338. From puberty to perimenopause: Why women deserve the whole story about their bodies with Dr. Lauren Streicher

Dr. Lauren (00:00):

This whole notion of menopause, this makes it sound like it’s on pause and then you’re going to start again. Or when people say, I’m done with menopause, you’re done with menopause when you die because menopause is, you’re no longer making estrogen. Now, leading up to that, what you’re talking about is perimenopause. Perimenopause is when you start to have fluctuations in your estrogen levels, and it’s not as if it starts high and it just goes down. It’s a fluctuation, it’s a roller coaster.

Dr. Sarah (00:31):

Most of us got some type of talk about puberty when we were kids, but almost none of us got to talk about menopause, and yet it’s something every woman will go through. So I am so excited to be joined this week by Dr. Lauren Streicher, a clinical professor of obstetrics and gynecology at Northwestern University’s Feinberg School of Medicine, and the author of multiple books on women’s health. And she’s also the host of the podcast, Dr. Streicher’s Inside Information: Menopause, Midlife, and More. She has dedicated her career to debunking myths, fighting stigma, and giving women the evidence-based tools we need to navigate menopause with clarity and confidence. In our conversation, we talk about everything from how mood changes, sleep struggles, and even relationship shifts can actually be tied to hormones, what to look for in a truly menopause informed clinician. How to talk with your daughters about the whole reproductive life cycle and why preparing before symptoms begin can make all the difference. So whether you’re in your thirties, your forties, or beyond, this is a conversation that every woman needs to hear.

(01:34):

Hi, I’m Dr. Sarah Bren, a clinical psychologist and mom of two. In this podcast, I’ve taken all of my clinical experience, current research on brain science and child psychology, and the insights I’ve gained on my own parenting journey and distilled everything down into easy to understand and actionable parenting insights. So you can tune out the noise and tune into your own authentic parenting voice with confidence and calm. This is Securely Attached.

(02:07):

Hello everyone. Welcome back to the podcast, Dr. Streicher. I am so excited to have you here today. Thank you for being here.

Dr. Lauren (02:17):

I’m very happy to be here with you.

Dr. Sarah (02:19):

Yes. So to start, I’m hoping you could share with the securely attached listeners a little bit about yourself, your journey and what drew you to menopause and women’s sexual health as a focus.

Dr. Lauren (02:31):

I started off of course as a general OB-GYN, doing what general OB-GYNs do, delivering babies, seeing women for their routine annual care. And then over time I developed a real interest in surgery, specifically minimally invasive surgery, and I became someone who was doing a lot of hysterectomies because I was a good surgeon, I liked doing surgery and I found that it’s not just enough to do the hysterectomy, you have to be able to talk to the woman about the repercussions of what happens to her after the hysterectomy. Now, hysterectomy of course, does not cause menopause, but if someone has ovary removal with the removal of the uterus, then they do enter menopause. So I started to have an interest in that, and along the way I was always an educator, not just in the medical world, but in the consumer world. I was a writer.

(03:22):

My first book was about hysterectomy and alternatives to hysterectomy. I was writing a column in the paper, I was getting all kinds of questions, and I found that increasingly those questions were about menopause. So I started to educate myself about menopause. I became interested in it, and then over time I realized that it was a huge unmet need, and I thought, okay, there’s a lot of other doctors out there that can deliver babies. If I stop delivering babies, those babies will get delivered just fine. So I stopped doing obstetrics after 3000 babies, I’d done my share. I think you put your time in, and then just started moving into that. And then I was approached to write another book that was specifically about sexual medicine with a emphasis on menopause. And really as I got more into that world, I found it to be just fascinating. And so that’s really not unusual of the journey of most menopause specialists because there is no fellowship when you do OB-GYN and you could say, oh, I want to do fertility, and you do a fertility specialist or you want to do high risk obstetrics, and there’s a fellowship for that. There is no fellowship in menopause. So what that means is if someone develops an interest in that, it’s really something they have to explore on their own.

Dr. Sarah (04:40):

Why do you think that is? I’m curious, is that saying something about where our medical systems kind of just fell off?

Dr. Lauren (04:49):

Well, it’s a valid question. It’s a difficult question to answer because when we look at specialties in any field, there’s always going to be areas that are untouched. A lot of people say, oh, well, it’s because there’s no menopause in medical school and this and that. And it’s really about recognizing it as a field that there is enough there to validate it as a subspecialty. Certainly we can make the case in high risk obstetrics or in fertility. And up until recently, I think the feeling was there isn’t enough to justify a fellowship. This is something that people can just do on their own. Now, strictly speaking, strictly speaking, menopause falls under the umbrella of the fertility specialists. Why? Because they are the reproductive endocrinologists and fertility specialists are supposed to be the ones that know everything about reproductive hormones throughout the lifespan. In reality, that’s not what happened. They’re all out there doing fertility, but a lot of the original menopause experts and some of the older experts, that’s what their training was. It was in reproductive endocrinology and infertility, and then they chose to go the root of menopause.

Dr. Sarah (05:57):

Got it. And so clearly you had to be sort of self-driven and seek out this information, this specialization on your own through experience, right.

Dr. Lauren (06:07):

Well, not through experience. I mean, you take courses, you read, you subscribe to journals that do this. The Menopause Society, which used to be known as the North American Menopause Society, was really a goldmine for me of not only being able to go to conferences and hear the newest research and the newest data presented, but even more important, I found my people, I found my colleagues, I found all these other menopause experts, and while we hear that menopause is having a moment, I mean we all just roll our eyes at that because we’ve been at it for decades. I’ve been talking about menopause and studying menopause and teaching menopause not only to doctors but to women for literally 30 years. And there are many people out there also. I’m not the only one, but these are the people that we found our community and we have always been sharing information and research.

