Ep. 237 Perimenopause and Menopause: What You Didn’t Know with Dr. Felice Gersh

Cynthia Thurlow: Welcome to Everyday Wellness podcast. I’m your host, nurse practitioner, Cynthia Thurlow. This podcast is designed to educate, empower, and inspire you to achieve your health and wellness goals. My goal and intent is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives.

Today, I had the honor of reconnecting with Dr. Felice Gersh. We connected earlier this year on Episode 221, discussing polycystic ovarian syndrome and metabolic health. Today she joined me to deep dive into perimenopause and menopause. We spoke at length about the issues surrounding the Women’s Health Initiative how that has created in a fearful environment, not only for providers but also women with a tremendous amount of misinformation. We chatted about estrogen as a family of hormones, estrogen-mimicking chemicals, the role of synthetic hormones, including calling oral contraceptives endocrine-disrupting chemicals, the importance of thyroid function, the pro-inflammatory state of a loss of estrogen in perimenopause and menopause, the importance of lifestyle including nutrition and exercise to help with metabolism.

We also spoke specifically about less common known changes that occur in menopause, including body odor changes, constipation, sarcopenia, osteoporosis, and vocal changes. I will definitely have Dr. Gersh back again, I hope our next podcast will be focused on women and mitochondrial health. And we will probably have a fourth in 2023 that will be encompassing her newest book, Menopause: 50 Things You Need to Know. It is one of my favorite resources to recommend to patients. I hope that you will find it as beneficial as I do.

Dr. Gersh, on our last podcast, we really laser-focused in on polycystic ovarian syndrome. And you graciously agreed to come back again. And now talk about middle age and perimenopause and menopause. But I would really love to start the conversation talking about the Women’s Health Initiative. As many of the listeners know this is a study that came out in 2002. And I was just starting as a new nurse practitioner and being in cardiology kind of safely tucked away. I didn’t really have to deal with the ramifications too much. But I would imagine it probably created some significant ripple effect in your practice as a GYN.

Felice Gersh: Well, I would say more like a tsunami, definitely-

[laughter]

Felice Gersh: -because the whole paradigm of what hormones do if they’re good or bad, completely shifted when that study abruptly ended. It didn’t end as planned, it ended because they felt right then and there that more harm was being incurred than benefit and they just stopped the study. It really created a huge 20-year ramification of harm. It’s been so devastating to women’s health, and it really completely created a mass of misunderstanding about what hormones are and what they do, and what menopause is even all about in the woman’s body. I’m really happy to have this opportunity because the Women’s Health Initiative was like so many things. It was begun with the best of intentions. It was actually believed at that point when it was being created, which took a long time. It was a hugely expensive study funded by the National Institutes of Health. It was designed to actually show all the benefits that was the original thinking. The benefits that would come to women from being on hormones, but they already had an inkling they should have had from a previous study called the Hertz study, which was to look at women who had already documented cardiovascular disease. And then they were given what was the hormone dujour, which was the conjugated equine estrogens, the brand name Premarin combined with medroxyprogesterone acetate, which is a progestin. Progestin is a made-up word for progesterone, endocrine disruptor, meaning that it actually binds to progesterone receptors, but not with the same actual effect as if it were the human bioidentical produced progesterone.

So, in some cells, it could act almost like a blocker, what we call an antagonist. In other cells, it can act as a promoter, like what we call an agonist. So, it has different effects. And the drug that was used for the estrogen that conjugated equine estrogens are actually hormones. It’s not just estrogens, it’s actually combined with other stuff like different androgens and other things that are coming out in a pregnant horse’s urine. And this was all they could do initially in the day, they took this urine, they dried it, and they put it into a tablet form and then they gave it to human women. And it actually did work to suppress hot flashes and night sweats, because although it was a horse’s estrogen that it was trying to get rid of, that’s why they call it conjugated. It has already gone through the liver, gone through a transformational process that changed it into becoming water soluble, so it could go out with the urine.

So the horse was trying to get rid of it, it didn’t want it anymore. And it came along with many different kinds of estrogens that would be found in a horse but never in a human. And so just the fundamental understanding of what is estrogen is so important because they use estrogen, they toss it around like it’s all one thing. And estrogen, it’s a family of hormones. There are different estrogens. A horse makes equine estrogens, they’re different from humans, they have different molecular compositions. And the human female has different forms of estrogen. The one that the ovary makes is called estradiol.

Now the placenta in pregnancy makes a different one as a dominant one. It also makes the other estradiol but the dominant one is estriol. And then when you have a conversion of androgens to estrogens in, for example, other peripheral tissues, other sites, the dominant organ that makes estrogen in menopausal women is fat, or adipose tissue because it has the enzyme that can convert androgens predominantly coming from the adrenal gland into a different estrogen called estrone. And it turns out that estrogen can bind to different types of receptors and the different types of estrogens bind differently. And estrone, the dominant estrogen of menopausal women binds to the alpha receptor. Estriol, the dominant one in pregnancy binds to the beta. And then estradiol has a balanced binding. And there is other receptors on the cell membranes that we call like [unintelligible [00:07:30]. So, it’s more complex. Every time we learn, there’s more complexity. These receptors are not static, they’re dynamic, they’re transformational, and they interact with each other.

So, you have really different effects. If you have one type of estrogen or another, it would be like saying, you need a B vitamin. Well, which B vitamin? B vitamins are a family, everybody knows that there’s B1, B2, B12, different Bs. They’re not all the same. And estrogens are the word is tossed around. And then on top of that, when they talk about estrogens, they throw in other endocrine disrupters, chemicals that can interfere with every aspect of estrogen, its production, distribution, its degradation, its elimination, its receptor binding, and they throw that all in with estrogens. These are healthcare professionals at the top of their game from major universities like Harvard, and they’re tossing these terms around like they’re all the same. And then so here’s my analogy, which sounds crazy, but it really applies to the Women’s Health Initiative.

They did this study with these different chemicals that are never found in a human body, the estrogen product, the conjugated equine estrogen was given orally, which means it gets even transformed through digestion and the liver, so that when it enters the bloodstream, it enters with all these horse estrogens plus, the other is predominantly turned into estrone, which works on the binder that the receptor which is called alpha, so it’s not the same as having estradiol.

You do a study with strawberry-flavored jelly beans, and you find, lo and behold, it increases cavities and diabetes, and obesity. So, what’s the conclusion? Never eat an organic strawberry. I mean talk about you’re making this incredible conclusion that has nothing to do with what you studied, and that’s what they did. But in the paper itself, it said these conclusions only apply to what was studied. But that isn’t how it was spoken about. Even by the people involved in this study. They suddenly applied it across the board to every dose, every form, every type of estrogen, and then remember, what they used was medroxyprogesterone acetate, which turned out to be really bad, really, really bad for women. And that was actually underlined most of the bad outcome was actually not even from this other crazy stuff, the Premarin, but actually from the medroxyprogesterone acetate.

