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The Diary Of A CEO with Steven Bartlett

Women's Fertility & Lifestyle Debate: Dangers Of Not Having A Period! Fasting Can Backfire For Women

Published October 16, 2025
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About This Episode

The host convenes four female health experts from exercise physiology, fertility, OB/GYN menopause care, and orthopedics to discuss women's hormonal health across the lifespan. They cover research bias against women, differences between male and female physiology, menstrual cycles as a vital sign, PCOS and endometriosis, contraception, fertility planning, perimenopause and menopause, and the role of lifestyle and hormone therapy in long-term health. Throughout, they emphasize that missing or irregular periods, chronic inflammation, and insulin resistance are early warning signs and that women can and should advocate for better-informed care.

Topics Covered

Women's health advocacy Hormones and metabolism PCOS Endometriosis Infertility Perimenopause and menopause Fasting Intermittent fasting Insulin resistance Bone density and osteoporosis

Disclaimer: We provide independent summaries of podcasts and are not affiliated with or endorsed in any way by any podcast or creator. All podcast names and content are the property of their respective owners. The views and opinions expressed within the podcasts belong solely to the original hosts and guests and do not reflect the views or positions of Summapod.

Quick Takeaways

  • A regular, predictable menstrual cycle is a core marker of whole-body health; chronic irregularity or absence of periods is a red flag, not a convenience.
  • PCOS and endometriosis are common, underdiagnosed, and underfunded conditions that begin as hormonal and inflammatory problems but strongly affect long-term metabolic, cardiac, and fertility health.
  • Most contraception options work by suppressing or overriding natural hormone signaling, which can have downstream consequences for bones, mood, libido, and performance, especially in young women.
  • Chronic inflammation and insulin resistance-shaped heavily by diet, sleep, stress, and exercise-are central drivers of many women's hormone-related problems, from PCOS and infertility to poor egg quality.
  • Perimenopause often begins in the late 30s or 40s, long before periods stop, and is characterized by chaotic hormonal swings that can profoundly affect mood, cognition, sleep, and cardiovascular and bone health.
  • Only a small fraction of eligible women are offered or use menopause hormone therapy, despite evidence it can alleviate symptoms and slow some disease processes when started at the right time.
  • Female physiology-including muscle fibers, bone behavior, heart disease patterns, and cellular responses-is fundamentally different from male physiology and cannot be treated as a niche variant.
  • Amenorrhea from overtraining, under-eating, or contraceptive use is harmful, especially during critical bone-building years; building muscle and eating adequately are protective for lifelong health.
  • Fertility declines steeply with age due primarily to egg quality, not just egg count, and egg freezing in the late 20s or early 30s can preserve options, though it is not a guarantee.
  • Employers can materially improve women's health and productivity by offering flexibility, understanding cyclical variation, and providing practical supports like childcare and compassionate leave around pregnancy and loss.

Podcast Notes

Framing the conversation: why women's health needs its own discussion

Opening stakes and scope of the episode

Host states that irregular or absent menstrual cycles are harmful to long-term health, affecting brain, mental health, energy, mood, and libido[0:12]
Episode will address fertility, hormones, PCOS, birth control, miscarriage, menopause, diet, and exercise for women[0:42]
Four leading female health experts with over 80 years combined experience join to discuss women's health from different fields[0:28]
Host calls this one of the most important conversations ever on Diary of a CEO and urges listeners to share it with both women and men[1:42]

Guest backgrounds and lenses

Stacey: exercise physiology and sports medicine background[3:13]
• Focuses on how activity and nutrition affect stress, adaptation, health span, mood, and body composition
• Worked with endurance and high-performance athletes, now applies that knowledge to active and recreational women
Natalie: fertility doctor and IVF clinic owner[3:55]
• Daily work is helping patients get pregnant via IVF
• After her own pregnancy losses, became passionate about natural fertility and how environment and lifestyle change hormones and aging of eggs and hormones
Mary: OB/GYN with focus on menopause after her own experience[5:15]
• Realized during her own menopause that her training had siloed women's health to reproductive organs only
• Left an academic post and residency program directorship to re-educate herself on menopause care and now wants to change training
Orthopedic sports surgeon guest: focus on mobility, aging, and women's whole health[4:56]
• Has cared for elite athletes and researches musculoskeletal aging and longevity
• Career mantra is to change how we age by preserving mobility to prevent chronic disease

