The Case for Progesterone in Perimenopause | Dr. Jerilynn Prior (Episode 625)

Full Transcript: Episode 625

Lisa: I’m so excited to have you back on the show, Dr. Prior. It’s been a while. Welcome to the show.

Dr. Prior: Thank you.

Lisa: We were talking before we even hit record, and you have been blowing my mind. You mentioned that you are now retired, but busy, because you are still just making so many contributions to the field. I’m so thrilled to have you back on the show. I’m always excited when I see a new paper come out with your name on it. Your contribution to the field is just immeasurable. I would love to start, for anyone who is not familiar with your work, would you share a little bit about your work, what your main focus has been, and even how your focus may have shifted in the last several years?

Dr. Prior: Okay, so I’m an endocrinologist. In general, endocrinologists are part of internal medicine, and we don’t study women’s reproduction. But I decided I wanted to be an academic when I came to British Columbia. Within the field of endocrinology, I needed a specialty. So I began to focus on the menstrual cycle and very quickly learned that our understanding was biased toward estrogen and ignoring the importance of progesterone, including the current dogma that progesterone only works in the uterus to change the lining of the uterus and prevent endometrial cancer and make a pregnancy possible and maintain a pregnancy.

My work started with trying to help athletes to train for and run a marathon safely without having risks to bone or risks of their menstrual cycle. That led to an understanding that you need progesterone as well as estrogen, or in other words, you need to ovulate as well as have a cycle in order to prevent bone loss as a premenopausal menstruating woman. The difficult thing is that ovulation is hard to track. Almost all of the apps and the watches and the various things are based on invalid or not validated background. I decided early that I would take the old-fashioned basal temperature method and make it into something scientific. That’s what I did. I learned that it’s not just ovulating that matters. It’s the length of the luteal phase, or the length of time from ovulation until the next period. That’s the key to knowing if you have enough progesterone or not.

Lisa: There’s so much in what you said there. I was saying to you before we started recording that your work was my first foray into the connection between hormones and bone formation. Being that your work was my first foray, I almost heard what you said when you said that they had focused only on estrogen, but I kind of was still surprised when I looked at the research for myself and saw, even in hypothalamic amenorrhea, they define it as an estrogen deficiency, not even acknowledging that there’s also no progesterone. Your work has really drawn attention to the importance of progesterone. I know we’ll talk a little bit about that. We’re going to get into some of that research. But I wanted to start by asking about menopause, because what you were telling me before we started recording was really relevant. Before we started this recording, I was on a call with some of our band practitioners and we were talking about perimenopause. Of course, a huge topic right now is the role of HRT.

Dr. Prior: I don’t even like that term. We should throw it away because it’s not replacement. It should be understood as therapy. That was a very clever marketing term developed in the 40s and 50s by the makers of Premarin.

Lisa: Interesting. Please tell me more.

Dr. Prior: HT, menopausal hormone therapy, not HRT.

Lisa: I think I understand what you’re getting at, but I do want you to go a little bit deeper into that. So hormone replacement therapy obviously makes it sound like we’re replacing hormones that we should have.

Dr. Prior: Right. Menopause is normal. The low estrogen and the low progesterone in menopause are giving women at last a break from the demands of these very powerful hormones, which is why it’s important during the premenopausal years to have had a normal balance so that we don’t have to worry about consequences or needing hormone therapy when we hit menopause or perimenopause.

Now, that’s not to say that some of us, and I was someone who had a very symptomatic perimenopause. I was not sleeping at all. I was waking in the middle of the night and not getting back to sleep. I was having night sweats. I was having sore breasts continuously. I had several major episodes of heavy flow. I would get nauseated intermittently, so I would almost gag when I was brushing my teeth. All of those are things of high estrogen. I recognized that, but the literature didn’t say so. So I set out to see if I could find evidence. When I looked, the evidence was there. Perimenopausal estrogen levels are higher than in the premenopausal years, in a meta-analysis of studies that were looking at comparisons within each center, because estrogen level of the lab test differs between centers.

That’s totally different than the message we normally get, which is perimenopause is symptomatic because estrogen is too low.

