How to Balance Your Hormones: What Your Doctor Isn’t Telling You About Menopause

Mel Robbins: Hey, it's your friend Mel, and welcome to the Mel Robbins podcast. I am so happy you chose to listen to today's episode. It's going to make you feel completely seen and understood because our expert is the extraordinary Dr. Jen Gunter. She is the number one OBGYN that people turn to for trusted science-backed advice regarding menopause. And she is here to bust the myths and clear through the misinformation. And it is so prevalent on the topic of menopause.

Mel Robbins: In fact, Dr. Gunter is so in demand that I've been waiting a year to have this conversation with her. She has jumped on a plane, flown across the country to be here for you, to set the record straight and to answer your questions. Are my symptoms normal? Is hormone replacement therapy safe? What exactly are bioidentical hormones and are they better than normal ones? What are compounded hormones? How do I talk to my doctor and my family about this?

Mel Robbins: Today, you are getting the exact specific protocol you need from one of the most respected experts in women's health on the planet. And if menopause is not impacting you personally, do not change this episode. Do not touch that dial because it is impacting someone you love. And simply listening and learning is going to help you love them even better. Because today we are busting the myths and you are getting the facts about menopause.

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Mel Robbins: Hey, it's Mel. I am so thrilled to bring this episode and conversation to you today. Dr. Jen Gunter is here to tell you everything you need to know about menopause with a very particular focus on exactly what to do in order to feel better. Now, Dr. Gunter has been called the internet's favorite OBGYN. She is a double board certified, fellowship trained medical doctor, and she is a fierce advocate for women's health. She is also the bestselling author of three international bestsellers, including *The Menopause Manifesto* and her latest bestseller *Blood*.

Mel Robbins: She's known for myth busting and no-nonsense facts. And you are going to love this conversation with her today. And I want to remind you, this is not just for you. Please be generous and share this with every single woman that you know, because what you're about to hear will change her life and yours. Without further ado, please help me welcome Dr. Jen Gunter to the Mel Robbins podcast.

Dr. Jen Gunter: I am so glad to be here.

Mel Robbins: So Dr. Gunter, thank you so much for jumping on a plane, flying all the way across the country to be here with us in Boston. I cannot wait to jump in and talk about menopause, bust the myths, have you empower us. I want to start by having you speak directly to the person who's listening, who is either about to hit menopause, going through menopause, or maybe they're listening to this episode because somebody that they love has sent it to them. Could you talk to the person listening about what they are going to experience and what they're going to learn and how they're going to feel after they're done learning from you today?

Dr. Jen Gunter: Yeah. So I want you to feel seen if you're going through the menopause transition. I think so often women are made to feel small and they're not important. And women are uniquely affected by ageism. So you kind of have the double whammy at this time. So I'm hoping that you'll feel that your concerns are valid and they're important. And there are lots of options to do from a health standpoint. And there are many ways to take care of yourself. And I can give you some tools to reframe what's going on with your body so you kind of know where you are and also give you tools to find help if you're struggling.

Mel Robbins: What do you want to say to women who are in menopause?

Dr. Jen Gunter: Yeah, team menopause. I'm on it too. So I would say that menopause is a normal part of the ovulatory cycles that we have. And just like you went through puberty, which might have been challenging and had some symptoms and caused a lot of physical changes through your body, that menopause is in many ways the same thing. You can think about it as puberty in reverse. It is not a sign that your body is going to fall apart the next day. It is not some new experience.

Dr. Jen Gunter: I know there's a lot of people out there who think that, oh, because women are living longer now they're just experiencing menopause, but that's not true. The ancient Greeks knew that the average age was about 50, which is about what it is now. And if we erase menopause, then we erase all the grandmothers in history, right? So it is a normal experience, but normal doesn't have to mean pleasant, right? So just like when you went through puberty, maybe you got acne, or maybe you had really heavy irregular periods, or pregnancy, also a normal experience. Maybe you had terrible nausea and vomiting. Maybe you had other complications. So normal things can have complications.

Dr. Jen Gunter: And I would say that there are things about menopause that can be very unpleasant for people. There's things that can be very liberating. People who've had terrible, painful periods who now don't have them think it's amazing. People who've had maybe terrible PMS find that the steady, the lack of ups and downs of hormones are liberating. And so I would say that if you're suffering, there is often medical treatment for that. And that the best way to know how to make it a more pleasant experience or less onerous experience, depending on the spectrum you're on, is to get informed and have accurate information.

Mel Robbins: I've never heard anybody call it puberty in reverse. That actually makes a lot of sense.

Dr. Jen Gunter: Yeah. Well, just like you're, it's a different physiologic process, but you have a winding up, right? So when you go through puberty, you don't start and bang on, have cycles regular, they sort of start and stop, they might be heavy, you have that sort of flirting with it, if you will. Well, you have that same in kind of the last couple of years, you have the starting and stopping with the periods, you're having the winding down of ovulation. So yeah, they're like bookends, a little bit different, maybe like sisters, not twins.

Mel Robbins: What is happening to the body when you're going through menopause?

Dr. Jen Gunter: So menopause, the menopause transition, which is the time leading up to menopause that you might also think of heard called perimenopause or premenopause.

Mel Robbins: How long does that last?

Dr. Jen Gunter: Well, anywhere from sort of four to 10 years, depending, just kind of like puberty, right? Like a big range in how long it can last. Some people seem to have these late growth spurts, goes on forever. Some people relatively short, kind of the same thing.

Mel Robbins: Oh, wait a minute. Okay. So when you were talking about puberty, I was just thinking about getting my period. I wasn't thinking about all the other things that happened, like your breasts coming in, your body shape changing, the fact that you grow taller. Do we shrink when we're going through menopause?

Dr. Jen Gunter: Not really. Certainly, if you develop osteoporosis, you can. But no, otherwise not. And it would be rare to develop osteoporosis in your late 40s or early 50s. That would be really a sign that there should be something else going on significant. But over time, if you have osteoporosis, you certainly can lose height. And we want to protect that. But yeah, puberty is a many years experience, right? You start to get pubic hair. You start to grow. You get breast buds. Your body shape changes. You may have mood swings. You may have acne. This whole experience.

