Dr. Jen Gunter, MD, FRCS(C), FACOG, DABPM, ABPMR, is an internationally bestselling author, obstetrician, and gynecologist with more than three decades of experience as a vulvar and vaginal diseases expert. Her New York Times and USA Today bestselling book, The Vagina Bible, has been translated into nineteen languages and The Guardian calls her “the world’s most famous—and outspoken—gynecologist.” The recipient of the 2020 North American Menopause Society Media Award, she is a columnist for The New York Times and features in CBC/Amazon Prime series Jensplaining, a video series that highlights the impact of medical misinformation on women. Dr. Jen’s TED Talk was one of 2020’s Top Ten.
Barb: Dr. Jen Gunter is an OB/GYN and author who has done much to help raise awareness about women’s health in a really bold and clear way. I’m excited to be able to speak with her today because her second book, The Menopause Manifesto, really spoke to me, especially as a fellow healthcare provider, and particularly with my interest in focusing on perimenopause, menopause, and sexual health. So this is going to become an important resource, I think, for both me and my patients. So thanks for joining me, Jen.
Jen: Thank you so much for having me!
Barb: You’ve written in the manifesto—there’s just tons of material in there—but I wanted to explore with you kind of what’s the main message you’d like to communicate to women?
Jen: Sure. You know, that menopause isn’t a disease. It’s not a sign of ovarian failure, and essentially almost every message that you’ve received about it, you know, has been filtered to you through a lens of a patriarchal society. So keep all of that in mind when you are taking information in.
Barb: And when you say that, how can you suggest to women that they better understand this journey of perimenopause and menopause given what we know about the information today that’s been disseminated?
Jen: By first of all, learning about the basic biology. You know most people have a basic understanding of the biology of pregnancy, right? And they probably have a basic biology of menstruation. But most people have no idea of the basic biology of menopause because our society has taught us that this is shameful; this is something not to be talked about. I mean, who wants to learn about something that’s an expiration—that’s been sold as an expiration date. I think just learning the basic biology, first of all, so that when things happen to your body, you’re not taken by surprise.
Barb: I often will use the analogy of pregnancy and delivery when I talk to women about menopause, in that we understand some basic physiology that happens for women in the sense of pregnancy and labor and delivery, but we all experience it so vastly differently. I think menopause is an area that is easily generalized about what women should expect to happen. My experience has been that it is so variable and individual. In this generalization, back when I was having babies—about epidurals—it was sort of seen as a cop-out, and there was some sense of pride of getting through labor without an epidural, for instance.
I feel like some of that same language happens for women in menopause, of somehow, some badge going along with just gutting it out. I don’t know. I wonder what your views are on that.
Jen: Yeah. So there’s a lot of, I think, really complicated messaging in there, and I really agree. First of all, menopause is a vast diaspora, and there are people who have bad symptoms, and there’s people who don’t. And there’s every permutation and combination in between. I also like that pregnancy analogy because, you know, I have a friend whose first pregnancy was a three-hour labor, and she wasn’t sick at all during the pregnancy, right? Just pushed it out, and done. I got sepsis and almost died in my pregnancy, right? So that’s a huge, huge spectrum.
As for the messaging, yeah. So this is a complex mix. A lot of it is purity culture related, right? Words like “natural” and “natural order,” and “being like nature”: those are all very much tied in to purity culture, which is something that women have been subjected to since the beginning of time. So you take that into there. But there’s also this competing messaging so that one message of just suck it up and be all natural, because that’s the natural order of things, which there is no real natural order.
But then you also get this alternative, completely opposite messaging of this “feminine forever.” That you must look the way you looked at the age of twenty, you must prepare yourself for the male gaze at all ages or you’re irrelevant. That is also a form of purity culture. It’s just weaponizing things in different ways to [laughs] I guess, get the broadest negative effect.
Barb: Interesting. I guess I hadn’t really thought of it that way, but you are absolutely right.
