If every facet of the reproduction process is based in evolution, how does menopause, something where reproduction is no longer possible, benefit our species? We think it’s because of an idea called the wise woman hypothesis, says Dr. Jen Gunter, an OB/GYN and author.

The wise woman hypothesis describes the idea that historically for humans, having a grandmother in your family unit meant you had an extra pair of knowledgeable hands that themselves weren’t occupied with child-rearing. Someone who could go out and help gather food, build shelter, find water, and pass on historical knowledge from other generations.

Menopause represents evolution in the long game, the idea that we retain our power as we age. Dr. Jen Gunter explains the science and debunks common myths behind the biological process of menopause, as well as how to know who to trust to guide you through it.

JEN GUNTER: Most animals die after they finish reproducing. Animals that keep on living after reproduction are quite uncommon. So humans are the big one, orcas are another one, and there may be a few other species as well but it's not as well studied. If everything about reproduction is really evolution, getting that next generation and the next generation, how does menopause, something where reproduction is no longer possible, how is that beneficial? It turns out we think it's because of something called the grandmother or the wise woman hypothesis. The idea is that historically for humans, having a grandmother associated with the family unit meant you had an extra pair of knowledgeable hands that themselves weren't occupied with child-rearing. So you had someone who could go out and help gather food, building shelter, finding water, passing on historical knowledge from other generations. And so menopause represents evolution in the long game, it's the idea that we retain our power as we age. Now, just like there are hormonal changes that lead up to the first period, there are hormonal changes that lead up to the last period, and that time is known as the menopause transition, but you may have also heard it as perimenopause or pre-menopause. The menopause transition is anywhere between four to seven years, maybe even a little bit longer, and it is this winding down of reproductive hormones. Over time, menstruation starts to space out. People might go more and more time in between and eventually they'll start skipping periods. And when people are skipping periods, we generally believe they're, you know, probably about one to three years from their final period. Medically, we use the word menopause to describe the day of the final period, but you never really know it's the day until afterwards, and we say everything after that final period is post menopause. We say menopause has occurred when you are a year from your last period. So the typical age is between the ages of 45 and 55. If your final period happens between ages 40 and before 45, then we call that premature menopause. And if your periods stop before age 40, we call that primary ovarian insufficiency. Now, people can also have surgical menopause. You can have your ovaries removed and then that puts you into menopause. Menopause is associated with a large constellation of symptoms, and because this has been historically really understudied, I don't think we have a full handle on how many symptoms are common and in what percentage of people would be expected to experience all of them. But the ones that we know a lot about are hot flashes and night sweats, which are known as vasomotor symptoms. Another common one is vaginal dryness or pain with sex, brain fog, palpitations, mood changes, and joint pain. Those are some of the more common ones that we hear about, but of course the list is quite long. The hormonal chaos time that leads up to menopause has an average duration of about four to seven years. However, symptoms don't always correlate with that. So some people have their worst symptoms earlier on and some people have their worst symptoms towards the end of the menopause transition and some around the time of their final period or even afterwards. It's really important for people to understand that while we do have medications for many symptoms, medications can only do so much. However, one of the most important things is having a good health foundation going in, and that is exercise. And I don't like that answer anymore than anybody else, but we can't deny the impact of exercise on all of the domains that menopause touches. And if you want the one thing, if exercise were a drug, that would be the thing we'd be giving to everybody. To keep that in mind, and it's not just aerobic exercise but strength building, so that would be the most important foundation for treating menopause. We do have other treatments as well, and one of the treatments that people have heard a lot about is menopausal hormone therapy, or MHT. We used to call it hormone replacement therapy and we do not use that term anymore because we are not replacing estrogen that you should have. We expect menopause to happen, we expect estrogen levels to change, but we also don't expect people to suffer, and so it's a therapy. Also, menopausal hormone therapy is the gold standard treatment for hot flashes and night sweats, vasomotor symptoms. But when people are suffering with changes in their vagina, then we use vaginal estrogen. So the big question is, should I take it? Like any medication, do you need it? That's what you should be asking yourself. Because while menopausal hormone therapy can help many parts of menopause, there's also parts that it can't help, right? So you only wanna take a medication for what it can do. There is no broad agreement that every person should be on menopausal hormone therapy. So I often think about menopausal hormone therapy as things that are really evidence-based, and those would be the green light indications. So that would be hot flashes and night sweats, or prevention of osteoporosis for people who are at high risk. There are also what I would consider yellow light reasons, meaning it might help some people, it might not, and that takes a much more individual discussion in the office. A good example would be depression in the menopause transition. There are some studies that show that estrogen can help with