E120: The Environmental Domain of Perimenopause

Kirtly: I only wanted to use one of my eggs, and I wanted to use it in June of 1983. Actually, we only wanted to use one of my eggs, my husband and I. But I didn't really let him in on exactly when I wanted to use it. But we used it, and we have a wonderful son that we have.

But I wanted that egg to be a really great egg, a Grade A egg, sorted from the hundreds of eggs that might run the egg race in my ovary that month of June in 1983. If I didn't have many eggs left, the competition might not make a Grade A egg and a successful pregnancy. And if the eggs were too old, there might be problems.

I'm Dr. Kirtly Jones from Obstetrics and Gynecology at the University of Utah. I'm a reproductive endocrinologist who's been thinking about eggs, all eggs, but especially human eggs, since I was in college.

Over the past episodes of the "7 Domains of Women's Health" series, we've been working on the 7 Domains of Perimenopause. And this time, we'll be talking about the environmental domain of perimenopause. How does the environment affect the age of perimenopause? And how does the environment affect a person's experience of perimenopause?

With me is my co-host, Katie Ward. She's a professor in the School of Nursing and has a midlife women's clinical practice. She has a PhD in anthropology, and she's going to help me not get too much into the weeds here on the environmental domain.

Katie: I'll try.

Kirtly: You're going to try. Well, sorry. This has been my life. My life has been about eggs, and there you go. So it's hard not to get in the weeds.

But a reminder from the physical domain, our first episode of perimenopause, is that menopause happens because we run out of functional eggs and the follicles, the tiny hormone-producing cysts around them that determine how they grow and when they're released and make estrogen, progesterone, and androgens.

When the follicles and their eggs run out, we go through menopause. When there are only a few left, there might not be one to develop and ovulate each month and periods and hormones become irregular. At menopause, there are still some eggs and follicles, but they just aren't able to function, to hear the call to develop and grow and make hormones and ovulate.

There are factors in the developing female fetus that determines the number of eggs and predicts early menopause. Chromosomal abnormalities in the X chromosome and genetic metabolic diseases can cause all the eggs to be gone before puberty or can cause early menopause.

There are some studies in mice that suggest that maternal exposure to air pollution at the level seen in smokers or in some cities can lead to baby mice with fewer eggs in their ovaries.

So conditions during life, including exposure to chemotherapy or radiation for cancer or other diseases, can cause a rapid decline in egg number, leading to premature menopause and menopause.

Diseases that lead to operations on the ovary, like endometriosis, and a necessary removal of the ovary can lead to a decline in the number of eggs and earlier menopause. Although many women who've had an ovary removed go through menopause at the same time.

Women with autoimmune diseases that can strike eggs or women with autoimmune thyroid disease may go through earlier perimenopause and have a decline in egg number.

All of these things are on my mind as a clinician when people come to me and say, "I'm just having irregular periods, and I don't feel right. Is this perimenopause?" And then I start asking questions about things that might actually lead to that.

How does the environment determine how quickly we run out of eggs? Well, the European Society of Human Reproduction and Embryology, in their fact sheet on human reproduction and the environment, note that cigarette smoking and living in poor air quality lowers ovarian reserve and decreases the age of perimenopause and menopause.

Other man-made chemicals have been associated with diminished ovarian reserve and an increase in endometriosis, which can lead to surgery and remove parts of the ovaries.

So is there a test to see how many eggs we have left? Well, the best test of ovarian reserve and egg quality is the ease of getting pregnant, but you have to test out the system and try to get pregnant to find that out. Maybe you don't want to yet, and there may be other factors like sperm that can decrease fertility.

Another test, other than taking the ovaries in your body out for a pregnancy drive, is to measure a hormone called AMH, anti-Müllerian hormone, which is made by small follicles and decreases with diminishing ovarian reserve.

Or you can get out the trusty ultrasound probe, which I did for years and years and years, and count the little tiny follicles. Not the ones that ovulate, but might ovulate in the months to come.

These tests can be good predictors of how many eggs you might make if you went through IVF, but they aren't really good predictors of your overall fertility, and they really aren't great predictors of when you might run out of usable eggs, when you might go through menopause or perimenopause, or if you are in menopause.

So menopause is inevitable for women with ovaries, and perimenopause is inevitable unless you have your ovaries removed, in which menopause happens all of a sudden.

Okay, that's a little bit of weeds.

Katie: I was supposed to stop you. Sorry about that.

Kirtly: Stop me now.

Katie: But you're the expert on eggs. I think one of the most interesting things you just said, though, is sometimes we do have to take out one ovary in somebody, and even though then you might get a measurement that says that their ovarian reserve is less, somehow the egg knows to sort of slow that down and people still don't go through menopause until the normal time. And it's interesting that our bodies adapt to that.