Dr. Sarah (07:01):

That’s great to hear because it’s funny as you’re talking about menopause, I’m thinking my own personal parallel is parenting, right? In graduate school, you learn about child development, you learn about development across the lifespan. There’s no focus on parenting like the psychology of parents at all. And so a lot of the things that I’ve kind of in starting a specialization in this, which happened kind of organically, I had to go seek out so much secondary education.

Dr. Lauren (07:28):

Well, what’s funny along those lines is when I was doing obstetrics and every single woman who got pregnant, what would she do? She would immediately sign up for classes about labor and delivery, go to classes for months about what to do in labor and delivery. And I wouldn’t say this, but I’m thinking, oh my God, this is going to be 10 hours out of your life. You should be taking parenting classes now. I will get that baby out and I will give you that baby, and you’re going to take that baby home and it’s going to be just fine. And micromanaging your entire labor experience is really kind of missing the point. You need to know what to do with that baby once you get that baby home. Not to mention, once they reach puberty and go to high school, oh my God, we’ve all been there. It’s very challenging. So it’s funny how people kind of glom onto, oh my God, I’m pregnant. I’ve got to take classes and labor and delivery. And it’s like, yeah.

Dr. Sarah (08:20):

Well, I think it’s a way to manage the anxiety, right? It’s like when we feel out of control or we feel like there’s a big unknown, we try to grab onto things that help us feel like we have a sense of control and predictability.

Dr. Lauren (08:32):

A false sense of control. I mean, let’s just face it, you could sit there and have a 10 page list of what you want to happen in labor and then all of a sudden you come in and the baby’s coming out to she first and it’s like your entire list. You could just put it through the shredder because none of it is relevant. So that’s the nature of obstetrics and quite frankly of raising a child. But how’d we go to that from menopause.

Dr. Sarah (08:52):

You can have a million goals and your baby and child and your adolescent, they are just going to rip it up. The universe teaches us that we have less control than we like to think we do. For sure. So going back to this work that you’ve done though, because really you have a lot of knowledge in the subject matter, which is clearly something you have to really dedicate your efforts to come by in your field. I’m imagining you have worked with countless people who have gone through this, and I’m sure there’s things you wish people knew more about because one question is who needs to hear the conversation you and I are about to have? And my guess is it’s not the age group that we might think.

Dr. Lauren (09:40):

Yeah. Well, first of all, the answer is everybody. Every single girl who goes through puberty, her mother sits her down and talks to her about what to expect and periods, and here’s pads and here’s tampons, and this is what you do for your cramps, yet there’s no discussion at any point of the entire reproductive life cycle. So this is something that girls need to know about, that women need to know about, that men need to know about. It’s like anything else, this is just important human information, but to your point, a lot of people think that menopause is really for grandma, for people who are a little bit older, and in fact, these hormonal changes start much younger than most people imagine. While the typical age to stop producing estrogen is 51 in the United States, and women start to have a decrease in estrogen production and fluctuation in estrogen production in the forties.

(10:36):

There are many women in their thirties that for a variety of reasons are menopausal and they really feel very isolated, very excluded. We have women that first of all, as a result of cancer treatments, we have a lot of young adults who have a variety of cancers, whether it’s breast cancer, uterine cancer, ovarian cancer or rectal cancer, many cancers, chemotherapy may put them into either temporary or permanent menopause. We have women who surgically enter menopause at a young age, sometimes women with endometriosis or other issues. So while that is certainly not the majority, I think we have to remember that population of women as well, which is again why it is so important that everybody have some awareness of what menopause is, what you might expect, and most important why we need to know this, what can you do about it? What symptoms are important to deal with, what symptoms are not.

(11:34):

All of these things are part of the conversation, and people always ask, well, so who is it that I’m talking to? And I talk to both healthcare clinicians and to non-healthcare clinicians. And one of the reasons that a lot of people, quite frankly follow me and listen to me is because I don’t dumb it down. I don’t care who you are, women are smart and if you explain things in the right way using the right language, they can have the same level, the same level of information as I’m going to give to a medical student or another physician. And in fact, in the people who follow me on my podcast in Substack and show up to my monthly, ask me anything webinars, it’s about 50 50 for clinicians and non-clinicians because I will take any information no matter how complex it is, and my goal is to make it understandable.

Dr. Sarah (12:28):

And even I think that your point to this should be part of the conversation at the start. I would imagine a 13-year-old could probably also get the same information when we shroud this stuff in secrecy. This is like an intergenerational transmission of secrecy and trauma in some way.

Dr. Lauren (12:50):

And shame and shame. Let’s talk about shame for a minute because in our culture, in our society, there is a great deal of emphasis put on youth and sexuality. And for a lot of people what menopause to them means is the end of youth, the end of sexuality. And in fact, nothing could be further than the truth. I mean, that’s ridiculous. But women would always be ashamed to say, I’m menopausal, or in the workplace, that’s a whole nother discussion. I’m having hot flashes. I haven’t slept because there is this stigma about aging – losing your sexuality, and that’s all wrapped up in the menopause discussion. So you’re right when you have that discussion with your, actually you said I think 12 or 13 now, girls are getting their periods when they’re 10. So you start to have to have that discussion when they’re nine. And this is part of the thing, okay, this is how your body works and this is what your body does at this point in your life, and this is what’s going to happen over the next 20, 30 years. And that at some point your body’s going to be doing different things. And let me just kind, they don’t need to know the nitty gritty, but it’s kind of the overview overview.

Dr. Sarah (14:01):

I love the idea that it’s a cycle, we’re not telling you just the first 30%, let’s tell you the whole cycle, because I actually think that’s more grounding for a kid.

