Hey, it's your friend Mel, and welcome to the Mel Robbins podcast. I am so happy you chose to listen to today's episode. It's going to make you feel completely seen and understood because our expert is the extraordinary Dr. Jenn Gunther. She is the number one OB/GYN that people turn to for trusted science-back advice regarding menopause. She is here to bust the miss We can clear through the misinformation, and it is so prevalent on the topic of menopause. In fact, Dr. Gunther is so in demand that I've been waiting a year to have this conversation with her. She has jumped on a plane, flown across country to be here for you to set the record straight and to answer your questions. Are my symptoms normal? Is hormone replacement therapy safe? What exactly are bioidentical hormones and are they better than normal ones? What are compounded hormones? How do I talk to my doctor and my family about this? Today, you are getting the exact specific protocol you need from one of the most respected experts in women's health on the planet. If menopause is not impacting you personally, do not change this episode. Do not touch that dial because it is impacting someone you love.

Simply listening and learning is going to help you love them even better. Because today, we are busting the myths and you are getting the facts about menopause. Hey, it's Mel. I am so thrilled to bring this episode and conversation to you today. Dr. Jenn 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. Gunther has been called the Internet's Favorite OB/GYN. She is a double board certified, fellowship-trained medical doctor, and she is a fierce advocate for women's health. She is also the best-selling author of three international best sellers, including The Menopause Manifesto and her latest bestseller, Blood. She's known for myth-busting and no-nonsense facts, and you are going to love this conversation with her today. 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. Jenn Gunther to the Mel Robbins podcast.

I am so glad to be here.

Dr. Gunther, 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 Mist, 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?

Yeah. 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. Women are uniquely affected by ageism, so you have the double whammy at this time. I'm hoping that you'll feel that your concerns are valid and they're important. There are lots of options to do from a health standpoint, and there are many ways to take care of yourself. I can give you some tools to reframe what's going on with your body so you know where you are, and also give you tools to find help if you're struggling.

What do you want to say to women who are in menopause?

Yeah, team menopause. I'm on it, too. I would say that menopause is a normal part of the ovulatory cycles that we have. Just like you went through puberty, which might have been challenging and had some symptoms and caused a lot of physical changes through your body, that menopause is in many ways the same thing. You can think about it as puberty in reverse. It is not a sign that your body is going to fall apart the next day. It is 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. If we erase menopause, then we erase all the grandmothers. In history. That it is a normal experience, but normal doesn't have to mean pleasant. 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 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 steady, 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. And that the best 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.

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

Yeah, well, just like you're... It's a different physiologic process, but you have a winding up. When you go through puberty, you don't start and bang on, have cycles regular. They start and stop. They might be heavy. They have that like, flirting with it. If you will, well, you have that same in the last couple of years. You have the starting and stopping with the periods, you're having the winding down of ovulation. They're like bookends, a little bit different. Maybe like sisters, not twins, I don't know.

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

So the menopause transition, which is the time leading up to menopause that you might also think of heard called perimenopause or premenopause. How long does that last? Well, anywhere It's from 4-10 years, depending. Just like puberty, a big range in how long it can last. Some people seem to have these late growth spurts, goes on forever. Some people relatively short, the same thing.

Oh, wait a minute. Okay. 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, the fact that you growed Are we taller? Do we shrink when we're going through menopause?

Not really. Certainly, if you develop osteoporosis, you can. But no, otherwise not. It would be rare to develop osteoporosis in your late 40s or early 50s. That would be really a sign. There'd usually be something else going on, significant. But over time, if you have osteoporosis, you certainly can lose height, and we want to protect that. But yeah, puberty is a many years experience. You start to get pubic hair, you start to grow, you get breast buds, your body shape changes, you may have mood swings, you may have acne, you have this whole experience. Just like puberty might have ended at a different time for different people. Some people stopped growing in grade seven. I was still growing in grade 10, grade 11. You have this big range. It's the same thing with the menopause transition. I just encourage people to think about it more that way, that it is a change. These changes don't happen overnight. It's this physiologic change, and it's related to the decrease in the number of follicles or eggs that can ovulate. What happens in response to the decreasing levels of estrogen that are produced. You get other hormonal changes.

