The Myths of Meno pause

THE MENOPAUSE MANIFESTO

THE DIGITALLY SAVVY BAY AREA DOCTOR WHO

has been called “the world’s most famous gynecologist” returns to take on myths and misunderstandings about menopause in her usual fashion: facts, science, historical perspective, expert advice and humor. From the June 2, 2021, online program “Dr. Jen Gunter with Samantha Bee: The Menopause Manifesto” held on June 2, 2021. An Inforum and Marin Conversations program, presented with support from Relevant Wealth Advisors. Dr. JEN GUNTER, M.D., OB/GYN and Pain Medicine Specialist; Author, The Menopause Manifesto SAMANTHA BEE, Comedian; Host, “Full Frontal with Samantha Bee,” TBS SAMANTHA BEE: I am so excited to speak with Dr. Jen Gunter, an obstetriciangynecologist, friend to all the women, a fearless advocate for women’s health. Her new book, which is right here on my child’s book case, The Menopause Manifesto, it’s so informative and it’s a deeply humorous work to counter the stubborn myths, attitudes and misunderstandings that society has about menopause.

Dr. Jen Gunter, welcome. I’m so excited to talk to you.

JEN GUNTER: I’m so excited to talk to you, too. And thank you so much for hosting. BEE: It is my deep pleasure. So let’s talk about your good news. Your book is already [a success]. GUNTER: It hit The New York Times bestseller list, first week out. And it was the number one book for all of Canada. BEE: I was telling you before we began that I am so not surprised, because people really want to read this book. I wanted to read this book. I’m 51 years old, so from the moment I heard that this book was coming, boy, I was ready.

Okay. Let’s get right into it. Do you recall the first time that you began to conceptualize menopause? When was that real for you? Even a little bit. GUNTER: Well, the first time I actually just heard of any concept about it, I think was when I got my own period. A few days later, because my mother wasn’t very observant or maternal, she said, “Oh, that’s started.” And I said, “Yeah, I’ve got it covered. It’s okay.” And she said, “Well, what are you using?” And I showed her the pads with sticky back on them. And she’s like . . . “They didn’t have those when I had that. I’m all done with that.” That was the extent of it. I’m all done with that. She’d use menstrual belts. For those of who don’t know, people are probably like “What? A menstrual belt?” Google them. BEE: Oh my God, “I’m all done with that.” GUNTER: Yeah. So that was it. That was the extent of it. I don’t believe I had heard it mentioned really until I got to medical school. I mean, I just can’t remember it being mentioned. BEE: Right. I mean, I think for a lot of families, it’s really a story told in whispers, and knowing looks, and things like “I’m done with that” around the kitchen table. GUNTER: Right. Or windows being flung open. BEE: Yes. Oh my gosh, my own step-mom used to wear Bjorn Borg tennis wristlets and head band when she would walk around New York City, and I was like, “What is going on with you?” She was just like, “I’m hot. I’m just so hot all the time.”

Okay, we can get into some more technical stuff. You speak in the book about how, because of your intense medical training, you knew a lot about menopause. But when you yourself began to go through it, were there surprises? Were you even surprised by what surprised you? GUNTER: Well, so there weren’t really any surprises, because I knew what was going to happen. So I was prepared. For example, when I had irregular bleeding or heavy bleeding, I wasn’t surprised. But I was, I would say, a little bit taken aback by what a hot flash actually felt like, right? BEE: Right. GUNTER: Because you can conceptualize what heavy bleeding is like, but it’s not like having a fever. I thought it was going to be like having a fever and it’s not; it’s this bizarre wave that comes over you. And I found the term hot flash inept. I didn’t like hot flashes either. When I started doing research for the book and I found out women used to call them hot blooms, I was like, “That’s exactly what it feels like.” BEE: Right yes. The tingling in your toes that just crawls its way up your body and then flies up the top of your head. GUNTER: Yeah, it really does feel like it’s coming out of your head. It’s so strange. And so, now actually in the office, I tell women about the [term] hot blooms and everyone goes, “Oh yeah, that’s better.” BEE: That makes a lot of sense. I’m actually always personally surprised by the number of intelligent, educated women in my own social circle who have little to no information about menopause. And then because I’m personally very unafraid to talk about it, I just do a little tiny probe and the floodgates open. You know what I mean? Once you start the conversation, it’s unstoppable. And a lot of people that I know really base their knowledge on that old study from the nineties. There is so much misinformation out there or lack of information and so much shame. Is this why you wanted to write this book? GUNTER: Absolutely. When I was on tour for The Vagina Bible, in the olden days when we used to do book tours and there’d be an audience and you’d do questions at the end, everybody wanted to talk about menopause, every time. As soon as one woman asked, then others would stand up. Then when people come up and you autograph the book, “What did you think about this book on menopause? What did you think about it?” It was just question after question.

