324. Perimenopause is Real

Summary

Podcast Summary: You Are Not Broken – Ep. 324 "Perimenopause is Real"

Host: Dr. Kelly Casperson, MD
Guest: Jackie, Women's Health Nurse Practitioner
Release Date: June 29, 2025

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Episode Overview

In this engaging and informative episode, Dr. Kelly Casperson welcomes women's health nurse practitioner Jackie to have a candid, nuanced conversation about perimenopause—what it really is, why it's so misunderstood, and how care and treatment need to evolve. With humor, candor, and personal anecdotes, they smash the myths and dismissals women face during this transition, empower listeners with science-backed insights, and advocate for symptom-driven, preventative, and individualized care.

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Key Discussion Points & Insights

1. Defining Perimenopause: Demystifying the Taboo

• What is Perimenopause?
  • Textbook definition: "The time around menopause," but this is vague and insufficient ([04:16]).
  • Median age: 47 (from studies like the SWAN study), but wide individual variation—symptoms and onset can start even in the mid-30s.
  • Menopause = one year without a period; Perimenopause = the lead-up, often 4 years but very variable ([04:16]–[06:31]).

“The perimenopause zeitgeist is brand new. I feel like it's a year old to the three years that menopause has had.”
— Dr. Kelly Casperson ([02:43])

• Traditional medical education covers menopause, but barely touches perimenopause, leading to a lack of awareness even among clinicians.

2. Common Myths & Dismissals

• Myth: It’s Not Real / You’re Too Young
  • Age-based definitions cause unnecessary dismissal of younger symptomatic women ([06:31]–[07:28]).
  • Many clinicians rely solely on age and menstrual status, missing the vast spectrum of experience.

"Age is what you can drive at and vote at and drink at, but it's not what you should make medical decisions upon."
— Dr. Kelly Casperson ([07:33])

• Myth: You Must Stop Having Periods to be Perimenopausal

  • Many people (and providers) wrongly depend on the absence of periods to 'diagnose' menopause, ignoring the multitude of symptoms women experience while still menstruating ([10:42]–[12:24]).

• Myth: Everything That Happens is Perimenopause

  • While not every symptom is due to perimenopause, every woman with ovaries experiences it eventually—though other medical causes should always be ruled out ([12:50]–[14:16]).

3. Symptoms & Lived Experience

• Perimenopause is driven by erratic and declining ovarian function, leading to chaotic hormone fluctuations.
• Symptoms can include: mood swings, night sweats, menstrual irregularities, migraines, breast tenderness, libido changes, fatigue, bone loss, and more.
• The real question women are asking is:
  "Can I get treatment for this?" ([14:16]–[14:42])

"The treatment options are safe, cheap, effective. Like, why not try?... Tolerance of women suffering until menopause is insane to me."
— Dr. Kelly Casperson ([14:42])

4. Medical Understanding & Science Breakdown

• Hormonal Landscape
  • Perimenopause involves “chaotic” communication between brain and ovaries, erratic hormone spikes, and atrophy/fibrosis of the ovaries ([16:25]–[18:24]).
  • It's not simply running out of eggs, but a complex hormonal “shit show” that’s unique to each woman ([20:53]–[21:01]).

“Our bodies being the size they are… Elephant ovaries are bigger.”
— Dr. Kelly Casperson ([16:25])

• Ovaries may still produce some hormones even post-menopause; “zombie ovaries” may explain some ongoing symptoms ([20:53]–[22:21]).
• Testosterone: Declines more linearly from the 20s; the significance is debated ([21:01]–[23:49]).

5. Understanding “Estrogen Dominance”

• Term is often misused online, not a fixed state—high estrogen can fluctuate wildly, leading to migraine storms, breast tenderness, mood changes, etc.
• "Estrogen dominance is oversimplifying...all women in perimenopause are in an estrogen dominant state until they're in an estrogen void state" ([24:36]–[28:10]).
• Cycle irregularity reflects brain/ovary miscommunication—"the wires are totally crossed ... this shit show of a period" ([28:10]–[29:21]).

6. Treatment Approaches: Symptom-Driven, Flexible, Individualized

• Hormone Therapy:
  • Birth control pills: Steady “lazy river” of hormones; can help with certain symptoms, especially if contraception is also needed.
  • Menopausal hormone therapy (bioidentical or “natural”): Targeted, tailored dosing, sometimes only during symptomatic weeks ([30:27]–[33:46]).
  • Progesterone-only therapy can also be effective, especially for sleep/mood ([33:46]–[37:34]).
  • Some clinicians, like Dr. Casperson and Jackie, “grab a surfboard and ride the waves,” adjusting doses as symptoms shift.

“Treating perimenopause with menopausal hormone therapy [is] like grabbing a surfboard and ... getting ready to ride the waves.”
— Jackie ([32:08])

• When to Use Birth Control Pills

  • For cycle control, symptom suppression, and contraception (especially with sperm exposure).
  • Particularly helpful in severe PMDD (linked to drospirenone-containing pills) ([39:00]–[41:50]).
  • Risks: Higher blood clot risk than natural hormone therapy—should be off by age 55 ([41:50]).

• Myth-busting:

  • It is absolutely possible to have hot flashes and periods simultaneously.
  • Migraines may be due more to hormone fluctuation than the hormone level itself ([42:01]).

7. Why Perimenopause Matters: More Than Just Symptoms

• Accelerated health risks during perimenopause:
  • Increased risk of cardiometabolic syndrome, bone density loss, arterial stiffness, lipid changes, and viscosity fat gain.
  • Majority of bone loss happens in the two years prior to the final period ([44:26]–[46:43]).
  • “Not feeling like myself” is a hugely common—but difficult to quantify—marker ([43:38]).

“These are not sex hormones, these are brain hormones.”
— Dr. Kelly Casperson ([46:43])

8. Practical Takeaways & Modern Paradigms

• Individualized assessment: Track symptoms, use data, empower women to direct their own plans.
• Start with low-hanging fruit: Address hot flashes, vaginal dryness, sleep, mood, with safe, proven interventions first ([51:12]–[51:52]).
• Prevention: Early intervention may decrease future risk of osteoporosis, heart disease, diabetes ([49:19]–[51:52]).

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Notable Quotes & Memorable Moments

• On Medical Gaslighting:
  “Gaslighting them and telling them to suck it up. Hope that helps. Thanks for your copay.”
  — Dr. Kelly Casperson ([16:25])

• “Estrogen Dominance” Reality Check:
  "Calling someone estrogen-dominant oversimplifies the issue…it's just Tuesday, next month your estrogen could be in the bucket again."
  — Dr. Kelly Casperson ([23:53])

• On Baseline Dismissal:
  “Every woman in her 30s is completely dismissed.”
  — Dr. Kelly Casperson ([56:11])

• On Tracking and the Millennial Generation:
  “We've been tracking shit on our phones since 2002...we know how to track stuff. We've got rings and earrings and watches and phones and everything to get data.”
  — Jackie ([35:15])

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Timestamps for Key Segments

• Intro & Importance of Perimenopause: [00:48]–[02:43]
• Defining Perimenopause; Medical History & Studies: [04:16]–[06:31]
• Myths About Age & Symptoms: [06:31]–[08:57]
• Symptoms, Treatment, and Suffering: [08:57]–[15:17]
• Science of Hormones & Ovarian Aging: [16:25]–[22:21]
• Estrogen Fluctuations & "Estrogen Dominance": [23:53]–[29:41]
• Treatment Philosophy — "Surfing the Waves": [30:27]–[33:46]
• Stages of Perimenopause & Tracking: [35:15]–[37:34]
• Birth Control — When & Why: [37:34]–[41:50]
• Migraines in Perimenopause: [42:01]–[43:38]
• Accelerated Health Risks (“the gas pedal”): [44:26]–[46:43]
• Lab Testing & Preventative Care: [49:19]–[51:52]
• Bone Loss & Osteoporosis: [51:52]–[54:06]
• Healthcare System Strain & Solutions: [54:06]–[55:32]
• Dismissal of Young Women: [56:11]–[57:27]
• At-Home Hormone Testing & Consumer Trends: [58:15]–[60:00]
• Expert’s Role: Patient Navigator, Not Gatekeeper: [60:00]–[60:53]

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Final Takeaways

• Perimenopause is real, complex, and worth treating. Every woman’s journey will be different—care must be individualized and proactive.
• Symptoms are valid. Whether you’re 35 or 55, being dismissed on the basis of age or menstrual patterns is unacceptable.
• Both hormone therapy and birth control have their place—tools, not dogma.
• Prevention, education, and self-tracking will be increasingly vital, especially as a new, empowered generation hits midlife.
• The conversation is evolving rapidly. Nuance, openness, and patient-centered care are the future.