Why women's health is different and under-researched

Women are the majority, yet treated as a niche in medicine and research

Women are 51% of the population and make 80% of healthcare decisions, but less than 1% of $450 billion in research funding goes to women over 40[6:56]
Women live about six years longer than men but spend about 20% more of their lives in poor health with chronic disease or mental health disorders[7:30]
Women have roughly twice the rate of mental health disorders, are twice as likely to end up in nursing homes, and more likely to lose independence from frailty or dementia compared to age-matched men[7:56]

Historical and structural bias in research

Modern medicine and science were built by men who excluded women based on beliefs like 'smaller brains', leading to male bodies being the default study model[8:56]
Many foundational trials (e.g., aspirin for heart attacks, ACE inhibitors) were done in men and generalized to women[9:23]
Women were not required to be included in clinical studies until 1993, and even then there were loopholes and women still are not at 50% representation[9:56]

Key physiological differences between women and men

Muscle and metabolism differences[11:02]
• Men have more fast-twitch muscle fibers suited for power; women have more endurance-oriented fibers, affecting metabolism and glucose handling
• Men have stronger bones, larger hearts, bigger lungs, and more hemoglobin; testosterone plays a central role in these differences
Cardiovascular disease differences[12:14]
• Men often develop large artery blockages near where coronary arteries leave the aorta (e.g., 'widowmaker' LAD lesions)
• Women tend to have more diffuse, microvascular disease deeper in the heart muscle, leading to different heart attack presentations labeled 'atypical'
Cellular-level sex differences[13:26]
• Satellite (muscle-derived stem) cells from XX individuals were better at making cartilage and muscle, while XY-derived cells were better at making bone under identical lab conditions
• Every cell carries XX or XY and expresses genes differently, so sex differences extend to all tissues, not just reproductive organs

Cultural dismissal of women's symptoms and pain

Training-era attitudes: 'whiny woman' stereotype

Mary recounts being taught to label a 40-year-old woman with vague complaints as a 'WW' or 'whiny woman' and to just pat her on the knee and suggest wine and date night[15:27]
• She later realized this was not about one bad supervisor but a systemic bias taught across specialties, with similar slang like 'whiny-gyny', 'status Hispanicus', 'TBD (total body dolor)' used elsewhere
Historical pathologizing of women's midlife symptoms as 'hysteria' or mental illness led to institutionalization for what we now recognize as menopausal symptoms[17:07]

Sport culture and suppression of menstruation

Exercise physiology texts historically depicted only male bodies; female athletes were mainly discussed in terms of pathologies like iron deficiency and the female athlete triad[18:26]
Historically, amenorrheic women were more accepted in sport because they were considered 'more like men', despite amenorrhea indicating illness and overtraining/under-recovery[18:36]

Women minimizing and delaying care for their own pain

Women frequently downplay pain ('no more than regular') and gaslight themselves to avoid being seen as whiny or not taken seriously[19:19]
Orthopedic surgeon observes women often preface complaints by insisting they have a 'really high pain tolerance', reflecting conditioning to avoid seeking help until severely impaired[20:10]

Hormones 101 and the menstrual cycle as a health barometer

What hormones are and where sex hormones act

Hormones are the body's communication system-chemical messengers dictating actions between organs and cells[23:13]
Estrogen receptors are widespread: in brain, bones, endothelium of blood vessels around the heart, and many other tissues[22:55]
Hormones are dynamic by design, responding constantly to multiple stimuli; there is no single static 'hormone level' that explains everything[24:08]

Basic physiology of the menstrual cycle

Brain-ovary communication[27:44]
• Follicle-stimulating hormone (FSH) from the brain drives growth of ovarian follicles (each containing an egg), which produce estradiol (estrogen)
• When estradiol reaches about 200 pg/mL for 50 hours, the brain releases a surge of luteinizing hormone (LH), triggering ovulation and transformation of the follicle into a corpus luteum
Follicular vs luteal phase[28:34]
• Follicular phase: first half of cycle, estrogen-dominant, from menstruation to ovulation
• Luteal phase: second half, after ovulation, when corpus luteum makes progesterone (and some estrogen); progesterone prepares the endometrial lining for potential pregnancy
Progesterone's systemic effects[29:31]
• Progesterone drives glycogen storage in the endometrial lining, shifting how the body handles carbohydrates and influencing exercise intensity capacity
• About three days after ovulation, core body temperature rises, resting heart rate increases, heart rate variability falls, fatigue and appetite increase, and immune function shifts in anticipation of pregnancy

