Caroline Ford: My name is Caroline Ford and I'm a cancer researcher here at the University of New South Wales.
 
I am absolutely delighted to welcome everybody to Science Week. I’d like to firstly begin by acknowledging that we are meeting on the lands of the Bidjigal people who are the traditional custodians of this land. I’d like to pay my respects to Elders past and present and extend that respect and regards to any Aboriginal or Torres Strait Islanders that might be joining us this evening. I think it’s also pertinent to mention in Science Week that Aboriginal and Torres Straight Islanders have a longstanding and deep scientific knowledge ways of thinking about things, and it’s really nice to think how that compliments but is also unique to our traditional knowledge of scientific history.
 
So, tonight you’re all in for a massive treat. We have the pleasure of welcoming the wonderful Dr Jennifer Gunter to discuss her most recent book called ‘Blood’, and to really help us unpack the myths and ideas that are out there around blood, menstruation and menopause.
 
So, I’m going to do a little bio but it’s brief. Many of you I know are big fans already, but Dr Jen Gunter is an internationally renowned obstetrician and gynecologist based in San Francisco. In addition to her most recent and excellent book 'Blood: The Science, Medicine and Mythology of Menstruation', she is the author of two New York times best sellers, 'The Vagina Bible' and 'The Menopause Manifesto'.
 
Applause
 
Jennifer Gunter: Thank you.
 
Caroline Ford: I love the early applause. Jen is one of our fiercest advocates for women’s health and utilises both traditional and social media to educate and really take on medical misinformation. So, we’re really lucky to have her. I also just want to make a quick note about tonight’s event, we’re going to be talking about blood, we’re going to be talking about menstruation, we’re going to be talking about menopause, and we note that not all people who menstruate identify as women and not all women menstruate. So, amongst others, trans men, non-binary people menstruate and go through menopause and it’s actually really important to recognise that our traditional branding of women’s health doesn’t’ really apply to everyone or certainly fly with everyone. So we’ll be aiming to use inclusive language tonight but we might use the term woman when we’re talking about historical studies and the history of medicine because that is the word that has been used. So however, you personally identify I really hope we can all agree these topics are relevant for everyone in the audience and I think you’re all absolutely going to learn something tonight and hopefully have a great time.
 
So, that's enough background, please join me in officially welcoming in Jennifer.
 
Applause
 
So, I’m going to start with one of my period related stories. So, legend has it that in 1983, when I was five for those that want to calculate, NASA sent the first US female astronaut, Sally Ride, to space for one week. The engineers and staff that were stocking the space capsule, which you can imagine is a very precise thing and they need to be very, very exact and account for every gram actually asked Sally Ride if 100 tampons would be enough for a seven-day trip to space. 100! So, Jen, why is this so hilarious? Why are people laughing? Why is this funny to people who menstruate?
 
Jennifer Gunter: Well, it is this idea that they would have no concept whatsoever what’s happening. They probably had no idea the volume of blood. Maybe these men had no idea where this blood was even coming from. Which would not surprise me. There’s three holes? Wow! And they’re like NASA engineers too.
 
Laughter
 
So yeah, this idea that people just have no, no concept at all. It’s like, so you don't even know how much is in a box of tampons. Right? Like you could have gone to the store and looked at a box and said, “Oh there’s 30 in a box. Okay, that might be a good guestimate maybe." But nothing, no thought whatsoever.
 
Caroline Ford: I tell that story to everybody. I find it very instructive. So, let’s go back to the basics about menstruation. So, the NASA engineers didn’t quite get it. Can you talk through what a period actually is and what happens when people are bleeding. So, what sort of volume are we talking about? Is there a normal colour that blood should be? And how should people in the audience know what is a normal period?
 
Jennifer Gunter: Yeah, so. Talking about the actual mechanics of it, studies tell us it is about 80mm of blood. And I know that up to 80mm is normal and I know a lot of people are up here thinking “what?” that’s the actual blood, not the volume. So menstrual blood is about 50% blood and about 50% plasma and sort of other inflammatory mediators that go along with it. We think that you have heavy bleeding if you think you have heavy bleeding. We also think you have heavy bleeding if you are bleeding through your clothes, you have to double up on menstrual products, if when you stand up you have a feeling of gushing. These are all things that tell us you might be bleeding too much. I’m not sure what the equivalent coin would be here but if you have clots that are bigger than the size of a quarter.
 
Caroline Ford: Maybe a 20 cent?
 