Lisa: Does that make sense? It does. In your case, because you shared your personal experience, did you seek a solution?

Dr. Prior: Yeah, the solution I sought was progesterone. This was actually before oral micronized progesterone was available. So I asked my doctor for medroxyprogesterone, which is the closest progestin or synthetic knockoff of progesterone. It was helpful. It definitely helped my heavy flow episodes several times.

I think it’s helpful to understand why estrogen goes high and why it is so erratic. The reason is that our body has obviously a fail-safe mechanism to give us lots and lots and lots of eggs. We’re born with millions. Each follicle that surrounds an egg makes estrogen. Now, the body needs to get rid of those extra follicles so we don’t have periods into our 90s. In order to do that, it has to break the feedback loop between the hypothalamus, pituitary, and ovary and allow more follicles to get stimulated, which makes more estrogen, and then absorbed.

Lisa: This is really interesting because I’ve never heard anyone talk about it this way. When you look at the literature, they talk about the gradual depletion of our egg supply, and then when the magical year of 35 or 37, that there’s a dramatic drop.

Dr. Prior: That’s right. That drop in follicle numbers, which is what they’re looking at, the anatomy of the ovary, is associated — I mean, where did they go? They get stimulated, they make more estrogen, and then they get absorbed.

Lisa: This is really interesting. Immediately my mind went right to the research that shows this dramatic decline. What you’re saying tracks. What you’re saying, what you’re experiencing, what you’re seeing in the research is that these egregious symptoms are then not a sign of low estrogen, but a sign of high estrogen.

Dr. Prior: That’s right. For a temporary period of time while your ovaries are kind of reaching that endpoint.

Lisa: I love logical questions like that, where it’s like, okay, we know that there’s a dramatic drop in the follicles, where are they going? What happens? Tell us more, because this is really blowing my mind.

Dr. Prior: Okay, so I’ll just tell another story on myself. I was looking and looking and looking in the literature, and women’s voices were totally missing before about the mid-80s from anything. There was one book that said, “I think, doctor, I think I have high estrogen.” And the doctor wouldn’t agree or disagree. Just, “I’m not sure.”

Lisa: Right, dismissive answer.

Dr. Prior: I knew. I had been in Australia, invited there as a guest speaker in the early 90s. I knew there was a research program in Melbourne that was starting. It was a random sample of women from the census roll in Melbourne, the voting record, actually. They were looking for women who were over 45 who had menstruated within the last three months and who were willing to be in a study. It was a longitudinal study. We followed over years. They ended up recruiting somewhere in the middle of 400 or so women. These were healthy women. They were the ones who always got their mammograms on time and went for their pap tests and didn’t smoke. Although a random sample, the ones who agreed were healthier.

What the scientists at that time, they had no clue about how to stratify the changes across time in perimenopause. They said, okay, we’ll stratify women based on their periods. So women with regular periods were considered to be premenopausal, even though they were over 45. Women who had changes in flow, either less or more, changes in cycle length, less or more, changes in both flow and cycle length, and then had been three to 12 months without a period.

They did a blood test for estrogen in the morning during the early part of the menstrual cycle for people who are still having cycles. So days five to eight of the cycle, follicular phase, when estrogen levels should be pretty low. Thankfully, they printed it in the Journal of Clinical Endocrinology as a dot plot. Each woman’s value was a dot. I looked at the data, and I could see that there were sky-high estrogen levels. It was just incredible how high some of those estrogen levels were. I kind of said, “Yes, this is confirmation of what I knew already.” Then I read the article. The abstract said that estrogen levels were dropping. The reason was that they compared the premenopausal with the women three months or more from their last period and said that there was a statistically significantly lower level then, and they ignored all those high levels. 20 or more were higher than estrogen should ever be in the menstrual cycle. The estrogen peak level was not the highest. There were levels double that. And yet they couldn’t see it because they didn’t expect it.

Lisa: This is really interesting. The question that I have for you, because you said something really interesting before we started recording about this phenomena. You said something like 30% of perimenopausal women will have problematic symptoms that require help, which was even interesting to hear because word on the street is that everybody’s just comatose with all of the menopausal symptoms. Everyone just has the most horrible time, because it’s presented as an illness nowadays. You’re looking at this sample, and you said 20% of these women had estrogen that had no business being that high. Which women were the ones that had the high estrogen?

