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Changes Bodies Series: Dr. Jen Gunter

The audio version of this episode is available here.

Annie [00:00:04] Hello and welcome to Changes, it is Annie Macmanus here! Delighted to have you with me for what is the second episode in our Bodies mini series. We opened it all up last week with pop star CMAT. She let it all out. She actually called me a witch and said that I made her cry, but she was incredibly open and honest and just giving, I suppose, when it came to talking about her own body issues over the years. Everything from having terrible acne when she was a teenager to, you know, fluctuating weight, eating disorders, and taking Ozempic even, there was no stone left unturned and you absolutely loved the conversation. Thank you for your comments. Hello to Aubrey, Justine and Ornya who all loved it. Violet said 'God, CMAT is a tonic. I wish I'd been half as clued up as her at her age. She's fabulous' and Cara said, 'gosh, this was such a brilliant conversation. I don't know how you couldn't listen to CMAT and not want to be her friend immediately #FreeTheCrack' *laughs*. The crack being the bum crack that CMAT so controversially exposed with her dress at the Brits. So thank you for your comments, I'm glad you're delighted with episode one. Now, this week we are continuing to delve into our ever changing bodies, but this time it is you and your questions which formulate this episode. We are joined by the world's most renowned gynaecologist, advocate for women's health and bestselling author, Doctor Jen Gunter. Jen's books include The Vagina Bible and The Menopause Manifesto. They were both instant New York Times bestsellers and her incredible new myth busting book Blood delves into the science and mythology of menstruation, that was out in January of this year. I really believe that Doctor Jen is like the sex education teacher for grown ups we all need in our lives. She is the godmother of all things bodies, and her amazing work is about making information accessible so that we can better understand our bodies and be empowered. So here in this episode we get into ageing, sex, orgasms, periods, hormones, menopause, perimenopause, incontinence... We cover it all! Now, before getting into your questions, I started by asking Doctor Jen what changed in her life to make her want to dedicate so much time to educating people about their bodies? 

Dr Jen [00:02:36] You know, I mean, I think, you know, along the way, as a doctor, obviously, you know, you're spending a lot of time educating people about, you know, the medical conditions that lead them to see you, about the medications but- 

Annie [00:02:50] Yeah. 

Dr Jen [00:02:51] For me, sort of realising how much of a gulf there really was, about how difficult it was for people to navigate the health care system, happened when I had my own pregnancy and I had triplets and delivered very prematurely, and one of my sons died, and my other two were in the hospital for a very long time with a lot of serious health conditions as well. They're 20 now, my two boys, and you know, I found myself falling down rabbit holes, I wondered how people did this without a medical degree. Now, obviously having kids in the ICU is kind of really far on the technical medical end, right? You know, but still, I started to really think about all of these communication gaps that we have and I would see other parents struggling because when you're in the intensive care unit, you kind of get to know the cohort of parents that kind of go through with you. And so I just kind of realised that we really needed to do a much better job about communication and the other thing is, we needed to do a better job about raising the knowledge level because it was just, you know, it was so much easier for me to have so many more conversations with my kids providers based on having the knowledge that I had. So I started to think about how that might apply to my world in gynaecology and I kind of decided that that's where I was going to kind of plant my flag, so to speak. And here we are. 

Annie [00:04:09] And, you know, looking at your Instagram, and obviously your books are these timeless things, but the Instagram feels like people really rely on you to be able to give them the facts because there's so much misinformation out there. It's typical, it's like they say you should never Google a symptom because you're going to go straight to the worst possible thing on the internet. What's your experience been, I suppose, of how people gather *laughing* their information with regards to their bodies? 

Dr Jen [00:04:36] Well, I would say sadly most of us are pretty bad at it, and there's a lot of studies now that are showing that, you know, a lot of the studies came out because of, you know, the Covid pandemic and where people were going. And the problem is, is unless you are trained in research, most people mistake a Google search for a quality search, right. And there's a big difference because Google depends on where you live, it depends on advertising, it depends on how different people have partaken in search engine optimisation. And there's another thing that often happens, especially in women's health where things may be understudied or, with the latest scam where there's nothing written about it because it's like brand new, if you Google something and there's a big data void, then what happens is this really bad junk just kind of comes to the top. So there's a lot of reasons why it can be very challenging for people to look up health information online. 

Annie [00:05:32] So we thank everyone who got in touch with questions for you. This is the first time we've ever done this type of an episode and- 

Dr Jen [00:05:38] *Gasps*. 

Annie [00:05:38] Yeah, no, we're really excited. So we've got questions about everything from menopause to menstruation to sex and all sorts of things but I just wanted to just start with a general one from someone called Julie who says, 'how can you get more comfortable with and in your own body as it changes with age?'. 

Dr Jen [00:05:55] Well, you know, I think especially for women that's harder because we're judged in so many different ways. The best thing to get comfortable with your body and changes is to accept that changes happen and that changes are part of it. And if everything stayed the same all the time, it would be pretty boring. It would be some sterile sci fi, you know, background. And so I think that, yeah, embrace the change but be educated about the change so you can make sure your, whatever is happening to you is the healthiest possible that's kind of within your, you know, locus of control. 

Annie [00:06:29] Okay. Here's one from someone who wanted to remain anonymous, who said erm, 'I would like to ask about women and orgasms. I've never had one, but I've had multiple partners of both genders'. 

Dr Jen [00:06:41] First of all, penile intercourse is the least reliable way to achieve orgasm- 

Annie [00:06:45] Hang on. Penile intercourse, is that the technical way of saying, like-? 

Dr Jen [00:06:49] Yeah, yeah penile- receptive penile intercourse. 

Annie [00:06:50] Heteronormative? Yeah, a penis and a vagina.

Dr Jen [00:06:53] Yeah, penis and the vagina. Penis in the vagina is the least reliable way to achieve orgasm. So for someone listening if that's all you're doing and you haven't had an orgasm, I'm not surprised. Most people need direct clitoral stimulation and that might vary depending on, you know, the clitoris is a really large organ, it's not just the glands that you see. You can stimulate it through the labia, you can stimulate it through the vagina. So I would say for someone who's, you know, never had an orgasm, first of all, you know, you'd want to make sure that they've been, you know, using a vibrator, they've, they've tried different sex education sites. You know, maybe they've looked at a book like Come as You Are, that's also a good book. There's, you know, quite a few books out there. 

