How to Balance Your Hormones: What Your Doctor Isn’t Telling You About Menopause

1. 0:00 – 11:32

   intro

   1. MRMel Robbins0:00

      Everything you need to know about menopause.

   2. JGDr. Jen Gunter0:02

      Just like you went through puberty, which might have been challenging and had some symptoms, menopause is n- in many ways the same thing. You can think about it as puberty in reverse.

   3. MRMel Robbins0:12

      That actually makes a lot of sense. You know, when I was going through perimenopause, I got bioidentical hormones from a compound pharmacy, and I thought I was fancy.

   4. JGDr. Jen Gunter0:24

      Move away from using bioidentical and just call them compounded, 'cause bioidentical doesn't mean anything. So bioidentical is a marketing term used to describe hormones that are plant-based. They're just making things up.

   5. MRMel Robbins0:37

      There were all these warnings like, "Don't expose to light. Don't do this. Do that." Now, did I follow those? Of course not.

   6. JGDr. Jen Gunter0:42

      So this is the analogy I use. Using FDA-approved hormones is like going to the gas station. You fill your car and you have a working gas gauge, and you're like, "I know what's in there," and that's important. Getting these compounded formulations is like buying gas from a dude on the side of the road who's telling you he has bespoke gas for you.

   7. MRMel Robbins1:00

      I am speechless. Hey, it's Mel. I am so thrilled to bring this episode and conversation to you today. Dr. Jen Gunter is here to tell you everything you need to know about menopause, with a very particular focus on exactly what to do in order to feel better. Now, Dr. Gunter has been called the internet's favorite OBGYN. She is a double board-certified, fellowship-trained medical doctor, and she is a fierce advocate for women's health. She is also the bestselling author of three international bestsellers, including The Menopause Manifesto and her latest best-seller, Blood. She's known for myth-busting and no-nonsense facts, and you are going to love this conversation with her today. And I want to remind you, this is not just for you. Please be generous and share this with every single woman that you know, because what you're about to hear will change her life and yours. Without further ado, please help me welcome Dr. Jen Gunter to the Mel Robbins Podcast. Dr. Gunter, I'm so glad you're here.

   8. JGDr. Jen Gunter2:10

      I am so glad to be here.

   9. MRMel Robbins2:11

      So, Dr. Gunter, thank you so much for jumping on a plane, flying all the way across country to be here with us in Boston. I cannot wait to jump in and talk about menopause, bust the myths, have you empower us. I want to start by having you speak directly to the person who's listening who is either about to hit menopause, going through menopause, or maybe they're listening to this episode because somebody that they love has sent it to them. Could you talk to the person listening about what they are going to experience and what they're going to learn and how they're going to feel after they're done learning from you today?

   10. JGDr. Jen Gunter2:49

       Yeah. So I want you to feel seen if you're going through the menopause transition. I think so often women are made to feel small and they're not important, and women are uniquely affected by ageism. So you kind of have the double whammy at this time. So I'm hoping that you'll feel that your concerns are valid and they're important, and there are lots of options to do from a health standpoint, and there are many ways to take care of yourself. And I'm hoping that I can give you some tools to reframe what's going on with your body so you kind of know where you are and also give you tools to find help if you're struggling.

   11. MRMel Robbins3:30

       Well, Dr. Gunter, I'm in. I can't wait to hear everything you're about to teach us. Is there anything else?

   12. JGDr. Jen Gunter3:36

       Yeah. Team Menopause, I'm on it too. So I would say that menopause is a normal part of the ovulatory cycles that we have. And just like you went through puberty, which might have been challenging and had some symptoms and caused a lot of physical changes with your body, that menopause is n- in many ways the same thing. You can think about it as puberty in reverse. It is, you know, not a sign that your body is going to fall apart the next day. It is, um, not some new experience. I know there's a lot of people out there who think that, "Oh, because women are living longer now, they're just experiencing menopause," but that's not true. The ancient Greeks knew that the average age was about 50, which is about what it is now. And if we erase menopause, then we erase all the grandmothers in history, right?

   13. MRMel Robbins4:18

       Mm.

   14. JGDr. Jen Gunter4:18

       So, um, that it is a normal experience, but normal doesn't have to mean pleasant, right? So just like when you went through puberty, maybe you got acne or maybe you had really heavy irregular periods or pregnancy. Also a normal experience. Maybe you had terrible nausea and vomiting. Maybe you had other complications. So normal things can have complications. And I would say that, that there are things about menopause that can be very unpleasant for people. There's things that can be very liberating. People who've had terrible painful periods who now don't have them think it's amazing. People who've had maybe terrible PMS find that the, you know, the steady, you know, those, the lack of ups and downs of hormones are liberating. And so I would say that if you're suffering, there is often medical treatment for that.

   15. MRMel Robbins5:00

       Mm-hmm.

   16. JGDr. Jen Gunter5:00

       Uh, and that the best way to know how to make it a more pleasant experience or less onerous experience, depending on the spectrum you're on, is to get informed and have accurate information.

   17. MRMel Robbins5:11

       I've never heard anybody call it puberty in reverse. That actually makes a lot of sense.

   18. JGDr. Jen Gunter5:17

       Yeah. Well, just like your, you know, it's a, it's a different physiologic process, but, you know, you have a winding up, right? So when you go through puberty, you don't start and bang on have cycles regular. You, they sort of start and stop. They might be heavy. They, uh, you know, have the, have that sort of like flirting with it, if you will. Well, you have that same in kind of the last couple years. You have the starting and stopping with the periods, you're having the winding down of, um, ovulation. And so yeah, so they are, they're like bookends, a little bit different. Um, you know, and maybe like sisters, not twins. I don't know.

   19. MRMel Robbins5:46

       (laughs) What is happening to the body when you're going through menopause?

   20. JGDr. Jen Gunter5:51

       Yeah. So menopause, the menopause transition, which is the time leading up to menopause that, you know, you might also think o- heard called perimenopause or pre-menopause.

   21. MRMel Robbins6:00

       How long does that last?

   22. JGDr. Jen Gunter6:01

       Well, anywhere kind of from sort of 4 to 10 years depending. Just kinda like puberty, right? Like, a big range in how long it can last. Some people seem to have these late growth spurts, goes on forever. You know, some people relatively short, kind of the same thing.

   23. MRMel Robbins6:14

       Oh, wait a minute-Okay. So when you were talking about puberty, I was just thinking about getting my period. I wasn't thinking about all the other things that happened, like your breasts coming in, your body shape changing-

   24. JGDr. Jen Gunter6:31

       You're growing.

   25. MRMel Robbins6:31

       ... the fact that you grow taller.

   26. JGDr. Jen Gunter6:33

       Yeah.

   27. MRMel Robbins6:34

       Do we shrink when we're going through menopause?

   28. JGDr. Jen Gunter6:37

       Uh, not really. Um, certainly if you develop osteoporosis, you can. Um, but, uh, but no, otherwise not. And you, and it would be rare to develop osteoporosis, you know, in your late 40s or early 50s. That would be a really a sign there'd usually be something else going on significant. Um, but y- but over time, if you have osteoporosis, you certainly can lose height, and we wanna, wanna protect that. But yeah, puberty is, is a many years experience, right? You start to get pubic hair. You start to grow. You get breast buds. Your body shape changes. Um, you know, you, uh, you may, um, have mood swings. You may have acne, sort of this whole experience. And just like puberty might have ended at a different time for different people, some people stopped growing in grade seven. I was still, you know, growing in grade 10, grade 11, right? You have this big range. It's the same thing with-

   29. MRMel Robbins7:26

       Hmm.

