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If someone's menstrual cycle is irregular, should they be concerned?

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Yes, yes, yes.

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Your body is meant to work like clockwork,

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and our monthly cycle is so much more than getting ready to have a baby.

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Especially when we're looking at exercise.

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And it's important to say if you don't have a period,

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it's very harmful to long-term health.

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Brain health and mental health, low energy, mood, and libido.

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And I don't want the younger generations to have to go through the stuff that we've gone through.

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So it's an important discussion that we need to have.

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We are joined by four leading female health experts from very different fields.

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To have a crucial conversation about women's health.

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With over 80 years combined experience,

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they're sharing the truth about what every woman and every man needs to hear.

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We asked a thousand women to submit their questions ahead of this conversation,

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and I've got so many questions around fertility,

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understanding hormones, PCOS, both control pills, and miscarriage.

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And I'll say this, Stephen, it's because we haven't had these discussions publicly.

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When we look at finding a woman's health at horrible,

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like less than 1% is spent on women over 40.

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Women are living 20% more of our lives with chronic disease

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or mental health disorders.

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I mean, 50% of patients with unexplained infertility have endometriosis,

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but yet it takes women 7 to 10 years to get a diagnosis after symptoms start.

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But also, there are things that we do that will inherently arm our fertility

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because we're not taught this.

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And it predisposes you to many medical problems later in life.

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And patients will say,

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like, I have a really high pain tolerance.

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Yes, like it's a badge.

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So they gaslight themselves,

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and that's where I'll try to fight her.

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But there are a lot of things we can do to deal with this.

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And then I want to talk about menopause.

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So in medical school, menopause just gets shoved into a tiny box.

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And this is scary, so to say.

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So, oh my god.

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It's crazy.

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I just think it's insane.

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This is why we need to create change.

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This might be one of the most important conversations we ever have on the Diary of a CO.

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Because women's health has long been a total mystery to so many people,

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and so many people are struggling with all of the issues that we're going to talk about today

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with their menstrual cycles,

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PCOS, endometriosis, with diet,

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with understanding how to exercise as a woman.

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It's probably never going to be the case again that these four individuals,

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that at the very top of women's health in their fields

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will be in the same place at the same time having this conversation.

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We structured this conversation into two parts.

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They cover completely different subjects,

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but they're fundamentally interlinked.

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For me, the understanding that I got from this conversation at this table

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with these four women has fundamentally changed my life.

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It's going to change how I deal with my romantic partner,

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my sister, my team members that I work with every single day.

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And funnily enough, because it's a conversation I wouldn't have clicked as a man,

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it turned out to be the conversation that I needed the most.

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

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but if there was ever an episode to share with a loved one,

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then this is that episode.

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Please share this episode with as many women as you can,

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but also with as many men as you can.

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Ladies, we should start with some introductions.

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Could you give me a brief introduction at Stacey,

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as it relates to your perspective and your experience,

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and what your sort of biases as it comes to this debate?

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When I say bias, I mean, you're your experience

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and your research that you're lending to this conversation today.

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I come from the exercise phase in sports med background,

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so I'm always looking through the lens of activity and nutrition,

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and how that has impact on our stress and our stress outcomes,

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and how we can adapt to specific applied stressors,

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especially when we're looking at improving health span,

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improving mood, improving body composition, all of those things.

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I've worked with and still worked with the subset of active women,

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I've come from an endurance and a high profile high performance sport background,

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so that's where I've gotten my chops and then brought it over into the general

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recreational female athlete kind of perspective.

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Natalie.

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I'm a fertility doctor, and every day I help patients with IVF,

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get pregnant because I have an IVF clinic,

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but my big passion has always been natural fertility after I experienced my own pregnancy losses,

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trying to understand how we interact with the world and how that changes our hormones,

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and help women understand what their hormones are,

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what natural fertility is, what happens as we age to our bodies, our eggs in our hormones,

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and let them be better stewards of their own fertility and their own health decisions.

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Mary.

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I have a background in general OBGYN, so I'm considered to be a women's health specialist,

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and it wasn't until I kind of went through my own menopause that I realized that there was

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significant gap in my training, you know, hearing, watching Dr. Sims on, I think, your podcast,

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talking about how women are not little men really struck such a chord with me,

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and maybe realized I was siloing women's health to the reproductive organs, the breast,

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the uterus, the ovaries, the vagina, and that if I really did wanted to make a difference in a

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woman's whole health life, this last 30 years, 30, 40 years of her life, I needed to refocus

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what we were thinking about women's health for the long term. So I come from a background in

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academics. I was a professor for 20 years. I was a residency program director, stepped away from

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that so I could focus on the lack of my own education and knowledge in menopause care,

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and now I want to step back into the academic world to bring everything I've learned and change

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the way we educate our providers. I am a orthopedic sports surgeon by training, and I sit at the

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unique juxtaposition of orthopedics and performance, having taken care of elite athletes most of my

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life, aging and longevity, most of my academic research, I too as an academic, is on subjects of

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musculoskeletal aging. But many years ago, added a third circle of the whole health of a woman,

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and so sitting in this place, it fits directly into the mantra of my career, which has always been,

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I am going to change the way we age in this country and the world, because the tool that I bring to

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the table is the fact that if I save your mobility, I'm going to save you from the ravages of

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chronic disease. And so the work that I do is not only educational, it's research and it's now

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education of the world about these subjects. Explain this to me like I'm an idiot, ladies.

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Why do we need to have a conversation about women's health and not just health broadly?

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I think the statistic that people don't realize on a day-to-day basis is that women are 51 percent

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of the population. We're actually not a minority, we're the majority, and yet often our health,

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our health care access, the research treats us as if we're a niche product, but we are the majority

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product. We have to have this conversation because data show that of the $450 billion spent on

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research in this country alone, less than 1 percent is spent on women over 40. And yet we are

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nearly 90 million people and we make 80 percent of all the health care decisions in this country for

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ourselves and everyone we touch. And so even though when you look at the long-term data, women are

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winning the longevity race here, we're living an average of six years longer than men, but as all of us

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talk about all the time, women suffer longer. We're living 20 percent more of our lives versus

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our male counterparts in poor health with chronic disease or mental health disorders. And so Mackenzie

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looked at the data and it was for the Gates Foundation. And what they found was, yes, we live longer,

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we've all known that. However, we have, you know, twice as high of mental health disorders,

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we're two times as more likely to end up in a nursing home. We are much more likely to lose

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our long-term independence from frailty or dementia much more than our age-matched male counterparts.

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And that's, I think, what we're all trying to fight here. And diseases that impact women

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specifically and only, things like PCOS, endometriosis are extensively underfunded and not

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research. It takes women seven to ten years to get a diagnosis of endometriosis after symptoms

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and we know this is a disease that impacts your entire body in addition to your fertility.

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But women are dismissed. They're not taken seriously. And there's not research guiding

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what we can do in a lot of these situations to try to help them the best.

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Why isn't the research there? Why don't they research if women are the majority of the population?

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Why is all the funding going to researching men? You have to think about who was in the room when

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medicine the science first started. So if you think about back when the industrial revolution

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and the modernization of what we know as medicine, women were pushed out because they were

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believed to have smaller brains, thanks to Darwin, and not thought to have a seat at the table.

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So when you're thinking about designing studies, it was pretty much designed on the male physiology,

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on the male body, and then women were an afterthought. So there wasn't any real in-depth look of

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while women are different from birth or in utero, XX is different from XY. So all the research

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has just been generalized to women, even things like aspirin for heart attacks and thinning blood.

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They can have it ours. Yeah, all of us was done on men and then just generalized to women.

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And now that we're having this global conversation on women's health, people are like, well,

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where is the information specific for women? And there's just a very small subset. So we're looking

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in trying to expand that, but we have a lot of catching up to do. And that's primarily not only

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because of what you said, but the shocking statistic is that not until 1993,

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were women required to be represented in studies. 1993, I mean, we were all far into our lives

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and research by then. Isn't that a shocking? And there were still loopholes where people were

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finding ways to exclude women. And we're still not at 50%. No, we're harder to study. You've

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menstrual cycle, hormonal fluctuations, even a pause, pre-peave in the animal models.

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It's not that we're harder to study. It just makes it presumed harder to study. There's more variables

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at play. Right. It's more of a complexity to the research, but it's not more difficult.

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And this is where I bring it. And it's like if a woman had a seat at the table when all the study

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designs were started, it wouldn't be a question. It would just have been assimilated. But because we've

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been so drawn into we have a crossover. Here's one week crossover next week because of male physiology

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when you add women's hormone fluctuations and people are like, oh, it's too complex. Right. But it's

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not. What is it that make? And this is a super dumb question, but an important one. What is it that

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makes men and women different from a physiological standpoint? Because to understand why research would

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need to be done separately, we need to understand the differences. Yeah. Well, I mean, we can look

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from a morphological standpoint where men have more of our fast switch fibers. Women are born

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more enduring fibers, which is muscle, right? We're talking about muscle, yeah. So men have more of

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the ability to do power and really fast energetic type activities or women are more attuned to

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enduring type activities. And this affects metabolism, it affects blood glucose,

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hormone stasis. And when we're looking at bone and bone density, men have stronger bones.

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They can acquire more load. They hold on to it better than women do. We see smaller lungs,

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smaller heart, less hemoglobin in women than men. And that's an offshoot of what testosterone does.

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So there are just basic physiological differences between XX and XY that people don't really

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assimilate and understand. And the way I like to say it is you go into a shop and you have a

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men's section and a woman's section. And there are touch points on the external that really

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identify gender and or sex. But when you look intrinsically, no one is identifying those

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touch points until now. Also, when we look at how we disease, so in cardiovascular diseases,

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is athletic disease is the best example. Men tend to have their blockages. So athletic disease

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is basically the plaques that build up in the coronary arteries around the heart. Men tend to develop

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their plaques very early right as those arteries exit the aorta and dive into the heart muscle.

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So we get what we call the widomaker. It's called that for a reason because men die and they make

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a widow. And so that's the left anterior descending artery. Women by and large tend to not have these

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larger artery blockages, but their blockages are diffuse and microvascular deeper into the heart

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muscle, which is why we present with a heart attack much differently than a man does. And those

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we're not teaching are, you know, we're not educating our clinicians as to these differences.

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Women are considered to have atypical chest pain. Dr. Wright, 51 percent of the population is

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female. Why are why is my heart attack atypical and a man's typical. But this happens not only at the

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organ level, it makes sense that if we have a population with XX chromosomes, a population with

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XY genetically and the way we express those genes are differently. But I think we miss the fact

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that down to a cellular level, every cell from an XX is expresses these tissue changes, tissue

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manifestations differently than an XY. Our lab used to study, we called the muscle derived stem

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cells, so look 20 years ago, now they're called satellite cells. But when we harvested them and

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asked them to behave in different environments, satellite cells from XX people and XX animals,

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women, females were better under the same circumstances, experimentally, at making cartilage and

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muscle. XY, male were better under the same circumstances in making bone. So down to a cellular

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level, we express our genes differently. It should be no mystery to us or anybody else that there

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are differences. And yet there is the propensity just to lump us all in the same basket. And

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almost say, I almost sometimes feel as pejorative to say, oh, the women are different. Of course,

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they're different. We're genetically different. Down to every cell in our body. Every cell,

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so it should be no surprise to anybody. But it seems to be a surprise.

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Oh, all the time. Yeah. Get pushed back all the time. There's no difference. Yes, there is.

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There is. And it's not just me saying that. It's just this. Yeah.

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Yeah. Yeah. Because at one point, that was quite a controversial thing to say, wasn't it

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to point at the differences between men and women? Outside of, you know, our different organs.

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Yeah. Yeah. And because of this research gap in the bias in medicine, women have been misunderstood

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by their male counterparts in a number of ways. I remember, I think it was you, Mary,

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that was telling me about this whiny women thing that you were exposed to.

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When I was in training, and you all may have similar stories, and I just heard a new one the other

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day, my first patient in gynecology clinic, I'm an intern. I'm very excited. You know, we have

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our stacks of charts. That's how old I am. We had paper charts. I pick up the chart, open it up.

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It's a 40-year-old woman with multiple vague complaints. She's gained some weight. She's a

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little bit depressed. Her libido's off. Her blood pressure's a little bit up. Her cholesterol

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starting to rise. And she's seen family medicine. Like, we're the third or fourth doctor at this point.

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And so my upper level, who happened to be male, this, you know, it could have been anyone,

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walks down the hall in his cowboy boots because Texas. And he's like, what you got? And I said,

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well, I have Miss Smith, whomever. You know, she's a 40-year-old woman with, and I list the

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complaints. And he goes, did you check her thyroid, family medicine, did you check this? You

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know, a few simple labs. And he goes, hmm, you got a WWE. And I said, what's, I don't know this,

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you know, and he said, uh, don't write this in the chart, but we call that a whiny woman around here.

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And I said, okay, he said, listen, women just tend to go through this at this age. And

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we're not really going to be able to help her. Pat her on the knee, tell her to have some wine,

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go on date night, you know, show get better, but we're not going to be able to help her.

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And that stayed with me. Now, I was, you know, a good girl. I did what I was told, you know,

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it took me 20 years of internalization to realize this, you know, I don't want to blame him.

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It's not a bad guy. This was taught to him. But this kind of thinking, I mean, I saw this in the ER,

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I saw this in the OR, I saw this in every clinic. And so I've asked other clinicians around the

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country. And I've heard whiny guinea, status, panicus, total, TBD, total body, delur. Like in different

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regional areas, there was a name for this kind of vague complaints from this middle aged woman.

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And we couldn't quite put our finger on it. And I realized this was systemic bias built into

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the system where women, their sister will call, you know, precedent for this, the wandering

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uterus, the hysteria, you know, these were real medical terms, just until like not even a generation

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ago. Yeah, they used to put women into asylum. Yeah, because of hysteria. And it was hot flashes,

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all the things that are now known with parimenopause. They used to think it was some kind of insanity

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and put women into insane asylum to lock them down. But this is pervasive, not just an OB, you

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are not the only guilty. It's every medical subspecialty has some culture of for lack of better

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words blowing women off. It, right, for not having the curiosity that defines medicine,

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we are supposed to be curious people. But yet when it comes to this, why do we stop at just

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seems to be something that happens in middle aged women, right? That's written in the orthopedic

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literature, seems to happen in middle aged women. Where's the curiosity? Where was it? Yeah.

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Well, in ex-fist texts, you always had the representative of him or they and the visuvious man

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and all the angles of the male body. But there was never representation of women. The only time

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you heard about a female athlete was all the pathophysiology. You know, they ironed efficiency,

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the female athlete triad, which we now call relative energy deficiency in sport. And when you're

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looking at the historical idea of sport, the only way women were actually included and accepted

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is when they were amenoriac because then they were quote more like men. And then there wasn't a

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problem with training them and then they could work as hard. But we know that that's not appropriate.

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That's a sign of illness and overtraining under recovery. So it is pervasive everywhere. It's not

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just the medical, but it goes into when you think about what it means to be successful in sport. It's

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the power, it's the aggression. It's the unfalability of being human and a woman having a

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menstrual cycle was deemed a fallibility. So they're trying to push it aside. This is so systemic,

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though, that women downplay their own complaints. They gaslight themselves. It takes them a long time

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to seek care because they're afraid of the response. They are not always honest with what's going

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on in their body. I'll say, do you have pain? Oh, no more than regular. They downplay everything.

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You have to really ask. And it's almost the society. I don't want to be viewed as this way.

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I don't want to be not taken seriously and it causes them to have an even harder time to get to

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a diagnosis because they don't feel comfortable sharing some of these symptoms or they've downplayed

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them in their life so much. This is why they have to get so sick to often present to even try to get

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care. And they come to me almost to a woman after I'm talking about whatever musculoskeletal thing.

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They'll say, even before they want to describe it to me, they'll say, but you know, I have a really

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high pain tolerance. Yes. Like it's a badge because we've been conditioned to not come for any

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pain. But I've suffered. I've tried. That's why your arm doesn't move anymore. I've got such a

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high pain tolerance, but I couldn't take it anymore. I didn't want to come. And I feel like,

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why does that have to be that way? So you train treating both males and females. I do. I was

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locked in a room with women for 25 years. And so it's so fascinating to me to hear how man and woman

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coming with the same complaint in your clinic and your fellowship, all those years you spent training.

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And yet you were taught to treat them differently. And the urologists say the same thing.

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I don't think I was aware of it. There was just that's so much bias. I didn't realize. I didn't

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either. Because like you, until I went through my own parry menopause, I might not have paid

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it attention to it. I may have been less sensitive. I was a terrible menopausitor.

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Just give me 30 seconds of your time. Two things I wanted to say. The first thing is a huge thank you

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for listening and tuning into the show week after week means the world to all of us. And this

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really is a dream that we absolutely never had and couldn't have imagined getting to this place.

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But secondly, it's a dream where we feel like we're only just getting started. And if you

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enjoy what we do here, please join the 24% of people that listen to this podcast regularly and

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follow us on this app. Here's a promise I'm going to make to you. I'm going to do everything in

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my power to make this show as good as I can now and into the future. We're going to deliver the

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guests that you want me to speak to and we're going to continue to keep doing all of the things you

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love about this show. Thank you. Is that in part because we know very little about hormones as well?

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When I was speaking to our audience, we asked a thousand women to submit their questions ahead

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of this conversation. And one of the most asked questions, all the most asked questions sort of

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related to understanding hormones. I think the conversation around hormones is quite a new one

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in society. And I actually think it's been driven a lot by a heightened understanding of

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menopause generally. I think the the conversation of hormones around outside of fertility and the

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general menstrual cycle, I can right now draw a memory, the exactly what's going to happen in a

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normal menstrual cycle. We were taught that, you know, very, very well. But when I saw maybe three

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years ago, an academic paper that showed all of the locations of the G coupled estrogen receptors

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in the human body, I lost my mind. So basically where are the estrogen receptors in the human body?

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And they're everywhere. The brain, the bones, the muscle, the gut, you know, the every almost nothing,

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the endothelial, the lining of the individual blood vessels around our heart. You know,

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it's really radical to me to think about how all these sex hormones or the progesterone estrogen

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testosterone hormones are everywhere. What is a hormone? Not actually sex hormones.

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Hormones are your body's communication system, right? So it is really how your body is sending out

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messengers to communicate. So a hormone is dictating an action. And I think there's going to be a

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lot of great discussion. But one thing that I think is very important to your point, Steven,

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is even things that we were readily taught about, the menstrual cycle and estrogen progesterone,

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testosterone, the public is now becoming aware of because we've not done a good job at public education

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that this is what's really happening in your body. This is what your menstrual cycle is.

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This is what happens when you go through menopause. This is what happens when you're trying to train

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for a sport. We haven't had these discussions publicly that we are seeing. And I think that is

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highlighting interest in all of this, even if some of us were taught some of this. But when it comes

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to hormones, everybody wants really easy fast. Draw my level, tell me what to do, give me a medicine,

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fix it. And I think the most important thing to understand is that by definition, your hormones

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are dynamic. Your body is responding to the hormonal signal it sees and just terminating what next

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signal to send out. So constant fluctuation throughout the day in response to multiple stimuli.

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And that's how it's supposed to be. If we didn't do that, we'd all be dead. It's a symphony.

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But that makes it really hard for somebody to understand on the other end who's not in medicine,

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who says, well, is it my hormones? Because there's no one test that's going to give you one answer.

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You have to really interpret it in context of the full body. And it makes it really hard for

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practitioners who do not understand the hormones as well. And we see a lot of mismanagement of

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hormonal scenarios and situations right now that are actually detrimental to patients. So I'm glad

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you're having this discussion because that's not a stupid question. What is a hormone? Many people

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don't really understand that. What is that? I really want to make sure that if someone for both

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the men that probably have less understanding, but also for more conversations I've realized in

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the feedback I've gotten a lot of women don't understand their own hormones and their

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menstrual cycles. What is the most basic level that we have to start out to give people an

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understanding that we can then build on of what's going on here? As I say, I want to get rid of this

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graph. Okay. So leave it out. But it shows just a textbook of what a menstrual cycle is.

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But it doesn't show the daily perturbations of estrogen and the luteinizing hormone pulses.

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And all the things that go as Natalie is saying to make it to make it work.

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It's an EC2 organs there, the ovary and the endometrial lining. You're not seeing the muscle,

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the bone, the brain. All of those organs are affected by these normal monthly fluctuations.

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And the conversation that we're having now in research methodology is the fact that there is

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no real definition of normal because every woman's cycle is a variable. So when we look at this,

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everyone thinks that this is normal, but we don't actually know if that is.

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For the fact that a woman's variation, this can change cycle to cycle. This can change cycle to

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cycle. Sometimes we have an ovulatory cycles. So until a woman can identify what her own normal is,

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we can't rely on this graph to actually explain to them. How does a woman know what their normal is

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versus, you know, because a lot of women are on birth control pills since a very young age.

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I think my partner, Melanie, she was on birth control for about a decade. So she didn't have her

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cycle. And then it came back and it was every, I don't know, 60, 90 days. And then she changed her

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diet a little bit and it kind of went down to 30 days over time. But I don't think she knew what

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normal was. Is there such thing as normal? I mean, there is what should be normal for you. So you

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should have a regular predictable period, which means that you are having a menstrual bleed at a

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predictable interval. It can range person to person. But for you, really, it should be within

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a couple days month to month. I always tell patients, I should be able to give you a calendar,

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you should be able to take your finger, pick when your next period is coming and within a few days

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be accurate. Now, usually that range is somewhere between 25 and 35 days for the average person.

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When it starts to get shorter or longer, it can be a warning sign that something is going on.

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When it comes to the menstrual cycle, because I think we're going to talk about these hormones

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really well. And I talk about this every day. Let's give a one minute explanation. If we think about

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to Stacy's point from the brain, the brain is sitting out pulses of hormones, but FSH drives

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at growth. It's called follicle stimulating hormone and each egg is inside a follicle. So you

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have a group of follicles inside the ovary. FSH comes from the brain, grabs one of them and gets

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it to grow and it makes estrogen. And this estrogen from the ovary as the egg is growing is called

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estradiol and it's the primary type of estrogen in your body. So it is rising and when it gets to

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a peak level, and the body is so fascinating because it's 200 pg for 50 hours. It's a very exact

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amount. Then the brain says, we must have a mature egg and it kicks out a surge of luteinizing

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hormone or LH. And that is going to allow the follicle to rupture, the egg to be released,

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and the follicle to reform and then become a corpus ludium. And then the brain's going to send out

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pulses of LH giving you pulses of progesterone. So Stacey's point, that's an average and those

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numbers on the little graph are nowhere in your accurate because progesterone goes up and down the

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entire second half of the cycle known as the luteal phase. What's progesterone? Progesterone is

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also made from the ovary. So the two main hormones when it comes to a premenopausal female are

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going to be estrogen and progesterone. Progesterone is the progestational hormone or pro pregnancy.

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It is going to change the endometrial lining and it is essential to get pregnant. It opens and

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closes the implantation window within the uterus and it completely changes the physiology of your

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body. And we're going to talk a lot. That is why in the luteal phase, your body works differently

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when you have progesterone. And the luteal phases. After ovulation when you have a corpus ludium.

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So when LH is coming from the brain, you have a corpus ludium. It makes progesterone. This is the

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second half of the cycle known as the luteal phase. The first half when you have estrogen only

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is the follicular phase. So you have an estrogen dominant phase and then you have a phase where you

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have both estrogen and progesterone. And your body is made, yes. So we have our estrogen dominant

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phase, the follicular phase. And then we have where we have both estrogen and progesterone here

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in the luteal phase. And your body is made to function differently in these because in the progesterone

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side, it's preparing you for pregnancy. It thinks every month you might get pregnant and it starts

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to change how your body is going to work on a cellular level. But if you don't get pregnant,

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that progesterone level is going to drop and the cycle starts back over. And from like an exercise

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in sports point of view, when we get into this progesterone's job is to build this lush

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endometrial lining. And it creates a lot of glycogen stores. So we often hear about glycogen

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in the muscle and that's what we're using for fuel. It has a way of shuttling a lot of the

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carbohydrate away and storing it into the endometrial lining, which is why we see differences in

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intensity and the way that a woman can respond to exercise if she has ovulated. So is this

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in preparation of a potential baby? Yeah. Correct. Yeah. And the second half of the cycle, your

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core body temperature increases. Your resting heart rate is higher. Your heart rate variability

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is lower. You have increase in fatigue. You have an increased appetite. Your body is shifting

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function. In case an embryo comes in so that it can start to divert energy and change what it

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is doing right down to your immune system changes. And that's roughly from day 14, roughly.

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Roughly. Yeah. At ovulation. About three days after ovulation. If you'd like to be specific,

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it's about three days after ovulation until when you get your next period. Yeah.

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You will talk about how menstrual cycles can be a broader sign of whole body health.

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And so if someone's menstrual cycle is irregular, should they be concerned? Yes.

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I thought you were going to say no. How irregular. What's like, if I'm not getting my menstrual cycle?

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Absolutely not good. You should go see a doctor. Yeah. If your cycle is irregular,

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if the calendar trick you're putting your finger and it's nowhere near when your cycle is coming,

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or I have women who say, oh, there's no way I could predict it. Or I know it will come,

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but it'll come every four to six weeks. Your body's meant to work like clockwork when it comes to

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your hormones and your menstrual cycle. And yes, you can always have one abnormal month always.

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But when you consistently are having irregularity, that is a sign that something else is going on.

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It's one of the biggest red flags that we have for early hormonal health or systemic problems.

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But to your earlier point, Stephen, we have a generation of women on contraceptive options

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who are not tracking their cycles. We have women who are not taught how to track their cycles.

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They don't know when ovulation occurs. They don't know how long their luteal phase is.

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If I say the first sign of ovulatory dysfunction or having a problem with your cycle

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is a short luteal phase. Well, you only know that if you're tracking when ovulation occurs,

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because otherwise you could still have a regular cycle, but you don't know that something's abnormal.

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And that luteal phase again is the last half of your cycle.

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But I think that the conversation that's happening now is not just at this table,

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but in society that our monthly cycle is so much more than getting ready to have a baby.

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Because I think that none of us knew this because at 17 I wasn't that interested in having a baby.

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So it didn't occur to me that I should care. Right. And it's the only time

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if you're thinking about it in that way that you're worried about your period is if you don't have one

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and pregnancy, right. And so if we're shifting the conversation to this is physiology.

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This has to do with every part of female physiology.

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Maybe it will be easier for people to know. Right.

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Yeah, I often put it with my athletes. That is a marker of health that if you are able to take

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on the load of training, the load of travel and maintain your normal menstrual cycle,

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then you are robust enough to be able to progress. But if there becomes a misstep in your menstrual cycle,

399
00:33:32.720 --> 00:33:38.480
then we need to look at all the stressors that are in the allostalk load and pull you back and see,

400
00:33:38.480 --> 00:33:42.960
what do we need to address? Do you need to eat more? Do you need to recover more? What are the

401
00:33:42.960 --> 00:33:48.480
things that are missing to bring you back to normal? I was diagnosed with polycystic ovarian syndrome

402
00:33:48.480 --> 00:33:53.040
in medical school. And so like every medical student, of course, it was like gloom and doom.

403
00:33:53.040 --> 00:33:57.920
And I thought I had the most extreme case ever known to mankind. It was really just garden

404
00:33:57.920 --> 00:34:03.440
variety PCOS. And I had very serious boyfriend quickly engaged, looking forward to having a

405
00:34:03.440 --> 00:34:10.400
family with him, starting a family with him, and the terror around my own fertility and what the

406
00:34:10.400 --> 00:34:15.600
impact was. What was never taught to me and what I didn't understand until much later was the

407
00:34:15.600 --> 00:34:20.480
metabolic impact. Like PCOS is a symptom. There's nothing wrong with my ovaries. They're just

408
00:34:20.480 --> 00:34:26.480
responding to this high insulin level I was born with. And no one really sat me down and talked to me

409
00:34:26.480 --> 00:34:30.960
about my first research project was women with irregular periods and the risk of developing

410
00:34:30.960 --> 00:34:35.920
gestational diabetes. And I didn't even know what insulin resistance was at the time.

411
00:34:36.720 --> 00:34:43.280
And now we're coming to understand that when these young women are coming, I only do menopause

412
00:34:43.280 --> 00:34:47.840
now. But before I left that practice, you know, when women were coming with irregular cycles

413
00:34:47.840 --> 00:34:52.000
and we were making these diagnosis immediately, I was launching into the discussion about her metabolic

414
00:34:52.000 --> 00:34:57.360
health long term. And what this, you know, it's a gift to know this. So now we can start making

415
00:34:57.360 --> 00:35:04.400
interventions, nutrition, diet, exercise to give you a better system to deal with this thing that

416
00:35:04.400 --> 00:35:08.800
you were born with and her fertility, of course. A huge amount of women have PCOS and I think that's

417
00:35:08.800 --> 00:35:13.680
one of the leading, one of the leading, one of the top causes of having irregular menstrual cycles.

418
00:35:14.640 --> 00:35:19.680
You mentioned insulin resistance and metabolic dysfunction there. And you said something like

419
00:35:19.680 --> 00:35:27.600
just gestational diabetes? Diabetes in pregnancy. So someone who was non-diabetic before pregnancy

420
00:35:27.600 --> 00:35:32.480
and then develops diabetes. So her blood sugars have now reached a threshold where they are

421
00:35:32.480 --> 00:35:37.120
higher than normal and can cause, you know, problems for her pregnancy in her self-long term.

422
00:35:37.840 --> 00:35:44.480
And up to 50% of those patients who develop diabetes in pregnancy will develop type two

423
00:35:44.480 --> 00:35:50.800
diabetes within 10 to 15 years after that gestation, after being pregnant. And so what we know now

424
00:35:50.800 --> 00:35:55.840
is like we have warning signs of this well before pregnancy where we can set these women up for

425
00:35:55.840 --> 00:36:00.560
success before it's just we wait till we make the diagnosis. Everybody gets their glucose test

426
00:36:00.640 --> 00:36:07.120
and off you go. But now with this PCOS diagnosis, we are monitoring earlier. We're starting her

427
00:36:07.120 --> 00:36:11.280
on the nutrition. You know, we're treating her like a diabetic with nutrition and exercise

428
00:36:11.280 --> 00:36:17.760
recommendations rather than waiting till she reaches the criteria. Steven, having infertility.

429
00:36:17.760 --> 00:36:25.440
This is scary statistic. It predisposes you to many medical problems later in life, including an 80%

430
00:36:25.440 --> 00:36:29.920
higher chance of having a heart attack, 75% higher chance of having metabolic syndrome,

431
00:36:29.920 --> 00:36:35.200
higher risk of cancer and early death. Why infertility? Well, it's not exactly that infertility is

432
00:36:35.200 --> 00:36:40.960
causing this, but it's that for many women, we'll use Dr. Haver's example. You're healthy

433
00:36:40.960 --> 00:36:45.760
until you get this diagnosis. It's one of the first warning signs your body's giving you

434
00:36:45.760 --> 00:36:51.440
that there might be inflammation and insulin resistance or something impacting your hormone,

435
00:36:51.440 --> 00:36:57.280
your menstrual cycle, your ability to conceive, that if it is not corrected now is setting you up

436
00:36:57.280 --> 00:37:05.120
for many problems down the road. PCOS is an example of this because in PCOS, you have a lot of eggs

437
00:37:05.120 --> 00:37:11.120
inside the ovaries. Actually, something that genetically runs in families, likely there's something

438
00:37:11.120 --> 00:37:16.320
that happens when you're a baby inside your mom that predisposes your ovary to not lose as many

439
00:37:16.320 --> 00:37:21.360
eggs as it should and it changes how they respond to insulin. What happens is you end up having

440
00:37:22.080 --> 00:37:27.200
more eggs on an average. Your brain doesn't know this, and since I'll be average signals,

441
00:37:28.080 --> 00:37:32.000
but that gets diluted amongst all the eggs. You're not getting into these

442
00:37:32.000 --> 00:37:37.120
ovulatory stages of Stacy's favorite graph here. What happens from there is that you're actually

443
00:37:37.120 --> 00:37:43.200
in a relatively lower estrogen phase than you should be. You never see the progesterone. What

444
00:37:43.200 --> 00:37:49.600
happens is you start to completely shift the ovary itself actually becomes insulin resistant. What

445
00:37:49.600 --> 00:37:56.400
this means is that throughout your entire body, you start to develop high glucose, which is the blood,

446
00:37:56.400 --> 00:38:00.480
right? That's your blood sugar. Your blood sugar is the fuel for all your cells, all your cells

447
00:38:00.480 --> 00:38:05.280
knee glucose. Well, insulin is the hormone that helps that glucose go from the bloodstream into

448
00:38:05.280 --> 00:38:10.400
your cells. Well, in insulin resistance, when your body sees high glucose all the time, it starts

449
00:38:10.400 --> 00:38:15.280
to send out more insulin saying, hey, we need to get this into cells, but the cells start to,

450
00:38:15.920 --> 00:38:20.560
oh, I'm used to insulin being here, so I'm not going to respond. It's going to take a higher

451
00:38:20.560 --> 00:38:26.720
insulin signal to get the cell to open up the door and let glucose come in. This becomes very

452
00:38:26.720 --> 00:38:32.240
problematic, especially in, we'll say PCOS, because that insulin is very inflammatory,

453
00:38:32.240 --> 00:38:38.240
causes you to get extra fat stored in different places. It also just completely changes how your

454
00:38:38.320 --> 00:38:42.800
body, your metabolic health in general, but also your hormonal health and in your brain, because

455
00:38:42.800 --> 00:38:47.440
your brain sees this and says, why are we keeping glucose in our bloodstream? What's going on?

