Women’s Fertility & Lifestyle Debate: Dangers Of Not Having A Period! Fasting Can Backfire For Women

0:00:05 if someone’s menstrual cycle is irregular should they be concerned yes yes yes your body’s meant
0:00:11 to work like clockwork and our monthly cycle is so much more than getting ready to have a baby
0:00:16 especially when we’re looking at exercise and it’s important to say if you don’t have a period it’s
0:00:22 very harmful to long-term health brain health mental health low energy mood and libido and i
0:00:26 don’t want the younger generations to have to go through the stuff that we’ve gone through so it’s
0:00:30 an important discussion that we need to have we are joined by four leading female health experts
0:00:35 from very different fields to have a crucial conversation about women’s health with over 80
0:00:39 years combined experience they’re sharing the truth about what every woman and every man needs to hear
0:00:43 we asked a thousand women to submit their questions ahead of this conversation and i’ve got so many
0:00:48 questions around fertility understanding hormones pcos birth control pill and miscarriage and i’ll say
0:00:53 this steven it’s because we haven’t had these discussions publicly when we look at funding in
0:00:58 women’s health it’s horrible like less than one percent is spent on women over 40 women are living
0:01:03 20 more of our lives with chronic disease or mental health disorders i mean 50 of patients with
0:01:08 unexplained infertility have endometriosis but yet it takes women seven to ten years to get a diagnosis
0:01:13 after symptoms start but also there are things that we do that will inherently harm our fertility
0:01:19 because we’re not taught this and it predisposes you to many medical problems later in life and
0:01:24 patients will say like i have a really high pain tolerance yes like it’s a badge so they gaslight
0:01:28 themselves and that’s we’re all trying to fight here but there are a lot of things we can do to deal
0:01:33 with this and then i want to talk about menopause so in medical school menopause just gets shoved into
0:01:41 a tiny box this is a scary statistic so oh my god it’s crazy i just think it’s insane this is why we need to
0:01:46 create change this might be one of the most important conversations we ever have on the
0:01:52 diary of a ceo because women’s health has long been a total mystery to so many people and so many people
0:01:55 are struggling with all of the issues that we’re going to talk about today with their menstrual cycles
0:02:02 pcos endometriosis with diet with understanding how to exercise as a woman it’s probably never going to be
0:02:08 the case again that these four individuals that at the very top of women’s health in their fields
0:02:13 will be in the same place at the same time having this conversation we structured this conversation
0:02:19 into two parts they cover completely different subjects but they’re fundamentally interlinked
0:02:24 for me the understanding that i got from this conversation at this table with these four women
0:02:29 has fundamentally changed my life it’s going to change how i deal with my romantic partner
0:02:34 my sister my team members that i work with every single day and funnily enough because it’s a
0:02:40 conversation i wouldn’t have clicked as a man it turned out to be the conversation that i needed the
0:02:45 most and i don’t think i’ve ever said this before but if there was ever an episode to share with a loved
0:02:50 one then this is that episode please share this episode with as many women as you can but also
0:02:52 with as many men as you can
0:03:02 ladies we should start with some introductions could you give me a brief introduction stacy as
0:03:07 relates to your perspective and your experience and what your sort of biases as it comes to this
0:03:12 debate when i say bias i mean your your experience and your your research that you’re lending to this
0:03:19 conversation today i come from the exercise phys and sports med background um so i’m always looking
0:03:26 through the lens of activity and nutrition and how that has a impact on our stress and our stress
0:03:32 outcomes and how we can adapt to specific applied stressors especially when we’re looking at improving
0:03:39 health span improving mood improving body composition all of those things i’ve worked with
0:03:45 and still work with uh the subset of active women um i come from an endurance and a high profile
0:03:50 high performance sport background so that’s where i’ve gotten my chops and then brought it over into
0:03:57 the general recreational female athlete kind of perspective natalie i’m a fertility doctor and every
0:04:03 day i help patients with ivf get pregnant because i have an ivf clinic but my big passion has always been
0:04:09 natural fertility after i experienced my own pregnancy losses trying to understand how we interact with
0:04:14 the world and how that changes our hormones and help women understand what their hormones are
0:04:21 what natural fertility is what happens as we age to our bodies our eggs and our hormones and let them be
0:04:28 better stewards of their own fertility and their own health decisions mary i have a background in general
0:04:34 ob-gyn so i’m considered to be a women’s health specialist and it wasn’t until i kind of went through my own
0:04:42 menopause that i realized that there was significant gap in my training you know hearing watching dr sims
0:04:49 on um i think your podcast talking about how women are not little men really struck such a chord with me
0:04:55 and made me realize i was siloing women’s health to the reproductive organs the breast the uterus the ovaries
0:05:02 the vagina and that if i really wanted to make a difference in a woman’s whole health life this last 30 years
0:05:08 30 40 years of her life i needed to refocus what we were thinking about women’s health
0:05:15 for the long term so i come from a background in academics i was a professor for 20 years i was a
0:05:20 residency program director stepped away from that so i could focus on the lack of my own education and
0:05:25 knowledge in menopause care and now i want to step back into the academic world to bring everything
0:05:32 i’ve learned and change the way we educate our providers wonder i am a orthopedic sports surgeon
0:05:38 by training and i sit at the unique juxtaposition of orthopedics and performance having taken care of
0:05:45 elite athletes most of my life aging and longevity most of my academic research i too as an academic
0:05:52 is on subjects of musculoskeletal aging but many years ago added a third circle of the whole health
0:05:59 of a woman and so sitting in this place it fits directly into the mantra of my career which has
0:06:04 always been i am going to change the way we age in this country in the world because the tool that i bring
0:06:11 to the table is the fact that if i save your mobility i’m going to save you from the ravages
0:06:19 of chronic disease and so the work that i do is not only educational it’s uh research and it’s now
0:06:25 education of the world about these subjects explain this to me like i’m an idiot ladies why do we need to
0:06:31 have a conversation about women’s health and not just health broadly i think the statistic that people
0:06:37 don’t realize on a day-to-day basis is that women are 51 percent of the population we’re actually not a
0:06:45 minority we’re the majority and yet often our health our health care access the research treats us as if
0:06:55 we’re a niche product but we are the majority product we have to have this conversation because data show
0:07:03 that of the 450 billion dollars spent on research in this country alone less than one percent is spent
0:07:11 on women over 40 and yet we are nearly 90 million people and we make 80 percent of all the health care
0:07:19 decisions in this country for ourselves and everyone we touch and so even though when you look at the
0:07:25 the long-term data women are winning the longevity race here we’re living an average of six years
0:07:32 longer than men but as all of us talk about all the time women suffer longer yeah we’re living 20 percent
0:07:38 more of our lives versus our male counterparts in poor health with chronic disease or mental health
0:07:45 disorders and so mckenzie looked at the data and it was for the gates foundation and what they found was
0:07:52 yes we live longer we’ve all known that however we have you know twice as high of mental health disorders
0:07:58 we’re two times as more likely to end up in a nursing home we are much more likely to lose our long-term
0:08:04 independence from frailty or dementia much more than our age-matched male counterparts and that’s i think
0:08:09 what we’re all trying to fight here and diseases that impact women specifically and only things like
0:08:16 pcos endometriosis are extensively underfunded and not research it takes women seven to ten years to
0:08:23 get a diagnosis of endometriosis after symptoms start and we know this is a disease that impacts your
0:08:30 entire body in addition to your fertility but women are dismissed they’re not taken seriously and there’s
0:08:35 not research guiding what we can do in a lot of these situations to try to help them the best
0:08:42 why isn’t the research there why don’t they research if women are the majority of the population
0:08:47 why is all the funding going to researching men you have to think about who was in the room when medicine
0:08:54 and science first started so if you think about back when the industrial revolution and the modernization
0:08:59 of what we know is medicine women were pushed out because they were believed to have smaller brains thanks
0:09:06 to darwin and not thought to have a seat at the table so when you’re thinking about designing studies it was
0:09:12 pretty much designed on the male physiology on the male body and then women were an afterthought so there
0:09:19 wasn’t any real in-depth look of well women are different from birth or in utero xx is different from xy
0:09:26 so all the research has just been generalized to women even things like aspirin for heart attacks
0:09:32 and thinning blood inhibitors yeah all of this all of this was done on men and then just generalized to
0:09:37 women and now that we’re having this global conversation on women’s health people are like
0:09:43 well where is the information specific for women and there’s just a very small subset so we’re looking
0:09:49 and trying to expand that but we have a lot of catching up to do and that’s primarily not only
0:09:57 because of what you said but the shocking statistic is that not until 1993 were women required to be
0:10:06 represented in studies 1993 i mean we were all far into our lives and research by then isn’t that a
0:10:10 shocking that’s great and there were still loopholes where people were finding ways to exclude women
0:10:16 and then we’re still not at 50 no we’re not a critical mass you have menstrual cycle hormonal
0:10:23 fluctuations even a pause pre even the animal models it’s not that we’re harder to study it just makes
0:10:29 it presumed harder to say there’s more variables at play right it’s more of a complexity to the research
0:10:33 but it’s not more difficult and this is where i bring it in it’s like if a woman had a seat at the
0:10:38 table when all the study designs were started it wouldn’t be a question it would just have been
0:10:45 assimilated and but because we’ve been so drawn into we have a crossover here’s one week crossover next
0:10:49 week because of male physiology when you add women’s hormone fluctuations and people like oh it’s too
0:10:54 complex right but it’s not what is it that make and this is a super dumb question but an important one
0:11:00 what is it that makes men and women different from a physiological standpoint because to understand why
0:11:05 research would need to be done separately we need to understand the differences yeah well i mean we can
0:11:13 look from a morphological standpoint where men have more of our fast twitch fibers women are born with
0:11:18 more endurance fibers which is muscle right uh when we’re talking about muscle yeah yeah so uh men have
0:11:26 more of the ability to do power and and really fast energetic type activities or women are more
0:11:30 attuned to endurance type activities and this affects metabolism it affects blood glucose
0:11:38 and when we’re looking at bone and bone density men have stronger bones uh they can acquire more load
0:11:46 they hold on to it better than women do we see smaller lungs smaller heart less hemoglobin in women than men
0:11:52 and that’s an offshoot of what testosterone does so there are just basic physiological differences
0:11:59 differences between xx and xy that people don’t really assimilate and understand and the way i like
0:12:03 to say it is you go into a shop and you have a men’s section and a women’s section and there are touch
0:12:10 points on the external that really identify gender and or sex but when you look intrinsically no one is
0:12:16 identifying those touch points until now also when we look at how we disease so in cardiovascular diseases
0:12:24 is atherosclerotic disease is the best example men tend to have their blockages so atherosclerotic disease
0:12:29 is basically the plaques that build up in the coronary arteries around the heart men tend to develop their
0:12:35 plaques very early right as those arteries exit the aorta and dive into the heart muscle so we get what we
0:12:40 call the widow maker okay it’s called that for a reason because men die and they make a widow and so
0:12:46 that’s the left anterior descending artery women by and large tend to not have these larger artery
0:12:52 blockages but their blockages are diffuse and microvascular deeper into the heart muscle which is why
0:12:59 we present with a heart attack much differently than a man does and those we’re not teaching our you know
0:13:04 we’re not educating our clinicians as to these differences women are considered to have atypical chest
0:13:11 pain dr right 51 of the population is female why are why is my heart attack atypical right and a man’s
0:13:18 typical but this happens not only at the organ level it makes sense that if we have a population
0:13:24 with xx chromosomes a population of xy genetically and the way we express those genes are differently
0:13:33 but i think we miss the fact that down to a cellular level every cell from an xx is expresses these
0:13:41 tissue changes tissue manifestations differently than an xy our lab used to study we called the
0:13:46 muscle derived stem cells so look 20 years ago now they’re called satellite cells but when we harvested
0:13:56 them and asked them to behave in different environments satellite cells from xx people and xx animals women
0:14:09 were better under the same circumstances experimentally at making cartilage and muscle xy male were better under the same
0:14:18 circumstances in making bone so down to a cellular level we express our genes differently it should be no mystery to us or
0:14:26 anybody else that there are differences and yet there is the propensity just to lump us all in the same basket and
0:14:33 almost say i almost sometimes feel as pejorative to say oh the women are different of course they’re
0:14:38 different yeah we’re genetically different down to every cell in our body every cell so it should be
0:14:44 no surprise to anybody but it seems to be a seems to be a surprise all the time yeah get pushed back
0:14:50 all the time there’s no difference yes there is there is and it’s not just it’s not bad it’s just is yeah
0:14:55 yes at one point that was quite a controversial thing to say wasn’t it to point at the differences
0:15:01 between men and women outside of you know our different organs yeah you know yeah and because
0:15:06 of this research gap and the bias in medicine um women have been misunderstood by their male
0:15:10 counterparts in a number of ways i remember i think it was you mary that was telling me about
0:15:15 this whiny women thing that you were exposed to when i was in training and and you all may have
0:15:21 similar stories and i just heard a new one the other day my first patient in gynecology clinic
0:15:25 i’m an intern i’m very excited you know we have our stacks of charts that’s how old i am we had paper
0:15:31 charts i pick up the chart open it up it’s a 40 year old woman with multiple vague complaints she’s
0:15:36 gained some weight she’s a little bit depressed her libido’s off her blood pressure’s a little bit up
0:15:41 her cholesterol’s starting to rise and she’s seen family medicine like we’re the third or fourth doctor
0:15:45 at this point and so my upper level who happened to be male this you know it could have been anyone
0:15:51 walks down the hall in his cowboy boots because texas and um and he’s like what you got and i said
0:15:56 well i have miss smith whomever you know she’s a 40 year old woman with and i list the complaints and he
0:16:00 goes did you check her thyroid family medicine did did you check this you know a few simple labs
0:16:10 and he goes hmm you got a ww and i said what i don’t know this you know and he said uh don’t write
0:16:17 this in the chart but we call that a whiny woman around here oh my gosh and i said okay he said listen
0:16:24 women just tend to go through this at this age and we’re not really going to be able to help her
0:16:29 pat her on the knee tell her to have some wine go on date night you know she’ll get better but
0:16:34 we’re not going to be able to help her and that stayed with me now i was you know a good girl i did
0:16:41 what i was told you know it took me 20 years of internalization to realize this you know i don’t
0:16:47 want to blame him he’s not a bad guy this was taught to him but this kind of thinking i mean i saw this in
0:16:52 the er i saw this in the or i saw this in every clinic and so i’ve asked other clinicians around
0:16:59 the country and i’ve heard whiny guiny status hispanicus total tbd total body dolor like in
0:17:04 different regional areas there was a name for this kind of vague complaints from this middle-aged woman
0:17:11 and we couldn’t quite put our finger on it and i realized this was systemic bias built into the system
0:17:17 where women there’s historical you know precedent for this the wandering uterus the hysteria you know
0:17:23 these were real medical terms just until like not even a generation ago yeah they used to put women
0:17:30 into asylums yeah because of hysteria and it was hot flashes all the things that that are now known
0:17:36 with perimenopause they used to think it was some kind of insanity and put women into insane asylums
0:17:41 to lock them down but this is pervasive not just an ob you are not the only guilty
0:17:51 it’s every medical subspecialty has some culture of for lack of better words blowing women off
0:17:59 right for not having the curiosity that defines medicine we are supposed to be curious people
0:18:05 but yet when it comes to this why do we stop at just seems to be something that happens to middle-aged
0:18:10 women right it that that’s written in the orthopedic literature seems to happen to middle-aged
0:18:17 where’s the curiosity where was it yeah well in ex-phys text you always had the representative
0:18:24 of him or they and the vesuvius man and all the angles of the male body but there was never representation
0:18:29 of women the only time you heard about a female athlete was all the pathophysiology you know the
0:18:36 iron deficiency the female athlete triad which we now call relative energy deficiency in sport
0:18:42 and when you’re looking at the historical idea of sport the only way women were actually included
0:18:47 and accepted is when they were amenorrheic because then they were quote more like men and then there
0:18:53 wasn’t a problem with training them and then they could work as hard but we know that that’s not
0:18:58 appropriate that’s a sign of of illness and overtraining under recovery so it is pervasive
0:19:03 everywhere it’s not just the medical but it goes into when you think about what it means to be
0:19:08 successful in sport it’s the power it’s the aggression it’s the unfallibility of being human
0:19:14 and a woman having a menstrual cycle was deemed a fallibility so they’re trying to push it aside
0:19:21 this is so systemic though that women downplay their own complaints they gaslight themselves it takes
0:19:27 them a long time to seek care because they’re afraid of the response they are not always honest with
0:19:32 what’s going on in their body i’ll say do you have pain oh no more than regular they downplay
0:19:37 everything you have to really ask and it’s almost the society i don’t want to be viewed
0:19:45 as this way i don’t want to be not taken seriously and it causes them and to have an even harder time to
0:19:50 get to a diagnosis because they don’t feel comfortable sharing some of these symptoms or they’ve downplayed
0:19:56 them in their life so much this is why they have to get so sick to often present to even try to get
0:20:03 care and they come to me almost to a woman after i’m talking about whatever musculoskeletal thing
0:20:10 they’ll say even before they want to describe it to me they’ll say but you know i have a really high
0:20:18 pain tolerance yes like it’s a badge because we’ve been conditioned to not come for any pain but i’ve
0:20:23 suffered i’ve tried that’s why your arm doesn’t move anymore i’ve got such a high pain tolerance but i
0:20:30 couldn’t take it anymore i didn’t want to come and i feel like why does it have to be that way so you
0:20:36 train treating both males and females i do i i was locked in a room with women for 25 years you know and
0:20:44 so it’s so fascinating to me to hear how man and woman come in with the same complaint in your clinic
0:20:49 and your fellowship all those years you spent training and yet you were taught to treat them
0:20:54 differently you know and the urologists say the same thing you know i don’t think i was aware of it yeah
0:21:02 there was just that’s so much bias yeah i didn’t realize i didn’t either because like you until i went
0:21:09 through my own perimenopause i might not have paid attention to it yeah i may have
0:21:15 been less sensitive i was a terrible menopause doctor just give me 30 seconds of your time
0:21:20 two things i wanted to say the first thing is a huge thank you for listening and tuning into the show
0:21:25 week after week means the world to all of us and this really is a dream that we absolutely never had
0:21:30 and couldn’t have imagined getting to this place but secondly it’s a dream where we feel like we’re
0:21:36 just getting started and if you enjoy what we do here please join the 24 of people that listen to
0:21:41 this podcast regularly and follow us on this app here’s a promise i’m going to make to you i’m going
0:21:47 to do everything in my power to make this show as good as i can now and into the future we’re going to
0:21:51 deliver the guests that you want me to speak to and we’re going to continue to keep doing all of the
0:21:57 things you love about this show thank you is that in part because we know very little about hormones as
0:22:01 well when i was speaking to our audience we asked a thousand women to submit their questions ahead of
0:22:06 this conversation and one of the most asked questions all the most asked questions sort of
0:22:13 related to understanding hormones i think the conversation around hormones is quite a new one
0:22:18 in society and i actually think it’s been driven a lot by a heightened understanding of menopause
0:22:25 i think the conversation of hormones around outside of fertility and the general menstrual cycle i can
0:22:31 right now draw from memory the exactly what’s going to happen in a normal menstrual cycle we were taught
0:22:39 that you know very very well but when i saw maybe three years ago an academic paper that showed all of the
0:22:47 locations of the g-coupled estrogen receptors in the human body what’s that i lost my mind so basically where are the
0:22:52 estrogen receptors in the human body and they’re everywhere the brain the bones the muscle the gut
0:23:00 you know the the every almost nothing the the endothelial the lining of the individual blood vessels around our
0:23:07 heart you know it’s really radical to me to think about how all these sex hormones or the progesterone
0:23:14 estrogen testosterone hormones are everywhere what is a hormone not actually sex hormones hormones are your body’s
0:23:20 communication system right so it is really how your body is sending out messengers to communicate so a hormone
0:23:25 is dictating an action and i think there’s going to be a lot of great discussion but one thing that i think
0:23:32 is very important to your point steven is even things that we were readily taught about the menstrual cycle
0:23:37 and estrogen progesterone testosterone the public is now becoming aware of because we’ve not done a good job
0:23:42 at public education that this is what’s really happening in your body this is what your menstrual cycle is
0:23:47 this is what happens when you go through menopause this is what happens when you’re trying to train
0:23:54 for a sport we haven’t had these discussions publicly that we are seeing and i think that is highlighting
0:24:00 interest in all of this even if some of us were taught some of this but when it comes to hormones
0:24:07 there’s everybody wants really easy fast draw my level tell me what to do give me a medicine fix it
0:24:12 and i think the most important thing to understand is that by definition your hormones are dynamic
0:24:20 your body is responding to the hormonal signal it sees and determining what next signal to send out
0:24:26 so constant fluctuation throughout the day in response to multiple stimuli and that’s how it’s
0:24:31 supposed to be if we didn’t do that we’d all be dead it’s a symphony but that makes it really hard for
0:24:37 somebody to understand on the other end who’s not in medicine who says well is it my hormones because
0:24:42 there’s no one test that’s going to give you one answer you have to really interpret it in context of
0:24:47 the full body and it makes it really hard for practitioners who do not understand the hormones
0:24:52 as well and we see a lot of mismanagement of hormonal scenarios and situations right now that
0:24:57 are actually detrimental to patients so i’m glad you’re having this discussion because that’s not a
0:25:03 stupid question what is a hormone many people don’t really understand that what is the i really want to
0:25:07 make sure that if someone for both the men that probably have less understanding but also from our
0:25:11 conversations i’ve realized and the feedback i’ve gotten a lot of women don’t understand their own
0:25:16 hormones and their own menstrual cycles what is the most basic level that we have to start at to give
0:25:22 people an understanding that we can then build on of what’s going on here i was gonna say i want to get
0:25:29 rid of this graph okay so none of that no leave it out leave it out but it it shows just a textbook
0:25:36 of what a menstrual cycle is is but it doesn’t show the daily perturbations of estrogen and the
0:25:42 luteinizing hormone pulses and all the things that go as natalie’s saying to make it to make it work
0:25:47 it’s an you see two organs there the ovary and the endometrial lining you’re not seeing the muscle
0:25:53 the bone the brain all of those organs are affected by these normal monthly fluctuations
0:26:00 and the conversation that we’re having now in research methodology is the fact that there is no real
0:26:06 definition of normal because every woman’s cycle is variable so when we look at this everyone thinks
0:26:12 that this is normal but we don’t actually know if that is for the fact that a woman’s variation
0:26:20 this can change cycle to cycle this can change cycle to cycle sometimes we have an ovulatory cycles
0:26:26 so until a woman can identify what her own normal is we can’t rely on this graph to actually explain to
0:26:31 them how does a woman know what their normal is versus you know because a lot of women are on
0:26:35 birth control pills since a very young age so i think my partner melanie she’s she was on birth
0:26:40 control for about a decade so she like didn’t have her cycle and then it came back and it was every
