Hormone & Fertility Experts: We've Been Lied To About Women's Health! If This Happens, Call A Doctor

If someone's menstrual cycle is

irregular, should they be concerned?

Yes.

Yes. Yes. Yes. Your body is meant to

work like clockwork.

And our monthly cycle is so much more

than getting ready to have a baby,

especially when we're looking at

exercise. And it's important to say if

you don't have a period, it's very

harmful to long-term health, brain

health, mental health, low energy, mood,

and libido. And I don't want the younger

generations to have to go through the

stuff that we've gone through. So, it's

an important discussion that we need to

have. We are joined by four leading

female health experts from very

different fields

to have a crucial conversation about

women's health. With over 80 years

combined experience, they're sharing the

truth about what every woman and every

man needs to hear.

We asked a thousand women to submit

their questions ahead of this

conversation. And I got so many

questions around fertility,

understanding hormones, PCOS, birth

control pill, miscarriage.

And I'll say this, Stephen, it's because

we haven't had these discussions

publicly. When we look at funding in

women's health, it's horrible. like less

than 1% is spent on women over 40.

Women are living 20% more of our lives

with chronic disease or mental health

disorders. I mean 50% of patients with

unexplained infertility have

indometriosis. But yet it takes women 7

to 10 years to get a diagnosis after

symptoms start. But also there are

things that we do that will inherently

harm our fertility because we're not

taught this and it predisposes you to

many medical problems later in life.

And patients will say but I have a

really high pain tolerance like it's a

badge. And so they gaslight themselves.

And that's what we're all trying to

fight here. But there are a lot of

things we can do to deal with this.

And then I want to talk about menopause.

So in medical school, menopause just

gets shoved into 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 create change.

This might be one of the most important

conversations we ever have on the diio

because women's health has long been a

total mystery to so many people and so

many people are struggling with all of

the issues that we're going to talk

about today with their menstrual cycles,

PCOS, endometriosis, with diet, with

understanding how to exercise as a

woman. It's probably never going to be

the case again that these four

individuals that at the very top of

women's health in their fields will be

in the same place at the same time

having this conversation. We structured

this conversation into two parts. They

cover completely different subjects, but

they're fundamentally interlin. For me,

the understanding that I got from this

conversation at this table with these

four women has fundamentally changed my

life. It's going to change how I deal

with my romantic partner, my sister, my

team members that I work with every

single day. And funnily enough, because

it's a conversation I wouldn't have

clicked as a man, it turned out to be

the conversation that I needed the most.

And I don't think I've ever said this

before, but if there was ever an episode

to share with a loved one, then this is

that episode. Please share this episode

with as many women as you can, but also

with as many men as you can.

[Music]

Ladies, we should start with some

introductions. Could you give me a brief

introduction, Stacy, as it relates to

your perspective and your experience and

what your sort of bias is as it comes to

this debate? When I say bias, I mean

your your your experience and your your

research that you're lending to this

conversation today.

I come from the exercise fizz and sports

med background. Um, so I'm always

looking through the lens of activity and

nutrition and how that has a impact on

our stress and our stress outcomes and

how we can adapt to specific applied

stressors especially when we're looking

at improving health span, improving

mood, improving body composition, all of

those things. I've worked with and still

work with uh the subset of active women.

Um, I come from an endurance and a

high-profile high performance sport

background. So, that's where I've gotten

my chops and then brought it over into

the general recreational female athlete

kind of perspective. Natalie,

I'm a fertility doctor and every day I

help patients with IVF get pregnant

because I have an IVF clinic. But my big

passion has always been natural

fertility after I experienced my own

pregnancy losses. trying to understand

how we interact with the world and how

that changes our hormones and help women

understand what their hormones are, what

natural fertility is, what happens as we

age to our bodies, our eggs and our

hormones, and let them be better

stewards of their own fertility and

their own health decisions.

Mary,

I have a background in general OBGYn, so

I'm considered to be a women's health

specialist. And it wasn't until I kind

of went through my own menopause that I

realized that there was significant gap

in my training. You know, hearing

watching Dr. Sims on um I think your

podcast talking about how women are not

little men really struck such a chord

with me and made me realize I was

siloing women's health to the

reproductive organs, the breast, the

uterus, the ovaries, the vagina and that

if I really wanted to make a difference

in a woman's whole health life, this

last 30 years, 30, 40 years of her life,

I needed to refocus

what we were thinking about women's

health for the long term. So I come from

a background in academics. I was a

professor for 20 years. I was a

residency program director. Stepped away

from that so I could focus on the lack

of my own education and knowledge in

menopause care. And now I want to step

back into the academic world to bring

everything I've learned and change the

way we educate our providers. Vonda

I am a orthopedic sports surgeon by

training and I sit at the unique

juxtaposition of orthopedics and

performance having taken care of elite

athletes most of my life aging and

longevity most of my academic research I

too as an academic is on subjects of

muscularkeeletal aging but many years

ago added a third circle of the whole

health of a woman and so sitting in this

place it fits directly into the mantra

of my career which has always been I am

going to change the way we age in this

country and the world because the tool

that I bring to the table is the fact

that if I save your mobility I'm going

to save you from the ravages of chronic

disease and so the work that I do is not

only educational it's uh research and

it's now education of the world about

these subjects

explain this to me like I'm an idiot

ladies why do we need to have a

conversation about women's health and

not just health broadly.

I think the statistic that people don't

realize on a day-to-day basis is that

women are 51% of the population. We're

actually not a minority. We're the

majority and yet often our health, our

healthc care access, the research treats

us as if we're a niche product,

but we are the majority product.

We have to have this conversation

because data show that

of the $450 billion dollars spent on

research in this country alone, less

than 1% is spent on women over 40.

And yet we are nearly 90 million people.

And we make 80% of all the health care

decisions in this country for ourselves

and everyone we touch. And so even

though when you look at the the

long-term data, women are winning the

longevity race here. We're living an

average of 6 years longer than men. But

as all of us talk about all the time,

women suffer longer.

Yeah.

We're living 20% more of our lives

versus our male counterparts in poor

health with chronic disease or mental

health disorders. And so McKenzie looked

at the data and it was for the Gates

Foundation and what they found was yes,

we live longer. We've all known that.

However, we have, you know, twice as

high of mental health disorders. We're

two times as more likely to end up in a

nursing home. We are much more likely to

lose our long-term independence from

frailty or dementia, much more than our

age matched male counterparts. And

that's I think what we're all trying to

fight here. And diseases that impact

women specifically and only things like

PCOS, endometriosis are extensively

underfunded and not researched. It takes

women 7 to 10 years to get a diagnosis

of endometriosis after symptoms start.

And we know this is a disease that

impacts your entire body in addition to

your fertility. But women are dismissed.

They're not taken seriously. and there's

not research guiding what we can do in a

lot of these situations to try to help

them the best.

Why isn't the research there? Why why

don't they research if women are the

majority of the population? Why is all

the funding going to researching men?

You have to think about who was in the

room when medicine and science first

started. So if you think about back when

the industrial revolution and the

modernization of what we know is

medicine, women were pushed out because

they were believed to have smaller

brains. thanks to Darwin and not thought

to have a seat at the table. So when

you're thinking about designing studies,

it was pretty much designed on the male

physiology on the male body and then

women were an afterthought. So there

wasn't any real in-depth look of well

women are different from birth or in

utero XX is different from XY. So all

the research has just been generalized

to women. Even things like aspirin for

heart attacks and thinning blood

inhibitors. Yeah, all of this all of

this was done on men and then just

generalized to women and now that we're

having this global conversation on

women's health, people are like, well,

where is the information specific for

women? And there's just a very small

subset. So, we're looking and trying to

expand that, but we have a lot of

catching up to do. And that's primarily

not only because of what you said, but

the shocking statistic is that not until

1993

were women required to be represented in

studies. 1993,

I mean, we were all far into our our

lives in research by then.

Isn't that a shocking?

That's crazy.

And there were still loopholes where

people were finding ways to exclude

women and then

right, we're still not at 50%. No,

we're harder to study. You have

menstrual cycle, hormonal fluctuations,

even menopause, pre even the animal

models.

It's not that we're harder to study. It

just makes it presumed harder to study.

There's more variables at play,

right? It's more of a complexity to the

research, 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 table

when all the study designs were started,

it wouldn't be a question. It would just

have been assimilated in. because we've

been so drawn into we have a crossover,

here's one week crossover, next week

because of male physiology. When you add

women's hormone fluctuations and people

like, "Oh, it's too complex."

Right? But it's not.

What is it that makes, and this is a

super dumb question, but an important

one. What is it that makes men and women

different from a physiological

standpoint? Because to understand why

research would need to be done

separately, we need to understand the

differences.

Yeah. Well, I mean, we can look from a

morphological standpoint where men have

more of our fast twitch fibers. Women

are born with more endurance fibers,

which is muscle, right?

Uh when we're talking about muscle.

Yeah. So, uh men have more of the

ability to do power and and really fast

energetic type activities or women are

more attuned to endurance type

activities. And this affects metabolism.

It affects blood glucose homeostasis.

And when we're looking at bone and bone

density, men have stronger bones. Uh

they can acquire more load. They hold on

to it better than women do. We see

smaller lungs, smaller heart, less

hemoglobin in women than men. And that's

an offshoot of what testosterone does.

So there are just basic physiological

differences between XX and XY that

people don't really assimilate and

understand. And the way I like 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 points on the external

that really identify gender andor sex.

But when you look intrinsically no one

is identifying those touch points until

now. Also when we look at how we disease

so in cardiovascular disease is is

aththeroscerotic disease is the best

example. Men tend to have their

blockages. So aththeroscerotic disease

is basically the plaques that build up

in the coronary arteries around the

heart. Men tend to develop their plaques

very early right as those arteries exit

the aorta and dive into the heart

muscle. So we get what we call the

widowmaker. Okay? It's called that for a

reason because men die and they make a

widow. And so that's the left anterior

descending artery. Women by and large

tend to not have these larger artery

blockages, but their blockages are

diffuse and microvascular deeper into

the heart muscle, which is why we

present with a heart attack much

differently than a man does. And those

we're not teaching our, you know, we're

not educating our clinicians as to these

differences. Women are considered to

have atypical chest pain. Dr. Wright,

51% of the population is female. Why are

why is my heart attack atypical

and a man's typical? But this happens

not only at the organ level. It makes

sense that if we have a population with

XX chromosomes, a population with XY

genetically and the way we express those

genes are differently. But I think we

miss the fact that down to a cellular

level, every cell from an XX is

expresses these tissue changes, tissue

manifestations differently than an XY.

Our lab used to study, we called them

muscle derived stem cells so 20 years

ago. Now they're called satellite cells.

But when we harvested them and asked

them to behave and in different

environments,

satellite cells from XX people and XX

animals, women, females were better

under the same circumstances

experimentally

at making cartilage and muscle. XY male

were better under the same circumstances

in making bone. So down to a cellular

level, we express our genes differently.

It should be no mystery to us or anybody

else that there are differences. And yet

there is the propensity just to lump us

all in the same basket and almost say I

almost sometimes feel as pjorative to

say, oh the women are different. Of

course they're different. Yeah,

we're genetically different

down to every cell in our body.

Every cell. So, it should be no surprise

to anybody, but it it seems to be a

surprise.

Seems to be a surprise all the time.

Yeah. I get pushed back all the time.

There's no difference. Yes, there is.

There is. And it's not just bad. It's

just is.

Yeah. There's Yeah.

Because at one point that was quite a

controversial thing to say, wasn't it?

To point at the differences between men

and women.

Mhm. Outside of, you know, our different

organs. Yeah. You know.

Yeah. And because of this research gap

and the bias in medicine, um, women have

been misunderstood by their male

counterparts in a number of ways. I

remember I think it was you, Mary, that

was telling me about this whiny women

thing that you were exposed to.

When I was in training and and you all

may have similar stories and I just

heard a new one the other day, my first

patient in gynecology clinic, 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 charts. I pick up

the chart, open it up. It's a

40-year-old woman with multiple vague

complaints. She's gained some weight.

She's a little bit depressed. Her libido

is off. Her blood pressure is a little

bit up. Her cholesterol is starting to

rise. And she's seen family medicine.

Like we're the third or fourth doctor at

this point. And so my upper level who

happened to be male this, you know, it

could have been anyone. Walks down the

hall in his cowboy boots cuz Texas. And

um and he's like, "What you got?" And I

said, "Well, I have Miss Smith,

whomever, you know, she's a 40-year-old

woman with." And I list the complaints.

And he goes, "Did you check her thyroid?

Family medicine did. Did you check this,

you know, a few simple labs?" And he

goes "Hm

you got a WW."

And I said, "What's I don't know this,

you know." And he said, "Uh, don't write

this in the chart, but we call that a

whiny woman around here."

Oh my gosh.

And I said, "Okay." He said, "Listen,

women just tend to go through this at

this age, and we're not really going to

be able to help her. pat her on the

knee, tell her to have some wine, go on

date night, you know, she'll get better,

but 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 what I

was told. You know, it took me 20 years

of internalization to realize this, you

know, I don't 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 the ER. I saw this in the O. I

saw this in every clinic. And so I've

asked other clinicians around the

country and I've heard whiny gyne status

Hispanicus total TBD total body delore

like in different regional areas there

was a name for this kind of vague

complaints from this middle-aged woman

and we couldn't quite put our finger on

it and I realized this was systemic bias

built into the system where women and

there's historical you know precedent

for this the wandering uterus the

hysteria you know these were real

medical terms just until like not even a

generation ago.

Yeah. They used to put women into

asylums.

Yeah.

Because of hysteria and it was hot

flashes, all the things that that are

now known with permenopause. They used

to think it was some kind of insanity

and put women into insane asylums to

lock them down.

But this is pervasive. Not just an OB.

You're not the only guilty. It's every

medical subsp specialty has some

culture

of for lack of better words blowing

women off it right. We're not having the

curiosity that defines medicine. We are

supposed to be curious people. But yet

when it comes to this, why do we stop at

just seems to be something that happens

to middle-aged women, right? it that

that's written in the orthopedic

literature seems to happen to

middle-aged. Where's the curiosity?

Where was it?

Yeah. Well, in X-fist text, you always

had the representative of him or they

and the vuvius man and all the angles of

the male body, but there was never

representation of women. The only time

you heard about a female athlete was all

the pathophysiology. You know, the iron

deficiency, the female athlete triad,

which we now call um relative energy

deficiency in sport.

And when you're looking at the

historical idea of sport, the only way

women were actually included and

accepted is when they were amenic

because then they were quote more like

men and then there wasn't a problem with

training them and then they could work

as hard. But we know that that's not

appropriate. That's a sign of of illness

and overtraining under recovery. So, it

is pervasive everywhere. It's not just

the medical, but it goes into when you

think about what it means to be

successful in sport. It's the power.

It's the aggression. It's the

unfallibility of being human. And a

woman having a menstrual cycle was

deemed a fallibility. So, they're trying

to push it aside. This is so systemic

though that women downplay their own

complaints. They gaslight themselves. It

takes them a long time to seek care

because they're afraid of the response.

They are not always honest with what's

going on in their body. I'll say, "Do

you have pain?" "Oh, no more than

regular." They downplay everything. You

have to really ask. And it's almost the

society, I don't want to be viewed as

this way. I don't want to be not taken

seriously. And it causes them an to have

an even harder time to get to a

diagnosis because they don't feel

comfortable sharing some of these

symptoms or they've downplayed them in

their life so much. This is why they

have to get so sick to often present to

even try to get care. And they come to

me almost to a woman after I'm talking

about whatever muscularkeeletal thing

they'll say even before they want to

describe it to me. They'll say, "But you

know, I have a really high pain

tolerance." Yes. Mhm.

Like it's a badge because we've been

conditioned to not come for any pain.

But I've suffered. I've tried. That's

why your arm doesn't move anymore. I've

got such a high pain tolerance, but I

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 train treating both males and

females. I I was locked in a room with

women for 25 years, you know, and so

it's so fascinating to me to hear how

men and women come in with the same

complaint in your clinic, in your

fellowship, all those years you spent

training, and yet you were taught to

treat them differently, you know, and

the urologists say the same thing, you

know who

I don't think I was aware of it.

Yeah.

There was just that's

so much bias. Yeah.

I didn't realize. I didn't either

because like you, until I went through

my own pmenopause,

I might not have paid it attention to

it.

Yeah,

I may have been less sensitive.

I was a terrible menopause.

I see messages all the time in the

comments section that some of you didn't

realize you didn't subscribe. So, if you

could do me a favor and double check if

you're a subscriber to this channel,

that would be tremendously appreciated.

It's the simple, it's the free thing

that anybody that watches this show

frequently can do to help us here to

keep everything going in this show in

the trajectory it's on. So, please do

double check if you've subscribed and uh

thank you so much because it's strange

where you are you're part of our history

and you're on this journey with us and I

appreciate you for that. So, yeah, thank

you. Is that in part because we know

very little about hormones as well. When

I was speaking to our audience, we asked

a thousand women to submit their

questions ahead of this conversation.

And one of the most asked questions, all

the most asked questions sort of related

to understanding hormones. I think the

conversation around hormones is quite a

new one in society and I actually think

it's been driven a lot by a heightened

understanding of menopause generally. I

think the the conversation of hormones

around outside of fertility and the

general menstrual cycle. I can right now

draw from memory the exactly what's

going to happen in a normal menstrual

cycle. We were taught that, you know,

very very well. But when I saw maybe 3

years ago an academic paper that showed

all of the locations of the G-coupled

estrogen receptors in the human body,

what's that?

I lost my mind. So basically, where are

the estrogen receptors in the human

body? And they're everywhere. The brain,

the bones, the muscle, the gut, you

know, the the every almost nothing. The

the the endothelial, the lining of the

individual blood vessels around our

heart, you know, it's really radical to

me to think about how all these sex

hormones are the progesterone, estrogen,

testosterone, hormones are everywhere.

What is a hormone?

They're not actually sex hormones.

hormones are your body's communication

system, right? So, it is really how your

body is sending out messengers to

communicate. So, a hormone is dictating

an action and I think there's going to

be a lot of great discussion. But one

thing that I think is very important to

your point, Stephen, is even things that

we were readily taught about the

menstrual cycle and estrogen,

progesterone, testosterone, the public

is now becoming aware of because we've

not done a good job at public education

that this is what's really happening in

your body. this is what your menstrual

cycle is. This is what happens when you

go through menopause. This is what

happens when you're trying to train for

a sport. We haven't had these

discussions publicly that we are seeing.

And I think that is highlighting

interest in all of this even if some of

us were taught some of this. But when it

comes to hormones there, everybody wants

really easy fast. Draw my level. Tell me

what to do. Give me a medicine. Fix it.

And I think the most important thing to

understand is that by definition, your

hormones are dynamic. Your body is

responding to the hormonal signal it

sees and determining what next signal to

send out. So constant fluctuation

throughout the day in response to

multiple stimuli. And that's how it's

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 somebody to understand

on the other end who's not in medicine

who says, "Well, is it my hormones?"

Because there's no one test that's going

to give you one answer. You have to

really interpret it in context of the

full body. And it makes it really hard

for practitioners who do not understand

the hormones as well. And we see a lot

of mismanagement of hormonal scenarios

and situations right now that are

actually detrimental to patients. So,

I'm glad you're having this discussion

because that's not a stupid question.

What is a hormone? Many people don't

really understand that.

What is the I really want to make sure

that if someone for both the men that

probably have less understanding but

also from our conversations I've

realized and the feedback I've gotten a

lot of women don't understand their own

hormones and their own menstrual cycles.

What is the most basic level that we

have to start at to give people an

understanding that we can then build on

of what's going on here?

I was say I want to get rid of this

graph.

Okay. So that leave it out. Leave it

out. But it it shows just a textbook of

what a menstrual cycle is is, but it

doesn't show the daily perturbations of

estrogen and the luteinizing hormone

pulses and all the things that go as

Natalie is saying to make it to make it

work.

You see two organs there, the ovary and

the endometrial lining. You're not

seeing the muscle, the bone, the brain.

All of those organs are affected by

these normal monthly fluctuations.

Yeah. And the conversation that we're

having now in research methodology is

the fact that there is no real

definition of normal cuz every woman's

cycle is variable. So when we look at

this, everyone thinks that this is

normal but we don't actually know if

that is for the fact that a woman's

variation

this can change cycle to cycle. This can

change cycle to cycle. Sometimes we have

an ovulatory cycles. So until a woman

can identify what her own normal is, we

can't rely on this graph to actually

explain to them.

How does a woman know what their normal

is versus, you know, because a lot of

women are on birth control pills since a

very young age. So I think my partner

Melanie, she's she was on birth control

for about a decade. So she like didn't

have her cycle and then it came back and

it was every I don't know 60 90 days.

Mhm.

And then she changed her diet a little

bit and it kind of went down to 30 days

over time. But I don't think she knew

what normal was. Is there such thing as

normal?

I mean there is what should be normal

for you. So you should have a regular

predictable period which means that you

are having a menstrual bleed at a

predictable interval. It can range

person to person but for you really it

should be within a couple days

monthtomonth. I always tell patients I

should be able to give you a calendar.