The bottom line is that none of this that I just said was understood. I mean, we did know, but it wasn’t conveyed to anyone, anywhere. The general message came out, “Don’t prescribe hormones. Don’t prescribe them.” It was like sort of a dogma, “don’t prescribe them.” But if you must, because they do work best for night sweats and hot flashes, they couldn’t get off, get out of that one. So, if you have to prescribe it, then you give at the very tiniest possible dose to try to suppress the symptoms for the very shortest period of time. And this dogma, which is erroneous, simply has stuck.

And 20 years later, despite all the scientific data we have, it just– which I’m working so hard to undo this totally wrong mindset about hormones. When you study something that is not human, that has other effects, that are actually technically endocrine disruptors. I always say, if I gave you a little plastic cup and I put it in some kind of special kind of modified Vitamix, you know, and it turned it into powder. So now I have a plastic cup that has been powderized. and then I put it in a capsule, and I said, “Here, take your hormone every day. This is it.” You would say, “That’s my hormone?” But that’s really an analogy because the plastic is actually an endocrine disruptor, a xenoestrogen. It can interfere with estrogen and all sorts of ways.

Well, so too is the conjugated equine estrogens. And it’s same thing for progestin, it’s not progesterone. Even in I’ve read articles that are published in major prestigious journals, and they use the word progesterone when they’re referring to this chemical manmade progestin. And they’re the same and they’re not the same. It’s the same strawberry flavor, jelly beans versus organic strawberries. It’s created massive confusion and fear. So, I’m just here to set the story right now. Just get it right, let’s talk about what really is the science of hormones, what really is menopause, and what it really does to a woman’s organ systems in terms of everything, her metabolic status, and metabolism, which is tossed around that word a lot, is really the spark of life, the creation, distribution, storage, utilization of energy, which is so critical because you want to eat to provide energy, but you don’t want to overeat, you don’t want to under-eat, we have systems in the body in place to actually make everything just right. But now they’ve been so mucked around with people don’t know, if they’re hungry, they’re not hungry, they eat, there’s so dysregulated all the rhythms of the body. And much of this is controlled through estradiol, the estrogen made by the ovaries, which some very smart people, and it wasn’t me, came up with how to create an exact replica, and complete clone, completely indistinguishable from estradiol made by the ovaries. And we now, which we didn’t have that way back years ago. But now we have that. So, why are we not utilizing that and recognizing menopause for what it is? Natural, universal, and not helpful. And those are not synonymous. Everything that’s natural, isn’t beneficial. Like, “Oh, how about tornadoes and hurricanes and fires and tsunamis?”

There are natural things, I won’t go into climate change, but there are natural things that have always happened that are not beneficial. We need to look at death. Well, death is probably good for the planet as a whole, because just think, there’d be no room for anyone new, but for the individual, not so great. Aging is inevitable, but not so great for the individual.

I look at aging, not as how many years you’ve lived, but how many deficiencies you’ve acquired. When you don’t have hormones, you are definitely going to get major additional deficiencies because every organ system, including the gastrointestinal system, whereby you digest and absorb vital nutrients macronutrients, micronutrients is not going to function optimally. And that sets the stage for cellular dysfunction, immune dysfunction, chronic inflammation, and all these diseases that we consider chronic diseases of aging. And all of these can be delayed. I’m not saying you can never get old and you can’t have conditions. But all of these things can be really dramatically delayed when you incorporate hormones alongside of all the other essential lifestyle types of procedures and styles and living, and all the things that you have to do because it’s not one thing. It’s the total package of how you live your life. But you can’t be healthy, optimally, if you don’t have the right amount, the right rhythms of these essential ingredients. I call them the life hormones, not sex hormones, life hormones. Our estradiol and our progesterone.

Cynthia Thurlow: I think you did such a beautiful job explaining not only on the Women’s Health Initiative, but the differentiators between synthetic hormones versus bioidentical hormones. I was coming of age as a new nurse practitioner in the early 2000s. And I watched my mom and all of her sisters stop all of their hormones. I am now looking at my aunts, all of them I’m very close to and love. I’m starting to see some of the side effects for those that have not been on bioidentical replacement of hormones, the cognitive changes, bone health issues, heart health issues. I really think that perhaps my generation, as we’re evolving into menopause, as you mentioned, it’s a natural process to no longer have periods or fertility, but with greater awareness. And I think many of us are looking at this from a point of empowerment that we now know way more than perhaps we did 20 years ago. But we’re starting to see the impact of women and providers. And I’d say all the time, there’s a whole generation of providers and a whole generation of women who are fearful of hormones, and it shouldn’t be that way.

Felice Gersh: Oh, my goodness, I see it every day. Like yesterday, I had patients come in and their doctor said, “No way can you be on hormones. You can’t be on hormones, they’re bad for you.” And it’s like, “Oh, my gosh,” like back to the drawing board. This person doesn’t understand that– if you understand like a basic premise of what does a hormone do, it delivers vital information to the cell, so basically, it can trigger the production of signaling agents. It can produce through the nucleus for nuclear receptors, it can produce vital enzymes and proteins, but none of this will happen properly if you don’t have the signal to tell the cell what to do. So, it’s like, the old adage that, “What you are going to do with an orchestra if you don’t have a conductor?” So you can have great musicians but if the conductor never shows up and tells them what to do, they’re going to be silent, or they’re going to create noise because without the conductor, they’re going to be off each section. The winds and the percussionist and the strings, they’re all going to be off like one measure, or even a few notes, so it’s going to be noise.

You have to have the great coordinator of all the organ systems to work in sync in the same time zone. And to do the right things, so that one thing ends up in the proper sequence to the next. And that requires these vital hormones. And they interact, like a lot of people don’t know that, for example, estradiol upregulates, so it makes more functional, the receptors for thyroid hormone. So, that’s why every woman when she goes into menopause, she often well– a lot of them, they go to the doctor, and they say, “I googled this. Dr. Google said these are the symptoms of low thyroid. And guess what? I have all of them. I must have low thyroid.” And then the tests are done and the thyroid levels are within the reference range for what always that means either, that means 95% of random people had from this value to this value, but you’re in that range. So, they say, “You’re fine.” And then, of course, they think “Oh, another woman who needs antidepressants,” or something right tranquilizers like she’s another mental case. She is hypothyroid because it doesn’t matter how much hormone you have if it doesn’t work properly on the receptor. We know that very well with insulin, people talk about insulin resistance, you can have plenty of insulin, but it isn’t working to get the glucose from the blood into the cell.

And then if you have plenty of thyroid hormone but it’s not getting onto the receptor to create the desired effect in the cell, then it doesn’t matter because it’s the equivalent of being hypothyroid. Testosterone receptors are dependent on estradiol receptors. Progesterone and estradiol, they up and downregulate each other’s receptors. I mean, it’s a very complex and dynamic system that’s going on, that changes how cells work. And we’re talking about other systems as well, the signaling systems. Like these hormones, like estradiol work along with, and this is like trendy now, like peptides, a lot of people know, “Oh, peptides.” What tells the peptides to do anything? I mean, estradiol. And then people are talking about these magical coenzymes and these other enzymes called the sirtuins, and there’s the SIRT1, 2, 3, and they’re very involved in metabolism and in burning fat and rejuvenation.