Dr. Jen Gunter: And just like puberty might have ended at a different time for different people. Some people stopped growing in grade seven. I was still growing in grade 10, grade 11, right? You have this big range. It's the same thing with the menopause transition. And so I just encourage people to think about it more that way, that it is a change. And these changes don't happen overnight. So it's this physiologic change. And it's related to the decrease in the number of follicles or eggs that can ovulate.

Dr. Jen Gunter: So what happens in response to the decreasing levels of estrogen that are produced, you get other hormonal changes. Your brain is trying harder to get the ovaries to ovulate, it can start to get discoordinated. So you might get one ovulation right on top of each other. So some cycles, you might have higher estrogen levels than normal. Some cycles, you may not have progesterone. Some cycles might be shorter. Some you might develop estrogen, not get progesterone, but still menstruate. So it's basically hormonal chaos.

Dr. Jen Gunter: And so people mistakenly think of it as this gradual, smooth transition, but it's more like... obviously there's variation. My best friend had regular cycles and then her period stopped and she had one hot flash. And I'm like, that's kind of the equivalent of showing up. That's a unicorn.

Mel Robbins: Well, that's like showing up late at the hospital and you're like, oh, I feel a little contractions. And you're nine centimeters and go, oh, the baby comes out, right? There are people who have those experiences and then there's people who have 72 hour labors. So yeah, it's this wide experience and there are many things that can affect it.

Mel Robbins: Dr. Gunter, what are the biggest myths of menopause?

Dr. Jen Gunter: Oh gosh, the biggest myth. I would say the biggest myth is that your life is over, that this is the end. Once you age out of being a breeder, for lack of a better term, you've lost value. But I would say that many women, once the menopause transition is over, really describe that they have a greater clarity and they feel great. And maybe it's not having the hormonal fluctuations. Maybe it's the fact they just don't care anymore because they're older. It's wisdom with age. I don't know the answer to that.

Dr. Jen Gunter: Maybe it's the fact that all of the part of your brain that was tied up with ovulation is now gone because your brain prunes pathways. It doesn't need any more. I don't know the answer, but I would say that for some people it can be very rocky, and for some people it isn't. And for people who it's very rocky, we have treatment. That's true.

Mel Robbins: You know, I think the biggest myth, if I'm kind of just thinking about what my friends are talking about, is that you're going crazy. And it feels very liberating when a doctor tells you, oh, that brain fog, that can be explained by menopause. Oh, frozen shoulder, that can be explained by menopause. And so understanding that there's an underlying reason for all of these things suddenly coalescing for me has been the biggest, most liberating thing. To kind of understand what's going on instead of feeling like I'm a victim to what's going on.

Dr. Jen Gunter: Yeah, I think education about how your body works is very liberating. So then you don't think that you're uniquely broken or uniquely crazy. You know, what is specific? Why is my body behaving this way and no one else's? And you're like, oh, lots of people are behaving this way. Okay, I don't feel so alone. So sometimes there's safety or comfort in numbers.

Mel Robbins: What are the top three non-hormone interventions that you recommend all women do to impact their health?

Dr. Jen Gunter: Well, I would say the top recommendation is exercise. I would put that over hormones. Absolutely.

Mel Robbins: But in menopause in particular, how come?

Dr. Jen Gunter: Well, exercise touches almost every single domain that is affected by menopause. So if you think that menopause can start to change the trajectory for risk of osteoporosis and risk of dementia, risk of muscle loss, all of these things. Exercise touches all those domains. So in the menopause transition, there's an increased risk of depression. Exercise can treat depression. Exercise can help protect bone mass. Exercise can help build muscle strength, build muscle mass. Exercise is great for your heart. It's great for your brain. Basically, exercise treats almost everything in menopause except hot flashes and vaginal dryness. And we have great medications for those.

Dr. Jen Gunter: So what I'm saying is that going into menopause with that strong foundation, and it's not just cardio, resistance training. Exercise helps with your balance. So you're less likely to fall. The number one risk factor for breaking a bone is actually falling, right? So all of these things can be protected with exercise. But that's not a sexy sell.

Mel Robbins: That's true. Like if you could only ever do one thing for your health, it would be to get your exercise. I mean, you don't want to play favorites and say, well, you can only do one thing. But I'm just trying to emphasize how important exercise is and resistance training and building muscle. And I'm always inspired by all these women in their 50s, 60s and 70s on Instagram that are showing like they're flexing their backs or they're just like cuts. And I'm just like, oh, yeah, never too late.

Dr. Jen Gunter: Yeah, well, I'm working on it. So yeah, so exercise, eating 25 grams of fiber a day, trying to have more protein. Many women don't eat enough protein and trying to have more plant-based protein in your diet and having more vegetables. I mean, it's not the sexy stuff, but it's the stuff. And then obviously not smoking.

Mel Robbins: I just love how you explain this stuff. What is hormone replacement therapy?

Dr. Jen Gunter: So menopausal hormone therapy, which is what we call it, is giving hormones to treat symptoms of menopause or to prevent complications associated with menopause like osteoporosis.

Mel Robbins: Can you explain the different types of hormone replacement therapies, Dr. Gunter?

Dr. Jen Gunter: Yeah. So there's evidence-based FDA approved and then there are scams. I would think that's the best way to sort it out. So many people get hung up on the term bioidentical, which is really a meaningless term. It's a medically meaningless term. Whether a hormone is the same or similar to what your body makes doesn't make it safe. I could give you a high amount of epinephrine and cause harm to you, but that's something your body makes, right? So I can give somebody tons of estrogen and give them endometrial cancer. So whether something similar to what your body makes or not doesn't make it safe.