So I think it speaks to a couple kinds of adaptability. One is to sort of slow down and still postpone menopause until the normal time, and the responsiveness to the environment. If you live in an environment that's a little bit toxic to you, maybe it's better to quit reproducing sooner. So those are both sort of two interesting accelerators and brakes that . . .

Kirtly: It is, but we don't really understand . . .

Katie: We don't. Right.

Kirtly: . . . ovarian atresia, the business of losing eggs from the minute we have most of our eggs when we're a 20-week fetus. We don't really understand that, and it's a wonderful question. It's a great question.

Katie: It really is. This is what I tell my patients, is that if you have ovaries and you're lucky enough to live long enough, you are going to go through menopause. And the question is how that's going to be as you get there, because perimenopause is different for everyone.

And that test you just mentioned, the AMH test that you mentioned, does not actually . . . It tells you how many eggs you have, but it doesn't predict when you're going to go through menopause.

One of my little pet peeves right now is that if you open your phone, you can buy one of these AMH test kits. It's going to be sold to you as a fertility score, like, "Here's your biology clock and you can see what time it is." And I would encourage people not to waste their money because it's sort of a trap.

I think people think if they have that number, they can make decisions around it. But as you said, there are a lot of things contributing to whether or not somebody can get pregnant. So what are the sperm doing, and whether or not the sperm and the egg can get together.

And so you can't just take that number and say, "Yes, I can definitely live my wild life a bit longer and be guaranteed to get pregnant down the road." And it doesn't actually tell you the age at which you're going to go through menopause.

So it's a great test, and as a healthcare provider, it can be really useful if you're thinking about laying down a bunch of money for IVF. But if you're just sitting at home in your kitchen, that number isn't nearly as interpretable.

Kirtly: Right. It may be that you don't have many eggs left, but you're not that old and your eggs you have that are great. So even people with low ovarian reserve who go through IVF and don't make many eggs, they still get pregnant, but maybe they only have one or two embryos, and they don't have any to freeze.

And it makes a difference. Maybe it's a test that's useful when people come in, and they say, "Well, I want to freeze my eggs because I'm getting older." It kind of might help people decide how many they're going to have to freeze. But it doesn't tell you how really fertile they are. So it's a test I think that reproductive endocrinologists can use, and most everybody doesn't.

Well, how do you adjust your personal environment for perimenopause? I've been thinking about this. I mean, any of you who listen know that Katie and I skipped our perimenopause hormonally. But before that, I used to sit in the bathtub, and that was my personal private space.

Anyway, keep menstrual protection always available and nearby, as your periods might become unpredictable. Not only in timing, but in flow. So that one extra tampon and one pad while you go on a trip may not be enough. You might need to stash a couple.

And keep your sleep room as cool as possible and with flexible bedding for your sleep partner who might not sleep as hot as you do.

So be aware of your mood and how it might affect others. And ask for a minute to collect your thoughts. My favorite phrase for personal timeout to think for a minute before a grumpy response or a forgetful outburst. It can be helpful to let your housemates, read partner, parents, children, children's friends, dogs, cats, pets, know what you're going through. But you might like some privacy.

My mother, who was a dental hygienist, was a great hot flusher. She could do it, and she could bring it and really sweat. But she would lean over her patients doing their dental hygiene stuff and drip on them when she'd have a hot flush. So that's an unfortunate outward and visible sign of an inward and spiritual state. I don't think she was happy with that, so she got some hormones and that made that better.

Anyway, you might like some privacy. So your response to heat and brain fog and emotional ups and downs and unpredictable bleeding will have to be as measured as you can make them.

Katie: Yeah. I was going to share with you a story some colleagues of mine in Rwanda told me. It just stuck with me. They were talking about there . . . keep in mind, Rwanda is a place where people don't have air conditioning. But they have these beautiful fans made out of these beautiful fabrics, and people use them. Little kids use them. Young women use them. The clearly elderly people, the grandmothers, use them.

But women in midlife stop using their fans, and it's because they told me it's a tell. So when you know that you're starting to go through perimenopause, if you use a fan, then people don't know whether or not you're just sort of ambiently hot or you're having a hot flash.

So it's sort of like they are for us. There's a little bit of stigma about going through menopause. And so these poor people put down their fans so as not to display their menopausal status. And I think it's just being in a society that values youth and fertility, and you don't want to show that off.

Kirtly: Yeah, it's a little hard. I mean, sometimes if you're flushing and then your face gets red and then everybody at the table . . . It's the same mechanism. A hot flush is the same mechanism as when you get upset or when you're embarrassed. The blushing, flushing mechanism is the same.

But do you flush and fan yourself and then everybody at the table is looking at you? And the answer is yeah, maybe so. Some people blow their nose at the table. Some people pick their nose when no one's looking. I mean, when I think about things that happen in public spaces . . .