You should be able to take your finger

pick when your next period is coming and

within a few days be accurate. Now

usually that range is somewhere between

25 and 35 days for the average person.

when it starts to get shorter or longer,

it can be a warning sign that something

is going on. When it comes to the

menstrual cycle, because I think we're

going to talk about these hormones

really well, and I talk about this every

day, let's give a one minute

explanation. If we think about to

Stacy's point from the brain, the brain

is sending out pulses of hormones, but

FSH drives egg growth. It's called

follicle stimulating hormone, and each

egg is inside a follicle. So, you have a

group of follicles inside the ovary. FSH

comes from the brain, grabs one of them

and gets it to grow and it makes

estrogen and this estrogen from the

ovary as the egg is growing is called

estradiol and it's the primary type of

estrogen in your body. So it is rising

and when it gets to a peak level and the

body is so fascinating because it's 200

pogs for 50 hours is a very exact

amount. Then the brain says we must have

a mature egg and it kicks out a surge of

luteinizing hormone or LH and that is

going to allow the follicle to rupture

the egg to be released and the follicle

to reform and then become a corpus

ludium and then the brain's going to

send out pulses of LH giving you pulses

of progesterone. So Stacy's point

that's an average and those numbers on

the little graph are nowhere near

accurate because progesterone goes up

and down the entire second half of the

cycle known as the ludial phase. What's

progesterone?

Progesterone is also made from the

ovary. So, the two main hormones when it

comes to a premenopausal female are

going to be estrogen and progesterone.

Progesterone is the progesterational

hormone or progreg. It is going to

change the endometrial lining and it is

essential to get pregnant. It opens and

closes the implantation window within

the uterus and it completely changes the

physiology of your body. And we're going

to talk a lot that is why in the ludal

phase your body works differently when

you have progesterone

and the lutial phases

after ovulation when you have a corpus

ludium. So when LH is coming from the

brain you have a corpus ludium it makes

progesterone. This is the second half of

the cycle known as the ludal phase. The

first half when you have estrogen only

is the follicular phase. So you have an

estrogen dominant phase and then you

have a phase where you have both

estrogen and progesterone. And your body

is made Yes. So we have our estrogen

dominant phase, the follicular phase,

and then we have we have both estrogen

and progesterone here in the ludial

phase. And your body is made to function

differently in these because in the

progesterone side, it's preparing you

for a pregnancy. It thinks every month

you might get pregnant and it starts to

change how your body's going to work on

a cellular level. But if you don't get

pregnant, that progesterone level is

going to drop and the cycle starts back

over.

And from um like a exercise and sports

Yeah. point of view. When we get into

this, the progesterone's job is to build

this lush endometrial lining and it

creates a lot of glycogen storage. So,

we often hear about glycogen in the

muscle and that's what we're using for

fuel. It has a way of shuttling a lot of

the carbohydrate away and storing it

into the endometrial lining, which is

why we see differences in intensity and

the way that a woman can respond to

exercise if she has ovulated. So is this

in preparation of a potential baby?

Yeah, correct. Yeah. In the second half

of the cycle, your core body temperature

increases, your resting heart rate is

higher, your heart rate variability is

lower, you have increase in fatigue, you

have an increased appetite, your body is

shifting function in case an embryo

comes in so that it can start to divert

energy and change what it is doing right

down to your immune system changes.

And that's roughly from day 14 roughly.

Roughly. Yeah. Yeah. At ovulation, it's

about 3 days after whatever day. If

you'd like to be specific, it's about 3

days after ovulation until when you get

your next period.

Yeah.

You all talk about how our menstrual

cycles can be a broader sign of whole

body health.

Mhm.

And um so should if someone's menstrual

cycle is irregular, should they be

concerned?

Yes.

Yes.

I thought you were going to say no.

How irregular? What's like if I'm not

getting my menstrual cycle?

Absolutely not good. You should go see a

doctor. Yeah, if your cycle is

irregular, if the calendar trick, you're

putting your finger and it's nowhere

near when your cycle's coming. Or I have

women who say, "Oh, there's no way I

could predict it." Or, "I know it will

come, but it'll come every 4 to 6

weeks." Your body's meant to work like

clockwork when it comes to your your

hormones and your menstrual cycle. And

yes, you can always have one abnormal

month, always. But when you consistently

are having irregularity, that is a sign

that something else is going on. It's

one of the biggest red flags that we

have for early hormonal health or

systemic problems. But to your earlier

point, Stephen, we have a generation of

women on contraceptive options who are

not tracking their cycles. We have women

who are not taught how to track their

cycles. They don't know when ovulation

occurs. They don't know how long their

ludal phase is. If I say the first sign

of ovulatory dysfunction or having a

problem with your cycle is a short ludal

phase, well, you only know that if

you're tracking when ovulation occurs

because otherwise you could still have a

regular cycle, but you don't know that

something's abnormal.

And that lut your phase again is the

last the last half of your your cycle.

Exactly. But I think that the

conversation that's happening now is so

not just at this table but in society

that our monthly cycle is so much more

than getting ready to have a baby

because I think that none of us knew

this.

No.

Because at 17 I wasn't that interested

in having a baby. So it didn't occur to

me that I should care.

Right.

Right. And it's the only time if you're

thinking about it in that way that

you're worried about your period is if

you don't have one and pregnancy, right?

And so if we're shifting the

conversation to this is physiology, this

is has to do with every part of female

physiology,

maybe it will be easier for people to

know,

right?

Yeah. I often put it with u my athletes

that it's a marker of health that if you

are able to take on the load of

training, the load of travel and

maintain your normal menstrual cycle,

then you are robust enough to be able to

progress. But if there becomes a misstep

in your menstrual cycle, then we need to

look at all the stressors that are and

the allosic load and pull you back and

see what do we need to address? Do you

need to eat more? Do you need to recover

more? what are the things that are

missing to bring you back to normal?

I was diagnosed with polycystic ovarian

syndrome in medical school and so like

every medical student of course it was

like gloom and doom and I you know

thought I had the most extreme case ever

known to mankind. It was really just

garden variety PCOS and I had very

serious boyfriend quickly engaged you

know looking forward to having a family

with him starting a family with him and

the terror around my infertility and

what the impact was. What was never

taught to me and what I didn't

understand until much later was the

metabolic impact. Like PCOS is a

symptom. There's nothing wrong with my

ovaries. They're just responding to this

high insulin level I was born with. And

no one really sat me down and talked to

me about my first research project was

women with irregular periods and the

risk of developing gestational diabetes

and and you know I didn't even know what

insulin resistance was at the time. And

now we're coming to understand that, you

know, when these young women are coming,

you know, I only do menopause now, but

before I left that practice, you know,

when women were coming with the regular

cycles and we were making these

diagnosis, immediately I was launching

into the discussion about her metabolic

health long term and what this, you

know, it's a gift to know this. So now

we can start making interventions,

nutrition, diet, exercise to give you a

better system to deal with this thing

that you were born with and her

fertility. Of course,

a huge amount of women have PCOS and I

think that's one of the leading one of

the leading one of the top causes of

having irregular menstrual cycles. You

you mentioned insulin resistance and

metabolic dysfunction there. And you

said something like diabet gestational

diabetes,

diabetes in pregnancy. So someone who

was non-diabetic before pregnancy and

then develops diabetes. So her blood

sugars have now reached a threshold

where they are higher than normal and

can cause you know problems for her

pregnancy and herself long term. And up

to 50% of those patients de who develop

diabetes in pregnancy will develop type

2 diabetes within 10 to 15 years after

that gestation after being pregnant. And

so what we know now is like we have

warning signs of this well before

pregnancy where we can set these women

up for success. Before it's just we wait

till we make the diagnosis, everybody

gets their glucose test and off you go.

But now with this PCOS diagnosis, we are

monitoring earlier. We're starting her

on the nutrition. You know, we're

treating her like a diabetic with

nutrition and exercise recommendations

rather than waiting till she she reaches

the criteria. Stephen, having

infertility, this is a scary statistic.

It predisposes you to many medical

problems later in life, including an 80%

higher chance of having a heart attack,

75% higher chance having metabolic

syndrome, higher risk of cancer, and

early death. Why infertility? Well, it's

not exactly that infertility is causing

this, but it's that for many women,

we'll use Dr. Haver's example, you're

healthy until you get this diagnosis.

It's one of the first warning signs your

body's giving you that there might be

inflammation and insulin resistance or

something impacting your hormones, your

menstrual cycle, your ability to

conceive that if it is not corrected now

is setting you up for many problems down

the road. PCOS is a example of this

because in PCOS you have a lot of eggs

inside the ovary. It's actually

something that genetically runs in

families. likely there's something that

happens when you're a baby inside your

mom that predisposes your ovary to not

lose as many eggs as it should and it

changes how they respond to insulin. So

what happens is you end up having more

eggs on an average. Your brain doesn't

know this and sends out the average

signals but that gets diluted amongst

all the eggs and so you're not getting

into these ovulatory stages of Stacy's

favorite graph here. Well, what happens

from there is that you're actually in a

relatively lower in estrogen phase than

you should be. You never see the

progesterone. And what happens is you

start to completely shift. The ovary

itself actually becomes insulin

resistant. And what this means is that

throughout your entire body, you start

to develop high glucose, which is the

blood, right? That's your blood sugar.

Your blood sugar is the fuel for all

your cells. All your cells need glucose.

Well, insulin is the hormone that helps

that glucose go from the bloodstream

into your cells. Well, in insulin

resistance, when your body sees high

glucose all the time, it starts to send

out more insulin saying, "Hey, we need

to get this into cells, but the cells

start to, oh, I'm used to insulin being

here, so I'm not going to respond." It's

going to take a higher insulin signal to

get the cell to open up the door and let

glucose comes in. This becomes very

problematic especially in we'll say PCOS

because that insulin is very

inflammatory causes you to get extra fat

stored in different places. It also just

completely changes how your body your

metabolic health in general but also

your hormonal health and in your brain

because your brain sees this and says

why are we keeping glucose in our in our

bloodstream is what's going on heightens

everything. And so this resistance to

insulin actually shifts how your brain's

going to respond to hormones, therefore

the hormones it's sending out. And it's

a self-perpetuating cycle. And a lot of

when we talk about lifestyle mechanisms

to improve hormonal health, which I know

that we all will, a lot of that is

targeting improving insulin resistance

and combating inflammation because those

two players, a lot of it is controlled

by the world around us and what we do to

some degree. And especially if you have

an underlying diagnosis like PCOS,

endometriosis, which is a chronic

inflammatory disease, autoimmune

disease, you're at even higher risk. I

always say your scale is already tipped

in a way that's going to be really hard

for you. You have to make active steps

to fight what is happening inside your

body.

We'll talk about some of the ways one

can reverse their PCOS, if that's even a

possibility. Um, but again on the causal

factors, is it something So my

girlfriend's got PCOS. She's been very

public about that. Um, is it something

she did? Is it something she ate? Is it

She was Is this the way she was born?

So, she was born with a predisposition

of having too many eggs. You lose most

of the eggs inside your body when you're

a baby inside your mother's womb. You

lose the next biggest set before you

ever have your first period. Now, if you

don't lose them for some reason, you're

born with more and it interferes with

how your hormones are supposed to

communicate leading to this metabolic

issue and this insulin resistance. She

did nothing to cause this. Nobody with

PCOS caused it. However, what you said

earlier, oh, she changed how she ate and

her cycles got more regular.

You can influence the severity of the

symptoms that you experience with it. So

even if you don't cause your disease cuz

you did not,

choices you make can make it absolutely

can make it better or worse, just like

any disease.

And when you use the word insulin, I I

think of or insulin resistance, I think

of sugar.

Mhm.

Yeah. Because glucose is sugar

essentially. And many people, and I'll

have patients tell me this, I don't need

to worry about insulin resistance

because I don't have diabetes or it's

not in my family. And we've so we've

ingrained this word insulin resistance

or talking about glucose or checking

glucose with a diabetic or pre-diabetic

state. But the world around us honestly

promotes insulin resistance. It's it

that's how our bodies we live in this

obesogenic environment. I mean there's

no doubt at least in the US you know and

most industrialized nations our

environment is what we call obesogenic

insulin you know and insulin resistant

so it you have to fight against kind of

the systems that are in place now for

most of us unless we have some genetic

predisposition to just be you know

magical um to because the way we process

food the way food is delivered to

communities the way you know our lack of

exercise you know everyone's working

from home now just just modern life is

is really you have to fight against.

One of the questions that came in from

the audience was I would like to know

how best to manage my PCOS.

When it comes to managing your PCOS,

targeting those two factors that we

talked about earlier, insulin resistance

and inflammation are really the key. And

I'll let these two speak to a little bit

of some of the exercise changes that we

can try to impact. But what I'll say is

that the best way to decrease

inflammation in your body is going to be

to start by focusing on your gut. Your

gut health controls a lot of the

inflammatory burden that your body sees.

The foods you choose to eat, they can be

both helpful if they have a lot of fiber

in them. They can feed your gut

microbiome, which is important in

estrogen metabolism, but they can also

be very harmful if they are

ultrarocessed foods that are even

causing more inflammation, not feeding

your gut microbiome at all and

worsening. So, I always say it's like a

scale. If you think every little food I

eat, it can make my insulin or it can

make my inflammation better, it can make

it worse. And so how we structure the

food that we put in our body is one of

the biggest changes the majority of

people can make that is going to make a

difference. And that's going to be a

very plantforward diet. Doesn't mean

it's plant only, but plants have fiber.

Fruits and vegetables have fiber. So we

have to make sure we're getting fiber as

a big change. That's what we see. I see

a lot of patients with PCOS specifically

being told I shouldn't eat fruit. I

shouldn't do this. I I need to avoid

do the ketogenic. You need to do keto.

Yes. So, we see people avoiding certain

food groups. And I always say it's not a

really sexy diet, but it's a it's a diet

we all know.

Lots of whole foods, fruits and

vegetables, healthy fats, healthy

sources of protein, avoiding the

ultrarocessed foods. That's going to be

probably the biggest change most people

can make. In addition to foundational

changes of your day, which is going to

be sleep more, that is when your body

fights inflammation, fights insulin

resistance. work on decreasing chronic

stress. To Stacy's point, you're not

running from the bear. So, your body is

not using that challenge, but you get a

email. You get stressed and your body

releases a lot of glucose so it can have

sugar and fuel to run from a bear and

there's no bear, right? And previous

days that would happen and then you'd go

run and that glucose would go into all

of your muscles and your body would go

back to normal. But now, we're

chronically stressed. So, actively

decreasing stress and then exercise,

building and using skeletal muscle is

one of the most effective ways to combat

insulin resistance that exists. And

since 80% of patients with PCOS have

insulin resistance, a large portion of

women with infertility, even without

PCOS, have insulin resistance, that is a

huge thing that people are missing,

especially when it comes to the exercise

discussion. And I know you guys probably

have things to add on that one. No, but

based on what you just I just took a

phone call this morning from a patient

when and it's just such a typical

conversation. She doesn't like the way

her body looks.

Her solution is not to eat. It's this

happens almost every day when I'm

talking to people. It's we're having

coffee for breakfast. We don't eat till

midday when we do eat. So the the gut

reaction because of the way many women

are raised is that we're going to starve

ourselves which is the opposite of good

when it comes to physiologic wholeness

and then you don't have the energy to do

the kind of exercise you need or on the

other side the response is I am going to

work so hard every single day that you

actually increase your stress there is

over there is overtraining

so you're just getting behind the

eightball with starving yourself and

overtraining. None of which are going to

solve either the core problem due to

PCOS or the core problem in any stage of

a woman's life. Right.

And this is where we look at the

socioultural effect of what a woman is

supposed to look like.

Yeah.

And that's the thing that I really

pushing out. It's like we want to think

about how strong we can be and how much

muscle we can build because muscle is a

massive metabolic help. Mhm.

And as as well as bone, right? So, we

talk about it and then when I get the

push back of, oh, I'm going to do fasted

training or I'm going to fast till noon.

I'm like, wait a second. Not only were

we going to interfere with our circadian

rhythm and our hormone pulses, we're

also acutely interfering with our

appetite hormones because if we're

looking at gerolin, which is our active

form of of our appetite, makes us

hungry. It's elevated with cortisol. And

so if we're thinking about that

elevation and we're not doing anything

to drop it and tell our body we have

food, then it goes in and directly

affects our neuropeptides, which then

affects our hormone, our hormone pulses.

So when a woman's like, I'm just having

coffee for breakfast and I'm going to

hold my fast. It's like, okay, well,

here we go. Cortisol is going up. As

Gary, you're going to get hungrier. Then

you're going to learn not to respond to

that hunger. You're going to hold your

fast. And we see from the research that

women who do that end up craving more

simple carbohydrates in the afternoon

moving incidentally less and

contributing to poor sleep because

they've now phase shifted. So when we're

talking about sleep and how important

sleep is, we also have to think about

the circadian rhythm and how it is

affected by food intake, light,

darkness, and all of the things. And we

need women to understand we want to

build muscle. We want to sleep well and

that requires food. Well, and it this

goes back this whole thing you just said

goes back to very early in this

conversation where I was talking about

sometimes we like to focus on the bright

shiny gadgets

when we haven't taken our health from

fine to optimize because everything you

just talked about

it isn't a gadget it's basic lifestyle

in the medical model of PCOS when I'm

talking about what we're taught and how

we train our clinicians.

We go into the, you know, we we aren't

taught a lot about disease prevention or

and I hate to use the term root cause

because I think it's been usurped by

certain members of, you know, the

wellness community.

Take it back.

Yeah, we're going to take it back. And

so, especially for PCOS, I was taught to

give a patient birth control pills or

Clomid when she's ready to get pregnant.

And so nothing nothing around nutrition,

exercise, lowering inflammation and I

was a program director until 2018 and

there was nothing in the curriculum

around this which affects at least 10%

of women probably more this condition

that how important lifestyle is. You

know, she went on for 10 minutes about

all the lifestyle change, which is

amazing.

Which is amazing.

But but patients,

but I'm sitting there thinking birth

control pills, birth control pills. I

mean, that was a knee-jerk reaction. I

mean, I was treated for my own

polycystic ovarian syndrome for 20 years

with oral contraceptive agents. And I

learned online through chat rooms about

the nutrition end of it.

Yeah. when I have athletes because we

see a higher percentage of PCOS in

successful female athletes.

Why

like what do I do? And it's looking at

what kind of training they're doing. So,

we're putting this more short, sharp,

high intensity to get that post exercise

response of anti-inflammatory,

growth hormone response, all of these

things that then bring down total body

inflammation. And then we're very

careful about food intake and when we're

doing it and what kinds of food so that

they don't have to go down the route of

oral contraceptive pills because that to

them has an effect on their performance.

When we're talking about the top end and

when we bring it back down into

recreational female athletes, we can do

the same thing. It's just we have to

educate and say these are our lifestyle

choices and then these are our medical

choices and what's optimal for your life

at this point. Mhm.

It's important to say at this table, and

we all talked about it last night, you

need to have a period if you're not

preventing a period with hormonal

contraception and you're in your

reproductive years. Because very often

women with PCOS or hypothalamic

amenorhea will say, I don't have a

period, but I didn't really like that

anyway, so it doesn't bother me, right?

How many women have said, well, I didn't

get my period for a year, but that was

fine by me. But that's not fine by your

body. That is hypoestrogenic time. It is

low estrogen.

Yeah. Very low estrogen. It's bad for

your body on so many reasons to be low

estrogen during these crucial bone

building years. But for we're talking

about how your hormones communicate

back. It's very harmful to long-term

health to have low estrogen

at all.

Brain health.

But yeah, but especially in young years

when you're still developing.

Why would a woman say that she didn't

want to have her period? I mean, this is

a super naive question as a guy, but I

understand it's painful.

I mean, do you want to bleed from

Do you want that?

I mean, if it was a choice now,

actually knowing now what I know now

and for my own young daughters, I'm

like, we have got to make sure you have

a period. But when I was young, I was a

dancer and an athlete. I had very low

body fat and I wouldn't have periods for

6 to9 months. And I'm like, yes.

Do you know what's interesting? I was

thinking of Mel.

She because of what she's been through

and also because she's listened to the

conversations I've had with all of you

and she understands the value and

importance of her period, she now

celebrates it. It's like a celebration

in our house when it arrives because

because if you understand the importance

that it has in sort of full body health

and the role it's playing, then the

pain, the downside

is weighted against your understanding

of the upside, which to her means she's

healthy, she's fat,

hormonal health is working, things are

great. And that's the conversation shift

that I'm hoping is gonna instead of

being a detriment and a downer and

talked about she must be on whatever

derogatory yes derogatory things are

said about us that oh my gosh she is so

healthy.

Yeah. I remember sitting in a high

performance meeting just maybe three

years ago and the leading athletics

coach stood up and said I know when my

athletes are ready to perform on the

world stage when their periods stop. And

all of us went what?

It's like no, that's the time where like

we have to really look at your athlete

is getting ready to crack and be

injured.

And it's still this pervasive idea and

it's still pervasive even in the fitness

industry that losing your period is okay

cuz that means you're training harder.

They actually are very resistant to

getting it back.

