Perimenopause Symptoms and Hormone Health After 40 (Episode 364)

Full Transcript: Episode 364

Lisa: Welcome to the Fertility Friday Podcast, your source for information about the Fertility Awareness Method and all things fertility. I’m your host, Lisa Hendrickson-Jack. I’m the author of The Fifth Vital Sign and the Fertility Awareness Mastery charting journal. I’m a certified fertility awareness educator and holistic reproductive health practitioner with nearly 20 years of experience teaching women to connect to their fifth vital sign through menstrual cycle charting, balancing hormonal health, and optimizing the menstrual cycle without hormones. I’m outspoken about hormonal birth control and its impact on fertility and overall health because you have the right to know how your body works and how artificial hormones disrupt that natural process. I host live coaching programs to help you achieve optimal fertility and health because it’s important to have healthy menstrual cycles, regardless of whether or not you want to have babies. I’m also a wife and mother of two beautiful boys. This podcast is designed to empower you to take full control of your cycles, your fertility, and your overall health. And I’m so excited that you’re here with us today.

Today I’m sharing my most recent interview with Dr. Lara Briden. We are talking about menopause and pre-menopause — the 10-year period that comes before your very last period — the hormonal shifts that you can expect to see, and how you can prepare. What I love about conversations about that pre-menopause phase of life is the opportunity to really shatter some of the myths and commonly held notions that we have been taught about this time of life. We’ve been taught to expect that it’s going to be horrible and terrible and that we’re supposed to have all of these really negative symptoms, when that is far from the truth. And there are plenty of things that we can do to minimize those types of negative effects during this phase. We could even argue that the reason that many women do experience some of those negative responses is because our modern, busy lives often find us living out of sync from essentially how it was supposed to be.

A little bit about Dr. Lara Briden: Lara is a naturopathic doctor and author of the bestselling books Period Repair Manual and her newest book, Hormone Repair Manual. She has more than 20 years’ experience in women’s health and currently has a consulting room in Christchurch, New Zealand, where she treats women with PCOS, PMS, endometriosis, perimenopause, and many other hormone and period-related health problems. So without further ado, let’s go ahead and jump into today’s episode.

Lisa: So I’m really excited to have Lara Briden back on the podcast. Welcome to the show, Lara.

Dr. Briden: Hi Lisa. Thanks for having me.

Lisa: Well, thanks for coming on and congratulations on your new book, Hormone Repair Manual. I’m holding it here. I’ll make sure to link back to our previous episodes. I think we have two previously. I won’t go into a ton of it — I think people know who you are — but I would love to hear you just share why did you choose to write this book now?

Dr. Briden: For sure. You know what, it was similar to my first book with Period Repair Manual. With this book, I was responding to what I felt was a gap in the conversation around what it means hormonally to be 40-something. For a lot of women, we hear about menopause and we think it’s often some distant future — something that happens when you’re 50, maybe 60-something. And yet a lot of my patients and followers who are in their late 30s and early 40s are experiencing changes with their menstrual cycle, not understanding that that’s part of second puberty or perimenopause. I was trying to communicate that and also at the same time trying to normalize it and de-stigmatize it to some degree. And I’m quite happy because one of the reviews I had on Amazon so far was from a woman just saying the book made her feel like everything is going to be all right — which is exactly what I was going for. This is a normal life phase. It can be turbulent, it can be uneventful. That really depends on the woman. But bottom line: it’s normal. It’s not something to be ashamed of or feel bad about.

Lisa: I think a good place to start might even be just to talk about the word “menopause” itself. My understanding is that it refers to your last period and doesn’t necessarily refer to this giant period of time when life is horrible — whereas the words “perimenopause” and “pre-menopause” tend to focus on that kind of period of time. So I’d love to hear how you describe that and kind of demystify what it actually is. What is menopause?