I enjoyed your recent New York Times column, and I was also interested in reading the responses, which were predictable, I think [laughs], for women who read through it. Mostly, I’m obviously supportive of you getting the message out and continuing this—this messaging about thinking about menopause in somewhat of a new light—and it sounds like education is going to be the number one antidote to women successfully experiencing this menopause transition. I’m just curious about what maybe you see as some of the more effective ways of improving that. Is it going to be training residents in a better way so more providers have knowledge? Is it more women reading The Menopause Manifesto? How do you think we need to elevate the conversation?
Jen: Well I think it needs to start with what we call sex education in schools. You know, I don’t think we should be waiting until women are in their late 30s or 40s to be telling them about menopause. I think everybody should know about the scope of ovarian and uterine function. But if you look at what passes for so-called “sex education” in schools, you know, it’s about preventing pregnancy. There’s very little practical information about your ovary or your uterine health. Right? And so again, purity culture.
So, I think we need to start by explaining that ovarian function has a start and an end, and that’s not a sign of failure; that’s just the way it is. It’s just like pregnancy has a start and an end. Some things have starts and ends, and some things don’t. And I think it’s also really important that we… there’s sort of this narrative that women have this great loss with menopause because they are no longer able to be pregnant; but that men, because they can keep impregnating women their whole lives, you know, they’re different. That’s also part of the patriarchal narrative that we have to get rid of because in reality, men in their 60s and 70s are not effective reproducers. Many of them have erectile dysfunction—at the age of 60, 60 percent of men have erectile dysfunction. Their sperm has a higher incidence of resulting in miscarriage and pregnancy complications, so we have to make sure that we are being accurate and not sort of portraying women as barren, and men as sort of fertile.
We have to get rid of those narratives, and we have to raise the level of education, and we have to expect medicine to do better. More people need to be educated about menopause—absolutely. But we also have to realize that a doctor can’t possibly educate you about menopause in a 15-minute visit.
Barb: So that’s where your resource comes in. I will advocate for women to make The Menopause Manifesto part of their reading selections because I think it was very comprehensive, and I appreciate it. And I really largely appreciate it because it supports evidence-based medicine. I feel like that in menopausal health it feels like—I don’t know—in some way been seen as a negative, because it’s been such an area where kind of magic cures and herbal supplements and all sorts of alternative treatments have been put out there for women. I’m just wondering if you can speak into that: why you think this has been such a boom industry for alternative options.
Jen: Yeah. So, I absolutely agree. I mean this menopause is not only having a moment, but it’s also having a scam moment, you know? Sort of the pink gray tax where [laughs] we’re going to charge you more for useless products.
There’s a long history of what I call useless therapies for menopause. I detail that a lot in the book, going back to the 1700s/1800s and before. Obviously, we had a different concept of what was going wrong at that time with the body, or what was causing the symptoms—going wrong is the wrong term to use. They didn’t have an understanding of the biology. So, fast-forward to kind of the 1970s and early 1980s, sort of the nascence of so-called “functional medicine,” which is a made-up term. This is where this whole concept of these sort of “natural hormones” and things that have percolated.
But that didn’t really get air time until the Women’s Health Initiative Study came out, and created a bit of a temporary void in our ability to properly explain to women the risks and the great benefits—the risks are low—of menopausal hormone therapy. During that time is when these hormone profiteers took off. That has only escalated. And I think that the people who promote these therapies are incredibly savvy about how they market themselves on social media, what they tell patients—I mean look, if you tell someone, “I have a 100-percent safe, effective therapy that’s a miracle—this is a doctor who is trying to practice evidence-based medicine and saying the words—like these are the risks. Why would you want to go to the person who is telling you there are some downsides when there’s someone else telling you that there’s something that’s better? How does an average person know the difference?
Barb: So how does the average person know the difference? I mean, what do you see as our marching orders to try and enlighten women to stop what they are doing and promoting more scam products and making people who are taking advantage of them wealthy, so to speak?
Jen: Yeah! So I think there’s a several-pronged approach. The first is getting people educated so they can spot the difference. So they can learn that the word “natural” means nothing, and “bioidentical” is a marketing term. The estrogen that you make by your ovaries, that your ovaries make, which is the most bioidentical estrogen possible. And it causes breast cancer for some women. And it causes endometrial cancer. Right? It causes blood clots. So this idea that, because it’s from your ovaries means it’s good for you, that’s ridiculous. Is the therapy safe and effective? You try to explain that to people.