Dr. Jen Gunter: What makes it safe is, is it studied? Is it safe? Is it effective? And is it something where we know exactly how much you're getting? So one of the big problems is a lot of people are using compounded medications or pellets. And we don't know what's actually in those things from an actual amount of hormones. So if I give you an estrogen patch, I know how much is going to be absorbed. There have been studies that have been done. I know if you put it on a different body part, that's going to affect absorption. So all of this has been done. With compounded products, none of that exists. None of it. I don't know how much is getting across your skin. I don't know how much you're ingesting. I don't know how much is being absorbed. You would want to know what you're putting into your body, right?

Dr. Jen Gunter: So I would say there are FDA approved therapies and there are many good ones out there. So there's estradiol, which is the main hormone that the ovary makes. And we have pharmaceutical variations of those.

Mel Robbins: Another big myth is that some hormones are plant based. And that again is a marketing. Is that not true?

Dr. Jen Gunter: Well, I mean, petroleum is plant based, too, if you want to look at it that way. Right. So yeah, it's plant based, but it's not. They used a starting chemical found in a plant and converted it into estradiol. That doesn't make it any better than if I made estradiol by assembling it from different molecules. It's the same thing. Your body can't tell the difference. We just make it from soybeans, which is called a semi-synthesis, because it's cheaper than making it by synthesis, which is assembling the molecules itself. So it's a total marketing thing. Plant-based, it means nothing. Nobody's grinding up yams and putting them into pills and giving them to you.

Mel Robbins: How do I know that I'm doing the right thing? Like I listened to you and I'm like, yes, yes, yes. I love it. Take it down. Take it down. Go, go, go. Dr. Gunter. Thank God you're out there cleaning up the internet for us. But then I like, what am I asking? What am I ask my doctor? So if I go into my gynecologist and I'm interested in hormone replacement therapy, what is the proper thing to ask for so that I am in the land of research and in the land of things that we can measure versus in the kind of fringe areas of the other stuff?

Dr. Jen Gunter: So if you're getting a prescription that doesn't have a package insert with it.

Mel Robbins: What does a package insert mean?

Dr. Jen Gunter: Whenever you get any prescription and there's this little folded up book and you unfold it, it's all the risks and benefits. And it's like this big thing. If it doesn't have that, then it's not FDA approved.

Mel Robbins: Oh, okay. So all the things that you get from the compound pharmacy, not FDA approved.

Dr. Jen Gunter: No. Because how could they be? The packaging has been through clinical trial after clinical trial, and it's had to have been tested and passed through all these hoops for your safety and so that you as a doctor can understand what you're actually prescribing me.

Mel Robbins: Yeah.

Dr. Jen Gunter: So there's this whole loophole for compounded medications. And so they don't have to have that package insert. They don't have to tell you about risks of blood clots or risks of this. They don't have to tell you any of that. So that's a big problem and it makes people think that they're safer because look, if I gave you two things, one had a list that said it had a black box warning on it and the other one didn't, you're going to automatically think the one that doesn't have the black box warning on is safer. Well, it doesn't have the black box warning because it wasn't required because it's not FDA approved.

Mel Robbins: Oh my God. You know, when I was going through perimenopause, I got bioidentical hormones from a compound pharmacy and I thought I was fancy. I thought this is like high end medicine. They have taken something for me. This is how uninformed I was. Because of the word bioidentical, I thought it meant, oh, well, somehow this is custom formulated for me to match my hormones. It is bioidentical, which sounds really fancy and trustworthy. And then I would get this packet from a compound pharmacy and it would have these tubes in it. And there were all these warnings like, don't expose to light. Don't do this, do that. Now, did I follow those? Of course not. Was I precise in how much I would squirt on my wrist? No, if I'm being honest. And so I thought that I was having the better result when I can see now what you're basically saying is that no, not really. You were having the inferior. You were paying more and getting less.

Dr. Jen Gunter: Because we all think when someone's customizing something for us that we're getting better. We're trustworthy. We believe people. And no menopause society recommends compounded hormones. They're not recommended by the North American or we now call them the Menopause Society. The National Academies for Science, Medicine and Engineering don't recommend compounded hormones. The International Menopause Society, the British Menopause Society, none of them recommend compounded hormones because it takes science and research to know how to get hormones through a skin. It takes science and research to know how to get them from your gut into your bloodstream.

Dr. Jen Gunter: When you make hormones, they just get dumped into your bloodstream from your body. You're not eating them. You're not absorbing them. You're not rubbing them on your skin. You didn't evolve to get hormones that way. Now, it doesn't matter that we have modern medicine for a reason. So it doesn't mean you shouldn't take them because we didn't evolve for that. But it takes science to figure out how to make these molecules work for us. And so there are several issues with using compounded products.

Dr. Jen Gunter: People may be getting more of a hormone than they think they're getting. So you might be getting more estrogen than you need, which could put you at risk for endometrial cancer. You might be getting not enough progesterone, which would put you at risk for endometrial cancer, or you might not be getting enough estrogen, putting you at risk for osteoporosis. So you think that you're preventing osteoporosis, but you're not.

Dr. Jen Gunter: So this is the analogy I use. Using FDA approved hormones is like going to the gas station that has the gallons on and you can choose whichever gas you want. You fill your car and you have a working gas gauge and you're like, I know what's in there. And that's important. Going to get these compounded formulations or pellets is like buying gas from a dude on the side of the road who's telling you he has bespoke gas for you. And let him fill your tank. And oh, he's going to flip that switch off so you don't know how much is in there because you should trust him because he knows. That's the difference.

Mel Robbins: I am speechless. It's not very often that I don't have anything to say. And you just took a flamethrower to the entire idea of bioidentical hormones. I would never, ever try it again. And then I would add on top, by the way, you've brought the science and the research and a very compelling analogy. I'm going to add one more. As somebody who already has ADHD and has increased brain fog due to menopause, I am not that great at being consistent at storing things the right way or using it the right way. And so I'm probably over-underdosing even if it was made in a way that was clinically sound. And so case closed, not doing bioidentical hormones.

Dr. Jen Gunter: Yeah, and I would say move away from using bioidentical and just call them compounded. Because bioidentical doesn't mean anything. So bioidentical is a marketing term used to describe hormones that are plant-based, that are identical to what your body makes. But estradiol that you get from an FDA-approved company, I use an estrogen patch. It's estradiol. I've got it on right now. The estradiol in the patch is no different from the estradiol the compounding pharmacy is using. They're both buying the raw hormone from the same place.

