The Menopause Timeline Most Women Never Learn Until Midlife | Dr. Jessica Shepherd

0:00Dr. Jessica Shepherd: So here's a myth. Menopause is something to survive quietly and get through as fast as possible. Turns out that myth might be more dangerous than the symptom it describes because it's exactly what keeps women from asking the right questions at the moment that they have the most leverage over the next several decades of health. In this conversation, you'll discover why perimenopause itself splits into an early, mid, and late phase and why the late phase carries the most weight in hormone decisions. You'll learn how to build the kind of symptom storyline that gets a doctor to actually listen. The real risk versus benefit math behind hormone therapy beneath the headlines.

0:40Dr. Jessica Shepherd: You'll learn why the data on menopause symptoms looks different by race and what that means long-term and why nearly half a woman's life happens after menopause even begins. Sitting in as my guest host is a dear friend, author, and leadership consultant, Karen Walren. In conversation with board certified OBGYN and Generation M author, Dr. Jessica Shepard. I'm Jonathan Fields, and this is Good Life Project. And we'll jump right in after this short break.

1:12Dr. Jessica Shepherd: This episode is brought to you by Choiceology, an original podcast from Charles Schwab, hosted by Katie Milkman, an award-winning behavioral scientist and author of the bestselling book, How to Change. Choiceology is a show about the psychology and economics behind our decisions. Hear true stories from Nobel laureates, authors, athletes, and everyday people about why we do the things we do. Listen to Choiceology at schwab.com slash podcast or wherever you listen. Good Life Project is sponsored by Nature Raised Farms. If there's one thing I have learned after 14 years of deep conversations about living well, it's this.

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3:09Dr. Jessica Shepherd: Elevated, personal, quieter than you'd expect. The kind of thing that transforms your morning routine without you even fully realizing it. That's what good design does. And Kohler has been doing it, refusing to accept that every day has to be ordinary for over 150 years. Discover Kohler Smart Toilets at Kohler.com. I am so grateful that Jonathan asked me to do this. I'm just going to tell you because I have so many questions. So it's like he knew that I was going to have all these questions for you. So I've read your book. I love the book. Thank you so much for writing the book. I'm going to start by sort of the myths of menopause.

3:51Dr. Jessica Shepherd: You argue that the most dangerous part of menopause isn't a single symptom. It's actually the myth. So can you talk a bit about what we have wrong about menopause and what that costs us by having that myth around menopause?

4:05Karen Walrond: yeah there are so many myths that are behind menopause and that's really why i i wrote generation m was to kind of broaden the view i think one there's a fear factor behind it right so it's been kind of categorized as something that we should be afraid of so there's that that i want to change that narrative but also we really look at estrogen the worth of women what their ovaries are worth in the context of what they do to the pelvis, right? So it's kind of like all this linear fashion of how we view women in who they are and what they're able to do. Outside of that, the context of menopause really is a whole body experience, right?

4:49Karen Walrond: So I'll tell you like from, you know, from the head to the head to the toe is we have brain changes, we have mood changes. But even going down to just our skin, we have changes in how our skin feels, itchy skin. So because women were not able to see it from that perspective, they were going through these symptoms of, you know, whole laundry list, but not connecting the dots to this is a midlife transition that is biological is going to happen. But what do I do in those moments where I feel, is it brain fog? Do I have ringing in my ears? Am I irritable? All of those play a part in it. And the more that we understand, the more that we're able to make better decisions on how we navigate through it, because we're all going to experience it differently.

5:35Dr. Jessica Shepherd: Yeah. You know, it's so funny. I said at the top, so I'm in post-menopause, and I want to talk a little bit about that. But I feel like so much of the experience that I've had in midlife, like the symptoms or things that I've remembered or figured out after the fact, like, oh, that was probably paramenopause, you know, that kind of thing. So let's just start from sort of the beginning, right? Like menopause isn't one event. There's three different stages of menopause. So can you talk a little bit about like, what is menopause and what are the three stages that we go through?

6:09Karen Walrond: The full range of it is hormonal in the sense of hormonal shifts when they start, when they end or when the decline is pretty significant. And so in our premenopause phase, I guess would be more of our reproductive years, when our body is in default to get pregnant, right, that the ability to get pregnant is there. Now, when we go into perimenopause, is really where I use the gas tank analogy, it's the easiest to remember is where your gas tank is not at full, you know, at estrogen in this reproductive phase, and it's not any better, it's just where our hormones are, starts to go more into like three-quarter tank, half tank, because as estrogen and progesterone start fluctuating, even as early as the age of 35, carrying on, it's going through this shift preparing for menopause.