Annie [00:07:30] Who's that by Jen? 

Dr Jen [00:07:32] Emily Nagoski. 

Annie [00:07:32] We'll put it in our notes. 

Dr Jen [00:07:34] Okay. And then also speaking with a sex therapist, you know, making sure that, you know, going- sometimes people have past trauma that can have an impact. So there's a lot of different reasons that can happen. It can happen because you're not getting- you don't have good technique. It can happen because, you know, maybe there is past trauma or maybe you have an issue with your pelvic floor, um pelvic floor muscle spasm. There are medications that can affect orgasm. So there can be a lot of different reasons, and so making sure that you have, again, the right knowledge, you have the right tools and then going to maybe talk to a sex therapist. Those would be some ways to start. And also possibly seeing a gynaecologist for an exam to make sure that everything is normal. You know, there are a few skin conditions that can affect the vulva and sometimes that can have an impact as well, although I'd put that lower down on the list of possibilities. 

Annie [00:08:21] Okay. Let's just keep it then around sexual desire for a bit, because there's a couple of questions that are interesting here. One from someone asking, 'how do I find my sexual desire again after having children?'. And I thought, before you try and answer that, you can just remind people of the decimation that happens *laughs* upon vaginal labour. Like, well, what can go on down there? We have to kind of remind ourselves of what happens there before we then talk about the desire to have sex. 

Dr Jen [00:08:49] Yeah. So obviously if you're having a vaginal delivery, or a C-section, you may be in pain for quite some time, right? You know, if you have a C-section you might not want anybody on top of you, right, so you got to think about that. So, you know, if you have a vaginal delivery, you know, many people are still- I mean, not many, but some people are still having pain at 6 to 8 weeks and so you definitely need to have that looked into. If you're breastfeeding, you can have low oestrogen in the vagina, which can cause pain and that can be treated with vaginal oestrogen. And obviously so if you're having any pain, then we would want the pain to be treated because you know, pain can obviously impact desire, right? 

Annie [00:09:22] Did you just say that when you breastfeed you lose oestrogen in your vagina, thus your vagina can become more dry or painful? 

Dr Jen [00:09:30] You can! Some people do. 

Annie [00:09:30] I never knew that about breastfeeding. Ever. 

Dr Jen [00:09:32] Yeah so- well breastfeeding suppresses ovulation and you get your oestrogen from ovulation. 

Annie [00:09:37] And what's the function of it suppressing ovulation? Because it's, you've had your baby now, so don't have another one basically? 

Dr Jen [00:09:43] Right! It would be really bad for you to get pregnant right away because- evolutionarily speaking, because breastfeeding is the most metabolically demanding thing a human can do, and it's very hard to absorb enough nutrients to support a pregnancy and support breastfeeding at the same time. 

Annie [00:09:58] I remember when I breastfed my baby, I used to have these kind of erm, these kind of err, like pulsing feelings in my stomach. Someone was like, oh, that's your stomach contracting. Because you're breastfeeding, the stomach is now getting smaller because it's getting messages that your body's breastfeeding. Is that a thing or no? 

Dr Jen [00:10:16] Umm well, so the oxytocin that's released during breastfeeding can cause uterine contractions for some people. So it could be that. And not everybody gets low oestrogen when breastfeeding, it's kind of a hit or miss thing. But so, if you don't have any libido after having a couple kids, you want to make sure that there isn't a pain with sex problem. Then you want to look at the division of labour in your household. 

Annie [00:10:38] *Duh duh duhhh*. 

Dr Jen [00:10:39] Yeah. So we are all sold this narrative that, you know, in a heterosexual relationship that women are hot and horny all the time at the drop of a hat for the touch of a man, right. That's what you see in the news. That's what you see in movies. That's what you see all the time. But desire needs to be cultivated. And so whenever anybody says to me that they don't have any desire I always say, and what has your partner done in the last month to cultivate desire in your relationship? And I don't ever think I've had someone give me an answer that would make me think, oh, okay, well they're really trying. So I think that's really important. In a heterosexual relationship, the bulk of the labour in the household almost always falls on the woman. The bulk of the child rearing almost always falls on the woman. And there's studies that even show when a male partner is timewise equal, they're doing more of the fun stuff. So they're in the front yard playing with the ball, and the woman is cleaning the dirty diapers. So there could be reasons in a relationship that might affect, and most people don't know that desire needs to be cultivated. 

Annie [00:11:49] Yeah, I like the idea of it not all being on the the person who- 

Dr Jen [00:11:54] Right, it's not. 

Annie [00:11:54] Who's just had the kid, you know, you're a couple, you need to work at it together. Yeah, it's nice. It shouldn't be another burden on them. Yeah. 

Dr Jen [00:12:01] Exactly. And so many people have a receptive desire. So a spontaneous desire is *clicks* I want to go right now, I'm horny. And a receptive desire is, yeahhh I don't really think so. But then, you know, maybe you get into bed with your partner and ohh, he took his shirt off and you feel his nakedness against you and then maybe he strokes your cheek and, and you know, and he, he cleaned up after dinner because you were dividing your chores equally. And now that sex is presented sort of, or the idea of sex is presented in a way, oh, all of a sudden it's appealing. And so now you're interested. And in fact, for women, desire can kick in after physical arousal. So that's also important to know. So when anybody has a desire problem I recommend the book Better Sex Through Mindfulness by Doctor Lori Brotto. She's a world expert in desire disorders and the book is all about, you know, checking in with your relationship and how to cultivate desire. 

Annie [00:12:56] Hmm, so desire through mindfulness. So kind of, it's about training your thoughts because it feels to me like in every relationship I know which involves a woman, a lot of the time, I can't generalise, there's too much on their minds. They're thinking about what they have to do the next day and what hasn't been done and what- you know, it's so much about getting your head straight. Whereas for men it seems like it's way just more simple. It's like, it's just body, it's just physical. 