Dr. Jen Gunter: The difference is the pharmaceutical company has studied how to give that estradiol to you in a reliable dosing manner. The compounding pharmacy has not done that work. They don't have that. And because of that, they're not FDA approved because you have to show to the FDA and it's expensive. You have to do all those kinds of things. So they haven't submitted that data. They're just making things up. So you have a precise studied formulation. But the big thing is they're not buying fancier hormones. All the raw hormone comes from the same one or two plants in the world. It's like me buying Cheerios and putting them in a Cheerio box or putting them in a glass jar with a ribbon around. But they're the same product.

Mel Robbins: Gotcha. Except the delivery mechanism is different.

Dr. Jen Gunter: Gotcha. So that's why I tell people, every estrogen that I would prescribe you from an FDA approved source, with the exception of Premarin, is bioidentical. So everything is the same. Just forget that word.

Mel Robbins: Okay. Yeah.

Dr. Jen Gunter: Because when people use the word bioidentical, it tells me that they think women are dumb.

Mel Robbins: Well, clearly I am in this area.

Dr. Jen Gunter: Well, no, seriously, I can own it because here's the thing. It is confusing as hell. And there's so much misinformation.

Mel Robbins: Right. And when you walk into the doctor's office and you are simultaneously erupting at your family because you're all over the place with your emotions, I'm speaking for myself here. And then next thing you know, you're sweating like Niagara Falls. And then next thing you know, your vagina feels like the Sahara Desert. And next thing you know, you can't remember where your car keys are or where you put your dog because you can't remember. And you are losing your mind. And somebody says to you, oh, bioidentical. And I can send you out. You're like, thank you. I'll take it, whatever. And so I had no idea. Yeah. And I used it for three years. And I thought I had the fancy thing.

Mel Robbins: And so I want to be very clear about something. And you listen keenly to me, Dr. Gunter, to make sure I have this correct. Because I'm putting my lawyer hat on. And I'm feeling the association of compounding pharmacists writing us a cease and desist letter. And so I want to be very clear about what she has said. Number one, it is a fact that the Menopause Society does not recommend that you use a compound delivery formula for any kind of hormone replacement therapy because it has not gone through FDA approval. And number two, the distinction that we're talking about is not the actual hormone. Okay, so they're using the same stuff. The reason why it is important that you understand this is because the delivery mechanism of the pharmaceutical product like Estradil has gone through FDA approval, which means the researchers and scientists and doctors know how your body's going to absorb it. They know the rate of delivery. They know that it has been tested. And so it is what the menopause society is recommending if you are going to do hormone replacement therapy. Did I get that right?

Dr. Jen Gunter: Yeah. And so, the other important thing is when you have an FDA approved medication, they're batch tested. So what that means is whatever, however many, one bottle in 50, one bottle in I don't know what it is, is tested to make sure it has what it claims. But when you're mixing up product after product one at a time, there's no batch testing that can be done, right? So the quality, you're talking about a whole different thing in quality control.

Dr. Jen Gunter: So the only time we ever recommend a compounded product is if there is a true allergy. There's no pharmaceutical option because of a true allergy. And that's where we rely on compounding pharmacies for that situation. So one example might be Prometrium, oral progesterone. The brand in the United States is made with peanut oil. So if you have a peanut allergy, you can't take that product. So the options are then to take a different pharmaceutical or to get progesterone compounded by a compounding pharmacy without peanut oil. That makes sense. So in that instance where you have a real allergy, you might recommend a compound pharmacy. But otherwise, 100% as literally the number one gynecologist, myth busting, you are out there setting the medical facts straight. The menopause society and your medical recommendation is to absolutely not be using the compounding formulas, but to be using the FDA approved delivery mechanisms that are prescribed by your OB-GYN.

Mel Robbins: Right. I am learning so much and I know you are too. And we need to take a quick break to hear a word from our sponsors. And while you listen to the amazing sponsors, would you please share this episode with someone who needs to hear it, which is basically every single woman in your life. And don't you dare go anywhere because when we come back, we are going to keep talking about exactly what you can do to relieve the symptoms of menopause. We have so much more to learn from the amazing Dr. Jen Gunter. And later on, we're going to talk about exactly how you can talk to your doctor in order to get the care that you need. All right, stay with us. We'll be right back.

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Mel Robbins: Welcome back. It's your friend Mel Robbins, and I am here with the incredible, myth-busting, and unbelievably empowering Dr. Jen Gunter. She is telling you everything that you need to know about menopause. So, Dr. Gunter, how do I know that I'm doing the right thing?

Dr. Jen Gunter: What people need to remember, the takeaway is, there's really very few things you need to know about hormones. The two main estrogens that we recommend are either estradiol. And if you're stuck on the term bioidentical, that is bioidentical. Now, I'd like people to throw that term away, but sometimes it's hard. So the estradiol that I would give you in a patch or a pill from a pharmaceutical company, that is bioidentical, right?

Dr. Jen Gunter: So you have that. You want to learn estradiol, and then you want to learn Premarin, which is conjugated equine estrogens. And that's only actual natural estrogen because it comes from horse urine. So "natural" means the substance exists in nature and it's being used unchanged.

Mel Robbins: How the hell did they figure out that horse urine is something that...

Dr. Jen Gunter: Yeah, horse urine has got all kinds of estrogens in it. It's a crazy thing. So those are the two things you need to learn: estradiol and Premarin, which is the trade name for conjugated equine estrogens. And then you need to learn oral, transvaginal, or transdermal—so against the skin, through the vagina, or by mouth.

Mel Robbins: Gotcha.

Dr. Jen Gunter: And we recommend the number one starting treatment is transdermal estradiol. Here, I'll show you. I'm going to show you mine right now because I'm probably due to take it off. I have to do it every four days. [Pause] Oh, look, I wear black underwear. Let me get down here. Okay. You guys will never watch YouTube again. Okay, here it is. So this is—and look, my dead skin is on it. That's disgusting.