6:59Karen Walrond: And so that shift can be anywhere from 10 years, 12 years, from when you start, all the way up until that menopausal shift, which is where estrogen has completely declined. and now it is not giving off enough estrogen to elicit a possibility of pregnancy, right? So let's see how it kind of reverts back to the body is going through pregnancy. It can get pregnant. Perimenopause is where it could, but it's less likely because of the shift into menopause where it's not. So that's on a pregnancy hormonal level. But during all of those times is where we start to have symptoms. And the moment you start to have fluctuations in hormones is where women will start to exhibit symptoms.

7:41Karen Walrond: Granted, that can be differences in severity, intensity, frequency, duration. And so that really is the struggle of figuring out, oh, this is the symptom that I'm going to go through. And it might be more severe and frequent than my sister or the colleague that I work with. And that is where the conversation really needs to build into, I'm having this happen. what can I do to navigate it and it should be no blame or shame behind it yeah you know it's I remember um at one point and having like heart palpitations right um and like really sort of

8:20Dr. Jessica Shepherd: freaking out about it and this was way before I thought I was in perimenopause right I was probably in my 40s and like can you just talk a little bit or like what are some of the symptoms because I feel like that might have been a symptom of it. Like, like, the symptoms are really wide ranging, right? Oh, yeah.

8:39Karen Walrond: And the reason is because estrogen receptors and testosterone and progesterone, I want to show them love as well. But estrogen really is our kind of predominant, I guess you can say hormone when we speak in the context of menopause and perimenopause are all over the body. So the best place to think of how I have these symptoms, why am I having these symptoms, are because there are estrogen receptors all over the body, brain, muscle, heart, bone. And so a hormone, all it is, is a chemical messenger. It's really just sending out a signal every day. And usually it follows a very tight schedule. But when you go through perimenopause and menopause, that schedule gets very jolted, shifted.

9:22Karen Walrond: It shows up one day, doesn't. So if it's sending a message to a part of your body, brain, heart, all the things I mentioned before, and all of a sudden that message is not as clear, not as frequent, not as consistent, then the organ that receives the message to do what it needs to do, whether that's with cognition or my bone being strong or my muscle mass being strong, then it can't do that. And that's what is happening over time is we are feeling the symptoms of something that is deficient, not as soften, declining, etc.

9:55Dr. Jessica Shepherd: So okay, so this is so interesting to me. How can you discern whether or not what's happening, the brain fog, whatever else is happening? Like, I feel like a lot of times we're like, is it is it menopause? Is it perimenopause? How do we get to a point where we can be like, Oh, this is probably what that is. I need to go talk to my doctor about it.

10:14Karen Walrond: Oh, I think panic mode, granted, most people get there. And it's more of an art of I'm aware of what's going on. How severe is it? Is it impacting my daily life? Is it something that I felt three months ago and now I feel it now? And I can maybe give it some pause to see if it's going to happen again. Those are moments that people can have. And then also finding a provider that will actually listen. And I know that sounds hard. I mean, that's cute. even being a physician myself you know i understand how we were trained and and not excusing it but we were there to like fix a problem and you know the hierarchy of medicine of we really know everything and you're coming in and we're going to fix you right that is you know in kind of in the culture of how we practice medicine what we are starting to see now you know very small numbers and it's growing is this experiential part of perimenopause and menopause that was really never addressed before.

11:16Karen Walrond: Before we were addressing it in the context of, is your hormone here? Is your hormone here?

11:20Dr. Jessica Shepherd: Okay.

11:21Karen Walrond: That's what we need to do on a lab. Yep. What we were not bringing into the conversation was, how do you feel? How is your experience different than the lady who came to me before with the same numbers, right? The labs can be all the same for a group of 10 women, but they all experience it differently. And that's where we need to shift the conversation into how are you actually experiencing it? And where can I meet you there?

11:45Dr. Jessica Shepherd: Okay, so imagine I'm in my 40s or something and things are feeling weird, right? I'm getting those things. And I start to think, you know what? Maybe I'm starting to enter into perimenopause or something like that. What do I need to do? How do I prepare myself to go to the doctor? What do I need to do in order to prepare for that?

12:06Karen Walrond: Like any visit, I would say, even outside of menopause, is to really have a good story behind it. Like we work well with data, right? So it doesn't help us when a patient comes in. It's like, I'm having a hot flush. And we're like, oh my goodness, how long have you been having it? How often? How does it feel? And people are like, I don't know. I just know I have a hot flush. We're like, yeah, guilty. So being like, no, I noticed it six months ago is very slight. Now I noticed that I have to stop what I'm doing. Now it wakes me up at night. I'm also having some anxiety, which I never had before.