0:26:45 i don’t know 60 90 days and then she changed her diet a little bit and it kind of went down to
0:26:50 30 days over time but i don’t think she knew what normal was is there such thing as normal i mean
0:26:56 there is what should be normal for you so you should have a regular predictable period which means
0:27:01 that you are having a menstrual bleed at a predictable interval it can range person to person but for you
0:27:05 really it should be within a couple days month to month i always tell patients i should be able to
0:27:10 give you a calendar you should be able to take your finger pick when your next period is coming and within
0:27:17 a few days be accurate now usually that range is somewhere between 25 and 35 days for the average
0:27:23 person when it starts to get shorter or longer it can be a warning sign that something is going on
0:27:28 when it comes to the menstrual cycle because i think we’re going to talk about these hormones really well
0:27:33 and i talk about this every day let’s give a one minute explanation if we think about to stacy’s point
0:27:39 from the brain the brain is sending out pulses of hormones but fsh drives egg growth it’s called follicle
0:27:45 stimulating hormone and each egg is inside a follicle so you have a group of follicles inside the ovary
0:27:51 fsh comes from the brain grabs one of them and gets it to grow and it makes estrogen and this
0:27:55 estrogen from the ovary as the egg is growing is called estradiol and it’s the primary type of
0:28:02 estrogen in your body so it is rising and when it gets to a peak level and the body is so fascinating
0:28:08 because it’s 200 picograms for 50 hours it’s a very exact amount then the brain says we must have a
0:28:14 mature egg and it kicks out a surge of luteinizing hormone or lh and that is going to allow the
0:28:20 follicle to rupture the egg to be released and the follicle to reform and then become a corpus luteum
0:28:26 and then the brain is going to send out pulses of lh giving you pulses of progesterone so stacy’s point
0:28:31 that’s an average and those numbers on the little graph are nowhere near accurate because progesterone
0:28:36 goes up and down the entire second half of the cycle known as the luteal phase what’s progesterone
0:28:42 progesterone is also made from the ovary so the two main hormones when it comes to a premenopausal female
0:28:47 are going to be estrogen and progesterone progesterone is the progestational hormone or
0:28:53 pro-pregnancy is going to change the endometrial lining and it is essential to get pregnant it opens
0:28:59 and closes the implantation window within the uterus and it completely changes the physiology of your
0:29:05 body and we’re going to talk a lot that is why in the luteal phase your body works differently when
0:29:11 you have progesterone and the luteal phase is after ovulation when you have a corpus luteum so when lh is
0:29:15 coming from the brain you have a corpus luteum it makes progesterone this is the second half of the
0:29:22 cycle known as the luteal phase the first half when you have estrogen only is the follicular phase so you
0:29:26 have an estrogen dominant phase and then you have a phase where you have both estrogen and progesterone
0:29:31 and your body is made yes so we have our estrogen dominant phase the follicular phase and then we
0:29:36 have where we have both estrogen and progesterone here in the luteal phase and your body is made to
0:29:40 function differently in these because in the progesterone side it’s preparing you for a pregnancy
0:29:45 it thinks every month you might get pregnant and it starts to change how your body is going to work
0:29:51 on a cellular level but if you don’t get pregnant that progesterone level is going to drop and the cycle
0:29:59 starts back over and from like an exercise and sports point of view when we get into this progesterone’s
0:30:06 job is to build this lush endometrial lining and it creates a lot of glycogen storage so we often hear
0:30:12 about glycogen in the muscle and that’s what we’re using for fuel it has a way of shuttling a lot of the
0:30:19 carbohydrate away and storing it into the endometrial lining which is why we see differences in intensity and
0:30:23 the way that a woman can respond to exercise if she has ovulated
0:30:26 so is this in preparation of a potential baby
0:30:27 yeah
0:30:34 correct yeah and the second half of the cycle your core body temperature increases your resting heart rate is higher
0:30:39 your heart rate variability is lower you have increase in fatigue you have an increased appetite
0:30:46 your body is shifting function in case an embryo comes in so that it can start to divert energy and change
0:30:51 what it is doing right down to your immune system changes and that’s roughly from day 14 roughly
0:30:56 roughly yeah at ovulation about three days after whatever day you’d like to be specific it’s about
0:31:01 three days after ovulation until when you get your next period yeah you will talk about how
0:31:09 menstrual cycles can be a broader sign of whole body health and um so should if someone’s menstrual cycle
0:31:13 is irregular should they be concerned yes yes i thought you were going to say no
0:31:20 how irregular what’s like if i’m not getting my menstrual cycle absolutely not good you should go
0:31:26 see a doctor yeah if your cycle is irregular if the calendar trick you’re putting your finger and it’s
0:31:30 nowhere near when your cycle is coming or i have women who say oh there’s no way i could predict it
0:31:37 or i know it will come but it’ll come every four to six weeks your body’s meant to work like clockwork when
0:31:42 it comes to your your hormones and your menstrual cycle and yes you can always have one abnormal
0:31:48 month always but when you consistently are having irregularity that is a sign that something else is
0:31:54 going on it’s one of the biggest red flags that we have for early hormonal health or systemic problems
0:31:59 but to your earlier point steven we have a generation of women on contraceptive options who are not tracking
0:32:03 their cycles we have women who are not taught how to track their cycles they don’t know when ovulation
0:32:09 occurs they don’t know how long their luteal phase is if i say the first sign of ovulatory dysfunction
0:32:15 or having a problem with your cycle is a short luteal phase well you only know that if you’re
0:32:21 tracking when ovulation occurs because otherwise you could still have a regular cycle but you don’t know
0:32:26 that something’s abnormal and that luteal phase again is the last the last half of your cycle
0:32:34 but i think that the conversation that’s happening now is not just at this table but in society that
0:32:42 our monthly cycle is so much more than getting ready to have a baby because i think that none of us knew
0:32:48 this yeah because at 17 i wasn’t that interested in having a baby so it didn’t occur to me that i
0:32:55 should care right right and it’s the only time if you’re thinking about it in that way that you’re
0:33:01 worried about your period is if you don’t have one and pregnancy right and so if we’re shifting the
0:33:08 conversation to this is physiology this has to do with every part of female physiology
0:33:17 maybe it will be easier for people to know right yeah i often put it with my athletes that it’s a
0:33:23 marker of health that if you are able to take on the load of training the load of travel and maintain
0:33:30 your normal menstrual cycle then you are robust enough to be able to progress but if there becomes
0:33:36 a misstep in your menstrual cycle then we need to look at all the stressors that are and they
0:33:41 allostalic load and pull you back and see what do we need to address do you need to eat more do you need
0:33:46 to recover more what are the things that are missing to bring you back to normal i was diagnosed with
0:33:52 polycystic ovarian syndrome in medical school and so like every medical student of course it was like
0:33:56 gloom and doom and i you know thought i had the most extreme case ever known to mankind it was
0:34:02 really just garden variety pcos and i had very serious boyfriend quickly engaged you know looking
0:34:09 forward to having a family with him starting a family with him and the terror around my infertility
0:34:15 and what the impact was what was never taught to me and what i didn’t understand until much later
0:34:20 was the metabolic impact like pcos is a symptom there’s nothing wrong with my ovaries they’re just
0:34:26 responding to this high insulin level i was born with and no one really sat me down and talked to
0:34:31 me about my first research project was women with irregular periods and the risk of developing
0:34:36 gestational diabetes and and you know i didn’t even know what insulin resistance was at the time
0:34:42 and now we’re coming to understand that you know when these young women are coming you know i only do
0:34:48 menopause now but before i left that practice you know when women were coming with irregular cycles and
0:34:51 we’re making these diagnoses immediately i was launching into the discussion about her metabolic
0:34:57 health long term and what this you know it’s a gift to know this so now we can start making
0:35:04 interventions nutrition diet exercise to give you a better system to deal with this thing that you
0:35:09 were born with and her fertility of course a huge amount of women have pcos and i think that’s one of
0:35:15 the leading one of the leading one of the top causes of having irregular menstrual cycles you you mentioned
0:35:21 insulin resistance and metabolic dysfunction there and you said something like diabetes just gestational
0:35:28 diabetes diabetes and pregnancy so someone who was non-diabetic before pregnancy and then develops
0:35:33 diabetes so her blood sugars have now reached a threshold where they are higher than normally and can
0:35:39 cause you know problems for her pregnancy and herself long term and up to 50 of those patients
0:35:46 who develop diabetes and pregnancy will develop type 2 diabetes within 10 to 15 years after that
0:35:53 gestation after being pregnant and so what we know now is like we have warning signs of this well before
0:35:58 pregnancy where we can set these women up for success before it’s just we wait till we make the diagnosis
0:36:05 everybody gets their glucose test and off you go but now with this pcos diagnosis we are monitoring
0:36:10 earlier we’re starting her on the nutrition you know we’re treating her like a diabetic with nutrition
0:36:17 and exercise recommendations rather than waiting till she she reaches the criteria steven having infertility
0:36:25 this is a scary statistic it predisposes you to many medical problems later in life including an 80
0:36:30 higher chance of having a heart attack 75 higher chance of having metabolic syndrome higher risk of
0:36:36 cancer and early death why infertility well it’s not exactly that infertility is causing this but it’s
0:36:43 that for many women we’ll use dr haver as the example you’re healthy until you get this diagnosis it’s
0:36:48 one of the first warning signs your body’s giving you that there might be inflammation and insulin
0:36:55 resistance or something impacting your hormones your menstrual cycle your ability to conceive that if it is not
0:37:02 corrected now is setting you up for many problems down the road pcos is a example of this because
0:37:09 in pcos you have a lot of eggs inside the ovary it’s actually something that genetically runs in families
0:37:15 likely there’s something that happens when your baby inside your mom that predisposes your ovary to
0:37:21 not lose as many eggs as it should and it changes how they respond to insulin so what happens is you end up
0:37:28 having more eggs on an average your brain doesn’t know this and sends out the average signals but that
0:37:33 gets diluted amongst all the eggs and so you’re not getting into these ovulatory stages of stacy’s
0:37:39 favorite graph here what happens from there is that you’re actually in a relatively lower in estrogen
0:37:44 phase than you should be you never see the progesterone and what happens is you start to
0:37:50 completely shift the ovary itself actually becomes insulin resistant and what this means is that
0:37:56 throughout your entire body you start to develop high glucose which is the blood right that’s your
0:38:02 blood sugar your blood sugar is the fuel for all your cells all your cells need glucose well insulin is
0:38:07 the hormone that helps that glucose go from the bloodstream into your cells well in insulin resistance
0:38:13 when your body sees high glucose all the time it starts to send out more insulin saying hey we need to get
0:38:18 this into cells but the cells start to oh i’m used to insulin being here so i’m not going to respond
0:38:25 it’s going to take a higher insulin signal to get the cell to open up the door and let glucose comes in
0:38:31 this becomes very problematic especially in we’ll say pcos because that insulin is very inflammatory
0:38:38 causes you to get extra fat stored in different places it also just completely changes how your body
0:38:43 your metabolic health in general but also your hormonal health and in your brain because your
0:38:47 brain sees this and says why are we keeping glucose in our in our bloodstream is what’s going on
0:38:54 heightens everything and so this resistance to insulin actually shifts how your brain’s going to respond to
0:39:01 hormones therefore the hormones it’s sending out and it’s a self-perpetuating cycle and a lot of when we talk
0:39:07 about lifestyle mechanisms to improve hormonal health which i know that we all will a lot of that is
0:39:14 targeting improving insulin resistance and combating inflammation because those two players a lot of it
0:39:19 is controlled by the world around us and what we do to some degree and especially if you have an underlying
0:39:26 diagnosis like pcos endometriosis which is a chronic inflammatory disease autoimmune disease you’re at even
0:39:32 higher risk i would say your scale is already tipped in a way that’s going to be really hard for you have
0:39:38 to make active steps to fight what is happening inside your body we’ll talk about some of the ways
0:39:44 one can reverse their pcos if that’s even a possibility um but again on the causal factors is it
0:39:50 something so my girlfriend’s got pcos she’s been very public about that um is it something she did
0:39:56 is it something she ate is it she was this is the way she was born so she was born with a predisposition
0:40:01 of having too many eggs you lose most the eggs inside your body when you’re a baby inside your
0:40:07 mother’s womb you lose the next biggest set before you ever have your first period now if you don’t lose
0:40:12 them for some reason you’re born with more and it interferes with how your hormones are supposed to
0:40:18 communicate leading to this metabolic issue and this insulin resistance she did nothing to cause this
0:40:23 nobody with pcos caused it however what you said earlier oh she changed how she ate and her cycles
0:40:31 got more regular you can influence the severity of the symptoms that you experience with it so even if
0:40:36 you don’t cause your disease because you did not choices you make can make it absolutely can make
0:40:42 it better or worse just like any disease yeah and when you use the word insulin i think of or insulin
0:40:48 resistance i think of sugar yeah because glucose is sugar essentially as many people and i’ll have
0:40:52 patients tell me this i don’t need to worry about insulin resistance because i don’t have diabetes or it’s not
0:40:59 in my family we’ve so we’ve ingrained this word insulin resistant we’re talking about glucose or checking
0:41:07 glucose with a diabetic or pre-diabetic state but the world around us honestly promotes insulin
0:41:14 resistant it that’s how our bodies we live in this obesogenic environment i mean there’s no doubt at
0:41:21 least in the u.s you know and most industrialized nations our environment is what we call obesogenic
0:41:27 and you know and insulin resistant agent so it you have to fight against kind of the systems that are in
0:41:32 place now for most of us unless we have some genetic predisposition to just be you know magical
0:41:40 um to because the way we process food the way food is delivered to communities the way you know our lack
0:41:46 of exercise you know everyone’s working from home now just just modern life is is really you have to
0:41:51 fight against one of the questions that came in from the audience was i would like to know how best to
0:41:57 manage my pcos when it comes to managing your pcos targeting those two factors that we talked about
0:42:02 earlier insulin resistance and inflammation are really the key and i’ll let these two speak to a
0:42:08 little bit of some of the exercise changes that we can try to impact but what i’ll say is that the best
0:42:14 way to decrease inflammation in your body is going to be to start by focusing on your gut your gut health
0:42:21 controls a lot of the inflammatory burden that your body sees the foods you choose to eat they can be both
0:42:26 helpful if they have a lot of fiber in them they can feed your gut microbiome which is important in
0:42:32 estrogen metabolism but they can also be very harmful if they are ultra processed foods that are
0:42:38 even causing more inflammation not feeding your gut microbiome at all and worsening so i always say it’s
0:42:44 like a scale if you think every little food i eat it can make my insulin or it can make my inflammation
0:42:49 better it can make it worse and so how we structure the food that we put in our body
0:42:55 is one of the biggest changes the majority of people can make that is going to make a difference
0:43:01 and that’s going to be a very plant forward diet doesn’t mean it’s plant only but plants have fiber
0:43:07 fruits and vegetables have fiber so we have to make sure we’re getting fiber as a big change that’s what
0:43:14 we see i see a lot of patients with pcos specifically being told i shouldn’t eat fruit i shouldn’t do this
0:43:20 i need to avoid do the ketogenic i need to do keto yes so we see people avoiding certain food groups and
0:43:24 i always say it’s not a really sexy diet but it’s a it’s a diet we all know yeah lots of whole foods
0:43:31 fruits and vegetables healthy fats healthy sources of protein avoiding the ultra processed foods that’s
0:43:36 going to be probably the biggest change most people can make in addition to foundational changes
0:43:42 of your day which is going to be sleep more that is when your body fights inflammation bites insulin
0:43:48 resistance work on decreasing chronic stress to stacy’s point you’re not running from the bear so
0:43:57 your body is not using that challenge but you get an email you get stressed and your body releases a lot of
0:44:02 glucose so it can have sugar and fuel to run from a bear and there’s no bear right in previous days that would
0:44:07 happen and then you’d go run and that glucose would go into all of your muscles and your body would go
0:44:14 back to normal but now we’re chronically stressed so actively decreasing stress and then exercise
0:44:20 building and using skeletal muscle is one of the most effective ways to combat insulin resistance that
0:44:27 exists and since 80 percent of patients with pcos have insulin resistance a large portion of women with
0:44:35 infertility even without pcos have insulin resistance that is a huge thing that people are missing especially
0:44:39 when it comes to the exercise discussion and i know you guys probably have things to add on that one
0:44:45 no but based on what you just i just took a phone call this morning from a patient when and it’s just such
0:44:53 a typical conversation she doesn’t like the way her body looks her solution is not to eat
0:45:00 it’s this happens almost every day when i’m talking to people it’s we’re having coffee for breakfast we
0:45:08 don’t eat till midday when we do eat so the the gut reaction because of the way many women are raised is
0:45:14 that we’re going to starve ourselves which is the opposite of good when it comes to physiologic wholeness
0:45:21 and then you don’t have the energy to do the kind of exercise you need or on the other side the response
0:45:29 is i am going to work so hard every single day that you actually increase your stress there is over
0:45:35 there is overtraining so you’re just getting behind the eight ball with starving yourself and overtraining
0:45:43 none of which are going to solve either the core problem due to pcos or the core problem in any
0:45:48 stage of a woman’s life right and this is where we look at the sociocultural effect of what a woman is
0:45:55 supposed to look like yeah and that’s the thing that i’m really pushing out it’s like we want to think
0:46:01 about how strong we can be and how much muscle we can build because muscle is a massive metabolic help
0:46:09 and as as well as bone right and so we talk about it and then when i get the pushback of oh
0:46:13 i’m going to do fasted training or i’m going to fast till noon i’m like wait a second not only are we
0:46:20 going to interfere with our circadian rhythm and our hormone pulses we’re also acutely interfering with
0:46:26 our appetite hormones because if we’re looking at acylated ghrelin which is our active form of of our
0:46:31 appetite makes us hungry it’s elevated with cortisol and so if we’re thinking about that
0:46:36 elevation and we’re not doing anything to drop it and tell our body we have food then it goes in and
0:46:42 directly affects our neuropeptides which then affects our hormone and our hormone pulses
0:46:46 so when a woman’s like i’m just having coffee for breakfast i’m going to hold my fast it’s like okay
0:46:50 well here we go cortisol is going up acetyl ghrelin you’re going to get hungrier then you’re going to
0:46:55 learn not to respond to that hunger you’re going to hold your fast and we see from the research that
0:47:00 women who do that end up craving more simple carbohydrates in the afternoon moving incidentally
0:47:06 less and contributing to poor sleep because they’ve now phase shifted so when we’re talking about sleep
0:47:11 and how important sleep is we also have to think about the circadian rhythm and how it is affected by
0:47:17 food intake light darkness and all of the things and we need women to understand we want to build muscle
0:47:23 we want to sleep well and that requires food well and this goes back this whole thing you just said
0:47:32 goes back to very early in this conversation where i was talking about sometimes we like to focus on the
0:47:41 bright shiny gadgets when we haven’t taken our health from fine to optimize because everything you just
0:47:50 talked about it isn’t a gadget it’s basic lifestyle in the medical model of pcos when i’m talking about
0:47:58 what we’re taught and how we train our clinicians we go into the you know we aren’t taught a lot about
0:48:03 disease prevention or and i hate to use the term root cause because i think it’s been usurped by
0:48:07 certain members of you know the wellness community take it back yeah we’re going to take it back and
0:48:13 so especially for pcos i was taught to give a patient birth control pills or clomid when she’s ready to
0:48:21 get pregnant and so nothing nothing around nutrition exercise lowering inflammation and i was a program
0:48:28 director until 2018 and there was nothing in the curriculum around this which affects at least 10 percent of
0:48:36 women probably more this condition that how important lifestyle is you know she went on for 10 minutes
0:48:41 about all the lifestyle check which is amazing which is amazing but patients but i’m sitting here
0:48:46 thinking birth control pills birth control i mean that was a knee-jerk reaction i mean i was treated for
0:48:53 my own polycystic ovarian syndrome for 20 years with oral contraceptive agents and i learned online
0:49:01 through chat rooms about the nutrition end of it yeah when i have athletes because we see a higher
0:49:08 percentage of pcos and successful female athletes like well what do i do and it’s looking at what
0:49:13 kind of training they’re doing so we’re putting this more short sharp high intensity to get that
0:49:19 post-exercise response of anti-inflammatory growth hormone response all of these things that then
0:49:25 bring down total body inflammation and then we’re very careful about food intake and when we’re doing
0:49:30 it and what kinds of food so that they don’t have to go down the route of oral contraceptive pills
0:49:36 because that to them has an effect on their performance we’re talking about the top end and
0:49:40 when we bring it back down into recreational female athletes we can do the same thing it’s just we have
0:49:46 to educate and say these are our lifestyle choices and then these are our medical choices and what’s optimal
0:49:52 for your life at this point it’s important to say at this table and we all talked about it last night
0:49:58 you need to have a period if you’re not preventing a period with hormonal contraception and you’re in your
0:50:05 reproductive years because very often women with pcos or hypothalamic amenorrhea will say i don’t have a
0:50:11 period but i didn’t really like that anyway so it doesn’t bother me how many women have said well i didn’t get
0:50:17 my period for a year but that was fine by me but that’s not fine by your body that is hypoestrogenic
0:50:24 time it is low estrogen yeah very low estrogen it’s bad for your body on so many reasons to be low estrogen
0:50:29 during these crucial bone building years but for we’re talking about how your hormones communicate
0:50:37 back it’s very harmful to long-term health to have low estrogen at all brain health but yeah but
0:50:43 especially in young years when you’re still developing what why would a woman say that she
0:50:46 didn’t want to have a period i mean this is a super naive question as a guy but i understand it’s painful
0:50:50 i mean do you want to bleed i mean do you want that i mean if it was a choice now
0:50:57 actually knowing now what i know now and for my own young daughters i’m like we have got to make
0:51:04 sure you have a period yeah but when i was young i was a dancer and an athlete i had very low body fat
0:51:09 and i wouldn’t have periods for six to nine months and i’m like yes you know what’s interesting i was
0:51:16 thinking of mel she because of what she’s been through and also because she’s listened to the
0:51:20 conversations i’ve had with all of you and she understands the value and importance of her period
0:51:26 she now celebrates it it’s like a celebration in our house when it arrives because because
0:51:30 if you understand the importance that it has in sort of full body health and the role it’s playing
0:51:37 then the pain the downside is weighted against your understanding of the upside which to her means
0:51:41 she’s healthy she’s fatal hormonal health is working yes are great and that’s the conversation
0:51:47 shift that i’m hoping is gonna instead of being a detriment and a downer and talked about she must be on
0:51:54 whatever derogatory yes derogatory things are said about us that oh my gosh she is so healthy
0:52:01 yeah i remember sitting in a high performance meeting just maybe three years ago and the leading
0:52:06 athletics coach stood up and said i know when my athletes are ready to perform on the world stage when
0:52:14 their periods stop and all of us went what it’s like no that’s the time where like we have to really
0:52:20 look at your athlete is getting ready to crack and be injured and it’s still this pervasive idea and
0:52:26 it’s still pervasive even in the fitness industry that losing your period is okay because that means
0:52:32 you’re actually very resistant to getting it back yes like it’s a sign of failure of their sport or their
0:52:38 athletic endeavor because this is is so pervasive and i think that’s why it’s important to have these
0:52:43 discussions and i love hearing that mel now says yay my period is here because that’s a sign of hormonal
0:52:48 health and things are working well because that is how we should feel but i think the other part of
0:52:55 it is for women who have meharanja or heavy bleeding and heavy cramping they don’t realize that they can
