'When you don't talk about it, people suffer in silence': Dr. Jen Gunter's menopause manifesto
Dr. Gunter spoke on Sickboy podcast about menopause, misinformation, and the patriarchy's impact on healthcare
Menopause is often shrouded in shame, fear and a general lack of understanding; Dr. Jen Gunter is here to set the record straight.
Dr. Gunter is a Canadian ob-gyn and fierce women's health advocate, best known for her TED Talks and for writing The Vagina Bible. Her new book, The Menopause Manifesto, not only informs readers about what to expect during the transition, but it also encourages them to advocate for themselves to make the most of it. She also hosts a show called Jensplaining on CBC Gem.
The doctor, writer and speaker joined the hosts of the Sickboy podcast — Jeremie Saunders, Taylor MacGillivary and Brian Stever — for a discussion on de-stigmatizing menopause, the gaps in knowledge on men's and women's health in the medical field and how just a small amount of knowledge can make a big difference in navigating healthcare. Here is part of their conversation, edited for length and clarity.
Jeremie Saunders: Can you tell us a little bit about the very important work that you do?
Dr. Jen Gunter: I'm a health educator trying to raise the general level of knowledge for the public. The more informed people are, the better they can advocate for themselves. Especially with this growing trend of online health influencers, we need to be more aware and more sceptical of a lot of the misinformation we encounter.
Saunders: One of the things that we've come to learn through the podcast is that there is a massive gap between women's and men's health. Why do you think that is?
Dr. Gunter: If you go back to the ancient roots of medicine, men were considered to be the ideal and a woman was literally a physically inferior version of a man. And all of the explanations for menstruation and pregnancy revolved around that inferiority. Medicine mirrors society's patriarchal view of women in many ways.
You have to remember, even up until the early 1900s, people didn't even know what hormones were. As we evolved into the era of modern medicine and a basic understanding of biology, all studies were male-centric. What we know about heart disease was about what happened to white men with heart disease. Everything we knew about diabetes was about what happened to white men with diabetes. This very narrow lack of diversity in all studies has been perpetuated.
There have been improvements with every generation, but we're still behind the eight ball in many ways. I think the development of COVID-19 vaccines is a great example of that — people who are pregnant weren't enrolled in the studies. Some of that's due to not wanting to take the risk, and some of it's due to institutions not forcing the need for diversity in studies.
Taylor MacGillivary: I think our generation is pretty progressive, and yet the huge stigmas, taboos and lack of education around women's health remains. Do you see them being reduced now that we're in an era where we have much more access to information?
Dr. Gunter: I don't see it improving significantly. I think at a grassroots level, I'd say yes — there's many more people sharing experiences on social media. I think that we have a huge problem at a governmental and institutional level. What you learn about reproductive biology in schools is about not getting pregnant. It's all framed in purity culture. It's not about how the menstrual cycle works. It's not about how reproduction happens. It's not about the scope of the changes that could happen to your body. It's not about useful biological information. That's purity culture — you have these voids in school because of it.
I think one of the dangers of looking around us and saying, 'we're accepting in our generation' is that it's almost like a complacency — that you think everybody else is like you.
MacGillivary: It also seems like many of the women we've talked to on the show have dealt with having to jump through hoops with their physician to be diagnosed with painful conditions like endometriosis or PCOS, and it ends up being a long time before they're diagnosed.
I think the lack of knowledge [about menopause] goes back to purity culture and how the worth of a woman's body is related to her childbearing potential and menopause isn't related to that.- Dr. Jen Gunter
Brian Stever: They often hear a period is supposed to be painful and pain is just a part of life.
Dr. Gunter: That's part of a larger problem of dismissal of symptoms that women have, especially when they have to weigh 'how bad does it have to be to get help?' It shouldn't take five years to get a diagnosis of endometriosis. People should be able to get diagnoses in a six to 12 month process, like most medical conditions that are not easy to fix.
Saunders: Let's talk about menopause. I want to start with a question that feels silly: what is menopause? What can people expect when facing menopause?
Dr. Gunter: Biologically, menopause is the end of ovarian function. There's a lot of complex interactions between the ovaries and the brain. Medically, we define menopause as the last menstrual period onwards. But because symptoms can start before that time, we call the menopause transition perimenopause or premenopause. It's useful to think about the whole experience as menopause, because your last period is only a useful marker for a couple of things: deciding when you can get pregnant and how we manage irregular bleeding. So, the early-to-mid-40s onwards is the menopause-ish era where hormonal changes can cause symptoms and start to increase the risk of several medical conditions.
That's menopause in a nutshell. Not everybody has horrible symptoms — there's a big diverse range, just like how some people have really terrible pregnancies and other people have super easy ones.
Stever: Why is it fairly common that many people don't know anything about menopause, especially guys?
Dr. Gunter: I think the lack of knowledge goes back to purity culture and how the worth of a woman's body is related to her childbearing potential and menopause isn't related to that. And if you look at all your popular media, you see men who are 60 partnered with 25-year-olds as if that's the standard. 35-year-old women are considered too old for the role. I think that's why we don't talk about it — who wants to talk about aging out of society?
When you don't talk about it, people don't know that there are medications that they could take. When you don't talk about it, people suffer in silence. And that really sucks when you're suffering. And quality of life is affected by these symptoms. Menopause starts a chain of events that increases the risk of cardiac disease, osteoporosis, diabetes and other serious things that can shorten your lifespan or dramatically affect your quality of life.
There are actually a lot of good treatments for many of the symptoms of menopause — it's been a pretty active area of research for some time. Still, we can always do better and more is always good.
