Menopause is often thought of with mixed feelings – part impending doom, part excitement never to deal with your period again. And truthfully, it’s always been this thing that’s seemed so far off. It doesn’t help that I have to do the mental math whenever someone asks me how old I am – my memory seems to have frozen me at 30. But I digress…
Menopause isn’t actually a fixed point in time. And there can be quite a long lead up with a myriad of symptoms – it’s not just about hot flashes!
Like our periods, menopause seems to be this thing we just have to deal with, suffer through, and not talk about. To that, I say NO WAY.
I had a great conversation with Dr. Jordan Robertson on this very topic because we deserve to have information to support decision-making along our journey towards menopause.
She is a naturopathic doctor with a background in medical research and the analytical data-driven side of healthcare. She brings a really unique perspective and I’m excited to share her take on menopause and hormone replacement therapy.
You can listen on the podcast or keep reading for the summary Q+A.
Q: What led you to where you are today, how did you become a naturopath and what is your focus on really being heavy into the research and data driven clinical work.
A: My background is actually in what we call critical appraisal, meaning, how do we dissect a problem, learn, like, think about the research that we know about that problem, and then come up with solutions.
I always say my undergraduate was in personal development. I learned time management and communication and leadership skills and critical appraisal, which is basically trying to figure out if the research that’s published on something is accurate and how we would use that information to help people make decisions.
That was my training and I went to naturopathic medicine with my interest being in preventative care and nutrition and exercise. I felt like I would be more like myself if I could hang out in that realm of medicine rather than working in a hospital setting.
I also decided to pursue naturopathic medicine right around the time that my grandfather passed away from cancer. Watching my grandpa move through conventional care with his cancer diagnosis, which was misdiagnosed just long enough that it became terminal for him, I chose a different path rather than going down the medicine route – naturopathic medicine.
When I graduated, still having this very evidence-based mindset, I wanted to work in the field of medicine where I knew I could have the greatest impact and that their research was really pointing towards an integrative solution, actually being the best solution.
And yet there’s this whole area of medicine, specifically female hormonal medicine, where there is a massive component that’s correlated with nutrition and exercise and stress management and all of those pieces that we can either do a better job than it gets done in conventional care or the outcomes we have if we marry the two are just so profound.
And that’s how I got in this sphere of medicine, it’s actually what we have the best evidence for, maybe with the exception of cardiovascular disease, because we know we can really help those patients too. But those patients with hormonal concerns, an integrated approach is a must. And so I love hanging out there because that’s where all the research lies for women’s health.
Q: What is the research saying about women’s hormonal health and how has that shifted?
A: One thing that I’m really a strong advocate for, is that there’s been massive diagnostic delay for most concerns that women present with in their early teens and twenties.
Much of the research in the last 15 years and the research I’m the most interested in is around how we predict a future woman’s health outcomes based on her hormonal experience in her teens and twenties.
So I think the research actually is pointing a lot towards how we identify these women earlier? What steps can we take to support these populations to slow down, change their outcomes in a way that is preventative?
I’m so grateful that I have so much time to spend with my women. Because I have the ability to enquire about what about those migraines? And what about that last pregnancy? And tell me about your fertility experience, even though the woman’s in her late forties, because it matters. It literally will change what we do with her, what we think about her future health, but only because I have the time to actually dive into it.
Q: So this might be an obvious question, but what is menopause?
A: Menopause itself means that people who are menstruating have gone a full 12 months without a menstrual cycle or ovulation. The term menopause is one that people look towards as sort of like this gate post that they’re going to, like they’re working towards or move towards.
But really what we call it, is a retrospective diagnosis, meaning that in the last 12 months you did not have a period.
That definition is important to understand because it’s one that we make looking backwards.
That said, the peri-menopause is the transition between regular menstrual cycling and menopause. It’s this window of time in between where ovarian function starts to slow down.
So we’re born with this finite amount of follicles when we’re conceived in our ovaries and we let go of those follicles every month and that is what creates that reproductive cycle. But because it’s a finite amount of follicles, somewhere over the age of 40-ish, we do start to see some reduction in the consistency at which women can ovulate. And so our pool that we’re working from is smaller and may have lower quality eggs than ones that had been released in your twenties.
We start to see a decrease in production of hormones month over month, because we’re having that slow, “ovaries sailing off into the sunset” kind of experience. And It’s becoming less consistent that you’re able to recruit a follicle to ovulate.
It’s only when we have done that for 12 months where nothing has successfully been ovulating for 12 months that we would then consider women menopausal.
The myth there that I always want to bust for women, is that you can easily still have menstrual cycles and yet be symptomatic.
Even though you’re still cycling, you can still have all of those menopausal symptoms, maybe for five or six years leading into that official menopause diagnosis, because that hormone pool is starting to decline.
So hot flashes, I think, are one of the most common symptoms that people seem to expect or consider as normal.
Q: What are some of the other symptoms that people might experience that would suggest they are heading towards menopause?