456
00:38:48.080 --> 00:38:54.480
Hightens everything. This resistance to insulin actually shifts how your brain's going to respond

457
00:38:54.480 --> 00:39:00.240
to hormones. Therefore, the hormones it's sending out and it's a self-perpetuating cycle. A lot of,

458
00:39:00.800 --> 00:39:06.160
when we talk about lifestyle mechanisms to improve hormonal health, which I know that we all will,

459
00:39:06.160 --> 00:39:12.480
a lot of that is targeting improving insulin resistance and combating inflammation, because those two

460
00:39:12.480 --> 00:39:18.720
players, a lot of it is controlled by the world around us and what we do to some degree. Especially

461
00:39:18.720 --> 00:39:24.160
if you have an underlying diagnosis like PCOS, endometriosis, which is a chronic inflammatory

462
00:39:24.160 --> 00:39:29.440
disease, autoimmune disease, you're at even higher risk. I always say your scale is already

463
00:39:29.440 --> 00:39:35.280
tipped in a way that's going to be really hard for you to make active steps to fight what is

464
00:39:35.360 --> 00:39:40.640
happening inside your body. We'll talk about some of the ways one can reverse their PCOS if that's

465
00:39:40.640 --> 00:39:47.360
even a possibility. But again, on the causal factors, is it something, so my girlfriend's got PCOS.

466
00:39:47.360 --> 00:39:52.320
She's been very public about that. Is it something she did? Is it something she ate? Is it, is it,

467
00:39:52.320 --> 00:39:58.400
is this the way she was born? So she was born with a predisposition of having too many eggs. You

468
00:39:58.400 --> 00:40:02.160
lose most of the eggs inside your body when you're a baby and your mother's womb. You lose the

469
00:40:02.240 --> 00:40:07.920
next biggest set before you ever have your first period. Now, if you don't lose them for some

470
00:40:07.920 --> 00:40:12.960
reason, you're born with more and it interferes with how your hormones are supposed to communicate,

471
00:40:12.960 --> 00:40:18.560
leading to this metabolic issue and this insulin resistance. She did nothing to cause this. Nobody

472
00:40:18.560 --> 00:40:23.680
with PCOS caused it. However, what you said earlier, oh, she changed how she ate and her cycles

473
00:40:23.680 --> 00:40:30.720
got more regular. You can influence the severity of the symptoms that you experience with it. So

474
00:40:30.720 --> 00:40:35.520
even if you don't cause your disease because you did not, choices you make can make it,

475
00:40:35.520 --> 00:40:40.240
absolutely can make it better or worse, just like any disease. And when you used the word

476
00:40:40.240 --> 00:40:45.600
insulin, I think of insulin resistance, I think of sugar. Yeah, because glucose is sugar,

477
00:40:45.600 --> 00:40:50.560
essentially. And many people and I'll have patients tell me this, I don't need to worry about insulin

478
00:40:50.560 --> 00:40:55.920
resistance because I don't have diabetes or it's not in my family. We've so we've ingrained

479
00:40:56.000 --> 00:41:01.680
this word insulin resistance. We're talking about glucose or checking glucose with a diabetic

480
00:41:01.680 --> 00:41:09.280
or pre-diabetic state. But the world around us honestly promotes insulin resistant. That's how

481
00:41:09.280 --> 00:41:15.520
our bodies have announced it. Obesogenic environment. I mean, there's no doubt, at least in the US,

482
00:41:15.520 --> 00:41:21.600
you know, and most industrialized nations, our environment is what we call a besogenic insulin

483
00:41:22.000 --> 00:41:28.320
and insulin resistant agenic. So you have to fight against the systems that are in place now,

484
00:41:28.320 --> 00:41:32.960
for most of us, unless we have some genetic predisposition to just be magical.

485
00:41:34.400 --> 00:41:39.600
To because the way we process food, the way food is delivered to communities, the way

486
00:41:39.600 --> 00:41:46.640
our lack of exercise, everyone's working from home now, just modern life is really, you have to

487
00:41:46.640 --> 00:41:50.560
fight against. One of the questions that came in from the audience was, I would like to know how

488
00:41:50.640 --> 00:41:56.800
best to manage my PCOS. When it comes to managing your PCOS, targeting those two factors that we

489
00:41:56.800 --> 00:42:01.680
talked about earlier, insulin resistance and inflammation are really the key. And I'll let

490
00:42:01.680 --> 00:42:06.720
these two speak to a little bit of some of the exercise changes that we can try to impact.

491
00:42:06.720 --> 00:42:11.840
But what I'll say is that the best way to decrease inflammation in your body is going to be to start

492
00:42:11.840 --> 00:42:18.080
by focusing on your gut. Your gut health controls a lot of the inflammatory burden that your body sees.

493
00:42:18.080 --> 00:42:23.440
The foods you choose to eat, they can be both helpful. If they have a lot of fiber in them,

494
00:42:23.440 --> 00:42:28.320
they can feed your gut microbiome, which is important in estrogen metabolism,

495
00:42:28.960 --> 00:42:33.760
but they can also be very harmful if they are ultra-process foods that are even causing more

496
00:42:33.760 --> 00:42:38.880
inflammation, not feeding your gut microbiome at all and worsening. So I always say it's like a

497
00:42:38.880 --> 00:42:44.880
scale. If you think every little food I eat, it can make my insulin or it can make my inflammation

498
00:42:44.880 --> 00:42:49.920
better. It can make it worse. And so how we structure the food that we put in our body

499
00:42:49.920 --> 00:42:55.600
is one of the biggest changes the majority of people can make that is going to make a difference.

500
00:42:55.600 --> 00:43:00.960
And that's going to be a very plant-forward diet, doesn't mean it's plant-only, but plants have

501
00:43:00.960 --> 00:43:05.200
fiber. Fruits and vegetables have fiber. So we have to make sure we're getting fiber

502
00:43:05.760 --> 00:43:11.280
as a big change. That's what we see. I see a lot of patients with PCOS specifically being told I

503
00:43:11.280 --> 00:43:16.960
shouldn't eat fruit. I shouldn't do this. I need to avoid the ketogenic. I need to do keto,

504
00:43:16.960 --> 00:43:21.520
yes. So we see people avoiding certain food groups. And I always say it's not a really sexy diet,

505
00:43:21.520 --> 00:43:27.200
but it's a diet we all know. Yeah. Lots of whole foods, fruits and vegetables, healthy fats,

506
00:43:27.200 --> 00:43:31.680
healthy sources of protein, avoiding the ultra-process foods. That's going to be probably the

507
00:43:31.680 --> 00:43:37.120
biggest change most people can make in addition to foundational changes of your day, which is going to

508
00:43:37.440 --> 00:43:42.800
sleep more. That is when your body fights inflammation, fights insulin resistance,

509
00:43:43.520 --> 00:43:48.640
work on decreasing chronic stress to Stacey's point. You're not running from the bear. So your

510
00:43:48.640 --> 00:43:56.640
body is not using that challenge, but you get an email and you get stressed. And your body releases

511
00:43:56.640 --> 00:44:01.120
a lot of glucose. So we can have sugar and fuel to run from a bear. And there's no bear, right?

512
00:44:01.120 --> 00:44:06.160
In previous days, that would happen. And then you'd go run and that glucose would go into all of your

513
00:44:06.160 --> 00:44:11.440
muscles and your body would go back to normal. But now we're chronically stressed. So actively

514
00:44:11.440 --> 00:44:17.360
decreasing stress. And then exercise. Building and using skeletal muscle is one of the most

515
00:44:17.360 --> 00:44:24.080
effective ways to combat insulin resistance that exists. And since 80% of patients with PCOS

516
00:44:24.080 --> 00:44:29.760
have insulin resistance, a large portion of women with infertility even without PCOS have

517
00:44:29.760 --> 00:44:35.680
insulin resistance, that is a huge thing that people are missing, especially when it comes to the

518
00:44:35.680 --> 00:44:39.840
exercise discussion. And I know you guys probably have things to add on that one.

519
00:44:39.840 --> 00:44:44.160
No, but based on what you just I just took a phone call this morning from a patient when

520
00:44:44.880 --> 00:44:50.240
and it's just such a typical conversation, she doesn't like the way her body looks.

521
00:44:51.280 --> 00:44:58.880
Her solution is not to eat. This happens almost every day when I'm talking to people. We're having

522
00:44:58.880 --> 00:45:06.240
coffee for breakfast. We don't eat till midday when we do eat. So the gut reaction because of the way

523
00:45:06.240 --> 00:45:11.840
many women are raised is that we're going to starve ourselves, which is the opposite of good

524
00:45:11.840 --> 00:45:18.240
when it comes to physiologic wholeness. And then you don't have the energy to do the kind of exercise

525
00:45:18.240 --> 00:45:25.280
you need. Or on the other side, the response is, I am going to work so hard every single day

526
00:45:26.160 --> 00:45:32.640
that you actually increased your stress, there is over there is over training. So you're just

527
00:45:32.640 --> 00:45:37.120
getting behind the eight ball with starving yourself and over training, none of which are going to

528
00:45:37.120 --> 00:45:44.560
solve either the core problem due to PCOS or the core problem in any stage of a woman's life.

529
00:45:44.560 --> 00:45:48.720
Right. And this is where we look at the sociocultural effect of what a woman is supposed to look

530
00:45:49.360 --> 00:45:55.520
like. Yeah. And that's the thing that I'm really pushing out. It's like, we want to think about

531
00:45:55.520 --> 00:46:01.680
how strong we can be and how much muscle we can build because muscle is a massive metabolic help.

532
00:46:02.560 --> 00:46:09.360
And as well as bone, right? We talk about it. And then when I get the pushback of, oh,

533
00:46:09.360 --> 00:46:13.600
I'm going to do fasted training or I'm going to fastill noon, I'm like, wait a second. Not only

534
00:46:13.840 --> 00:46:19.200
we're going to interfere with our circadian rhythm and our hormone pulses. We're also acutely

535
00:46:19.200 --> 00:46:25.440
interfering with our appetite hormones because we're looking at acylated garylon, which is our active

536
00:46:25.440 --> 00:46:31.280
form of our appetite makes us hungry. It's elevated with cortisol. And so for thinking about that

537
00:46:31.280 --> 00:46:36.640
elevation and we're not doing anything to drop it and tell our body we have food, then it goes in

538
00:46:36.640 --> 00:46:42.240
and directly affects our neuropeptides, which then affects our hormone and our hormone pulses.

539
00:46:42.240 --> 00:46:46.000
So when a woman's like, I'm just having coffee for breakfast and I'm going to hold my fast is

540
00:46:46.000 --> 00:46:49.840
like, okay, well, here we go. Cortisol is going up, acylated garylon, you're going to get hungrier,

541
00:46:49.840 --> 00:46:54.320
then you're going to learn not to respond to that hunger. You're going to hold your fast and we see

542
00:46:54.320 --> 00:46:59.600
from the research that women who do that end up craving more simple carbohydrates in the afternoon,

543
00:46:59.600 --> 00:47:05.200
moving incidentally less and contributing to poor sleep because they've now phase shifted.

544
00:47:05.200 --> 00:47:09.360
So when we're talking about sleep and how important sleep is, we also have to think about the

545
00:47:09.360 --> 00:47:15.120
circadian rhythm and how it is affected by food intake, light darkness and all of the things

546
00:47:15.120 --> 00:47:19.920
and we need women to understand, we want to build muscle, we want to sleep well and that requires

547
00:47:19.920 --> 00:47:26.720
food. Well, and this goes back, this whole thing you just said goes back to very early in this

548
00:47:26.720 --> 00:47:33.600
conversation where I was talking about sometimes we like to focus on the bright shiny gadgets.

549
00:47:34.240 --> 00:47:41.680
When we haven't taken our health from fine to optimize because everything you just talked about,

550
00:47:42.880 --> 00:47:50.560
it isn't a gadget, it's basic lifestyle. In the medical model of PCOS when I'm talking about

551
00:47:50.560 --> 00:47:58.720
what we're taught and how we train our clinicians, we go into the, we aren't taught a lot about

552
00:47:58.720 --> 00:48:02.160
disease prevention or and I hate to use the term root cause because I think it's been

553
00:48:02.160 --> 00:48:07.520
usurped by certain members of the wellness community. Take it back. We're going to take it back.

554
00:48:07.520 --> 00:48:12.640
And so especially for PCOS, I was taught to give a patient birth control pills or plummet when

555
00:48:12.640 --> 00:48:20.640
she's ready to get pregnant and so nothing, nothing around nutrition, exercise, lowering inflammation

556
00:48:20.640 --> 00:48:26.960
and I was a program director until 2018 and there was nothing in the curriculum around this,

557
00:48:26.960 --> 00:48:34.880
which affects at least 10% of women, probably more this condition that how important lifestyle is.

558
00:48:34.880 --> 00:48:39.920
You know, she went on for 10 minutes about all the lifestyle check, which is amazing, which is amazing.

559
00:48:39.920 --> 00:48:43.600
But patients, I'm seeing her taking our control pills, first control, I mean, that was a

560
00:48:43.600 --> 00:48:49.280
knee jerk reaction. I mean, I was treated for my own polycystic ovarian syndrome for 20 years

561
00:48:49.920 --> 00:48:56.800
with oral contraceptive agents and I learned online through check rooms about the nutrition end of it.

562
00:48:56.800 --> 00:49:04.960
Yeah, when I have athletes because we see a higher percentage of PCOS and successful female athletes,

563
00:49:04.960 --> 00:49:10.400
why? I go, what do I do? And it's looking at what kind of training they're doing. So we're putting

564
00:49:10.400 --> 00:49:16.000
this more short, sharp high intensity to get that post-sectorous response of anti-inflammatory,

565
00:49:16.640 --> 00:49:22.000
growth hormone response, all of these things that then bring down total body inflammation and

566
00:49:22.000 --> 00:49:27.440
then we're very careful about food intake and when we're doing it and what kinds of food so that

567
00:49:27.440 --> 00:49:33.200
they don't have to go down the route of oral contraceptive pills because that to them has an

568
00:49:33.200 --> 00:49:37.520
effect on their performance. We're talking about the top end and when we bring it back down into

569
00:49:37.520 --> 00:49:42.080
recreational female athletes, we can do the same thing. It's just we have to educate and say,

570
00:49:42.080 --> 00:49:47.280
these are our lifestyle choices and then these are our medical choices and what's optimal for your

571
00:49:47.280 --> 00:49:52.400
life at this point. It's important to say at this table and we all talked about it last night,

572
00:49:53.280 --> 00:49:57.840
you need to have a period if you're not preventing a period with hormonal contraception and you're

573
00:49:57.840 --> 00:50:05.040
in your reproductive years because very often women with PCOS or hypothelamic amenorrhea will say,

574
00:50:05.040 --> 00:50:10.240
I don't have a period but I didn't really like that anyway so it doesn't bother me. How many women

575
00:50:10.240 --> 00:50:15.280
have said, well, I didn't get my period for a year but that was fine by me but that's not fine by

576
00:50:15.280 --> 00:50:21.840
your body. That is hypoestrogenic time. It is low estrogen. Yeah, very low estrogen. It's bad for

577
00:50:21.840 --> 00:50:28.000
your body on so many reasons to be low estrogen during these crucial bone-building years but for

578
00:50:28.000 --> 00:50:32.800
we're talking about how your hormones communicate back. It's very harmful to long-term health

579
00:50:32.800 --> 00:50:40.240
to have low estrogen. That's not bad at all. But yeah, but especially in young years when you're

580
00:50:40.800 --> 00:50:44.320
still developing. Why would a woman say that she didn't want to have a period? I mean,

581
00:50:44.320 --> 00:50:48.000
this is a super-nive question as a guy but I understand it's painful. Do you want to bleed for my

582
00:50:48.000 --> 00:50:53.600
thought of it? I mean, if it was a choice now. Actually, knowing now, would I know now?

583
00:50:54.400 --> 00:50:59.440
And for my own young daughters, I'm like, we have got to make sure you have a period. But when I was

584
00:50:59.440 --> 00:51:05.760
young, I was a dancer and an athlete, I had very low body fat and I wouldn't have periods for

585
00:51:05.760 --> 00:51:09.840
six to nine months and I'm like, yes. You know what's interesting? I was thinking of Mel.

586
00:51:11.840 --> 00:51:16.400
She, because of what she's been through and also because she's listened to the conversations

587
00:51:16.400 --> 00:51:20.720
I've had with all of you and she understands the value and importance of her period.

588
00:51:20.720 --> 00:51:26.720
She now celebrates it. It's like a celebration in our house when it arrives because if you understand

589
00:51:26.720 --> 00:51:32.240
the importance that it has in sort of full body health and the role it's playing, then the pain,

590
00:51:32.320 --> 00:51:37.760
the downside is weighted against your understanding of the upside, which to her means she's healthy,

591
00:51:37.760 --> 00:51:42.320
she's fat. Well, no, no health is working. Yes. That's a great. And that's the conversation shift

592
00:51:42.320 --> 00:51:46.720
that I'm hoping is going to instead of being a detriment and a downer and talked about she

593
00:51:46.720 --> 00:51:53.280
must be on whatever derogatory, yes. Derogatory things are said about us that, oh my gosh,

594
00:51:53.280 --> 00:51:59.600
she is so healthy. Yeah. I remember sitting in a high performance meeting just maybe three years

595
00:51:59.600 --> 00:52:05.120
ago and the leading athletics coach stood up and said, I know when my athletes are ready to perform

596
00:52:05.120 --> 00:52:12.480
on the world stage when their periods stop and all of us went, what? It's like, no, that's the time

597
00:52:12.480 --> 00:52:18.480
where like we have to really look at your athlete is getting ready to crack and be injured. And it's

598
00:52:18.480 --> 00:52:24.960
still this pervasive idea and it's still pervasive even in the fitness industry that losing your

599
00:52:24.960 --> 00:52:29.040
period is okay because that means you're training hard. Actually, very resistant to getting it back.

600
00:52:29.040 --> 00:52:35.520
Yes. It's a sign of failure of their sport or their athletic endeavor because this is so pervasive.

601
00:52:35.520 --> 00:52:40.240
And I think that's why it's important to have these discussions. And I love hearing that

602
00:52:40.240 --> 00:52:44.720
Mel now says, yeah, my period is here because that's a sign of hormonal health and things are

603
00:52:44.720 --> 00:52:50.240
working well because that is how we should feel. But I think the other part of it is for women who

604
00:52:50.240 --> 00:52:55.600
have made heringer or heavy bleeding and heavy cramping, they don't realize that they can get

605
00:52:55.600 --> 00:53:00.080
help with that as well. And that's the conversation that isn't followed through when we're like, yes,

606
00:53:00.080 --> 00:53:04.480
get your period. But if you're someone who suffers from really bad cramps, we also have to educate

607
00:53:04.480 --> 00:53:09.920
that there are things that we can do to help with that. Does the size of the bleed matter? Because

608
00:53:09.920 --> 00:53:13.840
she turned around to me the other day and she said with her last cycle, she said she didn't bleed

609
00:53:13.840 --> 00:53:19.120
much and she seemed slightly concerned. Obviously, I had no idea what to say to that. It depends.

610
00:53:19.280 --> 00:53:20.560
Well done. I'm so sorry.

611
00:53:20.560 --> 00:53:25.280
Venerages. So we have definitions and there are, you know, we don't walk around with measuring cups

612
00:53:25.280 --> 00:53:29.600
generally between our legs to measure how much blood's coming out each month. But women know.

613
00:53:29.600 --> 00:53:36.000
But women know your period should not cause you with modern, you know, period products.

614
00:53:36.640 --> 00:53:41.920
Your cycle shouldn't cause you any stress in your life. You should just roll with it, right?

615
00:53:41.920 --> 00:53:45.600
And so that's when I'm like, when is it a problem? Bleed through your clothes. You should be able

616
00:53:45.600 --> 00:53:48.560
to sleep through the night. You should be able to get through an athletic performance. You should

617
00:53:48.560 --> 00:53:54.800
be able to do X, Y, and Z. Now, when we do start measuring and you should not be anemic. So I'm

618
00:53:54.800 --> 00:54:01.440
not waiting till anemia. I am anemia is low red blood cell count, you know, to the point where

619
00:54:01.440 --> 00:54:05.600
your performance has affected your ability to carry oxygen is effective. So the red blood cells

620
00:54:06.240 --> 00:54:14.320
are what carries oxygen in our bodies. And women who have heavy periods, however, that's defined

621
00:54:15.120 --> 00:54:20.000
can lead to anemia. But the first thing that we notice is their ferritin is dropping. That's

622
00:54:20.000 --> 00:54:23.520
the first sign. My daughter, my daughter, we just had some blood work done. She was feeling a little

623
00:54:23.520 --> 00:54:27.840
fatigued. And her ferritin and iron saturations were really low. And I was like, talk to me about

624
00:54:27.840 --> 00:54:31.600
your period. Turns out she's not eating a lot of iron rich foods. We're dealing with that. But,

625
00:54:31.600 --> 00:54:37.200
you know, we can get so far ahead of this. And looking at these ferritin levels, the transfer,

626
00:54:37.200 --> 00:54:42.640
you know, these iron studies before she's actually anemic, which is like the last thing that happens

627
00:54:42.640 --> 00:54:47.840
when her red blood cell count drops or they become so small and what we call microscopic, you know,

628
00:54:47.840 --> 00:54:52.880
we need to do a better job at recognizing these things. We're not going to walk around and measure

629
00:54:52.880 --> 00:54:58.480
how much blood's coming out because I could maybe squeak out 200cc's, you know, a period. And

630
00:54:58.480 --> 00:55:02.960
you could be 300 and we're both doing fine. You know, we both have great. So I think it's really

631
00:55:02.960 --> 00:55:07.840
looking at, you know, how much bleeding is too much. Now, how little is too much, that's probably

632
00:55:08.080 --> 00:55:12.400
better. Yeah. Is any change from what you consider normal? We would all say this is a normal

633
00:55:12.400 --> 00:55:17.920
amount. So if it gets heavier than that or less than that and it stays that way, that is concerning.

634
00:55:17.920 --> 00:55:23.680
You can always have a one off. Estrogen is the driver of growing the uterine lining. So if you have

635
00:55:23.680 --> 00:55:28.800
a lighter bleed one month, we are concerned that you did not grow as thick of a lining your body

636
00:55:28.800 --> 00:55:33.920
didn't see as much estrogen. Most of the time you ovulated earlier that cycle, your cycle came a

637
00:55:33.920 --> 00:55:39.200
little bit sooner than you're used to it coming. And it's not quite a big deal. But this can be

638
00:55:39.200 --> 00:55:46.000
concerning if we see consistently light periods, especially if we have history of progesterone

639
00:55:46.000 --> 00:55:51.360
contraception, which progesterone thins out the lining and estrogen grows it. So progesterone

640
00:55:51.360 --> 00:55:55.360
actually stabilizes it. But for the sake of the discussion, we'll say estrogen grows it,

641
00:55:55.360 --> 00:56:01.600
progesterone thins it. When you only see progesterone, like a progesterone IUD, the progesterone shot,

642
00:56:01.600 --> 00:56:08.080
even continuous birth control pills because they give you a type of synthetic estrogen and progesterone

643
00:56:08.080 --> 00:56:14.960
every day, your uterine lining gets thinner and thinner and thinner. And so we see it can take

644
00:56:14.960 --> 00:56:20.880
months to return to normal after coming off of hormonal contraception. You also can get damaged

645
00:56:20.880 --> 00:56:25.040
to the endometrial lining. There's stem cells in the endometrium that regenerate every month.

646
00:56:25.920 --> 00:56:31.120
After you bleed, they regenerate so that the next group can grow in response to estrogen.

647
00:56:31.600 --> 00:56:37.440
And this can get damaged from typically anything inside the uterus. So most commonly this is

648
00:56:38.080 --> 00:56:44.880
post-birth, traumatic birth, a retained placenta, a DNC procedure, which is sometimes used after

649
00:56:44.880 --> 00:56:50.880
birth or in a miscarriage or even IUDs or intrauterine surgery. And it can form scar tissue in the

650
00:56:50.880 --> 00:56:56.800
uterus that can cause a light period. So if you said, oh, Mel had a miscarriage and had this

651
00:56:56.800 --> 00:57:01.280
procedure, and now her periods are lighter, I'm highly concerned. Versus...

652
00:57:01.280 --> 00:57:04.560
Hashemann's interesting. Yeah, so that is concerning for scar tissue in the uterus.

653
00:57:05.280 --> 00:57:11.200
If you said, oh, she was on a birth control pill for a while, and now it's a little bit lighter,

654
00:57:11.200 --> 00:57:16.320
I'm less concerned that's probably going to get better. Or if this period came closer together.

655
00:57:16.320 --> 00:57:19.920
Or if you traveled around the world three times this last month or...

656
00:57:19.920 --> 00:57:25.520
So one off is no big deal, but a change from your baseline can be concerning. In addition,

657
00:57:25.520 --> 00:57:30.560
we should say that that graph is beautiful, but you know, your thyroid, your pituitary gland,

658
00:57:30.560 --> 00:57:36.080
it makes prolactin, prolactin also changes the endometrium. So there's subtle signs of other

659
00:57:36.080 --> 00:57:42.160
hormonal issues that your menstrual cycle is the first warning sign that something is off.

660
00:57:42.160 --> 00:57:46.240
What about pain? She two months ago, she had like excruciating pain that I've never seen before,

661
00:57:47.040 --> 00:57:52.880
during her menstrual cycle. Well, it's not pleasant to have your uterus contract and expel its

662
00:57:52.880 --> 00:57:59.360
contents in any form. But what if it's like way above the norm? One time way above the norm is

663
00:57:59.360 --> 00:58:05.280
probably situational based on other things that are contributing to inflammatory burden or response.

664
00:58:05.920 --> 00:58:10.560
Your body is also healing from the corpus ludium assist on your ovary that can also feel

665
00:58:10.560 --> 00:58:15.120
painful and at the time of your period it is also healing. So there's multiple things that can

666
00:58:15.120 --> 00:58:23.280
cause pain. Tavanda's point, so many people say, I have a high pain tolerance. This is okay because

667
00:58:23.280 --> 00:58:28.560
we don't talk about our own pain. So I don't know if my pain is normal compared to somebody else's.

668
00:58:28.560 --> 00:58:34.080
Your pain should not keep you out of your activities of daily living. You shouldn't call in sick to

669
00:58:34.080 --> 00:58:40.560
school, call in sick to work, cancel dinner plans with friends consistently. Again, everybody can

670
00:58:40.560 --> 00:58:45.120
have a one-off month where something is off. But if this happens every month, oh, it's my

671
00:58:45.120 --> 00:58:50.240
period. I'm going to cancel that. That is a warning sign that something else could be going on.

672
00:58:50.240 --> 00:58:55.520
And Demetrius is adnomeiosis and uterine fibrates. You mentioned the way to iron a second to go,

673
00:58:55.520 --> 00:59:02.560
Dr. Mary, what is iron got to do with this and what is iron? So iron is an element that is in our

674
00:59:02.560 --> 00:59:07.520
diets and we do tend to store quite a bit of iron in our bodies and it's an essential when we look

675
00:59:07.520 --> 00:59:12.480
at the structure of the red blood cell and of hemoglobin specifically. So hemoglobin is the

676
00:59:12.480 --> 00:59:17.920
actual molecule that is inside of the red blood cell that carries the oxygen. So iron is really

677
00:59:17.920 --> 00:59:24.880
critical to the formation of healthy, you know, iron carrying red blood cells. And we store iron

678
00:59:24.880 --> 00:59:32.240
in our bodies and so in a lot in the bone marrow and is stored in this particular molecule called

679
00:59:33.040 --> 00:59:38.080
ferritin. So when we're measuring ferritin levels in the blood, that is, you know, the first

680
00:59:38.080 --> 00:59:42.560
sign that your iron stores are getting low is when we see these low ferritin levels.

681
00:59:42.560 --> 00:59:48.720
Are women more iron deficient than one would think? Like is the general population

682
00:59:48.720 --> 00:59:52.320
iron deficient? Or what do you tend to see when you run lab tests?

683
00:59:52.320 --> 00:59:57.760
A menstruating woman, yes. A menstruating woman is often iron deficient.

684
00:59:57.840 --> 01:00:03.520
Yes. And I do see it in our postmenopausal patients as well that's usually nutritional and

685
01:00:03.520 --> 01:00:10.080
inflammation related. So ferritin is also something that will decrease in times of chronic

686
01:00:10.080 --> 01:00:13.840
inflammation. So you're not able to utilize the iron that's coming in and store it because

687
01:00:13.840 --> 01:00:19.040
this inflammatory state is kind of inhibiting that. So in a menstruating patient, I'm always

688
01:00:19.040 --> 01:00:22.640
thinking, is she bleeding too much the first time? You know, and is that bleeding menstrual?

689
01:00:22.640 --> 01:00:26.160
Is it coming from her rectum? Is it coming from her gastrointestinal track? You know,

690
01:00:26.160 --> 01:00:30.320
does she have gastritis? Or, you know, we have to go through the, you know, the algorithm of

691
01:00:30.320 --> 01:00:35.440
why that might happen? In a postmenopausal patient, we can remove vaginal bleeding from the issue,

692
01:00:35.440 --> 01:00:40.000
you know, uterine bleeding of that period. But then now I'm looking at nutrition. I'm looking

693
01:00:40.000 --> 01:00:42.880
at exercise and looking at inflammation as causative factors.

694
01:00:42.880 --> 01:00:46.720
And the global pitch here is the World Health Organization estimates that roughly 30% of women aged

695
01:00:46.720 --> 01:00:51.920
15 to 49 worldwide are inemic with iron deficiency being the leading cause. And in some

696
01:00:52.400 --> 01:00:57.280
regions of South Asia and sub-Saharan Africa, prevalence can be up to 50% of women are

697
01:00:57.920 --> 01:01:00.800
anemic with iron deficiency being the leading cause.

698
01:01:02.400 --> 01:01:08.880
Notice the norms have changed. So depends on who you read. Yeah. Again, you know, when you're

699
01:01:08.880 --> 01:01:14.800
looking at male normative curves versus what, you know, we're, we tend to accept lower levels for

700
01:01:14.800 --> 01:01:21.120
female, but now that we're looking at performance and, you know, looking at other factors besides

701
01:01:21.120 --> 01:01:26.720
just what is this ferritone level? There's a lot, great new research coming out that we are

702
01:01:26.720 --> 01:01:31.840
looking at this differently and that we're, in our clinic, we are looking for 60 to 100 for

703
01:01:31.840 --> 01:01:38.080
a ferritone level to be considered optimal. Very different than, you know, the baseline for,

704
01:01:38.960 --> 01:01:44.800
you know, keeping you out of, out of hospital versus you functioning at your absolute best.

