This Podcast Will Kill You - Ep 135 Menopause is whatever you want it to be

Episode Date: February 13, 2024

For our season 6 finale, we’re spending some time with menopause. How many nicknames can you think of for menstruation? Quite a few, I’m sure. “That time of the month”, “Aunt Flo”, “the red wave”, “period”, the list goes on. But what about euphemisms for menopause? We’ve got “the change” or “change of life”, “climacteric”, and… that’s it? There may be more out there, but the comparison is revealing. Despite the fact that roughly half of the global population has or will one day experience menopause, the lack of nicknames demonstrates the silence, often tinged with shame, still enveloping it. In this episode, we explore the roots of this silence and the many historical misconceptions about menopause that frame our current perspective. We also examine the effect that this silence has on our understanding of the physiological processes underlying this transition. Why do some people experience symptoms and others do not? Why do humans experience menopause? What is the grandmother effect? What’s the latest on hormone replacement therapy? These are only a sampling of the many questions we delve into in this info-packed, frustration-laden, and eye-opening episode. See omnystudio.com/listener for privacy information.

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23. But what if we didn't get the whole story? I would have this been made to fit. The moment you look at the whole picture, the case collapsed. What if the truth was disguised by a story we chose to believe? Oh my God, I think she might be innocent. Listen to doubt the case of Lucy Lettby on the IHeartRadio app, Apple Podcasts, or wherever you get your podcasts. Hi, my name's Marika.

Well, this is one of the strangest times in my life. In my late 20s to early 40s, I was hyperproductive, high achieving, goal oriented, and I was just able to get a lot done. I was able to be highly productive with little sleep. However, now with brain fog and high levels of fatigue, some days it's difficult to complete a simple list of tasks. It's like living with my head in a cloud. Some days I'm so tired. The fatigue is really challenging and limits my ability to want to do things outside of my work and home responsibilities. I have also experienced a substantial weight gain of about 50 pounds, which no amount of physical activity or calorie restriction seems to address. And oh my gosh, the heat. I used to get cold easily. Now I long for those days. My first hot flash or flush

felt like a wave that started at my feet and slowly moved up my body and unfurled and unleashed its heat on me. It was wild and almost anxiety producing because it felt unlike anything I had experienced previously. Since then, I have had many more, but something I've really noticed is how hot I am most of the time. Interestingly, now I experience fewer hot flashes and instead just feel hot most of the time. I've also had really itchy inner ears, which I thought was just a strange issue I was having, but as I've read more, I found that it's a common symptom for women at my stage in life. And the darndest thing is, no matter the amount of scratching I do, which looks really pretty, the itch persists. What's going on? So menopause is defined.

as one year following one's last period. However, I had an endometrial ablation in 2007 and haven't had a period since then. So the monitoring aspect of where I am in the time frame of menopause or perimenopause is based solely on my symptoms. I found it hard to find a practitioner who's truly knowledgeable about menopause and perimenopause. My OBGYN is not my former general practitioner. an integrative health professional was not, although she claimed to be. It took me years to find a North American Menopause Society or NAMS certified provider in my rural area. And in fact, it took me a long time to even find out about NAMS. Meeting my certified NAMS provider was a relief because all the scientific information I had read about prior to our meeting was reinforced during the meeting.

This led to complicated discussions and a lot of reading about hormone replacement therapy or HRT for short. There are so much conflicting information out there. I'm an alternative medicine type of girl and although I'm very pro-vaccine, I've always prided myself on not taking a lot of meds or finding herbal remedies for many ailments. When I was in grad school in 2001, the large research studies. called the Women's Health Initiative was grounded and halted all recommendations for HRT meds due to the cost of treatment outweighing the benefits. One of my statistic professors was in the research group for this trial and talked to us then about the problems with stopping the trials

prematurely, including how the data were being misinterpreted, and little did I know how this would affect me later. It turns out the misinterpretation. of the data led to misinformation and led me to being really scared to try HRT. As a result, I first chose bioidentical hormones, those that mimic the ones created by our bodies, but derived from plants, or in this case, sweet potatoes. When I was having little or inconsistent results, my provider gently shared the data and ideas about taking more traditional HRT. She mentioned that the traditional. H.R.T., which is bought at a standard pharmacy, meets the standards for consistent dosing,

is recommended by NAMS, and is effective when started prior to the cessation of symptoms. So now I'm six years in, and while my symptoms are better across the board, they're still present. I look forward to the day when they are behind me totally. It's been so interesting to find how different people's experiences are. Some people have zero symptoms and don't know where they are if they've completed menopause or not, and others have more extreme symptoms than I do. I'm happy to have great physicians to follow, such as Dr. Jen Gunter. She's an OBGYN who wrote the Menopause Manifesto and actively works to debunk myths about menopause, as well as educate us about what's going on with our bodies. Thank you so much,

Marika for sharing your story with us. We really appreciate it. Yeah, thank you. Hi, I'm Aaron Welsh. And I'm Aaron Elman Updike. And this is, this podcast will kill you. Welcome to the last episode of this season. Yeah, I hope that we've been, I can't remember, have we been saying that like we're wrapping up this episode or this season? Whoops. Not even a little bit. So, surprise. But we're making it an extra long, extra fun, extra fascinating one. Yeah. Talking today about menopause. We say this a lot.

This could have been a two-parter, a three-parter, a three-parter, a four-parter, a season. Maybe it should be. Maybe it should be. Maybe it should be. Yeah. But I had such a great time researching for this episode. I am super excited. I honestly, I think that I've probably annoyed so many people because I cannot stop talking about it.

I've lost friendships because I will not shut up about menopause. You're probably not the first one, Aaron. Oh, that's exciting. I'm really excited to hear your entire section. Like, I feel like you have given me just enough of a glimpse of, like, the general topics that I'm like, ooh, I can't wait. I hope I do it justice. Oh, same. But before we get to all of that, should we, is it?

It's quarantini time. Oh, yeah. What are we drinking this week? We could be drinking nothing other than blood, sweat, and beers. I love it. Me too. I also love the recipe because it's more or less Michelada. It's something that we've done before.

But we're spicing it up this time by adding cucumber and jalapeno and lime juice. I don't know how. Like, you know what? It's going to be delicious. It is. It is. And we will post the full recipe for the quarantini and the non-alcoholic placebo breeder on our website, this podcast will kill you.com as well as on all of our social media channels.

On our website, this podcast will kill you.com, you can find so many things like our bookshop. dot org affiliate account. You can find our Goodreads list. You can find Bloodmobile, our music, and our merch and our Patreon, and transcripts from all of our episodes and our sources from every episode. All the list is long. So, so many things, check it out. I don't think there's any other business besides, you know, this is the last episode of the season. Oh yeah. We will not make you wait very long for the next season. Don't worry. And the next season will be jam-packed full of very many fun, cool things. We have so much entirely unplanned, but so many ideas. It's going to be a really

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That's T-H-E-B-A-L-M-B-O-X.com. Balm, like healing and care. The balm box, because cancer patients don't need bouquets and brownies. They need balm. So the definition of menopause, according to textbooks and doctors and all the papers, the definition of menopause is 12 months of... amenorrhea or 12 months of no period, specifically as a result of the cessation of ovarian function.

That is like the clinical definition. And menopause is like clinically defined. There's not like a single test that you can do to say menopause or not menopause. So in a person who menstruates, after Menarch, which is like the start of getting your periods, some number of years later, once you then go 12 months without a period, without anything like contraceptives or IUD or pregnancy or breastfeeding or even cancer or chemotherapy or something that's altering your hormones temporarily, once you have 12 months with no period because your ovaries are no longer having function, we call that menopause. If you think of it as a reproductive lifespan, people with ovaries and uteruses have the beginning of their reproductive lifespan with

Menarch. That's like your first period, anywhere from like 10 to 16 years old. And someday we'll do an episode about menstruation. We really, really need to. Feels like a missed opportunity. could have done that one first, but we start where we start. Yep. So Menarch is the beginning of this reproductive lifespan, as it were, and then menopause is like the end of it. And so after menopause, you are postmenopausal, but still alive for a really long time, hopefully. Okay, question. I love it. Already, okay? Already. Okay. Like, how long do the ovaries take to stop function? Is menopause a before and after snapshot in time or is it a progression? Is it something that happens over time?

Okay. This is such a good question. So it is both a process and a single event and it depends on what you're truly talking about because a lot of people call menopause a whole period in which they are experiencing symptoms that they're relating to menopause. Right. So we're going to talk a lot about like, what is happening in your ovaries, in your brain, in your body during this whole transition.

But because the clinical definition of menopause is this time point at which you've had 12 months with no periods. That's like the clinical in the doctor's office definition. Leading up to that period, there is a lot of hormonal changes that are happening that may or may not result in symptoms. This time period is called perimenopause or the menopausal transition. And a lot of people just call that period menopause. Yeah, I certainly, I think, use the two kind of interchangeably like menopause to mean cessation of ovarian function, but also going through menopause as like a term. Yeah. Yeah. And it's kind of like, you know, it's all the menopausal transition. I think that's my favorite of the terms for it. And so this, in theory, can happen any time

in a person who menstruates. But to be called menopause, it generally has to happen toward the end of the 40th or beginning of the 50th decade of life. And the average age globally is about 48 to 52. And there's some variation geographically, but not a ton of variation in this. If, If menopause happens between age 40 and 45, we call it early menopause. And if it happens before age 40, so if you have cessation of periods for 12 months before age 40, we don't call it menopause at all. We call it premature ovarian insufficiency. And I'm not going to get into that because it is something different. But part of the reason for that is that there's a lot of things that can cause premature ovarian insufficiency, and they're not all permanent. So sometimes ovarian function can

return in the case of premature ovarian insufficiency, and sometimes it can't. Whereas with menopause, it's happening because the ovaries are done ovulating. What if you're taking some form of birth control that results in either really light or non-existent periods? Erin, there's so much more to it than just if you're taking birth control. Okay. So I'm so glad you asked, though. Because this criteria that we use to define menopause is entirely dependent on bleeding, right? It's dependent on menstrual bleeding.