Menstrual cycle regularity as an early health signal

A regular, predictable period (often 25-35 days, consistent within a few days for the individual) is expected; consistent irregularity is a major red flag[31:43]
Lack of education around ovulation timing and luteal phase length means many women can't detect early ovulatory dysfunction (e.g., short luteal phase)[32:09]
Stacey uses menstruation as a marker of health in athletes: if training and travel loads are tolerated while maintaining a normal cycle, they're robust; disruptions signal excessive allostatic load[33:21]

PCOS, insulin resistance, and metabolic health

PCOS as more than a fertility diagnosis

Mary's experience with PCOS[33:56]
• Diagnosed in medical school, initially focused only on infertility fears; was not taught metabolic implications
• Later realized irregular cycles signaled high insulin and long-term metabolic risk (e.g., gestational diabetes, type 2 diabetes)
PCOS prevalence and risks[35:06]
• PCOS is common and a major cause of irregular cycles and infertility; up to 50% of women who develop gestational diabetes will develop type 2 diabetes within 10-15 years
• Infertility itself is associated with an ~80% higher heart attack risk, ~75% higher risk of metabolic syndrome, higher cancer risk, and earlier death; infertility is often an early warning sign of underlying inflammation and insulin resistance

Insulin resistance explained

Glucose and insulin basics[38:00]
• Glucose in the blood is cellular fuel; insulin is the hormone that facilitates glucose entry into cells
• In insulin resistance, chronic high glucose leads to chronically high insulin; cells become less responsive so higher insulin signals are needed, creating a self-perpetuating cycle
PCOS-specific insulin resistance[38:48]
• In PCOS, ovaries become insulin resistant and respond abnormally; many eggs in the ovary dilute normal brain signals, preventing orderly progression to ovulation and progesterone exposure
• High insulin is inflammatory, promotes ectopic fat storage, alters brain hormonal feedback, and worsens both metabolic and reproductive function
Environmental drivers[40:05]
• Modern life is described as 'obesogenic' and 'insulin-resistance-agenic' due to processed food availability, sedentary work (e.g., working from home), and chronic stress

Managing PCOS with lifestyle

Dietary strategies: gut and inflammation[41:55]
• Gut health strongly influences inflammatory burden; fiber-rich plant foods support a healthy microbiome crucial for estrogen metabolism
• Ultra-processed foods fail to feed the microbiome and drive inflammation and insulin resistance
• Natalie recommends a plant-forward (not necessarily plant-only) diet emphasizing whole foods, fruits, vegetables, healthy fats and proteins, and minimizing ultra-processed foods
Foundational lifestyle changes[43:30]
• Prioritize sufficient sleep, as it's when the body fights inflammation and insulin resistance
• Actively reduce chronic stress; modern 'bear' is email or work, which still triggers glucose release without physical outlet
• Regular exercise and building skeletal muscle are among the most effective tools to combat insulin resistance; most women with PCOS and many with infertility have insulin resistance
Common but harmful responses: starvation and overtraining[45:28]
• Many women unhappy with their bodies respond by not eating (coffee for breakfast, delaying eating until midday) which undermines physiologic health and exercise capacity
• Others respond by training excessively every day, raising stress instead of resolving it; both starving and overtraining worsen core issues like PCOS and metabolic health
Sociocultural pressure and fasting pitfalls[45:44]
• Cultural ideals (e.g., 1990s 'heroin chic') push women toward thinness, caloric restriction, and fasted training, undermining muscle and bone strength
• Stacey explains that skipping breakfast and doing fasted training elevates cortisol and acylated ghrelin, increasing hunger and disrupting appetite hormones and circadian rhythms
• Research shows women who extend fasts this way tend to crave simple carbs later, move less incidentally, and sleep worse due to phase-shifted rhythms
Medical model vs lifestyle model in PCOS care[47:45]
• Mary was trained to treat PCOS primarily with birth control pills or Clomid when pregnancy desired; prevention and lifestyle were not emphasized
• She herself was treated for PCOS with oral contraceptives for 20 years and learned about nutrition through online communities, not formal training
• Stacey adjusts training programs for athletes with PCOS toward shorter, high-intensity sessions that produce anti-inflammatory and growth hormone responses, plus careful fueling, to avoid defaulting to oral contraceptives

Why regular periods matter and the dangers of amenorrhea

Health implications of not having a period

Experts stress that women in reproductive years need to have a menstrual cycle; skipping periods is not benign[49:54]
Amenorrhea in youth (e.g., from low body fat, overtraining, or under-eating) is especially harmful because it's a hypoestrogenic state during crucial bone-building years[50:24]
Low estrogen in young women damages long-term brain health, bone density, and overall physiology, even if the woman feels 'fine' not bleeding[50:29]