Jennifer Gunter: Okay. So those are what we would consider to be abnormal from a bleeding standpoint. And it’s super important because so many women actually have heavy periods but don’t actually know because it’s what they’ve always had. This happens in the office all the time, I’ll say, “So are your periods heavy?”, “Oh no, not at all” and then I go through those questions I’ve just said and we’ll tick of five, and then I’m like “You actually do have heavy periods”. But if nobody ever tells you, what heavy is you would just assume your experience is normal, and if you’re not allowed to talk about it because it’s a taboo, where would you go to?
 
Caroline Ford: Or if, perhaps all the people in your family have the same types of period or we do a lot of endometriosis research in my group and that is definitely familial in some regards. So, if you’re used to pain or have grown with a mother that speaks about it in a certain way it’s quite likely you’ll feel similar.
 
Jennifer Gunter: A friend of mine had terrible periods, it turned out that she had a bleeding disorder. Well, it turned out her mother had the same bleeding disorder. So, she had no cultural reference of anything different.
 
Caroline Ford: As someone who has researched and talked about periods for many, many years. I’m so curious as to what some of your favourite euphemisms for what periods are. I was a teenager in the 90s, so I’m a fan of riding the crimson wave and that’s how my friends and I refer to it. What are the best terms you’ve heard around the world?
 
Jennifer Gunter: One I really like is. Party at the red roof inn. The English are coming, you know because of the red uniforms.
 
Laughter
 
This one I believe is Danish, but there’s communists in the funhouse.
 
Laughter
 
Caroline Ford: Oh yes! That’s a great one.
 
Jennifer Ford: I love the idea of a euphemism that is way more graphic and, in some ways, disturbing than the actual term. Like, you have to dance around same menstrual blood so much you have to come up with something like shark week.
 
Laughter
 
Caroline Ford: So, the idea of women as inferior is steeped in patriarchy and has deep roots in historical Western science and medicine. As you so eloquently write in ‘Blood’, and this is quoting from Jen’s book. “Medicine was created for men and then retrofitted poorly for women. For many years, studying the reproductive tract mattered mostly for improving pregnancy outcomes rather than improving the lives who lived with those reproductive tracts.”
 
So, this absolutely resonated with me because this is a real bugbear as a women's health researcher for me. So, the constant focus of women's health on fertility I feel dismisses, excludes so many people and years of health and even for those who choose to have children, there seems to be this entire second half of life, post 40, that is not researched and not understood and not valued.
 
And so, I research chronological cancers. They are mostly diagnosed post menopause, and I feel like there is such an absence of good information both for the public, but actually as a scientist as well. So, what can we do about this?
 
Jennifer Gunter: I think first of all, talking about it is really important and understanding that what your risk factors are, demanding education about your body. But also thinking about what you are voting for and who makes the decisions about where this money goes. If nobody makes a noise and you keep electing all the same people, then nothing ever changes. For example, in the United States, the people who run the NHS, the National Institute of Health, where most of the research dollars come from, they are all people appointed by elected officials.
 
If nobody says anything, then nothing changes. It is that same experience. Why is women's health lumped under maternal and child health? Maternal health as part of it, but also children's health. Like, really? I don't deserve some kind of information about my body that is separate from being someone who has reproduced.
 
I feel it is really being in the last maybe 10 to 15 years where gynecology itself has sort of become something that is really worthy of high-quality research. It is always sort of lesser quality and maybe some of it was driven by malpractice concerns with obstetrics. Certainly, that would be part of it. Also, people want to give money to help babies have better lives. I'm not saying it is not important, I have children who have significant health issues who benefited from that kind of research.
 
It doesn't have to be one for the exclusion of the other. We should be able to say this is also important. I mean the number of women for example with endometrial cancer who have no idea that is even a kind of cancer they can get. You hear about ovarian cancer because celebrities talk about their risk factors and if they have tested positive. Of course, the news loves to talk about breast cancer because it is breasts.
 
I'm not trying to play disease favourites, but if it is about the breasts or vaginas, it makes the news. If it is not about those things, it doesn't. Because you don't hear about how prevalent endometrial cancer is and also how preventable it is for a lot of people. So we have people come into the office with a cancer that could have been prevented, many of them but the whole system was set up to never give them any information about it.
 
Caroline Ford: I think that’s absolutely true and certainly in Australia, endometrial cancer is our fastest rising cancer and the lack of awareness of that and how it is so tightly linked to obesity and a lot of other modifiable factors is something we are trying to fix. But definitely needs broader recognition.
 