Dr. Prior: The women with the most symptoms.

Lisa: Okay.

Dr. Prior: The women like me with sore breasts and heavy flow and night sweats and waking at night.

Lisa: Does that mean that some women have low estrogen?

Dr. Prior: No, some women have only a small increase. A lot of it has to do — I don’t know, nobody understands it actually — but I think part of it has to do with the metabolism of estrogen. If it’s slow, and I’ve come to believe that I have slower metabolism of estrogen, then you get more symptoms. If it’s fast, then you get fewer. There’s evidence. People talk about women from Japan and China not having very many symptoms. In reality, genetically, that group of East Asian women metabolize estrogen more quickly.

Lisa: Back to the researchers. You’re saying that the researchers looked at this data, and I complain about this all the time, not about the perimenopause studies. Whatever study I’m looking at, I could complain about when there’s a finding that they don’t expect that is outside of their kind of paradigm. The abstracts are wild compared to what the actual data will say in those situations on a very consistent basis. How did the researchers then come to the conclusion that the estrogen was statistically significantly lower?

Dr. Prior: Because if you look only at the geometric mean, which is what they looked at, the change in geometric mean between those two extreme groups. They just didn’t see the trees for thinking about the forests.

Lisa: I just want to make sure I’m understanding. The women then who did not have these sky-high levels, their levels would have been like normal for a perimenopausal woman, which would be lower than — is that correct?

Dr. Prior: What one would expect when you measured early in the menstrual cycle is that they would be around the average for that time of the cycle, which is not very high.

Lisa: Is that why they were saying it was lower? Because they didn’t recognize that at that time of the menstrual cycle, the levels would be a bit lower?

Dr. Prior: They should have. Henry Berger was the primary author on that paper. I was so frustrated, well, angry actually, when I saw the diagram and then read the conclusion that was in the abstract, that I tried to connect with him in Australia. I got his poor statistician instead. She said, “I just did what he asked me to do.” I guess he hadn’t looked actually at the data. I’m so glad that they did that dot plot.

Basically what happens is that estrogen rises erratically in perimenopause, and it drops. It has to drop. The drop in estrogen causes bone loss. We know that. But it turns out the drop in estrogen also causes night sweats and hot flushes. The most recent evidence is that it also causes depression in people who are vulnerable.

Lisa: If I’m painting this correctly, this is so interesting. I’m doing a review for my own brain benefit. We have, we’re reaching the end of our reproductive years, we are seeing a rapid decline in the number of ovarian follicles. But as you so eloquently said, they have to go somewhere. So this process of breaking them down is releasing estrogen erratically. And so you have women whose estrogen is skyrocketing, partially because of this natural process that is taking place, but partially because women who don’t break down estrogen as well are going to have a harder time coping with this significantly increased estrogen temporarily. But then once this process is essentially done and the ovarian follicles are depleted, then there’s a massive drop because they were high temporarily. And then there’s symptoms associated with it being high and there’s symptoms associated with it crashing.

Dr. Prior: That’s right. It’s on purpose. It’s a long transition. Mine was well more than 10 years. The early part, I didn’t recognize I was in perimenopause. This is another important thing. We now know that perimenopause begins in women with regular cycles. Typically they’re shorter than their usual. So if their usual was 28 days, now they’re down in 27, 25 days. Which also is a sign of higher estrogen, by the way. Shorter cycles have higher estrogen, longer cycles have lower within the sort of normal range.

Lisa: Is that because — when you look at the research around menstrual cycle length as a valid factor, even looking at ovarian reserve, because it’s associated with this decline. Is this part of that lead-up, this part of the finale?