Dr. Lauren (14:10):

Well, it is because you’re placing so much importance on reproduction. See, that’s the other thing too. And if you go back to what are girls learning in health class, if they get it in school, which they don’t for a lot of times, but if they do, what are they getting? They’re getting ways to prevent pregnancy and ways to prevent sexually transmitted infections. And they’re talking about consent a lot, which is great, but no one is having a discussion about pleasure. And boys expect when they start to have sex that they’re going to have pleasure. And in fact, they intuitively know how to masturbate and give themselves pleasure girls that is not part of health class that they should expect pleasure and they don’t, don’t necessarily know how to give themselves pleasure. And this then expands into adulthood. So it all starts when people are young. The messaging is very, very important that this shame and that this is normal and this is healthy, and let’s talk about what a healthy body does.

Dr. Sarah (15:09):

And I can’t help but keep going back to this idea that the orientation that we, the person having the conversation with the child, and we’ll talk, I think we’re going to get into what cop flashes adults need to think about. But just because I can never not think about kids and parenting when I look at this stuff, I’m sure there are moms listening that are like, oh, wait, I need to talk to my daughter about this. What do I say? How do I, and the thing that’s striking me so much about this, and it’s the first time I’ve ever had someone ever suggest this, and I think it is brilliant, not just because it helps kids make sense of the whole story, and we know that when we can make sense of what is happening to us in a more complex or I guess complete way, we feel more grounded because getting your period and having this talk is a little uncomfortable and also can be anxiety provoking for kids.

(15:59):

But what I think I really want to emphasize here is this fact that when the parents sitting down with our daughter to talk to her about this, come at it from the vantage point of you don’t want to get pregnant. You don’t want to get a sexually transmitted infection, which is also important. We don’t want to not say that, but if that’s the emphasis, it also talks, it embeds this sort of implicit communication that our bodies have this sort of job to do versus what’s our relationship with our body? I want to know how my body works because my body is powerful, my body is amazingly interesting and complex, and it could do these great things. We can create life and we have our own life cycle. And it doesn’t, there’s just a lot of richness there, I think.

Dr. Lauren (16:50):

Right. You lead with pleasure. This is what our body can do. Isn’t this amazing? Isn’t this great that we’ve been given this kind of a body that can give us pleasure? And what you need to know most things in life is with pleasure comes responsibility and making sure that you don’t have problems, and then you get into the contraception and sexually transmitted infections. It’s interesting. I dunno if you know this, my daughter’s a sex therapist. She’s a PhD in clinical sexology. And so we have these discussions all the time because this is what she’s talking about with her clients is what did they grow up being exposed to? What were they told? What were the cultural taboos that they are now still dealing with later in life? And so we are out there together. Rachel and I go out and talk all the time.

(17:36):

In fact, we’re talking at a sex therapist conference together in a couple of months. And it’s kind of the yin and the yang from the therapist’s point of view in terms of sexuality and what’s important for women to know at a young age, but then what is also the reality of the medical biologic and the inner workings of that. And for me, it’s one of my favorite things to do is to be out there in the world talking with my daughter Rachel. Rachel Zar, Dr. Zar is her name, different last name because you can’t have one without the other. And I’m very careful to stay in my lane. People a lot of times because I do sexual medicine work, they think I’m a therapist. I’m not a therapist. I have different training. Completely, completely. That’s why we need each other. And when I started the Center for Sexual Medicine and Menopause at Northwestern, at the top of my list was to hire a number of very, very talented therapists because I can’t imagine having these conversations with women without addressing the psychosocial aspects of everything that someone experiences, whether it’s hormonal changes, sexual issues, all of those things. So when you invited me on and I saw that you were a therapist, and I thought, well, great, because these are the conversations we need to be having.

Dr. Sarah (19:01):

Yes, let’s talk about that then, because I do think I really love this idea of how we talk to our kids about it. And I think that that’s a piece that’s important to take away from this. But I also think there’s this whole other world because a lot of us are grownups who didn’t get that conversation when we were growing up, and we’re just entering into the bubble and it’s all new. So could you explain truly what is menopause? What happens to our bodies when as it begins? Also, it’s not like a, today I wake up and I’m menopause. It’s like this is a process that unfolds.

Dr. Lauren (19:46):

Well for some people. Interestingly, if you look at the typical experience, if there is such a thing as a typical experience, essentially menopause is when your body is no longer producing estrogen. And a lot of times you’ll hear menopause has been when you’ve been without a period for 12 months. And I hate that definition because first of all, about almost half of women don’t get periods. Maybe they’ve had a hysterectomy, maybe they have an IUD, maybe they’re on birth control pills, maybe they’ve had a uterine ablation. So it’s really an outmoded definition which is not meaningful and can be confusing. So the simple definition is your body is no longer making estrogen and is never going to, again, this whole notion of menopause, this makes it sound like it’s on pause and then you’re going to start again. Or when people say, I’m done with menopause, you’re done with menopause when you die because menopause is, you’re no longer making estrogen.

(20:37):

Now, leading up to that, what you’re talking about is perimenopause. Perimenopause is when you start to have fluctuations in your estrogen levels. And it’s not as if it starts high and it just goes down. It’s a fluctuation, it’s a roller coaster. You have surges that might even be higher than what you have when you were 20. That causes breast tenderness and crazy mood swings and all of that. And it can be up and down and all over the place. And for some women, perimenopause lasts for years. For some people, it’s not even something they notice. And for women who enter menopause as a result of surgery or chemotherapy, they do not experience perimenopause. They go right from, I’m producing a ton of estrogen to zero estrogen, which makes it a very different experience. So let’s talk about symptoms because again, there is no universal experience.

(21:27):

80% of women have symptoms that they’re aware of. That means 20% of people don’t. So is it possible that someone is going to be in that group where they don’t experience hot flashes and vaginal dryness and all that? Of course, but 80% of women will experience symptoms. The most common being hot flashes, sleep disturbance, and then we get into things like crazy moods or feeling sad or just not feeling like yourself. And then we get into the below the bell changes. When we look at the changes that happen in the vulva and the vagina and the bladder, a lot of women are blindsided by that because symptoms like dryness or pain with penetrative sex or bladder problems like recurrent urinary tract infections or that got to go feeling, that doesn’t always happen the same time as someone’s periods disappear or the same time as they get hot flashes.