   30. JGDr. Jen Gunter7:26

       ... the menopause transition. And so I would just encourage people to think about it more that way, that it is a change. And these changes, you know, don't happen overnight. Um, and, and it does suck that you get to go through it twice, and, and (laughs) you know, people without ovaries only get to go through it once. Um, but, but yeah, so it's, it's this physiologic change. And it's related to the, uh, decrease in the number of follicles or eggs that can ovulate. And so what happens sort of in response to the decreasing levels of estrogen that are produced, you get other hormonal changes. Your, your brain is trying harder to get the ovaries to ovulate. It can start to get, um, discoordinated, so you might get one ovulation right on top of each other. So some cycles you might have higher estrogen levels than normal. Some cycles you may not have progesterone. Some cycles might be shorter. Some you might preven- develop estrogen, not get progesterone, but still menstruate. So there's, it's basically hormonal chaos. And so it's, people mistakenly think of it as sort of this gradual smooth transition, but it's more like ch, ch, ch, ch, ch, ch, ch, ch, ch. But obviously there's variation. Uh, my best friend had regular cycles, and then her period stopped and she had one hot flash. And I'm like, that's kind of the-
2. 11:32 – 13:41

   3 non-hormonal interventions that will help with menopause symptoms..

   1. JGDr. Jen Gunter11:32

      So, but so what I'm saying is, is that, you know, going into menopause with that strong foundation, and it's not just, you know, cardio, resistance training. Exercise helps with your balance so you're less likely to fall. I mean, the number one risk factor for breaking a bone is actually falling, right? So, um, you know, so all of these things can be protected with exercise, but that's not a sexy sell. Like, if you could only ever do one thing for your health, it would be to get your exercise. I mean, and you don't wanna play favorites and say, "Well, you can only do one thing." But you know, you get what I mean. I'm just trying to emphasize how-

   2. MRMel Robbins12:04

      Mm-hmm.

   3. JGDr. Jen Gunter12:04

      ... important exercise is, and resistance training-

   4. MRMel Robbins12:06

      Mm-hmm.

   5. JGDr. Jen Gunter12:06

      ... and building muscle. And I'm always inspired by all these women in their 50s, 60s, and 70s on Instagram that are, like, showing, like, they're flexing, and their backs are just, they're just, like-... cut. And I'm just like, "Oh, yeah."

   6. MRMel Robbins12:19

      Never too late.

   7. JGDr. Jen Gunter12:19

      Yeah. Well, I'm working on it. So, um, so yeah. So exercise, eating, you know, 25 grams of fiber a day, um, trying to have, you know, more protein, many women don't eat enough protein, and trying to have more plant-based protein in your diet and having more vegetables. I mean, it's not the sexy stuff but it's the stuff. And then obviously not smoking.

   8. MRMel Robbins12:39

      Dr. Gunter, I just love how you explain this stuff. What is hormone replacement therapy?

   9. JGDr. Jen Gunter12:44

      So menopausal hormone therapy, which is what, what we call it, is, uh, giving, um, hormones to, uh, treat symptoms of menopause or to prevent, um, complications associated with menopause like osteoporosis.

   10. MRMel Robbins12:56

       Can you explain the different types of hormone replacement therapies, Dr. Gunter?

   11. JGDr. Jen Gunter13:01

       Yeah. So there's evidence-based, FDA-approved, and then there are scams. I would think that's the best way to sort it out. So many people get hung up on the term bioidentical, which is really a meaningless term. It's a medically meaningless term. Whether a hormone is the same or similar to what your body makes doesn't make it safe. I could give you a high amount of epinephrine, um, and, and, you know, cause harm to you. But that's something your body makes, right? So I can give somebody tons of estrogen and give them endometrial cancer. So whether something's similar to what your body makes or not doesn't make it safe. What makes it safe is, is it studied, is it safe, is it effective, and is it something that can be,

3. 13:41 – 14:47

   What is hormone replacement therapy and what are the different types?

   1. JGDr. Jen Gunter13:41

      um, we know exactly how much you're getting?

   2. MRMel Robbins13:43

      Mm.

   3. JGDr. Jen Gunter13:43

      So one of the big problems is a lot of people are using compounded medications or pellets. And we don't know what's actually in those things from a, you know, from an actual amount of hormone. So if I give you an estrogen patch, I know how much is gonna be absorbed. I c- I, you know, there, there have been studies that have been done. I know if you put it on a different body part, that it's gonna affect absorption 'cause all of this has been done. With compounded products, none of that exists.

   4. MRMel Robbins14:11

      Mm.

   5. JGDr. Jen Gunter14:11

      None of it. I don't know how much is getting across your skin, I don't know how much you're ingesting, I don't know how much is being absorbed. And would you wanna have a, a broken gas gauge or would you wanna have a gas gauge that works? You would wanna know what you're putting into your body, right? So, um, so I would say there are FDA-approved therapies and there are many good ones out there. So there are, you know, um, es- there's estradiol, which is the main hormone that the ovary makes and we have pharmaceutical variations of those. Another big myth is that some hormones are plant-based, and, um, you know, that again is, um, a marketing jargon.

   6. MRMel Robbins14:46

      Is that not

4. 14:47 – 16:12

   Is plant-based hormone replacement therapy even a thing?

   1. MRMel Robbins14:47

      true?

   2. JGDr. Jen Gunter14:48

      Well, I mean, petroleum's plant-based too if you wanna look at it that way, right? So, you know, so I, you take soybeans and then you ex- you expose the chemical that you extract from soybeans to a multi-step chemical process to break bonds and convert it into estradiol. So yeah, it's plant-based but it's not. You know, they use just starting chemical found in a plant and converted it into estradiol. That doesn't make it any better than if I made estradiol by assembling it from different molecules.

   3. MRMel Robbins15:27

      Mm.

   4. JGDr. Jen Gunter15:27

      It's the same thing. Your body can't tell the difference. We just make it from soybeans, which is called semisynthesis, 'cause it's cheaper than making it by synthesis, which is assembling the molecules itself. So it's a total marketing thing. It, plant-based, it means nothing. Nobody's grinding up yams and putting them into pills and giving them to you.

   5. MRMel Robbins15:50

      How do I know that I'm doing the right thing? Like, I, I listen to you and I'm like, "Yes, yes, yes, I love it. Take it down, take it down. Go, go, go. Dr. Gunter, thank God you're out there (laughs) cleaning up the internet for us." But then I'm like, "Shit, what, what am I ask, what am I asking my doctor?" Like how, like so, so if I'm going into my gynecologist

5. 16:12 – 18:34

   What you should ask your doctor about your hormones for the next appointment.

   1. MRMel Robbins16:12

      and I'm interested in hormone replacement therapy-

   2. JGDr. Jen Gunter16:14

      Mm-hmm.

   3. MRMel Robbins16:16

      ... what is the proper thing to ask for so that I am in the land of research and in the land of things that we can measure versus in the kind of fringe areas of-

   4. JGDr. Jen Gunter16:28

      Right.

   5. MRMel Robbins16:28

      ... the other stuff?

   6. JGDr. Jen Gunter16:29

      So if you're getting a prescription that doesn't have a package insert with it, like, you know-

   7. MRMel Robbins16:33

      What does the package insert mean?

   8. JGDr. Jen Gunter16:34

      So, you know, you, whenever you get any prescription and there's this little folded up book and you unfold it and it's like all the risks and benefits and it's like-

   9. MRMel Robbins16:40

      Oh, yeah.

   10. JGDr. Jen Gunter16:41

       ... this big thing. If it doesn't have that, then it's not FDA-approved.

   11. MRMel Robbins16:44

       Oh.

   12. JGDr. Jen Gunter16:45

       Okay?