Yes. Like it's a sign of failure of

their sport or their athletic endeavor

because this is is so pervasive. And I

think that's why it's important to have

these discussions. And I love hearing

that Mel now says, "Yay, my period is

here." Because that's a sign of hormonal

health and things are working well

because that is how we should feel. But

I think the other part of it is for

women who have mayoria or heavy bleeding

and heavy cramping. They don't realize

that they can get help with that as

well. Mhm.

And that's a conversation that isn't

followed through when we're like, "Yes,

get your period, but if you're someone

who suffers from really bad cramps, we

also have to educate that there are

things that we can do to help with that.

Does the size of the bleed matter?"

Because she turned around to me the

other day and she said with her last

cycle, she said that she didn't bleed

much and she seemed slightly concerned.

Obviously, I had no idea what to say to

that.

It depends.

Congratulations. Well done. I'm so

sorry. minora. So we have definitions

and there are you know we don't walk

around with measuring cups generally

between our legs to measure how much

blood's coming out each month. But

but women know

but women know your period should not

cause you with modern you know period

products your cycle shouldn't cause you

any stress in your life. You should just

roll with it, right? And so that's when

I'm like when is it a problem?

Shouldn't bleed through your clothes.

You should be able to sleep through the

night. You should be able to get through

an athletic performance. You should be

able to do X, Y, and Z. Now when we do

start measuring and you should not be

anemic. So I'm not waiting till anemia.

I am anemia is low red blood cell count

you know to the point where your

performance is affected. Your ability to

carry oxygen is effective. So the red

blood cells are what carries oxygen in

our bodies. And women who have heavy

periods however that's defined can lead

to anemia. But the first thing that we

notice is their feritin is dropping.

That's the first sign my do my daughter

we just had some blood work done. She

was feeling a little fatigued and her

ferotin and iron saturations were really

low and I was like talk to me about your

period. Turns out she's not eating a lot

of iron rich foods. So we're dealing

with that. But you know we can get so

far ahead of this and looking at these

ferotin levels the transfer you know

these iron studies before she's actually

anemic which is like the last thing that

happens when her red blood cell count

drops or they become so small and what

we call microitic. you know, we are we

need to do a better job at recognizing

these things. We're not going to walk

around and measure how much blood's

coming out because I could maybe squeak

out 200 cc's, you know, a period and you

could be 300 and we're both doing fine.

You know, we both have great. So, I

think it's really looking at, you know,

how much bleeding is too much. Now, how

little is too much? That that's probably

better in your

Yeah. Is any change from what you

consider normal? We would all say this

is a normal amount. So if it gets

heavier than that or less than that and

it stays that way, that is concerning.

You can always have a one-off. Estrogen

is the driver of growing the uterine

lining. So if you have a lighter bleed

one month, we are concerned that you did

not grow as thick of a lining. Your body

didn't see as much estrogen. Most the

time you ovulated earlier that cycle,

your cycle came a little bit sooner than

you're used to it coming, and it's not

quite a big deal. But this can be

concerning if we see consistently light

periods, especially if we have history

of progesterone contraception, which

progesterone thins out the lining and

estrogen grows it. So progesterone

actually stabilizes it, but for the sake

of the discussion, we'll say estrogen

grows it, progesterone thins it. When

you only see progesterone, like a

progesterone IUD, the progesterone shot,

even continuous birth control pills,

because they give you a type of

synthetic estrogen and progesterone

every day, your uterine lining gets

thinner and thinner and thinner. And so

we see it can take months to return to

normal after coming off of hormonal

contraception. You also can get damage

to the endometrial lining. There's stem

cells in the endometrium that regenerate

every month after you bleed. They

regenerate so that the next group can

grow in response to estrogen. And this

can get damaged from typically anything

inside the uterus. So most commonly this

is post birth, you know, a traumatic

birth, a retained placenta, a DNC

procedure, which is sometimes used after

birth or in a miscarriage or even IUDs

or intrauterine surgery. and it can form

scar tissue in the uterus that can cause

a light period. So if you said, "Oh, Mel

had a miscarriage and had this procedure

and now her periods are lighter." I'm

highly concerned.

Versus amen.

Yeah. So that is concerning for scar

tissue in the uterus.

Okay.

If you said, "Oh, she was on a birth

control pill for a while and now it's a

little bit lighter." I'm less concerned

that's probably going to get better. or

if this period came closer together

or if you traveled around the world

three times this last month or

so one one off is no big deal but a

change from your baseline can be

concerning in addition we should say

that that graph is beautiful but you

know your thyroid your pituitary gland

it makes prolactin prolactin also

changes the endometrium so there's

subtle signs of other hormonal issues

that your menstrual cycle is the first

warning sign that something is off

what about pain She 2 months ago she had

like excruciating pain that I've never

seen before during her menstrual cycle.

Well, it's not pleasant to have your

uterus contract and expel its contents

in any form.

But what if it's like way above the

norm?

One time way above the norm is probably

situational based on other things that

are contributing to inflammatory burden

or response. your body is also healing

from a the corpus ludium's a cyst on

your ovary that can also feel painful

and at the time of your period it is

also healing so there's multiple things

that can cause pain

to Vonda's point so many people say I

have a high pain tolerance this is okay

because we don't talk about our own pain

so I don't know if my pain is normal

compared to somebody else's your pain

should not keep you out of your

activities of daily living you shouldn't

call in sick to school call in sick to

work, cancel dinner plans with friends

consistently. Again, everybody can have

a one-off month where something is off.

But if this happens every month, oh,

it's my period. I'm going to cancel

that. That is a warning sign that

something else could be going on.

Endometriosis, adnomiiosis, and uterine

fibroids.

You mentioned the word iron a second

ago, Dr. Mary. 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 tend to store quite a bit of iron in

our bodies and it's an essential when we

look at the structure of the red blood

cell and of hemoglobin specifically. So

hemoglobin is the actual molecule that

is inside of the red blood cell that

carries the oxygen. So iron is really

critical to the formation of healthy you

know iron carrying red blood cells and

we we store iron in our bodies and so

and a lot in the bone marrow and in and

it's stored in this particular molecule

called feritin. So when we're measuring

ferotin levels in the blood that is you

know the first sign that your iron

stores are getting low is when we see

these low feritin levels. Are women more

iron deficient than one would think?

Like is the general population iron

deficient or what do you tend to see

when you run lab tests?

A menstruating woman. Yes.

A menstruating woman is is often

iron deficient.

Yes. And I we I do see it in our post

post-menopausal patients as well. That's

usually nutritional and inflammation

related. So ferotin is also something

that will decrease in in times of

chronic inflammation. And so you're not

able to utilize the iron that's coming

in and store it because this

inflammatory state is kind of inhibiting

that. So in a menstruating patient, I'm

always thinking is she bleeding too much

the first time, you know, and is that

bleeding menstrual? Is it coming from

her rectum? Is it coming from her

gastrointestinal tract? You know, does

she have gastritis or, you know, we have

to go through the, you know, the

algorithm of why that might happen. In a

post-menopausal patient, we can remove

vaginal bleeding from the issue, you

know, uterine bleeding, a period, but

then now I'm looking at nutrition. And

I'm looking at exercise. I'm looking at

inflammation as causitive factors.

And the global pitch here is the World

Health Organization estimates that

roughly 30% of women aged 15 to 49

worldwide are anemic with iron

deficiency being the leading cause. And

in some reason regions of South Asia and

subsaharan Africa prevalence can be up

to 50% of women are anemic with iron

deficiency being the leading cause. H

you noticed the norms have changed.

So it depends on who you read.

Yeah. again, you know, when you're

looking at male male normative curves

versus what you know, we're we're tend

to accept lower levels for a female. But

now that we're looking at performance

and, you know, looking at other factors

besides just what is this feritin level,

um there's a lot great new research

coming out that we are looking at this

differently and that that we're in our

clinic, we are looking for 60 to 100 for

a feritin level to be considered

optimal. very different than, you know,

the baseline for, you know, keeping you

out of out of a hospital versus you

functioning at your absolute best.

Yeah. Because the norms that often get

measured for us

because they tripled, right? They were

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

women who are sitting 20 to 30, they

can't get help.

They cannot get help. And it's like,

whoa, it was maybe four or five years

ago. If you were below 50, then we would

look to get help. But now with the norms

that have shifted with the sicker

population,

we can't get women help unless they are

below 20. So when we say normal, I think

this is important for everybody watching

or listening. Normal in medicine means

common,

not non-pathological,

okay?

Not bad, you know, doesn't mean it's not

bad. And so norms shifting meaning we're

getting sicker as a population and we're

willing to accept lower levels although

they're not optimal for health. The lab

reference range what they say when you

get your blood work drawn and you see

the reference range is based on

population averages. And so if the

population is more anemic this is going

to accept a lower levels being normal

even though they're by no means optimal.

And I think that's one thing we all talk

about is well how are you feeling your

symptomology? What do we see? And you

have to interpret blood work in context

of the whole person and what is

happening. And that is one issue we do

see with getting your own blood work

drawn or these online companies when

nobody's interpreting it or helping you

interpret it on the other end. You see

something that is in a normal range but

it's not at all optimal for you and it

could be the reason why insurance. Yeah,

exactly. I want to talk about

endometriosis. I we have a team member

who's been with the Davosio since the

very beginning called Liv.

Yes.

Are you familiar with Liv?

I am.

So at age 13, she had her first period

and she experienced agonizing pain with

heavy bleeding.

At age 14, she was put on the pill to

manage the symptoms. Between age 15 and

24, she continued to have severe stomach

pain which resulted in multiple A&E

visits. She was often dismissed as

having gastriisitis.

Mhm. And it led to having her appendix

removed.

Oh my god.

Why'd you say oh my god

can get surgery?

But she had major surgery and

um I' I've seen this course before and

it's it's devastating cuz she's going

years and years and years now of

Yeah. age 25 she came off the pill to

see how she felt without it but her

periods worsened and she fainted from

the pain. So she went to accident and

emergency. At age 26, she got an

ultrasound which suggested

endometriosis, but no NHS diagnosis was

given.

We ultimately had a conversation with

you on the podcast, Natalie, and she

felt very heard and she was actually

there. And so afterwards, Jamaima in the

team, who you you guys know, um told Liv

to come and speak to me. And Liv told me

after you left about um the symptoms,

did she speak directly to you at that

time? She did. Okay. So, she came and

she spoke to us about her endometriosis,

which is the first time I'd ever heard

of it. Um, and then we offered to help

support her privately so she could get

private support with it. Um, and she got

an MRI scan privately, which confirmed

stage 4 infiltrating endometriosis.

Oh gosh.

Liv then pushed um on with her NHS

appointments, the National Health

Service in the UK, but the pain was so

much that she took me up on my offer to

pay for it privately. So, we paid for it

privately. Uh, and the endometriosis by

that point had spread to her bowels and

pelvis. And I've got this picture of

this four cm cyst. If you're all

faint-hearted, I mean, I don't know

where we'll put this on the screen, but

this is from her operation.

Yeah. It's called an endometrioma. It's

huge.

For anyone that can't see, it kind of

looks like a tumor.

Yeah.

Um, next to her ovaries

and it had spread at that point to her

bow and pis pelvis. It had become about

4 cm big. Her ovaries were stuck

together and attached to her womb and

her bowels. She then needed to book an

appointment for surgery. And before the

surgery, because of the scale of her

endometriosis, she had her eggs frozen

to protect her future fertility, which I

guess came from your advice. This

process took her 7 years and she was in

pain for 17 years because she did not

get a diagnosis.

Her story is unfortunately not uncommon.

This is a very typical story for

somebody who suffers from endometriosis.

Endometriosis is an inflammatory

condition. And the way I like to explain

it is when your body responds abnormally

to a normal process. You have immune

dysfunction as well. So let's think of

it as an autoimmune disease and a

chronic inflammatory disease. When you

have your period, you bleed out

indometrial cells in your menstrual

blood. We're used to that. In everybody,

you also have some indometrial cells

that will escape out the fallopian

tubes. That's not a big deal. If you

take out somebody's appendix while

they're on their period, you'll actually

see menstrual blood in their abdominal

cavity. In the regular person without

endo, your body says, "Oh, she's just on

her period." In the person who has

endometriosis, this creates a huge

inflammatory response where your body

starts to attack indometrial cells and

you get these implants throughout the

what's called the peritineal cavity or

the abdominal cavity of indometriallike

tissue that gets worse every time your

body sees estrogen which because it's

feeding the endometrium just like it

would in the uterus and so it gets worse

over time. The more ovulatory cycles you

have the disease gets worse. It's so

inflammatory that it's not uncommon to

get extensive

organ scarring. You get anatomical

distortion. These are some of the

toughest surgical cases in addition to

managing lifelong health but also

fertility as well.

Just obliterate the anatomy like because

the infiltration you'll these implants

will start growing into other organs

because they'll find new blood supply.

They'll steal blood, you know, blood

supply from from the bowel from because

all of our pelvic organs are just

sitting there on top of each other, the

bladder, the bowel, the c, you know, and

so

it sounds like it's alive, like it's a

cancer or something.

Think of it like velcro is what I say

almost these little patches of velcro

and they just start sticking together.

And that's what inflammation and

scarring does throughout your whole

body. And what happens here is that

because the primary symptoms of

endometriosis is pain. So again, back to

women's pain being taken seriously.

That's one of the issues and why the

average time to diagnosis is 7 to 10

years. Truly 17 years in this case from

when she had pain.

But the other symptoms do include

sometimes also pain with intercourse.

Typically though, that is very hard to

ascertain from somebody, but it's

usually with certain positions. Deep

penetration tends to be what really

stimulates pain. But you also see a lot

of GI manifestations that we don't talk

about. So if I have somebody who has

painful periods and they say they have

irritable bowel syndrome or a lot of

vague GI complaints,

that is a really big red flag to me

because like you said, these little

indometrial implants on the bowel, the

intestine, this high inflammation that's

happening irritates your intestine and

you get this GI response as well. One of

the hardest things about indometriosis

is that it's a surgical diagnosis only.

To be honest, we can means

have to do surgery to fully see and

diagnose that you have this.

It's one of those no meat, no treat, you

know, in in in medicine where you can't

make the diagnosis until you have a

tissue sample. So meat means you go and

take a biopsy.

Okay. See? Okay.

So you can suspect it based on imaging.

We're not great at this. And Dr.

Crawford, why don't we have a cure?

Mhm. Well, because it hasn't been

studied is one of is the primary answer.

Uh the secondary answer is that often

the the goals are tough with endo

because if estrogen feeds it, we all are

going to sit at this table and talk

about how important estrogen is for your

body. And a a lot of the treatments that

exist for endometriosis take estrogen

away to try to not feed these lesions.

And that has a slew of other symptoms

and long-term health implications as

well. Truly, we don't even give women

options to try to feel better. They are

given birth control pills because, hey,

I'm going to stop the ovulatory cycle.

I'm going to you're going to have less

what we call unopposed estrogen days.

We do have symptomatic relief.

Yeah. But we have and that's going to

help hopefully with some of your

symptoms. And it can for some women. It

doesn't reverse disease. It doesn't cure

it. It doesn't make anything better, but

it can slow down the progression any of

these treatments that do halt the

ovulatory process, but it severely

impacts I mean beyond so many layers of

your your mental your emotional health,

your relationships, but your fertility.

Stage three or four disease, regardless

of your age, you're going to have a less

than a 20% chance of conceiving

naturally over the course of your life

if you have stage three or four disease.

Every stage is impactful to your

fertility because of the inflammation.

Once you have anatomical distortion, an

indometrium or cyst inside the ovary,

removing that cyst is going to decrease

your egg count. That that's going to

have a major implication on your

potential. That's why we froze eggs

before we to cyst out so that we could

get those eggs, at least some that we

could out of the body before we went and

did something that was going to destroy

part of the ovarian tissue. What you

said, Stephen, is it seems like

indometriosis is alive. And that's a

really great analogy because it does

just feed into tissue and it's highly

destructive and if it distorts the

anatomy, we need a healthy floppy

fallopian tube generally that can swing

around and pick up this egg that's

floating around our abdominal cavity for

and then you need a place for the egg

and sperm to meet which is generally a

healthy non-inflamed fallopian tube. So

they're also at increased risk for

infertility but ectopic pregnancies.

That's where I see them, you know, is

when I was a hospitalist is in the O,

you know, emerently from a ruptured

fallopian tube from this, you know, and

I go in and I'm making not only she's

lost a wanted pregnancy now I and I'm

making the diagnosis of indometriosis at

the same time and they are just

devastated. I just feel sitting here not

being anywhere within this field

thinking wait a minute because I was a

cancer nurse first right before I did

this wait a minute there's got to be a

cell surface marker that's unique to the

endometrium that we could make a

monoconal antibbody against

there's got to be a cell surface marker

and I will say that there are people now

doing lovely and wonderful research on a

cellular level of indometriosis trying

to look at the endometrium itself what

cell markers are similar in indometrial

implants

Can you diagnose this on an endometrial

biopsy in somebody?

We haven't seen it get to the point

where it needs to, but at least people

are paying attention. So, I do think we

might have emergent technology that will

change the course of this for people.

Right now, I think awareness is key. And

one thing I always say is that

especially as a teenager because women

adjust. You accommodate to the world

around you. That's one of the things

that I think makes women so resilient. I

mean, if you have pain every single

month of your life, you are going to

convince yourself this is normal for a

degree of time because what other option

do you have? Has to get so bad. But when

you're a teenager, you don't know that.

And so, if when you are a teen, you

would stay home from school, 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 it actually is a very

high predictive marker that you do have

indometriosis.

So pain out of proportion to being able

to complete your normal life as a

teenager is a really big warning flag. I

ask every patient about that when we

talk about their periods because 50% of

patients with unexplained infertility

have indometriosis.

It is so hard to diagnose and

underdiagnosed yet impactful to our

body.

26 years old. The advice given to her by

the NHS was to go back on the pill to

solve for the the pains that she was

getting. We certainly have a lot of

dismissive doctors and people who don't

take pain seriously, but also a disease

that is underfunded and not researched.

We do have limited options for how you

can help somebody. And I think we have

to acknowledge that both things can be

right. Now, getting to the root cause of

your pain is always going to be really

important versus just saying here's a

birth control pill that should take care

of it. Some women with endometriosis

love being on the birth control pill.

does highly improve their symptom

profile and it's an important part of

their treatment regimen. Other women do

not find any benefit from it and it's

really important to have the discussion

especially with indometriosis in regards

to your family planning goals. Do you

want kids? When is that going to be?

What might this look like? Because we

know if you have a higher rate of

infertility, a higher rate of needing

IVF, do we need to intervene sooner? But

that's going to impact some of the

treatment options we're able to give you

because some of them do delay ovulation

from for a prolonged period of time.

What I find in the patients, you know,

when we made the diagnosis was they're

forced into making these kind of

life-changing decisions about around

their fertility and ability to conceive

before they were ever before their peers

were even thinking about it. It's pretty

devastating.

It is. We have some pilot data looking

at taking some of the nuances of

recovery and looking at how to dampen

inflammation. So we have some pilot data

that's showing when women do cold

exposure

that it dampens inflammation and

improves their symptomology. So I'm

always thinking on the outside like what

other things can we do to dampen

inflammation in a positive way to

improve symptomology.

How does that work? So, if we're

thinking about the responses to cold

exposure, and we're not talking about

ice, we're talking about cold water

exposure. It creates a cascade of immune

responses that kind of protects the

body. So, we're reducing inflammation,

we're improving parasympathetic, which

reduces stress. Mhm.

So, if we're timing it and they know

when their period is and they can go,

okay, well, for the next or the 10 to 14

days before my period starts, I'm going

to have 10 minutes of cold water

exposure. And over the course of 3 to 4

months, that immune response becomes

learned. So, it reduces symptomology.

So, it becomes one of the treatment

options that we have for some of our

athletes that have endo and interferes

with their training. Mhm.

So I mean the cold water exposure is

available there. So that's how we

started the pilot study.

Um trying someone wanted to do this at

home.

10° C. So what is that about

40? Yeah. It feels really cold but not

an ice bath.

Not an ice bath because ice is

Ice is not good for

Can you get that in the shower?

You you need to

This is like cold submersion.

Can you do that at a home tub just with

turning on the spigot?

You could if you get really cold. Yeah.

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

the popular media because that is way

too cold for a woman's body. It does the

opposite. It's a severe stress and

causes a stress response rather than a

parasympathetic calming response that we

want.

Okay. Like Stacy said, decreasing

inflammation in an inflammatory disease

is key to controlling the factors you

can. And much like we talked about

inflammation and PCOS, we heard the same

word right here with endometriosis.

Chronic inflammatory diseases are the

number one thing that we see across the

board impacting the population but

especially women.

And so these same strategies to work on

decreasing your own inflammation

and for endo it's a little different

because you can target it for when you

expect to have that high inflammatory

burden. But that's really an important

part that we don't talk about. I don't

see that the NHS talked about an

anti-inflammatory diet or getting more

sleep or cold exposure.

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Now, on this point of birth control, one

of the questions that came in from the

audience was, "How terrible is birth

control to female hormones?"

