Dr. Jen Gunter: I'm an active physician. I see patients in the office. I see a lot of communication issues. I hear a lot from patients online about difficulties interacting with their health care provider or people who have fallen down rabbit holes with disinformation and gone down routes that may not have been helpful to them. And I realized some time ago that medicine had a big communication gap. And so I really view everything that I'm doing as trying to close that communication gap, trying to give people information about their body so they can be informed because you can't make an empowered, educated decision about your body if you don't have the right information on this subject.

Dr. Jen Gunter: I want people to have the information so when they're in the office with a medical provider, they can advocate for good care so they know what's harmful, what's normal. And I also want people to have that information so when they encounter things they see online that they'll know what's factual and what's not. So I'm very interested in educating the public about science and medicine because there's huge gaps in communication. You can't be an empowered patient without accurate information. So, I view myself as someone trying to close those gaps by getting knowledge about your body out to people so they can advocate for themselves in the doctor's office and so when they see health information online, they can sort through what's factual and what is likely snake oil. Hi, my name is Dr. Jen Gunter. I'm a San Francisco Bay Area OBGYN and author and health communicator. And my latest book is Blood: The Science, Medicine, and Mythology of Menstruation.

Big Think: Thank you for watching Big Think. If you'd like to support our work, we encourage you to join our members community. As a member, you'll receive our quarterly print magazine, a beautifully designed collection of the ideas and interviews that matter most. Big Think is for curious people who want to take deep dives into big ideas. To support the media you want to see in the world, go to bigthink.com/membership. And now back to the interview. Chapter 1, the science of menstruation.

Dr. Jen Gunter: For many years, thousands of years, maybe longer, society has viewed menstruation as something that is toxic or dirty or potentially dangerous to men. Something that reflects a problem with the body. So the ancient Greeks believed that men were perfectly in balance fluid-wise and women were not and menstruation was evidence of that. They believed that every cell in our body was overly moist and so if you can't handle your fluid appropriately, you need basically an overflow valve and that was really what they thought menstruation was. So it was a physical sign of inferiority and that banner has long been carried by medicine, by many different societies and also by many religions. It's been weaponized against women as a sign of inferiority when really it's simply a biological function.

Dr. Jen Gunter: We know very little about how women cared for their menstrual cycle for their periods because almost everything that has been written historically has been written by men. In fact, there are people who have gone through diaries from, you know, women in the 1700s, 1800s trying to understand, you know, what they might have done and they have information about how many pairs of underwear you might need or information about other things. But there's almost no information about how they cared for their menstruation which is probably a sign of how much of a taboo it is to talk about the subject which is related to the shaming of women and women's bodies and possibly also because maybe they thought everybody knew how to take care of it. So maybe it wasn't information that needed to be included in some things. But we do definitely have an information gap about how women have handled periods historically.

Dr. Jen Gunter: So there are so many potential negative outcomes when people don't know about the menstrual cycle. We've often viewed these negative outcomes as a risk of unplanned pregnancy and not being able to time pregnancy. And that's certainly one of the issues. However, it's also important to understand that when people don't know what's happening to their body, they don't know what's normal or what's abnormal, then they don't know when to seek care. They don't know if they should be asking for help or if what's happening is totally expected. There's also issues about not knowing what is the best care when you are suffering. So, if you don't really understand what's going on and you don't really understand the science, then the therapies might not make sense to you or snake oil that you meet online might sound like a good idea, but if you understood the biology, you'd be saying, "Wait, no, no, that's not something I should be paying attention to." So, it's really important that, while knowledge about contraception is very important and that is one part of the menstrual cycle, not everybody has a need for contraception. And there are much broader discussions as well. So we need to have this information because people live their whole lives with this menstrual cycle and they need to understand the biology.

Dr. Jen Gunter: I think historically education about the menstrual cycle has been dismal. I can't speak for every country but I think in a lot of places because the people that I encounter and I speak to lots of people who are from a lots of different places and they all have questions about the biology of the reproductive tract, some basic questions. And speaking to people in the United States it seems that what they're taught varies from nothing to perhaps very little. And so people don't really learn practical information if they do learn some things. It's all framed in context of pregnancy and preventing pregnancy as opposed to about the menstrual cycle and what menstruation is and what it means for a person's body. So, it's a very narrow view that doesn't really provide them with a lot of useful information.

Dr. Jen Gunter: Everybody should care about menstruation because if you're watching this, you're only here because somebody had a menstrual cycle. The menstrual cycle is the wheel that drives humanity. It was an essential part of human evolution. To get the big brains that we have required a menstrual cycle. So if you're using a computer, if you're driving a car, if you're reading a book, all that technology comes to you because of the menstrual cycle. If you're here on Earth, somebody had a menstrual cycle to bring you into this world, right? You might know someone with a menstrual cycle. You might love someone with a menstrual cycle. You might have children with a menstrual cycle and maybe knowing that information would be helpful so you can help care for your family members or friends or lovers when they're having problems. You know, we should know more about our biology. And for centuries, maybe for thousands of years, possibly longer, medicine has been medicine for men. And we need to step back from that, be far more inclusive. And a good way to start is to learn more about the menstrual cycle.

Dr. Jen Gunter: Lots of people for years, again, thousands of years, have used euphemisms to talk about periods because obviously if it's a shameful topic, you can't use the word. So, one term that I've heard a lot, which I hate, is called the rag, which is related to people having to use rags as menstrual products. One that I love and I do love the idea of subversive euphemisms is there's communists in the fun house. And another euphemism that I really like is a party at the Red Roof Inn. But Shark Week is another one. And I do love the idea of a graphic euphemism that basically takes the idea that you think it's shameful and you don't want me to say I'm bleeding or I'm menstruating. Well, I'm going to say something that is way more graphic. So, it's Shark Week. So, the word menstruation comes from both a Latin and a Greek root, and it's for the word for monthlies or a monthly occurrence. And so, it reflects the idea that the menstrual cycle, the menstrual period was expected to come about once a month, like the moon. Now, that doesn't mean that your menstrual cycle is tied with the lunar cycle at all. It's related to a monthly occurrence. And so it has nothing to do with the word men. People always ask that. And everything to do with the word month or monthly occurrence.

Dr. Jen Gunter: Many people have historically believed that the menstrual cycle was every 28 days. And that's something that we see in a lot of textbooks. And there really is no scientific proof for that. That that is sort of an a idealized or the most common menstrual cycle. It might be an average at certainly some ages, but there can be a wide variation in the menstrual cycle depending on the different classification system that you that people use. So it could be anywhere from 24 to 38 days or from 21 to 35. And again, it just depends on sort of which system that you use. But understanding that there is no good scientific evidence or even historical proof that that most people have a 28 day cycle. There's actually quite a bit of variation even cycle to cycle which a lot of people don't know. So it could be very normal for you to have a 26 day cycle for one cycle and then the next one it be 32 days. So within a 7-day swing in either direction is a normal sort of built-in variability.