By that definition, we can define menopause in a lot of people who menstruate, but a lot of people get left out. So that includes, yes, people who are taking oral contraceptives or people who have something like a progestin IUD who might not have any periods because they have an IUD in place. Also, people who've had a hysterectomy or an endometrial ablation, they're not going to be bleeding at all. It also means it's difficult to diagnose in people with PCOS who might have really variable cycles to begin with. Or, for example, trans men who might still have ovaries and even a uterus, but be on various hormones so that they're not menstruating. there are so many people that are left out by this specific definition of menopause.

And yet, if they have ovaries, they're still going to eventually stop functioning and therefore have gone, quote unquote, through menopause or through this menopausal transition, whether they realized it or not. This is also, quote unquote, natural menopause, which is different than surgical menopause. which is when the ovaries are removed surgically for any number of reasons. And as we'll talk about, this causes a really rapid decrease in hormones and results in menopause, but it's different than, quote, natural menopause. Okay.

There's so much here, Erin. There is so much here. So because of that, there are other diagnostic criteria that we can use to help diagnose menopause. part of it is if someone is of the right age, if they are having symptoms that we correlate to menopause, then we can also check certain hormone levels, and we'll get into that. And if these hormone levels have risen the way that we expect with menopause, then you can use all of this together to say, yes, you have gone through menopause or maybe are in the midst of the menopausal transition. I have another question, but I'm worried that like I'm

just I've stalled us out at the very beginning of the biology. There's so much, though, Erin. There's so much. So if it's like getting ahead of things, we can just wait and answer it later. Okay. Why is it important to know whether someone has or has not yet gone through menopause besides something like, you know, fertility? Mm-hmm.

Mm-hmm. So fertility is a big one. If people want to know either whether they could still have children or make sure that they can no longer have children if they're, for example, wanting to come off of birth control or something like that. It also, as we'll talk about, risks of certain diseases do change after menopause because of these changes in hormone balance. So perhaps it would be worth knowing for that reason. But really, if someone is not experiencing symptoms related to this menopausal transition, there is not a need to do any testing necessarily to say you are or you are not menopausal or post menopausal.

It really comes down to what somebody is experiencing and what their desires are in terms of knowing what's going on or what has or hasn't happened kind of a thing. So let's talk about that, shall we? Let's talk about like what is we defined menopause and now we're like, well, what the heck is that? 40 questions. Right? So let's talk about what is happening physiologically during this time. And then I will talk about the, quote, symptoms that can occur during this menopausal transition. But first, let's just talk about what the hormones are happening doing.

Okay? Yeah. To do that, let's remind ourselves briefly of what. What is going on hormonally in people who menstruate prior to menopause? Like, what is menstruation exactly? Okay? Just the basic. Just the basics.

So the menstrual cycle itself, which again starts with Menarch, like in the teenage years, the menstrual cycle has two main phases. The follicular phase at the beginning and the ludial phase. The follicular phase starts when you start your first day of bleeding. That's how we define the start of a menstrual cycle. And every month-ish, during this follicular phase, follicles in the ovary are recruited and start to mature. These are basically baby eggs, okay?

Yeah. After a period of maturation, and in response to hormone surges, specifically estrogen and lutenizing hormone, one mature follicle, aka one egg, is released and that is ovulation. Following ovulation, we then enter the ludial phase, which lasts about 14 days. And at the end of that phase,

if there's no embryo that gets implanted, then menstruation occurs. That is the shedding of uterine lining and vaginal bleeding. Cool. And you've started your next cycle. During this menstrual cycle, there are a lot of hormonal fluctuations

that are happening. And these hormonal fluctuations, fluctuations are a very complex interplay of positive and negative feedback cycles that are happening between our ovaries, which are making hormones that you've heard of, like estrogen, progesterone, testosterone, but also a lot of lesser known, but not less important hormones, like anti-Mularian hormone and inhibin B. And these hormones travel through our bloodstream and interact with and are then affected by hormones released in our brain, specifically by this axis in our brain called the hypothalamic pituitary axis,

so like two different areas in our brain. And these are hormones like gonadotropin releasing hormone, follicle stimulating hormone, FSH, and lutenizing hormone, or LH. We don't have to understand all of the nitty-gritty of this cycle, in part because that's another episode, but also because what we just need to understand to understand menopause is that there are these cyclic ups and downs of all of these hormones that are happening in communication between our ovaries and our brain. And as our ovaries start to deplete these follicles, big shifts start to

happen. So because we are born, if you're born with ovaries, you have a set number of ovarian follicles that you're born with. We don't make any more. Unlike people born with testes who are constantly just making more sperms like all the time, the ovary has a certain number of follicles and they don't make any more. So as these follicles are literally depleted because they are used up and either ovulated out or just half matured but then never quite ovulated, this ovary loses a number of follicles. And as this happens, hormone levels start to shift. Specifically, anti-mulary hormone or AMH and inhibin B, which are two hormones the ovary produces, slowly starts to fall as we age. They peak at like around age 25 and then slowly, slowly, slowly, slowly start to go down. Over time,

this has an effect on our brain of slowly increasing hormones like FSA. which is what stimulates our follicles to make an egg for ovulation, to make like a ripe egg for ovulation. And as we see these declines in the number of follicles and these hormones like AMH and inhibin, what we see is an ovary and follicles that are less responsive. So they need higher and higher amounts of FSAH to be able to respond appropriately, if that makes sense.

Yeah. Kind of like in our diabetes episode when we talked about like your pancreas needs, like your pancreas is making more and more insulin because your tissues just aren't responding. It's kind of like that. Mm-hmm. But eventually, you get to a point where there are so few follicles that ovulation just isn't going to happen. But you're still going to get this increase in FSAH because of all these complex feedback loops. And at the same time that all of this is happening,

Estrogen declines pretty drastically. So by the end of menopause, what has happened is that we have depleted all of those follicles. There's no more eggs left in your ovaries to ovulate. And our hormone levels have shifted from estrogen being high, which is what it looks like during the reproductive years, and FSAH being low on average, to a reverse where FSAH is high and estrogen is now low. And that is the big change that occurs by the point that you've gotten to menopause. That is, 12 months without a period. So if there are no more Fs for FSA to act on or stimulate, then what is FSA doing? Great question. Not much, but it's still going to be.

there, right? Because our brain doesn't necessarily know, like, hey, FSAH, like, you're not doing much. Like, we can just chill out with you. It's more like we have lost the negative feedback. Inhibin has decreased. And so now there's no negative feedback to say, hey, we don't need this anymore. And so that's how it remains for, like, after menopause. The whole time, we're just still making FSAH. Yeah. And it's possible that there's a point at which it, like, slowly started. starts to kind of go down from like a peak or something like that. But realistically, for the rest of your postmenopausal life, estrogen is low and FSAH is high. I am, okay. I don't know why that like I'm so hung up on this. Yeah. Well, it's interesting, right? Because it's basically you've lost

this, what used to be cycles. You've lost it. Yeah. You've lost that cycling. Now, during the menopausal transition, right, during this time frame when your ovaries are still, making eggs, they're still ovulating, but the number of follicles has started to decline. What we see is a lot more erratic hormone changes because your ovaries still have enough to sometimes ovulate and they're still making enough estrogen that they might sometimes cause a cycle to happen even if it's not an ovulatory cycle. So it gets really complicated in that time frame that we call perimenopause or the time leading up to menopause. And that is a time frame in which sometimes people might have symptoms, but it's also after that menopause transition and the years

thereafter where your body is getting used to this new normal of low estrogen and high FSAH. And it's not just fSH and estrogen. Because this alteration in hormone production, remember, is affecting our brains, our hypothalamic pituitary axis. And the hormone production alterations that happen in our hypothalamus also have direct effects on other pathways, like our noradrenergic pathway, our serotonergic pathway. We can see decreases in growth factors and growth hormones and insulin. This can alter the lipid profile. There's a change in the activity of GABA.

Like, this is affecting the hormonal milieu of our brain entirely. in addition to our body experiencing a very significant decline in estrogen specifically. Does that kind of make sense? Yes. There's a whole lot of stuff going on. Yeah. And it's not just estrogen. It's not just estrogen.

Okay. Yeah. Erin, I have so many questions. Me too. Have we been able to quantify these effects and how much? variation is there, you know, from individual to individual? Oh, I don't have an answer for that, except that like, yes, lots. Yeah. Yeah. So I think what we could start to talk about is, like, what does this end up looking like? Like, what are the quote unquote symptoms of menopause or of this

transition? Right. And I want to take a moment here to say that we're going to spend time on what these symptoms are because they're really important. Because what I think is tricky about menopause, is that these are changes that are happening hormonally in people's bodies that have ovaries always. Like it will always, it is an inevitability, right? And it is a natural phenomenon. It is, it really is like an inevitability if you've got ovaries still in place. It's life.

It's life, yeah. Yeah. So I think what's difficult about menopause is balance. the very real experience that people have and their symptoms, some of which, as we'll talk about, might be very unpleasant or distressing or significantly impacting their life, while at the same time not over pathologizing something that is a normal physiologic process. And understanding that while everyone with a uterus and ovaries will experience menopause because their ovaries will eventually stop ovulating, not everyone with the uterus and ovaries will experience it in the same way at all.