The birth control pill shuts off the

brain's desire to send the signal to the

ovary to make hormones. So, it is

ethanol estradiol, a synthetic estrogen,

and a type of a synthetic progesterine

or progesterone. These work, the brain

thinks that you have estrogen and

progesterone present. As we said, that's

the ludial phase. And so, your brain

says we don't need an egg to grow.

Ovulation starts in the brain. Y, right?

So, no FSH comes out and you're not

going to get ovulation. So they're very

effective for prevention of ovulation

which is makes it a very effective

contraceptive option. But as far as hor

hormonal shifts, yeah, your brain's not

sending out FSH and LH. Your ovaries are

not going to be making estradiol or

progesterone

or testosterone.

True.

And so that is how they are sometimes

helpful if you have, you know, uh some

women get hemorrhagic cysts with

ovulation. every every time you ovulate,

you when you rupture that cyst, you get

a lot of bleeding. The birth control

pill can prevent ovulation, therefore

prevent some women from being in

terrible pain. If you have PCOS, they're

often handed out like candy. One reason

is because it will regulate your cycle

so that you don't have these prolonged

irregular periods, but also will

decrease testosterone levels, which is

sometimes a good side effect of the pill

for women who have PCOS,

back to a normal level.

Yeah. But if you don't have PCOS or the

regular person, a lot of times your

body's tissues are not responding to

synthetic estrogen and progesterone the

same way it does to natural. I think

that's a very important point. So my

niece who competes uh at a national

level and she's 14 started suffering

from as she was going through her

adolescence her acne got outrageous and

she's a 14-year-old girl 13. start at 12

and a half. And of course, you know, she

goes to the dermatologist and they're

trying some topicals. And then finally,

as you go down the algorithm for how we

treat acne, one of the off label uses is

birth control pills will lower the

testosterone. Their skin can clear up.

So, her father, a little concern, comes

to me. Um, her mom passed away. Her

stepmom had passed away. So, he didn't

have the mom in the house to, you know,

the immediate mom to talk to. And for

the first time, I immediately thought of

her athletic performance. Thank you, Dr.

Sims and I thought she wants to go to

the Olympics. There's no way I'm going

to let her testosterone levels drop.

Like, we're going to throw everything

topical at this. And we finally found

the right combination. Her skin looks

great and she's super happy. But like,

the next logical thing was to put this

14-year-old, you know, on a birth

control pill to get her acne under

control, which is the end result. But

what no one's thinking of is her

athletic performance. How is it going to

affect her

training years leading

and her training years? Like, this is

critical for her. 16 is when the next

trials are up for her. So that's 2 years

from now. So we were able to get her

acne under control, avoid the birth

control pill, but that was nothing I'd

ever thought of before.

Well, I'm sitting here from a

muscularkeeletal standpoint thinking

about the high percentage of women who

have endometriosis and PCOS and the

complete soundingly

imbalance of natural hormones. Plus,

for a lot of reasons now, girls are not

cycling normally.

Mhm.

And I'm sitting here terrified for their

bones.

Yep. 100%.

Because we build bone from 15 to 25.

And if we are so inflamed that we're

producing all kinds of inflammatory

cytoines IG interlucan 6 and uh C

reactive protein and tumor necrosis

factor which halt bone development we

don't have enough estrogen for whatever

reason we're going to shut off our

testosterone because it makes us feel

better

and we're not exercising

and we're sitting around.

No wonder I have 20 and 30 year olds

with no bone density that are then going

to go into pmenopause which we will get

to and lose another 20%.

So I was pretty feeling pretty hopeful

that the generation Xers are going to

get to the millennials and get to the

whatever they're called after that.

It is

we're gonna be you're gonna see it get

worse before it gets better. Exactly.

That's what I'm sitting here terrified

like. Okay. I thought, okay, baby

boomers, those women missed out. Xers,

we're doing the best we can.

Millennials, but no, cuz now you're

telling me our 15 to 25 year olds are

still in the same detriment with muscle

and bone building.

We are trying to change the narrative.

That's the group we're trying to target

right now. And I do think by educating

across the lifespan, we're going to

change how those of us who have 11 and

12 year olds what we recommend. I I

treat girls in their teen years when

they come to me without their period

much differently than a lot of other

people do. But this is learned

experience. Instead of just you don't

have a period, here's a birth control

pill. Say you're not making estrogen and

this is a crucial time for you. Let's

give you estrogen. Let's talk about why

you're not. what can we do to change it?

And so this discussion is more than just

disease state important like PCOS and

endometriosis. It's truly important

across the lifespan of a woman. The

choices that are being made in her early

reproductive timeline is going to impact

her longevity.

Can I ask all of you what you would have

done differently

for ourselves?

Yeah, for yourselves. Obviously, I know

several of you have daughters as well,

but what would you have done? I wish

everybody could see all of your faces.

Oh yeah, I've talked about this before.

I mean, I was amenoric until I was 20.

What's amenoric?

Didn't have periods.

Okay.

Because of high stress, high sport, you

know, didn't care, didn't eat well in

the whole um mindset of the, you know, '

90s of calories in, calories out. If

you're thinner, then you'll run better.

If you're running better, then you're

going to hit different metrics. cuz I

was a runner in high school and then

joined the crew team. Same thing. So, if

I could go back and talk to my younger

self, I would have been like, "You need

to eat, you need to recover, you need to

eat, you need to recover." Instead of

the mantra of calories in, calories out,

more cardio, lose weight, lose weight,

lose weight. Because now I educate

people is you want to take up space, you

want to be strong, you want to look at

um not the idea of losing something, but

gaining something, gaining that power,

gaining that strength, gaining that

bone, gaining that muscle, gaining your

period. Those are the things that I'm

trying to educate the younger generation

cuz that was not impressed upon me as a

younger athlete, which then had a lot of

repercussions later in life. Luckily, my

bone density is fine.

So,

were you on the contraceptive pill? No,

you might. Okay.

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 experience though and

apply what you've learned in this this

high int, you know, working with these

intense athletes to the to the regular,

you know, to people who don't exercise

at that level. And

you know, I completely fell under the

the expectation of the aesthetics of it.

When I did exercise, I exercised to look

a certain way. And then in my 30s, I

exercised for performance. I started

running half marathons. I was doing baby

triathlons, really short ones with my

girlfriends. It was a social thing and

it was super fun. You know, I was

running for time. Now I'm exercising for

my old lady body. Yep. You know, I'm

exercising to be in a bigger body cuz I

know my mother and my grandmother. So,

my grandmother spent the last 10 years

of her life in a bed incontinent with

dementia and completely frail.

And my mother is on the same course. My

mother is 88, fell and broke her hip in

January. She just now is walking on a

walk or she's in assisted living

facility for Alzheimer's.

I want to change that legacy for my

children. I don't want that to be my

path and I don't want my children to

have that to be an expectation.

So all of the things I would have done

differently was

I wanted to be thin. Thin was healthy.

That is what I learned in medical

school. The thinner you were up to

starvation, you know, up to you want the

lowest body mass index possible without

being a little bit too low, you know.

And I kind of skirted that line because

I stopped eating in medical school due

to stress. I would have fed myself. I

would have lifted weights. I would have

stopped doing so much cardio because

knowing I was chipping away at my bone

density. I was chipping away. I was

raising my inflammation levels. I was

chipping away at my ability to resist

the Alzheimer's, you know, and dementia

that runs in my family. And that's what

I'm trying to impress. My girls are 21

and 25. 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 the

supermodels of the '9s and Kate Moss and

it was all

heroin chic.

Yes, heroin chic, which is the worry now

with the GLP1s coming back and the

ballerina body and all the things that

we're seeing come back again.

And it's it is worrisome.

You know, when I think about I mean,

I've already told the world now about

having low body fat, maybe being POS and

not knowing it, not ever talking about

that, having no periods, but then so

there was that in my youth that that I

would have done better, but that it

didn't end in my youth. I mean, I went

to college, same. I went to grad school,

still same. I went to medical school and

in medical school and

four years of medical school, seven

years of residency and fellowship. Still

didn't eat, still wasn't having periods.

I didn't sleep for about 11 years,

whether between call every third night

and then I had a baby and then I was

awake for two years cuz she slept with

me. That's another discussion. But I

think of all these things that I wish I

knew then that I know now. 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 allowed to hit

a wall like some of us may because we

didn't know.

And were you on the birth control pill?

You know, intermittently. Uh probably

totally in my life about 10 years, but

um not continuously.

And Mary, I forgot to ask, were you on

the birth control? Yeah, you were off

and on for 20 years.

So, polycystic ovarian syndrome that was

the treatment. I mean, I learned about

nutrition kind of on the back end. But

the life that I had set up for myself

between, you know, medical school,

residency, and then going into the field

of OBGYn with limited sleep, you know,

working 100hour weeks there. I didn't

have a environment that would have been

conducive to be able to manage that

disease

with lifestyle

and I can look back and say that

honestly now

um

with without using the crutch of the

birth control pill to manage my

symptoms.

I was on the birth control pill for

probably 15 years continuously. And you

know, we have to give credit where

credit's due because I was able to

pursue medical training and not worry

about what family building looked like

for me, which was really important

because I was not ready to have a child.

So, anytime we frame a discussion around

birth control, I 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,

you know, different stages of life,

different things are important. I didn't

stop it soon enough to learn to track my

cycle. I didn't recognize cycle

abnormalities when I had recurrent

miscarriages. I had a really hard time

knowing is this how my cycle's supposed

to be or not because I never had the

opportunity to just have periods and see

what is my normal. I stopped it and

started trying right away and got into a

cycle of having a pregnancy and that

would last for a while and then I would

lose it. So I really lost the

opportunity to say this is my baseline

and oh there might be a problem here or

to intervene. I wish id advocated more

when I had my own pregnancy losses. I

was told over and over, there's nothing

you can do. This is nothing. Just keep

trying. And even as somebody in the

field, that felt very dismissive and is

a fuel for a lot of what I do now. But

on a personal level, you know, 10 years

after having those pregnancy losses, I

was diagnosed with celiac disease

because I had osteopenia on a dexa scam.

And so I had

to explain what that is.

Yeah. So celiac disease is essentially

an allergic reaction to gluten. So when

I was taking gluten, which is in most of

your carbohydrates

or the good stuff like breads and

pastas, when I was eating those, it was

causing an inflammatory reaction inside

my body, making my gut unhealthy and

kind of creating a baseline level of,

let's say, chronic inflammation.

And recurrent pregnancy loss can be one

of the signs and symptoms of it in

addition to just some other what feel

like very generalized symptoms. fatigue,

low energy, headaches, GI distress,

WW.

Yeah, I was a whiny woman. And when some

of these symptoms finally got to a state

where they were getting worse, probably

with hormonal change with age, and my

doctor ordered a bone scan, and it came

back that I had osteopenia, which is

very low density of my bones for my age

and especially at the time, you know, no

known medical problems. And so luckily

had somebody who was very committed to

not labeling me a WW and saying I think

you're not absorbing something correctly

to get on this pathway to figure out

that because of this autoimmune disease

celiac disease I wasn't my gut was

inflamed. I wasn't be able to absorb the

nutrients that I needed.

But somebody had to be committed on the

other end because these symptoms went on

for so long. I just accepted them. I let

them be. But I also am scared because

those critical bone building years I was

on the

PEL

and I used it continuously which means

every single day all the time

I you know I know I was chronically

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 late and that

is scary

and can you catch up?

Yes. Yes, you can build bone. Um

because you know I see all these grass

wonder that

you know you kind of

yes

you go

curve but yeah and then it goes down

from your wherever you manage to get it

up to. So I'm telling all my friends at

the moment thanks to you I'm telling all

of them to get their muscle and their

bone as high as possible because it's

probably going to fall with age

naturally.

Well everyone

ages. Yeah. Age is the most natural

thing we do from the minute of our

birth. But men and women age at

different rates, especially

after pmenopause with the the lack of

estrogen, we rate we age very

differently from that point on. But your

point being made is can we please

maximize our bone density and our muscle

mass and everything else frankly

in our youth when we're probably not

aware, right? When we're in college and

doing all the things kids do, it's the

last thing on our mind. And yet it's the

most critical time because you want to

start both your bone and your muscle

from the highest possible level. Now,

can you through lifestyle and hormones

build bone again? Yes, actually you can.

But wouldn't it have been better to

start out with the maximum so that the

natural decline doesn't take you into

dangerous levels?

Right.

Mhm.

On that point of birth control, what are

you saying to your daughters that wasn't

said to you? Are you Because Mel

regrets, my girlfriend, she's very open.

She regrets being on the birth control

pill for 10 years because she had no

idea what it what it was doing to her

body. And then obviously when she came

off her cycle, I think she spent like

you, Natalie, 2 years trying to figure

out what was going on and she didn't

have her period for an extended period

of time after she came off. What are you

saying to your daughters about the birth

control pill that wasn't said to you?

Are you recommending them to use it how

you guys used it or

I mean, we were started on it so young.

I I do see a trend towards not starting

it as young as it was started in our

generation and I think that that is

important. I see, you know, personally,

my daughter is not quite at that stage

yet. So, we haven't had to make these

decisions as um they have had to, but I

do think it's cycle awareness is one of

the few early signs you have of your

body's health as a young woman. And so,

to purposefully never get to know what

that is, is a detriment to saying, "I'm

aware of what's healthy for me and I

know what's happening in my body." But

you guys have had these discussions at

different time periods. For my youngest

daughter,

we I was worried about uh she was a

dancer also. She was teeny tiny. So tiny

even though she had great muscle mass,

but she like me wasn't having periods.

And so the advice was to put her on

birth control to regulate periods. But I

was always uncomfortable with that

because she didn't to be a dancer. She

didn't have to be quite as tiny as she

was. And so what we have done now is

I've encouraged her to gain a little

weight and get a little bit more body

fat because I took her off of that. She

only had to gain 5 lbs. I think I said

to you, maybe seven and it has more

regulated her and she's having her own

periods now. And so I don't know what

she's going to decide. She's going to be

18 soon. And but I think what we should

be telling our daughters is all the

information so that they can make an

educated decision because I just did

what I was 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 is that it's synthetic

that this is how it works this is what

it doesn't do. So I would want to give

my daughters all the information so that

they can make an educated decision.

So my oldest, the first one coming

through, uh wanted it for contraception.

And so when we talk about contraception,

it's not just most people automatically

think the oral birth control pill, but I

did go through all of the options with

her and then sent her to a trusted

friend um to let her go and make her own

decision. and she decided to have an an

IUD inserted, which I thought was a

great choice for her cuz she had normal

regular periods before we did this.

There were no issues. And she had it

inserted and then within a week she

started having severe cramping, called

me into the bathroom. And this is my

daughter who has not let me see her

unclothed since she was 7 years old.

She's just very private and she's like

writhing on the floor. Bless her little

heart. And she had expelled the IUD on

her own. She had cramped it out uterus

pushed it out of her body and it was

extraordinarily painful and so we

basically delivered the IUD on her

bathroom.

So do you know what an IUD is?

Is not the coil

is

that's one form of an IUD. She had a

different form but she basically pushed

out her own IUD her uterus

uterine device. So it's birth control

that is placed inside the uterus

and it's shaped like a tea.

It is shaped like a most is shaped like

a tea. the UK they use the coil still

quite a bit which is copper and so um

there's different there's different

options for the IUD some contain

progesterine some contain just the

copper and so the way an IUD works is

that it creates an inflammatory response

in the uterus so that um the cervical

mucus thickens so that when we are

fertile in our for fertility window

midcycle and jump in if I mess this up

the mucus of the cervix thins to the

point where sperm can actually get

through most of the month probably 85 to

90% of the month the sperm cannot

traverse the cervix you cannot you know

so in our fertility window right at

ovulation the cervical mucus thins and

then the sperm can transmit so the you

the the presence of the IUD creates an

inflammatory environment that will

basically is toxic to sperm and thickens

the cervical mucus where it becomes a

plug that's how it works works very very

well Katherine within a week her uterus

ejected it so she cramped so much that

it pushed it through and so that wasn't

an option for her. She wasn't willing to

go through that again. So then at that

point she had to go through the hormonal

options for for that and she decided to

have the implant. So it's progesterone

only implanted in her arm. Quickly we

realized she needed some estrogen. So we

she supplements estrogen on top of that.

Stephen, I think the contraceptive

discussion we have to say that there are

options that are highly effective at

preventing pregnancy and at some times

in your life that is the number one most

important goal and we need to choose a

highly effective option. However,

certain some of those options included

have downstream impacts that have not

been discussed about. The typical

contraceptive discussion says here are

some side effects you may have. If you

want to still proceed, let's go for it.

We're not talking about long-term

implications of these. We're just

talking about how you're going to feel,

not exactly what is happening in your

body. A lot of these contraceptive

options are progesterone only. And so,

you know, by your new favorite graph

that you don't see progesterone every

single day. So, when you have

progesterone only, it is shifting your

hormonal profile. And a lot of women,

this progesterone is so high that it

works by also preventing ovulation.

Makes it highly effective. But if you're

not ovulating, you're not going to be

making those high estrogen levels. And

Dr. Haver and I have even talked about

how we wish there was a contraceptive

option that had estradiol in it so that

your body could still have some estradi.

Estradiol. So this ethanol estradiol is

very different than plain estradiol.

They've they've put this estester group

on the end which makes it bind to the

estrogen receptor in the brain 300 times

more

powerful

powerful than regular estradile.

Yeah.

Which is why it's so effective. you know

why we do it in a micro dose versus

estradiol is dosed in milligrams and

ethanol estradile is dosed in micrograms

because it is that much more potent. Um

so very very different. Now in the UK

and in other places in Europe there is a

new form of contraception that has

asteratrol which is the fetal estrogen.

So we have four natural estrogens in the

body. The ovary produces estradile.

That's the one we all know. It it it's

really the biggest bang for our buck.

The placenta produces something called

estriol. Our fat cells and in the

peripheral tissues, the tissues outside

of the ovaries can produce something

called estrone. And then we have this

fetal estrogen called eststeratrol, if

I'm pronouncing it correctly. And so

they've they've compounded they've been

able to formulate that. Um, so it is one

of the natural estrogens and they've put

it in a birth control pill that is

available in the UK.

If you were 18, what choice would you

make for contraception? No,

studies have proven within a shadow of a

doubt that relying on natural family

planning at most ages is not a reliable

form of contraception. So I would not

recommend that and relying on condoms.

What do you mean by natur relying on

natural family?

So you timing your intercourse.

Oh okay.

So cycle tracking we know that the

fertile window is the 5 days before and

the day of ovulation

5 days before

5 days before and then the day of. Sperm

can live for 5 days in the female

reproductive tract. The egg lives for 24

hours. So on this graph, where is

Yep. So the line right is ovulation and

then the 5 days before.

Yeah.

Yeah. So in popular culture, you would

call that natural family planning.

Okay. Fine.

Avoiding intercourse.

Abstaining any time in that window.

But but if I if I'm trying to get male

pregnant, then I should really be

aiming.

Yeah. Those are your target days.

Yeah.

There apps for that you can track.

Yeah.

Oh, I've got the app. Yeah.

Okay.

Oh, he knows. Remember the variability.

He's made download it nine times.

There's a few different ways you can do

natural family planning to hijack the

discussion for a minute and they have

different degrees of effectiveness, but

one of the main issues is that they have

very large abstinence windows. So, it's

often not very sustainable to say,

"Well, we're just not going to have

intercourse for 18 days out of the month

or some very long time period, depending

on which one, because your cycle's never

perfect. What if you did ovulate sooner?

If this is all you're relying on for

your prevention of pregnancy, you have

to really assure that you know when that

ovulation is happening, it can be an

effective way to prevent pregnancy if

your cycles are very regular. But in my

brain, I wish that's what you stop the

birth control pill at least 6 months

before you want to get pregnant. And

then you start learning how to track

your cycles and you're using some

natural family planning if you're not

quite ready then because the margin of

error, oopsies, it didn't work. the

acceptance of well we were going to try

to get pregnant soon is usually okay.

It's not an effective contraception for

most of the population. We have to

factor in when we're looking at, you

know, I was trained and taught to only

look at birth control through the lens

of contraception, right? We know that

they might have some weird bleeding and

maybe a few headaches. And for some a

DVT, if they have, you know, deep venus

thrombosis, you can have blood clots.

It'll increase your risk, especially if

you have a pre-genetic disposition to

that. But what we didn't talk about were

mental health, mood, and some of the

long downstream libido effects. So,

of of taking,

right? And so then I'm looking at it

through the lens of, you know, if I'm

only looking at on the lens of she

doesn't want to be pregnant

younger patient. So you're talking about

18 is less likely to remember to do

something every day.

Correct.

Okay.

So then to take the impetus of

remembering to take a pill every day or

change a patch once a week um for the

patch option. Then we're looking at

maybe a vaginal ring that she inserts

for 3 weeks and removes for one for her

period.

Pick one. If I had to pick one right

now, if I was if it was available in the

US, I think I would go with the

Asteratrol.

What's that

option? That's the 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. And it's it's because it

it more

it looks like so far it's newer that it

has less of the downstream effects. So

you're not having that complete

suppression, you know, that complete

binding and it's it's, you know, may

have and also probably has less risk of

um DVT of blood.