Dr. Jen Gunter: Relatively few mammals menstruate. So there's humans and some great apes. There are some bats. There is the spiny mouse and the elephant shrew. So it's kind of like this motley crew of species. And what we think is that menstruation evolved four separate times. So once for us and the great apes and then three other times for the other animals that I mentioned. Every other mammal has an estrus cycle which is a little different. They don't shed the lining and we do. And so a menstrual cycle means that the lining of the uterus has undergone a change called decidualization. And for humans that happens after ovulation occurs and is due to the release of progesterone. Decidualization is a real physical change in the tissue. And if you want to think about the decidua as kind of like a catcher's mitt in the uterus, it's all prepared and ready for an embryo. If there's no decidualization, implantation can't occur.

Dr. Jen Gunter: The decidua is so thick because humans have an incredibly invasive placenta. Wants to get a lot of oxygen to feed those big brains, right? So, an invasive placenta has to be handled or it could grow through the uterus and cause problems. So, humans have evolved especially thick decidua to deal with that. In addition, the decidua actually senses embryo fitness in some ways and is part of regulating which pregnancies actually take, if you will, and which are incredibly early miscarriages. So, what happens when you don't get pregnant in a cycle is that you have this big thick tissue that's got nowhere to go. It can't be reabsorbed by the body. So, the only way to get rid of it is to dump it. And so menstruation involves chemical changes that cleave the decidua from the uterus, opening up blood vessels that then push that fluid out with the decidua of the tissue and then the cycle can start a new. When you have an estrus cycle, you still need decidualization for a pregnancy. However, the trigger for decidualization comes from the embryo itself. So you don't have to have that catcher's mitt

Speaker: waiting there. Once the embryo contacts, then the changes happen that trigger decidualization, but if there's no embryo, there's no decidualization. So there's nothing that needs to come out and any little tissue that's there can easily be absorbed. And so that's kind of a summary of the difference between a menstrual cycle and estrus.

Speaker: So one analogy I often use to describe menstruation is pulling the sheets off the bed. So, you don't get pregnant, you're pulling the sheets off the bed, you got to remake the bed for company again. And I just want to preface this by the fact that we're not all meant to get pregnant. So, just to keep that in mind. This is just to describe the physiology and why it exists this way. So, just like to put that out there.

Speaker: If menstruation is pulling the sheets off, the menstrual cycle is already starting again while you're menstruating. So basically like ironing the sheets and getting them ready while you're pulling them off. So the beginning of the cycle starts actually with the first day of bleeding. And during that time, follicles in the ovary that have been on about a 300day journey are now ready to accept signaling from the brain to potentially ovulate.

Speaker: They're triggered by a hormone called follicle stimulating hormone um and then later by a hormone called luteinizing hormone. These hormones trigger the follicles to develop and fairly soon one becomes a dominant follicle. The follicles produce estradiol which is the most potent estrogen. And there's a communication signaling that's going between the estrogen that's produced by the follicles and the brain.

Speaker: And that estrogen is also going through the body and stimulating breast tissue, affecting the immune system and causing the lining of the uterus to grow. When the estradiol levels get to a certain point, that communication between the brain and the follicles triggers um a surge in luteinizing hormone. And what that does is trigger ovulation. So the follicle now releases an egg.

Speaker: And after that happens, the leftover tissue from the follicle organizes itself into a structure called the corpus luteum. And the corpus luteum produces progesterone. And it's the progesterone then that now takes over and takes these cells from the lining of the uterus that have been thickened from the estrogen and now converts them into decidua, tissue that can accept a potential embryo for implantation. And that is required for pregnancy to happen.

Speaker: The corpus luteum has a natural lifespan of you know 10 14-ish days. And if there is no pregnancy that happens to send signaling back to the corpus luteum to say hey hang around for a little bit we're working on making a placenta. If that signaling doesn't happen then the corpus luteum stops producing progesterone and it is the withdrawal of progesterone that is the trigger for menstruation. So the role of progesterone is decidualization. It also has other impacts throughout the body as well getting ready for pregnancy. But what it does is it controls that decidualization that necessary change in the endometrium. So it can be receptive to implantation. And so without that progesterone implantation can't happen.

Speaker: With an estrus cycle that's not the signaling. The signaling comes from the embryo. So, one analogy that I often use is uh with humans, it's like uh the restaurant's making a dish. Whether or not you show up, it's going to be made. But with estrus, it's only making the dish if it's been ordered. So, meaning that there has to be an embryo that has presented itself.

Speaker: We often divide the menstrual cycle into two phases. The follicular phase and the luteal phase. The follicular phase describes what's happening in the ovaries with the changing in the follicles and that communication back and forth with the brain with stimulating of follicle stimulating hormone. The luteal phase happens with ovulation. So the surge of the luteinizing hormone and then the triggering of ovulation from ovulation onwards is the luteal phase.

Speaker: Now some people also divide menstruation up as a separate phase but that's part of the follicular phase and I think it's too clunky to start subdividing and subdividing and so the luteal phase is governed or thought of primarily that way because of the changes with the follicle switching to becoming the corpus luteum and now that's producing the hormone progesterone.

Speaker: So many people describe pain with ovulation and that's called mittelschmerz which you might be surprised to know is not named after a doctor middles. That was something that actually surprised me and we believe it's actually due to release of prostaglandins that actually trigger cramp-like pain. So that's what it's from.

Speaker: A lot of people envision the follicle like bursting out from the ovary, but that's not what happens. It's enzymes dissolving and less of a dramatic exit, if you will, from the ovary. Many people also have heard that you don't always ovulate from the same side or you go back and forth and maybe it's one month this side and one month the other side and it's a bit of a kind of a haphazard.

Speaker: So it's not a a one two one two like a tennis game. It's you know one month maybe this this ovary maybe two months in a row or two cycles in a row then the other side and it kind of goes back and forth. However, if you have one ovary removed, then the remaining ovary picks up the slack and it's doing the the bulk all of the work. And we don't really understand that signaling. And I think it's a really important thing that we don't understand a lot of the signaling behind the menstrual cycle and some of the unique aspects of of um ovulation and sort of the incredible journey that uh that an egg takes from uh from when it's dormant to when it can accept um the stimulation to potentially ovulate.

Speaker: So I'm often asked what happens if I'm on the birth control pill and I don't get a period. Is that harmful? Is there something building up? And what's going on then with all that decidua? So, when you're taking hormones every day in the menstrual cycle, you're getting exposed to a progesterone, which is like progesterone, every day of the cycle, not just for half the cycle.