I think the other really important thing is to also explain to people how to look for information. Right? We don’t teach people that. We don’t teach people how to use the internet to get health information. For example, if someone is selling compounded bioidentical hormones—that’s what they are calling it—they are profiting from that. I think we have to call people out for that and say, “You can’t get health information from someone profiting from selling you a product.”
It’s fascinating to me that so many of these so-called natural doctors will say, “I’m a pharma sell, even though I haven’t taken any money from pharmacists since 2003.” Obviously I’m not, but many of them are making money hand over fist from offering scammy treatments. I think that we have to call people out.
Christine Northrup was one of the biggest vectors of misinformation about Covid. And she’s long been held up by somebody to look to for menopause. But you know what? She’s always been anti-vaccine. So that’s the thing I tell people is, “If the person is giving you health information, look into their history. Have they been anti-vaccine? That’s a conspiracy theory. You do not want to listen to anyone who is a conspiracy theorist.”
Barb: Let’s talk specifically about hormone therapies. What do you hear as the biggest misunderstanding or misrepresentation of menopausal hormone therapy?
Jen: I hear two completely opposite things. I hear that it is unsafe and risky, and I hear that every single woman should be on it, and it’s going to fix everything. [laughs] I hear both ends of the spectrum. The truth is it’s somewhere in the middle to that. No treatment is zero percent, has zero-percent risk. I mean, driving your car doesn’t have zero-percent risk. There’s always some risk, but the risks of menopausal hormone therapy, for the right candidate, for the right indications, are very, very low, and for many people, it’s fantastic therapy. But it’s also not a cure-all. When people take it and it’s sold as being something that is magical, they’re going to be disappointed.
I spoke to someone in a call-in show recently, and she said that she went from having 60 hot flashes a day to 30 on her hormones. She felt that meant they weren’t working for her. And I’m like, “Wait a minute. You had an 80-percent improvement!” We have to sort of frame things with realistic expectations.
Barb: Right. The other thing I find is that women who have found their way to me often have found a number of things, so they see hormone therapy as sort of a last resort. And, they’ve suffered greatly over a significant amount of time. My suggestion to them is to just try it. Let’s take twelve weeks and see if we can make any of these symptoms better. Maybe we can. Maybe we can’t.
I have to say the buy-in for me with women in hormone therapy has been fairly promising, but I do think trying to be realistic about the outcome is important. And I think it’s a unique time where we can help women maybe think about lifestyle, and making lifestyle alterations as well. But I also think there’s so much more to menopause than hot flashes, and that’s where I appreciated your book in trying to help women understand the variety of symptoms that might accompany menopause.
Jen: Right. I think we often do it through this very narrow lens of one thing. I absolutely agree. When I see people in the office I’m like, “Look, menopausal hormone therapy—I mean three months of transdermal therapy with oral progesterone—or an IUD or whatever.” It’s the lowest risk of a thing you can try. Right? There really isn’t anything lower risk than that. That’s about as low-risk as it gets.
And, you’re not going to get breast cancer from three months of treatment. And, yeah, you’ll know in three months, has this made a substantial difference in your quality of life or not? And then to go from there, you also have to give it the three months. At three weeks or four weeks, you may not know yet.
I think so many of us have binary thinking about starting medications. Like it’s all or none, or if I start it, I’ll have to be on it forever. But no, you can stop it. It’s not a marriage or a tattoo. It’s something that you can back out of pretty easily.
Barb: I was intrigued in your book, you and I have some similarities in that I started hormone therapy because my mother died of a complication of a hip fracture when she was in her early 60s. I think you highlighted that as a concern regarding family history as well. I really think that skeletal health is underestimated for importance, and one of our most important therapies can be hormone therapy. Women don’t come in with that on their radar really, hardly ever. I just think the conversation has to go beyond breast.
