The science of menopause in 13 minutes

Most animals die after they finish reproducing

Animals that keep on living after reproduction are quite uncommon. So humans are the big one, orcas are another one

and there may be a few other species as well, but it's not as well studied

If everything about reproduction is really evolution, getting the next generation and the next generation

How does menopause, something where reproduction is no longer possible, how is that beneficial

It turns out we think it's because of something called the grandmother or the wise woman hypothesis

The idea is that historically for humans, having a grandmother associated with a family unit meant you had an extra pair of knowledgeable hands that themselves weren't occupied with child rearing

So you had someone who could go out and help gather food, building shelter, finding water

passing on historical knowledge from other generations. And so menopause represents evolution the long game

It's the idea that we retain our power as we age. Now, just like there are hormonal changes that lead up to the first period

there are hormonal changes that lead up to the last period. And that time is known as the menopause transition

But you may have also heard it as perimenopause or premenopause. The menopause transition is anywhere between four to seven years

maybe even a little bit longer. And it is this winding down of reproductive hormones

Over time, menstruation starts to space out. People might go more and more time in between

and eventually they'll start skipping periods. And when people are skipping periods

we generally believe they're probably about one to three years from their final period

Medically, we use the word menopause to describe the day of the final period

but you never really know it's the day until afterwards. And we say everything after that final period is post-menopause

We say menopause has occurred when you are a year from your last period

So the typical age is between the ages of 45 and 55. If your final period happens between ages 40

and before 45, then we call that premature menopause. And if your periods stop before age 40

we call that primary ovarian insufficiency. Now people can also have surgical menopause. You can

have your ovaries removed and then that puts you into menopause. Menopause is associated with a

large constellation of symptoms. And because this has been historically really understudied

I don't think we have a full handle on how many symptoms are common and in what percentage of

people would be expected to experience all of them. But the ones that we know a lot about

are hot flashes and night sweats which are known as vasomotor symptoms Another common one is vaginal dryness or pain with sex brain fog palpitations mood changes and joint pain Those are some of the more common ones that we hear about but of course the list

is quite long. The hormonal chaos time that leads up to menopause has an average duration of about

four to seven years. However, symptoms don't always correlate with that. So some people have

their worst symptoms earlier on, and some people have their worst symptoms towards the end of the

menopause transition, and some around the time of their final period or even afterwards

It's really important for people to understand that while we do have medications for many symptoms

medications can only do so much. However, one of the most important things is having a good

health foundation going in. And that is exercise. And I don't like that answer any more than anybody

else, but we can't deny the impact of exercise on all of the domains that menopause touches

And if you want the one thing, if exercise were a drug, that would be the thing we'd be giving to

everybody to keep that in mind. And it's not just aerobic exercise, but strength building

So that would be the most important foundation for treating menopause. we do have other treatments as well and one of the treatments that people have heard a lot about

is menopausal hormone therapy or mht we used to call it hormone replacement therapy and we do not

use that term anymore because we are not replacing estrogen that you should have we expect menopause

to happen we expect estrogen levels to change but we also don't expect people to suffer and so it's

a therapy. Also, menopausal hormone therapy is the gold standard treatment for hot flashes and

night sweats, vasomotor symptoms. But when people are suffering with changes in their vagina

then we use vaginal estrogen. So the big question is, should I take it

Like any medication, do you need it? That's what you should be asking yourself. Because while

menopausal hormone therapy can help many parts of menopause, there's also parts that it can't help

right? So you only want to take a medication for what it can do. There is no broad agreement that

every person should be on menopausal hormone therapy. So I often think about menopausal hormone

therapy as things that are really evidence-based, and those would be the green light indications

So that would be hot flashes and night sweats or prevention of osteoporosis for people who are at

high risk. There are also what I would consider yellow light reasons, meaning it might help some

people, it might not, and that takes a much more individual discussion in the office. A good example

would be depression in the menopause transition. There are some studies that show that estrogen

can help with that. Interestingly, it doesn't help after menopause. So if someone were two years

after their final period and said they wanted to start estrogen for depression, that wouldn't

be an evidence-based recommendation. But if they were having irregular cycles, then that

would be Other yellow light indications might be joint pain The studies aren great but it might help some people And there is some data that shows it may reduce the incidence of type 2 diabetes

But there isn't a global recommendation to give menopausal hormone therapy for prevention