Speaker: So, when you're exposed to it at the beginning, the lining never develops in the same way that it would if you weren't on that medication. So you don't get that thick lining developing and you don't have the withdrawal because you're not stopping the medication if you take it continuously every day. So that's why when people are on hormonal contraception like the birth control pill, their periods are often lighter because they didn't have as much lining developing. They always had that sort of opposition from the progesterone.

Speaker: If you think of broadly estrogen as stimulating the lining, progesterin or progesterone are kind of stabilizing and holding it in check. So if you have that holding in check hormone the whole cycle, it never gets really thick. And if you don't withdraw the progesterone, you don't take seven days or 4 days off each cycle, then the lining just is really very thin and there really isn't anything to come out and so it's not harmful.

Speaker: Another myth that I hear is that the menstrual cycle is a way to release toxins from the body. So, if you're on the birth control pill and you're not having that um cyclic release, then that might be problematic. Well, if we needed the menstrual cycle to get rid of toxins, then I have bad news for women in menopause and all of men, right?

Speaker: Some people wonder if there's toxins that come out with your menstrual cycle. And so, then would it be concerning if you're taking the pill every day and not having a cycle? And the answer is no. Humans don't actually have toxins and the menstrual cycle isn't a form of excretion. It doesn't remove things from our body in the same way that the liver and the kidneys do.

Speaker: It's very important when we're discussing the menstrual cycle to recognize that we need to be inclusive. While the majority of people who menstruate are cisgendered women, there are trans men and non-binary people who menstruate. And not everybody who's a woman has a menstrual cycle. So there are women who've had hysterectomies, women who've had their ovaries removed, women who are menopausal, and there are trans women. So it's really important for us to remember that and be inclusive. And that's why I usually just use the term people because I trust people to know if what I'm talking about applies to them or not.

Speaker: There's a big range in onset for the age of menstruation. And basically, if it hasn't happened by age 16, then it's time to have a discussion with your medical provider. And if it's happening before age 8 or nine, that's also a time to definitely discuss with a medical provider.

Speaker: The age of onset of your period has nothing to do with when it's going to stop. They're actually different biological phenomenon because some people always wonder, well, if I started early, am I going to stop early? And the answer to that is no. The average age for a menstruation stopping is around 51, but the normal or typical range is between 45 and 55. So, it's kind of a larger range for when we expect it to stop than than when we expect it to start.

Speaker: If you go through menopause, which is the end of menstruation between the ages of 40 and 44, we call that premature menopause. And if menstruation stops before age 40, we typically call that primary ovarian insufficiency and that needs to be investigated for a lot of different reasons.

Speaker: So menstrual pain is unfortunately a common experience for many people and it can range from, you know, being a minor symptom to something that is being really incredibly intrusive and painful and damaging for an individual. It can result in missed school, missed work. It can result in multiple surgeries. It can result in having all kinds of medical therapies and all of the expenses related to all of that.

Speaker: So the expenses of missed education, the expense of missed work, the expense of medical procedures. So all of these things weigh on an individual. We know it's a significant problem, but because this is Understudied, it's really hard to know the exact significance. Also many people just have to suck it up and go in because they don't have financial choices. So really understanding the true potential impact I think is is challenging for us but it's a significant problem.

Speaker: So there are a constellation of negative symptoms that can be associated with the menstrual cycle. Some are seen just around the time of menstruation or close to the time of menstruation and some are triggered around the time of ovulation or potentially triggered around the time of ovulation. Premenstrual syndrome is a constellation of symptoms that happen only in the luteal phase. So after ovulation and those can include breast tenderness, moodiness, a feeling of hopelessness or anhedonia that those types of symptoms. Uh they can also involve food cravings which are really very common.

Speaker: Then there are menstrual cramps which happen either the day before or starting with menstruation and those can vary in significance from being mild to being incredibly severe. People can also get menstrual diarrhea which again happens at the same time either right before or during the menstrual cycle. And of course there's also pain that can happen with ovulation which is mittelschmerz which we believe is actually more related to

Speaker: muscle spasm that's triggered by the chemicals that are released with ovulation. PMS is the broader term used to describe the constellation of symptoms that can happen to a lot of people. Premenstrual mood dysphoric disorder or PMDD is also something that can occur, but it's much less common. Some people think of it as a variant of PMS, which it probably is a more severe form, although truthfully, we don't know if they're different or part of the same spectrum, if you will. And so PMDD has more severe symptoms. It has a bigger impact or a significant impact on activities of daily living and tends to also have more depressive symptomatology associated with it.

Speaker: Let's talk about menstrual cramps. We call that dysmenorrhea. And primary dysmenorrhea is painful cramps not related to another medical condition versus secondary dysmenorrhea means cramps that we think are related to something else. The most common example for that would be the medical condition endometriosis. Why are cramps primary dysmenorrhea? Like what's up with that? Why do we have cramps? And they're a very common experience. 70 to 80% of people will have them and they really vary in intensity person to person.

Speaker: So we think that menstrual cramps exist as uh basically part of the mechanism to stop bleeding. So what happens with all the chemical soup that's released with ovulation? You have to release chemicals that cause the tissue, the decidua, to cleave off the uterus. Among those chemicals that are produced are substances called prostaglandins. So prostaglandins trigger pain. They also trigger the uterus to contract. And if you think about it, you have now all these open blood vessels because just like when you peel a scab off, you have open blood vessels that bleed. That's the same thing that happens when the decidua peels off. you now have all these open blood vessels that were thick and developing because they were getting ready to provide nutrients to an embryo, right?

Speaker: So now you have all this bleeding. So you have all this chemical soup to stop the bleeding. You have things that cause vasospasm, so to cause those blood vessels to contract down. The uterus cramps down, you know, in the same way that you put pressure on a wound to stop bleeding. The cramping itself is painful. The reduction in blood flow is painful. And some of the chemicals that are reduced can also affect pain thresholds. So you have muscle cramps, you have these prostaglandins floating everywhere, you have reduced blood flow. And so that's what produces cramps. And there really is a wide range of experience how people um experience them and how they respond to therapy as well.

Speaker: About 12% of people who menstruate will also have something called menstrual diarrhea, which is from the prostaglandins that are released. Prostaglandins cause diarrhea. So you're dumping a bunch of prostaglandins into the blood circulation and that can also trigger uh diarrhea with the bowels. We need prostaglandins because it's part of stopping, you know, it's part of triggering menstruation. It's part of triggering the release of the decidua and it's part of stopping the bleeding. So if we didn't have prostaglandins, menstruation would have to happen a different way or we'd need a different type of menstrual cycle. So they're a critical critical hormone. Prostaglandins are important in our body in all different kinds of ways. So it's not just a menstrual cycle related chemical. But uh but we do think as far as uh menstrual pain and menstrual diarrhea that they are the big troublemakers.