Shifting attitudes toward menstruation

Host shares that his partner now 'celebrates' her period because she understands it as a sign of overall health and hormonal function[51:19]
Stacey notes persistent high-performance sport beliefs that losing periods shows readiness for elite competition, which experts counter as a sign of imminent injury and breakdown[51:54]
Some women, especially athletes or dieters, resist regaining their period because they view its absence as a sign of training hard or being lean, reflecting harmful norms[52:26]

Heavy or light bleeding, anemia, and iron

When is bleeding too heavy?[52:51]
• Periods should not cause bleeding through clothes, prevent sleep, or interfere with normal activities; if so, it's too heavy
• Heavy bleeding can cause iron deficiency anemia; first lab sign is low ferritin and iron saturations before red cell counts fall
Light bleeding and potential concerns[55:04]
• Any persistent change from a woman's personal baseline (heavier or lighter) is concerning, though a single odd cycle is usually not
• Consistently light periods after progesterone-only contraception, or after uterine procedures (birth, D&C, IUD, intrauterine surgery), can signal a thinned or scarred endometrium (e.g., Asherman syndrome)
Iron deficiency prevalence and changing lab 'normals'[59:32]
• World Health Organization estimates ~30% of women 15-49 are anemic globally, with up to 50% in some South Asian and sub-Saharan African regions, mainly due to iron deficiency
• Clinic targets ferritin 60-100 ng/mL as optimal, higher than typical lab reference ranges; 'normal' labs reflect a sicker population and only mean 'common', not 'healthy'

Endometriosis: underdiagnosed, painful, and systemic

Liv's 17-year journey to diagnosis

From menarche to severe chronic pain[1:03:46]
• Liv had agonizing periods with heavy bleeding from age 13; put on the pill at 14 for symptom control
• Between 15 and 24, had severe stomach pain, multiple emergency visits, often dismissed as gastritis; appendix removed
• At 26, ultrasound suggested endometriosis but she received no firm NHS diagnosis; later private MRI confirmed stage 4 deep infiltrating endometriosis
• By surgery, disease had spread to bowel and pelvis; a 4-cm endometrioma cyst stuck ovaries together and to womb and bowel; she froze eggs before surgery to preserve fertility

Pathophysiology and systemic impact

Endometriosis as inflammatory and possibly autoimmune-like[1:06:16]
• Everyone has some menstrual cells that go out the fallopian tubes during periods; in most, the body ignores them, but in endometriosis, immune dysfunction causes an exaggerated inflammatory response
• Endometrial-like tissue implants throughout the peritoneal cavity and worsens with each estrogen exposure, causing widespread inflammation and scarring
Anatomical distortion and surgical challenges[1:07:28]
• Endometrial implants act like Velcro, sticking organs together; can infiltrate bowel, bladder, and other pelvic structures, stealing blood supply and causing organ damage
• Advanced cases are among the toughest surgeries; distorted tubes and inflamed tissue increase infertility and risk of ectopic pregnancies
Symptoms and diagnostic delay[1:08:10]
• Primary symptoms are pain (especially period pain) and sometimes deep pain with intercourse, particularly with deep penetration
• GI symptoms are common: inflammatory implants on bowel irritate intestines, mimicking irritable bowel syndrome
• Average time to diagnosis is 7-10 years; about 50% of women with unexplained infertility have endometriosis
• Diagnosis is surgical ('no meat, no treat'): imaging can suggest disease but biopsy or direct visualization is needed for certainty
Treatment limitations and fertility impact[1:10:53]
• Many treatments work by reducing estrogen (e.g., birth control pills, other suppressive therapies), which can slow progression and reduce symptoms but don't cure disease and have other health trade-offs
• Stage 3-4 endometriosis leads to less than 20% lifetime chance of conceiving naturally; all stages impair fertility via inflammation and sometimes reduced egg count after cyst removal
Emerging research and lifestyle adjuncts[1:12:28]
• Researchers are investigating cell-surface markers on endometrial tissue and implants to enable less invasive diagnosis, but it's early-stage
• Pilot data suggest 10 minutes of 10°C cold-water immersion daily for 10-14 days before menses, repeated for several months, can dampen inflammation and reduce symptoms by training immune and parasympathetic responses