Mel Robbins: Yeah, so you have a patch.

Dr. Jen Gunter: Yeah, so I have a patch. I'm going to hold it up right there. I have to replace it every four days. Changed my life. And so I can trust knowing that if I put this on every four days, and this is considered transdermal. That's transdermal. It goes through the skin. You don't want to stick it just anywhere. You only want to put it in the place that the package insert says, because it's been studied. They've studied it in different locations, and the absorption can change. So if you put it on your belly versus your thigh or your butt, you might get a different absorption of the amount of estrogen. And you don't want that. You want to know what you're getting.

Mel Robbins: That's right. And I've also learned—because I had no idea—that you could also insert something into the vagina for hormone replacement therapy.

Dr. Jen Gunter: Yes. So there's a transvaginal ring that also has estrogen and can be absorbed that way into the body. And there's also a ring where the estrogen just stays in the vagina. If you're having vaginal dryness, urinary tract infections, pain with sex, vaginal estrogen can be very effective for that. Some people who have no other symptoms of menopause feel fine, but they have vaginal dryness. They don't want to take a medication that goes throughout their body. They want to just use a vaginal estrogen. So we have that. That's a great option. When you're using estrogen that goes through your body, about 50% of people will get a good level in their vagina, but some people won't. From a take-home standpoint, there is absorbing through the skin or through the vagina, and there is taking it by mouth. And we believe that absorbing it through the skin has the lower risk of blood clots. So that's why the first-line therapy for menopause is transdermal estradiol.

Mel Robbins: You mentioned pellets a couple of times. What are those?

Dr. Jen Gunter: Pellets are implants that you go to a medical doctor or a nurse practitioner. I think maybe even in some places there are naturopaths who insert them. I don't really know because I'm not really involved with it. They can either have estrogen, or estrogen and testosterone, or maybe other hormones. I don't really know. They're made in compounding pharmacies and they're implanted. They're not batch tested, so you don't know how much hormone you're getting. My understanding is it's based on a proprietary system. You get your blood drawn, they follow your hormone levels, and then they decide when you get the next pellet based on that. But we don't recommend hormone levels for giving hormone therapy. It's not based on levels. It's based on symptoms. I don't need to know what your estrogen level is if you're 47 and starting it. I don't even need to know what your estrogen level is when you're 42. I only need to know if I'm worried that you have premature menopause. So this sort of system is not recommended. There've also been issues with pellets—complications and side effects not being reported to the FDA, which is another concern. We don't actually know how many people have problems versus pharmaceutical companies, where adverse events are passed on to the FDA because there are big penalties for not doing that.

Mel Robbins: So is the pellet a delivery mechanism?

Dr. Jen Gunter: Yeah, it's an implant that sits in the body. Because I don't do it, I don't really know much about it because it's not recommended. What can happen is it can produce very, very high levels of hormones, and then it drops off. In some cases, you can be exposed to levels of testosterone that we might give someone if they're transitioning—the kind that can cause you to develop an enlarged clitoris, the kind that can cause changes from having too high testosterone. We don't know when you're using those hormones how much progesterone to give you to protect your uterus. So there are all different kinds of issues associated with them, and they're very expensive as well. They're just not recommended.

Mel Robbins: Do you have to have your blood drawn to have this assessed effectively?

Dr. Jen Gunter: No. And if anybody—if you're 45 years or older—you do not need a blood test to get started on menopausal hormone therapy. If you're 11 and having a growth spurt, no one says, "Ooh, why are you having a growth spurt? We should check your blood." We would expect you to have a growth spurt at age 11. If you had a growth spurt at age three, that would be different. And that's the same thing for menopause. So if you're 45 or older and you're having hot flashes, vaginal dryness, irregular periods, it's not a mystery. We're expecting it to happen. The average age of menopause is 51. However, if it's happening to you when you're 39, that's different. We need to know: is this an earlier menopause, or is this happening for another reason? If you're under the age of 45, you need the blood work because you need to make sure you understand why your periods have stopped. If you're just having hot flashes, that's a different story. The blood work is really if you've skipped periods. Say you're 42 and you haven't had a period in three months—you need blood work because we should figure out why that's happened. But if you're 45 and you're having bad hot flashes and a couple of irregular periods, that's no mystery. You're starting the menopause transition. The average age of onset for the menopause transition is 45. Well, 50% of people are going to be younger than 45 and 50% are going to be older. So it has to be put in context. The internet wants absolutes: "Test my hormones, don't test my hormones." The internet wants this or that, but medicine is more nuanced than that. The only absolute I can say is if you're younger than 45 and you've skipped more than two periods, then you need blood work because we need to know why. Is it an earlier menopause? Is it another condition? If you're 45 or older, it's not a mystery why you've gone two months without a period.

One thing we didn't talk about is one of the contraindications for starting estrogen: being more than 10 years from your last period or over the age of 60. In general, that is associated with an increased risk of dementia and an increased risk of cardiovascular disease. So we want to avoid starting it when people are older. It doesn't mean that at age 60 on one day it's a hard stop. If somebody's last period was at 55, we might not cut them off at 60. There might be a bit of wiggle room. But in general, we recommend that if people are going to start hormones, it should be within 10 years and under the age of 60. That's the ideal situation and the lowest risk situation.

Mel Robbins: I can't believe how much I'm learning from you today. I thought I knew a lot about this topic, but you're just constantly amazing me with new information. And I know as you listen, you're thinking the same thing. We also need to take a quick break to hear a word from our sponsors because they allow me to bring you world-class expert advice from the amazing Dr. Jen Gunter. So do me a favor, listen to our sponsors, and please take a minute and share this episode with someone who needs to hear this. This could truly change their life. And don't you dare go anywhere because when we come back, I'm going to be waiting here with Dr. Gunter and you're going to hear more on how to deal with your symptoms, plus how to talk to your loved ones so that they better understand what you're going through and how to talk to your doctor so you get the care that you deserve. Stay with us.