Speaker: So a lot of people have questions about well this doesn't seem like it's really a smart evolutionary design. if a lot of people have pain and 12% of people have diarrhea like this seems like a pretty troublesome thing and also if you add in that some people can have very heavy periods and they can get anemia so you know it's associated with problems so there's a couple of answers to that I mean obviously we don't know what menstrual cycles were like 10,000 years ago so so we don't know that but there is this romanticization or romantic thinking about nature that nature has everything perfect and that everything works perfectly And I think that nature's motto is probably best summed up as just good enough, right? So it's just good enough. You can all like you're half-dressed and slap you on the back and push you out the door. Just good enough. Go on. Go on out into the world. Because evolution doesn't care about an individual person's suffering. It cares is this design going to work enough to perpetuate the species. And so I often think that again this is another reason for everybody to know about menration because the pain and the problems associated with perpetuating the species have been uniquely born by half the population.

Speaker: So how do you explain menstrual pain to someone who hasn't had it? So obviously it's a difficult experience to understand pain that you've never experienced. To put it in perspective, the amount of, you know, pressure generated when someone has, you know, menstrual cramps uh can be the same as the pressure generated in labor when you're pushing. So, just kind of put that in perspective. And I'll add that uh some people have equated the pain uh the pain in labor is equivalent to cutting a finger off without an anesthetic. So, just to kind of put that in perspective, there are people who've come up with sort of menstrual cramp machines to try to get people to uh appreciate how much it it hurts. I'm not sure how accurate those things are because menstrual pain is a visceral deep pain and that you know those those devices are creating a pain on the surface.

Speaker: But the important point is that it can be very very painful for a lot of people and that pain is often minimized and uh and it shouldn't be. I think it's really important that people understand that if they have cramps that are affecting their activities of daily living that that's time to talk with a medical provider. And obviously that's going to mean different things for different people. But if the cramps are affecting you in that way or they're affecting a loved one or your child or your your friend in that way, then that's time to talk about seeing a medical provider.

Speaker: In addition to the suffering from having pain, um there is some data that suggests that having untreated pain can also have other ramifications with your nervous system. It may raise your rate of having other pain conditions because pain kind of primes the nervous system in many ways. This is an active area of research. Uh but I think it speaks to the fact that you know we don't understand the full implications of this. But also people shouldn't be suffering in the here and now. We we don't need fancy science about other downstream effects to say your pain needs treated needs treating. If you have pain, you have pain and it should be treated. It should be recognized. And also we need to make a decision about is this pain that needs to be investigated because is it a warning sign that there's something else going on.

Speaker: So one of the most common treatments for menstrual pain are taking non-steroidal anti-inflammatory drugs u that we also call NSAIDs. And what these drugs do are they block prostaglandins and that's why they're very very effective. However, there are some people they don't work for. And when they don't help, that could be a sign there's something else causing your pain, like endometriosis. But also, for some people, they just don't work well. And we don't really understand why that is. But that is an evidence-based approach to treating menstrual pain, taking medications that block prostaglandins, non-steroidal, anti-inflammatory drugs.

Speaker: I often get asked if people should track their menstrual cycles. I always say, well, what's the reason that you think you need to do that? Are you having symptoms that you're not sure if they're related to your menstrual cycle? Yes. Then what we call sort of a menstrual calendar or menstrual diary would be very helpful because, for example, I can't make the diagnosis of PMS unless I know that your symptoms always start after when we think you've ovulated. That can be very helpful to sort out symptoms. If you're having pelvic pain and we want to know is this really related just to when you're having your period or if this is more pelvic pain that's not related to your cycle or headaches. Some people have menstrual migraines. So tracking your cycle can be very useful to provide your medical provider with two or three months worth of data to help.

Speaker: But we're also seeing this explosion of what we call the quantified self of tracking sort of for the purposes of tracking that you're going to glean bits of information that's going to help you optimize your body and we don't have any data to support that. So, one of the issues, especially with menstrual tracking apps, is many of them use proprietary data or proprietary algorithms that researchers can't analyze to see how accurate they are. And if you're just tracking based on a calendar and an app is using calendar input to predict when your next cycle is going to come, that can be quite inaccurate. And there was a study where they looked at women who had tracked their cycles. And what happened was when their period didn't come when the app predicted, the women blamed their bodies as opposed to blaming the app for being incorrect with the prediction. Meaning the app made you less informed about your body than more informed.

Speaker: There's also a lot of talk on social media about athletes using their menstrual cycle to optimize performance or you should only lift weights at this time of your cycle and do cardio here. And none of that is really grounded in good science. So we do not have data that says that during the first week of your cycle you need to do this kind of exercise and in days 10 to 15 you need to do this kind. there is no robust data there at all to support that. Also, in my mind, evolutionarily that doesn't seem to make a lot of sense because we wouldn't have choices, you know, when you need to gather food and water about what you could or couldn't do. Um, it's probably not fair to bring that into it, but it always makes me think of that.

Speaker: Now, it is true that if you're trying to optimize your physical fitness, there may be times of the month where, for example, if your breasts hurt, you might not want to do upper body working, right? So, you're listening to your body. Or if you've got menstrual diarrhea, maybe going out for a long run isn't going to work for you. Now, those are kind of intuitive. You don't need an app to tell you that. If you are a professional athlete and missing two days of arms at a critical time could have an impact for you because the difference between winning maybe the gold and the silver is, you know, based on a millimeter of this or a millisecond of that. You know, we're talking about tiny tiny fractions. Then perhaps doing a workout schedule that takes into account when you can or can't do arms or when you can or can't do a long run is going to help you optimize your training. But for everybody else, we we really just don't have data to say except listen to your body. If your body's telling you that something's hurting at this time, then maybe leave that exercise for a time when it's not hurting. And certainly, we don't have

Speaker: good data to say hormonally you're going to do better working on muscles a certain way at different times of the cycle. That the data just isn't there. So, I think it comes down to trusting your body and with the caveat that we can't be sure that apps will help you trust your body. There is a dark side to menstrual tracking apps that people absolutely need to know about, whether they're tracking just to see what's going on with their cycle or whether they're using an app that's part of a fertility awareness method.

Speaker: So that data can be subpoenaed by a district attorney and could be used to build a case against someone if they live in a place where abortion is illegal and where people are prosecuted for having abortions or even prosecuted for the belief that they might have had an abortion. And so when you're collecting this data at the time you're collecting it, you don't know that you might want to seek an abortion in a month or two months or three months. But that data that tells someone when your last period is being collected and people can have cases built against them from data that has been harvested from their phones.

