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24:18Mel Robbins:Wait a minute. The options that have been around for 60 years are medically safe and reliable. Wait a minute. They're not going to impact fertility. What are the top three things you would recommend to the person who's now thinking, maybe I should consider the IU do. Maybe I should take a, like, what would you? Think about the timeframe that you, you know, that you're trying to not get pregnant in. If you say, absolutely, I don't want to have a baby for five years, then I think the LARCs or the IUDs or the implants are fantastic because again, the margin error is so small because it's not like, well, I forgot to take my pill.

25:02But if you say, I don't want to get pregnant now, but maybe within the year, then it doesn't make sense to get a long-acting reversible contraceptive because you can leave them in place for years. That's a situation where maybe a birth control pill may be useful. But again, what are the consequences? This is also, I think, is really important. What are the consequences of you getting pregnant inadvertently? If you say, well, I want to get pregnant in a year, but if I got pregnant in six months, it'd be like, oh, well, not what I planned, but it's okay. Versus I am in the middle of finishing, defending my dissertation, or I've got a trip planned to Antarctica.

25:44Or I'm living paycheck to paycheck, and I can barely take care of myself. What are the consequences? How would that affect my life if it happened? Not just what would happen if I did, what would happen if I didn't? How would my life be changed by that? And I think that central question will determine which one you choose and when. And how quickly could you get pregnant after you stop taking the pill? The first time you ovulate, which is usually most women who have regular cycles, will get another cycle usually within a month or a month and a half of having stopped the pills. So it's pretty quick.

26:22All you need to do is ovulate.

26:24Mel Robbins:PCOS has recently been renamed to PMOS, and I'm getting so many listener questions about PCOS. Could you explain what this is? I happen to have a daughter that was diagnosed with this in her late teens. But there's a lot of misinformation, and this is a really important thing that impacts a lot of women. I have thoughts on this, Mel. I'm not surprised, Dr. Malone. But PCOS, I'll give you just a little bit of the history of PCOS. PCOS is polycystic ovarian syndrome. Before it was polycystic ovarian syndrome, it was polycystic ovarian disease. So we changed the name from disease to syndrome because disease makes us sound like— Yeah, sounds terrible.

27:12So that was the first name change. And then now we've gone from polycystic ovarian syndrome to polyendocrine metabolic syndrome. Okay. Ovarian syndrome. PMOS is what it is. Okay, well, that's great. We've changed the name. Have we changed the diagnostic criteria for PCOS? No, we haven't. It's the exact same things. How I would make the diagnosis today is the same way I would have made the diagnosis 20 years ago. We just changed the name.

27:44Mel Robbins:Dr. Mullen, what are the symptoms that somebody who has PMOS or PCOS? PCOS. Okay. Generally speaking, I think what gets people derailed is when you say polycystic ovarian syndrome, that means poly just means many. You've got normally in the course of a menstrual cycle, you know, you'll start recruiting eggs. One will take over and you'll ovulate from one egg. Well, with polycystic ovarian syndrome, you don't really ovulate regularly. So they get the signal, okay, but no one takes over and it's not just one egg that ovulates. So you get this sort of chronic overproduction of estrogen. you also because you don't ovulate you also don't get that second half hormone which is your progesterone that you kick in the second half and so it makes your cycles irregular they're irregular maybe once every three months and maybe once a year so irregularity of cycles is usually the first point the second point is that there are also other things going on a lot of women will find that they have signs of what we say androgen excess.

28:55That just means that your ovaries are also making testosterone. They make more than just estrogen and progesterone. They make testosterone. And so when you don't ovulate, you get this sort of chronic overproduction of testosterone. And what happens when you get a lot of testosterone? Acne. Oh, acne. Acne, facial hair. Women will find that they start to get chin hair or hair around the nipples. So there's a sort of a more of a male pattern hair growth. Because you've got that, it can also lead to hair loss. But the endocrine part of it is that we've also realized that it's not just, again, it's never just the ovaries.

29:37There are other organ systems that are affected. And the endocrine part is there's an overproduction of insulin. So there's a degree of insulin resistance because you're not responding to the insulin. So you overshoot it and you're making too much insulin.

29:54Mel Robbins:So acne, weight gain, higher levels of insulin, irregular cycles, those criteria are basically the same. And I think that when you get caught up on the polycystic part of it, you think you're going to do an ultrasound, instead of seeing one follicle, you're going to see 20 little ones. Well, you don't see it. That's not an integral part of making the diagnosis. So we've made a lot of progress in terms of changing the name, but you know where we haven't made a lot of progress? Finding out why it happens and having new treatments for how to deal with it. That's where the attention needs to be focused.

30:34So when I say I have thoughts, it's like, yeah, great. I'm glad you changed the name, but we need to focus on, okay, now what are we going to do about it? We need more research.