Sometimes women even don’t want to bring it up in the office, and you have to probe to get them to talk about it. So there’s been so much culture of shame about this just normal phase of life. I wanted to try to put an end to that. BEE: I have found in my own life that many doctors can be incurious about the wonderful world of a woman’s body. How has the study of female medical topics like menopause changed as more women have entered the medical

“I hear so many women say that they’re just brushed off and told this is just part of being a woman.”

—JEN GUNTER

workforce? How is the knowledge changing? How is it growing? And what will it look like 30 years from now? GUNTER: Well, for example, when I was training, we were taught that menopause was not quite a disease, but not far off it. They use terms like ovarian failure in lectures and things like that. So we looked at it through this lens of failure. I think as we’ve had greater diversity—and obviously it took a while, right? Because you think about how few women were originally in medicine. All those women had to get to be the age, to even be menopausal, and had to stick it out through all the rigors because it’s stacked against you just like in everywhere else. So, yeah, I think that that diversity of finally getting women in menopause who are actually being able to say, “Hey, wait a minute, these symptoms matter,”—because I hear so many women say that they’re just brushed off and told this just part of being a woman. BEE: Right. GUNTER: And no one ever says that to men. Oh, well, erectile dysfunction. That’s just part of being a man. BEE: “You’ll be fine. You’ll get over it.” I mean, you won’t get over it, but you’ll learn to live with it. GUNTER: That’s your new normal, sweetie? BEE: So how do we reform the language around menopause? Because the term itself could use a reworking. GUNTER: Yeah. I think we have to look at all the words we use to describe women’s bodies, because so many of the words are dismissive or diminutive. For example, they used to call the changes in the vagina that we see with menopause atrophy. That’s just not acceptable. We don’t say penile shrinkage, so why would we say vaginal atrophy? Even the word menopause itself, I find problematic because first of all, your last menstrual period is one of the least important things about what’s happening to you. And secondly, doesn’t it seem a bit odd to describe me in relation to my last period? When I was 25, we didn’t describe (continued on page 27)

Dr. Jen Gunter. (Photo by Jason LeCras.)

U.S. / Tel Aviv, Israel Depart on flights to Israel.

Tuesday, February 22

Tel Aviv / Jerusalem Upon arrival at Ben Gurion Airport, transfer to Jerusalem and check into our centrally located hotel. As most flights arrive in the evening, there are no group activities this day. Herbert Samuel Jerusalem

Wednesday, February 23

Jerusalem After a tour orientation, explore the Old City of Jerusalem and sites important to the three major monotheistic religions. Visit the Dome of the Rock on the Temple Mount, one of the most important sites to Muslims. Walk portions of the Via Dolorosa and enter the Church of the Holy Sepulchre, said to be the site where Christ was crucified and buried. Following lunch visit the Western Wall. Then enjoy free time to browse the alleys and shops. Tonight gather for a welcome dinner. Herbert Samuel Jerusalem (B,L,D)

Thursday, February 24

Ramallah / Jerusalem We continue to Ramallah, the provisional capital of the Palestinian Authority, where we hear from Palestinians about the issues they face and their hopes for a settlement in this long, unresolved issue. Return to Jerusalem in the late afternoon. After a pre-dinner discussion, explore Mahane Yehuda, once a popular fruit and produce market, it’s now a hub of gourmet food stalls, restaurants and cafes. Herbert Samuel Jerusalem (B,L)

Jerusalem / Bethlehem Experience Yad Vashem, a powerful living memorial dedicated to the Holocaust. Visit the West Bank with our Palestinian guide, starting with Bethlehem to see the Christian holy sites, including the Church of the Nativity, said to mark the place of Jesus’ birth. Herbert Samuel Jerusalem (B,L,D)

Saturday, February 26

Masada / Dead Sea This morning we drive to Masada, the location of the mountaintop fortress where Jews sacrificed their lives rather than succumb to the Romans. The importance of Masada remains in the psychological and political mindset of many Israelis. Continue to the Dead Sea, the lowest point on the earth. Swim or float in the relaxing salt waters and experience the health benefits of its natural minerals. Return to Jerusalem in the early evening. Herbert Samuel Jerusalem (B,L)

Sunday, February 27

Safed / Galilee Travel north stopping in Safed, a charming city known for being a center of art and religious mysticism. Continue to the more rural area of Upper Galilee. Learn about the important role of kibbutzim in the development of Israel in the 20th century. Merom Golan (B,L,D)