(22:23):

That can be later on. So when you look at the symptoms of menopause, the major thing to keep in mind is that we have estrogen receptors throughout our body. It’s not as if it’s just in the reproductive organs. We have estrogen receptors in our skin and in our mouth and in our gastrointestinal tract, you name it, there’s an estrogen receptor there, which is why you can have such a wide variation in symptoms. And then we look at the long-term repercussions of no longer making estrogen. Things like our bone health, things like long-term issues in the vulva and vagina, things like cardiovascular health, all of these are part of the menopause experience, but not for everybody. Everyone’s experience is different. And that’s part of the challenge is that when you say, okay, well women want to know what to expect, well certainly we can talk about what might happen, but what might happen is not going to necessarily be your experience.

(23:24):

And when I started the menopause clinic, one of the things that I did was every woman before her first visit would get a questionnaire that would be pages and pages and pages and would literally list every single symptom. And she would check off, this bothers me. This doesn’t bother me. I’m experiencing it. I don’t. And it was important for us to have that in advance. We wanted to know what someone’s experience was. And also women want to know that if they feel validated, they would come in and I would say we would actually look at these things, then write up a summary and say, well, it sounds like these are the major things you’re experiencing. And that’s very, very important because then you can then hone in on what are the big issues for that woman. Other thing that’s individualized, challenging. But the other thing that’s challenging is this whole idea of is it menopause or is it midlife?

(24:14):

Because there’s this tendency for women to attribute every single thing that’s happening them because of a change in hormones, and there’s a lot of other things going on too. Or it might be a different hormone, like maybe your thyroid hormone that’s making your hair fall out and making you sluggish and making you gain weight and your estrogen levels may be just fine. So that’s part of the detective work when someone is experiencing symptoms is to not just blanketly say, oh, this is menopause, but to say, let’s look at these symptoms. Let’s figure out what’s going on because that’s the way that someone is going to get the help that they need.

Dr. Sarah (24:58):

In today’s episode, we’re talking about some of the big transitions women go through and how those changes can impact not just our bodies, but also our emotions, our relationship, and our sense of self. At Upshur Bren Psychology Group, we specialize in supporting women through all of life’s major transitions, whether that’s stepping into parenthood, navigating relationship changes, or moving through the shifts that come with menopause and midlife. Our clinicians help women make sense of what they’re experiencing, manage the stress and uncertainty that can come with these changes and find strategies that support their mental health and wellbeing. We know these seasons of life can feel overwhelming, but you don’t have to go through them alone. So if you’re listening and thinking, I could really use some extra support right now, I invite you to reach out. You can find the link in the episode description to schedule a free consultation, call and learn more about the resources available to you, or you can go to upshurbren.com. Alright, now let’s dive back into my conversation with Dr. Lauren Streicher.

Dr. Lauren (26:02):

Now, a lot of women ask about doing home menopause tests or getting their blood levels checked. And while there are exceptions to this rule, in most cases that is just not helpful at all. And the reason why is because during perimenopause, as I mentioned, hormone levels are fluctuating. So women might go to her doctor and say, will you check my estrogen level please? I think I’m perimenopause. And the doctor who isn’t necessarily knowledgeable in this and to be helpful will say, sure. And then they measure the level and call you up and say, oh no, your hormone levels are just fine. And the reality is, her estrogen level might’ve been just fine on two o’clock on Tuesday when her blood was drawn and then a week later it takes a nose dive. And the same thing with these home menopause tests. So during perimenopause, it’s generally not helpful and post menopause, if someone comes to me and says, I’m 55 years old, I haven’t had a period in five years, and my vagina’s like the Sahara Desert and I can’t get a decent night’s sleep, I do not need to get an estrogen level to know that this woman is post menopause. It is in no way helpful.

Dr. Sarah (27:06):

Would you ever, I’m just curious, you were saying some of these symptoms can be overlapping, right? They could be due to another other things.

Dr. Lauren (27:13):

And so do I ever get a helpful then of course I do, particularly with younger women, particularly when there’s other things going on, but it needs to be interpreted by an expert. You can’t just get one random level and make assumptions based on that. Most menopause experts will get more than one level. They might time it in various places.

Dr. Sarah (27:35):

Get? I’m just curious. Obviously you want to test for estrogen levels, but it’s also you want to test for thyroid hormone level. What other things could it be? What do you rule out?

Dr. Lauren (27:43):

Thyroid is at the top of the list. We are always going to do a thyroid screen. We are going to get an estrogen level sometimes. Sometimes we might get a progesterone level that needs to, we want to know if someone’s still ovulating, particularly if we’re worried about if someone needs contraception. FSH and LH are pituitary hormones that also give us some indication of what’s going on with estrogen levels. So there are a number of different things we can look at, and it really is very individualized. Now, some women will get roped into doing these Dutch tests or urine tests and they’re wasting their money. This is absolutely ridiculous. I dunno if you’ve ever heard of this stuff. I hope not. But for anyone out there, if someone has tried to take your money to do one of these Dutch tests, it is crazy.

(28:28):

They’re expensive, they’re useless, and it’s just another money grab that We’re seeing a lot of that going on, particularly in the influencer world. And people have to be careful because the problem is, the big problem as we talk about this is women generally are not getting this information from their own physicians or nurse practitioners or clinicians. And so they are turning to the TikTok world and to the Instagram world. And while there is some very good information out there, there’s also very bad information and it’s very hard for women to know the difference. And I was doing, on my podcast, I was interviewing somebody who I know who Tamson is. She does a lot of helping women. She’s not a physician. You navigate through menopause and this and that. And I said to her, well, so how are women supposed to know? And she said, well, they should do research. And I’m thinking, come on, that’s not really fair to women. What kind of research? How are you supposed to know? And certainly I have a podcast and I’m my subic. I have a whole article about how to know if someone’s an expert and what you can go through. But women, it’s just unfair to say you have to know if this person knows what they’re talking about or not that.