Contraception, hormones, and their systemic effects

How the birth control pill works

Mechanism of ovulation suppression[1:19:39]
• Combined pills contain synthetic estrogen (ethinyl estradiol) and a progestin; the brain interprets this as a luteal-phase state and stops sending FSH and LH, preventing ovulation
• Synthetic hormones suppress not only estradiol and progesterone production but also ovarian testosterone production
Ethinyl estradiol vs natural estradiol[1:19:57]
• Ethinyl estradiol has an ester group that makes it ~300 times more potent at binding estrogen receptors in the brain than estradiol, hence it's dosed in micrograms vs milligrams

Non-contraceptive use and side effects

Acne treatment example[1:21:07]
• Mary's niece with severe teen acne was offered birth control pills as a later-line dermatologic treatment to lower testosterone and clear skin
• As an aspiring elite athlete, Mary worried about suppressing testosterone and harming performance, so they pursued topical treatments instead
Concerns about bone and long-term health[1:22:34]
• Orthopedic surgeon worries about young women with unbalanced or suppressed natural hormones missing the 15-25 age window when most bone is built

IUDs and progesterone-only methods

IUD mechanisms and potential issues in young women[1:39:27]
• Intrauterine devices create a local inflammatory response and thicken cervical mucus, making the environment toxic to sperm and blocking passage
• Mary's daughter expelled a progesterone IUD within a week due to intense cramping; insertion and expulsion were extremely painful
• Progesterone-only IUDs in young women can sometimes suppress ovulation, lowering estrogen; because amenorrhea is often dismissed as 'just an IUD side effect', low-estrogen harms can be missed
Global variation and new pills[1:41:58]
• A newer pill in the UK uses estetrol, a natural fetal estrogen, combined with progestin; it may have fewer downstream effects and lower clot risk than ethinyl estradiol, but is not widely available everywhere

Hormonal contraception vs natural family planning

Fertile window and NFP limitations[1:42:51]
• The fertile window is the five days before ovulation plus the day of ovulation; sperm can live ~5 days, the egg ~24 hours
• Natural family planning methods that rely solely on cycle timing have high abstinence demands and are not very reliable as primary contraception for most people
Side effects often overlooked in prescribing[1:44:53]
• Clinicians historically considered mostly pregnancy prevention and obvious side effects (irregular bleeding, headaches, clots) but not mental health, mood, and libido changes
• Prescribing priorities differ by age; adherence challenges in teens can make 'fit-and-forget' methods attractive but with their own risks

What the experts would do differently and advise their daughters

Stacey's retrospective on overtraining and under-eating[1:25:03]
• She was amenorrheic until age 20 due to high stress, intensive sport, low body fat, and 1990s 'calories in, calories out' mindset
• Now she would tell her younger self to eat and recover adequately and focus on gaining strength, muscle, bone, and a period instead of losing weight
Mary's shift from thinness to strength and longevity[1:27:11]
• She under-ate and prioritized thinness and cardio in earlier life; now exercises to be in a 'bigger body' with more muscle to resist frailty, dementia, and fractures seen in her mother and grandmother
Natalie's experience with prolonged pill use and celiac diagnosis[1:29:49]
• Took the pill continuously ~15 years, then had recurrent miscarriages and was repeatedly told nothing could be done
• A decade later, low bone density on DEXA led to celiac disease diagnosis; chronic gut inflammation had impaired nutrient absorption
• She worries about being on the pill and chronically inflamed during critical bone-building years and is now trying to 'catch up' in her 40s

Fertility fundamentals, egg reserve, and planning

Five fertility non-negotiables

Natalie emphasizes that while fertility isn't fair, many behaviors can harm or help it even when using IVF[2:02:35]
• Non-negotiables: adequate sleep; active stress reduction (e.g., boundaries, morning light, walks); exercise and muscle-building; anti-inflammatory, high-fiber diet; reducing environmental toxins

Egg count, egg quality, and age

Vault analogy and egg loss over time[2:04:57]
• Women are born with all the eggs they'll ever have; a 'vault' in the ovary holds them and loses eggs every month starting before birth
• Egg count falls from ~6-7 million at 5 months in utero to 1-2 million at birth, then to ~500,000 by puberty; only ~400 are ever ovulated
Egg quality decline[2:06:30]
• Eggs age with the woman; chromosomal alignment and mitochondrial function deteriorate over time, leading to higher rates of chromosomal abnormalities, lower fertility, and more miscarriages with age
• Perimenopause and diminished ovarian reserve are essentially two perspectives on the same low-egg-count state