Dr Jen [00:13:22] Well, but they also are less likely to have the emotional labour of a household to deal with. 

Annie [00:13:26] Yeah. 

Dr Jen [00:13:27] And at work, a woman is more likely to take on emotional labour than a man. So, you know, if all things are equal, maybe it might be equal. But it's many, many women have receptive desire and that's okay. And it needs to be cultivated. And people can go through times in their life when they have more spontaneous desire and they can have more receptive desire. You know, if you've got two young kids clawing at you and you got to feed them and they're like, all over you, it might be pretty normal to not want to have someone else to touch you, right? *Annie humms in agreement*. Especially if you have to do a lot of caregiving for that person. However, what if that person is someone who, 'I'm taking the kids out for the whole day. Why don't you go to the spa and why don't you, you know, go watch a movie with your girlfriends or whatever, like, have a day, get yourself restored. Let's make sure we're doing this equally' that would be totally different. And you can cultivate desire in lots of ways. I mean, I always say to people, have you ever, like, watched a, you know, a movie and been like ooo, or read a book like, erotica, porn? You know, for me, it's watching the movie Pride and Prejudice *Annie laughs* because there's like so much sexual tension right, between Keira Knightley and I can't remember his name, whoever plays Darcy, right? Or, you know, Outlander, like, whatever. Like, people have, you know, that's why romance novels are so popular, right? They cultivate desire, fantasy, and that's okay. And that's what that book Better Sex Through Mindfulness does, it helps people learn how to, like, cultivate desire. 

Annie [00:14:50] Okay, brilliant. Keeping it with desire but erm, for a different period in your life, perimenopause. Nikki's asked about that period of your life where you start perimenopause and you, apparently, have a lack of libido. Is this true that your libido falls upon experiencing perimenopause symptoms? 

Dr Jen [00:15:12] Well, it can for some, but it's also complex because at this point in someone's life, if they've been with a partner, they might have been with that same partner for 20 years. So what has been going on to cultivate desire over the past 20 years, right? Sometimes you've just kind of like, had enough. Also, if you're not sleeping well because of hot flashes or night sweats, right? So if you're not sleeping well, that might affect desire. There's an increased risk of depression in the menopause transition so if you have depression that might affect desire. So it's really very complex. 

Annie [00:15:40] But isn't it just basic testosterone? Like men-

Dr Jen [00:15:43] No, not at all. 

Annie [00:15:43] Women, women lose testosterone way quicker than men at that age, no? 

Dr Jen [00:15:46] No, it has nothing to do with testosterone. Testosterone levels don't predict female sexual response at all. 

Annie [00:15:52] Okay. 

Dr Jen [00:15:53] Yeah, that's kind of a male, heteronormative, horny myth, right? They want women to be hot and horny so let's give them all testosterone. 

Annie [00:15:59] Right. 

Dr Jen [00:15:59] It's true that low doses of testosterone can help in desire disorders, but it's not that- it's not like that effective. On average, people have 1 to 2 extra episodes of sex a month, right, so it's not like it's sort of- you know, so it can help. But for- but when you look at medical mindfulness, that's actually far more effective than testosterone, cultivating desire. 

Annie [00:16:21] Right. Okay. 

Dr Jen [00:16:23] Yeah, so, so it's not- and also an important thing to say in the menopause transition is that people can also get vaginal dryness from low oestrogen *Annie humms*. And again, if sex is painful it will be normal not to desire it. So you need to go through all the things you know, is sex painful? Am I getting the stimulation that I need? What's going on with my partner? Does my partner have erectile dysfunction? Okay, that comes up a lot too. At the age of 40, 40% of men have erectile dysfunction. At 50, it's 50%, it goes on and on. 

Annie [00:16:50] Whoa! I never knew that. I never knew that. So half of men have erectile dysfunction by the time they're 50?! 

Dr Jen [00:16:55] It's very common as they age, yeah! 

Annie [00:16:57] But that's so unknown as a thing. Like, well obviously they don't want to talk about it but that's, that's huge!

Dr Jen [00:17:02] Yeah! That's why you see- well that's why you see those ads for Viagra everywhere. We have them here. So and I mean, I might- maybe it's 40% but you know, it's really common. 

Annie [00:17:09] Yeah. 

Dr Jen [00:17:10] So if you're somebody who's 50 and your partner maybe is 52 or 53, if he's got an erectile dysfunction it doesn't mean the penis never works, like it can be fine sometimes and other times not, right? So, so if that's now in your relationship, sometimes women feel that that's because their partner doesn't desire them enough. And then that affects things or they're fumbling, they've got to do everything exactly right for when his penis is ready. So, you know, so there's, you know, a lot of different working parts. It's absolutely way more complex than testosterone and I would say testosterone is the least important part of the equation. 

Annie [00:17:43] I was, I was thinking like, before you even get to sex, do you know what I mean? The desire to want to have sex... Does that not? 

Dr Jen [00:17:50] Well not ev- Not everybody has that before. Some people, desire kicks in after, you know, their partner has presented sex to them. That's called a receptive desire and that's normal *Annie humming*. So many women are led to believe that receptive desire is abnormal. So a lack of desire means yeah, no way, no how, I'm just like, so not interested in this no matter what. Like, you know, you can- you can do anything till the cows come home. I mean, it's really important that we don't medicalise women to make up for incompetent men. 

Annie [00:18:22] Oooft, Jen! Drop the mic. 

Dr Jen [00:18:26] Yeah, well, you know, it's- there's a lot of mediocre men out there, and there's a lot of mediocre men skating around and often by the time people have been with somebody for 20 years, right, the cracks start to be there. Maybe you've been really busy with kids and other things, and now you finally have time to focus on your relationship but if you haven't been focusing on your relationship for a long time, it's hard to kind of go from 0 to 60 overnight, right? So, just important to think about it holistically, you know, everybody throws around this word holistically, but what it really means is looking at the whole person and looking at everything. 