They’re often triggered, as you well know, by fasting. Well, guess what? NAD, which is a coenzyme for the enzyme. Now, if you don’t have the coenzyme, the enzyme is like mega sluggish, like it won’t work. So, it’s like the on switch, you need to have this coenzyme that is NAD for the sirtuins. Well, guess what? They’re all interrelated in a bidirectional way, by the way, the sirtuins and the estradiol, bidirectional, they work together, like so many things, they’re not one direction. And then you need estradiol for proper function of these enzymes. These sirtuins are called histone deacetylases, which are triggered, like we said, by stressors like fasting, but you need that estradiol there. So, I keep saying, a lot of the systems in the body that people are focusing on, and even the people who are advocating for these things, they don’t get it that these won’t work properly if you don’t have the estradiol.

And then when you look at, you can learn a lot by looking at reproduction, I keep going back to that. I figured this out because I did thousands of deliveries, that the body’s immune system has to make drastic changes to allow a pregnancy to occur. And all of the enzyme systems, the signaling agents, they all exist within the reproductive system, as well as the circulatory system. People don’t even know that. Like cardiologists, like you started in cardiology, they don’t have any clue. For example, that the renin-angiotensin aldosterone system is all of those agents, they’re in the reproductive tract too. Everything’s about fertility and reproduction. Sorry, guys, whether you want to have babies or not, that’s how we evolved. And every system links to that, including, of course, the immune system. And pregnancy is when you have to have massive adaptations of the immune system.

So, if you look at like the hormones, like what happens, you got to downregulate the innate immune system, so it doesn’t attack and kill the fetus. What calms down that system? Well, guess what? It’s the progesterone is very big on acting as a calming agent. So, what happens if you don’t have that? And that in the brain, it actually can help to reduce neuroinflammation as can estradiol. So, everything is working in this beautiful, symbiotic, coordinated way to regulate the immune system, which ultimately is what they call aging, inflammaging. And young people who have this accelerated inflammatory state of that’s chronic, they now someone labeled it metaflammaging. Metabolic issues leading to chronic states of inflammation.

Well, every immune cell in the body has receptors for these vital hormones, every immune cells. And why is that? Well, of course, because you’ve got to regulate the immune system during pregnancy. And what’s so interesting is that low levels of estradiol are more proinflammatory. If you think about the menstrual cycle, you can learn so much from female reproductive system. During the menstrual cycle, estradiol levels are super low, and it’s a proinflammatory state, you have inflammation in the uterus, you produce these proinflammatory agents called prostaglandins that create a little bit of cramping. It’s supposed to be like a mini, mini, mini labor, you get a little cramping, the same system kind of in more like mega states is what happens that initiates labor.

S, you have a little bit of cramping because you’re getting rid of this old dead lining tissue, which has to come out, but at the same time, you have to regulate the immune cells because some of this dead dying tissue is going to come out the fallopian tubes into the pelvis. And so, you have to program the immune cells. And this is all done through the endocannabinoid system, and it’s all done through the hormones so that you don’t have an overabundance of inflammation, and that the immune cells gobble up these dead dying cells that are coming out from the uterine lining. And that becomes very dysregulated in women, for example, who have endometriosis. Now we have triggered that, tie that back to types of endocrine disrupters for progesterone, so we learn a lot from these different conditions and so on. And so we have this more inflammatory state that needs to be controlled. And if you have really massive menstrual cramps, that’s a sign of too much inflammation. And that can be due to hormonal imbalances, nutrient imbalances, chronic stress, environmental toxicants, nothing simple, that’s why you have to be like the medical detective. And then, when you are having a spike of estradiol that precedes ovulation, that actually becomes very anti-inflammatory, because you don’t want the immune cells to attack the incoming sperm or the newly created embryo.

The whole thing is so interactive. And that’s why understanding how hormones work in the body, then it will set the stage for understanding best ways to give hormones when our ovary cease to make them. And understanding that reproduction being the prime directive of life. When we lose reproductive capability with menopause, we also lose the ability to regulate all the systems that are essential for reproductive success because you have to have, for example, a very robust circulatory system, the heart, has to pump way more blood because of the blood volume about doubles in a pregnant woman. So, the female heart is quite different. Even though it looks kind of the same than the male heart, it is much more capable of producing energy. But without estradiol, it loses that energy and it develops what’s called mild diastolic dysfunction, which is sort of like a stiffening or energy-deficient heart, which can be seen on an echocardiogram. And it’s usually ignored by the cardiologists who say, “Ah, we see that all the time.” Yeah, but it’s a sign that the heart is suffering from a lack of energy and it’s stiffer, and that can lead to what’s called heart failure with preserved ejection fraction. It’s a different kind of heart failure than what is called generally congestive heart failure, but it can lead to congestive heart failure.

We need to understand the differences between male and female physiology with the immune system. Women have way more immune cells than men, women make more antibodies, they are able to amount a bigger, robust inflammatory response to an infectious agent, like women are better at surviving sepsis than men prior to menopause. Understanding how the female body works and why it works that way and how these hormones are essential for every system in the body will help to understand the consequences, this really cataclysmic event that is really the loss of ovarian function. It’s really important to stop even thinking of menopause as a moment in time, which is defined menopause by 12 consecutive months without a spontaneous bleed. Where did that come from? Well, that was made up? Why is it not 13 months? Could it be six months? It could be whatever you make it up to be. So, stop thinking of it that way. Think of menopause as a process of ovarian aging or senescence and it starts long before that last official menstrual period because we never know that except in hindsight, if you even let that happen.

In my patients, I don’t want that to happen. Why would I want them to go 12 months in a hormone-severe deficiency state? What am I accomplishing? Nothing. We already know that vascular disease, like thickening of the lining of the arteries, inflammation, plaque development, hypertension developing, which is not an early sign of vascular disease, that’s already you got advanced state by the time you have hypertension. All of that is happening during the years preceding that last menstrual cycle, as the hormones go in this sort of crazy downward trajectory with up and down spikes, it’s a crazy time. That’s why it’s like a crazy roller coaster. But we need to understand that if we really want to optimize female health, and then understand that when a woman gets to that stage of life, I call it her health savings account.

What she has done all those decades preceding menopause, will set the stage for how she’s going to go through menopause in terms of the degree of symptoms, and also the sequela. So, if you go into menopause with a great set of bones and muscles, and your brain is working well, you’re not in a state of brain fog, you have a great cardiovascular system, lots of muscles. If you enter menopause in great shape, then what I say is like your engines on your plane in perimenopause, if you have a two-engine plane, one engine goes out, but you still fly, but you have one engine out. But when you hit full-blown no more hormones from your ovaries state, your testosterone is a separate thing but no more ovulation, no more estrogen in the form of estradiol, no more progesterone, then you got two engines out. So, at that point, depending on the health you have at that point, you either go into a nosedive, crash and burn, or your plane turns into a glider, then you get to kind of sail the winds, you are ultimately going to go down and hit the Earth. But you can do it gradually and smoothly. And I want to turn it into a really long journey as a glider but you will do better. And I can do better as a doctor if you enter the menopausal transition in a state of health rather than metabolic chaos, which we know many women who are in their reproductive years are not exactly in prime health.