Egg freezing and timing

Rationale for egg freezing[2:08:20]
• Freezing eggs earlier preserves options in a society where childbearing is purposefully delayed; it's a game plan, not a guarantee
• Endometriosis, ovarian surgery, smoking, chemotherapy, and radiation can all reduce egg count; having frozen eggs can buffer against such hits
Optimal age and financial realities[2:10:33]
• Natalie says 32 is a clear age by which, if not ready to conceive, egg freezing makes sense financially and biologically; her own daughter will freeze eggs in her 20s if kids are a life goal
• Cost (~$10,000 per cycle) and lack of insurance coverage are major barriers; when companies cover egg freezing, uptake rises dramatically

Natural fertility rates by age

Monthly probability of conception (fecundability)[2:21:26]
• In 20s: ~25% chance per month with regular cycles and timed intercourse; at 30: ~20% per month
• At 35: ~10-12% per month; at 38: ~5%; at 40: ~3% per month for a first-time pregnancy attempt
• These declines are driven mainly by egg and sperm quality, not merely egg count, because natural conception uses one egg per cycle

Improving egg and sperm quality via lifestyle

Egg quality levers[2:23:26]
• Age-related chromosomal damage cannot be reversed, but chronic inflammation and insulin resistance can be lowered through lifestyle, improving mitochondrial function and cellular health
• Endometriosis and PCOS predispose to higher inflammation and insulin resistance, so affected women must be especially proactive
PCOS, ovulation patterns, and perimenopause[2:24:54]
• Women with PCOS are born with more eggs and ovulate less regularly when young; as egg counts drop with age, some begin ovulating regularly for the first time
• A woman with longstanding PCOS who suddenly develops regular cycles may actually be losing egg reserve quickly and entering perimenopause, not 'curing' PCOS
Male fertility factors and modifiable risks[2:25:48]
• Half of infertility cases involve male factors; men continuously make sperm, with a ~90-day life cycle (72 days to produce, ~18 days through the tract)
• Men can improve sperm quality by avoiding cannabis, cigarettes, heavy alcohol, and heat to testicles (saunas, hot tubs, prolonged cycling); diet and inflammation also play key roles
• Marijuana suppresses brain FSH/LH, reduces sperm motility and morphology, and increases sperm DNA fragmentation, raising partners' pregnancy loss rates

Pregnancy loss, work culture, and support

Prevalence and language of pregnancy loss

About one in four pregnancies end in loss; most women should not have two consecutive losses, and that pattern warrants evaluation[2:27:54]
Term 'pregnancy loss' is used to encompass miscarriages, ectopic pregnancies, and any failed pregnancy after a positive test, rather than the narrower 'miscarriage'[4:05:52]

Emotional and occupational realities

All four experts experienced pregnancy loss and describe working through it immediately due to training and work culture expectations[2:28:54]
US medical training often allows only a few weeks off after birth; returning early undermines maternal recovery and breastfeeding (milk supply drops under stress)[4:10:07]
Pregnancy loss and postpartum involve abrupt drops from extremely high estrogen/progesterone levels, producing severe mental health and mood effects due to the sharp hormonal 'delta'[4:15:13]

How employers can better support women

Principles for workplace support[4:18:23]
• Offer grace, support, and flexibility around pregnancy, postpartum, and child illness; rigid schedules magnify stress for working mothers
• Provide on-site or 'stopgap' childcare for emergencies (e.g., nanny no-show, sick child), which improves loyalty and productivity
• New Zealand example: 20 hours of funded childcare per week up to age five and policies for menstrual and menopause leave; flexible work hours and extra leave can be used for cramps, menopause symptoms, mental health, or childcare

Perimenopause, menopause, and postmenopause

Definitions and physiology of perimenopause

Perimenopause as ovarian 'stubbornness'[4:32:13]
• As egg numbers decline to a critical threshold (jar partly empty), ovaries become less responsive; the brain sends stronger FSH/LH signals but fewer eggs respond, leading to shorter, then erratic cycles
• Perimenopause starts hormonally before cycles become irregular; women often feel symptoms while cycles are still regular
Symptom profile: 'I don't feel like myself'[4:36:46]
• First reported symptom is often a vague sense of not feeling like oneself (IDFLM), despite unchanged external stressors and still-regular cycles
• Sleep disruption, increased anxiety/depression, and cognitive changes (word-finding difficulty, memory lapses, losing track of destinations) are common
Timing and genetic influence[4:41:41]
• Average menopause (ovarian failure) occurs at 51-52; perimenopause begins ~7-10 years before, so often in late 30s to 40s
• A first-degree relative with menopause before 46 gives a woman ~6x increased risk of early menopause; most patients don't know their mothers' menopause age