Dr. Briden: Well, perimenopause is anywhere between two to up to 12 years before the final period — technically before the one year after the final period, which would mark the end of perimenopause. Perimenopause is actually the time of symptoms, if there are going to be symptoms. They occur during perimenopause — what I call second puberty. Menopause — and I use Professor Geraldine Prior’s definition because I think it’s perfect — she describes menopause as the life phase that begins one year after the final period. So it’s the next three to four decades. It’s a time of low estrogen, kind of low progesterone. We re-enter a time of low hormones. The way I’m starting to see it is that as much as I love the reproductive years — and I do, I’m a cheerleader for estrogen, progesterone, cycles, and ovulation — they’re really only supposed to be there for three to four decades. We have our girlhood and childhood when we’re in a low hormone state, and then we re-enter that hormone state with menopause. So just to kind of situate that. And perimenopause is really what I’m talking about in this book — which is the possibly turbulent time of transition.

Lisa: And you call it the second puberty. I’ve actually been referring to pregnancy in a way as another type of puberty because it’s a time when you’re exposed to so many hormones and it makes all of these really interesting and fascinating changes in your body. But I’d love to hear more about why you’re calling it the second puberty.

Dr. Briden: In chapter one I provide an image from one of Professor Prior’s papers about ovarian hormones over the lifespan, and she shows low hormones in childhood and then estrogen spikes up first before progesterone kicks in — because it takes girls a few years to start producing good levels of progesterone as they mature their menstrual cycles. So in first puberty you’ve got high estrogen with really not very much progesterone coming through to counterbalance that. Then hopefully through our reproductive years, we have a good balance of both estrogen and progesterone, especially during pregnancy when you have massive amounts of progesterone. And then in our 40s, it’s a mirror image of first puberty. Just like progesterone took a while to kick in during first puberty, in second puberty in our 40s, progesterone drops away first. We start to have more anovulatory cycles where we don’t ovulate. We start to have cycles with shorter luteal phases. Even if we’re doing everything right, this is just part of the process of the change to the ovarian follicles. So progesterone starts to drop away and estrogen stays high. In fact, in second puberty — perimenopause — estrogen spikes up to up to three times what it was in our reproductive years, which is part of the symptom picture for some women. So you’ve got this very high estrogen, lowish progesterone — analogous to first puberty. And that’s where you get a lot of symptoms that young teenagers would get and then get again in their 40s. Examples would be heavy periods, painful periods potentially, and an increased frequency of migraines. If you’ve ever had clients say they got migraines when they were teenagers and then they went away during their reproductive years and then they came back in their 40s — that’s another example. And mood is another example of course, affected by this dynamic of high estrogen and low progesterone.

Lisa: Before I knew what I know now, I was under the impression — and I think maybe a lot of young women are — that perimenopause is just this horrible time where everyone has hot flashes and you can’t remember your first name. Now that I’m a bit older, I see it differently. I’m 39 now and I feel like this phase — the late 30s to early 40s — is when you really realize you’re not 20 anymore and you can’t get away with what you could before. So is it normal? Because I feel like our culture tells us it’s normal for this time to suck.

Dr. Briden: It’s not normal. Just like period pain is common but not normal — similar to how we’re told this narrative that periods are difficult, periods are painful, and yet of course in both our books we talk about how actually, when the body’s healthy, the menstrual cycle should be symptomless. It’s an expression of health. The same is true for the perimenopause transition. Now, I never want to give the impression that if women have symptoms, it’s because they’re doing something wrong — it’s not that simple. In the book, I talk a little bit about evolutionary mismatch, because I’m an evolutionary biologist, so I see everything through that lens. Menopause — the transition to not cycling anymore, this post-reproductive phase — is something that evolved. It’s something our ancestors have had for a long time. In the book I debunk the idea that menopause is the result of an accident of living too long. That’s just not the case. Several lines of evidence suggest that the human lifespan has been 70 or 80 for a long time, and actually the beneficial post-reproductive years for women — the benefit to their community — has been there for a long time and may even have been selected for from an evolutionary perspective. So menopause is part of being human.

Dr. Briden: Most information we have from existing forager groups and traditional peoples: they report menopause — they know you stop getting your period, you stop being able to make babies in your late 40s — but they don’t report symptoms associated with it. I think traditionally what it would have been is: you have your last baby in your early 40s, then you breastfeed for a few years, and then you just cruise into it — no more ovulations, without symptoms. So the fact that we have symptoms in our modern world is the result of lots of different things, including food environment, stress levels, and environmental toxins to some degree. I share a couple of papers in the book about lead exposure and the body burden of lead in our bones that we would have accumulated over a lifespan. The body stores that in bones, and the final stages of perimenopause are associated with increased bone turnover. So you’re potentially releasing some of those toxins. There’s a couple of papers to suggest that at least some of the mood symptoms and even brain fog and cognition problems could in part be attributed to exposure to lead. That’s not the only thing going on, but there are several reasons why in our modern society this should-be-normal, symptomless transition is associated with symptoms. And in the book I provide all kinds of strategies for relieving those symptoms, because we don’t want women to suffer. My experience is that for most of my patients, there’s a way to feel better. It’s always possible.