Jen: You know, I couldn’t agree more. I’ve done quite a lot of interviews, and it’s really upsetting in a way to have the whole conversation be about libido. Right? In fact, nobody’s going to be having libido if they are dead from their hip fracture. Let’s also put that in perspective. Nobody is having sex if they had an awful hip fracture, and they are in chronic pain afterwards, and they’re never going to be able to find a comfortable position for sex again.
So while libido is important, you know what? Staying alive and being able to walk is actually more important. The idea that I feel that we absolutely neglect heart health and bone health in menopause. We forget. We expect women to diminish and shrivel up, and that’s okay. It’s not! And people need to understand that there are many things they can do to protect their bones. Estrogen may be one of it for some people, but exercise and quitting smoking and all these other things, it makes me think that we are only focusing on the sexual aspects as opposed to “This is a whole person, and we have to focus on everything.” We need to be truly holistic here.
Barb: Can you speak a little bit into your understanding of brain health and what we understand about hormones?
Jen: Yeah. We do know that the earlier you have menopause, the greater your risk of dementia. So we do know there’s a correlation there. There is some concern that if people start hormones later in life—over the age of 60—there could possibly be an increased risk of dementia associated with that. But starting at a lower age—within 10 years of your final menstrual period or under the age of 60—it seems that it’s possible estrogen might be protective, but we don’t have enough really long-term data yet. The problem with long-term data is it takes a long time to get it. You know? If you want to know if you’re going to start women at the age of 50 on hormones, and then you want to know if that’s going to be protective for dementia, you have to follow them for 20 years, right, 20 or 25 years. So, it’s not data we can get right away. We are getting more and more data on that, and hopefully, we’ll have better long-term data that can help people. But certainly with transdermal therapy, that seems to be the safest thing that we can offer people.
Barb: So just changing topics a bit, just today I read a quote that got published in People Management, which is a publication around businesses and employers. I would like to share a clip of that and would like your feedback. “Companies are beginning to realize that middle-age burnout may not be burnout, but perimenopause, which can arrive at the same moment. So a positive, well-communicated strategy for supporting women going through this inevitable stage in their lives is not just vital for their individual performance of mental health, but imperative for any employer committed to gender equality and developing and retaining coveted professional skills.”
I’m curious about what you might have to say about industry recognizing this and supporting women.
Jen: I think that anytime you are talking about menopause, I think it’s good. Because the more you talk about it, the less it becomes shameful. I mean it shouldn’t be shameful, but the more you talk about it the more people are going to be comfortable having their symptoms. I mean so many women feel embarrassed when they have a hot flash in public, and they’re just like drenched in sweat, and then everybody’s looking at them. Well, if people are aware that that’s a thing that happens—never mind that maybe if people could actually… If somebody is struggling with hot flashes, maybe if they got to control the temperature of the room... right? Maybe that would just make a difference for some people. I swear I read a study about that somewhere and I’ve never been able to find it, so perhaps I made it up in my head?
But knowing you can control the temperature of the room or control the temperature around you should a hot flash happen feels to me like it would be a stress reliever. I know I feel better when I’m in control of it.
Barb: Right. It makes me hopeful that maybe businesses, employers, industry could in some way take a lead around education. If they really believed this and incorporated this, maybe they would be an avenue of education as well for women.
Jen: Right. Absolutely. And you know, if you’ve been working for a company for any length of time, and you are a valued employee, I mean companies know that turnover isn’t good, right? Anything that you can do to support the the health of your employees is actually rightfully going to make your business better.
Having a curriculum so people understand that there’s options. But that also includes in the United States, for example, making sure that the insurance you provide doesn’t have astronomical prices for therapies for menopause. I would much rather—I mean obviously, you want to have it all. But it is a bit hypocritical for a company to say, “Oh we’ve brought in this menopause consultant saying we’re going to change things.” But then when someone goes to get a prescription for their vaginal estrogen, it’s six hundred dollars.
Barb: Yeah, that has been absolutely a barrier to excellent quality care.