[00:18:58] *Short musical interlude*

Annie [00:19:08] We'll come back to menopause. I've got some pretty basic questions about that, that I think I would love to hear you answer but erm, a couple on periods now and menstruation. Asher, and I love just the phrasing of this question, I feel like she's like in the middle of PMS when she's asked it. 'Do we literally only have one week for normality a month in the menstrual cycle?'.

Dr Jen [00:19:27] So, that would be a very atypical experience, and so if somebody has that experience then I would encourage them to talk with their health care provider. PMS shouldn't be only one week free. So for PMS and premenstrual dysphoric disorder, which is the more severe form, you can't have any symptoms before ovulation. So you got to have at least ten days of the cycle where you feel really good. So if someone's telling me that they only have a week where they feel good, then I want to know is it because you're bleeding for 12 days? Is it because you have PMS? Or do you have, not PMS but depression that's actually changing by your cycle and so maybe it's more depression throughout the whole month. So that's something that needs to kind of be interrogated because that wouldn't be a typical experience. I hate to say normal because it's normal for that person perhaps but that wouldn't be a typical experience. 

Annie [00:20:17] Yeah, okay. Great. Thank you. Someone else asked, 'why do my chronic illness symptoms spike and get worse during PMS?'. 

Dr Jen [00:20:26] Well, so some medical conditions can worsen during different times of the menstrual cycle and some can improve, and it really depends on the condition. Some are related to a drop in hormone levels, so it's change in levels that typically cause symptoms. So one of the best examples is menstrual migraines, those happen when oestrogen levels drop at the end of the cycle, it's related to the rapid drop of oestrogen. and so some symptoms are related to the presence of the hormone progesterone. And so because oestrogen is going up and it's going down and it's going up again during the cycle, and progesterone is low low low and then goes up, both of those hormones can have interactions on the immune system, on the nervous system, on many things. And so you can see definitely, fluctuations in different medical conditions. 

Annie [00:21:14] Okay, so you've just mentioned oestrogen and I'm gonna ask you now to really explain in a very simple way what oestrogen does for our body. 

Dr Jen [00:21:23] *Deep breath* Well, umm- 

Annie [00:21:23] Or *pronounces it differently* oestrogen, we say oestrogen just in case anyone's confused about that. 

Dr Jen [00:21:28] Yeah it's oestrogen. So oestrogen is, is one of the we call reproductive hormones. It's produced in large amounts by the follicles when you ovulate in the ovaries, but it's also produced in small amounts by many organs, like your brain produces oestrogen and bones produce oestrogen and fat produces oestrogen and muscle produces oestrogen. And they're producing local oestrogen to use. The oestrogen in the follicles is produced in very large amounts because it has to go into the bloodstream, it has to travel to the brain to communicate back and forth with the brain. It also has to go to the uterus and cause the uterine lining to get thick in preparation for a potential pregnancy. It goes to the breast and starts breast- you know, the breast changes each cycle. And, you know, in addition, it's supporting brain function, it's supporting bone function, it's doing many different things. And so, you know, kind of in a nutshell, a hormone is basically a communication tool that the body has. And so oestrogen is a messenger. And so it takes different messages to different parts of the body, and it interacts with receptors and that's how it transmits its message. It's really interesting messages can, you know, change based on other hormones that are present because those can down regulate receptors. So it's kind of like your lock can be constantly getting easier to use or harder to use. You know, oestrogen also has a role in the vaginal microbiome and in, you know, insulin regulation. So, you know, because it's a messenger hormone and it does many things but, you know, in a nutshell, those are some of the more, more common things. 

Annie [00:22:57] Yeah, that's great. We've had so many questions about just hormones in general and I think it's sometimes good just to break down exactly what they do. I wanted to ask you as well, in the introduction to your book Blood you talk about period diarrhoea, and that's something I'd never heard of, I've never experienced, but I have a friend who, who does and um, it really shocked me how many people suffer from it. Would you mind just relaying the facts? The statistics? 

Dr Jen [00:23:21] Yeah, yeah, absolutely. And I also just want to say for people who want to know more about hormones, there's a whole chapter on that in the book where I talk about each hormone in detail- 

Annie [00:23:28] Amazing, great. 

Dr Jen [00:23:28] So yeah, menstrual diarrhoea is something that happens, you know, with your menstruation and it's diarrhoea. I mean, it's kind of one of those, you know what it is by it's term. And it's generally thought to be believed to be release of prostaglandins that trigger it, because prostaglandins make your bowels contract and move things along. And prostaglandins are also hormones, they're hormones that are made at the site of inflammation or injury and so when the uterine lining cleaves off for menstruation. Yeah, that's released as large amounts of prostaglandins and so they can get in the bloodstream and, you know, they can cause you to have diarrhoea. And it's something that affects 12% of people who menstruate or, you know, *Annie interjects* that's 1 in 6 people so yeah.

Annie [00:24:09] 12% of people who menstruate!!

Dr Jen [00:24:11] Yeah. And yet so many people have no idea it exists. I mean, if you, if you look at the entire population that would mean like 6% of the world's population would have experienced menstrual diarrhoea, right? And the incidence of asthma is like 8% and everybody's heard of that right. 

Annie [00:24:26] It's crazy. 

Dr Jen [00:24:26] So it just goes along with the culture of shame. Every single time, there will be people listening to this podcast who are like *gasps* I thought I was the only one. 

Annie [00:24:34] Yeah, right. You're not the only one if you're listening, 12% of people who menstruate have that. Someone, err Becky has said 'my teenager vomits and gets headaches every month when they have their period needing 2 or 3 days off school, can you suggest any help?'. Vomiting feels intense. I mean, that's- 

Dr Jen [00:24:51] It's hard to know what that would be without more information. If the vomiting was related to the headaches, then that would be menstrual migraines. And there is absolutely treatment for menstrual migraines. So somebody who's significantly affected by menstrual migraines could easily not be able to go to school for a couple of days, and seek care from your health care provider. Depending on the type of migraine and other things, hormonal birth control is actually highly effective because what it does is it trumps, there's no up and down of the oestrogen because it's the, it's the up and then the down that triggers menstrual migraines. So with the birth control pill we can just do that. And we can take away menstruation completely so you never have those ups and downs. So the thing that triggers the migraine doesn't exist. So without knowing more, it sounds like bad menstrual migraines but there could be other things going on too. 