12:42Karen Walrond: And that's how we can like discourse and being like, okay, I'm going to bring in my medical perspective and ask you questions that are going to help the story evolve. And that's where we can have a good starting point into what is really going on with you because it's going to be different than the lady who walks in behind you. What's your story? There are some good apps out there, actually. One is Natural Cycles. Okay. And it actually helps you kind of like put less work and build more efficiency into building that story of hot flashes, night sweats. Not only does it help you identify them, but then it will track it for you so that when you do go to a doctor, you're like, look at my spreadsheet and storyboard.

13:24Karen Walrond: And that leads into a better conversation, especially since in medicine, we don't really give time. We're like, tell me in 30 seconds your whole life.

13:34Dr. Jessica Shepherd: Right, right, right, right, right. So like, should we, like, do you want a month of data? Do you want six months of data? Like if things, because what sort of panics me about that is like, if I sit there and I think it's perimenopause, but it's actually something serious, and I should be in an emergency room because it's something different. Like, I don't want to feel like, oh, you should be keeping track of things for a year, right? And something's deteriorating or something like that. So what's most helpful?

14:03Karen Walrond: I think what is most helpful and this is actually a harder question to answer is because everyone walks in at different intensities yeah so even outside of the menopause experiencing like we see that in heart disease people will be like oh my gosh I've had this pain in my chest for two years we're like why didn't you come see us right right right right different just with their acuity their awareness they're like I had so then you have the other extreme of that I had a pain at lunchtime today and I'm here to see you. And we're like, is that the first time you've had the phone? You know, so that's, that is really going to go down to the person of them evaluating.

14:42Karen Walrond: How long do I typically, that usually is a very personal thing. Like people will either procrastinate or they'll be like, I had it done today and I need it done and fixed right now immediately. So that's where, you know, I don't know if I have a correct answer, but what I will say is, you know, for anyone who's listening, when we are just speaking about perimenopause and menopause is the attunement of awareness in your body is always helpful. Yep. Not letting it go too long before you address it, because it can always be monitored. It could always maybe go away and not come back for some time, maybe years.

15:16Karen Walrond: But the goal really is to kind of get some eyes on it. Yeah. And the more that we can do that, the more that I've had patients, for example, come to me and they're like, you know, they're annual. So they're not even there for perimenopause, menopause. I typically will bring it up because I know that, you know, not everyone is aware of it. And they'll be like, you know what, now that you've said that I have noticed some hot flashes or sleep disturbances. And I'll be like, great. How long have you been having that? And they're like, you know, maybe three months. I'll be like, okay, let's even bring in, does it disrupt you three nights a week seven and they're like no it's not that significant i'm like that's okay if it starts to now get worse or you're noticing that it does these things and disrupting your sleep i need you to come back to me and they're like got it yeah so those are you know ways of of creating storyboards and and enhancing this conversation because before it was just very i've hit a wall yeah or i don't have a symptom yeah i mean i think what's really been helpful

16:18Dr. Jessica Shepherd: about what you're saying here is also that you can start having symptoms as early as 35 or 40. And so I think just by us talking, sort of having that cognition that, oh, you know, if something is weird happening, just note it and be able to talk to your doctor about it the next time that you see it. So that's really helpful. Okay. We don't get into the big stuff now. All right. HRT, hormone replacement therapy. I want to talk a little bit about that. And I'm going to admit to myself, I mean, I admit to you, like, not that I'm skeptical. I'm not skeptical. I believe, you know, hormone replacement therapy definitely helps me and stuff like that.

16:54Dr. Jessica Shepherd: But I will say that I've been very wary about it. And sort of my thinking is, if my body is naturally supposed to be getting rid of estrogen, all this other stuff, is it really healthy for me to be putting it back in? Or am I supposed to just sort of like, this is life and just like getting my period was life. Like this is sort of a life cycle. So can you talk a little bit about like, what is HRT? What are the options? Who should get it? Like, just sort of demystify it for me. And we'll be right back after a word from our sponsors. This episode is brought to you by Choiceology, an original podcast from Charles Schwab, hosted by Katie Milkman, an award-winning behavioral scientist and author of the best-selling book, How to Change.

17:45Dr. Jessica Shepherd: Choiceology is a show about the psychology and economics behind our decisions. Hear true stories from Nobel laureates, authors, athletes, and everyday people about why we do the things we do. Listen to Choiceology at schwab.com slash podcast, or wherever you listen. Good Life Project is sponsored by Bombas. So this summer has been full, hanging out with friends, a wedding out of town, hundreds of miles of early morning hikes, and through it all, my feet, and honestly, my whole family's feet, have been in Bombas, and it has been that way for, I think, over a decade now. The sport socks are the real deal, cushioned right where you need it, sweat wicking, your feet feel as good at the finish as they do at the start.