And some, many, might never experience any quote-unquote symptoms related to it, while others might have very significant symptoms during this time. So it's a very interesting phenomenon, I think. And I know, Erin, you're going to talk more about the like cultural history of it all. But it's even biologically, really interesting that the experience can be so different. Yeah. Everything, like there are so many different components that go into this. And I feel like menopause has at the same time been, its importance has been overstated and understated. Yes, I agree. I feel like it still is. Yeah, totally. So that's why we're doing this episode. Yeah. Okay. So anyways, let's talk about it. Yeah. So let's talk about these symptoms. I will say there's a lot of big buckets of symptoms.

that people associate with menopause, not all of them are actually clearly attributable to menopause itself. And when I'm saying menopause, I mean this hormonal transition itself. And some of them definitely are. Like we know the kind of mechanics of estrogen withdrawal causing X, Y, and Z, right? So what I will try and do is at least mention all of these symptoms that are often associated and then talk about which ones have the. more support for truly being menopause-driven versus perhaps a result of aging and happen in like even wider population or it might be just happening in all populations but we're only studying it in certain populations if that makes sense.

Yeah, yeah, yeah. So the most classic, the most strongly associated and the most, I don't know, really is just the most classic are vasomotor symptoms. That is the hot flash. Dunna. Yep. I also, hot flush. I've seen that. Hot flash, hot flash, night sweats. Night sweats. Yeah. Like, it's all, they're all vasomotor symptoms is what these are all called. And these are exactly what they sound like. They're often sudden feelings of maybe like a head rush, sweating, feeling hot, and then sometimes they're after feeling cold and chills. These type of vasomotor symptoms can start as early as a couple of years,

before the actual final menstrual period. But they often tend to peak a year or so after that. So kind of after the true, quote unquote, menopause point. And then they can continue. And in some people for years thereafter. So in a lot of the literature, it's reported that the median time of experiencing vasomotor symptoms for people who experience these is about seven years, which is a pretty long time.

That is a long time. Typically, vasomotor symptoms have been attributed directly to estrogen withdrawal, but it's thought that it's actually more a manifestation of the declining sensitivity of that hypothalamic pituitary axis to estrogen because a lot of times they start happening before that estrogen has truly declined, right? during that time when menstrual cycles are maybe more erratic and estrogen is still cycling, but in a perhaps different way than it used to during the peak reproductive years. Yeah. We still don't have a perfect explanation for like X, Y, and Z is what causes vasomotor symptoms, but we do think that it's directly related to changes in temperature regulation. And I'll get into a little bit more of that in the current event section because there's some new

medicines that are not estrogen hormonal related that affect vaso motor symptoms, which are really interesting. Huh. Yeah. And so you get into like the mechanistic. A little bit more. It's basically like because estrogen is affecting your brain hormones, there are other brain hormones that are related to your temperature regulation set point that we can also target

to treat vasomotor symptoms. Okay. Yeah. But also hot flashes or hot flashes or hot. hot flushes are not unique to perimenopausal or postmenopausal people? Absolutely not. And they're not universal in postmenopausal or perimenopausal people. Right. So have you come across studies that looked at the breakdown of like let's say people who are nowhere near the age of menopause or people without ovaries? Like how much, who experiences, is it significantly higher in people who are

going through menopause? It's a good question. I don't, I don't, I don't, I didn't look at papers that specifically look at those comparisons. And even looking like geographically, there's pretty huge variation in people reporting vasomotor symptoms across the globe, although vasomotor symptoms do tend to be one of the most commonly reported if there are going to be symptoms associated with menopause. But I think if we think about this as menopause is a time when hormones are affecting our brain and causing changes in those hormones that could affect temperature regulation, there are lots of other states in our lives, whether you have ovaries or you don't have ovaries, that can also affect your temperature regulation because it's affecting hormones in your

brain, right? So it's not that surprising that other people can also have hot flashes, even if they're not menopausal, and that menopause can directly cause these vasomotor symptoms. Does that make sense? Yes. What about the geographic variation? I don't have a great explanation for that, because some thought is like, oh, is it also related to ambient temperature, but not necessarily because there's not seasonal effects. I don't know, Erin, there's too much. There's too much. And I've only said one symptom so far. There's a lot more. It's going to be a long episode. Mm-hmm. Another one that's commonly associated with menopause is sleep disturbance.

And sometimes this tends to be conflated with the vasomotor symptoms because these hot flashes do often occur at night and can lead to a lot of nighttime awakenings. But other than that, this idea of menopause directly causing sleep disturbance, we don't have a lot of great data on like, A, what the mechanisms are, or B, is it truly menopause or is it other things that are? happening that is not directly attributable to menopause. And that is true for a lot of the symptoms like the laundry list that are often associated with menopause. Depression and anxiety, in some cases, are reported as higher during the menopausal transition compared to premenopause. Cognitive changes, including declines in memory and concentration, are sometimes associated with this perimenopausal time period and sometimes reported as transient during. this time period. Weight changes are sometimes reported as related to menopause. That one especially,

there's really not good data that menopause itself has any influence over weight gain. But all of these are things that people might experience at any point in their lives. And for some people, they might experience it in association with this hormone fluctuation. And in some people, they might not. But we don't have like hard data to say that menopause is causing any of those type of symptoms, especially not universally. In our migraine episode, we talked about how sometimes migraine headache can increase in frequency during perimenopause and often decrease postmenopause. But again, this is not universal.

Yep. There's so many caveats on everything I'm saying. But it is something that sometimes people might experience because we know that migraines are sometimes strongly associated with things like estrogen. So if you're having these sometimes extra fluctuations in estrogen in that menopausal transition period and then a decline in estrogen thereafter, you might see a similar effect on your migraines with an increase in frequency and then a decline thereafter, maybe. A couple of things that we do know are associated with the estrogen withdrawal that happens

postmenopause. So now I'm not talking about menopausal transatlational. symptoms, but really post-menopause, where we have this shift from high estrogen to low estrogen, right? There are a few things that we see are strongly associated with this time period. One is an increase in risk of cardiovascular disease. This is something that we see, especially in the cases of like surgical menopause, when the ovaries are removed at a potentially young age, but they're also removed entirely where you have a very drastic decline now. in estrogen, cardiovascular disease risk increases significantly. And postmenopause, we see an increase in cardiovascular disease risk compared to age-matched male, so people with testes, controls of the

same age. Does that make sense? Yeah. Why? How does, what is estrogen doing or like what is its withdrawal doing? We don't fully know, classic, but estrogen is kind of protective in, a way where it reduces the low-density lipoprotein levels. That's our LDL cholesterol, which is the most strongly associated type of cholesterol with cardiovascular risk. And estrogen helps to increase our high-density lipoprotein or our good cholesterol levels. And it has benefits to our endothelial function in our vascular, especially in our coronary arteries. So estrogen itself is protective and we have higher levels of it during the reproductive years and then low levels of it post menopausal. So we see an increase in risk independent of age after someone has gone through

menopause. Okay. To where your risk looks more like someone with testicles than someone with ovaries that are still functioning. Is that? Yeah, yeah. Yeah. Right? Pretty similar. So that is like a known risk associated with lower estrogen levels. Another thing is eugenital symptoms. And this can really run the gamut and is definitely not universal. But the tissues of the vagina, the bladder, and like the whole vulvar area are very estrogen receptor heavy. So they are very dependent on estrogen. As estrogen declines, and over time, I'm talking many years postmenopause, not immediately postmenopause, usually. This lower level of estrogen causes changes to the tissues of the vagina and the vulva and like the urethral opening. So for some people, this can result in a wide variety of symptoms.

It could be things like recurrent UTIs or vaginal dryness or pain with vaginal intercourse. and this could then result in sexual dysfunction for people, especially if they're having a lot of pain with intercourse. So this is more directly related to that low levels of estrogen. But again, this is something that's happening usually a pretty long time post menopause once these tissues have significantly changed because of that low level of estrogen. And finally, though not the final symptom that people have associated with. Nope.

With menopause. But the other one that we see a really strong association with this decrease in estrogen is a decrease in bone density. So a significantly increased risk of osteopenia and osteoporosis and therefore fractures associated with that. Because estrogen has direct effects on our bone formation and remodeling. So the decline in estrogen causes a shift so that bone resorption is exceeding formation. And so overall, you're losing bone mass as a result of this loss of estrogen. That's not fair. I know, it really isn't, right?

Like, but why? But why? I mean, all of these things. Yeah, yeah. It's very interesting. It is, I know. And there's like so many moving parts to this, which I think is the thing that I struggle with. like how does it affect hearts and bones? And I don't know. I know. I know. It's really,

it's a lot. And so I think, again, it comes back to this idea that like these are changes that are happening as a result of the natural aging process of the ovaries. And at the same time, can potentially cause quite a lot of symptoms and result in morbidity, like, from that, right? Right. Okay. So I know we talked a little bit about hot flashes and how they are certainly not universally experienced. Is something like the cardiovascular disease risk? Is that more or less universal? Like everyone experiences an increase in risk and then the urogenital symptoms? Like, what is breakdown of the symptoms that we talked about after hot flashes? Yeah. The breakdown is, I don't have numbers for you on the breakdown. The increase in risk, like, yes, everyone's

cardiovascular disease risk is going to increase, but everyone's cardiovascular disease risk increases as we age, period. And everyone's baseline cardiovascular disease risk is different, period, because of genetics, because of environment, because of so many other factors. So I can't say that like everyone's risk postmenopause increases by blank percent. It's very individual. Okay. And similarly with the urogenital changes, those tissues are likely to undergo some degree of change in most everyone. Though I don't know that we have data to say like, yes, everyone experiences changes to the vaginal mucosa.