“If we all agreed on everything all the time, the earth would still be flat.”
— Dr. Kelly Casperson ([61:31])

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Resources & Further Learning

• Monday Night HER Medicine — Dr. Lisa Larkin hosts weekly clinician education on menopause and perimenopause ([62:41]).
• Dr. Kelly Casperson—Adult Sex Education Masterclass & Membership:
  www.kellycaspersonmd.com

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This episode is a must-listen for anyone approaching midlife, those experiencing mysterious symptoms in their 30s or 40s, or partners looking to support loved ones. Dr. Casperson and Jackie offer a validating, actionable, science-based conversation about what perimenopause is—and why it’s time for cultural and clinical change.

Transcript

[Dr. Kelly Casperson]

This is a real good story about Bronx and his dad, Ryan, Real United Airlines customers.

[Ryan (United Airlines customer, Bronx's dad)]

We were returning home and one of the flight attendants asked Bronx if he wanted to see the flight deck and meet Kath and Andrew.

[Jackie (Women's Health Nurse Practitioner)]

I got to sit in the driver's seat.

[Ryan (United Airlines customer, Bronx's dad)]

I grew up in an aviation family.

[Dr. Kelly Casperson]

And seeing Bronx kind of reminded me of myself when I was that age.

[Jackie (Women's Health Nurse Practitioner)]

That's Andrew, a real United pilot.

[Dr. Kelly Casperson]

These small interactions can shape a kid's future.

[Jackie (Women's Health Nurse Practitioner)]

It felt like I was the captain.

[Ryan (United Airlines customer, Bronx's dad)]

Allowing my son to see the flight deck will stick with us forever.

[Dr. Kelly Casperson]

That's how good leads the way.

[Podcast Host (Dr. Kelly Casperson, intro/outro)]

Welcome to the youe Are Not Broken podcast. I'm your host, Dr. Kelly Casperson, a.

[Dr. Kelly Casperson]

Board certified urologist, thought leader, and conversation.

[Podcast Host (Dr. Kelly Casperson, intro/outro)]

Starter on midlife living, hormones and sexuality. Enjoy the show.

[Dr. Kelly Casperson]

Perimenopause. What is it? Is it real? Does it exist? Is there treatment? Should everybody just be on birth control? That's what we're going to talk about today. Thank you so much for coming to the you're Not Broken podcast, Jackie.

[Jackie (Women's Health Nurse Practitioner)]

Oh, thanks so much for having me.

[Dr. Kelly Casperson]

Kelly, tell us where you practice.

[Jackie (Women's Health Nurse Practitioner)]

Okay. Yeah, I practice in north of Atlanta in a town called Marietta.

[Dr. Kelly Casperson]

And you're current, you're currently studying for your doctorate?

[Jackie (Women's Health Nurse Practitioner)]

Oh, yes. Yeah, I'm finishing that up. So I did a really cool project where we integrated routine menopause care paradigm into primary care. So. So I am in the process of finishing that up. I'll be done, God willing, in a couple of. Yeah, congratulations. Couple of weeks. Thank you.

[Dr. Kelly Casperson]

So how did you get into the perimenopause talks?

[Jackie (Women's Health Nurse Practitioner)]

I think perimenopause became particularly interesting to me over the last seven years, probably because of all the crap I dealt with after having my second baby. And just hormone land was not a peaceful place for me anymore after kids. And then when you've been in women's health for the better part of two decades, you start kind of drawing these parallels between your patients and yourself and you're able to kind of share stories. Isn't that what we all used to do, is sit around fires and share stories with each other and like commiserate? So I started kind of. I had some postpartum depression and anxiety, and then I would kind of, kind of listened to some of my patients and their stories and what they'd be going through and just started drawing these parallels together. And then I started my perimenopausal symptoms at 36, which is about three years ago. And then it just kind of took me down this rabbit hole like we don't learn anything about perimenopause. You learn about menopause in med school and nurse practitioner school and PA school. And then that's like it. It's like menopause. No more periods and end of sentence. And then like, cool. We're just send us off into the sunset. Right?

[Dr. Kelly Casperson]

Yeah. The perimenopause zeitgeist is brand new. I feel like it's a year old to, like, the three years that menopause has had.

[Jackie (Women's Health Nurse Practitioner)]

That's the thing. It's like menopause is having a moment. Right. But I think that there is going to be a surge of the discussion shifting to perimenopause. And when I actually was digging more into perimenopause. We have to understand, too, that the millennial generation, which is on the cusp either just entering. So the geriatric millennials, as we lovingly like to refer to ourselves. So that's going to be anybody from, like, your late portion of your 30s into your early 40s. We're just dipping our toes into the perimenopause water.

[Dr. Kelly Casperson]

We're basically all perimenopausal at this point.

[Jackie (Women's Health Nurse Practitioner)]

Yeah, yeah.

[Dr. Kelly Casperson]

The elder millennials.

[Jackie (Women's Health Nurse Practitioner)]

I mean, we're like the largest aging generation, next to the baby.

[Dr. Kelly Casperson]

Yeah. Because Gen X is like the wee, teeny bits. Actually, Gen X, the oldest of the Gen x is turning 60 this year, which blew my freaking mind, because I don't think. I don't think of it that way. But somebody said on my Instagram this week, they're like, well, it's too late for Gen X. So hopefully the many millennials will, like, figure out how to treat perimenopause and menopause. And I was like, excuse me. Like, it is not too late for the Gen next. Hold on. We're not moving that fast. So for people, like, the many myths about perimenopause, a common one is. Is it even real? So let's start with the definition. When people ask you what perimenopause is, how do you answer that?

[Jackie (Women's Health Nurse Practitioner)]

So, literally speaking, if you were to go look it up in a textbook, it translates to the time around menopause. What the hell does that even mean?

[Dr. Kelly Casperson]

Yeah, do you know when you're going to have your last period? Because then we'll be able to tell you if you are within 10 years of that.

[Jackie (Women's Health Nurse Practitioner)]

No, I think didn't even start writing about. You know, we have historical accounts of menopause dating all the way back to, like, ancient Greece and Hippocrates, but we didn't even start like actually documenting what we call the climacteric is what it's sometimes referred to, or perimenopause until like the early 1900s. So this is a fairly new concept. And it was always associated with just stopping of the periods, right, the tracking of the periods all around, like fertility and whether or not a woman could get pregnant. And we've only more recently started associating it with all the other barrage of symptoms, right, that so many of us are starting to really connect the dots to. But textbook wise, it means the time surrounding menopause or leading up to menopause. And we've decided in this country that the median age is 47. And that's largely based on observational studies. There's a study out of Australia, there's the Seattle Midlife Women's Health Study that was done. And then the biggest one that's lended us the most data is called the SWAN study or the Study of Women across the Nation study. And basically what they did is they just took women. And here's the kicker, they took women ages like 40 to 45. There's no studies that took women in their mid to late 30s. So they took women 40, 45 and over. And then they basically did some blood work on them and they had some symptom tracker and some menstrual cycle tracking data and just basically said, all right, when did you start? When did you start to experience these symptoms in and around your menstruation? And they've plotted it and decided the median age is 47 and then the median symptom duration is 4 years. But then that was kind of updated with the SWAN study that came out showing that your ethnicity also changed the years in which you experienced death either shorter or longer.

[Dr. Kelly Casperson]

I think the age based nomenclature is so troubling both for menopause and perimenopause, because when you say a number, people aren't thinking that's the mean and 50% percent is below that. And what's the two standard deviations within that, which is what that number is meant to do. But instead we say, oh, 47 for Perry, 51 for menopause. So you're too young. And like Jackie, you would be dismissed because you're in your 30s and you're. Whatever thing you're experiencing is something different because you're too young for perimenopause. I get that all the time. I'm too young.

[Jackie (Women's Health Nurse Practitioner)]

People don't understand the basic statistical concepts. They literally just say, oh, it's this age, they don't understand that it means that there's an equal probability of experiencing it at a younger age. And at an older age, it's not that age. So it's super frustrating because if I had a dollar for every time a woman told me she was dismissed because somebody told her she was too young.

[Dr. Kelly Casperson]

Age is what you can drive at and vote at and drink at, but it's not what you should make medical decisions upon.