30:45Mel Robbins:It almost sounds like it's a hormone imbalance that is just wreaking havoc on your body, your menstrual cycle, your ovaries, other organs, insulin, sort of like menopause does. You know, you write about endometriosis in your bestselling book, and I was really surprised to hear that it affects one in 10 women, and it's also one of the leading causes of painful periods and infertility. Can you explain what endometriosis is and what are the symptoms? Yes. Endometriosis is simply that same tissue that lines the uterine cavity, the tissue that gets stimulated every month with estrogen before you ovulate and sloughs every month if you don't conceive during that cycle.

31:34That's endometrial tissue, which is why it's called endometriosis. Well, it belongs in the lining of your uterus. But for reasons that we don't really know why, it can migrate or spontaneously generate in places where it doesn't belong. So it can be on your ovaries. It can be the lining of your abdominal cavity. It can be on your bladder. It can be on your bowel, anywhere. But it's just not supposed to be there. We don't know how it got there. There are a lot of theories, but it's there. And so those same hormonal triggers that you are getting every month to tell the lining of your uterus to grow and shed is happening.

32:15Remember, it's talking to the endometrial implant that's on your bladder, and it's doing the same thing. And chronically, it can lead to scarring because, remember, when you get your period, you're sloughing that tissue out. Well, what happens? It has nowhere to go. So it's there, and that chronic inflammation really can cause pain, scarring, and in the worst cases, infertility. And as I said, a lot of women walk around. I think it is probably more underdiagnosed than PCOS because when you say one of the signs is painful periods, well, do you know how many women walk around with painful periods and they just figure, well, I'll just take more Motrin or I'll do something else, or I'll just assume that that's normal.

33:03Now, the other thing about endometriosis is that it's called really the great masquerader because suppose you have it, it's on your bowel and your symptoms may be, oh, I have, you know, really bad diarrhea or bowel issues or sometimes even on your bladder. So it is causing the problems where it lands. If you have really bad endometriosis, the scarring can make sex unbearable for women. So, you know, again, you need to have someone to talk to who says, you know, yeah, I kind of see the pattern here. But women are often treated individually for their symptoms. So you've got bowel symptoms, you go see a GI doctor.

33:49Oh, you have a bladder thing, you go see a urologist. And not really understanding that it all goes together. And that's why it's a delay in diagnosis for most women. The delay in diagnosis is seven to nine years before they're adequately diagnosed and treated for their endometriosis. Yeah, it's a long time. Women with endometriosis have had multiple, multiple trips to the doctor. It's not like they were not complaining about it. It's just that being able to make the diagnosis. And as physicians, we like objective data. We like to be able to do some lab work and see it or do an ultrasound and see it or a CT.

34:31And the problem with endometriosis, the reason why a lot of times it's not visualized on a scan, is because the little spots of endometriosis will be so small that they're below the resolution of whatever you're trying to do to look at it. So you can't see it on a scan. Well, then how do you diagnose it? Well, you have the clinical presentation. But sometimes if you're really concerned, you need to do a laparoscopy, which is that's where you just take a look, go through a scope, and look in there, and you see it. And that's how you can definitively make the diagnosis. The one thing that the laparoscopy will allow you to do is that if you see it, in addition to being able to treat it medically, if I see endometriosis, I can go in with my laser and I can zap it and correct the things that I see, then do the medical treatment afterward.

35:25Mel Robbins:That is so helpful. I could listen to you all day. I have so many more questions, but here's what I want to do. Let's take a quick pause because I want to give our sponsors a chance to share a few words. And I also want to give you a chance to send this episode to your sister, your mom, your best friend, or like me, your daughters. I'm also going to send this to the women that I walk with on Wednesday mornings because this is information we all need. And don't go anywhere because after the break, Dr. Malone is going to talk about hot flashes in a way you may have never heard any medical professional explain them.

36:01Mel Robbins:to you. They're trying to tell you something. And she's also going to tell you what the one thing is that prevents osteoporosis. And I think it's going to surprise you. So stay with me. We'll be right back.

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38:33Mel Robbins:Welcome back. It's your friend Mel Robbins. And today, you and I have the honor of learning from and being empowered by board-certified OBGYN, Dr. Sharon Malone. Today, she's answering your questions in an extraordinary episode all about women's hormonal health at every age. So, Dr. Malone, since you also said that endometriosis is one of the big causes of infertility, let's just talk more about fertility. What do you want women in their 20s and 30s to understand about how fertility changes as you age? Well, your peak fertility years are really in your 20s, probably in your late teens through your 20s.

39:19And then when you get into your early 30s, it's a little different, but it's not markedly different. You know, what's the difference between 32 and 28? Probably not that much. But once you get to about 35, 36, then we start to see some of the more of the age-related fertility decline. Our fertility is declining, but it's more rapid once you get to your mid-30s to the point where by the time you get to your early 40s, then it's even lower. I mean, you know, the likelihood that you will conceive at 40 is way less than what it would be if you try to conceive at 20. So we have two things. We have number of eggs, and that's more of an issue when you're 50.