Dr. Sarah (29:40):

But I suppose having the credentials to actually be, that’s where you start literate in the subject matter, could be a pretty good indicator, not a guarantee.

Dr. Lauren (29:51):

Absolutely. And that’s where you start with what is it? Does this person have a degree? Do they have specific menopause training? Are they involved with societies like the Menopause Society? Are they affiliated with an academic institution? Have they ever run a menopause clinic? Have they published, have they published scientific papers in the menopause world and a big red flag? Are they selling something? If someone is selling something, more often than not, you do need to kind of say, I don’t know. I don’t know. Most of the academic menopause people are not selling something. I would like to sell something. But other than selling books.

Dr. Sarah (30:33):

Well, you sell good books.

Dr. Lauren (30:35):

I sell books I sell. Right? They’re kind of stuff.

Dr. Sarah (30:37):

But they’re vetted.

Dr. Lauren (30:38):

But as far as products, I’m not saying that every single person who’s selling something does not have worthwhile information. I’m just saying it’s a red flag. It’s something to look at.

Dr. Sarah (30:46):

Yeah, worth doing your due diligence.

Dr. Lauren (30:48):

Yeah.

Dr. Sarah (30:49):

So we talked a little bit about what actually menopause is and some of the symptoms and how you do the differentials, the appropriate. If you have questions like, is this this or could it be something else? Then what do we do? Let’s say we’re definitely clear perimenopause is occurring or estrogen levels are fluctuating or they’re gone. There’s treatments, correct.

Dr. Lauren (31:18):

There’s treatments. And when people say, okay, so what’s the best treatment? Well, there is no a best treatment. Essentially what you have to look at is what are your symptoms? What is your medical history and what are your goals? And then based on that, you come up with an individualized plan. But one of the things that is very important to appreciate is a lot of women are told either culturally or quite frankly, from a medical professional, this is normal. Just tough it out, just tough it out. And the problem with that is that it’s not just about quality of life and not, I’m feeling miserable and all of that, but we know that there are long term repercussions from a lot of these symptoms. So as an example, hot flashes. Hot flashes are not harmless. We know that women that have moderate to severe hot flashes over years, and the average length of time that someone has hot flashes is seven years.

(32:14):

But a lot of women, particularly black women, it’s much longer, 10 or more years or even lifetime. And we know that these hot flashes are associated with cardiovascular disease with loss of bone, because every time you have a hot flash, there’s an inflammatory response, there’s a little surge of cortisol. So this idea of dress in layers and carry a fan is not appropriate. Likewise, women who are not sleeping well, we know that sleep is one of the number one complaints in women who are per and post menopause. And hot flashes is part of the reason, but it’s not the whole reason. There are a lot of other reasons. People have aches and pains. We know that their sleep disturbance in the brain even if someone doesn’t have hot flashes. And we also know that aside from not being functional the next day and being crabby and not exercising and making poor food choices and all of that, we know that long-term women that get less than five hours of sleep a night are going to have a dramatically higher rate of long-term problems in terms of cardiovascular disease, dementia, et cetera. So we talked about a little mood, mood, mood, mood. We can talk about mood because mood is huge.

Dr. Sarah (33:27):

Because I know for me in my area, and I’m staying in my lane here, I’m here to learn. I want to know everything there is to know. But what I do know is a lot of the symptoms that come with these developmental changes can increase someone’s vulnerability to mood disorders as well.

Dr. Lauren (33:44):

It’s a window of vulnerability when we talk about the brain and menopause. And the brain, of course, is what controls everything. So no matter what part, when we talk about libido and hot flashes and everything, that’s all because of changes in the brain. Because there are estrogen receptors in the brain, there are testosterone receptors in the brain, there are progesterone receptors in the brain, and your brain panics when suddenly there’s no estrogen and progesterone around. And it’s like, oh my God. And as a result of this, as a result of this, we see a lot of these experiential, if you will, kinds of symptoms that people have. So mood is at very, very high on the list. And we know that women who have new onset mood issues, and I want to be very careful to differentiate from the woman who’s had a lifetime of dealing with anxiety, depression, mood, mobility, all that stuff.

(34:40):

That’s a different situation than the woman who says, for the first time in my life, I like crying for no reason. My mood is all over the place. I’m feeling anxious. I’m not feeling like myself. I’m snapping at people. Is this your menopausal brain talking? You bet. You bet. And so what happens is many of these women, if they do see someone for this, what happens? They’re immediately put on an SSRI. And the problem with an antidepressant, and SSRIs of course, are the most common antidepressants that women are given. The problem with that is it may help them, but we also know that SSRIs have side effects. Libido sometimes can impact on the ability to have an orgasm weight gain, all of that. And while I’m not saying that women should never be put on an SSRI, it should not necessarily be first line because we know that if it is a mood disturbance that is specifically, specifically because of these hormonal changes that very often perimenopausal or postmenopausal hormone therapy is not only going to solve the mood problem, but it’s going to solve a lot of other problems as well. And right now, roughly one out of three women over the age of 50 is taking an SSR. I mean, think about that. That’s just insane. And again, I’m not talking about women that have been on it for management long term.

Dr. Sarah (36:06):

Right. Well, I think it speaks to this idea that I don’t know that statistic, but I would be really curious what percentage of those women on an SSRI are being prescribed by a primary care physician or someone who’s treating something medical versus something psychiatric, if they’re having a psychiatrist giving them that medication. Like it’s interesting, right?