Speaker: So, I think it's just very important when people are living in areas where they do not have the legal right to have an abortion or where prosecution for having abortions is happening that people are mindful about how they use these apps. I think a lot of people are unaware about the amount of data their phone is collecting on them. We've all had that experience of talking about wanting a certain meal or doing something and then all of a sudden there's an ad that appears for it, you know, on your social media, you know, within seconds. It seems it's not a stretch that all the data that pins you to your menstrual cycle could be harvested by someone.

Speaker: And we've certainly seen even in some states pharmacists being refusing dispense medication because it could potentially cause a miscarriage, you know, for somebody who's on it for an immune system problem or for something else and having to sort of show proof that that they couldn't possibly be pregnant. So, I don't think it's a stretch that in some places this kind of data could lead to all kinds of problems down the road.

Speaker: So people just need to be very mindful about where we're going. That ignorance about the menstrual cycle is clearly very common even even amongst medical providers. That weaponizing this ignorance is basically becoming law uh in many places and that these are really troubling times even now more than ever. This is when people need to actually know the facts so they can speak up and hopefully turn this tide because we are definitely seeing in many parts of the United States a shift towards viewing women solely as breeders and that your life outside of pregnancy has less value than your role as basically carrying a pregnancy.

Speaker: So people who are pregnant not being able to get the medical care that they need because of a potential harm to a fetus. We have seen people being denied chemotherapy, being denied treatment for cancers because they are pregnant and they live in places where they can't get an abortion. This is all along the line of basically reducing half the population to being potential breeders. And I don't think we can sound enough alarms about that.

Speaker: So I think everybody needs to know about menstruation. If we can't talk about it, if we can't share knowledge about it, then the implication is that it's shameful and that it doesn't matter. We know that the menstrual cycle has a significant impact on the half the population that has it. A lot of that impact is understudied. We don't have enough knowledge about how that can affect medications. And I'm not talking about medications just for the reproductive tract. talking about how does that affect taking your blood pressure medication? How does that affect your cancer care? How does that affect all these things? We are really behind with our knowledge in that area.

Speaker: So if you have a menstrual cycle, if you love someone who has a menstrual cycle, and I know that you came from someone who had a menstrual cycle, you should want everybody to be able to access the same level of care. In addition, we know that people who have the menstrual cycle, who have a menstrual cycle, have other issues related to that. They can have heavy periods. They can have painful periods. They can have medic medical problems related to having their periods. And we want everybody to know about that so people aren't suffering at home.

Speaker: We want people to know how much blood is too much, how much pain is a concern, has your period started too late. All these things are important to know about so you can advocate for yourself. Because if we're not talking about menstruation, how do people know about these things? They don't. and they just think maybe their body is uniquely broken or maybe they don't think anything's wrong and they don't seek care when they have a medical problem. The only people who are served by not talking about ministration is the patriarchy. It is the political powers that exist. Those are the only things that are served by not talking about the menstrual cycle. It's not shameful. We deserve to be able to have conversations about it and we deserve to know what's happening to our bodies and to be able to have a say in the medicine and the research so everybody can have access to quality care.

Speaker: >> Chapter 2, the science of menopause. Everybody who has a menstrual cycle will at some point have that menstrual cycle stop. The winding down of the menstrual cycle is the menopause transition and the stopping is menopause. But even though everybody's going to experience that, very few people understand what it is and are really unaware of the biological changes that they're going to experience. And to me, that's unacceptable that this is a universal experience and yet it's really not spoken about at all. Depending on how long you live, you may spend a third or maybe even a half of your life in menopause.

Speaker: Understanding about it is really important, not just for you personally, but medically, we need to understand it because we don't know, might medications act differently when somebody has finished menstruating versus when they're still having the menstrual cycle. And not just reproductive medications, obviously we're talking about other medications, cancer care, hypertensive care, care for diabetes, all of these things. So if you're going to live a half or a third of your life in a particular phase, we should know about that phase.

Speaker: Often I hear menopause framed as a disease and it's not. Uh we don't consider puberty a disease and we don't consider pregnancy a disease and menopause is not a disease. That thinking uh is based on pharmaceutical marketing uh from the 1960s that uh suggested that now that women were living long enough, they were experiencing menopause. You know, that life expectancy was now over the age of 50. So now we're experiencing menopause. But that erases everybody's grandmother and great-grandandmother. And and we know it's simply not true. uh because nobody ever has that question about life expectancy and men do they?

Speaker: Most animals die after they finish reproducing. So they keep reproducing, they keep reproducing and they go all the way to the end. Animals that keep on living after reproduction are quite uncommon. The humans, so humans are the big one. Orcas um are another one and there may be a few other species as well, but it's not as well studied.

Speaker: So the question is if everything about reproduction is really evolution getting that next generation and the next generation how does menopause something where reproduction is no longer possible how is that beneficial? It turns out, we think it's beneficial because of something called the grandmother or the wise woman hypothesis

Speaker: that when you finish menstruating, you finish having more offspring. And when you don't have to run around after a seven or an 8-year-old or a 10-year-old, you are now able to help your children. You are able to offload work that they have. And so the idea is is that historically for humans having a grandmother associated with the family unit meant you had an extra pair of knowledgeable hands that themselves weren't occupied with child rearing. You had someone who could go out and help gather food. You had someone that could help with child care. You had someone who could help with building shelter, finding water, passing on historical knowledge from other generations about what you did during a drought, what you did when the cold weather came. All of this wisdom would also be passed down, as well as having the helping hands.

Speaker: And so the idea is that menopause represents evolution, the long game. you're not helping your immediate offspring, you're helping your grand offspring live longer and or producing more offspring. So, it's not your genetics per se passing along, but your grand genetics that you're helping with. And so, that's the the main theory for the existence of menopause is that it was very beneficial evolutionarily. So, it's the idea that we retain our power as we age.

Speaker: So we say menopause has occurred when you are a year from your last period. If you're over the age of 45, between the ages of 45 and 55, that is the expected range for that to happen. Now, just like there are hormonal changes that lead up to the first period, there are hormonal changes that lead up to the last period. And that time of hormonal change is known as the menopause transition. But you may have also heard it discussed as Perimenopause or pre-menopause.

Speaker: Now the menopause transition is sort of anywhere between four to seven years, maybe even a little bit longer. And it is this sort of winding down of reproductive hormones, but it's not a general decline. In fact, it's actually much more chaotic. So you may have some months where you produce more estradiol, the main estrogen, than you normally would, and other months where you produce less. But what happens is over time menstruation starts to space out. People might go more and more time in between. Eventually they'll start skipping periods. And when people are skipping periods, we generally believe they're, you know, probably about 1 to 3 years from their final period.