   13. MRMel Robbins16:45

       So all the things that you get from the compound pharmacy, not FDA-approved.

   14. JGDr. Jen Gunter16:50

       No.

   15. MRMel Robbins16:50

       Because they haven't, like how could they be?

   16. JGDr. Jen Gunter16:52

       Right.

   17. MRMel Robbins16:52

       'Cause the packaging has been through clinical trial after clinical trial and it's had to have been tested and passed through all these hoops for your safety and so that you as a doctor can understand-

   18. JGDr. Jen Gunter17:03

       Right.

   19. MRMel Robbins17:04

       ... what you're actually prescribing me.

   20. JGDr. Jen Gunter17:05

       Yeah. So there's this whole sort of loophole for compounded medications, and so they don't have to have that package insert. They don't have to tell you about risks of blood clots or risks of this. They don't have to tell you any of that. So that's a big problem and it makes people think that they're safer because, look, if I gave you two things, one had a list, it had a, it said, it had a black box warning on it-

   21. MRMel Robbins17:25

       Right.

   22. JGDr. Jen Gunter17:25

       ... and the other one didn't, you're gonna automatically think the one that doesn't have the black box warning on is safer. Well, it doesn't have the black box warning 'cause it wasn't required 'cause it's not FDA-approved.

   23. MRMel Robbins17:34

       Oh my God. You know, when I was going through perimenopause, I got bioidentical hormones from a compound pharmacy and I thought I was fancy. I thought, "This is, like, high-end medicine. They have taken something from me." I, like this is how, how uninformed (laughs) I was. They have literally, because of the word bioidentical-

   24. JGDr. Jen Gunter17:57

       Right.

   25. MRMel Robbins17:57

       ... I thought it meant, "Oh, well, somehow this is custom formulated for me to match my hormones. It is bioidentical," which sounds really fancy and trustworthy. And then I would get this packet from a compound pharmacy and it would have these, like, tubes in it and there were all these warnings like, "Don't expose to light. Don't do this. Do that." Now, did I follow those? Of course not. Was I precise in how much I would squirt on my wrist?No, if I'm being honest. Um, and so I thought that I was having the better result when I can see now

6. 18:34 – 20:22

   Don’t make this ONE menopause mistake.

   1. MRMel Robbins18:34

      what you're basically saying is that, no, not really.

   2. JGDr. Jen Gunter18:37

      You were having the inferior. You were paying more and getting less because we all think when, when someone's customizing something for us that we're getting better. Uh, we're trustworthy. We, we believe people. And, uh, no menopause society recommends compounded hormones. They're not recommended by the North American, or we now call them, they're now called the Menopause Society. The National Academies for, uh, Science, Medicine and Engineering don't recommend compounded hormones. The International Menopause Society, the British Menopause Society, none of them recommend compounded hormones because it takes science and research to know how to get hormones through a skin. It takes science and research to know how to get them from your gut into your bloodstream. When you make hormones, they just get dumped into your bloodstream from your body. You're not eating them. You're not absorbing them. You're not rubbing them on your skin. You didn't evolve to get hormones that way. Now, it doesn't matter, you, that we have modern medicine for a reason.

   3. MRMel Robbins19:32

      Right.

   4. JGDr. Jen Gunter19:32

      So, you know, it doesn't mean you shouldn't take them because we didn't evolve for that. But funny thing, it takes science to figure out how to make these molecules work for us. And so there are several issues with using compounded products. People may be getting more of a hormone than they're, they, they think they're getting.

   5. MRMel Robbins19:49

      Mm-hmm.

   6. JGDr. Jen Gunter19:49

      So you might be getting more estrogen than you need, which could put you at risk for endometrial cancer. You might be getting not enough progesterone, which would put you at risk for endometrial cancer, or you might not be getting enough estrogen putting you at risk for osteoporosis so you think that you're, you're preventing osteoporosis, but you're not. Why would you want... So this is the analogy I use. Using FDA approved hormones is like going to the gas station that has the gallons on it and you can choose, you know, whichever gas you want. You fill your car and you have a working gas gauge, and you're like, "I know what's

7. 20:22 – 26:02

   What you need to know about “compounded” hormones.

   1. JGDr. Jen Gunter20:22

      in there," and that's important. Going to, uh, getting these compounded formulations or pellets is like buying gas from a dude on the side of the road who's telling you he has bespoke gas for you. And let him fill your tank, and oh, he's gonna flip that switch off so you don't know how much is in there 'cause you should trust him because he knows. That's the difference.

   2. MRMel Robbins20:43

      I am speechless. Like it's, it's not very often that I don't have anything to say.

   3. JGDr. Jen Gunter20:50

      (laughs)

   4. MRMel Robbins20:50

      And you just took a flamethrower to the entire idea of bioidentical hormones. I would never ever try it again. And then I would add on top, by the way, you've brought the science and the research and a very compelling analogy. I'm gonna add one more. As somebody who already has ADHD and has increased brain fog due to menopause, I am not that great at being consistent, at storing things the right way, or using it the right way. And so I'm probably over or under dosing even if it was made in a way that was clinically sound. And so case closed, not doing bioidentical hormones.

   5. JGDr. Jen Gunter21:37

      Yeah. And I would say move away from using bioidentical and just call them compounded 'cause bioidentical doesn't mean anything. So bioidentical is a marketing term used to describe hormones that are plant-based, that are identical to what your body makes. But estradiol that you get from an FDA approved, uh, company, uh, you know, I use an estrogen patch. It's estradiol.

   6. MRMel Robbins22:02

      I've got it on right now.

   7. JGDr. Jen Gunter22:03

      The estradiol in the patch is no different from the estradiol the compounding pharmacy is using. They're both buying the raw hormone from the same place.

   8. MRMel Robbins22:12

      Mm-hmm.

   9. JGDr. Jen Gunter22:13

      The difference is the pharmaceutical company has studied how to give that estradiol to you in a reliable dosing manner. The compounding pharmacy has not done that work. They don't have that. And because of that, they're not FDA approved because you have to show to the FDA, and it's expensive. You have to do all those kinds of... So, so they, they haven't submitted that data. They're just making things up. So you have a precise studied formulation, but the big thing is they're not buying fancier hormones. All the raw hormone comes from the same one or two plants in the world. It's like me buying Cheerios and putting them in a Cheerio box or putting them in a glass jar-

   10. MRMel Robbins22:59

       Mm-hmm.

   11. JGDr. Jen Gunter22:59

       ... with a ribbon around, but it, they're the same product, ex-

   12. MRMel Robbins23:02

       Gotcha.

   13. JGDr. Jen Gunter23:03

       ... except-

   14. MRMel Robbins23:04

       The delivery mechanism.

   15. JGDr. Jen Gunter23:04

       ... the delivery mechanism is different.

   16. MRMel Robbins23:06

       Gotcha.

   17. JGDr. Jen Gunter23:06

       So that's why I tell people, you know, the, every, every estrogen that I would prescribe you from the FDA or from an FDA approved source with the exception of Premarin, is bioidentical and

   18. MRMel Robbins23:21

       So bio-

   19. JGDr. Jen Gunter23:22

       ... plant-based.

   20. MRMel Robbins23:22

       So everything is the same.

   21. JGDr. Jen Gunter23:23

       So just forget that, we just forget that word.

   22. MRMel Robbins23:25

       Got it. Okay.

   23. JGDr. Jen Gunter23:26

       Yeah, because the s- so when people use the word bioidentical, it tells me that they think women are dumb.

   24. MRMel Robbins23:33

       Well, clearly I am in this area.

   25. JGDr. Jen Gunter23:34

       No.