Lisa: My perspective is really interesting because I look at everything through the lens of the menstrual cycle. The way I look at it: there’s a whole lot of women who use birth control. If I see the menstrual cycle as a vital sign, and there were some hints that your cycle was trying to give you — a little bit of spotting before your period, or some increased PMS symptoms associated with low progesterone — you’re not necessarily getting those subtle hints on a regular basis if you’re on hormonal contraceptives. And then at some point, many women have children and their partner gets a vasectomy and they find themselves having a natural cycle when they’re a bit older — without having had those years of practice to kind of work with it. Women in their 20s can not sleep, go on a drinking binge, work themselves to the bone, and kind of recover. Women in their 40s can’t really get away with it. I’d be really interested to hear your take on how stress affects us differently as we get older.

Dr. Briden: All those are excellent points. First, to agree with your point that if a woman’s having trouble with her periods in her 40s, but those are the first menstrual cycles she’s had in 15 years as opposed to pill bleeds, then yeah, you can’t blame all of that on perimenopause. Maybe she’s revealing what’s kind of going on with her menstrual cycle — especially if she didn’t have an opportunity over her reproductive years to really mature her menstrual cycle. The first time I ever really knew about that was when you interviewed Geraldine Prior. I was getting my hair done and listening and I was like, “Oh my goodness — it takes 12 years to mature the menstrual cycle.” It makes perfect sense. If any of you women listening remember when you first got your breast buds — it’s not like you woke up with breasts. It took several years to mature. So it makes perfect sense it would take time for all of these mechanisms to mature.

Dr. Briden: So in one scenario, if a woman’s been able to menstruate naturally all her life — and perhaps had some pregnancies in there, which as you point out is also a maturation process — she may move into her 40s and find her cycles pretty stable and perhaps not getting as many symptoms. Versus someone who spent decades on the pill. And there’s the other half of what you were just talking about — because the menstrual cycle is our monthly report card, if there are things going on with our health they show up in our cycle. It’s just in general, just being human, there are going to be more things going on with our health in our 40s. We’re trending more to insulin resistance, for example — which is a big theme in my book. There may be a higher degree of some sort of brain inflammation that’s making it less easy to cope with stress. And you also particularly have a lot going on in your life just because of being that age. So there’s a combination of things that are perhaps making it harder to have that vital, healthy menstrual cycle. And then that’s compounded with the fact that you’re just generally on a trajectory where the ovarian follicles are becoming less responsive, because they’re genetically programmed to do that at some point in your 40s. I do want to acknowledge the genetic component — some women stop menstruating up to 10 years before others. Having your periods stop in your late 40s isn’t necessarily a sign that you did something wrong in terms of your lifestyle.

Lisa: That’s interesting. I mean, one of the factors is how many eggs you have left. We’re born with all the eggs we’ll ever have, and menopause happens when you have about a thousand left. But what’s interesting is that there does seem to be a genetic programming — and then there’s a point at which there’s no more eggs. I’ve been watching the science of ovarian stem cells.

Dr. Briden: So in both books I talk a little bit about this. The science at the moment is that there are no ovarian stem cells, although there’s some evidence to the contrary. Without question, the ovary stops ovulating in our mid to late 40s, early 50s — that’s definitely genetically programmed and happening. Through my scientist and biologist background, I am not convinced of the “we run out of eggs” version of it. What’s interesting is that it still happens. If we were to play with the stem cell conversation, it would involve a lot of technology. But the reality is: the activity of the ovarian follicles drops dramatically by our late 40s — that’s a biological reality. I would argue that it was selected for from an evolutionary perspective. It’s just philosophically — and kind of as a feminist — my narrative is that potentially, if the science backs it up, we don’t run out of eggs. Because that really is a very depletion, deficiency narrative. Instead, we could have kept ovulating for longer, but we don’t — because it was selected for women to stop reproducing about the time their children are of adult age. The grandmother age. An intentional switching off of the ovaries. That’s just a lot more empowering to me than the “we ran out of eggs” scenario.