Annie [00:25:42] Thank you. Lindsay, 'I'm 42. My hormones are WILD' caps, 'doc says it's not perimenopause, but PMDD and to go on the coil or SSRIs'. 

Dr Jen [00:25:55] What I can tell you is that for some people, PMDD can absolutely get worse in the menopause transition. Because what can happen is some people can get a little bit of a shortening of the first part of their menstrual cycle, so that means you're spending a longer percentage of each cycle in the time that you have PMDD. And also, there's more hormonal fluctuations, and it's the fluctuations that we think are part of PMDD. So um, an IUD, a coil is not going to help PMDD at all. It's not any kind of treatment for it. The first line treatment is the oestrogen containing birth control pill, again, to give you that absolutely smooth-

Annie [00:26:33] Line, yep. 

Dr Jen [00:26:33] Line, or antidepressants. Antidepressants are also very effective for PMDD. And so, you know, it kind of depends on personal preference as to which one somebody wanted to start with. 

Annie [00:26:45] So PMDD being a kind of very extreme version of PMS, am I right in saying that?  

Dr Jen [00:26:50] Yeah, I mean there are a little bit, there are a few nuances and, you know in the book, there's a whole chapter on it in the book. But there absolutely are treatments and so, you know, it's not something that you have to suffer for but you want to have the right treatment, right? And not everybody can take the oestrogen containing birth control pill, you know, for example say you have migraines -- or you've had a history of a blood clot for example then that option wouldn't be available to you. But yeah, there's antidepressants. And the great thing about antidepressants and these sort of cyclic mood conditions is people can also just take them during the time of the cycle they need them. They don't have to be on them every day of the month. So you can take them like for two out of every four weeks. 

Annie [00:27:27] I- so there's always that kind of common erm, again, it could be a myth that doctors prescribe women in menopause- or perimenopause with SSRIs wrongly because they should just take HRT, but- 

Dr Jen [00:27:42] Yeah. Well that's disinformation from people who I think make money prescribing hormones, I don't know. I'm very pro- pro menopausal hormone therapy but I'm more pro the correct therapy. And if you look at the studies for depression in the menopause transition, the people who are most likely to get depression are people who've had it before. And the studies for oestrogen are very small. We're starting to look at people like 30 patients in a group, 60 pa-, 50. So there isn't a lot of data to support oestrogen for depression in the menopause transition. We recommend it as kind of like a softer call. You know, like we have great data for hot flashes so absolutely. Depression in the menopause transition, it's very reasonable to prescribe oestrogen but to say that it is wrong to prescribe antidepressants would be bad medicine, because we actually have better clinical trials looking at a couple of different antidepressants in the menopause transition. And there's data that shows that the two can actually work synergistically and people can even get a better effect. So, you know, people need the treatment they need and I really hate this narrative that it's all MHT, MHT, MHT, which is what we call it now in the states, menopausal hormone therapy. 

Annie [00:28:52] Which is HRT, which is what we call hormone replacement therapy, yeah. 

Dr Jen [00:28:55] Yeah, but they are trying in, in where you are to move it to menopause hormone therapy. 

Annie [00:29:00] Okay, good to know. 

Dr Jen [00:29:01] Because HRT is actually incorrect. 

Annie [00:29:03] Oh? 

Dr Jen [00:29:03] Because it's not a replacement. We're not trying to replace what your ovaries make. Many people go through menopause and don't need it. It's menopausal hormone therapy. So we're trying to position menopause as, you know, it's an optional treat it, you don't have to, depends how you feel, right? 

Annie [00:29:19] Sure, yeah. 

Dr Jen [00:29:19] Replacement would be like you have a thyroid disorder, you absolutely need to be on it. 

Annie [00:29:22] Got it. 

Dr Jen [00:29:23] And so it's a, you know, a bit of a nuance but it's important. And so yeah, so there are good therapies and so- you know I have patients who have tried five, six, seven different hormone regimens and they're miserable. And they refuse to go on antidepressants because of crap they heard on social media, and then they get on an antidepressant and they're like oh my God, this was like the answer for me. And, you know, we see people coming in on, sometimes on catastrophically high doses of oestrogen, like higher than the birth control pill because they keep increasing it thinking it's going- then they'll finally get to the point where it helps their depression. So it's good to have options and some people feel awful on hormones, right? So it just depends. And I just think anybody who wants to restrict good options for women doesn't have women's medical best interests at heart. 

Annie [00:30:12] Love it. 

Dr Jen [00:30:12] That's my opinion. 

Annie [00:30:13] That's great. Thank you. Someone has said 'I'm a 48 year old woman. I had an IUD' which is a coil 'for 17 years. No periods in that time. When should I remove it?'. 

Dr Jen [00:30:26] You probably need to go talk with your doctor, because there are two different kinds of IUDs or coils, there's ones with hormones and ones without. 

Annie [00:30:34] Yeah. 

Dr Jen [00:30:35] And the ones without should not affect your menstrual cycle at all. So if you're 48 and you haven't had a period in 17 years since you were 31, your doctor might want to figure out why that is. Did you have early menopause? Did you have, you know, there are other medical conditions that can affect your period, so that needs to be figured out. If you had a hormonal IUD, you shouldn't really get a loss of periods with that for longer than about 7 or 8 years, right. But it's possible for some people, it might work for a little bit longer, right, for nine, ten years. So if you're saying it was in for 17 years, then you're telling me your periods stopped when you were like 41, 42, so having menopause at 48, totally normal. But if that started when you were 31, that's kind of a different conversation about health screening and other things. 

Annie [00:31:24] Someone else has said, 'I've been on the pill for 20 years since the age of 16', is there any problem with that? With being on the pill for that long? 

Dr Jen [00:31:32] Nope. There's no problem at all with being on the pill that length of time. You know, like any medication, as long as you need it, fine. Most people like to have the cycle control and I don't have any issue with that. I mean, being able to predict when your period comes or being able to stop your period and just take it continuously is a very big *Annie humming* quality of life change for many people. Periods should be optional if you don't want to have 'em. We have big brains for a reason. Our big brains came up with great medicine. So yeah, there's no health risk for it at all. Fertility returns, you know, in less than two months after stopping it, if that's what you want. But if you don't want it, that's great. You know, I personally was on it for about 15 years straight, like, you know, good on ya. 