So, it’s never too early, like from conception on, to try to be healthy because we know that everything starts actually even prior to conception with the state of the eggs in the mother before she even get them fertilized. So, that’s why I’m into big preconceptual planning and health because you really got to plan for the future very early to get through all those menopause years and have what is everybody’s goal. Healthy longevity. That you live to be, I just say 100, maybe you can get to 120. But I’m just being very modest here, let’s get you to 100 in great shape that you can live a really high-quality life, as opposed to just existing. And you can’t have that, really, unless you’re like this one in a million, there’s always the point of the exception to the rule, someone who has genes no one’s ever seen before, but in general, okay, and the vast majority of human females, you can’t have optimal health and functioning without having those hormones. And it’s so critical to not be afraid of them, to embrace them, to love them.

And understand that your ovaries didn’t go from being your friends to producing these wonderful hormones, to suddenly when they stop working, which can be anywhere really over 20 years that you can have menopause, that from being our friends are friendly hormones to being are deadly hormones because the average age of menopause, what’s called normal menopause in the US is 45 to 55. That’s a decade right there. Okay, and so if a woman goes in menopause at 45, or 55, 10 years apart, her estrogen in the form of estradiol becomes evil for this woman at 45 but it’s okay until this woman at 55. And then there’s late menopause, which is 55 plus, and then early, which is 40, up to 45. And then, unfortunately, I fell into that group, I think because I was up at night all the time, circadian rhythm problems with all those deliveries. And then premature menopause, which is before the age of 40. So, there’s quite a bit of range.

So, if you figure 40 to 60, that’s going to encompass the vast majority of women who go into menopause, that’s 20 years. So, women, who have early menopause, like I did at 43, they are supposed to be hormone deficient for an extra decade or more than another woman. And then we already know what happens women who have early onset of menopause have early onset of all the diseases of aging, like, duh, it’s not how many years you lived, it’s how many years you’ve lived without your hormones. So, that’s why I’m a huge advocate. I never stopped saying menopause is natural, but that doesn’t matter. Everything we do in medicine is to counter so-called natural, like come on replacing joints is natural, putting in new lenses for your eyes to replace your cataract is natural? Stents in your arteries are natural? All those pharmaceuticals are natural? I’m trying to do something that is not natural, but in a natural way so that you don’t end up with all that other unnatural, bad consequence. And then all the other interventions so that you just replaced what’s missing, that nature didn’t really care about you having because you’re no longer reproductive, and maybe for the planet and the species, maybe you’re not so important as an individual. But we kind of say, “I’m not giving up my seat anytime soon but I want to enjoy my stay.”

We’re going to be here, why are we just promoting longevity, so we can keep people alive with no quality of life. I just want to be super proactive and understand what aging is really about, what hormones are about. And just say, okay, so we’ll just give it like, how great is that? How simple is that? To give hormones to recreate the hormonal environment of a young healthy reproductive woman in an older woman. In fact, they did this with testosterone. They gave males who were metabolically unhealthy 65-ish males, testosterone levels to equal that of a robust, healthy 19-year-old guy. And guess what happened? They lost belly fat, they put on muscle mass, they had cognitive improvement. Oh, my gosh, hormones actually change how you feel, how your body works like, duh, of course. If somebody took out someone’s thyroid gland, because they had a big benign tumor, this happens, nobody would say, “Well, that’s okay. Go on Prozac.” “That’s okay, meditate more.” You don’t have a thyroid gland. You don’t have any thyroid, not Prozac, but all those other things can be beneficial, but they’re not going to replace your thyroid hormone that’s missing.

When you don’t have the estradiol and the progesterone coming from your ovaries, nothing else is going to replace them other than them. So, let’s just give women what they lose, so that they can stay the beautiful healthy creatures that they have been, hopefully, and want to be. And if they weren’t that healthy before, it’s never too late, as long as you’re here to do better, to help them with much better lives and start from where you are and build a better future.

Cynthia Thurlow: Well, thank you for so much insights and advocacy for women because I still feel like every day, I know you must get these questions. People express fear about if they start hormones, what’s going to happen? Are they going to gain weight, which, unfortunately, is a common concern that there’s a lot of fear-mongering about hormones in general. But if you’re just understanding that even at a cellular level, replacing these hormones has a huge net impact, not only in your quality of life but the way you sleep, the way you interact with your family and your loved ones, your personal private relationships as well. Let’s really pivot a little bit and let’s talk about the changes that are occurring in perimenopause to set our bodies up.

I feel in particular, even though I trained at a big research hospital, even though I have a lot of medical professionals in my family, nothing prepared me for perimenopause, absolutely nothing. I don’t recall ever having a conversation about it with my GYN. When I did actually have an appointment, and I was explaining to her my periods were getting very heavy, it just so coincided that my yearly annual exam and my GYN said, “Oh, my gosh, your periods are so heavy.” I said, “Yes. I’ve been telling you this.” And the options that were given to me were oral contraceptives, an IUD, and ablation or, she said, “You’re in your early 40s, you’re done having kids, we could just do a partial hysterectomy.” And I just said, “Timeout.” [laughs] This is not what I want to be doing. But let’s unpack what’s starting to happen physiologically, in these perimenopausal years, as you mentioned, can be a protracted amount of time could be 10 to 15 years prior to women actually go into menopause, but it’s these changes.

I jokingly say God has a sense of humor because I have teenagers, and I’m going through reverse puberty. I think it’s important for women to really understand what’s changing in our bodies that are contributing to symptoms that maybe initially we don’t think are a big deal but then we realize, three or four years later, the sleep is bad, the anxiety and depression are bad, the periods are heavy, they’re gaining weight, the things that they used to do to help maintain body composition and overall health are no longer working for them.

Felice Gersh: Well, honestly, perimenopause in the menopausal transition is more difficult to treat than full-blown menopause because you still have ovarian function, but it’s unpredictable. So, what happens is, you have a lowered amount of eggs, you also have less healthy eggs. So, they are not going to respond to the same degree from the stimulus from the brain through the pituitary, which then the pituitary makes these hormones called gonadotropins, LH, luteinizing hormone, and FSH, follicle-stimulating hormone. So, the brain is the great sensor of the body.

In the beginning, what’s going to happen is because you have fewer eggs and you have they’re not as healthy, the amount of estradiol that’s going to be produced, and also then ultimately, progesterone is less. And often when I do testing, like menstrual mapping, I will see that even though they’re still ovulating, even the ones who are still having regular cycles, the amounts of hormones are less. And then of course, as things progress, the cycles can become quite changed. Often the luteal phase, the time after ovulation until the bleeding, which is when the progesterone is produced is not as done as well. So, you have a shorter luteal phase. So, you have shorter cycles in terms of like maybe you had 28, goes down to even 21. And that’s part of the ovarian aging process, which would of course, as well reflect on fertility.