705
01:01:45.680 --> 01:01:51.360
Yeah, because the norms that often get measured for us, because they tripled, right?

706
01:01:51.360 --> 01:01:56.960
They were 15 and then they went up to, to 40. So now they're saying 20 and above is normal.

707
01:01:57.680 --> 01:02:02.000
And when I look at a lot of women who are sitting 20 to 30, they can't get help.

708
01:02:02.720 --> 01:02:06.800
They cannot get help. And it's like, whoa, it was maybe four or five years ago.

709
01:02:07.520 --> 01:02:12.800
If you were below 50, then we would look to get help. But now with the norms that have shifted

710
01:02:12.800 --> 01:02:18.880
with the sicker population, we can't get women help unless they are below 20.

711
01:02:18.880 --> 01:02:25.520
So, when we say normal, I think this is important for everybody watching or listening, normal in medicine

712
01:02:25.520 --> 01:02:32.960
means common, not non-pathological. Not bad, you know, it doesn't mean that it's not bad. And so

713
01:02:32.960 --> 01:02:38.960
norms shifting, meaning we're getting sicker as a population. And we're willing to accept lower

714
01:02:39.040 --> 01:02:43.680
levels, although they're not optimal for health. The lab reference range, what they say when

715
01:02:43.680 --> 01:02:48.880
you get your blood work drawn and you see the reference range is based on population averages.

716
01:02:48.880 --> 01:02:56.800
And so if the population is more anemic, this is going to accept a lower levels being normal,

717
01:02:56.800 --> 01:03:02.240
even though they're by no means optimal. And I think that's one thing we all talk about is,

718
01:03:02.240 --> 01:03:06.240
well, how are you feeling, your symptomology? What do we see? And you have to interpret

719
01:03:06.240 --> 01:03:12.160
blood work in context of the whole person and what is happening. And that is one issue we do see

720
01:03:12.160 --> 01:03:16.800
with getting your own blood work drawn, or these online companies, when nobody's interpreting it

721
01:03:16.800 --> 01:03:22.320
or helping you interpret it on the other end, you see something that is in a normal range,

722
01:03:22.320 --> 01:03:27.600
but it's not at all optimal for you. And it could be the reason why assurance. Yeah, exactly.

723
01:03:27.600 --> 01:03:31.040
I want to talk about endometriosis. We have a team member who's been with the Diary of

724
01:03:31.120 --> 01:03:34.640
Assault since the very beginning called Liv. Yes. Are you familiar with Liv?

725
01:03:34.640 --> 01:03:39.840
I am. So at age 13, she had her first period and she experienced agonizing pain with heavy bleeding.

726
01:03:40.880 --> 01:03:46.240
At age 14, she was put on the pill to manage the symptoms. Between age 15 and 24,

727
01:03:46.240 --> 01:03:51.600
she continued to have severe stomach pain, which resulted in multiple and 80 visits. She was

728
01:03:51.600 --> 01:03:58.160
often dismissed as having gastritis. And it led to having her appendix removed.

729
01:03:58.720 --> 01:04:04.800
Oh, my God. Why do you say? Oh, my God, I can't get surgery, but she had major surgery.

730
01:04:05.840 --> 01:04:13.600
And I've seen this course before and it's devastating because she's going years and years and

731
01:04:13.600 --> 01:04:19.600
years now. Yeah. At age 25, she came off the pill to see how she felt without it, but her periods

732
01:04:19.600 --> 01:04:24.640
worsened and she fainted from the pain so she went to accident and emergency. At age 26, she got

733
01:04:24.640 --> 01:04:29.840
an ultrasound, which suggested endometriosis, but no NHS diagnosis was given.

734
01:04:31.600 --> 01:04:37.440
We ultimately had a conversation with you on the podcast Natalie and she felt very heard.

735
01:04:37.440 --> 01:04:42.480
And she was actually there. And so afterwards, Jamima and the team who you guys know told Liv

736
01:04:42.480 --> 01:04:48.960
to come and speak to me and Liv told me after you left about the symptoms. Did she speak directly

737
01:04:48.960 --> 01:04:53.120
to you at that time? So she came and she spoke to us about her endometriosis, which is the first

738
01:04:53.120 --> 01:04:59.040
time I'd ever heard of it. And then we offered to help support her privately so she could get

739
01:04:59.040 --> 01:05:04.880
private support with it. And she got an MRI scan privately, which confirmed stage for

740
01:05:04.880 --> 01:05:13.120
infiltrating endometriosis. Liv then pushed on with her NHS appointments, the National Health

741
01:05:13.120 --> 01:05:18.480
Service in the UK, but the pain was so much that she took me up and offered to pay for it privately.

742
01:05:18.560 --> 01:05:23.360
So we paid for it privately. And the endometriosis by that point had spread to her bowels and pelvis.

743
01:05:24.000 --> 01:05:28.640
And I've got this picture of this four centimeter cyst. If you're a faint hearted, I mean,

744
01:05:28.640 --> 01:05:31.840
I don't know why we'll put this on the screen, but this is from her operation.

745
01:05:31.840 --> 01:05:34.160
Yes, it's called an endometrioma. It's huge.

746
01:05:35.040 --> 01:05:41.120
For anyone that can't see, it kind of looks like a tumour. It next to her ovaries.

747
01:05:42.000 --> 01:05:46.400
And it had spread at that point to her bowel and pelvis. It'd become about four centimeters big.

748
01:05:46.480 --> 01:05:50.160
Her ovaries were stuck together and attached to her womb and her bowels.

749
01:05:50.880 --> 01:05:54.080
She then needed to book an appointment for surgery. And before the surgery, because of the

750
01:05:54.080 --> 01:05:58.160
scale of her endometriosis, she had her eggs frozen to protect her future fatality, which

751
01:05:59.120 --> 01:06:05.520
gets came from your advice. This process took her seven years and she was in pain for 17 years

752
01:06:06.160 --> 01:06:13.440
because she did not get a diagnosis. Her story is unfortunately not uncommon. This is a very

753
01:06:13.440 --> 01:06:20.240
typical story for somebody who suffers from endometriosis. Endometriosis is an inflammatory

754
01:06:20.240 --> 01:06:25.520
condition. And the way I like to explain it is when your body responds abnormally to a normal

755
01:06:25.520 --> 01:06:29.840
process. You have immune dysfunction as well. So let's think of it as an autoimmune disease

756
01:06:29.840 --> 01:06:35.040
and a chronic inflammatory disease. When you have your period, you bleed out endometrial cells

757
01:06:35.040 --> 01:06:39.120
in your menstrual blood where you used to that. In everybody, you also have some endometrial

758
01:06:39.120 --> 01:06:42.560
cells that will escape out the fallopian tubes. And that's not a big deal. If you take out some

759
01:06:42.560 --> 01:06:46.000
of these appendix while they're on their period, you'll actually see menstrual blood and their

760
01:06:46.000 --> 01:06:53.280
abdominal cavity. And then regular person without endo, your body says, oh, she's just on her period.

761
01:06:53.280 --> 01:06:58.640
And the person who has endometriosis, this creates a huge inflammatory response where your body

762
01:06:58.640 --> 01:07:03.840
starts to attack endometrial cells and you get these implants throughout what's called the

763
01:07:03.840 --> 01:07:09.600
peritoneal cavity or the abdominal cavity of endometrial like tissue that gets worse every time

764
01:07:09.600 --> 01:07:15.040
your body sees estrogen, which because it's feeding the endometrium, just like it would in the

765
01:07:15.040 --> 01:07:21.840
uterus. And so it gets worse over time. The more ovulatory cycles you have, the disease gets worse.

766
01:07:21.840 --> 01:07:29.680
It's so inflammatory that it's not uncommon to get extensive organ scarring. You get anatomical

767
01:07:29.680 --> 01:07:37.680
distortion. These are some of the toughest surgical cases. In addition to managing lifelong health

768
01:07:37.680 --> 01:07:43.040
but also fertility. You want to just obliterate the anatomy because the infiltration, these implants

769
01:07:43.040 --> 01:07:48.160
will start growing into other organs because they'll find you blood supply. They'll steal blood,

770
01:07:48.160 --> 01:07:52.880
you know, blood supply from the bowel from because all of our pelvic organs are just sitting there

771
01:07:52.880 --> 01:07:58.640
on top of each other, the bladder, the bowel, you know, and so it sounds like it's alive,

772
01:07:58.640 --> 01:08:01.760
like it's a cancer or something. Think of it like Velcro is what I say almost. These little

773
01:08:01.760 --> 01:08:06.160
patches of Velcro and then you start sticking together. And that's what inflammation and scarring does

774
01:08:06.160 --> 01:08:12.000
throughout your whole body. And what happens here is that because the primary symptoms of

775
01:08:12.000 --> 01:08:19.520
endometriosis is pain. So again, back to women's pain being taken seriously. That's one of the

776
01:08:19.520 --> 01:08:25.680
issues and why the average time to diagnosis is seven to 10 years, truly 17 years in this case

777
01:08:25.680 --> 01:08:31.200
from when she had pain. But the other symptoms do include sometimes also pain within her course,

778
01:08:31.920 --> 01:08:38.000
typically though, that is very hard to ascertain from somebody, but it's usually with certain

779
01:08:38.000 --> 01:08:43.040
positions. Deep penetration tends to be what really stimulates pain. But you also see a lot of GI

780
01:08:43.040 --> 01:08:47.440
manifestations that we don't talk about. So if I have somebody who has painful periods and they say

781
01:08:47.440 --> 01:08:54.320
they have irritable bowel syndrome or a lot of vague GI complaints, that is a really big red

782
01:08:54.400 --> 01:08:59.920
flat to me. Because like you said, these little endometrial implants on the bowel, the intestine,

783
01:08:59.920 --> 01:09:05.920
this high inflammation that's happening irritates your intestine and you get this GI response as well.

784
01:09:06.640 --> 01:09:11.760
One of the hardest things about endometriosis is that it's a surgical diagnosis only to be

785
01:09:11.760 --> 01:09:18.240
honest. We can have to do surgery to fully see and diagnose that you have. It's one of those

786
01:09:18.240 --> 01:09:24.160
no-meat, no-treat in medicine where you can't make the diagnosis until you have a tissue sample.

787
01:09:24.160 --> 01:09:30.960
So meat means you go and take a biopsy. So you can suspect it based on imaging. We're not

788
01:09:30.960 --> 01:09:37.600
great at this. And Dr. Crawford, why don't we have a cure? Well, because it hasn't been studied,

789
01:09:37.600 --> 01:09:45.280
is the primary answer. The secondary answer is that often the goals are tough with endo. Because

790
01:09:45.280 --> 01:09:49.920
if estrogen feeds it, we all are going to sit at this table and talk about how important estrogen is

791
01:09:50.000 --> 01:09:56.240
for your body. And a lot of the treatments that exist for endometriosis take estrogen away to try

792
01:09:56.240 --> 01:10:02.160
to not feed these lesions. And that has a slew of other symptoms and long-term health implications as

793
01:10:02.160 --> 01:10:11.600
well. Truly, we don't even give women options to try to feel better. They are given birth control

794
01:10:11.600 --> 01:10:16.320
pills because, hey, I'm going to stop the ovulatory cycle. I'm going to, you're going to have less

795
01:10:16.320 --> 01:10:20.240
what we call unopposed estrogen days. It's symptomatic relief. Yeah, but we have been,

796
01:10:20.240 --> 01:10:25.280
that's going to help hopefully with some of your symptoms. And it can for some women. It doesn't

797
01:10:25.280 --> 01:10:30.720
reverse disease, it doesn't cure it, it doesn't make anything better. But it can slow down the

798
01:10:30.720 --> 01:10:37.760
progression, any of these treatments that do halt the ovulatory process. But it severely impacts,

799
01:10:38.400 --> 01:10:43.440
I mean, beyond so many layers of your your mental, your emotional health, your relationships,

800
01:10:43.440 --> 01:10:47.760
but your fertility stage three or four disease. Regardless of your age, you're going to have

801
01:10:47.760 --> 01:10:52.400
less than a 20% chance of conceiving naturally over the course of your life if you have stage three

802
01:10:52.400 --> 01:10:56.320
or four disease. Every stage is impactful to your fertility because of the inflammation.

803
01:10:56.880 --> 01:11:02.800
Once you have anatomical distortion and endometrioma or cyst inside the ovary, removing that cyst

804
01:11:02.800 --> 01:11:08.320
is going to decrease your egg count. That's going to have a major implication on your potential. That's

805
01:11:09.280 --> 01:11:13.360
why we froze eggs before we took a cyst out so that we could get those eggs, at least some that

806
01:11:13.360 --> 01:11:19.040
we could out of the body before we went and did something that was going to destroy part of

807
01:11:19.040 --> 01:11:23.840
the ovarian tissue. What you said, Steven, is it seems like endometriosis is alive. And that's

808
01:11:23.840 --> 01:11:30.400
a really great analogy because it does just feed into tissue and it's highly destructive. And if it

809
01:11:30.400 --> 01:11:37.360
distorts the anatomy, we need a healthy floppy fallopian tube generally that can swing around and

810
01:11:37.360 --> 01:11:42.400
pick up this egg that's floating around our abdominal cavity. And then you need a place for the

811
01:11:42.400 --> 01:11:47.440
egg and sperm to meet, which is generally a healthy non-inflamed fallopian tube. So they're also

812
01:11:47.440 --> 01:11:52.320
at increased risk for infertility but ectopic pregnancies. That's where I see them. You know,

813
01:11:52.320 --> 01:11:58.880
is when I was a hospitalist is in the ovar, you know, emergently from a ruptured fallopian tube

814
01:11:58.880 --> 01:12:03.280
from this. You know, and I go in, I'm making not only is she's lost a wanted pregnancy,

815
01:12:04.240 --> 01:12:08.640
now I and I'm making the diagnosis of endometriosis at the same time and they are just devastated.

816
01:12:09.200 --> 01:12:13.600
I just feel sitting here not being anywhere within this field thinking, wait a minute,

817
01:12:13.600 --> 01:12:18.560
because I was a cancer nurse first right before I did this. Wait a minute. There's got to be a

818
01:12:18.560 --> 01:12:23.920
cell surface marker that's unique to the endometrium that we could make a monoclonal antibody against.

819
01:12:24.800 --> 01:12:29.520
There's got to be a cell surface marker. And I will say, there are people now doing

820
01:12:29.520 --> 01:12:34.800
lovely and wonderful research on a cellular level of endometriosis, trying to look at the endometrium

821
01:12:34.800 --> 01:12:40.640
itself. What cell markers are similar in endometrial implants? Can you diagnose this on an

822
01:12:40.640 --> 01:12:47.280
endometrial biopsy in somebody? We haven't seen it get to the point where it needs to,

823
01:12:47.280 --> 01:12:51.920
but at least people are paying attention. So I do think we might have emergent technology

824
01:12:51.920 --> 01:12:57.760
that will change the course of this for people. Right now, I think awareness is key. And one thing I

825
01:12:57.760 --> 01:13:04.320
always say is that especially as a teenager, because women adjust, you accommodate to the world

826
01:13:04.320 --> 01:13:09.200
around you. That's one of the things that I think makes women so resilient. If you have pain

827
01:13:09.200 --> 01:13:14.240
every single month of your life, you are going to convince yourself this is normal for a degree of time

828
01:13:14.240 --> 01:13:20.320
because what other option do you have? Has to get so bad. But when you're a teenager, you don't know

829
01:13:20.320 --> 01:13:26.160
that. And so if when you are a teen, you would stay home from school, you would not go to the football

830
01:13:26.160 --> 01:13:32.880
game or go out to dinner with friends. That to me is a huge red flag, but it actually is a very

831
01:13:32.880 --> 01:13:39.120
high predictive marker that you do have endometriosis. So paying out a proportion to being able to

832
01:13:39.120 --> 01:13:44.640
complete your normal life as a teenager is a really big warning flag. I ask every patient about

833
01:13:44.640 --> 01:13:49.520
that when we talk about their periods because 50% of patients with unexplained infertility have

834
01:13:49.520 --> 01:13:55.840
endometriosis. It is so hard to diagnose and under diagnosed yet impactful to our body.

835
01:13:56.720 --> 01:14:04.080
26 years old, the advice given to by the NHS was to go back on the pill to solve for the pains

836
01:14:04.080 --> 01:14:08.640
that she was getting. We certainly have a lot of dismissive doctors and people who don't take

837
01:14:08.640 --> 01:14:15.040
pain seriously, but also a disease that is underfunded and not researched. We do have limited options

838
01:14:15.040 --> 01:14:19.760
for how you can help somebody. And I think we have to acknowledge that both things can be right.

839
01:14:19.760 --> 01:14:25.440
Now getting to the root cause of your pain is always going to be really important versus just saying

840
01:14:25.440 --> 01:14:30.480
here's a birth control pill that should take care of it. Some women with endometriosis love being

841
01:14:30.480 --> 01:14:35.040
on the birth control pill. It does highly improve their symptom profile and it's an important

842
01:14:35.040 --> 01:14:39.840
part of their treatment regimen. Other women do not find any benefit from it and it's really

843
01:14:39.840 --> 01:14:44.800
important to have the discussion especially with endometriosis in regards to your family planning

844
01:14:44.800 --> 01:14:50.880
goals. Do you want kids? When is that going to be? What might this look like? Because we know if you

845
01:14:50.880 --> 01:14:56.640
have a higher rate of infertility, higher rate of needing IVF, do we need to intervene sooner?

846
01:14:56.640 --> 01:15:00.240
But that's going to impact some of the treatment options we're able to give you because some of them

847
01:15:00.240 --> 01:15:06.560
do delay ovulation for prolonged period of time. What I find in the patients when we made the

848
01:15:06.560 --> 01:15:12.000
diagnosis was they're forced into making these kind of life changing decisions about around their

849
01:15:12.000 --> 01:15:19.200
fertility and ability to conceive before they were ever before their peers are even thinking about

850
01:15:19.200 --> 01:15:25.360
it. It's pretty devastating. It is. We have some pilot data looking at taking some of the nuances

851
01:15:25.360 --> 01:15:31.920
of recovery and looking at how to dampen inflammation. So we have some pilot data that's showing

852
01:15:32.000 --> 01:15:38.560
when women do cold exposure, that it dampens inflammation and improves their symptomology.

853
01:15:38.560 --> 01:15:44.080
So I'm always thinking on the outside like what other things can we do to dampen inflammation

854
01:15:44.800 --> 01:15:50.560
in a positive way to improve symptomology? How does that work? So if we're thinking about

855
01:15:50.560 --> 01:15:56.160
the responses to cold exposure and not talking about ice, we're talking about cold water exposure,

856
01:15:56.800 --> 01:16:04.480
it creates a cascade of immune responses that kind of protects the body. So we're reducing inflammation,

857
01:16:04.480 --> 01:16:10.400
we're improving parasympathetic, which reduces stress. So if we're timing it and they know when

858
01:16:10.400 --> 01:16:17.440
their period is and they can go, okay, well, for the next or the 10 to 14 days before my period starts,

859
01:16:17.440 --> 01:16:23.680
I'm going to have 10 minutes of cold water exposure. And over the course of three to four months,

860
01:16:23.680 --> 01:16:29.840
that immune response becomes learned. So it reduces symptomology. So it becomes one of the

861
01:16:29.840 --> 01:16:35.360
treatment options that we have for some of our athletes that have endo and interferes with their

862
01:16:35.360 --> 01:16:40.160
training. So I mean the cold water exposure is available there. So that's how we started the

863
01:16:40.160 --> 01:16:46.480
pilot study. Um, trying cold like for someone wanted to do this at home, 10 degrees Celsius. So what

864
01:16:46.480 --> 01:16:52.000
is that about? 3040. Yeah, it feels really cold, but not a nice bath, not a nice bath,

865
01:16:52.000 --> 01:16:57.520
because ice is not different when you get that in the shower. You need this is like cold

866
01:16:57.520 --> 01:17:01.920
submerge. Yes. Yeah. Can you do that at a home tub just with turning on this big? You could get

867
01:17:01.920 --> 01:17:05.520
that if you get really cold. Yeah, you might want to add a little bit of ice and let it melt.

868
01:17:05.520 --> 01:17:11.360
Okay. But not ice baths that we see in all the popular media because that is way too cold

869
01:17:11.360 --> 01:17:16.880
for a woman's body. It does the opposite. It's a severe stress and causes a stress response

870
01:17:16.880 --> 01:17:21.920
rather than a parasympathetic calming response that we want. Okay. Like Stacey said,

871
01:17:21.920 --> 01:17:27.440
decreasing inflammation in an inflammatory disease is key to controlling the factors you can.

872
01:17:27.440 --> 01:17:33.440
And much like we talked about inflammation in PCOS, we heard the same word right here with endometriosis.

873
01:17:33.440 --> 01:17:38.480
Chronic inflammatory diseases are the number one thing that we see across the board impacting

874
01:17:38.480 --> 01:17:45.760
the population, but especially women. And so the same strategies to work on decreasing your own

875
01:17:45.760 --> 01:17:52.160
inflammation for endo. It's a little different because you can target it for when you expect

876
01:17:52.160 --> 01:17:56.880
to have that high inflammatory burden. But that's really an important part that we don't talk about.

877
01:17:56.880 --> 01:18:03.440
I don't see that the NHS talked about an anti-inflammatory diet or getting more sleep or cold exposure.

878
01:18:04.800 --> 01:18:09.120
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890
01:19:08.960 --> 01:19:12.080
On this point of birth control, one of the questions that came in from the audience was

891
01:19:12.080 --> 01:19:20.320
how terrible is birth control to female hormones? The birth control pill shuts off the brain's

892
01:19:20.320 --> 01:19:24.960
desire to send the signal to the ovary to make hormones. So it is ethanol estradiol,

893
01:19:24.960 --> 01:19:31.840
a synthetic estrogen and a type of a synthetic progestin or progesterone. These work the brain

894
01:19:31.840 --> 01:19:37.280
thinks that you have estrogen and progesterone present. As we said, that's the loodial phase.

895
01:19:37.280 --> 01:19:41.680
And so your brain says we don't need an egg to grow. So relation starts in the brain. Yep.

896
01:19:41.680 --> 01:19:47.280
Right. So no FSH comes out and you're not going to get ovulation. So they're very effective

897
01:19:47.280 --> 01:19:53.440
for prevention of ovulation, which makes it a very effective contraceptive option. But as far as

898
01:19:53.440 --> 01:19:58.640
hormonal shifts, yeah, your brain's not sitting out FSH and LH, your ovaries are not going to be

899
01:19:58.640 --> 01:20:04.800
making estradiol or progesterone or testosterone. True. And so that is how they are sometimes

900
01:20:04.800 --> 01:20:11.280
helpful if you have, you know, some women get hemorrhagic cysts with ovulation. Every time you

901
01:20:11.280 --> 01:20:16.240
ovulate you, when you rupture that cyst, you get a lot of bleeding. The birth control pill can

902
01:20:16.240 --> 01:20:21.360
prevent ovulation, therefore prevent some women from being in terrible pain. If you have PCOS,

903
01:20:21.360 --> 01:20:27.360
they're often handed out like candy. One reason is because it will regulate your cycle so that you

904
01:20:27.360 --> 01:20:32.240
don't have these prolonged irregular periods, but also will decrease testosterone levels,

905
01:20:32.240 --> 01:20:37.600
which is sometimes a good side effect of the pill for women who have PCOS back to a normal.

906
01:20:37.600 --> 01:20:43.920
Yeah. But if you don't have PCOS or the regular person, a lot of times your body's tissues are

907
01:20:43.920 --> 01:20:48.320
not responding to synthetic estrogen and progesterone, the same way it does to natural. I think that's

908
01:20:48.320 --> 01:20:56.400
a very important point. So my niece who competes at a national level and she's 14 started suffering

909
01:20:56.480 --> 01:21:01.200
from where she was going through her adolescence. Her acne got outrageous and she's a 14-year-old

910
01:21:01.200 --> 01:21:06.320
girl, 13 and a start at 12 and a half. And of course, you know, she goes to the dermatologist and

911
01:21:06.320 --> 01:21:11.680
they're trying some topicals. And then finally, as you go down the algorithm for how we treat acne,

912
01:21:11.680 --> 01:21:17.200
one of the off label uses is birth control pills will lower the testosterone. Their skin can clear

913
01:21:17.200 --> 01:21:22.400
up. So her father, little concern, comes to me. Her mom passed, her stepmom had passed away,

914
01:21:22.400 --> 01:21:27.600
she didn't have the mom in the house to, you know, the immediate mom to talk to. And for the

915
01:21:27.600 --> 01:21:32.720
first time, I immediately thought of her athletic performance. Thank you, Dr. Sims. And I thought,

916
01:21:32.720 --> 01:21:37.840
she wants to go to the Olympics. There's no way I'm going to let her testosterone levels drop.

917
01:21:37.840 --> 01:21:40.800
Like we're going to throw everything topical at this. And we finally found the right

918
01:21:40.800 --> 01:21:45.680
combination of skin looks great. She's super happy. But like the next logical thing was to put

919
01:21:45.680 --> 01:21:50.960
this 14-year-old, you know, on birth control pill to get her acne under control, which is the

920
01:21:50.960 --> 01:21:56.080
end result. But what no one's thinking of is her athletic performance. How is it going to affect

921
01:21:56.800 --> 01:22:00.480
her training years? They didn't hear her training years. Like this is critical for her.

922
01:22:00.480 --> 01:22:05.200
16 is when the next trials are up for her. Yep. So that's two years from now. So we were able to

923
01:22:05.200 --> 01:22:10.240
get her acne under control, avoid the birth control pill. But that was nothing I'd ever thought of

924
01:22:10.240 --> 01:22:17.440
before. Well, I'm sitting here from a musculoskeletal standpoint, thinking about the high

925
01:22:17.440 --> 01:22:24.080
percentage of women who have endometriosis and PCOS and the complete, soundingly,

926
01:22:25.200 --> 01:22:35.040
imbalance of natural hormones. Plus, for a lot of reasons now, girls are not cycling normally.

927
01:22:36.240 --> 01:22:44.320
And I'm sitting here terrified for their bones. Yep. 100%. Because we build bone from 15 to 25.

928
01:22:45.280 --> 01:22:51.440
And if we are so inflamed that we're producing all kinds of inflammatory cytokines, IG,

929
01:22:52.240 --> 01:22:59.840
interleukin six and C-reactive protein and tumor necrosis factor, which halt bone development,

930
01:22:59.840 --> 01:23:04.480
we don't have enough estrogen for whatever reason. We're going to shut off our testosterone

931
01:23:04.480 --> 01:23:08.160
because it makes us feel better. And we're not exercising. And we're sitting around.

932
01:23:08.400 --> 01:23:16.720
Yeah. No wonder I have 20 and 30 year olds with no bone density that are then going to go into

933
01:23:16.720 --> 01:23:24.080
parimenopause, which we will get to and lose another 20%. So I was feeling pretty hopeful

934
01:23:24.800 --> 01:23:30.720
that the generation X's are going to get to the millennials and get to the whatever they're called

935
01:23:30.720 --> 01:23:35.760
after this. It is. We're going to be, you're going to see it get worse before we get better. Exactly.

936
01:23:35.840 --> 01:23:40.560
That's what I'm sitting here terrified like, okay, I thought, okay, baby boomers,

937
01:23:41.520 --> 01:23:46.880
those women missed out. X's were doing the best we can. Millennials, but no.

938
01:23:48.000 --> 01:23:55.440
Because now you're telling me our 15 to 25 year olds are still in the same detriment with muscle

939
01:23:55.440 --> 01:24:01.680
and bone building. We are trying to change the narrative. That's the group we're trying to

940
01:24:01.680 --> 01:24:07.840
target right now. And I do think by educating across the lifespan, we're going to change how

941
01:24:07.840 --> 01:24:14.640
those of us who have 11 and 12 year olds, what we recommend. I treat girls in their teen years when

942
01:24:14.640 --> 01:24:20.400
they come to me without their period much differently than a lot of other people do, but this is

943
01:24:20.400 --> 01:24:25.200
learned experience. Instead of just, you don't have a period. Here's a birth control tool. Say,

944
01:24:25.200 --> 01:24:30.400
you're not making estrogen. And this is a crucial time for you. Let's give you estrogen. Let's

945
01:24:30.400 --> 01:24:35.520
talk about why you're not. What can we do to change it? And so this discussion is more than just

946
01:24:35.520 --> 01:24:42.320
disease state important, like PCOS and endometriosis. It's truly important across the lifespan of a woman,

947
01:24:42.320 --> 01:24:49.360
the choices that are being made in her early reproductive timeline is going to impact her longevity.

948
01:24:49.360 --> 01:24:55.360
I ask all of you what you would have done differently for ourselves. Yeah, for yourselves. Obviously,

949
01:24:55.440 --> 01:25:00.560
I know several of you have daughters as well, but what would you have done? I wish everybody could

950
01:25:00.560 --> 01:25:07.360
see all of your faces. Oh, yeah, I've talked about this before. I mean, I was a menoriac until I was

951
01:25:07.360 --> 01:25:13.360
20. What's a menoriac? I didn't have periods. Okay. Because of high stress, high sport, you know,

952
01:25:13.360 --> 01:25:20.960
didn't care, didn't eat well in the whole mindset of the, you know, 90s of calories in, calories out.

953
01:25:21.040 --> 01:25:25.360
If you're a sinner, then you'll run better. If you're running better, then you're going to

954
01:25:25.360 --> 01:25:29.760
hit different metrics because I was a runner in high school and then join the crew team same thing.

955
01:25:30.400 --> 01:25:34.800
So if I could go back and talk to my younger self, I would have been like, you need to eat.

956
01:25:34.800 --> 01:25:39.280
You need to recover. You need to eat. You need to recover. Instead of the mantra of calories in,

957
01:25:39.280 --> 01:25:44.160
calories out more cardio, lose weight, lose weight, lose weight. Because now I educate people is

958
01:25:44.160 --> 01:25:49.920
you want to take up space. You want to be strong. You want to look at not the idea of losing something,

959
01:25:49.920 --> 01:25:54.240
but gaining something, gaining that power, gaining that strength, gaining that bone, gaining that

960
01:25:54.240 --> 01:25:59.760
muscle, gaining your period. Those are the things that I'm trying to educate the younger generation.

961
01:25:59.760 --> 01:26:06.560
Because that was not impressed upon me as a younger athlete, which then had a lot of repercussions

962
01:26:06.560 --> 01:26:12.240
later in life. Luckily, my bone density is fine. So. Well, you want the contraceptive bone? No.

963
01:26:12.320 --> 01:26:22.400
You want it? Okay. I was not an athlete, so mere mortal. But you've been able to take that

964
01:26:22.400 --> 01:26:27.680
experience though and apply what you've learned in this high end to working with these intense

965
01:26:27.680 --> 01:26:37.600
athletes to the regular two people who don't exercise at that level. And I completely fell

966
01:26:38.160 --> 01:26:45.680
under the expectation of the aesthetics of it. When I did exercise, I exercised to look a certain

967
01:26:45.680 --> 01:26:51.280
way. And then in my 30s, I exercised for performance. I started running half marathons. I was doing

968
01:26:51.280 --> 01:26:55.920
baby triathlon, so really short ones. With my girlfriends, it was a social thing and it was super fun.