Dr. Prior: Yeah. There also is a study that most people don’t know about. The author is Bowman. Ursula was his wife, and Bowman was the gynecologist in a small town in Switzerland. They got all these patients and their daughters and everything to collect basal temperature and figured out a way to evaluate them for ovulation. In fact, the first quantitative basal temperature method, and that’s the one that’s on the CeMCOR website that we validated. Anyone can use it. They show that ovulation gradually starts changing — shorter luteal phases, more anovulatory cycles as you go toward menopause, while this chaos of estrogen is happening. That’s one of the problems, because progesterone’s job is to counterbalance the tissue effects of estrogen. So if estrogen is higher and progesterone is lower, then that imbalance also creates the symptoms that we know as part of perimenopause.

Lisa: I have a question, and I’m pretty sure that you would guess the next question. This is probably everyone’s next logical question. Why is it that they’re giving HRT, the phrase that you despise? Why are they giving women estrogen? Why are the women saying that the estrogen has changed their life and they feel so much better?

Dr. Prior: I think they feel better because they’re doing what their husbands and their doctors want them to do, and they expect to feel better, and therefore they do. There’s a huge placebo effect, and that wears off very quickly for most women. Because of the physiology I’m telling you about, the hormonal changes, and because of my own experience in finding that progesterone was so helpful in controlling the heavy flow, which is related to the high estrogen, low progesterone, in controlling the night sweats, and in helping with sleep, which is a fundamental issue, problematic during menopause — I got Canadian Institutes for Health Research funding to do a randomized control trial of progesterone for symptomatic perimenopause.

We showed, even though it was the first study ever in only perimenopausal women, so we didn’t know how many women we needed to test, we didn’t have quite enough for the primary outcome to be statistically significant. But we asked everyone at the end of the trial before they had finished their meds, “What change did you experience in hot flushes, night sweats, sleep, menstrual flow?” They could answer minus five or plus five. It got worse or it got better. There was a statistically significant improvement in night sweats and a highly significant improvement in sleep. We have a therapy that makes physiologic sense and that’s been proven in a randomized controlled trial. Why don’t doctors know about it? Why is it not taught to medical students and to women?

Lisa: I have more questions. Are more women now taking estrogen and progesterone when they do their replacement, what they call it?

Dr. Prior: I hope so. Don’t say replacement.

Lisa: Okay. Therapy. I’ll say therapy. Menopausal hormone therapy. I will. When you said that, there’s going to be a whole lot of women that are super offended and upset, because what I hear over and over again is, “Basically, my life was horrible. I couldn’t function.” These are symptomatic women. These are women who really — and they say, “Then I did the HRT and everything was better. I could sleep now.” One of the questions I have is, is it possible that they’re taking the estrogen and the progesterone and the progesterone is giving them the relief, but they’re attributing it to the estrogen?

Dr. Prior: Unfortunately, the dose of progesterone that’s usually given is lower than a physiologic level. All of the menopausal hormone therapy prescriptions that are dictated by the guidelines are very estrogen dominant. They’ll have a higher than normal or normal estrogen dose, but a low progesterone dose.

Lisa: What is the estrogen doing? I also have heard about newer therapeutic options that are looking to give estrogen at very high levels to allow women to continue having bleeds into their 70s.

Dr. Prior: That’s a weird thing to do.

Lisa: The thought behind it is, there’s no end, we just keep taking it. The thought behind it is that estrogen makes me feel young, it makes my skin shine. Why would I, if I can have access to these hormones and feel like I’m 20 forever, like, why not?

Dr. Prior: Because it actually causes harm. There’s no scientific evidence that in asymptomatic women, in women without bad night sweats and sleep problems, that it improves heart disease. It does improve bone density while you’re taking it, but as soon as you stop, there’s rapid loss again. You can even fracture because of the rapid loss. There’s solid evidence that it does not improve skin. The evidence or the idea that it produces youthfulness is a cultural and not a scientific idea. You can’t change aging. Aging is a process that’s going on. There’s clear evidence that taking estrogen into the 70s is harmful. We learned for sure from the randomized control trial, the Women’s Health Initiative — that was a prevention study — and it showed increased cardiovascular disease, both strokes and heart attacks, plus blood clots in women who took estrogen into their 70s.