I want to move on to something else, which is sport. You have been in Australia for all of two days, but you may have noticed a lot of our pride comes from sporting achievements in Australia. We have just come off the highs of the Olympics recently. It got me thinking a little bit about menstruation and exercise and athleticism.
 
So, my question is, can athletes optimise their performance by aligning their training with their menstrual phase? The reason why I ask is because I have a friend who used to be an elite swimmer and she absolutely used to swear that all of her personal best times came on day one and a two of her period and she was really bummed out if she wasn't in a race that day or training that day and she was convinced and she convinced all of us. But she was an elite athlete.
 
Is there any evidence for this and how should the very slow jogger consider this in my training regime?
 
Jennifer Gunter: Right, so Instagram loves those kinds of things. So, Instagram worthy, I don’t know why, but it is. I wish I understood the algorithm. So, no, there is really no data to support that. It has actually been studied fairly well considering and there has been a couple of women who I read some great work from a woman at McMaster University who did her PhD thesis on this. So there have been some women who really looked at the data and combed it back. There is no noticeable difference at all.
 
I think for a couple of reasons. If you think about it from an evolutionary perspective, if you are better from running away from whatever was hunting you during a certain time of your cycle, that would probably be very beneficial. But if you also think about it from how you think about yourself and your body, if you really believe that you're going to perform better on a different day, then of course you will perform better. Absolutely. That is why people have their lucky tokens or this or that. The power of your mind is incredible.
 
I would say probably for that individual person. You can also start talking about, well, for example, if you have breast pain and PMS, and well maybe doing arm weights during that time might not be good for you. But that is commonsense, right?
 
If you feel more bloated or maybe you have got period diarrhea, so maybe a long run is not the best time. But these are all common sense. I don't think we need science to tell us this. Sort of in the same way that if you feel cold, you should put a jacket on. I don't think you need science to tell you that. I think there is some of that in there. I think that what the harm that comes of it is that it leaves a lot of people to not engage in exercise. Because you are not doing it perfect. "If I can't optimise it” and there is a little bit of paralysis that can come from that. So, I do see that, I mean it is the same way we see people become fixated on specific diets, but they are missing the forest for the trees. "All you need to do is eat more fiber, all you need to do is get out and move, don't worry about it." If you become an elite athlete and you need to worry about getting all your planks in at a certain time, you will figure it out, you will have a coach.
 
Caroline Ford: I’m going to quote again from your book ‘Blood’, if you can bear it. So, in ‘Blood’, Jen writes "the practice of viewing female physiology as both toxic and lesser throughout the ages has left the damaging legacy of inadequate research, dismissal by a patriarchal medical system, and uncaring society and insufficient education about how the female body works. The consequences are that people struggle to get care and the gaps in medicine are subsequently exploited by a rogue gallery of medical charlatans from the wellness industrial complex."
 
Can you tell the audience what drives you to take on these medical charlatans and this medical misinformation?
 
Jennifer Gunter: Yeah, so, I see harm from this all the time. I mean, people don't get cancer treatment and then who go there is a horrible centre in Arizona where people get IV vitamins for cancer.
 
Caroline Ford: That will fix it.
 
Jennifer Gunter:  Yeah, and then they’ll show up and then eventually they will have the right care, but they have had catastrophic consequences. So, I see people who have a lot of very complex vulva and vaginal issues. So maybe they had a cancer that would have been treatable, but now they have had to have catastrophic pelvic radiation, so now they have really, really bad vaginal damage from that. Or they have had to have massive surgery where they had to have their bladder removed. So, I see those kinds of consequences and that is very bothersome. It just really, really weighs on you. I also see people who come in with bags of supplements that they have bought, and they are not any better.
 
Or they have spent thousands and thousands of dollars on things. And it just breaks your heart. There will also be situations where someone will come and I will say something that I think, something I would say to any patient, and they are, "How did I not know that? How am I 28 years old and how did I not know that?" I keep thinking, "How do people not know that?" It is the fault of our educational system, it’s a fault of our medical system, it’s the fault of our newspapers, it’s the fault the way the news is, it is everything, right?
 
That's what keeps me going. I [SW1] think people deserve information about their body. That's the ultimate in health disparity to have a class of people that know more about their bodies than other people and that is one way to level the playing field.
 