   26. MRMel Robbins23:34

       Well, no, seriously. I, I'm, I can own it because here's the thing, it is confusing as hell.

   27. JGDr. Jen Gunter23:39

       Right.

   28. MRMel Robbins23:39

       And there's so much misinformation.

   29. JGDr. Jen Gunter23:41

       Right.

   30. MRMel Robbins23:42

       And when you walk into the doctor's office and you are simultaneously erupting at your family because you're all over the place with your emotions, I'm speaking for myself here. And then next thing you know you're sweating like Niagara Falls. And then next thing you know your vagina feels like the Sahara Desert. And next thing you know you can't remember where your car keys are or where you put your dog because you can't remember. Like, and you are losing your mind. And somebody says to you, "Oh, bioidentical, and I can send you out." You're like, "Thank you, I'll take it." Whatever. And so I had no idea.
8. 26:02 – 28:48

   How do you even know what is FDA approved and safe to use?

   1. JGDr. Jen Gunter26:02

      right? So the quality, you're talking about a whole different thing in quality control, right? So the only time we ever recommend a compounded product is if there is a true allergy to an ex- to, you know, there's no pharmaceutical option because of a true allergy. And that's where we, you know, rely on compounding pharmacies for that situation. So, you know, one example might be, um, Prometrium, w- uh, pro- oral progesterone. The brand in the United States is made with peanut oil. So if you have-

   2. MRMel Robbins26:35

      Mm.

   3. JGDr. Jen Gunter26:36

      ... a peanut allergy, you can't take that product. So the options are then to take a different pharmaceutical-

   4. MRMel Robbins26:42

      Mm-hmm.

   5. JGDr. Jen Gunter26:43

      ... or to get progesterone compounded by a compounding pharmacy without peanut oil.

   6. MRMel Robbins26:48

      That makes sense.

   7. JGDr. Jen Gunter26:49

      Right. So-

   8. MRMel Robbins26:49

      So in that instance, where you have a real allergy, you might recommend a compound pharmacy, but otherwise, 100% as literally the number one gynecologist myth busting, you are out there setting the medical facts straight, the Menopause Society and your medical recommendation is to absolutely not be using the compounding formulas, but to be using the FDA approved delivery mechanisms that are prescribed by your OB GYN.

   9. JGDr. Jen Gunter27:19

      Right.

   10. MRMel Robbins27:19

       Wow. I am learning so much and I know you are too. And we need to take a quick break to hear a word from our sponsors. And while you listen to the amazing sponsors, would you please share this episode with someone who needs to hear it, which is basically every single woman in your life? And don't you dare go anywhere, because when we come back, we are going to keep talking about exactly what you can do to relieve the symptoms of menopause. We have so much more to learn from the amazing Dr. Jen Gunter, and later on we're going to talk about exactly how you can talk to your doctor in order to get the care that you need. All right, stay with us. We'll be right back. Welcome back. It's your friend Mel Robbins and I am here with the incredible myth busting and unbelievably empowering Dr. Jen Gunter. She is telling you everything that you need to know about menopause. So Dr. Gunter, how do I know that I'm doing the right thing?

   11. JGDr. Jen Gunter28:15

       What people need to remember to, the takeaway is, there's really very few things you need to know about hormones. The, the two main estrogens that we recommend are either estradiol, and if you're stuck on the term bioidentical, that is bioidentical. Now, I'd like people to throw that term away, but sometimes it's hard. So the estradiol that I would give you in a patch or a pill from a pharmaceutical company, that is bioidentical, right?

   12. MRMel Robbins28:40

       Mm-hmm.

   13. JGDr. Jen Gunter28:41

       So you have that. So you, you want to learn estradiol and then you want to learn Premarin, which is conjugated equine estrogens.

9. 28:48 – 30:03

   The only 2 hormones you need to know about for longevity & vitality.

   1. JGDr. Jen Gunter28:48

      And that's only actual natural estrogen 'cause it comes from horse urine. So nat-

   2. MRMel Robbins28:52

      Horse urine?

   3. JGDr. Jen Gunter28:53

      Yeah.

   4. MRMel Robbins28:53

      Ooh.

   5. JGDr. Jen Gunter28:53

      Natural, natural means the substance exists in nature-

   6. MRMel Robbins28:57

      Okay.

   7. JGDr. Jen Gunter28:57

      ... and it's being used unchanged. So-

   8. MRMel Robbins28:59

      How the hell did they figure out that horse urine is something that-

   9. JGDr. Jen Gunter29:02

      Oh. Yeah, horse urine's got all kinds of estrogens in it. It's a crazy thing. So, those are the two things you need to learn. You need to learn estradiol and you need to learn Premarin, which is the trade name for conjugated equine estrogens. And then you need, then you need to learn oral or transvaginal or transdermal. So against the skin, through the vagina, or by mouth.

   10. MRMel Robbins29:22

       Gotcha.

   11. JGDr. Jen Gunter29:22

       Right? And we recommend, the number one starting treatment we generally recommend is transdermal estradiol.

   12. MRMel Robbins29:29

       Here, I'll show you. I'm about to show you mine right now.

   13. JGDr. Jen Gunter29:31

       (laughs)

   14. MRMel Robbins29:31

       'Cause I'm probably due to take it, um, oh, I have to do it like every four days. Let me get down here. Okay, here it is. So this is... And look, my dead skin is on it. That's disgusting.

   15. JGDr. Jen Gunter29:41

       Yeah. So you have a patch? Yeah.

   16. MRMel Robbins29:42

       Yeah, so I have a patch. I'm gonna hold it up right there.

   17. JGDr. Jen Gunter29:45

       Yeah.

   18. MRMel Robbins29:45

       I have to replace it every four days. Changed my life. And so I can trust, I trust knowing that if I put this on every four days, and this is considered transdermal?

   19. JGDr. Jen Gunter29:55

       That's transdermal. It goes through the skin, yeah.

   20. MRMel Robbins29:57

       So if you were to like, I wouldn't put it here obviously.

   21. JGDr. Jen Gunter29:59

       Yeah, you don't wanna-

   22. MRMel Robbins30:00

       But you just stick it to yourself.

   23. JGDr. Jen Gunter30:01

       Yeah, but you only want to put it in

10. 30:03 – 32:07

    Do you want to see Mel’s hormone replacement therapy patch?

    1. JGDr. Jen Gunter30:03

       the place that the package insert says.

    2. MRMel Robbins30:05

       Yeah.

    3. JGDr. Jen Gunter30:05

       Because it's been studied, they've studied it in different locations that the absorption can change. So if you put it on your belly versus putting it on your thigh or putting it on your butt, you might get a different absorption of the amount of estrogen, and you don't want that. You want to know what you're getting. Right?

    4. MRMel Robbins30:19

       Yeah. That's right. And you know, I, I've also learned, 'cause I had no idea that you could also insert something into the vagina...... for hormone replacement therapy.

    5. JGDr. Jen Gunter30:28

       Yeah.

    6. MRMel Robbins30:29

       I should probably button my pants to finish the, uh-

    7. JGDr. Jen Gunter30:31

       (laughs) .

    8. MRMel Robbins30:31

       ... the interview here.

    9. JGDr. Jen Gunter30:32

       Yes. So there's, um, a transvaginal ring that also has estrogen and can be absorbed that way into the s- into the body, and there's also a ring where the estrogen just stays in the vagina. And, uh, if you're having vaginal dryness, you have urinary tract infections, pain with sex, vaginal estrogen can be very effective for that.

    10. MRMel Robbins30:52

        Mm.