Of course, there’s a very strong correlation between ovarian aging and reduced fertility, like every woman knows, at in the early 40s, her fertility is nothing like it was in the early 20s. And this is a consequence of the quality of eggs and then relating to the production of these hormones. And this is going to change the cycles. Women can have very different types of cycles because the uterine lining tissue, the endometrium, grows and is transformed by these hormones. What happens, what can happen that can give you these crazy heavy periods, and then also some women get very sporadic periods. It’s very unpredictable, even for the same woman over time. And that’s why there’s everyone is the same. It’s such a unique time for each woman. But as the egg quality and production of estradiol goes down, then the brain sensors says, “Oh, I need more estradiol produce.” So it triggers more production of LH and FSH from the pituitary gland.

Now, when you produce more LH, the precursor to all estradiol, a 100%, no exceptions, is testosterone. So, the ovary makes testosterone in one group of cells, and then the testosterone that produced travels, it goes to another part to the granulosa cells, where it’s then converted to the enzyme aromatase, into estradiol. And when things are right, you have this other little hormone called anti-mullerian hormone, which is a crazy name, I wish they would change it to follicle recruiting hormone because in the ovaries, that’s what it does. And it recruits all these little follicles, and each one is saying choose me, choose me, I want to be the ovulating one, but ultimately one or sometimes two, then you get twins is chosen. And that’s done to some magical thing. We don’t totally understand which egg is chosen, but it gets ovulated out after you get an LH surge and then you have a little FSH surge.

And then that shuts down the production of the anti- mullerian hormone. So, you stop making on recruiting all those follicles, you get the ovulation, and then you have what’s remaining turned into the corpus luteum. That’s another structure in the ovary that produces progesterone. So, what happens though, as you’re transitioning into menopause, is that you have higher amounts of LH and FSH produced because the ovary is less responsive. But if you push it hard enough, kind of like once again, like think of insulin resistance in the stages that evolve into diabetes, when you’re in that pre-diabetes phase, your pancreas will make more insulin. When you have more, it will help control the glucose and help get the glucose, so you can have normal blood sugars. But if you check insulin levels, they’ll be high. So, you can still sort of have normal estrogen levels, but the FSH and LH can go up and down and be higher.

What happens when you have more LH, is you will make more testosterone. That’s why many perimenopausal women will say, “What the heck?” Talk about reverse puberty. “Why am I getting acne?” Because they actually are making more testosterone, because that’s the precursor to estradiol and the brain is saying, “Please, ovaries, give me more estradiol.” And so, the only way to get it is by making more testosterone. But if you have a little glitch in the production line and so you’re not converting it as efficiently or as well into estradiol, you end up with a surplus, too much testosterone, and then suddenly, “Uh-oh, what the heck? Why am I getting whiskers? What the heck is this?”

[Cynthia laughs]

Many women as they’re approaching menopause are like, “What is happening? I’m getting acne, I’m getting facial hair. And not only that, where’s the hair on my head going? I’m getting androgenic alopecia.” So, this is like a problem. And nobody, no woman likes this at all. But this is part of that process. Now, in addition, the estradiol level that’s produced is going to be less. And then they’re going to often make a lower amount of progesterone. So, this can change how the uterine lining is growing and then shedding. So, you can have changes, you can have some irregular spotting, you may have midcycle spotting, you may skip ovulation altogether some months, you may have heavier bleeding because you don’t have enough progesterone to properly convert the lining into what we call secretory. So, estradiol is a growth type of hormone.

Now some people think that’s bad, evil growing. No, no, no. Growth is what we do when we rejuvenate, when we heal, when replace dead cells, that’s how you get a burn or a cut on your skin, estradiol to the rescue. In fact, the skin makes estradiol. That’s how men get a lot of estradiol. They make it from their testosterone through the enzyme aromatase that’s present in many organs peripherally, but after menopause, well, women don’t have a lot of testosterone and their systems aren’t really set up to do that, to the degree that men can do it. But that’s how men have tons of estradiol in their body, but it’s produced locally from their testosterone, it’s not circulating. But it’s really important for men to have plenty of testosterone, like I said, when they tested, they did studies in older men, they did great when they had adequate amounts of testosterone. But a lot of the action is actually by its conversion into estradiol.

The bottom line is a growth hormone is essential for rejuvenation for neuro and mitogenesis to create new neurons, to create new cells. So, it can helps to create like vascular endothelial growth factor, brain-derived neurotrophic factor, things that create new blood vessels, new tissue, brain health, but like old growth, you want to have control growth, you’re in a city that just grows out of control. No. And the part of the control system for the estradiol is the progesterone. So, progesterone, when it comes on the scene after ovulation, it stops that growth, what we call proliferation, and it changes into this lush garden that we call secretory. And then when you’re not pregnant, and the progesterone drops, to pretty acutely, then everything shuts out. But what happens when you don’t have enough progesterone because you’re not making good ovulation and things are not quite right, the corpus luteum isn’t right. And you have a shorter luteal phase, and you’re not even getting as many days of your progesterone and you don’t make the proper secretory status, you don’t have proper complete shedding.

So, if you don’t get all the dead lining out, then it keeps trying to get out and blood vessels are open. And that’s where the blood is coming from. What the menstrual period is about is trying to get rid of the tissue, the blood just comes along for the ride. And you also need to have the myometrial cells, the muscle cells to contract, to act like a tourniquet on those blood vessels. But a lot of that is triggered through systems of calcium channels and everything that hormonally controlled. So, if your hormones are even a little bit out of whack, all these systems can be a little bit offline, so they’re not working properly. And that’s where sometimes giving supplemental bioidentical hormones, as opposed to birth control pills, which are endocrine disruptors and shut down your hormones altogether and have a lot of other negative effects that you can try to supplement with human bioidentical hormones, understanding what’s going on. And you can actually measure the hormones through an entire menstrual cycle with menstrual mapping, of course, it’s one cycle and that is not necessarily every cycle, there can be different, but you can get a good idea.

So, you don’t even have to be guessing you can actually measure, or, of course, sometimes you could just give it to your best clinical guess as well. But understanding the mechanisms will help prevent a lot of surgeries, especially hysterectomies. And, by the way, they now have shown that the uterus has a communication with the brain, isn’t that interesting? That if you take the uterus out before– well, nobody’s done the studies in really elderly women, but in women who still have functioning of their ovaries, you actually have some cognitive decline. The uterus, everything’s more complicated than we ever guessed. So, if you don’t need to take out an organ, then please don’t take out the organ, don’t say, “It’s past its prime,” or, “You’re not going to have babies anymore.” Things are more complicated than we ever thought the way that they’re signaling agents and things communicate. So, if you have to, if you have cancer, that’s another story. But don’t take it out if you don’t have to take it out, especially like in your circumstances. Even the fact that that was offered makes my hair stand on. By the way, the Mirena IUD is not a progesterone IUD, it has levonorgestrel, which is multiple endocrine disruptor. And it does get absorbed systemically and half of the women stopped the first couple of years or so at least stop ovulating, so it’s going to change their estrogen production and their rhythms. So, you just have to call a spade a spade.