[Ad break]

Mel Robbins: Welcome back. It's your friend Mel Robbins. I am here with Dr. Jen Gunter. So Dr. Jen Gunter, one of the things I'm sitting here thinking about is the fact that my friends and I all talk about menopause because we're all in the thick of it. But more than half of the women I know are scared of HRT. I know it's because of that huge study released in 1991—the Women's Health Initiative—that cast HRT in a negative light. I understand the study has been harshly criticized. It's now 30 years later, but it's very clear to me that the fear it created is still lingering and keeping a lot of women from even exploring hormone replacement therapy as a safe option. Can you tell us more about this study and how you think about it as a medical doctor?

Dr. Jen Gunter: The Women's Health Initiative was the largest clinical trial ever done. It was designed to tell whether menopausal hormone therapy would reduce the risk of heart disease without increasing the risk of breast cancer. There were other arms that looked at exercise and calcium replacement. The arm with estrogen plus a progestin—Premarin plus a progestin—was stopped early because they reached the threshold of concern about breast cancer. Going into the Women's Health Initiative, we knew there was a very low risk of breast cancer associated with menopausal hormone therapy. So this wasn't a surprise; it was the threshold that was reached. It was communicated to the public in a way that is typically not done. Usually there aren't press releases when a study is halted. Usually we wait, get the data, the article is published, it's peer reviewed. That didn't happen. That created this big hoopla where lots of things got taken out of context and accelerated in ways that were uncontrollable because fear sells. I don't know how many major news stories were dedicated to the WHI, but it was really out of proportion. When more information came out and more studies were published, that never gets the same attention.

We know that estrogen plus a progestin is associated with an increased risk of breast cancer, but those aren't the hormones we typically prescribe now. That's the difference. We believe that the progestins—which are slightly different molecules than progesterone—carry the higher breast cancer risk. It's still acceptable and in the safe range to take. The hormone progesterone is lower risk. And if you don't need a progesterone or a progestin, that risk is the lowest. I would say to people: if you're taking a transdermal estrogen and oral progesterone—our standard starting therapy—we believe the risk of breast cancer is very low. It's probably not zero, but it is very, very low. If you're taking estrogen alone, that risk is even lower. Some people believe it's zero. Other people believe it may be a little bit higher. It depends how you look at the data. For the majority of people suffering with symptoms related to menopause that hormone therapy can treat, menopausal hormone therapy appears to be a very, very safe option. You just have to look at it in context. If you're at higher risk for cardiovascular disease but not super high risk, transdermal is probably okay, but oral isn't because there's a higher risk of blood clots. You have to look at what it's going to do for you.

I'm very high risk for osteoporosis. My mother died from osteoporosis. I have quite a high FRAX score, which is a risk calculator. That's the main reason I'm on menopausal hormone therapy—because my risk of osteoporosis is pretty significant. I'm already getting closer and closer to osteoporosis or osteopenia. It's a concern for me from a health standpoint. People always want us to say zero risk. Getting in a car has a risk. I like to not talk in absolutes and say: what's the reason you're on it? What is the risk-benefit ratio for you? For the majority of people, the risk-benefit ratio is absolutely going to be in the favor of benefit. But there are some situations where it might not be—someone at very high risk for cardiovascular disease, someone who's previously had a blood clot, someone who's previously had a heart attack. You have to put it in perspective.

Mel Robbins: Thank you for that. Dr. Gunter, I've been really surprised by the number of my friends who are suffering through menopause and perimenopause—their quality of life is completely impacted—who have been afraid to try hormone replacement therapy or even talk to their doctor about it because somewhere in the back of their head, they think it causes breast cancer. That's why they're not even considering it. I appreciate you clearing the air so that people know they should at least go talk to their doctor about it.

Dr. Jen Gunter: Yeah. And there are calculators that can help you determine your breast cancer risk. I think we heard it was Olivia Munn who was talking about this recently. She had a breast cancer risk assessment, which led to her having an MRI, which led to an early diagnosis of breast cancer. There are several easy tools we can use to explain things in context for you. If somebody comes to me and they have something that menopausal hormone therapy can help with, I do something called an ASCVD score. It calculates your cardiovascular risk. We need your lipids, your blood sugar, your blood pressure, and a few other things. We can calculate that. I need to see a mammogram and ask some questions about your breast cancer history risk. That's important because at a certain level, when your breast cancer risk is higher based on other factors, there's also a conversation to be had about medications that lower your risk of breast cancer. There are bigger discussions to have. You can do these risk calculators and say, "Look, I'm somebody with hot flashes. Menopausal hormone therapy is the gold standard. I have low risk for these other reasons." There would be no reason not to go on it. But everybody weighs risks differently. Versus somebody with pretty high cardiovascular risk—can we talk about one of these other treatments for your hot flashes? Or somebody with a history of breast cancer—can we talk about one of these other medications for hot flashes?

Mel Robbins: I want to ask a couple more questions about HRT. Someone listens to this episode, feels very seen and validated, goes into their OB-GYN, says they want to assess the risks. Let's say you try it. You make the personal decision with the recommendation of your doctor to go on the standard protocol. How do you know if it's working?

Dr. Jen Gunter: Are your symptoms improving? It's really that simple. Unless you're someone like me taking it for osteoporosis prevention, because I don't feel any different. That's a really important reason to take an FDA-approved medication—I need to know what I'm absorbing to protect my bones. If you have hot flashes, most people see a pretty significant improvement within four weeks. Depending on how much better people feel, sometimes we might give an eight-week try before switching doses. It just depends on how people feel on the medication. Usually with hot flashes, you'll see an improvement pretty quickly. With depression, usually within a couple of months as well.

I always like to talk about green light indications—FDA-approved, solid reasons. Hot flashes, night sweats: gold standard. Osteoporosis prevention: FDA approved. And we didn't talk about this: if you have menopause before the age of 45, we recommend everybody take hormones regardless of symptoms until at least the average age of menopause. At that average age, you can decide if you want to stay on or not like everybody else.

Mel Robbins: What is the average age of menopause?