969
01:26:55.920 --> 01:27:02.000
You know, I was running for time. Now I'm exercising for my old lady body. You know, I'm exercising

970
01:27:02.080 --> 01:27:07.600
to be in a bigger body because I know my mother and my grandmother, so my grandmother spent the

971
01:27:07.600 --> 01:27:15.120
last 10 years of her life in a bed in continent with dementia and completely frail. And my mother

972
01:27:15.120 --> 01:27:21.040
is on the same course. My mother is 88, fell and broke her hip in January. She just now is walking

973
01:27:21.040 --> 01:27:26.480
on a walker. She's an assisted living facility for Alzheimer's. I want to change that legacy for my

974
01:27:26.480 --> 01:27:33.520
children. I don't want that to be my path. And I don't want my children to have that to be an

975
01:27:33.520 --> 01:27:41.440
expectation. So all of the things I would have done differently was I wanted to be thin. Thin

976
01:27:41.440 --> 01:27:45.440
was healthy. That is what I learned in medical school. The thinner you were up to starvation,

977
01:27:45.440 --> 01:27:52.640
you know, up to you want the lowest body mass index possible without being a little bit too low.

978
01:27:52.640 --> 01:27:56.880
You know, and I kind of skirted that line because I stopped eating a medical school due to stress.

979
01:27:56.880 --> 01:28:01.520
I would have fed myself. I would have lifted weights. I would have stopped doing so much cardio

980
01:28:01.520 --> 01:28:06.800
because knowing I was chipping away at my bone density. I was chipping away. I was raising my

981
01:28:06.800 --> 01:28:11.600
inflammation levels. I was chipping away at my ability to resist the Alzheimer's, you know,

982
01:28:11.600 --> 01:28:16.560
and dementia that runs in my family. And that's what I'm trying to impress. My girls are 21 and

983
01:28:16.560 --> 01:28:23.200
25. What I'm trying trying to impress on them. But that's the mentality that we grew up in,

984
01:28:23.200 --> 01:28:29.120
right? When you're looking at the supermodels of the 90s and Kate Moss and it was arrow and she.

985
01:28:29.120 --> 01:28:35.520
Yes, heroin chic, which is the worry now with the GLP ones coming back and the ballerina body

986
01:28:35.520 --> 01:28:39.840
and all the things that we're seeing come back again. And it's it is worrisome.

987
01:28:40.800 --> 01:28:46.880
You know, when I think about, I mean, I've already told the world now about having low body fat,

988
01:28:46.880 --> 01:28:53.120
maybe being PSOS and not knowing it, not ever talking about that, having no periods. But then,

989
01:28:53.120 --> 01:28:59.440
so there was that in my youth that that I would have done better, but that it didn't end in my youth.

990
01:29:00.320 --> 01:29:08.240
I mean, I went to college, same. I went to grad school, still same. I went to medical school,

991
01:29:08.240 --> 01:29:14.000
and in medical school, and four years of medical school, seven years of residency and fellowship,

992
01:29:14.960 --> 01:29:21.840
still didn't need, still was having periods. I didn't sleep for about 11 years, whether between

993
01:29:21.840 --> 01:29:26.560
call every third night and then I had a baby and then I was awake for two years because

994
01:29:26.560 --> 01:29:32.560
she slept with me. That's another discussion. But I think of all these things that I wish I knew then,

995
01:29:32.560 --> 01:29:41.040
that I know now, I have the same goal. I have four 30-year-old daughters and I have a 17-year-old,

996
01:29:41.040 --> 01:29:47.680
and they are not going to be allowed to hit a wall, like some of us may, because we didn't know.

997
01:29:48.320 --> 01:29:54.800
And were you on the birth control pill? You know, intermittently, probably totally in my life,

998
01:29:54.800 --> 01:30:03.120
about 10 years, but not continuously. And Mary, I've got to ask, were you on the birth control?

999
01:30:03.120 --> 01:30:08.960
Yeah, they're off and on for 20 years. So, politics was a very uncertain dream. That was the

1000
01:30:08.960 --> 01:30:14.640
treatment. I mean, I learned about nutrition kind of on the back end, but the life that I had

1001
01:30:14.640 --> 01:30:20.880
set up for myself between, you know, medical school residency and then going into the field of

1002
01:30:20.880 --> 01:30:28.720
OBGYN with limited sleep, you know, working 100-hour weeks, there, I didn't have a environment

1003
01:30:28.720 --> 01:30:35.520
that would have been conducive to be able to manage that disease with lifestyle. And I can look

1004
01:30:35.520 --> 01:30:43.440
back and say that honestly now, without using the crutch of the birth control pill to manage my

1005
01:30:43.440 --> 01:30:50.240
symptoms. I was on the birth control pill for probably 15 years continuously. And, you know,

1006
01:30:50.240 --> 01:30:56.480
we have to give credit where credits to because I was able to pursue medical training and not worry

1007
01:30:56.480 --> 01:31:03.360
about what family building looked like for me, which was really important because I was not ready

1008
01:31:03.360 --> 01:31:08.240
to have a child. So, anytime we frame a discussion around birth control, I always want to say,

1009
01:31:08.240 --> 01:31:12.000
it's not ever going to fit into one bucket of all good or all bad. It's going to be, you know,

1010
01:31:12.000 --> 01:31:16.160
different stages of life, different things are important. I didn't stop it soon enough to learn

1011
01:31:16.160 --> 01:31:22.000
to track my cycle. I didn't recognize cycle abnormalities. When I had recurrent miscarriages,

1012
01:31:22.000 --> 01:31:26.880
I had a really hard time knowing, is this how my cycle is supposed to be or not? Because I never

1013
01:31:26.880 --> 01:31:32.720
had the opportunity to just have periods and see what is my normal. I stopped it and started

1014
01:31:32.720 --> 01:31:38.800
trying right away and got into a cycle of having a pregnancy and that would last for a while,

1015
01:31:38.800 --> 01:31:43.360
and then I would lose it. So, I really lost the opportunity to say, this is my baseline,

1016
01:31:43.360 --> 01:31:48.640
and oh, there might be a problem here or to intervene. I wish I'd advocated more when I had my

1017
01:31:48.640 --> 01:31:53.200
own pregnancy losses. I was told over and over, there's nothing you can do, this is nothing,

1018
01:31:53.200 --> 01:31:58.640
just keep trying, and even as somebody in the field, that felt very dismissive and is a fuel

1019
01:31:58.640 --> 01:32:03.840
for a lot of what I do now. But on a personal level, you know, 10 years after having those pregnancy

1020
01:32:03.840 --> 01:32:11.440
losses, I was diagnosed with celiac disease because I had osteopenia on a dexascam. And so I had

1021
01:32:11.520 --> 01:32:16.560
to explain what that is. Yeah. So, celiac disease is essentially an allergic reaction to gluten.

1022
01:32:16.560 --> 01:32:21.680
So, when I was taking gluten, which is in most of your carbohydrates, or the good stuff,

1023
01:32:21.680 --> 01:32:27.680
like breads and pastas, when I was eating those, it was causing an inflammatory reaction inside my

1024
01:32:27.680 --> 01:32:33.120
body, making my gut unhealthy and kind of creating a baseline level of, let's say, chronic inflammation.

1025
01:32:33.840 --> 01:32:38.800
And recurrent pregnancy loss can be one of the signs and symptoms of it in addition to just some

1026
01:32:38.800 --> 01:32:45.520
other, what feel like, very generalized symptoms. Fatigue, low energy, headaches,

1027
01:32:45.520 --> 01:32:53.120
GI distress. W-W. Yeah, that's a whiny woman. And when some of these symptoms finally got to a

1028
01:32:53.120 --> 01:32:58.240
state where they were getting worse, probably with hormonal change with age, and my doctor ordered a

1029
01:32:58.240 --> 01:33:04.720
bone scan, and it came back that I had osteopenia, which is very low density of my bones for my age,

1030
01:33:04.720 --> 01:33:10.720
and especially at the time, no, no medical problems. And so, luckily, I had somebody who was very

1031
01:33:10.720 --> 01:33:15.920
committed to not labeling me a WW, and saying, I think you're not absorbing something correctly,

1032
01:33:15.920 --> 01:33:21.200
to get on this pathway to figure out that because of this autoimmune disease, celiac disease,

1033
01:33:21.200 --> 01:33:26.640
my gut wasn't inflamed, I wasn't able to absorb the nutrients that I needed. But somebody had to

1034
01:33:26.640 --> 01:33:31.200
be committed on the other end, because these symptoms went on for so long, I just accepted them,

1035
01:33:31.200 --> 01:33:37.120
I let them be. But I also am scared, because those critical bone-building years I was on the

1036
01:33:37.120 --> 01:33:44.560
PAL, and I used it continuously, which means every single day all the time. I, you know, I know I was

1037
01:33:44.560 --> 01:33:50.400
chronically inflamed, and so now I'm at a stage of my life at 43, saying, I've got to try to catch up

1038
01:33:50.400 --> 01:33:56.640
before it's too late, and that is scary. And can you catch up? Yes. Yes, you can build bone.

1039
01:33:57.120 --> 01:34:03.440
Because, you know, I see all these grass funders that, you know, you kind of, yes, you go

1040
01:34:03.440 --> 01:34:08.240
chelker. Then it goes down from wherever you manage to get it up to. So, I'm telling all my

1041
01:34:08.240 --> 01:34:10.880
friends at the moment, thanks to you, I'm telling all of them to get their muscle and their

1042
01:34:10.880 --> 01:34:16.000
bone as high as possible, because it's probably going to fall with age naturally. Well, everyone

1043
01:34:17.280 --> 01:34:22.560
ages, yeah, ages is the most natural thing we do from the minute of our birth. But

1044
01:34:23.200 --> 01:34:31.280
men and women age at different rates, especially after perimenopause with the lack of estrogen,

1045
01:34:31.280 --> 01:34:36.720
we rate, we age very differently from that point on. But your point being made is,

1046
01:34:37.440 --> 01:34:42.480
can we please maximize our bone density and our muscle mass and everything else, frankly,

1047
01:34:43.760 --> 01:34:49.040
in our youth when we're probably not aware, right? When we're in college and doing all the things,

1048
01:34:49.040 --> 01:34:53.120
kids do, it's the last thing on our mind. And yet it's the most critical time.

1049
01:34:53.680 --> 01:34:58.640
Because you want to start both your bone and your muscle from the highest possible level.

1050
01:34:58.640 --> 01:35:06.560
Now, can you through lifestyle and hormones build bone again? Yes, actually, you can. But wouldn't

1051
01:35:06.560 --> 01:35:12.480
it have been better to start out with the maximum so that the natural decline doesn't take you

1052
01:35:12.480 --> 01:35:17.200
into dangerous levels? On that point of birth control, what are you saying to your daughters?

1053
01:35:17.280 --> 01:35:22.720
That wasn't said to you. Because Mel regress, my girlfriend, she's very open. She regress being on

1054
01:35:22.720 --> 01:35:26.640
the birth control pill for 10 years because she had no idea what it was doing to her body. And then

1055
01:35:26.640 --> 01:35:30.240
obviously when she came up with her cycle, I think she spent like you in actually two years trying

1056
01:35:30.240 --> 01:35:34.400
to figure out what was going on and she didn't have her period for an extended period of time after

1057
01:35:34.400 --> 01:35:39.040
she came off. What are you saying to your daughters about the birth control pill? That wasn't said

1058
01:35:39.040 --> 01:35:43.120
to you. Are you recommending them to use it? How you guys used it? I mean, we were started on

1059
01:35:43.120 --> 01:35:50.480
it so young. I do see a trend towards not starting it as young as it was started in our generation.

1060
01:35:50.480 --> 01:35:55.920
And I think that that is important. I see, you know, personally, my daughter is not quite at that

1061
01:35:55.920 --> 01:36:02.720
stage yet. So we haven't had to make these decisions. They have had to. But I do think it's in

1062
01:36:02.720 --> 01:36:08.560
cycle awareness is one of the few early signs you have of your body's health as a young woman.

1063
01:36:08.640 --> 01:36:14.080
And so to purposefully never get to know what that is, is a detriment to saying, I'm aware of

1064
01:36:14.080 --> 01:36:17.840
what's healthy for me. And I know what's happening in my body. But you guys have had these

1065
01:36:17.840 --> 01:36:24.880
discussions at different time periods. For my youngest daughter, I was worried about

1066
01:36:25.600 --> 01:36:32.320
she was a dancer also. She was teeny tiny, so tiny, even though she had great muscle mass. But she

1067
01:36:32.400 --> 01:36:38.320
liked me wasn't having periods. And so the advice was to put her on birth control to regulate

1068
01:36:38.320 --> 01:36:44.160
periods. But I was always uncomfortable with that because she didn't, to be a dancer, she didn't

1069
01:36:44.160 --> 01:36:50.640
have to be quite as tiny as she was. And so what we've done now is I've encouraged her to gain

1070
01:36:50.640 --> 01:36:57.040
a little weight and get a little bit more body fat because I took her off of that. She only had

1071
01:36:57.040 --> 01:37:03.280
to gain five pounds. I think I said to you, maybe seven. And it has more regulated her.

1072
01:37:03.280 --> 01:37:08.720
And she's having her own periods now. And so I don't know what she's going to decide. She's going

1073
01:37:08.720 --> 01:37:15.600
to be 18 soon. But I think what we should be telling our daughters is all the information so that

1074
01:37:15.600 --> 01:37:23.760
they can make an educated decision because I just did what I was told. And I'm a doctor and I,

1075
01:37:23.760 --> 01:37:30.640
and but I'm not an OB. So I don't understand the nuances of what the pill is that it's synthetic

1076
01:37:30.640 --> 01:37:37.360
that this is how it works. This is what it doesn't do. So I would want to give my daughters all

1077
01:37:37.360 --> 01:37:43.120
the information so that they can make an educated decision. So my oldest, the first one coming

1078
01:37:43.120 --> 01:37:49.680
through wanted it for contraception. And so when we talk about contraception, it's not just most

1079
01:37:49.680 --> 01:37:54.560
people automatically think the oral birth control pill. But I did go through all of the options

1080
01:37:54.560 --> 01:38:00.160
with her and then sent her to a trusted friend to let her go and make her own decision. And she

1081
01:38:00.160 --> 01:38:04.640
decided to have an IUD inserted, which I thought was a great choice for her because she had normal

1082
01:38:04.640 --> 01:38:12.000
regular periods before we did this. There were no issues. And she had it inserted. And then within a

1083
01:38:12.000 --> 01:38:16.480
week she started having severe cramping called me into the bathroom. And this is my daughter who

1084
01:38:16.560 --> 01:38:21.520
is not let me see her unclowed since she was seven years old. She's just very private and she's

1085
01:38:21.520 --> 01:38:27.760
like riding on the floor. Bless her little heart. And she had expelled the IUD on her own. She had

1086
01:38:27.760 --> 01:38:32.880
cramped it right out. Uterus pushed it out of her body because it was extraordinarily painful.

1087
01:38:32.880 --> 01:38:37.440
And so we basically delivered the IUD on her bathroom. So do you know what an IUD is?

1088
01:38:37.440 --> 01:38:43.440
Is not the coil ish. That's one form of an IUD. She had a different form. But she basically

1089
01:38:44.000 --> 01:38:49.840
pushed out her own IUD her uterine device. So it's birth control that is placed inside the uterus.

1090
01:38:49.840 --> 01:38:56.000
It's shaped like a tea. It's shaped like a tea. It's the UK. They use the coil still quite a bit,

1091
01:38:56.000 --> 01:39:02.640
which is copper. And so there's different options for the IUD. Some contain progestines,

1092
01:39:02.640 --> 01:39:08.720
some contain just the copper. And so the way an IUD works is that it creates an inflammatory

1093
01:39:08.720 --> 01:39:15.360
response in the uterus so that the cervical mucus thickens so that when we are fertile in our

1094
01:39:15.360 --> 01:39:20.000
fur fertility window, mid cycle and jump. And if I miss this up, the mucus of the cervix

1095
01:39:20.000 --> 01:39:24.880
thins to the point where sperm can actually get through. Most of the month, probably 85 to 90%

1096
01:39:24.880 --> 01:39:29.920
of the month, the sperm cannot traverse the cervix. You cannot, you know, so in our fertility

1097
01:39:29.920 --> 01:39:36.480
window, right at ovulation, the cervical mucus thins and then the sperm can transmit. So the

1098
01:39:36.480 --> 01:39:41.520
presence of the IUD creates an inflammatory environment that will basically is toxic to sperm

1099
01:39:41.520 --> 01:39:46.000
and thickens the cervical mucus where it becomes a plug. That's how it works. Works very, very well.

1100
01:39:46.640 --> 01:39:51.840
Catherine, within a week, her uterus ejected it. So she cramped so much that it pushed it through.

1101
01:39:52.480 --> 01:39:57.360
And so that was an option for her. She wasn't willing to go through that again.

1102
01:39:58.240 --> 01:40:04.320
At that point, she had to go through the hormonal options for that. And she decided to have the

1103
01:40:04.320 --> 01:40:09.200
implant. So it's progesterone only implanted in her arm. Quickly, we realized she needed to

1104
01:40:09.200 --> 01:40:13.520
mastergent. So we, she supplements estrogen on top of that. She's even, I think the contraceptive

1105
01:40:13.520 --> 01:40:18.880
discussion, we have to say that there are options that are highly effective at preventing pregnancy.

1106
01:40:18.880 --> 01:40:23.840
And at some times in your life, that is the number one most important goal. And we need to choose

1107
01:40:23.840 --> 01:40:29.840
a highly effective option. However, certain some of those options included have downstream impacts

1108
01:40:29.840 --> 01:40:34.320
that have not been discussed about. The typical contraceptive discussion says here are some

1109
01:40:34.320 --> 01:40:39.120
side effects you may have. If you want to still proceed, let's go for it. We're not talking about

1110
01:40:39.120 --> 01:40:43.680
long-term implications of these. We're just talking about how you're going to feel, not exactly

1111
01:40:43.680 --> 01:40:49.920
what is happening in your body. A lot of these contraceptive options are progesterone only. And so you

1112
01:40:49.920 --> 01:40:55.520
know by your new favorite graph that you don't see progesterone every single day. So when you have

1113
01:40:55.600 --> 01:41:01.520
progesterone only, it is shifting your hormonal profile. And a lot of women, this progesterone,

1114
01:41:01.520 --> 01:41:07.040
is so high that it works by also preventing ovulation, makes it highly effective. But if you're not

1115
01:41:07.040 --> 01:41:11.760
ovulating, you're not going to be making those high estrogen levels. And Dr. Haver and I've even

1116
01:41:11.760 --> 01:41:18.080
talked about how we wish there was a contraceptive option that had estradiol in it so that your body

1117
01:41:18.080 --> 01:41:24.480
could still have some estradiol. So this ethanol estradiol is very different than plain estradiol.

1118
01:41:24.480 --> 01:41:30.480
They've put this ester group on the end, which makes it bind to the estrogen receptor in the brain.

1119
01:41:31.440 --> 01:41:39.120
300 times more powerful than regular estradiol. It was just why it's so effective. You know,

1120
01:41:39.120 --> 01:41:44.880
why we do it in a microdose versus estradiol is dosed in milligrams. And ethanol estradiol is dosed

1121
01:41:44.880 --> 01:41:52.480
in micrograms because it is that much more potent. So very, very different. Now in the UK and

1122
01:41:52.480 --> 01:41:56.960
in other places in Europe, there is a new form of contraception that has esterotrol,

1123
01:41:56.960 --> 01:42:01.760
which is the fetal estrogen. So we have four natural estrogens in the body. The ovary produces

1124
01:42:01.760 --> 01:42:07.120
estradiol. That's the one we all know. It's really the biggest bang for our buck. The placenta

1125
01:42:07.120 --> 01:42:12.640
produces something called estriol. Our fat cells and the peripheral tissues, the tissues outside

1126
01:42:12.640 --> 01:42:18.640
of the ovaries can produce something called estrone. And then we have this fetal estrogen called

1127
01:42:18.720 --> 01:42:23.120
esterotrol, I'm pronouncing it correctly. And so they've compounded, they've been able to

1128
01:42:23.120 --> 01:42:28.560
formulate that. So it is one of the natural estrogens and they've put it in a birth control pill

1129
01:42:28.560 --> 01:42:33.040
that is available in the UK. If you ate anything, what choice would you make for contraception now?

1130
01:42:33.520 --> 01:42:39.680
Studies have proven within shadow of a doubt that relying on natural family planning at most

1131
01:42:39.680 --> 01:42:46.000
stages is not a reliable form of contraception. So I would not recommend that. And relying on condoms.

1132
01:42:46.080 --> 01:42:49.760
Would you mean relying on natural family planning? So you timing your intercourse?

1133
01:42:49.760 --> 01:42:54.320
Oh, okay. So cycle tracking, we know that the fertile window is the five days before and the day

1134
01:42:54.320 --> 01:42:59.200
of ovulation. Five days before. Five days before and then the day of sperm can live for five days

1135
01:42:59.200 --> 01:43:05.200
and the female reproductive track, the egg lives for 24 hours. So on this graph, where is the line

1136
01:43:05.200 --> 01:43:10.400
right as ovulation and then the five days before? Yeah. So in popular culture, you would call that

1137
01:43:10.400 --> 01:43:16.320
natural family planning. Okay, fine. Avoiding intercourse, staining any time in that window.

1138
01:43:16.320 --> 01:43:19.600
But if I'm trying to get male pregnant, then I should really be aiming.

1139
01:43:19.600 --> 01:43:23.280
Those are your target days. Yeah. Out of your apps for that, you can try.

1140
01:43:23.280 --> 01:43:27.920
Yeah. Oh, I've got the app. Okay. Oh, you know, remember the very ability.

1141
01:43:27.920 --> 01:43:33.520
Yes. She's made download it my time. There's a few different ways you can do natural family planning

1142
01:43:33.520 --> 01:43:37.760
to hijack the discussion for a minute. And they have different degrees of effectiveness.

1143
01:43:37.760 --> 01:43:41.760
But one of the main issues is that they have very large abstinence windows.

1144
01:43:41.760 --> 01:43:46.400
So it's often not very sustainable to say, we're just not going to have intercourse for 18 days out

1145
01:43:46.400 --> 01:43:52.880
of the month or some very long time period depending on which one. Because your cycles never perfect.

1146
01:43:52.880 --> 01:43:58.800
What if you did ovulate sooner? If this is all you're relying on for your prevention of pregnancy,

1147
01:43:58.800 --> 01:44:04.400
you have to really assure that you know when that ovulation is happening, it can be an effective way

1148
01:44:04.400 --> 01:44:10.320
to prevent pregnancy if your cycles are very regular. But in my brain, I wish that's what you stop

1149
01:44:10.320 --> 01:44:14.080
the birth control pill at least six months before you want to get pregnant. And then you start

1150
01:44:14.080 --> 01:44:18.000
learning how to track your cycles and you're using some natural family planning if you're not

1151
01:44:18.000 --> 01:44:24.240
quite ready then. Because the margin of error oopsies, it didn't work. The acceptance of

1152
01:44:24.240 --> 01:44:29.680
we were going to try to get pregnant soon is usually okay. Yeah. It's not an effective contraception

1153
01:44:29.680 --> 01:44:34.320
for most of the pops. So we have to factor in. When we're looking at, you know, I was trained

1154
01:44:34.320 --> 01:44:39.520
and taught to only look at birth control through the lens of contraception, right? We know that

1155
01:44:39.520 --> 01:44:43.920
they might have some weird bleeding and maybe a few headaches. And for some of DVT, if they have,

1156
01:44:43.920 --> 01:44:47.360
you know, deep venous thrombosis, you cannot blood clots, it'll increase your risk, especially if

1157
01:44:47.360 --> 01:44:52.720
you have a progenetic disposition to that. But what we didn't talk about were mental health mood and

1158
01:44:52.720 --> 01:44:59.760
some of the long down-to-dream, libido effects. So, right. And so then I'm looking at it through the

1159
01:44:59.760 --> 01:45:04.320
lens of, you know, if I'm only looking at the lens of she doesn't want to be pregnant,

1160
01:45:05.440 --> 01:45:11.280
a younger patient, so you're talking about 18, is less likely to remember to do something every day.

1161
01:45:11.280 --> 01:45:17.040
Correct. Okay. So then to take the impetus of remembering to take a pill every day or change

1162
01:45:17.040 --> 01:45:23.520
your patch once a week for the patch option, then we're looking at maybe a vaginal ring that she

1163
01:45:23.520 --> 01:45:28.080
inserts for three weeks and removes for one for a period. If you take one. If I had to pick one,

1164
01:45:28.080 --> 01:45:34.560
right now, if I was, if it was available in the US, I think I would go with the esterotrol.

1165
01:45:34.560 --> 01:45:38.640
What's that? Option. That's the one she's saying is in the UK, a newer option that we don't have.

1166
01:45:38.640 --> 01:45:47.120
No, it's a pill. It's still a pill. Yeah. And it's, because it more, it looks like so far, it's newer

1167
01:45:47.120 --> 01:45:52.800
that it has less of the downstream effects. So you're not having that complete suppression,

1168
01:45:52.800 --> 01:45:59.440
you know, that complete binding and it's, it's, you know, may have an also probably has less risk of

1169
01:46:00.720 --> 01:46:05.120
DVT, of blood loss. Yeah. I'll jump on this. I do not love

1170
01:46:05.120 --> 01:46:10.480
intrauterine device for a patient who is 18 for a multitude of reasons. Now, I'm going to

1171
01:46:10.480 --> 01:46:15.520
preface this to say it is an highly effective contraceptive choice. It's one of the most effective

1172
01:46:15.520 --> 01:46:20.000
ones that we have. And so there are certainly circumstances where that is the right thing to do.

1173
01:46:20.240 --> 01:46:26.160
We've had IUDs in practice for a really long time. For the majority of this, we were only placing

1174
01:46:26.160 --> 01:46:31.040
them in women after they had given birth at least once because of their size and being able to

1175
01:46:31.040 --> 01:46:35.520
pass them through the cervix. Now we have different options and we are offering them to women younger,

1176
01:46:35.520 --> 01:46:42.000
which is wonderful. However, when we're putting IUDs and the uterus of women who are really young,

1177
01:46:42.000 --> 01:46:47.040
sometimes the progesterone dose in them is so high that it is preventing ovulation. And we are seeing

1178
01:46:47.040 --> 01:46:52.640
young women who are not ovulating and they are not making estrogen, therefore. And they don't even

1179
01:46:52.640 --> 01:46:59.680
really realize it because that's not disclosed as one of the main mechanisms of a progesterone IUD

1180
01:46:59.680 --> 01:47:04.080
because it doesn't happen in enough people to effectively prevent conception that way.

1181
01:47:04.720 --> 01:47:09.600
It works through the inflammation, the cervical mucus changes. And why does that matter? Because if

1182
01:47:09.600 --> 01:47:15.600
you are not ovulating and you're not making estrogen, you are going to have low libido, low energy,

1183
01:47:15.600 --> 01:47:20.640
you're not going to build your bones during critical years. Let's say that IUD lasts five to seven

1184
01:47:20.640 --> 01:47:26.480
years. You're 18 to 25. These are some of the most critical years in your mental health, your bone

1185
01:47:26.480 --> 01:47:32.560
health, your cardiac health. And being low estrogen during that time is going to set you up

1186
01:47:32.560 --> 01:47:38.720
on a different risk trajectory for your entire life. And the worst thing here about the progesterone

1187
01:47:39.680 --> 01:47:45.280
is that because of the progesterone, which will thin the lining, many women just say, I don't have

1188
01:47:45.280 --> 01:47:52.560
my period because my lining is so thin and that's a side effect of the IUD. If that same woman was

1189
01:47:52.560 --> 01:47:58.080
not ovulating and came to me and said, I haven't had a period in seven years and I knew she was low

1190
01:47:58.080 --> 01:48:04.160
estrogen and not ovulating. We're highly concerned about her health. But because she has an IUD,

1191
01:48:04.160 --> 01:48:09.840
what happens? Well, that's a side effect of the IUD. No big deal. So we're missing the moment

1192
01:48:09.840 --> 01:48:16.400
to understand where some of these symptoms just side effect of the IUD or they having a much

1193
01:48:16.400 --> 01:48:22.800
bigger role in what's going to happen to that woman's long term trajectory for being low estrogen

1194
01:48:22.800 --> 01:48:27.680
during crucial years. And I'll say this, Steven, I'm very biased. I'm a fertility doctor. I see

1195
01:48:27.680 --> 01:48:33.360
patients who have trouble getting pregnant. That is a narrow subset. That is not the majority of

1196
01:48:33.360 --> 01:48:38.160
women who have IUDs. So what would you suggest if you had to pick one contraceptive? Visectomy.

1197
01:48:40.560 --> 01:48:45.280
I would still do the pill right now. The pill or the vaginal ring. I think they are both

1198
01:48:45.280 --> 01:48:50.480
depending on somebody's personal preference. I just think that it's really important if you're

1199
01:48:50.480 --> 01:48:54.800
using the birth control pill. I do think it's important to give your brain a break from the

1200
01:48:54.800 --> 01:48:59.520
pill at times. And even if you're cycling it monthly, there's options now. I took the pill

1201
01:49:00.240 --> 01:49:09.040
an active pill every single day for years, a decade probably, meaning suppressed my brain

1202
01:49:09.040 --> 01:49:16.160
completely for that long. Now your brain sends out hormone signals that impact your entire body,

1203
01:49:16.160 --> 01:49:20.400
right? So we already talked about the hormones and how is this beautifully conducted symphony.

1204
01:49:21.280 --> 01:49:24.560
But if you even, if you're going to take the pill at that young age, I would say,

1205
01:49:25.520 --> 01:49:30.400
take it so that you have the seven days of not taking a pill. Let your brain have a moment of

1206
01:49:30.400 --> 01:49:35.520
release from the suppression and then take it again. That's still a very effective way to use the pill.

1207
01:49:35.520 --> 01:49:40.240
But because women don't love having periods, we've offered these other options, which are not

1208
01:49:40.880 --> 01:49:48.000
wrong, but they just have a bigger consequence downstream than we're talking about. But the pill is

1209
01:49:48.000 --> 01:49:53.200
very short-acting. It only has a half-life of 28 hours, meaning it is out of your body very quickly.

1210
01:49:53.200 --> 01:49:58.080
So you do want to stop the pill and see what is happening and track your cycles. That is something

1211
01:49:58.080 --> 01:50:04.400
nice about it versus an implant or an IUD that is fitted for the fit and forgets. Yeah.

1212
01:50:06.080 --> 01:50:10.640
The question that came in from the 1,000 women we spoke to in the diversity of audience was,

1213
01:50:10.640 --> 01:50:15.840
is there any way to control hormonal mood swings during the lethal phase of the menstrual cycle,

1214
01:50:15.840 --> 01:50:20.480
which I now know is the second phase of the menstrual cycle? You've learned so much. Yes,

1215
01:50:20.480 --> 01:50:26.560
that's great. In the luteal phase, we do tend to see more mood changes and physical changes.

1216
01:50:26.560 --> 01:50:32.880
And a lot of this is because we have an increase in estrogen and progesterone and then a decrease in

1217
01:50:32.880 --> 01:50:37.920
both of these hormones. And what we find is that some women are simply more sensitive to these

1218
01:50:37.920 --> 01:50:42.880
changes. They feel them quite profoundly. And there's even something called PMDD, pre-menstrual

1219
01:50:42.880 --> 01:50:48.000
dysphoric disorder, which is when those hormones are dropping. You get these terrible mood swings,

1220
01:50:48.000 --> 01:50:53.680
this terrible depression and anxiety. In addition to physical changes with terrible fatigue,

1221
01:50:53.680 --> 01:50:58.240
you just feel like you can't accomplish any of your tasks and somnia, quite similar to a lot of

1222
01:50:58.240 --> 01:51:04.640
the things that we talk about. Anytime we talk about a low estrogen state. Right. We see it in

1223
01:51:05.200 --> 01:51:10.720
postpartum depression. It's a very similar and in the perimenopausal transition, we have a 40%

1224
01:51:10.720 --> 01:51:16.560
increase in mental health changes. And we know this because women tell us and we believe them,

1225
01:51:16.560 --> 01:51:20.480
but what's happening is that our neurotransmitters, especially GABA,

1226
01:51:20.960 --> 01:51:26.160
serotonin and dopamine levels, are highly tied to what our hormone levels are doing.