0:53:00 get help with that as well and that’s the conversation that isn’t followed through when we’re like yes get
0:53:04 your period but if you’re someone who suffers from really bad cramps we also have to educate that there
0:53:10 are things that we can do to help with that does the size of the bleed matter because she turned around
0:53:14 to me the other day and she said with her last cycle she said she didn’t bleed much she seemed
0:53:19 slightly concerned obviously i had no idea what to say to that it depends congratulations well done
0:53:24 i’m so sorry mineraja so we have definitions and there are you know we don’t walk around with
0:53:29 measuring cups generally between our legs to measure how much blood’s coming out each month but but women
0:53:38 know but women know your period should not cause you with modern you know period products your cycle
0:53:42 shouldn’t cause you any stress in your life you should just roll with it right and so that’s when i’m
0:53:46 like when is it a problem bleed through your clothes you should be able to sleep through the night you
0:53:50 should be able to get through an athletic performance you should be able to do x y and z
0:53:58 now when we do start measuring and you should not be anemic so i’m not waiting till anemia i am anemia is
0:54:03 low red blood cell count you know to the point where your performance is affected your ability to carry
0:54:12 oxygen is effective so the red blood cells are what carries oxygen in our bodies and women who have heavy
0:54:19 periods however that’s defined can lead to anemia but the first thing that we notice is their ferritin
0:54:22 is dropping that’s the first sign my daughter my daughter we just had some blood work done she
0:54:27 was feeling a little fatigued and her ferritin and iron saturations were really low and i was like
0:54:30 talk to me about your period turns out she’s not eating a lot of iron rich foods so we’re dealing
0:54:36 with that but you know we can get so far ahead of this and looking at these ferritin levels the
0:54:42 transferrin you know these iron studies before she’s actually anemic which is like the last thing
0:54:47 that happens when her red blood cell count drops or they become so small and what we call microcytic
0:54:52 you know we are we need to do a better job at recognizing these things we’re not going to walk
0:54:57 around and measure how much blood’s coming out because i could maybe squeak out 200 cc’s you know a
0:55:02 period and you could be 300 and we’re both doing fine you know we both have great so i think it’s
0:55:07 really looking at you know how much bleeding is too much now how little is too much that that’s
0:55:12 probably better yeah is any change from what you consider normal we would all say this is a normal
0:55:18 amount so if it gets heavier than that or less than that and it stays that way that is concerning you
0:55:24 can always have a one-off estrogen is the driver of growing the uterine lining so if you have a lighter
0:55:29 bleed one month we are concerned that you did not grow as thick of a lining your body didn’t see as
0:55:34 much estrogen most of the time you ovulated earlier that cycle your cycle came a little bit sooner
0:55:41 than you’re used to it coming and it’s not quite a big deal but this can be concerning if we see
0:55:47 consistently light periods especially if we have history of progesterone contraception which progesterone
0:55:52 thins out the lining and estrogen grows it so progesterone actually stabilizes it but for the
0:55:58 sake of the discussion we’ll say estrogen grows it progesterone thins it when you only see progesterone
0:56:04 like a progesterone iud the progesterone shot even continuous birth control pills because they give you
0:56:11 a type of synthetic estrogen and progesterone every day your uterine lining gets thinner and thinner and
0:56:17 thinner and so we see it can take months to return to normal after coming off
0:56:22 off of hormonal contraception you also can get damage to the endometrial lining there’s stem
0:56:28 cells in the endometrium that regenerate every month after you bleed they regenerate so that the
0:56:34 next group can grow in response to estrogen and this can get damaged from typically anything inside the
0:56:43 uterus so most commonly this is post birth you know a traumatic birth a retained placenta a dnc procedure
0:56:49 which is sometimes used after birth or in a miscarriage or even iud’s or intrauterine surgery
0:56:54 and it can form scar tissue in the uterus that can cause a light period so if you said
0:56:59 oh mel had a miscarriage and had this procedure and now her periods are lighter i’m highly concerned
0:57:07 versus ashram and central yeah so that is concerning for scar tissue in the uterus if you said oh she was
0:57:12 on a birth control pill for a while and now it’s a little bit lighter i’m less concerned that’s probably
0:57:18 going to get better or if this period came closer together or if you traveled around the world three
0:57:25 times this last month so one one off is no big deal but a change from your baseline can be concerning in
0:57:30 addition we should say that that graph is beautiful but you know your thyroid your pituitary gland it
0:57:37 makes prolactin prolactin also changes the endometrium so there’s subtle signs of other hormonal issues
0:57:43 that your menstrual cycle is the first warning sign that something is off what about pain she two months
0:57:49 ago she had like excruciating pain that i’ve never seen before during her menstrual cycle well it’s not
0:57:55 pleasant to have your uterus contract and expel its contents in any form but what if it’s like
0:58:02 way above the norm one time way above the norm is probably situational based on other things that are
0:58:08 contributing to inflammatory burden or response your body is also healing from the corpus luteum’s
0:58:13 assist on your ovary that can also feel painful and at the time of your period it is also healing so
0:58:20 there’s multiple things that can cause pain to vonda’s point so many people say i have a high
0:58:26 pain tolerance this is okay because we don’t talk about our own pain so i don’t know if my pain is
0:58:33 normal compared to somebody else’s your pain should not keep you out of your activities of daily living
0:58:39 you shouldn’t call in sick to school call in sick to work cancel dinner plans with friends consistently
0:58:44 again everybody can have a one-off month where something is off but if this happens every month
0:58:50 oh it’s my period i’m going to cancel that that is a warning sign that something else could be going on
0:58:56 endometriosis adenomyosis and uterine fibroids you mentioned the word iron a second ago dr mary
0:59:03 what is iron got to do with this and what is iron so iron is an element that is in our diets and we do
0:59:08 tend to store quite a bit of iron in our bodies and it’s an essential when we look at the structure of the
0:59:14 red blood cell and of hemoglobin specifically so hemoglobin is the actual molecule that is inside
0:59:20 of the red blood cell that carries the oxygen so iron is really critical to the formation of healthy
0:59:27 you know iron carrying red blood cells and we we store iron in our bodies and so in a lot in the bone
0:59:34 marrow and in and it’s stored in this particular molecule called ferritin so when we’re measuring ferritin
0:59:40 ferritin levels in the blood that is you know the first sign that your iron stores are getting low
0:59:47 is when we see these low ferritin levels are women more iron deficient than one would think like is the
0:59:53 general population iron deficient or what you tend to see when you run lab tests a menstruating woman yes a
1:00:01 menstruating woman is is often iron deficient yes and i we i do see it in our post postmenopausal
1:00:06 patients as well that’s usually nutritional and inflammation related so ferritin is also
1:00:12 something that will decrease in in times of chronic inflammation so you’re not able to utilize the iron
1:00:16 that’s coming in and store it because this inflammatory state is kind of inhibiting that
1:00:21 so in a menstruating patient i’m always thinking is she bleeding too much the first time you know and
1:00:25 is that bleeding menstrual is it coming from her rectum is it coming from her gastrointestinal tract
1:00:30 you know does she have gastritis or you know we have to go through the you know the algorithm of
1:00:35 why that might happen in a postmenopausal patient we can remove vaginal bleeding from the issue you know
1:00:41 uterine bleeding a period but then now i’m looking at nutrition i’m looking at exercise i’m looking at
1:00:45 inflammation as causative factors and the global pitch here is the world health organization estimates that
1:00:50 roughly 30 percent of women aged 15 to 49 worldwide are anemic with iron deficiency being the leading
1:00:56 cause and in some recent regions of south asia and sub-saharan africa prevalence can be up to 50
1:01:04 percent of women are anemic with iron deficiency being the leading cause you notice the norms have
1:01:10 changed so it depends on who you read yeah again you know when you’re looking at mountain male normative
1:01:16 curves versus what you know we’re we tend to accept lower levels for a female but now that we’re looking
1:01:22 at performance and you know looking at other factors besides just what is this ferritin level
1:01:29 um there’s a lot great new research coming out that we are looking at this differently and that we’re in
1:01:35 our clinic we are looking for 60 to 100 for a ferritin level to be considered optimal very different than
1:01:44 you know the baseline for you know keeping you out of out of a hospital versus you functioning at your
1:01:51 absolute best yeah because the norms that often get measured for us because they tripled right they were
1:01:58 15 and then they went up to to 40 so now they’re saying 20 and above is normal and when i look at a lot of
1:02:05 women who are sitting 20 to 30 they can’t get help they cannot get help and it’s like whoa it was maybe
1:02:12 four or five years ago if you were below 50 then we would look to get help but now with the norms that
1:02:20 have shifted with the sicker population we can’t get women help unless they are below 20 so when we say
1:02:26 normal i think this is important for everybody watching or listening normal in medicine means
1:02:34 common not non-pathological okay not bad you know it doesn’t mean it’s not bad and so norms shifting
1:02:40 meaning we’re getting sicker as a population and we’re willing to accept lower levels although they’re
1:02:44 not optimal for health the lab reference range what they say when you get your blood work drawn and you
1:02:51 see the reference range is based on population averages and so if the population is more anemic
1:02:59 this is going to accept a lower levels being normal even though they’re by no means optimal and i think
1:03:05 that’s one thing we all talk about is well how are you feeling your symptomology what do we see and you
1:03:11 have to interpret blood work in context of the whole person and what is happening and that is one issue we do
1:03:16 see with getting your own blood work drawn or these online companies when nobody’s interpreting it or
1:03:22 helping you interpret it on the other end you see something that is in a normal range but it’s not at
1:03:29 all optimal for you and it could be the reason why yeah exactly i want to talk about endometriosis i we
1:03:34 have a team member who’s been with the diarovus here since the very beginning called live yes are you
1:03:39 familiar with this i am so at age 13 she had her first period and she experienced agonizing pain with heavy
1:03:46 bleeding at age 14 she was put on the pill to manage the symptoms between age 15 and 24 she
1:03:52 continued to have severe stomach pain which resulted in multiple any visits she was often dismissed
1:03:59 as having gastritis and it led to having her appendix removed oh my god
1:04:09 why do you say oh my god endo can’t get surgery but she had major surgery and um i’ve seen this
1:04:14 course before and it’s it’s devastating because she’s going years and years and years now yeah
1:04:20 age 25 she came off the pill to see how she felt without it but her periods worsened and she fainted
1:04:26 from the pain so she went to accident and emergency at age 26 she got an ultrasound which suggested
1:04:33 endometriosis but no nhs diagnosis was given we ultimately had a conversation with you on the
1:04:40 podcast natalie and she felt very heard and she was actually there and so afterwards jemima and the
1:04:45 team who you know you guys know um told live to come and speak to me and live told me after you left
1:04:51 about um the symptoms did she speak directly to you at that time she did okay so she came and she spoke
1:04:56 to us about her endometriosis which is the first time i’d ever heard of it um and then we offered to
1:05:03 help support her privately so she could get private support with it um and she got an mri scan privately
1:05:12 which confirmed stage four infiltrating endometriosis oh my gosh live then pushed um on with her nhs
1:05:17 appointments the national health service in the uk but the pain was so much that she took me up on my
1:05:21 offer to pay for it privately so we paid for it privately and the endometriosis by that point had
1:05:27 spread to her bowels and pelvis and i’ve got this picture of this four centimeter cyst if you’re
1:05:31 faint-hearted i mean i don’t know why we’ll put this on the screen but this is from her operation
1:05:37 yeah it’s called an endometrioma it’s huge for anyone that can’t see it kind of looks like a tumor
1:05:45 um next to her ovaries and it had spread at that point to her bowel and pelvis pelvis it become about
1:05:50 four centimeters big her ovaries were stuck together and attached to her womb and her bowels
1:05:54 she then needed to book an appointment for surgery and before the surgery because of the scale of her
1:05:59 endometriosis she had her eggs frozen to protect her future fertility which i guess came from your
1:06:07 advice this process took her seven years and she was in pain for 17 years because she did not get a
1:06:15 diagnosis her story is unfortunately not uncommon this is a very typical story for somebody who suffers
1:06:23 from endometriosis endometriosis is an inflammatory condition and the way i like to explain it is when your
1:06:28 body responds abnormally to a normal process you have immune dysfunction as well so let’s
1:06:33 think of it as an autoimmune disease and a chronic inflammatory disease when you have your period you
1:06:38 bleed out endometrial cells in your menstrual blood we’re used to that in everybody you also have some
1:06:42 endometrial cells that will escape out the fallopian tubes and that’s not a big deal if you take out
1:06:46 somebody’s appendix while they’re on their period you’ll actually see menstrual blood and their abdominal
1:06:53 cavity and then regular person without endo your body says oh she’s just on her period and the person
1:06:59 who has endometriosis this creates a huge inflammatory response where your body starts to attack
1:07:04 endometrial cells and you get these implants throughout the what’s called the peritoneal
1:07:10 cavity or the abdominal cavity of endometrial like tissue that gets worse every time your body sees
1:07:16 estrogen which because it’s feeding the endometrium just like it would in the uterus and so
1:07:23 it gets worse over time the more ovulatory cycles you have the disease gets worse it’s so inflammatory
1:07:31 that it’s not uncommon to get extensive organ scarring you get anatomical distortion these are some of the
1:07:39 toughest surgical cases in addition to managing lifelong health but also fertility it’s one just
1:07:44 obliterate the anatomy like because the infiltration you’ll these implants will start growing into other organs
1:07:49 because they’ll find new blood supply they’ll steal blood you know blood supply from from the
1:07:54 bowel from because all of our pelvic organs are just sitting there on top of each other the bladder
1:07:59 the bowel the called you know and so it sounds like it’s alive like it’s a cancer or something think
1:08:03 of it like velcro is what i say almost these little patches of velcro and they just start sticking
1:08:09 together and that’s what inflammation and scarring does throughout your whole body and what happens here
1:08:17 is that because the primary symptoms of endometriosis is pain so again back to women’s pain being taken
1:08:24 seriously yeah that’s one of the issues and why the average time to diagnosis is seven to ten years truly
1:08:30 seventeen years in this case from when she had pain but the other symptoms do include sometimes also pain with
1:08:37 intercourse typically though that is very hard to ascertain from somebody but it’s usually with
1:08:42 certain positions deep penetration tends to be what really stimulates pain but you also see a lot of gi
1:08:47 manifestations that we don’t talk about so if i have somebody who has painful periods and they say they have
1:08:56 irritable bowel syndrome or a lot of vague gi complaints that is a really big red flag to me because like you said
1:09:02 these little endometrial implants on the bowel the intestine this high inflammation that’s happening
1:09:07 irritates your intestine and you get this gi response as well one of the hardest things about
1:09:15 endometriosis is that it’s a surgical diagnosis only to be honest we can sometimes have to do surgery to
1:09:21 fully see and diagnose that you have it’s one of those no meat no treat you know in in medicine where you
1:09:26 can’t make the diagnosis until you have a tissue sample so meat means you go and take a biopsy okay
1:09:34 so you can suspect it based on imaging we’re not great at this and dr crawford why don’t we have a cure
1:09:41 well because it hasn’t been studied is one of is the primary answer the secondary answer is that
1:09:48 often the goals are tough with endo because if estrogen feeds it we all are going to sit at this
1:09:53 table and talk about how important estrogen is for your body and a lot of the treatments that
1:09:59 exist for endometriosis take estrogen away to try to not feed these lesions and that has a slew of
1:10:06 other symptoms and long-term health implications as well truly we don’t even give women
1:10:13 options to try to feel better they are given birth control pills because hey i’m going to stop the
1:10:18 ovulatory cycle i’m going to you’re gonna have less what we call unopposed estrogen days you have
1:10:22 symptomatic relief yeah but we have been that’s going to help hopefully with some of your symptoms
1:10:28 and it can for some women it doesn’t reverse disease it doesn’t cure it it doesn’t make anything
1:10:35 better but it can slow down the progression any of these treatments that do halt the ovulatory
1:10:41 process but it severely impacts i mean beyond so many layers of your your mental your emotional
1:10:47 health your relationships but your fertility stage three or four disease regardless of your age you’re
1:10:52 gonna have a less than a 20 chance of conceiving naturally over the course of your life if you have
1:10:56 stage three or four disease every stage is impactful to your fertility because of the inflammation
1:11:03 once you have anatomical distortion and endometrioma or cyst inside the ovary removing that cyst is going to
1:11:08 decrease your egg count that that’s going to have a major implication on your potential that’s why
1:11:13 we froze eggs before we took a cyst out so that we could get those eggs at least some that we could
1:11:20 out of the body before we went and did something that was going to destroy part of the ovarian tissue
1:11:25 what you said steven is it seems like endometriosis is alive and that’s a really great analogy because it
1:11:32 does just feed into tissue and it’s highly destructive and if it distorts the anatomy we
1:11:38 need a healthy floppy fallopian tube generally that can swing around and pick up this egg that’s floating
1:11:44 around our abdominal cavity for and then you need a place for the egg and sperm to meet which is generally
1:11:50 a healthy non-inflamed fallopian tube so they’re also at increased risk for infertility but ectopic
1:11:56 pregnancies that’s where i see them you know is when i was a hospitalist is in the or you know
1:12:01 emergently from a ruptured fallopian tube from this you know and i go in i’m making not only is she’s
1:12:07 lost a wanted pregnancy now i and i’m making the diagnosis of endometriosis at the same time and
1:12:12 they are just devastated i just feel sitting here not being anywhere within this field thinking wait a
1:12:18 minute because i was a cancer nurse first right before i did this wait a minute there’s got to be
1:12:23 a cell surface marker that’s unique to the endometrium that we could make a monoclonal
1:12:29 antibody against there’s not to be a cell surface marker and i will say there are people now doing
1:12:34 lovely and wonderful research on a cellular level of endometriosis trying to look at the endometrium
1:12:41 itself what cell markers are similar in endometrial implants can you diagnose this on an endometrial
1:12:48 biopsy in somebody we haven’t seen it get to the point where it needs to but at least people are
1:12:53 paying attention so i do think we might have emergent technology that will change the course of this for
1:13:00 people right now i think awareness is key and one thing i always say is that especially as a teenager
1:13:06 because women adjust you accommodate to the world around you that’s one of the things that i think makes
1:13:11 women so resilient i mean if you have pain every single month of your life you are going to convince
1:13:18 yourself this is normal for a degree of time because what other option do you have has to get so bad but
1:13:24 when you’re a teenager you don’t know that and so if when you are a teen you would stay home from school
1:13:31 you would not go to the football game or go out to dinner with friends that to me has is a huge red flag but
1:13:38 it actually is a very high predictive marker that you do have endometriosis so pain out of proportion
1:13:44 to being able to complete your normal life as a teenager is a really big warning flag i ask every
1:13:49 patient about that when we talk about their periods because 50 of patients with unexplained infertility
1:13:57 of endometriosis it is so hard to diagnose and underdiagnosed yet impactful to our body 26 years
1:14:04 old the advice given to her by the nhs was to go back on the pill to solve for the the pains that she
1:14:09 was getting we certainly have a lot of dismissive doctors and people who don’t take pain seriously
1:14:16 but also a disease that is underfunded and not researched we do have limited options for how you can
1:14:21 help somebody and i think we have to acknowledge that both things can be right now getting to the
1:14:26 root cause of your pain is always going to be really important versus just saying here’s a birth control
1:14:31 pill that should take care of it some women with endometriosis love being on the birth control pill
1:14:36 it does highly improve their symptom profile and it’s an important part of their treatment regimen
1:14:41 other women do not find any benefit from it and it’s really important to have the discussion
1:14:46 especially with endometriosis in regards to your family planning goals do you want kids when is that
1:14:52 going to be what might this look like because we know if you have a higher rate of infertility
1:14:57 higher rate of needing ivf do we need to intervene sooner but that’s going to impact some of the
1:15:02 treatment options we’re able to give you because some of them do delay ovulation from for a prolonged
1:15:08 period of time what i find in the patients you know when we made the diagnosis was they’re forced into
1:15:14 making these kind of life-changing decisions about around their fertility and ability to conceive before
1:15:22 they were ever before their peers are even thinking about it it’s pretty devastating it is we have some
1:15:29 pilot data looking at taking some of the nuances of recovery and looking at how to dampen inflammation
1:15:36 so we have some pilot data that’s showing when women do cold exposure that it dampens inflammation
1:15:42 improves their symptomology so i’m always thinking on the outside like what other things can we do to
1:15:49 dampen inflammation in a positive way to improve symptomology how does that work so if we’re thinking
1:15:56 about the responses to cold exposure i’m not talking about ice we’re talking about cold water exposure
1:16:03 it creates a cascade of immune responses that kind of protects the body so we’re reducing
1:16:10 inflammation we’re improving parasympathetic which reduces stress so if we’re timing it and they know
1:16:16 when their period is and they can go okay well for the next or the 10 to 14 days before my period starts
1:16:23 starts i’m gonna have 10 minutes of cold water exposure and over the course of three to four
1:16:29 months that immune response becomes learned so it reduces symptomology so it becomes one of the
1:16:36 treatment options that we have for some of our athletes that have endo and interferes with their training so
1:16:40 i mean the cold water exposure is available there so that’s how we started the pilot study
1:16:46 um trying cold like someone wanted to do this at home 10 degrees celsius so what is that about
1:16:52 40 40 feels cold yeah it feels really cold but not an ice bath not an ice bath because ice is
1:16:58 ice is not good for when you get that in the shower you you need to this is like cold submersive yes yeah
1:17:03 can you do that at a home tub just with turning on the spigot you could if you get really cold yeah
1:17:08 you might want to add a little bit of ice and let it melt okay but um not ice baths that we see in all
1:17:14 the popular media because that is way too cold for a woman’s body it does the opposite it’s a severe
1:17:21 stress and causes a stress response rather than a parasympathetic calming response that we want okay
1:17:26 like stacy said decreasing inflammation in an inflammatory disease is key to controlling the
1:17:31 factors you can and much like we talked about inflammation in pcos we heard the same word right
1:17:37 here with endometriosis chronic inflammatory diseases are the number one thing that we see across the
1:17:45 board impacting the population but especially women and so these same strategies to work on decreasing your
1:17:52 own inflammation and for endo it’s a little different because you can target it for when you expect to
1:17:57 have that high inflammatory burden but that’s really an important part that we don’t talk about i don’t see
1:18:03 see that the nhs talked about an anti-inflammatory diet or getting more sleep or cold exposure
1:18:09 working in the sales team at a startup can be a strange experience because one month you’re chasing
1:18:14 leads like the future of the business depends on it which often it does and then the next month you’re
1:18:19 buried in them pressure builds up and eventually it starts clouding your judgment then you end up making
1:18:25 a reactive decision instead of an informed one our sponsor pipe drive is the number one crm tool for
1:18:31 small to medium businesses made by salespeople for salespeople it helps you get brutally clear on
1:18:36 exactly where your focus should be it shows you what opportunities have stalled and what is worth your
1:18:43 time and focus and my team have been using the new pipe drive prospector tool which uses ai to search
1:18:49 through over 400 million profiles to find verified decision makers and shares their contact information
1:18:57 with you so if you’re interested in learning more head to pipedrive.com/ceo where you can get a 30 day
1:19:03 free trial and that’s just for my audience pipedrive.com/ceo so it’s time to join the 100 000 companies that are
1:19:10 already using pipedrive by going to pipedrive.com/ceo now on this point of birth control one of the questions
1:19:17 that came in from the audience was how terrible is birth control to female hormones the birth control
1:19:24 pill shuts off the brain’s desire to send the signal to the ovary to make hormones so it is ethanol