Your brain is trying harder to get the ovaries to ovulate. It can start to get 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 develop estrogen, not get progesterone, but still menstruate. So it's basically hormonal chaos. And so people mistakenly think of it as this gradual smooth transition, but it's more like... But obviously there's variation. My best friend had regular cycles, and then her period stopped and she had one hot flash. I'm like, that's the equivalent of showing up- That's a unicorn. Well, that's like showing up in the hospital and you're like, I feel a little contractions, and you're like, nine centimeters and go, the baby comes out. There are people who have those experiences, and then there's people who have 72 hours labor. It's this wide experience, and there are many things that can affect it.

Dr. Gunther, what are the biggest myths of menopause?

Well, oh, gosh, the biggest myth. I would say the biggest myth is that that your life is over, that this is the end. Once you age out of being a breeder, for lack of a better term, you've lost value. But I would say that many women, once the menopause transition is over, really describe that they have a greater clarity and they feel great. Maybe it's not having the hormonal fluctuations. Maybe it's the fact they just don't care anymore because they're older. It's wisdom with age. I don't know the answer to that. Maybe it's the fact that all of the part of your brain that was tied up with ovulation is now gone because your brain prunes pathways. It doesn't need anymore. I mean, I don't know the answer. But I would say that for some people it can be very rocky, and for some people it isn't. For people who it's very rocky, we have treatment. That's true.

I think the biggest myth, if I'm just thinking about what my friends are talking about, is that you're going crazy. It feels very liberating when When a doctor tells you, Oh, that brain fog, that can be explained by menopause. Oh, frozen shoulder, that can be explained by menopause. And so understanding that there's an underlying reason for all of these things suddenly coalesce blessing for me, has been the biggest, most liberating thing, is to understand what's going on instead of feeling like I'm a victim to what's going on.

Yeah, I think education about how your body works is very liberating. So then you don't think that you're uniquely broken or uniquely crazy or something that what is specific? Why is my body behaving this way and no one else's? You're like, Oh, lots of people are behaving this way. Okay, I don't feel so alone. Sometimes there's safety or comfort in numbers.

What are the top three non-hormone interventions that you recommend all women do to impact their health?

Well, I would say the top recommendation is exercise. I would put that over hormones. Absolutely.

But in menopause in particular, how come?

Well, exercise touches almost Every single domain that is affected by menopause. If you think that menopause can start to change the trajectory for risk of osteoporosis and risk of dementia, risk of muscle loss, all of these things. Exercise touches all those domains. So in the menopause transition, there's an increased risk of depression. Exercise can treat depression. Exercise can help protect bone mass. Exercise can help build muscle strength, build muscle mass. Exercise is great for your heart. It's great for your brain. Basically, Basically, exercise treats almost everything in menopause except the hot flashes and vaginal dryness. And we have great medications for those. But so what I'm saying is that going into menopause with that strong foundation, and it's not just 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 all of these things can be protected with exercise, but that's not a sexy sell. That's It's true. If you would only ever do one thing for your health, it would be to get your exercise. I mean, you don't want to play favorites and say, Well, you can only do one thing.

But you get what I mean. I'm just trying to emphasize how important exercise is and resistance training and building muscle I'm always inspired by all these women in their 50s, 60s, and 70s on Instagram that are showing... They're flexing their backs or they're just cut. I'm just like, Oh, yeah.

Never too late.

Yeah. Well, I'm working on it. So Yeah. So exercise, eating 25 grams of fiber a day, trying to have 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.

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

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

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

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 and 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 similar to what your body makes or not doesn't make it safe. What makes it safe is it's studied Is it safe? Is it effective? And is it something that can be... We know exactly how much you're getting. 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 actual amount of hormone. So if I give you an estrogen patch, I know how much is going to be absorbed. There have been studies that have been done. I know if you put it on a different body part, that's going to affect absorption because all of this is It's been done.

With compounded products, none of that exists. 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. You would want to know what you're putting into your body. I would say there are FDA-approved therapies, and there are many good ones out there. 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. That, again, is a marketing- Is that not true? Well, I mean, petroleum is plant-based, too, if you want to look at it that way. Yeah, it's plant-based, but it's They used a 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. It's the same thing. Your body can't tell the difference. We just make it from soybeans, which is called a semi-synthesis, because it's cheaper than making it by synthesis, which is assembling the molecules itself. It's a total marketing thing. Plant-based, it means nothing. Nobody's grinding up yams and putting them into pills and giving them to you.