[Jackie (Women's Health Nurse Practitioner)]

A hundred percent.

[Dr. Kelly Casperson]

Ever. And so I'm like, at my daughter's soccer practice and this woman comes up, one of the moms comes up to me and she's like, I need to come see you. Because I was just at my doctors and they said, I'm too young to go on hormones. And like, this woman's symptomatic. And I'm like, how old are you? And she said, her age, which was my age. And I'm like, you're not too young. And furthermore, like, where the thought leaders are. And I'm jumping ahead because we're like, okay, it's real. It's like it happens when you're young. And the thought leaders are treating perimenopause with hormones because we're in the belief of why are we going to lose our maximum bone density and then try to make up for it? Why are we going to wait for depression and then treat it? Why are we going to wait for our labia to go away and then try to bring it back? Like, I think really in the 10 year, if we can jump straight ahead of like, where's perimenopause care going to be 10 years from now? It's gonna be way more preventative than it is right now. And I think that's reflected in the thought leaders who say, you know what, let's preserve bone health, let's preserve mental health, let's preserve genital urinary function, let's start hormones. And certainly the use of a period existing in your life to say whether or not you can use something is absolutely meaningless.

[Jackie (Women's Health Nurse Practitioner)]

Yeah, no, a hundred percent. I think that this is the crux of the essence of primary preventative care. Right. And not just telling women when they present with XYZ symptoms, oh, you're too young for that, or, oh, you have a while, so you have to worry about that. Or, or, or it's like, okay, well, let's actually look at what's happening with the typical age that this happens at. And let's. If you're not having anything now, let's prepare for it, or if you are, let's assess what you're experiencing and how that's going to affect you five to ten years from now. What can you do right now to make changes or to work smarter, not harder, or whatever you're doing in now? Because the plan to keep us out of a declining frail state in our 70s and 80s starts now in the 30s and the 40s and makes me like want to strangle the people that tell women this.

[Dr. Kelly Casperson]

And I just, I want to drive home the point for the listeners of like, I'm sorry you're miserable but you still have a period, so you're just going to have to deal until your period ends. The absolute lack of logic to that statement, huh? Okay, I'll throw an IUD in you so you don't have a period. Will you treat my perimenopause now? Oh, I'll get a uterine ablation so you don't have a period. Will you treat your perimenopause now? Completely irrelevant. And I think where it comes from. Tell me if you have a different opinion. People's lack of understanding what the heck perimenopause is in the first place, which is massively fluctuating hormones towards the eventual decline of hormones. If you don't know what perimenopause is, then you can't possibly understand why it would be important to treat it.

[Jackie (Women's Health Nurse Practitioner)]

No, certainly I think that it's the complete lack of understanding on what exactly is. Because we've based the definition of menopause on this concept of you have to be the biggest issue. And the most problematic thing is that we base the definition of menopause on one full year without a menstrual cycle. And that leaves so many women out of the conversation. And it leaves so many women out of the conversation right now. I mean, one in 10 women are of reproductive age. Are utilized long term forms of contraception. Well, most women who have IUDs are not having regular periods, so how the hell are they going to know when they've been one year without a period? I mean, I've been eight years without a period. So I mean, when we have the definition of menopause as one full year without a period, then we leave out so much of the experience of perimenopause from that conversation. And we also get hung up or get in trouble or dismissed when they're having regular menstrual cycles still and having perimenopausal symptoms. And their clinicians or whomever they're seeing will say, oh you can't be perimenopausal because you're having a normal menstrual cycle.

[Ryan (United Airlines customer, Bronx's dad)]

This episode is brought to you by Progressive Insurance. Do you ever find yourself playing the budgeting game? Well, with the name your price tool from Progressive you can find options that fit your budget and potentially lower your bills. Try [e-mail] Progressive Casualty Insurance Company and affiliates Price and coverage match limited by state law, not available in all states.

[Jackie (Women's Health Nurse Practitioner)]

And that's ridiculous. You can still have fairly regular menstrual cycles and be experiencing symptoms of perimenopause that can be mediated by certain interventions. And yet we just have this like we've put, we put the period up on such this pedestal of like this one parameter that needs to be met in order for you to check any box that is worth anybody to listen to you.

[Dr. Kelly Casperson]

Yeah, I mean I think the other common thing that's said is like everybody just thinks everything is perimenopause. And it's like, no, everybody doesn't think everything is perimenopause. But this does happen to a hundred percent of women. This is a hundred. Thyroid issues could be, could masquerade, diabetes can masquerade as it. But those two things don't happen to a hundred percent of women. So actually the common denominator is in this point in life, perimenopause is happening to everybody with ovaries because this is the start of the end of the ovarian lifespan.

[Jackie (Women's Health Nurse Practitioner)]

Yeah, well, and that's, I think the one area where the time sensitivity of this issue actually helps us because it's like, well, not everything is perimenopause. But we do know in and about around this time women are going to start experiencing this. So there's a pretty damn good chance that this is what it is. And if it's not, this is a great opportunity to come on into the office. And I'm sure you've got a question for this Kelly about when to check if not to check hormone levels, et cetera, et cetera. But I actually use this time in women that come to me as a, as a clinician and say let's look at some other things because there are also, you know, thyroid is one of the things is very commonly will appear in midlife as becoming under functioning and other things will appear. Well, let's check for those. And if those are all good to go, well then what else is it going to be? I mean save working you up for like we call it unicorns versus horses.

[Dr. Kelly Casperson]

Usually in the medical world probably it's commonly the horse. So, like, a woman came in, she was perimenopausal age, and she's like, but is it perimenopause? But is it perimenopause? And she just kept, like, harping on it. And, like, you learn a thing or two after talking to people for this many years, and you realize they're asking it. They're actually asking a different question. What she's actually asking is, can I get treatment for this?

[Jackie (Women's Health Nurse Practitioner)]

Yeah, right. Can I do something?

[Dr. Kelly Casperson]

Can we do something about it? And so it's like. Cause it's like, it might be, it might not be. There's no clinical test. I can't put you in a CAT scan yet at this point and scan you for perimenopause the way Dr. Moscone's going with the tracers in the brain and how accurate it is as predicting menopause. Like, there's going to be something at some point. But the treatment options are safe, cheap, effective. Like, why not try the whole, like, tolerance of women suffering until menopause is insane to me.

[Jackie (Women's Health Nurse Practitioner)]

No, 100%. And I think we've just sort of normalized this experience. And I'm like, oh, this is just what it is. Like, sorry. And we make a large effort at other parts of women's lives when they're having babies or going through difficulty having babies or going through puberty and experiencing menstrual cycle changes in that time of their lives. And I think that we, you know, gynecology is. That's the world that I come from as a women's health nurse practitioner is that, you know, we really do a full court press in those areas to try to help women navigate these challenges. But somehow, when we get to perimenopause and menopause like crickets, all of a sudden it's like, oh, no, no, no. This is just a part of getting older. And so I think we just need to largely change that conversation and say, well, what can we do? And it doesn't always have to involve a prescription pad, although usually it does, but it doesn't have to involve pharmaceuticals. There are a lot of things that we can do to help women feel better. But again, the one thing for sure that's not going to help them feel better is just saying that this is a part of getting older.

[Dr. Kelly Casperson]

Gaslighting them and telling them to suck it up. Hope that helps. Thanks for your copay. So just for people to understand, the ovary makes follicles. Follicles make the hormones within the follicle is the egg. Rewind this and listen again if you need to, because we're going fast. But the follicle is starting to putz out. There's only so many follicles based upon the size of the ovary. Our ovaries are the size they are because of the. Our bodies being the size they are. Elephant ovaries are bigger. So ovary is a certain size at some point. With years on Earth, the follicles, you're. We're just starting to run out of them. As we're running out of hormones, the brain is saying, hold on, you're not making as many hormones regularly as you used to. So the brain starts telling the ovary, hey, work a little bit more to get this going. And then sometimes we'll actually have pretty high hormone spikes because the ovary kind of like doubles up on some shitty follicles to try to keep the party going. Would you like to explain that in any different way?

[Jackie (Women's Health Nurse Practitioner)]

No, I think. I mean, I think you explained the chaotic ness of it really, really well. I always tell people that perimenopause is very much a moving target in terms of symptoms, but also in terms of what's happening biochemically when the hormones. So, yes, I mean, we are born with the amount of eggs and follicles that we will have. And over our lifespan, they. We either will ovulate them or we. They will die off. And each month we prepare a certain amount, and then one is chosen as that dominant follicle that either ovulates or doesn't ovulate. And then the rest kind of die off. And then this repeats itself over and over. And then by the time we get to whatever our personal natural age of menopause is going to be, we have pretty much run out of. And also the quality goes down. Right? Just like every.