1:19:32 estradiol a synthetic estrogen and a type of a synthetic progestin or progesterone these work the brain thinks
1:19:38 that you have estrogen and progesterone present as we said that’s the luteal phase and so your brain
1:19:43 says we don’t need an egg to grow so ofulation starts in the brain right so no fsh comes out
1:19:49 and you’re not going to get ovulation so they’re very effective for prevention of ovulation which is
1:19:55 makes it a very effective contraceptive option but as far as home hormonal shifts yeah your brain’s not
1:20:01 sitting out fsh and lh your ovaries are not going to be making estradiol or progesterone or testosterone
1:20:09 true and so that is how they are sometimes helpful if you have you know some women get hemorrhagic
1:20:14 cysts with ovulation every every time you ovulate you when you rupture that cyst you get a lot of
1:20:19 bleeding the birth control pill can prevent ovulation therefore prevent some women from being in terrible
1:20:25 pain if you have PCOS they’re often handed out like candy one reason is because it will regulate your
1:20:31 cycle so that you don’t have these prolonged irregular periods but also will decrease
1:20:37 testosterone levels which is sometimes a good side effect of the pill for women who have PCOS back to
1:20:43 a normal yeah but if you don’t have PCOS or the regular person a lot of times your body’s tissues
1:20:48 are not responding to synthetic estrogen and progesterone the same way it does to natural i think
1:20:54 that’s a very important point so my niece who competes uh at a national level and she’s 14
1:21:00 started suffering from where she was going through her adolescence her acne got outrageous and she’s a
1:21:06 14 year old girl 13 and started 12 and a half and of course you know she goes to the dermatologist and
1:21:12 they’re trying some topicals and then finally as you go down the algorithm for how we treat acne one of the
1:21:17 off-label uses is birth control pills will lower the testosterone their skin can clear up so her
1:21:22 father a little concern comes to me um her mom passed away her stepmom had passed away so he didn’t
1:21:28 have the mom in the house to you know the immediate mom to talk to and for the first time i immediately
1:21:34 thought of her athletic performance thank you dr sims and i thought she wants to go to the olympics
1:21:39 there’s no way i’m going to let her testosterone levels drop like we’re going to throw everything topical
1:21:43 at this and we finally found the right combination her skin looks great she’s super happy but like the
1:21:49 next logical thing was to put this 14 year old you know on a birth control pill to get her acne under
1:21:55 control which is the end result but what no one’s thinking of is her athletic performance how is it
1:22:01 going to affect her training years leading her training years like this is critical for her 16 is when
1:22:05 the next trials are up for her yep so that’s two years from now so we were able to get her acne under
1:22:11 control avoid the birth control pill but that was nothing i’d ever thought of before well i’m sitting
1:22:19 here from a musculoskeletal standpoint thinking about the high percentage of women who have endometriosis
1:22:31 and pcos and the complete soundingly imbalance of natural hormones plus for a lot of reasons now
1:22:42 girls are not cycling normally and i’m sitting here terrified for their bones yep 100 because we build bone
1:22:52 from 15 to 25 and if we are so inflamed that we’re producing all kinds of inflammatory cytokines ig interleukin
1:23:00 6 and c-reactive protein and tumor necrosis factor which halt bone development we don’t have enough
1:23:06 estrogen for whatever reason we’re going to shut off our testosterone because it makes us feel better and
1:23:14 we’re not exercising and we’re sitting around yeah no wonder i have 20 and 30 year olds with no bone
1:23:22 density that are then going to go into perimenopause which we will get to and lose another 20 percent so i was
1:23:29 feeling pretty hopeful that the generation xers are going to get to the millennials and get to the
1:23:34 whatever whatever they’re called after this it is we’re going to be you’re going to see it get worse
1:23:38 before it gets better exactly that’s what i’m sitting here terrified like okay i thought
1:23:46 okay baby boomers those women missed out xers were doing the best we can millennials but no
1:23:55 because now you’re telling me our 15 to 25 year olds are still in the same detriment with muscle and bone
1:24:02 building we are trying to change the narrative that’s the group we’re trying to target right now
1:24:08 and i do think by educating across the lifespan we’re going to change how those of us who have
1:24:15 11 and 12 year olds what we recommend i i treat girls in their teen years when they come to me
1:24:21 without their period much differently than a lot of other people do but this is learned experience
1:24:26 instead of just you don’t have a period here’s a birth control pill say you’re not making estrogen
1:24:32 and this is a crucial time for you let’s give you estrogen let’s talk about why you’re not what can
1:24:37 we do to change it and so this discussion is more than just disease state important like pcos and
1:24:44 endometriosis it’s truly important across the lifespan of a woman the choices that are being made
1:24:51 in her early reproductive timeline is going to impact her longevity i ask all of you what you
1:24:56 would have done differently for ourselves yeah for yourselves obviously i know several of you have
1:25:01 daughters as well but yeah what would you have done your i wish everybody could see all of your faces
1:25:08 oh yeah i’ve talked about this before i mean i was amenorrheic until i was 20 what’s amenorrheic
1:25:14 didn’t have periods okay because of high stress high sport you know didn’t care didn’t eat well
1:25:22 in the whole mindset of the you know 90s of calories in calories out if you’re thinner then you’ll run
1:25:27 better if you’re running better then you’re gonna hit different metrics because i was a runner in high
1:25:33 school and then joined the crew team same thing so if i could go back and talk to my younger self i would
1:25:38 have been like you need to eat you need to recover you need to eat you need to recover instead of the
1:25:43 mantra of calories in calories out more cardio lose weight lose weight lose weight because now i educate
1:25:49 people is you want to take up space you want to be strong you want to look at not the idea of losing
1:25:54 something but gaining something gaining that power gaining that strength gaining that bone gaining that
1:25:59 muscle gaining your period those are the things that i’m trying to educate the younger generation
1:26:06 because that was not impressed upon me as a younger athlete which then had a lot of repercussions
1:26:12 later in life luckily my bone density is fine so were you on the contraceptive pill no you weren’t okay
1:26:22 i was um not an athlete so mere mortal and um uh but it’s so you’ve you’ve you’ve been able to take that
1:26:27 experience though and apply what you’ve learned in this this high into you know working with these
1:26:33 intense athletes to the to the regular you know to people who don’t exercise at that level and
1:26:44 you know i completely fell under the the expectation of the aesthetics of it when i did exercise i exercised
1:26:50 to look a certain way and then in my 30s i exercised for performance i started running half marathons i was
1:26:55 doing baby triathlons really short ones with my girlfriends it was a social thing and it was super
1:27:01 fun you know i was running for time now i’m exercising for my old lady body yeah you know
1:27:07 i’m exercising to be in a bigger body because i know my mother and my grandmother so my grandmother
1:27:12 spent the last 10 years of her life in a bed incontinent with dementia and completely frail
1:27:20 and my mother is on the same course my mother is 88 fell and broke her hip in january she just now is
1:27:26 walking on a walker she’s in assisted living facility for alzheimer’s i want to change that legacy for my
1:27:34 children i don’t want that to be my path and i don’t want my children to have that to be an expectation
1:27:42 so all of the things i would have done differently was i wanted to be thin thin was healthy that is what i
1:27:48 learned in medical school the thinner you were up to starvation you know up to you want the lowest body mass
1:27:54 index possible without being a little bit too low you know and i kind of skirted that line because i stopped
1:27:59 eating in medical school due to stress i would have fed myself i would have lifted weights i would have
1:28:06 stopped doing so much cardio because knowing i was chipping away at my bone density i was chipping away
1:28:11 you know i was raising my inflammation levels i was chipping away at my ability to resist the alzheimer’s
1:28:17 you know and dementia that runs in my family and that’s what i’m trying to impress my girls are 21 and 25
1:28:24 what i’m trying trying to impress on them but that’s the mentality that we grew up in right when you’re looking at
1:28:31 the supermodels of the 90s and kate moss and it was heroin chic yes heroin chic which is the worry now with
1:28:37 the glp1s coming back and the ballerina body and all the things that we’re seeing come back again
1:28:45 and it’s it is worrisome you know when i think about i mean i’ve already told the world now about
1:28:52 having low body fat maybe being pso s and not knowing it not ever talking about that having no periods
1:28:59 but then so there was that in my youth that that i would have done better but that it didn’t end in
1:29:07 my youth i mean i went to college same i went to grad school still same i went to medical school
1:29:14 and in medical school and four years of medical school seven years of residency and fellowship
1:29:21 still didn’t need still wasn’t having periods i didn’t sleep for about 11 years whether between
1:29:27 call every third night and then i had a baby and then i was awake for two years because she slept with
1:29:34 me that’s another discussion but i think of all these things that i wish i knew then that i know now
1:29:42 i have the same goal i have four 30 year old daughters and i have a 17 year old and they are not going to be
1:29:49 allowed to hit a wall like some of us may because we didn’t know and were you on the birth control pill
1:30:00 you know intermittently uh probably totally in my life about 10 years but um not continuously
1:30:06 and mary i forgot to ask were you on the birth control yeah we’re off and on for 20 years so
1:30:11 polycyx ovarian syndrome that was the treatment i mean i learned about nutrition kind of on the back
1:30:19 end but the life that i had set up for myself between you know medical school residency and
1:30:27 then going into the field of ob-gyn with limited sleep you know working 100 hour weeks there i didn’t
1:30:33 have a environment that would have been conducive to be able to manage that disease with lifestyle
1:30:42 and i can look back and say that honestly now um with without using the crutch of the birth control
1:30:48 the birth control pill to manage my symptoms i was on the birth control pill for probably 15 years
1:30:54 continuously and you know we have to give credit where credit’s due because i was able to pursue
1:31:00 medical training and not worry about what family building looked like for me which was really
1:31:07 important because i was not ready to have a child so anytime we frame a discussion around birth control i
1:31:11 always want to say it’s not ever going to fit into one bucket of all good or all bad it’s going to be
1:31:16 you know different stages of life different things are important i didn’t stop it soon enough to
1:31:22 learn to track my cycle i didn’t recognize cycle abnormalities when i had recurrent miscarriages i had a
1:31:28 really hard time knowing is this how my cycle supposed to be or not because i never had the opportunity to
1:31:34 to just have periods and see what is my normal i stopped it and started trying right away and got
1:31:40 into a cycle of having a pregnancy and that would last for a while and then i would lose it so i really
1:31:46 lost the opportunity to say this is my baseline and oh there might be a problem here or to intervene
1:31:52 i wish i’d advocated more when i had my own pregnancy losses i was told over and over there’s nothing you can
1:31:57 do this is nothing just keep trying and even as somebody in the field that felt very dismissive
1:32:03 and is a fuel for a lot of what i do now but on a personal level you know 10 years after having
1:32:09 those pregnancy losses i was diagnosed with celiac disease because i had osteopenia on a dexa scam
1:32:16 and so i had to explain what that is yeah so celiac disease is essentially an allergic reaction to gluten
1:32:22 so when i was taking gluten which is in most of your carbohydrates or the good stuff like breads and
1:32:28 pastas when i was eating those it was causing an inflammatory reaction inside my body making my gut
1:32:35 unhealthy and kind of creating a baseline level of let’s say chronic inflammation and recurrent pregnancy
1:32:40 loss can be one of the signs and symptoms of it in addition to just some other what feel like very
1:32:51 generalized symptoms fatigue low energy headaches gi distress ww yeah i was a whiny woman and when some
1:32:56 of these symptoms finally got to a state where they were getting worse probably with hormonal change with
1:33:02 age and my doctor ordered a bone scan and it came back that i had osteopenia which is very low density of
1:33:09 my bones for my age and especially at the time you know no known medical problems and so luckily had
1:33:14 somebody who was very committed to not labeling me a ww and saying i think you’re not absorbing
1:33:20 something correctly to get on this pathway to figure out that because of this autoimmune disease celiac
1:33:26 disease i wasn’t my gut was inflamed i wasn’t able to absorb the nutrients that i needed but somebody had
1:33:31 to be committed on the other end because these symptoms went on for so long i just accepted them i let
1:33:37 them be but i also am scared because those critical bone building years i was on the pell
1:33:45 and i used it continuously which means every single day all the time i you know i know i was chronically
1:33:51 inflamed and so now i’m at a stage of my life at 43 saying i’ve got to try to catch up before it’s too
1:33:59 late and that is scary and can you catch up yes yes you can build bone um because you know i see all these
1:34:06 graphs wonder that you know you kind of yes you go tell curve yeah and then it goes down from your
1:34:09 wherever you manage to get it up to so i’m telling all my friends at the moment thanks to you i’m telling
1:34:14 all of them to get their muscle and their bone as high as possible because it’s probably going to fall
1:34:21 with age naturally well everyone ages yeah age is the most natural thing we do from the minute of our birth
1:34:31 but men and women age at different rates especially after perimenopause with the the lack of estrogen
1:34:38 we rate we age very differently from that point on but your point being made is can we please maximize
1:34:46 our bone density and our muscle mass and everything else frankly in our youth when we’re probably not aware
1:34:51 right when we’re in college and doing all the things kids do it’s the last thing on our mind
1:34:56 and yet it’s the most critical time because you want to start both your bone and your muscle from
1:35:05 the highest possible level now can you through lifestyle and hormones build bone again yes actually
1:35:11 you can but wouldn’t it have been better to start out with the maximum so that the natural decline
1:35:16 doesn’t take you into dangerous levels right on that point of birth control what are you saying
1:35:21 to your daughters that wasn’t said to you are you because mel regrets my girlfriend she’s very open
1:35:25 she regrets being on the birth control bill for 10 years because she had no idea what it what it was
1:35:29 doing to her body and then obviously when she came off her cycle i think she spent like you natalie
1:35:33 two years trying to figure out what was going on and she didn’t have a period for an extended period
1:35:37 of time after she came off what are you saying to your daughters about the birth control pill
1:35:42 that wasn’t said to you are you recommending them to use it how you guys used it or i mean
1:35:49 we were started on it so young i i do see a trend towards not starting it as young as it was started
1:35:55 in our generation and i think that that is important i see you know personally my daughter is not quite at
1:36:02 that stage yet so we haven’t had to make these decisions as um they have had to but i do think
1:36:07 it’s in cycle awareness is one of the few early signs you have of your body’s health as a young
1:36:14 woman and so to purposefully never get to know what that is is a detriment to saying i’m aware of
1:36:18 what’s healthy for me and i know what’s happening in my body but you guys have had these discussions at
1:36:27 different time periods for my youngest daughter we i was worried about uh she was a dancer also she was
1:36:34 teeny tiny so tiny even though she had great muscle mass but she like me wasn’t having periods and so
1:36:41 the advice was to put her on birth control to regulate periods but i was always uncomfortable
1:36:45 with that because she didn’t to be a dancer she didn’t have to be quite as tiny as she was
1:36:53 and so what we’ve done now is i’ve encouraged her to gain a little weight and get a little bit more
1:36:59 body fat because i took her off of that she only had to gain five pounds i think i said to you maybe
1:37:07 seven and it has more regulated her and she’s having her own periods now and so i don’t know what she’s
1:37:13 going to decide she’s going to be 18 soon and but i think what we should be telling our daughters
1:37:21 is all the information so that they can make an educated decision because i just did what i was
1:37:29 told and i’m a doctor and i and but i’m not an ob so i don’t understand the nuances of what the pill
1:37:34 is that it’s synthetic that this is how it works this is what it doesn’t do so i would want to give
1:37:40 my daughters all the information so that they can make an educated decision
1:37:47 so my oldest the first one coming through uh wanted it for contraception and so when we talk
1:37:52 about contraception it’s not just most people automatically think the oral birth control pill
1:37:58 but i did go through all of the options with her and then sent her to a trusted friend to let her go and
1:38:03 make her own decision and she decided to have an iud inserted which i thought was a great choice for
1:38:09 her because she had normal regular periods before we did this there were no issues and she had it
1:38:15 inserted and then within a week she started having severe cramping called me into the bathroom and this
1:38:20 is my daughter who has not let me see her unclothed since she was seven years old she’s just very
1:38:27 private and she’s like writhing on the floor bless her little heart and she had expelled the iud on her
1:38:32 own she had cramped it right out uterus pushed it out of her body because then it was extraordinarily
1:38:37 painful and so we basically delivered the iud on her bathroom so do you know what an iud is is that
1:38:44 the coil ish that’s one form of an iud she had a different form but she basically pushed out her own
1:38:50 iud her uterus her uterine device so it’s birth control that is placed inside the uterus and it’s
1:38:55 shaped like a t it is shaped like a t most is shaped like a t in the uk they use the coil still quite
1:39:01 a bit which is copper and so there’s different there’s different options for the iud some contain
1:39:08 progestin some contain just the copper and so the way an iud works is that it creates an inflammatory
1:39:15 response in the uterus so that um the cervical mucus thickens so that when we are fertile in our
1:39:20 fertility window mid-cycle and jumping if i mess this up the mucus of the cervix thins to the point
1:39:25 where sperm can actually get through most of the month probably 85 to 90 percent of the month the
1:39:32 sperm cannot traverse the cervix you cannot you know so in our fertility window right at ovulation the
1:39:38 cervical mucus thins and then the sperm can transmit so the the the presence of the iud creates an
1:39:42 inflammatory environment that will basically is toxic to sperm and thickens the cervical mucus where it
1:39:49 becomes a plug that’s how it works works very very well katherine within a week her uterus ejected it
1:39:56 so she cramped so much that it pushed it through and so that wasn’t an option for her she wasn’t willing
1:40:02 to go through that again so then at that point she had to go through the hormonal options for for that
1:40:08 and she decided to have the implant so it’s progesterone only implanted in her arm quickly we
1:40:12 realized she needed some estrogen so we she supplements estrogen on top of that steven i think
1:40:17 the contraceptive discussion we have to say that there are options that are highly effective at
1:40:22 preventing pregnancy and at some times in your life that is the number one most important goal
1:40:28 and we need to choose a highly effective option however certain some of those options included have
1:40:34 downstream impacts that have not been discussed about the typical contraceptive discussion says here are some
1:40:39 side effects you may have if you want to still proceed let’s go for it we’re not talking about
1:40:43 long-term implications of these we’re just talking about how you’re going to feel not exactly what
1:40:50 is happening in your body a lot of these contraceptive options are progesterone only and so you know by
1:40:55 your new favorite graph that you don’t see progesterone every single day so when you have
1:41:01 progesterone only it is shifting your hormonal profile and a lot of women this progesterone is
1:41:07 so high that it works by also preventing ovulation makes it highly effective but if you’re not ovulating
1:41:12 you’re not going to be making those high estrogen levels and dr haver and i’ve even talked about how
1:41:18 we wish there was a contraceptive option and that had estradiol in it so that your body could still
1:41:24 still have some estradiol estradiol so this ethanol estradiol is very different than plain estradiol
1:41:30 there they’ve put this ester group on the end which makes it bind to the estrogen receptor in the brain
1:41:39 300 times more powerful powerful than regular estradiol yeah which is why it’s so effective you know
1:41:44 why we do it in a microdose versus estradiol is dosed in milligrams and ethanol estradiol is dosed in
1:41:52 micrograms because it is that much more potent um so very very different now in the uk and in
1:41:57 other places in europe there is a new form of contraception that has esterotrol which is the
1:42:02 fetal estrogen so we have four natural estrogens in the body the ovary produces estradiol that’s
1:42:07 the one we all know it it it’s really the biggest bang for our buck the placenta produces something
1:42:13 called estriol our fat cells and in the peripheral tissues the tissues outside of the ovaries can produce
1:42:20 something called estrone and then we have this fetal estrogen called esterotrol if i’m pronouncing it
1:42:25 correctly and so they’ve they’ve compounded they’ve been able to formulate that um so it is one of the
1:42:30 natural estrogens and they’ve put it in a birth control pill that is available in the uk if you
1:42:36 were 18 what choice would you make for contraception now studies have proven within the shadow of a
1:42:42 doubt that relying on natural family planning at most stages is not a reliable form of contraception
1:42:47 so i would not recommend that which i’m relying on condoms what do you mean by natural relying on
1:42:52 natural family so you timing your intercourse oh okay so cycle tracking we know that the fertile
1:42:57 window is the five days before and the day of ovulation out five days five days before and then
1:43:01 the day of sperm can live for five days on the female reproductive tract the egg lives for 24 hours
1:43:07 so on this graph where is yep so the line right is ovulation and then the five days before
1:43:13 yeah yeah so in popular culture you would call that natural family planning okay fine avoiding
1:43:18 intercourse abstaining any time in that window but but if i if i’m trying to get male pregnant then i
1:43:23 should really be aiming yeah those are your target days yeah have your apps for that you can track
1:43:30 yeah oh i’ve got the app okay oh he knows remember the variability aspect she’s been downloaded one
1:43:34 time one of the there’s a few different ways you can do natural family planning to hijack the discussion
1:43:39 for a minute and they have different degrees of effectiveness but one of the main issues is that
1:43:44 they have very large abstinence windows so it’s often not very sustainable to say we’re just not
1:43:49 going to have intercourse for 18 days out of the month or some very long time period depending on which
1:43:56 one because your cycle’s never perfect what if you did ovulate sooner if this is all you’re relying on
1:44:01 for your prevention of pregnancy you have to really assure that you know when that ovulation is
1:44:07 happening it can be an effective way to prevent pregnancy if your cycles are very regular but in my brain
1:44:12 i wish that’s what you stop the birth control pill at least six months before you want to get
1:44:16 pregnant and then you start learning how to track your cycles and you’re using some natural
1:44:22 family planning if you’re not quite ready then because the margin of error oopsies it didn’t work
1:44:28 the acceptance of we were going to try to get pregnant soon is usually okay yeah it’s not an
1:44:33 effective contraception for most of the population we have to factor in when we’re looking at you know
1:44:39 i was trained and taught to only look at birth control through the lens of contraception right we
1:44:43 know that they might have some weird bleeding and maybe a few headaches and for some a dvt if they
1:44:47 have you know deep venous thrombosis you can have blood clots it’ll increase your risk especially if
1:44:52 you have a pre-genetic disposition to that but what we didn’t talk about were mental health mood and
1:44:59 some of the long downstream libido effects so of of taking right and so then i’m looking at it through
1:45:04 the lens of you know if you’re i’m only looking on the lens of she doesn’t want to be pregnant
1:45:11 a younger patient so you’re talking about 18 is less likely to remember to do something every day
1:45:17 correct okay so then to take the impetus of remembering to take a pill every day or change
1:45:23 your patch once a week um for the patch option then we’re looking at maybe a vaginal ring that she
1:45:29 inserts for three weeks and removes for one for her period pick one if i had to pick one right now if i
1:45:36 was if it was available in the u.s i think i would go with the esterotrol what’s that option that’s the
1:45:40 one she’s saying is in the uk a newer option that we don’t have no it’s still a pill it’s still a pill yeah
1:45:49 and it’s it’s because it it more it looks like so far it’s newer that it has less of the downstream
1:45:54 effects so you’re not having that complete suppression you know that complete binding
1:46:03 and it’s it’s you know may have and also probably has less risk of um dvt of blood clots i’ll jump on
1:46:10 this i do not love intrauterine device for a patient who is 18 for a multitude of reasons now i’m going to
1:46:15 preface this to say it is a highly effective contraceptive choice it’s one of the most
1:46:19 effective ones that we have and so there are certainly circumstances where that is the right
1:46:25 thing to do we’ve had iud’s in practice for a really long time for the majority of this we were
1:46:30 only placing them in women after they had given birth at least once because of their size and being
1:46:35 able to pass them through the cervix now we have different options and we are offering them to women