I'll jump on this. I do not love

intrauterine device for a patient who is

18 for a multitude of reasons. Now, I'm

going to preface this to say it is an

highly effective contraceptive choice.

It's one of the most effective ones that

we have. And so there are certainly

circumstances where that is the right

thing to do. We've had IUDs in practice

for a really long time. For the majority

of this, we were only placing them in

women after they had given birth at

least once because of their size and

being able to pass them through the

cervix. Now we have different options

and we are offering them to women

younger, which is wonderful. However,

when we're putting IUDs in the uterus of

women who are really young, sometimes

the progesterone dose in them is so high

that it is preventing ovulation. And we

are seeing young women who are not

ovulating and they are not making

estrogen therefore and they don't even

really realize it because

that's not disclosed as one of the main

mechanisms of a progesterone IUD because

it doesn't happen in enough people to

effectively prevent conception that way.

It works through the inflammation, the

cervical mucus changes.

And why does that matter? Because if you

are not ovulating and you're not making

estrogen, you are going to have low

libido, low energy, you're not going to

build your bones during critical years.

Let's say let's say the IUD lasts 5 to

seven years. You're 18 to 25. These are

some of the most critical years in your

mental health, your bone health, your

cardiac health. And being low estrogen

during that time

is going to set you up on a different

risk trajectory for your entire life.

And the worst thing here about the

progesterone IUD is that because of the

progesterone, which will thin 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 the

IUD. If that same woman was not

ovulating, and came to me and said, "I

haven't had a period in 7 years, and I

knew she was low estrogen and not

ovulating." We're highly concerned about

her health. But because she has an IUD,

what happens? Well, that's a side effect

of IUD. No big deal.

So, we're missing the moment to

understand where are some of these

symptoms just side effect of the IUD or

are they having a much bigger role in

what's going to happen to that woman's

long-term trajectory for being low

estrogen during crucial years? And I'll

say this, Stephen, I'm very biased,

right? I'm a fertility doctor. I see

patients who have trouble getting

pregnant. That is a narrow subset. That

is not the majority of women who have

IUDs.

So, what would you suggest if you had to

pick one contraceptive?

Vasectomy.

Yeah,

I would still do I would still do the

pill right now. The pill or the vaginal

ring? You know, I think they are both

depending on somebody's personal

preference. I just think that it's

really important if you're using the

birth control pill. I do think it's

important to give your brain a break

from the pill at times and even if

you're cycling it monthly, you there's

options now. I took the pill, an active

pill. every single day for for years, a

decade probably, meaning suppressed my

brain completely for that long. Now,

your brain sends out hormone signals

that impact your entire body, right? So,

we already talked about the hormones and

how it's this beautifully conducted

symphony. But if you even if you're

going to take the pill at that young

age, I would say take it so that you

have the seven days of not t not taking

a pill. let your brain have a moment of

release from the suppression and then

take it again. That's still a very

effective way to use the pill. But

because women don't love having periods,

we've offered these other options which

are not wrong, but they just have a

bigger consequence downstream

than we're talking about. But the pill

is very short acting. It only has a

halfife of 28 hours, meaning it is out

of your body very quickly. So, you do

want to stop the pill and see what is

happening and track your cycles. That is

something nice about it versus an

implant or an IUD. That is

fit and forget.

The fit and forgets that people like

set it and forget.

Yeah.

Yeah. The question that came in from the

10,00 women we spoke to in the diarrhea

audience was, is there any way to

control hormonal mood swings during the

luil phase of the menstrual cycle, which

I now know is the second phase of the

menstrual cycle.

Stephen, you've learned so much. Yes,

that's great. I love that. In the ludal

phase, we do tend to see more mood

changes and physical changes. And a lot

of this is because we have an increase

in estrogen and progesterone and then a

decrease in both of these hormones. And

what we find is that some women are

simply more sensitive to these changes.

They feel them quite profoundly. And

there's even something called PMDD,

premenstrual dysphoric disorder, which

is when those hormones are dropping. You

get these terrible mood swings, this

terrible depression and anxiety in

addition to physical changes with

terrible fatigue. You just feel like you

can't accomplish any of your tasks,

insomnia, quite similar to a lot of the

things that we talk about anytime we

talk about a low estrogen state,

right? Like po we see it in um

postpartum depression. It's a very

similar and in the permenopause

transition, we have a 40% increase in

mental health changes. And we know this

because women tell us and we believe

them. But what's happening is that our

neurotransmitters, especially GABA,

serotonin, and dopamine levels are

highly tied to what our hormone levels

are doing.

Yeah. So is this

is the mood swing or is the is the

what's the right term to describe a mood

when someone doesn't feel great?

Dysphoria.

Dysphoria

is the deoria mood after the period or

before it.

It's often it's before. So the estrogen

is dropping before and it stays low

through. So what happens is about the

week before your period and then the

week we'll say of your period you are

estrogen low. The rise of estrogen from

that next egg being recruited is

actually what stops you from bleeding

and helps you start to feel better.

Because of this, a lot of people will

throw a birth control pill at this

situation because they will say, "I will

give you constant hormone levels every

day and now you will not have these PMDD

symptoms anymore." However, a lot of

women don't want to be on the pill for a

variety of the different reasons we've

talked about. They just feel bad, let's

say, this week or this 7 to 10 day

interval. They don't want to suppress

ovulation. I find that a lowd dose

estrogen in the ludial phase can be very

effective in targeting after ovulation.

I'm going to take some estrogen helping

alleviate these symptoms without

interfering with ovulatory function. But

I was trained to give them an SSRI for

those 7 to 10 days.

An anti-depressant pill.

Yes, an anti-depressant only for those

two weeks. Saraphim was that the brand

name of it. And it does tend to help.

But what no one taught me and what

clinical experience has taught me and

talking to all these other smart people

is a lowd dose estrogen like

treating the root cause

treating the root cause. Just just give

her estrogen back during that time

period and she gets remarkably better.

In some of the nutrition research

finding that low iron and low vitamin D

are huge contributors to it. So there's

that research to investigate too, which

is interesting because there are some

women also who don't want to go on SSRI

or

estradile.

So, you know, the endocrine society does

not recommend routine testing of vitamin

D.

It's crazy. I I just think it's insane.

Yeah.

With my partner, I should anticipate

that her mood might drop in the leadup

to her having her period.

Mhm. It's very common.

And then after her period, it would

might recover. And whether or not that

becomes clinically significant, whether

or not it's life disruptive for her

rather than she just has a little bit of

a low mood, most women can tolerate

that. But for those who can't and that

it is disrupting their day-to-day

activities and how they feel about the

world, we have options.

Yeah.

Cuz I'm trying to understand I want to

understand her better. So I'm looking at

this little graph here which says the

brain during the menstrual cycle. So the

menstrual cycle starts when her period

starts

by convention. Yes. That's what we say.

Day one is the first day you start

bleeding.

Okay. And so what is she going to go

through for the next 29 days? And how

might I support her better through that

journey?

Like I want to understand what's going

on in her brain.

Her brain starts by s from a

reproductive hormone level. The brain

starts by sending out FSH, follical

stimulating hormone, which is going to

get her ovary to start growing an egg

which lives inside a follicle and making

estrogen. And that rise in estrogen as

it's growing will stop her from

bleeding. So the beginning that cycle

day one, the bleeding that she's

experiencing or her period is because

she didn't get pregnant in the month

before. So it's getting rid of that

indometrial lining, cleaning the slate.

She's estrogen and progesterone low

during that time period. And then once

her bleeding stops, it's because an egg

has been chosen. Estrogen is then going

to rise until it gets to 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 convention if you had a 28 day

cycle which only about 13% of women

actually do but all of these graphs if

you look at usually use 28 days because

it's easy to go week by week

and that's the lunar calendar.

Yeah 28 days.

We see that but we have to acknowledge

that most women don't have a 28 day

cycle. So but it is roughly the first

two weeks for most women to get up to

that ovulatory time period. So the time

from I have started bleeding until I am

now ovulating, that is all considered

the follicular phase.

And on this little image that I have in

front of me here, it says in those first

14 days, she's going to have better

spatial skills and be more anxious.

So once you get to your estrogen

dominant, so you have a lot of estrogen

and you don't have progesterone, most

women can are have increased

concentration. They have more focus.

They actually can sleep better. They

have higher libido. you feel like your

performance even for athletes

performance tends to be improved

aggression concentration more yeah

during what we call the late follicular

phase so that means the time period when

you're really making that estrogen let's

call it days 7 to 14 for ease so I'm now

done bleeding a follicle is growing

meaning an egg is making enough estrogen

to stop that bleeding I've not yet

ovulated and seen progesterone this is

where we typically have our best

performance overall from how our body is

functioning

and then From day 14 onwards,

I'm she's going to be calmer.

Well, progesterone slows your body's

metabolism down. It It's preparing you

for that pregnancy. Calmer is a nice way

to put it, but essentially, your

metabolic rate is going to change. Your

body's going to shift how it functions.

Many women actually have fatigue.

They're hungry. Specifically in the

brain, progesterone levels as they rise,

we see an increase in GABA, which is a

neurotransmitter, one of our brain

hormone, one of our brain, you know,

hormones that talks, you know, jumps

between one one neuron to the other. And

that is more of a calming hormone. So

women tend to we see sleep changes more.

You see deeper sleep, longer sleep in

that ludial phase.

She's and on this it says she's going to

have she's going to be horny for day 14.

I don't know how else to say it.

Because she has an egg available

because that's that peak estrogen. That

estrogen level of 200 pograms is

heightening everything. To have peak

libido when an egg is released, the body

is made that way on purpose.

This is a bit off script, but my

girlfriend always talks about her HRV

being very different. And so she she has

really great HRV scores and then once

every month for a period of time they're

terrible and she can't explain it. So

this is where wearables come into play.

Yeah.

So wearables are not designed to capture

women's physiology. So what happens

after ovulation is your respiratory rate

goes up, your resting heart rate goes

up, and your HRV plummets. So on the

wearables, most women about 5 days

before their periods start will never be

in the clear, so to speak. They will

never look recovered. They will never

look like they can take on a lot of

stress. They're not stress resilient

because of the way the algorithms are

reading this change that is natural that

is produced by progesterone to alter our

respiratory rate and our heart rate. It

doesn't mean that she's not stress

resilient is what the wearable is

saying.

Ah cuz she came downstairs and she said,

"Oh god, my recovery is so bad." And

then I think a couple of days later, a

little while later, she had a period.

I'm not sure. I can't remember the time

frames, but she came downstairs and she

was like shocked that she had done

everything right,

but her recovery on on her wearable said

that she was in terrible state.

This is why we do not let athletes use

wearables leading up to a peak event

because they feed into what the wearable

respond or telling them and it's not

true data with regards to how their body

can actually perform. So wearables data

masters then need to segate segregate

populations and make new norms for women

and maybe new norms for different

fitness levels of women.

Exactly. I've always been pushing for

the past five or six years interacting

with wearable companies is like if you

want to capture it well then you need to

be able to compare follicular to

follicular and ludial to ludal.

What does that mean? So comparing

like we know your HIV is going to be

different in your follicular phase.

This is not a bad thing.

People could could theoretically do that

on their wearables and look at the

previous month and see the the level

you're at then theoretically. Obviously

the wearable companies could do a lot

more here to to

definitely helpful but no you then it

comes back again on the woman trying to

understand and interpret the data

herself which can be a little bit

problematic because there's so many

women out there like my wearable told me

that I'm in the red I can't do anything

today when in fact physically and

psychologically they can do what they

set out to do. It's just now they have

this little seed saying that no, you

can't do it because of an improper

algorithm on their wearable.

Probably a good time to disclose that

I'm an investor in

push.

Okay.

Yeah,

I will send this to them.

Please. Yeah.

You wear Do you wear any devices to

track your health data?

I wear I wear a CGM and a Whoop.

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close off on the subject of fertility

because it was um heavily asked by our

audience and I I guess I'm well placed

to ask some of these questions because

I'm in that journey myself of trying to

have a child at the moment. Natalie, you

have five fertility non-negotiables that

you talk about.

I do and I think it's really important

to think about

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 if

it's not. And that's this narrative that

gets propagated. And fertility is

certainly not fair. Meaning people will

have infertility and do everything

right. But there are things that we do

that will inherently also harm our

fertility and our hormonal health and

make it harder to get pregnant. And

that's even when we are doing

treatments. So a lot of times people

say, "I'm doing IVF so I don't need to

worry about these non-negotiables." And

that's also not true. meaning things

that we need to do. We need to, as we've

all said, get more sleep. That's going

to be number one. We need to actively

work to decrease stress. That is 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 going to set some

boundaries and not have late meetings.

I'm going to see morning light. I'm

going to take a walk outside. We live in

a stressful world and chronic stress

itself can impact your fertility, your

natural fertility, and IVF success

rates. We're going to work on exercise

to build muscle and try to improve our

muscular health since it's part of our

metabolism. We're going to eat an

anti-inflammatory diet. That's

definitely key, high in fiber. And we're

going to look at the world around us and

work on pulling toxins out of our world

that we know we haven't even entered the

discussion about how environmental

toxins is harming our body, our hormonal

health, our fertility, our ovaries, our

organs. And so these are all things that

we make active choices on that we have

to start paying attention to and kind of

changing.

We'll go into detail in the lifestyle

factors and the environmental toxins um

in our second episode together. I I've

always been quite shocked by this graph

because it's quite um

quite significant. This is just showing

the

um egg count by age. Slide that into

that direction. um what do men and women

need to understand about egg counts in

order to make better family planning and

fertility decisions?

Okay. Well, I've asked you this last

time. So, Stephen, how many sperm do you

make a second?

Millions.

You make 1500 a second. You mean you

make millions every day? Is okay. But

still, you still you make a ton of

sperm. You make sperm every single day.

You have germ cells that create sperm.

Women are born with all the eggs you're

ever going to have. And yes, my favorite

vault analogy. So, I like to imagine

that this is a vault inside your ovary

that is storing all of your eggs. And

so, we'll use this cup with all of the

beads as that analogy. And every single

month, since before you are born, eggs

come out of this vault. And what happens

is that when the vault is more full,

more eggs come out every month. And as

the vault starts to get emptier, fewer

come out. And this means that we lose

the majority of our eggs, you can see

the line, well before our reproductive

years even start. So you lose the most

before you're born. So from being a

5-month baby to birth, your egg count

goes from 6 to 7 million to 1 to 2

million.

Millions of eggs lost before you're even

born. From birth to puberty, let's say

you go from 1 to 2 million to half a

million to simplify numbers. So, the

second biggest drop before you're ever

ovulating, before you ever have a chance

to get pregnant, and then you only

ovulate around 400 eggs over the course

of your reproductive lifespan, as that

egg count starts to drop over time, the

other really, really big important

factor is that our eggs have been in our

body our whole life. Two different

things are happening at the same time.

One is that our chromosomes start to

leave their perfect position. They

absorb the wear and tear of years. So we

see more chromosome abnormalities as we

get older. It's why it's harder to get

pregnant and why we see an increase in

miscarriage as we age. But also

concurrently our metabolic health is

poor as we are older too. And

mitochondrial function in eggs. The

metabolic capacity becomes less capable.

And so we see that it's harder to get

pregnant not because women are running

out of eggs but because the quality of

the eggs declines. But everybody will

run out of eggs. You'll have a period of

time where you have a very low egg

count. We call it diminished ovarian

reserve in the fertility world. We call

it perry menopause more globally. And

this this is two words to describe the

same thing. As your egg count starts to

get very low, you start to have an

unpredictable response to your ovary and

your brain is trying to compensate for

that. And so you see various hormone

changes, but these start before you

might recognize even menstrual cycle

changes. But everybody will run out of

eggs. Every woman will. your ovaries

will go into what we call ovarian

failure and no longer respond to

hormonal signals from the brain or

artificial signals that we give.

Meaning, I will see older women come in

and think that I have magic medicines

with IVF that can still help them get

pregnant, but I can only get the eggs

outside the vault to grow in IVF. And

so, shouldn't we then be freezing our

eggs?

You're right. As a society, if we are

purposely delaying childbearing, we know

that it gets harder to get pregnant with

age. And if having kids is a life goal,

putting eggs into the freezer earlier is

a way to save that opportunity. It's not

an insurance plan. It's not a guarantee,

but it is a smart game plan, especially

as we are waiting longer. Because even

with IVF, we can't always overcome age

related infertility if we have fewer

eggs and more genetic abnormalities. The

technology helps us identify healthy

eggs, helps us have more eggs, able to

grow in a certain month and take them

out and test embryos in a lab, but I'm

working with the eggs and sperm that

you're giving me. Meaning, if there's

not many of them, if there's a lot of

chromosomeal damage, if there's a lot of

mitochondrial dysfunction, if the sperm

quality is not great, that doesn't mean

we're going to be able to have success.

So, what you're doing on a daily basis

to impact egg and sperm quality is still

crucial. But egg freezing has gotten a

lot of bad rap. It's still a new

technology. It's only been around about

10 years off experimental purposes.

Meaning that women who froze their egg

10 years ago, you know, they have much

poorer egg survival rates. They were

older at the time. Their experience is

very different than the modern woman who

is freezing her eggs now, maybe in her

upper 20s or early 30s.

What is the optimal age? If you are want

to have a child as a life goal and

you're not ready to conceive by age 32,

that is when there's a clear delineation

that it makes smarter financial sense as

well as likelihood sense. The short

answer like my daughter will freeze her

eggs in her 20s. The younger you are,

the more eggs that you have. If she

says, "I want to have kids as a life

goal," then that will be something that

we will do in order to help her keep

that because there's so many other

variables which impact your ability to

get pregnant or your egg count.

Endometriosis decreases your egg count,

right? People will develop an ovarian

cyst and they'll have

surgery,

surgery, they'll have a twisting of

their ovary and maybe they'll lose an

ovary,

smoking chemo radiation

smoking, marijuana, any abdominal

surgery. So many things can impact your

your eggs because you only have this

group. You're born with them. So we we

plan for life goals differently. And

we've never really talked about our

fertility life goals until more

recently. Meaning when we went

professional career, right? We knew what

we had to do to get into medical school,

to get into residency, to get your PhD,

you had this list of things and you set

goals and you worked to achieve them.

But I always wanted to be a mom. Yet, I

already told you I took a birth control

pill every single day and I didn't even

think about it until that moment was in

front of me. And that's the part of the

discussion that we do have to start to

have earlier is if this is a life goal

for you, what do we need to do?

Understand our body better, our

fertility better, and maybe that does

include freezing eggs because it does

give many women an opportunity that time

would eliminate.

I had a conversation with you Natalie on

the podcast but then many other women

over the course of the last two to three

years and one of the things that I

learned from that was that we as you say

we don't family plan and then we have to

deal with the consequences of not family

planning. So, as an interviewer, when I

do life story episodes, I go through a

woman's life story. And obviously, the

women that's sitting in front of me are

typically high performers, high

achievers in some capacity. And then we

arrive at the end of the conversation

when we talk about family and kids and

all those kinds of things. And there's

often a lot of tears. And it was in

those conversations sitting here with

several women that were on the show.

What was the straw that broke the

camel's back? It was the UFC fighter

Ronda Rousey. It just so happened that

when I interviewed her, she had just

found out that her seventh round of IVF

had failed. And so she was very, very

emotional. I left that interview and had

a conversation with my girlfriend. I was

like, "Listen, I've I've seen too many

of um too many women 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 me. I think we should have a

conversation about this. Should we

freeze our eggs?" I mean, me and my

partner are both 33 now. And um at first

I don't know, maybe it was the way I

worded it.

She was offended.

She was like, "You don't want to have a

baby with me?"

It was like Yeah. It was like, "You

don't want to have sex with me?" Like I

like didn't word it well. Like I didn't

I didn't really think I didn't really

think about the emotions surrounding it.

I think that was really what it

You were trying to make a pragmatic

decision.

Yeah. I was as men often do. Like I was

just like we should free but I didn't

think about what that meant. And there's

this this prevailing narrative in

society that if something's not quote

unquote natural, then it's not good.

And that IVF or egg freezing is not

natural.

And that like torments people's brains

because they want to live a natural life

even though they're in like

planes and on on iPhones. We want this

one area of our life to be

natural. And after honestly five minutes

of that conversation,

I think the framing that m flipped her

mood was that wouldn't we want to give

ourselves the option,

right?

And it's actually about having options.

But I wanted to throw that out there

because, you know, I don't think people

family plan. I think as you said, we

focus on our careers, then we pop up at

35, 36, 37 and assume that we can.

Mhm.

But that is not the case.

Yeah. Especially if you live a healthy

life, you you think, "Oh, this will be

easy for me." or if you're a high

achiever and you've achieved other

things, many women are really taken

aback by not being able to achieve this

or not having control over infertility

and what is a natural process to run out

of eggs and to go into menopause. If you

are lucky to live long enough, this is

going to happen. I got my diagnosis of

PCOS in medical school before I was

ready to start, you know, family

planning. And I knew I was probably

going to struggle. And so it took us

about 3 years to successfully conceive

the first time. And

you can't even though I'm working in the

business, you know, I'm running between

patients to go and have another

ultrasound or go get a shot or go do all

the things that it took, you know, you

you can't remove the emotion from it.