A: It is a natural process for our ovaries to run out of eggs. The consequence of that happening means that people experience low hormone symptoms and the most common ones that they start to experience are things like hot flashes, insomnia, changes to mood, specifically an increase in anxiety or new onset depression, or maybe a return of depression that you felt like was well-managed from before.
People may experience vaginal dryness. They may experience an increase in joint pain. They may experience changes in their cognitive function.
So that often brings up a loss of confidence at work.
Women may notice just a bit more rawness to the emotions that they feel so much more teary, more irritable, more depressed.
We also will see some cycle changes, so you can have all of those other symptoms, even if you’re having semi-regular menstrual cycles, but you may also start to see some cycle changes.
People may report really heavy menstrual bleeds. So a gushing experience or way heavier periods than they’d had in the past. People may experience a change in their cycle length, meaning that the full menstrual cycle, which is supposed to be about 28 days, may start to shift in the number of days of your month.
Peri-menopause by definition is that there’s been a change by more than seven days in your menstrual cycle, from what you normally experienced. So it’s seven days shorter. That’s often the first phase. Another part of this phase of perimenopause is often that your cycle gets seven days shorter than it has been in the past.
And so now we’re into things like iron deficiency and a whole bunch of other things that start to complicate the perimenopause experience because of heavier, more frequent periods. And then phase two of perimenopause, we see a lengthening between those cycles.
The women may have a 45 day cycle and again, often a very heavy experience. So those are all the things that we can look for. All of those things are (I’m going to use the word) normal.
Normal, because that’s a consequence of what the changes that you’re experiencing are. Does it mean that people can’t be supported now?
And I think that this is a really important thing to think about, of what it means to have a natural aging experience versus a well aging experience. This often comes up in my office. People will say, well, I don’t want to support my menopause because it’s natural.
It is natural, but it’s also not natural that you live alone. And that you have to raise these three kids and that you work two jobs, etc… none of this is natural. And these women that are in their fifties that have aging parents and adult children and running a household. And at the pinnacle of their career, like part of our menopausal experience in North America is, is amplified by our lifestyle.
Q: Women have been going through menopause forever, but we didn’t used to live very long. So a lot of people may not have suffered with it. But also we’re doing so much more later in life now. It’s probably one of those things that we were conditioned not to talk about and so we didn’t talk about it. And then we made all of these incredible strides and I’m going to call them advancements in careers and being working parents, and then shifts and how we live as well. And not being as supported by a community and having to support parents and kids and all of these things.
It’s almost like we are experiencing this stage of life in a completely new way that past generations have not. Is that accurate?
A: Absolutely. And I think about that often. I think about my grandmas when I think about menopause. My one grandma had a hysterectomy because she was done having kids. And that’s what you did then. You’ll just take it all out. And then my other grandma – no one has any record of what my other grandma’s experience was, because they just bottled that #@*! up and never talked about it. And it was not, they weren’t allowed to have a menopause experience.
When I think about family dynamics and the traditional roles that those women played in their households, I don’t think they were allowed to have menopause.
And so whether they suffered with their mood or were up all night or whatnot, I’m not sure anyone ever knew. This is different, we are demanding a better experience, which means we’re starting to talk about our experience. Which means we’re going to stop tolerating that experience.
And so, that’s what I want, that shifting conversation to be, is that women don’t want to have menopause like those other generations did. They want muscle mass. They want to be strong. They want to still be able to show up in their life and their career.
All of those things, we can’t do if we don’t feel well. Do you want this to happen naturally? Or do you want to be well during it?
Q: What do those two options look like then?
A: You can support almost all the symptoms of menopause. I’m going to say “naturally” only because I’m also going to call hormone replacement therapy, “natural” as well. To me, if you’re using sage for your hot flashes, that is the same as using estrogen for your hot flashes.
If you lay out all of the things that can go wrong in menopause, there are non-hormonal ways of treating all of it. There are solutions for hot flashes. There are solutions to try and support your mood. There are some great vaginal moisturizers out there right now that can support vaginal atrophy.
However, the root cause of your menopause symptoms is hormone – I’m going to call it – deficiency. That is a contentious conversation and the hormone world, but I’m going to use that word for clarity. Technically you’ll have those symptoms because estrogen is low.
And so the root cause is because estrogen is low, is an opportunity to microdose that hormone to a place where you don’t have those symptoms.
Q: How is hormone replacement therapy for menopause different from prescribing the pill for cycle regulation?
A: The thing that the pill does beautifully is contraception. For women in their forties, who are struggling with symptoms, if her main goal is contraception, the pill or an IUD might be the right solution for her.
I don’t want to say that the pill is never the right choice or to say, oh, well, HRT is way better than the pill because HRT does not give you contraception. Because the ultimate goal for lots of women is contraception.
Q: Are there reasons the pill is prescribed for menopause, other than for contraception?