    11. JGDr. Jen Gunter30:52

        And, uh, so some people who have no other symptoms of menopause, feel great, they feel fine, but they have vaginal dryness, they don't wanna take a medication that goes throughout their body, they wanna just use a vaginal estrogen. So we have that. That's a great option. Uh, when you're using, uh, estrogen that goes through your body, about 50% of people will get a good level in their vagina, but some people won't. But from a take-home standpoint, there's absorbing through the skin or through the vagina-

    12. MRMel Robbins31:16

        Mm-hmm.

    13. JGDr. Jen Gunter31:17

        ... and there is taking it by mouth. And we believe that absorbing it through the skin has the lower risk of blood clots. So that's why what people need to learn is the first line therapy for menopause is transdermal estradiol.

    14. MRMel Robbins31:31

        You mentioned pellets a couple times. What are those?

    15. JGDr. Jen Gunter31:34

        So pellets are implants that you go to a medical doctor or a nurse practitioner, and I think maybe even in some places there's naturopaths who insert them, I don't really know 'cause I- I'm not really involved with it. Maybe they don't. I- I'm not sure. Uh, and they, um, they ha- they can either have estrogen, they can have estro- estrogen and testosterone, maybe they have other hormones in that, I don't really know, and they're, um, made in compounding pharmacies and they're implanted. They're not batch-tested, so you don't know how much hormone you're getting, and it's... My understanding of it is it's based on a proprietary

11. 32:07 – 38:29

    What the heck are “pellets” and are they safe to use?

    1. JGDr. Jen Gunter32:07

       system. So you get your blood drawn, they follow your hormone levels, and then they decide when you get the next pellet based on that. But we don't recommend hormone levels for- for, you know, for giving hormone therapy. It's not based on levels, it's based on symptoms. I don't need to know what your estrogen level is if you're 47 and starting it. I don't even need to know what your estrogen level is when you're 42; I only need to know that if I'm worried that you have premature menopause, right? So th- this sort of system, and it's just, it's not recommended. Um, there have also been issues with pellets, with, um, with complications and side effects not being reported to the FDA, which is also another, you know, another concern. So we don't actually know how many people have problems versus, you know, pharmaceutical companies when they're- get adverse events reported, those are, you know, passed on to the FDA, 'cause there's big penalties, my understanding, for not doing that. So...

    2. MRMel Robbins32:56

       So is the pellet a delivery mechanism?

    3. JGDr. Jen Gunter32:58

       Yeah. So it's a, it's a implant that, you know, that sits in the body. I- I, it's 'cause I don't do it, I don't really know that much about it 'cause it's not recommended, right?

    4. MRMel Robbins33:06

       Right.

    5. JGDr. Jen Gunter33:06

       You know, I don't know that much about it. But, um, it can, what it can happen is it can produce very, very high levels of hormones, and then it drops off. And in some cases, you know, you can be exposed to the levels of testosterone that, you know, we might give someone if they're transitioning, right? So the kind that can, you know, cause you to develop an enlarged clitoris, the kind that, you know, can cause you to develop, you know, these changes from having too high of a testosterone. We don't know, when you're using those hormones, then how much progesterone to give you to protect your uterus. So there's all different kinds of issues associated with them, and they're very expensive as well. So, you know, they're- they're just not recommended.

    6. MRMel Robbins33:42

       Do you have to have your blood drawn to have this, uh, assessed-

    7. JGDr. Jen Gunter33:46

       No.

    8. MRMel Robbins33:46

       ... effectively? No?

    9. JGDr. Jen Gunter33:46

       No. And if anybody, if you're 45 years or older, you do not need a blood test to get started on menopausal hormone therapy. You know, if you're 11 and having a growth spurt, no one's like, "Ooh, why are you having a growth spurt? We should check your blood." We would expect you to have a growth spurt at age 11. If you had a growth spurt at age three, that would be different.

    10. MRMel Robbins34:06

        True.

    11. JGDr. Jen Gunter34:06

        And that's the same thing for menopause. So if you're 45 or older and you're having hot flashes, you're having vaginal dryness, you're having irregular periods, it's not a mystery. We're expecting it to happen. The average age of menopause is 51, right? However it's happening to you when you're 39, well, that's different.

    12. MRMel Robbins34:23

        Mm-hmm.

    13. JGDr. Jen Gunter34:24

        We need to know is this m- an earlier menopause, or is this happening for another reason? And so if you're under the age of 45, you need the blood work because you need to make sure that you understand why your periods have stopped. Now, if you're just having hot flashes, that's a different story. So the blood work is really if you've skipped periods. So say you're 42, you haven't had a period in, in three months, you need to have blood work, 'cause we should figure out why that's happened.

    14. MRMel Robbins34:50

        Yep.

    15. JGDr. Jen Gunter34:51

        But if you're 45 and you're having bad hot flashes and you've had a couple of irregular periods-

    16. MRMel Robbins34:56

        That was me.

    17. JGDr. Jen Gunter34:56

        ... that's no mystery. You're starting in the menopause transition. And right, if the, the average age of onset for the menopause transition is 45, well, you know what? 50% of people are gonna be younger than 45, and 50% of people are gonna be older. So yeah, so it has to be put in context. And so that's... The internet wants absolutes. The internet wants, "Test my hormones, don't test my hormones." The internet wants, you know, this or that. But medicine is more nuanced than that, and so the only absolute I can say is if you're younger than 45 and you've skipped more than two periods, then you need to have blood work done, 'cause we need to know why. Is it an earlier menopause? Is it another condition that's caused your periods to stop? If you're 45 or older, w- it's not a mystery why you've gone two months without a period.

    18. MRMel Robbins35:40

        Mm-hmm. That makes a lot of sense.

    19. JGDr. Jen Gunter35:42

        One thing that we didn't talk about is one of the, uh, contraindications for starting estrogen is being more than 10 years from your last period or over the age of 60. And so, in general, um, that is associated with an increased risk of dementia and an increased risk of cardiovascular disease. So we sort of want to avoid starting it when people are older. Now, it doesn't mean like, you know, age 60, if you're 60 years and one day, that that's like, you know, a hard stop, you know? But I think it's just important for people to understand that, uh, that there's a kind of a timing. And so, you know, so if somebody, for example, their last period was 55, y- we might not cut them off at 60, 'cause you know, they've-D- so, it's a bit of-- there might be a bit of wiggle room there. But in general, we recommend, you know, if people are going to start hormones, that it's gonna be within 10 years, uh, under the age of 60. That's kind of the ideal situation and the lowest risk situation.

    20. MRMel Robbins36:38

        I can't believe I didn't know this. In fact, I can't believe how much I'm learning from you today. I thought I knew a lot about this topic, but you're just constantly amazing me with new information. And I know as you listen, you're thinking the same thing. And we also need to take a quick break to hear a word from our sponsors because they allow me to bring you world-class expert advice from the amazing Dr. Jen Gunter. So, do me a favor, listen to our sponsors, and please take a minute and share this episode with someone who needs to hear this. This could truly change their life. And don't you dare go anywhere because when we come back, I'm gonna be waiting here with Dr. Gunter, and you're gonna hear more on how to deal with your symptoms, plus how to talk to your loved ones so that they better understand what you're going through, and how to talk to your doctor so you get the care that you deserve. Stay with us. Welcome back. It's your friend, Mel Robbins. I am here with Dr. Jen Gunter. So, Dr. Jen Gunter, one of the things that I'm sitting here thinking about is the fact that my friends and I all talk about menopause, right, because we're all in the thick of it. But more than half of the women that I know are scared of HRT. And I know it's because of the fact that, I think it was 1991 when there was a huge study that was released, I think it was the Women's Health Initiative, that cast HRT in a negative light. And if I really think about it, it was 1991, I was just out of college and my mom was going through menopause. And I remember the huge debate was that HRT causes cancer, and it casts such a negative light on this therapy that's available for women to treat menopause symptoms. And I understand that the study has been harshly criticized.