And I can't tell you how many times I

cried. And of course, all of my

co-residents, my four best friends, all

got pregnant in succession, our poor

chief residents, and with no trouble,

you know, and even like crying to my

mother about the struggles I was having,

she's like, I just I got pregnant eight

times with no trouble, you know, and

then my first pregnancy resulted in a

miscarriage and, you know, in the middle

of work and all my friends were there

and they were cheering. They were so

excited I was finally pregnant and then

we lost the baby and you know and having

to like push through and work through

it's like it was yesterday like you know

I have two healthy kids thank God and

you know we were never after those two

we tried again we were never able to get

pregnant again which you know I had two

kids and put a bow on it and we're done

but it is impossible to remove the

emotion because

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 performing you know someone who's

like you check all the boxes and you

make all the good grades and you do

everything right and this is the one

thing that suddenly you didn't think

much about and then it becomes

everything

when that ch that that becomes hard or

it's taken away from you but I think

women 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 heard you say this, the the it's

a two-way street and and the issue is

not always the woman. A high percentage

of the time it's her partner. And so I

don't think we absorb that information

upfront either until we start

investigating it. But I'm in awe of this

story that four of your residents got

pregnant immediately because in

orthopedics that does not happen. Mhm.

Every orthopedic surgeon in my

generation that I know if we got

pregnant we miscarried and maybe that

was lifestyle and maybe that was not

eating for 40 hours. Maybe it's all the

radiation that we undertake. I think

it's better now for the younger

generation and we as the I'm not that

old but I am older than the current

residents. Um, we encourage all of them.

If you are not partnered and wanting to

have a child now, then please consider

freezing your eggs if that's a goal

because we can't predict our futures and

our residencies extend into our 40s.

Well, I love that you're helping

facilitate that discussion because that

certainly wasn't the culture back when

we were in training. I am one of the

ones who sat here and cried in front of

Steven myself when talking about my own

pregnancy loss journey just because you

know I see it every day you know and I

tell patients every day news that they

do not want to hear

50% of infertility is due to male factor

50% is due to female factors one of the

most important things I want to convey

when we on this topic is that IVF is an

amazing technology that has helped 13

million babies be born. It has been

life-changing and world changing. And

things don't have to be natural.

Sometimes the natural progression of

disease is death. So we have technology

and science that exists to optimize and

improve life and to help life exist. And

that's part of what IVF is. And I think

that's important because we do see a

narrative right now that IVF is

inherently bad and natural fertility

approaches are inherently good. And we

truly need to say both things are good.

Do women need to learn about their

bodies earlier? Talk about cycle

tracking, take better care of

themselves, get an earlier investigation

when things aren't going well?

Absolutely true. But also, needing to

have fertility treatments is not a

failure. Needing to see a fertility

doctor is not a failure. If you need

IVF, that is okay. All the other stuff

is still really important to the outcome

of your journey. But this narrative of

IVF isn't natural, so it's bad, or egg

freezing isn't natural, so we shouldn't

do it. That's harmful to society and to

women who do carry the burden, whether

they need to or not, women do carry the

burden of family planning for the

future.

Hearing you talk about that is very

interesting to me because in other parts

of medicine, in my own medicine, right,

we were talking outside about how I I

now do knee surgery through needles.

It's an advancement of technology. We

celebrate that. We like better things

for people. It's not natural. Live with

your thing, right? But I'm capable of

helping you live a better life.

Right.

So, it's interesting to me.

It's the stigma of women's health and

work.

That's right. This has because this is

women's health. We're going to control

it. We're going to protect these gals.

We're not going to apply the vast

knowledge. I'm a little offended by it

actually. If you want to know the truth,

why can I be so encouraged and and be

considered top of my field when I adopt

new technologies?

But in your field, 13 million parents or

26 million parents

would be told that technology is not

okay.

I agree. It's a terrible narrative that

is happening right now in the political

landscape. And I think it's important to

say scientific advancement is good and

it changes the lives for so many people.

And I think it's just highlighting this

idea about natural doesn't always mean

better. I think as you know scientists

and people in medicine there's also been

a disservice to not trying to get to the

root cause and not working on preventive

medicine and so going towards treatments

and technology which has made the lay

person feel like half of the picture

wasn't discovered or talked about

and so we can do better on both ends of

it and that comes to women's health more

than anything because there is stigma

when it comes to isolation there's in I

mean when it comes to infertility

there's isolation

you know being left behind your peer

group. Questioning a life goal will make

you question who you are, your life

meaning, your purpose. And that is an

extremely stressful and challenging

state for somebody to go through. And we

should be giving more support to that.

We should be saying freeze your eggs.

You're at a stressful lifetime instead

of the narrative that we are seeing

right now. So would the message be to

young men and women that want to have

kids at some point in their life to

freeze their eggs in their 20s? Is that

what you would advise?

You know, most people in their 20s maybe

don't have good awareness of these

goals, but certainly your, you know,

later 20s, your early 30s are the prime

opportunity where you still, for the

average person, you're going to have a

high number of eggs. You're still high

on the graph and your egg quality is

still going to be high. meaning it's

going to be easier to get the outcome

that you want. Certainly in your 20s

would be ideal if you but it's

expensive. A lot of people don't have

the financial resources to freeze their

eggs and their 20s they're in training

or they're starting their career. So to

have an extra $10,000 lying around isn't

always realistic.

And I think that's why people are often

waiting because that feels, you know,

elective, you know, like, oh, that's

extra money. I don't know that I have

that right now. when we see insurance

that starts to cover egg freezing as an

option, we see huge uptake in women

going to freeze their eggs. So you will

see at companies where almost less than

5% of women would freeze their eggs

before age 35. And then they introduced

a health plan that would cover egg

freezing and up to 50% of them would. So

you can see that both financially and

access and awareness, they all go hand

in hand. But that's a big player in

being able to do that because it is an

expensive process.

So Dr. Crawford, I think what most

people don't understand, what is the

spontaneous fertility rate by age in

general?

Yeah. So if you are 30, your odds of

getting pregnant monthly. We we use a

monthly rate called fundability. It's

going to be at best 20% per month. When

you're in your 20s, it's a little bit

higher. Can get up to 25% per month

if you're having sex

monthly and regular periods. So if

you're having unprotected intercourse

and you have regular cycles, your best

odds in a given month are going to be

about 20% at age 30.

How much sex do you have to be having?

Well, really just have to have it in

that fertile window. The

what? Just once or

really just once? Yeah, sex solely on

the day of ovulation would be the ideal

time, but you just need to have at least

intercourse at least once in that

fertile window. But that number drops

quite significantly to what Dr. Caver is

saying. So, at age 35, if you're trying

to get pregnant, it's going to be 10 to

12% per month odds of getting pregnant.

At age 38, it's going to be 5% per

month. At age 40, it's going to be 3%.

This if you're trying for the first

time, they're a little bit higher if

you've had a child already because

there's some proven fertility factors.

But if we look at that, you say, "I'm

chasing these dreams. I'm going to try

to have my first baby at age 38." You

have a 5% chance per month. That's not

zero, but that means the greatest

probability is that by 6 months time

frame, you won't be pregnant. And then

you're going to start a pathway of

trying to investigate why that is

happening. And if you do need

intervention, you're further down this

graph, too. You're going to have less

eggs to work with, and their quality is

going to be less good. That's why those

numbers drop rapidly. Natural fertility

rates are not about being out of eggs

because you ovulate just one egg at a

time. It doesn't matter if you have 20

eggs outside that vault or five eggs.

You're ovulating one egg at a time. So

natural fertility is all about egg and

sperm quality. So the this huge drop we

see from 20% to 5% is because of the

change of our egg quality as we get

older during our 30s which most of us

feel like is really young.

And what can I do to because I know

weight has a role in egg quality right?

If you're underweight or overweight, is

there anything else that has a a really

pertinent impact on the quality of my

eggs?

Yes. So, we have two factors. We'll say

age, which you can't control to an

extent, right? Chromosome damage is

going to happen even if you are

exceptionally healthy because tincture

of time. They've been sitting inside

your body. Chromosome damage builds up.

But the variables that you can is

everything that impacts cellular health.

So chronic inflammation and insulin

resistance are the two things that are

going to most dramatically harm your

eggs metabolic function. It's going to

harm your mitochondria. You're going to

get mitochondrial damage. We know that

when we start looking at older women,

they have more dysfunctional

mitochondria. They're shaped abnormally.

The products inside their follicular

fluid show higher levels of inflammation

just based on age that happens, but also

if they start having infertility versus

not having infertility. So we know that

inflammation and insulin resistance are

key players even in patients without

known PCOS or endometriosis but they

play a role in aging and specifically

your egg health as you age. So if you

say getting pregnant is a life goal. I'm

tracking my cycles. I don't want to

freeze my eggs right now, but what

should I do? All these things that we

talk about and we're going to talk more

about to decrease inflammation inside

our body. That's it. and from a young

age because these changes build up over

time.

And if I have PCOS, how does that

even more important because you're at a

higher predisposition to have insulin

resistance? Your cells are more

sensitive to how they're going to

respond.

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 born with a

little bit more, but because you lose

eggs based on how many you have,

essentially, you're going to catch up.

So during your reproductive years, you

tend to have more eggs out of the vault,

which interferes with normal hormonal

signaling, making all of the hormonal

metabolic changes worse. Very

interesting thing, as women with PCOS

tend to get older, and their egg count

starts to drop, and they have fewer eggs

coming out of the vault, they'll often

start naturally ovulating, even if they

didn't earlier. And so I'm always a

little concerned when somebody said, "I

used to never have periods, but now I

do. Did I cure my PCOS?

Maybe they did make some good lifestyle

changes along the way, but honestly,

that's a red flag for me that she's now

more rapidly declining in her egg count,

approaching what will be penmenopause

for her because her egg count is low

enough to then respond to the brain

signals. Like nodding your head over

here.

And as a man, is there anything I can do

to increase the odds that I'm going to

impregnate? Mel,

you can stop using um cannabis and

smoking cigarettes, um drinking alcohol.

We need to avoid heat. So the testicles

are outside the body for a reason. They

need to be at a lower body temperature

in order to adequately make normally

functioning sperm. So hot tubs, saunas,

those should be off limits if you're

wanting to get pregnant. Same with

highintensity exercise and compression

of the testicles. So this is notably

cycling for long periods of time. So an

hour on the bike or more routinely can

actually compress the testicles and

increase their heat.

What about sitting in a chair for 5

hours? choose. She'll be fine. I want to

Same thing. Sitting in a chair, boxers

breathe, being in a room that's hot.

Those things aren't quite enough to

truly raise that core testicular

temperature quite like some of these

other things. We also see diet playing a

big role. The great thing about men,

you're making sperm every single second.

The sperm lifespan is 90 days, 72 days

to make a sperm, 18 days to get out the

ejaculatory system. But that means you

could make a singular change in your

health and see a different outcome in

your sperm. that is so rare that doesn't

exist in women's health that one

variable can move the needle so much.

Marijuana is a huge one. Marijuana use

works at the brain to prevent those FSH

and LH signals which are crucial to tell

your testicles to make sperm and they

also impact inflammatory environment. So

sperm are not as modal. They are not

shaped as well. The DNA inside their

heads is more fragmented. In fact, men

who use marijuana, their partners have a

higher rate of pregnancy loss, even if

their partners are not around it at all.

You're using the word pregnancy loss

versus the word that we're aware of in

the UK called miscarriage. Is that is

that intentional?

Miscarriage can mean, you know, a to a

lot of different things to people and a

pregnancy loss, an unsuccessful

pregnancy depending on when you

medically lose a pregnancy or if a

pregnancy is in the fallopian tube and

it's an ectopic pregnancy, that's still

a pregnancy loss. meaning you had a

positive pregnancy test that did not end

up in a baby. So, it's a little more

inclusive for a variety of different

stages of when and how loss can occur.

Miscarriage kind of infers when we say

it, you know, on my end is that the

pregnancy was in the uterus and now it's

it's we we either have to evacuate it or

it's it's self evacuating.

And you were saying a second ago, Vonda,

that it from your experience, pregnancy

loss, miscarriage is much higher with

women who have high stress careers and

jobs. Well, I don't know the real

statistics, but my I'm sure they exist.

But in my experience as a high capacity,

high stress, not sleeping for 11 or 22

years,

I have seen it a lot and it happened to

me.

Yeah, chronic stress is associated with

a higher rate of pregnancy loss.

Is there anything else that people

misunderstand about pregnancy loss in

miscarriage that is worth talking about?

Well, it's not talked about, I think.

Yeah. That's one of the things that

people still think it's it's taboo and

rare, but I think all of us around the

table had pregnancy loss.

Yep. Two, at least two.

And when I had mine, I was in training

and uh a I didn't want to call my

attending and tell them cuz he was a

man.

And I didn't want to I didn't think I

could take any time off.

Same.

I went back the next day. I would have

gone back the same day, but I could

barely move.

I was running labor and delivery like at

night.

I got discharged. Ivy pulled out in my

hand and went back on the war.

Yeah. Like so I think hopefully part of

this international conversation about

women's health not just

gynecological health but health in

general will give women grace because

there's no way that I should have been

expected to go back to an orthopedic

surgery residency the day after I lost a

child

or frankly I don't know what your

experiences were but in my generation of

doctors and I'm sure it happens

everywhere. I went back to work less

than five weeks after delivering a child

and I think other European countries

have it right.

Oh yeah, New Zealand is a year time.

I I

weeks.

Six weeks.

I six weeks with one and three weeks

with the other because if I wanted to

leave my fellowship on time,

that's right.

I wanted to graduate on time, I couldn't

exceed the total vacation. So these

internships and fellowships and I'm I'm

sure that built into these programs we

sign up for, they were all developed for

men

who had had they had a family, had a

wife, you had someone at home to like

take care of that business.

Yeah.

And we're have, you know, we're all in

supportive relationships and, you know,

that wasn't the issue, but like I went

back before my body was ready.

Yeah. because I would

before that baby was ready to to unlatch

and my milk supply dropped immediately

the minute why I went back to work

and I tried to pump but you get called

for a crash C-section or emergency

surgery and you're like pulling the pump

off the breast and I'm running down the

hall hooking my nursing bra back on

trying to get to the O and you know all

that cortisol just my milk you know so I

was able to breastfeed while I was home

with the baby and but like once I went

back to work my my milk production just

shattered a picture of day in the

hospital and it was a day after I gave

birth. My laptop is open. I'm trying to

breastfeed because we launched a company

the month before I gave birth and

instead of my male co-workers going,

"Okay, we'll give you some grace." No, I

had a week and then they were at my

house having meetings. There's such a

different discussion about miscarriage

now than when I went through it. I told

nobody. I didn't either.

I mean, it was so secretive. I didn't

feel like I could. And we are seeing a

different generation where I do think

talking about women's health and Stephen

you having these discussions on a bigger

stage are lessening the stigma for what

is something that people go through. One

out of four pregnancies will end in a

pregnancy loss. That is not a low

percentage of people. In the same

breath, most people should not have two

in a row. And if you do, you should go

get an evaluation because there are

medical things that can contribute to

pregnancy loss that we would love to

identify a lot earlier and see if

there's something we can do to make that

different. What do I need to understand

about what a woman goes through either

in the wake of pregnancy loss or in the

wake of a pregnancy and uh a birth

physiologically, psychologically as an

employer to be able to create a better

environment for the women that are going

through either of those two things? Like

what's what's going on inside the body?

Cuz I I wouldn't know, right? So,

one of the, you know, simplest things to

say that's going on is that pregnancy is

one of the most hormone robust times you

have, even just momentarily pregnant. If

you have a placenta starting to implant,

you are now making levels of estrogen

and progesterone that you will not ever

make at any other time period of your

life. When that doesn't when you lose

that pregnancy or when you're

postpartum, let's say you're having this

huge hormone crash. Suddenly you go from

this very high level of these hormones

dropping off immediately. And in

addition to all the physical changes,

the emotional changes that has a huge

impact, you've heard us talk a lot about

low estrogen and how that feels. The

very interesting thing most studies

about estrogen show is that the hardest

time for women is when estrogen is

changing. So going from high to low is

actually when your body is having

your brain can't keep up.

Can't keep up. Doesn't know what's

happening. And the higher you were and

the faster you come down, we'll use this

analogy too. Even in IVF, when we go do

an egg retrieval and somebody had many

eggs, they have a much higher estrogen

they naturally would. I go and put a

needle in each one and drain the eggs

out and destroy those cells and their

estrogen plummets and they expect to go

the next day and feel normal or they

expect to feel worse during the

stimulation process when they're using

hormone shots. And I always say, you're

actually going to feel worse when I'm

done with you. It's going to be that

week after the egg retrieval where your

hormones go from the highest they've

ever been very quickly down low. It's

that delta, that change. And that

happens anytime you have that. But

pregnancy and loss and postpartum are

some of the most profound times that you

experience this.

And one of the other things is the

identity shift. So if you're working,

you know, we are all very highly

motivated and became parents. But it's

that whole identity shift of now how do

I interact in my life and how do I

interact with my peers? I'm a mom. How

am I being identified? What are the

implications? So there's a complete

identity shift that also isn't discussed

and that can also perpetuate some of the

postpartum that we see as well.

Mhm.

And anxiety and lack of control, right?

Because you don't know what you're

supposed to do, especially if you're a

mother for the first time. that is can

be very anxietyprovoking in addition to

hormone changes and not getting sleep.

But lack of control, you don't control

your schedule. You don't control when

you sleep. You don't control if your

child gets sick.

And so I would say from an employer

standpoint,

grace, support, and flexibility. You

know, if I had had better support

structures to say when your child is

sick, it's not the end of the world if

you are not here physically at the

office. That didn't exist. meaning that

my child getting sick became this

extremely

stressful situation.

God,

but for the average woman working a 9

toive job, whether it's in medicine or

other fields, if you could design their

working month around their menstrual

cycle around, I don't know, potentially

a pregnancy, whatever. How would you

design redesign their month? Because we

we have inherited this sort of I think

it's like from the industrial

revolution, this like 9 to5 working

hours. We don't work Saturday and

Sunday. We do that four times across a

month. What would you change? What

should women change? Because I've heard

some countries or systems are are trying

to give women time off around certain

parts of their cycle, for example. Would

any of you change anything? Well, there

are a couple of companies in New Zealand

who are pretty flexible, especially

after the pandemic, where they have

allocated certain hours that are free to

work at home. You just have to get the

work done

to the point where they have 4 day

working weeks. And then they're also

putting into the annual leave what they

call menstrual leave or menopause leave.

And it's you just say, you know, I can't

come today. Some people are using it for

child care. Some people are using it for

really bad cramping days. Other people

are using it for mental health days. But

it's a it's there to be used for

however. And you don't have to identify

it as being menstrual cycle day or

menopause. It's just extra leave. And

people don't care as long as you get the

work done. And I think that having that

flexibility across, you know, if you

have that ability to have more flex

hours or shared time space or something

like that greatly benefits productivity

as well as the feeling of empowerment

and inclusivity, which then feeds

forward to better productivity.

If I've got an extremely high stress

job, is there any part of the cycle

where I should theoretically be avoiding

stress?

Well, that's an individual thing. It's

how because you know we hear all the

stuff about cycle tracking and it's

about understanding your own responses

to your own hormone flux

because Mel partner says to me that she

needs to not do work. there's like a

couple of days a month where she's like,

I'm just gonna nest all those.

That could be her her responses and

she's like, I just don't have the stress

tolerance to be able to do XYZ and

understanding that in her own cycle is

great because then she can allocate

tasks that take more stress for other

days. For most people, it's peak ludal.

Also when your progesterone is the

highest tends to be when people have a

harder time focusing and concentrating

or getting tasks done now

which is where on

which is going to be the middle of the

ludal phase at the middle of this second

half of the cycle when you have that

oneish.

So when you have that progesterone you

know really high your body might be

ready to implant an embryo if there was

one that tends to be when people say

they feel more fatigue and less energy

and less focus and concentration. So if

you are looking at your month and you

might notice that it is and you have the

flexibility to say okay I'm going to try

to write this paper get this study done

do these tasks that call these tasks

that call for an increased focus in my

follicular phase when I'm estrogen

dominant have high estrogen and no

progesterone for the average person that

is typically when they're easier have an

easier time achieving those tests

which is the first 14

yeah the first couple weeks the time

period before ovulation, but there is an

individual response and I definitely

will see some people who they feel

immensely better when progesterone's

present and not so great the other time.

So, I think we use generalizations just

as a rule of thumb because that's what

it is for most people, but hormones

specifically, there's always an

individualized response and learning to

listen to your own body is key and

knowing what you need to do. I want to

close off on this point about just how

employers and you know the way that we

work can be better suited to a woman's

health. Is there anything else we missed

there?

Flexibility. I think we mentioned before

the ability to make a decision for

yourself. This is a day that I can do

these, you know, tasks. I think every

woman wants to do a really good job and

she is going to frontload those tasks on

a time that she feels better and offload

in a time where she's not feeling as

well, but she's going to get it done

for sure. And so giving her the

flexibility is going to allow her to be

her most productive rather than

demanding she have x amount every single

day. And I think support can come in a

lot of ways, but the um financial burden

to a large corporation of having a stop

gap child care at work. So maybe if

you're not going to offer full child

care because you're getting a lot of

productivity out of women if they know

their children are on campus and can go

at lunchtime. But if you're not willing

to do that, if you have a stop gap where

instead of calling your attending or one

day my nanny didn't show up and I had to

find some way

just for those emergencies within the

corporation that breeds loyalty that

will increase productivity and so I

think it's money well spent.