Speaker: Medically, we use the men the word menopause to describe kind of the day of the final period, but you never really know it's the day until afterwards. And it doesn't really signify anything. You know, it's really of no value. And medically, we say everything after that final period is post-menopause. Although I would say colloquially most of us use the term menopause to describe kind of the day of the final period and everything afterwards.

Speaker: You know, for simplicity's sake, the typical age for menopause for the final period happening is between the ages of 45 and 55. If your final period happens between ages 40 and before 45, then we call that premature menopause. And if your periods stop before age 40, we call that primary ovarian insufficiency. Now, people can also have surgical menopause. You can have your ovaries removed and then that puts you into menopause. And we sort of categorize it based on the age. So, if surgical menopause happens at age 45 and older, then that's in the typical time range. If it happens under the age of 45, we would consider it in that sort of

Doctor: premature sort of grouping or folding, if you will. A lot of people ask about hormone testing for menopause. And I always say, well, you got through puberty without hormone testing and everything worked okay. If menopause is happening at the time we expect it to happen, then we don't need hormone tests. Cuz if you're 49, we expect your periods to stop. That's not a surprise. If you're 39, we don't expect your periods to stop and you need hormone testing. So, what matters is, is this change happening in a time that we would predict it to happen?

Doctor: Now, it's also important to remember there are other medical conditions that can cause periods to stop. So sometimes people might need testing for other things, but hormone testing, meaning the reproductive hormones, is actually not a reliable way to see where you are sort of in that menopause continuum, where you are in the menopause transition. And it really only reliably tells you that you are menopausal until you are well and done with your final period. So it doesn't help because you know that you're well and done. So there's nothing that can predict based on hormone tests. We don't treat someone who is over the age of 45 based on their hormone tests. We do recommend hormone testing when people are under the age of 45 because that is not when menopause is expected. So if you're 42 and your periods stop, we need to know is that premature menopause or is there another medical condition causing that? So, it's all about understanding if the changes are happening at the time when they're expected to happen.

Doctor: Menopause is associated with a large constellation of symptoms. And because this has been historically really understudied, I don't think we have a full handle on how many symptoms are common and in what percentage of people would be expected to experience all of them. But the ones that we know a lot about that are quite common that are really often part of the general conversation are hot flashes and night sweats which are known as vasomotor symptoms. Another common one is vaginal dryness or vaginal irritation or pain with sex. Brain fog is another common symptom that's experienced. palpitations. People will describe palpitations and joint pain, another common experience. And so those are some of probably the more common ones that we hear about, but of course the list is quite long.

Doctor: So the menopause transition, the hormonal chaos time that leads up to menopause has an average duration of about 4 to 7 years. However, symptoms don't always correlate with that. So, some people have their worst symptoms earlier on in the menopause transition and some people have their worst symptoms towards the end of the menopause transition and some people have their worst symptoms around the time of their final period or even afterwards. So, there's a large variation and I think that a good way to think about that is there's a large variation of how people experience pregnancy, right? That there's a wide constellation of symptoms. Some people have severe uh severe morning sickness and other people don't have it at all. Some people have a lot of swelling, some people don't. And so we're kind of used to that range of experiences with pregnancy. And I think that's a really similar way to think about the range of experiences with menopause. So a lot of experiences that cross many domains.

Doctor: There are a lot of symptoms in menopause and in medicine. We do have a toolkit to help manage many of them. However, one of the most important things is having a good health foundation going in. And that is exercise. And I I don't like that answer any more than anybody else. But we can't deny the impact of exercise on all of the domains that menopause touches. When people go through menopause, that changes their trajectory for risks for type two diabetes, for heart disease, uh for dementia, for depression. It has all these impacts. It changes your trajectory for your risk of osteoporosis. And the thing that touches all of those domains is exercise. You get stronger bones. You get more muscle mass. You lower your risk of type two diabetes. It's good for your heart. It helps with mood. And it protects against dementia.

Doctor: So I think that it's really important for people to understand that while we do have medications for many symptoms, medications can only do so much. And if you want the one thing, if exercise were a drug, that would be the thing we'd be giving to everybody. So to keep that in mind and it's not just aerobic exercise, but strength building that is super important, resistance training as well. So that would be the most important foundation for treating menopause.

Doctor: There are many symptoms in menopause and one of the treatments that people have heard a lot about is menopausal hormone therapy or MHT. We used to call it hormone replacement therapy and we do not use that term anymore because we are not replacing estrogen that you should have. We expect menopause to happen. We expect estrogen levels to change but we also don't expect people to suffer. And so it's a therapy. Menopausal hormone therapy is the gold standard treatment for hot flashes and night sweats, vasomotor symptoms. We do have other treatments as well. We have um uh a new drug that's specifically for hot flashes. And then we also have some drugs that are in the category for uh treating epilepsy and treating depression that we also use for hot flashes. But menopausal hormone therapy is the gold standard. It will treat night sweats. It will treat hot flashes. When people are suffering with uh changes in their vagina, then we use vaginal estrogen. There are also some other products as well. We don't generally recommend taking menopausal hormone therapy for the only purpose of treating the vagina because it's not quite as good as putting the products in the vagina. So, you want the best treatment.

Doctor: A lot of people ask about menopausal hormone therapy. And the big question is, should I take it? Like any medication, do you need it? That's what you should be asking yourself because while menopausal hormone therapy can help many parts of menopause, there's also parts that it can't help, right? So, you only want to take a medication for what it can do. There is no broad agreement that every person should be on menopausal hormone therapy when they go through menopause. Meaning, we do not recommend it universally as preventative care.

Doctor: So I often think about menopausal hormone therapy as things that are really evidence-based and those would be the green light indications. So that would be hot flashes and night sweats or prevention of osteoporosis for people who are at high risk. Those are things that in the United States the packaging label states the FDA states that you can advertise for those reasons and those have been shown in good studies. There are also what I would consider yellow light reasons for starting menopausal hormone therapy. meaning it might help some people, it might not. And that takes a much more individual discussion in the office.

Doctor: So, a good example would be depression in the menopause transition. There are some studies that show that estrogen can help with that. Interestingly, it doesn't help after menopause. So, if someone were 2 years after their final period and said they wanted to start estrogen for depression, that wouldn't be an evidence-based recommendation. But if they were having irregular cycles and in their menopause transition, then that would be other yellow light indications for starting hormones might be joint pain. The studies aren't great, but it might help some people. So, if you're someone who has bad joint pain, then it might be worth trying to see if you're in the percentage it can help. And there is some data that shows it may reduce the incidence of type 2 diabetes. And so, if someone is at very high risk for that, that might be part of a discussion with your provider. But there isn't a global recommendation to give menopausal hormone therapy for prevention of type two diabetes.