Caroline Ford: Absolutely. I think medicine can't get such a free pass though, right? Not everyone is fortunate enough to have you as their clinician and lots of people have been or had experiences of being dismissed by doctors and so I think it's interesting to consider why they turn to these other solutions. What do you think it is? Is it about the fact that some of these snake oil merchants as you refer to them are expressing care and listening and understanding in a way that may be traditional medicine doesn't have time for? What do you think is the appeal of some of these?
 
Jennifer Gunter: I think it is a complex mix of things. First of all, in medicine, we have to use, if you think about it in rhetoric, we think and double times. We have to say cancer and chemotherapy and medications and side-effects. If you only use God terms which are like pure, clean, natural, there is this built-in propaganda first of all.
 
Having an illness is scary. So, if someone is promising that they can treated with a supplement. If they are promising these things, there is all that and then you add in the fact that you might not have had enough time with your physician to talk about it. Maybe they are the greatest physician in the world, but they can't undo all your fears in 15 minutes. And what if you didn't get the greatest physician in the world, you got someone who dismissed you? So, you have all those layers, right?
 
It can sometimes take people two, three, four visits to wrap their minds around ideas, to kind of get comfortable with things. We all think that is kind of normal, but the medical system doesn't allow for that. And so, in the same way that knowing more about your body can help you weed out the charlatans, it can also help you know if you're getting good care in the office. As a specialist, I am lucky. I have a lot longer time with people and often what I'm saying is the same thing they were told, but they have had time to absorb it. We can have a greater discussion, and I can explain the back story.
 
I would say 50% of the time, "Now I understand, sure, great." But no one was able to put it in the terms that work for that person. If we are all OK with publicly funded health care systems that just give women twelve and a half minutes in the office, what else are we going to expect? It is a whole separate conversation about underfunding of primary care and the whole office space structure is built around acute care. You have a sore ear, and you get it looked at. Or it’s coming in and you need something operated on. But the people who use the bulk of adult medicine in the office are people who have vaginas and uteruses and ovaries because they’re the ones who bleed heavily and they’re the ones who have vaginal discharge and they’re ones who get recurrent bladder infections. If you look at all of these things that happen, they only happen to people who have one set of physiology. And It’s not until you starting get prostate problems that I think that parity starts to pick up. And so, you have a whole half of the population that is really underserviced by the healthcare model because the whole model was never designed to think that that mattered.
 
Caroline Ford: Exactly. So, you’re all going to leave here much more educated about all of this stuff and I think that is a big step that we can all make. So, we are going to play a little game, Jen. I am going to read out a bunch of statements related to menstruation and menopause, and I want you to respond as to whether they are true or false. So, super simple.
 
We are not going to delve too much into the evidence for or against them, you can all buy the book and read about it.
 
Laughter
 
Jennifer Gunter: She is a great saleswoman.
 
Caroline Ford: Alright, so the first one is kind of cool, I’m a nerd. Menstruation is the only scarless healing that occurs in the human body.
 
Jennifer Gunter: That is true. Isn't that really cool?
 
Caroline Ford: It’s very cool.
 
Jennifer Gunter: Can I just add… Imagine… Imagine if we’d been actually studying this for a long time, what do you think the kind of therapies we might have been able to come up to maybe help burn victims? Seriously. That’s really amazing physiology and you hear about, "We are going to study whatever salamanders that can have their tails cut off and regrow" and that is really cool, but we also have this cool physiology and half the population and maybe if we understood how that worked, we might be able to apply that. I'm just saying.
 
Laughter
 
Caroline Ford: Excellent, love it. My next statement is menstruation is linked to the moon.
 
Laughter
 
Jennifer Gunter: No.
 
Caroline Ford: The average age at which people get their first period is getting younger and younger.
 
Jennifer Gunter: It is. It is.
 
Caroline Ford: People that live together often end up syncing their periods.
 
Jennifer Gunter: No, they don't! I know everybody here is, "What!" It's not true, they don't. Read the book.
 
Laughter
 
Caroline Ford: Skipping your period by taking consistent hormonal medication or skipping sugar or placebo pills in your contraception is dangerous.
 
Jennifer Gunter: No. Not at all. Why have a period? Period is optional.
 
Laughter
 
Caroline Ford: Menstrual blood is great for the veggie patch or garden.
 
Jennifer Gunter: I am not a gardener.
 
Laughter
 
So, I can't actually speak about that being good, but I think maybe coffee grounds might be better.
 
Caroline Ford: You are more likely to be struck by lightning than die from toxic shock syndrome from wearing a tampon.
 