Jen: So I would say in the United States, until things change health-wise, the first thing a company can do for showing it’s dedicated to the health their employees across the menopause continuum to make sure that all the therapies are affordable.
Barb: Exactly. And I don’t know how much optimism we can have about that or how, hopefully, we can—with the organizations we belong to—we can have some activism around that.
Jen: Well, I can tell you that I am waiting to write the paper on it. So as soon as I see a company make a claim about how they are going to have a menopause-friendly atmosphere or whatever, I’m going to find out what health plan they have, and I’m going to find out what their vaginal estrogen costs are on that health plan.
Jen: Because you know what? You can have all the talk…. It’s just the same thing when they talk about employee wellness, and it’s just a cover or a show. I’m like, “Really, what are you doing?” Employee wellness, but you give two weeks’ vacation. Hmmm. I think it’s important that companies actually walk the walk, and walk the walk in a way that is useful for women because if you can’t afford your therapies, it doesn’t matter how much you can control. Maybe controlling the temperature in your office is going to matter, but women need to be able to afford their treatment.
Barb: Exactly. Yes, some companies support gym memberships for their employees. Maybe supporting certain classes of therapies—like hormone therapy—maybe we’ll be able to crack the door on that, and I sure hope so.
Jen: Yeah, and I mean especially the vaginal therapies. You know I’ll tell you, I’ve been a physician for 30 years and Estrace cream, you know, it’s been around a long time before I was a doctor, so 40-50 years, it’s been around forever, this Estradiol cream. When I moved to the States, I'm sure it was like thirty dollars generic—thirty or forty dollars—I’ve never heard anybody talk about the expense of it. Now you see these products are four or five hundred dollars for three months. It’s not that some new molecule was invented.
Barb: No, I know. It’s discouraging to try to support women to find a solution only to find out that it is frankly not affordable.
Jen: Yeah. I know. I think that the very first thing companies need to do is to be like—especially, especially the vaginal products because they are so effective. I mean if you just look at the impact on recurrent urinary tract infections, never mind anything else. Never mind enjoying sex or any of those other things. You know the amount of money the health care plan would probably save long-term in preventing bladder infections, and then all the fall-out. Like resistant bacteria and antibiotic-associated diarrhea and other complications—the financial fall-out just from that would have to be beneficial.
Barb: Right. Absolutely.
How did you find yourself becoming a voice for women’s health? Take me along your journey a little bit to help me understand how we’ve come to recognize your voice and appreciate your voice in women’s health.
Jen: Well, I think it was because I was mad as hell and I couldn’t take it anymore. [laughs]
Barb: [laughs] okay. Good for you!
Jen: Yeah, I do a lot of things out of righteous indignation; I guess that’s a big motivator for me, rage and anger. [laughs] And I had, as the internet sort of came to be, I began to realize because I had, as I alluded to before, a very complicated pregnancy, and my two boys were born extremely prematurely and were in the intensive care unit for a long time, and had all kinds of medical complications, and I turned to the internet and was like, “Oh my God, how do people navigate this?”
And then it started to make me think about all the patients I had seen in the office who were convinced that the topical progesterone that they had gotten from a compounding pharmacy was just ground up yams and they were convinced it was just going to cure everything. And I started to really think about all the things I had been hearing from people in the office, almost all around hormones that were just misinformation. And I started to put two and two together and I was like, this is just ridiculous! How are we entering this age of information, and yet everyone has disinformation. Like, what’s up with that?!
And so I really decided—and this is such a naive—but you know, I know nothing about computers or the internet or anything, but I decided I was going to fix the medical internet. With a backpack on my back and go out there and like, put up my little sign on the internet and be like, Medical Facts Here For Free, because I figured that it's better for everyone. If my patients come in and see me and they have quality information, that’s better for them, it's better for me, it's probably even better for the health insurance company. The only people it might not be better for is the ones selling the scammy supplements of the pharmaceutical industry.