40:03But when you are in that window of declining fertility, like between 35 and your 40s, there's also another component that we don't think of, that some of it's genetic, some of it's environmental, and that is your eggs have an expiration date stamped on them. So you don't know when yours is. It is helpful to know your family history. That's why I encourage young women, I said, please talk to your mother. Ask your mother, mom, did you have trouble conceiving? How old were you when you had your last baby? When did you stop using birth control? That tells you a lot of things. It tells you, you know, knowing your family history about endometriosis, about fibroids, about infertility is important.

40:49It helps you be proactive going forward. It helps you perhaps make a decision. Maybe I won't have my first baby at 37. Maybe I'll have it at 34. It's kind of, I say it's data. And you do with that data what you will. Does freezing your eggs impact the expiration date? No, it does not. Remember I told you your peak fertility years are in your 20s. So if you were going to freeze eggs, if I were just saying theoretically, when would I get the best yield from egg freezing and retrieval? It'd be in your 20s. But the flip side of that is, well, what's the likelihood that I would ever come back for those eggs?

41:31Because if you're in your 20s, you've got a whole life in front of you. So you meet someone at 30 and you get married and you get pregnant. If you get pregnant on your own, are you ever coming back for those eggs that you've spent tens of thousands of dollars for? So even though the yield is better, the likelihood that you will ever need them goes down. Got it. So I think the sweet spot is somewhere probably late 20s, early 30s for freezing. But let me be clear about egg freezing. Egg freezing gives you the possibility of pregnancy. It does not guarantee anything.

42:08Mel Robbins:That makes a lot of sense. Yeah. What, Dr. Malone, are surprising reasons for infertility? I think the most surprising and frustrating one is unexplained infertility. Now, we do a whole workup. You know, we've done an ultrasound and we look at the lining of the uterus and we know your tubes are open, all of that. And sometimes every single thing checks off on the list. You're good, your spouse or your partner's good, and you're still not pregnant. That, I think, is probably more frustrating to people than saying, oh, I have fibroids or I had a polyp or my tubes were blocked. Because everybody likes to have a reason.

42:48And I think that's frustrating. I think the other thing about infertility that we don't talk enough about is that it's not just a me problem. It's an us problem. And upwards of 50 % of infertility cases sometimes is male factor infertility. 50 %? Yeah. Women get blamed, but, you know, it's like, it may not be me. It may be you. But again, but there are answers even for how to do that. That's what IVF is for. That's what something called ICSI. When you have male factor infertility, then that's just intracytoplasmic sperm injection, ICSI. You see why we say ICSI? Yes, I do. But all you're doing is now you're just giving that sperm something.

43:34You're like, I know you're not going to get there on your own, so I'll just directly put it into the egg. You're giving it pre-workout, basically. No, you're just going ahead and giving it a whole head start. but that's helpful and that has helped a lot of couples so it's not just like oh poor me you know the more you know the better choices you're able to make and I would also say to young women who are thinking about you know where they are in their careers and should I do it now should do it two years from now the other important point to make here is that freezing embryos which is what we do in IVF, where you've already got a known egg and a known sperm, and then we freeze them and come back for them later.

44:18That's more successful than egg freezing. The procedure is the same. You have to take all the same medications for IVF that you would for an egg retrieval. You're retrieving eggs. That part of the procedure is the same. The only thing is like, what are you doing after you've retrieved the eggs? Are we fertilizing them now, or are we freezing the eggs? And fertilizing them now with a known partner is always the better option if you have a known partner. Dr. Merlin, what's the connection between fertility and perimenopause? Oh, well, they go together and it's an age-related thing. Now, here's the connection that I think a lot of people don't understand.

44:59Remember I told you there's a natural age decline in your fertility, right? Associated with age. Well, suppose I tell you, we'll do a little thought experiment here. We say the average age is 51 for having gone through menopause. Completed, end of discussion, shop is closed. Oh, nothing's happening there, right? No ovaries. No estrogen from those ovaries. 51. Well, perimenopause, that window, that long span between your peak reproductive years and the end of your reproductive years, okay, it can be four to ten years. So if I tell you you're menopausal at 50, all right, then perimenopause can start as early as 40, and then it takes you 10 years to go through that process.

45:45And there is also diminished ability to conceive because, again, now you're 40-something in addition to these hormones are changing. But suppose you're menopausal, you've talked to your mom and you find out, oh, my mom had an early menopause. She was menopausal at 42. Back it up four to 10 years. That means that for you, you might be perimenopausal in your 30s, your early 30s, when you think, relatively speaking, I should be pretty good on the fertility front. But you don't, you can't predict where you are in that spectrum necessarily. So that's why I say it's important to know your family history.

46:27So you can say, all right, mom, well, I did not know, mom, that you were menopausal at 40. Then that, you know, it's not a one-to-one, but it is a very important data point if you're the daughter.

46:38Mel Robbins:If you're listening and you have not talked to your mom or your grandmother, she's still here, what are the questions you want every daughter to ask their mother? You want to know all about their medical history But particularly, you want to know about things. Mom, did you have cramps? That's a sign. Did you have these painful, awful periods that could be indicative of endometriosis? Because we know that daughters of women with endometriosis have a higher incidence of endometriosis. You want to know about whether or not your mom had fibroids. You want to know, because again, that increases your risk of having fibroids at some point in your reproductive life.