[Dr. Kelly Casperson]

It's not totally true that you have no eggs left. You do have egg. The follicles are kind of shitty at this point. They're just old.

[Jackie (Women's Health Nurse Practitioner)]

It's the. So we experience something called atrophy within the ovary. And then we also. There's something called fibrosis, where the tissue kind of becomes. It's kind of what happens to other areas of our body, right? I mean, the aging process happens everywhere, and it's happening within the ovary, and the follicles and the ovary are just not as able to produce functioning eggs that will produce a healthy baby, if that's the goal at that age. And so essentially what happens is the ovary becomes less responsive to those hormones. And the brain doesn't take the hint. So the brain just continues to pump out its hormones and just kind of provide as much gas as it thinks it needs to in order to elicit a response from the ovary. So this is where we see a certain hormone called follicle stimulating hormone. We're not very creative in medicine. It's liter, literally, follicle stimulates, stimulating the follicles in the ovary. And it raises up, it goes high, and then the estrogen levels go down low. But in the midst of the beginning to the middle part of perimenopause, these hormones can be all over the place. And it's really hard to catch them consistently. Where you're gonna get an accurate picture of it's more towards the end of the perimenopause journey, really within that last like one to three years where you start getting more consistently elevated follicle stimulating hormones. Because ovary is for the most part, just completely out to lunch. It's done. It's like, no more. No thank you. Closed for business. So I sometimes will say it's like the ovary going out of business sale. But I did want to say one more thing to what you said earlier, is that one thing that drives me crazy. And as a women's health np, I cringe every time a woman tells me, oh, yeah, I had a hysterectomy and I just had my ovaries removed. They said, I'm done with those. And you actually had somebody on your podcast. And I can't remember the exact episode, but I still think of it all the time. And I'm like, we don't know what the ovaries are doing in a menopausal state, because nobody has cared to study that. And it is also a myth that once you're menopausal, you'll never have a bleeding episode again sparked by ovarian hormones. I call it the zombie ovaries. The zombie ovaries. They'll come back. Because your ovaries do have some potential to create hormones in a menopausal state. It's not to the degree that's usually going to bring a normal menstrual cycle and fertility. But I could go off on a tangent on this forever. It's fascinating science to me. And I'm like, we need to know more about this.

[Dr. Kelly Casperson]

I think the other thing, I see this a lot in the testosterone dismissive culture of like, but your testosterone doesn't go down with menopause. And I'm like, That's true. The ovary has a more linear decline of testosterone starting from your 20s. But that's like a big. People will use that as like a. Testosterone doesn't fall off a clip with menopause. And I'm like, well, that's kind of. That's a fact, but also kind of meaningless when it comes to, like, should we treat women or not? But, you know, I had a gynecologist, she did a bilateral oophorectomy with a hysterectomy. And a woman in her 70s. And you, you would assume and think like, the ovaries aren't doing much, right? And she's like, this woman literally hit a wall. She could hardly get out of bed. And it was above and beyond what, like surgery, you know, surgery is a hit and takes a while to recover. She's like, this woman acted as if I put her into menopause. She hadn't had periods for decades, but she acted as if I put her into menopause that day from the surgery, do you think I should put her on some testosterone? And I'm like, it's not going to hurt her. Put her on the testosterone. She's like, so she did. And she's like, she came back, man, like. And so for us to assume that the ovary is doing nothing, absence of evidence doesn't mean evidence of absence. Meaning just because we haven't researched it doesn't mean there's nothing there.

[Jackie (Women's Health Nurse Practitioner)]

Right. Well, and I always say it's like, how do you explain. How do you explain the women that are able to very vibrantly and actively live in, you know, without, you know, we're just now, within the last five years, really heavily starting to have a good hormone conversation about the resurgence of menopausal hormone therapy. Right. And I think it's only going to continue to grow like a snowball. But how do you explain all these women that have lived in this largely hormone void past two decades? But there are, there are a group of women who have lived into their 80th and 90th decade and have been relatively healthy and have good bones. And you know what is different about them?

[Dr. Kelly Casperson]

I mean, the other, going back to testosterone, like, we've totally segued off of perimenopause. Sorry, listeners, we'll get back on there. But like, you know, we know that testosterone has a little bit of, call it a surge, call it a bump, whatever you want in the 70s. And the theory is that's actually heart protective for those people. But what I've never Seen is are all those people that have that surge, do they all still have ovaries? I haven't seen that breakdown. Do people who've had oophorectomies not get that, you know, natural testosterone surge when you're in your, and we're not talking 20 year old testosterone here, but like enough of a bump that it seems to have a cardioprotective effect? Is that only in people who've had ovaries preserved? The researchers probably know I haven't looked short of this conversation. I haven't actually thought about that.

[Jackie (Women's Health Nurse Practitioner)]

Well, there we go. There's your, there's your weekend.

[Dr. Kelly Casperson]

There's my weekend research. So the other question about perimenopause before we get into treatment is something called the loop cycle or the really high estrogen. Let's describe that for people. And I think we're. What I hate about the term estrogen dominance is number one, it's tend to be used by people who aren't prescribers on social media. But what I, the other thing I don't like about it is people tend to behave as if it's a fixed state. And the fact that I'm estrogen dominant means I'm going to be estrogen dominant for my entire life. And that's not what anybody actually means by estrogen dominant. Of like, no, it's just Tuesday next month, your estrogen could be in the bucket again. So let's talk about the loop cycle and how that has and the truth of the estrogen dominance from time to time.

[Jackie (Women's Health Nurse Practitioner)]

Well, estrogen dominance is oversimplifying the whole process of perimenopause. I mean most women, or should I be so cavalier to say all women that are in perimenopause are in an estrogen dominant state until they're in a estrogen void devoid state. I mean, that's just kind of the nature of it. And so let's explain that a little bit. So your entire reproductive life, your body has relied upon, let's just say if you haven't been on oral contraceptive pills to navigate your cycle. But if you're on nothing, your body's relied on this beautiful dance between the brain which we were talking about, and your ovary and then responding to one another and the brain soliciting a response from the ovary, the ovary developing a hormonal response to that solicitation and then them chatting. You know, we call that a feedback mechanism. And so them talking back and forth to one another to send messages back to let everybody Know what the status is and what that Status is, is 1, did the ovary generate a follicle in order to produce an egg for that month, for which to turn into an embryo for fertility that month? And the second is, did the uterus respond, ingest and prime that uterine lining in order to receive that egg, that fertilized egg, and that has become an embryo in order to develop into a pregnancy, if that's what happens for that month. And so we're used to that sink first, we start with estrogen the first half of the cycle, and we build up. That's where we have high estrogen levels. And then the estrogen declines. And then we see coming in of the progesterone, which is made largely from the follicle that ovulated on the ovary. We call that a corpus luteum. So when we go into perimenopause and we lose a lot of the good quality egg function from our ovary, what ends up happening is we get a dysfunction in that cyst, in that corpus luteum on our ovary, which produces progesterone. So we're not producing enough progesterone to stabilize out that lining. So estrogen builds the lining of the uterus into this thick, lush tissue, right? And that's what our period is. And so the progesterone supports it, it kind of stabilizes. I kind of call it the mortar. Estrogen is like the bricks. Progesterone is like the mortar. And so you have that, you have a corpus luteum dysfunction where it just doesn't last as long, it's not producing enough progesterone. It's like the months you think you ovulated, but then you did an ovulation stick and you didn't come back with an ovulatory level. And then what ends up happening too is you get this. The messages become mixed and the wires become crossed and you almost get like a superimposed period over period. So the lining, the in the lining of the uterus doesn't really know which phase it in. Is it in a growing phase or is it in a shedding phase? And so the loop cycle essentially is you just get these out of phase events where you either don't bleed at all or you bleed all the time. And these are the people that are the patients or the women that will come to me and say, great, I had two periods this month that was cool. Or they'll say, oh, I skipped, you know, six weeks, eight weeks, whatever it was, and then boom. I had a period and now I'm regular again. So this whole dance between the pituitary gland in the brain and the ovary and the uterus, the wires are totally crossed. So you get this shit show. Sorry. Of a period or lack thereof. And that's what a loop phase is.