Monday, February 28

Galilee / Golan Heights Meet with an officer from the IDF (Israel Defense Forces). Then hear from people in a Druze town in the Golan Heights area. Druze are an Arabic-speaking sect found primarily in the mountainous areas of northern Israel, Syria and Lebanon. Later visit a winery and learn about Israel’s growing wine industry. Merom Golan (B,L,D)

Nazareth / Caesarea / Tel Aviv Journey to Nazareth, the largest Arab town within Israel’s pre-1967 borders. See the Church of the Annunciation, believed to be where archangel Gabriel visited Mary. We also visit an Arab tech firm. Continue to the coast and explore the archaeological site and Roman city of Caesarea. Arrive in Tel Aviv in the early evening for dinner on your own. The Hotel Carlton (B,L)

Wednesday, March 2

Tel Aviv / Jaffa Visit Jaffa, also known as Yafo in Hebrew, a mixed Jewish-Arab town, just south of Tel Aviv. Enjoy lunch on your own and time in the flea market with its wonderful mix art and antiques. Then continue to the Rabin Center, named after Prime Minister Yitzhak Rabin. Enjoy dinner at one of Tel Aviv’s seaside restaurants. The Hotel Carlton (B,D)

Thursday, March 3

Tel Aviv Learn about Tel Aviv’s various neighborhoods and architectural styles. See Bauhaus architecture, Dizengoff Street, Neve Tzedek, and the Florentine district. Enjoy a free afternoon to visit galleries, the beach, or rent bikes to travel the coastal path around Tel Aviv. Gather tonight for a special farewell dinner. The Hotel Carlton (B,D)

Friday, March 4

Tel Aviv / U.S. After breakfast at the hotel, transfer to the airport for flights home. (B)

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“I have found in my own life that many doctors can be incurious about the wonderful world of a woman’s body.”

—SAMANTHA BEE (continued from page 22) me in relation to my first period. And some of the words we use, for example the word pudendum in medicine, which describes the outside of the vulva, the Latin root of that is to shame. And the hymen is named after the Greek god of marriage. BEE: Do you see progress? How do you change the language? How do you evolve that GUNTER: So there has been change. So for example, what we used to call atrophy, we now call genital urinary syndrome of menopause. It’s not exactly catchy acronym, but it works. It’s better. And what we used to call premature menopause, we now call primary ovarian insufficiency. So medicine can change. We can do better. It takes a lot of effort because the way we’ve always done it is the way the patriarchy has always done it. BEE: Right. Is there any cultural situation like books, movies, television, which you think have portrayed menopause well? It usually feels like a punchline; but have you seen depictions of menopause that you admire or you think this is good? GUNTER: Well, I like Grace and Frankie, with Jane Fonda and Lily Tomlin. I mean, they’re obviously years past their final period, but I think that there’s [realistic portrayals]. I think they did a great job. And I liked how Grace was married to a man younger than her. BEE: Can you show us what is behind you? GUNTER: Sure. When I was researching the book, something someone said to me, and I can’t remember if it was a tweet or if it was at a book tour, there was no culture of menopause. She felt lonely. That’s why I really took this deep dive into the history behind the word, the evolution of the medicine, and also looked at some of the older therapies. And it’s amazing what you can find on Etsy. Let me tell you.

When other people were doing other pandemic shopping, I was trolling Etsy for cultural items of menopause. I have some medication from the 1920s. This bottle is Lydia Pinkham Vegetable Compound, which

was a home brew recipe from the 1800s containing nothing that could help you. But it was sold as if it could treat everything. And when it was finally tested, it was 18 percent alcohol. BEE: Sure. GUNTER: You were supposed to sip on it on those days when you felt fit for nothing. BEE: That sounds right to me.

How much respect did you gain for earlier generations of women when you were researching some of these antiquated cures or treatments? GUNTER: The history of menopause and medicine is one of at most, I would say division. Women were considered inferior to begin with, and you helped yourself get rid of toxic, build ups of fluid with menstruation. Men were perfect, they didn’t have that toxic buildup, right? But then when you went through menopause, it’s not like you elevated to a higher social status. What happened is that stuff you weren’t releasing with your menstruation now was accumulating in your body. So that’s why you became even more ill. So if a 60-year-old man was working hard and hurt his shoulder, well it’s because he was working hard. But if it was a 60-year-old woman, it was because of her uterus.

So all the therapies were designed to release fluid, to make you sweat, things like that. So the older therapies, if there were any, they were vaginal injections of lead, leeches on the vulva. BEE: I’m sorry, I’m just . . . GUNTER: Yeah, I know, right? Like every woman’s legs went together.