Critique of menopause definitions and research gaps

Anachronistic definition of menopause[4:47:00]
• Medically, menopause is defined as a single day: 12 months after the final menstrual period; this requires a year of low estrogen before diagnosis
• Experts argue this definition is outdated and arbitrary (e.g., leap year question) and forces women to suffer a year of estrogen deprivation before many doctors will treat
Severe under-research of perimenopause[4:47:00]
• On PubMed, 'pregnancy' yields ~1.2 million articles, 'menopause' ~99,000, and 'perimenopause' only ~8,000, reflecting where time, funding, and attention have gone
• Mary reports only a single hour on menopause in medical school, and very minimal structured training in residency; perimenopause was essentially ignored

Mental health, suicide risk, and hormone dynamics

Hormone swings vs static levels[4:58:32]
• Data show a ~40% increase in mental health disorders (new or worsening) across the perimenopause transition; SSRI prescriptions double
• Estrogen fluctuations, not just low levels, drive symptoms; the sharp drop from high pregnancy levels (or stimulation cycles) to low levels causes intense brain and mood effects
Suicide risk window[4:58:32]
• Highest suicide risk for women is between ages 45 and 55, aligning with peak perimenopausal hormonal chaos
• In postmenopause, once estrogen levels have stabilized at a low level, mental health often improves and women respond better to SSRIs than they did during volatile perimenopause

Hormone therapy in perimenopause and menopause

Perimenopausal use of estrogen[5:00:22]
• Low-dose transdermal estradiol during perimenopause can calm brain hormone centers without suppressing ovulation, raising baseline estrogen to reduce symptom swings
• Studies suggest early hormone therapy in perimenopause can improve mood and cognition more effectively than SSRIs in some women, whereas this benefit is less clear if started later in postmenopause
Postmenopause as a new baseline[5:05:02]
• After ovarian failure (empty jar), ovaries no longer produce eggs, estradiol, or progesterone; the brain's FSH remains high but cannot extract estrogen from the ovary
• Bones, muscle, cardiovascular system, and vagina continue to decline in low-estrogen state; hormone therapy can slow some of these changes but not stop all aging
Low uptake and risk framing[5:28:26]
• In one US study, only ~4% of eligible women were using FDA-approved menopause hormone therapy; compounding might add slightly more, but uptake remains very low
• Orthopedic surgeon emphasizes that women may think they are 'getting away with' avoiding hormones if symptoms aren't severe, but they can't feel bone loss, microvascular heart disease, or brain changes
Personal HRT regimens[5:10:03]
• Orthopedic surgeon went from high-functioning to severe night sweats, brain fog, palpitations, and body pain around 45; after extensive research, she chose to use estradiol (patch), progesterone, and small-dose testosterone alongside strength training, cardio, diet, and sleep focus
• Mary uses a transdermal estradiol patch plus low-dose oral estradiol at night (to reach bone-protective levels), oral micronized progesterone, and a low-dose testosterone gel (borrowed from male formulations)
• Natalie, still cycling regularly but with shorter cycles, uses low-dose estrogen and finds it clearly improves day-to-day functioning; many reproductive endocrinologists expect to stay on estrogen lifelong

Sex, relationships, and the genitourinary syndrome of menopause

Libido, testosterone, and relationship dynamics

Mary's sexual health experience[5:35:06]
• She reports having the best sex of her life postmenopausally, attributing it partly to testosterone therapy (increased desire and initiation) and partly to better communication and life stage (no kids bursting in, focused relationship work)
• Testosterone is studied for hypoactive sexual desire disorder (HSDD), defined as low desire that bothers the woman; not all women want higher desire, but for those who do, T can help

GSM: painful sex and local estrogen

Physiology and symptoms of GSM[5:41:43]
• Genitourinary syndrome of menopause (GSM) arises when low estrogen leads to atrophy of vaginal and vulvar tissues; sex can feel like 'razor blades' and cause bleeding
• Women often don't tell partners; men may interpret avoidance as rejection, not realizing the physical pain involved
Local estrogen and DHEA treatments[5:43:47]
• Vaginal estrogen (creams, tablets, rings) at low dose restores tissue elasticity, lubrication, and resilience; doses are low enough to be considered non-systemic and not to raise breast cancer risk
• DHEA (prasterone) vaginal inserts are converted locally to estrogen and testosterone, improving sexual function and tissue health, though expensive and often not covered by insurance
• Local estrogen also helps prevent chronic urinary tract infections and supports pelvic floor and uterine support, decreasing prolapse risk
• Important caveat: using standard oral estradiol tablets vaginally can create substantial systemic absorption; only products formulated as local therapies are considered 'non-systemic'