[Dr. Kelly Casperson]

Yep. And the estrogen can go really high. And that's where women are like, my breasts are really tender. I'm super moody, maybe I've got crazy headaches. So they really do present estrogen dominance. But that's not a permanent condition.

[Jackie (Women's Health Nurse Practitioner)]

Right. Well, and when the progesto. When you have. And we call them anovulatory cycles, where you didn't ovulate that month because your body didn't have the hormones or the ovarian function to produce ovulation that month and so you don't have progesterone. Well, yeah, you're going to be estrogen dominant because you likely were producing estrogen in anticipation for that ovulation and then you didn't. So you are inherently estrogen dominant in and of itself with that. And so that's what I'm saying. Saying somebody's estrogen dominant oversimplifies the issue. But again, yeah, these erratically high estrogen levels are what bring on the migraines or the heavy cycles, the erraticness of the cycles, the mood going all over the place. It's the. We're used to this reliable, our employees showing up to work when they're meant to show up to work and the operations work smoothly. And then all of a sudden things are going crazy.

[Dr. Kelly Casperson]

But I think that's why perimenopause is a challenge to even menopause providers. Because post menopause, the dogma is start with the estrogen, do you need a progesterone or not? Based upon uterus. And then testosterone's like the super special sidekick that some people know about and are fine with.

[Jackie (Women's Health Nurse Practitioner)]

Right.

[Dr. Kelly Casperson]

Like that's your post menopause hormone diorama. And then in perimenopause, though it's not always right to start with estrogen. You can start with progesterone. You can start with testosterone, even for some people. And again, this is not lab test based because you can test labs. I'm not saying don't test labs, test labs if you want to see where things are. But know it's a moving target. And we really do, we do treat symptoms more and that might look like the week before your period. We treat you with hormones, you know, or for the first two weeks after Your period. We don't treat you with hormones and then you do. So it's very symptom based. Based upon what's bothering her and understanding it is a moving target.

[Jackie (Women's Health Nurse Practitioner)]

Yeah, well, and that's how I, whenever I go at treating perimenopause with my patients, I, I use this analogy. I say either when we look at, there's two different rooms, I guess you could say in terms of how we treat perimenopause, old school, you know, the old kind of dogma. And thinking of how you treat perimenopausal symptoms is to put somebody on a birth control pill. And that's largely based on trying to just dampen this hormonal fluctuations and this chaos. Because hormonal birth control pills come in and they override the communication system between your brain and your ovaries and they give you a steady state of hormones all month long. So I liken that to we say the perimenopause roller coaster and then we're putting you on the carousel. That's my analogy that I like to use.

[Dr. Kelly Casperson]

I was thinking of like the lazy river.

[Jackie (Women's Health Nurse Practitioner)]

Yeah. Or lazy. Yeah, that's great. The lazy river.

[Dr. Kelly Casperson]

Being on the lazy river, you're not gonna jump. Go down the water slide. I agree with you. Two rooms, two doors, two camps, blah, blah, blah. We have things in our toolbox. We have natural hormone therapy and we have birth control pills. One isn't inherently the only answer we've got. I think true experts know when to use one, when to use the other. I think it's a little heavy handed to say natural hormones for everybody or birth control for everybody. They're both tools in the toolbox.

[Jackie (Women's Health Nurse Practitioner)]

But yeah, if you want to use natural hormones, which in my practice is almost always what I use because most people don't struggle to get a pack of birth control pills from their, you know, primary care, that would be. So my, I'm a little biased because my patient population is coming to me for the menopausal hormone therapy approach. But you have to be pretty darn flexible with that.

[Dr. Kelly Casperson]

And what's that mean? What's that mean to you?

[Jackie (Women's Health Nurse Practitioner)]

Like you said, we base treatment largely off of symptoms. And if perimenopause is a moving target, the, the intervention could look different depending on the time of the month. And so we can dig into this a little bit more. But I'd liken treating perimenopause with menopausal hormone therapy like grabbing a surfboard and getting out there and getting ready to ride the waves. I Mean, that is like my analogy that I like to use, because you might be high during that month, and your estrogen might be really, really, really high, and you didn't ovulate, and all of a sudden you're having sleepless nights, night sweats, all the things, and you're feeling those low progesterone symptoms. And so progesterone might be really great for you, or you might be somebody who is used to having a certain state of estrogen, and you crash when you have low estrogen levels. You get a low mood anhedonia where you just could care less about anything. These are my people that, like, want to sell their home and, like, leave their lives and say goodbye to everything. Or you have migraines because the crash of the estrogen gives you migraines. Well, this is where we're going to say, hey, you can use estrogen during this small window of time, and that might help you. That is a really difficult concept for a lot of clinicians to sit with because it is so much easier. We, like, control, right? Inherently, I think clinicians and medical providers, like, control over things. And we like to know when we implement a treatment modality, it's going to have this effect. That's why we like randomized controlled clinical trials so much. And in perimenopause, that just doesn't happen. It is a moving target, and you have to be okay with it being such a. Yep.

[Dr. Kelly Casperson]

I had a woman, and it was. She was like, the week before my period is hell, I feel awful. Blah, blah, blah, blah, blah, blah. And I'm like, why don't we just throw on a patch the week before? I'm like, do you kind of regularly know when that week is? She's like, oh, yeah, I know. Like, she knows, right? And so I'm like, all right, let's throw on a patch that just that week, see how you do. Saw her back. I'm like, hey, how's that patch going that week before your period? And she's like, it's my favorite week of the month now. That was the big aha, right? It was like, dude, you can change one week for people. It's pretty sweet. And so then I was like, well, do you want to take the patch, like, every week of the month? And she's like, can I? And I'm like, yeah. And I think the other. Another myth is that if you're on birth control, oral birth control is what we're talking about, or that you can't be on the natural hormone therapy is like, no, we're actually. You can play with both at the same time. And some might argue everybody on oral birth control should be on supplemental testosterone because of how much it messes with your testosterone.

[Jackie (Women's Health Nurse Practitioner)]

I think we're just starting to pull the layers of the onion back on that one and start to really admit and recognize the impact that oral contraceptives have on women's sexual function.

[Dr. Kelly Casperson]

Whenever you want to blow people's minds, you tell them two things. You tell them, number one, your labia minora can disappear after post menopause because that seems to explode heads. And the second thing is like, yeah, do you know we actually have data that women probably marry different men based upon if they're on birth control or not? And I'm like, yeah, well, they know there's data.

[Jackie (Women's Health Nurse Practitioner)]

Yeah, we've got a long way to go. We've got a lot of unpacking to do. We've got a lot of dogma to undoing. You know, we've got a lot of. A lot of things. But, yeah, that's the cool thing about perimenopause, too. And I think it's really important for people and women to recognize that there are actually two different stages of perimenopause, which is really kind of cool. There's what we call the early perimenopause and late perimenopause and symptoms. And of early. And you hinted at this with your estrogen patch trick, which is great. I use it all the time, too. Is that in early perimenopause, it's more subtle things changing. It's more like, oh, I just get night sweats during these four days out of the month, or, I just want to kill my husband these days of the month. And so it's because you're not seeing large fluctuations in your menstrual cycle, and thus your hormones are still. They're starting to not be as reliable. You're just getting these little gaps of symptoms. And you can, if you're not using an oral contraceptive to kind of just kind of calm the storm. You can. This is where tracking becomes your best friend in perimenopause and getting data. Now, this is why the millennial generation is not going to take no for an answer, because we've been tracking shit on our phones since 2002. So we're used to tracking. We know how to track stuff. We've got rings and earrings and watches and phones and everything to get data. And so when you can get data and know, okay, this is the time where I'M feeling these symptoms, you can target your treatment to those. And then when you move into the late perimenopausal stage, which is where we actually start to see the period, the menstrual cycles pulling apart from each other. That's when you're like, oh, I skipped a total period this month. I've gone 60 days or more without a cycle. That's actually where you're going to be somebody that's going to probably feel a lot better using menopausal hormone therapy. More like a fully menopausal patient just doing it all the time, consistently. You may need to toggle your dose up and down a little bit, Use a little bit more, use a little bit less. Maybe, you know, if your breasts get super swollen, maybe your ovaries decided to, like, wake up a little bit more that month, you're going to know that. But this is where education and empowerment is so important, because we need to trust that women can know their bodies and we can pass the torch a little bit back to women.