[00:32:15] *Short musical interlude* 

Annie [00:32:26] Okay, let's move on to menopause. So many of our questions then were around menopause and perimenopause. Can you start um, just again, being really basic, but just for those in case we need a bit of clarity, what is the difference between perimenopause and menopause, please? 

Dr Jen [00:32:42] So medically speaking, menopause is the day of the final period. Everything after that is post menopause, and the time leading up to that where there's hormonal changes is the menopause transition. Now the older term perimenopause was the menopause transition plus the first year after the last period, because technically we can't say you're menopausal till it's been a year since the last period. And many people, just like I just did, use kind of menopausal to kind of talk about the whole thing so it really kind of depends on the context. But in general, perimenopause is before you know for sure you're menopausal, and then menopause or post menopause is after. 

Annie [00:33:26] Lucy wants to know, 'are there tests for perimenopause?' 

Dr Jen [00:33:30] No, there are no tests for perimenopause at all. And anybody who tells you there is, you should just block them or not go back to see them. 

Annie [00:33:37] So blood tests, blood tests not a thing? 

Dr Jen [00:33:39] No, because we can't tell. We, we- I can't do a blood test and tell you when your period is going to stop or tell you where you are in the perimenopause. So blood tests need to be done for a reason. So I would say to somebody, what is the reason you want to have your blood work done? So the average age of menopause, your period stopping, is 45 to 55. So if you're 47 and you're going five months between periods, it's no shocker! *Annie laughs* you're almost in menopause. Just like if you were 12 and you got your period, we wouldn't need to do blood work to find out why you're bleeding. We go, oh! You're 12, you're puberty, you got your period. Great. So it depends on the timing. If you are under the age of 45 and your periods stop or you are skipping periods, then you absolutely need blood work. But it's not just to check- it's not to check for perimenopause, it's to see are you in early menopause or are there other reasons to explain your skipped periods, right, because there could be. If you're 45 and just kind of feeling unwell and not having any period changes, hormone tests will tell you nothing useful because your oestrogen levels change every day of the cycle. The FSH, which is a brain hormone that we often test as well when we're looking for early menopause, also changes every day of the cycle. And people can have menopausal looking blood work one month, and then the next month they can ovulate and be completely back to normal. And the reverse is true. You can have a completely normal looking cycle, and the next month your periods can stop forever. 

Annie [00:35:11] This is what I've learned is that menopausal symptoms can kind of come in spurts and then go away for ages. There's no consistency to the symptoms, so it's so hard to determine whether you are actually experiencing perimenopause because there's no pattern. 

Dr Jen [00:35:25] Right. And so I would say to people, you have been through this before with puberty. 

Annie [00:35:30] Right. 

Dr Jen [00:35:30] Nobody said 'oh, I need to check, I'm nine, I'm starting to grow'. 'Oh! I grew for a while, then I slowed down, then I grew for a while and slowed down'. Nobody was rushing you off to get bloodwork to see where you were in the puberty continuum. However, if you were three and that was happening, you absolutely need to have bloodwork, right. So you have to look at, am I having symptoms that match menopause and are they happening when they're expected. But say you're 42 and you're having hot flashes, but your periods are coming once every month, the tests are not going to be useful because the hormone levels at that age when you're having regular cycles, they don't correlate with menopause symptoms. So people can have, you know, normal oestrogen and have bad hot flashes. And people can have lower levels of oestrogen and have none at all. So, you know, so it's really important that people just think about, is this a normal thing happening at a normal time. And you got through puberty without having bloodwork *Annie laughs* to figure out why you had a growth spurt. 

Annie [00:36:32] Kat, 'how best do we deal with the myriad of perimenopause symptoms? Bloating, joint pain, weight gain, hormonal migraines, etc.?'. 

Dr Jen [00:36:41] Err, read my book The Menopause Manifesto. 

Annie [00:36:44] There ya go, Kat! 

Dr Jen [00:36:44] I mean I hate to be -- about it but, yeah, but I can't answer- I can't answer all of that in one thing. I can tell you that weight gain is not due to menopause. 

Annie [00:36:53] It's just age, right? 

Dr Jen [00:36:55] It's age related. There's no metaboli- there's no metabolism change. So keep that in mind. I would say for every single person listening, if you want the magic hack that 'they' are keeping from you, in air quotes, for menopause it's exercise. And it's weight bearing exercise and doing lifting as well as aerobic. Every single symptom, except probably hot flashes, and every single medical condition that increases with menopause is improved with exercise. It's good for your bones. It's good for your mental health. It's good for your mood. It's good for reducing your risk of Alzheimer's. It's good for your heart. It's good for your muscles. It's good for everything. So I would say when people are worried about a myriad of symptoms, while you're reading my book you should also be thinking about how can I look at my exercise routine? And you may also want to think about am I getting 25g of fibre a day in my diet, which is the minimum that I need to have? Am I trying to have maybe a bit more plant protein? Am I trying- am I getting two servings of fish a week? So looking at kind of the dietary basics and of course, if you're a smoker quitting. So the three most important things that you can do in the menopause, transition in menopause, are not take hormones, it's making sure that you're exercising, it's making sure that you're eating right and it's not smoking. And only 8% of people do all three of those things. 

Annie [00:38:21] *Whispers* wow! 

Dr Jen [00:38:22] Yeah. I mean, that's a U.S. study, it might be different elsewhere so- 

Annie [00:38:26] Amy wants to know, and this is a great question, you know, let's say we're doing all of that stuff and we're trying our best to look after ourselves and all of that, 'when should we think about menopause treatments?'. 