Closing themes: agency, lifestyle, and advocacy

You have more control than you think

Natalie stresses that chronic inflammation and insulin resistance are central to many hormone issues, and women can influence both via sleep, stress, diet, movement, and environmental choices[5:50:14]
Understanding one's own body, cycle, and symptoms allows women to advocate effectively and not feel that menopause or other changes are simply 'happening' to them without options[5:50:14]

Harmful historical treatments and a call for better

Mary describes her mother being given a combination of estrogen and a barbiturate sedative ('mother's little helper') during perimenopause, marketed as enabling her to do housework cheerfully[5:50:37]
Her mother never had a bone density scan, later developed osteoporosis, Alzheimer's, and a hip fracture; Mary is determined to ensure younger generations get proactive, evidence-based care instead of sedation[5:53:13]

Adopting the same advocacy for ourselves that we use for our children

Vonda urges women to approach midlife with the same determination they would use to get answers for a sick child: refuse dismissal, keep asking, and demand appropriate evaluation and treatment[5:55:06]
All agree that more open dialogue, education, and structural support are needed so future generations of women do not repeat their experiences of ignorance, dismissal, and preventable suffering[5:55:30]

Lessons Learned

Actionable insights and wisdom you can apply to your business, career, and personal life.

1

A regular menstrual cycle is not just about fertility; it is a vital sign of your overall health, and persistent irregularity or absence of periods signals that something in your system-energy balance, stress, hormones, or metabolism-is off and deserves investigation.

Reflection Questions:

  • • What does the pattern of my last 6-12 menstrual cycles tell me about my stress, nutrition, and training habits?
  • • How might shifting from seeing my period as an inconvenience to viewing it as a health barometer change the way I respond to irregularities?
  • • What specific step could I take in the next month (e.g., tracking cycles, booking labs, adjusting training) to better understand and protect my hormonal health?
2

Chronic inflammation and insulin resistance sit at the center of many modern health problems-from PCOS and infertility to poor egg quality and perimenopausal symptoms-and are heavily shaped by everyday choices around sleep, food, movement, and stress rather than by a single test or pill.

Reflection Questions:

  • • Where in my current routine do I most clearly see patterns that could be driving inflammation or insulin resistance (sleep, food, stress, or movement)?
  • • How would my daily decisions change if I treated sleep and muscle-building as primary 'medications' for my hormones and metabolism?
  • • What is one realistic experiment I could run over the next 30 days (e.g., plant-forward meals, strength training twice a week, consistent bedtimes) to see if key symptoms improve?
3

Medical systems and research were largely built around male physiology, so women need to be especially proactive-asking questions, seeking second opinions, and learning basic physiology-to avoid dismissal and get care that reflects their biology and life goals.

Reflection Questions:

  • • In past medical encounters, when have I felt my symptoms were minimized or not explored deeply enough, and what did I do in response?
  • • How could I prepare differently for my next healthcare visit (questions, data, history) to increase the chances of getting thorough, sex-specific answers?
  • • Who could I add to my support network (a particular clinician, mentor, or informed friend) to help me advocate more effectively for my own or my loved ones' health?
4

Fertility and midlife health are far easier to protect when you plan ahead: understanding age-related declines, considering options like egg freezing, and addressing perimenopausal changes early gives you more degrees of freedom later than reacting in crisis.

Reflection Questions:

  • • What are my actual long-term goals around family, career, and health, and have I translated those into any concrete timelines or actions?
  • • If I imagine myself 10-15 years from now, what do I wish I had done earlier about fertility planning, bone health, or hormone literacy?
  • • What single proactive step (consultation, fertility assessment, DEXA scan, or financial planning) could I schedule in the next quarter to align my present choices with my future goals?
5

Lifestyle and hormone therapy work best as a package: hormones alone rarely restore full wellbeing, and lifestyle alone may not be enough for everyone; combining evidence-based medication with sleep, strength, nutrition, and stress management offers the strongest platform for healthy longevity.

Reflection Questions:

  • • Where am I currently relying too heavily on either 'a pill' or 'willpower and lifestyle' without considering how the two could complement each other?
  • • How might my risk-benefit view of hormone therapy change if I weighed not just symptom relief but also long-term bone, brain, and heart health?
  • • What combination of lifestyle habits and, if appropriate, medical options could I map out with a clinician to support my health over the next decade?

Episode Summary - Notes by Casey

Women's Fertility & Lifestyle Debate: Dangers Of Not Having A Period! Fasting Can Backfire For Women
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