47:21You want to know what age she was when she conceived. Was it difficult? And you also want to know what was your pregnancy like? Because, again, these are very, very important points that may affect your history. Whether they do or do not, it makes you aware such that if any of those things come up for you, you don't wait two or three years to go get that diagnosed. You mentioned that to your doctor, by the way. oh, yes, my mother had endometriosis. Well, guess what? That's going to help me get to the diagnosis point with you sooner than if you don't know that.

47:58Mel Robbins:So even just knowing makes you recognize that, okay, this is something I need to pay attention to, which is really important. If you've gotten a diagnosis of PCOS or PMOS earlier in your life, will that potentially impact your fertility as well? It may. Because in PCOS, as I told you, the treatment depends on what's your goal. Yep. And if you have PCOS and you're trying to get pregnant, you may ovulate irregularly, and you don't know when that is. So you may are going to ovulate three months from now. So when you're trying to get pregnant, and that's a very different situation than for someone who has a period once a year, your opportunities for pregnancy are less.

48:40You know, for someone who has a monthly cycle, well, at least you have the opportunity every month. For someone who has PCOS, maybe you ovulate three times a year. So, yes, that affects your fertility. But we do have medications that we can induce ovulation with.

48:55Mel Robbins:Dr. Malone, I am learning so much. And I know as you're listening, you're nodding along thinking, I wish I had had this sooner. I am so happy I have this as a resource right now. And I want to take a quick break so that we can have our sponsor share a few words with you. Do not go anywhere because we're going to return and Dr. Malone is going to explain why you should consider hormone therapy way sooner than you may think. So stay with me.

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52:25Mel Robbins:Welcome back. It's your friend Mel Robbins. And today, you and I are here with board-certified OBGYN and world-renowned women's health expert, Dr. Sharon Malone. And today, she's answering your questions in this extraordinary episode all about women's hormone health. I'm loving it. I know you and every woman you love is loving it, too. So thank you for being here. So Dr. Malone, let's talk about menopause. What is it really, and Dr. Malone, what do you want women to really know and take seriously when this change starts to happen in your body? What I want women to understand is this, is that menopause is not an event.

53:07It is a life stage. You will spend 30 to 40 % of your life after you have completed menopause. You will spend more time in menopause than you did in your reproductive years. It is probably, if you're lucky enough and you don't get hit by a car, that will be the longest of your reproductive phases that you are in. That's why I don't like the term post-menopause, because when you say post-menopausal, and I get it why we say it that way, but I don't want you to think of it that way, is because that gives the impression that you're over menopause. Yes. And you're not. You're never over menopause. The effects of the lack of estrogen and hormones in your body will affect you from that point forward.

53:56Your bones, your brain, your skin, your hair, all of it. So that's why I said I don't want people to go, oh, I'm over it. And you know what they mean when they say I'm over menopause? They're usually, they're saying that their hot flashes went away. And menopause is so much more than a hot flash. I mean, that's the least of the things. But hot flashes are often harbingers of things to come.

54:21Mel Robbins:Wait, hold on a second, because harbingers of things to come sound like the orcs are rattling over the mountain. And I do have a question here. Why do I still have hot flashes at 58? eight. I haven't had my period in over two years. So if you're still having hot flashes, what is this a signal of things to come, Dr. Malone? Well, women who have more severe hot flashes and more frequent hot flashes, sometimes it is a marker for impending cardiac issues, because what happens to women who have a lot of hot flashes? And who has the most hot flashes? black women do. They have hot flashes that are more severe, they last longer, and they start earlier.

55:05So, you know, when I told you perimenopause is four to 10 years, if you're an African-American woman in this country, it's closer to 10 years. So you are most symptomatic during perimenopause. So all the time, you may be still getting your period. That's the worst. I'm getting my period and hot flashes, but it can happen. And then there's also about 20 % of women whose hot flashes will continue into their 60s, 70s, and beyond. Dr. Malone, don't be telling me this. Really? Yes.

55:34Mel Robbins:Why? See, who knows why? Do you think there's a connection with stress? Like when I hear the stat that you said about Black women having more severe hot flashes, it's starting earlier, lasting longer. What came into my mind was the statistic that Dr. Gabor Mate shared on this episode about autoimmune diseases and the 4X rise of them in the last 20 years. and it was his theory, and I know there's a lot of research around this, that chronic stress and chronic caregiving and micro traumas and aggression and bias that Black women deal with that I don't have to deal with because I'm not being discriminated against in microaggressions every day, that that chronic stress creates conditions in your body that impact your immune system, do you think that that is contributing to these symptoms?