Dr. Jen Gunter: 51. So you've got these green light indications. Great. Everybody believes the benefits outweigh the risks as long as you're in the right category. Then there are yellow light indications—things where it hasn't been recommended in the guidelines, but there's pretty good data to support it. For example, depression in the menopause transition can be very helpful. Many of us would try it if somebody has a sleep disturbance, even if they don't think they're waking up with hot flashes. Sometimes people don't wake up, but it disrupts your sleep architecture, so you don't have as much deep sleep. It might be worth a try. I still get the occasional hot flash. Even when I thought I didn't wake up, I was so hot I woke my partner up. I'm a super deep sleeper, but I still had disrupted sleep. You might not realize that. The data for joint pain isn't really that great. Maybe it helps 20% of people with joint pain. It wouldn't be wrong to try, but if it doesn't work, you're not going to keep pushing the dose higher and higher. There is some evidence it may reduce your risk of type 2 diabetes. If you're at very high risk, that might be a conversation to have. Those are the yellow light indications.

If you have brain fog, there aren't studies to tell us that estrogen treats brain fog. In fact, people perform better than they think on cognitive testing when they have brain fog. It's a symptom we don't really understand. You could have brain fog from depression, from not sleeping well, from other factors. If your only symptom were brain fog, it's less clear you'd get a benefit. But if we did a depression questionnaire and you're scoring higher for depression, brain fog is a symptom of depression too. Let's get that treated and see. And let's work on the other foundations like exercise and eating healthy. There is one study that looked at the healthy things you're supposed to do in menopause—get the right exercise, eat a fiber-rich healthy diet, and not smoke. Only 8% of women did all three.

Mel Robbins: You wrote this unbelievable article that went crazy viral. Dr. Gunter, you say, "Don't use menopause to excuse mediocre men." What does that mean?

Dr. Jen Gunter: I think everybody knows exactly what I mean. There's this edge of a knife when you're a woman. Women are too hormonal, too this, too that. But you can also have symptoms related to that. Because of the history of calling women hysterical, the mad woman in the attic—all of that—I think it's super important to be accurate when we're assigning fault. There was this advice column in The Guardian. A woman had written in. I can't remember the specifics now, but she and her husband had a contract or verbal agreement about how they would raise their children. He was clearly not living up to what they'd agreed upon. He was basically her third child. I think a lot of women know exactly what I'm talking about. She wanted to leave him because she didn't want to be a mother to him. I hear this from a lot of women. She was writing in for advice. Because he wasn't vacuuming, he wasn't doing any of the stuff. She was doing it all. The answer was: "Maybe it's menopause. Maybe you're intolerant because of your hormones." Really? Maybe she'd go on hormone therapy. She didn't say she had hot flashes. She didn't say she was sleeping poorly. She clearly laid out that they had agreed to be equal partners, and here she was doing all the grunt work while he was out at the pub. It was the most obvious—pull the plug, get divorced, save yourself, run, don't look back, run. And no, maybe it was your hormones. I know that when I was going through menopause, I had a shorter temper. So I think it's really important that we are not excusing the bad ways that society treats women and saying, "Oh, if you just took hormones, it would be better." The answer to being mistreated is not taking hormones. The answer to being mistreated is to be treated correctly. I think it's really important that we're clear about these things.

Now, if somebody comes to me and says, "Oh my God, I had the perfect relationship and my husband does everything. Now that I'm not sleeping at night and I'm soaked in sweat all the time, I've got a super short temper." Yeah, your hormones might be having something to do with that. Maybe if you actually had a good night's sleep, this would be better. I think most people can agree with that. But that wasn't the situation being presented. It's really important, especially in the workplace too. Many women in the workplace are treated terribly, especially as they age. There are so many glass ceilings. While it's super important that workplaces accommodate menopause, we also don't want to use that as lip service to excuse all the bad policies keeping women from advancing. "Oh look, we're letting you control the temperature," when really there's a massive glass ceiling. Accuracy in all things.

Mel Robbins: Well said. Can you speak directly to the woman who's listening to you right now, Dr. Gunter, especially if she's not getting the support from her family or her partner, and she's going through menopause or perimenopause right now?

Dr. Jen Gunter: I would say that's a pretty awful place to be if you don't feel supported. Whether it's menopause, pregnancy, or any other health condition, you want the person who loves you to support you. I would say that's an awful place to be. If you feel safe having that conversation, explain what's going on. Maybe say, "Here are some things you could read so you have a better understanding of where I'm at."

Mel Robbins: A lot of women are going to forward this episode to their family members and partners. I would love to have you speak directly to the partner, the children, the family members of a woman going through menopause. What could they do to be more supportive?

Dr. Jen Gunter: If you have a family member—your mother, your sister, a loved one—going through menopause, learn about it. Also think about what you can do around the house to make it easier. Everybody needs a bit of help. In many heterosexual households, women are doing the burden of the labor around the house. There's a study that shows even when hour per hour it's the same, women do more of the less fun work. That doesn't surprise anybody. If you take hour per hour, the man is more likely to be out in the yard playing with the kids, and the woman is more likely to be doing the laundry. So four hours, four hours. How can you think about having a more equitable division of labor in your house? If you have a family member who's struggling, wouldn't you want to carry some extra load to make it easier for them? That's just being a human.

Mel Robbins: I would imagine any kind of support that lowers the stress level makes you feel better too, from a health standpoint.

Dr. Jen Gunter: Absolutely. Ask, "Can I go with you to a doctor's appointment? Can I be your scribe?" Buy The Menopause Manifesto, my book. Think about how you can do little things to help. Look at the chores you're doing in the house. Think about how you can pick up more. Think about how you can listen. Just sit and listen. Not everybody wants an answer. Sometimes people just want to talk. There's a great episode of Parks and Rec where Anne is pregnant and her spouse—played by Rob Lowe—just wants to solve everything. "Let me get you this, let me get you this." She just wants him to sit and listen. I think a lot of people just want you to sit and listen too.

Mel Robbins: I think I speak on behalf of the person listening, and I know myself, when I say: can you be my gynecologist? I want somebody as informed as you. Can you offer any scripts or advice for how we can have better conversations with our OB-GYNs, or how we can find somebody who is really in tune with all the research and the recommendations of the Menopause Society?