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20:21Karen Walrond: Yeah, I love you framed it that way and brought in your own personal experience so that I can fire back and you can be like, Oh, I did. Where I, I will challenge you on a few things. This is this is why we have this conversation is to bring awareness, curiosity and challenge into it is one, you said something, and I'm glad you just like were like really honest about how you asked the question is why would I want to put it back if it's naturally going away? So what I always phrase or, you know, or give a storyline behind is the advancement of life in women, right? So in the early 1900s, the life expectancy was about 59.

21:03Karen Walrond: And a lot of that from the science I'll talk about later, is it's pretty much if you think of reproductive kind of, you know, cavemen, we reproduce, right? And then we're like, okay, well, we're done with that. And life expectancy, right? Now, what we have done in science and technology and innovation for both men and women is advanced life expectancy. So now it's about 79 for women, Right, right, right. So 20 years, say, we've expanded that. What we haven't done for those 20 years of being like, you can live longer, whether that's antibiotic use or just like how we have our food, all of that.

21:45Karen Walrond: We did not account for the loss of estrogen at the end of reproductive years. And now that the science clearly shows us that estrogen really is a proponent of longevity in how our organs function from head to toe, it makes sense that for 20 year gap without estrogen, we really haven't done much for how our organs preserve or function for that timeframe, which is why women, we did well because women live longer than men. But there is about a 10 year to 12 year gap at that end of life stage where women live poorer health than men. Oh, wow. So that is where, you know, when you kind of like demystified and look at it from, you know, a broad lenses, you don't actually do not have to take estrogen or any hormone.

22:40Karen Walrond: Right. That is a personal choice. Okay. What we do know now is, you know, from the WHI study 20 years ago, which was the worst PR campaign for women is that hormones, even if, you know, what people's mind usually go to is the risk associated with it, whether that's cancer, whatever it is, we now know the benefits clearly outweigh all of the risk that could ever come with taking hormones. Why is that? Because it's such a vital part of how our body functions and the ability for us to give it its best opportunity to do its good work. And I'm not shaming anyone if they don't take it. But here's another question I pose to you.

23:21Karen Walrond: When we have thyroid disruption, decline, not functioning, what do people not have a problem with doing? Taking thyroid medicine, taking medication.

23:31Dr. Jessica Shepherd: Yeah.

23:32Karen Walrond: Thyroid is a hormone. What? Yeah. Thyroid hormone, thyroid stimulating hormone. Thyroid secretes hormone. It's the same thing it secretes that messenger that i was talking about earlier to tell the body what to do it's our metabolism hormone but we don't treat the ovary like that it gets such a bad rap it's still cute i do a lot of when i look at the ovary i'm like you're just so cute hanging out there by yourself just dangling cute little one and we vilify it and we're like you are dead and we will not help you. So you know, the thyroid's like, the meds you want. So okay, so wait, so are you

24:13Dr. Jessica Shepherd: saying that we should all be taking HRT?

24:17Karen Walrond: Like, if I wanted to get on a soapbox and be that type of advocate, I would be like, I am a complete advocate for hormones and see the benefit and feel that women get really good bang for their buck when they are in HRT, not only for symptoms, but for longevity and improvement in how our bodies are long term. Do I think that everyone should, has to be, needs to be on it? No, because it's personal choice. That's where I kind of let you decide what journey would you like to take? What adventure do you pick? Up to you.

24:50Dr. Jessica Shepherd: So what are the options? Like what are the different types of HRT that we can look into?

24:54Karen Walrond: Well, the three hormones, which I mentioned earlier, estrogen, progesterone, and testosterone, all start to shift decline from the age of 35. Progesterone is actually the first hormone that starts to decline. And then we have testosterone, which, you know, kind of for both men and women steadily over the decades start to decline. And then estrogen does take a pretty good hit in the 40s and then completely declines by 50. All of those can be taken by women with careful discussion, obviously, in what I want to take, what modality I want to take it in, which I'll go over and which combination of it, right?

25:31Karen Walrond: Some of my patients are on all three. Some patients are just on testosterone. Some people are on just progesterone and testosterone. Some people are on estrogen and progesterone. Like it really is like a menu of options and how you can take it. Estrogen typically has most of the modalities because it's our most kind of vital joie de vivre hormones. So you can take it in oral, patch, pellet, sublingual, cream. Like, it's so full of variety. And that's why I love being able to have these discussions because most women are like, what? I didn't know that. And that's the beauty of picking your own adventure.