12. 38:29 – 42:25

    Does HRT increase the risk of breast cancer?

    1. MRMel Robbins38:29

       It's now 30 years later, but it's very clear to me that the fear that it created, it's still lingering, and it's keeping a lot of women from even exploring hormone replacement therapy as a safe option for them. Can you tell us more about this study and how you think about it as a medical doctor?

    2. JGDr. Jen Gunter38:48

       Well, the Women's Health Initiative was the largest clinical trial I think that's ever been done. So, it was designed to tell whether hormone therapy, menopausal hormone therapy was going to actually reduce the risk of heart disease, um, and, uh, without increasing the risk of breast cancer. And it was also, there were other arms that looked at exercise, that looked at calcium, so the, the, calcium replacement. So, there were quite a- quite a few different arms with the Women's Health Initiative.

    3. MRMel Robbins39:13

       Mm-hmm.

    4. JGDr. Jen Gunter39:14

       And the arm with estrogen plus, uh, so, when it was Premarin that was used, Premarin plus a progestin. Um, that was stopped early because they reached the threshold of concern about breast cancer. Now, going into the Women's Health Initiative, we, we knew that there was a very low risk of breast cancer associated with menopausal hormone therapy. So, this wasn't, like, a surprise. This was kind of the threshold that was reached. And it was communicated to the public, you know, in a way that is typically not done. You know, usually there aren't press releases when a- when a study is halted. Usually, we wait, we get the data, the jor- the article is published. So, you know, it's peer-reviewed and we have all of that, and that didn't happen, and that created this big hoopla where lots of things got taken out of context, lots of things sort of accelerated in ways that, you know, were uncontrollable because fear sells, right? So, it- I don't know how many major news stories were dedicated to the WHI, but it was really out of proportion, right? And then when- when more information came out and when there were more studies that came out, you know that never gets the same attention, right?

    5. MRMel Robbins40:25

       Yes.

    6. JGDr. Jen Gunter40:25

       So, we know that estrogen plus a progestin is associated with an increased risk of breast cancer. But those aren't the hormones that we typically prescribe now. So, that's kind of the difference. You know, we- we believe that the progestins, which are slightly different molecules than progesterone, carry the higher breast cancer risk. It's still acceptable and in the safe range to take that the hormone progesterone is lower risk, and that if you don't need a progesterone or a progestin, that that risk is the lowest. So, I would say to people, you know, if you're taking a transdermal estrogen and oral progesterone, which is our standard starting therapy, we believe that the risk of breast cancer is very low. You know, we- it's not probably zero, but that it is very, very low. We believe that if you're taking estrogen alone, that risk is even lower. Some people believe it's zero, other people believe it may be a little bit higher. So, this- and again, it depends how you look at the data. So, absolutes are very difficult, right? Um, and- and so the risks are very low. So, if you're somebody suffering with hot flashes, if you're somebody who is at high risk for osteoporosis, if you're someone who's struggling with depression in the menopause transition, if you have things that estrogen can treat, then those risks are likely very small, you know, in comparison. However, if you're at someone at very high risk for cardiovascular disease, uh, then estrogen may not be the best therapy for you. Um, and so it really comes down to kind of an individualization. But I would say for the majority of people who are suffering with symptoms related to menopause, who have things that hormone therapy can treat, that menopausal hormone therapy appears to be a very, very safe option. Um, and you just have to look at it in context. If you're somebody who is at h- you know, higher risk for cardiovascular disease, but not super high risk, then transdermal is probably okay,

13. 42:25 – 46:12

    How to know if HRT is a safe option for you?

    1. JGDr. Jen Gunter42:25

       but oral isn't, because there's a higher risk of blood clots associated with oral.

    2. MRMel Robbins42:29

       Gotcha.

    3. JGDr. Jen Gunter42:29

       So, you just have to look at what is it gonna do for you. So, I'm very high risk for osteoporosis. My mother died from osteoporosis. I have quite a high FRAX score, which is a risk calculator. And so, that's the main reason that I'm on menopausal hormone therapy because...... my risk of osteoporosis is pretty significant, and I'm already kind of, you know, getting closer and closer to osteoporosis. I have osteopenia. So, and, you know, it- it's, you know, it's a concern for me from a health standpoint. So, so that's why I'm taking it. And so, you know, people always want us to say, like, zero risk-

    4. MRMel Robbins43:01

       Mm-hmm.

    5. JGDr. Jen Gunter43:01

       ... for this and, and, you know, getting in a car has a risk. So, so I always like to sort of not talk in those kinds of absolutes and say, say, "What's the reason you're on it? And what is the risk-benefit ratio for you?" And for the majority of people, the risk-benefit ratio is absolutely gonna be in the favor of benefit. But there are some situations where it might not be. So for example, um, you know, somebody at very high risk for cardiovascular disease, someone who's previously had a blood clot, someone who's previously had a heart attack. So you have to put it in perspective.

    6. MRMel Robbins43:35

       Thank you for that because, Dr. Gunter, I've been really surprised by the number of my friends who are suffering through menopause and perimenopause and just completely the quality of their life is impacted, who have been afraid to try hormone replacement therapy or even talk to their doctor about it because somewhere in the back of their head, they're, they think it causes breast cancer, and that's why they're not even considering it. And so I appreciate you just kind of clearing the air a little bit so that people know that you should at least go talk to your doctor about it.

    7. JGDr. Jen Gunter44:16

       Yeah, and there are calculators that can help you determine your breast cancer risk, right? So I would recommend, we- I think we heard it was Olivia Munn who was talking about... I- I believe that's who it was recently talking about she'd, you know, had a breast cancer risk assessment which led to her having an MRI, which led to an early diagnosis of a breast cancer. And so there's all kinds of sort of, there's several easy tools that we can do to help explain things more in context for you. So if somebody comes to me and, and they have something that menopausal hormone therapy can help, well, I do something called an ASCVD score. It calculates your, your cardiovascular risk. And, you know, we need your lipids and we need to know your blood sugar and your blood pressure and a few other things, and so we can calculate that. I need to see a mammogram and I need to ask you some questions about your breast cancer history risk. And that's important because at a certain level, when your breast cancer risk is higher based on other factors-

    8. MRMel Robbins45:06

       (clears throat)

    9. JGDr. Jen Gunter45:06

       ... there's also a conversation to be had about medications that lower your risk of breast cancer. So, you know, there, so it, there's bigger discussions to have, but so you, you can do these risk calculators and you say, "Look, well, I'm somebody who's got hot flashes." Menopausal hormone therapy's the gold standard. "I have low risk for these other reasons, so there would be no reason not to go on it." But again, everybody weighs risks differently, right? And so, you know, versus you're somebody that, ooh, you've, you've got a pretty high cardiovascular risk, so can we talk about one of these other treatments for your hot flashes? Or you're somebody who's got a history of breast cancer, so can we talk about one of these other medications for hot flashes?

    10. MRMel Robbins45:43

        I wanna, uh, ask a couple more questions about HRT. So someone listens to this episode. They feel very seen and validated. They go into their OB GYN. They, you know, kinda say, "I wanna, I wanna assess the risks." And let's just say you try it. Okay, you make the personal decision with the recommendation of your doctor to go on the standard protocol.

    11. JGDr. Jen Gunter46:10

        Mm-hmm.

    12. MRMel Robbins46:10

        How do you know if it's working?

14. 46:12 – 48:02

    If you are struggling with menopause, you need to hear this.

    1. MRMel Robbins46:13

    2. JGDr. Jen Gunter46:13

       Well, so are your symptoms improving? So it's really, you know, except- except for-

    3. MRMel Robbins46:19

       And how long does it take?