It also doesn't work for weight gain in menopause. And we do not recommend starting menopausal hormone therapy for prevention of dementia or Alzheimer's disease or cardiovascular disease

There may be some benefits for starting it early, but it hasn't reached the threshold where it's a universal recommendation

We also don't recommend it for brain fog. There are quite a few studies that show that it doesn't have any short-term impact on brain functioning

And one caveat to that might be if you're someone who's sleeping very poorly because of hot flashes

One symptom that isn't discussed enough in the menopause transition are menstrual irregularities

People obviously can have skipped periods, but people can also have heavier periods

For many people, hormones are a part of controlling bleeding problems. And one way we often do that is with the estrogen-containing birth control pill

It is good at controlling heavy bleeding, and people also get the benefit of estrogen and contraception

But there are other options too. We can use a hormonal IUD, and then if people want to start menopausal hormone therapy, they certainly can

So whether or not you should start it would really depend on, do you have something that

it can help? And if it is a safe therapy for you, then it may well be worth trying

And like any therapy, if you start it and you're not seeing the benefit that you want

to get, then it should be reassessed. When we're talking about menopausal hormone therapy, we're talking about pharmaceutical

preparations, meaning a pill, a patch, a transdermal lotion, or a gel. And it is very

important that products be pharmaceutical because making hormones into something that's absorbed

reliably either from the gut or across the skin is actually quite challenging. It takes years of

research to do this. So we know that they contain what they claim. When you get a compounded product

you have none of that research and development. And so there can be issues with absorption

There can be issues with dose. Also, compounded products don't contain the same warning labels

that pharmaceutical products do, which gives them the illusion of safety. Because when people see

a warning label, they get concerned. And if they don't see it, they think, well, they don't need to

be concerned, but it's just that the rules in the United States don't require that warning label to

be on it. And I would include pellets that are injected as part of compounded hormones

Pellets often deliver very high doses of estrogen or testosterone or both, depending on the pellet

They're also not batch tested and they are associated with a lot of adverse events

And the big problem with these adverse events often don't get reported. Now, one question I get

well, but I want to take bioidenticals. Bioidentical is a marketing term that has essentially no medical meaning

The belief is that it a hormone that is identical to what your ovaries make But being the same as what your ovaries make doesn make a hormone safe What makes something safe is if it has been tested and studied and we know that it is safe

But here's the kicker, is that almost every pharmaceutical hormone that I would prescribe for you

could be considered bioidentical because it's all estradiol. It's all made generally from soybeans

and it all comes from generally the same plant. I mean, plant as in factory

not as in plant that's grown. And testosterone is not part of menopausal hormone therapy

We don't recommend adding it in for fatigue. We don't recommend adding it in for brain fog. We

don't recommend adding it in for hot flashes. The only indication for it is in people who are

suffering from libido or desire problems who have a relationship that's not the cause of those

desire-related issues. So how do you sort the snake oil from science online? Because there is a

lot of medical content out there. I have a few good rules of thumb. In general, if something sounds

too good to be true, it probably is. There is no influencer or doctor who has discovered a secret

that no one else knows about. If the information's out there, we all know about it. Number two

Be very mindful about what you read online because you need to fact check immediately

Many people actually end up with incorrect information because people who sell snake

oil are really good at search engine optimization. So how do you fact check

How do you do that? What I recommend people do is take the subject matter, put it into your Google search and

add ACOG, American College of Obstetrics and Gynecology or Menopause Society. the CDC, you could put the WHO, put your question and then put that in afterwards. And what that

will do is it will force the algorithm to bring content from those societies up to the top

Number three, be mindful about who you're seeing. So is this person truly an expert

Are they a physician who is board certified in that area? Or are they someone who has less

expertise, for example, a naturopath or a chiropractor. Does the person sell supplements

Okay. Supplements are untested, unregulated pharmaceuticals. If I sold a birth control pill

if I had Dr. Jen Gunter's birth control pill, you would probably rightly think that my information

about contraception might be suspect. When you have somebody who makes money advertising supplements

or even has their own brand of supplements, you should really consider all of their medical

information as contaminated, because how do you know it's not a subtle cell to promote their

supplements? I would be very mindful about getting health advice or health recommendations from

celebrities. While it's great that people want to raise awareness, often the way they talk about

different medical conditions or physiologic states like menopause isn't always evidence-based. Want to dive deeper

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