that. Interestingly, it doesn't help after menopause. So, if someone were two years after their final period and said they wanted to start estrogen for depression, that wouldn't be an evidence-based recommendation. But if they were having irregular cycles, then that would be. Other yellow light indications might be joint pain. The studies aren't great but it might help some people, and there is some data that shows it may reduce the incidence of type 2 diabetes, but there isn't a global recommendation to give menopausal hormone therapy for prevention. It also doesn't work for weight gain in menopause and we do not recommend starting menopausal hormone therapy for prevention of dementia or Alzheimer's disease or cardiovascular disease. There may be some benefits for starting it early, but it hasn't reached the threshold where it's a universal recommendation. We also don't recommend it for brain fog. There are quite a few studies that show that it doesn't have any short-term impact on brain functioning. And one caveat to that might be if you're someone who's sleeping very poorly because of hot flashes. One symptom that isn't discussed enough in the menopause transition are menstrual irregularities. People obviously can have skipped periods, but people can also have heavier periods. For many people, hormones are part of controlling bleeding problems, and one way we often do that is with the estrogen-containing birth control pill. It is good at controlling heavy bleeding and people also get the benefit of estrogen and contraception. But there are other options too. We can use a hormonal IUD and then, if people wanna start menopausal hormone therapy, they certainly can. So, whether or not you should start it would really depend on, do you have something that it can help? And if it is a safe therapy for you, then it may well be worth trying. And like any therapy, if you start it and you're not seeing the benefit that you wanna get, then it should be reassessed. When we're talking about menopausal hormone therapy, we are talking about pharmaceutical preparations, meaning a pill, a patch, a transdermal lotion or a gel. And it is very important that products be pharmaceutical because making hormones into something that's absorbed reliably, either from the gut or across the skin, is actually quite challenging. It takes years of research to do this so we know that they contain what they claim. When you get a compounded product, you have none of that research and development, and so there can be issues absorption, there can be issues with dose. Also, compounded products don't contain the same warning labels that pharmaceutical products do, which gives them the illusion of safety. Because when people see a warning label, they get concerned. And if they don't see it, they think, well, they don't need to be concerned. But it's just that the rules in the United States don't require that warning label to be on it. And I would include pellets that are injected as part of compounded hormones. Pellets often deliver very high doses of estrogen or testosterone or both, depending on the pellet. They're also not batch tested and they're associated with a lot of adverse events, and the big problem is adverse events often don't get reported. Now, one question I get, well, but I wanna take bioidenticals. Bioidentical is a marketing term that has essentially no medical meaning. The belief is that it's a hormone that is identical to what your ovaries make. But being the same as what your ovaries make doesn't make a hormone safe. What makes something safe is if it has been tested and studied and we know that it is safe. But here's the kicker, is that almost every pharmaceutical hormone that I would prescribe for you could be considered bioidentical because it's all estradiol, it's all made generally from soybeans and it all comes from generally the same plant. I mean plant as in factory, not as in plant that's grown. And testosterone is not part of menopausal hormone therapy. We don't recommend adding it in for fatigue, we don't recommend adding it in for brain fog, we don't recommend adding it in for hot flashes. The only indication for it is in people who are suffering from libido or desire problems who have a relationship that's not the cause of those desire-related issues. So how do you sort the snake oil from science online? Because there's a lot of medical content out there. I have a few good rules of thumb. In general, if something sounds too good to be true, it probably is. There is no influencer or doctor who has discovered a secret that no one else knows about. If the information's out there, we all know about it. Number two, be very mindful about what you read online because you need to fact-check immediately. Many people actually end up with incorrect information because people who sell snake oil are really good at search engine optimization. So how do you fact-check, how do you do that? What I recommend people do is take the subject matter, put it into your Google search, and add ACOG, American College of Obstetrics and Gynecology, or Menopause Society, the CDC, you could put the WHO. Put your question and then put that in afterwards, and what that will do is it will force the algorithm to bring content from those societies up to the top. Number three, be mindful about who you're seeing. So is this person truly an expert? Are they a physician who is board-certified in that area? Or are they someone who has less expertise, for example, a naturopath or a chiropractor? Does the person sell supplements, okay? Supplements are untested, unregulated pharmaceuticals. If I sold a birth control pill, if I had Dr. Jen Gunter's birth control pill, you would probably rightly think that my information about contraception might be suspect. When you have somebody who makes money advertising supplements or even has their own brand of supplements, you should really consider all of their medical information as contaminated, because how do you know it's not a subtle sell to promote their supplements? I would be very mindful about getting health advice or health recommendations from celebrities. And while it's great that people wanna raise awareness, often the way they talk about different medical conditions or physiologic states like menopause isn't always evidence-based.