But because those are hormone-sensitive tissues, it is likely that all of those tissues are going to undergo some version of change. That doesn't mean everyone's going to notice that there's any changes, right? And that is definitely something that the data on people's reporting and experiences is all over the map, as you can imagine, especially because some of those symptoms that get associated with menopausal changes aren't actually menopausal related. Like there can be increases in urinary incontinence that happens post menopause, but some of that is not due to the estrogen changes, but is due to a whole bunch of other things that also change as we age, or is associated with how many children someone has had, or whether they've had a hysterectomy or like so many other things that also coincide with menopause. Like, it's just so complicated. And then when you get into like sexual function, depending on who you're talking to, people might have very different experience.

expectations, willingness to talk to researchers about their sexual function. So it's really all over the map. What are some of the factors, or do we know what factors contribute to or are associated with age at menopause and likelihood of experiencing these symptoms during menopause? Yeah, it's a really good question. There's a lot of things that can influence the age at menopause. and there's not at this point anything that we can do to predict at what age someone is going to go through menopause. But there are a lot of things that potentially influence it, some of which we don't understand like why or how.

But things like smoking status can influence the age at menopause. Parity. So how many children someone has had at what age they've had them and how long they breastfed for. There's some relation maybe between environmental factors, like how much. much things like soy and other things that have isoflavones in them that kind of act like estrogen in our bodies. Genetics plays a huge role. So like at what age your mom went through menopause can maybe help you predict at what age you might go through menopause, but it's not like a one to one at all. So there's a huge range of things that can affect. And we don't,

again, fully understand like what is it? Is it also like the number of fall? that you happen to be born with, or is it things that are altering how quickly your follicles are being depleted and why that is? So there's a whole range. I remember going down a rabbit hole trying to figure out, okay, well, if you're on combination contraceptives, right, like an estrogen progesterone contraceptive, then you are not ovulating. So then shouldn't you have a greater reserve of ovarian follicles? So then would you have a later age of menopause. And there's people who thought maybe that that's the case, but there's not really actually data to support that when we've looked at the literature, which is so interesting.

So it's very complicated, but there are definitely a lot of factors that can influence, especially whether you are at higher risk of having an early menopause. And then you also ask, like, what influences the risk of whether or not you have symptoms? And that is a can of worms that I don't feel qualified enough to dive into because there's a lot. Oh, because it's also like we think this is associated, like with some of the symptoms that have previously been associated, but yeah. And one thing that I think is important is so we can also talk about like how do you treat these symptoms?

Like what do you do if someone is having potentially really bad symptoms that might be associated with menopause? And very often the answer is hormone replacement therapy or HRT. And there's a lot of controversy. regarding, like a lot of controversy regarding hormone replacement therapy. And for some people, hormone replacement therapy completely resolves their symptoms. Whether or not we have data to say that this symptom is definitely associated with menopause, does it matter that much if hormone replacement therapy resolves the symptoms, right?

Or if any of the other therapies that we use to treat menopause specifically is helping, with those symptoms, then it's associated with menopause, even if it's not on a, like, a scientific level that we can have enough data to support it, right? It's, right. Like, if it's, if it's menopause or if it's aging, period, like, does it matter the I mean, I think it does matter to distinguish between the two just because it often seems like if you're a woman and you are aging and you experience something, there's a tendency to be like, oh, it's menopause.

Oh, we're attributing everything to menopause. Right. Right. Always. Always. And then we're not treating it because it's just menopause. Uh-huh. So that's an interesting, like, what?

Yeah. Yeah. That's all I got, Erin. I mean, I don't know if that was enough or too much. No, totally. And are you going to talk about HRT later on? Because I am very curious. Yeah.

I can talk about it later. I can talk about it now if you want. I mean, totally up to you. What do you want to know about HRT? I guess I want to know, okay, because when I did a little bit, and I'll talk more about this in the history section, but like coming across the HRT as the solution and then people finding out that like we actually don't know with some of the earlier HRTs, is this working in the way that we expect? Is it working at all? And is it actually associated with an increase in risk of things like cancer? Yeah. And so when are people advised to try HRT and when are they not?

Yeah. It's a great question. So there was a time period in which hormone replacement therapy was the holy grail and the answer for anyone with ovaries going through menopause or the menopausal transition or anything when they were in their 40s, 50s, 50s, 70s, and beyond. And there was a lot of thought for a time period that part of the reason to treat with hormone replacement therapy, even if someone had no symptoms whatsoever,

was to reduce the risk of osteoporosis and fractures and reduce the risk of cardiovascular disease. Because remember, we know that those are associated with declines in estrogen. So there was this huge study in the late 90s when it was all the rage where everyone was getting hormone replacement therapy if you were above a certain age and had ovaries. And this study was trying to look at the risks and benefits and like the protective benefit, if there was one, of hormone replacement therapy in post-menopausal women. And they found something unexpected. And that was an increase in breast cancer risk and either

no change or in some cases an increase in cardiovascular risk in their study of hormone replacement therapy versus placebo. So after that study came out in like the early 2000s, it was like, no one can have hormones, take them all the way, absolutely not. Hormone replacement therapy is the worst thing ever. And as pendulums often do in medicine, it swung from one extreme to another. and I think that we have landed in a place that's much more in the middle. Because as this same cohort of women that were in this study has been subsequently followed through, the last paper I read was through like 2016, the data that they collected has now been stratified and reanalyzed. And with this longer term follow-up, it turns out that the results of the study are actually a lot more nuanced than that and not nearly as scary as they seemed into that.

Right. So what it comes down to really is the timing of the initiation of hormone replacement therapy. And the data suggests that when people are prescribed hormone replacement therapy within that first 10 years postmenopause, which means the first 10 years after that final menstrual period, then it is actually protective against cardiovascular disease. We see small but significant decreases in the risk of coronary artery disease. We see decreases in the risk of hip fracture. We see decreases in all-cause mortality. And when it comes to breast cancer, there are some studies that actually suggest a protective effect of hormone replacement therapy and some that suggests perhaps a slight increase in risk. And so it's thought that it's more of like a net neutral overall. Okay. But this is in people who start

hormone replacement therapy early on. Gotcha. There's also nuance if you have a uterus or don't have a uterus, whether you need progesterone or not and what type of progesterone. So there's like definitely a lot of nuance there. But it's, it is not the horrible thing that it was thought to be like in the early 2000s. At the same time, there are some risks associated with it, especially if we're starting it after that 10-year time frame. And for some people, they might not be candidates for estrogen, especially oral estrogen at all, because there are reasons premenopause that we don't recommend estrogen for people if they have a history of migraines with aura or a history of blood clotting disorders,

because estrogen, though it decreases your cardiovascular disease risk, can't increase your risk for clotting and for strokes in certain people. So again, there's a lot of nuance, but it's often very effective for treating some of the vasomotor symptoms, and it can be protective in these cases. So where the medical literature has landed as of now, 2023, is like, we don't use hormone replacement therapy as a preventative, but it's perfectly reasonable to use it if you're experiencing symptoms. Okay. Does that kind of make sense? Yes. Another question. Uh-huh. What about manopause or are there substantial hormone changes in people with testes?

Oh, it's such a good question. I didn't do any digging. I didn't do any research on this, Erin. So I don't know, but I know it's a thing that people look at. The testes are a whole different organ than our ovaries. So we should just do an episode about aging testicles. Just old balls. Old balls.

Because I don't want to say things that I don't know. Okay. Fair enough. So, Aaron, with that, can you please tell me? I don't know what to ask, Erin. I have so many questions. Well, you know what? I'll just try to preempt them by getting started on my very long history section right after this break.

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It'll cause so much harm at every single level of the British establishment of this is wrong. Listen to Doubt, the case of Lucy Lettby on the Iheart Radio app, Apple Podcasts, or wherever you get your podcasts. After spending the past few weeks reading books and articles about menopause, watching videos about menopause, thinking about menopause, talking so much about menopause, and writing about menopause, I feel at the same time, like much more informed about menopause and also completely totally lost. You know the saying that's like the more you know, the more you know what you don't. don't know, something like that. That's exactly how I feel. The more that I learned about the possible

adaptive reasons for menopause, the more I learned about the cultural history of menopause and the variation in its perception across cultures about the huge diversity of symptoms and the gap in clear mechanistic research on menopause, the more I came to see menopause as not one thing, but so very many things. For some people, it's a relief. It's freedom from not having to worry about pregnancy or your menstrual blood ruining your clothes. For others, it's a nightmare with distressing symptoms

and a loss of feeling socially significant, maybe. Or maybe for someone else, it's the reason why humans have evolved big brains and live cooperatively, the key to what makes us human. Or perhaps it perfectly, encapsulates the pathologizing of women's bodies by Western medicine over the centuries. I love it. And some people might find it to be a combination of all of those things, while others may not even think about menopause or have a word for it. If I wanted to keep this history section short,

I'd be tempted to leave you with just one sentence. Menopause is whatever you want it to be. For me, someone who has not yet gone through menopause, I've been thinking so much about this over the past few weeks. Like, how do I feel about it? And, you know, hopefully someday I will go through menopause. Like, I'll be lucky enough to reach that age. Menopause is right now a thing on the horizon. Like, I feel curious about it. Not really apprehensive, but, like, what will it be like? Will I notice it at all? So I'm one of those ones that takes birth. control pills continuously, so I don't get periods. But how will I know when it's done? When is my last, like, did I already have my last period, technically? I'd be lying if I said I didn't struggle with getting older. You know, I blame our culture's obsession with youth for that one and my own vanity. Come on. But I also think I'll feel a sense of relief. I've never wanted to have kids. And so hopefully with menopause comes an end to the, when are you going to have kids? Why don't you have kids? Oh, you'll change your mind and want them someday. That I do get from time to time, though not

from my family, thankfully. Then again, while I know I'm not going to change my mind about having kids, maybe I will feel differently about menopause when I'm in it. But one thing is for certain. I know I'll feel grateful to be going through menopause in a time when there are so many amazing resources, books, articles, documentaries, podcasts about menopause, should I feel like I need them? When menopause has started to appear on TV as more than just a punchline on a sitcom, and when the silence surrounding menopause has slowly started to lift, are things perfect? Of course not. But they're a heck of a lot better than they used to be. And so speaking of which, maybe it's about time I actually got started with the history of menopause.