How do I know that I'm doing the right thing? I listen to you and I'm like, Yes, I love it. Take it down. Take it down. Go, go, go, Dr. Gunther. Thank God you're out there cleaning up the internet for us. But then I'm like, Shit, what am I asking my doctor? If I'm going into my gynecologist and I'm interested I'm interested in hormone replacement therapy, 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 fringe areas of the other stuff?

If you're getting a prescription that doesn't have a package insert with it- What does a package insert mean? Whenever you get any prescription and there's this little folded up book and you unfold it, it's all the risks and benefits, and it's this big thing. If it doesn't have that, then it's not FDA-approved.

Oh, okay. So all the things that you get from the compound pharmacy, not FDA-approved? No. Because they haven't... How could they be? Because the packaging has been through clinical trial after clinical trial, and it's had to have been tested and pass through all these hoops for your safety and so that you as a doctor can understand what you're actually prescribing me.

Yeah. There's this whole 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. 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 that had a black box warning on it, and the other one didn't, you're going to automatically think the one that doesn't have the black box warning on is safer. Well, it doesn't have the black box warning because it wasn't required because it's not FDA approved.

Oh, my God. When I was going through perimenopause, I got bioidentical hormones from a compound pharmacy, and I thought I was fancy. I thought this is high-end medicine. They have taken something for me. This is how uninformed I was. They have literally, because of the word bioidentical, 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. Then I would get this packet from a compound pharmacy, and it would have these tubes in 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. I thought that I was having the better result when I can see now what you're basically saying is that, no, not really.

You were having the inferior. You were paying more and getting less. Because we all think when someone's customizing something for us that we're getting better. We're trustworthy. We believe people. And no Menopause Society recommends compounded hormones. They're not recommended by the North American, or we now call them that they're now called the Menopause Society. The National Academies for a 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 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 that we have modern medicine for a reason. 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. There are several There are a lot of issues with using compounded products.

People may be getting more of a hormone than they think they're getting. 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 preventing osteoporosis, but you're not. So this is the analogy I use. Using FDA-approved hormones is like going to the gas station that has the gallons is on it and you can choose whichever gas you want. You fill your car and you have a working gas gage, and you're like, I know what's in there, and that's important. 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 going to flip that switch off so you don't know how much is in there because you should trust him because he knows. That's the difference.

I am speechless. It's not very often that I don't have anything to say. And you just took a flamethrower to the entire idea of bioidentical hormones. I would never Never, ever try it again. Then I would add on top, by the way, you've brought the science and the research and a very compelling analogy. I'm going to add one more. As somebody who already has ADHD and has 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. I'm probably over-undedosing, even if it was made in a way that was clinically sound. And so case closed, not doing bioidentical hormones.

Yeah, and I would say, move away from using bioidentical and just call them compounded, because 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 company, I use an estrogen patch, it's estradiol.

I've got it on right now.

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. 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. Because of They're not FDA approved 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. So 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 with a ribbon around, but they're the same product. Except the delivery mechanism is different. Got you. So that's why I tell people, every estrogen that I would prescribe you from an FDA-approved source With the exception of Premrin, is bioidentical.

So everything is the same.

Just forget that. Got it. Just forget that word. When people use the word bioidentical, it tells me that They think women are dumb.

Well, clearly, I am in this area. Well, no, seriously, I can own it because here's the thing. It is confusing as hell, and there's so much misinformation. 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. You are losing your mind and somebody says to you, Oh, bioidentical, and I can send you. You're like, Thank you. I'll take it, whatever. I had no That's an idea. I used it for three years, and I thought I had the fancy thing. I want to be very clear about something, and you listen keenly to me, Dr. Gunther, to make sure I have this correct, because I'm putting my lawyer head on, and I'm feeling the association of compounding pharmacists writing us a seiths and desists letter. I want to be very clear about what she has said.