56:35I think it is a big factor because I think that the reason why black women tend to experience these symptoms more, and this would be true of any chronic disease, it's not just perimenopause and menopause, is that chronic stress is toxic to whether you're talking about weight gain, whether you're talking about your cancer risk, it accelerates the aging process, even for Alzheimer's or dementia. People who have chronic stress, all of this, tend to higher risk. And who has higher risk of stress of anything? Black women. We have twice the risk of dementia than white women. I did not know that until I wrote the book, because I was like, wow, I never knew that.

57:19I never knew that women had twice the risk of Alzheimer's or dementia than men. So it's clearly something that's happening, and it starts somewhere in our midlife. But getting back to the hot flash and the connection to chronic disease, the hot flash is women who have higher incidence of hot flashes. This is what we know. Women who have hot flashes have night sweats. People who have night sweats have disrupted sleep. We know that disrupted sleep is a risk factor for cardiovascular disease. We know that women who have disrupted sleep are more likely to have hypertension. Women who have disrupted sleep are more likely to develop type 2 diabetes because it leads to, when your sleep is disrupted for months, years on end, chronic fatigue.

58:09If you're chronically fatigued, guess what you're not going to do the next day? You're certainly not going to go to the gym. You're not going to get up in the morning like, I think I'm going to go on a three-mile run. So that's why I said a hot flash is often the inciting event for a lot of other things and behaviors that will increase your risk for heart disease as you age.

58:31Mel Robbins:I would love to hover just a little longer on the hot flashes. And maybe it's selfish because this was something that was chronic for probably seven years for me. I would wake up and the entire side of my bed, it was almost as if somebody had thrown a bucket of water under me, and they've mitigated thanks to HRT. What would you say, Dr. Malone, are the top three things you want someone to be aware of that you should be checking out to mitigate this? One, I would say this. Know that hot flashes are not benign. That's what we've been socialized to believe, that suffering, pain, misery, they're just part of womanhood.

59:20So we should just grin and bear it and don't worry, close your eyes, it'll be over in a decade or so. That's ridiculous to me. And I do this all the time because, you know, now people have these little portable fans that they walk around with. Yes, I had one. And I will see a portable fan and I will just walk up to somebody and say, girl, you know we have something for that, don't you? We don't have to walk around with a fan. Fix it. Do it. What do I do? It's hormone therapy. I mean, the most effective treatment, FDA approved, is hormone or estrogen particularly for the symptoms of menopause, vasomotor symptoms or hot flashes.

1:00:05It works. But it's the fear factor that keeps women away from the most effective treatment for the symptoms of menopause.

1:00:14Mel Robbins:You know what's interesting is it's happening to women in their 20s because there's so much misinformation and lies being spread about birth control. Right. Which in many cases is low doses of estrogen. Yes. And the same thing is happening to women in our 40s and 50s when it comes to the misinformation and lies related to hormone replacement therapy, which is not only safe for the vast majority of women, but it is shockingly effective. Like, I remember this when I started hormone replacement therapy. It took about five weeks, and all of a sudden I thought, oh, my God. Like, I feel like myself.

1:00:53Mel Robbins:Yeah. What the hell was I doing? Why didn't I start this sooner? Why didn't I start this sooner? And there's really even more of a medical benefit for starting sooner, because the sooner you start and treat those symptoms, the more benefit you get in the long term. What do you mean? I mean, in terms of your cardiovascular risk, in terms of weight gain, in terms of being able to sleep, all of those things. Perimenopause does not have a bright line that defines it the way menopause has a bright line that says when you're done. Okay. But when to start treatment, when to use hormone therapy in some form or fashion in perimenopause, again, depends on what your treatment goals are, and it depends on how bothered you are by your symptoms.

1:01:41And that is what I want women to understand. If you're between the ages of 35 and 45, which is usually about the time that perimenopause or the menopausal transition starts, you seek treatment when you are bothered by your symptoms.

1:01:56Mel Robbins:Like, I wish I had known you like five years ago. Yeah. Because when I think about how revelatory it is to me that I didn't even consider the age range of 35 to 45 and that there's no benefit to waiting until you're suffering. And if you just don't feel like yourself, the world is hard enough. Right. And if this is something that can help you feel like yourself again, it's going to make you feel better equipped to handle what's going on in your life instead of like, because what ends up happening is you describe any of those symptoms. I can't really sleep. Like something's wrong. I'm gaining weight.

1:02:35Mel Robbins:I don't know what's going on. Oh, here's an SSRI. You might be depressed. Right. Here's a sleeping pill. Yes. Versus this is clearly something going on with hormones because women's entire life. In fact, when we did a poll online, have you ever felt like your hormones are affecting your mood, energy, sleep, weight, or cycle? 98 % yes. See, they could have just asked women. We would have told you. I think the reason why women tend to wait, there are probably two reasons. One is they don't realize that this is all part of perimenopause and the menopausal transition. And the second thing is that we have been laboring, women have been laboring under the misconception for a very long time that they can only take hormone therapy for a small amount of time because the direction once was, we'll take the smallest amount for the least amount of time possible.