The word menopause was coined in 1821, but that was far from when menopause was first recognized. Ancient Greek and Chinese medical texts both describe menstruation and fertility ending around the 40th year, but it was mostly in the context of just, this is what happens in aging, rather than, and here's a list of miserable symptoms you're going to experience. There were lots of ancient remedies for menstruation, but not really for the cessation of menstruation. Interesting. Yeah. In ancient Greece, life was thought to take place in seven-year stages, with considerable change happening across each stage. The seventh stage of life happening in the 49th year was called the climactic, which eventually became synonymous with menopause.

Oh, my God. I saw that word written, and I was like, I don't understand what this word. Why are they calling it this? That is so interesting. Yeah, I think they used it occasionally to mark like periods of very substantial change or meaningful change. Yeah. Yeah. And this isn't to say that menopause was just casually described as a totally normal part of life and nothing to be feared. Women's bodies in general were pathologized in ancient Greece and Rome with women generally being seen. as inferior to men and defined by their differences to men. For example, under the humoral theory of disease, the balance of the humors in men's bodies made them warm and dry while women's bodies were considered cold and wet.

To maintain that balance, men sweated and women bled, which was used by ancient Greek physicians as a justification for menstruation as like a normal and necessary process. So it purged women's bodies of what they viewed as toxic and poisonous, aka menstrual blood. Oh, my God, I can't. Oh, buckle up, hon. Okay. Yeah.

But in this way, bloodletting, which was like such a popular thing to do, didn't need to be done as often for menstruating women. but as soon as menstruation ended, boom. You were told that you had lost that superpower. Okay. And so some ancient Greek physicians believed that as you got older, you got drier overall. And so women in menopause didn't need to bleed to balance their humors. Okay.

Yep. But others thought that bleeding continued for all of your life and that in menopause, it just stayed in your body. and that it would accumulate and accumulate, and eventually that toxic buildup would cause breast cancer, uterine cancer, epilepsy, consumption, dropsy, etc. Okay. Some physicians went even so far as to suggest that this fictional menstrual blood buildup made the woman herself toxic,

with one book claiming that if a woman who stopped menstruating looked at a baby in a cradle that baby's eyes would be damaged. I like, you can't even, oh my goodness. It's like bending over backwards to just make cruel things up. Yeah, for like what? For what? Dudes? Like, come on.

Medieval clout. I have no idea. And this taboo surrounding menstrual blood, it being deemed, as unclean, it's found in many cultures around the world, both historical and contemporary, and it's a theme that we've touched on before, at least in our endometriosis episode. But it's also very relevant to the history and meaning of menopause. So where this taboo is very strong, like in cultures where menstruating women are supposed to be kept separate or forbidden to prepare food, or who must undergo ritual cleansing after menstruating, menopause. Menopause,

is sometimes seen as like a positive thing, as freedom from these taboos. We don't know, of course, how women in the ancient world felt about menopause, since the texts that we do have are written almost entirely by men. But I don't think it's a stretch to imagine that there was relief from this taboo in places where it existed. But from these male perspectives in ancient Greece, menopause was not just an internal buildup or a drying out of menstrual blood. To some, it signified a return to the baseline ideal state. In other words, once a woman stopped bleeding, she became more like a man, quote unquote, manly-hearted, and less feminine in the words of Galen. Okay. And sometimes this was taken to mean

that a woman who couldn't produce children any longer was not worthy of keeping around. She held no more relevance. But on the other hand, some priestesshoods in ancient Greece were reserved for post-menopausal women, which I think is interesting. It's all so interesting, Erin. But overwhelmingly, menopause was described simply as a stage of life. And that continued to be the case really until the 18th century, which isn't to say that post-menopausal life wasn't written about as though it was like this most horrid condition. Many physicians, almost entirely men, advised that once you're past menopause, it's a quick march to decrepitude and death.

And of the few voices of women from this time, there isn't really much said about menopause. But I'm sure that there was knowledge shared, probably by midwives, but also by women of any occupation or status. A quote from an early gynecological handbook from the Middle Ages in England, written by a woman, says, quote, and so, to assist women, I intend to write of how to help their secret maladies so that one woman may aid another in her illness and not divulge her secrets to such discourteous men. End quote.

I love that. Yeah. This element of fear and shame is completely understandable when you have male physicians comparing postmenopausal women to trees that no longer bore fruit and should be cut. down and burned. Oh, okay. Yeah. Yeah. These attitudes about menopause that were perpetuated by the predominantly male medical writers, they persisted for like really hundreds of years. And they're still around today to one degree or another, like a lingering fart. And in the 18th century, like a lingering fart, Aaron. I know. It's really the first thing that came to mom.

I mean, it paints a picture. Thank you. And in the 18th century, they served as the backdrop to the reframing of menopause as a disease, as a diseased condition. A quote from a physician in 1739, quote, It will not be amiss to touch upon the disorders that most women labor under when being between 40 and 50 years of age, their courses begin first to dodge and at last to leave them, for then they are frequently troubled with a severe pain in the head and back and about the loins, off times also with colic pains,

gripes and looseness, at other times with vapors to a violent degree, likewise feverish heats, wandering rheumatic pains, and general uneasiness." Wow. Wow. So, yeah. General uneasiness. I'm feeling like, that right now. I mean, I feel that often. He then, of course, went on to prescribe bloodletting. And if that didn't work, his purging pills or his uterine drops, which, of course, he charged, you know, a pretty penny for. I don't want to know what's in a uterine drop. I don't just say that. I do. I absolutely do. I absolutely do. The reasons why menopause began to be labeled as a disease during this time are too many to count,

but one of them is certainly because it made physicians indispensable to those going through menopause. It was an opportunity to expand into a new market, if you will. And something that is still happening today, like I came across a New York Times article from December 2020. titled Welcome to the Menopause Gold Rush. And in, yep, and in the article, it mentioned how a lot of well-known, quote-unquote, wellness companies and other startups are beginning to get into the menopause biz. Like selling products, I don't know. I feel, anyway, I'll just keep going.

Because, I mean, it's really just reiterating what you already said, which is that Some people do experience things, the symptoms that can absolutely use management, and those are completely valid. Right. But at the same time, I really don't like the predatory nature of some of these things that can reinforce or act as like self-fulfilling prophecy through corporation and marketing, I guess. I don't know. It is a really, really interesting interplay and balance, I think, when it comes to menopause.

specifically. Mm-hmm. Mm-hmm. Yeah. Also, I don't know if I've said this yet, but if I have, it bears repeating anyway, that the vast majority of the cultural and social history of menopause that I'm covering is from the quote-unquote Western world, aka mostly like Europe and North America. And part of that is because the focus of most sources is the history of menopause in the

Western world. But part of it is also that menopause in many other places wasn't really consistent. a major change warranting medical attention. And there's at least one culture I read about that didn't have a word for it or it was not really recognized as a constellation of symptoms. But what's really interesting too, and I don't really talk about this, but in the mid-20th century with sort of the spread of Western medicine, places that previously had never treated for symptoms associated with menopause began to do that. that or begin to include it in textbooks.

Anyway, interesting. Oh, it's so interesting, Erin, because then it is it like that people were actually suffering with symptoms but just didn't have words for it? Right? Because that's a thing, too, of just like not, you know, ignoring things and then just not having any kind of access to treatment for it because it's just like, oh, well, this is just life, but I am actually miserable, but I just didn't, like, it is just life. So it's so much. It's so much. And so I know that there has been some work done on this about

people who have done work on like contemporary foraging societies or contemporary societies who don't have a lot of exposure to like Western medicine. And it does seem to be kind of a mixed bag where some of those people do experience symptoms of menopause that or symptoms that we traditionally associate with menopause and others don't seem to. And so how much. of it too is like the biases of the researchers themselves asking these questions expecting that like oh you seem to be around this age do you experience these things instead of what changes have you experienced if any yeah well and i read it i read a paper those oh my word i know i'm interrupting you so much but i read a paper that was looking at like the the biological and cultural differences

that was also like, that's also really difficult to disentangle because then if you have differences in environmental exposure and in diet, then do you have differences in what your symptoms may or may not be because of differences like that are now biological, like, right? Like how much is it biological differences versus perception differences versus culture differences? What is culture? And then throwing aging into the mix. Like how many of those things can you? can you attribute to aging versus menopause versus diet culture, like all of these things, yeah.

Why are we doing this? It's too much. I love it. Please keep going. I know, I know. I know. But yeah. So anyway, the inclusion of menopause as an official medical entry in the 18th century marked a new era. One where medical intervention was seen as necessary to help women survive, what had previously mostly mostly been considered just a natural progression of life. It also provided ample opportunities for physicians to express their hateful contempt of women, which was thinly veiled as medical observation. Okay. I know. Just brace yourself. From the 18th century, quote, with the shrinking of the ovaria, there is a corresponding change in the outer form. The form becomes angular, the body lean, the skin wrinkled. The hair changes in color and loses its luxuriency. The skin is less transparent

and soft, and the chin and upper lip become downy. With this change in the person, there is an analogous change in the mind, temper, and feelings. The woman approximates, in fact, to a man. This unwomanly condition undoubtedly renders her repulsive to man, while her envious overbearing temper renders her offensive to her own sex, and quote. Like, medical description. I should not be as shocked as I am. I know. It just, wow. I know.

Well, things didn't get much better in the 19th century. Okay. In 1870, Augustus Gardner wrote, quote, The body itself does not long delay entering into decrepitude. And soon we see the woman, once so favored by nature, when she was charged with the duty of reproducing the species, degraded to the level of a being who has no further duty to perform in the world. End quote.

Just like, tell us what you really think. I feel like that's also something we, like, didn't even get into yet of just, like, if your role is only reproduction, now you. you are useless. Uh-huh. Oh, ooh, feelings.