Doctor: We do not recommend currently starting menopausal hormone therapy for prevention of dementia or Alzheimer's disease. And we do not currently recommend it for prevention of cardiovascular disease. There may be some benefits for starting it early for cardiovascular disease, but it hasn't reached the threshold where it's a universal recommendation. We do not recommend menopausal hormone therapy for brain fog. There are quite a few studies that show that it doesn't have any short-term impact on brain functioning. One caveat to that might be if you're someone who's sleeping very poorly because of hot flashes. So, if you're up eight times at night with hot flashes kicking the sheets off your bed, it might well be worth a trial of menopausal hormone therapy to see if sleeping better and getting a good night's sleep helps your brain function. Right? So, in that context, it may well be helpful. But for the symptom of brain fog alone, no, it doesn't work for that.

Doctor: It also doesn't work for weight gain in menopause. And that's something that people ask about as well. So whether or not you should start it would really depend on do you have something that it can help or that it could possibly help um based on your individual sort of risk profile. And if it is a safe therapy for you, then it may well be worth trying. And like any therapy, if you start it and you're not seeing the benefit that you want to get, then it should be reassessed.

Doctor: One symptom that isn't discussed enough in the menopause transition are menstrual irregularities. So people obviously can have skipped periods because that's part of the menopause transition, but people can also have heavier periods and in addition they accumulate medical conditions, specifically fibroids that can contribute to heavy periods as well as another condition called adnomiiosis. So for many people, hormones are also an important part of controlling bleeding problems. And one way we often do that is with the estrogen containing birth control pill. And the reason we do that is it is good at controlling heavy bleeding. And people also get the benefit of estrogen. And if people need contraception, they have the benefit of contraception. So that is one option for people. And if people are at low risk for problems related to the estrogen containing birth control pill, they can actually take it up to the age of 55. But there are other options too. We can use a hormonal IUD to treat heavy periods. And then if people want to start menopausal hormone therapy, they certainly can. And that would be at the standard doses for menopausal hormone therapy.

Doctor: So when we're talking about menopausal hormone therapy, we're talking about pharmaceutical preparations that come from a pharmaceutical company. meaning a pill, a patch, a transdermal lotion or a gel that comes labeled from a pharmaceutical company. And it is very important that products be pharmaceutical because making hormones into something that's absorbed reliably either from the gut or across the skin is actually quite challenging. It takes years of research to do this. So when I prescribe a pharmaceutical patch or I prescribe a pharmaceutical pill, I know exactly how much is being absorbed and I know what dose protects the bones. I know what dose can help with hot flashes. So this is very important information. When you

Dr. Jen Gunter: When you get a compounded product, you have none of that research and development. You do not know if the product will be absorbed well. You do not know if the vehicle it's being compounded with has been studied. When you get a pharmaceutical product, these things are batch tested. So, we know that they contain what they claim. That doesn't happen with a compounded product. And so, there can be issues with absorption. There can be issues with dose. Also, compounded products don't contain the same warning labels that pharmaceutical products do, which gives them the illusion of safety. Because when people see a warning label, they get concerned. And if they don't see it, they think, well, they don't need to be concerned. But it's just that the rules in the United States don't require that warning label to be on it.

Dr. Jen Gunter: And I would include pellets that are injected as part of compounded hormones. Pellets often deliver very high doses of estrogen or testosterone or both depending on the pellet. They're also not batch tested and they are associated with a lot of adverse events. And the big problem with compounded products is adverse events often don't get reported. It's very important that people use a pharmaceutical preparation so they can get a safe dose and they can get something that has been studied and we know works.

Dr. Jen Gunter: Now, one question I get, well, but I want to take bioidenticals. Bioidentical is a marketing term that has essentially no medical meaning. The belief is that bioidentical means that it's a hormone that is identical to what your ovaries make. But being the same as what your ovaries make doesn't make a hormone safe. I could extract a bunch of estrogen from a bunch of ovaries and give it to someone and over time give them endometrial cancer and that would be from an estrogen from an ovary. So what makes something safe is if it has been tested and studied and we know that it is safe. But here's the kicker is that almost every pharmaceutical hormone that I would prescribe for you could be considered bioidenticals because it's all estradiol. It's all made generally from soybeans and it all comes from generally the same plant. I mean plant as in factory, not as in plant that's grown. And so if you are purchasing raw estradiol from a compounding pharmacy and mixing it up, or you're a pharmaceutical company and you're purchasing raw estradiol, it's coming from the same place. They don't have a special soy estradiol tree that they are picking their hormone from. And the only exception is conjugated equine estrogens which are made from horse urine. They're not really made. They're extracted. And so technically they are the only natural estrogen because they are unchanged from how they are found in nature. But if I'm prescribing estradiol from you, it is plant-based and it is bioidentical and you can get that from a pharmaceutical company.

Dr. Jen Gunter: Testosterone is not part of menopausal hormone therapy. Meaning there is no universal recommendation to add that in. We don't recommend adding it in for fatigue. We don't recommend adding it in for brain fog. We don't recommend adding it in for hot flashes. You should think of testosterone as a medication for a specific indication. And the only indication for it is in people who are suffering from libido or desire problems who have a relationship that's not the cause of those desire issues, and for people who have explored other therapies. So for example, medical mindfulness is highly effective for libido and desire disorders. And there's a lot of disinformation out there about what desire actually is. So I always encourage people to get educated about that subject. But that is the only evidence-based indication for testosterone is for desire related issues.

Dr. Jen Gunter: So how do you sort this snake oil from science online? Because there is a lot of medical content out there, whether it's about the menstrual cycle or about menopause. So, I have a few good rules of thumb. In general, if something sounds too good to be true, it probably is. There is no influencer or doctor who has discovered a secret that no one else knows about. If the information's out there, we all know about it. So, be really careful about people making bold promises. You should be able to look that up and if it's true, you should be able to find major news stories about that thing.

Dr. Jen Gunter: Number two, does the person sell supplements? Okay, supplements are untested, unregulated pharmaceuticals. If I sold a birth control pill, if I had Dr. Jen Gunter's birth control pill, you would probably rightly think that my information about contraception might be suspect. So, when you have somebody who makes money advertising supplements or even has their own brand of supplements, you should really consider all of their medical information as contaminated because how do you know it's not a subtle sell to promote their supplements.

Dr. Jen Gunter: Number three, be very mindful about what you read online because you need to fact check immediately. If you keep engaging, that might stick in your brain. So, how do you fact check? How do you do that? What I recommend people do is take the subject matter, whatever it is, put it into your Google search and add, if it's about, for example, reproductive health, ACOG, American College of Obstetrics and Gynecology, or SOGC, Society of Obstetricians and Gynecologist of Canada, or Menopause Society. Put your question and then put that in afterwards. And what that will do is it will force the algorithm to bring content from those societies up to the top. Because one of the big problems with doing your own research online is many people actually end up with incorrect information because people who sell snake oil are really good at search engine optimization. So you want to trump that by putting in a medical professional society. You could also put the CDC. You could put the WHO. You could ask your doctor if it's something about your gut or something about brain health. What's the medical society that they trust? So you can put that in.