Number one, it is a fact that the Menopause Society does not recommend that you use a compound delivery formula for any hormone replacement therapy because it has not gone through FDA approval. Number two, the distinction that we're talking about is not the actual hormone. They're using the same stuff. The reason why it is important that you understand this is because the delivery mechanism of the pharmaceutical product like Estradol has gone through FDA approval, which means the researchers and scientists and doctors know how your body is going to absorb it. They know the rate of delivery. They know that it has been tested. It is what the Menopause Society is recommending if you are going to do hormone replacement therapy. Did I get that right?

Yeah. The other important thing is when you have an FDA-approved medication, they're batch tested. So what that means is, however many, one bottle in 50, one bottle in, I don't know what it is, is tested to make sure it has what it claims. But when you're mixing up product after product, one at a time, there's no batch testing that can be done. You're talking about a whole different thing in quality control. So the only time we ever recommend a compound product is if there is a true allergy. There's no pharmaceutical option because of a true allergy. And that's where we rely on compounding pharmacies for that situation. So one example might be Prometrium, oral progesterone. The brand in the United States is made with peanut oil. So if you have a peanut allergy, you can't take that product. So the options are then to take a different pharmaceutical or to get progesterone compounded by a compounding pharmacy without peanut oil.

That makes sense. 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 I'm staying. 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. Right. I am learning so much, and I know you are, too. We need to take a quick break to hear a word from our sponsors. 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. Jenn Gunther. 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. Jenn Gunther. She is telling you everything that you need to know about menopause. Dr. Gunther, how do I know that I'm doing the right thing?

What people need to remember, the takeaway is, there's really very few things you need to know about hormones. 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. The estradiol that I would give you in a patch or a pill from a pharmaceutical company, that is bioidentical. You have that. You want to learn estradiol, and then you want to learn premrin, which is conjugated equine estrogens. That's only actual natural estrogen because it comes from horse urine. Horse urine? Yeah. Natural means the substance exists in nature and it's being used unchanged.

How the hell they figure out that horse urine is something that...

Yeah, horse urine has got all kinds of estrogens in it. It's a crazy thing. Those are the two things you need to learn. You need to learn estradiol and Then you need to learn premrin, which is the trade name for conjugated equine estrogens. Then you need to learn oral or transvaginal or transdermal. So against the skin, through the vagina or by mouth. Got you. We recommend the number one starting treatment we generally recommend is transdermal estradiol.

Here, I'll show you. I'm going to show you mine right now because I'm probably due to take it off. I have to do it every four days. Look, I wear black under it. Let me get down here. Okay, you guys will I'm going to watch YouTube again. Okay, here it is. Look, my dead skin is on it. That's disgusting. Yeah, so you have a patch. I have a patch. I'm going to hold it up right there. I have to replace it every four days. Change my life. I can trust knowing that if I put this on every four days. This is considered transdermal.

That's transdermal. It goes through the skin.

If you were to like, I wouldn't put it here, obviously, but you just stick it to yourself.

Yeah, but you only want to put it in the place that the package insert says. Because it's been studied. They've studied it in different locations that the absorption can change. If you put it on your belly versus putting it on your thigh or putting 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.

Yeah, that's right. I've also learned because I had no idea that you could also insert something into the vagina for hormone replacement therapy. I should probably butt my pants to finish the interview here.

There's a transvaginal ring that also has estrogen and can be absorbed that into the body. And there's also a ring where the estrogen just stays in the vagina. If you're having vaginal dryness, you have urinary tract infections, pain with sex, vaginal estrogen can be very effective for that. And so some people who have no other symptoms of menopause feel great, they feel fine, but they have vaginal dryness. They don't want to take a medication that goes throughout their body. They want to just use a vaginal estrogen. So we have that. That's a great option. When you're using 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 is absorbing through the skin or through the vagina, and there is taking it by mouth. And we believe that absorbing it through the skin has the lower risk of blood clots. That's why what people need to learn is the first-line therapy for menopause is transdermal estradiol.

You mentioned pellets a couple of times. What are those?

So pellets are implants that you go to a medical doctor or a nurse practitioner. I think maybe even in some places, there's natropaths who insert them. I don't really know because I'm not really involved with it. Maybe they don't. I'm not sure. They can either have estrogen They can have estrogen and testosterone. Maybe they have other hormones, and I don't really know. They're made in compounding pharmacies, and they're implanted. They're not batch tested, so you don't know how much hormone you're getting. My understanding of it is it's based on proprietary 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 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. So this system, and it's not recommended. There are There's also been issues with pellets, with complications and side effects not being reported to the FDA, which is also another concern.