26:09Karen Walrond: But we have to give, I think, you know, just society and doctors have to build so much more foundational education around questions that you ask. Why would I take it? What does it mean? Am I replacing something that really should not be there? Those are great questions. So two questions.

26:26Dr. Jessica Shepherd: One is, if I feel generally fine, is there any reason to do it? Like if I feel okay, I'll use me as an example. Yes, I get hot flashes. Yes, I've woken up in the middle of the night. But I sleep fine. I actually sleep eight hours a day, right? And if I wake up, I go right back to sleep. And hot flashes, yeah, they're annoying, but they're fine. Like, if I feel generally okay, should I still be talking to my doctor about it? Or is it really for people who are being impacted negatively by the symptoms? Is it too late for me? Like, when is too late to start? Like, talk a little bit about that.

27:09Karen Walrond: So all great questions because I have most women, you know, typically asking those questions of my symptoms are not that bad. Yeah. Do you need to go on it? And I'm like, guess what? You have choice because even if they're not that bad, you could minimize them a little bit more if you wanted to. You could actually not go on hormones and being like, I'm okay. Yeah. That's choice. The other part of that. So that's like in a symptom bucket. I put them in two buckets. Symptom bucket. Yeah. Longevity bucket. Right. So the symptoms like, oh my God, I cannot even go to work, finish my day. It's debilitating.

27:45Karen Walrond: Correct. Yeah. And I still have women who have that debilitating and still choose not to. Their choice. Yeah, yeah. So that's symptoms. Now when I was talking about that 20-year gap, what our organs can do, brain function, we know it's cardioprotective. Estrogen is cardioprotective. Wow, okay. You know that it does not cause breast cancer. We know that our bones are stronger when we're on estrogen, right? So when we get older, do I particularly want to maybe give my bones the best ability to be strong? Testosterone, when we're trying to look at muscle mass and building muscle so we're strong later and we have better metabolism older, do I want to give myself testosterone to help with that, to aid with that?

28:30Karen Walrond: So that's a longevity discussion on do you want to be on it for internal things that may not even be symptomatic and not impacting your daily, like how we see life and how we experience it? How do you want to show up at 70, 80 and 90? A lot of times to me is determined in mid-age on what you do with nutrition, exercise and considering hormones.

28:52Dr. Jessica Shepherd: Wow. And is it ever too late to start HRT?

28:56Karen Walrond: That is a beautiful question. So what we typically have heard is you can only go on it for a certain amount of time. And if it's past a certain time, it's too late. We are changing that conversation because of the longevity piece, which I just spoke to. But when women are older, I have a different conversation with them because they usually have gone now a portion of time without hormones. What happens in that timeframe is acceleration of disease, plaque in the arteries, decline in bone, right? So we kind of have to have a different conversation. This is terrifying. Where are you now? And what can we still offer you?

29:38Karen Walrond: Because most of my patients who start later, I do not say not have it. We just have to maybe do more testing, do more maybe cardiac tests to see what are you still not, I don't want to use the word eligible, but what can still benefit you? What are you, everything I say when a person walks in a doctor's office is risk and benefit. Yep. Assessing personal risk and benefit is really how people make decisions. Because I have people who have had breast cancer. and even if i'm like you know is it estrogen or progesterone receptor positive or not we have that discussion how bad are your symptoms and what are you willing to risk if you want to start hormones and i have had women who have like my quality of life is so bad and even if there's a risk of maybe having breast cancer because i'm on estrogen i'm willing to take that risk yeah wow who have not had breast cancer ever or even in their family history will be like, I just don't want any risk of getting breast cancer that might be associated if I took estrogen.

30:46Karen Walrond: I'm not going on hormones. I'm like, okay. Wow.

30:49Dr. Jessica Shepherd: So, you know, you've talked about earlier and later, like, when is the right time to at least, even if you choose that you're never going to do hormone replacement, like, is there a specific age? Is there, like, is it as soon as you're experiencing perimenopause system? Is it like just, you know, like how they do with breast exams or anything else? Like at age 43, you should be talking to your doctor about HRT. Is there any sort of guidance you can give to listeners about when to have that?

31:18Karen Walrond: And the good thing is we have data behind that. So when we look at a timing perspective, you know, timing really is what can I do before the gas tank is depleted, which would be menopause. And what we do from a perspective of what's going to give us our best cardio protection, bone protection, brain protection is before the hormone is completely depleted. So actually in that late perimenopausal phase, if we were to kind of cut perimenopause into three stages, early, mid and late, latter mid into late perimenopause is actually from a timing perspective, when we're looking at organ functionality and being protective is the best time to start.

32:00Karen Walrond: Okay. But that does not mean that someone who's outside of that phase cannot be on hormones. That's two different statements.