Sometimes you have to give pharmaceuticals, including contraceptive hormones and so on, to control out of control bleeding while you get things under control. But it’s not supposed to be a long-term solution and it’s not giving women hormones to control. They’re not a human hormone. I wish they would just call them endocrine disruptors instead of hormones because it gives people the wrong idea. It’s like you wouldn’t lick plastic every day and [crosstalk] [Cynthia laughs] testing my hormones. I mean, that’s how I see it with the skull and crossbones. Slow poison. It’s not going to kill you, but you did lot of slow poisons. We live in a world of slow poison. We definitely don’t want to intentionally put them in our bodies, we get exposed to enough unintentionally as it is. So, perimenopause is really interesting because you can have giant spikes. When your estrogen level goes down and then the brain says, “More estrogen,” and I’m saying estrogen, but it’s estradiol. And it ups the FSH and LH. So, you get this big surge.

And then if you’re still got functioning ovaries, although not so great, you may put out two eggs. And then that’s why women in perimenopause, early 40s, for example, have more twins, fraternal twins than at any other age in a woman because of this, hyperstim, it’s like what we do if we’re collecting eggs for egg freezing or to create embryos for IVF, we hyperstim because we don’t want to have women go through like hundreds of cycles where we get one egg each time. So, they try to hyperstim to get a bunch of eggs out and they use like FSH, LH equivalent. And nature can do that, and you can hyperstim your cell. And you could get pregnant with twins if that could happen. But if say that doesn’t happen, what happens when you hyperstim? You produce more estradiol.

So. this is the only time in a woman’s life when she can have to make crazy amounts. So, normally, even at the peak of estradiol, it’s under 500. That would be the one day when she has her spike, but I’ve seen levels in perimenopausal women 800 something, it’s like, no wonder they don’t feel great because estradiol is wonderful. But women who get hyperstim like when we’re doing triggering for egg collection or for embryo making, that’s a dangerous thing when you hyperstim, and you make too much estrogen. You can die from water, but you can’t live without water. You always have too much of a good thing, and too much estradiol can be responsible for a lot of the terrible symptoms, like suddenly having migraines and edema. So, estradiol is more like fluid retaining, whereas progesterone, it’s more like a diuretic.

Everything’s Yin Yang. I don’t know how the Chinese were so smart, the push-pull, hot-cold. And so you have this, fluid retention, fluid exit. And so, if you have really, really, high estradiol, like suddenly I’m like puffy and I have bloating and estradiol tends to be more constipating, progesterone, the more laxative effect. I’m like constipated, I’m bloating, I have a headache. Oh, my gosh. The good news is it’s temporary because that’s like– I like liken it to if you go to a firework show, and right before the end of the fireworks and the whole show is over, they have this unbelievable display. It’s like the whole sky is lit up with all these fireworks. And then, poof, total blackness. So, that’s what you get, you get this explosion of estradiol, and then, poof, it’s all gone. This is like craziness, but this is the years of it.

And then in terms of mood because of these fluctuating hormones and then the ultimate downward. So, it’s like you’re going down, but along the way down, you’re getting these giant spikes up. Wow, what a roller coaster, but because the ultimate trajectory is down. And estradiol is anxiolytic. It reduces anxiety. It’s a mood stabilizer. And a lot of this probably works through the endocannabinoid system, like maybe for another day. That’s a whole, like fatty acid, these come from omega-6s, that’s why I have to defend omega-6, they’re not pro-inflammatory. If you get them from processed food with oxidized oils, but it’s essential to life and they’re not pro or anti-inflammatory, they’ve directed in the direction the body needs them to go depending on the situation. And the whole endocannabinoid system derives from omega-6s. And they are anxiolytic, they help reduce anxiety in the right amounts. Like people who smoke too much marijuana, which I’m not advocating for it all, they can actually have anxiety and they start slow. The dose is the poison or whatever that expression. So, how much you get, triggers how you respond. But you need to have estradiol for mood stabilization and progesterone as well is neuroprotective and calming. That’s why a lot of women who take oral progesterone they say, “Wow, I’m so calm.” It increases GABA, you sleep better. All of these things are amazing. Guess what? When you are having these big dips and it’s going down, women in perimenopause are double the risk, double the incidence of anxiety and depression.

And if they have a history in the past of like postpartum depression, PMS, or just anxiety depressive disorders, their risk goes up 400% that they’ll have a mood disorder as they’re transitioning through this time into the menopause. And that’s why huge numbers percentages of women in their 40s are put on mood stabilizers and antidepressants. And it’s like, “Hey, guys, how about some hormones?” So, here’s a trick, part of the reason or the reason why you get these crazy swings, and it’s going down, is because the brain is sensing, “I don’t have enough estrogen.” And then it’s like, “Now I have too much. Now I have too little. Now I have too much.”

[laughter]

The brain is like, “I’m trying my best to get this regulated. These ovaries are not cooperating.” So, if you give some estradiol, so that the brain always has the feeling and it’s true, it’s not a phony feeling. It’s like this woman’s body has enough estradiol. I don’t need to put out a crazy amount of FSH by stimulating the pituitary. By stabilizing things, the brain won’t feel the need to overstim and then understim and then overstim and understim. This is not conventional and this doesn’t make any sense. They’d rather give antidepressants and tranquilizers and gabapentin and all these other drugs that have a lot of side effects and negative effects, that they’re willing to give those drugs rather than give the body what it’s trying out for. Like, how about a little stability with some hormones here? And if you do that, you can totally change the paradigm of what perimenopause is like but rather than shutting down the ovaries. That’s another option, you go on birth control pills, and some women like that, but they’re not realizing that it is actually not a health pill because it’s like taking that ground-up plastic cup and then swallowing it every day. And I know that sounds so crazy, but it isn’t. It really an endocrine disruptor. In fact, you can go to toxicology.gov, that’s part of the NIH, National Institutes of Health, and you’ll see every component, every ingredient in a birth control pill, officially listed as an endocrine disruptor.

I’m just calling a spade a spade. I don’t want to take them. I get enough of them just by breathing the air and eating food that I can’t help, it’s packaged in plastic. You can buy the most expensive grass-fed beef, and by law, they have to ship it to you from another state encased in plastic. That’s like, “What the heck?” You can go to a store and get organic apples and they’re all encased in plastic, individually. And we’ll talk about waste, don’t do that, don’t buy apples in their own individual plastic containers. Okay, please be an environmentalist. Our planet will thank you and so will future generations, and your own health will thank you because plastic is not– what’s the minimum daily requirement of mercury? Oh, zero. You don’t need any plastic. It’s not considered a nutrient that you need. You have an RDA, how much should you get every day? So, we know we want to avoid that because that just compounds the problem.