Lisa: I love that. I feel like I’m one of the few people in these women’s lives who is talking about menopause in a positive way. Even I can sense the hesitancy. But our culture is saying: you’re dried up, you’re running out of eggs, you’re depleted, you’re done. I look at it very differently. When we talked about this whole concept of menopause as being something really incredible — even looking at it as a second puberty — it means that you’re transitioning to a new, perfectly normal, and potentially wonderful phase where your energy is no longer necessarily primarily involved in reproduction and mothering. I actually look at menopause as a positive and very natural shift. And I think the problem is the way our culture looks at women as only reproductive units.

Dr. Briden: In the book I talk about a book by historian Susan Mattern called The Slow Moon Climbs. She weaves together all these lines of evidence that from an evolutionary perspective — menopause, the value of women’s post-reproductive years, the value for their group and for their individual genes in their grandchildren — that women being post-reproductive was so valuable that it was the reason, from an evolutionary perspective, for the evolution of a longer human lifespan. She basically makes the argument that humans evolved to live to 80 so that women could spend three decades post-reproductive. That’s how important it was for the group. In most forager groups today, women in their 50s, 60s, even into their 70s gather more food per capita than any other individual. And that’s really the only way humans could have evolved — we always had to have quite a high ratio of adults to children because human children take a lot of work and can’t look after themselves for years. There had to be this biological mechanism in place, and post-reproductive women were part of that. When I started seeing it through that lens — not only are we not dried up and done, but that being a post-reproductive female was hugely important for everything to work — that’s when it kind of cracked open for me. This is part of who we are.

Lisa: I want to jump back to hormones. Even beyond the topic of menopause, progesterone is this hot topic. From a menstrual cycle standpoint, I find it fairly straightforward to support a woman to improve her progesterone. The first steps have been to ensure she’s eating adequate food overall — including protein and fat — and to get sufficient sleep and manage stress. But I’ve found this topic to be very interesting because when women have very clear and obvious severe signs of progesterone issues, there are usually very clear and obvious holes in her lifestyle and dietary habits that correspond. The trend I’m seeing is that now doctors are much more comfortable prescribing progesterone — it’s like everyone and their dog is on progesterone. So in your opinion: do you think women need this? Is it a prerequisite when you go through menopause? Do we all need progesterone? Or do you think it’s over-prescribed?

Dr. Briden: The starting place is no — I don’t think everyone needs it. I think it’s for symptoms. What you’re saying is true: if you’re healthy, if you don’t have insulin resistance, you can keep progesterone going for longer potentially. At some point in everyone’s late 40s, it’s going to drop away — that’s just going to happen because that’s the first phase of stopping ovulation. But women can navigate that if they’re very healthy, if they don’t have insulin resistance, if they’re not suffering from heavy periods or migraines, and they’re maintaining all of that with movement, eating well — and I would argue magnesium is a big one — they can go through that unassisted. So no, I don’t think everyone needs progesterone. I think if a woman needs help with symptoms — particularly let’s use heavy, crazy flooding periods of perimenopause as an example, which can be crazy — just to give it a number: a normal maximum amount of menstrual fluid lost during all the days of the cycle would be about 80 ml or five tablespoons. Some of the flooding periods of perimenopause can be 500 ml. So 80 versus 500. Two cups. That kind of bleeding is obviously very serious. This is when women end up in hospital, when they end up on the hormonal IUD — and when I started practising in the 90s, that’s when the uterus came out. No joke. I would say with all women in their late 40s in my practice at that time, at least half of them had their uterus taken out for this crazy heavy bleeding. It only goes on for a couple of years but it can be intense.

Lisa: So this is not something that every woman in her 40s experiences? Could you share a little bit about why this happens and not to all women? I personally have fibroids — I’m a Black woman and I made my doctor give me a referral when I was 24 because so many women in my family had fibroids. My mom struggled with it, had a hysterectomy — so that’s one reason for me. But you’re talking specifically about why this flooding happens to these women and not all women.