Well, anyway, what about the workplace? Because menopause and perimenopause are having a moment of social awareness, and there have been some moves to bring menopause awareness and menopause equity to the workplace, especially in Britain.

I'm not sure what menopause equity is. The Menopause Society and the Society for Women's Health Research have put out some roadmaps, and you can go catch them at their websites, Menopause Society or Society for Women's Health Research.

They put out some roadmaps toward a menopause-friendly work environment. And these documents are heavily weighted toward education of managers and recommended by stakeholders, read employees who are perimenopausal.

I'm not really a fan of legislation for specific women's health issues, but that's just me being a boomer. I think every bathroom should have pads available, or you could buy them, or maybe condoms, too. I don't know.

But I think that managers should be educated about many common health problems that might affect employees: painful periods or heavy periods in younger women, diabetes, epilepsy, breastfeeding, arthritis. I could make a great big list.

And all employees should feel as comfortable as possible in communicating health issues that might benefit from a timeout on occasion. The equity is not for menopausal women or for breastfeeding women or for women period, but for all employees who might need a moment to collect their thoughts, meaning check their blood sugar, splash cold water on their face, change their menstrual protection, deal with their irritable colon issues.

How do we make a workplace that is generous and accommodating to as many people as we can, understanding that you have to be productive?

Katie: Man. Well, I've been so lucky in this regard. When I'm at my academic setting, I have an office door I can close and a thermostat I can adjust a little bit. There's a small amount of play I can have on my thermostat, which may or may not work. But I also have a calendar I can mostly control.

So it's true. If I'm having a bad afternoon, I can shut the door and have my bad afternoon. But when I'm seeing patients, and I have a full schedule, it's not like I can step out of clinic because I'm warm and go get cold. And I don't know that any legislation would actually really fix that for me.

I mean, I see menopausal women, so I can go in and relate to them and say, "Oh, I'm having a hot flash. Sorry." And we can bond over that shared thing.

But I think that menopause equity . . . the idea is . . . I guess I'm sort of with you on that not naming specific conditions and saying, "We need equity or special treatment." But all around, we just need a workplace that allows understanding and maybe some thermostat control.

Kirtly: Right.

Katie: The problem is not laws specific to menopause. It's the same problem that women with the fans in Rwanda face. If we don't value women in this stage of life, then women are going to hide their fans or not ask for that accommodations.

I think the thing we need to fight is the stigma. We need to value our elders and value people that are different. So I don't know if the argument is for laws.

On the other hand, I was thinking about the ADA and thinking here are laws that change things to make the world more accessible for people who move around the world differently. And as we've implemented those changes, everyone has benefited.

I think as the laws change, sympathy follows. And so I think that the stigma is the issue, really, not naming any specific condition.

But I think the issue really is who has access to a decent working condition in the first place. As you mentioned, smoking and poor air quality, these are things that might make menopause come sooner and perimenopause come sooner. And those are not distributed equally. They cluster by jobs, by income, and probably most importantly by ZIP Code.

So people who are arriving at perimenopause early, those are disproportionately the same women that are working difficult jobs on assembly line or on a factory room floor or on the night shift or kind of in the toughest conditions. And those are the women who can't do the things we were just recommending, like go to the room with the timeout, close the door, change the thermostat, or have a schedule to adjust or the minute to collect their thoughts.

So I think the bad environment is the thing that we really need to fight, and probably more importantly than laws naming menopause equity.

Kirtly: Yeah, I think about some years ago, many years ago, when we called them stewardesses, when the people who were flight attendants were all women, they all had to be a certain size. They all had to wear these rather tight clothes. And they all had to wear pantyhose and high heels on their feet for four, six, eight hours. And I thought, that's just cruel. I mean, that's ridiculous.

And there are people who are serving or making your food over a hot stove or a frying grill or whatever. That's hard for everybody. How we try to take care of everyone in the workplace and in our environment . . .

There's an important insight from the big longitudinal study of women across the nation, the SWAN study, which looked at women across the nation, different backgrounds, cultural foundations, economics, education, racial self-identification.

Women who grew up in challenging environments with more young life stressors, more economic and social and personal adverse events, have more symptoms in the perimenopause than women who grew up with more advantages and a smoother home life.

Maybe having something go better for you may make you a little more resilient. Although I'm proud of everyone who manages to get up to perimenopause who had a really tough growing up. So maybe those folks are resilient, too.

But that's what the studies show. That the environmental domain includes the psychosocial environment in which the women grew up, and that can significantly dial up their menopause symptoms.

Katie: Serious question. This comes up for me kind of every week in clinic right now, and I want to chat with you about it a little bit. People come in, and they ask their mothers about their perimenopause. So women who are going through perimenopause right now, they're talking about it and they're like, "I asked my mom and she just blew it off. She hardly remembered it." My patients come in and say, "This is terrible. My mother didn't know that these symptoms were so bad. They must have been suffering, and we had no relief for them."