Dr. Jen Gunter: So how should you sort through things when you're trying to seek medical care or when you're seeking medical care? I encourage people to write down the things that are bothering them. What are the symptoms that you wish would go away? And you know what? That can be a list of two things. It can be a list of 12 things. So that can help your doctor try to work through that list with you. It might take more than one visit if there's a lot of issues, but trying to help you sort of think about how you're going to approach it in a systematic way. If you're not getting the care that you need, speak up as long as you feel safe doing that. So, if you don't think that your symptoms have been heard, it's very valid to say, well, you know, I read at the CDC that it's very safe for women to get vaccinated for COVID-19 and pregnancy. Why are you not offering me that? I'm pregnant. Right? So, come in with some information from some medical professional societies if you're worried about not being heard. You shouldn't need to do that, but that can help you know if you're getting the right care.

Dr. Jen Gunter: Be mindful about who you're seeing. So, is this person truly an expert? Are they a physician who is board-certified in that area or are they someone who has less expertise? For example, a naturopath or a chiropractor. You may also want to look to see how that person is connected with industry. So with doctors, you can actually look them up online and see if they have made money from pharmaceutical companies. But you know what? You can't look up if a doctor's made money from a supplement company. And you can't look up naturopaths and chiropractors. Or physical therapists or nurses or anybody else who's online offering information. So you need to just be wary about that. I would be very mindful about getting health advice or health recommendations from celebrities. They are not just like us. Often the way they talk about different medical conditions or physiologic states like menopause isn't always evidence-based. While it's great that people want to raise awareness, be mindful about specific medical recommendations that come from celebrities.

Dr. Jen Gunter: Chapter 3. Are supplements safe? I get asked a lot about supplements and it's a really big and sometimes even confusing topic. And in addition, there are so many ads that come to us all the time on social media, either clear ads where someone's, you know, pushing a vitamin or soft ads where an influencer is just talking about it off the cuff and you don't actually know if it was paid for or not. So, the truth is there are very few supplements that have good evidence-based medicine to support them. And the term supplement is really meant to be a dietary supplement, meaning something that is supplementing a dietary shortfall, right? The greatest example is probably prenatal vitamins. There is good evidence-based medicine to support using prenatal vitamins because the average person doesn't get enough folate and other micronutrients in their diet to support a real healthy pregnancy. So prenatal vitamins are a good evidence-based treatment or a good evidence-based recommendation. We also recommend multivitamins for people who've had bariatric surgery because they are not absorbing because of the surgery all of the nutrients as well. So those are examples of nutritional shortfalls, right? Either because your physical state has changed pregnancy or because your gut isn't absorbing enough of what you need. And so there are obviously a few other indications along those lines. So, for example, if somebody is, you know, has an illness and they're having trouble eating for four or six weeks, a multivitamin might be recommended for that person to make up a nutritional shortfall. So, you think about that.

Dr. Jen Gunter: We also recommend supplements to treat specific nutritional shortfalls. So, for example, if you have iron deficiency anemia, it's really hard to get enough iron from your diet to treat that. And so, we might recommend an iron supplement. There are medications that can affect levels of different micronutrients in our body. So for example, there are some water pills, diuretics that cause us to lose potassium. So some people might need to take a potassium supplement. So those are what we would consider sort of the kind of evidence-based examples, and that is not an inclusive list, but that's how to think about it.

Dr. Jen Gunter: Then there's this other class of supplements, meaning a reported medical benefit. Although in the United States, supplement companies can't actually say their product does anything. They all have these little FDA disclaimers. But that might be some things that are grounded in pretty good science or good science even. So magnesium to treat constipation. But there's also things that aren't grounded in good science like black cohosh for hot flashes. So each one of these needs to be investigated and looked at the evidence. Another common one that we see all the time is biotin for hair growth, but there's no data to support that. And there's a wide range of things that potentially have good science behind them and things that have no science behind them and things that might be kind of in between. So each one of those has to be looked at independently. And then there are another category of

Speaker: supplements where there's a whole bunch of vitamins and minerals and herbals and botanicals all lumped together in a product for like ovary support or adrenal support or thyroid support or metabolism booster or fat burner. And these are things where there is an insinuation that there's some kind of benefit for your organ or for your health or for weight loss. And none of these are studied in any meaningful way. And many of them are actually adulterated. And that is one big concern with supplements is you do not know what you are getting.

Speaker: And so especially with products that are for libido, for metabolism, for sport enhancement, those products have a much higher risk of contamination. But there's also products that can be contaminated with lead or toxic molds or fungi. And so this is a huge problem. And that's actually why pharmaceuticals have a standard so none of these things happen. and they get tested and that doesn't happen with supplements.

Speaker: So, how do you decide? Well, you want to ask your doctor if the supplement you want to take falls in a good recommendation. So, for example, prenatal vitamins, bariatric surgery, or if ask them about the ovary support and hopefully they're going to tell you there's no indication for that. So, being mindful about whether you should even take the product in the first place.

Speaker: If it's something that you've decided you want to take or something that you need to take because your doctor says, "Look, you need iron. you have iron deficiency and you can't get enough in your diet, then the best that we can do in the United States are to look for third-party verifications. For example, a USP-verified label means that there's been third-party checking. That's really the best that we can do because in the United States, we don't have the ability of the government to require testing for purity. And it's important because one, you want to make sure that the product you're taking isn't contaminated with heavy metals or mold or fungi or things like that, but you also want to make sure it contains what it claims.

Speaker: Three ways to think about supplements. One, is this something you really need to take? Is there good evidence to support it? Places to look would be the CDC, Centers for Disease Control. If it's for a reproductive health issue, it might be the American College of Obstetricians and Gynecologists. And also in the US, the US government has the office of dietary supplements. So there are good places to go to find out is this something recommended for the reason that you want. So number one, do you really need it?

Speaker: Number two, who is recommending this to you? Is it someone who's selling a product or is this someone saying these are the recommendations of multiple medical societies? So look at the source of the recommendation. And number three, you want to take a product that has been tested by a third party. That's the best that we can do in the United States, but that is better than not having any testing.

Speaker: And let me add a fourth. Don't take something that's for sport enhancement or metabolism boosting. And be very wary about Ayurvedic products because they are actually very likely to be contaminated with lead. About 20% of them are. So we know that metabolism boosters, things like that are more likely to be adulterated and Ayurvedic medications have a high risk of being contaminated with lead.

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