1227
01:51:27.360 --> 01:51:36.160
So is this is the mood swing or is the what's the right time to describe a mood when someone

1228
01:51:36.160 --> 01:51:42.320
doesn't feel great? dysphoria. Is the dysphoria mood off to the period or before it?

1229
01:51:42.960 --> 01:51:47.600
It's off to it's before. So the estrogen is dropping before and it stays low through.

1230
01:51:47.600 --> 01:51:52.800
So what happens is about the week before your period and then the week will say of your period,

1231
01:51:52.800 --> 01:51:57.840
you are estrogen low. The rise of estrogen from that next egg being recruited is actually what stops

1232
01:51:57.840 --> 01:52:02.400
you from bleeding and helps you start to feel better. Because of this, a lot of people will throw

1233
01:52:02.400 --> 01:52:07.040
a birth control pill at this situation because they will say, I will give you constant hormone

1234
01:52:07.040 --> 01:52:13.280
levels every day and now you will not have these PMDD symptoms anymore. However, a lot of women

1235
01:52:13.280 --> 01:52:16.640
don't want to be on the pill for a variety of the different reasons we've talked about. They just

1236
01:52:16.640 --> 01:52:21.520
feel bad. Let's say this week or this seven to 10 day interval, they don't want to suppress

1237
01:52:21.520 --> 01:52:27.760
ovulation. I find that a low dose estrogen in the luteal phase can be very effective in targeting

1238
01:52:27.760 --> 01:52:33.760
after ovulation. I'm going to take some estrogen helping alleviate these symptoms without interfering

1239
01:52:33.760 --> 01:52:39.200
with ovulatory function. But I was trained to give them an SSRI for those seven to 10 days.

1240
01:52:39.200 --> 01:52:42.240
An anti-depressant group? Yes, an anti-depressant. Only for those two weeks,

1241
01:52:42.240 --> 01:52:48.240
a seraphim was in the brand name of it and it does tend to help, but when no one taught me

1242
01:52:48.240 --> 01:52:54.320
in what clinical experience has taught me and talking to all these other smart people is a low dose

1243
01:52:54.320 --> 01:53:00.320
estrogen, like treating the root cause. Just just give her estrogen back during that time

1244
01:53:00.400 --> 01:53:06.560
period and she gets remarkably better. In some of the nutrition research, finding that low iron

1245
01:53:06.560 --> 01:53:12.480
and low vitamin D are huge contributors to it. So there's that research to investigate too,

1246
01:53:12.480 --> 01:53:18.320
which is interesting because there are some women also who don't want to go on SSRI or SRO.

1247
01:53:20.000 --> 01:53:25.040
The Antiquant Society does not recommend routine testing of vitamin D. It's crazy. I just think

1248
01:53:25.040 --> 01:53:30.720
it's insane. With my partner, I should anticipate that her mood might drop in the lead up to having

1249
01:53:30.720 --> 01:53:36.560
her period. It's very common. And then after her period, it might recover. And whether or not that

1250
01:53:36.560 --> 01:53:40.720
becomes clinically significant, whether or not it's life disrupted for her, rather than she just

1251
01:53:40.720 --> 01:53:46.400
has a little bit of a low mood, most women can tolerate that. But for those who can't and that it

1252
01:53:46.400 --> 01:53:51.360
is disrupting their day-to-day activities and how they feel about the world, we have options.

1253
01:53:52.320 --> 01:53:56.800
Because I'm trying to understand, I want to understand her better. So I'm looking at this little

1254
01:53:56.800 --> 01:54:02.000
graph here, which says the brain during the menstrual cycle. So the menstrual cycle starts when

1255
01:54:02.000 --> 01:54:06.400
her period starts. By convention, yes. That's what we say day one is the first day you start bleeding.

1256
01:54:06.960 --> 01:54:12.160
Okay. And so what is she going to go through for the next 29 days and how my eye support her

1257
01:54:12.160 --> 01:54:16.080
better through that journey? I want to understand what's going on in her brain.

1258
01:54:16.080 --> 01:54:21.360
Her brain starts from a reproductive hormone level. The brain starts by sending out FSH,

1259
01:54:21.360 --> 01:54:26.560
follicle stimulating hormone, which is going to get her ovary to start growing an egg, which

1260
01:54:26.560 --> 01:54:31.520
lives inside a follicle and making estrogen. And that rise in estrogen as it's growing will stop

1261
01:54:31.520 --> 01:54:36.800
her from bleeding. So at the beginning, that cycle day one, the bleeding that she's experiencing

1262
01:54:36.800 --> 01:54:41.440
her period is because she didn't get pregnant in the month before. So it's getting rid of that

1263
01:54:41.520 --> 01:54:47.520
endometrial lining, cleaning the slate. She's estrogen and progesterone low during that time period.

1264
01:54:47.520 --> 01:54:52.800
And then once her bleeding stops, it's because an egg has been chosen. Estrogen is then going to rise

1265
01:54:52.800 --> 01:54:57.680
until it gets to that peak level. During that time, she's going to feel her best for most women.

1266
01:54:57.680 --> 01:55:02.960
So is that the first 14 days? So the week by convention, if you had a 28 day cycle, which

1267
01:55:02.960 --> 01:55:08.000
only about 13% women actually do. But all of these graphs, if you look at usually use 28 days,

1268
01:55:08.000 --> 01:55:14.240
because it's easy to go week by week. And that's the lunar calendar. So 28 days. We see that,

1269
01:55:14.240 --> 01:55:19.280
but we have to acknowledge that most women don't have a 28 day cycle. So, but it is roughly the first

1270
01:55:19.280 --> 01:55:24.960
two weeks for most women to get up to that ovulatory time period. So the time from I have started

1271
01:55:24.960 --> 01:55:31.520
bleeding until I am now ovulating, that is all considered the follicular phase. And on this

1272
01:55:31.520 --> 01:55:35.280
little image that I have in front of me here, it says in those first 14 days, she's going to have

1273
01:55:35.280 --> 01:55:40.800
better spatial skills and be more anxious. So once you get to your estrogen dominant, so you have

1274
01:55:40.800 --> 01:55:46.720
a lot of estrogen, and you don't have progesterone. Most women have increased concentration.

1275
01:55:46.720 --> 01:55:51.040
They have more focus. They actually can sleep better. They have higher libido. You feel like

1276
01:55:51.040 --> 01:55:55.760
your performance, even for athletes, performance tends to be a more aggression during concentration,

1277
01:55:55.760 --> 01:55:59.440
more, yeah. During the what we call the late follicular phase. So that means the time period when

1278
01:55:59.440 --> 01:56:06.000
you're really making that estrogen, let's call it days seven to 14 for ease. So I'm now done

1279
01:56:06.000 --> 01:56:10.880
bleeding. A follicle is growing. Meaning an egg is making enough estrogen to stop that bleeding.

1280
01:56:10.880 --> 01:56:15.840
I've not yet ovulated and seen progesterone. This is where we typically have our best

1281
01:56:15.840 --> 01:56:21.280
performance overall from how our body is functioning. And then from day 14 onwards,

1282
01:56:22.960 --> 01:56:28.960
I'm she's going to be calmer. Well, progesterone slows your body's metabolism down. It's preparing

1283
01:56:29.120 --> 01:56:34.560
you for that pregnancy. Calmer is a nice way to put it. But essentially, your metabolic rate is

1284
01:56:34.560 --> 01:56:39.440
going to change. Your body's going to shift how it functions. Many women actually have fatigue,

1285
01:56:39.440 --> 01:56:45.440
they're hungry. Specifically in the brain, progesterone levels, as they rise, we see an increase in

1286
01:56:45.440 --> 01:56:51.440
GABA, which is a neurotransmitter, one of our brain, one of our brain hormones that talks,

1287
01:56:51.440 --> 01:56:57.440
you know, jumps between one neuron to the other. And that is more of a calming hormone. So women tend

1288
01:56:57.920 --> 01:57:03.120
to we see sleep changes, more you see deeper sleep, longer sleep in that luteo phase.

1289
01:57:03.600 --> 01:57:08.240
She's and on this it says she's going to have she's going to be horny at four day 14. I don't know

1290
01:57:08.240 --> 01:57:12.720
how else to say it because she has an egg available because that peak estrogen, that estrogen level

1291
01:57:12.720 --> 01:57:18.720
of 200 pg is heightening everything to have peak libido when an egg is released. The body is

1292
01:57:18.720 --> 01:57:24.080
made that way on purpose. This is a bit off script, but my girlfriend always talks about her

1293
01:57:24.160 --> 01:57:30.000
HRV being very different. And so she has really great HRV schools and then

1294
01:57:31.200 --> 01:57:35.840
once every month for a period of time, they're terrible and she can't explain it.

1295
01:57:36.400 --> 01:57:41.760
So this is where wearables come into play. So wearables are not designed to capture women's

1296
01:57:41.760 --> 01:57:47.440
physiology. So what happens after ovulation is your respiratory rate goes up, your resting heart

1297
01:57:47.440 --> 01:57:53.440
rate goes up in your HRV plummets. So on the wearables, most women about five days before their

1298
01:57:53.440 --> 01:58:00.320
period start will never be in the clear so to speak. They will never look recovered. They will never

1299
01:58:00.320 --> 01:58:05.120
look like they can take on a lot of stress. They're not stress resilient because of the way the

1300
01:58:05.120 --> 01:58:11.920
algorithms are reading this change that is natural that is produced by progesterone to alter

1301
01:58:12.000 --> 01:58:17.120
our respiratory rate and our heart rate. It doesn't mean that she's not stress resilient is what

1302
01:58:17.120 --> 01:58:23.520
the wearable is saying. Because she came downstairs and she said, oh god, my recovery is so bad.

1303
01:58:24.320 --> 01:58:29.440
And then I think a couple of days later, a little while later, she had a period. I'm not sure,

1304
01:58:29.440 --> 01:58:32.640
I can't remember the timeframes, but she came downstairs and she was like shocked that she

1305
01:58:32.640 --> 01:58:38.240
done everything right. But her recovery on her wearables said that she was in terrible state.

1306
01:58:38.240 --> 01:58:46.080
This is why we do not let athletes use wearables leading up to a peak event because they feed into

1307
01:58:46.080 --> 01:58:52.080
what the wearables respond or telling them. And it's not true data with regards to how their

1308
01:58:52.080 --> 01:59:01.440
body can actually perform. So wearables data masters then need to segregate populations and make

1309
01:59:01.440 --> 01:59:08.000
new norms for women and maybe new norms for different fitness levels of women. Exactly. I've

1310
01:59:08.000 --> 01:59:12.720
always been pushing for the past five or six years interacting with wearable companies is like,

1311
01:59:12.720 --> 01:59:17.920
if you want to capture it well, then you need to be able to compare follicular to follicular

1312
01:59:17.920 --> 01:59:24.480
and luteal to luteal. What does that mean? So comparing like we know your HIV is going to be different

1313
01:59:24.480 --> 01:59:29.040
in your follicular phase. That's exactly the case. This is not that thing. People could theoretically

1314
01:59:29.040 --> 01:59:33.440
do that on their wearables and look at the previous month and see the level you're at then

1315
01:59:33.440 --> 01:59:36.960
theoretically. Obviously, the wearable companies could do a lot more here to make it. Definitely

1316
01:59:36.960 --> 01:59:42.720
helpful. But no, then it comes back again on the woman trying to understand and interpret the

1317
01:59:42.720 --> 01:59:48.800
data herself, which can be a little bit problematic because there's so many women out there like,

1318
01:59:48.800 --> 01:59:54.560
my wearable told me that I'm in the red. I can't do anything today. When in fact physically

1319
01:59:54.560 --> 02:00:00.960
and psychologically, they can do what they set out to do. It's just now they have this little

1320
02:00:00.960 --> 02:00:07.760
seed saying that no, you can't do it because of an improper algorithm on their wearable.

1321
02:00:08.960 --> 02:00:10.960
Big a ton of disclosed that I'm an investor in Woot.

1322
02:00:12.720 --> 02:00:16.240
I can't push. Okay. I'll send this to them. Please.

1323
02:00:16.240 --> 02:00:21.280
Yeah, you wear Woot. Do you wear any devices to track your health data?

1324
02:00:21.280 --> 02:00:24.000
I have a wearable. I wear a seat here. I wear them in a Woot.

1325
02:00:25.360 --> 02:00:29.680
Just give me a minute of your time and I'll tell you about a device that my team has been using

1326
02:00:29.680 --> 02:00:34.560
that they won't seem to shut up about. It's called the Note Pro and it's by our sponsor,

1327
02:00:35.200 --> 02:00:42.080
Claude. This tiny card clips onto the back of your phone and captures everything. But why it's so

1328
02:00:42.080 --> 02:00:47.040
clever is that it picks up multiple voices at the same time. And when someone says something

1329
02:00:47.040 --> 02:00:52.560
important, you just push this tiny little button here and that moment gets highlighted in your

1330
02:00:52.560 --> 02:00:58.320
notes and captured. It records the conversations that it hears, takes those conversations, creates a

1331
02:00:58.320 --> 02:01:04.800
transcript and it uses AI to synthesize all of that information into whatever template suits you.

1332
02:01:04.800 --> 02:01:10.080
You get a summary, action points, highlights, and even a mind map sent straight to the

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02:01:10.080 --> 02:01:15.120
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1339
02:01:43.040 --> 02:01:47.920
feet the opportunity that they desperately want to need to strengthen. We're living in a comfort

1340
02:01:47.920 --> 02:01:53.520
crisis and that at all times in our lives we're making this trade of whether to have more comfort now

1341
02:01:53.520 --> 02:01:59.120
and therefore more discomfort in the future or a little bit less comfort now, but to be stronger

1342
02:01:59.120 --> 02:02:02.640
and healthier in the future. And research from Liverpool University has backed this up. They've

1343
02:02:02.640 --> 02:02:09.280
shown that wearing Vivo Barefoot shoes for six months can increase foot strength by up to 60%.

1344
02:02:09.280 --> 02:02:15.600
So if you want to start strengthening your feet and your body, visit VivoB Barefoot.com-steven

1345
02:02:15.600 --> 02:02:22.640
and you'll get 20% off when you use code Stephen B20, a checkout that also comes with a 100-day

1346
02:02:22.640 --> 02:02:27.920
money back guarantee. I want to close off on the subject of fertility because it was heavily

1347
02:02:27.920 --> 02:02:32.640
asked by audience and I guess I'm well placed to ask some of these questions because I'm in

1348
02:02:32.640 --> 02:02:37.680
that journey myself of trying to have a child at the moment. Natalie, you have five fertility

1349
02:02:37.680 --> 02:02:42.560
non-negotiables that you talk about. I do and I think it's really important to think about

1350
02:02:44.640 --> 02:02:48.720
for too long we've been told you know your fertility is luck it's good luck if you get pregnant,

1351
02:02:48.720 --> 02:02:54.160
it's bad luck if it's not and that's this narrative that gets propagated and fertility is

1352
02:02:54.160 --> 02:02:58.880
certainly not fair meaning people will have infertility and do everything right but there are

1353
02:02:58.880 --> 02:03:03.680
things that we do that will inherently also harm our fertility and our hormonal health and make

1354
02:03:03.680 --> 02:03:10.080
it harder to get pregnant and that's even when we are doing treatments so a lot of times people

1355
02:03:10.080 --> 02:03:14.720
say I'm doing IVF so I don't need to worry about these non-negotiables and that's also not true

1356
02:03:15.280 --> 02:03:20.560
I mean things that we need to do we need to as we've all said get more sleep that's going to be number

1357
02:03:20.560 --> 02:03:27.200
one we need to actively work to decrease stress that is not a I'm just gonna live a stress-free life

1358
02:03:27.200 --> 02:03:30.800
but all these things I'm going to not take call I'm gonna set some boundaries and not have late

1359
02:03:30.800 --> 02:03:35.920
meetings I'm going to see morning light I'm gonna take a walk outside we live in a stressful

1360
02:03:35.920 --> 02:03:41.280
world and chronic stress itself can impact your fertility your natural fertility and IVF success

1361
02:03:41.280 --> 02:03:48.560
rates we're going to work on exercise to build muscle and try to improve our muscular health

1362
02:03:48.560 --> 02:03:53.200
since it's part of our metabolism we're gonna eat an anti-inflammatory diet that's definitely

1363
02:03:53.200 --> 02:03:58.400
key high in fiber and we're gonna look at the world around us and work on pulling toxins out

1364
02:03:58.400 --> 02:04:03.120
of our world that we know we haven't even entered the discussion about how environmental toxins

1365
02:04:03.120 --> 02:04:08.320
is harming our body our hormonal health our fertility our ovaries our organs and so these are

1366
02:04:08.320 --> 02:04:13.120
all things that we make active choices on that we have to start paying attention to and kind of

1367
02:04:13.120 --> 02:04:19.680
changing we're going to detail in the lifestyle factors environmental toxins in our second episode

1368
02:04:19.680 --> 02:04:24.160
together I've always been quite shocked by this graph because it's quite quite significant this

1369
02:04:24.160 --> 02:04:33.040
is just showing the egg count by age slide that into that direction what do men and women need

1370
02:04:33.040 --> 02:04:37.440
to understand about egg counts in order to make better family planning and fertility decisions

1371
02:04:37.440 --> 02:04:42.000
okay well I've asked you this last time so Stephen how many sperm do you make a second

1372
02:04:43.840 --> 02:04:50.560
millions you make 1500 a second I mean you make millions every day okay but still you still you

1373
02:04:50.560 --> 02:04:54.960
make a ton of sperm you make sperm every single day you have germ cells that create sperm women are

1374
02:04:54.960 --> 02:05:00.800
born with all the eggs you're ever going to have and yes my favorite vault analogy so I like to

1375
02:05:00.800 --> 02:05:05.680
imagine that this is a vault inside your ovary that is storing all of your eggs and so we'll use

1376
02:05:05.680 --> 02:05:11.600
this cup with all of the beads as that analogy and every single month since before you are born

1377
02:05:11.600 --> 02:05:16.880
eggs come out of this vault and what happens is that when the vault is more full more eggs come out

1378
02:05:17.680 --> 02:05:23.120
and as the vault starts to get emptier fewer come out and this means that we lose the majority

1379
02:05:23.120 --> 02:05:28.400
of our eggs you can see the line well before our reproductive years even start so you lose the

1380
02:05:28.400 --> 02:05:33.120
most before you're born so from being a five-month baby to birth your egg count goes from six to seven

1381
02:05:33.120 --> 02:05:39.360
million to one to two million millions of eggs lost before you're even born from birth to puberty

1382
02:05:39.360 --> 02:05:43.840
let's say you go from one to two million to half a million to simplify numbers so the second

1383
02:05:43.840 --> 02:05:48.480
biggest drop before you're ever ovulating before you ever have a chance to get pregnant and then

1384
02:05:48.480 --> 02:05:54.160
you only ovulate around 400 eggs over the course of your reproductive lifespan as that account

1385
02:05:54.160 --> 02:05:59.600
starts to drop over time the other really really big important factor is that our eggs have been in

1386
02:05:59.600 --> 02:06:05.200
our body our whole life two different things are happening at the same time one is that our chromosomes

1387
02:06:05.200 --> 02:06:11.280
start to leave their perfect position are they absorb the wear and tear of years so we see more

1388
02:06:11.280 --> 02:06:15.840
chromosome abnormalities as we get older it's why it's harder to get pregnant and why we see an

1389
02:06:15.840 --> 02:06:22.960
increase in miscarriage as we age but also concurrently our metabolic health is poor as we are older too

1390
02:06:22.960 --> 02:06:28.720
and mitochondrial function in eggs the metabolic capacity becomes less capable and so we see that

1391
02:06:28.720 --> 02:06:33.120
it's harder to get pregnant not because woman are running out of eggs but because the quality of

1392
02:06:33.120 --> 02:06:37.840
the eggs declines but everybody will run out of eggs you'll have a period of time where you have a

1393
02:06:37.840 --> 02:06:42.160
very low account we call it diminished ovarian reserve in the fertility world we call it

1394
02:06:42.160 --> 02:06:48.240
perimenopause more globally and this this is two words to describe the same thing as your account

1395
02:06:48.240 --> 02:06:53.360
starts to get very low you start to have an unpredictable response to your ovary and your brain

1396
02:06:53.360 --> 02:06:59.840
is trying to compensate for that and so you see various hormone changes but these start before you

1397
02:06:59.840 --> 02:07:05.360
might recognize even menstrual cycle changes but everybody will run out of eggs every woman will

1398
02:07:05.360 --> 02:07:09.840
your ovaries will go into what we call ovarian failure and no longer respond to hormonal signals

1399
02:07:09.840 --> 02:07:15.200
from the brain or artificial signals that we give meaning I will see older women come in and think

1400
02:07:15.200 --> 02:07:20.480
that I have magic medicines with IVF that can still help them get pregnant but I can only get the eggs

1401
02:07:20.480 --> 02:07:27.040
outside the vault to grow in IVF and so shouldn't we then be freezing our eggs? You're right as a

1402
02:07:27.040 --> 02:07:32.240
society if we are purposely delaying childbearing we know that it gets harder to get pregnant with age

1403
02:07:32.240 --> 02:07:38.400
and if having kids is a life goal putting eggs into the freezer earlier is a way to save that

1404
02:07:38.400 --> 02:07:45.680
opportunity it's not an insurance plan it's not a guarantee but it is a smart game plan especially

1405
02:07:45.680 --> 02:07:52.320
as we are waiting longer because even with IVF we can't always overcome age related infertility if

1406
02:07:52.320 --> 02:07:58.560
we have fewer eggs and more genetic abnormalities the technology helps us identify healthy eggs helps

1407
02:07:59.040 --> 02:08:03.920
have more eggs able to grow in a certain month and take them out and test embryos in a lab

1408
02:08:03.920 --> 02:08:07.680
but I'm working with the eggs and sperm that you're giving me meaning if there's not many of them

1409
02:08:07.680 --> 02:08:12.400
if there's a lot of chromosomal damage if there's a lot of mitochondrial dysfunction if the sperm

1410
02:08:12.400 --> 02:08:17.280
quality is not great that doesn't mean we're going to be able to have success so what you're doing

1411
02:08:17.280 --> 02:08:23.600
on a daily basis to impact egg and sperm quality is still crucial but egg freezing has gotten a lot

1412
02:08:23.680 --> 02:08:28.800
of bad rap it's still a new technology it's only been around about 10 years off experimental

1413
02:08:28.800 --> 02:08:34.560
purposes meaning that women who froze their egg 10 years ago you know they have much poor egg

1414
02:08:34.560 --> 02:08:40.400
survival rates they were older at the time their experience is very different than the modern woman

1415
02:08:40.400 --> 02:08:46.000
who is freezing her eggs now maybe in her upper 20s or early 30s what is the optimal age if you

1416
02:08:46.000 --> 02:08:51.200
want to have a child as a life goal and you're not ready to conceive by age 32 that is when there's

1417
02:08:51.200 --> 02:08:58.320
a clear delineation that it makes smarter financial sense as well as likelihood sense

1418
02:08:58.320 --> 02:09:02.880
the short answer like my daughter will freeze her eggs in her 20s the younger you are the more

1419
02:09:02.880 --> 02:09:07.440
eggs that you have if she says I want to have kids as a life goal then that will be something that

1420
02:09:08.080 --> 02:09:13.280
we will do in order to help her keep that because there's so many other variables which

1421
02:09:13.280 --> 02:09:18.640
impact your ability to get pregnant or your egg count endometriosis decreases your egg count

1422
02:09:18.720 --> 02:09:22.960
right people will develop an ovarian cysts and they'll have surgery surgery they'll have a

1423
02:09:22.960 --> 02:09:28.160
twisting of their ovary and maybe they'll lose an ovary smoking chemo ready eggs smoking marijuana

1424
02:09:28.160 --> 02:09:33.760
any of them so many things can impact your your eggs because you only have this group you're born

1425
02:09:33.760 --> 02:09:40.160
with them so we we plan for life goals differently and we've never really talked about our

1426
02:09:40.160 --> 02:09:45.280
fertility life goals until more recently meaning we went professional career right we knew what we

1427
02:09:45.280 --> 02:09:49.040
had to do to get into medical school to get into residency to get your PhD you had this list of

1428
02:09:49.040 --> 02:09:54.560
things and you set goals and you work to achieve them but I always wanted to be a mom yet I already

1429
02:09:54.560 --> 02:09:58.960
told you I take a birth control pill every single day and I didn't even think about it until that

1430
02:09:58.960 --> 02:10:03.120
moment was in front of me and that's the part of the discussion that we do have to start to have

1431
02:10:03.120 --> 02:10:09.040
earlier is if this is a life goal for you what do we need to do understand our body better our

1432
02:10:09.040 --> 02:10:13.920
fertility better and maybe that does include freezing eggs because it does give many women an

1433
02:10:13.920 --> 02:10:21.120
opportunity that time would eliminate I had a conversation with you Natalie in the podcast but

1434
02:10:21.120 --> 02:10:25.280
then many other women over the course of the last two to three years and one of the things that I

1435
02:10:25.280 --> 02:10:30.000
learned from that was that we as you say we don't family plan and then we have to deal with the

1436
02:10:30.000 --> 02:10:33.920
consequences of not family planning so as an interviewer when I do life story episodes I go

1437
02:10:33.920 --> 02:10:37.680
through a woman's life story and obviously the women sit that's in front of me a typically high

1438
02:10:37.680 --> 02:10:41.280
performance high achievers and some capacity and then we arrive at the end of the conversation when we

1439
02:10:41.280 --> 02:10:47.680
talk about family and kids and all those kinds of things and there's often a lot of tears and it

1440
02:10:47.680 --> 02:10:52.720
was in those conversations sitting here with several women that were on the show what was the straw

1441
02:10:52.720 --> 02:10:58.960
that broke the camel's back it was the UFC fighter Ronda Rousey it just so happened that when I

1442
02:10:58.960 --> 02:11:06.400
interviewed her she had just found out that her seventh round of IVF had failed and so she was very

1443
02:11:06.400 --> 02:11:10.800
very emotional I left that interview and had a conversation with my girlfriend I was like listen

1444
02:11:10.800 --> 02:11:17.840
I've seen too many of too many women over the age of 35 maybe sort of under the age of 50 but

1445
02:11:17.840 --> 02:11:23.840
really under the age of 45 in tears in front of me I think we should have a conversation about this

1446
02:11:23.840 --> 02:11:32.640
should we freeze our eggs I mean me and my partner are both 33 now and at first I don't know maybe

1447
02:11:32.640 --> 02:11:38.880
it was the way I worded it she was offended she was like you don't want to have a baby with me it

1448
02:11:38.880 --> 02:11:44.320
was like yeah it was like you don't have sex with me like I like didn't word it well like I didn't

1449
02:11:44.320 --> 02:11:47.280
I didn't really think I didn't really think about the emotions surrounding it I think that was

1450
02:11:47.280 --> 02:11:51.040
really what you were trying to make a pragmatic yeah I was as men often do like I was just like we

1451
02:11:51.040 --> 02:11:55.840
should free but I didn't think about what that men and this is this prevailing narrative in society

1452
02:11:55.840 --> 02:12:03.680
that if something's not quote-unquote natural then it's not good and that IVF or egg freezing is

1453
02:12:03.680 --> 02:12:08.720
not natural and that like torments people's brains because they want to live a natural life even

1454
02:12:08.720 --> 02:12:13.680
though they're in like fucking planes and on iPhones we want this one area of our life to be natural

1455
02:12:14.320 --> 02:12:20.400
and after honestly five minutes of that conversation I think the framing that

1456
02:12:21.040 --> 02:12:25.520
met flipped her mood was that wouldn't we want to give ourselves the option right and it's

1457
02:12:25.520 --> 02:12:29.600
actually about having options but I wanted to throw that out there because I don't think people

1458
02:12:29.600 --> 02:12:35.360
family plan I think as you said we focus on our careers then we pop up at 35 36 37 and assume that

1459
02:12:35.360 --> 02:12:40.400
we can mm-hmm but that is not because yeah especially if you live a healthy life you think oh this

1460
02:12:40.400 --> 02:12:46.720
will be easy for me or if you're a high achiever and you've achieved other things many women are

1461
02:12:47.520 --> 02:12:54.800
really taken aback by not being able to achieve this or not having control over infertility

1462
02:12:54.800 --> 02:13:01.600
and what is a natural process to run out of eggs and to go into menopause if you are lucky to live long

1463
02:13:01.600 --> 02:13:09.440
enough this is going to happen I got my diagnosis of PCOS in medical school before I was ready to start

1464
02:13:09.440 --> 02:13:17.600
you know family planning and I knew I was probably going to struggle and so it took us about three

1465
02:13:17.600 --> 02:13:25.360
years to successfully conceive the first time and you can't even though I'm working in the business

1466
02:13:25.360 --> 02:13:30.160
you know I'm running between patients to go and have another ultrasound or go get a shot or go do

1467
02:13:30.160 --> 02:13:36.080
all the things that it took you know you you can't remove the emotion from it and I can't tell you

1468
02:13:36.080 --> 02:13:41.520
how many times I cried and of course all of my co-residents my four best friends all got pregnant

1469
02:13:41.520 --> 02:13:46.800
in succession our poor chief residence and with no trouble you know and even like crying to my

1470
02:13:46.800 --> 02:13:52.720
mother about the struggles I was having she's like I just I got pregnant eight times with no trouble

1471
02:13:52.720 --> 02:13:57.760
you know and then my first pregnancy resulted in a miscarriage and you know in the middle of work

1472
02:13:57.760 --> 02:14:00.960
you know my friends were there and they were cheering they were so excited I was finally pregnant

1473
02:14:01.040 --> 02:14:06.240
and then we lost the baby and you know and having to like push through and work through it's like

1474
02:14:06.240 --> 02:14:11.040
it was yesterday like you know I have two healthy kids thank God and you know we were never after

1475
02:14:11.040 --> 02:14:15.440
those two we tried again we were never able to get pregnant again which you know had two kids and

1476
02:14:15.440 --> 02:14:23.200
put a bow on it and we're done but it is impossible to remove the emotion because you because

1477
02:14:23.200 --> 02:14:33.120
in the mindset it's luck or it's something we did we caused this and it's I you know as a

1478
02:14:33.120 --> 02:14:36.960
high performing you know someone who's like you check all the boxes and you make all the good

1479
02:14:36.960 --> 02:14:41.440
grades and you do everything right and this is the one thing that suddenly you didn't think much

1480
02:14:41.440 --> 02:14:48.000
about and then it becomes everything when that that that becomes harder it's taken away from you

1481
02:14:48.080 --> 02:14:55.360
but I think women assume that it's our burden because we assume that if we can't conceive it's

1482
02:14:55.360 --> 02:15:03.680
just us or something but I think I heard you say this the the it's a two-way street and the issue

1483
02:15:03.680 --> 02:15:08.400
is not always the woman a high percentage of the time it's her partner and so I don't think we

1484
02:15:08.400 --> 02:15:15.120
absorb that information up front either until we start investigating it but I'm in awe of this

1485
02:15:15.120 --> 02:15:20.320
story that four of your residents got pregnant immediately because in orthopedics that does not

1486
02:15:20.320 --> 02:15:27.520
happen every orthopedic surgeon and many generation that I know if we got pregnant we miscarried

1487
02:15:28.160 --> 02:15:32.720
and maybe that was lifestyle and maybe that was not eating for 40 hours maybe it's all the

1488
02:15:32.720 --> 02:15:39.440
radiation that we undertake I think it's better now for the younger generation and we as the I'm

1489
02:15:39.520 --> 02:15:44.080
not that old but I am older than the current residents we encourage all of them

1490
02:15:45.040 --> 02:15:49.920
if you are not partnered and wanting to have a child now then please consider freezing your eggs

1491
02:15:49.920 --> 02:15:55.360
if that's a goal because we can't predict our futures and our residences extend into our 40s

1492
02:15:55.360 --> 02:15:59.840
well I love that you're helping facilitate that discussion because that certainly wasn't the

1493
02:15:59.840 --> 02:16:03.840
culture back when we were in training I am one of the ones who sat here and cried in front of