There are medications that can work on hot flashes, sleep disturbances and to help prevent osteoporosis. If hormones aren't for you, there's weight-bearing exercise, eating healthy. There are a lot of things that can be done.
Menopausal hormone therapy can be helpful and is very safe to use for many women. Side effects and complications have been overblown in the press because there's a lot of money in scaring women about treatments. So if you only got your information about menopausal hormone therapy from the press, you would believe it was really dangerous and you should never take it.
What are women supposed to do, just sit in a corner and crumple up and die? Risks are never put in perspective because scary things sell papers, right? They get page clicks.
Saunders: Please correct me if I'm wrong, but I'm assuming that every woman, every person with a vagina will experience menopause at one point in their life, if they live long enough?
Dr. Gunter: If you're a woman and you were born with ovaries, yes. If you're a trans woman, then you didn't have ovaries to begin with, so that's a different situation. Trans women who are on estrogen could end up having some menopausal-like symptoms when stopping the estrogen. But there's a lot of things there that we just don't have good information on, unfortunately, because all of the studies are based on cisgender people at this point.
So if you're a woman born with ovaries, yes, you will definitely go through menopause. Also, some trans men who keep their ovaries can also have menopause symptoms, but whether or not they're on testosterone can have an impact. We're only born with a certain amount of oocytes, or eggs — about 300,000. Through aging and ovulation, the numbers decrease and you get to a point when there's no more oocytes left that can ovulate, so you have no more estrogen. And that interrupts all the signaling with the brain. All of the estrogen that we make comes from the eggs.
MacGillivary: That's so wild.
Dr. Gunter: Yeah, it's not from the actual ovarian tissue itself, it's from ovulation. These tiny layers of cells are churning out massive amounts of estrogen because that estrogen is what causes breast development and changes fat distribution. Every month there has to be enough estrogen in the bloodstream to stimulate growth in the lining of the uterus. All of these things happen because of the massive amount of estrogen produced from the little follicles in your ovaries. So when there are no more follicles capable of ovulation, your estrogen levels start to change. Then the brain responds because there's a connection between ovaries, brain and hormones. All of that signaling can affect multiple organ systems.
Saunders: These treatments that exist for aiding women through menopause, are they essentially treatments to trick the body into thinking it's still ovulating?
Dr. Gunter: Not really, because we're not giving the levels of estrogen that you would normally be having.
Saunders: Why aren't we doing that? Is that a dumb question? Why aren't we just pumping people full of estrogen? [Laughs]
Dr. Gunter: Well, because super high levels of estrogen are also associated with complications — you have to give people what's safe. Very high levels of estrogen can be associated with cardiac complications and other issues. You want to give the dose that's the safest and will produce the benefit that you want and lower levels of estrogen can achieve that. It also can help reverse some of the changes in the brain hormones that are happening because of menopause.
But there are also medications that work directly on the brain that can be helpful for hot flashes, like some antidepressants and a couple of medications for epilepsy, because the hot flashes come from the brain. It's your brain telling you that you're hot when you're not. Some of that is due to complex changes in hormone signaling, but everything you experience is because your brain tells you it's happening. If you cut your foot, it's not painful because you've cut your foot. It's painful because your brain assembled the signals and told you it's painful.
Stever: I didn't know that. That's crazy. How much do people with vaginas who are coming up into their forties know about menopause? What role does the doctor play in educating and providing guidance?
Dr. Gunter: I think most people are really in the dark about it, but I think it's a reflection of being in the dark about their biology in general. If you ask people to draw the menstrual cycle and what happens hormonally and what causes the lining of the uterus to get thick, most people won't know that and that's a shame.
Stever: I have no idea.
Dr. Gunter: Well, it's the estrogen from the oocytes building the layer. Think about the lining of the uterus like bricks. It's building this thick blood because the embryo needs to implant it in it.
Knowing what's happening to your body sometimes is super empowering. It's not some weird out of control thing in your body- it's biological. And when you know the biology, then me explaining the different treatments and how they work on those biological steps can make it easier for people to welcome therapies or understand that when they still don't want to take those drugs.
It's the same with menopause. I mean, I think that it's even worse because there's nothing discussed about menopause, people just just don't know. And that's a shame.
I think if everybody had knowledge about their body, it's so much easier to have conversations and be empowered. It's your body. You should know how it works.- Dr. Jen Gunter
MacGillivary: And anxiety-inducing. When something's happening and you don't know what, then you don't know what to do, who to ask, what to ask. I got hit by a car a couple of years ago and in the ambulance, the paramedics said, "Hey, you're about to go into a room with 20 doctors because you broke your pelvis. There could be some really bad damage. And that's why there's so many doctors. Because if you go in there and we hadn't told you that, you'd have no idea why there are so many doctors there and you might think that you're dying. So, we're telling you so you don't freak out." That was helpful.
Dr. Gunter: It's amazing how even a tiny bit of information can be so important. Knowing what's happening to your body allows you to take charge of your health and make better decisions.
Saunders: That really speaks to me. I live with cystic fibrosis and for the majority of my life, I didn't really look into how it affects my internal organs. And then I think with the conversations that we've had on this podcast, I began to do a little bit more digging into what is happening within me biologically. And it completely shifted the conversations I was having with my healthcare providers.
Dr. Gunter: You're speaking the same language. The secret is a lot of it's not that hard. You think about cystic fibrosis and yeah, on one hand, it's obviously incredibly complex and it involves every organ system. But on the other hand, it doesn't take that much to know a little bit about what's happening in your pancreas or your lungs and once you have those puzzle pieces, you can start to put them together.
I think if everybody had knowledge about their body, it's so much easier to have conversations and be empowered. It's your body. You should know how it works.