1:03:30That's not true. You can start getting treated when you're symptomatic. You can take it for as long as you like. There is no time limit on how long you can take hormone therapy. Now, bear in mind, there may be some subtle differences in terms of how we prescribe in perimenopause and how we prescribe in menopause. Because you remember, sometimes we have different mission. You're perimenopausal. Remember, I told you your fertility is decreased. It's not gone. So do you need birth control or no? The bad PR campaign that's going on about birth control pills in 20-somethings is also happening about people sort of really disparaging the use of birth control pills in perimenopause.

1:04:15So women need to understand that misery should not be your resting place. Lord knows, there's enough of that in the world that you cannot control. But for things like this, when you are feeling out of control, why wouldn't you fix that? I don't get it.

1:04:36Mel Robbins:I love that you're reminding us that you don't need things to get worse before you can start feeling better. And that there are such safe, effective, and almost immediate things. I love my patch so much, I will be wearing it on my deathbed. Like, I am not ever spending any time without that sticker on my body because it has made such a difference. And in fact, you know, it has been on the headlines that there's a shortage of estrogen patches. What is going on, Dr. Malone, and what should you do if that's affecting you? We're not waking up! I know. I mean, I'm delighted because it means that there's more demand for it.

1:05:15And I think what is distressing to me is that you didn't see this coming. I mean, when I tell you, I have personally been out here in this space talking about menopause publicly for over five years. I've been talking about it privately for 35 years. So the notion that now that women are aware, that's the only difference, that more women are aware. We've knocked down a lot of the misconceptions about breast cancer and all the bad negative press about HRT. could you not have seen, can you not read the room here that there was going to be more demand for hormone therapy? Well, you know, again, I think that there's not a lot of attention being paid to women's health, but that's another issue.

1:06:03But the point is, is that the estrogen patch is not your only option. Systemic estrogen falls into two categories. There's transdermal, of which the patch is transdermal, which just means it just goes through the skin. So if you're out of patches, if you want to say, oh, but I really want to stay with the transdermal, you can use a spray, you can use a gel. Those are readily available. And even different doses of the patch are available. So I don't think anyone needs to panic because you can't find a patch. We have options. Then there's also oral. And again, oral hormone therapy gets maligned as if that's something terrible.

1:06:47It's like you can use oral. Most of the information, the data that we have on the benefits, all of the things about hormone therapy really comes from the data that we have on oral.

1:06:57Mel Robbins:I really just appreciate that you are explaining this in a way that's easy to understand with a level of depth that doesn't make me feel like an idiot for really going either I've never heard it that way or I actually understand it at a deeper level. And one of the topics that I recently feel like, oh, wait, I never really understood that there's a difference between HRT and what vaginal estrogen might do. And it was after learning about the benefits of vaginal estrogen for UTIs, for overall health in your sexual health that I started taking vaginal estrogen as a supplement. I can't believe the difference.

1:07:47Mel Robbins:And so could you explain, Dr. Malone, what the vaginal estrogen supplement is for? how it relates to HRT and how you want women to think about this, especially as we get older. Right. That's an excellent point because, you know, sometimes it gets all mushed in together. But when I'm talking about HRT, generally we're talking about systemic, which means that you are using estrogen and a progestogen of some type at a level that, again, controls the symptoms, hot flashes, the mood swings, all the brain fog that we typically associate with perimenopause and menopause. So we're taking estrogen at a level that will take care of those symptoms.

1:08:38Okay. So you can do it orally, you can do it transdermally as a patch, but it is going, it's a systemic because it is going throughout your body. Got it. Okay. Topical or vaginal estrogen is used just locally. You put it in your vagina, and you can use it even on the outside, on the vulva, on the labia, basically, because it is addressing the genital urinary syndrome of menopause, or GSM. That's vaginal dryness, painful sex, urinary frequency urgency, and frequent urinary tract infections. You can treat that using local topical vaginal estrogen, and it will take care of those symptoms, but it basically stays where you put it.

1:09:25Okay. It's not going anywhere. And so it's not enough in vaginal estrogen. If you have hot flashes and you're using vaginal estrogen, you'll still have hot flashes. You'll still have sleepiness. Because it's not systemic. It's not going through your whole body. No. It's like a pimple patch.

1:09:39Mel Robbins:You're like putting it here, but it's not in your whole body. You put it where you want it to work. Got it. Okay. And the same is true of like topical estrogen that you use for your face. Remember, one of the things that happens in menopause with estrogen depletion, you lose 30 % of your collagen in your skin in the first five years of menopause. So what we know is that the skin has estrogen receptors. Your vagina, your vulva has estrogen receptors in it. So you can use it at a level that increases the hydration, collagen formation. And again, we've known this for quite some time. But again, it's not enough to treat your other symptoms.

1:10:19So that's why even women who are on systemic hormone therapy may still need to use a little bit of extra vaginal estrogen.

1:10:27Mel Robbins:Wow. Dr. Malone, talk to us about the importance of muscle loss and bone health and strength. That is so important because one of the things that happens in menopause is you start this cycle of bone loss. Because remember, estrogen affects everything, your skin, your muscles, your bones. So that starts in menopause? That really starts in late perimenopause and certainly continues through menopause at a more rapid clip once you are finally done with menopause. You tend to lose muscle, you lose bone, and you gain fat. so that even when you are weight neutral in menopause, you are still changing your body composition.