Yeah. Feelings. Feelings. We can talk about it. Yeah. Oh, my God. But symptoms first. So menopause has been blamed for a long, long list of symptoms.

I found this list. Quote, hot flushes, cold sweats, night sweats, weight gain, backache, tingling, fatigue, headaches, palpitations, arthralgia, dizzy spells, irritability, nervousness, anxiety, apathy, depression, early awakening, emotional instability, fears, feelings of suffocation, forgetfulness, insomnia, lack of concentration, lightheadedness, loss of interest, loss of self-worth, feelings of panic, sadness, tenseness, osteoporosis, depression, dyserania, paristhesia, chest pains, breast pains, constipation, diarrhea, facial hair, vaginal dryness, changes in libido in skin and hair and worry about the body, end quote.

Sounds about right. also saw rabies mentioned once. I'm sorry. I'm going to veto that one and just say no. That's, you get one veto. You veto the rabies. Got it. That's my veto. And Edward Tiltz in the 19th century considered, quote, melancholia, mania, alcoholism, uncontrollable murderous instincts, and other types of mental derangement typical of menopause. I quote. Like you could use menopause as a defense against murder. A legal defense based on Edward Tilt. Have him on the witness stand.

I also came across an example. I'm just going to keep going from the 1920s where a physician met with a woman who was coughing up blood and told him, I think I have tuberculosis. And he was like, no, hon, you're just metapausal. This is your body's way of getting rid of the extra blood. You just in the 1920s? 1920s, yeah. 1920s, like when my grandparents were born. Yeah. Okay, cool, yeah, great.

Uh-huh. Uh-huh. You're just coughing up your menstrual blood. Yep. Okay, like we know from our endometriosis episode that technically in theory, you could have endometrial implants in your lungs, but that's not what's happening. No.

Yeah. Wow. Okay. Great. And if it wasn't enough that menopause was responsible for all kinds of horrible things, women were also told that they were responsible, their diet, their temperament, whatever, for when menopause happened and how bad it was. To be clear, the 18th and 19th centuries were a time of enormous growth in the medical and surgical

fields in the rise of patent medicines and in the pathologization of bodies overall. Menopause was not the only thing targeted or impacted. See our tonsils episode. Exactly. But this new framing of menopause as a disease cemented it for centuries up through today as something to be feared, survived, battled against. And my intention is absolutely not to dismiss anyone's experiences or feelings about menopause, or say that menopausal symptoms are made up or no big deal,

especially as someone who hasn't had menopause. My intention is simply to try to understand how the male-dominated medical community in the Western world has over the centuries constructed and pushed a concept of menopause that may not be representative of the huge variety of experiences that people may actually have. Yes. And while some physicians, like John Fothergill in the late 1700s, maintained that menopause was not dangerous or not associated with any change in health, but just in case he sold Father Gil's pill to help, other physicians sought as a drastic transformation, regardless of whether it was quote unquote, like natural menopause or if it was menopause after. after surgical removal of ovaries. So Virchow, who's the famous surgeon,

was referring to the surgical removal of ovaries and wrote this in the 19th century. Quote, To remove the ovary means we shall have before us a masculine woman, ugly half form with the coarse and harsh features, the heavy bone formation, the mustache, the rough voice, the flat chest,

the sour and egotistic mentality, and the distorted outlook. All that we admire and respect in woman as womanly is merely dependent on her ovaries, end quote. Oh, wow, Aaron. Yeah. That is a quote. Isn't that a quote?

All that we admire and respect that is womanly can be a true. we did it to the ovaries. Also, who are you admiring and respecting? Because like, I, like, I wish that I could better articulate the way that I feel about all of this. Same, same, same, same. Um, because I, it's just there's so much feeling of like, what? Yeah. I don't know. Okay. I'll keep, I feel like we're just going to rage the whole time. I should keep going. Let's keep going. I love it. Because then we have the expectations around how a postmenopausal woman should act, which are utterly ridiculous. Essentially, the expectation was for you to fade into the background, to no longer feel desire or feel capable of having a sex life, to act sweet and polite, and just wait peacefully until death takes you.

I'm sorry. Oh, gosh. If a post-mental palsal person expressed sexual desire or wore form-fitting clothes, if they flirted, drank alcohol, spoke their mind, or just acted like a human being, that could be grounds for a diagnosis of hysteria at a minimum, or just grounds to have you locked up in an asylum, which did happen. Okay. Cool, cool, cool. I mean, not that different is premenopause, honestly. Yeah, I mean, that's the thing. It's that it was like hysteria. People were just, like, handing out hysteria diagnosis all over the place. And menopause was sometimes thought to trigger hysteria, which we all know is like a fake diagnosis. Check out our endometriosis episode.

It's a good one. And so some of this extreme blaming of menopause for everything began to be reigned in as the 20th. century began. But around that same time, menopause was about to undergo another major transformation. And this transformation would simultaneously shed much more light on the mechanisms of menopause and in understanding what's actually happening to our bodies. But it would also solidify its status in some ways as a disease. So one of the areas that was very much booming, in research developments in the early 1900s was the field of endocrinology hormones. And so maybe someday I'll tell this part of the story in more detail.

But long story short, the discovery of estrogen redefined menopause as a problem of hormones, as a disease of deficiency. This meant that all of the things people might experience during menopause were sometimes reduced to just a lack of estrogen. It became about biology, not about the individual and their experiences. So even if physicians couldn't make a mechanistic link between, say, like, estrogen and depression or weren't able to immediately, they would just point towards estrogen levels and go, yep, there's your problem right there.

Couldn't possibly be our society's dismissal of women over the age of 50, you know, and maybe it's not that. maybe it is estrogen, but like there wasn't sufficient research then or now to make those distinctions and also acknowledging individual differences. For one person, it could be biology. For somebody else, it could be what their life is at that moment or a combination of both. Like menopause is whatever you want it to be. And this also especially played into this idea of mood swings and menopause. If you're experiencing mood swings, she's just hormonal.

Couldn't possibly be the microaggressions and condescension that you're faced with, like every day at work or even at home, right? And while it was great that the discovery of estrogen promised potential symptom relief to those who wanted to explore that, it also told women to feel inferior in some ways, to view menopause as a time of loss. Early hormone replacement therapies were advertised as quote unquote restoring femininity as essential if you didn't want to drive your husband away with your erratic mood swings and changing libido, which by the way, as we talked about, there has not been shown any universal effect of menopause on libido. And I also think it's fascinating that as the author of one of the books I read pointed out, the focus shifted to be on sexual sexual. symptoms of menopause in the mid-20th century as marriage became more an institution based on love

and sex. I don't know. That's just something, I don't know the research in that, but I thought, that's interesting. But overall, physicians in the 20th century seemed dead set on establishing menopause as a major shift in health and identity. In the 1966 book Feminine Forever, author Robert Wilson wrote, quote, No woman can be sure of escaping the horror of this living decay. Every woman faces the threat of extreme suffering and incapacity. Holy, guacamole. I know.

A few years later, in the 1969 book, Everything You Always Wanted to Know About Sex, author David Rubin writes, quote, As estrogen is shut off, a woman becomes as close. as she can to being a man. Having outlived their ovaries,

they have outlived their usefulness as human beings, end quote. Whoa, whoa, whoa, whoa, whoa. Whoa, whoa, whoa, whoa, whoa. 1962, we have outlived our usefulness as human beings. I mean, I feel like I've heard certain people on the internet say that today. Oh, whoa, whoa, whoa, whoa, whoa.

And it wasn't only men doing the fear-mongering and perpetuating these stereotypes, this concept of menopause. Some women were also guilty, like Helene Deutsch, colleague of Freud, who wrote in the 1940s that, quote, The changes that take place in the body of a menopausal woman have the character not only of the cessation of physiologic production, but of general dissolution. women's biological fate manifests itself in the disappearance of her individual feminine qualities at the same time that her service to the species ceases. With the lapse of her reproductive service, her beauty vanishes, and usually the warm, vital flow of feminine emotional life as well, end quote. This is so much more than I even, like, I knew that this was going to be a lot, Erin, but I...

Wow. Wow. I, yep, yeah, wow indeed. I mean, with all of this, is it any wonder that hormone replacement therapy became so hugely popular and widespread throughout the early 20th century, even before proper testing. That's not surprising at all. You must remain vital to your species. Yeah, right? And I know that, you know, we talked a bit about how. how the hormone replacement therapy used today has gone through a lot of changes and there's been a lot more better research or more like thorough research on them. But my point is that the construct of menopause as a disease was so strong that medical intervention was seen as necessary, even if

physicians weren't sure whether the cure, aka these early before being well tested hormone replacement therapies would be worse than the quote-unquote disease. Wow. Yeah. There was a 1975 ad in JAMA. Okay. From a pharmaceutical company. In JAMA.

In JAMA. And this company made HRT. And the ad stated, quote, I can't. Okay. Almost any tranquilizer might calm her down. But at her. age, estrogen might be what she really needs." End quote.

So this is advertising to medical professionals, right? Like, oh my God, Erin. I can't. I'm sweating so much right now, like, with anger. And just like, I laugh because otherwise I'd cry, right? Okay, there's more. Because another company advertised its estrogen pills. And I think this advertisement was more widely, not just in JAMA, but it advertised its estrogen pills, quote, for the menopausal symptoms that bother him most.

And quote. Okay. Please keep going. Uh-huh. Uh-huh. But HRT was not without controversy, is not without controversy. and many researchers over the decades advocated for a closer examination of what HRT actually did, what side effects were associated with long-term use, whether there was any clear benefit and how to use it safely.