Dr. Briden: Different reasons to have heavy bleeding. Fibroids can cause heavy bleeding, but only about one in ten fibroids will do that — it’s the location and size more than anything. In terms of the frequency of fibroids amongst Black women — I think part of what’s going on is vitamin D status. I include a little bit of that research in my book. There’s going to be a genetic component. And when you mention hair straightener used from teenage years — if you leave it on the scalp it burns right through, there’s a lot of toxins in those products, and there’s some research around the body burden of those toxins. Products specifically geared to Black women that contain additional chemicals that are banned in certain countries — that’s a really important area for more research. And the body burden of those toxins from a young age is something to noodle on. I’d like to see more research around that, and around vitamin D status and fibroid vulnerability. Fibroids are a tough one — there’s no easy natural treatment, but prevention and conversations like this will hopefully change the incidence in future generations.

Dr. Briden: And then there’s just the whole unopposed estrogen side of heavy bleeding, which can go alongside fibroids. So you can get fibroids growing in part because of high estrogen exposure through various mechanisms — including environmental toxins and anovulatory cycling — and then you know, unopposed estrogen bleeding because of that. At some point, if intervention is needed, my position drawing on Professor Prior’s work is: if you’re going to need to do something, natural progesterone — called Prometrium or Utrogestan — is almost always going to be a better choice than a progestin, if you can make it work. I do talk a lot about using progesterone for heavy periods, migraines, sleep, and mood potentially. But some women don’t need that.

Lisa: Can we just talk a little bit about hysterectomy and keeping your uterus?

Dr. Briden: I mean, looking at the science and the evidence, there are lots of reasons to try to keep your uterus after menopause. I’m done with the narrative that if you’ve had your babies, the uterus is optional — that is not the case at all. For so many reasons. Anatomically and structurally, it’s part of the pelvis — the bladder and other things connect to it. It actually affects body shape to some degree just because of that structural role. It’s important for orgasm — I really can’t emphasize that enough. The whole topic of orgasm and the role of the cervix and the uterus is somewhat controversial. The cervix has three different nerve supplies, including the vagus nerve — and very few organs have direct innervation by the vagus. There is some evidence that manipulating, damaging, or removing the cervix affects women in ways that weren’t intended, including potentially impairing their ability to have an orgasm. Some women can have their cervix taken out and still have a clitoral orgasm. Some can’t. It’s this whole nerve network that is understudied. So I think if you can keep your uterus, please do. And there’s even some suggestion from animal studies that when female animals have their uterus removed, their spatial memory goes down — like the uterus is part of a brain-uterus nerve network that affects cognition.

Lisa: And beyond that, there are also other consequences — an increased risk of other life-threatening health conditions, heart conditions. It’s not much of a surprise that it’s not really well known and studied, given the history of medicine.

Dr. Briden: If you’re ever faced with a procedure, the two strategies I give in the book are: one, ask “could this be a watch-and-wait situation?” — is it possible to just cruise and check back in six months? Sometimes the answer is no, if it’s a more dire cancer situation. But if it’s pre-cancer cells, can we just watch and wait? Get that answer. And second: get a second opinion, especially from another gynecologist. I can’t tell you how many patients I’ve had who were told they had to have their uterus out or had to have a certain procedure, and then they talked to someone else and were told there are other ways to manage this. When we’re sitting in a doctor’s office and a doctor says you need to have a hysterectomy, something shuts off in our brain and we forget we have options. We constantly need to give women permission to ask: is this a watch-and-wait situation? And then go get a second opinion.

Lisa: Weight loss is something that I think a lot about — one of the things that changes. We can get away with things in our 20s and even early 30s, but all of a sudden in the late 30s and early 40s the weight kind of sticks, and it sticks to certain places. And then we start adopting certain practices to try to lose this weight that are not necessarily helping the hormones. Share your thoughts on weight in our 40s.