1:46:41 women younger which is wonderful however when we’re putting iud’s and the uterus of women who are really
1:46:46 young sometimes the progesterone dose in them is so high that it is preventing ovulation and we are
1:46:52 seeing young women who are not ovulating and they are not making estrogen therefore and they don’t even
1:46:59 really realize it because that’s not disclosed as one of the main mechanisms of a progesterone iud because
1:47:05 it doesn’t happen in enough people to effectively prevent conception that way it works through the
1:47:11 inflammation the cervical mucus changes and why does that matter because if you are not ovulating
1:47:16 and you’re not making estrogen you are going to have low libido low energy you’re not going to build your
1:47:22 bones during critical years let’s say let’s say the iud lasts five to seven years you’re 18 to 25 these
1:47:28 are some of the most critical years in your mental health your bone health your cardiac health and being low
1:47:35 estrogen during that time is going to set you up on a different risk trajectory for your entire life
1:47:42 and the worst thing here about the progesterone iud is that because of the progesterone which will thin
1:47:49 the lining many women just say i don’t have my period because my lining is so thin and that’s a side effect of
1:47:56 the iud if that same woman was not ovulating and came to me and said i haven’t had a period in seven
1:48:02 years and i knew she was low estrogen and not ovulating we’re highly concerned about her health
1:48:09 but because she has an iud what happens well that’s a side effect of the iud no big deal so we’re missing
1:48:15 the moment to understand where are some of these symptoms just side effect of the iud or are they
1:48:22 having a much bigger role in what’s going to happen to that woman’s long-term trajectory for being low
1:48:27 estrogen during crucial years and i’ll say this steven i’m very biased right i’m a fertility doctor
1:48:33 i see patients who have trouble getting pregnant that is a narrow subset that is not the majority of
1:48:38 women who have iud so what would you suggest if you had to pick one contraceptive vasectomy
1:48:44 yeah i would still do i would still do the pill right now the pill or the vaginal ring you know i
1:48:50 think they are both depending on somebody’s personal preference i just think that it’s really important
1:48:54 if you’re using the birth control pill i do think it’s important to give your brain a break from the
1:49:01 pill at times and even if you’re cycling it monthly there’s options now i took the pill an active pill
1:49:10 every single day for for years a decade probably meaning suppressed my brain completely for that
1:49:17 long now your brain sends out hormone signals that impact your entire body right so we already talked
1:49:22 about the hormones and how it’s this beautifully conducted symphony but if you even if you’re going
1:49:28 to take the pill at that young age i would say take it so that you have the seven days of not to not
1:49:33 taking a pill let your brain have a moment of release from the suppression and then take it again that’s
1:49:38 still a very effective way to use the pill but because women don’t love having periods we’ve offered
1:49:46 these other options which are not wrong but they just have a bigger consequence downstream than we’re
1:49:52 talking about but the pill is very short-acting it only has a half-life of 28 hours meaning it is out of
1:49:56 your body very quickly so you do want to stop the pill and see what is happening and track your cycles
1:50:04 that is something nice about it versus an implant or an iud that is a fit and forget the fit and forgets
1:50:10 yeah yeah yeah yeah the question that came in from the 1000 women we spoke to in the diverse audience was
1:50:16 is there any way to control hormonal mood swings during the luthiel phase of the menstrual cycle which i now know
1:50:21 is the second phase of the menstrual cycle even you’ve learned so much yes that’s great yes in the
1:50:27 luteal phase we do tend to see more mood changes and physical changes and a lot of this is because we
1:50:34 have an increase in estrogen and progesterone and then a decrease in both of these hormones and what
1:50:40 we find is that some women are simply more sensitive to these changes they feel them quite profoundly and
1:50:45 and there’s even something called pmdd premenstrual dysphoric disorder which is when those hormones are dropping
1:50:51 you get these terrible mood swings this terrible depression and anxiety in addition to physical changes
1:50:56 with terrible fatigue you just feel like you can’t accomplish any of your tasks insomnia
1:51:02 quite similar to a lot of the things that we talk about anytime we talk about a low estrogen state right
1:51:09 like put we see it in postpartum depression it’s a very similar and in the perimenopause transition we
1:51:16 have a 40 increase in mental health changes and we know this because women tell us and we believe them
1:51:23 but what’s happening is that our neurotransmitters especially GABA serotonin and dopamine levels are highly
1:51:34 tied to what our hormone levels are doing so is this is the mood swing or is the is the what’s the
1:51:41 right term to describe a mood when someone doesn’t feel great dysphoria is the dysphoria mood after the
1:51:47 period or before it it’s often it’s before so the estrogen is dropping before and it stays low through so
1:51:53 what happens is about the week before your period and then the week we’ll say of your period you are
1:51:58 estrogen low the rise of estrogen from that next egg being recruited is actually what stops you from
1:52:03 bleeding and helps you start to feel better because of this a lot of people will throw a birth control
1:52:08 pill at this situation because they will say i will give you constant hormone levels every day and now you
1:52:14 will not have these pmdd symptoms anymore however a lot of women don’t want to be on the pill for a
1:52:18 variety of the different reasons we’ve talked about they just feel bad let’s say this week or this
1:52:24 seven to ten day interval they don’t want to suppress ovulation i find that a low dose estrogen in the
1:52:29 luteal phase can be very effective in targeting after ovulation i’m going to take some estrogen
1:52:36 helping alleviate these symptoms without interfering with ovulatory function but i was trained to give
1:52:41 them an ssri for those seven to ten days an antidepressant yes an antidepressant only for
1:52:48 those two weeks like serafim was that the brand name of it and it does tend to help but when no one taught
1:52:54 me and what clinical experience has taught me and talking to all these other smart people is a low dose
1:52:59 estrogen like treating the root cause treating the root cause just just give her estrogen back during
1:53:06 that time period and she gets remarkably better in some of the nutrition research finding that low iron
1:53:12 and low vitamin d are huge contributors to it so there’s that research to investigate too which is
1:53:19 interesting because there are some women also who don’t want to go on ssri or estradiol so lots you
1:53:24 know the endocrine society does not recommend routine testing of vitamin d it’s crazy i i just
1:53:30 think it’s insane yeah with my partner i should anticipate that her mood might drop in the lead up
1:53:36 to having a period it’s very common and then after her period it would might recover and whether or not
1:53:40 that becomes clinically significant whether or not it’s life disruptive for her rather than she just has
1:53:47 a little bit of a low mood most women can tolerate that but for those who can’t and that it is disrupting
1:53:52 their day-to-day activities and how they feel about the world we have options yeah because i’m trying
1:53:58 to understand i want to understand her better so i’m looking at this little graph here which says the
1:54:04 brain during the menstrual cycle so the menstrual cycle starts when her period starts by convention
1:54:08 yes that’s what we say day one is the first day you start bleeding okay and so what is she going to
1:54:14 go through for the next 29 days and how might i support her better through that journey like i want to
1:54:19 understand what’s going on in her brain her brain starts by from a reproductive hormone level the
1:54:25 brain starts by sending out fsh follicle stimulating hormone which is going to get her ovary to start
1:54:30 growing an egg which lives inside a follicle and making estrogen and that rise in estrogen as it’s
1:54:36 growing will stop her from bleeding so the beginning that cycle day one the bleeding that she’s experiencing
1:54:41 or her period is because she didn’t get pregnant in the month before so it’s getting rid of that
1:54:47 endometrial lining cleaning the slate she’s estrogen and progesterone low during that time period and then
1:54:53 once her bleeding stops it’s because an egg has been chosen estrogen is then going to rise until it gets to
1:55:00 that peak level during that time she’s going to feel her best for most women so is that the first 14 days so the week by
1:55:06 convention if you had a 28 day cycle which only about 13 percent women actually do but all of these graphs
1:55:11 if you look at usually use 28 days because it’s easy to go week by week and that’s the lunar calendar
1:55:18 yeah so 28 days we see that but we have to acknowledge that most women don’t have a 28 day cycle so but it is
1:55:24 roughly the first two weeks for most women to get up to that ovulatory time period so the time from i have
1:55:31 started bleeding until i am now ovulating that is all considered the follicular phase and on this
1:55:35 little image that i have in front of me here it says in those first 14 days she’s going to have better
1:55:42 spatial skills and be more anxious so once you get to your estrogen dominant so you have a lot of estrogen
1:55:47 and you don’t have progesterone most women can are have increased concentration they have more focus
1:55:52 they actually can sleep better they have higher libido you feel like your performance even for athletes
1:55:57 performance tends to be more aggression during concentration more yeah during what we call the
1:56:02 late follicular phase so that means the time period when you’re really making that estrogen let’s call
1:56:09 it days seven to 14 for ease so i’m now done bleeding a follicle is growing meaning an egg is making enough
1:56:15 estrogen to stop that bleeding i’ve not yet ovulated and seen progesterone this is where we typically have
1:56:21 our best performance overall from how our body is functioning and then from day 14 onwards
1:56:28 i’m she’s going to be calmer well progesterone slows your body’s metabolism down it’s preparing
1:56:35 you for that pregnancy calmer is a nice way to put it but essentially your metabolic rate is going to
1:56:40 change your body’s going to shift how it functions many women actually have fatigue they’re hungry
1:56:46 specifically in the brain progesterone levels as they rise we see an increase in gaba which is a
1:56:52 neurotransmitter one of our brain hormone one of our brain you know hormones that talks you know jumps
1:56:58 between one one neuron to the other and that is more of a calming hormone so women tend to see we see
1:57:05 sleep changes more you see deeper sleep longer sleep in that luteal phase she’s been on this it says she’s
1:57:10 gonna have she’s gonna be horny at day 14 i don’t know how else to say it because she has an egg
1:57:15 available because that’s that peak estrogen that estrogen level of 200 picograms is heightening
1:57:20 everything to have peak libido when an egg is released the body is made that way on purpose this is a
1:57:28 bit off script but my girlfriend always talks about her hrv being very different and so she she has really
1:57:35 great hrv scores and then once every month for a period of time they’re terrible and she can’t explain
1:57:41 it so this is where wearables come into play yeah so wearables are not designed to capture women’s
1:57:47 physiology so what happens after ovulation is your respiratory rate goes up your resting heart rate
1:57:54 goes up and your hrv plummets so on the wearables most women about five days before their periods start
1:58:01 will never be in the clear so to speak they will never look recovered they will never look like they
1:58:05 can take on a lot of stress they’re not stress resilient because of the way the algorithms are
1:58:13 reading this change that is natural that is produced by progesterone to alter our respiratory rate and our
1:58:19 heart rate it doesn’t mean that she’s not stress resilient is what the wearable is saying ah because she
1:58:26 came downstairs and she said oh god my recovery is so bad and then i think a couple of days later
1:58:31 a little while later she had a period i’m not sure i can’t remember the time frames but she came
1:58:36 downstairs and she was like shocked she’d done everything right but her recovery on on her wearable
1:58:43 said that she was in terrible state this is why we do not let athletes use wearables leading up to
1:58:49 a peak event because they feed into what the wearables respond or telling them and it’s not
1:58:57 true data with regards to how their body can actually perform so wearables data masters then
1:59:05 need to segregate segregate populations and make new norms for women and maybe new norms for different
1:59:10 fitness levels of women exactly i’ve always been pushing for the past five or six years interacting
1:59:16 with wearable companies is like if you want to capture it well then you need to be able to compare
1:59:23 follicular to follicular and luteal to luteal what does that mean so comparing like we know your
1:59:28 hrv is going to be different in your follicular phase that’s expected this is not a bad thing people could
1:59:33 could theoretically do that on their wearables and look at the previous month and see the level you’re
1:59:36 up then theoretically obviously the wearable companies could do a lot more here to me that’s
1:59:42 definitely helpful but no you then it comes back again on the woman trying to understand and interpret
1:59:49 the data herself which can be a little bit problematic because there’s so many women out there like my
1:59:54 wearable told me that you know i’m in the red i can’t do anything today when in fact physically and
2:00:02 psychologically they can do what they set out to do it’s just now they have this little seed saying that no
2:00:10 you can’t do it because of an improper algorithm on their wearable probably a good time to disclose
2:00:18 that i’m an investor in whoop okay yeah i’ll send this to them please yeah you wear i wear whoops do you
2:00:26 wear any devices to track your health data i i wear a cgm and a whoop just give me a minute of your
2:00:31 time and i’ll tell you about a device that my team’s been using that they won’t seem to shut up about it’s
2:00:39 called the note pro and it’s by our sponsor plaud this tiny card clips onto the back of your phone
2:00:46 and captures everything but why it’s so clever is that it picks up multiple voices at the same time
2:00:51 and when someone says something important you just push this tiny little button here and that moment
2:00:57 gets highlighted in your notes and captured it records the conversations that it hears takes those
2:01:02 conversations creates a transcript and it uses ai to synthesize all of that information into whatever
2:01:10 template suits you you get a summary action points highlights and even a mind map sent straight to the
2:01:15 plaud app so i highly recommend you check out plaud’s products using the link in the description below
2:01:23 don’t tell anybody this but if you use code doac22 you’ll get 22% off on some of plaud’s products
2:01:28 do any of you remember a conversation i had on this podcast with anthropologist daniel
2:01:33 lieberman it was one of our most viewed conversations of all time and the most replayed moment
2:01:38 in that conversation was when i talked about this product these are what i call barefoot shoes by
2:01:44 vivo barefoot which have significantly reduced support which gives my feet the opportunity that
2:01:49 they desperately want to need to strengthen we’re living in a comfort crisis and that at all times
2:01:54 in our lives we’re making this trade of whether to have more comfort now and therefore more discomfort
2:02:00 in the future or a little bit less comfort now but to be stronger and healthier in the future and
2:02:05 research from liverpool university has backed this up they’ve shown that wearing vivo barefoot shoes for
2:02:10 six months can increase foot strength by up to 60 percent so if you want to start strengthening your
2:02:17 feet and your body visit vivo barefoot dot com slash steven and you’ll get 20 off when you use code
2:02:25 steven b20 at checkout that also comes with a 100 day money back guarantee i want to close off on the
2:02:31 subject of fertility because it was um heavily asked by our audience and i i guess i’m it well placed to ask
2:02:35 some of these questions because i’m in that journey myself of trying to have a child at the moment
2:02:41 natalie you have five fertility non-negotiables that you talk about i do and i think it’s really
2:02:42 important to think about
2:02:49 for too long we’ve been told you know your fertility is luck it’s good luck if you get pregnant it’s bad luck
2:02:55 if it’s not and that’s this narrative that gets propagated and fertility is certainly not fair
2:03:00 meaning people will have infertility and do everything right but there are things that we do that will inherently
2:03:06 also harm our fertility and our hormonal health and make it harder to get pregnant and that’s even when
2:03:11 we are doing treatments so a lot of times people will say i’m doing ivf so i don’t need to worry about
2:03:18 these non-negotiables and that’s also not true i mean things that we need to do we need to as we’ve all said
2:03:24 get more sleep that’s going to be number one we need to actively work to decrease stress that is
2:03:29 not a i’m just going to live a stress-free life but all these things i’m going to not take call i’m
2:03:33 going to set some boundaries and not have late meetings i’m going to see morning light i’m going
2:03:39 to take a walk outside we live in a stressful world and chronic stress itself can impact your fertility
2:03:46 your natural fertility and ivf success rates we’re going to work on exercise to build muscle and try to
2:03:52 improve our muscular health since it’s part of our metabolism we’re going to eat an anti-inflammatory diet
2:03:58 that’s definitely key high in fiber and we’re going to look at the world around us and work on pulling toxins
2:04:02 out of our world that we know we haven’t even entered the discussion about how environmental toxins
2:04:08 is harming our body our hormonal health our fertility our ovaries our organs and so these are all things
2:04:14 we make active choices on that we have to start paying attention to and kind of changing we’ll go
2:04:19 into deep detail in the lifestyle factors and the environmental toxins um in our second episode
2:04:24 together i i’ve always been quite shocked by this graph because it’s quite um quite significant this is
2:04:33 just showing the um egg count by age slide that in that direction um what do men and women need to
2:04:38 understand about egg counts in order to make better family planning and fertility decisions okay well i’ve asked
2:04:46 you this last time so steven how many sperm do you make a second millions you make 1500 a second you
2:04:52 mean you make millions every day okay but still you still you make a ton of sperm you make sperm every
2:04:56 single day you have germ cells that create sperm women are born with all the eggs you’re ever going to
2:05:03 have and yes my favorite vault analogy so i like to imagine that this is a vault inside your ovary that is
2:05:09 storing all of your eggs and so we’ll use this cup with all of the beads as that analogy and every
2:05:14 single month since before you were born eggs come out of this vault and what happens is that when the
2:05:20 vault is more full more eggs come out every month and as the vault starts to get emptier fewer come out
2:05:26 and this means that we lose the majority of our eggs you can see the line well before our reproductive
2:05:31 years even start so you lose the most before you’re born so from being a five-month baby to birth your
2:05:37 account goes from six to seven million to one to two million millions of eggs lost before you’re even
2:05:43 born from birth to puberty let’s say you go from one to two million to half a million to simplify numbers
2:05:48 so the second biggest drop before you’re ever ovulating before you ever have a chance to get pregnant
2:05:52 and then you only ovulate around 400 eggs over the course of your reproductive lifespan
2:05:58 as that account starts to drop over time the other really really big important factor is that our
2:06:03 eggs have been in our body our whole life two different things are happening at the same time
2:06:09 one is that our chromosomes start to leave their perfect position are they absorb the wear and tear of
2:06:15 years so we see more chromosome abnormalities as we get older it’s why it’s harder to get pregnant and
2:06:21 why we see an increase in miscarriage as we age but also concurrently our metabolic health is poor as
2:06:28 we are older too and mitochondrial function in eggs the metabolic capacity becomes less capable and so
2:06:33 we see that it’s harder to get pregnant not because women are running out of eggs but because the quality of
2:06:38 the eggs declines but everybody will run out of eggs you’ll have a period of time where you have a very low
2:06:41 egg count we call it diminished ovarian reserve in the fertility world we call it
2:06:47 perimenopause more globally and this this is two words to describe the same thing as your
2:06:53 egg count starts to get very low you start to have an unpredictable response to your ovary and your brain
2:07:00 is trying to compensate for that and so you see various hormone changes but these start before you might
2:07:06 recognize even menstrual cycle changes but everybody will run out of eggs every woman will your ovaries will
2:07:11 go into what we call ovarian failure and no longer respond to hormonal signals from the brain or
2:07:15 artificial signals that we give meaning i will see older women come in and think that i have magic
2:07:20 medicines with ivf that can still help them get pregnant but i can only get the eggs outside the
2:07:27 vault to grow in ivf and so shouldn’t we then be freezing our eggs you’re right as a society if we
2:07:32 are purposefully delaying childbearing we know that it gets harder to get pregnant with age and if having
2:07:40 kids is a life goal putting eggs into the freezer earlier is a way to save that opportunity it’s not an
2:07:47 insurance plan it’s not a guarantee but it is a smart game plan especially as we are waiting longer
2:07:53 because even with ivf we can’t always overcome age-related infertility if we have fewer eggs and
2:08:00 more genetic abnormalities the technology helps us identify healthy eggs helps us have more eggs able
2:08:05 to grow in a certain month and take them out and test embryos in a lab but i’m working with the eggs and
2:08:09 sperm that you’re giving me meaning if there’s not many of them if there’s a lot of chromosomal damage
2:08:14 if there’s a lot of mitochondrial dysfunction if the sperm quality is not great that doesn’t mean we’re
2:08:19 going to be able to have success so what you’re doing on a daily basis to impact egg and sperm
2:08:26 quality is still crucial but egg freezing has gotten a lot of bad rap it’s still a new technology it’s
2:08:31 only been around about 10 years off experimental purposes meaning that women who froze their egg 10
2:08:38 years ago you know they have much poorer egg survival rates they were older at the time their experience is
2:08:44 very different than the modern woman who is freezing her eggs now maybe in her upper 20s or early 30s what
2:08:49 is the optimal age if you want to have a child as a life goal and you’re not ready to conceive by age 32
2:08:57 that is when there’s a clear delineation that it makes smarter financial sense as well as likelihood
2:09:02 sense the short answer like my daughter will freeze her eggs in her 20s the younger you are the more
2:09:08 eggs that you have if she says i want to have kids as a life goal then that will be something that we will
2:09:14 do in order to help her keep that because there’s so many other variables which impact your ability
2:09:19 to get pregnant or your egg count endometriosis decreases your egg count right people will develop
2:09:24 an ovarian cyst and they’ll have surgery surgery they’ll have a twisting of their ovary and maybe
2:09:29 they’ll lose an ovary smoking chemo radiation smoking marijuana any abdominal surgery so many
2:09:37 things can impact your your eggs because you only have this group you’re born with them so we we plan
2:09:41 for life goals differently and we’ve never really talked about our fertility life goals until more
2:09:46 recently meaning when we went professional career right we knew what we had to do to get into medical
2:09:50 school to get into residency to get your phd you had this list of things and you set goals and you
2:09:55 work to achieve them but i always wanted to be a mom yet i already told you i took a birth control
2:10:00 pill every single day and i didn’t even think about it until that moment was in front of me and that’s
2:10:05 the part of the discussion that we do have to start to have earlier is if this is a life goal for you
2:10:11 what do we need to do understand our body better our fertility better and maybe that does include
2:10:16 freezing eggs because it does give many women an opportunity that time would eliminate
2:10:22 i had a conversation with you natalie on the podcast but then many other women over the course
2:10:27 of the last two to three years and one of the things that i learned from that was that we as you
2:10:31 say we don’t family plan and then we have to deal with the consequences of not family planning so as
2:10:35 an interviewer when i do life story episodes i go through a woman’s life story and obviously the
2:10:39 women that sit in front of me are typically high performers high achievers in some capacity and then
2:10:45 we arrive at the end of the conversation when we talk about family and kids and all those kinds of
2:10:49 things and there’s often a lot of tears and it was in those conversations sitting here with
2:10:54 several women that were on the show what was the straw that broke the camel’s back it was the ufc
2:11:02 fighter ronda rousey it just so happened that when i interviewed her she had just found out that
2:11:08 her seventh round of ivf had failed and so she was very very emotional i left that interview and had
2:11:13 had a conversation with my girlfriend i was like listen i’ve i’ve seen too many of um too many women
2:11:20 over the age of 35 maybe sort of under the age of 50 but really under the age of 45 in tears in front of
2:11:25 me i think we should have a conversation about this should we freeze our eggs i mean me and my partner
2:11:33 we’re both 33 now and um at first i don’t know maybe it was the way i worded it
2:11:39 she was offended she was like you don’t want to have a baby with me it was like yeah it was like
2:11:45 you don’t have sex with me like i like didn’t word it well like i didn’t i didn’t really think i
2:11:48 didn’t really think about the emotions surrounding it i think that was really what you were trying to
2:11:52 make a pragmatic yeah i was as men often do like i was just like we should free but i didn’t think
2:11:56 about what that meant and there’s this prevailing narrative in society that if something’s not
2:12:05 quote-unquote natural then it’s not good and that ivf or egg freezing is not natural and that like
2:12:09 torments people’s brains because they want to live a natural life even though they’re in like
2:12:15 fucking planes and on on iphones we want this one area of our life to be natural and after honestly