Jennifer Gunter: Yeah, that’s true. It is really not that common. But it is about the vagina, so the press just makes it bigger. It is serious, but it is like low probability, high consequence like lots of things.
Caroline Ford: Stem cells in menstrual blood make a really great face mask.
 
Laughter
 
Jennifer Gunter: Oh.
 
Caroline Ford: But the Kardashians told me that was true, come on!
 
Jennifer Gunter: I know. Oh my god. But the same woman who started the whole menstrual facemask thing on Instagram, I know right. She was just this week using her poo on her face.
 
Laughter, gasps from audience
 
So, I guess she ran out of the attention from the one. So, anyway. She has hundreds and thousands of followers. I’m like, block, block! Hit the block button.
 
Caroline Ford: The COVID-19 vaccine delayed people's periods.
 
Jennifer Gunter: Well, yes but by like less than half a day.
 
Caroline Ford: The colour of your menstrual blood is meaningful and we should be paying attention.
 
Jennifer Gunter: No, it’s not. It’s not like a Rorschach test.
 
Laughter
 

Caroline Ford: Okay, and my last one. Vaginal steaming should be part of every menstruator’s self-care regime.
 
Laughter
 
Jennifer Gunter: No. And we won’t talk about Gwyneth. I don’t need to punch down.
 
Laughter. Applause
 
Caroline Ford: Amazing. So, let’s move on a little bit to the other end of the menstrual bookend as you so lovingly call it. So, perimenopause and menopause. So, what do we actually need to know? Because there is a lot of catastrophizing about this at the moment, I feel, in the press. What are the common symptoms? And my kind of trickier question for you is how do we actually disentangle those symptoms from all the other things that are happening at that phase of life? So maybe people are in the sandwich of young kids and older parents. Maybe they have a really stressful job, maybe they are just ageing, maybe they have arthritis. How do we actually know what is menopause and what is just being of a certain age and living in 2024?
 
Jennifer Gunter: It can be difficult to disentangle. And we do have this really great studio called The Swan Study, which followed women from before their perimenopause, all the way through to track symptoms. And those kinds of studies are really important because you’re following people not just as they age, but you can tell when they are peeling out into menopause by their hormone levels. So, you can see what’s changing with hormones, what’s kind of more with age. We certainly know that there are a lot of symptoms associated with both the menopause transition and menopause.
 
Some people get those symptoms before their final period in what we cause the menopause transition or perimenopause, and some people get them after, and some people don’t get them at all, and some people get them through the whole thing. I always tell people it's a bit like pregnancy and everybody's experience is different. Some people feel the best they ever felt during their pregnancy and other people feel the worst they’ve ever felt, and there’s everything in between. So, the most common symptoms would be hot flashes, night sweats, difficulty sleeping, brain fog, depression in the menopause transition, joint pain. Those are some of the most common ones, vaginal dryness can happen as well.
 
Some of those are really uniquely linked to menopause. So, for example, vaginal dryness. So, while there are other causes that wouldn’t be an age-related thing, it’s definitely a menopause related thing. But for example, brain fog can be caused by difficulty sleeping. It can be caused by depression. It can be caused by iron deficiency. It can be caused by a medication. It can be caused by sleep apnea. So, you do have to have a full workup.
 
Hot flushes, probably always going to be menopause. But if you are nearly started on Zoloft, that can cause terrible hot flushes at nighttime where people soak the sheets. So, it’s always important to have the full discussion. When you talk about things like difficulty sleeping, depression, feeling down and you hear someone who has to get up at 6 in the morning and get the kids ready for school, and they are working all day and have to pick up the groceries and the kids, and they are making dinner and they have to put the kids to bed, and then they are folding laundry and it is 11 o'clock. I'm tired of listening to that, right. And those are what a lot of people's lives are like.
 
That pace might have been sustainable when you are 25 or 26 but after so many years doing it, eventually, you kind of get, like, what the fuck? This is too much. So[SW2] , it's important that we treat menopause with the respect it needs and the medical care it needs. But it is also important that we don't make excuses for how society treats women, and brush it off as menopause. Right. They are both complex concepts, but we have to hold space for both.
 
What I’m seeing is that everything is sort of being blamed on menopause. And it’s like, sometimes it is a mediocre man.
 
Laughter
 
Applause
 
Caroline Ford: I think that is so true. So, rage comes up a lot as well. Anger and rage. And I think, ‘no people are just angry’. They have good reason to be angry.
 
