One of the most valuable tips I’ve taken away from 70 podcasts came from Dr Annice Mukherjee, way back in the beginning.
She is the British endocrinologist who wrote 2021’s The Complete Guide to the Menopause - one of my top-recommended books that everyone should have - and I quote her often.
That’s because she’s one of the people who has the most reasonable, evidence-based approaches to the menopause. She is an expert on human hormones and how to prescribe them, she had breast cancer, and she did not take HRT to get through the menopause that ensued. She has a book, yes, but no private clinic or products to pump. She’s principled, bound by her work with professional societies, unable and unwilling to endorse anything for profit, or be involved in any endeavor that could be a conflict of interest or be seen to be a conflict of interest.
My point is that I rate Dr Mukherjee very highly. And she was the one who told me way back at the start, in episode 4, that one of the most important things we can do during this transition is to ‘treat your energy like a bank account’.
When we don’t – and we all have to do this to varying degrees – we pay.
“Sometimes, you end up having to pay back with interest as well. The energy is lost because your equilibrium, your balance isn't there. You use what you haven't got and then you can crash.
It's not that you ‘can't’ do it. Sometimes people say to me: ‘I've got this big wedding coming up, a friend is getting married, and it's a really good friend’, and I say, ‘Look, just accept that you'll be a bit wiped out after that. Just try and not do too much before and around that time’. The other thing is, if you do implement healthy lifestyle approaches, like good nutrition and you exercise, you will build up your level. You'll be able to do more before it hits you, before fatigue, or that burnout feeling, hits you.”
Our body is going through a major transition, and we simply cannot afford to be making endless withdrawals without significant deposits. Even if we have gotten very used to do that in our previous lives. Even if it does not.seem.fair.
I’m not here for your ‘enterpainment’
I was appalled at some of the “humour” out there when I launched Hotflash Inc.
It’s gotten better - the IG account @whatthemenopause has blown up for a reason (because hilarious) - but there is a lot of other stuff that I don’t love, still.
I have experience with this: I became a chubby kid around 8, when I learned to eat my feelings, and that’s around the time I began a long history of providing “enterpainment” for others.
I was also mostly single through my 30s, and had a Sex and the City style column in the 2000s about love and dating that was filled with it. (I remember my sweet brother visiting and saying, at the height of it, “Annie, I don’t know if this is good for you”, and in hindsight, he was right.)
I’ve learned the hard way there is a fine line between being able to laugh at ourselves, and being cruel to ourselves while doing it. It’s very, very damaging.
It took until my late 40s to start to unravel it. And it actually hurts to see people doing it to themselves now for yuks. I’m also concerned about the message that we are sending our younger sisters with this stuff: that this is all awful, all the time. When the truth is, it’s hard some of the time (maybe a lot), but there is help available - eventually! - and it does pass.
And we know from the research that the more fear and negativity we take into it, the worse time women tend to have. So you won’t see me making chin hair jokes or covering myself in ice packs or fumbling with belly fat or making faces smelling my armpits or scratching myself.
I make jokes, but I’m not the joke - see the difference? And you aren’t the joke either.
Science stuff
Score one more for the ‘window of opportunity’… No matter where you are on the HRT spectrum, from maximalist to minimalist to moderate to never-ist (and here at Hotflash inc, all approaches are considered valid), one thing that is becoming clear from the still-paltry amount of research we have on this transition is that when it comes to going on it, earlier is better. And if you go through early menopause, as in before the age of 45, earlier is vital. In a new study published in Jama Neurology, researchers looked at PET scans for almost 300 adults with adept cognitive function – 193 of them women – between 2006 and 2021.
In those participants with elevated amyloid, an inflammation-related condition associated with later cognitive decline and Alzheimer’s Disease (AD), female participants who had gone through early menopause and were on hormone therapy also exhibited higher amounts of tau proteins in the brain, another AD-associated signal. But Ann Marie, I can hear you saying, everyone is saying hormone therapy prevents dementia. Well, at this point that’s something HRT maximalists – and no guiding bodies – are claiming, and lots of others are suspecting. When it comes to dementia, there are many, many contributing factors: air pollution, poor diet, diabetes, metabolic syndrome, poor bone health, lack of social connection, a sedentary lifestyle, trauma, smoking, high blood pressure, a lack of cognitive engagement etc etc etc. It’s just not as simple as ‘estrogen protects the brain therefore add estrogen, save the brain’; and this study is just one of a bunch of very mixed research that is not nearly long-term enough at this particular juncture to say otherwise.