2:12:23 five minutes of that conversation i think the framing that flipped her mood was that wouldn’t
2:12:27 we want to give ourselves the option right and it’s actually about having options but i wanted to throw
2:12:32 that out there because i don’t think people family plan i think as you said we focus on our careers
2:12:38 then we pop up at 35 36 37 and assume that we can but that is not the case especially if you live
2:12:43 a healthy life you think you think oh this will be easy for me or if you’re a high achiever and you’ve
2:12:52 achieved other things many women are really taken aback by not being able to achieve this or not having
2:13:00 control over infertility and what is a natural process to run out of eggs and to go into menopause if you
2:13:07 are lucky to live long enough this is going to happen i got my diagnosis of pcos in medical school
2:13:15 before i was ready to start you know family planning and i knew i was probably going to struggle and
2:13:24 so it took us about three years to successfully conceive the first time and you can’t even though
2:13:28 i’m working in the business you know i’m running between patients to go and have another ultrasound or
2:13:34 go get a shot or go do all the things that it took you know you you can’t remove the emotion from it
2:13:40 and i can’t tell you how many times i cried and of course all of my co-residents my four best friends
2:13:46 all got pregnant in succession our poor chief residents and with no trouble you know and even
2:13:51 like crying to my mother about the struggles i was having she’s like i just i got pregnant eight
2:13:56 times with no trouble you know and then my first pregnancy resulted in a miscarriage and you know in
2:14:00 the middle of work you know my friends were there and they were cheering they were so excited i was
2:14:06 finally pregnant and then we lost the baby and you know and having to like push through and work through
2:14:10 it’s like it was yesterday like you know i have two healthy kids thank god and you know we were never
2:14:15 after those two we tried again we were never able to get pregnant again which you know i had two kids and
2:14:20 put a bow on it and we’re done but it is impossible to remove the emotion because
2:14:33 you because in the mindset it’s luck or it’s something we did we caused this and it’s i you know as a high
2:14:37 performing you know someone who’s like you check all the boxes and you make all the good grades and you
2:14:42 you do everything right and this is the one thing that suddenly you didn’t think much about and then
2:14:48 it becomes everything when that that that becomes harder it’s taken away from you but i think women
2:14:58 assume that it’s our burden because we assume that if we can’t conceive it’s just us or something but i think i
2:15:05 i heard you say this the the it’s a two-way street and and the issue is not always the woman a high
2:15:11 percentage of the time it’s her partner and so i don’t think we absorb that information up front either
2:15:18 until we start investigating it but i’m in awe of this story that four of your residents got pregnant
2:15:24 immediately because in orthopedics that does not happen every orthopedic surgeon in my generation that i know
2:15:30 if we got pregnant we miscarried and maybe that was lifestyle and maybe that was not eating
2:15:36 for 40 hours maybe it’s all the radiation that we undertake i think it’s better now for the younger
2:15:43 generation and we as the i’m not that old but i am older than the current residents um we encourage
2:15:49 all of them if you are not partnered and wanting to have a child now then please consider freezing your
2:15:55 eggs if that’s a goal because we can’t predict our futures and our residencies extend into our 40s
2:15:59 well i love that you’re helping facilitate that discussion because that certainly wasn’t the
2:16:04 culture back when we were in training i am one of the ones who sat here and cried in front of steven
2:16:10 myself when talking about my own pregnancy loss journey just because you know i see it every day
2:16:18 you know and i tell patients every day news that they do not want to hear 50 of infertility is due to
2:16:24 male factor 50 is due to female factors one of the most important things i want to convey when we are on this
2:16:33 topic is that ivf is an amazing technology that has helped 13 million babies be born it has been life
2:16:38 changing and world changing and things don’t have to be natural sometimes the natural progression of
2:16:46 disease is death so we have technology and science that exists to optimize and improve life and to help
2:16:51 live life exist and that’s part of what ivf is i think that’s important because we do see a narrative
2:16:57 right now that ivf is inherently bad and natural fertility approaches are inherently good and we
2:17:02 truly need to say both things are good do women need to learn about their bodies earlier talk about cycle
2:17:08 tracking take better care of themselves get an earlier investigation when things aren’t going well
2:17:15 absolutely true but also needing to have fertility treatments is not a failure needing to see a
2:17:20 fertility doctor is not a failure if you need ivf that is okay all the other stuff is still really
2:17:27 important to the outcome of your journey but this narrative of ivf isn’t natural so it’s bad or egg
2:17:33 freezing isn’t natural so we shouldn’t do it that’s harmful to society and to women who do carry the burden
2:17:38 do carry the burden whether they need to or not women do carry the burden of family planning for the
2:17:44 future hearing you talk about that is very interesting to me because in other parts of medicine
2:17:51 in my own medicine right we were talking outside about how i i now do knee surgery through needles
2:17:59 it’s an advancement of technology we celebrate that we like better it’s not natural it’s not natural
2:18:04 live with your thing right but i’m capable of helping you live a better life right yeah so it’s
2:18:10 interesting to me it’s the stigma of women’s health and work that’s right this has because
2:18:15 this is women’s health we’re going to control it we’re going to protect these gals we’re not going
2:18:21 to apply the vast knowledge i’m a little offended by it actually if you want to know the truth why can i
2:18:30 be so encouraged and and be considered top of my field when i adopt new technologies but in your field
2:18:39 13 million parents or 26 million parents would be told that technology is not okay
2:18:45 i agree it’s a terrible narrative that is happening right now in the political landscape and i think it’s
2:18:53 important to say scientific advancement is good and it changes the lives for so many people and i think
2:19:00 it’s just highlighting this idea about natural doesn’t always mean better i think as you know
2:19:05 scientists and people in medicine there’s also been a disservice to not trying to get to the root
2:19:11 cause and not working on preventive medicine right and so going towards treatments and technology which has
2:19:18 made the layperson feel like half of the picture wasn’t discovered or talked about and so we can do
2:19:23 better on both ends of it and that comes to women’s health more than anything because there is stigma
2:19:28 when it comes to isolation there’s and i mean when it comes to infertility there’s isolation you know
2:19:34 being left behind your peer group questioning a life goal will make you question who you are your life
2:19:40 meaning your purpose and that is an extremely stressful and challenging state for somebody
2:19:45 to go through and we should be giving more support to that we should be saying freeze your eggs you’re
2:19:51 in a stressful lifetime instead of the narrative that we are seeing right now so would the message be to
2:19:58 young men and women that want to have kids at some point in their life to freeze their eggs in their
2:20:04 20s is that what you would advise you know most people in their 20s maybe don’t have good awareness
2:20:10 of these goals but certainly your you know later 20s your early 30s are the prime opportunity where
2:20:15 you still for the average person you’re going to have a high number of eggs you’re still high on the
2:20:20 graph and your egg quality is still going to be high meaning it’s going to be easier to get the outcome
2:20:26 that you want certainly in your 20s would be ideal if you but it’s expensive a lot of people don’t have
2:20:31 the financial resources to freeze their eggs and their 20s they’re in training or they’re starting
2:20:37 their career so to have an extra ten thousand dollars lying around isn’t always realistic and i think that’s
2:20:44 why people are often waiting because that feels you know elective you know like oh that’s extra money
2:20:49 i don’t know that i have that right now when we see insurance that starts to cover egg freezing as
2:20:55 an option we see huge uptake in women going to freeze their eggs so you will see at companies
2:21:01 where almost less than five percent of women would freeze their eggs before age 35 and then they
2:21:06 introduced a health plan that would cover egg freezing and up to 50 percent of them would so you
2:21:13 you can see that both financially and access and awareness they all go hand in hand but that’s a
2:21:19 big player and being able to do that because it is an expensive process so dr crawford i think what
2:21:25 most people don’t understand what is the spontaneous fertility rate by age in general yeah so if you are
2:21:30 30 your odds of getting pregnant monthly we use a monthly rate called fecundability it’s going to be
2:21:36 at best 20 percent per month when you’re in your 20s it’s a little bit higher can get up to 25 percent
2:21:42 per month if you’re having sex monthly and regular periods so if you’re having unprotected intercourse
2:21:48 and you have regular cycles your best odds in a given month are going to be about 20 percent at age 30
2:21:52 how much sex do you have to be having well really just have to have it in that fertile window
2:21:59 what just once or really just once yeah sex solely on the day of ovulation would be the ideal time
2:22:04 but you just need to have at least intercourse at least once in that fertile window but that number
2:22:09 drops quite significantly to what dr caver is saying so at age 35 if you’re trying to get pregnant it’s
2:22:15 going to be 10 to 12 percent per month odds of getting pregnant at age 38 it’s going to be five
2:22:20 percent per month at age 40 it’s going to be three percent let’s see if you’re trying for the first
2:22:25 time they’re a little bit higher if you’ve had a child already because there’s some proven fertility
2:22:29 factors but if we look at that you say i’m chasing these dreams i’m going to try to have my first baby
2:22:37 at age 38 you have a five percent chance per month that’s not zero but that means the greatest probability
2:22:42 is that by six months time frame you won’t be pregnant and then you’re going to start a pathway
2:22:48 of trying to investigate why that is happening and if you do need intervention you’re further down this
2:22:53 graph too you’re going to have less eggs to work with and their quality is going to be less good
2:22:58 that’s why those numbers drop rapidly natural fertility rates are not about being out of eggs
2:23:04 because you ovulate just one egg at a time it doesn’t matter if you have 20 eggs outside that
2:23:09 vault or five eggs you’re ovulating one egg at a time so natural fertility is all about egg and sperm
2:23:16 quality so the this huge drop we see from 20 to five percent is because of the change of our egg
2:23:21 quality as we get older during our 30s which most of us feel like is really young and what can i do to
2:23:26 because i know weight has a role in egg quality right if you’re underweight or overweight is there
2:23:32 anything else that has a really pertinent impact on the quality of my eggs yes so we have two factors
2:23:37 we’ll say age which you can’t control to an extent right chromosome damage is going to happen
2:23:41 even if you are exceptionally healthy because tincture of time they’ve been sitting inside your
2:23:46 body chromosome damage builds up but the variables that you can is everything that impacts cellular
2:23:51 health so chronic inflammation and insulin resistance are the two things that are going to most dramatically
2:23:57 harm your eggs metabolic function it’s going to harm your mitochondria you’re going to get mitochondrial
2:24:02 damage we know that when we start looking at older women they have more dysfunctional mitochondria
2:24:07 they’re shaped abnormally the products inside their follicular fluid show higher levels of
2:24:13 inflammation just based on age that happens but also if they start having infertility versus not
2:24:19 having infertility so we know that inflammation and insulin resistance are key players even in patients
2:24:26 without known pcos or endometriosis but they play a role in aging and specifically your egg health as you
2:24:32 age so if you say getting pregnant is a life goal i’m tracking my cycles i don’t want to freeze my eggs
2:24:37 right now but what should i do all these things that we talk about and we’re going to talk more about to
2:24:43 decrease inflammation inside our body that’s it and from a young age because these changes build up over
2:24:49 time and if i have pcos how does it even more important because you’re at a higher predisposition
2:24:54 to have insulin resistance your cells are more sensitive to how they’re going to respond
2:24:58 but do i have less eggs if i have pcos so you’re going to run out of eggs around the same time you’re
2:25:03 born with a little bit more but because you lose eggs based on how many you have essentially you’re going
2:25:09 to catch up so during your reproductive years you tend to have more eggs out of the vault which interferes
2:25:15 with normal hormonal signaling making all of the hormonal metabolic changes worse very interesting thing
2:25:21 as women with pcos tend to get older and their egg count starts to drop and they have fewer eggs coming
2:25:27 out of the vault they’ll often start naturally ovulating even if they didn’t earlier and so i’m
2:25:33 always a little concerned when somebody said i used to never have periods but now i do did i cure my pcos
2:25:39 maybe they did make some good lifestyle changes along the way but honestly that’s a red flag for me that
2:25:45 she’s now more rapidly declining in her egg count approaching what will be perimenopause for her
2:25:51 because her egg count is low enough to then respond to the brain signals nodding your head over here
2:25:55 and as a man is there anything i can do to increase the odds that i’m going to impregnate now you can
2:26:03 stop using um cannabis and smoking cigarettes um drinking alcohol we need to avoid heat so the testicles
2:26:08 are outside the body for a reason they need to be at a lower body temperature in order to adequately make
2:26:13 normally functioning sperm so hot tubs saunas those should be off limits if you’re wanting to get
2:26:19 pregnant same with high intensity exercise and compression of the testicles so this is notably
2:26:25 cycling for long periods of time so an hour on the bike or more routinely can actually compress
2:26:29 the testicles and increase their heat what about sitting in a chair for five hours
2:26:36 same thing sitting in a chair boxers briefs being in a room that’s hot those things aren’t quite enough to
2:26:41 truly raise that core testicular temperature quite like some of these other things we also see diet
2:26:47 playing a big role the great thing about men you’re making sperm every single second the sperm lifespan is
2:26:54 90 days 72 days to make a sperm 18 days to get out the ejaculatory system but that means you could make a
2:27:00 singular change in your health and see a different outcome in your sperm that is so rare that doesn’t exist in
2:27:06 women’s health that one variable can move the needle so much marijuana is a huge one marijuana use works
2:27:12 at the brain to prevent those fsh and lh signals which are crucial to tell your testicles to make
2:27:19 sperm and they also impact inflammatory environments so sperm are not as modal they are not shaped as well
2:27:25 the dna inside their heads is more fragmented in fact men who use marijuana their partners have a higher
2:27:30 rate of pregnancy loss even if their partners are not around it at all you’re using the word pregnancy
2:27:35 loss versus the word that we’re aware of in the uk called miscarriage is that is that intentional
2:27:41 miscarriage can mean you know a to a lot of different things to people and pregnancy loss an
2:27:47 unsuccessful pregnancy depending on when you medically lose a pregnancy yeah or if a pregnancy is in the
2:27:52 fallopian tube and it’s an ectopic pregnancy that’s still a pregnancy loss meaning you had a positive
2:27:58 pregnancy test that did not end up in a baby so it’s a little more inclusive for a variety of
2:28:02 different stages of when and how loss can occur miscarriage kind of infers when we say it you know
2:28:08 on my end is that the pregnancy was in the uterus and now it’s it’s we either have to evacuate it or
2:28:13 it’s it’s self-evacuating and you were saying a second ago wonder that it’s from your experience
2:28:21 pregnancy loss miscarriage is much higher with women who have high stress careers and jobs well i don’t
2:28:28 know the real statistics but my i’m sure they exist but in my experience as a high capacity high stress
2:28:37 not sleeping for 11 or 22 years i have seen it a lot and it happened to me yeah chronic stress is
2:28:43 associated with a higher rate of pregnancy loss is there anything else that people misunderstand about
2:28:49 pregnancy loss and miscarriage that is worth talking about well it’s not talked about i think yeah it’s
2:28:55 one of the things and people still think it’s it’s rare taboo and rare but i think all of us around the
2:29:02 table had a pregnancy loss yeah two at least two and when i had mine i was in training and uh
2:29:10 a i didn’t want to call my attending and tell them yes he was a man and i didn’t want to i didn’t think i
2:29:15 could take any time off same i went back the next day i would have gone back the same day but i could
2:29:20 barely move i was running labor and delivery like at night i got discharged ivy pulled out of my hand
2:29:28 and went back on the ward yeah like so i think hopefully part of this international conversation
2:29:37 about women’s health not just gynecological health but health in general will give women grace because
2:29:43 there’s no way that i should have been expected to go back to an orthopedic surgery residency the day
2:29:50 after i lost a child or frankly i don’t know what your experiences were but in my generation of
2:29:58 doctors and i’m sure it happens everywhere i went back to work less than five weeks after delivering
2:30:03 a child and i think other european countries have it right oh yeah oh yeah new zealand’s a year
2:30:12 i i i weeks six weeks i had six weeks with one and three weeks with the other because if i wanted to
2:30:17 if i want my fellowship on time that’s right i wanted to graduate on time i couldn’t exceed the total
2:30:23 vacation so these internships and fellowships and i’m i’m sure that it built into these programs we
2:30:28 sign up for they were all developed for men who had had they had a family had a wife you know had
2:30:36 someone at home to like take care of that business yeah and we’re have you know we’re all in supportive
2:30:43 relationships and you know that wasn’t the issue but like i went back before my body was ready yeah
2:30:48 because i would before that baby was ready to to let unlatch and my milk supply dropped immediately
2:30:54 the minute why i went back to work and i tried to pump but you get called for a crash c-section or
2:30:58 emergency surgery and you’re like pulling the pump off the breast and i’m running down the hall hooking my
2:31:04 nursing bra back on trying to get to the or and you know all that cortisol just my milk you know so i was
2:31:10 able to breastfeed while i was home with the baby and but like once i went back to work my my milk
2:31:16 production just but i think a picture of me in the hospital and it was a day after i gave birth
2:31:23 my laptop is open i’m trying to breastfeed because we launched a company the month before i gave birth
2:31:30 and instead of my male co-workers going okay we’ll give you some grace no i had a week and then they’re
2:31:35 at my house having meetings there’s such a different discussion about miscarriage now than when i went
2:31:40 through it i told nobody i didn’t either i mean it was so secretive i didn’t feel like i could
2:31:47 and we are seeing a different generation where i do think talking about women’s health and steven you
2:31:53 having these discussions on a bigger stage are lessening the stigma for what is something that
2:31:58 people go through one out of four pregnancies will end in a pregnancy loss that is not a low percentage of
2:32:04 people and the same breath most people should not have two in a row and if you do you should go get
2:32:10 an evaluation because there are medical things that can contribute to pregnancy loss that we would love
2:32:15 to identify a lot earlier and see if there’s something we can do to make that different
2:32:21 what do i need to understand about what a woman goes through either in the wake of pregnancy loss or in
2:32:30 the wake of a pregnancy and a birth physiologically psychologically as an employer to be able to
2:32:34 create a better environment for the women that are going through either of those two things
2:32:39 like what’s what’s going on inside the body because i i wouldn’t know right so one of the you know
2:32:45 simplest things to say that’s going on is that pregnancy is one of the most hormone robust times
2:32:50 you have even just momentarily pregnant if you have a placenta starting to implant you are now
2:32:55 making levels of estrogen and progesterone that you will not ever make at any other time period of your
2:33:02 life when that doesn’t when you lose that pregnancy or when you’re postpartum let’s say you’re having
2:33:09 this huge hormone crash suddenly you go from this very high level of these hormones dropping off immediately
2:33:14 and in addition to all the physical changes the emotional changes that has a huge impact you’ve
2:33:19 heard us talk a lot about low estrogen and how that feels the very interesting thing most studies about
2:33:25 estrogen show is that the hardest time for women is when estrogen is changing so going from high to low
2:33:31 is actually when your body is having brain can’t keep up can’t keep up doesn’t know what’s happening and
2:33:37 the higher you were and the faster you come down and we’ll use this analogy too even in ivf when we go do an
2:33:42 egg retrieval and somebody had many eggs they have a much higher estrogen they naturally would i go and
2:33:48 put a needle in each one and drain the eggs out and destroy those cells and their estrogen plummets and
2:33:53 they expect to go the next day and feel normal or they expect to feel worse during the stimulation
2:33:58 process when they’re using hormone shots and i always say you’re actually going to feel worse when
2:34:02 i’m done with you it’s going to be that week after the egg retrieval where your hormones go from the
2:34:07 the highest they’ve ever been very quickly down low it’s that delta that change and that happens
2:34:14 anytime you have that but pregnancy and loss and postpartum are some of the most profound times that
2:34:21 you experience this and one of the other things is the identity shift so if you’re working you know we’re
2:34:27 all very highly motivated and became parents but it’s that whole identity shift of now how do i interact
2:34:32 in my life and how do i interact with my peers i’m a mom how am i being identified what are the
2:34:38 implications so there’s a complete identity shift that also isn’t discussed and that can also perpetuate
2:34:44 some of the postpartum that we see as well and anxiety and lack of control right you don’t know
2:34:49 what you’re supposed to do especially if you’re a mother for the first time that is can be very
2:34:55 anxiety provoking in addition to hormone changes and not getting sleep but lack of control you don’t
2:34:59 control your schedule you don’t control when you sleep you don’t control if your child gets sick
2:35:06 and so i would say from an employer standpoint grace support and flexibility you know if i had had better
2:35:12 better support structures to say when your child is sick it’s not the end of the world if you are not
2:35:17 here physically at the office that didn’t exist meaning that my child getting sick became this
2:35:25 extremely stressful oh my god but for the average woman working a nine-to-five job whether it’s in
2:35:33 medicine or other fields if you could design their working month around their menstrual cycle around i
2:35:38 don’t know potentially a pregnancy whatever how would you design redesign their month because we we have
2:35:42 inherited this sort of i think it’s like from the industrial revolution it’s like nine to five
2:35:48 working hours we don’t work saturday and sunday we do that four times across a month what would you
2:35:53 change what should women change because i’ve had some countries or systems are trying to give women
2:35:58 time off around certain parts of their cycle for example would any of you change anything
2:36:02 well there are a couple of companies in new zealand who are pretty flexible especially after the pandemic
2:36:09 where they have allocated certain hours that are free to work at home and just have to get the work
2:36:17 done to the point where they have four day working weeks and then they’re also putting into the annual
2:36:23 leave what they call menstrual leave or menopause leave and it’s you just say you know i can’t come today
2:36:27 some people are using it for child care some people are using it for really bad cramping days other
2:36:32 people are using for mental health days but it’s a it’s there to be used for however and you don’t
2:36:38 have to identify it as being menstrual cycle day or menopause it’s just extra leave and people don’t
2:36:44 care as long as you get the work done and i think that having that flexibility across you know if you have
2:36:50 that ability to have more flex hours or shared time space or something like that greatly benefits
2:36:58 productivity as well as the feeling of empowerment and inclusivity which then feeds forward to better
2:37:03 productivity if i’ve got extremely high stress job is there any part of this cycle where i should
2:37:10 theoretically be avoiding stress well that’s an individual thing it’s how because you know we hear all
2:37:15 the stuff about cycle tracking and it’s about understanding your own responses to your own
2:37:21 hormone blocks because mel my partner says to me that she needs to not do work there’s like a couple
2:37:27 of days a month where she’s like i’m just gonna nest that could be her her responses and she’s like i just
2:37:34 don’t have the stress tolerance to be able to do xyz and understanding that in her own cycle is great
2:37:40 because then she can allocate tasks that take more stress for other days for most people it’s
2:37:45 peak luteal so when your progesterone is the highest tends to be when people have a harder time focusing
2:37:50 and concentrating or getting tasks done now which is where which is gonna be the middle of the luteal phase
2:37:56 at the middle of this second half of the cycle when you have that out there 21 ish so when you have that
2:38:02 progesterone you know really high your body might be ready to implant an embryo if there was one that
2:38:08 tends to be when people say they feel more fatigue and less energy and less focus and concentration so
2:38:13 if you are looking at your month and you might notice that it and you have the flexibility to
2:38:21 say okay i’m gonna try to write this paper get this study done do these tasks that call these tasks that
2:38:26 call for an increased focus in my follicular phase when i’m estrogen dominant have high estrogen and no
2:38:33 progesterone for the average person that is typically when they’re easier have an easier