    4. JGDr. Jen Gunter46:20

       Um, pretty quick. So, so unless you're someone like me taking it for osteoporosis prevention, 'cause I don't feel any different, right?

    5. MRMel Robbins46:28

       (laughs)

    6. JGDr. Jen Gunter46:28

       So, you know, and that's, again, a really important reason to take an FDA approved medication 'cause I want it to protect my bones. I need to know what I'm absorbing, right? So, um, so if you're, have hot flashes, most people see a pretty significant improvement within four weeks. Um, you know, depending on how, how much better people feel, sometimes we might, you know, give an eight-week try before switching doses. Uh, and it just depends on how people feel on the medication. So yeah, so, you know, usually with something like, uh, hot flashes, you know, you're gonna see an improvement pretty quickly. With depression, usually within a couple of months as well. And, uh, you know, e- there are also... So I always like to talk about with menopausal hormone therapy, there's sort of green light indications, meaning these are, like, the FDA approved, you know, solid reasons. Hot flashes, night sweats, gold standard. Uh, uh, osteoporosis prevention, FDA approved. And if you have... And we didn't talk about this, but if you have menopause before the age of 45, we do recommend everybody take hormones regardless of symptoms until at least the average age of menopause. And then at that average age, you can decide if you wanna stay on or not like everybody else.

    7. MRMel Robbins47:38

       What is the average age of menopause?

    8. JGDr. Jen Gunter47:40

       51. So, um, but so say you're starting it for... So you've got these green light indications. Great. Everybody believes that the, you know, the, the benefits outweigh the risks as long as you're in the, you know, the right category for that. Um, then there are sort of more yellow light indications, things where it hasn't broached where it's recommended in the guidelines, but there's pretty

15. 48:02 – 50:30

    What the real reason for brain fog during menopause is.

    1. JGDr. Jen Gunter48:02

       good data to support it. So for example, depression in the menopause transition can be very helpful for that. Many of us would try it if somebody's got a sleep disturbance, even if they don't think they're waking up with hot flashes, because sometimes people don't wake up, but what it's doing is it's disrupting your sleep architecture and then you're, so you don't have as much deep sleep. So it might be worth a try to see. Like for example, I still get the occasional hot flash, but even when I was, like, I don't wake up, but I'm so hot I wake my partner up.

    2. MRMel Robbins48:29

       Mm.

    3. JGDr. Jen Gunter48:30

       I'm just a super deep sleeper, right? But I've still had disrupted sleep. So you might not realize that, so it might be worth a try to see. Um, the data for joint pain, it's not really that great. I mean, maybe it's gonna help 20% of people with joint pain, so it wouldn't mean it would be wrong to try, but it would be, you know, you just wanna, you know, if it, it doesn't work, you're not gonna keep, like, pushing the dose higher and higher and higher 'cause you're like, "Oh, well, you know, it, it was a chance and, you know, maybe it's gonna work, maybe it's not."There is some evidence to show that it may reduce your risk of type II diabetes. So again, if you're somebody at very, very high risk, that might be a conversation to have. So those are kinda, like, these yellow light indications. Um, and then, you know, there are, you know, if you have brain fog. So, brain fog specifically, there aren't studies to tell us that estrogen treats brain fog. And in fact, people perform better than they think when they have brain fog, so on cognitive testing. So it's kind of this symptom that don't, we don't really understand. So you could certainly have brain fog from depression, right?

    4. MRMel Robbins49:32

       Mm.

    5. JGDr. Jen Gunter49:32

       You could have brain fog 'cause you're not sleeping well. You could have, you know, so all of these other things could come into play. So- so, but if your only symptom were brain fog, then I might be like, "Mm, you know, it's less clear you're gonna get a benefit from that." Um, and you know, maybe there's a discussion to have about what might be the other factors. But if you've also sc-, you know, we've done a depression questionnaire, you're scoring higher for depression, well brain fog's a symptom of depression too, right? So let's get that treated and let's see. And then let's also work on the other foundations, like exercise and eating healthy. Because there is one study that looks at, um, you know, the healthy things you're supposed to do in menopause, get your right exercise, eat a, you know, a fiber-rich, healthy diet, and not smoke, and I think it was only 8% of women did all three.

    6. MRMel Robbins50:17

       Wow. Um, you wrote this unbelievable article that went crazy viral. Um, and Dr. Gunter, you say, "Don't use menopause to excuse mediocre men."

    7. JGDr. Jen Gunter50:29

       (laughs)

    8. MRMel Robbins50:29

       What does that

16. 50:30 – 1:06:01

    Don’t use menopause to excuse mediocre men!

    1. MRMel Robbins50:30

       mean? (laughs)

    2. JGDr. Jen Gunter50:31

       I think everybody knows exactly what I mean, but yeah. Um, so there's this edge of a knife, I think, when you're a woman, right? So, you know, we like to, women are too hormonal, too this, too that. But you can also have symptoms related to that. So it's just really important to make sure that because of this history of causing wo-, calling women hysterical, calling them, you know, the madwoman in the attic, all of that kind of stuff, because of that history, I think it's super important to be accurate when we're assigning fault as to what the fault is. So yeah, there was this advice column in- in The Guardian, and this woman had written in and, I can't remember the specifics now, but her and her husband had had a contract or, you know, a verbal agreement about how they would be raising their children. And he was clearly not living up to what they'd agreed upon, and he- he was basically, whatever, her third child. And I think a lot of women out there know exactly what I'm talking about. Anyway, he was her third child and she wanted to leave him, 'cause she was just like, uh, like, "I don't th-, I don't wanna be a m-, a- a mother to him." And this, I hear this from a lot of women. And she was writing in for advice, and 'cause he wasn't vacuuming, he wasn't, he wasn't doing any of the stuff, she was basically doing it all. And the answer was, "Maybe it's menopause. Maybe you're intolerant because of your hormones."

    3. MRMel Robbins51:57

       (laughs) Really?

    4. JGDr. Jen Gunter51:59

       Yeah. "Maybe you should go on hormone therapy." She didn't say she'd having hot flashes. She didn't say she was sleeping poorly at night. She clearly laid out that they had agreed to be equal partners, and here she was now in this relationship that we talked about earlier where she was doing all the grunt work, all the nasty stuff and yo, you know, he was out at the pub. Like it was, it was sort of the most obvious, like, pull the plug, get divorced, save yourself, run, don't look back, run. And no, maybe it was your hormones, 'cause I know that, you know, when I was going through menopause, you know, I had a, had a shorter temper. So I think it's really important that, you know, when we're talking about depression and menopause, when we're talking about how women feel, that we are not excusing the bad ways that society treats women and saying that, "Oh, if you just took hormones, it would be better," right? Because the answer to being mistreated is not taking hormones. The answer to being mistreated is to be treated correctly. And so I just think that it's really important that we're clear about these things. Now, if somebody comes to me and says, "Oh my god, like, I had the perfect relationship and my husband-"

    5. MRMel Robbins53:12

       Mm.

    6. JGDr. Jen Gunter53:12

       "... does everything, and now that I'm not sleeping at night and I'm soaked in sweat all the time, I've got a super short temper," yeah, yeah, your hormones might be having something to do with that. You know, maybe if you actually had a good night sleep, things would be better. I think most people can agree with that, right? But that wasn't the situation that was being presented. So I just think that, you know, it's really important, and especially, like, in the workplace too, right, you know, that, um, many women in the workplace are treated terribly, especially as they age, that there's so many glass ceilings, right? And while it's super important that workplaces accommodate menopause, we also don't wanna use that as kind of lip service, so then y- we can excuse all the bad policies that are keeping women from advancing, right? "Oh, look, you know, we're- we're c-, we're letting you control the temperature," when really there's also a massive glass ceiling. So I just think accuracy in all things.