32:06Dr. Jessica Shepherd: Okay. And so, so we're having, so I come into your office and I'm like, okay, it's time, it's time to have, start having this conversation. Like, what kind of tests are there labs that I should get? Like, what kinds of things should I be getting tested in order to figure out like where I am and what I might need?

32:23Karen Walrond: labs typically in the perimenopausal phase like once you're still having a cycle whether it's regular or irregular labs really don't tell us much because we know your cycle right yeah the hormones say yeah you're having a cycle it's a regular regular i can still produce an egg which then makes your uterus shed yeah i know this right so the lab is not going to tell me if you're in perimenopause, I already know you are, usually based on age. Now, what I will say is I, you know, for my personal practice and a few other physicians practice this way is we will still run labs because it still gives us a really nice foundation for what you're going to experience later and things that we can compare later.

33:07Karen Walrond: The most important part, think of labs is not always just the hormones. I actually want to look at your metabolic profile. I want to look at your hemoglobin A1c. How are you metabolizing glucose and what is your fasting insulin like? What are your cardioprotective labs look like? Because I know once you decline estrogen, you're going to see an increase in cardiovascular kind of disease progression. What does your thyroid look like? So I actually run a whole slew of other things outside of the how are your ovaries looking right into being your whole body experience because that's your starting point that's your starting that estrogen once it declines is actually going to come back and impact those other labs as well and we can now do some work in preparation in a preventative mode then waiting for everything to fail or start to kind of like being like now i'm having a symptom a symptom really is your body's already been depleted it's just telling you outwardly now So trends are very helpful, but we should not chase trends when I mean it should not be every three months, six months.

34:16Karen Walrond: This can be something that's annual, maybe every other year, because then we start chasing numbers, and that's not a good thing as well. But trends are really helpful, so we can say, oh, my, maybe in the last year I've noticed that your hemoglobin A1C has started to creep up. Maybe your cardiovascular markers are starting to showcase something that they didn't last year. I do believe that trends help us give a better picture and lay a better protective layer.

34:44Dr. Jessica Shepherd: And we'll be right back after a word from our sponsors. Good Life Project is sponsored by Wild Alaskan Company. So one thing that I have noticed getting deeper into midlife, consistency beats intensity. It's not the elaborate stuff that sticks. It's what's easy to reach for and genuinely good. So I'm not talking myself into it every time. That's what Wild Alaskan Company has become for me. They deliver wild-caught seafood straight from Alaskan waters. I'm talking sockeye salmon, Pacific halibut, Pacific cod, individually portioned, vacuum sealed, and quick frozen right at the source, locking in texture and flavor and omega-3s, no GMOs, no antibiotics, no additives, just fish and the Alaskan fisherman whose whole history is tied to this water and this work.

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37:26Dr. Jessica Shepherd: Apply for Apple Card now and use in minutes with Apple Pay. Subject to credit approval, Apple Card is issued by Goldman Sachs Bank USA, Salt Lake City branch, terms and more at applecard.com. So this is great. I mean, let's be clear. You're a great doctor and you are interested in this and you're an expert at this. But if I'm going to my GP or even if I'm going to like, they may not be as well trained as you, one, or may think that it's a silly thing to even worry about. Right. And oh, that's cute little woman. You're in menopause. Just deal with it. Move along. So what are the things that you say in order to advocate for yourself with your doctor to say, no, no, I know my body.

38:17Dr. Jessica Shepherd: This is something. How do you pursue it? So what's the best thing to say to them?

38:22Karen Walrond: That is a very important question because that is more of what we're seeing now than not, right? Because, yes, in the menopause landscape of curriculum, what we're taught, how the experiential medicine part that I talked about early on is not there. Uh, well, we get there. I'm very hopeful. And I think that I'm, you know, seeing shifts in how we train and how we bring up menopause and midlife. But this is the opportunity for patients to advocate for themselves in a way that says, like you said, no, I really am feeling this way. and listening to my body and I'm staying in tune with it, the response is going to tell you, do I stay here or do I now go elsewhere to find care?

39:07Karen Walrond: The answer, maybe I'm not as well versed in menopause, but I can refer you somewhere. Tell me more about that experience so I can see what else we can look into. And if it's not in that family of answers, that's when without having you know like you know angry attack maybe a fight from the office is being like our time has ended here I need to find relationship with a provider who is really going to address the experiential portion of what I am going through and that actually can be done in various ways like there are websites that showcase doctors and you know nurse practitioners that are trained in menopause.