And I end up wondering, "Well, were the symptoms . . . are they worse now? Were they just not as bad back then, and women just didn't have the education to be upset about them? Or were they really less?"

Or is there a third option? And maybe the stigma is the same thing here, that right now people are being told that perimenopause is the first sign of impending menopause, that things after menopause are going to be really awful, and there's nothing but downhill after that.

And so I think there's something about the attention economy or the attention environment right now, that people are really attributing all of these things to this really difficult time in life. And when you talk to your mother, she's like, "Oh, yeah. I don't know. I just went, 'My period stopped.'"

Kirtly: Yeah. Well, we talked earlier in another session about pioneer women's diaries didn't really talk about perimenopause. I mean, women were really leading difficult lives.

And my own mom, who could really sweat up a storm even when she was younger . . . I mean, her husband had just died. She had four kids and no money and had to go back and study to have a job that she could actually afford to have a roof over her head. I don't think perimenopause was number one on her concern.

And she'd had a hysterectomy for prolapse years before, so she didn't have the bleeding to tell her. She had her ovaries still, but it wasn't on her mind. She had many, many other things on her mind.

Katie: Right. Well, I want to talk a little bit about a website that I really like. I think these people are doing some great work and I want folks to know about this and get on and bookmark them.

So this is a website called Women Living Better. And you can find it at womenlivingbetter.org. It's a dot-org, not dot-com. And they've actually been around for a long time, and I just found them. They've been doing some research, which I think is helpful in kind of unpacking some of this.

So this is a research-forward website. They're not selling any products. They're very clear about that on their front page. There's nothing here to buy.

And they also are trying really hard not to create fear about perimenopause or menopause. But they do have blogs and a lot of information from some of the just A-list menopause experts that I really respect. So some of the people behind the stages of reproductive aging that we've talked about and the women's health across the nation. These are the people who have been looking at that and constructing those studies.

And so, on their website, they have a bunch of great information about self-care, seeking healthcare, links to books, and new studies that are just coming out. And they're still collecting data, so you can go on this website and you can contribute to their data collection.

They published a study a while back that was on like 2,400 women, 2,500 women, and really looked at the symptoms that we're now identifying as being related to perimenopause. So this irritability and "not feeling like myself," I think they kind of coined that term, and fatigue and brain fog.

And one of the things that they pointed out in that research is that those symptoms were not so much perimenopause. They were happening in the late reproductive years. Now, we're really talking about these things as being the early signs of perimenopause, but in fact, they may be more something that has to do with the late reproductive years. And so we might be miscategorizing them a little bit.

So I think their work is interesting, and it's worth looking at. It just has a ton of great resources and contributes to the work being done by the people who I think are really doing the best research that we've got right now.

I would love for everybody to bookmark that website, womenlivingbetter.org, and then block all these other social media influencers who are really scaring you about what's going on in the perimenopause.

Kirtly: Katie, you're right. I spent some time on that website after you recommended it, and it's excellent. It's clearly data-driven, and it's got some great graphics. And so it's not something you can whisk through. There is stuff that you can listen to. It's kind of reading and visual-heavy, but you can listen to things as well. And it is really one of the best websites on this perimenopause issue that I've ever seen, so I recommend it as well.

Well, your perimenopausal and menopausal and midlife experience is a blend of your psychology, your social environment, your inner psychological makeup, and the physical environment in which you live and have lived. And self-awareness of this combination can help you sort things out when you take a minute to collect your thoughts or stick your head under cool water in the sink.

Your medical environment also plays a factor in terms of who you can access for options to manage this perfectly normal but not perfectly wonderful time of life.

But if you need some help, there's help out there. Reach out for menopause clinicians in your area. You can also go to menopause.org and look for certified menopause clinicians.

Try to craft your home environment to make it tolerable for you and the people around you as you manage your thermal, and cognitive, and psychological ups and downs.

And bring some empathy to your workplace for those who might have similar issues, or no matter what their medical or psychosocial challenges. Give everyone a chance to gather their thoughts if they need it. Every workplace could use a small quiet space for a tiny personal timeout.

And if this is your first domain of the perimenopause, check out the other domains of this important time in women's lives, one of the critical transitions that makes us human beings. You should check out the social domain of perimenopause to learn more about how perimenopause made us humans, and being humans with big brains and needy children made us go through menopause.

So you can get these episodes and all of the "7 Domains of Women's Health" podcasts wherever you get your podcasts, or at womens7.com. And that doesn't mean we're making money on it, but it's a dot-com.

Thank you for being with us. And thanks, Katie, for keeping me out of the weeds.