1:11:12That's why it's like, wait a minute, why do I all of a sudden have this weight around the middle? Why do I have this spare tire? It is because the lack of estrogen causes this sort of redistribution of body fat and loss of muscle. So now if you go through the next 20 years and you're losing muscle and you're losing bone, Well, now you're more susceptible to osteoporosis. Why is that important? Because then you're more likely to fracture a bone, be it your spine, be it your hip or wrist. Your bones are thinner and more fragile. Now, this is where it's a dangerous combo. If you are not careful and mindful of your muscle mass, now you're weaker.

1:11:58So now you've got less muscle, less bone. What happens if you trip and fall? you're weak. You've got no cushioning, you're doing whatever. So when you go down, you go down like a tree and you break things. And that is really why I think our goals as we age, yes, we do hormone replacement therapy because hormone replacement therapy or the estrogen component is the only medication that we have that prevents osteoporosis.

1:12:26Mel Robbins:Wait, estrogen is the only thing that we have that can prevent osteoporosis? Estrogen and the hormone replacement therapy that you take has an FDA indication for the prevention of osteoporosis. So if you are at risk for osteoporosis. Aren't we all? Well, not everybody. Not everybody's going to break something. I mean, it just depends. And see, there's a genetic component that you bring to it. I have great bone density because I'm a bigger person and I have. But it's dependent on your exercise level that you have growing up. How much bone did you form in the first place? Some of it's genetics. Some of it's from your activity.

1:13:10How much calcium? Were you a milk drinker as a kid? That's why your mom always says drink your milk. Whether or not you've had enough calcium and vitamin D to actually create that bone. And then whether you've been able to maintain it. And exercise matters. not just cardiovascular exercise, but that's where the weight training comes in because your bones will respond to whatever load you give it. So the more stress you put on it, the better your muscles are, the more weight bearing you can do, you tend to preserve more of your bone mass. So that's where you enter menopause. But regardless of where you start, you're going to start to lose it after menopause.

1:13:51And if your bone density is really high, it may take me 35 or 40 years to get to the fracture point.

1:13:58Mel Robbins:But if you start really low, you're going to get there sooner. If you're already losing bone density, maybe you have a diagnosis or not. Maybe you just feel frail or nervous about it. Will weight training pause what's happening? Will it help you regrow? Here's the thing about most bone loss. Most of it, when it happens, you very rarely get back to where you started. So once you're coming in 10 years after the fact, you may be able to sort of slow the train down a little bit. But for the most part, what's lost is lost. You can maintain your bone density. And estrogen and resistance training, building muscle helps you?

1:14:40Mel Robbins:Yes. The estrogen, I'll give you an example where I think it will be helpful for women to know. Right now, the current recommendation for getting a bone density is, they said, recommendation is do it at 65. Why would you do it that late? Isn't that a good question? Why would you wait? Remember, I told you the most rapid phase of bone loss happens in the first five years after menopause. by the time you get it at 65, that's 15 years of bone loss that you're not going to be able to recoup. It makes more sense to me. And what I would advise my patients to do is that once you get to menopause, you don't need to do a bone density when you're 30, but once you get to menopause, say, let's do a snapshot right now and see what my bone density is.

1:15:28It's going to be good, not so good, or maybe it's fantastic. If it's not so good, that doesn't necessarily mean, that also doesn't mean that you're going to fracture. But I would be more aggressive in terms of saying, all right, well, what we can do to prevent you losing further bone is to do hormone therapy at that point. Got it. You see? Yes, I do see. And if I wanted to say, oh, I don't know if I want to do it, then I would do it once at menopause. And I'd say, let's do it at 18 months to two years later. And see if you're declining. If it's declining, then now I can make the case to you that see what's happening, and then you might want to reconsider at that point.

1:16:06Mel Robbins:Even if you are in a place where, all right, we blew it, and I now am in osteoporosis or I am losing bone density, how would weight training or building up your muscles, how would that protect you and impact your health positively in that case? Your muscles help protect and support your bones. I think we kind of think of our bones as once you've grown to adult height and whatever, and your bones are just your bones, your bones are constantly remodeling. They're being broken down and they're building up. And they will build and break down depending upon the stress that you put upon them. So if you're exercising, if you're doing weight-bearing exercise, you will build stronger bone in the earlier phases than someone who does nothing.

1:17:02I think about this a lot as being an older person and on the road and traveling all the time. I need to be able to put that carry-on in that overhead compartment here. And, you know, that's a matter of just being able to know that I have enough upper body strength to be able to lift. I need to know that if I trip, that I'm not going to go down like a tree. You have some core strength to be able to sort of prevent you going down like that. I mean, think about that. If you were 20 years old and you tripped on the sidewalk out front, you are very unlikely to break your hip. Correct. because one, you can break a fall, you can do all these things.