A: It can help with heavy bleeding, hot flashes, and cycle regularity, but it’s not really getting to the root cause.
But for lots of women, it’s hitting enough check boxes that we shouldn’t totally throw it out as a solution.
Q: Can you talk more about HRT?
A: A lot of the beliefs that people have about HRT come from medications that we no longer use. We’ve evolved and shifted the types of hormones that are used in those medications, and they’re prescribed a little bit differently. For example, we used to give estrogen orally and now it’s through the skin.
As far as some of the risks that go with HRT, when it’s done orally versus delivering estrogen through the skin or topically, that really changes the safety profile of estrogen.
We’re being more proactive about HRT than we had been in the past, meaning that most of the research in the past was done in much older women, in their mid sixties.
So let’s say that you stopped your period at 50 and we did nothing for you. And then at 65, we put you on HRT. You’ve accumulated 15 years of estrogen deficiency. As far as your cardiovascular health goes, breast tissue changes, and now we add hormones back in, that’s like giving hormones to someone who’s never had estrogen. And it definitely has some negative implications.
We now know that we need to catch women before they turn menopausal. We probably should be giving women HRT when they’re 48. Or 49 to 51 – catching them in this window of time where they still make a little bit of their own hormone, but we’re topping them up so that they never have to have any risks developed by having no estrogen. Which is what happens if we do nothing for 10 years and then try and treat you.
Q: If you go on HRT, do you stay on it for the rest of your life? How does that work?
A: I followed a lot of this research for a long time. My guess is we’re going to change our answer about that in about 10 or 15 years.
I turned 40 in a couple of months. I’m going to do it, and probably as long as humanly possible given what I know about the benefits.
This generation that’s embarking on menopause right now is this in-between generation where they’re going to have to be open to the fact that we’re going to change our mind about the answer, which is what happens in medicine all the time.
As it stands right now, if women start HRT in that last year or so of their last menstrual period, they can really safely do it probably up until about 58 before we question whether or not we’re going to take her off of it.
When we get to that moment in time, that certainly requires a risk benefit conversation with her practitioner. What you actually need is someone who can have that dynamic conversation with you over that 10 year window of your health, because your prescription probably will change three times between 48 and 50, 58. Your needs are going to change. Your health is going to change and therefore your prescription should change. It’s not a set it and forget it kind of prescription.
Q: Do we know if there are risks of keeping the body in a state that has more hormones than it would “naturally” be in? Is there a concern with cancer or other things that we kind of tend to associate with elevated or increased or changes in hormones?
A: We have to remember that when we support them with HRT, you’re not getting medicated, like back into your twenties.
We’re trying to provide a safety net of low dose hormone therapy so that you don’t experience the symptoms of what happens when your hormones fall to undetectable levels.
So really those hot flashes and insomnia are happening when your estrogen falls to undetectable levels in your blood. The small amount of HRT that is required for you to be symptom free is just enough so that your estrogen levels are barely detectable in your blood.
There is a much more estrogenic experience when you’re taking the pill, because it’s like a sledgehammer from an estrogen perspective versus HRT, which is low dose Estradiol.
If women start later, like after 52, we do think that there’s an increased likelihood that they will be diagnosed with breast cancer, but it doesn’t change their outcomes. Meaning that there aren’t more deaths from breast cancer.
I know nobody wants breast cancer, but when we think about the overall picture of that woman’s health, the cardiovascular and some of the other benefits we gain from being HRT, often outweigh the risks associated with any other type of cancer that has maybe a small increase in incidents over time.
When women start HRT at an appropriate age, which is maybe 48 – 52, there is maybe a decreased risk in the likelihood of her getting breast cancer. My guess is in 10 – 15 years we’re going to have a lot to say about that conversation, but we do not think that HRT increases your risk of dying from breast cancer right now.
Q: If you could give one piece of advice to those who are approaching, or in the thick of menopause, what would it be?
A: I think my overarching themes and goals, is that you don’t need to suffer. If you find yourself using the word, “just” to describe anything that you’re experiencing, I think you need to reframe that a little bit. You’re not “just” having hot flashes or “just” can’t sleep through the night.
Those symptoms matter.
There are symptoms of the hormone that you’re missing that is also “just” increasing your cholesterol and your risk of diabetes and your risk of cognitive decline and your risk of osteoporosis. And so those are whispers of what’s happening on the inside and it’s worthy to listen to them.
And if you’re feeling dismissed by your health care experience, or if you’re being told that you’re too young or it’s not time to have that conversation or that if your practitioner doesn’t believe in HRT, you’re worth it to have a positive experience.
When I think about what my mission is, mother that’s through sharing on my podcast or through Instagram, it’s that I need women to feel well. When I look at all the wonderful things that women are doing as leaders in their companies and corporations and leading the next generation as teachers or whatever it is.
I need you to show up feeling pretty good to your world. And so I don’t want you to feel down and out for 10 years of your life because of your hormones, because this is a solvable problem.