Therapies like that. I read a lot of journals from the 1920s because again, everything’s online. These stories of these women coming in suffering, and people having very little to offer them because this was just the beginning of understanding anything about hormones. And so many of these women actually had radiation therapy to their pelvis for pelvic pain. They were left with early severe menopause. So yes, it’s just the suffering. And so the ability to mass produce hormones really I think alleviated a lot of suffering. BEE: How early do you think that we should start educating young people about menopause? GUNTER: Middle school? BEE: Middle school. GUNTER: Yeah. BEE: We have so many battles over sex education curriculum. I can’t imagine the battle if you try to add menopause into the order of the day. But it feels valuable to me. GUNTER: Right. BEE: I’m very inclined actually to take your book and give it to my husband. Because even though I talk about it constantly, I do think he just tunes me out a little bit. I wonder if a lot of the people who are watching this feel the same way, to have a partner who could share the experience, feels very valuable. GUNTER: Yeah. My partner read the book. He feels very up-to-date on everything on menopause.

But back to getting into schools: We teach sex ed, we frame it with stopping pregnancy. That’s it. It’s very purity culture as opposed to learning how your bodies work. I personally believe if everybody knew what good sex was early, actually people might be making different choices, right? People do things because they’re curious and they don’t know. Wouldn’t it be better for people to know how everything works? And how everything works should be the full scope of your life. But if we can’t get it into middle school, which I’m still not going to stop on that mission— BEE: No, listen, I’ll join you in that mission. GUNTER: But I think everybody should know. We do a bad job of teaching biology in general. But I think anybody who partners with anybody who’s going through menopause could really learn about it. If your mom’s going through it, your sister, or your wife, your cousin, your partner, anybody could learn, because even if you’re not going through menopause yourself, maybe you should learn about why those jokes could be so hurtful to somebody. BEE: As with a lot of things, people with low information have many large scale opinions about things such as menopause. You have said that you expect a lot of hate mail for your chapter on supplements. Why is that? GUNTER: Well, I’m telling the truth and supplements make a lot of people a lot of money. For a lot of people, it’s like a religion. What’s fascinating to me about this belief in supplements, so many people who promote supplements say, “Well, look at all the harms in medicine. Look how medicine has harmed people.” And yeah, so let’s look at how medicine has harmed people. How did thalidomide harm people? Oh, it harmed people by not being studied adequately and getting out there. How did DES harm people? By not being studied adequately and getting out there. Are we studying supplements adequately? No, we’re not.

So when you look at it from that framework, if you’re expecting something to have a physical effect in your body, it’s got an active ingredient and the assumption should not be that that is a beneficial active ingredient. So, yeah, it’s a lot of people making a lot of money off of it. If your product is so great and so safe, you should go out and prove it. Don’t women deserve that? Don’t women deserve the studies to prove it’s safe and effective? BEE: Right. Why do you think that information from the study in the nineties is so pervasive even today? Because I tell you, I talked to a lot of people who still quote that information, and they’re hearing it from their own doctors, and that is alarming to me. GUNTER: Absolutely. Unfortunately, in medicine it can take 10 to 20 years from something that’s studied to make it into the office, which is not acceptable, but just so you know how long it takes. Cancer headlines are super scary and they scare doctors as well.

And the headlines from the Women’s Health Initiative in 2002 were just ridiculous. It kept going over and everybody was frightened. Then the lawyers come out and, “Oh, have you taken menopausal hormone therapy? Contact us. Do you have . . .” So it’s this whole cycle of just completely spreading the misinformation. And it’s like when there’s an

“People do things because they’re curious and they don’t know. Wouldn’t it be better for people to know how everything works?”

—JEN GUNTER

error in a newspaper, right? They print the retraction on the fifth page.