2:38:38 time achieving those tasks which is the first which is those 14 yeah the first couple weeks the time
2:38:43 period before ovulation but there is an individual response and i definitely will see some people who
2:38:49 they feel immensely better when progesterone’s present and not so great the other time so i think
2:38:54 we use generalizations just as a rule of thumb because that’s what it is for most people but
2:38:59 hormones specifically there’s always an individualized response and learning to listen to your own body
2:39:04 is key and knowing what you need to do i want to close off on this point about just how employers and
2:39:10 you know the way that we work can be better suited to a woman’s health is there anything else we missed
2:39:16 flexibility i think absolutely mentioned before the ability to make a decision for yourself this is
2:39:21 a day that i can do these you know tasks i think every woman wants to do a really good job
2:39:30 and she is going to front load those tasks on a time that she feels better and offload in a time
2:39:35 where she’s not feeling as well but she’s going to get it done for sure and so giving her the flexibility is
2:39:40 going to allow her to be her most productive rather than demanding she have x amount every
2:39:48 single day and i think support can come in a lot of ways but the um financial burden to a large
2:39:56 corporation of having a stop gap child care at work so maybe if you’re not going to offer full child
2:40:00 care because you’re going to a lot of productivity out of women if they know their children are on campus
2:40:07 and can go at lunch time but if you’re not willing to do that if you have a stop gap where instead of
2:40:14 calling your attending or one day my nanny didn’t show up and i had to find some way just for those
2:40:22 emergencies within the corporation that breeds loyalty that will increase productivity and so i think it’s
2:40:28 money well spent talk about having a competitive woman she would probably want to work for you
2:40:34 but yeah you know and is offering those things to make her mothering easier while she’s trying to
2:40:39 work i think you would have the most competitive workforce and what does that mean so that would
2:40:44 mean having and that is that having a nanny on site or is that daycare on site on site whether it’s full
2:40:53 time like bring your children full time there or that’s a that’s a big corporate but a smaller corporate
2:41:01 commitment would be this emergency child care so that your kid’s not there all the time but maybe
2:41:07 they’re sick or maybe somebody didn’t show up and then you have days you have a licensed child care
2:41:13 provider available yeah you know who could yeah which is a fault of the u.s system yes yeah what happens
2:41:20 in new zealand you have 20 hours free daycare a week a week yeah so it’s um yeah 20 hours funded
2:41:27 uh and then it’s a very small nominal fee for hours over that for up to year five or when they’re five
2:41:32 years old because then they start school on the first day that they turn five it’s like you turn
2:41:40 five happy birthday but it does help significantly um kind of keep productivity and a little bit of the
2:41:47 worry off what am i going to do with my child amazing yeah what does this um conversation
2:41:54 around eggs and fertility dovetail into menopause and specifically perimenopause i guess that’s the
2:42:00 next you can’t have one without the other right so perimenopause is basically in this fertility decline
2:42:05 area okay so so you don’t fertility is not an issue you don’t want to ever have a baby you’re still
2:42:11 going to go through perimenopause and so perimenopause is defined medically in the worst
2:42:19 way as the transition from normal menstrual cycles to no menstrual cycle ever again okay so when we look
2:42:25 at definitions menopause is defined as one year after the final menstrual period what it really means is
2:42:32 ovarian failure and that offends people but that’s actually medically what it is you have run out of eggs
2:42:39 and you run out of the ability of the ovary to produce hormones and so perimenopause begins
2:42:48 medically at the straw staging is the very complicated um methodology to define the stages of perimenopause
2:42:55 and a lot of it is based on menstrual cycle irregularity but hormonally what’s happening
2:43:02 starts well before a period’s become irregular so as those egg levels decline and and the ability to
2:43:08 respond to the stimulus coming from the brain remember ovulation starts in the brain so when
2:43:12 estrogen levels normally get low during the cycle the brain doesn’t like it the hypothalamus so the
2:43:17 gland in our brain starts looking for estrogen it likes estrogen and then when the estrogen levels are
2:43:23 high it’s happy and so when estrogen levels decline naturally in a cycle it says whoa where’s my where’s my
2:43:28 estrogen and it sends a signal to a second gland in the brain called the pituitary and that makes the lh and the fsh
2:43:35 so i’m trying to figure out what causes menopause perimenopause what causes a lack of eggs
2:43:40 so it’s the loss of eggs and the loss of the the group of eggs to respond to these signals so here
2:43:46 we go we’re beginning perimenopause we’ve reached a critical threshold level where our ovaries cannot
2:43:51 respond and that might be i don’t know millionaire so when you’re not out of eggs but just the count
2:43:58 is low right let’s see if you’re a jar yeah so if menopause is going to be for simplicity the jar is empty
2:44:04 when the jar gets like this so we’ll say if you had full the jar is not empty but it’s it’s gotten lower
2:44:09 and what is happening is the ovary doesn’t want to be out of eggs so what dr haver saying is the brain
2:44:14 is working harder to get an egg to grow because the ovary becomes more stubborn it wants to hold
2:44:19 on to them it doesn’t want to lose them the brain has to send out stronger signals to get an egg to
2:44:24 grow because there’s not as many we don’t lose as many per month so that’s great but that means we have
2:44:31 years of being at this low unreliable ovary stage where the brain is working really hard there’s not as
2:44:38 many eggs that are here they will still ovulate but it starts to happen at a less predictable rate
2:44:42 but is that perimenopause when there’s yes and there’s not a definition i think that which makes
2:44:48 it the hardest to say your point what number of eggs equals perimenopause different there is a unique
2:44:54 response to each person at what level your ovary gets to where it will start to respond dysfunctionally
2:44:59 but what happens is that the hormone changes start shifting in the brain the ovarian response starts
2:45:05 shifting and before you have irregular cycles you will first see a shortening of your cycles very
2:45:10 predictably the brain will send out a stronger signal an egg will ovulate faster you start to get
2:45:16 shorter cycles and there’s hormone fluctuations but they’re still regular and so what will happen is a
2:45:22 woman will start to feel these hormone shifts it’s less predictable she is having some change but it’s still a
2:45:29 regular cycle and so she is often told your hormones are fine you have a regular cycle so and in the brain
2:45:35 as we talked about those neurotransmitters there are not only is estrogen changing and the amount that
2:45:41 we’re producing actually in perimenopause quite often we’ll have much higher estradiol levels than we did in
2:45:47 in our premenopausal years where we had that kind of predictable ebb and flow of our monthly monthly
2:45:54 hormones there’s also independent fsh receptors outside of so these hormones that are pumping out to talk
2:46:01 to the ovaries are also back talking to different parts of the brain so the first symptoms that patients
2:46:05 feel and they’ve done a great study on this is i don’t feel like myself
2:46:13 i don’t feel like myself and they even call it idflm and so you can’t put your finger on it
2:46:19 periods are regular but your environment hasn’t changed your normal stressors haven’t changed the
2:46:24 life you built that you could manage you’re suddenly losing resilience and that’s because of a hormone
2:46:31 fluctuation that is so we see sleep disruptions mental health challenges increase 40 increase
2:46:36 across perimenopause transition and the cognitive changes and that is what really scares my patients
2:46:42 the most and they come in and most of them are you know we’re all high functioning in some degree some of
2:46:46 us in academia some of us in the or some of us but you know most women are high functioning because
2:46:51 they’re juggling so many jobs so even if she didn’t choose to go the routes that we’ve chosen
2:46:56 she is managing children you know school drop-offs you know all the things that women tend to put on
2:47:03 their plates and suddenly she can’t remember all the things she used to remember where are her keys
2:47:08 you know word salad you’re you’re struggling to find i can’t tell you how many times i am like i i see
2:47:15 people and like i cannot remember their names or i can’t remember i get in the car and i can’t remember
2:47:19 where i’m going or what my purpose of getting in the vehicle was you have to think for a second
2:47:26 and so all of that is related to the hormonal changes at what age well i think that there’s
2:47:33 a tendency in medicine to want to have definitions yes so i personally and i know a lot of us who talk
2:47:40 all the time think that this random 366 days after your last period that’s your menopause day i think
2:47:47 that’s pretty random and i don’t know who made that up but when i have because i’m not an ob but when i have
2:47:53 patients come in to me for their musculoskeletal things and they’re of a certain age and i don’t
2:47:58 just focus on whatever the musculoskeletal body part is but we start talking about their whole health
2:48:02 and they start talking about these things i am often the first one to say to them
2:48:10 you know what you are probably in perimenopause and they’re like but my cycles are regular i’m like but
2:48:17 you are beginning this transition which i call mental lessons but it’s this right i would propose
2:48:24 that most people don’t seek out a lot of help earlier but they should just assume that they’re
2:48:30 perimenopausal anytime after 35 they don’t feel like themselves and start down a road of learning or
2:48:36 investigating or let’s feel better and what do i need to do about it you know it’s frustrating to us
2:48:41 all of us we talked a little bit about this last night is the people who kind of make the rules
2:48:48 the institutions that make the guidelines and and the academic kind of ivory tower you know they’re
2:48:57 like whoa back off slow down we shouldn’t be blaming everything on menopause you know like
2:49:00 and i don’t think that’s what we’re saying we’re not
2:49:09 like completely dismissing the female experience and not at all like including this cataclysmic
2:49:15 hormonal change is hurting women so the average age of menopause is 51 to 52 and so let’s say that
2:49:20 is when your ovaries are in failure they will no longer make eggs make hormones or respond to brain
2:49:27 signals so all the eggs all the little marbles are all the way gone at 51 52 for most women about seven to
2:49:32 10 years before that they will start to enter into what we will call perimenopause or the
2:49:38 unpredictable response of the ovary and the brain i say their communication system their best friends
2:49:43 who aren’t communicating well their signals are getting interfered they’re not responding
2:49:48 appropriately the ovaries getting more stubborn the brain is trying to work harder you get these higher
2:49:54 peaks these lower troughs and essentially that is the time period so it is unique to an individual
2:49:59 because everybody’s born with a different number they lose them at a different rate some factors
2:50:05 that we control impact that rate but some things that we do not your mom’s age of menopause is a
2:50:11 predictive factor if you’re had a first degree relative go through menopause at 46 or sooner you
2:50:18 have a six times likelihood of going into early menopause so knowing having this conversation almost
2:50:22 every patient i ask what age did your mom go through menopause they do not know the answer because
2:50:25 the moms haven’t talked about it moms haven’t talked about it there’s so much stigma about
2:50:30 reproductive health so knowing that information is really important if you have mom or older sisters
2:50:36 what age is normal for your family so that you can be a little more in tune if there’s some genetic
2:50:41 predisposition for you the general idea of what dr haver is saying is that in these last seven to
2:50:47 ten years of ovarian lifespan it becomes more stubborn and less predictable and it does cause hormonal
2:50:51 shifts that most women can’t detect with their cycles we do know that if you are actively tracking
2:50:57 actually when ovulation is happening and looking at your follicular and luteal phase and you know
2:51:03 what’s normal for you you will most likely be able to detect these hormone shifts in that time period but
2:51:09 that’s not what women are taught their tracking is just that it’s coming regular and we do have a
2:51:15 generation of women that were on contraception and then went through childbearing and then on
2:51:20 contraception again until now they’re suddenly entering this transitional period and they don’t
2:51:26 know what their own normal is right making it even worse correct so like she said the average age of
2:51:32 menopause if we look at the math uh is is 51 but under that 90th percentile curve you know with
2:51:40 five percent on each end it’s about 45 to 55 that’s menopause right that’s full menopause now now let’s
2:51:47 just do math and back it up seven to ten years so we’re looking at the mid to late 30s to 40 so when
2:51:53 i have a 46 47 48 year old patient come in who’s still cycling she has almost a hundred percent chance
2:51:59 of being in perimenopause just based on her age alone knowing the statistics around that yeah okay so with
2:52:04 my partner between the age of sort of 35 to 45 is when i can expect her to go through perimenopause
2:52:12 where there’s very little marbles left in the jar um and her hormones might be less predictable less
2:52:17 predictable and one of the questions we had in from the audience was how can i manage the symptoms of
2:52:25 perimenopause and they use the word naturally well we don’t have a single large-scale study done
2:52:30 on the treatment of perimenopause so let me break it down for you when we look at funding in women’s
2:52:37 health it’s horrible okay but if we if i go into pubmed which is the you know database that i go to
2:52:44 look up metal medical journal articles and i type in the word pregnancy i will get today 1.2 ish
2:52:49 million articles for pregnancy amazing so important we need healthy pregnancies if i type in the word
2:52:59 perimenopause right now i think it’s about 99 000 so those numbers represent time brain power funding
2:53:06 what what what is important in women’s health okay if i type in the word perimenopause we are about at
2:53:14 8 000 yep very very very very small your name’s on a couple of thanks
2:53:24 thanks so is the last third of my life from an academic standpoint from funding from brain power
2:53:31 from where we focus not as important than when i had the ability to be pregnant more women will go
2:53:35 through perimenopause and then menopause because we’re going to lose a few to accidents and cancers and
2:53:40 you know early deaths more women will go through perimenopause then get pregnant
2:53:47 yet in my training so in medical school i got one hour one one hour lecture on menopause nothing on
2:53:53 peri and in my ob-gyn training and i’d love to hear what you have to say as part of our reproductive
2:53:59 endocrinology blocks i had one block about my second year in those six weeks i got one one hour lecture
2:54:06 each week no clinics no focus nothing and then as a program director where i was in charge of the
2:54:12 education of residents of over 100 residents over about 10 years i know exactly what the curriculum
2:54:19 required and menopause just gets shoved into a tiny box and then what happens when we run out of marbles
2:54:26 in the the glass there what’s really interesting and one thing we’ve said a couple times is this happens
2:54:32 this is ovarian failure you’re going to go into a state of low estrogen because the ovaries no longer
2:54:37 have the ability to make eggs therefore they are not going to make estrogen or progesterone and just
2:54:42 to be clear that the eggs were sending a signal up to the brain to make estrogen and the eggs well the
2:54:48 low the eggs in the brain communicate yes when you didn’t have an egg ovulating your estrogen would be
2:54:53 low and that typically is the brain signal to send out more fsh that’s still happening meaning
2:55:01 estrogen is low but the brain is sending out all the fsh it has fsh is very high in menopause
2:55:06 and the ovary cannot respond because there’s no more eggs there’s nothing left to respond i need to
2:55:11 explain that that explained again so i’m trying to understand why estrogen drops when the eggs disappear
2:55:16 the estrogen is made from the cells that surround each egg so when there’s no more eggs there’s no more
2:55:23 cells that make estrogen the follicle goes away too okay okay so estrogen is made in the ovaries so the
2:55:27 estrogen is made in the ovaries and the primary type of estrogen that we’re talking about and it’s made
2:55:32 from the cells that surround each follicle called the granulosa cells and as the follicle gets bigger as
2:55:39 the egg matures more of those cells become more active and you make more estrogen so even when you have a
2:55:45 little bit left when you’re on your period we’ll say but you’re some eggs here you’re still making
2:55:50 some estrogen it’s not as high as when you’re ovulating but these little eggs will each make a
2:55:55 little bit do i make estrogen yeah you do but i just make it somewhere else yeah it gets converted
2:56:01 over to testosterone okay so we have enzymes in our body that convert estrogen and testosterone back and
2:56:09 forth so there’s no more eggs so this is menopause so this is well in my world yes ovarian failure and
2:56:14 we’re calling it ovarian failure on purpose because at this moment you’re not going to make estrogen the
2:56:19 brain is sending out all the signals it can very high fsh trying to get estrogen to be made there’s no
2:56:26 eggs so there is no estrogen what dr haver has said which is correct our our friends in the medical world
2:56:32 do not define this moment as menopause they make you sit here and be estrogen low for a year
2:56:38 and have no period for a year before they will say you’re in menopause if they even decide to treat
2:56:44 or offer treatment you know or even begin the discussion because of our training you must thou shalt
2:56:52 go without one year so we’re absolutely sure that the ovaries have have moved on before we would even
2:56:58 consider but what is the point of that we’ve made estrogen our entire lives it’s a fabulous question
2:57:02 what is the point of starving our brains our hearts our bones our muscles they didn’t think they were
2:57:09 doing that i don’t think that people you know the medical community has recognized estrogens effects
2:57:16 outside of reproduction until very recently i think there’s been isolated pockets but there’s no no one owns
2:57:22 menopause like no one you think it would be ob-gyn but there’s no one in charge of women’s health
2:57:28 after reproduction ends like there’s there’s no czar so what’s the harm of waiting a year before people
2:57:34 take it seriously what happens suicide mental health changes rapidly decrying bone density i mean you can
2:57:41 be healthy without estrogen wants estrogen all vaginas need estrogen so your brain your bones your heart
2:57:47 your blood vessels your vagina your body has estrogen receptors everywhere that we’ve already
2:57:53 established and suddenly you’ve lost the ability to make your primary source of estrogen and what
2:57:59 happens is that you know medicine has a lot of definitions that we use that are very antiquated
2:58:04 even how we date pregnancies right when we talk about how far along you are in a pregnancy we date back to
2:58:11 the last period you had which meant two weeks of pregnancy are before you ever ovulated an egg before
2:58:18 you three weeks before you ever implanted an embryo yet we still use this pregnancy timeline based on when
2:58:25 your last period was even though we know two weeks of that you weren’t in fact pregnant at all now menopause
2:58:30 in my opinion is the exact same way we’re using an antiquated definition saying you have to prove to
2:58:35 me you’re an ovarian failure by lack of your period for 12 months because it represents a time period
2:58:40 where we didn’t fully understand what was happening in the ovary or didn’t have the ability to test and
2:58:46 know what we know now we are making women suffer to get that diagnosis if i believe i shouldn’t treat
2:58:53 you until you have menopause you have to prove that you’re in it i don’t think it’s where we’re going
2:58:58 i don’t think it’s what’s right for women and that being this low estrogen is hugely impactful at your
2:59:05 life at any age the female body needs estrogen to function normally i mean i’m looking at this chart
2:59:11 here about suicidation yeah suicide for the most likely time for a woman to commit suicide is between
2:59:22 the ages of 45 and 55 and is do you think that’s linked to 100% menopause right so we know that mental health
2:59:29 we have an increase in mental health disorders either pre-existing getting worse or new onset of
2:59:36 about 40 across the transition and we look at ssri prescriptions which are antidepressants they double
2:59:41 across the menopause transition now there’s a couple reasons for that one is we weren’t treating menopause
2:59:47 with hormones so they just ssris can actually help a hot flash certain types so you know paxil is one of
2:59:52 the ones that has been proven to decrease hot flashes some it’s not great but it works a little bit and
2:59:58 with all of the mental health changes a lot of women are ending up on these antidepressant medications
3:00:04 so we don’t want to go a year without estrogen so we know that some of the new data coming out when
3:00:10 i was researching for the new perimenopause there’s a really great window of using hormones to treat
3:00:18 mental health disorders and seeing improvement in mood and also some in cognition by giving estrogen or
3:00:24 estrogen plus the progestin early in perimenopause before the periods actually stop rather and it
3:00:29 actually works better than an ssri so say she’s on an on an ssri and has done well she’s had a long
3:00:35 history of depression suddenly she’s not controlled suddenly her symptoms are back and she’s on the same
3:00:42 medication rather than doubling or adding a second agent we really should be giving these women a
3:00:49 hormonal therapy now that doesn’t hold post menopause so this is really a perimenopausal
3:00:54 kind of window of opportunity in post menopause they aren’t responding as well and probably because
3:01:00 the estrogen labels have stabilized so when we give a woman back adapts yeah you’ll adapt so post menopause
3:01:08 the menopause that’s why the suicide rates kind of peak in this key perimenopause area and we think
3:01:15 and so in post menopause they that hormone levels stabilize so women tend to get better and so they
3:01:20 do respond better to the ssris for for new onset anxiety and depression in those patients and i want
3:01:27 to do a randomized control trial where we add some creatine oh that would be amazing 20 grams yeah well
3:01:34 no it’s 0.38 per kilogram yes so you’re saying if i’m a 45 year old woman and i’m i’ve still got my
3:01:40 menstrual cycle at that time before i’ve hit menopause i should be considering some type of
3:01:45 hormonal therapy so when we give someone menopausal dosed menopause hormone therapy in the form of
3:01:51 estradiol usually in a patch because you have that nice steady state it is enough to feed back to the
3:01:57 hyper to that brain to calm down but not enough to suppress ovulation so she’s often giving estrogen
3:02:02 support in very low doses and menopause hormone therapy is basically microdosing compared to what we do
3:02:08 naturally and so we’re giving enough to calm the brain down and stabilize what’s happening in the
3:02:14 brain without suppressing her natural ovulation giving enough what to raise you back to maybe what
3:02:20 that baseline would be giving enough estrogen estrogen yeah correct giving enough estrogen to raise the
3:02:25 baseline level so it’s not as low it’s not so high that it’s preventing ovulation but it’s going to
3:02:31 alleviate some of these drastic highs and lows that you’re having and it’s going to create a more stable
3:02:36 hormone environment it’s the delta that we were talking about post-presence exactly the delta chaos
3:02:48 the space is what bothers us not the high nor the low eventually so i have uh i run out of eggs and
3:02:58 then i’m by definition menopausal at this stage and my body adapts so there’s going to be a drop and then
3:03:03 there’s going to be a we’re specifically talking about mental health because you brought up the
3:03:09 suicide chart uh and so post menopause like once everything comes down and you’re fully menopausal
3:03:14 you’re out of the zone of chaos the hormones have just they’re slow your bones continue to deteriorate
3:03:19 a lot of other things are happening but our cognitive our mental our brain tends to calm down
3:03:22 and things get better in the brain when do i become post-menopausal instead of menopausal
3:03:28 menopausal oh menopause is a day right oh menopause is medically menopause is one day in your life
3:03:36 one day exactly after your but that’s the point of that what’s the point agree right because what if
3:03:41 what if it’s leap year do we go 366 days what if it’s what if you’ve had an iud what if you’ve had
3:03:46 all these things it’s like it’s really an antiquated definition and we really need to modernize so it’s
3:03:50 really you’re perimenopausal then you’re postmenopausal correct right okay and when i’m
3:03:57 postmenopausal forever forever your new biological state that’s right for now i’m sure someone’s
3:04:02 working on something to change something i do wonder that i do wonder if they’re going to figure
3:04:09 out a way to extend fertility i mean they’re trying they’re trying but then i think about it as if you’re
3:04:14 you’re a 60 year old woman would you still want to be worried about worried about that so what they’re
3:04:20 doing is looking at is there a way to extend let’s say ovarian function ovarian function with low level
3:04:25 baseline enough to keep you out of osteoporosis you know enough to slow that down yeah and heart
3:04:31 doesn’t protect your heart without pregnancy i’m now postmenopausal lots of things change my body
3:04:36 i’m guessing because i i no longer have the same levels of estrogen did the levels of estrogen ever go up
3:04:42 again naturally or do i then need to start outside of a tumor no i mean so do i need to consider
3:04:47 hormone replacement therapies and things like that you might and that’ll help me fend off what
3:04:54 the sleep issues the it’ll slow the rate of change okay but it doesn’t stop it you still have to put in
3:05:01 your lifestyle modifications to improve and or stop the sarcopenia and the bone density loss and all the
3:05:07 things that people associate with postmenopause and did any of you have menopause hormone therapy
3:05:14 yes yeah and what was the decision and what what impact does it have so i think what stacy just said
3:05:21 in framing where we’re going with this conversation is so now we’re perimenopausal it’s a new physiology
3:05:27 what used to work for all of our exercising if we even did because we know it at least in this country
3:05:35 that 60 to 80 percent of people aren’t intentional with their lifestyle so to frame this next part of