Talk about having a competitive woman.

She would probably want to work for you.

Yeah. you know, and offering those

things to make her mothering easier

while she's trying to work. I think you

would have the most competitive

workforce.

And what does that mean? So that would

mean having a n is that having a nanny

on site or is that

take care on site? Take care on site. on

site again,

whether it's full-time, like bring your

children full-time there, or

that's a that's a big corporate, but but

a a smaller corporate commitment would

be this emergency child care so that

your kids's not there all the time, but

maybe they're sick or maybe somebody

didn't show up and then you have days

have a licensed childare provider

available, you know, who could

which is a fault of the US system

because Yeah. What happens in New

Zealand?

You have 20 hours free daycare

a week.

A week?

Yeah.

So, it's um Yeah. 20 hours funded. Uh

and then it's a very small nominal fee

for hours over that for up to year five

or when they're 5 years old cuz then

they start school

on the first day that they turn five.

It's like you turn five, happy birthday.

But it does help significantly

um kind of keep productivity and a

little bit of the worry off. What am I

going to do with my child?

Amazing.

Yeah.

What does this um conversation around

eggs and fertility dove tail into

menopause and specifically permenopause?

I guess that's the next

you can't have one without the other,

right? So per menopause is basically in

this fertility decline area. Okay. So

you don't fertility is not an issue. You

don't want to ever have a baby. You're

still going to go through pmenopause.

And so per menopause is defined

medically in the worst way as the

transition from normal menstrual cycles

to no menstrual cycle ever again. Okay.

So when we look at definitions,

menopause is defined as one year after

the final menstrual period. What it

really means is ovarian failure. And

that offends people, but that's actually

medically what it is. You have run out

of eggs and you run out of the ability

of the ovary to produce hormones. And so

per menopause begins

medically at the straw staging is the

very complicated um methodology to

define the stages of pmenopause and a

lot of it is based on menstrual cycle

irregularity but hormonally what's

happening starts well before our periods

become irregular. So as those egg levels

decline and and the ability to respond

to the stimulus coming from the brain,

remember ovulation starts in the brain.

So when estrogen levels normally get low

during the cycle, the brain doesn't like

it. The hypothalamus, so the gland in

our brain starts looking for estrogen.

It likes estrogen. And then when the

estrogen levels are high, it's happy.

And so when estrogen levels decline

naturally in a cycle, it says, "Whoop,

where's my where's my estrogen?" And it

sends a signal to a second gland in the

brain called the pituitary. And that

makes the LH and the FSH.

So I'm trying to figure out what causes

menop per pmenopause. What causes

menopause? Lack of eggs.

So it's the loss of eggs and the loss of

the the group of eggs to respond to

these signals. So here we go. We're

beginning pmenopause. We've reached a

critical threshold level where our

ovaries cannot respond. And that might

be I don't know millionaire.

So when you're not out of eggs but just

the count is low, right? Let's if you're

a jar. Yeah. Yeah. So if menopause is

going to be for simplicity, the jar is

empty. 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.

And what is happening is the ovary

doesn't want to be out of eggs. So what

Dr. Haver is saying is the brain is

working harder to get an egg to grow

because the ovary becomes more stubborn.

It wants to hold on to them. It doesn't

want to lose them. The brain has to send

out stronger signals to get an egg to

grow. Because there's not as many, we

don't lose as many per month. So that's

great, but that means we have years of

being at this low unreliable ovary stage

where the brain is working really hard.

There's not as many eggs that are here.

They will still ovulate, but it starts

to happen at a less predictable rate.

But

so is that permenopause when there's

Yes. And there's not a definition I

think that which makes it the hardest of

say your point what number of eggs

equals per menopause. There is a unique

response to each person at what level

your ovary gets to where it will start

to respond dysfunctionally. But what

happens is that the hormone changes

start shifting in the brain. The ovarian

response starts shifting and before you

have irregular cycles, you will first

see a shortening of your cycles very

predictably. The brain will send out a

stronger signal. An egg will ovulate

faster. You'll start to get shorter

cycles. And then

there's hormone fluctuations,

but they're still regular. And so what

will happen is a woman will start to

feel these hormone shifts. It's less

predictable. She is having some change,

but it's still a regular cycle. And so

she is often told, "Your hormones are

fine. You have a regular cycle." So, and

in the brain, as we talked about those

neurotransmitters, there are not only is

estrogen changing and the amount that

we're producing, actually in

permenopause, quite often we'll have

much higher estradile levels than we did

in our premenopausal years where we had

that kind of predictable eb and flow of

our our monthly monthly hormones.

There's also independent FSH receptors

outside of so these hormones that are

pumping out to talk to the ovaries are

also back talking to different parts of

the brain. So the first symptoms that

patients feel and they've done a great

study on this is I don't feel like

myself.

I don't feel like myself. And they even

call it IDFM. And so you can't put your

finger on it. periods are regular, but

your environment hasn't changed. Your

normal stressors haven't changed. The

life you built that you could manage,

you're suddenly losing resilience.

And that's because of a hormone

fluctuation that is hard to

So, we see sleep disruptions, mental

health challenges increase, 40% increase

across pmenopause transition and the

cognitive changes and that is what

really scares my patients the most. And

they come in and most of them are, you

know, we're all high functioning in some

degree. Some of us in academia, some of

us in the O, some of us, but you know,

most women are high functioning because

they're juggling so many jobs. So even

if she didn't choose to go the routes

that we've chosen, she is managing

children, you know, school drop offs,

you know, all the things that women tend

to put on their plates. And suddenly

she can't remember all the things she

used to remember. Where are her keys?

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 people and

like I cannot remember their names or I

can't remember I get in the car and I

can't remember where I'm going or what

my purpose of getting in the vehicle

was. You have to think for a second. And

so all of that is related to the

hormonal changes.

At what age?

Well, I think that there's a tendency in

medicine to want to have definitions.

Yes. So, I personally, and I know a lot

of us who talk all the time, think that

this random 366 days after your last

period, that's your menopause day. I

think 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

patients come in to me for their

muscularkeeletal things and they're of a

certain age and I don't just focus on

whatever the muscularkeeletal body part

is, but we start talking about their

whole health and they start talking

about these things, I am often the first

one to say to them, you know what, you

are probably in pmenopause. And they're

like, but my cycles are regular. I'm

like, but you are beginning this

transition which I call meolescence, but

it's this right. I would propose that

most people don't seek out a lot of help

earlier.

But they should just assume

that they're permenopausal anytime after

35 they don't feel like themselves and

start down a road of learning or

investigating or let's feel better and

what do I need to do about it?

You know, it's frustrating to us all of

us. We talked a little bit about this

last night is the people who kind of

make the rules, the institutions that

make the guidelines and and the academic

kind of

ivory tower, you know, they are like,

whoa,

back off, slow down. We shouldn't be

blaming everything on menopause, you

know, like. And I don't think that's

what we're saying. We're not trying

but completely dismissing the female

experience and not at all like including

this cataclysmic hormonal change

is hurting women. So the average age of

menopause is 51 to 52. And so let's say

that is when your ovaries are in

failure. They will no longer make eggs,

make hormones or respond to brain

signals.

So all the eggs, all the little marbles

are out

all the way gone at 51 52. For most

women about 7 to 10 years before that

they will start to enter into what we

will call pmenopause or the

unpredictable response of the ovary and

the brain. I say their communication

system their best friends who aren't

communicating well. Their signals are

getting interfered. They're not

responding appropriately. The ovary is

getting more stubborn. The brain is

trying to work harder. You get these

higher peaks, these lower troughs. And

essentially that is the time period. So

it is unique to an individual because

everybody's born with a different

number. They lose them at a different

rate. Some factors that we control

impact that rate, but some things that

we do not. Your mom's age of menopause

is a predictive factor. If you're had a

first-degree relative go through

menopause at 46 or sooner, you have a

six times likelihood of going into early

menopause.

So knowing having this conversation,

almost every patient I ask, what age did

your mom go through menopause? They do

not know the answer. because the moms

haven't talked about it.

Moms haven't talked about it. There's so

much stigma about reproductive health.

So, knowing that information is really

important if you have mom or older

sisters, what age is normal for your

family so that you can be a little more

in tune if there's some genetic

predisposition for you? The general idea

of what Dr. Haver is saying is that in

these last 7 to 10 years of ovarian

lifespan, it becomes more stubborn and

less predictable and it does cause

hormonal shifts that most women can't

detect with their cycles. We do know

that if you are actively tracking

actually when ovulation's happening and

looking at your follicular and ludial

phase and you know what's normal for

you, you will most likely be able to

detect these hormone shifts in that time

period. But that's not what women are

taught. Their tracking is just that it's

coming regular. And we do have a

generation of women that were on

contraception and then went through

childbearing and then on contraception

again until now they're suddenly

entering this transitional period and

they don't know what their own normal is

making it even worse.

Correct.

So like she said the average age of

menopause if we look at the math uh is

is 51 but under that 90th percentile

curve you know with 5% on each end it's

about 45 to 55. That's menopause, right?

That's full menopause. Now, now let's

just do math and back it up 7 to 10

years. So, we're looking at the mid to

late 30s to 40. So, when I have a 46,

47, 48y old patient come in who's still

cycling, she has almost 100% chance of

being in pmenopause just based on her

age alone, knowing the statistics around

that.

Yep.

Okay. So with my partner between the age

of sort of 35 to 45 is when I can expect

her to go through permenopause where

there's very little marbles left in the

jar. Um and her hormones might be

disabled less predictable

and one of the questions we had in from

the audience was how can I manage the

symptoms of permenopause and they use

the word naturally

well we don't have a single largecale

study done on the treatment of per

menopause. So, so let me break it down

for you. When we look at funding in

women's health, it's horrible. Okay? But

if we, if I go into PubMed, which is

the, you know, database that I go to

look up metal medical journal articles,

and I type in the word pregnancy, I will

get today 1.2ish million articles for

pregnancy. Amazing. So important. We

need healthy pregnancies. If I type in

the word menopause right now, I think

it's about 99,000.

So those numbers represent time, brain

power funding

what what what is important in women's

health. Okay. If I type in the word

perry menopause, we are about at 8,000.

Yep. Very very very very small. Your

name's on a couple of Thanks.

So is the last third of my life from an

academic standpoint, from funding, from

brain power, from where we focus not as

important

than when I had the ability to be

pregnant. More women will go through

pmenopause than menopause because we're

going to lose a few to accidents and

cancers and, you know, early deaths.

More women will go through pmenopause

then get pregnant. Yet in my training,

so in medical school, I got one hour one

one-hour lecture on menopause, nothing

on Perry. And in my OB/GYN training, and

I'd love to hear what you have to say,

as part of our reproductive

endocrinology blocks, I had one block of

that my second year. In those six weeks,

I got one one-hour lecture each week. No

clinics, no focus, nothing. And then as

a program director where I was in charge

of the education of residents of over

100 residents over about 10 years, I

knew exactly what the curriculum

required and menopause just gets shoved

into a tiny box.

And then what happens when we run out of

marbles in the the glass there?

What's really interesting and one thing

we've said a couple times is this

happens. This is ovarian failure. you're

going to go into a state of low estrogen

because the ovaries no longer have the

ability to make eggs. Therefore, they

are not going to make estrogen or

progesterone.

And just to be clear there, the eggs

were sending a signal up to the brain to

make estrogen.

And the eggs well the low the eggs in

the brain communicate. Yes. When you

didn't have an egg ovulating, your

estrogen would be low and that typically

is the brain signal to send out more

FSH. That's still happening. Meaning

estrogen is low, but the brain is

sending out all the FSH it has. FSH is

very high in menopause and the ovary

cannot respond because there's no more

eggs. There's nothing left to respond.

I need to explain that that explained

again. So, I'm trying to understand why

estrogen drops when the eggs disappear.

The estrogen is made from the cells that

surround each egg. So, when there's no

more eggs, there's no more cells that

make estrogen. Follicle goes away, too.

Okay. Okay. So, estrogen is made in

the ovaries. So the estrogen is made in

the ovaries and the primary type of

estrogen that we're talking about and

it's made from the cells that surround

each follicle called the granulosa

cells. And as the follicle gets bigger,

as the egg matures, more of those cells

become more active and you make more

estrogen. So even when you have a little

bit left

when you're on your period, we'll say,

but you're some eggs here, you're still

making some estrogen. It's not as high

as when you're ovulating, but these

little eggs will each make a little bit.

Do I make estrogen at times? You do,

but I just make it somewhere else.

Yeah. It gets converted over to

testosterone.

Okay.

So, we have enzymes in our body that

convert estrogen and testosterone back

and forth.

So, there's no more eggs. So, this is

menopause.

So, this is men. Well, in my world, yes,

ov this is ovarian failure. And we're

calling it ovarian failure on purpose

because at this moment, you're not going

to make estrogen. The brain is sending

out all the signals it can. Very high

FSH trying to get estrogen to be made.

There's no eggs, so there is no

estrogen. What Dr. Haver has said, which

is correct, our our friends in the

medical world do not define this moment

as menopause. They make you sit here and

be estrogen low for a year and have no

period for a year before they will say

you're in menopause. If they even decide

to treat

or offer treatment, you know, or even

begin the discussion because of our

training, you must thou shalt go without

one year. So, we're absolutely sure that

the ovaries have have moved on before we

would even consider.

But what is the point of that? We've

made estrogen our entire lives.

It's a fabulous question. That's a great

question.

Starving our brains, our hearts, our

bones, our muscles.

They didn't think they were doing that.

I don't think that people, you know, the

medical community has recognized

estrogen's effects outside of

reproduction until very recently. I

think there's been isolated pockets, but

there's no no one owns menopause. Like

no one you think it would be OBGYn, but

there's no one in charge of women's

health after reproduction ends.

Like there's there's no zar.

So what's the harm of waiting a year

before people take it seriously? What

happens?

Suicide, mental health changes, rapidly

declining bone density. I mean, you can

be healthy without estrogen.

Wants estrogen.

All vaginas need estrogen. So your

brain, your bones, your heart, your

blood vessels, your vagina,

your body has estrogen receptors

everywhere that we've already

established. And suddenly you've lost

the ability to make your primary source

of estrogen. And what happens is that,

you know, medicine has a lot of

definitions that we use that are very

antiquated. Even how we date

pregnancies, right? When we talk about

how far along you are in a pregnancy, we

date back to the last period you had,

which meant 2 weeks of pregnancy or

before you ever ovulated an egg, before

you 3 weeks before you ever implanted an

embryo. Yet, we still use this pregnancy

timeline based on when your last period

was, even though we know two weeks of

that you weren't in fact pregnant at

all.

Now, menopause, in my opinion, is the

exact same way. We're using an

antiquated definition saying you have to

prove to me you're an ovarian failure by

lack of your period for 12 months

because it represents a time period

where we didn't fully understand what

was happening in the ovary or didn't

have the ability to test and know what

we know now. We are making women suffer

to get that diagnosis. If I believe I

shouldn't treat you until you have

menopause, you have to prove that you're

in it. I don't think it's where we're

going. I don't think it's what's right

for women. And that being this low

estrogen is hugely impactful at your

life at any age. The female body needs

estrogen to function normally.

I mean, I'm looking at this chart here

about suicidation. Yeah. Suicide.

So, the most likely time for a woman to

commit suicide is between the ages of 45

and 55.

And do you is do you think that's linked

to

100% menopause?

Right. So we know that mental health

we have an increase in mental health

disorders either pre-existing getting

worse or new onset of about 40% across

the transition. And we look at um SSRI

prescriptions which are

anti-depressants. They double across the

menopause transition. Now there's a

couple reasons for that. One is we

weren't treating menopause with

hormones. So they just SSRIs can

actually help a hot flash. Uh certain

types. So, you know, Paxel is one of the

ones that has been proven to decrease

hot flashes some. It's not great, but it

works a little bit. And with all of the

mental health changes, a lot of women

are ending up on these anti-depressant

medications.

So, we don't want to go a year without

estrogen. So, we know that some of the

new data coming out when I was

researching for the new pmenopause,

there's a really great window of using

hormones to treat mental health

disorders um and seeing improvement in

mood and also some in cognition by

giving estrogen or estrogen plus the

progesterine early in pmenopause before

the periods actually stop ra and that

actually works better than an SSRI. So,

say she's on an on an SSRI and has done

well. She's had a long history of

depression. Suddenly, she's not

controlled. Suddenly, her symptoms are

back and she's on the same medication.

Rather than doubling or adding a second

agent,

we really should be giving these women a

hormonal therapy.

Now, that doesn't hold postmenopause.

So, this is really a pmenopausal kind of

window of opportunity.

In postmenopause, they aren't responding

as well and probably because the

estrogen labels have stabilized. So when

we give a woman back

adapts yeah you'll adapt. So

postmenopause the menopause um that's

why the suicide rates kind of peak in

this key per menopause area and we think

and so in postmenopause

they the hormone levels stabilize so

women tend to get better and so they do

respond better to the SSRIs for for new

onset anxiety and depression in those

patients.

And I want to do a randomized control

trial where we add some creatine.

Oh that would be amazing. 20 g of

Well, no, it's 38 per kilogram of body

gram. Yes.

So, you're saying if I'm a 45year-old

woman and I'm I've still got my

menstrual cycle

Mhm.

at that time before I've hit menopause,

I should be considering some type of

hormonal therapy. So when we give

someone menopausal dosed menopause

hormone therapy in the form of estradile

usually in a patch because you have that

nice steady state it is enough to feed

back to the hypo to that brain to calm

down but not enough to suppress

ovulation. So she's often giving

estrogen support in very low doses and

menopause hormone therapy is basically

micro doing compared to what we do

naturally. And so we're giving enough to

calm the brain down and stabilize what's

happening in the brain without

suppressing her natural ovulation.

giving enough what?

To raise you back to maybe what that

baseline would be.

Giving enough estrogen. Correct. Giving

enough estrogen to raise the baseline

level so it's not as low. It's not so

high that it's preventing ovulation, but

it's going to alleviate some of these

drastic highs and lows that you're

having and it's going to create a more

stable hormone environment.

It's the delta that we were talking

about post pregnancy. The delta

chaos. The space is what bothers us, not

the high nor the low eventually.

So,

I have uh I run out of eggs and then I'm

by definition menopausal at this stage

and

my body adapts.

So, there's going to be a drop and then

there's going to be a

We're specifically talking about mental

health because you brought up the

suicide chart. Uh and so postmenopause

like once everything calms down and

you're fully menopausal you're out of

the zone of chaos. The hormones have

just your bones continue to deteriorate

a lot of other things are happening but

our cognit our mental our brain tends to

calm down and things get better in the

brain.

When do I become postmenopausal instead

of menopausal?

Oh go menopause is a day right medically

menopause is one day in your life. one

day exactly after your final menstrual

period.

That's the point of that random agree,

right? Because what if 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 all these things? It's like

it's really a antiquated definition and

we really need to modernize.

So, it's really you're permenopausal,

then you're postmenopausal.

Correct.

Right.

Okay. And when I'm postmenopausal

forever,

forever.

That's your new biological state.

That's right. for now. I'm sure

someone's working on something to change

something.

I do wonder that. I do wonder if they're

they're going to figure out a way to

extend fertility. I mean, they're

trying.

They're trying.

But then I think about it as if you're a

60-year-old woman, would you still want

to be

worried about

worried about that?

So, what they're doing is looking at is

there a way to extend

we'll say ovarian function. ovarian

function with lowle baseline

enough to keep you out of osteop you

know enough to slow that down and heart

disease protect your heart without

pregnancy

I'm now post menopausal lots of things

change in my body I'm guessing because I

I no longer have the same levels of

estrogen

did the levels of estrogen ever go up

again naturally or do I then need to

start considering

outside of a tumor no I mean

so do I need to consider hormone

replacement therapies and things like

that to

you might

and that will help me fend off what the

sleep issues, the

it'll slow the rate of change,

okay?

But it doesn't stop it. You still have

to put in your lifestyle modifications

to improve andor stop the circenia and

the bone density loss and all the things

that people associate with

postmenopause.

And did any of you have menopause

hormone therapy?

Yes.

Yeah.

Mhm.

And what was the decision and what what

impact has it had? So, I think what

Stacy just said in framing where we're

going with this conversation is so now

we're permenopausal. It's a new

physiology.

What used to work for all of our

exercising if we even did because we

know it at least in this country that 60

to 80% of people aren't intentional with

their lifestyle. So to frame this next

part of the conversation, I'm sure we're

going to talk a lot about hormones, and

I'll tell you my hormone decision-m, but

uh I think it's important to all of us.

It's only one of the building blocks to

rebuilding a great life, right? It's

interesting that the five steps of

fertility that you went over are

actually

exactly the same.

Curious, isn't it?