[Dr. Kelly Casperson]

These medications are so safe, too. What I love to do for progesterone and sleep, and I'm like, take one to two a night. You're gonna know, like, that's what I do. I'm like, am I gonna need a little more help sleeping tonight? I might dose 200. I think that's where a lot of hormone experts are, is like, dude, is this stuff safe? And I trust that you can dose based upon where you are and how well you think you're gonna sleep. And now with, like, the whoop and the aura ring, and you could track your sleep. I'm not saying people have to do that, but, like, you can start seeing, like, my gosh, I'm sleeping better when I do the patch or the progesterone or what it may be. Let's talk about again, because I want to demystify. I think one of the myths is, like, the menopause experts who are. Who are, you know, big, super fans of natural hormone therapy, that we hate birth control pills. And I want to dismantle that of like, no, no there. If you've got sperm in your life that you ain't want to make a baby with, natural hormone therapies is not going to help you. You get pregnant on that stuff. Furthermore, that stuff's used in fertility clinics, right? Like, watch out. If you're still getting periods, you can get pregnant. Protect yourself from sperm if that's what you want to do. So if you need to protect, that's what I always ask women because they love how I say it, because I like to shock them a little bit. I'm like, do you need to protect yourself from sperm? And they're like, what? Birth control, great for protecting yourself from pregnancy. Mellows out the super heavy periods. 20% of women will have the heavy periods in perimenopause. When else are we going to use birth control?

[Jackie (Women's Health Nurse Practitioner)]

Specifically, there's a condition called premenstrual dysphoric disorder, which is. Is like the evil twin sister of PMS or premenstrual syndrome. So PMS or premenstrual syndrome really is like, I'm bloated, I'm a little bit moody and irritated right before my period. I want to, you know, grab a bag of potato chips and just sit on the couch and watch Gilmore Girl reruns. Like for, you know, that's pms, right? But PMDD is the evil, evil twin of that. Where it is. I mean, it is a true deep, dark dip into a depression. Oftentimes it can be a rage. I mean, it's. It's what we liken to, like, almost a very parallel condition of, like, severe postpartum depression where the decline and the fluctuating nature of the perimenopausal hormone chaos your brain. And we, and we think there's a vulnerability. We think that there is a vulnerability in some people's brains that they just cannot, cannot take that up and down and side to side. They need a steady state of hormone production. And those individuals do much better on a combined oral contraceptive pill. And there's one specifically that works better than the others. And it's when the progestin or the form of progesterone is in something called drospirenone. And there's a couple different products out there that have drosparenone specifically in them. Nextellis, Slend and then Yaz, Yasmin B. Yaz. And as long as you know those. Those types of products. But that pmdd. And then when periods are hell and control your life and when you, as you say, you need protection against sperm, those are the big ones that are going to. Oral combined contraceptives are going to be better in perimenopause. They just are.

[Dr. Kelly Casperson]

Risks of oral combined contraceptives, the risk of blood clot is higher than natural hormone therapy. It's still low, but it's there. And it is higher than natural hormone therapy. Just for the statistics nerds, it's lower than your risk of clot with pregnancy. So it's still very low. But I think, you know, when we're looking at putting older and older women on birth control pills, oral birth control pills, that is a risk. I heard from a woman this week that, you know, she was perimenopause, started on an oral birth control pill, got a blood clot, and is now super freaked out that she can't be on natural hormone therapy because she got a blood clot on birth control pills. Right. So it's like, well, no, transdermal eliminates that risk, and natural hormone therapy is much lower. But that's one thing to consider that I think people. People blow off risks of some meds and then overemphasize risks to other meds. And I think that's not applying the weight of risks fairly. And then they usually say, at age 55, you should be off the oral birth control pills.

[Jackie (Women's Health Nurse Practitioner)]

Yep. And they say that because 90% of women will have gone through natural menopause by age 55. So that's actually where that recommendation comes from.

[Dr. Kelly Casperson]

Yeah. Average age of menopause is 51. But if you stop birth control and then you still have periods, you can still get pregnant. And so they're like a year with no natural periods is when they say, you don't need birth control if you. If you have sperm in your life that you need to protect yourself from. The other myth I want to talk about is women will say, oh, I can't have estrogen because I have such bad migraines. And it gets worse in perimenopause. And the thing I always want to tell them is the brain's very sensitive to fluctuation more than what the actual level is. So people assume the migraine is from estrogen when the migraine can be from fluctuating hormones.

[Jackie (Women's Health Nurse Practitioner)]

It's why the symptoms. And this. This goes back to, like, the first part of our conversation, Kelly. It's why perimenopause, in my mind, is almost more important than menopause or the term menopause is because this is when it all is happening and the things. This is where it's the worst. Because, honestly, a lot of stuff actually tends to level out once you. Once your ovaries have fully decided that they're done and this is over and no more periods. A lot of the hot flashes and the night sweats do tend to level out. Things tend to get better. So a lot of women, the migraine storms and the things that happen actually accelerate in perimenopause because it's the estrogen going from super duper high to then crashing up and down. And that which is where a lot of times the symptoms become problematic. Is that that fluctuating nature of perimenopause?

[Dr. Kelly Casperson]

Yeah, I love that. And I think, you know, you, you have recently done a talk about perimenopause, and one of the things you emphasize that I really like, because again, people are like, oh, it's just fluctuating hormones. Yes. And what that means, increased cardiometabolic syndrome, increased bone density loss, increase arterial stiffness, increase in lipid changes, increases in visceral fat gain. Biggest bone loss is in the two years prior to last period. So your body is changing. It's not just, are you feeling things? Are you not feeling things? And I want you to expand on that. But one more thing is the rate of women saying, quote, I don't feel like myself is about 60% in perimenopause. If my arteries can't dilate as well, that's a big problem. But I can't feel it. But I certainly can feel if I don't feel like myself.

[Jackie (Women's Health Nurse Practitioner)]

So I think it's really important to know that in perimenopause, your body is kind of stepping on the gas in terms of a lot of these biological health risk, it's accelerating. And so a lot of these health risks that we associate with a postmenopausal state, it accelerates. So these cardiovascular disease markers, like you said, it gets increases. And if you look at it on the charts where they studied it, you'll see this, like this straight shot up in terms of these risk factors accelerating. You know, the interesting thing you say about not feeling like myself, that was actually a paper that was published in 2024, is that you can measure the thickness of the arteries, you can measure body fat composition, you can measure bone parameters. You can't measure not feeling like myself, can't measure that. And so I think that's where a lot of women, where we find ourselves in this culture of dismissal, because it's like, oh, you're just being a woman kind of thing. And that's why we can get brushed off, because these things that we can't quantify. But I do think, like you said, 60% of women report not feeling like themselves. And I think that when we have this cultural narrative that menopause is hot flashes and night sweats, and we don't recognize that a lot of it is also these changes that are less measurable, it's really important for us to kind of change this narrative, because I think a lot of Women miss out on some of these when we see that these health risks accelerate in perimenopause. But yet we take women who are not feeling like themselves and that's what they're coming into the office saying, we're brushing them off instead of recognizing that this is a hallmark of this and this is when we should intervene and try to promote these things and say, oh my gosh, I'm so glad you brought that up. You're not feeling like yourself. This is why, this is what happens to your hormones and why they make these changes in your brain and your body and your fatigue level and all of these things. And this is why that's happening. And I'm so glad you brought that up because you know what else is happening? All these other things, and this is the time where we can really make sure that we're going to set you out the door on the right foot.

[Dr. Kelly Casperson]

It speaks to two things. Number one, the fact that these are brain hormones, these are not sex hormones, these are brain hormones. Not feeling like myself is a brain thing. That's a brain blood flow thing. And then number two, what you were saying in the beginning of the podcast, which is all of these things that we don't want when we're 74. I can't guarantee you're not gonna get em, but if you wanna decrease your risk of getting them, you need to start early. And what's early? Early is within 10 years of menopause. But the new data says perimenopause. It's going to take a long time to get this data. But what we're going to do is we're going to look at the perimenopausal women who've been treated with hormones and we're going to look at their outcomes 10 years down the line compared to the people who didn't get the hormones. And that's where the data is going to be. Frankly. I'm not going to sit around holding my breath waiting for that because I will be 58 when that data comes out.

[Jackie (Women's Health Nurse Practitioner)]

Right?