1494
02:16:03.920 --> 02:16:10.320
Stephen myself when talking about my own pregnancy loss journey just because you know I see it

1495
02:16:10.320 --> 02:16:17.040
every day you know and I tell patients every day news that they do not want to hear 50% of

1496
02:16:17.040 --> 02:16:23.120
infertility is due to male factor 50% is due to female factors one of the most important things I

1497
02:16:23.120 --> 02:16:29.760
want to convey when we are on this topic is that IVF is an amazing technology that has helped 13

1498
02:16:29.760 --> 02:16:36.560
million babies be born it has been life changing and world changing and things don't have to be

1499
02:16:36.560 --> 02:16:42.880
natural sometimes the natural progression of disease is death so we have technology and science

1500
02:16:42.880 --> 02:16:49.200
that exists to optimize and improve life and to help life exist and that's part of what IVF is

1501
02:16:49.200 --> 02:16:54.240
and I think that's important because we do see a narrative right now that IVF is inherently bad

1502
02:16:54.240 --> 02:17:00.160
and natural fertility approaches are inherently good and we truly need to say both things are good

1503
02:17:00.160 --> 02:17:04.320
do women need to learn about their bodies earlier talk about cycle tracking take better care of

1504
02:17:04.320 --> 02:17:11.120
themselves get an earlier investigation when things aren't going well absolutely true but also

1505
02:17:11.120 --> 02:17:16.080
needing to have fertility treatments is not a failure needing to see if fertility doctor is not

1506
02:17:16.080 --> 02:17:21.920
a failure if you need IVF that is okay all the other stuff is still really important to the outcome

1507
02:17:21.920 --> 02:17:27.760
of your journey but this narrative of IVF isn't natural so it's bad or egg freezing isn't

1508
02:17:27.760 --> 02:17:34.240
natural so we shouldn't do it that's harmful to society and to women who do carry the burden whether

1509
02:17:34.240 --> 02:17:40.640
they need to or not women do carry the burden of family planning for the future hearing you talk

1510
02:17:40.640 --> 02:17:47.440
about that is very interesting to me because in other parts of medicine in my own medicine right we

1511
02:17:47.440 --> 02:17:52.960
were talking outside about how I I now do knee surgery through needles it's an advancement of

1512
02:17:52.960 --> 02:18:00.400
technology we celebrate that we like better it's not natural it's not natural with your thing right

1513
02:18:00.400 --> 02:18:06.000
but I'm capable of helping you live a better life right yeah so it's interesting to me

1514
02:18:07.200 --> 02:18:11.440
it's as this stigma of women's health and war that's right this has because this is women's

1515
02:18:11.440 --> 02:18:16.000
health we're going to control it we're going to protect these gals we're not going to apply the

1516
02:18:16.000 --> 02:18:22.240
vast knowledge I'm a little offended by it actually if you want to know the truth why can I be so

1517
02:18:22.240 --> 02:18:30.640
encouraged and and be considered top of my field when I adopt new technologies but in your field

1518
02:18:31.600 --> 02:18:39.840
13 million parents or 26 million parents would be told that technology is not okay

1519
02:18:41.360 --> 02:18:45.520
I agree it's a terrible narrative that is happening right now in the political landscape and I

1520
02:18:45.520 --> 02:18:52.240
think it's important to say scientific advancement is good and it changes the lives for so many

1521
02:18:52.240 --> 02:18:59.600
people and I think it's just highlighting this idea about natural doesn't always mean better I think

1522
02:18:59.600 --> 02:19:05.040
as you know scientists and people in medicine there's also been a disservice to not trying to get

1523
02:19:05.040 --> 02:19:09.920
to the root cause and not working on preventive medicine right and so going towards treatments

1524
02:19:10.000 --> 02:19:16.320
and technology which has made the lay person feel like half of the picture wasn't discovered or

1525
02:19:16.320 --> 02:19:21.040
talked about and so we can do better on both ends of it and that comes to women's health more

1526
02:19:21.040 --> 02:19:25.520
than anything because there is stigma when it comes to isolation there's and I mean when it comes

1527
02:19:25.520 --> 02:19:32.400
to infertility there's isolation you know being left behind your peer group questioning a life goal

1528
02:19:32.400 --> 02:19:38.560
will make you question who you are your life meaning your purpose and that is an extremely stressful

1529
02:19:38.560 --> 02:19:43.360
and challenging state for somebody to go through and we should be giving more support to that we

1530
02:19:43.360 --> 02:19:47.920
should be saying freeze your eggs you're at a stressful lifetime instead of the narrative that we

1531
02:19:47.920 --> 02:19:54.080
are seeing right now so would the message be to young men and women that want to have kids

1532
02:19:54.720 --> 02:20:01.520
at some point in their life to freeze their eggs in their 20s is that what you advice you know most

1533
02:20:01.520 --> 02:20:07.200
people in their 20s maybe don't have good awareness of these goals but certainly your you know

1534
02:20:07.200 --> 02:20:13.120
later 20s your early 30s are the prime opportunity where you still for the average person you're going

1535
02:20:13.120 --> 02:20:17.520
to have a high number of eggs you're still high on the graph and your egg quality is still going to

1536
02:20:17.520 --> 02:20:22.720
be high meaning it's going to be easier to get the outcome that you want certainly in your 20s

1537
02:20:22.720 --> 02:20:27.920
would be ideal if you but it's expensive a lot of people don't have the financial resources to

1538
02:20:27.920 --> 02:20:33.360
freeze their eggs and their 20s their in training or they're starting their career so to have an extra

1539
02:20:33.360 --> 02:20:40.160
$10,000 line around isn't always realistic and I think that's why people are often waiting because

1540
02:20:40.160 --> 02:20:45.200
that feels you know elective you know like oh that's extra money I don't know that I have that

1541
02:20:45.200 --> 02:20:52.480
right now when we see insurance that starts to cover egg freezing as an option we see huge uptake

1542
02:20:52.480 --> 02:20:58.240
in women going to freeze their eggs so you will see at companies where almost less than five

1543
02:20:58.240 --> 02:21:02.720
percent of women would freeze their eggs before age 35 and then they introduced a health plan that

1544
02:21:02.720 --> 02:21:10.480
would cover egg freezing and up to 50% of them would so you can see that both financially and

1545
02:21:10.480 --> 02:21:15.680
access and awareness they all go hand in hand but that's a big player and being able to do that

1546
02:21:15.680 --> 02:21:20.480
because it is an expensive process so Dr. Crawford I think what most people don't understand what

1547
02:21:20.480 --> 02:21:26.240
is the spontaneous fertility rate by age in general yeah so if you are 30 you're odds of getting

1548
02:21:26.240 --> 02:21:32.480
pregnant monthly we use a monthly rate called for condability it's going to be at best 20% per month

1549
02:21:32.880 --> 02:21:38.320
when you're in your 20s it's a little bit higher can get up to 25% per month if you're having sex

1550
02:21:38.320 --> 02:21:44.720
monthly and regular periods so if you're having unprotected intercourse and you have regular cycles

1551
02:21:44.720 --> 02:21:49.840
your best odds in a given month are going to be about 20% at age 30 how much sex do you have to

1552
02:21:49.840 --> 02:21:54.320
be having well really just have to have it in that fertile window the what just once so really

1553
02:21:54.320 --> 02:22:00.640
just once yes sex solely on the day of ovulation would be the ideal time but you just need to have

1554
02:22:00.720 --> 02:22:05.120
at least intercourse at least once in that fertile window but that number drops quite significantly

1555
02:22:05.120 --> 02:22:10.720
to what Dr. Crawford saying so at age 35 if you're trying to get pregnant it's going to be 10 to 12

1556
02:22:10.720 --> 02:22:18.080
percent per month odds of getting pregnant at age 38 it's going to be 5% per month at age 40 it's

1557
02:22:18.080 --> 02:22:21.760
going to be 3% let's see if you're trying for the first time they're a little bit higher if you've

1558
02:22:21.760 --> 02:22:27.360
had a child already because there's some proven fertility factors but if we look at that you say

1559
02:22:27.360 --> 02:22:33.120
I'm chasing these dreams I'm going to try to have my first baby at age 38 you have a 5% chance per

1560
02:22:33.120 --> 02:22:39.920
month that's not zero but that means the greatest probability is that by six months time frame you

1561
02:22:39.920 --> 02:22:44.240
won't be pregnant and then you're going to start a pathway of trying to investigate why that is

1562
02:22:44.240 --> 02:22:49.840
happening and if you do need intervention you're further down this graph too you're going to have

1563
02:22:49.840 --> 02:22:55.200
less eggs to work with and their quality is going to be less good that's why those numbers drop

1564
02:22:55.280 --> 02:23:00.640
rapidly natural fertility rates are not about being out of eggs because you ovulate just one egg at a

1565
02:23:00.640 --> 02:23:06.880
time it doesn't matter if you have 20 eggs outside that vault or five eggs you're ovulating one

1566
02:23:06.880 --> 02:23:12.640
egg at a time so natural fertility is all about egg and sperm quality so the this huge drop we see

1567
02:23:12.640 --> 02:23:19.120
from 20% to 5% is because of the change of our egg quality as we get older during our 30s which

1568
02:23:19.120 --> 02:23:24.000
most of us feel like is really young and what can I do to because I know the weight has a role in egg

1569
02:23:24.000 --> 02:23:29.120
quality right if you're underweight or overweight is there anything else that has a really pertinent

1570
02:23:29.120 --> 02:23:34.480
impact on the quality of my eggs yes so we have two factors we'll say age which you can't control

1571
02:23:34.480 --> 02:23:39.280
to an extent right chromosome damage is going to happen even if you are exceptionally healthy

1572
02:23:39.280 --> 02:23:44.000
because tincture of time they've been sitting inside your body chromosome damage builds up

1573
02:23:44.000 --> 02:23:48.560
but the variables that you can is everything that impacts cellular health so chronic inflammation

1574
02:23:48.560 --> 02:23:53.440
and insulin resistance are the two things that are going to most dramatically harm your eggs

1575
02:23:53.440 --> 02:23:57.920
metabolic function it's going to harm your mitochondria going to get mitochondrial damage

1576
02:23:57.920 --> 02:24:02.320
we know that when we start looking at older women they have more dysfunctional mitochondria they're

1577
02:24:02.320 --> 02:24:08.240
shaped abnormally the products inside their follicular fluid show higher levels of inflammation

1578
02:24:08.240 --> 02:24:13.360
just based on age that happens but also if they start having infertility versus not having

1579
02:24:13.360 --> 02:24:19.280
infertility so we know that inflammation and insulin resistance are key players even in patients

1580
02:24:19.360 --> 02:24:25.840
without known PCOS or endometriosis but they play a role in aging and specifically your egg health

1581
02:24:25.840 --> 02:24:32.320
as you age so if you say getting pregnant as a life goal I'm tracking my cycles I don't want to

1582
02:24:32.320 --> 02:24:36.880
freeze my eggs right now but what should I do all these things that we talk about and we're going

1583
02:24:36.880 --> 02:24:42.160
to talk more about to decrease inflammation inside our body that's it and from a young age because

1584
02:24:42.160 --> 02:24:48.160
these changes build up over time and if I have PCOS how does even more important because you're

1585
02:24:48.160 --> 02:24:52.960
at a higher predisposition to have insulin resistance your cells are more sensitive to how

1586
02:24:52.960 --> 02:24:57.120
they're going to respond but do I have less eggs if I have PCOS so you don't have one out of eggs

1587
02:24:57.120 --> 02:25:02.240
around the same time you're born with a little bit more but because you lose eggs based on how many

1588
02:25:02.240 --> 02:25:07.120
you have essentially you're going to catch up so during your reproductive years you tend to have

1589
02:25:07.120 --> 02:25:12.160
more eggs out of the vault which interferes with normal hormonal signaling making all of the hormonal

1590
02:25:12.160 --> 02:25:19.200
metabolic changes worse very interesting thing as women with PCOS tend to get older and their

1591
02:25:19.200 --> 02:25:23.600
egg count starts to drop and they have fewer eggs coming out of the vault they'll often start

1592
02:25:23.600 --> 02:25:29.440
naturally ovulating even if they didn't earlier and so I'm always a little concerned when somebody

1593
02:25:29.440 --> 02:25:35.600
said I used to never have periods but now I do did I cure my PCOS maybe they did make some good

1594
02:25:35.600 --> 02:25:40.960
lifestyle changes along the way but honestly that's a red flag for me that she's now more rapidly

1595
02:25:41.040 --> 02:25:46.560
declining in her egg count approaching what will be pairing menopause for her because her

1596
02:25:46.560 --> 02:25:51.680
egg count is low enough to then respond to the brain signals with nodding your head over here

1597
02:25:51.680 --> 02:25:55.440
and as a man is there anything I can do to increase the odds that I'm going to impregnate male

1598
02:25:55.680 --> 02:26:02.800
you can stop using cannabis and smoking cigarettes drinking alcohol we need to avoid heat so the

1599
02:26:02.800 --> 02:26:07.280
testicles are outside the body for a reason they need to be at a lower body temperature in order to

1600
02:26:07.280 --> 02:26:13.040
adequately make normally functioning sperm so hot tubs saunas there should be off limits if you're

1601
02:26:13.040 --> 02:26:18.800
wanting to get pregnant same with high-intensity exercise and compression of the testicle so this

1602
02:26:18.800 --> 02:26:25.280
is notably cycling for long periods of time so an hour on the bike or more routinely can actually

1603
02:26:25.280 --> 02:26:29.280
compress the testicles and increase their heat what about sitting in a chair for five hours?

1604
02:26:31.040 --> 02:26:35.520
same thing sitting in a chair boxers breathe speed in a room that's hot those things aren't

1605
02:26:35.520 --> 02:26:40.560
quite enough to truly raise that courtesticular temperature quite like some of these other things

1606
02:26:40.560 --> 02:26:46.320
we also see diet playing a big role the great thing about men you're making sperm every single second

1607
02:26:46.320 --> 02:26:52.960
the sperm lifespan is 90 days 72 days to make a sperm 18 days to get out the ejaculatory system

1608
02:26:52.960 --> 02:26:57.760
but that means you could make a singular change in your health and see a different outcome in your

1609
02:26:57.760 --> 02:27:03.200
sperm that is so rare that doesn't exist in women's health that one variable can move the needle so

1610
02:27:03.200 --> 02:27:09.360
much marijuana is a huge one marijuana use works at the brain to prevent those FSH and LH

1611
02:27:09.360 --> 02:27:15.440
signals which are crucial to tell your testicles to make sperm and they also impact inflammatory

1612
02:27:15.440 --> 02:27:21.360
environment so sperm are not as modal they're not shaped as well the DNA inside their heads is more

1613
02:27:21.360 --> 02:27:27.120
fragmented in fact men who use marijuana their partners have a higher rate of pregnancy loss

1614
02:27:27.120 --> 02:27:31.520
even if their partners are not around it at all you're using the word pregnancy loss first is

1615
02:27:31.760 --> 02:27:35.040
the word that we're aware of in the UK called miscarriage is that is that intentional?

1616
02:27:35.760 --> 02:27:41.360
miscarriage can mean you know a to a lot of different things to people and pregnancy loss

1617
02:27:41.360 --> 02:27:46.480
an unsuccessful pregnancy depending on when you medically lose a pregnancy yeah or if a

1618
02:27:46.480 --> 02:27:51.360
pregnancy is in the fallopian tube and it's an ectopic pregnancy that's still a pregnancy

1619
02:27:51.360 --> 02:27:56.000
loss meaning you had a positive pregnancy test that did not end up in a baby so it's a little more

1620
02:27:56.000 --> 02:28:01.120
inclusive for a variety of different stages of when and how loss can occur. miscarriage kind of

1621
02:28:01.120 --> 02:28:06.640
infers when we say it you know on my end is that the pregnancy was in the uterus and now is it's

1622
02:28:06.640 --> 02:28:11.760
we either after evacuated or it's it's self evacuating and you were saying a second

1623
02:28:11.760 --> 02:28:17.040
of your wonder that it's from your experience pregnancy loss miscarriage is much higher with women

1624
02:28:17.040 --> 02:28:24.160
who have high stress careers and jobs well I don't know the real statistics but my I'm sure they

1625
02:28:24.160 --> 02:28:31.120
exist but in my experience as a high capacity high stress not sleeping for 11 or 22 years

1626
02:28:33.680 --> 02:28:38.240
I have seen it a lot and it happened to me yeah chronic stress is associated with a higher rate of

1627
02:28:38.240 --> 02:28:45.520
pregnancy loss is there anything else that people misunderstand about pregnancy loss in miscarriage

1628
02:28:45.520 --> 02:28:50.640
that is worth talking about well it's not talked about I think yeah it's one of the things and

1629
02:28:50.720 --> 02:28:57.440
people still think it's rare taboo and rare but I think all of us around the table had a pregnancy

1630
02:28:57.440 --> 02:29:04.640
loss to at least two and when I had mine I was in training and a I didn't want to call my

1631
02:29:04.640 --> 02:29:10.560
attending and tell them because he was a man and I didn't want to I didn't think I could take

1632
02:29:10.560 --> 02:29:15.440
any time off same I went back the next day I would have gone back the same day but I could barely

1633
02:29:15.440 --> 02:29:20.320
move I was running labor and delivery like at night I got discharged I've pulled out of my hand

1634
02:29:20.320 --> 02:29:28.480
and went back on the work yeah like so I think hopefully part of this international conversation

1635
02:29:28.480 --> 02:29:36.240
about women's health not just gynecological health but health in general will give women grace

1636
02:29:37.040 --> 02:29:42.880
because there's no way that I should have been expected to go back to an orthopedic surgery

1637
02:29:42.960 --> 02:29:49.840
residency the day after I lost a child or frankly I don't know what your experiences were but in

1638
02:29:49.840 --> 02:29:57.040
my generation of doctors and I'm sure it happens everywhere I went back to work less than five

1639
02:29:57.040 --> 02:30:03.120
weeks after delivering a child and I think other European countries have it right oh yeah New Zealand

1640
02:30:03.200 --> 02:30:11.440
year I'm yeah I wait six weeks I'd six weeks with one and three weeks with the other because

1641
02:30:11.440 --> 02:30:16.960
if I wanted to leave my fellowship on time that's right I wanted to graduate on time I couldn't

1642
02:30:16.960 --> 02:30:22.480
exceed the total vacation so these internships and fellowships and I'm sure that built into these

1643
02:30:22.480 --> 02:30:28.560
programs we sign up for they were all developed for men who had had they had a family had a wife

1644
02:30:28.640 --> 02:30:35.920
you had someone at home to like take care of that business yeah and we're have you know we're all

1645
02:30:35.920 --> 02:30:42.000
in supportive relationships and you know that wasn't the issue but like I went back before my

1646
02:30:42.000 --> 02:30:47.680
body was ready yeah because I was before that baby was ready to let unlatch and my milk supply

1647
02:30:47.680 --> 02:30:53.200
dropped immediately the minute why I went back to work and I tried to pump that you get call for

1648
02:30:53.200 --> 02:30:57.600
a crash C-section or emergency surgery and you're like pulling the pump off the breast and I'm running

1649
02:30:57.600 --> 02:31:02.640
down the hall he'll keep my nursing bra back on trying to get to the OR and you know all that

1650
02:31:02.640 --> 02:31:08.240
cortisol just my milk you know so I was able to breastfeed while I was home with the baby and but

1651
02:31:08.240 --> 02:31:14.240
like once I went back to work my my milk production just but I think you're me in the hospital

1652
02:31:14.240 --> 02:31:20.560
and it was a day after I gave birth my laptop is open I'm trying to breastfeed because we launched

1653
02:31:20.560 --> 02:31:27.280
a company the month before I gave birth and instead of my male co-workers going okay we'll give you

1654
02:31:27.280 --> 02:31:32.960
some grace no I had a week and then they're at my house having meetings there's such a different

1655
02:31:32.960 --> 02:31:39.520
discussion about miscarriage now then when I went through it I told nobody I mean it was so secret

1656
02:31:39.520 --> 02:31:45.200
of I didn't feel like I could and we are seeing a different generation where I do think talking

1657
02:31:45.840 --> 02:31:51.040
about women's health and Stephen you having these discussions on a bigger stage are lessening the

1658
02:31:51.040 --> 02:31:55.680
stigma for what is something that people go through one out of four pregnancies will end in a

1659
02:31:55.680 --> 02:32:01.680
pregnancy loss that is not a low percentage of people and the same breath most people should not

1660
02:32:01.680 --> 02:32:07.520
have two in a row and if you do you should go get an evaluation because there are medical things that

1661
02:32:07.520 --> 02:32:13.280
can contribute to pregnancy loss that we would love to identify a lot earlier and see if there's

1662
02:32:13.280 --> 02:32:17.520
something we can do to make that different what do I need to understand about what a woman goes

1663
02:32:17.520 --> 02:32:24.160
through either in the wake of pregnancy loss or in the wake of a pregnancy and a birth

1664
02:32:26.720 --> 02:32:32.160
physiologically psychologically as an employer to be able to create a better environment for the

1665
02:32:32.160 --> 02:32:36.720
women that are going through either of those two things like what's what's going on inside the

1666
02:32:36.720 --> 02:32:42.320
body because I I wouldn't know right so one of the you know simplest things to say that's going on

1667
02:32:42.320 --> 02:32:47.520
is that pregnancy is one of the most hormone robust times you have even just momentarily pregnant

1668
02:32:47.520 --> 02:32:52.400
if you have a placenta starting to implant you are now making levels of estrogen and progesterone

1669
02:32:52.400 --> 02:32:58.800
that you will not ever make at any other time period of your life when that doesn't when you lose

1670
02:32:58.800 --> 02:33:04.400
that pregnancy or when you're postpartum let's say you're having this huge hormone crash suddenly

1671
02:33:04.400 --> 02:33:10.000
you go from this very high level of these hormones dropping off immediately and in addition to all

1672
02:33:10.000 --> 02:33:15.280
the physical changes the emotional changes that has a huge impact you've heard us talk a lot about

1673
02:33:15.280 --> 02:33:19.920
low estrogen and how that feels the very interesting thing most studies about estrogen show is that

1674
02:33:19.920 --> 02:33:27.520
the hardest time for women is when estrogen is changing so going from high too low is actually when

1675
02:33:27.520 --> 02:33:32.240
your body is heavy brain can't keep up can't keep up doesn't know what's happening and the higher you

1676
02:33:32.240 --> 02:33:37.840
were and the faster you come down and we'll use this analogy to even an IVF when we go do an

1677
02:33:37.840 --> 02:33:42.480
egg retrieval and somebody had many eggs they have a much higher estrogen they naturally would

1678
02:33:42.480 --> 02:33:47.440
I go put a needle in each one and drain the eggs out and destroy those cells and their estrogen

1679
02:33:47.440 --> 02:33:52.880
plummets and they expect to go the next day and feel normal or they expect to feel worse during

1680
02:33:52.880 --> 02:33:57.360
the stimulation process when they're using hormone shots and I always say you're actually going to

1681
02:33:57.360 --> 02:34:02.000
feel worse when I'm done with you it's going to be that week after the egg retrieval where your hormones

1682
02:34:02.000 --> 02:34:07.440
go from the highest they've ever been very quickly down low it's that delta that change and that

1683
02:34:07.440 --> 02:34:13.760
happens anytime you have that but pregnancy and loss and postpartum are some of the most profound

1684
02:34:13.760 --> 02:34:20.320
times that you experience this and one of the other things is the identity shift so if you're working

1685
02:34:20.320 --> 02:34:25.840
you know we're all very highly motivated and became parents but it's that whole identity shift

1686
02:34:25.840 --> 02:34:31.360
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

1687
02:34:31.360 --> 02:34:36.240
identified what are the implications so there's a complete identity shift that also isn't discussed

1688
02:34:36.960 --> 02:34:43.200
and that can also perpetuate some of the postpartum that we see as well and anxiety and lack of control

1689
02:34:43.200 --> 02:34:48.240
right you don't know what you're supposed to do especially if you're a mother for the first time

1690
02:34:48.240 --> 02:34:53.840
that is can be very anxiety-provoking in addition to hormone changes and not getting sleep

1691
02:34:53.840 --> 02:34:57.840
but lack of control you don't control your schedule you don't control when you sleep you don't

1692
02:34:57.840 --> 02:35:03.280
control if your child gets sick and so I would say from an employer standpoint grace support

1693
02:35:03.280 --> 02:35:09.920
inflexibility you know if I had had better support structures to say when your child is sick it's not

1694
02:35:09.920 --> 02:35:16.400
the end of the world if you are not here physically at the office that didn't exist meaning that my

1695
02:35:16.400 --> 02:35:23.760
child getting sick became this extremely stressful my God but for the average woman working a

1696
02:35:23.760 --> 02:35:31.280
9-5 job whether it's in medicine or other fields if you could design their working month around

1697
02:35:31.280 --> 02:35:37.120
their menstrual cycle around I don't know potentially a pregnancy whatever how would you design

1698
02:35:37.120 --> 02:35:41.120
redesign their month because we we have inherited this sort of I think it's like from the industrial

1699
02:35:41.120 --> 02:35:46.880
revolution it's like 9-5 working hours we don't work Saturday and Sunday we do that four times

1700
02:35:46.880 --> 02:35:50.960
across a month what would you change what should women change because I've had some

1701
02:35:50.960 --> 02:35:55.840
countries or systems are trying to give women time off around certain parts of their cycle for

1702
02:35:55.840 --> 02:36:00.560
example would any of you change anything well there are a couple of companies in New Zealand who

1703
02:36:00.560 --> 02:36:07.280
are pretty flexible especially after the pandemic where they have allocated certain hours that

1704
02:36:07.280 --> 02:36:11.520
are free to work at home and just have to get the work done to the point where they have four

1705
02:36:11.520 --> 02:36:18.880
day working weeks and then they're also putting into the annual leave what they call menstrual

1706
02:36:19.120 --> 02:36:24.400
leave or menopause leave and it's you just say you know I can't come today some people are using

1707
02:36:24.400 --> 02:36:28.480
it for child care some people are using it for really bad cramping days other people are using

1708
02:36:28.480 --> 02:36:33.920
for mental health days but it's it's there to be used for however you don't have to identify it as

1709
02:36:33.920 --> 02:36:38.880
being menstrual cycle day or menopause it's just extra leave and people don't care as long as you

1710
02:36:38.880 --> 02:36:44.720
get the work done and I think that having that flexibility across you know if you have that

1711
02:36:44.720 --> 02:36:50.960
ability to have more flex hours or shared time space or something like that greatly benefits

1712
02:36:50.960 --> 02:36:58.000
productivity as well as the feeling of empowerment and inclusivity which then feeds forward to

1713
02:36:58.000 --> 02:37:03.040
better productivity if I've got an extremely high stress job is there any part of this cycle where

1714
02:37:03.040 --> 02:37:09.920
I should theoretically be avoiding stress well that's an individual thing it's how because you know

1715
02:37:10.080 --> 02:37:15.120
we hear all the stuff about cycle tracking and it's about understanding your own responses to

1716
02:37:15.120 --> 02:37:21.520
your own hormone blocks because melt my partner says to me that she needs to not do work there's

1717
02:37:21.520 --> 02:37:26.880
like a couple of days a month where she's like I'm just gonna nest that could be her her responses

1718
02:37:26.880 --> 02:37:32.960
and she's like I just don't have the stress tolerance to be able to do XYZ and understanding that

1719
02:37:32.960 --> 02:37:39.040
in her own cycles great because then she can allocate tasks that take more stress for other days

1720
02:37:39.120 --> 02:37:44.160
for most people it's peak luteal so when your progesterone is the highest tends to be when people

1721
02:37:44.160 --> 02:37:48.880
have a harder time focusing and concentrating or getting test done now which is where I'm just

1722
02:37:48.880 --> 02:37:54.000
going to be the middle of the luteal phase at the middle of this second half of the cycle when

1723
02:37:54.000 --> 02:37:59.680
you have that the 21ish so when you have that progesterone you know really high your body might be

1724
02:37:59.680 --> 02:38:05.680
ready to implant an embryo if there was one that tends to be when people say they feel more fatigue

1725
02:38:05.680 --> 02:38:11.120
and less energy and less focus and concentration so if you are looking at your month and you might

1726
02:38:11.120 --> 02:38:17.120
notice that it it and you have the flexibility to say okay I'm gonna try to write this paper get

1727
02:38:17.120 --> 02:38:23.840
this study done do these tasks that call these tasks that call for an increased focus in my

1728
02:38:23.840 --> 02:38:29.360
follicular phase when I'm estrogen dominant have high estrogen and no progesterone for the average

1729
02:38:29.920 --> 02:38:35.680
that is typically when they're easier have an easier time achieving those tasks which is the first

1730
02:38:35.680 --> 02:38:40.560
which is those 14 yeah the first couple weeks the time period before ovulation but there is an

1731
02:38:40.560 --> 02:38:45.600
individual response and I definitely will see some people who they feel immensely better when

1732
02:38:45.600 --> 02:38:51.280
progesterone's present and not so great the other time so I think we use generalizations

1733
02:38:51.280 --> 02:38:56.160
just as a rule of thumb because that's what it is for most people but hormone specifically there's

1734
02:38:56.160 --> 02:39:01.200
always an individualized response and learning to listen to your own body is key in knowing what

1735
02:39:01.200 --> 02:39:05.360
you need to do want to close off on this point about just how employers and you know the way that we

1736
02:39:05.360 --> 02:39:12.080
work can be better suited to a woman's health is there anything else we missed there flexibility I

1737
02:39:12.080 --> 02:39:17.200
think absolutely mentioned before the ability to make a decision for yourself this is a day that I

1738
02:39:17.200 --> 02:39:24.080
can do these you know tasks I think every woman wants to do a really good job and she is going to

1739
02:39:24.080 --> 02:39:31.040
front load those tasks on a time that she feels better and offload in a time where she's not feeling

1740
02:39:31.040 --> 02:39:35.920
as well but she's going to get it done for sure and so giving her the flexibility is going to allow

1741
02:39:35.920 --> 02:39:42.080
her to be her most productive rather than demanding she have X amount every single day and I think

1742
02:39:42.080 --> 02:39:50.880
support can come in a lot of ways but the financial burden to a large corporation of having a stop

1743
02:39:50.880 --> 02:39:56.960
gap child care at work so maybe if you're not going to offer full child care because you're

1744
02:39:56.960 --> 02:40:01.440
going to a lot of productivity out of women if they know their children are on campus and can go

1745
02:40:01.440 --> 02:40:07.680
at lunchtime but if you're not willing to do that if you have a stop gap where instead of calling

1746
02:40:07.680 --> 02:40:14.560
your attending or one day my nanny didn't show up and I had to find some way just for those

1747
02:40:14.560 --> 02:40:20.560
emergencies within the corporation that breeds loyalty that will increase productivity

1748
02:40:21.200 --> 02:40:25.200
and so I think it's money well spent talk about having a competitive woman

1749
02:40:26.160 --> 02:40:32.080
she would probably want to work for you yeah you know and I was offering those things to make

1750
02:40:32.080 --> 02:40:38.000
her mothering easier while she's trying to work I think you would have the most competitive workforce

1751
02:40:38.000 --> 02:40:41.920
and what does that mean so that I mean having and that is that having a nanny on site or is that

1752
02:40:41.920 --> 02:40:47.840
a care on site on site whether it's full-time like bring your children full-time there or

1753
02:40:48.880 --> 02:40:56.880
that's a that's a big corporate but a smaller corporate commitment would be this emergency

1754
02:40:56.880 --> 02:41:03.120
child care so that your kids not there all the time but maybe they're sick or maybe somebody

1755
02:41:03.120 --> 02:41:11.360
didn't show up and then you have days you can do that yeah which is a fault of the US system

1756
02:41:11.920 --> 02:41:15.360
yes yeah what happens in New Zealand you have 20 hours free daycare

1757
02:41:16.400 --> 02:41:24.000
oh I'm not a week yeah so it's yeah 20 hours funded and then it's a very small nominal fee for