Jennifer Gunter: Sometimes there’s a justifiable reason and last year, oh my god. Last year there was a piece in the Guardian, this woman wrote in, and literally describing her lump of a husband. I’m not kidding. Like he was as useful as a piece of furniture. And when they got married they had promised to share the parenting. And here she was doing the cooking and the cleaning, and he was going to the pub. Right. She was doing everything, and she wanted to get divorced and she was writing in and she was worried about the impact on her kids. And the female psychologist who wrote the reply said maybe it is your hormones and you should go HRT. And I’m like “what the fuck, sister?...like, like hello?” The woman didn't say that everything was perfect up until she started getting hot flashes or everything was perfect until I was not sleeping well. She had justifiable rage. Like sometimes, it’s okay to be angry and it felt like this is sort of the extension of calling a woman too hormonal. It’s sort of like the opposite of it. And sometimes your rage is absolutely justifiable. And the idea that you should be medicating that, like where does it come from? So, well it comes from the patriarchy, right? So, it’s just really, really important that we hold space for is this a medical situation where somebody is doing poorly because they have symptoms that really match that. Or do they have a lot that life is throwing at them, and they have just been doing it for 20 years or 10 years and at some point, something has got to give.
 
Caroline Ford: And I do think some of it is so clearly gendered. Like the brain fog example, which does have some physiological evidence for that being affected by menopause. It feels very similar to like the throwaway idea of baby brain, which absolutely drove me bananas when I was pregnant with my kids and this assumption that baby brain is real thing. And so, it does feel like sometimes, again, without good evidence to disentangle what’s just tiredness and refocusing from what is happening biologically, is really challenging.
 
Jennifer Gunter: Brain fog is one of those really interesting things because what is it? Like lots of things can cause brain fog. Iron deficiency can cause brain fog, being tired can cause brain fog, depression can cause brain fog, lots of medications can cause brain fog. How do you sort all that out? And what’s really interesting is, is when women who have brain fog are tested or who report those symptoms, they all perform better than they think they perform. And in fact, in one study they still outperform the men.
 
Laughter
 
And so, what does happen is there is a little bit of loss in an area of verbal recall. And so, it’s kind of like the word finding.
 
Now, it's very difficult to disentangle because if you are having hot flashes that wake you up 5 times at night and you’re never getting your REM sleep, then your brain fog may absolutely be related to this lack of sleep issue. Which would be normal if you kept anybody up, like you woke anybody up like that night after night. So, it’s just really important that we be kind of accurate about it. My husband always likes to say, so what does he get to blame it on when he forgets where his keys are? Because it happens to men too.
 
Caroline Ford: Yes, mal menopause.
 
Laughter
 
So, let’s talk about the positive aspects of menopause. I feel like it really has a bad rap. And many people I know talk about the absolute liberation of going through menopause and that it’s an absolute joy to not have to worry about having their periods anymore. That they actually have a clarity of thought once they get to the other side and just have a general, no Fs left to give attitude to life. So, what do you think about the great aspects of menopause?
 
Jennifer Gunter: Yeah, I mean not having a period is really awesome. I’ll tell you that right now. It’s really great planning a trip coming to Australia and not having to worry about having to pack any menstrual products. Although I hear you guys have, I’ve got to go to Priceline. Right? I’ve got to go to Priceline. And I’ve heard there is a brand of pads, that when you peel the thing off, they have like information and stuff?
 
Caroline Ford: Oh yes!
 
Jennifer Gunter: What’s the brand?
 
Caroline Ford: Fun facts
 
Audience: Libra?
 
Jennifer Gunter: Libra? Yeah, I’ve got to go buy a pack of Libra before I go back. I want to see those. So yeah, that’s great. I hear from a lot of women to about having this clarity afterwards. Who knows what that is from? Is it liberation from the male gaze? Is it no fuck’s left to give? Is it the fact that you have all these pathways in your brain for menstruation and they get pruned so you don’t have them anymore, and you actually have more pathways to use for other things. I don't think we have the answer, but I think what’s really important for people to know, if you have symptoms, we have lots of therapies to manage those symptoms. And for many people those symptoms are time limited. For a smaller percentage they are not. There are treatments for that, and that many people feel that things are really great on the other side.
 
Caroline Ford: So, is it true that there’s not a lot of other species that go through menopause?
 
Jennifer Gunter: Yeah, so humans do, and killer whales do. In fact, the orcas that ram the boats are all the grandmothers apparently.
 