And so we're in a much better place than we used to be. And starting in the 20th century also, women began to share their experiences of menopause more openly in books, on radio programs. And one of the themes that began to emerge was that women who had not yet gone through, menopause tended to have a much more negative perception of it than those who had. The fear of menopause was worse than menopause itself. And granted, this increased attention on menopause didn't always lessen the stigma or shame surrounding it. Books intending to be guides for quote unquote surviving or dealing with menopause, in some ways continued to perpetuate the idea that menopause was inherently a struggle for everyone who experienced it, something to be

dreaded. And that was something that more research was finding to not necessarily be the case. In fact, researchers were finding that in some cultures there appeared to be no word for hot flushes. And I think I mentioned earlier, but I read about at least one traditional foraging society that does not appear to have a word for menopause, as in the menopause that we think of with its collection of signs and symptoms. People, of course, did recognize that their period stopped, but there didn't seem to be this concept of the period during which that happened

and an increase in certain symptoms. And this research on menopause across cultures revealed that there is no standard definition of menopause as a, quote, unquote syndrome or collection of syndromes, nor is there one universal attitude towards menopause, dread, shame, anticipation, relief, feeling more respected, not feeling any particular way at all. These and so many other attitudes or feelings are real and valid. And as researchers began to ask these questions about how people feel about menopause, when menopause happens, what symptoms can be tied directly to the hormonal changes.

experienced during menopause, they also began to set their sights on another big, unanswered question. Why? Yes. Oh. Why does menopause exist? We don't know. Erin, I can't tell you how excited I am for this question because it's so, this is the part where I'm like, it is so cool that humans menopause. I know. Okay. So there is so much literature on this subject more than I could ever hope to cover it. Like I would have to go back into a PhD and then another one. And then by the time I finish that PhD, all the literature would have been updated, all of that. And then if I came back here and we did an episode, it would be like a 15 hour episode minimum. Yeah.

So what I'm going to do here is just give a short overview of some of the ideas that are out there, just enough of a taste so that you end up really curious and excited and brimming with questions. And then I can be like, go to our website. You can read more in our sources. But before we get into these various hypotheses, let's first consider why someone would ask this question of why menopause exists. Yeah, yeah. Metapause is actually very rare in the animal kingdom. Yeah.

More precisely, humans are one of a handful of species where females experience a significant part of their life after the reproductive lifespan ends. Not just a decline in fertility, but sterility. Right. And not just a few years, but often in the case of humans, decades. Right. Like more than half our life potentially. Mm-hmm. Mm-hmm. Yeah.

Studying whether menopause exists in wild animals is really challenging because you need to collect accurate data on lifespan, fertility over lifespan, and then determine whether it's a decline in fertility that you're observing or true sterility. For long-lived animals, that's incredibly difficult to do, both logistically and then like, where are you going to get the funding for that? And so while several animal species have been proposed to live a significant portion of their lives after their reproductive lives. lifespan ends. And so to make things easier, I'm just going to call that menopause for the rest of this section. Only a few species are widely considered to have or experience menopause. Humans, of course, orca whales and short-finned pilot whales. There are a few more out there that sometimes get mentioned. And there's a recent science paper about menopause in a chimpanzee population that we could probably spend an entire episode talking about, but I'll link to it on our site.

interesting, hard to say what's going on there. There's no grandmothering in this population in chimpanzees, I should say. So like, anyway. So that rarity of menopause is in itself interesting and invites the questions why so few species and why these species. Yeah. Yeah. Oh, Erin, it's also so interesting, and this is something we will have to talk about more in our menstruation episode, but like, because humans are also one of only a few species who menstruate. Uh-huh. But the group of species who menstruate is not the same as the group of species who undergo menopause with the exception of humans.

So it's like, what? Why do we do these two things that are kind of weird in the whole animal kingdom? Like, what? It's fascinating. It is so interesting. There is so much here. Like, honestly, I, it is, it's overwhelmingly cool. Yeah, it really is.

Yeah. And so the possible answers to the questions of why so few species and why these species, it depends on whether or not menopause was selected for, as in whether menopause provides an evolutionary advantage to those species, or whether it is just like a byproduct of something like the evolution of longevity and a natural expiration date to eggs. Because as you mentioned, we are born with all of the eggs that we will ever produce. So we can't make more. Is there just like, oh, those expire 50 years from now? Yeah. Is menopause an accident or is it intentional, essentially? Menopause must come with some cost because it limits the total reproductive output. But is that cost outweighed by the benefits of menopause? And if so, what could those

benefits be? Or is the cost of menopause not very big? Yeah. Or is it just really difficult to, for evolution, to act on increasing reproductive lifespan? I don't know. So the hypotheses of why menopause exists fall into two general groups, adaptive hypotheses where menopause provides a benefit and non-adaptive hypotheses where menopause is more like an artifact of aging. So, So let's get into a few of the adaptive hypotheses first, starting with the mother effect. So this is this idea that in species where offspring are dependent on parents for longer than a typical time between births, so you can have a child and then become pregnant again and have that child and your first child is still dependent on you for like survival and everything. Like you could have another baby in nine months, but your nine-month-old is still breastfeeding and etc.

And yeah. Yeah. So in those species, at a certain point, it's beneficial for the mother to stop reproducing because otherwise she'll have more offspring than she can care for, and they will all struggle as a result. Okay. On top of that, this is still within the mother effect, pregnancy becomes riskier with age, both for the pregnant person and the fetus. And so not being able to get pregnant after a certain age could be protective to the existing

offspring because if the mom dies, that could hurt the chances of survival for her existing offspring. Cool. There's not much evidence in support of this. Also, if the species is social and works in a cooperative group like humans, the death of a mother may be offset by care from the rest of the community. Okay. So then there's the grandmother effect. Under this hypothesis, longer lifespans and women were selected for because I'm just going

found a great quote in this book called The Slow Moon Climes by Susan Maddern. Quote, post-reproductive women helped their daughters, daughters-in-law, younger sisters, nieces, and granddaughters to feed and care for their infants and young children. This allowed the younger women to have more babies closer together, which in turn increased the inclusive fitness of the older women, end quote. So essentially, grandchildren who had grandmothers providing care were more likely to survive to reproduce. And so then they would tend to have, yeah, that's how sort of, it's like this indirect evolution of grandmothering. I don't know. Because you're still passing,

those are still your genes and so that that longevity is then being selected for in those genes that are surviving. Yeah. And there is, there's mixed evidence for this. And by mixed, I mean, like, not very strong and sometimes opposite. But it also varies, too, based on, like, paternal and maternal grandmother and social structure. So, like, do daughters stay with the mothers or do they go with their mates family and stuff like that? Like, there's a lot here. And why would it just be post-reproductive longevity that evolved because of grandmothering, not reproductive longevity as well? So a third adaptive hypothesis actually tries to answer that in a way.

So this is the reproductive conflict hypothesis. Yeah, it's a killer whale one. The killer whale one, yeah. So basically, by stopping reproduction, there's less competition between mothers and their offspring over resources. So if you and your daughter are both able to reproduce at the same time, there has been some work done on orcas that seems to suggest that the, the, offspring from the grandmother is less likely to survive than the offspring from the daughter than like the grandchild. I said that very confusingly. And I think I got that right. Yeah. No, that makes sense, though. And then what they're saying is that like then that's why it would be selected for that you at

some point would stop reproducing so then your grandchildren can survive even though it means that you have less children, but your children wouldn't have survived because they'd be competing with your other children, et cetera. Yeah, exactly. And your other children's, your grandchildren. Yeah. Yeah. But yeah, there are also many other adaptive hypotheses of menopause, like one that where it evolved to protect against certain cancers. But those seem to be the big three that I kept encountering. The mother effect, grandmother effect, and reproductive conflict hypothesis. And then there are the non-adaptive hypotheses where menopause is kind of like a byproduct. So one idea is called the patriarch hypothesis, where longer lifespans in males were selected for.

And then that led to like an overall increase in lifespan for both males and females, because like the longevity genes would be on autosomal chromosomes. I don't know. But extending reproduction in women wouldn't have led to much benefit. And so instead, women who lived past reproductive age would have helped by sharing knowledge and helping with foraging. I don't, like, I'm not super, I don't feel super familiar with this hypothesis. And so maybe that's like my poor presentation of it, but I'm like, I don't quite get how menopause fits into that. Yeah. But then there's this idea that eggs, that mammalian eggs have a shelf life and that we are just living beyond the shelf life. And it's true that a drop in fertility is observed in many

captive populations of animals where their lifespans tend to be much longer compared to in the wild, where in the wild they have to worry about like resource availability and predators. And so you can see sort of that decline in fertility that may normally be experienced if they didn't have to worry about predators and so long. Right. If they didn't just die in the wild. Yeah. But humans have, at least as far as we can tell,

lived beyond their reproductive lifespan, as in lived beyond the last egg, for a very long time. This notion that life expectancy was 40 in the middle ages is totally wrong, right? That life expectancy number is so low because of high childhood and infant mortality.

In foraging societies that today, that don't have access to modern health care, public sanitation, vaccinations, or reliable food supply, about a quarter is expected to live as grandparents for 15 to 20 years. And longevity, this longevity, is estimated to have evolved at least 130,000 years ago. Yeah. While most mammals do seem to have an average upper limit on fertility at around like 40 to 50 years,

there are a few species like the fin whale, which reaches sexual maturity around six or seven, and continues to reproduce until beyond 70, with maximum lifespans over 100. So maybe there's a shelf life, or maybe there isn't. And maybe part of the reason why we have no single leading hypothesis or no single convincing or satisfying hypothesis for why menopause exists is that we don't really know when it evolved or the context in which it evolved. it's also possible that menopause evolved for different reasons in those species that experience it.

Maybe not, you know, like orcas are social, they live in social groups. I actually don't know anything about the short fin pilot whale. So I think it's really challenging to try to disentangle this, particularly when you're talking about something that happened on the order potentially of millions or hundreds of thousands of years ago. Yeah. How do we understand what social groups were like then? I don't know. And also how variable they were. It's so, yeah, we don't know why menopause exists and we may never know. Yeah. And while I don't necessarily agree with the grandmother hypothesis or think it's the answer, this the sole answer, I do appreciate the sentiment that it inspires, particularly in our society today. And so I'll leave you with this quote from the slow moon climbs by Susan Madden. Quote, midlife is, and always has been, about relationships, about the roles we play in the community and in the family, the sacrifices we make, the experience we bring to bear.

