated.
Speaker 4: And all of the papers that I read that talk
Speaker 4: about menopause and look at menopause are focused entirely on
Speaker 4: cisgender women undergoing menopause. Some of them might distinguish between
Speaker 4: surgical menopause and quote natural menopause, and some papers don't
Speaker 4: even do that. So when it comes to the experience
Speaker 4: of menopause for people that are not cisgender women, I
Speaker 4: really have no data on that whatsoever. Yeah, so that's
Speaker 4: what I have for ependymology.
Speaker 3: Not a lot. So let's talk about where we're going
Speaker 3: in terms of menopause.
Speaker 5: Yeah, I don't know where we're going either, because again,
Speaker 5: for this, I feel like there's a lot that you
Speaker 5: could focus on.
Speaker 4: We could talk about, like where are we going culturally
Speaker 4: in terms of our perceptions in the United States, in Europe,
Speaker 4: in places that I have data for on what our
Speaker 4: perceptions of menopause are. From all of the papers that
Speaker 4: I read, it really seems like menopause is very much
Speaker 4: still a disease for a lot of people. A lot
Speaker 4: of the papers, even in really well respected journals that
Speaker 4: I read, really focused on menopause as the this time
Speaker 4: of great transition for women undergoing such times of stress,
Speaker 4: and like that is really the tenor of all of
Speaker 4: these papers, Yeah, which I find really interesting, especially now
Speaker 4: knowing so much more about the cultural history and medical
Speaker 4: history of how we have defined this time.
Speaker 2: Period, right, I mean, I think like the biggest thing
Speaker 2: is that, yes, the leading attitudes and perceptions of menopause
Speaker 2: have changed throughout history, but they all treat people who
Speaker 2: are going to go through menopause or who are going
Speaker 2: through menopause as one unit.
Speaker 3: Right, They're all the same, and that is definitely not
Speaker 3: the case.
Speaker 4: So what I really wonder, and this is me Aaron
Speaker 4: onmann Updike wondering, and this is not based on things
Speaker 4: that I read and data, but I really wonder if
Speaker 4: as we explore more of the deep nitty gritty biology
Speaker 4: of like what is happening in our brains as these
Speaker 4: hormone shifts happen, and can we predict because this is
Speaker 4: a big area of research. It's like, can we predict
Speaker 4: and diagnose menopause earlier? Can we know when someone is
Speaker 4: going to have their last menstrual period and how long
Speaker 4: things might be on the beforehand and the after in
Speaker 4: terms of when these hormones shift, Like, we don't. We
Speaker 4: can't do that yet, can we? In the future, are
Speaker 4: we going to see something like a splitting of various
Speaker 4: menopause related syndromes that might be more specific where if X,
Speaker 4: Y and Z is true in terms of the effects
Speaker 4: on all of these other various hormones that estrogen is
Speaker 4: affecting along your hypothalamic pituitary axis, you know, you're affecting
Speaker 4: your serotonin levels, your epinephrin levels. Like, if we can
Speaker 4: better identify those effects, can we then split things out
Speaker 4: in a way that doesn't lump every symptom that has
Speaker 4: ever been associated with menopause as menopause, but really call
Speaker 4: it what it is once we know what that is.
Speaker 2: Yeah, I mean, just I think teasing apart those hormonal
Speaker 2: pathways is something that, like menopause could teach us a
Speaker 2: lot about that definitely, especially when it comes to like,
Speaker 2: here's what you should expect, and here's what you shouldn't expect,
Speaker 2: and here's what is highly variable and why it's highly variable,
Speaker 2: versus like, yeah, this is a pretty much like more
Speaker 2: or less, there's a trend right right.
Speaker 4: And I couldn't help thinking why I was researching for this,
Speaker 4: about our endometriosis episode and the thought of how menstruation
Speaker 4: itself we know is not a disease, but there are
Speaker 4: disorders of menstruation, endometrios as being one of them. So
Speaker 4: might it be someday that menopause is not a disease,
Speaker 4: but there are perhaps disorders associated with menopause, and might
Speaker 4: we have better identifications of those for people who experience
Speaker 4: them someday.
Speaker 3: M h, I think that's really really interesting.
Speaker 4: Yeah, yeah, that's kind of a way that I've been
Speaker 4: conceptualizing it. And for that, I will say that there
Speaker 4: is also a lot of hope on the horizon for
Speaker 4: people who are experiencing especially vasomotor symptoms, which again are
Speaker 4: some of the most common associated with menopause, the hot flashes,
Speaker 4: which maybe I didn't emphasize this enough in the biology section,
Speaker 4: but they can be very debilitating for some people.
Speaker 2: Yeah, how long how long can hot flashes be? Or like,
Speaker 2: what's the time range? I know you said, like how
Speaker 2: long people can experience them? It's like seven.
Speaker 3: Years, but that's the average.
Speaker 2: But what's an individual hot flash?
Speaker 3: Oh, great question?
Speaker 4: A matter of minutes? Two hours perhaps? Okay, Yeah, they're
Speaker 4: short in timeframe, but people can experience anywhere from like
Speaker 4: one every couple of weeks to like multiple an hour.
Speaker 2: I mean hours, sounds like a very long time.
Speaker 3: I don't know that.