Lisa: This is so interesting. Like I said, this is not an area that I’ve specialized in, and because I haven’t personally gone through this all yet, I have minimized it because I feel like I would just be sharing opinions that I have not devoted a lot of time to the research yet. My thought process at this stage is kind of like, whenever we medicalize a normal stage of development or a normal process in the woman’s body, bad things happen. When we medicalize birth, that’s a good premise. So when we medicalize birth and we look at birth as an actual medical emergency, bad things happen to women, to mom and baby. When we medicalize even the menstrual cycle, all of these things — throughout my whole career, I have a lifelong study of the female body and understanding how it works so that we can support its natural inclinations. But then all of a sudden, when we get to this stage where we stop menstruating, everyone seems to be really okay with medicalizing perimenopause and making it into an illness. What you said about the process and explaining how it works — one of the practitioners in today’s call, we were talking about this. Her question is a question I think a lot of people have, but I certainly have the question also. She said, “Do we just take it forever? How long do we do this?” That’s something that has always confused me about the hormone therapy, which is that it seems as though this is a forever kind of thing where there’s no end. We just keep taking it. What you described was a really egregious but temporary process that concludes with the end of ovulation. I’ve always thought, well, puberty wasn’t great, there was all kinds of weird stuff going on, but eventually it stopped and then we were stable. So I would imagine that perimenopause isn’t great sometimes, and obviously for some women can be really egregious, but it’s not this thing that you deal with forever. It ends.

Dr. Prior: That’s right. The question of, do you take the hormones forever, is modulated. It’s important to understand that the brain reacts, as we said before, to a drop in estrogen, which makes it difficult to stop estrogen. In fact, the women who stopped estrogen in that original Women’s Health Initiative really struggled with an increase in hot flushes. Some of them had never had hot flushes before, and now they did. They started having sleep troubles and night sweats. Some had depression and most of them had bone loss. Estrogen is kind of addictive, really. Sometimes it takes higher and higher doses to be effective. We see that in the literature. There was a practitioner in Britain who was giving higher and higher doses into the toxic range, in fact.

The important thing is that progesterone is not like that. You can stop progesterone, and we showed this in a randomized control trial. You can stop progesterone, and after a month, your hot flushes are still not as bad as they were before you started it. You can stop progesterone anytime. If the hot flushes come back, you restart it. So my instruction to people is stop it once a year and see if you’re done with night sweats and hot flushes yet. If you’re not, just restart it again.

Lisa: To break down the main point that you’re talking about with your research and everything that you found, when you figure out what’s actually going on, giving more estrogen is one way to go about it. But if we were to focus on progesterone and using that as the therapy, it’s potentially just as effective and less addictive. From what you’re saying, it sounds like there’s an actual end date at some point that you could come off of it. I’m simplifying it quite a bit.

Dr. Prior: No, I took it for seven years because my night sweats lasted that long. Since I stopped it, I have only twice when I was under great stress, both times, had any night sweat. Like two occasions since.

But I think the important point to realize is that menopausal-type hormone therapy in perimenopause does not make scientific sense. If the feedback loops are broken — when we’re younger, like you take the pill, you have high estrogen from the pill, it suppresses your own estrogen. But that doesn’t happen in perimenopause. Your own estrogen keeps doing its thing, and you add on top of that more estrogen. You could run into quite toxic levels. The important message is we don’t know from randomized controlled trial data that menopausal hormone therapy is effective in perimenopause.

Lisa: How do they define effective? I’m going to ask that question, but I also want to position it. One of the things that you said before we started recording was that you were curious as to whether or not treating menopause improves health. I thought that was really interesting because that’s a logical question to ask, like, is this actually helping? What you said was that in women who were most symptomatic, treating it did help, but in women who were not symptomatic to the point that it was problematic, it didn’t actually help.

Dr. Prior: That’s right. There’s evidence from large population studies, one from Japan and one from the Netherlands, that hormone therapy in menopausal women in general is associated with an increased risk of dementia. There are several cohort studies that have shown that the women who were taking hormone therapy in menopause had benefits for heart and benefits for osteoporosis, but the prevention studies do not show that.