All the studies that have come out now putting those risks in perspective, explaining the benefits of menopausal hormone therapy, and the risks when they are there, those things don’t appear on the front page. Fear sells and fear sticks with us. People are still more afraid of breast cancer than they are of heart disease, even though heart disease is the number one killer of women. And it doesn’t mean people shouldn’t be concerned about breast cancer, but the thing that’s killing more women doesn’t seem to get very much attention. BEE: How do we ensure that the research being done on the products being offered don’t just cater to one specific white woman? GUNTER: Well, now we have rules that studies have to include diversity. And we’re seeing more and more studies like that. For example, the “Study of Women’s Health Across the Nation,” the SWAN, which I referenced a lot, has quite a diverse group of women. But even then, if you enroll Asian women, that’s still a huge grouping of different people, right? BEE: Right. GUNTER: So if you enroll Hispanic people, that’s still a huge grouping of different people. And so obviously we need more and more data so we can refine things. I think we’re moving in that direction, but we clearly need to keep moving in that direction. BEE: What would you say are the most pervasive myths that come up when people speak to you about menopause? You must get the same three questions, pretty much every time you hit the road. What are those? Have I asked those three probably? GUNTER: Well, one is about “isn’t menopausal hormone therapy risky?” I always start with that and I say, “Well, driving your car has risks, right? But you decide that there are benefits with it as well.” And they’re like, “Oh yeah.” I say there is a very low risk of breast cancer and some other things, but [with] transdermal therapy, the risk is actually incredibly low. For three or four years, the risk is essentially zero. It’s about as low risk as you can get. Risk needs to be put in perspective, and you have to decide what it’s doing for you. As long as it’s helping you, then that low risk may be something you can tolerate. So people have been brought up to think that menopausal hormone therapy is going to cause breast cancer for like 40 percent of people who take it. BEE: Right. GUNTER: As opposed to six per 10,000 women per year, and that mortality isn’t increased taking it. So there’s that. I think MHT was the biggest thing. The second is that there’s no good treatments. I’m like, “Well, actually there are quite a few. You probably just haven’t been offered them or offered them in a way that you could hear,” right? BEE: When you say that, what do you mean? GUNTER: Oh, well, so for example with the risks about MHT. “Oh, you could take a machine.” “Oh, doesn’t that cause cancer?” “Okay, well, let’s move on to the next thing.”

As opposed to the doctor stopping and saying, “Well, let’s talk about that.” Or, say, antidepressants. “Oh, I don’t want those. I heard there was a dangerous [risk].” “Well, let’s talk about what do you mean by what have you heard?” Actually listening to what the person is worried about and then actually answering the question. People just say, “Oh, I don’t want that,” because maybe they heard a bad thing about it from someone, but they also deserve to hear the information. So I think that’s a big thing.

And then the third thing is that it’s all over, everything’s just done. And it’s not. I mean, there’s so many women doing so many amazing things over the age of 50. This is a phase of life, this is not pre-death. BEE: Right. That’s good to hear. Thank you. Here’s a good question that came up in the chat. And I’m going to ask it, even though we’re not technically at that section, because it’s important. Do you have advice for people on how to speak up when you feel like your doctor isn’t taking your pain or your symptoms seriously enough? GUNTER: Yeah. I mean, that is definitely a challenge, and you shouldn’t feel like that in the office. But when that happens, I think that it’s important to say if you feel comfortable, “Well, I don’t think you heard me, and this is what’s really bothering me. And are you telling me there are no treatments, or are you telling me . . .” So, to rephrase it. I think that if you can’t get help from that person, if that doctor’s not jelling with you, then unfortunately you probably do need to find another provider. It shouldn’t be like that. The onus shouldn’t be on the person. I absolutely agree with that. But you also have to say, “Well, if you have this problem, what’s the fastest way to get the help that you need?”

I think also it’s very useful to know the guidelines for therapy, if you can, before you go to the office, right? So you have an idea if what you’re being told is actually in line with the guidelines, right? So for example, you could use my book as a reference for menopause or the North American Menopause Society. Because if you go in and you hear something that’s totally different, you might say, “Well, maybe this isn’t the provider for me anyway, because I want standard of care.” BEE: How can you tell the difference between memory loss that is a natural part of aging and the menopause transition, and something that might be a sign of something potentially more serious? GUNTER: That’s a great question. A lot of women experience something called brain fog during the menopause transition, where they can’t remember where the keys are. They’re just like a lot of people say when they have mommy brain, right? BEE: Sure. GUNTER: When you walk into a room and you just go, “Well, I knew I came in here for a purpose. I cannot find it,” or, “I came to the grocery store and I only needed one item, and no idea what that is. That’s why I didn’t write a list because it was only one item.”

Brain fog is something that happens and is normal. It’s worrying, but it’s not worrisome, and it’s temporary. I think if anyone has symptoms where they’re concerned that they should be seen, because there’s a lot of different things that can cause those symptoms. For example, you could have depression, and depression can manifest as brain fog. So you want to be screened for depression. If you’re not sleeping well, you know what? Sleep apnea increases both with age and after menopause. That could affect how your brain is functioning. So you might need to be screened for that.

If your memory loss is progressive, getting worse, then there are screening tools that your doctor can do concerning aspects of memory loss, and then refer you if appropriate. There are screening tools, questions, and an appropriate workup.