1:17:46Reaction time, all this stuff as you're older, not there, and your bones are more fragile. So that's why you need strong bones and strong muscles. Gotta have core strength for maintaining your balance. Wow, this is so, so good.

1:18:01Mel Robbins:You're so smart. And you have such an incredible way of explaining this. And I hear both the passion and the commitment to women's health. and the anger and frustration that you feel on our behalf, that the information and the access to these tools has not been as readily available and understood as women around the world deserve it to be. And so I appreciate the depth to which you went in each of these topics, because I think it can be really confusing. And, you know, we do live in a world where there is so much information flooded into the public space that it is easy to be gaslit. It's easy to have somebody prey on you and your fears and to have you start to question established medical science to your detriment.

1:18:59Mel Robbins:Right. And, you know, I guess that brings me to a question I'm curious about. If there was one question, Dr. Malone, that you believe every woman could be asking her doctor after listening to this episode, what would that important question be? I think you should come into your doctor and you should actually ask them two questions. When you are even contemplating having the discussion about hormone therapy and aging, just aging in general, which God willing, we will all do. When you are having a discussion about hormone therapy and whether or not it's right for you, it's not right for everybody, but it's the most effective treatment for most women.

1:19:41The conversation that you really need to have is what are the benefits of taking hormone replacement therapy? And what are the negative things will happen if I don't? Ooh, I love that, if I don't. Because most of us go, what's negative if I do? Right. What if I don't? What if I don't? What am I at risk for? And what are the things that will happen if I don't? And I think we don't have two sides of that conversation. Well, Dr. Malone, thank you for not only educating us.

1:20:14Mel Robbins:Thank you for not only being a voice that has been both privately in practice over 40 years and very publicly sharing this information for free and advocating for women. Thank you for writing this remarkable guide, Grown Woman Talk, that gives you the medical and scientific facts that every woman needs to understand and know so you can make informed choices and understand the ramifications of doing them or not. And thank you for also putting your effort into solving the access problem, because one of the things that I think a lot about is that I know with the global reach of this podcast, that step one is giving somebody access to a world-renowned expert like you in a way that makes you feel empowered, that makes you understand what's happening, that makes you understand the various options that you can and levers you can pull that can help you take control of your life, your health.

1:21:24You know, the message that I really want women to have is that you deserve to feel better. You deserve, with every tool available, to be able to age healthfully and gracefully, that should be the new goal, not all the negativity that's associated with aging. Some of that is going to come, but the reality is that you have way more control over how you navigate this final phase of your life than you think. That's why I'm grateful that you're here. Dr. Malone, what are your parting words? My parting words would be this. menopause is inevitable. It is the one universal female experience. So know what that is.

1:22:13Know it's coming. Don't be afraid because I will guarantee you this. I'll tell any 47-year-old out there now, and I'm 67. I'm having way more fun at 67 than I was at 47, really. But you got to feel well enough to be able to do it.

1:22:31Mel Robbins:Well, Dr. Malone, thank you for giving us the no BS, science-backed medical truth that we needed to hear so we can make informed decisions and understand what's going on. And I cannot wait to see how this impacts the lives of women and the people who love them around the world. Thank you. Thank you. Thank you. You are so welcome. and thank you for having me. I really enjoyed this conversation. I did too. And I also want to thank you. Thank you for taking the time and making the time to listen to something that will improve your health. I know you want to feel better. I know you want to do better.

1:23:13Mel Robbins:And what you learned today from Dr. Malone is going to give you the tools that you need to understand what's happening in your body and to make informed decisions so that you can feel better. And in case no one else tells you this today, as your friend, I wanted to tell you that I love you and I believe in you and your ability to create a better life. And as Dr. Malone just said, holy cow, you can create a better life, but you have to take responsibility for advocating for yourself and getting the support that you deserve. And I promise you, if you do that, you will have a better life because you're going to feel a lot better.

1:23:51Mel Robbins:All righty, I'll see you in the next episode. I'll welcome you in the moment you hit play.

1:23:58Mel Robbins:Not the most organized person. Because I'm burying myself in props here. Thanks, darling. Appreciate it. Okay. Okay. That makes it better. All right, here we go. Everybody, how we doing? Okay, excellent. I'm so excited you're here. I'm excited to be here. Oh, sorry, Scott's leaving. I'm like, where are you going, Scott? Do you need me to look at you? Do you want us to look at you? Dry it up like the Sahara Desert. No, I'm just kidding. No, you will. No, I will not. Now, if I put the estrogen lotion on my face, what's going to happen? It's not going to turn into a vagina, right? No. I did.

1:24:46Mel Robbins:Oh, and one more thing. And no, this is not a blooper. This is the legal language. You know, what the lawyers write and what I need to read to you. This podcast is presented solely for educational and entertainment purposes. I'm just your friend. I am not a licensed therapist. And this podcast is not intended as a substitute for the advice of a physician, professional coach, psychotherapist, or other qualified professional. Got it? Good. I'll see you in the next episode. Sirius XM Podcasts.

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