I can tell you for perimenopausal women if they have a high toxic load on top of having hormonal crazy fluctuations, but it’s an exciting time. You can certainly say with mood swings and, of course, it translates into lots of sleep issues. Oh, my gosh, because talk about the neurotransmitters. It turns out that estradiol is critical for serotonin neuron function. Serotonin is made in the brain, it’s also made in the gut, as we know, but it’s made in bones, it’s made in a lot of places, everything is multitasking. But in the brain, serotonin is very important and it’s like for mood, and also works on cognition as well. And serotonin is the precursor to melatonin, which is not optional as a very potent, the most potent renewable antioxidant in the body, and of course, related to sleep. And that’s why when you are sleeping, if you go to bed at a reasonable time at 2:00 AM, you have this giant, giant surge of melatonin, which is so wonderful. And at the same time, you have this big blood flow surge to the brain and all of that but isn’t going to happen if you’re not having proper sleep and you don’t have enough serotonin produced and so on, which is what’s happening in women because you need to have the proper hormones to make these neurotransmitters properly. And that’s not a little matter.

Acetylcholine, which is the neurotransmitter involved in cognition. In fact, that’s the neurotransmitter they’re trying to increase with Alzheimer’s drugs, like Aricept, but doesn’t really work. But nevertheless, that’s the attempt, that’s the theory. Acetylcholine is also critical. Dopamine receptors don’t work properly without estradiol and we can go on. I mean, these are not little things. All of this is related, so you have mood problems, you have sleep problems, and the immune system, every immune cell, because of pregnancy, you have to regulate the immune system, you have to downregulate the innate immune cells and so on during pregnancy, so it’ll kill the fetus. So, all the immune cells, every single immune cell. Women are robust, they have a bigger immune system, more aggressive and responsive immune system than males. And that’s why women survive infections and sepsis better than males up to a menopause, and a little bit more just because we got that extra X chromosome, another story for another day. But we’re a little special because we have two X chromosomes, and men only got one.

So, that actually gives us an edge in survival. That’s one of the also the reasons why we tend to live a little bit longer, but we live a lot worse. That’s the problem. Women have way more chronic diseases than men. Unfortunately, I had to detail that in my book, but I tried to make everything up, like happy, because we can do something about it. It’s not all bad news. But when you look at who has more joint replacements, osteoarthritis? Women. Who has 80% of osteoporotic fractures? Women. Who has twice at least as much mood disorders, sleep problems? Women. Who has more gastroesophageal reflux after menopause? Women. By age 65, who has more strokes, ruptured aneurysm? Women. Who has two and a half times or more the amount of Alzheimer’s disease? Women. Come on, we will live a little longer, but, oh, my gosh, we have way more chronic diseases. Once you hit 65, 75% of women have high blood pressure. Once you hit 65, at age 65, 75% of women have high blood pressure. By age 75, it’s 85% of women have hypertension.

When you go through perimenopause, what else happens? Insulin resistance and impaired gut barrier leaky gut. So, the gut microbial population varies depending on your hormonal status. And this has been proven, this is not conjecture, this is proven that when you have altered hormones as you go through perimenopause, the microbial population and the gut changes, and not for the better. So, by not having the right microbes, and this leads on another whole chain of events.

You don’t produce the proper metabolites, the short-chain fatty acids that include acetate, propionate, and butyrate. And they’re involved in signaling to the brain, signaling to the liver. And butyrate, in particular, has binding sites on the vagus nerve, which is a huge part of the autonomic nervous system. And the vagus nerve stimulates the production of the neurotransmitters for the parasympathetic or calming part. So, women after menopause and the perimenopause, they’re upregulated into a higher stress state because their parasympathetic is more offline, but the sympathetic ganglion are going gangbusters. So, they’re much more in a stressed state. So, anxiety grows, cortisol is produced in greater quantities. The stress hormone from the adrenal gland. What does cortisol do? Well, in chronic, elevated production amounts, it further causes leaky gut, impaired gut barrier, it alters immune function and creates a more pro-inflammatory state and dysregulates the circadian rhythm, which is already getting dysregulated, because estradiol from the ovaries is also a key regulator of the circadian rhythm.

So, basically, all women as they transition into menopause, they’re living a life of jetlag. So, it’s like, you’re traveling across the United States every other day, that is not good. Actually, I did that when I did all those deliveries all outside, that wasn’t good for me. I think that’s why I had that early menopause. Like it wore out my ovaries, they actually show that when you have inflammation in your body, it’s in the ovaries too. They’ve actually done like, pick up fluid from the follicle, it’s all full of inflammatory cells. So that prematurely ages the ovaries, which is so bad for us. We do not want to have this happen. But we have to have menopause. We can’t stop it. I mean, you can delay it a little bit. If you eat lots of vegetables and have the perfect lifestyle. Unlike me, you might have a little bit like maybe two years later, but it’s inevitable. You can yoga yourself forever and you’re not going to stop menopause. You may delay it a year or something like that.

We do have tricks, by the way, for women who are heading towards menopause and they still want fertility. So, there is a few tricks in the book to try to get the ovaries to get a little bit more life in them, but just so long. But we can do so much understanding this transition, and doing things to help women. And by the way, vital estrogen foods are amazing. There’s Neal Barnard who’s a vegan cardiologist. I don’t agree with everything, but I do love his study on this one. And he gave women a cup of soy, like a whole soy every day for 12 weeks. And these are women who had terrible night sweats and hot flashes. At the end of 12 weeks, they were almost completely eradicated in all the women because phytoestrogens are nature’s gift to women. Phytoestrogens are all plant foods. It’s just a question of degree and type.

So, the famous ones are soy, and I always have to defend soy whole organic soy, non-GMO, whole organic soy is a definite health food. It’s also fertility food, but not processed soy. Soy pretending to be something else, like cheese or burgers or something. [Cynthia laughs] No soy hotdogs, please. So, that has in it. Isoflavones, that’s a type of phytoestrogen. And then flax seeds, they’re pretty famous, and people do seed cycling for fertility. Although cycling is not necessary, there are no data on that. But there is seeds are good because they’re phytoestrogens, they help the ovaries. They help the brain, they’re very good. And the one that’s famous is flax seeds, they have a type of phytoestrogen called lignans, but all seeds, all nuts, all grains, all on beans, legumes, like soy is legumes, they all are phytoestrogens. And then like fruit, like red grapes, they have resveratrol, that’s actually a phytoestrogen. Pomegranates, which has fame as a superfood. Pomegranates have ellagic acid, another phytoestrogen from which drives urolithins A and B.

Most all the foods that are known as superfoods and healthy foods, oh, they’re really phytoestrogens, these magical ingredients that are not estrogens, but they can bind to estrogen receptors and help to make the body in every organ system healthier. But by combining lifestyle approaches, like what you eat and exercise, which will trigger the production of the sirtuins, as well as fasting, exercise is known as a fasting mimetic. It’s like mimics the same effect, like that little stressor on the body. But none of these things work properly, in an absence of these beautiful ovarian hormones. And it’s not just having them, you have to have a physiologic level.