39:53Karen Walrond: And I will say that there are GPs, there are internal medicine doctors, neurologists that actually have started, and even cardiologists, to change their focus in midlife in women. So there's that, which I'm grateful for. Then there's telehealth platforms. So for example, you know, I'm the chief medical officer at HRS. We implemented a perimenopause and menopause platform because we realized there is a need. There are other ones as well. There's about four or five other telehealth platforms that address this, right? So now we're kind of seeing the extensions of what this looks like, but it is not widespread.

40:26Karen Walrond: So in science, what we are guilty of for good and bad, good because we want to make sure that we are giving good care and we're not harming patients. Sure. In order to do that, typically we were like, what is the study? What did the study show? Did the study confirm the other study to make sure that what we're advocating for is correct? Yep. And in menopause, we're so early in this kind of timeframe, it's very hard to be certain, right? And that's what medicine do. And so guidelines are typically made on certainty. So because we're not all the way there of 1000 % certainty, it is very hard to train physicians who historically have been like we are the science tells us where we go.

41:11Dr. Jessica Shepherd: Yeah, yeah. Yeah, and also as I'm listening to you talk and talking about some people, some doctors are well-versed, some doctors are getting well-versed. One of the things in your book that really, I don't think I got it until I read it was the idea that menopause can affect you differently, not just as individual people. Obviously, we're all different people, so it will affect us differently. But also there's different impacts statistically based on race that some people and that it didn't even dawn on me that that could be a case. Right. So. Yeah. So like I think I don't want to quote you back to you, but I feel like sometimes they that that black women have more severe symptoms than people who are Asian or white, which I can you talk a little bit about that?

42:05Dr. Jessica Shepherd: because that was really, really surprising to me.

42:08Karen Walrond: Yeah, it's surprising to a lot of people, even, you know, physicians, as we start to see the literature, but there is a great study that was done, the SWAN study, that really kind of parsed out experience based on ethnicity. And it was great to see, you know, for me, for a provider, that that is helpful to know contextually from data, what my patient might experience different to another. And obviously, our biologies are, you know, function different, our DNA allows us to experience so you will see in every ethnicity and increase in one disease versus another. Yeah. Now, what that study showed is when we look at just take hot flashes in intensity and duration, meaning how many years women typically will experience it were lowest for Japanese women and highest for African American black Afro-Caribbean women.

43:03Karen Walrond: And what this shows is one difference is an experience. But now even linking that further is we do know that the more severe and as far as increase in duration of hot flashes that a woman experiences actually increases their risk for cardiovascular disease. What? And also later on in life, dementia. So when you have this kind of science behind, even as much as ethnicity, that allows us to address women's health so much more intricately and allowing women the space and time to sit with it. Yep. And being like, now what do I want to do when I hear these numbers? Yeah.

43:48Dr. Jessica Shepherd: And obviously, I mean, as you, I think, point out in the book, like every person, every person, even with that, with those statistics, every person is different. Okay, let's, let's move off from HRT and stuff like this. One of the things I think you said is that after menopause, like most of us have almost 40 % of our life still yet to live, right? so can we talk a little bit about the things especially now that you've talked to me about the fact that not only is the um are the symptoms things like whether or not in the moment that they're debilitating but it also has um knock-on effects on how well you live in in later years like what are some of the non-hrt things that we should be doing to help sort of survive symptoms to help us prepare us for longevity?

44:35Dr. Jessica Shepherd: Like what are some of the things that we should all be doing for that?

44:38Karen Walrond: Yeah, that question is very important because what we typically see when something's new to culture or society, it seems like it's kind of like the foghorn alert, right? So most people are like only hearing about hormones right now. And so there's a lot of fixation on it for good reason because it was so kind of negated in the past. So now we're seeing, oh my gosh, we need to talk about it. We're going to speak about it loudly. But the fact really remains when we look at aging, especially for women, I'm going to exclude men for this, both men and women age and with that comes disease progression and the ability to, you know, as far as when we get older, what that really means as far as age-related disease.

45:18Karen Walrond: And for women, we see that menopause is inextricably intertwined with aging and how we live that last third of our lives. So this will show up in the form of, when we think of cardiovascular disease, still the number one killer of women and men, but for women. But when we look at this sharp decline, typically after the age of 65, 70 for women, where now we have this consequence of frailty, decrease in physical mobility, Alzheimer's disease, which is, you know, part of the dementia kind of umbrella, but specifically for Alzheimer's is more in women than men. Okay. Three times more. Oh, okay. Yes.

46:03Karen Walrond: So when we look at age-related disease later on in life for women, most women are admitted or not admitted, but transition to a long-term care facility or aging facility because of UTI and urine incontinence. Yep. Right? So when you put all of this together, there is kind of like this model, which we have already seen. It happens. It's pretty true to number. what do we get to do in order to increase awareness and recognition of what's happening is that time frame in midlife where we kind of get to turn the cruise ship in a different direction okay and that's why i think it's imperative and i call it the magic of midlife is to look at aging for what it is it happens to all of us but what can we do early on to be preventative in order to have better longevity.