Laughter
 
Like, we can learn something from orca rage.
 
Laughter
 
I actually think the male orcas die earlier so it’s the females that keep living that but I’m not an expert on toothed whales. So, I will just say that. There is some evidence that maybe a certain kind of chimp might have a little bit as well. So, it’s hard. They don’t get maybe as well studied, I think, or they haven’t been. But I think it’s mostly the toothed whales and humans. It’s really a fascinating evolutionary thing because most species die very soon after they reproduce. The quote that I like is, life is basically turning the energy around you and to offspring. Everything is, whether you are a flower, whether you’re a butterfly. Everything is about the next generation.  
 
That doesn’t mean that your purpose here is to reproduce at all. It’s kind of like a grander, evolutionary thing. And so, if you think about it from that standpoint, what’s the benefit once you’re not able to reproduce? And the thinking is that cause you’re really useful. Right? That if you have an extra pair of hands, you know, if you’ve ever had a difficult task and you knew somebody who has done that task before and is actually useful and has a pair of hands, you’re like yeah! that would be really useful. So having a grandmother in the household, the thinking is evolutionary, thinking thousands and thousands of years ago. Then you actually have more help. You have someone who can help you with food, you have someone to help you with shelter.
 
It wouldn’t make sense that menopausal women, if that’s the evolutionary backing to it. It wouldn’t make sense that our brains would rot because it’s the knowledge that is actually important. Where to go gather the roots, where to find water. All of these things, this historical knowledge. So, it doesn’t make sense that we would become less capable as part of it, which is sort of the narrative. It’s all about the collective. I really like that. It’s more the wise woman hypothesis.
 
Caroline Ford: Love it
 
Jennifer Gunter: It’s a pretty cool concept.
 
Caroline Ford: I want to take us back to menstruation and I’ve got a bit of a complex question, so bear with me. I’m interested to hear what you think about the intersection between environmental awareness, menstruation and shame? So, menstruators have copped a lot of heat, particularly in the media for the impact of single use and disposable pads and tampons, and the impact that has on the environment.
In parallel, we’re in this age we’ve got these very cool modern period products such as period underwear, menstrual cups, reusable pads all of these things that certainly were not available when I was a teenager. But the thing I am interested in, those products I think force people to confront their blood in a different way. So, you’ve got to pour it down the sink, you see what’s being washed out of your underwear. Do you think this demystifies some of the myths and ideas around periods? But also how can an individual choose an ethical and sustainable period product? Or are we getting too wrapped up in it? What do you think about this?
 
Jennifer Gunter: Well, I think that we can start thinking about the ecological impact of menstrual products when every other ecological thing is taken care of. I really, I’m sorry.
 
Applause
 
It's hard enough to have your period. You think about all of the single use cups. You walk into a store, and you see all of these junky toys that cost a dollar and all these things that will go straight to landfill, and I think, you know what? We should really be focusing on those things.
 
It would be great. We should all reduce, reuse and recycle, all of that. But I feel that there is a lot of other low hanging fruit. And it can be difficult enough. And when you think about menstrual cups, not everybody has access to clean water. Right? Not everybody wants to change that in their work bathroom. Menstrual underwear is expensive and if you’re a heavy bleeder, that’s not going to get you through the day so then you’re going to have to take it off and where are you going to put it? And you’re going to take it off and unless you have the kind with snaps on the side then what if your bathroom floor is gross? There are all of these permutations and combinations. So, I think people should have whatever menstrual product they like. I’m like. If you like pads – you should have pads. If you want your own washable pads at home. If you like tampons. If you like cups. If you like discs. I think the more choices we have the better. Just don’t use those sea sponges because those are gross, and they will give you problems. Because they are sold on gyno Etsy, which you should never go to.
 
Laughter
 
But sometimes when I’m bored at night, I do. Because I’m like, what are they selling people?
 
So, I think it’s good to have the discussions. I like the fact that these new products have, when the menstrual underwear became anything, they had ads in subways. So, I think that is fantastic. I think they bring new options; they give new discussions. I think for some people, the idea of seeing the blood in that way is going to be good for them. Other people, it is like, "Whatever, who cares?"
 
I think the more options we have, the better. So, I'm sure that makes me… somewhere on social media someone will shame me for saying this, but honestly, people who menstruate suck up so much. Let's take care of a few other things first.
 