Dr Jen [00:38:37] Well, everybody's different, right? So there are- people have different tolerance levels, right. You know, you'll have people come in and say- and they say, well, you know, I'm having 20 hot flashes today, do you want to have those treated? Oh no, they don't bother me. Okay, I mean, we're all bothered by different things, right? And there's people who come in and they have three hot flashes and  hey really bother them. And you know, there's all kinds of individual, genetic variation, you know, so there's all of that. So I would say if your symptoms are affecting your activities of daily living, well that's something to think about treatment for. If your hot flashes are interrupting your sleep... So we know that sleep disturbance can have a lot of sort of, sort of domino effect on other things. And so if you're having really poor sleep, then that would be really a time to think about it. Now, there could be other causes of poor sleep like sleep apnoea and depression, so I'd also want someone to get screened for depression. And so it really just depends on, you know, are you bothered by your symptoms. And if you are, there is treatment. 

Annie [00:39:35] Emma's asked, 'I'm 41, I'm on the pill because my periods are so heavy. Will this reduce menopause effects?'. 

Dr Jen [00:39:43] It often does for people. 

Annie [00:39:45] No waaay! 

Dr Jen [00:39:45] There's lots of people on the pill who just sail right into menopause like they felt nothing, because you're not getting any of the hormonal ups and downs. You're getting a constant level of oestrogen. 

Annie [00:39:54] So what happens? You just stay on the pill until you reckon your periods are finished and then you just come off it and then-? 

Dr Jen [00:40:00] Yeah, so there's a couple ways to approach it. So first of all, if somebody needs it for contraception versus doesn't need it for contraception. So if somebody needs it for contraception and they're otherwise healthy from a heart standpoint, we actually think it's okay to be on until age 55 if you're on a lower dose pill. And then what I usually do at that point is because it's a higher level of oestrogen than your body makes, if you go from that to like menopause levels, it's like a *whoosh*. 

Annie [00:40:25] A it's too much of a drop yeah. 

Dr Jen [00:40:26] Yeah. So what I do is I step people down, you know, I put them on kind of like a, you know, a dose that I would kind of average to be kind of halfway between that and not on oestrogen and then sit there for, you know, three months and then see how people do. And if they're like, ahh I feel great, I'll say well, let's reduce the dose a little bit more. And then- and then kind of make a decision at that point, you know, how they're feeling, do they want to continue it or they want to stop it. It might depend on their risk factors for osteoporosis, which would be a reason to stay on it. There isn't like a hard and fast rule, but definitely I've had a lot of success with stepping people down that way and they're just like, yeah, I cruised through the whole thing, I felt nothing. 

Annie [00:41:02] Wow, that's such a great way to do it *laughs*. 

Dr Jen [00:41:06] Yeah. And then another option, you know, is someone might think about, well, you know, I'm 50, I don't really want to be on the pill between 50 and 55, I'm worried about like, clots or whatever. You know, even though we think it's safe, but the risk is still, you know, higher on the pill. Someone might say, well, I want to get a hormonal IUD, a hormonal coil, that'll manage my bleeding and maybe I'm going to try an oestrogen patch, which is a lower dose. So there's also other ways to do it but if somebody feels great on the pill I'm like, why mess with success? 

Annie [00:41:35] I um, I had an experience when I was, when I was much younger um, after having kids where I went to like a body pump class, which is really high intensity workout, lots of jumping and punching and kicking and stuff, and I kind of leaked a bit. And afterwards I said to my friend, oh God I just leaked like, that's embarrassing. And a woman heard me from behind and was like, 'babe, like, welcome to the world of being a woman, like it's what we do. Everyone does it'. And I remember looking at my friend going, what's she talk- is that a thing? Because I'd never known that that was a thing that happened. And now, as a 45 year old, I'm understanding that if you don't do the work earlier, it's quite common in the same way that period diarrhoea is, and please correct me if I'm wrong, it's really common for women of an older age to be incontinent and to have to deal with it. 

Dr Jen [00:42:26] Yeah, so and it definitely increases with age as well. And there's a lot of different risk factors so childbirth is one. But genetics play a big role as well. 

Annie [00:42:35] Right. So it's not all just- it's not all just childbirth? Wow. Okay. 

Dr Jen [00:42:38] No! I mean, I know people who've never been pregnant who have, you know, bad incontinence. And I know someone who's had five kids, and she's got like a pelvic floor of steel. 

Annie [00:42:47] Wow. 

Dr Jen [00:42:47] So, you know, there's genetics, you know, it's just the way it is. So there's different kinds of incontinence, right? So there's urge where you're like, you've got to go, you got to go. And there's like the coughing and sneezing and jumping which would be the kind that you'd have typically in exercise class. And they're treated in different ways, although physical therapy, pelvic floor physical therapy can be very effective for both. And so, you know, there is a whole range of different treatments, you know, always good to get in early and, you know, to try to get on it. But there's also medications, there's Botox injections in the bladder, there's surgeries. There's all different kinds of things. 

Annie [00:43:20] Botox injections in the bladder?! 

Dr Jen [00:43:23] Yeah, it's very effective. So when people have very bad overactive bladder, meaning you got to go, you got to go, like, you just, you got to go. Well, Botox is a paralytic. So what happens when you got to go, your bladder is having spasms, it's contracting when it shouldn't. And so you put Botox in and it doesn't contract like that. 

Annie [00:43:40] Woooah. 

Dr Jen [00:43:40] Yeah. 

Annie [00:43:41] But doesn't Botox freeze everything? So then like, how do you control the muscle? 

Dr Jen [00:43:45] It's not good enough to freeze everything- 

Annie [00:43:47] I see. 

Dr Jen [00:43:47] Yeah it just reduces some. Yeah, so it reduces it but there's still parts of it that work. It just, it works really quite well. I mean, again, if you have the right kind of incontinence to match it, you know, for that medication. And yeah, but there's medications, there's physical therapy. Vaginal oestrogen can be helpful for some people too, depending on the type of incontinence. And then there's incontinence pessaries, things that you can put in your vagina, they're super cool. They're like a ring. And, you can put them in and they help support the tissue. And a good analogy is, so when people have um, what we call stress incontinence, the coughing, the sneezing. 

Annie [00:44:23] Yeah. 