47:00Karen Walrond: And longevity does not mean increasing life expectancy. It means that as we age for as long as we're going to live, how do we improve our well span? And the ability for us to live those later years, strong, cognition, not having urinary incontinence, being able to still travel, function, it's functionality more so than just I lived long, great. Did you live long, great?

47:25Dr. Jessica Shepherd: Yeah, exactly. So what do you do? Like, what are some of the things we can do to make that happen?

47:31Karen Walrond: Exercise and nutrition, I think, are some of the most fundamental things outside of hormones that someone could start to change in midlife. Our body just takes on fuel differently. It metabolizes food differently. It stores food differently. And that's how we get what our outcome is. So that is not easy to do. I would say lifestyle changes, you know, even for my patients are some of the hardest things to do because it sounds so easy. Yeah, yeah. We're like, yeah, we're going to pay attention for fiber intake, increase our protein, you know, increase some of our supplementation and vitamin D, creatine, vitamin B12 complex.

48:06Karen Walrond: Okay, and I'm going to do it overnight. No, usually lifestyle changes, I would say take three to five years. Yeah, then with exercise, we were typically taught, you know, do cardiovascular exercise, which is still very important, but we were never understanding the muscle and muscle building and how it contributes to strength and metabolism later on in life. So women were like, Oh, I don't want to build muscle. I don't want to get big. Your muscle is already on its way out. So either you help it, might as well build muscle. Or you're literally like, bye bye, you know, muscle, because it's already on its way out.

48:46Karen Walrond: And muscle really is the ability for women to maximize their longevity and improve their life, even from the beginning stages in mid-age. So I would say, you know, the kind of the pyramid or trifecta of what we see in aging is specific to menopause is underlying with nutrition and exercise, specifically resistance training and weight training, and then kind of funneling up to the cherry on top with hormones and deciding how you want to do that, how long you want to do that. And that's what I would say is the building blocks and tools when we think of magic of midlife and longevity.

49:27Dr. Jessica Shepherd: Jessica, this has been so informative and so helpful for me. I feel like I've learned so much. So, you know, just to kind of wrap everything up, can you just, I'm going to ask you the question that Jonathan always asks every guest. What do you think it means to live a good life?

49:44Karen Walrond: You know, what really comes up when I think about that is this ability to strategize and change our lives at a very strategic moment that we never have been given the opportunity to do that. And so I hope that this conversation has enlightened and encouraged women to take their lives into their own hands and having the curiosity to keep going so that we can create more well-being in all of our lives. Dr.

50:13Dr. Jessica Shepherd: Jessica, this has been an amazing, amazing conversation. I am so grateful to Jonathan for asking me to be the guest host on this episode. Thank you so, so much for your time and your generosity and all your wisdom. Really, really appreciate it. So let's talk about some of the big actionable takeaways from Karen and Dr. Shepard's conversation. One thing that I've been sitting with after reviewing it is the gas tank, Dr. Shepard's image for perimenopause, hormones not broken, just slowly draining over years, not overnight, sometimes starting as early as your mid thirties. And right alongside that, the symptom bucket versus the longevity bucket, this idea that whether or not you ever go near hormone therapy, there's a decision buried in there about not just how you feel today, but about how you want the next 40 years to go.

51:02Dr. Jessica Shepherd: And that line about how we'll medicate a tired thyroid without a second thought, but somehow treat it declining ovary like it's already done. That one really stuck too. If you take one thing into your week, let it be this. Start writing down what your body is actually doing. Not to panic, just to start noticing. And hey, before you leave next week, we're sitting down with Priya Parker to talk about why conflict handled well. Fighting might be one of the things that makes your closest relationships stronger instead of weaker and what most of us get backwards about the moment right before it happens.

51:39Dr. Jessica Shepherd: So be sure to follow Good Life Project wherever you get your podcasts so you don't miss that or any upcoming episodes. And do me a quick favor, a seven-second favor. Share this conversation with just one person or leave us a review wherever you get your podcasts. It really helps us get discovered and reach more people. This episode of Good Life Project was produced by executive producers, Lindsay Fox and me, Jonathan Fields, guest hosted by Karen Walgren, editing help by Troy Young, Chris Carter crafted our theme music, and of course, if you haven't already, follow us wherever you get your podcasts so you never miss a conversation.

52:14Dr. Jessica Shepherd: Until next time, I'm Jonathan Fields signing off for Good Life Project.

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