So we don't actually know how many people have problems versus pharmaceutical companies when they get adverse events reported, those are passed on to the FDA because there's big penalties, my understanding, for not doing that.

Is the pellet a delivery mechanism?

Yeah. It's an implant that sits in the body because I don't do it. I don't really know much about it because it's not recommended. I don't know that much about it, but what it can happen is it can produce very high levels of hormones, and then it drops off. In some cases, you can be exposed to the levels of testosterone that we might give someone if they're transitioning. The kind that can cause you to develop an enlarged clitoris, the kind that can cause you to develop 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. There's all different of issues associated with them, and they're very expensive as well. So they're just not recommended.

Do you have to have your blood drawn to have this assessed effectively? No. No.

If you're 45 years or older, you do not need a blood test to get started on menopausal hormone therapy. If you're 11 and having a growth spurt, no one's like, Oh, 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. 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. We need to know, is this 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. The bloodwork is really if you've skipped periods. Say you're 42, you haven't had a period in three months, you need to have bloodwork because we should figure out why that's happened.

But if you're 45 and you're having bad hot flashes and you've had a couple of irregular periods. That was me. That's no mystery. You're starting in the menopause transition. If the average age of onset for the menopause transition is 45, well, you know what? 50% of people are going to be younger than 45 and 50% of people are going to be older. So it has to be put in context. The internet wants absolutes. The internet wants test my hormones, don't test my hormones. The internet wants this or that. But medicine is more nuanced than that. 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 bloodwork done because 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, it's not a mystery why you've gone two months without a period. One thing that we didn't talk about is one of the contraindications for starting estrogen is being more than 10 years from your last period or over the age of 60. In general, that is associated with an increased risk of dementia and an increased risk of cardiovascular disease.

We want to avoid starting it when people are older. Now, It doesn't mean like age 60, if you're 60 years on one day, that that's a hard stop. But I think it's just important for people to understand that there's a timing. If somebody, for example, their last period was 55, We might not cut them off at 60. There might be a bit of wiggle room there. But in general, we recommend if people are going to start hormones, that is going to be within 10 years under the age of 60. That's the ideal situation and the lowest risk situation.

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. I know as you listen, you're thinking the same thing. 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. Jenn Gunther. 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 going to be waiting here with Dr. Gunther, and you're going to 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. Jenn Gunther. Dr. Jenn Gunther. 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. I know it's because of the fact that I think it was 1991 when there was that huge study that was released. I think it was the Women's Health Initiative that cast HRT in a negative light. I understand that the study has been harshly criticized. 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?

Well, the Women's Health Initiative was the largest clinical trial I think that's ever been done. It was designed to tell whether hormone therapy, menopausal hormone therapy, was going to actually reduce the risk of heart disease without increasing the risk of breast cancer. It was also there were other arms that looked at exercise, that looked at calcium, so the calcium replacement. There are quite a few different arms of the Women's Health Initiative. The arm with estrogen plus... When that was p remarin, that was used. P remarin plus progestin. That was stopped early because they reached the threshold of learn about breast cancer. Now, going into the Women's Health Initiative, we knew that there was a very low risk of breast cancer associated with menopausal hormone therapy. So this wasn't like a surprise. It was the threshold that was reached. And it was communicated to the public in a way that is typically not done. Usually, there aren't press releases when a study is halted. Usually, we wait, we get the data, the article is published. So it's peer reviewed, and we have of that. That didn't happen. That created this big hoopla, where lots of things got taken out of context, lots of things accelerated in ways that were uncontrollable because fear sells.

I don't know how many major news stories were dedicated to the WHI, but it was really out of proportion. Then when more information came out and when there were more studies that came out, that never gets the same attention. 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. That's the difference. We believe that the progestin Tens, 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 or a progesterone or a progestin, that that risk is the lowest. I would say to people, 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. 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 a little bit higher. And again, it depends how you look at the data.