    7. MRMel Robbins54:05

       Mm. Well said. Can you speak directly to the woman who's listening to you right now, Dr. Gunter, and especially if she's not getting the support from her family or her partner and she's going through menopause or perimenopause right now?

    8. JGDr. Jen Gunter54:21

       I would say that's a pretty awful place to be if you don't feel supported. And I think whether it's menopause or pregnancy or you've got any other health condition, you want the person who loves you to support you. So, I would say that that's an awful place to be, and to maybe have a conversation, if you feel safe having that, you know, explaining what's going on, and you know, maybe saying, "Hey, here are some things that you could read so you have a better understanding about where I'm at."

    9. MRMel Robbins54:48

       Well, a lot of women are gonna forward this (laughs) episode to their family members and to their partners, and so I would love to have you-... speak directly to the partner, the children, the family members of a, um, woman that's going through menopause and what they could do to be more supportive?

    10. JGDr. Jen Gunter55:13

        Yeah. If you've got a family member, you know, your mother, your sister, you know, a loved one who is going through menopause, learn about it. Um, and also think about what you can do around the house to make it easier, you know. I would, you know... Everybody needs little bit of help and in many heterosexual households, women are doing the burden of the labor around the house. And even when there's, there's a study that shows even when hour per hour it's the same, women do more of the less fun work, right?I know it doesn't, it's not gonna surprise, it doesn't surprise you, it doesn't surprise anybody. So if you take hour per hour, well, the man is more likely to be out in the yard playing with the kids, and the woman's more likely to be doing the laundry. So four hours, four hours, right? So, you know, how can you think about having a more equitable division of labor in your house, right? And how, if you have a family member who's struggling, wouldn't you want to carry some extra load to make it easier for them? Like, that's just being a human.

    11. MRMel Robbins56:17

        Yeah. And I would imagine any kind of support that also lowers the stress level that you feel makes you feel better too-

    12. JGDr. Jen Gunter56:25

        Yeah.

    13. MRMel Robbins56:25

        ... from a health standpoint.

    14. JGDr. Jen Gunter56:26

        Absolutely. And, and, you know, ask, "Can I go with you to a doctor's appointment? Can I," you know, "can I be your scribe?" You know, buy The Menopause Manifesto, you know, my book. Um, you know, think about how you can, how you can do some little things to help, you know, just if you're not someone who's... Look at the chores that you're doing in the house. Think about how you can pick up more. Think about how you can listen. Just sit and listen as well. You know, not everybody wants an answer. Sometimes people just want to talk.

    15. MRMel Robbins56:53

        Mm.

    16. JGDr. Jen Gunter56:53

        You know, there's a great episode of Parks and Rec where, uh, I don't know if you've seen the show, but where Ann is pregnant and her, her spouse is, I can't remember his name, but he's played by Rob Lowe. And she's pregnant and she's just very uncomfortable. And she's talking about her aches and pains and this and that, and he just wants to solve everything, "Let me get you this, let me get you this, let me get you this," and she just wants him to sit and listen, right? So I think a lot of people just want you to sit and listen too.

    17. MRMel Robbins57:21

        I think I speak on behalf of the person listening, and I know myself when I say, "Can you be my gynecologist?"

    18. JGDr. Jen Gunter57:26

        (laughs) .

    19. MRMel Robbins57:26

        I mean, I want somebody as informed as you. So can you offer up any scripts or advice for how we can have better conversations with our OBGYNs or how we can find somebody that is really in tune with all the research and with the recommendations of The Menopause Society?

    20. JGDr. Jen Gunter57:48

        Yeah. So The Menopause Society does, um, have certified, you know, menopause providers, um, and you can certainly, you know, look for someone who is a certified menopause provider. That's not necessarily a guarantee that, um, you know, that they're gonna give you evidenced-based care. I understand there's some who also implant pellets. But in general, um, I think that's a good place to start. Um, if you ask your doctor about menopause and they don't, like, clam up, you know, if they're, if they can have a conversation about it, there's lots of great people who know how to care for menopause who, you know, haven't done the test and aren't members of The Menopause Society, right? So, um, you know, the other thing that I recommend people do is you can Google the, um, the 2020 North American Menopause Society Guidelines For Hormone Therapy, and you can download it. It's-

    21. MRMel Robbins58:36

        We'll link it-

    22. JGDr. Jen Gunter58:37

        It, it-

    23. MRMel Robbins58:37

        ... in the show notes.

    24. JGDr. Jen Gunter58:38

        It's, you know, it's a PDF. Now, there's a lot of, you know, um, you know, s- semi-interesting things in there talking about risk, you know, complex studies and things like that. But at the end of every section, they have a kind of a general good plain language summary, and I think that many, many people would find that quite illuminating and, you know, to read that a- and you can even take it with you. So, you know, if you're... Or you could read it and say, "Oh, I'm asking for something that isn't even mentioned in here. Maybe I'm asking for something that's a little bit out of spec, and so I'll ask." You know, do a word search. You know, do, what is it, control F or whatever you have to do. You know, if you've got a specific word, search the document for it and see what shows up in there. So that's a, it's a good place to kind of get some basic information that's evidenced-based. Um, they have some information on their website too, and, you know, I would just say that, that, um, that for the me- majority of people who want to try menopausal hormone therapy, a six-month to a year trial is as low-risk as anything can be. You know, when we look at the risks of, of breast cancer, if you assume that the studies that show risk are correct, again, we've had this spectrum of some studies showing one thing, other studies showing nothing, there's no risk with a couple of years. Like, like, it, that risk doesn't accumulate for a while. So if you're really scared, there's essentially, and you're a good candidate cardiovascularly, trying it for six months is about as low-risk a therapy as there can be. And if you try it and you're like, "Well, this hasn't improved my quality of life," you know?

    25. MRMel Robbins1:00:12

        There's your answer.

    26. JGDr. Jen Gunter1:00:12

        There's your answer. And if you're on it and you're like, "Wow, my quality of life has changed a lot," then there's your answer. Because, you know, there's lots of things that haven't been studied. You know, there's, you know, other sort of symptoms, like many women talk about they just don't feel like themselves. We don't have a scoring system for that. I don't know what that means. And you know what? You not feeling like yourself and me not feeling like myself might mean two completely different things.

    27. MRMel Robbins1:00:36

        Yeah.

    28. JGDr. Jen Gunter1:00:36

        Would be completely different biological phenomena, but we're using the same words to describe it. So because it's such a low-risk thing if you're using the FDA-approved therapies and you're in, you know, a low cardiovascular risk, there's very little downside for saying, you know, is an appropriate dose improving things? The one word of caution I would give to people is you want to, if you're not improving, to be very careful about dose escalation, right? So if you think about a, a-... an estradiol patch that has 100 micrograms of ethanol es- uh, sorry, not ethanol. If you think about an estrogen patch that has 100 micrograms of, of estradiol, that is about-

    29. MRMel Robbins1:01:16

        Mm-hmm.

    30. JGDr. Jen Gunter1:01:16

        ... equivalent, if you even it out through a whole month, to the amount of estrogen you make when you're ovulating. So if you're needing more than that, I would say, and you're over the age of 45, there probably needs to be a bit more reflection because why would you need, on average, more estrogen than your body was making? Might there be some chances where you may... Maybe. But again, you start to think about it, right? Like, okay, so, you know, 'cause there are some unfortunate situations where people just keep escalating and escalating and escalating.

Episode duration: 1:06:01