Speaker 4: They're generally hours, but I think that you can, like
Speaker 4: especially with the night sweats, you can wake up and
Speaker 4: it can disturb things for a longer time. But there's
Speaker 4: hope on the horizon. There's a new class of medicines,
Speaker 4: one of which was just approved in May of twenty
Speaker 4: twenty three, that are entirely different than hormone replacement therapy,
Speaker 4: which is one of the main things that's often used
Speaker 4: to treat hot flashes. Sometimes things like SSRIs, or selective
Speaker 4: serotonin reuptake inhibitors that we use for depression anxiety, can
Speaker 4: also be used, and things like gabapentin, which is an
Speaker 4: epilepsy drug that we use for a lot of non
Speaker 4: epilepsy things can be used for treatment of these, but
Speaker 4: I don't know how effective they actually.
Speaker 3: Tend to be.
Speaker 4: But here's a brand new one. It's a neurokinin antagonist.
Speaker 4: So this is targeting a whole different receptor in our
Speaker 4: brain that is involved in specifically regulating our internal thermostat,
Speaker 4: which we think gets disrupted in an indirect way as
Speaker 4: a result of all these hormonal shifts during and after menopause,
Speaker 4: and so neurokinin is one of the many hormones that
Speaker 4: can get disrupted and is directly related to our internal thermostat,
Speaker 4: as it were. And so this is a neurokinin antagonist
Speaker 4: that's basically blocking that and saying just put your temperature
Speaker 4: set back to a nice ninety eight degrees and let's
Speaker 4: leave it there. So one of these was just approved
Speaker 4: in May of twenty twenty three by the FDA in
Speaker 4: the United States. So that's pretty major and it's especially
Speaker 4: helpful for people who can't take estrogen for one reason
Speaker 4: or another. Right there are reasons why someone might not
Speaker 4: be a candidate for hormone replacement therapy, and so now
Speaker 4: we have more medication options, which is awesome.
Speaker 3: That's great.
Speaker 4: There's probably a lot more that I could say about
Speaker 4: where we could go with menopause, but I feel like
Speaker 4: I've talked enough.
Speaker 2: This is our longest episode in a while.
Speaker 4: I think it's a really but I think it's worth it,
Speaker 4: and I feel like we could have said so much
Speaker 4: more totally. If you would like to read more, we
Speaker 4: have a lot of sources for you, but also listeners.
Speaker 4: Since this is our last episode of the season and
Speaker 4: we're preparing for next season, we would really love to
Speaker 4: know not only if you enjoyed this episode, but also
Speaker 4: what other questions do you have about menopause, about menstruation,
Speaker 4: about I don't know, like anything related to this realm.
Speaker 4: I feel like we've had a lot of fun doing
Speaker 4: episodes similar to this, and I want to do more
Speaker 4: of them.
Speaker 3: Absolutely. I still think we should do a pregnancy series. Yes,
Speaker 3: there's so much there. There's so much there.
Speaker 2: The sources first, Yeah.
Speaker 3: I want to shout out too.
Speaker 2: In particular, I do have some papers, but there were
Speaker 2: two books that I took most of this from. One
Speaker 2: is the one that I've already mentioned, The Slow Moon
Speaker 2: Climbs by Susan Madturn, and the other one is called
Speaker 2: Hot Flushes Cold Science, A History of the Modern Menopause
Speaker 2: by Louise Foxcroft.
Speaker 4: I had a lot of sources for this episode and
Speaker 4: probably not even enough. A few that were really good
Speaker 4: on just the overall like overview of.
Speaker 3: Symptoms and things like that.
Speaker 4: One was by Monteleone in Nature Reviews Endochronology from twenty
Speaker 4: eighteen Symptoms of Menopause, Global Prevalence, Physiology and Implications. Another
Speaker 4: by Davis at All in twenty fifteen in Nature Reviews
Speaker 4: Disease Primers. Menopause is a disease. It was just called
Speaker 4: menopause primer. And then that people that I referenced a
Speaker 4: few times was by Melby at All from Human Reproduction Update.
Speaker 4: It was published in two thousand and five called Culture
Speaker 4: and Symptom Reporting at Menopause. I thought that was a
Speaker 4: really interesting read. But we'll post the list of all
Speaker 4: of our sources from this episode and every one of
Speaker 4: our how many hundreds episodes at this point on our website.
Speaker 4: This podcast will kill you dot com.
Speaker 2: We certainly will thank you again so much, Marika for
Speaker 2: sharing your story with us. We just just thank you,
Speaker 2: thank you, We appreciate it.
Speaker 4: Thank you also to Bloodmobile for providing the music for
Speaker 4: this episode and all of our episodes.
Speaker 2: Thank you to Tom bry Foegel for the audio mixing.
Speaker 3: Thank you exactly right, And.
Speaker 2: Thank you as always to our amazing, wonderful listeners. You
Speaker 2: make this possible.
Speaker 4: Truly, we we really like getting to make this podcast.
Speaker 4: Really excited for next season. Thank you for listening for
Speaker 4: six whole seasons. Yeah, we can't wait to bring you more.
Speaker 3: Tell us what you want to hear?
Speaker 4: Yeah, tell us and especial Thank you as always to
Speaker 4: our patrons. Thank you so much for your support, so
Speaker 4: so much.
Speaker 2: Well until next season, wash your hands you feelthy animals