1758
02:41:24.000 --> 02:41:29.120
hours over that for up to year five or when they're five years old because then they start to

1759
02:41:29.120 --> 02:41:35.440
school on the first day that they turn five it's like you turn five heavy birthday but it does help

1760
02:41:35.440 --> 02:41:41.680
significantly kind of keep productivity and a little bit of the worry off what am I going to do

1761
02:41:41.680 --> 02:41:49.840
with my child amazing yeah what is this um conversation around eggs and fertility dovetail

1762
02:41:49.840 --> 02:41:56.240
into menopause and specifically perimenopause I mean you can't have one without the other right

1763
02:41:56.240 --> 02:42:03.520
so perimenopause is basically in this fertility decline area okay so so you don't fertility is

1764
02:42:03.520 --> 02:42:07.760
not an issue you don't want ever have a baby you're still going to go through perimenopause and so

1765
02:42:07.760 --> 02:42:15.360
perimenopause is defined medically in the worst way as the transition from normal menstrual cycles to

1766
02:42:16.160 --> 02:42:22.560
no menstrual cycle ever again okay so when we look at definitions menopause is defined as one

1767
02:42:22.560 --> 02:42:28.000
year after the final menstrual period what it really means is ovarian failure and that offence

1768
02:42:28.000 --> 02:42:33.040
people but that's actually medically what it is you have run out of eggs and you run out of the

1769
02:42:33.440 --> 02:42:41.440
ability of the ovary to produce hormones and so perimenopause begins medically at the

1770
02:42:41.440 --> 02:42:48.640
straw staging is the very complicated um methodology to define the stages of perimenopause

1771
02:42:48.640 --> 02:42:55.280
and a lot of it is based on menstrual cycle irregularity but hormonally what's happening

1772
02:42:56.000 --> 02:43:02.480
starts well before a period's become irregular so as those egg levels decline and the ability

1773
02:43:02.480 --> 02:43:06.560
to respond to the stimulus coming from the brain remember ovulation starts in the brain

1774
02:43:07.360 --> 02:43:12.400
so when estrogen levels normally get low during the cycle the brain doesn't like it the hypothalamus

1775
02:43:12.400 --> 02:43:17.440
so the gland in our brain starts looking for estrogen it likes estrogen and when the estrogen

1776
02:43:17.440 --> 02:43:22.240
levels are high it's happy and so when estrogen levels decline naturally in a cycle it says whoa

1777
02:43:22.240 --> 02:43:26.320
where's my where's my estrogen and it sends a signal to a second gland in the brain called the

1778
02:43:26.320 --> 02:43:32.480
pituitary and that makes the LH and the FSH so I'm trying to figure out what causes menopery

1779
02:43:32.480 --> 02:43:38.640
menopause what causes menopause so it's the loss of eggs and the loss of the the group of eggs to

1780
02:43:38.640 --> 02:43:43.680
respond to these signals so here we go we're beginning perimenopause we've reached a critical

1781
02:43:43.680 --> 02:43:49.280
threshold level where our ovaries cannot respond and that might be I don't know a millionaires

1782
02:43:49.280 --> 02:43:54.640
so when you're not out of eggs but just the count is low it lets you fear a jar yeah so if menopause

1783
02:43:54.640 --> 02:44:00.560
is going to be for simplicity the jar is empty when the jar gets like this so we'll say if you

1784
02:44:00.560 --> 02:44:06.320
had full the jar is not empty but it's it's gotten lower and what is happening is the ovary doesn't

1785
02:44:06.320 --> 02:44:12.240
want to be out of eggs so what Dr. Havers saying is the brain is working harder to get an egg to grow

1786
02:44:12.240 --> 02:44:16.400
because the ovary becomes more stubborn it wants to hold on to them it doesn't want to lose them

1787
02:44:16.400 --> 02:44:21.040
the brain has to send out stronger signals to get an egg to grow because there's not as many we

1788
02:44:21.040 --> 02:44:26.320
don't lose as many per month so that's great but that means we have years of being at this

1789
02:44:26.320 --> 02:44:32.400
low unreliable ovary stage where the brain is working really hard there's not as many eggs

1790
02:44:32.400 --> 02:44:38.400
that are here they will still ovulate but it starts to happen at a less predictable rate but

1791
02:44:38.400 --> 02:44:43.040
so is that perimenopause when this yes and there's not a definition I think that which makes it

1792
02:44:43.040 --> 02:44:47.920
the hardest of say your point what number of eggs equals perimenopause different there is a

1793
02:44:47.920 --> 02:44:53.120
unique response to each person at what level your ovary gets to where it will start to respond

1794
02:44:53.120 --> 02:44:58.160
dysfunctionally but what happens is that the hormone changes start shifting in the brain

1795
02:44:58.160 --> 02:45:04.320
the ovarian response start shifting and before you have irregular cycles you will first see

1796
02:45:04.320 --> 02:45:08.880
a shortening of your cycles very predictably the brain will send out a stronger signal and

1797
02:45:08.880 --> 02:45:13.920
egg will ovulate faster it's hard to get shorter cycles and then this hormone fluctuations but

1798
02:45:13.920 --> 02:45:18.400
they're still regular and so what will happen is a woman will start to feel these hormone shifts

1799
02:45:18.400 --> 02:45:24.080
it's less predictable she is having some change but it's still a regular cycle and so she is

1800
02:45:24.080 --> 02:45:30.240
often told your hormones are fine you have a regular cycle so and in the brain as we talked about

1801
02:45:30.240 --> 02:45:36.000
those neurotransmitters there are not only as estrogen changing and the amount that we're producing

1802
02:45:36.000 --> 02:45:41.440
actually in perimenopause quite often will have much higher estradiol levels than we did in our

1803
02:45:41.440 --> 02:45:47.840
preimenopausal years where we had that kind of predictable ebb and flow of our monthly hormones

1804
02:45:47.840 --> 02:45:54.320
there's also a independent FSH receptors outside of so these hormones that are pumping out to talk

1805
02:45:54.320 --> 02:46:00.800
to the ovaries are also back talking to different parts of the brain so the first symptoms that

1806
02:46:00.800 --> 02:46:05.360
patients feel and they've done a great study on this is I don't feel like myself

1807
02:46:05.520 --> 02:46:13.280
I don't feel like myself and they even call it IDFLM and so you can't put your finger on it

1808
02:46:14.320 --> 02:46:18.960
periods are regular but your environment hasn't changed your normal stressors haven't

1809
02:46:18.960 --> 02:46:24.080
changed the life you built that you could manage you're suddenly losing resilience and that's

1810
02:46:24.080 --> 02:46:30.320
because of a hormone fluctuation yeah so we see sleep disruptions mental health challenges

1811
02:46:30.320 --> 02:46:35.520
increase 40 percent increase across perimenopause transition and the cognitive changes and that

1812
02:46:35.520 --> 02:46:41.200
is what really scares my patients the most and they come in and most of them are you know we're all

1813
02:46:41.200 --> 02:46:45.360
high functioning at some degree some of us in academia some of us in the OR some of us but you know

1814
02:46:45.360 --> 02:46:49.280
most women are high functioning because they're juggling so many jobs so even if she didn't choose

1815
02:46:49.280 --> 02:46:55.520
to go the routes that we've chosen she has managing children you know school drop-offs you know all

1816
02:46:55.520 --> 02:47:01.600
the things that women tend to put on their plates and suddenly she can't remember all the things

1817
02:47:01.600 --> 02:47:05.920
she used to remember where her keys you know word salad you're you're struggling to find I can't

1818
02:47:05.920 --> 02:47:12.080
tell you how many times I am like I I see people and like I cannot remember their names or I can't

1819
02:47:12.080 --> 02:47:17.760
remember I get in the car and I can't remember where I'm going or what my purpose of getting in

1820
02:47:17.760 --> 02:47:24.240
the vehicle was you have to think for a second and so all of that is related to the hormonal changes

1821
02:47:24.240 --> 02:47:30.640
at what age well I think that there's a tendency in medicine to want to have definitions yes so

1822
02:47:30.640 --> 02:47:38.400
I personally and I know a lot of us who talk all the time think that this random 366 days after

1823
02:47:38.400 --> 02:47:43.040
your last period that's your menopause day I think that's pretty random and I don't know who made

1824
02:47:43.040 --> 02:47:48.880
that up but when I have because I'm not a no-b but when I have patients come into me for their

1825
02:47:48.880 --> 02:47:54.960
musculoskeletal things and they're of a certain age and I don't just focus on whatever the

1826
02:47:54.960 --> 02:47:59.920
musculoskeletal body part is but we start talking about their whole health and they start talking

1827
02:47:59.920 --> 02:48:05.760
about these things I am often the first one to say to them you know what you are probably

1828
02:48:05.760 --> 02:48:11.520
impairing menopause and they're like but my cycles are regular I'm like but you are beginning this

1829
02:48:12.080 --> 02:48:19.280
transition which I call mental lessons but it's this right I would propose that most people don't

1830
02:48:19.280 --> 02:48:25.760
seek out a lot of help earlier but they should just assume that they're perimenopausal anytime

1831
02:48:25.760 --> 02:48:32.320
after 35 they don't feel like themselves and start down a road of learning or investigating or

1832
02:48:32.320 --> 02:48:37.840
let's feel better and what do I need to do about it you know it's frustrating to us all of us we

1833
02:48:37.840 --> 02:48:42.240
talked a little bit about this last night is the people who kind of make the rules the institutions

1834
02:48:42.240 --> 02:48:49.280
that make the guidelines and and the academic kind of ivory tower you know they are like whoa

1835
02:48:50.880 --> 02:48:58.640
back off slow down we shouldn't be blaming everything on menopause you know like and I don't

1836
02:48:58.640 --> 02:49:04.800
think that's what we're saying we're not trying to like completely dismissing the female experience

1837
02:49:04.800 --> 02:49:12.800
and not at all like including this cataclysmic hormonal change is hurting women so the average

1838
02:49:12.800 --> 02:49:17.920
age of menopause is 51 to 52 and so let's say that is when your ovaries are in failure they will

1839
02:49:17.920 --> 02:49:23.040
no longer make eggs make hormones or respond to brain signals all the eggs all the little marbles are

1840
02:49:23.040 --> 02:49:29.600
all the way gone at 51 52 for most women about seven to 10 years before that they will start to

1841
02:49:29.600 --> 02:49:35.120
enter into what we will call perimenopause or the unpredictable response of the ovary and the

1842
02:49:35.120 --> 02:49:40.240
brain I say their communication system their best friends who aren't communicating well their

1843
02:49:40.240 --> 02:49:45.600
signals are getting interfered they're not responding appropriately the ovaries getting more stubborn

1844
02:49:45.600 --> 02:49:51.680
the brain is trying to work harder you get these higher peaks these lower troughs and essentially

1845
02:49:51.680 --> 02:49:56.080
that is the time period so it is unique to an individual because everybody's born with a different

1846
02:49:56.080 --> 02:50:01.840
number they lose them at a different rate some factors that we control impact that rate but some

1847
02:50:01.840 --> 02:50:07.280
things that we do not your moms age of menopause is a predictive factor if you're had a first

1848
02:50:07.280 --> 02:50:13.280
degree relative go through menopause at 46 or sooner you have a six times likelihood of going

1849
02:50:13.280 --> 02:50:19.840
into early menopause so knowing having this conversation almost every patient I ask what age

1850
02:50:19.840 --> 02:50:23.600
of your mom go through menopause they do not know the answer because the moms have been talked

1851
02:50:23.920 --> 02:50:28.000
mom seven talked about it there's so much stigma about reproductive health so knowing that

1852
02:50:28.000 --> 02:50:33.040
information is really important if you have mom or older sisters what age is normal for your

1853
02:50:33.040 --> 02:50:37.920
family so that you can be a little more in tune if there's some genetic predisposition for you

1854
02:50:37.920 --> 02:50:42.320
the general idea of what Dr. Haver saying is that in these last seven to 10 years of ovarian

1855
02:50:42.320 --> 02:50:47.600
lifespan it becomes more stubborn and less predictable and it does cause hormonal shifts that

1856
02:50:47.600 --> 02:50:52.800
most women can't detect with their cycles we do know that if you are actively tracking actually

1857
02:50:52.800 --> 02:50:57.680
when ovulations happening and looking at your follicular and luteal phase and you know what's

1858
02:50:57.680 --> 02:51:03.520
normal for you you will most likely be able to detect these hormone shifts in that time period

1859
02:51:03.520 --> 02:51:08.480
but that's not what women are taught their tracking is just that it's coming regular

1860
02:51:08.480 --> 02:51:13.680
and we do have a generation of women that were on contraception and then went through child

1861
02:51:13.680 --> 02:51:19.120
bearing and then on contraception again until now they're suddenly entering this transitional

1862
02:51:19.200 --> 02:51:23.440
period and they don't know what their own normal is right making it even worse correct

1863
02:51:24.880 --> 02:51:30.400
so like she said the average age of menopause if we look at the math uh is is 51 but under

1864
02:51:30.400 --> 02:51:37.760
that 90th percentile curve you know with 5% on each end it's about 45 to 55 that's the menopause

1865
02:51:37.760 --> 02:51:43.520
right that's full menopause now now let's just do math and back it up seven to 10 years so we're

1866
02:51:43.600 --> 02:51:50.000
looking at the mid to late 30s to 40 so when I have a 46 47 48 year old patient come in who's

1867
02:51:50.000 --> 02:51:54.880
still cycling she has almost a hundred percent chance of being a perimenopause just based on her

1868
02:51:54.880 --> 02:52:01.040
age alone knowing the statistics around that yep okay so with my partner between the age of sort of

1869
02:52:01.040 --> 02:52:06.480
35 to 45 is when I can expect her to go through perimenopause where there's very little marbles

1870
02:52:06.480 --> 02:52:14.320
left in the jar and how hormones might be less predictable and one of the questions we had

1871
02:52:14.320 --> 02:52:19.920
in from the audience was how can I manage the symptoms of perimenopause and they use the word

1872
02:52:19.920 --> 02:52:28.240
naturally well we don't have a single large scale study done on the treatment of perimenopause so

1873
02:52:28.240 --> 02:52:32.400
something break it down for you when we look at finding in women's health it's horrible okay

1874
02:52:32.480 --> 02:52:38.400
but if we if I go into PubMed which is the you know database that I go to look up medical

1875
02:52:38.400 --> 02:52:44.560
medical journal articles and I type in the word pregnancy I will get today 1.2 ish million

1876
02:52:44.560 --> 02:52:49.840
articles for pregnancy amazing so important we need healthy pregnancies if I type in the word

1877
02:52:49.840 --> 02:52:59.520
menopause right now I think it's about 99,000 so those numbers represent time brain power funding

1878
02:52:59.520 --> 02:53:06.400
what what what is important in women's health okay if I type in the word perimenopause we are

1879
02:53:06.400 --> 02:53:20.400
about at 8,000 yep very very very small your name's on a couple of thanks so is the last third of my

1880
02:53:20.400 --> 02:53:27.600
life from an academic standpoint from funding from brain power from where we focus not as important

1881
02:53:27.920 --> 02:53:32.960
then when I had the ability to be pregnant more women will go through perimenopause than menopause

1882
02:53:32.960 --> 02:53:38.560
because we're going to lose a few to accidents and cancers and you know early deaths more women will

1883
02:53:38.560 --> 02:53:44.560
go through perimenopause then get pregnant yet in my training so in medical school I got one

1884
02:53:44.560 --> 02:53:50.960
hour one one hour lecture on menopause nothing on parry and in my OBGYN training and I'd love to

1885
02:53:50.960 --> 02:53:55.600
hear what you have to say as part of our reproductive inter chronology blocks I had one block of

1886
02:53:55.600 --> 02:54:02.960
that my second year in those six weeks I got one one hour lecture each week no clinics no focus

1887
02:54:02.960 --> 02:54:08.240
nothing and then as a program director where I was in charge of the education of residents of

1888
02:54:08.240 --> 02:54:13.760
over a hundred residents over about ten years I know exactly what the curriculum required

1889
02:54:13.760 --> 02:54:19.360
and menopause just gets shoved into a tiny box and then what happens when we run out of marbles in

1890
02:54:20.080 --> 02:54:26.320
the the glass that what's really interesting and one thing we've said a couple times is this

1891
02:54:26.320 --> 02:54:32.000
happens this is ovarian failure you're going to go into a state of low estrogen because the ovaries

1892
02:54:32.000 --> 02:54:37.040
no longer have the ability to make eggs therefore they are not going to make estrogen or progesterone

1893
02:54:37.040 --> 02:54:41.040
and just to be clear that the eggs were sending a signal up to the brain to make estrogen

1894
02:54:41.040 --> 02:54:46.560
and the eggs well the low the eggs in the brain communicate yes when you didn't have an egg

1895
02:54:46.560 --> 02:54:51.200
ovulating your estrogen would be low and that typically is the brain signal to send out more

1896
02:54:51.200 --> 02:54:59.200
FSH that's still happening meaning estrogen is low but the brain is sending out all the FSH it has

1897
02:54:59.200 --> 02:55:04.720
FSH is very high in menopause and the ovary cannot respond because there's no more eggs there's

1898
02:55:04.720 --> 02:55:10.080
nothing left to respond and he said that explained again so I'm trying to understand why estrogen drops

1899
02:55:10.080 --> 02:55:14.800
when the eggs disappear the estrogen is made from the cells that surround each egg so when there's

1900
02:55:14.800 --> 02:55:19.920
no more eggs there's no more cells that make estrogen a follicle goes away too okay okay so

1901
02:55:19.920 --> 02:55:26.320
estrogen is made in the ovaries so the estrogen is made in the ovaries and the primary type of

1902
02:55:26.320 --> 02:55:30.000
estrogen that we're talking about and it's made from the cells that surround each follicle

1903
02:55:30.000 --> 02:55:35.440
called the granulosa cells and as the follicle gets bigger as the agmatures more of those cells

1904
02:55:35.440 --> 02:55:40.080
become more active and you make more estrogen so even when you have a little bit left

1905
02:55:40.800 --> 02:55:46.880
when you're on your period we'll say but you're some eggs here you're still making some estrogen

1906
02:55:46.880 --> 02:55:50.800
it's not as high as when you're ovulating but these little eggs will each make a little bit

1907
02:55:50.800 --> 02:55:56.080
do I make estrogen yeah you do but I just make it somewhere else yeah it gets converted over to

1908
02:55:56.080 --> 02:56:01.440
testosterone okay so you have enzymes in our body that convert estrogen and testosterone back

1909
02:56:01.440 --> 02:56:08.080
and forth so there's no more eggs so this is menopause so this is menopause well in my world yes

1910
02:56:08.480 --> 02:56:12.480
this is ovarian failure and we'll call in at ovarian failure on purpose because at this moment

1911
02:56:12.480 --> 02:56:17.360
you're not going to make estrogen the brain is sending out all the signals it can very high FSH

1912
02:56:17.360 --> 02:56:22.560
trying to get estrogen to be made there's no eggs so there is no estrogen what Dr. Haver has said

1913
02:56:22.560 --> 02:56:29.200
which is correct are our friends in the medical world do not define this moment as menopause they

1914
02:56:29.200 --> 02:56:35.680
make you sit here and be estrogen low for a year and have no period for a year before they will

1915
02:56:35.680 --> 02:56:40.640
say you're in menopause if they even decide to treat or offer treatment you know even begin

1916
02:56:40.640 --> 02:56:46.480
the discussion because of our training you must they'll shout go without one year so we're

1917
02:56:46.480 --> 02:56:53.920
absolutely sure that the ovaries have have moved on before we would even consider but what is the

1918
02:56:53.920 --> 02:56:59.680
point of that we've made estrogen our entire lives fabulous question what is the point of starting

1919
02:56:59.680 --> 02:57:04.160
our brains our hearts our bones our muscles they didn't think they were doing that I don't think

1920
02:57:04.720 --> 02:57:10.640
people you know the medical community has recognized estrogen's effects outside of reproduction

1921
02:57:10.640 --> 02:57:16.880
until very recently I think there's been isolated pockets but there's no no one owns menopause like

1922
02:57:16.880 --> 02:57:23.120
no one you think it would be OBGYN but there's no one in charge of women's health after reproduction

1923
02:57:23.120 --> 02:57:28.800
ends like there's there's no czar so what's the harm of waiting a year before people take it

1924
02:57:28.800 --> 02:57:34.640
seriously we'll have to suicide mental health changes rapidly declining bone density I mean you

1925
02:57:34.640 --> 02:57:40.800
can be healthy without estrogen once estrogen all vagina's need estrogen so your brain your bones

1926
02:57:40.800 --> 02:57:46.880
your heart your blood vessels your vagina your body has estrogen receptors everywhere that we've

1927
02:57:46.880 --> 02:57:53.040
already established and suddenly you've lost the ability to make your primary source of estrogen

1928
02:57:53.120 --> 02:57:58.480
and what happens is that you know medicine has a lot of definitions that we use that are very

1929
02:57:58.480 --> 02:58:03.680
antiquated even how we date pregnancies right when we talk about how far along you are in a pregnancy

1930
02:58:03.680 --> 02:58:09.680
we date back to the last period you had which meant two weeks of pregnancy or before you ever

1931
02:58:09.680 --> 02:58:15.840
ovulated an egg before you three weeks before you ever implanted an embryo yet we still use this

1932
02:58:15.840 --> 02:58:22.000
pregnancy timeline based on when your last period was even though we know two weeks of that you

1933
02:58:22.000 --> 02:58:27.360
want in fact pregnant at all now menopause in my opinion is the exact same way we're using an

1934
02:58:27.360 --> 02:58:32.880
antiquated definition saying you have to prove to me you're an ovarian failure by lack of your

1935
02:58:32.880 --> 02:58:37.520
period for 12 months because it represents a time period where we didn't fully understand what was

1936
02:58:37.520 --> 02:58:42.560
happening in the ovary or didn't have the ability to test and know what we know now we are making

1937
02:58:42.560 --> 02:58:49.120
women suffer to get that diagnosis if I believe I shouldn't treat you until you have menopause

1938
02:58:49.280 --> 02:58:53.920
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

1939
02:58:53.920 --> 02:59:00.480
right for women and that being the slow estrogen is hugely impactful at your life at any age the

1940
02:59:00.480 --> 02:59:06.000
female body needs estrogen to function normally I mean I'm looking at this chart here about

1941
02:59:06.000 --> 02:59:11.600
suicideation yeah suicide out of the most likely time for a woman to commit suicide is between the

1942
02:59:11.600 --> 02:59:21.040
ages of 45 and 55 and she is do you think that's linked to 100 percent right so we know that mental

1943
02:59:21.040 --> 02:59:28.480
health we have an increase in mental health disorders either preexisting getting worse or new

1944
02:59:28.480 --> 02:59:34.400
onset of about 40 percent across the transition and we look at SSRI prescriptions which are any

1945
02:59:34.400 --> 02:59:39.360
depressants they double across the menopause transition now there's a couple reasons for that one

1946
02:59:39.360 --> 02:59:44.320
is we weren't treating menopause with hormones so they just SSRIs can actually help the hot

1947
02:59:44.320 --> 02:59:49.680
flash a certain type so you know paxole is one of the ones that has been proven to decrease hot

1948
02:59:49.680 --> 02:59:54.480
flashes some it's not great but it works a little bit and with all of the mental health changes a

1949
02:59:54.480 --> 03:00:00.800
lot of women are ending up on these anti-depressant medications so we don't want to go a year without

1950
03:00:00.800 --> 03:00:05.760
estrogen so we know that some of the new data coming out when I was researching for the new

1951
03:00:05.760 --> 03:00:12.400
Perry menopause there's a really great window of using hormones to treat mental health disorders

1952
03:00:13.600 --> 03:00:18.480
and seeing improvement in mood and also some in cognition by giving estrogen or estrogen

1953
03:00:18.480 --> 03:00:24.320
plus a progestin early in Perry menopause before the period is actually stopped and they actually

1954
03:00:24.320 --> 03:00:29.600
works better than an SSRI so say she's on an on an SSRI and has done well she's had a long history

1955
03:00:29.600 --> 03:00:35.040
of depression suddenly she's not controlled suddenly her symptoms are back and she's on the same

1956
03:00:35.040 --> 03:00:40.880
medication rather than doubling or adding a second agent we really should be giving these women

1957
03:00:41.840 --> 03:00:49.120
a hormonal therapy now that doesn't hold post menopause so this is really a Perry menopausal

1958
03:00:49.120 --> 03:00:54.960
kind of window of opportunity in post menopause they aren't responding as well and probably because

1959
03:00:54.960 --> 03:01:00.880
the estrogen labels have stabilized so when we give a woman back you'll adapt so post menopause

1960
03:01:00.960 --> 03:01:06.640
the menopause that's why the suicide rates kind of peak in this key Perry menopause area

1961
03:01:06.640 --> 03:01:13.840
and so we think and so in post menopause they that hormone levels stabilize so women tend to get

1962
03:01:13.840 --> 03:01:19.120
better and so they do respond better to the SSRIs for for nuanced anxiety and depression in those

1963
03:01:19.120 --> 03:01:25.360
patients and I want to do a randomized controlled trial where we add some creatine oh that would be

1964
03:01:25.520 --> 03:01:33.280
80 grams but no it's 0.38 per kg of body gram yes so you're saying if I'm 45 year old woman

1965
03:01:33.280 --> 03:01:39.920
and I'm I've still got my menstrual cycle at that time before I've hit menopause I should be

1966
03:01:39.920 --> 03:01:44.960
considering some type of hormonal therapy so when we give someone menopausal dose menopause hormone

1967
03:01:44.960 --> 03:01:49.200
therapy in the form of estradiol usually in a patch because you have that nice steady state

1968
03:01:49.200 --> 03:01:54.800
it is enough to feed back to the hyper to that brain to calm down but not enough to suppress

1969
03:01:54.800 --> 03:02:00.800
ovulation so she's often giving estrogen support in very low doses in menopause hormone therapies

1970
03:02:00.800 --> 03:02:06.160
basically micro dosing compared to what we do naturally and so we're giving enough to calm the

1971
03:02:06.160 --> 03:02:10.400
brain down and stabilize what's happening in the brain without suppressing her natural ovulation

1972
03:02:11.520 --> 03:02:15.760
giving enough what to raise you back to maybe what that baseline would be

1973
03:02:15.760 --> 03:02:21.520
eat giving enough estrogen yeah correct giving enough estrogen to raise the baseline level so it's

1974
03:02:21.520 --> 03:02:27.200
not as low it's not so high that it's preventing ovulation but it's going to alleviate some of

1975
03:02:27.200 --> 03:02:31.440
these drastic highs and lows that you're having and it's going to create a more stable hormone

1976
03:02:31.440 --> 03:02:37.280
environment it's the delta that we were talking about post-prose exactly the delta that I like to

1977
03:02:37.280 --> 03:02:47.360
rise up high the space is what bothers us not the high nor the low eventually so I have I run out of

1978
03:02:47.360 --> 03:02:57.760
eggs and then I'm by definition menopause at this stage and my body adapts so there's going to be

1979
03:02:57.760 --> 03:03:02.560
a drop and then there's going to be a we're specifically talking about mental health because you

1980
03:03:02.560 --> 03:03:08.880
brought up the suicide chart and so post menopause like once everything comes down and you're fully

1981
03:03:08.880 --> 03:03:13.920
menopause you're out of the zone of chaos the hormones have just lose your bones continue to

1982
03:03:13.920 --> 03:03:18.640
deteriorate a lot of other things are happening but our cognitive in our mental our brain tends to

1983
03:03:18.640 --> 03:03:22.640
calm down and things get better in the brain when do I become post menopausal instead of menopausal

1984
03:03:24.320 --> 03:03:29.840
menopause is a day right oh menopause is a day menopause is one day in your life one day

1985
03:03:29.840 --> 03:03:34.560
exactly after your but that final menstrual period what's the point of that right what's the point

1986
03:03:34.560 --> 03:03:40.320
agree right because what if what if it's leap year do we go 366 days what if it's what if you've

1987
03:03:40.320 --> 03:03:44.000
had a night you do what if you've had all these things it's like it's really an antiquated

1988
03:03:44.000 --> 03:03:47.920
definition and we really need to modernize so it's really your perimenopausal then your post

1989
03:03:47.920 --> 03:03:55.040
menopausal correct right okay and when I'm post menopausal forever for as your new biological state

1990
03:03:55.040 --> 03:04:00.720
that's right for now I'm sure someone's working on something to change something I do wonder

1991
03:04:00.720 --> 03:04:05.280
that I do wonder if they're going to figure out a way to extend fertility I mean they're trying

1992
03:04:05.280 --> 03:04:12.000
they're trying then I think about it as if you're a six-year-old woman would you still want to be

1993
03:04:12.000 --> 03:04:18.480
worried about that so what they're doing is looking at is their way to extend say ovarian function

1994
03:04:18.480 --> 03:04:23.680
ovarian function with low-level baseline enough to keep you out of osteopor you know enough to

1995
03:04:23.680 --> 03:04:29.840
slow that down yeah and hard to see protect your heart without pregnancy I'm now post menopausal

1996
03:04:29.840 --> 03:04:34.480
lots of things change my body I'm guessing because I I no longer have the same levels of estrogen

1997
03:04:35.200 --> 03:04:39.520
did the levels of estrogen ever go up again actually or do I then need to start considering outside

1998
03:04:39.520 --> 03:04:44.480
of a tumor no I mean so I do I need to consider hormone replacement therapies and things like that to

1999
03:04:45.760 --> 03:04:52.400
and that'll help me fend off what the sleep issues the it'll slow the rate of change okay but it

2000
03:04:52.400 --> 03:04:57.840
doesn't stop it you still have to put in your lifestyle modifications to improve and or

2001
03:04:58.640 --> 03:05:03.280
stop the circopingion the bone density loss and all the things that people associate with

2002
03:05:03.280 --> 03:05:10.720
postmenopause and did any of you have menopause hormone therapy yes yeah and what was the decision

2003
03:05:10.720 --> 03:05:15.760
and what what impact has it had so I think what Stacy just said in framing where we're going with

2004
03:05:15.760 --> 03:05:23.840
this conversation is so now we're perimenopausal it's a new physiology what used to work for all

2005
03:05:23.840 --> 03:05:30.160
of our exercising if we even did because we know it at least in this country that 60 to 80 percent

2006
03:05:30.160 --> 03:05:36.080
a people aren't intentional with their lifestyle so to frame this next part of the conversation I'm

2007
03:05:36.080 --> 03:05:40.720
sure we're going to talk a lot about hormones and I'll tell you my hormone decision making but

2008
03:05:41.840 --> 03:05:49.920
I think it's important to all of us it's only one of the building blocks to rebuilding a great life

2009
03:05:50.640 --> 03:05:55.280
it's interesting that the five steps of fertility that you went over are actually

2010
03:05:55.280 --> 03:06:04.960
saying that's curious it's great protein and anti-inflammatory nutrition it's a cardiovascular

2011
03:06:04.960 --> 03:06:11.040
fitness life it's a lifting life it's a stress detox whether it's environmental or relational

2012
03:06:11.680 --> 03:06:18.960
and sleep sleep sleep and then yes hormones are really a critical building block but as we enter

2013
03:06:18.960 --> 03:06:27.520
the conversation women are sentient beings and we get to decide and we get to make the changes

2014
03:06:27.520 --> 03:06:33.760
because we have agency so what we're going to describe is not a one-size-fits-all it is all the

2015
03:06:33.760 --> 03:06:39.360
tools on the tools that the tools on the table so I choose if I'm going to work my proverbial

2016
03:06:39.360 --> 03:06:45.600
rear end-off to be the best I can be for the rest of my life I choose to use all the tools not

2017
03:06:45.600 --> 03:06:50.400
everybody does that but to choose one tool and think that's going to be enough it never is

2018
03:06:51.200 --> 03:06:56.160
right so when I decided to and I've been pretty public about my

2019
03:06:57.120 --> 03:07:03.360
journey in this because you think I would have known after 22 years of formal education and all

2020
03:07:03.360 --> 03:07:08.560
this and being an agent a musculoskeletal aging researcher you would have think thought I would