3:05:39 the conversation i’m sure we’re going to talk a lot about hormones and i’ll tell you my hormone decision
3:05:49 making but i think it’s important to all of us it’s only one of the building blocks to rebuilding a
3:05:54 great life right it’s interesting that the five steps of fertility that you went over are actually
3:06:04 exactly the same it’s it’s great protein and anti-inflammatory nutrition it’s a cardiovascular
3:06:12 fitness life it’s a lifting life it’s a stress detox whether it’s environmental or relational and
3:06:19 sleep sleep sleep sleep and then yes hormones are really uh a critical building block but as we enter
3:06:27 the conversation women are sentient beings and we get to decide and we get to make the changes because
3:06:34 we have agency so what we’re going to describe is not a one size fits all yeah it is all the tools on the
3:06:40 tools put the tools on the table so i choose if i’m going to work my proverbial rear end off to be the
3:06:47 best i can be for the rest of my life i choose to use all the tools not everybody does that but to
3:06:54 choose one tool and think that’s going to be enough it never is right so when i decided to and i’ve been
3:07:02 pretty public about my journey in this because you think i would have known after 22 years of formal
3:07:07 education and all this and being an aging a musculoskeletal aging researcher you would have
3:07:12 thought i would have known but i honestly looking back maybe thought i was never going to age because
3:07:22 i was so healthy right so i have a baby at 40 i breastfeed till almost 41 and a half 42 and then
3:07:27 i’m back at my very quickly five weeks my high power high capacity to career
3:07:35 but things were getting really different about 45 for me and i think i went right from
3:07:45 postpartum to perimenopause with very little downtime so chaotic hormones to almost and so
3:07:54 i suffered for a while at 47 uh i i talk about it like i i went from this really high capacity to
3:08:00 thinking i was going to die not only because of night sweats brain fog the thing that lots of women
3:08:07 have but i started having heart palpitations and i call my cardiology friend because i worked at a
3:08:12 university i’m like ricky ricky i think i’m dying so he did put me on a stress test and my heart was
3:08:20 perfect right at that point and then i had arthralgia which is total body pain it’s part of the inflammatory
3:08:26 response of not having estrogen it’s part of the musculoskeletal syndrome of menopause
3:08:35 assembly of symptoms so much that i go from training to almost not being able to get out of bed
3:08:43 and these my experience of not knowing what was coming and hitting a wall is not uncommon right
3:08:51 and so i started educating myself and being an acquired expert i read what i consider the world’s
3:09:00 data on safety of hormone optimization as i like to call it and i made the decision that i was going
3:09:04 to do all the tools i was going to learn to lift heavy again which i hadn’t done since high school
3:09:11 because i was a runner and i changed the way i do my cardio and i changed my diet and i am so committed
3:09:18 to sleep do not call me after 9 30 at night because i am going to be in bed and just the the quiet times
3:09:28 of de-stress but i also decided to augment or to optimize my hormones with estradiol with progesterone
3:09:35 because i have a uterus and after i felt comfortable with those with very small doses of testosterone
3:09:42 and that makes me feel like myself again not just one because i think sometimes people think that
3:09:49 you can just make a hormone decision and feel like yourself again it takes lifestyle plus or minus this
3:09:55 decision is there a stigma associated with that decision um taking hormones taking the hormones but
3:10:03 also i guess just more broadly with entering perimenopause yeah um i think there is there is
3:10:08 absolutely i mean you can just look at popular media you can look at their representation the memes go
3:10:12 right now and give me an image it’s decreasing because of you though like we have to acknowledge
3:10:17 you are decreasing the stigma true and you’re sitting at the table with us i say that i think because
3:10:22 there’s a woman in my life who was telling me about her decision to start taking menopause hormone
3:10:27 therapy and she described the moment with her husband when she was looking at the box and she
3:10:33 was staring at the box and staring at the box and staring at the box and mulling it and there’s
3:10:39 clearly something emotional going on there that this decision to take this marks something which is
3:10:47 interesting because no one really questions ocs exactly oral contraceptive birth control and i treat both men
3:10:53 and women and when a man comes into my clinic with low energy popping all the tendons all over his body
3:11:00 everything hurts we very quickly test his testosterone and send him with no judgment because he’s trying
3:11:08 to be virile and i think it goes with the general compensate conversation about aging women when men talk
3:11:16 about living longer it’s called longevity yeah and we celebrate that and we take pictures of movie stars in the
3:11:21 south of being very distinguished distinguished with their green temples when women when we talk about women
3:11:29 living longer until right now because we’re all screaming about it it’s under the guise of anti-aging
3:11:38 a superficial like oh my god don’t let her age so i think part of that is the stigma of menopause
3:11:44 somehow because we’re no longer able to have a child there’s not we’ve aged out we’ve aged out of
3:11:51 the game which hopefully we’re pivoting this narrative because as i said earlier women are
3:11:57 winning the longevity battle we already live longer but it’s how we’re living that we’re trying to course
3:12:03 correct yeah and it’s not just humans that go through this like i like using the whale analogy because whales go
3:12:09 through it and then the whales that are no longer reproductive become like the senior everyone all
3:12:15 the other little whales listen to them it’s like i want to be like a whale where you have this seniority
3:12:24 and and respect the wisdom yeah exactly i love this part of my life you love this part of your life yes
3:12:35 why i have never felt like i’ve been in exactly where i’m supposed to be in this moment i feel like
3:12:42 i’m helping more people i have better relationships i’m having better sex i’m having better you know
3:12:50 everything in my life pretty much is better and i i don’t know if like menopause and and life
3:12:57 circumstances have just given me permission to like cut out the crap and focus on what’s really
3:13:05 important and you know don’t sweat the small stuff you know it’s like like something kind of switches
3:13:11 in our brain no filters it’s amazing and i don’t think i could have done this 10 years ago i was too
3:13:15 worried about what people thought i was too worried about being a good girl and following the rules and
3:13:20 checking the boxes and never stepping outside of the guidelines but until i realized that i wasn’t
3:13:27 really serving the population that i trained for x amount of years to that you know and they were being
3:13:34 left behind is really what allowed me to like be where i am today i think most of us describe this as
3:13:42 the most authentic we’re actually who we were made to be and the confidence we feel comes from our memories
3:13:47 of success i think that’s where confidence comes from we remember everything that we have learned
3:13:55 to fix over time probably we could figure anything out and so that comes with experience and frankly it
3:14:03 comes with aging the price of aging or the price of having wisdom and experience is aging right and so
3:14:08 the reps and so you get to this place and you’re like i’m gonna figure this out
3:14:13 we’re gonna figure this out and i don’t want the younger generations to have to go through the stuff that
3:14:20 we’ve got so if i can share my experiences to help them navigate then that is a good thing yeah i’m in
3:14:27 perimenopause so i’m a slightly different stage and i know this because my cycles are shorter but they’re still
3:14:35 very regular used to be 28 29 days now they’re 25 26 i know that means i have less eggs coming out of
3:14:41 my vault every month and that’s why i’m ovulating sooner but i can feel all the hormonal shifts much
3:14:47 more profoundly than before now as a reproductive endocrinologist what we call a fertility doctor
3:14:53 most fertility doctors now do ivf day in and day out and there’s a lot of corporate reasons why that is
3:14:58 but we’re also trained in puberty premature ovarian failure and hormones so i’m more of a
3:15:05 cowboy and quite cavalier at giving estrogen i’ve been told these ladies last night oh because i see
3:15:11 it i see people who are low estrogen states and you know every single day how it impacts their life
3:15:18 so i am on low dose estrogen right now even though i’m still cycling i’m still making my own progesterone
3:15:24 so i don’t have to take a progesterone right now but it clearly makes a difference in my day-to-day
3:15:31 function and how i feel and most reis like i am will jokingly say like you’ll put me in the ground on
3:15:39 estrogen because it has such a profound impact on you’re able how you can function and specifically
3:15:46 if we’re not forcing you to go through this empty glass period for years and years and years of your
3:15:53 life there’s more opportunity on how you can slow down part of the process that we all know is going
3:15:58 to happen with aging but to live i think bondi was it you know healthier your health span how are you
3:16:05 going to live healthy longer not just live longer well and i think your approach that i think it’s part of
3:16:10 the decision making is critical because uh
3:16:16 35 to 45 and early perimenopause are prime times for prevention
3:16:21 yeah it’s to get our standards set you don’t have to lose your bone like you’re going to
3:16:26 but it’s hard for women to get care and we also have to acknowledge that if you go into
3:16:31 right if you what you’re recommending and i also do the same thing for my patients very hard for somebody to get care
3:16:38 this is not happening in 99 of doctors offices like there is no that’s four birth control pill or
3:16:43 nothing which is all they were taught given that even in menopause only four percent of women have
3:16:50 chosen or have been educated the pros and cons of hormone optimization and then to that’s without
3:16:56 that’s an empty jar person yeah so four percent steven is that how many women that have
3:17:02 or 2023 they did a study in the u.s i’m not sure in other countries and on fda approved so when we add
3:17:08 in compounding it’s maybe a little bit higher but when you look at fda prescriptions only four percent of
3:17:15 eligible women meaning no risk factors right age are are utilizing are going to get their prescriptions
3:17:21 filled evidently this is going to change right with the education that you guys we hope at least
3:17:26 they’re being offered it and having a discussion so that each they may choose not to do it and that’s
3:17:31 their right but side effects are there side effects worth noting i know a lot of people are quite scared
3:17:36 of taking certain hormones so there’s risks and then there’s side effects so when we look at the side
3:17:42 effect profile anytime we give a woman estrogen progesterone and we’ll have to like look at them
3:17:47 individually but estrogen you can have headaches you can have irregular bleeding about 50 percent of
3:17:52 patients and more on the patch than on oral there’s a patch and there’s oral vonda you take the patch
3:17:56 right i do and that’s on your stomach yeah it’s right here actually and how often do you have to
3:18:03 replace that twice a week okay fine yeah so so when we look at menopause hormone therapy we have
3:18:10 estrogen we have progestogens and then we have testosterone basically and there’s different ways to get it
3:18:15 into your body there’s oral and non-oral roughly so an oral it’s pill you take it in non-oral we’re
3:18:21 looking at through the skin or through the mucosa so mucosa could be under the tongue it could be in the
3:18:27 vagina so mucosa is like the gastrointestinal tract is lined with mucosa and it’s a nice way to absorb
3:18:34 and in the rectum to absorb medication we don’t have a rectal form of estrogen yet and so um so and then
3:18:39 there’s also injectables you can inject it straight into the muscle or subcutaneous tissues so most
3:18:44 commercially available like fda approved we’re looking at a ring for the mucosa we’re looking at
3:18:50 a patch for transdermal or we’re looking at pills for oral and what do you take yes so i am on a patch
3:18:57 um and i’ve just but i’m not a great absorber through my skin um and i couldn’t get my estradiol levels
3:19:03 high enough where studies are looking like the best bone protection is so i’ve added about a half
3:19:08 milligram of oral estradiol at night i’m on oral micronized progesterone which is probably the best
3:19:14 way to get it into our system and i tolerate progesterone very well and testosterone i am on a
3:19:20 gel that is fda approved we i’m borrowing the men’s version because we don’t have an fda approved version
3:19:26 in this country for women so i don’t think anywhere borrow my husband australia australia
3:19:32 and i think the uk just has approved one that’s as new some news like in the last month yeah
3:19:41 so okay so i’m okay so it’s it’s it’s broadly advisable after doctor’s consultation to take some
3:19:46 form of hormone therapy definitely if you’re symptomatic if you have the classic vasomotor
3:19:52 symptoms it’s absolutely the gold standard but can i comment on that women say to me all the time
3:20:02 either i don’t have i don’t feel that bad or they say i want to do this naturally and those are the
3:20:10 things that say okay fine do it naturally but brain fog night sweats in the vape and hot flashes are not
3:20:17 the only thing going on and so if you’re making this decision fully informed well you’re a sentient
3:20:24 being make the incision but you cannot feel your bones crumbling until they’re broken you cannot feel
3:20:31 that you cannot feel your muscle going away you cannot feel your brain starving you can’t detect
3:20:36 microvascular disease of your heart so you may think you’re getting away with something and maybe you
3:20:43 don’t have night sweats brain fog but it doesn’t mean you’re not having a different physiology and if you
3:20:49 are fully aware of that and make a decision that you don’t want to optimize your hormones that’s your
3:20:54 decision and i’m fine with that but what i’m not fine with is people thinking they’re getting away with
3:21:00 something when they’re not true i am making the decision based on fear and not facts correct my last
3:21:04 question is about love and sex and menopause you said you’re having the best sex of your life
3:21:09 mary and um i’ve also heard you talk about how several people in this season of life end up
3:21:19 getting divorces you said they throw the the trash out so when we talk about you know menopause can
3:21:26 spur you know for some women it’s it’s this moment of empowerment they realize they have to circle the
3:21:31 wagons because the only way they’re going to survive through this cataclysmic you know upheaval for
3:21:36 so many women is to get rid of relationships that aren’t working put up boundaries and sometimes
3:21:41 that’s going to be the end of a marriage other times it’s going to strengthen a relationship because
3:21:46 you’re you’re kind of cutting out things that were getting in the way of your so i see many marriages
3:21:52 or many relationships really improve through the transition but it does take two you know sex is
3:21:58 biopsychosocial so like when i look at sex it’s not i think of the entire experience you know and
3:22:06 one as far as my desire for the frequency testosterone does seem to have given that an uptick so
3:22:12 it is a proof you know we have lots of studies done on libido for women which is in medicine we say
3:22:18 hypoactive sexual desire disorder and it has to bother you so a lot of women are like i don’t want to have
3:22:22 sex ever again and i don’t care there’s nothing wrong with that right unless it affects your
3:22:26 relationship and it it has to bother you but i have a lot of patients who come in and say
3:22:33 i love him i used to want to do it we used to have a really great frequency and everybody was happy about
3:22:38 it it was something i look forward to enjoy it and now there’s nothing i have nothing and for those
3:22:45 patients testosterone can be helpful not for everyone right and so there’s other emerging data on
3:22:51 looking at the musculoskeletal system i am naturally thin i was not an athlete growing up at best i was
3:22:56 a dancer you know and i didn’t do anything to protect my muscles and bones as as i was coming
3:23:02 up through the ranks and so here i am in my 50s just getting out of endurance you know you know
3:23:07 recreational endurance training and thinking what have i done to my bones and muscles i laid on that
3:23:11 dexa scan as nervous as i’ve ever been in my life like getting my board scores nervous like what
3:23:19 have i done and and it wasn’t bad okay but i’m like but i like to be perfect so i’m like what can
3:23:24 i do to you know i’m doing that i’m eating the protein i’m lifting the weights i’m starting to do
3:23:29 all these things and we know that women who have naturally higher testosterone levels from genetics
3:23:34 or whatever have less frailty as they age because that’s my focus if i run the cancer gauntlet which
3:23:40 probably 80 of my aunts and uncles have died of cancer and so if i run that gauntlet and i’m doing
3:23:45 everything lifestyle and preventative screening to do that and then the women end up with dementia
3:23:51 and frailty like my mother and grandmother so i’m like okay i want to have as much bone and muscle
3:23:58 strength as i can so i’m going to add some testosterone and see what happens i i at the time would not have
3:24:02 said i had any sexual dysfunction i did not qualify medically for hsdd
3:24:09 i go on testosterone and there’s definitely an uptick in the area and everyone is happier
3:24:16 like my interest is improved my initiation has improved and that had kind of waned time and stress
3:24:19 and kids and whatever the other thing we were empty nesting at the same time so that probably
3:24:24 no more kids were busting in our door at two in the morning letting us know they’re home from you know
3:24:30 whatever experience you guys will go through this later but also our communication is better you know
3:24:36 my husband’s retired from chevron and we are building this this company together you know our menopause
3:24:41 company and so our relationship has actually improved through all of that so all of the things that feed
3:24:48 into what we know is female desire and has it’s just better all the way around and and i think testosterone
3:24:55 had a little bit to do with it my ability to like focus and my ability to prioritize and put up the right
3:25:01 boundaries has really helped with that and we’re just having a lot more fun with it but i think that
3:25:06 we would be remiss in this part of the conversation and i’ll say it i’m the orthpod but i’m going to say it
3:25:14 anyway many men i just talked to my husband publicly about this because we’re trying to educate men is that
3:25:21 most men don’t realize that in perimenopause as estrogen wanes it affects all tissues and there is an entity
3:25:28 called the genitourinary syndrome of menopause where the vagina will actually atrophy and all the external
3:25:37 soft tissues that are usually used to engorging will become dry like a desert and steven sex can feel
3:25:44 like razor blades and men don’t know that and women are afraid to tell their partners so the men feel
3:25:51 are rejected like why doesn’t she love me or desire me anymore and it may be that but it’s probably not
3:25:59 that it’s it hurts and i bleed and women don’t know that this is normal when your estrogen is not that
3:26:04 it’s okay to shouldn’t be it shouldn’t be normal but when you’re in a low estrogen state regard
3:26:11 menopause birth control pills can do it postpartum breastfeeding even you know progesterone iud
3:26:18 these can all cause time periods where your estrogen levels are low enough that the vaginal
3:26:22 tissue is not having the right collagen and elasticity that it should so what’s the solution
3:26:30 estrogen not lubricant lubricant can sometimes aid but that’s not a root cause right it’ll help
3:26:37 with i recommend with symptoms right but if you’re part of the problem is that the tissue can’t respond
3:26:42 as it should that it’s frail that the orgasm then we really want to get to the root cause which is
3:26:49 estrogen is crucial for skin elasticity it’s like men going on testosterone right if he’s not having
3:26:56 an erection there are 29 solutions for that right now right but primarily funded solutions well solutions
3:27:05 but for women it’s not just desire it’s physiologic and so vaginal estrogen putting something putting in
3:27:09 your vagina and what you put in your vagina so there’s there’s several options we have creams
3:27:14 we have pills there’s a ring specifically designed just for that so we have different methods of
3:27:20 getting the you know estrogen into the vagina there’s also um uh something called prostorone which
3:27:27 is dhea basically which is a pre-hormone that the vagina miraculously will convert to estrogen and
3:27:33 testosterone so but it’s expensive it tends to not be covered by insurance but for our like our sex med
3:27:39 friends sexual medicine friends who specialize in this female sexual function they love it because
3:27:44 you’re not only getting a boost of estrogen to the vagina you’re also getting testosterone and there
3:27:50 are testosterone you know receptors in the vulva you know in the lower vagina and around the skin around
3:28:00 the vagina as well but here’s the bonus all of this plus vaginal estrogen will help prevent chronic utis
3:28:10 which kill old ladies and it will help support the pelvic floor and the uh uterus from prolapsing and so it
3:28:18 has all these added benefits and here’s another bonus it is such low dose it is not systemic so any risk
3:28:25 that you could think of that you might not want to do systemic estrogen including breast cancer is
3:28:31 unaffected by vaginal estrogen and so it is a huge solution and there’s no age that a woman can’t go on
3:28:37 it she’ll kill me she’ll never know this but i put my 86 year old mother on it so that we could prevent
3:28:47 utis and failure of tissue so she didn’t get sores and infections right isn’t that a miracle i know
3:28:52 steven’s like yeah and we should say the vaginal estrogen in preparations made for vaginal estrogen
3:28:58 there are low dose estrogen preparations you can give oral estradiol vaginally and it will be
3:29:02 systemically absorbed right because the vagina is highly absorptive so i don’t want somebody to hear
3:29:09 this and think that but just saying we often prescribe or recommend local treatment of vaginal
3:29:15 estrogen products which are in very low dose and they really impact the local tissues of we’ll say the
3:29:21 pelvic floor the urinary system the vulva the vagina and they improve your well-being and your health
3:29:26 without some of the risks that might come from systemic hormones and somebody who may not want to
3:29:32 take them i am all out of questions so i wanted to conclude this segment just by asking you what the
3:29:38 most important thing that i have missed on the subjects we’ve talked about menstrual cycles menopause
3:29:42 what is the most important subject you think we might have missed
3:29:51 i think we covered it but but to say that you control a large part we said over and over
3:29:58 inflammation and insulin resistance we we touched on different lifestyle factors that impact this because
3:30:05 when your body’s having hormone change there’s a lot of the external world around you or the choices you’re making
3:30:10 that can make some of that better or worse or influence what is happening yeah and i know we’re
3:30:15 going to go over more of this but i think this idea that i have no control over what’s happening to me
3:30:19 isn’t a hundred percent true i mean you don’t have control over when some of this stuff happens
3:30:25 but you can take control of a situation by understanding your body knowing what’s happening
3:30:32 knowing how to advocate for yourself and making active decisions to live a healthier better life
3:30:38 yes that’s the goal is to empower women to understand to ask the questions so they don’t feel
3:30:44 like something is happening to them and they don’t have control or options which is what our mother’s
3:30:50 generation had they were always gaslit told you know it’s all in your head there’s nothing we can do
3:31:00 so my mother was put on butalbatol it was called butasol um it’s basically a sedative and it was mother’s
3:31:07 little helper and i found an old magazine article where they if you look at the magazine articles from
3:31:14 the 50s and 60s on these medications mostly sedatives that were given to women it’s like now she can do the
3:31:21 laundry again now she’s flipping a pancake in the ad in the apron in the 1950s you know like get your mom
3:31:29 back get your wife back and it was a combination of estrogen plus a sedative and i was just absolutely
3:31:39 floored and i remember mom’s little bottle and it was called butasol and i it would sit on her counter
3:31:43 and she would talk about it like it was her talisman like it was her and i always thought of
3:31:48 it as mommy’s little helper you know like oh i need my butasol oh this happened where’s my butasol
3:31:54 where’s my butasol and when i was researching and writing and reading about these sedatives that were
3:31:59 given to women i was like wait mama i remember the bottle i remember what it was called because she
3:32:02 talked about it all the time i went and looked it up and it’s a derivative of phenobarbital
3:32:09 and it was heavily prescribed to women so barbiturate it’s a a drug it’s a class of drug that is
3:32:15 basically a sedative we use it in surgery we use it for seizures and they were sedating my mother
3:32:22 on the daily yep through her perimenopause now she had eight kids she was running a restaurant you know
3:32:28 she was very high functioning and i just refused for that to be that was her reality yeah and here she
3:32:35 lies in a bed with alzheimer’s and a fractured hip and she hasn’t walked in eight months you know she’s
3:32:41 she’s just now getting on a walker eight months after her hip fracture and from osteoporosis who’s
3:32:46 never had a bone density scan in her life and like our children deserve better it’s not going to be my
3:32:52 future because i have the you know i have the means i have access but like i i want every young girl
3:32:59 all of our children to have a better future than what was offered to our mothers exactly i think
3:33:08 ending this i would want every woman to approach her midlife life her new life with the same vigor
3:33:14 and the same curiosity and the same demanding of care that she would do for one of her children
3:33:19 if her child is sick she’s not going to take no she’s not going to take being blown off
3:33:23 she’s going to keep searching till the end of the earth until she finds an answer
3:33:29 and that’s what that is the same kind of taking control that i want women to do about this time
3:33:36 in their lives thank you so much we’re gonna record we’re gonna continue this conversation for the
3:33:40 viewers that are listening at home um i’ve been through all of these wonderful books that i have
3:33:46 in front of me and there’s so many lifestyle nutrition exercise related solutions to many of the
3:33:52 things we’ve talked about today to be in truly optimized um hormone healthy menstrual cycle
3:33:56 healthy woman which i want to talk about in our part two of this conversation
3:34:26 Thank you.