We become non-reproductive so that we can do other things. The transition is important, but not because of the symptoms it may or may not cause us to suffer. It is important on a much larger scale, and to reduce it to a medical condition is to trivialize it. The apprehension about menopause, the embarrassment, the tiresome jokes, the judgment and hostility aimed at older women in Western culture and in other cultures, today and in the past, are all unnecessary. But menopause is necessary. Humans have menopause because we need it. The contributions of post-reproductive women have brought us this far, and will lead us into whatever future we have, end quote.

I like that. I do too. And with that, over to you, Erin. Okay, no presh. No presh. We will talk about where we stand with menopause today right after this break. The epidemiology of, quote, menopause at this point. Yeah, like everyone with functional over.

ovaries will go through menopause. So I don't have numbers. Yeah, I mean, like, the end. I don't even know what to ask. Right. There's nothing. There's not. Thousands of people will reach the point of their ovaries

ceasing to function on any giving day. And in an aging population, of course, more and more people are living well and well and well past the age of menopause. And like you beautifully talked about, Aaron, there have been so many differences historically, even just in like Europe and North America and the quote unquote Western world, in the reporting and the perception of menopause and menopausal symptoms. And the literature is really difficult to try and understand beyond the perception of menopause. in the Western world.

There are some studies that report that there's like geographic variation in the reporting of symptoms. And I mentioned that one paper, which I'll mention again at the end, that really tried to dive into the like cultural and biological and cultural and biocultural differences in menopause, both the perception and the symptoms and everything. And it's just really difficult to try and assess. So I don't have for you today, like numbers, like 80% of people will experience vasomotor symptoms. Like, that's true in some studies.

And it's not true in other studies. Right. There is a study that looked in the United States called the Swan Study that really did try and specifically recruit across a wide range of racial and ethnic groups to see if there are differences in the experience. of menopause across these groups in the United States. And in the papers from the Swan Study, there are differences that they reported in symptoms across different racial and ethnic groups. But even that is still very limited because this is still people living in America. And as one example that this other paper that I mentioned will give, living in the United States as, for example, a Japanese American is not the same as a Japanese person who has lived their entire life in Japan, both in

terms of cultural as well as environmental exposures. And so, again, I don't have numbers for like the symptoms of menopause, even the age of menopause, which does vary a little bit geographically. And in some areas, seems to be declining. But I don't know that, again, we have enough data to say for sure that that's happening globally. Some papers will report that on an international level, whatever that means, 20% of women perceive menopause as a disease. So that's like a number that's cited. I don't know exactly how that number came about

and how many papers really gathered what kind of data to answer that question. So it's complicated. And all of the papers that I read that talk about menopause and look at menopause are focused entirely on cisgender women undergoing menopause. Some of them might distinguish between surgical menopause and quote, natural menopause. And some papers don't even do that. So when it comes to the experience of menopause for people that are not cisgender women, I really have no data on that whatsoever.

Yeah. So that's what I have for epidemiology. Not a lot. So let's talk about where we're going in terms of menopause. Yeah. I don't know where we're going either. Because again, for this, I feel like there's a lot that you could focus on. We could talk about like where are we going culturally in terms of our perceptions.

in the United States, in Europe, in places that I have data for on what our perceptions of menopause are. From all of the papers that I read, it really seems like menopause is very much still a disease for a lot of people. Yeah. A lot of the papers, even in really well-respected journals that I read, really focused on menopause as this time of great transition for women underwomen. going such times of stress. And like that is really the tenor of all of these papers. Yeah. Which I find really interesting, especially now knowing so much more about the cultural history and medical history of how we have defined this time period. Right. I mean, I think like the biggest thing is that yes, the leading attitudes and perceptions of menopause have changed

throughout history, but they all treat people who are going to go through menopause or who are going through menopause as one unit. Right. They're all the same. And that is definitely not the case. So what I really wonder, and this is me, Aaron, Amman Updike, wondering, and this is not based on things that I read and data. But I really wonder if as we.

explore more of the deep, nitty-gritty biology of like what is happening in our brains as these hormones shifts happen? And can we predict? Because this is a big area of research. It's like, can we predict and diagnose menopause earlier? Can we know when someone is going to have their last menstrual period and how long things might be on the beforehand and the after in terms of when these hormones shift? Like, we don't, we can't do that yet. Can we in the future? Are we going to see something like a splitting of various menopause-related syndromes that might be more specific, where if X, Y, and Z is true in terms of the effects on all of these other various hormones that estrogen is affecting along your hypothalamic pituitary axis, you know, you're affecting your serotonin levels, your noropenephrine levels. Like, if we can better identify those effects, can we then split things out in a way that doesn't lump every symptom that has ever been associated with menopause as menopause? But really call it what it is once we know what that is.

Yeah. I mean, just, I think teasing apart those hormonal pathways is something that like menopause could teach us a lot about that. Definitely. Especially when it comes to like, here's what you should expect and here's what you shouldn't expect and here's what is highly variable and why it's highly variable versus like, yeah, this is pretty much like more or less there's a trend. Right, right. And I couldn't help thinking while I was researching for this about our endometriosis episode. And the thought of how menstruation itself, we know is not a disease. but there are disorders of menstruation, endometriosis being one of them.

So might it be someday that menopause is not a disease, but there are perhaps disorders associated with menopause? And might we have better identifications of those for people who experience them someday? I think that's really, really interesting. Yeah. Yeah, that's kind of a way that I've been conceptualizing it. And for that, I will say that there is also a lot of hope on the horizon for people who are experiencing, especially vasomotor symptoms, which again are some of the most common associated with menopause, the hot flashes, which maybe I didn't emphasize this enough in the biology section,

but they can be very debilitating for some people. Yeah. How long can hot flashes be? Or like, what's the time range? I know you said like how long people can experience them. It's like seven years, but... That's the average. But what's an individual hot flash?

Oh, great question. A matter of minutes, two hours, perhaps? Okay. Yeah, they're short in time frame, but people can experience anywhere from like one every couple of weeks to like multiple an hour. I mean, hours sounds like a very long time. I don't know that they're generally hours, but I think that you can like, especially with the night sweats,

you can wake up and it can disturb things for... a longer time. But there's hope on the horizon. There's a new class of medicines, one of which was just approved in May of 20203 that are entirely different than hormone replacement therapy, which is one of the main things

that's often used to treat hot flashes. Sometimes things like SSRIs or selective serotonin reuptake inhibitors that we use for depression anxiety can also be used, and things like gabapentin, which is an epilepsy drug that we use for a lot of non-epilepsy things can be used for treatment of these, but I don't know how effective they actually tend to be. But here's a brand new one. It's a neurokinen antagonist. So this is targeting a whole different receptor in our brain

that is involved in specifically regulating our internal thermostat, which we think gets disrupted in an indirect way as a result of all these hormonal shifts during and after menopause. And so neurokinin is one of the many hormones that can get disrupted and is directly related to our internal thermostat, as it were. And so this is a neurokinin antagonist that's basically blocking that and saying,

just put your temperature set back to a nice 98 degrees and let's leave it there. So one of these was just approved in May of 2020 by the FDA in the United States. So that's pretty major. And it's especially helpful for people who can't take estrogen for one reason or another, right? There are reasons why someone might not be a candidate for hormone replacement therapy. And so now we have more medication options, which is awesome. That's great.

There's probably a lot more that I could say about where we could go with menopause. but I feel like I've talked enough. This is our longest episode in a while, I think. It's a really, but I think it's worth it. And I feel like we could have said so much more. Totally. If you would like to read more, we have a lot of sources for you. But also, listeners, since this is our last episode of the season and we're preparing for next season,

we would really love to know not only if you enjoyed this episode, but also what other questions do you have about menopause, about menstruation, about, I don't know, like anything related to this realm. I feel like we've had a lot of fun doing episodes similar to this, and I want to do more of them. Absolutely. I still think we should do a pregnancy series. Yes, there's a lot. There's so much there. There's so much there. The sources for this. First? Yeah. I want to shout out two in particular. I do have some papers. but there were two books that I took most of this from. One is the one that I've already mentioned,

the Slow Moon Climes by Susan Madden. And the other one is called Hot Flesh's Cold Science, a history of the modern menopause by Louise Foxcraft. I had a lot of sources for this episode and probably not even enough. A few that were really good on just the overall, like overview of symptoms and things like that, One was by Montalione in Nature Review's endocrinology from 2018, symptoms of menopause, global prevalence, physiology, and implications. Another by Davis at all in 2015 in Nature Review's disease primers.

Menopause as a disease. It was just called menopause primer. And then that paper that I referenced a few times was by Melby at all from Human Reproduction Update. It was published in 2005 called Culture and Symptom Reporting at Menopause. a pause. I thought that was a really interesting read. But we'll post the list of all of our sources from this episode and every one of our how many hundreds episodes at this point on our website, this podcast will kill you.com. We certainly will. Thank you again so much, Marika, for sharing your

story with us. We just, just thank you. Thank you. Yeah. We appreciate it. Thank you also to Bloodmobile for providing the music for this episode and all of our episodes. Thank you to tell you. Brian Fogle for the audio mixing. Thank you exactly right. And thank you, as always, to our amazing, wonderful listeners. You make this possible, truly. We really like getting to make this podcast. We're really excited for next season. Thank you for listening for six whole seasons. Yeah. We can't wait to bring you more. Tell us what you want to hear. Yeah. Tell us. And a special thank you as always to our patrons. Thank you so much for your support.

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