Also, you have to be careful about this. Most doctors aren’t recommending HRT solely for prevention, because guiding bodies aren’t, but lots are. So, back to that window and this “tau vulnerability” researchers found.
Rachel Buckley, co-author from the study and a cognitive neurologist at Massachusetts General Hospital, told Medpage Today the higher risk was only associated with those women who started hormone therapy more than five or six years after their early menopause.
This reminds me of a literature review conducted by the American College of Cardiology Cardiovascular Disease in Women Committee, which was published in the February issue of the American Medical Association Circulation journal. Ultimately, after looking at 96 papers, and as co-author Kathryn Lindley told me on Ep 66 of the Hotflash inc podcast, they recommended HRT for symptoms, not prevention of cardiovascular disease, and also within the window of opportunity. As Lindley told me: “It seems like it would make sense that if you gave patients hormone replacement therapy, it would delay or prevent cardiovascular disease”. But that’s not always the case.
Buckley echoes those findings here, but with the brain: “Counterintuitively, we found that women with elevated amyloid who reported taking hormone therapy also showed higher tau burden. One would have imagined taking hormone therapy might ameliorate the issues of lost estrogen because you are reintroducing estrogen into the body.”
For now, for the brain and the heart, the answer is something along these lines: not always, and sometimes, it makes it worse.
Have sex, ovulate longer? This isn’t a new study, just one I came across this week. I wanted to highlight it because it involves something that’s fun and good for you and free and kind of inneresting. You know how we are always hearing that sex – and the almighty orgasm – is good for us? Research published in Royal Open Society Journal in January 2020 found a possible association between women who engaged in regular sexual activity – at least once a week, versus monthly or less than that – and later menopause. (Sex covered anything from intercourse to self-stimulation.)
The observational study looked at 3,000 women from the Study of Women's Health Across the Nation, and aimed to test an association found in research that few people understand: that married women tend to have a later age of menopause than unmarried or divorced ones. It’s well-established that going through an early menopause increases risks on a number of disease fronts, which is why HRT is recommended by most guiding bodies, although that information doesn’t make it to every doctor – either in early menopause or in surgical menopause.
The thinking was that perhaps if you aren’t having very much sex around the time of perimenopause, it could hasten the process, and if you are having regular sex, it could delay it. And that’s exactly what researchers found an association with in this study: women who reported more sexual activity were 28 percent less likely to go through menopause during the studied time frame.
Researchers found that the something they believe has to do with a link between sexual activity and increased ovulatory cycles.
As the study’s lead author, Megan Arnot of the University College of London, explained at the time: "Ovulation requires a lot of energy, and it has also been shown to impair your immune function. From an evolutionary standpoint, if a person is not sexually active it would not be beneficial to allocate energy to such a costly process."
I had a certified Doctor Menopause Guru on the podcast this week: Dr Mary Claire Haver is a Texas-based board-certified ob-gyn and Certified Culinary Medicine specialist. She’s also TikTok’s top menopause doc with two million followers, runs the private clinic Mary Claire Wellness, published The Galveston Diet in January and is working on another book, this one specifically about menopause.
I spoke to Dr Haver in early April and we talked a lot about hormone therapy, including why she believes every woman should take it.
Highlights:
How the US healthcare system is preventing better menopause care
Why she chose to open a private clinic (and why she knows its elitist)
How far behind menopause research has been and continues to be
How she prescribes HRT
Her take on the progesterone-progestin question
How and why she pivoted to her pro-hormone therapy message
Podcast episode of the week:
Dr Tyna Moore is an outspoken American naturopathic physician and chiropractor who watched her mom go through a horrible menopause and was determined that it would not be that way for her. She’s one of the few people out there laying the blame for the tough time women are having in their 40s on their poor metabolic health, rather than on naturally fluctuating and declining hormones. (And of course they surely contribute, but this helps explain why so many men are having a hard time, too. It also helps calm that facial tic I get when people talk in an overly simplified manner about declining hormones as if they should not be happening, when we know that’s what nature intended) So this episode of The Dr Tyna Show podcast, How to Train for Menopause, is quite a bit different from the usual narrative. As in there is only a passing reference to hormone therapy. As in it’s up to you to prep for this, in the face of a whole bunch of challenges, or turn the ship around as soon as you can, and that if you do, the rewards you reap will be great.