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. And you just have to look at it in context. If you're somebody who is at higher risk for cardiovascular disease, but not super high risk, then transdermal is probably okay, but oral isn't because there's a higher risk of blood clots associated with You just have to look at what is it going to do for you. I'm very high risk for osteoporosis. My mother died from osteoporosis. I have quite a high FRAX score, which is a risk calculator. That's the main reason that I'm on menopausal hormone therapy, because my risk of osteoporosis is pretty significant, and I'm already getting closer and closer to osteoporosis and osteopenia. It's a concern for me from a health standpoint. That's why I'm taking it. People always want us to say zero risk. Getting a car has a risk. I always like to not talk in those kinds of absolutes and say, what's the reason you're on it? And what is the risk benefit ratio for you.

For the majority of people, the risk-benefit ratio is absolutely going to be in the favor of benefit. But there are some situations where it might not be. For example, somebody at very high risk for cardiovascular disease, someone who's previously had a blood clot, someone who's previously had a heart attack. You have to put it in perspective.

Thank you for that because, Dr. Gunther, 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 They even talk to their doctor about it because somewhere in the back of their head, they think it causes breast cancer, and that's why they're not even considering it. I appreciate you just clearing the air a little bit so that people know that you should at least go talk to your doctor about it.

Yeah, and there are calculators that can help you determine your breast cancer risk. I would recommend, I think we heard it was Olivia Munn who was talking about, I believe that's who it was recently talking about, she had a Breast cancer risk assessment, which led to her having an MRI, which led to an early diagnosis of a breast cancer. There's all kinds of... There's several easy tools that we can do to help explain things more in context for you. If somebody comes to me and they have something that menopausal hormone therapy can help. I do something called an ASCVD score. It calculates your cardiovascular risk. We need your lipids, and we need to know your blood sugar and your blood pressure, a few other things. 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, there's also a conversation to be had about medications that lower your risk of breast cancer. So there's bigger discussions to have. But so you can do these risk calculators and you say, look, well, I'm somebody who's got hot flashes.

Menopausal hormone therapy is 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. Versus you're somebody that, you've got a pretty high cardiovascular risk. 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. Can we talk about one of these other medications for hot flashes?

I want to ask a couple more questions about HRT. Someone listens to this episode, they feel very seen and validated. They go into their OB-Gene, they say, I want to assess the risks. 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. How do you know if it's working?

Well, so are your symptoms improving? It's really, except for- And how long does it take? Pretty quick. Unless you're someone like me taking it for osteoporosis prevention, because I don't feel any different. That's, again, a really important reason to take an FDA-approved medication because I wanted to protect my bones. I need to know what I'm absorbing. If you have hot flashes, most people see a pretty significant improvement within four weeks. Depending on how much better people feel, sometimes we might give an eight-week try before switching doses. It just depends on how people feel on the medication. Usually with Something like hot flashes, you're going to see an improvement pretty quickly. With depression, usually within a couple of months as well. I always like to talk about with menopausal hormone therapy, there's green light indications, meaning these are like the FDA-approved solid reasons. Hot flashes, night sweats, gold standard. Osteoporosis prevention, FDA-approved. 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. Then at that average age, you can decide if you want to stay on or not like everybody else.

What is the average age of menopause?

Fifty-one. But so say you're starting at for... So you've got these green light indications, great. Everybody believes that the benefits outweigh the risks as long as you're in the right category for that. Then there are more yellow light indications, things where It hasn't broached where it's recommended in the guidelines, but there's pretty good data to support it. 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, so you don't have as much deep sleep. So it might be worth a try to see. For example, I still get the occasional hot flash, but even when I was, I don't wake up, but I'm so hot, I wake my partner up. 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. The data for joint pain is not really that great. I mean, maybe it's going to help 20% of people with joint pain, so it wouldn't mean it would be wrong to try.

If it doesn't work, you're not going to keep pushing the dose higher and higher and higher because you're like, Oh, well, it was a chance, and maybe it's going to work, maybe it's not. There's some evidence to show that it may reduce your risk of diabetes. So again, if you're somebody at very, very high risk, that might be a conversation to have. Those are like these yellow light indications. And then 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 this symptom that we don't really understand. So you could certainly have fog from depression. You could have brain fog because you're not sleeping well. All of these other things could come into play. But if your only symptom were brain fog, then I might be like, it's less clear you're going to get a benefit from that. Maybe there's a discussion to have about what might be the other factors. But if you've also... We've done a depression questionnaire, you're scoring higher for depression, well, brain fog is a symptom of depression, too.