Dr. Lauren (36:32):

You are correct. You are correct. And in addition, when we talk about the woman who goes in and says, I’m not sleeping, I’m having hot flashes, and my mood is all over the place, SSRIs will help alleviate hot flashes in many women. And we have doctors and other clinicians who are not comfortable prescribing hormone therapy, but they are comfortable prescribing an SSRI. So they figure like, okay, this is going to, that’s bandaid. Every single mark here, I’m going to give this woman an SSRI, her hot flashes are going to be better. She’s going to sleep better, and this is going to help her mood. Yay. And the reality is, is that same woman might do much, much better on menopausal hormone therapy. And this comes to education of both clinicians and women. That an SSRI is not first line. It is not first line yet in this country right now, it is treated as first line. But just to circle back to the mood stuff, so important, I don’t want to give that short change here because first of all, when we look at mood, and some of it is absolutely changes in the brain, and we’re looking at neurotransmitters, dopamine, and serotonin and all the things that you talk about and know about, but what we’re also looking at is the impact of insomnia that I mentioned earlier.

(37:50):

That’s a big piece of it. We’re also looking at just the psychosocial issues of, for a lot of women, the end of feeling youthful, the end of their reproductive life for some women is some women are thrilled. They’re not going to get their period on anymore. Other women, this is really hard, particularly if they haven’t had children and they’re thinking, well, maybe that window hasn’t closed for me. So we have that. We have painful sex, loss of libido, impacts on relationship. So you’re a therapist, you could tick off around 50 boxes there of reasons beyond just the absolute change in hormones that are going to impact on mood. It’s a ripple effect. So if a woman comes to you as a therapist and says, I’m perimenopausal and my mood is all over the place, you’ve got a lot of work to do because you really do need to do the deep dive into, let’s talk about this. If you’re in a relationship, what’s going on with that? What does he or she know about menopause? What’s going on sexually? What’s going on with sleep? What’s going on with, how do you feel? Feel about these changes that are happening in your bodies? Is it a positive thing? Is it welcome for you?

Dr. Sarah (39:03):

Yeah. What story are you telling youself?

Dr. Lauren (39:05):

Exactly. What is your perimenopause story? And sometimes it’s rewriting that story because that’s what therapists do. That’s what you do. And again, just to mention, this is why I have to work with therapists. I don’t do that work. I can sit there and say, you’ve got hot flashes. I got you. Here’s the five things I can give you hormonal and non-hormonal, they’re going to help your hot flashes, vaginal dryness, no problem. I can get rid of that a hundred percent of the time, but can I get rid of all of these other things that women are experiencing? No. And that’s why I have to work with a really good therapist who gets what I’m doing, and I get what they’re doing.

Dr. Sarah (39:43):

Yeah, it’s a team. And that’s so funny. I mean, I work a lot more often with kids and parents and families and postpartum women, but as my practice is growing and as people have been with us longer and kids having kids, and now their kids are going off to college, and more people in my practice are kind of moving into this stage. And it just reminds me of the fact how, and maybe this is just because I come from the hospital world, but I think of a multidisciplinary team approach to treatment as the gold standard in my opinion. And so I’m always, I just think, I don’t like to work in a silo. I feel like being able to collaborate with the medical side when I’m working with someone, whether it’s a child, postpartum mom or a menopausal woman, there’s so much synergy that can happen in working with a team of providers.

Dr. Lauren (40:44):

When I started the Center for Sexual Medicine Menopause, and this was pre COVID, and it was unique in that I said, not only do I want to have pelvic floor physical therapists and therapists, we all need to physically be in the same spot. And it changed everything. Because what that meant is that first of all, we would meet as a group once a week and have these discussions about what was going on with clients, patients, all that kind of stuff. And it meant that we could give each other feedback. I mean, think about this. If I have a woman with pelvic pain, I am treating her pain with intercourse, with penetrative sex, and I might see her once every four months. She’s seeing the pelvic floor physical therapist every week. She’s seeing the sex therapist week for an hour, each of them talking, talking, talking, talking.

(41:37):

So it might be the therapist, the sex therapist who comes to me and says, did you know that she’s an abusive relationship and that her partner’s having an affair? And I’m like, no, I didn’t know that because I’m not necessarily going to get that level of information, but that’s critical information for me to be able to treat her. So the gift of having everyone physically in one spot was amazing. And then COVID hit. And so what that meant is all the therapists went offsite and we were still on site, but it did change it. It did change it, but still the model is so important if you have the luxury of having that.

Dr. Sarah (42:16):

Right. But even my practice doesn’t have anybody outside of therapeutic support in-house, but I’m regularly speaking with my patients psychiatrist or in certain cases.

Dr. Lauren (42:29):

How often do you talk to their gynecologist? Never.

Dr. Sarah (42:32):

Well, in postpartum I do with perinatal mood and anxiety disorders. That would be for sure a collateral conversation.

Dr. Lauren (42:40):

Right.

Dr. Sarah (42:40):

But you’re right. No, but I do talk to kids, pediatricians. We do talk it’s just, you know.

Dr. Lauren (42:48):

It’s a different population.

Dr. Sarah (42:49):

But if you are going important to either MD specializing in this or a therapist specializing in this, I recommend tell either provider, I’d like to sign a release of information so you can speak to my other people on my team. That is as a, you can advocate for yourself in that way. It’s called an ROIA release of information. You can ask your providers if you could sign that form and allow your different siloed providers to speak. You can create your own team and you can consent to them speaking together. And that’s a good to know that that’s available. You don’t have to.