In it she speaks to Catherine Staffieri, a registered dietitian at continuous glucose monitoring company (and the sponsor of the episode) Nutrisense.
At times it’s a bit like an ad for a CGM, which I’m not sold on, but for the sheer uniqueness and importance of her message, it’s well worth listening to.
The first 25 minutes are the best, addressing a range of really important factors: how progesterone can help with perimenopause; the “disaster” of drinking on blood sugar regulation and on estrogen detoxification, and on sleep; why using a continuous glucose monitor for just a short time can be illuminating in linking how we actually feel and sleep to the food we have eaten (for example, they both talk about how Vietnamese Pho and sushi are meals people think are healthy, but also tend to cause dramatic blood sugar spikes) ; why you shouldn’t eat anything your grandmother wouldn’t have; why you don’t want to kill yourself in cardio or ‘CrossFit or Orangetheory yourself in to oblivion’; why dwindling estrogen isn’t the bad thing everyone makes it out to be; why strength training and walking are the perfect peri-metabolic health combo; why we also need to lift and pull things as we move around our lives; and why you can add in all the creams and the hormones you want, but, as she says, “none of that is going to work for very long or very well if your metabolic health isn’t dialed in”.
Favorite quote, from Dr Tyna (I wonder if she’d add “cardiovascular disease is diabetes for the heart”?):
“I’m never going to be able to heal your joints if your joints are melting because of your disrupted metabolism; so in my opinion, osteoarthritis is diabetes for the joint. And osteoporosis is diabetes to the bone and dementia is diabetes for the brain. And so it’s all stemming from the same root cause, which is metabolic health.”
Click, read, listen, watch + follow
• NEW BOOK ALERT: Want to Be More In Control of Your Health and Reverse Disease? The Glucose Goddess Has Simple Hacks That'll Set You on Your Path ASAP The Sunday Paper
• It’s a nice headline, but when someone puts a ton of stress on their body for years, as this British Olympian did by the very nature of being a distance runner, I’m not sure they can lay all the blame for their physical pain on perimenopause (although we know that joint pain and body aches are definitely one of the symptoms). Also this is some kind of major perimenopause media tour, and I’d love to know the backstory on how it came about: Dame Kelly Holmes says she is in 'constant pain' from perimenopause Sky News
• Dr Jen Gunter is not a fan of vaginal lasers. The Vagenda
• Have you heard of the Sleepy Girl Cocktail? It’s all the rage on social media. We could do worse than drink it (as in, we could have wine instead and wake up sweating at 3am) Also, I might serve it the next time I have people over so they don’t stay too late: it’s tart cherry juice, magnesium powder, and some sort of soda. Buzzfeed
• So obviously they are plugging their brain support supplement, but this is a good article and what I particularly love about it is that it doesn’t suggest estrogen is the only way to saving our minds. Because, it’s not one of many: How Women Can Prevent Dementia In Their 40s (& Beyond) MindbodyGreen
• This Mail on Sunday podcast, featuring Dr Jen Gunter and MenoClarity founder Rachel Lankester, gently addresses the thorny and complicated suicide-perimenopause connection – and the overly simplified and possibly damaging way it’s often presented online and in media Medical Minefield
• It’s never too late: “Significant improvements in strength and muscle can be achieved with the right program”: How old is too old to start strength training? Medscape
Editor’s note
This newsletter was written on a layover at the Bangkok airport on my way back from a very important vacation. It was half not-working at a wellness center on Koh Samui, an experience I’ll be talking about a lot in the weeks ahead, and half working out of a cheap hut by the beach, listening to the waves and watching the sunrise and set and getting Thai massages and eating lots of curry and yoghurt and fruit and things that surprisingly didn’t bother my leaky, normally-troubled-but-now-healing gut. That time off has restored my energy, my health, my belief in myself and my resolve in Hotflash inc, and in the importance of getting the moderate, heterodox menopause message out. Yes, that’s what a rest and a fresh perspective and lots of moving and healing – and deposits in the energy bank I’m vowing to make regularly moving forward – can do.
Thank you for being here. I appreciate all of you more than you know.
AMx
*forgive the typos