Let's get that treated and let's see. Then let's We also work on the other foundations like exercise and eating healthy because there is one study that looks at the healthy things you're supposed to do in menopause. Get your right exercise, eat a fiber-rich healthy diet and not smoke. I think it was only 8% of women did all three.

Wow. He wrote this unbelievable article that went crazy viral. Dr. Gunther, you say, Don't use menopause to excuse mediocre men. What does that I mean.

I think everybody knows exactly what I mean, but yeah. There's this edge of a knife, I think, when you're a woman, right? We like to... Women are too hormonal to this, to that. But you can also have symptoms related to that. It's just really important to make sure that because of this history of calling women hysterical, calling them the mad woman in the attic, all of that 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. There was this advice column 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 a verbal agreement about how they would be raising their children. He was clearly not living up to what they'd agreed upon. He was basically, whatever, her third child. I think a 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 because she was like, I don't want to be a mother to him. And I hear this from a lot of women.

And she was writing in for advice because he wasn't vacuuming. 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 intoler because of your hormones.

Really? Yeah.

Maybe she should go on hormone therapy. She didn't say she'd She was 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. Here she was now in this relationship where she was doing all the grunt work, all the nasty stuff, and he was out at the pub. It was the most obvious, like pull the plug, get divorced, save yourself, run, don't look, back, run. And no, maybe it was your hormones because I know that when I was going through menopause, I had a shorter temper. So I think it's really important 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. 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, I had the perfect relationship, and my husband does everything. And now that I'm not sleeping at night and I'm soaked and sweat all the time, I've got a super short temper.

Yeah, your hormones might be having something to do with that. Maybe if you actually had a good night to sleep, this 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 it's really important, especially in the workplace, too, right? That 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 want to use that as lip service so then we can excuse all the bad policies that are keeping women from advancing, right? Oh, look, we're letting you control the temperature when really there's also a massive glass ceiling. So I just think accuracy in all things.

Well said. Can you speak directly To the woman who's listening to you right now, Dr. Gunther, 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.

I would say that's a pretty awful place to be if you don't feel supported. 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. I would say that that's an awful place to be and to maybe have a conversation if you feel safe having that, explaining what's going on and maybe saying, Hey, here are some things that you could read so you have a better understanding about where I'm at.

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

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

Yeah. I would imagine any support that also lowers the stress level that you feel makes you feel better, too, from a health standpoint.

Absolutely. Ask, Can I go with you to a doctor's appointment? Can I be your scribe? Buy the Menopause Manifesto, my book. Think about how you can do some little things to help. 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. Not everybody wants an answer. Sometimes people just want to talk. There's a great episode of Parks and Rec, I don't know if you've seen the show, but where Anne is pregnant and her spouse is, I can't remember his name, but it's played by Rob Lo. She's pregnant and she's just very uncomfortable. 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. She just wants him to sit and listen. I think a lot of people just want you to sit and listen, too.

I think I speak on behalf of the person listening, and I know myself when I say, Can you I'm my gynecologist. I mean, I want somebody as informed as you. Can you offer up any scripts or advice for how we can have better conversations with our OB-gens or how we can find somebody that is really in tune with all the research and with the recommendations of the Menopause Society?

Yeah. The Menopause Society does have certified menopause providers, and you can certainly Look for someone who is a certified menopause provider. That's not necessarily a guarantee that they're going to give you evidence-based care. I understand there's some who also implant pellets, but in general, I I think that's a good place to start. If you ask your doctor about menopause and they don't clam up, if they can have a conversation about it, there's lots of great people who know how to care for menopause who haven't done the test and aren't members of the Menopause Society. The other thing that I recommend people do is you can Google the 2020 North American Menopause Society guidelines for hormone therapy, and you can download it.

We'll link it in the show notes.