It is. It's it's

great protein and anti-inflammatory

nutrition. It's a cardiovascular fitness

life. It's a lifting life. It's a stress

detox whether it's environmental or

relational. And

sleep,

sleep,

sleep.

And then yes, hormones are really uh a

critical building block. But as we enter

the conversation,

women are sentient beings and we get to

decide

and we get to make the changes because

we have agency. So what we're going to

describe is not a one-sizefits-all.

It is

it's all the tools on the tools.

Put the tools on the table.

So I choose if I'm going to work my

proverbial rear end off to be the best I

can be for the rest of my life. I choose

to use all the tools. Not everybody does

that. But to choose one tool and think

that's going to be enough, it never is.

Right. So when I decided to and I've

been pretty public about my journey in

this because you think I would have

known after 22 years of formal education

and all this and being an aging a

muscularkeeletal aging researcher, you

would have think thought I would have

known. But I honestly looking back maybe

thought I was never going to age because

I was so healthy, right?

So I have a baby at 40. I breastfeed

till almost 41 and a half, 42. And then

I'm back at my very quickly 5 weeks, my

high power, high capacity to career.

But things were getting really different

about 45 for me and I think I went right

from postpartum

to perry menopause with very little

downtime. So chaotic hormones to almost

and so

I suffered for a while at 47. Uh I I

talk about it like I I went from this

really high capacity to thinking I was

going to die not only because of night

sweats, brain fog, the thing that lots

of women have. But I started having

heart palpitations. And I call my

cardiology friend because I worked at a

university. I'm like Ricky Ricky I think

I'm dying. So he did put me on a stress

test and my heart was perfect right at

that point. And then I had arthralgia

which is total body pain. It's part of

the inflammatory response of not having

estrogen. It's part of the

muscularkeeletal syndrome of menopause

uh assembly of symptoms. so much that I

go from training

to almost not being able to get out of

bed and these my experience of not

knowing what was coming and hitting a

wall is not uncommon,

right? And so I started educating myself

and being an acquired expert. I read

what I consider the world's data on

safety of hormone optimization as I like

to call it and I made the decision that

I was going to do all the tools. I was

going to learn to lift heavy again which

I hadn't done since high school cuz I

was a runner and I changed the way I do

my cardio and I changed my diet and I am

so committed 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 of d-stress. But I also

decided to um augment or to optimize my

hormones with estradiol,

with progesterone because I have a

uterus and after I felt comfortable with

those with very small doses of

testosterone and that makes me feel like

myself again, not just one because I

think sometimes people think that you

can just make a hormone decision and

feel like yourself again. It takes

lifestyle

plus or minus this decision.

Is there a stigma associated with that

decision? Um

taking hormones.

Taking the hormones, but also I guess

just more broadly with entering

menopause. Yeah.

Um I think there is there is absolutely

I mean you can just look at popular

media. You can look at their

representation.

Go right now and give me an image.

It's decreasing because of you though.

Like we have to acknowledge you are

decreasing the stigma.

True. and you're sitting at the table

with us.

I say that I think because there's a

woman in my life who was telling me

about her decision to start taking

menopause hormone therapy and she

described the moment with her husband

when she was looking at the box.

Mhm.

And she was staring at the box and

staring at the box and staring at the

box and mulling it and there was clearly

something emotional going on there that

this decision to take this marks

something

which is interesting because no one

really questions OC's.

Exactly. Oral contraceptive birth

control birth control

and I treat both men and women and when

a man comes into my clinic with low

energy popping all the tendons all over

his body everything hurts we very

quickly test his testosterone and send

him with no judgment because he's trying

to be viral and I think it goes with the

general composa conversation about aging

women when men talk about living longer

it's called longevity and we celebrate

that and we take pictures of movie stars

in the south of France very

distinguished distinguished with their

grain temples when women when we talk

about women living longer

until right now cuz we're all screaming

about it it's under the guise of

anti-aging

a superficial like oh my god don't let

her age so I think part of that is the

stigma of menopause somehow because

we're no longer able to have a

there's not a value. We've aged out of

the game,

which hopefully we're pivoting this

narrative because as I said earlier,

women are winning the longevity battle.

We already live longer, but it's how

we're living that we're trying to course

correct.

Yeah. And it's not just humans that go

through this. Like I like using the

whale analogy cuz whales go through it

and then the whales that are no longer

reproductive become like

the senior everyone all the other little

whales listen to them. is like I want to

be like a whale where you have this

seniority and and respect the wisdom

wisdom keepers.

Yeah,

exactly.

I love this part of my life.

You love this part of your life?

Yes.

Why?

I have never felt like I've

been in exactly where I'm supposed to

be. In this moment, I feel like I'm

helping more people. I have better

relationships. I'm having better sex.

I'm having better, you know, everything

in my life pretty much is better. And I

I don't know if like menopause and and

life circumstances have just given me

permission to like cut out the crap and

focus on what's really important

and, you know, don't sweat the small

stuff,

you know, it's like like something kind

of switches in our brain.

No filters. It's amazing. And I don't

think I could have done this 10 years

ago. I was too worried about what people

thought. I was too worried about being a

good girl and following the rules and

checking the boxes and never stepping

outside of the guidelines. But until I

realized that I wasn't really serving

the population that I trained for x

amount of years to that, you know, and

they were being left behind

is really what allowed me to like be

where I am today.

I think most of us describe this as the

most authentic. We're actually who we

were made to be. And the confidence we

feel comes from our memories of success.

I think that's where confidence come

from. We remember everything that we

have learned to fix over time. Probably

we could figure anything out. And so

that comes with experience and frankly

it comes with aging. The price of aging

or the pre the price of having wisdom

and experience is aging, right? And so

the the reps and so you get to this

place and you're like, I'm going to

figure this out. We're going to figure

this out.

And I don't want the younger generations

to have to go through the stuff that

we've gone through. So if I can share my

experiences to help them navigate, then

that is a good thing.

Yeah, I'm in pmenopause, so I'm a

slightly different stage. And I know

this because my cycles are shorter, but

they're still very regular. Used to be

28 29 days. Now they're 25 26. I know

that means I have less eggs coming out

of my vault every month and that's why

I'm ovulating sooner. But I can feel all

the hormonal shifts much more profoundly

than before. Now, as a reproductive

endocrinologist, what we call a

fertility doctor, most fertility doctors

now do IVF day in and day out. And

there's a lot of corporate reasons why

that is. But we're also trained in

puberty, premature ovarian failure, and

hormones. So, I'm more of a cowboy and

quite cavalier at giving estrogen. We

even told these ladies last night, oh,

because I see it. I see people who are

low estrogen states and you know, every

single day, how it impacts their life.

So, I am on lowd dose estrogen right

now, even though I'm still cycling. I'm

still making my own progesterone, so I

don't have to take a progesterone right

now. But, it clearly makes a difference

in my day-to-day function and how I

feel. And most REI like I am will

jokingly say like you'll put me in the

ground on estrogen because it has such a

profound impact on you're able how you

can function and specifically if we're

not forcing you to go through this empty

glass period for years and years and

years of your life

there's more opportunity on how you can

slow down part of the process that we

all know is going to happen with aging

but to live I think pond do is it you

know healthier your health span how are

you going to live healthy longer not

just live longer

well and I think your approach that I

think it's part of the decision making

is critical because

uh

35 to 45 and early pmenopause are prime

times for prevention

right it's to get our standards set

you don't have to lose your bone like

you're going to get

but it's hard for women to get care and

we also have to acknowledge that if you

go into

right if you what you're recommending

and I also do the same thing for my

patients

very hard for somebody to get care for

this is not happening in 99%

of doctor's offices like there is no

birth control pill or nothing which is

all they were taught

given that even in menopause only 4% of

women have chosen or have been educated

the pros and cons of hormone

optimization

and then to ex that's without that's an

empty jar person

so 4% Stephen

is that How many women that have

said 2023 they did a study in the US.

I'm not sure in other countries and on

FDA approved. So when we add in

compounding it's maybe a little bit

higher but when you look at FDA

prescriptions only 4% of eligible women

meaning no risk factors right age are

are utilizing are going to get their

prescriptions filled. Evidently this is

going to change right with the education

that you guys

we hope at least they're being offered

it and having a discussion so that each

one

they may choose not to the right and

that's their right but

side effects are there side effects

worth noting I know a lot of people are

quite scared of taking sen hormones

so there's risks and then there's side

effects so when we look at the side

effect profile anytime we give a woman

estrogen progesterone and we'll have to

like look at them individually but

estrogen you can have headaches you can

have irregular bleeding about 50% of

patients and more on the patch than on

oral.

There's a patch and there's oral. Vonda,

you take the patch, right?

I do.

And that's on your stomach.

Yeah, it's right here actually.

And how often do you have to replace

that?

Twice a week.

Okay, fine. And

yeah. So, so when we look at menopause

hormone therapy, we have estrogen, we

have progesterrogens, and then we have

testosterone basically. And there's

different ways to get it into your body.

There's oral and non-oral roughly. So,

in oral it's pill, you take it. In

non-oral, we're looking at through the

skin or through the mucosa. So mucosa

could be under the tongue. It could be

in the vagina. So mucosa is like the

gastrointestinal tract is lined with

mucosa and it's a nice way to absorb and

in the rectum to absorb medication. We

don't have a rectal form of estrogen

yet. And so um so and then there's also

injectables so you can inject it

straight into the muscle or subcutaneous

tissues. So most commercially available

like FDA approved. We're looking at a

ring for the mucosa. We're looking at a

patch for transdermal or we're looking

at pills for oral.

And what do you take?

Yes. So, I am on a patch. Um, and I've

just been I'm not a great absorber

through my skin. Um, and I couldn't get

my estradile levels high enough where

studies are looking like the best bone

protection is. So, I've added about a

half milligram of oral estradile at

night. I'm on oral micronized

progesterone, which is probably the best

way to get it into our system. And I

tolerate progesterone very well. And

testosterone. And I am on a gel that is

FDA approved. We I'm borrowing the men's

version because we don't have an FDA

approved version

for women

in this country for women. So

I don't think anywhere is

borrow my husband.

Australia.

Australia.

And I think the UK just has approved

one. This is new

some news like in the last month.

Yeah.

So okay. So um okay. So, so it's it's

broadly advisable

after doctor's consultation to take some

form of hormone therapy.

Definitely if you're symptomatic, if you

have the classic visual motor symptoms,

it's absolutely the gold standard.

But can I comment on that?

Women say to me all the time either, I

don't have I don't feel that bad

or they say I want to do this naturally.

And those are the things that say okay

fine, do it naturally. But

brain fog, night sweats in the V and hot

flashes are not the only thing going on.

And so if you're making this decision

fully informed, well, you're a sentient

being. Make the incision. But you cannot

feel your bones crumbling until they're

broken. You cannot feel that. You cannot

feel your muscle going away. You cannot

feel your brain starving. You can't

detect microvascular disease of your

heart. So, you may think you're getting

away with something and maybe you don't

have night sweats, brain fog,

but it doesn't mean you're not having a

different physiology. And if you are

fully aware of that and make a decision

that you don't want to optimize your

hormones, that's your decision. And I'm

fine with that. But what I'm not fine

with is people thinking they're getting

away with something when they're not.

True. I

You're making the decision based on fear

and not facts.

Correct.

My last question is about love and sex

in and menopause. You said you're having

the best ex of your life, Mary. And um

I've also heard you talk about how

several people in this season of life

end up getting divorces. You said they

throw the the trash out. So when I

So when we talk about, you know,

menopause can

spur, you know, for some women it's it's

this mo moment of empowerment. They

realize they have to circle the wagons

cuz the only way they're going to

survive through this cataclysmic, you

know, upheaval for so many women is to

get rid of relationships that aren't

working. Put up boundaries and sometimes

that's going to be the end of a

marriage. Other times it's going to

strengthen a relationship because you're

you're kind of cutting out things that

were getting in the way of your so I see

many marriages or many relationships

really improve through the transition.

But it it does take two. You know, sex

is biocschosocial. So like when I I look

at sex it's not I think of the entire

experience you know and one as far as my

desire for the frequency testosterone

does seem to have given that an uptick.

So it is approved you know we have lots

of studies done on libido for women

which is in medicine we say hypoactive

sexual desire disorder and it has to

bother you. So a lot of women are like I

don't want to have sex ever again I

don't care. There's nothing wrong with

that, right? Unless it affects your

relationship and it it bo it has to

bother you. But I have a lot of patients

who come in and say, "I love him. I used

to want to do it. We used to have a

really great frequency and everybody was

happy about it. It was something I look

forward to, enjoy it, and now there's

nothing. I have nothing." And for those

patients, testosterone can be helpful.

Not for everyone, right? And so there's

other emerging data on looking at the

muscular skeletal system. I am naturally

thin. I was not an athlete growing up.

At best, I was a dancer, you know, and I

didn't do anything to protect my muscles

and bones as as I was coming up through

the ranks. And so, here I am in my 50s

just getting out of endurance, you know,

you know, recreational endurance

training and thinking, what have I done

to my bones and muscles? I laid on that

DEXA scan as nervous as I've ever been

in my life, like getting my board

scores, nervous, like, what 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 I do to, you know, I'm

doing the I'm eating the protein, I'm

lifting the weights, I'm starting to do

all these things. And we know that women

who have naturally higher testosterone

levels from genetics or whatever, have

less frailty as they age cuz that's my

focus. If I run the cancer gauntlet,

which probably 80% of my aunts and

uncles have died of cancer. And so if I

run that gauntlet and I'm doing

everything lifestyle and preventative

screening to do that and then the women

end up with dementia frailty like my

mother and grandmother. So I'm like,

"Okay, I want to have as much bone and

muscle strength as I can. So I'm going

to add some testosterone and see what

happens." I I at the time would not have

said I had any sexual dysfunction. I did

not qualify medically for HSDD.

I go on testosterone and there's

definitely an uptick in the area and

everyone is happier like my interest has

improved my initiation has improved and

that had kind of waned time and stress

and kids and whatever the other thing we

were empty nesting at the same time so

that probably no more kids busting in

our door at 2 in the morning letting us

know they're home from you know whatever

experience and you guys will go through

this later but also our communication is

better you know my husband's retired

from Chevron and we are building this

this company together, you know, our

menopause company. And so our

relationship has actually improved

through all of that. So all of the

things that feed into

what we know is female desire and has is

just better all the way around and and I

think testosterone had a little bit to

do with it. My ability to like focus and

my ability to prioritize and put up the

right boundaries has really helped with

that. And we're just having a lot of

more fun with it. But I think that we

would be remiss in this part of the

conversation, and I'll say it. I'm the

orthod, but I'm gonna say it anyway.

Many men, I just talked to my husband

publicly about this because we're trying

to educate men, is that most men don't

realize that in pmenopause, as estrogen

waines, it affects all tissues. And

there is an entity called the genital

urinary syndrome of menopause where the

vagina will actually atrophy and all the

external soft uh tissues that are

usually used to engorging will become

dry like a desert and Stephen sex can

feel like razor blades

and men don't know that and women are

afraid to tell their partners. So the

men feel rejected like why doesn't she

love me or desire me anymore and it may

be that but it's probably not that it's

it hurts and I bleed

and women don't know that this is normal

when you're estrogen is in not that it's

okay to

it shouldn't be it shouldn't be normal

but when you're in a low estrogen state

regard menopause birth control pills can

do it postpartum breastfeeding even you

know progesterone IUD these can all

cause time periods where your estrogen

levels are low enough that the vaginal

tissue is not having the right collagen

and elasticity that it should.

So, what's the solution?

Not lubricant.

Lubricant can sometimes aid, but that's

not a root cause, right? It'll help with

I I help with symptoms, right? But if

your part of the problem is that the

tissue can't respond as it should, that

it's frail, that delay orgasm, then we

really want to get to the root cause,

which is estrogen is crucial for skin

elasticity.

It's like men going on testosterone,

right? If he's not having an erection,

there are 29 solutions for that right

now,

but primarily funded solutions as well.

Solutions. But for women, it's not just

desire, it's physiologic. And so

vaginal estrogen put putting something

up

putting in your vagina

and what you put in your vagina is

so there's there's several options. We

have creams, we have pills, there's a

ring specifically designed just for

that. So we have different methods of

getting the vag you know estrogen into

the vagina. There's also um uh something

called prosterone which is DHEA

basically which is a pre hormone that

the vagina miraculously will convert to

estrogen and testosterone. So but it's

expensive. It tends to not be covered by

insurance. But for our like our sex med

friends, sexual medicine friends who

specialize in this female sexual

function, they love it because you're

not only getting a boost of estrogen to

the vagina, you're also getting

testosterone and there are testosterone,

you know, receptors in the vulva, you

know, in the lower vagina and around the

skin around the vagina as well.

But here's the bonus.

All of this plus vaginal estrogen will

help prevent chronic UTI which kill old

ladies and it will help support the

pelvic floor and the uh uterus from

prolapsing and so it has all these added

benefits and here's another bonus it is

such low dose

it is not systemic so any risk that you

could think of that you might not want

to do systemic estrogen including breast

cancer

is unaffected by vaginal estrogen and so

it is a huge solution. And there's no

age that a woman can't go on 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 UTI and failure of

tissue so she didn't get sores and

infections, right? Isn't that a miracle?

I know Stephen's like,

"Yeah, and we should say that vaginal

estrogen in preparations made for

vaginal estrogen or lowd dose estrogen

preparations. You can give oral

estradiol vaginally and it will be

systemically absorbed because the vagina

is highly absorptive. So I don't want

somebody to hear this and think that but

just saying we often prescribe or

recommend

a local treatment of vaginal estrogen

products which are in very low dose and

they really impact the local tissues of

we'll say the pelvic floor, the urinary

system, the vulva, the vagina and they

improve your well-being and your health

without some of the risk that might come

from systemic hormones in somebody who

may not want to take them.

I am all out of questions. So I wanted

to conclude this segment just by asking

you what the most important thing that I

have missed on the subjects we've talked

about menstrual cycles, menopause,

everything in between. What is the most

important subject you think we might

have missed?

I think we covered it but but to stay

that you control a large part. We said

over and over inflammation and insulin

resistance. We we touched on different

lifestyle factors that impact this

because

when your body is having hormone change,

there's a lot of the external world

around you or the choices you're making

that can make some of that better or

worse or influence what is happening.

And I know we're going to go over more

of this, but I think this idea that I

have no control over what's happening to

me isn't 100% true. I mean, you don't

have control over when some of this

stuff happens, but you can take control

of a situation by understanding your

body, knowing what's happening, knowing

how to advocate for yourself, and making

active decisions to live a healthier,

better life.

Yes, that's the goal is to empower women

to understand, to ask the questions so

they don't feel like something is

happening to them and they don't have

control or options,

which is what our mother's generation

had. They were always gas lit, told, you

know, it's all in your head.

There's nothing we can do.

So, my mother was put on but it was

called butol.

Um, it's basically a sedative and it was

mother's little helper. And I found an

old magazine article where they if you

look at the magazine articles from the

50s and 60s on these medications, mostly

sedatives that were given to women. It's

like now she can do the laundry again.

Now she she's flipping a pancake in the

ad in the apron in the 1950s, you know,

like get your mom back, get your wife

back.

And it was a combination of estrogen

plus a seditive. And I was just

absolutely floored. And I remember mom's

little bottle and it was called butol

and I it would sit on her counter and

she would talk about it like it was her

talisman like it was her and I always

thought of it as mommy's little helper

you know like oh I need my butol oh this

happened where's my butol where's my

butol and when I was researching and

writing and reading about these

sedatives that were given in women I was

like wait mama I remember the bottle I

remember what it was called cuz she

talked about it all the time I went and

looked it up and it's a derivative of

pheninoarbatl.

Oh my gosh.

And it was heavily prescribed to women.

So

barbbituate. It's a a drug.

It's a class of drug that is basically a

sedative. We use it in surgery. We use

it for seizures.

And they were sedating my mother on the

daily.

Yep.

Through her pmenopause.

Mhm.

Now she had eight kids. She was running

a restaurant. You know, she was very

high functioning. And I just refused for

that to be that was her reality. Yeah.

And here she lies in a bed with

Alzheimer's and a fractured hip and she

hasn't walked in 8 months. You know,

she's she's just now getting on a walker

8 months after her hip fracture and from

osteoporosis who's never had a bone

density scan in her life. And like our

our children deserve better. It's not

going to be my future cuz I have the,

you know, I have the means. I have

access. But like I I want every young

girl, all of our children to

have a better future than what was

offered to our mothers.

Exactly.

I think ending this, I would want every

woman to approach her midlife

life, her new life with the same vigor

and the same curiosity and the same

demanding of care that she would do for

one of her children if her child is

sick. She's not going to take no. She's

not going to take being blown off. She's

going to keep searching till the end of

the earth until she finds an answer. And

that's what that is the same kind of

taking control that I want women to do

about this time in their lives.

Thank you so much. We're going to record

we're going to continue this

conversation for the viewers that are

listening at home. Um, I've been through

all of these wonderful books that I have

in front of me and there's so many

lifestyle, nutrition, exercise related

solutions to many of the things we've

talked about today to be an truly

optimized um, hormone healthy menstrual

cycle healthy woman, which I want to

talk about in our part two of this

conversation.

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