Dr. Lauren (43:29):

But the other thing also is there’s very often an assumption that someone is seeing a clinician who has expertise in this. And one of the things that my daughter and I’ve talked about quite a bit is because she treats women who have painful sex and chronic pelvic pain is when she says to them, have you seen a gynecologist? And they’re like, yeah. And they told me everything was fine. Well, she used to work in our Center for Sexual Medicine and Menopause, and she knows from her experience that 99% of the women that would show up in our clinic were self-referred because their own gynecologists were not helpful at finding the cause of pain. So a lot of women are quite frankly told that nothing is physically wrong with them when in fact they do have a physical problem that has treatment. So that’s also part of the role of the therapist, is to be able to make those all important referrals and to know who knows what they’re doing in this world, in the menopause world and who doesn’t, because you cannot assume that gynecologist, internist, family doctor has expertise in menopause. Sometimes they do, but a lot of times they don’t. And you just can’t say, oh, have you talked about your hot flashes with the gynecologist? Because they might come back and say, yeah, they gave me an SSRI or they said it’s something to worry about. Just dress in layers.

(44:48):

And it’s so important for therapists and women to understand that just because you haven’t been given good information doesn’t mean it’s not out there. Sometimes we have to do, and we do it for our kids, if you had a kid who had a big green lump growing out of their forehead and the pediatrician said, oh, that’s nothing to worry about, what mom would say, oh, okay, I’m fine with the big green lump that’s getting bigger every day growing out of his forehead. No, you’d go see the big green lump specialist, right? Right. You’d seek that person out. Yet women don’t do that for themselves.

Dr. Sarah (45:18):

Right. So actually that’s a question I wanted to ask you two questions. One is you were talking about, okay, what’s a good sort of to be an educated consumer of the kind of information that’s out there? We want to be aware of some of the red flags that this isn’t the best source of information. Are there additional, if you are talking to your actual, like a medical provider, and are there red flags to help you identify, you know what? I want to go get a second opinion. What would be a cue to a woman that this might not be the last stop on your train to figure out the appropriate care?

Dr. Lauren (45:52):

So when a woman is looking for a clinician, it’s not always easy. And let me start by saying that the person who’s been in their life forever, maybe the OB who’s delivered their babies or the internist they’ve been seeing for years may be an expert because it’s not as if it’s, oh, it’s always going to be an OB GYN, or it’s always going to be an internist. It’s really someone who has developed an interest in menopause and has taken the time to learn about menopause. And sometimes that’s going to be an internist. Sometimes it’s going to be a family doctor, sometimes it’s going to be a nurse practitioner. Sometimes it’s going to be a gynecologist. So the first thing to do is don’t assume that your own clinician doesn’t have expertise because they might. And one of the Substack articles that I wrote that it was actually one of the most popular things I ever wrote is, does your clinician know what they’re doing?

(46:38):

And basically it was kind of like 10 questions that were big red flags that would, like if you go and you say, oh, I’m having hot flashes, and they say, oh, take black koosh or dress in layers, that’s a big red flag that this person’s not an expert. So I actually give a script. I give questions. I give a whole thing for people to know. But the other thing also is people have this expectation that when they go for their once a year annual visit, that somehow they are going to get all this information at the same time. So you go in for your annual visit and they’re doing all the usual stuff, the pap test, the breast exam, they’re going through, do you need contraception, the pelvic exam, all that. And then someone says, oh, by the way, I’m having hot flashes, vaginal dryness.

(47:19):

I can’t remember why I walked into the room and my mood is all over the place. And you have this idea that they’re going to sit down and have a meaningful menopause discussion. That’s not going to happen. Typically, your 15 minutes is designated for that annual visit at best 30 minutes. A true menopause consultation, quite frankly, takes about 45 minutes to an hour. So number one, there has to be, if the clinician says, Hey, you know what? I need to have you come back for a consultation right there that tells you that this person probably has something to share with me.

Dr. Sarah (47:51):

Yeah.

Dr. Lauren (47:51):

As opposed to just kind of brushing it off. And certainly if someone is willing to give you options to say, let’s sit down and talk about this. You’re having hot flashes. This is what you can expect. This is how long they last. Here’s some hormonal options. Here’s some non-hormonal options. One big red flag is if someone says, I never prescribe hormone therapy, it tells you they’re not an expert. Any expert is going to offer both hormonal and non-hormonal options for every single symptom. But certainly if you want to say, okay, my own doctor’s clueless, where do I start? Well, the best place to start is there’s really two places I would recommend. One is if you live in a big city and you have access to a major medical center, most academic centers are going to either have a designated menopause clinic, menopause center, or are going to have identified clinicians, both nurse practitioners and doctors who have expertise.

(48:50):

So that’s number one. Number two is the Menopause Society. And the website is menopause.org is really professional society that women and men clinicians join. And again, it’s nurse practitioners, doctors who have an interest but also take a course to become a certified menopause practitioner. Now, when you go on this website and they have a clinician finder and you want to make sure that you designate someone who is certified and someone who is certified means that they have taken courses, they’ve taken a very difficult test to demonstrate expertise. Is that a guarantee? Absolutely not. There are some people out there who are doing hocus pocus stuff and selling junk and doing pellets and craziness, but they get their certification to legitimize themselves and then do other stuff. So it’s a really good starting point, but you cannot assume that because someone’s a certified menopause practitioner that they know what they’re doing.

(49:50):

But it’s a good starting place. The other thing is to follow people who do seem to have credibility. There are people on social media who do have some credibility. There are a lot of people who don’t, but certainly people who are using articles to demonstrate what they’re saying, who seem to be on top of things. I mean, I’m biased, of course. I think my information is the best information. And I am out there reviewing current medical literature. I’m giving the same kinds of lectures and giving the same kind of information that I give to doctors. But it is hard for women to know that. But you kind of get a feel for it too. And again, if someone’s selling something, for the most part.

Dr. Sarah (50:35):

I also think, I mean I’m going to speak for my amazing listeners, but this is an educated audience, these people that listen to this podcast. My favorite thing about my listeners is that they like to nerd out on the science. They like to know how they believe in being an educated consumer of content, because that’s what we talk a lot about on this podcast. And so I think this is a great, and once you find one person who is legitimately good and you want to build your knowledge base, you can also see who are they collaborating with? Who do they work with?