Dr. Briden: Think of it this way: estrogen and progesterone have metabolic-enhancing properties — they’re both insulin-sensitizing to some degree. Women having natural hormone cycles have a metabolic advantage over women on the pill or over men, in terms of insulin resistance. So when we start to lose those hormones, especially in the later phases of perimenopause when estradiol actually starts to be lower on average, we shift into insulin resistance. And that’s what I describe in the book as “testosterone dominance” — we get this thickening around the waist, not the hourglass figure we had in our 20s. The solution is to just kind of know that’s what’s happening. If insulin resistance has been a problem generally and it’s now compounded by perimenopause, you need to do all the things for insulin resistance: eat enough protein, find a way off sugar especially if you’re addicted to sugar, move your body, have a healthy gut microbiome. And it’s also about letting go of the expectation that we have to have the figure we had at 25. The body’s different. Also, some women shift to thyroid disease in their 40s — there’s quite a common flare-up of Hashimoto’s thyroid disease kicking in because of this remodeling of the immune system that happens during perimenopause. So it could be a combination of estrogen and progesterone changes of perimenopause, insulin resistance, and Hashimoto’s thyroid disease — that’s a perfect storm for weight gain, and all of those need addressing.

Lisa: I find this to be really interesting. It feels like before we were told what menopause was by men who don’t have it — and what they thought about it. And I feel like now as we go through it, we’re defining it for ourselves, talking about it, normalizing it, demystifying it, and sharing how to cope. Because it sounds like from our conversation: it doesn’t have to be this way. Even if you have symptoms, that’s still the vital sign saying: slow down, figure this out, whatever you’re doing isn’t working. If you’re not yet in that phase and you’re getting to know your cycles, it’s really good practice to learn to take care of yourself in your 30s so you’re more experienced with that in your 40s.

Dr. Briden: You’re spot on. The menstrual cycle is an expression of health, and perimenopause is too. I have a chapter in this book called “Cycle While You Can.” You’re getting that monthly report card, and if that’s going well, chances are the perimenopause transition is going to go well. I heard this analogy — I don’t know who first came up with it, but I love it: perimenopause is like a plane coming in for landing. So if it’s super turbulent and all over the place, it’s going to be a bumpy landing. If you can smooth that out through your last decade of menstrual cycles, you will hopefully just touch down. So your late 30s into your 40s — that’s the time to observe your menstrual cycles, see what they’re telling you, understand what are the underlying factors you need to address, whether it’s stress load, toxic body burden, gut health, insulin sensitivity, or a combination of those. Addressing those will help both your menstrual cycle and hopefully set you up for a smooth perimenopause transition landing.

Lisa: Wow. I feel like I couldn’t have ended it better. Well, Lara, thank you so much for being here. Could you tell the listeners a little bit about your book and where they can go to buy it?

Dr. Briden: Before I do that, thank you for having me again. I always feel like we’re kindred spirits — I think part of it is that we’re both Canadians. So yes, my second book is called Hormone Repair Manual: Every Woman’s Guide to Healthy Hormones After 40. It should be in all shops, all online shops, Amazon, all the usual places. And I’m easy to find — my blog is larabriden.com, where I also have a weekly newsletter. And all my social media is @larabriden.

Lisa: Awesome. We will make sure to put all of that in the show notes and thank you again for being here.

Thank you for listening. If you enjoyed today’s show, please share it with a friend. You’ll find the show notes page for today’s episode over at fertilityfriday.com/364. I hope that you enjoyed today’s episode with Dr. Lara Briden — always a pleasure to have her on the show and to talk about women’s issues, in particular this time talking about menopause, pre-menopause, perimenopause — that period of time before our last period — and really talking about some of the things that we can do. I love her concept of “cycle while you can.” Sometimes we just really need some go-to strategies for how to manage, and Dr. Briden’s book and her approach are really refreshing, especially in a world where we’re given so many negative messages about this period of time. To the point that we can forget that it’s a normal stage of life that we are supposed to go through.

What’s great about having these conversations with women who have gone through that phase of time, and really looking at it from the woman’s perspective instead of our patriarchal society’s perspective, is that we can really look at ways to lessen any potential health impacts that we may experience during that time. And we can really decide what this transitional phase means for us. So I hope that the Fertility Friday Podcast will remain as one of the places you can go to have positive discussions about this natural transition of life, so that we don’t have to approach it with fear and anxiety — that we can really approach it from a fresh perspective of being a natural process that we go through when we reach that stage of our reproductive lives. So with that said, I hope you have a wonderful week — whenever you’re tuning into the show — and of course, as always, until next time: be well and happy charting.