I think we have to understand that we need to treat symptomatic perimenopause and symptomatic menopause, because the symptoms themselves are associated with an increased risk for hip fracture, as it turns out in the data. In the perimenopausal data, those with the worst night sweats and the ones that continue the longest had almost a doubling of heart attacks, because night sweats and hot flushes are a stress response. The body is being put under a great deal of excess catecholamines, excess norepinephrine, and those are hard on all tissues of the body. So it’s important we treat symptomatic perimenopause and menopause.

In menopause, you have the choice of taking estrogen and progesterone, or — we’ve shown that progesterone alone is effective for hot flushes in menopause. So you could choose, if you wish, to take progesterone alone. In perimenopause, the only randomized controlled trial evidence that’s been shown is that progesterone is effective. There’s no other therapy that’s been shown effective for night sweats and hot flushes and sleep in perimenopause.

Lisa: This is really interesting. In birth control, it’s used off-label for all these things. It’s not necessarily that there was evidence to show that this helps. It’s just used to reduce symptoms. What you’re saying is that the actual — there’s evidence, randomized control trials — for menopause, after these women have stopped ovulating, menstruating for a year, for night sweats, for example, to meet the definition of menopause. For women who are not in that category, there’s not actually evidence that this is improving symptoms, like strong evidence, even though this is a very common practice for them too.

Dr. Prior: Everyone believes it. Most doctors believe that it’s helpful. And consequently, many women believe that it’s helpful, but there is no randomized controlled trial evidence.

Lisa: Are you saying that there’s no research that has been done? Or are you saying that the research that has been done doesn’t show a positive effect?

Dr. Prior: There has been no research only in perimenopause.

Lisa: Wow. That is so interesting.

Dr. Prior: That’s why it took five years and three months from the time I presented the data at the Endocrine Society, the randomized controlled trial progesterone in perimenopause data, before I could get it published.

Lisa: Because it kind of goes against the grain.

Dr. Prior: Do we just accept what everybody says? Or do we want to know?

Lisa: I have more questions. I feel like I could talk about this all day because this is so interesting. There’s been an explosion of discussion around this topic. As someone who graduated university, and then Facebook came out, social media, while it feels like it’s been here forever, wasn’t. There was a lot of young professionals that were prominently out there that are now turning 40-something, 50-something. That’s one of the reasons why it’s so out there, because these women were young when they were coming out on the social media channels, and now they’re like myself, going into older ages and experiencing this. You hear all these things. You hear them say that women need access to this, and it’s a myth that it’s associated with cancer and all of that. We need to correct those myths. We need to give women access to these hormones. They need them. There seems to be this personal mission, because a lot of these women were living their best lives trying to be healthy, and then the symptoms of perimenopause really kind of shook them. Personally, they really were bothered, and had a horrible personal experience, and found the hormones to come in and kind of save the day. That’s a story that I just hear over and over and over again.

Dr. Prior: You don’t really hear from women who maybe didn’t make that decision and maybe didn’t take the hormones. You don’t hear that. You don’t hear the voices of women who experienced the odd hot flush and embarrassment in perimenopause, who were able to manage without any hormones. We’re in a kind of a reaction period after the Women’s Health Initiative. The message was, “Don’t take hormones, period. It’s harmful. It’s bad.” But we didn’t pay attention to how that study was designed. It was a prevention trial. These were not symptomatic women.

There’s a huge difference between taking hormones when you don’t have any symptoms, trying to defy nature, to reconstruct, to pretend that aging isn’t happening, or taking hormones because you have bad symptoms. If those symptoms are treated with either progesterone or estrogen and progesterone, then you don’t end up getting bone loss, heart attacks, et cetera. So there is a prevention of negative effects if you treat symptoms. But there’s no prevention of negative effects if you’re treating something else that’s a made-up idea about menopause.

Lisa: This is so fascinating. I have a lot of different theories over years of just what I’ve been doing. One of the theories that I have is that it’s not good to base an entire protocol on your personal experience.

Dr. Prior: Sure.