2021
03:07:08.560 --> 03:07:13.280
have known but I honestly looking back maybe thought I was never going to age because I was so

2022
03:07:13.280 --> 03:07:23.840
healthy right so I have a baby at 40 I breastfeed to almost 41 and a half 42 and then I'm back at my

2023
03:07:23.840 --> 03:07:27.280
very quickly five weeks my high power high capacity to career

2024
03:07:29.920 --> 03:07:36.320
but things were getting really different about 45 for me and I think I went right from post

2025
03:07:36.400 --> 03:07:45.840
partum to perimenopause with very little downtime so chaotic hormones to almost and so

2026
03:07:47.440 --> 03:07:54.400
I suffered for a while at 47 I talk about it like I I went from this really high capacity to

2027
03:07:54.400 --> 03:07:59.760
thinking I was going to die not only because of night sweats brain fog the thing that lots of

2028
03:07:59.760 --> 03:08:07.040
women have but I started having heart palpitations and I call my cardiology friend because I worked

2029
03:08:07.040 --> 03:08:12.080
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

2030
03:08:12.080 --> 03:08:20.080
was perfect right at that point and then I had arthoralgia which is total body pain it's part

2031
03:08:20.080 --> 03:08:26.320
of the inflammatory response of not having estrogen it's part of the musculoskeletal syndrome of

2032
03:08:26.320 --> 03:08:34.560
menopause assembly of symptoms so much that I go from training to almost not being able to get

2033
03:08:34.560 --> 03:08:42.480
out of bed and these my experience of not knowing what was coming and hitting a wall is not uncommon

2034
03:08:43.040 --> 03:08:51.120
right and so I started educating myself and being an acquired expert I read what I consider

2035
03:08:51.120 --> 03:08:58.560
the world's data on safety of hormone optimization as I like to call it and I made the decision

2036
03:08:59.120 --> 03:09:03.520
that I was going to do all the tools I was going to learn to lift heavy again which I hadn't done

2037
03:09:03.520 --> 03:09:10.000
since high school because I was a runner and I changed the way I do my cardio and I changed my diet

2038
03:09:10.000 --> 03:09:15.760
and I am so committed to sleep do not call me after 9.30 at night because I am going to be in bed

2039
03:09:15.760 --> 03:09:25.360
and just the the quiet times of distress but I also decided to augment or to optimize my hormones

2040
03:09:25.360 --> 03:09:32.880
with estradiol with progesterone because I have a uterus and after I felt comfortable with those

2041
03:09:32.880 --> 03:09:40.320
with very small doses of testosterone and that makes me feel like myself again not just one

2042
03:09:40.320 --> 03:09:45.440
because I think sometimes people think that you can just make a hormone decision and feel like

2043
03:09:45.440 --> 03:09:52.320
yourself again it takes lifestyle plus or minus this decision. Is there a stigma associated with

2044
03:09:52.320 --> 03:09:58.080
that decision taking hormones? Taking the hormones but also I guess just more broadly with entering

2045
03:09:58.880 --> 03:10:06.240
period of pause yeah um I think there is there is absolutely you can just look at popular media

2046
03:10:06.320 --> 03:10:09.840
you can look at their representation. They're mean to go right now and give me an image. It's

2047
03:10:09.840 --> 03:10:14.240
decreasing because of you though like we have to acknowledge you are decreasing the stigma

2048
03:10:14.240 --> 03:10:18.240
true and you're sitting on the table with us. I say that I think because there's a woman in my

2049
03:10:18.240 --> 03:10:23.680
life who was telling me about her decision to start taking men of pause hormone therapy and she

2050
03:10:23.680 --> 03:10:29.680
described the moment with her husband when she was looking at the box and she was staring at the

2051
03:10:29.680 --> 03:10:33.680
box and staring at the box and staring at the box and mulling it and there was clearly something

2052
03:10:33.680 --> 03:10:39.680
emotional going on there that this decision to take this marks something which is interesting

2053
03:10:39.680 --> 03:10:47.680
because no one really questions OCs exactly oral contraceptive birth control and I treat both men

2054
03:10:47.680 --> 03:10:53.520
and women and when a man comes into my clinic with low energy popping all the tendons all over his

2055
03:10:53.520 --> 03:11:00.240
body everything hurts we were very quickly test his testosterone and send him with no judgment

2056
03:11:00.240 --> 03:11:06.160
because he's trying to be virile and I think it goes with the general conversation about aging

2057
03:11:06.160 --> 03:11:14.000
women when men talk about living longer it's called longevity yeah and we celebrate that and we

2058
03:11:14.000 --> 03:11:19.920
take pictures of movie stars in the south of Ferrari distinguished with their grain temples when

2059
03:11:19.920 --> 03:11:26.880
women when we talk about women living longer until right now because we're all screaming about it

2060
03:11:26.880 --> 03:11:35.440
it's under the guise of anti-aging a superficial like oh my god don't let her age so I think

2061
03:11:36.080 --> 03:11:42.560
part of that is the stigma of menopause somehow because we're no longer able to have a child

2062
03:11:42.560 --> 03:11:49.360
there's no we've aged out we've aged out of the game which hopefully we're pivoting this narrative

2063
03:11:49.360 --> 03:11:54.960
because as I said earlier women are winning the longevity battle we already live longer

2064
03:11:54.960 --> 03:11:59.600
but it's how we're living that we're trying to course correct yeah and it's not just humans that

2065
03:11:59.600 --> 03:12:04.560
go through this like I like using the whale analogy because whales go through it and then the

2066
03:12:04.560 --> 03:12:10.720
whales that are no longer reproductive become like the senior everyone all the other little whales

2067
03:12:10.720 --> 03:12:16.400
listen to them and it's like I want to be like a whale where you have this seniority and and

2068
03:12:16.400 --> 03:12:23.200
respect the wisdom with them keep it exactly yeah exactly I love this part of my life you love this

2069
03:12:23.200 --> 03:12:33.040
part of your life yes why I have never felt like I've been in exactly where I'm supposed to be

2070
03:12:33.040 --> 03:12:39.200
in this moment I feel like I'm helping more people I have better relationships I'm having better

2071
03:12:39.200 --> 03:12:47.600
sex I'm having better you know everything in my life pretty much is better and I don't know if

2072
03:12:47.600 --> 03:12:55.200
like menopause and and life circumstances have just given me permission to like cut out the crap

2073
03:12:55.920 --> 03:13:01.760
and focus on what's really important and you know don't sweat the small stuff

2074
03:13:03.120 --> 03:13:08.720
you know it's like like something kind of switches in our brain no filters it's amazing

2075
03:13:08.720 --> 03:13:12.320
and I don't think I could have done this 10 years ago I was too worried about what people

2076
03:13:12.320 --> 03:13:16.480
thought I was too worried about being a good girl and following the rules and checking the boxes

2077
03:13:16.480 --> 03:13:21.280
and never stepping outside of the guidelines but until I realized that I wasn't really serving

2078
03:13:21.280 --> 03:13:27.200
the population that I trained for X amount of years to that you know and they were being left

2079
03:13:27.200 --> 03:13:34.800
behind is really what allowed me to like be where I am today I think most of us described this as

2080
03:13:34.880 --> 03:13:41.200
the most authentic we're actually who we were made to be and the confidence we feel comes from

2081
03:13:42.000 --> 03:13:46.640
our memories of success I think that's where confidence comes from we remember everything that

2082
03:13:46.640 --> 03:13:53.760
we have learned to fix over time probably we could figure anything out and so that comes with

2083
03:13:53.760 --> 03:14:00.640
experience and frankly it comes with aging the price of aging or the price the price of having

2084
03:14:00.640 --> 03:14:06.800
wisdom and experience is aging right and so the the reps and so you get to this place

2085
03:14:06.800 --> 03:14:11.520
and you know I want to figure this out we're going to figure this out and I don't want the younger

2086
03:14:11.520 --> 03:14:16.720
generations to have to go through the stuff that we've got so far I can share my experiences

2087
03:14:16.720 --> 03:14:21.840
to help them navigate then that is a good thing yeah I'm in paryment apostro I'm a slightly

2088
03:14:21.840 --> 03:14:28.960
different stage and I know this because my cycles are shorter but they're still very regular

2089
03:14:28.960 --> 03:14:36.480
used to be 28 29 days another 25 26 I know that means I have less eggs coming out of my vault every

2090
03:14:36.480 --> 03:14:41.920
month and that's why I'm ovulating sooner but I can feel all the hormonal shifts much more

2091
03:14:41.920 --> 03:14:47.680
profoundly than before now as a reproductive endocrinologist what we call a fertility doctor

2092
03:14:47.680 --> 03:14:52.960
most fertility doctors now do IVF day in and day out and there's a lot of corporate reasons why

2093
03:14:53.040 --> 03:14:59.200
that is but we're also trained in puberty premature ovarian failure and hormone so I'm more of a

2094
03:14:59.200 --> 03:15:04.720
cowboy and quite cavalier at giving estrogen I mean told these ladies last night oh yeah because

2095
03:15:04.720 --> 03:15:11.040
I see it I see people who are low estrogen states and you know every single day how it impacts

2096
03:15:11.040 --> 03:15:16.960
their life so I am on low dose estrogen right now even though I'm still cycling I'm still

2097
03:15:16.960 --> 03:15:23.120
making my own progesterone so I don't have to take a progesterone right now but it clearly makes

2098
03:15:23.120 --> 03:15:30.400
a difference in my day to day function and how I feel and most are guys like I am well jokingly say

2099
03:15:30.400 --> 03:15:37.280
like you'll put me in the ground on estrogen because it has such a profound impact on you're able

2100
03:15:37.280 --> 03:15:44.000
how you can function and specifically if we're not forcing you to go through this empty glass

2101
03:15:44.000 --> 03:15:51.520
period for years and years and years of your life there's more opportunity on how you can slow down

2102
03:15:51.520 --> 03:15:55.600
part of the process that we all know is going to happen with aging but to live I think

2103
03:15:55.600 --> 03:16:01.040
fun to do is it you know healthier your health span how he's gonna live healthy longer not just

2104
03:16:01.040 --> 03:16:07.680
live longer well and I think your approach that I think it's part of the decision making is critical

2105
03:16:07.760 --> 03:16:17.920
because 35 to 45 and early perimenopause are prime times her prevention yeah it's to get

2106
03:16:17.920 --> 03:16:23.040
our standards set you don't have to lose your bone like you're gonna but it's hard for women to

2107
03:16:23.040 --> 03:16:28.320
get care and we also have to acknowledge that if you go into right if you what you're recommending

2108
03:16:28.320 --> 03:16:32.480
and I often do the same thing for my patients very hard for somebody to get care this is not

2109
03:16:32.640 --> 03:16:38.640
happening in 99% of doctor's offices like there is no that foreburned control pill or nothing

2110
03:16:38.640 --> 03:16:44.560
which is all they were taught given that even in menopause only 4% of women have chosen or have

2111
03:16:44.560 --> 03:16:51.440
been educated the pros and cons of hormone optimization and then to ex that's without that's an empty

2112
03:16:51.440 --> 03:16:58.800
jar person yeah so 4% Steven is that how many women that have or 2023 they did a study in the US

2113
03:16:58.800 --> 03:17:03.360
I'm not sure in other countries and on FDA approved so when we add in compounding it's maybe a

2114
03:17:03.360 --> 03:17:10.480
little bit higher but when you look at FDA prescriptions only 4% of eligible women meaning no risk

2115
03:17:10.480 --> 03:17:17.680
factors right age are utilizing are going to get their prescriptions filled as early this is

2116
03:17:17.680 --> 03:17:22.480
going to change right with more the education that you got we hope at least they're being offered

2117
03:17:22.480 --> 03:17:27.360
it and having a discussion so that each one they may choose not to do it and that's their right

2118
03:17:27.440 --> 03:17:31.440
side effects are their side effects worth noting I need a lot of people are quite scared of

2119
03:17:31.440 --> 03:17:36.800
taking send hormones so there's risks and then their side effects so when we look at the side

2120
03:17:36.800 --> 03:17:42.640
effect profile anytime we give a woman estrogen for just around and we'll have to like look at them

2121
03:17:42.640 --> 03:17:47.680
individually but estrogen you can have headaches you can have irregular bleeding about 50%

2122
03:17:47.680 --> 03:17:52.160
of patients and more on the patch than on oral there's a patch and there's a role you want to

2123
03:17:52.160 --> 03:17:56.400
take the patch right I do and that's on your stomach yeah that's right here actually and how often

2124
03:17:56.400 --> 03:18:02.880
you have to replace that twice a week okay fine yeah so so when we look at menopause hormone therapy

2125
03:18:02.880 --> 03:18:09.120
we have estrogen we have progesterogens and then we have testosterone basically and there's

2126
03:18:09.120 --> 03:18:14.160
different ways to get it into your body there's oral and non oral roughly so an oral it's pill you

2127
03:18:14.160 --> 03:18:19.920
take it and non oral we're looking at through the skin or through the mucosa so mucosa could be

2128
03:18:19.920 --> 03:18:25.520
under the tongue it could be in the vagina so mucosa is like the gastrointestinal track is lined

2129
03:18:25.600 --> 03:18:30.080
with mucosa and it's a nice weight absorb and in the rectum to absorb medication we don't have a

2130
03:18:30.080 --> 03:18:36.960
rectal form of estrogen yet and so so and then there's also injectable so you can inject it straight

2131
03:18:36.960 --> 03:18:42.080
into the muscle or subcutaneous tissues so most commercially available like FDA approved we're looking

2132
03:18:42.080 --> 03:18:47.360
at a ring for the mucosa we're looking at a patch for transdermal or we're looking at pills for

2133
03:18:47.360 --> 03:18:54.320
oral and what do you take yeah so I am on a patch and I've just but I'm not a great absorber

2134
03:18:54.320 --> 03:18:59.840
through my skin and I couldn't get my estradiol levels high enough where studies are looking like

2135
03:18:59.840 --> 03:19:05.840
the best bone protection is so I've added about a half milligram of oral estradiol at night

2136
03:19:05.840 --> 03:19:10.320
I'm on oral micronized progesterone which is probably the best way to get it into our system and I

2137
03:19:10.320 --> 03:19:16.800
tolerate progesterone very well and testosterone I am on a gel that is FDA approved we I'm borrowing

2138
03:19:16.800 --> 03:19:22.800
the men's version because we don't have an FDA approved version in this country for women so I

2139
03:19:22.800 --> 03:19:29.760
don't think anywhere borrow my husband australia australia and I think the UK just has approved one

2140
03:19:29.760 --> 03:19:37.760
it's new some news like in the last month yeah so okay so I'm making it so it's it's it's broadly

2141
03:19:37.760 --> 03:19:44.240
advisable after doctors consultation to take some form of hormone therapy definitely if you're

2142
03:19:44.240 --> 03:19:49.200
symptomatic because you have been classic visomotor symptoms it's absolutely the gold standard

2143
03:19:49.200 --> 03:19:56.800
but my trauma on that women say to me all the time either I don't have I don't feel that bad

2144
03:19:58.320 --> 03:20:04.960
or they say I want to do this naturally and those are the things that say okay fine do it naturally

2145
03:20:05.760 --> 03:20:12.640
but brain fog night sweats in the and hot flashes are not the only thing going on and so if you're

2146
03:20:12.640 --> 03:20:20.560
making this decision fully informed well you're a sentient being make the intense incision but you

2147
03:20:20.560 --> 03:20:26.480
cannot feel your bones crumbling until they're broken you cannot feel that you cannot feel your

2148
03:20:26.480 --> 03:20:32.320
muscle going away you cannot feel your brain starving you can't detect micro vascular disease

2149
03:20:32.320 --> 03:20:37.440
of your heart so you may think you're getting away with something and maybe you don't have

2150
03:20:37.600 --> 03:20:43.760
night sweats brain fog but it doesn't mean you're not having a different physiology and if you are

2151
03:20:43.760 --> 03:20:49.120
fully aware of that and make a decision that you don't want to optimize your hormone set your

2152
03:20:49.120 --> 03:20:54.000
decision and I'm fine with that but what I'm not fine with is people thinking they're getting away

2153
03:20:54.000 --> 03:21:00.240
with something when they're not true I am making the decision based on fear and not facts correct

2154
03:21:00.240 --> 03:21:03.760
last question is about love and sex in men and menopause you said you're having the best sex

2155
03:21:03.840 --> 03:21:09.600
of your life Mary and I've also heard you talk about how several people in this season of life

2156
03:21:09.600 --> 03:21:17.840
end up getting divorces you said they throw the the trash out so when we talk about you know

2157
03:21:18.480 --> 03:21:25.200
menopause can spur you know for some women it's it's this moment moment of empowerment they

2158
03:21:25.200 --> 03:21:28.800
realize they have to circle the wagons because the only way they're going to survive through this

2159
03:21:28.800 --> 03:21:34.800
cataclysmic you know upheaval for so many women is to get rid of relationships that aren't

2160
03:21:34.800 --> 03:21:39.200
working put up boundaries and sometimes that's going to be the end of a marriage other times it's

2161
03:21:39.200 --> 03:21:43.920
going to strengthen a relationship because you're you're kind of cutting out things that we're

2162
03:21:43.920 --> 03:21:48.880
getting in the way of you are so I see many marriages or many relationships really improve

2163
03:21:48.880 --> 03:21:54.880
through the transition but it does take to you know sex is biopsychosocial so like when I look

2164
03:21:54.960 --> 03:22:02.080
at sex it's not I think of the entire experience you know and one as far as my desire for the

2165
03:22:02.080 --> 03:22:09.040
frequency testosterone does seem to have given that an uptick so it is a proof you know we have

2166
03:22:09.040 --> 03:22:14.320
lots of studies done on libido for women which is in medicine we say hyperactive sexual desire

2167
03:22:14.320 --> 03:22:18.880
disorder and it has to bother you so a lot of women are like I don't want to have sex ever again

2168
03:22:18.880 --> 03:22:23.200
I don't care there's nothing wrong with that right unless it affects your relationship and it

2169
03:22:23.680 --> 03:22:30.000
has to bother you but I have a lot of patients who come in and say I love him I used to want to

2170
03:22:30.000 --> 03:22:33.840
do it we used to have a really great frequency and everybody was happy about it it was something I

2171
03:22:33.840 --> 03:22:40.000
look forward to enjoy it and now there's nothing I have nothing and for those patients testosterone

2172
03:22:40.000 --> 03:22:47.360
can be helpful not for everyone right and so there's other emerging data on looking at the musculoskeletal

2173
03:22:47.360 --> 03:22:53.040
system I am naturally thin I was not an athlete growing up at best I was a dancer you know and

2174
03:22:53.200 --> 03:22:57.920
I didn't do anything to protect my muscles and bones as as I was coming up through the ranks

2175
03:22:57.920 --> 03:23:02.880
and so here I am in my fifties just getting out of endurance you know you know recreational

2176
03:23:02.880 --> 03:23:07.760
endurance training and thinking what have I done to my bones and muscles I laid on that dexascant

2177
03:23:07.760 --> 03:23:12.640
as nervous as I've ever been in my life like getting my board scores nervous like what have I done

2178
03:23:13.200 --> 03:23:20.000
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

2179
03:23:20.960 --> 03:23:24.480
you know I'm doing that I'm eating the protein I'm lifting the weights I'm starting to do all

2180
03:23:24.480 --> 03:23:29.600
these things and we know that women who have naturally higher testosterone levels from genetics or

2181
03:23:29.600 --> 03:23:34.480
whatever have less frailty as they age because that's my focus if I run the cancer gauntlet which

2182
03:23:35.040 --> 03:23:40.400
probably 80% of my aunts and uncles have died of cancer and so if I run that gauntlet and I'm doing

2183
03:23:40.400 --> 03:23:45.440
everything lifestyle and preventive screening to do that and then the women end up with dimension

2184
03:23:45.520 --> 03:23:51.760
frailty like my mother and grandmother so I'm like okay I want to have as much bone and muscle

2185
03:23:51.760 --> 03:23:57.440
strength as I cancel I'm gonna add some testosterone and see what happens I and I at the time would

2186
03:23:57.440 --> 03:24:02.400
not have said I had any sexual dysfunction I did not qualify medically for HSDD

2187
03:24:04.560 --> 03:24:09.840
I go on testosterone and there's definitely an uptick in the area and everyone is happier

2188
03:24:09.840 --> 03:24:14.800
like my interest is improved my initiation has improved and I kind of waned

2189
03:24:15.360 --> 03:24:18.800
time and stress and kids and whatever the other thing we're empty nesting at the same time so

2190
03:24:18.800 --> 03:24:23.040
that probably no more kids will busting in our door to in the morning letting us know they're

2191
03:24:23.040 --> 03:24:28.080
home from you know whatever experience you guys will go through this later but also our

2192
03:24:28.080 --> 03:24:33.440
communication is better you know my husband's retired from Chevron and we are building this

2193
03:24:33.440 --> 03:24:38.400
this company together you know our menopause company and so our relationship was actually

2194
03:24:38.400 --> 03:24:44.400
improved through all of that so all of the things that feed into what we know is female desire

2195
03:24:45.200 --> 03:24:50.000
is just better all the way around and and I think testosterone had a little bit to do with it

2196
03:24:50.000 --> 03:24:56.640
my ability to like focus and my ability to prioritize and put up the right boundaries has really

2197
03:24:56.640 --> 03:25:02.240
helped with that and we're just having a lot more fun with it but I think that we would be remiss

2198
03:25:02.240 --> 03:25:06.800
in this part of the conversation and I'll say it I'm the orthod but I'm gonna say it anyway

2199
03:25:09.600 --> 03:25:14.080
many men I just talked to my husband publicly about this because we're trying to educate men

2200
03:25:14.080 --> 03:25:20.000
is that most men don't realize that in pairing menopause as estrogen wanes it affects all tissues

2201
03:25:20.560 --> 03:25:25.920
and there is an entity called the genital urinary syndrome of menopause where the vagina will

2202
03:25:25.920 --> 03:25:34.080
actually atrophy and all the external soft tissues that are usually used to engorging will become

2203
03:25:34.080 --> 03:25:41.360
dry like a desert and Stephen sex can feel like razor blades and men don't know that and women are

2204
03:25:41.360 --> 03:25:47.680
afraid to tell their partners so the men feel rejected like why doesn't she love me or desire me

2205
03:25:47.680 --> 03:25:55.200
anymore and it may be that but it's probably not that it's it hurts and I bleed and women don't know

2206
03:25:55.200 --> 03:26:01.360
that this is normal when your estrogen is not that it's okay to tolerate it shouldn't be it shouldn't

2207
03:26:01.360 --> 03:26:07.600
be normal but when you're in a low estrogen state regard menopause birth control pills can do it

2208
03:26:07.600 --> 03:26:15.840
postpartum breastfeeding even you know a progesterone IUD these can all cause time periods where your

2209
03:26:15.840 --> 03:26:21.040
estrogen levels are low enough that the vaginal tissue is not having the right collagen and elasticity

2210
03:26:21.040 --> 03:26:28.480
that it should it was the solution not lubricant lubricant can sometimes aid but that's not a

2211
03:26:28.480 --> 03:26:35.520
root cause right it'll help with loop I might help with symptoms right but if your part of the

2212
03:26:35.520 --> 03:26:41.120
problem is that the tissue can't respond as it should that it's frail the late orgasm then we

2213
03:26:41.120 --> 03:26:46.640
really want to get to the root cause which is estrogen is crucial for skin it's like men going

2214
03:26:46.640 --> 03:26:53.360
on testosterone right if he's not having an erection there are 29 solutions for that right now

2215
03:26:53.360 --> 03:27:00.560
but it primarily funded solutions by well solutions but for women it's not just desire it's

2216
03:27:00.640 --> 03:27:06.080
physiologic and so that's no estrogen putting something up putting in your vagina and what you

2217
03:27:06.080 --> 03:27:10.720
putting your vagina is so there's there's several options we have creams we have pills there's a

2218
03:27:10.720 --> 03:27:15.360
ring specifically designed just for that so we have different methods of getting the facial you know

2219
03:27:15.360 --> 03:27:22.800
estrogen into the vagina there's also something called presserone which is DHA basically which is

2220
03:27:22.800 --> 03:27:29.280
a pre hormone that the vagina miraculously will convert to estrogen and testosterone so but it's

2221
03:27:29.280 --> 03:27:35.120
expensive it tends to not be covered by insurance but for our like our sex med friends sexual medicine

2222
03:27:35.120 --> 03:27:40.640
friends who specialize in this female sexual function they love it because you're not only getting

2223
03:27:40.640 --> 03:27:44.960
a boost of estrogen to the vagina you're also getting testosterone and there are testosterone

2224
03:27:44.960 --> 03:27:50.160
you know receptors in the vulva you know in the lower vagina and around the skin around the

2225
03:27:50.160 --> 03:27:58.720
vagina as well but here's the bonus all of this plus vaginal estrogen will help prevent

2226
03:27:59.360 --> 03:28:08.240
chronic UTIs which kill old ladies and it will help support the pelvic floor and the uterus

2227
03:28:08.240 --> 03:28:15.200
from prolapsing and so it has all these added benefits and here's another bonus it is such low dose

2228
03:28:16.160 --> 03:28:22.240
it is not systemic so any risk that you could think of that you might not want to do systemic

2229
03:28:22.240 --> 03:28:29.520
estrogen including breast cancer is unaffected by vaginal estrogen and so it is a huge solution

2230
03:28:29.520 --> 03:28:34.160
and there's no age that a woman can't go on it she'll kill me she'll never know this but

2231
03:28:34.160 --> 03:28:41.280
I put my 86 year old mother on it so that we could prevent UTIs and failure of tissue so she

2232
03:28:41.280 --> 03:28:48.480
did it get sores and infections right isn't that a miracle I know Stevens like yeah and we should

2233
03:28:48.480 --> 03:28:53.760
say the vaginal estrogen in preparations made for vaginal estrogen there are low dose estrogen

2234
03:28:53.760 --> 03:28:59.680
preparations you can give oral estradiol vaginally and it will be systemically absorbed

2235
03:28:59.680 --> 03:29:02.880
right because the vagina is highly absorptive so I don't want somebody to hear this

2236
03:29:02.880 --> 03:29:08.880
oh no thank you for that but just saying we often prescribe or recommend a local treatment

2237
03:29:08.880 --> 03:29:14.160
of vaginal estrogen products which are in very low dose and they really impact the local tissues

2238
03:29:14.160 --> 03:29:19.920
of we'll say the pelvic floor the urinary system the vulva the vagina and they improve your

2239
03:29:19.920 --> 03:29:24.720
well-being and your health without some of the risks that might come from systemic hormones

2240
03:29:24.720 --> 03:29:30.720
and somebody who may not want to take them I am all out of questions so I wanted to conclude this

2241
03:29:30.720 --> 03:29:35.280
segment just by asking you what the most important thing that I have missed on the subjects we've

2242
03:29:35.360 --> 03:29:41.120
talked about menstrual cycles manopause everything in between what is the most important subject you

2243
03:29:41.120 --> 03:29:50.640
think we might have missed I think we covered it but but to say that you control a large part we

2244
03:29:50.640 --> 03:29:57.600
said over and over inflammation and insulin resistance we touched on different lifestyle factors

2245
03:29:57.600 --> 03:30:03.280
that impact this because when your body is having hormone change there's a lot of the external world

2246
03:30:03.280 --> 03:30:08.400
around you or the choices you're making that can make some of that better or worse or influence what

2247
03:30:08.400 --> 03:30:13.120
is happening and I know we're going to go over more of this but I think this idea that I have no

2248
03:30:13.120 --> 03:30:18.560
control over what's happening to me isn't 100% true I mean you don't have control over when some

2249
03:30:18.560 --> 03:30:24.960
of this stuff happens but you can take control of a situation by understanding your body knowing

2250
03:30:24.960 --> 03:30:31.200
what's happening knowing how to advocate for yourself and making active decisions to live a

2251
03:30:31.200 --> 03:30:36.560
healthier better life yeah that's the goal is to empower women to understand to ask the questions

2252
03:30:37.120 --> 03:30:41.840
so they don't feel like something is happening to them and they don't have control or options

2253
03:30:42.560 --> 03:30:48.400
which is what our mother's generation had they were always gaslit told you know it's all in

2254
03:30:48.400 --> 03:30:56.560
your head my nothing we can do so my mother was put on butalbitol it was called butasol

2255
03:30:57.520 --> 03:31:03.440
um it's basically a sedative and it was mother's little helper and I found an old magazine article

2256
03:31:03.440 --> 03:31:11.280
with a if you look at the magazine articles from the 50s and 60s on these medications mostly

2257
03:31:11.280 --> 03:31:16.240
sedatives that were given to women it's like now she can do the laundry again now she is she's

2258
03:31:16.240 --> 03:31:21.760
flipping a pancake in the ad and like the apron in the 1950s you know like get your mom back get

2259
03:31:21.760 --> 03:31:27.600
your wife back and it was a combination of estrogen plus a sedative and I was just

2260
03:31:29.200 --> 03:31:38.240
absolutely floored and I remember mom's little bottle and it was called butasol and I it would

2261
03:31:38.240 --> 03:31:43.040
sit on her counter and she would talk about it like it was her talisman like it was her and I

2262
03:31:43.040 --> 03:31:47.040
was thought of it as mommy's little helper you know like oh I need my butasol oh this happened

2263
03:31:47.040 --> 03:31:53.040
and I was my butasol where's my butasol and when I was researching and writing and reading about

2264
03:31:53.040 --> 03:31:58.640
the sedatives that were given to women I was like wait mama I remember the bottle I remember it was

2265
03:31:58.640 --> 03:32:02.080
called because she talked about it all the time I went and looked it up and it's derivative of

2266
03:32:02.080 --> 03:32:08.880
phenobarbital and it was heavily prescribed to women so barbituated it's a drug it's a

2267
03:32:08.880 --> 03:32:12.960
class of drug that is basically a sedative we use it in surgery we use it for seizures

2268
03:32:13.760 --> 03:32:21.440
and they were sedating my mother on the daily yep through her perimenopause now she had eight kids

2269
03:32:21.440 --> 03:32:25.840
she was running a restaurant you know she was very high functioning and I just refused for that

2270
03:32:25.840 --> 03:32:32.720
to be that was her reality yeah and here she lies in a bed without timers and a fractured hip

2271
03:32:33.440 --> 03:32:37.520
and she hasn't walked in eight months you know she's she's just now getting on a walk or eight

2272
03:32:37.520 --> 03:32:43.280
months after her hip fracture and from osteoporosis who's never had a bone density scan in her life

2273
03:32:43.920 --> 03:32:47.760
and like our children deserve better it's not going to be my future because I have the you know

2274
03:32:47.760 --> 03:32:55.200
I have the means I have access but like I want every young girl all of our children to have a

2275
03:32:55.200 --> 03:33:01.440
better future than what was offered to our mothers exactly I think ending this I would want every

2276
03:33:01.440 --> 03:33:10.720
woman to approach her midlife life her new life with the same vigor and the same curiosity and the

2277
03:33:10.720 --> 03:33:16.320
same demanding of care that she would do for one of her children if her child is sick she's not

2278
03:33:16.320 --> 03:33:21.440
going to take no she's not going to take being blown off she's going to keep searching to the end

2279
03:33:21.440 --> 03:33:28.080
of the earth until she finds an answer and that's what that is the same kind of taking control that

2280
03:33:28.080 --> 03:33:34.880
I want women to do about this time in their lives thank you so much we're going to record we're

2281
03:33:34.880 --> 03:33:38.880
going to continue this conversation for the viewers that are listening at home and I've been through

2282
03:33:38.880 --> 03:33:45.200
all of these wonderful books that have in front of me and there's so many lifestyle nutrition exercise

2283
03:33:45.200 --> 03:33:49.920
related solutions to many of the things we've talked about today to be in truly optimized

2284
03:33:49.920 --> 03:33:55.520
and hormone healthy menstrual cycle healthy woman which I want to talk about in our part two of this

2285
03:33:55.520 --> 03:34:19.520
conversation