Dr. Jen Gunter: The Menopause Society does have certified menopause providers. You can certainly look for someone who is a certified menopause provider. That's not necessarily a guarantee that they're going to give you evidence-based care. I understand there are some who also implant pellets. But in general, I think that's a good place to start. If you ask your doctor about menopause and they clam up, if they can't have a conversation about it... There are lots of great people who know how to care for menopause who haven't done the test and aren't members of the Menopause Society.

Dr. Jen Gunter: So, the other thing that I recommend people do is you can Google the 2020 North American Menopause Society guidelines for hormone therapy and you can download it. We'll link it in the show notes. It's a PDF. Now, there are a lot of semi-interesting things in there talking about risk, complex studies, and things like that. But at the end of every section, they have a kind of general, good, plain language summary. I think that many people would find that quite illuminating.

You could read it and even take it with you. If you're asking for something and it isn't even mentioned in there, maybe you're asking for something that's a little bit out of spec. Do a word search—Control F or whatever you have to do. If you've got a specific word, search the document for it and see what shows up. That's a good place to get some basic information that's evidence based. They have some information on their website, too.

I would just say that for the majority of people who want to try menopausal hormone therapy, a six-month to a year trial is as low risk as anything can be. When we look at the risks of breast cancer, if you assume that the studies that show risk are correct—again, we've had this spectrum of some studies showing one thing, other studies showing nothing—there's no risk with a couple of years. That risk doesn't accumulate for a while. So if you're really scared, and you're a good candidate cardiovascularly, trying it for six months is about as low risk a therapy as there can be.

If you try it and you think, "Well, this hasn't improved my quality of life," there's your answer. And if you're on it and you think, "Wow, my quality of life has changed a lot," then there's your answer. There are lots of things that haven't been studied. Many women talk about symptoms like they just don't feel like themselves. We don't have a scoring system for that. You not feeling like yourself and me not feeling like myself might mean two completely different things. They could be completely different biological phenomena, but we're using the same words to describe it.

Because it's such a low risk thing, if you're using the FDA-approved therapies and you have low cardiovascular risk, there's very little downside to saying, "Is an appropriate dose improving things?" The one word of caution I would give is that if you're not improving, be very careful about dose escalation. If you think about an estrogen patch that has 100 micrograms of estradiol, that is about equivalent—if you even it out through a whole month—to the amount of estrogen you make when you're ovulating. So if you're needing more than that and you're over the age of 45, it probably needs a little more reflection. Why would you need on average more estrogen than your body was making? If you're needing more than that, that might be a time for a reassessment of things. You might be on the right track, but I would say that's a time to reassess.

Mel Robbins: Dr. Gunter, if you could just speak to the person listening, and if there was one or two things that are the most important takeaways from everything that you shared today, what are the things that you would want the person listening to focus on?

Dr. Jen Gunter: I would want to say that accurate, evidence-based information is really the best way through any medical situation. We don't always have all the answers, and women's health has been underfunded. But having the information that we have is a lot better than just wild guesses. So keep that in mind: we do have quite a lot of information.

If you're not being heard by your physician, I know it's hard and it shouldn't be that way, but get a second opinion. And just be mindful of people that are selling product. There's a lot of incentive—or there can be—or there can be bias. You just need to be mindful about that. I get paid the same whether I talk to somebody about exercise or whether I give them hormones. I'm on salary. I don't have any kind of deal with a specific company. I don't take any money from any pharmaceutical company. You can look me up. The bias can come in all different kinds of ways. I just think it's important that if you're on social media and someone's also selling a product, to just be really wary of the message. That's all.

Mel Robbins: I just love how you explain this stuff. Thank you. Thank you so much for having me. It's been great. I feel so empowered. And I am also happy that I got to reveal to you how much I did not know and how much I was doing wrong. Because if I can save you the headache or the time or the heartache that I caused myself because I just didn't know, if that's what you get out of this, you learn from my mistakes. Holy smokes, that's absolutely incredible.

So thank you for spending time listening to something that could change your life. Thank you for sharing this episode with women in your life, because anybody that you share this with, it's going to help them take control of their health. And in case no one else tells you today, I wanted to be sure to tell you that I love you, I believe in you, and I believe in your ability to create a better life.

After today's conversation learning from Dr. Jen Gunter, I know that you have the research-backed facts and the medical advice that you need in order to be more empowered and informed about your health. And that is one of the best things that you could do to create a better life. Alrighty, I'll talk to you in a few days.

[Audio continues with off-mic chatter]

Mel Robbins: So Dr. Gunter, thank you for jumping on a plane and flying across—I can't even speak that. Okay, sorry.

Dr. Jen Gunter: What's that? You knew you were just warming up. It's all good.

Mel Robbins: Can I also—I just realized I should probably clean my glasses.

Dr. Jen Gunter: Yeah, I just took off a layer of street grime from mine. And now I'm like, "Oh wow, my God, I can actually see." It's amazing.

Mel Robbins: Do you like that?

Dr. Jen Gunter: Yeah, I'm going to do one more. Hold on a second. Okay, great, great, great. Okay, gotcha. You go up a little. Let me do it one more time.

Mel Robbins: Okay, what was that? Whatever it's called. You know, doctor or gangster. You know, you want me to do that right now? No problem. I'll do it.

Dr. Jen Gunter: Okay.

Mel Robbins: Go Tracy, go! All right. Thank you. Thank you for letting me talk so much.

Dr. Jen Gunter: Oh, thank God you did too. You were awesome.

Mel Robbins: Oh, and one more thing. And no, this is not a blooper. This is the legal language, you know what the lawyers write, and what I need to read to you.

[Mel reads disclaimer]

Mel Robbins: This podcast is presented solely for educational and entertainment purposes. I'm just your friend. I am not a licensed therapist, and this podcast is not intended as a substitute for the advice of a physician, professional coach, psychotherapist, or other qualified professional. Got it? Good. I'll see you in the next episode.