Lisa: What you’ve explained is very enlightening. Even the stats that you have on the percentage of women that do have symptoms, which would indicate, obviously, in any situation in life, that there is a spectrum. There’s a certain number of women that are going to have a smaller percentage of women that are really just going to have an outrageous experience that’s just very horrible. But there’s also women that have very little. It’s just not as egregious. What I have found the most interesting is that these very prominent voices seem to be suggesting that every woman needs to have this hormone therapy. I caught myself. There seems to be this, “Everyone needs it. Everyone needs access to it.” I’ve even heard women say, “Maybe should I be on it?” It’s this thing of, “We all need it.” Which is ironic, because throughout my life, working with women who are charting their cycles, there’s nothing that can take away your delusion that everyone is the same than working with women who chart their cycles and observing with your own eyes that one woman can do this and one woman can do that, and they can have a very different experience.

There’s a lot of questions that your research has answered for me in many ways, because one of the other big themes that I’m hearing from you is that we first of all need to just divide the women who are having these severe symptoms and the women who are not. We shouldn’t be treating all of these women the same. We should be treating the women with the symptoms differently than the women that have less severe symptoms.

Dr. Prior: Because we’re focusing on hormones, I don’t think that means that that’s the only way to deal with all of the symptoms. Continuing an exercise program, continuing to eat in a healthy way, having friends you can talk to about anything, and they’re not going to judge you or tell you what to do — all of those things are very, very, very important. The message is that perimenopause, no matter how symptomatic, ends. For those women who are symptomatic in perimenopause, menopause is a blessed relief.

Lisa: I’ve interviewed a number of different people. I like to hear different voices. I always think back to the interviews I’ve done with Sjanie Hugo Wurlitzer and Alexandra Pope. They wrote the book Wild Power. They’re looking at menopause through a very different lens. They talk about it, when it comes down to what you just said, in that way. As a woman who is still menstruating, as a woman who has had multiple children, I have a three-year-old as well as a 10-year-old and a 13-year-old. You have a lot of these reproductive years where you’re giving your energy, you’re birthing babies, you’re breastfeeding. The idea that at some point that comes to an end and you are able to kind of rest and your life takes a little bit of a different turn — I don’t think that that’s so bad. I just think it’s unfortunate that our society has really turned it into this youth-worshipping, “You’re shriveling up and you’re not useful anymore. We need to keep taking the hormones.” If you don’t take them, you’re no good. Turn into a prune.

Even one of the questions that came up today was kind of like, “What happens if you just don’t take the hormones?” The idea of just allowing your cycles to end, assuming that you’re not highly problematic and you don’t have egregious symptoms, but just like, what happens afterwards?

Dr. Prior: We should be celebrating when we have been a year without a period. That’s a major transition. That’s an achievement. Menopause is a walk in the park compared to perimenopause for someone like me who had a really bad time.

Lisa: Oh, my goodness. Well, there was so much more we wanted to talk about. I might have to have you back on the show to talk a little bit more about progesterone and bone formation, particularly in perimenopause. So we might have to do that another time, because there was just so much wonderful conversation that we had about this topic. But Dr. Prior, thank you so much for being here, for blowing my mind and I’m sure the mind of all of those who are listening, and breaking down some of this research, because it’s so needed. We need to have different voices. We need to have voices that are not just all repeating the same thing, that are actually looking at the data critically and asking the questions that we need to ask, so that as women, we can stop being preyed on by the medical or by the pharmaceutical industry.

Dr. Prior: And research that believes what women say.

Lisa: Yeah, I think that’s really important.

Dr. Prior: That’s the kind of research that the Centre for Menstrual Cycle and Ovulation Research is doing. You’ll find a daily perimenopause diary and a daily menopause diary on the CeMCOR website. They’re free for anyone to use. You’ll also find the way of documenting ovulation that’s been validated using the basal temperature.

Lisa: On that idea, we can link any of your recent papers and work that you would like to, so our listeners can go to the show notes page for that. Of course, you mentioned the CeMCOR website. Please let us know any other information you would like our listeners to know about and any other way if our listeners want to get in touch with you.

Dr. Prior: Okay. All right. I will do that.

Lisa: We will make sure to link all of that to the show notes page. Thank you so much, Dr. Prior, for being here with us today. This has been incredible.

Dr. Prior: It’s been fun.