Ultimately, I’m hoping I’m trying to get into a study going to look at mimicking the menstrual cycle and that’s been talked about for 20 years. But we have no data, we don’t know how to dose it, we have to have data, we can’t just be mavericks and do whatever the heck we want. But when you know physiology, when you know the ups and downs of the genes, like tumor suppressor genes that are triggered by the different levels, the up and downregulation of receptors, that it’s not just having hormones. It’s the rhythm of hormones. It’s just like we talked about in the beginning with food. It’s not just what you eat, it’s when you eat. Everything is timed, we always want to do things at the right time. It’s like, we want to eat, we want to not eat, we want to have hormones, and then we want to have lower hormones, like the beautiful rhythmic menstrual cycle. It’s not the same level all the time and it does turn on and off genes. These hormones work with gene expression and turn on and off genes. And then the genes in turn make the enzymes, like the sirtuins, and they’re involved with the coenzymes. And it’s just a beautiful, amazing story, but the story does not have the ultimate happiest ending if you don’t have those hormones. So, that’s why I defend the defenseless.

I defend soy, I used to have to defend fat, and I don’t have to do that anymore. And now have to defend carbs, but only whole carbs, non-processed carbs. And I have to defend estradiol, estrogen in that form, and real progesterone because these hormones starting with the women’s initiative. I mean, it just took us down the worst possible road of misunderstanding. And then I call it mistreatment of women, so they’re not getting informed consent.

Every woman can decide. I do, I don’t want to have hormones. It’s an individual choice, but how can you make an intelligent choice if you don’t even have the foundational information on which to base it? And that’s what they’re not getting.

Cynthia Thurlow: So great, and it’s interesting as I was taking notes during our conversation and referring to oral contraceptives as endocrine disruptors. And how many women of my generation took years and years and years of oral contraceptives to control our menstrual cycle or our symptoms, not realizing that we really never got informed consent. And the same goes for hormone replacement therapy. I love your book, Menopause: 50 Things You Need to Know. And I even told, Dr. Gersh, before we started recording. I said, “There were things in here that I didn’t know.” And I’d like to think I’m fairly savvy with the research, including things like body odor changes, vocal changes.

Felice Gersh: I know because they’re all the microbiomes. Once you know that estradiol, we’ll just say estrogen is key to every organ system functioning and that includes the microbiomes of every organ system. I mean, we now know the gut and most women now know well, and were in the our business, they know the vaginal microbiome, but they often forget things like the eyes, the skin. And the microbes that live on the skin, the way that they metabolize sweat and so on, and how we even produce sweat will lead to different scents.

And it’s so funny because anytime when people go into an old, aged home, there’s a different smell. It’s like this place smells old. And now we know, but what’s also interesting is pheromones where I don’t really talk about that because it’s not really a menopausal thing. But pheromones are those invisible scents that animals have, insects have that attract the other sex and also help you to be attracted. And when women are on oral contraceptives, and also in menopause, they stop producing pheromones the sexual– like mysterious, like magical sexual attracted. And honestly, I can’t prove this but I think that that is underlying a lot of male behavior, that when they have a midlife woman in their life, whether a partner, wife, and then they suddenly start being attracted to another woman that they don’t even know why because it’s not like conscious. It’s like how we’re programmed because we are in the animal kingdom, even though we’d like to think we’re computers or something. But we’re really animals in the animal kingdom, and we have programmed systems.

And the men naturally are attracted to these female pheromones, and the wife or the partner no longer has them. And women on birth control pills don’t have them. And so, the men, they’re genetically programmed to follow the scent, and, poof, and before they know it, they’re in an affair, and they didn’t really even want to. It’s just that they were no longer like, physiologically attracted to their partner. And they’ve actually done studies. This is like peer-reviewed studies, that women on oral contraceptives often do not know how to choose the right partner. And that’s not good, they end up choosing the wrong person. And then they all have miserable marriages or get divorced. These are natural things, like animals in the wild, like how did they pick their partners? Actually it’s through these magical things. And they somehow they’re designed to get people to be with the right person or the right partner.

So, anyway, I think they actually did a study. This is so interesting. They took women’s panties when they were ovulating. And they rubbed it onto a chair, one chair in a row, and put the chairs in a circle. And they changed the position of that rubbed chair with the panties. And I mean, these were clean panties, they just were worn by a woman who was ovulating. And then they’d got in a bunch of young 20 something males, and they thought they were coming on a pretense to like do a movie preview, and they were going to like critique the movie. And they said, “Before, let’s just take a seat anywhere in the circle.” And one guy would come in first and then pick any seat, just pick any sit, they’re all on a circle. He would always sit down on the one where the panty was rubbed and he had no idea why. So how amazing is that?

This is my personal theory that when women lose their hormones and they lose their pheromones, their spouses, and themselves, part of losing sex drive is they’re not putting out the pheromones, they don’t perceive the pheromones of the men either. There’s like, eh, it’s like a loss. But if you get on hormones, you’re going to recreate those pheromones, so that you’ll be more attracted to your partner, that partner will be more attracted to you because you know how there are so many times when women are going through menopause, and they’ve been married for like 25, 30 years, and suddenly they get divorced.? This happens all the time. I say, like, “What is with this?” They always say, “Well, the kids grew up and left.” But maybe it’s because they don’t have hormones anymore, so because hormones are destiny, they control our brains, our sex drives. Estradiol is big on sex drive. And oxytocin, that’s another hormone/peptide, its receptors and its production are dependent on estradiol. So, there you go, just another one. Yep. So getting back to body odor. Yes, that’s a hormonally related-thing.

Cynthia Thurlow: Yeah, it’s so interesting. And like I said, your book Menopause: 50 Things You Need to Know is a great adjunct to navigating perimenopause and to menopause. I could speak to you for hours, but I know you have patients to see, please let my listeners know how to connect with you. We’ll make sure we link up all of your accounts and your books. And your last podcast that we did together focused on PCOS. It’s such a gift to be able to connect with you and share your brilliance with our listeners.

Felice Gersh: Well, it’s my joy to be with you here. And so, I’m still old-fashioned doctor, I have a brick and mortar, I’m actually talking to you from one of my exam rooms. And so my practice is called the Integrative Medical Group of Irvine in Sunny Southern California in Orange County, where I see patients all the time and I can do telemedicine, it depends on the state and different circumstances and so on. But I can get started with just about anyone anywhere with telemedicine wherever you are, and then we can take it from there. And then I have just my own little Instagram that I have that I’d love for you to follow me. I’m not sure where the future will go, but right now, that I write books, I do lots of lectures, I enjoy being on programs and podcasts, and so on. And I have my little Instagram and trying to write more blogs. Most of the time I am a working Joe doctor. I’d see patients one-on-one, and I try to make each individual woman’s life better.

Cynthia Thurlow: Well, I’m so grateful for you and your friendship. Thank you again.

Felice Gersh: My pleasure.

Cynthia Thurlow: If you love this podcast episode, please leave a rating and review, subscribe and tell a friend.