Jen: So I just was like, why not? And I also, when my kids were sick, I had the advantage of being able to reach out to all kinds of experts. My kids had some really unusual complicated problems. and I would write a letter to Dr. So-and-So at the University of Michigan, and I would name drop, and I would say, hey I know so-and-so there, and I just want to pick your brain on something. And every single one of those people who I emailed in this time of desperate trying to figure things out did me the courtesy of replying. And what really struck me was, they were able to give me what I needed to know, with one or two lines. And I really was like, wow! So you can really get quality information about a lot of complicated things if you present your question in the way that—and to the right person who—can give you the answer. And so I really just kind of became obsessed with that, of getting the level of knowledge of people up to a different level medically. It’s actually not that hard. It's just, nobody's thought about doing it that way. Can we bring the collective medical knowledge up? So that just became my mission.
Barb: Well thank you. I recently did the Enneagram with a group of people, and I’m thinking you must be an Enneagram eight: The Challenger.
Jen: Oh, [laughs] I don’t know, I haven’t done any of that. We have a friend who is into, oh yeah, maybe it is the Enneagram. I think so. Oh, yeah, there’s nine things?
Barb: Right, yes.
Jen: Yes, yeah, I think he said I was an eight. And doesn’t each one have three different types in each one? Is that right?
Barb: Yes, yes. Well anyway, I am just smiling thinking about a vision, and passion, and anger, and getting the job done. So again, on behalf of women, and women healthcare providers, I want to say thank you to that.
Jen: Well, and thank you for being out there with your podcast. The more people have the information out there, and quality information and knowing that there’s doctors who want to give quality information. There’s healthcare professionals who want to give quality information. There’s people out there who really want to do that. I think we’re finally starting to get a little critical mass out there.
Barb: Yes. I agree, it feels like menopause is finding its moment here. So I would just want to encourage women to bring their book, The Menopause Manifesto to their book clubs and read and discuss. And I think you’re hosting some or participating in some book clubs. What are the couple of top questions you hope women would address as they discuss your book?
Jen: I actually really hope they talk a lot more about heart health. It is the number one killer of women. One in three women is going to die from a cardiovascular disease. And this isn’t something that happens necessarily when you are 97. So you want to have longevity and healthy longevity. So I’d like people to think more about their hearts.
I want people to think more about their muscles and bones. You know, your having—preventing loss of muscle mass with aging and strengthening your bones—so important. And I think the third thing I’d like people to think about is making sure that they consider all the therapies, and take everything in from a wider point of view than just hearing one therapy, and wanting to go for it. Because once you hear everything you may still have the same decision and that’s great, but then you’ve been more informed. And I think the analogy I like to use is, if you are booking a flight, and you only got to see one flight on your airline of choice, and you needed to fly somewhere, you’d probably pick that flight. But isn’t it better when you see a whole range of flights and options so you can pick the thing that works the best for you?
Barb: Yeah. Great analogy.
Jen: Information is empowerment, and that’s really the thing that I hope people take away. And that menopause isn’t a disease.
Barb: Okay, thank you. As we end our time together, I like to ask the question: where do you find fullness at this stage in your life?
Jen: Oh, where do I find fullness? Well, I am a sucker for learning. I love to read and learn new things. That’s sort of part of the drive behind my new podcast that’s just come out: "Body Stuff." Actually my next episode is on menopause. So learning is actually really my jam. And trying new recipes with my partner. We like to try cooking new things and new desserts and planning some travel. I used to really enjoy travel, and then we had this terrible time. Now we are starting to think about, ooo, should we take a bike trip somewhere? And hanging out with my kids, they’re pretty fun.
Barb: Good. Yeah, we’re all eagerly anticipating emerging from what we’ve just been through. I think many of us share your interest in expanding our horizons with great things like travel.
Jen: I know. We’ve had this real poverty of experience for the last year and a half. You don’t realize how much just seeing a stranger smile on the street or reading a new menu, how all those things contribute to quality of life.
Barb: Yes. Well thanks so much for your time today, Jen. It was my pleasure to hear from you and share what you think is important for women to know.
Jen: Well, thank you so much for giving me this platform, I really appreciate it.
Dr. Barb DePree, M.D., has been a gynecologist and women’s health provider for almost 30 years and a menopause care specialist for the past ten.