[Dr. Kelly Casperson]

But I look at the soccer mom and me at the beginning of this podcast and I'm like, shit, she's my age, she's told she's too young. What am I doing now? This. Cause I'm a thought leader in the space. But I got Estriol on my face, I've got some hormones in my vagina, I've got testosterone, I've got an estrogen patch that I don't wear when I have higher estrogen. Like breasts were Tender the other day I'm like, fuck, take this patch off, right? Like, because I'm in perimenopause and I dose my oral micro progesterone as needed for sleep with my progesterone iud. So I'm like, do you have two women who are the exact same age? One's actually going into her doctor suffering and being denied treatment. The other one's not suffering and is on all the things now. That's your N of two study. But it happened this week in my town.

[Jackie (Women's Health Nurse Practitioner)]

But I see it all the time. Everybody asks me, well, do you do any marketing? And I'm like, no, I don't do any marketing. Because you treat one woman and then she goes and goes to lunch with her girlfriend and then what happens? They're all like, I want that too. I want that too. I want to feel better and whatever that looks like, you know, not every person is going to have. We have pretty generalized prescribed like therapies and what's like a general kind of oh, you're not sleeping this. Okay. Usually we're going to give this. But most women have very differing regimens. And it's. It doesn't even always have to be hormones either. Like, I can see somebody at 39 that's just starting to feel this way or that way. And I'm like, okay, cool, let's just recognize this. Let's just start talk like tracking and charting and like, let's just get some data behind us and figure out what's what here. And just validating in that things can they are what they are and what that looks like over time for you.

[Dr. Kelly Casperson]

I think the role of checking labs, like, to me, I'm like, listen, my lipids started to move. And I would tell you I didn't. I wasn't eating anything different than I was before. Like, I'm that person, right? But it's like your lipids start to move. I didn't want to wait for my A1C to start to move.

[Jackie (Women's Health Nurse Practitioner)]

A lot of women are coming in and this is what I teach a lot of other clinicians and I teach a mentorship for clinicians. And they'll say, what do I do? While all these women coming to my office wanting their labs checked. And first I go, well, just check the damn labs. Like, it's not the hill to die on people. Just check them. And then when they come back, what they are teach. Right? That's what we're meant to do. Teach. But at the same time, I'll say, there's A lot of other things that you can, that you have an opportunity to check here that make a huge difference on somebody's assessment of their overall health. And that's where you make a difference in somebody's life. You dying on this hormone checking hill is, I don't know, I think it's a little ridiculous in my opinion. Everybody's like, we have to practice cost effective health care. And I'm like, well, yeah, I could find a lot of other. Yeah, I can find a lot of other things that were totally.

[Dr. Kelly Casperson]

And in the practice of checking labs is the clinician patient relationship of. I felt, listened to, I felt like they did care. I felt like they looked and it was fine. And that reassured me, right? It's like all of these soft touches. That is the point. Even if you don't air quotes, find something that was wrong. It's like you looked. And to me, I'm like, the fact that we tell people not to screen for vitamin D and then have like, crazy data on dementia, depression, osteoporosis, cancer, and all the other shit that low vitamin D cause, like, is related with, like, that's insane to me to tell people not to check a vitamin D. The party line is you don't check vitamin D. It's like, don't check vitamin D, but then only supplement when low. And I'm like, well, how do you know it's low if you aren't supposed to check for it in the first place? The whole guideline is messed up.

[Jackie (Women's Health Nurse Practitioner)]

No, 100%, 100%.

[Dr. Kelly Casperson]

I know, I know people, like, want guidelines, but it's like the guidelines that are out today will change. That's why we don't use guidelines from the 1970s, because shit's changed. It moves pretty fast. But at the end of the day, there's so many people are like, where do you even start? And I'm like, start with the low hanging fruit. Start with the very symptomatic women who clearly just need vaginal estrogen and like some hot flash control. Like the low hanging fruits being untreated. And then, you know, we, we get to podcast for hours about, like, do we do preventative health with hormones and blah, blah, blah. It's like I have the immense privilege of having that conversation, but it's like 80% of women have hot flashes. That's low hanging fruit.

[Jackie (Women's Health Nurse Practitioner)]

No, it is totally low hanging fruit. And one in, one in two women will have an osteoporotic fracture in her life. This is another, like, kicker that I get is that hormone therapy is FDA approved for the prevention of osteoporosis. Perimenopause is. We see an acceleration of bone loss. And so at this one could argue, you know, we're not doing enough in here, in this world there. So I think that, you know, there's a lot of cleaning up to do and there's a lot of kind of like sorting through the noise of what we should be doing and what we are doing. And I think that, you know, also I try largely not to throw my colleagues under the bus in this realm because I think that this type of care is also very nuanced. It takes a lot of time and attention and it takes a lot of not being in a space of being burnt out in your profession. Because you had a great post on Instagram the other day that was like OBGYN's day is, is really, really, really hard. And I just had, you know, a fetal demise and I had this that I had to work up. And I mean we have largely kind of nobody owns menopause. And if nobody owns menopause, then no one owns perimenopause at all. But if somebody owns it, it's OB GYNs, right? Because we've just thrown it onto them. And frankly, we don't have the time nor the mental space in the world of ob GYN to deal with this because that's where it's like, how do I have the time to sit here and talk to somebody about not feeling like themselves when I just had these medical complications that take up so much more brain space for me? I mean, we have to kind of see where that hierarchy is going in the. We only have so much capacity as human beings. Right. Like, and so I think that this is going to largely take like a lot of structural changes just in general. And I think it's why it's so important to push the narrative that we need to start focusing our efforts towards perimenopause and understanding and conceptualizing what is happening in perimenopause. Because what's happening is we're waiting for women to get so far off the deep end, so bad and so miserable from a symptom standpoint and then from a health standpoint that that overburdens the healthcare system. How are we going to do it, Kelly?

[Dr. Kelly Casperson]

It's very overwhelming. My opinion is like we're going to get telehealth and telemedicine to do one to many to get people out of the clinic, like to do basic, basic low hanging fruit and then we're Going to have concierge care so you can really get educated, understand it, get dialed in. Once you're steady, good to go, refills up. Primary care. We got to utilize every tool we can do here because they all are different pieces. And then, like, as far as the numbers game, we have 28,000 OB GYNs for 80 million women over the age of 40. That's not including the women who, like, are pregnant under the age of 40. And so I think one of the critiques that I get from OB gynes and, you know, not everybody again, of course, but it's like, these women are coming in complaining about these issues, and I'm already freaking busy. Listen, you can't stop the dam of an educated populace coming in and deserving what's they pay for health insurance, too.

[Jackie (Women's Health Nurse Practitioner)]

And we've got 72 million millennials coming down that dam. I mean, that's totally.

[Dr. Kelly Casperson]

I'm thinking of the millennials with the Tamagotchis. And they're like, we started out tracking the Tamagotchis, man. I know. I know exactly when my estrogen's high, I can take care of a Japanese fluffy computer. I can track my cycles. Because we're the older generations. Like, you don't want to track stuff. You don't want to do that. And they're like, oh, yeah, I did this in kindergarten. I can track.

[Jackie (Women's Health Nurse Practitioner)]

I think it starts by listening to women, trusting women that they can handle the information and they can handle navigating the space with a little. Little bit of our kind of medical support and access, I think access. And I agree with you, I think telehealth is massive into that. And then having a little bit more of an open mind about what is the experience of menopause, and is it what we've always thought it was? And there's some variability there to kind of what our standards are. I mean, I actually largely believe that our numbers criteria as far as, like, when this starts and how long this lasts, I think that will evolve too, as time goes on.

[Dr. Kelly Casperson]

Every woman in her 30s is completely dismissed. If women go into menopause at 45, which is within a standard, two standard deviations of 51, that means their perimenopause is mid-30s. Let's. I want to wrap up by going back to what you said in the beginning. You're talking about a pregnancy kind of like catapulted you into the perimenopause. I'm convinced. And this is me listening to women, not doing research, listening to women. There's something about a later pregnancy that is the final hurrah for the ovary. And then the ovary's done. Many, many, many women are like, I have my baby, then I hit menopause. I have my baby, then I hit super symptomatic perimenopause. And so I was at the menopause conference last fall, and there was a reproductive endocrinologist there. And I'm like, here's my theory. My theory is the older ovary that gets a pregnancy, does the pregnancy, and then it's freaking done. And there's no papers on that. What do you think? I'm like, I'm this crazy podcaster, urologist, right? But I've been like, you listen to enough people. And she's like, oh, totally. And I was like, I just felt so validated. I was like, okay, the reproductive endocrinologist thinks that's a thing because that's what all the women are telling me. Like, I had my last BA. Baby was at 41, and then perimenopause hell from there on out.