It's a PDF. Now, there's a lot of semi-interesting things in there talking about complex studies and things like that. But at the end of every section, they have a a general good plain language summary. I think that many people would find that quite illuminating. To read that, and you could even take it with you. Or you could read it and say, Oh, I'm asking for something, and it 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. Do a word search. Do what is it, control F or whatever you have to do. If you've got a specific word, search the document for it and see what shows up in there. It's a good place to get some basic information that's evidence-based. They have some information on their website, too. I would just say that for the 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. When we look at the risks 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. 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 could be. And if you try it, you're like, Well, this hasn't improved my quality of life. Of life. There's your answer. There's your answer. If you're on it, you're like, Wow, my quality of life has changed a lot, then there's your answer. Because there's lots of things that haven't been studied. There's other 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, I mean two completely different things. We mean completely different biological phenomena, but we're using the same to describe it. So because it's such a low risk thing, if you're using the FDA-approved therapies and you're in a low cardiovascular risk, there's very little downside for saying, is an appropriate dose improving things? The one word of caution I would give to people is, if you're not improving, to be very careful about dose escalation.

If you think about an estrogen patch that has 100 micrograms of estradiol, that is about equivalent if you Even it out through a whole month to the amount of estrogen you make when you're ovulating. If you're needing more than that, I would say, and you're over the age of 45, it probably needs to be a bit more reflection because why would you need, on average, more estrogen than your body was making. You just want to say, if you're needing more than that, then that might be a time for a reassessment of things. You might be on the right track, but I would I would say that that's the time to reassess.

Dr. Gunther, if you could just speak to the person listening. If there was one or two things that are the most important takeaways from everything that you shared today, what are the things that you would want the person listening to focus on?

Well, I would want to say that accurate evidence-based information is really the best way through any medical situation. We don't always have all the answers, and women's health has been underfunded. But having the information that we have is a lot better than just wild guesses. To just keep that in mind, that we do have quite a lot of information. That If you're not being heard by your physician, then I know it's hard, and that shouldn't be that way, but get a second opinion. Just be mindful of people that are selling product because there's a lot of incentivization. That's not even a word, is there? It's a lot of incentive.

It makes sense to me.

There's a lot of incentive, or there can be, or there can be bias. You just need to be mindful about that. I get paid the same. I'm on salary. I get paid the same whether I talk to somebody about exercise, whether I give them hormones. I don't have any deal with a specific company. I don't take any money from any pharmaceutical company. You can look me up. So that bias can come in all different kinds of ways as well. I just think it's important that if you're on social media and someone's also selling a product, to just be really wary of the message. That's all.

I just love how you explain this stuff.

Thank you. Thank you so much for having me. It's been great.

I feel so empowered, and I am also happy that I got to reveal to you how much I did not know and how much I was doing wrong. Because if I can save you the headache or the time or the heartache that I caused myself because I just didn't know, if that's what you get out of this, you learn from my mistakes, holy smokes, that's absolutely incredible. So thank you for spending time listening to something that could change your life. Thank you for sharing this episode with women in your life because you know anybody that you share this with, it's going to help them and it's going to help them take control of their health. And in case no one else tells you today, I wanted to be sure to tell you that I love you, I believe in you, and I believe in your ability to create a better life. And after today's conversation learning from Dr. Jenn Gunter, I know that you have the research-backed facts and the medical advice that you need in order to be more empowered and informed about your health. And that is one of the best things that you could do to create a better life.

All righty, I'll talk to you in a few days. Dr. Gunther, thank you for jumping on a plane and flying across comfort. I can't even speak that. Okay. Let me say, go, ma'am. Oh, sorry.

Okay. What's it you knew? You were just warming up.

It's all getting a lot. Three, two, one. Audio Are you recording? Can I also... I just realized I should probably clean my glasses.

I just took off a layer of street grime from mine. Now I'm like, Oh, wow, my God, I can actually see. It's amazing.

Do you like that? Yeah, all I'm going to do one more. Hold on a second. Okay, great. Okay, got you. Will you go up a little? Let me do it one more time. Okay, what was that? Whatever it's called. You know, Doc, you're a gungster. You know, you want me to do that right now? No problem. I'll do it. Okay. Go, Tracy.

Go. All right. Thank you. Thank you for letting me talk so much.

Oh, thank God you did, too. You were awesome. Oh, and one more thing. No, this is not a blooper. This is the legal language. You know what the lawyers write and what I need to read to you. This podcast is presented solely for educational and entertainment purposes. I'm just your friend. I am not a licensed therapist, and this podcast is not intended as a substitute for the advice of a physician, professional coach, psychotherapist, or other qualified professional. Got it? Good. I'll see you in the next episode.

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