Dr Jen [00:44:23] If you think about your urethra as like a garden hose, right, so when you, you start coughing, what happens is your body kind of contracts around the urethra tightly to stop the urine from coming out, right. When you're coughing and sneezing, you're also putting pressure on your bladder, but you put more pressure around your urethra. So that's kind of like having a garden hose on cement. And you put your foot down on it and you can cut it. You interrupt the flow of water and you don't leak. With stress incontinence, what happens is, you know, the collagen in the tissue changes, the support changes. And so it's like instead of the garden hose is on cement, it's like the garden hose is on muddy ground. So when you stomp your foot on that, you don't get as good a seal. 

Annie [00:45:06] Ahhh. 

Dr Jen [00:45:06] And so you have some leaking. So what an incontinence pessarie does is you put it in and it gives you a backstop. So it kind of adds a little extra support. And just like a vaginal contraceptive ring or a diaphragm, you don't feel it when it's in, right. And so the great thing about it, some people can just use those also like when they're going to exercise class, you can just kind of put it in when you need it. But yeah, so lots of different treatments and I agree we don't talk about incontinence enough. 

[00:45:30] *Short musical interlude*

Annie [00:45:39] Okay Jen, last question then from our listeners is from Emily. 'Can you ask about severe polycystic ovary syndrome and how to cope with it when GPs can't give solid advice as they don't know?', this is clearly coming from personal experience. 

Dr Jen [00:45:54] So polycystic ovarian syndrome, it's really sad that you're seeing someone who can't give you information about it because it's the most common hormone condition for women of reproductive age (Annie: 'wow'), right. So it's more common in thyroid disorders. It's, you know, it's like really common. About 10% of women of reproductive age will have polycystic ovarian syndrome. 

Annie [00:46:14] That's so many! 

Dr Jen [00:46:14] Yeah. It's a very complex condition that involves ovulation disorder so that follicles don't develop as they should and they kind of get stalled out. And this affects kind of hormonal production from, from the follicles. It's also associated with irregular periods and it's associated with increased levels of androgens which are sort of the 'quote quote' male hormones in the body. There's also many people who have insulin resistance as part of it. There can be an increased risk of diabetes and metabolic syndrome and heart disease, depression. It's it's basically this widespread condition, but the sort of the hallmarks are the irregular ovulation, the irregular bleeding and the increased male hormones. It's something that isn't hard to diagnose. There are definite treatments depending on the goals of the person. So if you're trying to get pregnant, that's a totally different thing and you'd want to see an infertility expert to manage that. But for someone who doesn't want to get pregnant, the oestrogen containing birth control pill is one of the most effective therapies because the oestrogen in the pill will treat the irregular bleeding and stop that and reduce your risk of getting endometrial cancer, which is another concern for people with PCOS. And the oestrogen will actually then lower those elevated levels of male hormones, so it can be very effective. There's a diabetes drug that can be very effective. There's a big myth that obesity causes polycystic ovarian syndrome, and that's not true. So unfortunately, a lot of people are pushed off and said, oh, it's because you're overweight, you don't, you know, if you just weren't overweight you wouldn't have PCOS. And that, that actually also harms people who aren't overweight because they're told that they can't possibly have it because (Annie: 'wow, okay') they're not overweight. Yeah. So what we know is, is that the incidence of polycystic ovarian syndrome is the same if we use strict criteria regardless of somebodys weight. However, because when people have more body weight they're more likely to have insulin resistance, what that can do is it can make the symptoms of PCOS worse. So if you look at clinics and people coming in for care, they are more likely to have more people with- who are overweight because they tend to have worse symptoms. But it's not a cause at all. 

Annie [00:48:27] Got you. Okay, brilliant. Before I let you go Jen, just so much of what you do, obviously, as a doctor, is based on studies and the discrepancy between studies on women's health and men's health I can imagine is quite large. Is it catching up? Are there enough studies? Is there enough things happening to increase our knowledge about what's going on with things like menopause and-? 

Dr Jen [00:48:51] There's a ton of studies with menopause. There's actually quite a lot of studies with PCOS. We don't really have anywhere near as many studies with endometriosis, which is a big problem. But we're also behind the eight ball with all these other things because we just haven't had the same investment in what um, what people should know as basic biology. So there's lots of different ways that, you know, that women are paying the price. And so I think we're starting to see some change. Remember, we're behind the eight ball for many decades so this isn't going to reverse. But I do think that the boat is shifting course, so that is good. 

Annie [00:49:25] So Blood the book is is out now as I said. The Vagina Bible and The Menopause Manifesto are Jen's other books which you must go and get. Anyone who has questions, any more questions, all the answers are in those books. Jen, what's your next thing that you want to write about? 

Dr Jen [00:49:41] Oh err, well, I'm going to be writing about- well, I write regularly on my blog The Vajender with a J,, so please follow me there. And my next book, it's a couple of years away but I'm going to be tackling the broader aspect of sexism in medicine. 

Annie [00:49:58] Ooooh, wow. Amazing. I very much look forward to reading that. Thank you so much for all the work you do, and thank you for sharing your knowledge with us today. I really appreciate it. 

Dr Jen [00:50:07] Oh, thank you so much for having me. I really appreciate it. 

Annie [00:50:12] Thank you so much for all of your questions. That was the first time we've done that, it was a buzz actually to be able to feel like we're serving you lot so directly in being able to answer your questions to a guest like Jen. I hope you found it useful, let me know what you thought on Instagram please, @anniemacmanus. Or you can hit us up on email, We love receiving your emails, so please, if you finished the ep and you just feel like you want to feedback just get on there., save it and then you have it to email us whenever you like. All the links we discussed with Jen are in the show notes if you want to go and do some further homework, and do go back and listen to CMAT from last week who was so brilliant in such a different way, discussing her personal journey with body image and weight. Please subscribe! Tell everyone about Changes and next week we will finish our little mini series on bodies with the world renowned journalist, activist and author Afua Hirsch. She is the author of the brilliant book Decolonising My Body, and she's going to be talking about her personal journey unpacking eurocentric beauty standards and unlearning some of the myths around women's bodies. You don't want to miss this. Changes is produced by Louise Mason with assistant production from Anna de Wolff Evans through DIN productions. See you next week folks!