[Jackie (Women's Health Nurse Practitioner)]

Well, what I wish is that we had more information on ovarian reserve and we knew just more. We were able to like, trap people, you know, the ovarian reserve. I think that this is just one of those areas where we simply. I don't know. I think it's fascinating.

[Dr. Kelly Casperson]

Anti mullerian hormone. Like, you know, the question is, like, what lab is gonna tell you? I can't quote it, but it's like if once you start skipping a period, that is a sign that you're within two years of menopause, right? And then like, you know, an FSH of a certain level, it's not 35, but it's not 2, right? And it's like that FSH is starting to show to go up. So people are like, starting to learn. And people are like, what are you going to do with that information? It's like, well, I don't know yet. But like, it's information more and more.

[Jackie (Women's Health Nurse Practitioner)]

Direct to consumers, right? Like, how many? I've had, like, three different companies reach out to me via social media on their, like, home hormone detection kits. And they're all right now under the guise of like, fertility, right? Like fertility tracking. But it's the natural progression is all into perimenopause.

[Dr. Kelly Casperson]

And this is big business too.

[Jackie (Women's Health Nurse Practitioner)]

They're not.

[Dr. Kelly Casperson]

Like, people aren't starting these companies to be nice. Like, there might be a nice intent behind it, but, like, there's big dollars. There's a company. I'm not going to name names. There's a company and all it does is labs, direct to consumer labs. Like crazy labs. Like, are you allergic to coffee? Right. And like very, very comprehensive labs for thousands of dollars. I'm like, it doesn't even solve the problem, it just gives you access to labs. You still have to find somebody to help you with any. So I had a friend who's like, dude, my husband did these. Paid over a thousand dollars for comprehensive labs on a very pretty website. This company is valued at over a billion dollars. All it does is labs and he can't find anybody to treat his low hormones.

[Jackie (Women's Health Nurse Practitioner)]

Yeah. So that's why I like tell people, I'm like, don't die. That's why I'm like, when I educate clinicians, I'm like, don't die on the hill of not checking women's hormones because be careful what you wish for. Because now all of a sudden you're going to get, now we're going to have a whole generation of women that have at home hormone testing. I'm not saying don't do it, but I'm just saying now we're going to self fed data and coming in with the binder of hey, I've been tracking my hormone levels and this is my 7,000 hormone levels over the last three months. What do you think about this? And so it's coming. And I think that the direct to consumer market is filling the void where women have felt gate kept and I think that. And where we have lack of data and lack of awareness.

[Dr. Kelly Casperson]

Yeah, I think the clinician's role isn't so much can you get labs or not? That ship is sailing. You can go get your own labs. Now the role is, let me help you interpret them. Because you can't just take one estrogen in perimenopause and one fsh and perimenopause and understand everything. Right. So it's really the expert becomes the navigator and the interpreter, not the gatekeeper.

[Jackie (Women's Health Nurse Practitioner)]

100%. Yeah. Let's navigate these symptoms together. What's going to work best for you and what's going to work best for you at different points in that journey of perimenopause. Because let's not forget this can be a 10 year long process. So it may not be the same treatment that you start with, certainly may not be the one that you end with. And you can switch it up in between. And like you said, you're on an iud. We've got this, we've got that. Like we can mix and Match treatment therapies. And it needs to be highly tailored to the individual. I mean, that's all about being patient, centered.

[Dr. Kelly Casperson]

And I'm glad you brought that up, because I never want anybody to be like, Casperson's on all these things. That's what I should do is like, I want people to understand your options, understand why you're on, what you're on. But this isn't a beauty pageant. This is not a compare and despair. This is not a somebody's got all the answers to the test. Like, this is an individual journey. Bonus points if you've got somebody like Jackie or me or somebody that you can actually help navigate.

[Jackie (Women's Health Nurse Practitioner)]

Yeah, but I know. I think we really just started the conversation, Kelly. It's like, this is such a can of worms and it will continue to be at the forefront of the conversation, even with it.

[Dr. Kelly Casperson]

Like, you know, I said like, perimenopause has been a year long discussion where menopause has been like three years at this point. But it's like it's moving fast. The black and white is already becoming nice and nuanced on. Like, check labs. Don't check labs, only oral birth control. No oral birth control. Plus, blah, blah, blah. Like, can you have a hot flash and periods at the same time? Yes, you can. You know, like the nuance, the. The black and white of it's already turning into this beautiful mosaic. And that's what we want. You know, like everybody, everybody's like, why can't everybody have a consensus? It's like, because if we all agreed on everything all the time, the earth would still be flat.

[Jackie (Women's Health Nurse Practitioner)]

We would have never gone to the moon would be. Yeah, right.

[Dr. Kelly Casperson]

The earth would still be revolving around the sun. Like, the conversation is the progress and the fact that it's happening is super exciting.

[Jackie (Women's Health Nurse Practitioner)]

No, 100% I agree with you.

[Dr. Kelly Casperson]

Ah, well, thank you so much for giving the talk on. On your Monday night. Let's plug that. So for clinicians, it's not secret. There's a secret Monday night consortium. It's actually run by Dr. Lisa Larkin. How can people kind of sign up for that if they want more education there?

[Jackie (Women's Health Nurse Practitioner)]

Yeah. So it's called her medicine. And Dr. Lisa Larkin, past president of the Menopause Society, started this platform. And it's. Monday nights are geared towards clinicians. Anybody? I mean, really anybody? It's more clinician facing. And then she also started. She's also starting a patient facing platform this year as part of a nonprofit. But yeah, so she brings on experts every Monday night. And she was so kind to asked me to come speak about perimenopause a couple Mondays ago. And it was a great experience. And yeah, we had almost 300, 250 people on there learning about perimenopause. So I'm all for it.

[Dr. Kelly Casperson]

I love it. One of my big question about perimenopause is if we start women on early to make their bodies not bottom out on the estrogen, right. Are we going to see less autoimmune disease? Are we going to see less thyroid issue? Are we going to see less kind of these things that start. It's like, you don't want to break your hip when you're 82. I get it. But it's a little trippy because it's four decades from now. But like, the right now thing is diabetes, autoimmune diseases, depression, the thyroid stuff that starts kicking in, and all of the osteopenia and bone loss that we're not tracking because we're not checking anybody's freaking dexis. So, like, that's going to be the interesting pair once we start doing re. Because it's like, who is. Besides Geraldine Pryor, who I don't think is doing tons of perimenopause research anymore, who are the perimenopause researchers?

[Jackie (Women's Health Nurse Practitioner)]

You know, it's. There's Nanette Santoro out of Colorado who's been doing this forever, but few and far between. But I agree. Yeah, Prior hasn't put out a paper in a while. Prior is a big progesterone person. I don't know, maybe it's you and me, Kelly.

[Dr. Kelly Casperson]

No, I'm having too much fun not doing research.

[Jackie (Women's Health Nurse Practitioner)]

I know somebody, somebody step up to the plate. Let us know who you are, publish.

[Dr. Kelly Casperson]

Your papers and come on my podcast. I am the translator, not. Not the grant writer. God help me. Thank you for joining us on the youe're Not Broken podcast. We're going to help a lot of people feel very validated, heard, and that perimenopause is something worth treating because shit's going down in your body and it's real. Thanks for coming on.

[Jackie (Women's Health Nurse Practitioner)]

Thank you for having me.

[Podcast Host (Dr. Kelly Casperson, intro/outro)]

Thank you for listening to this week's episode of youf Are Not Broken. If you want to dig deeper with me, sign up for my Adult Sex Education Masterclass where you learn adult things like communication skills, anatomy lessons and desire types, and how to talk to your doctor about sexual health concerns. If you want the Adult Sex Education Masterclass for free, join my monthly membership for more in depth exclusive content, more time with yours truly a private podcast coaching and educational empowerment and you can watch my interviews live and get them immediately without advertising. Head over to www.kellycaspersonmd.com for the membership and Adult Sex Ed Masterclass members. Get the masterclass for free. This podcast is presented solely for educational, entertainment and informational purposes only. I am a doctor but not your doctor in this format and all of my platforms and guests including on this podcast are not giving individual medical advice or practicing medicine. See and consult with your own care team for your individual needs and concerns. This podcast is not intended as a substitute for the care and advice of a physician and therapist or other qualified professional. This podcast does not constitute the practice of medicine in case you were curious about that and no doctor patient relationship is formed. But I still love you. Using the information on this podcast or any of my platforms is at your own risk. Until next time. Remember you are not broken.