Dr. Lauren (51:13):

Exactly, exactly. One of the things about social media, which is frustrating, and we could go on and on about this, is you can’t give this kind of information in 30 seconds or 60 seconds. TikTok, Instagram and all those are really not designed for giving good information. I love Substack. For people who are not familiar with is a platform which really started for writers. It’s expanded. There’s a lot of different specialties that are on it. And on Substack, I write articles and they’re in-depth articles. Dr. Jen Gunter is another one on Substack who writes in-depth articles. And what you will find for the most part is that the physicians and the menopause experts on Substack are people who have a depth of information that is not on TikTok. They’re not dancing around pointing to something.

Dr. Sarah (52:02):

If the only thing you can do is fill 32nd reels and you can’t fill the depth of content of an article. That’s another red flag.

Dr. Lauren (52:12):

Are you giving references? And when you look at those references, are they 20 years old or I just wrote an article on Substack that is doing very well about cherry picking, about this whole idea of a lot of these influencers, a lot of these people on social media, they make these blanket statements based on one article, which is taken out of context. And this whole concept of cherry picking and how it can be dangerous and it can be misleading. And how do you know? I mean, at the end of the day, my article is about how do you know, you know if someone’s cherrypicking versus that. This is really good information.

(52:46):

And one of the other things that people have no way of knowing this without doing a deep dive is in general, you can trust people that are asked to speak at medical conferences. You do not get invited to speak at a medical conference unless you are really a trusted leader in this field. So when I speak at the Menopause Society Annual Conference, that’s invited, I can’t apply to do that. I don’t pay to do that. They invite me. And they only invite people who they know that the information you’re going to give is medically accurate. And in fact, every single slide I have to give the reference. And that’s checked in advance. So if you have someone who is routinely invited to speak at medical conferences, that tells you something right there, how are you going to know that? Well, most doctors, if they’re doing that kind of thing, will give access to their cvs so that you can see.

(53:43):

So if you go on Substack, there’s a link that you could look at my 28 page CV that lists all my scientific publications and all the conferences that I’ve been asked to speak at and all the professional societies that I’ve been asked to join. And that’s pretty good. So those are the kinds of things people can do at, and it’s funny, without naming names, if you look at some of the biggest names on social media in menopause right now, and if you go to a woman on the street and say, have you heard of Fill in the blank? And they’re go go, she’s amazing. She’s the menopause specialist. If I go to the Menopause Society and go to the President of the Menopause Society and say, what do you think of, fill in the blank. And they’ll say who?

Dr. Sarah (54:23):

We live in, sometimes a little bit of our own little echo chambers.

Dr. Lauren (54:26):

Yeah, so it is a very different world. And I try and straddle both worlds, if you will, in that it’s very important to me to maintain my academic credibility, but I also want to get to where the women are. And that’s one of the problems. If you look to these big academicians who have incredible information, well, who cares if nobody’s talking to them, if they don’t have a megaphone?

Dr. Sarah (54:46):

It’s this balance. It’s, it’s tricky. I so relate to this because I’m like, I think there is this sort of pocket of people who are in the more clinical world. They know what they’re talking about because they’re doing the work, they’re reading the journals, they’re writing the journals, and they’re embedded in this sort of academic rigorous world. And sometimes what ends up happening is that information gets sort of stuck in that place and it doesn’t get translated. So when people like you who are actually creating these really important bridges.

Dr. Lauren (55:19):

Yeah. It’s very tricky.

Dr. Sarah (55:19):

To get the information in a very accessible way to women, that’s hard work. You don’t have to do that, and you choose to do that. And I think that that needs to be likes hard. It’s hard.

Dr. Lauren (55:32):

Because the other thing also is when I look at some of these social influencers, and some of them are quite good, but a lot of them, I don’t agree with their information, but I also think it’s important to know them, to talk to them and to be part of that world because otherwise, how do you get the good information out? These are the people that people are listening to. You have to be able in a positive, nice way to say, there’s some holes in that information you’ve been given, and this is why I’m suggesting something else. Instead of just saying, oh my God, they’re morons. Don’t listen to them because that doesn’t really get you any place.

Dr. Sarah (56:10):

No, I agree. Well, I love the work that you’re doing. I so appreciate you taking the time to share this with everyone that’s listening. You’ve mentioned a bunch of really important resources. If people want to connect with you, get in touch with you, learn more about your work, where should they go?

Dr. Lauren (56:28):

The best place to find me right now is on substack, and that’s Dr streicher.substack.com. S-T-R-E-I-C-H-E-R. And on substack, not only do I have articles that I have at least one article a week, sometimes more, but that’s also where my Come Again podcast is I have two podcasts. Come Again, is a limited podcast, meaning it is 32 episodes and it’s all about post menopause and perimenopause sexual function. And it is actually meant for both clinicians and for the general public. It’s very high level, but anyone can listen to it. And that is on Substack and will also be available as a separate standalone product that is a subscription product. That will be on my website, drstreicher.com. And then I have another podcast, which is free that I’m now in the fourth season that’s called Inside Information: Menopause Midlife and More. And in that podcast I am in general, sometimes it’s just me talking, but usually I am interviewing an expert, a real expert in the field of menopause, or sometimes it’s just someone who I think midlife women might be interested in hearing from.

Dr. Sarah (57:42):

That’s so cool. Well, I will put links to all of that in the show notes so people can connect with you. This was lovely. I really enjoyed this conversation. Thank you so much for coming on the show.

Dr. Lauren (57:52):

And thank you for the work that you do. I couldn’t do what I do if you didn’t do what you do. So it does take a village. It’s also important.

Dr. Sarah (57:59):

It does. Oh, I agree. We’ll talk soon.

(58:02):

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