Caroline Ford: Great. I’m going to ask a question about HRT or Hormone Replacement Therapy because we’ve only touched on it briefly and that’s a topic that many people are interested in. So, the very simple question on Slido is, is HRT safe? bioidentical? Or bioidentical it says. So that might tell us something?
 
Jennifer Gunter: So, if you look at the menopausal hormone therapy or HRT as a medication class, it’s very safe. The risks are in what we call the rare to very rare range. Bioidentical is a marketing term. It means absolutely nothing important. It’s got, it’s like saying something is natural or saying something is organic. In fact, every single estradiol you get is bioidentical because it’s estradiol. So, it’s kind of a smoke and mirrors thing. And so, I would just encourage people to not get hung upon that word or not to really assign it kind of any value. Also, the only natural estrogen is Premarin which is made from horse urine. Every single other estrogen and progesterone and progastrin is made in a lab by semi-synthesis. So, don’t get hung up. There’s no synthetic estrogen. It doesn’t matter if there is. But don’t get hung up on those things because they don’t mean much.
 
From a safety standpoint, it is like anything. If you need it and it’s safe for you, then that’s great. But if you don’t need it then, you don’t need it. And there are a small percentage of the population, a very small percentage for whom it’s not safe.
 
Caroline Ford: That’s right. And I think lots of people in the audience and in Australia would’ve heard some of the media coverage many years ago of a health study that showed a potential risk with cancer and then that’s really been dismissed, and we understand so much more now. But for those in the audience that might have in the back of their mind, oh no this is going to increase my risk of cancer, is there truth to that?
 
Jennifer Gunter: Yeah, I mean there is. So, if you take combination menopausal hormone therapy and estrogen plus a progesterone or progastrin, and we think your risk of breast cancer is about 1 and 1000 per year on that medication. Now that would mean that if you have terrible symptoms, that risk is probably worth it. That is actually considered a pretty low risk. If you don't have any symptoms at all, then why would you incur that very low risk? Right?
 
There is also a risk of endometrial cancer with menopausal hormone therapy if it is not done correctly for you. So, if you just take estrogen without a progesterone or progestin then you will eventually get endometrial cancer. Estrogen causes endometrial cancer. Right. The other medication is used to prevent that from happening if you have a uterus.
 
Now, there are some types of menopausal hormone therapy where we have progesterone or progestin that aren’t quite as good at preventing cancer, so that is why it is really important that you get the right combination for you. Some people will do better with the progesterone-based therapy, other people will need progestin-based therapy to prevent them from getting endometrial cancer. And I just need to put a plug-in, there are fantastic guidelines with the Australasian Menopause Society. You have one of the top menopause researchers in the world, Professor Susan Davis is Australian. She has written over four hundreds of papers, her works are quoted, she is like so commonsense and no-nonsense and really does incredible work.
 
Caroline Ford: So, I think as a follow-up to that and it is something many of my friends and colleagues have asked me, is where do they find high-quality information around this? Because If we have got a kind of deficit of good research and evidence, who do we trust? If we are not googling things, where should people go apart from your books?
 
Jennifer Gunter: I have this great book called 'The Menopause Manifesto' and I have a blog called 'The Vagenda' and I do a ton of hormone therapy information on there. But what I always tell people is, you want to go to the guidelines. There is a lot of disinformation about the guidelines on social media. People saying that they are out of date. Those are all people selling you something. They are either people have $1200 an hour practices or people that are selling you supplements. So, anybody giving you this fear based or slightly conspiracy theory-based information, you should always be aware of.
 
The best way to google something is to put in your concern, you could put in brain fog and menopause, you could put in hormone replacement therapy and breast cancer. Whatever. And then follow that by Australasian Menopause Society. That will force their content about that to the top of your search because that is what you want. You want stuff written by that society. They have great guidelines that I refer to the Australasian Menopause Society guidelines all the time. You can put in Menopause Society, International Menopause Society. They are all similar societies around the world that have the guidelines. Almost all identical.
 
When you look at the British Menopause Society, the International Menopause Society, the Menopause Society which is US because we always consider ourselves, we should say the American Menopause Society or whatever. In the Australasian Menopause Society. The guidelines, except for some minor things are almost identical. So that should tell you something that experts from all around the world have all looked at the research and come up with really the same thinking.
 
And they have to all disclose their biases. And you and I know getting a bunch of people in a room to come up with the guidelines, it is almost like…
 
Caroline Ford: Nightmare.
 
Jennifer Gunter: It gets really heated and people really defend their positions. So, put that in your Google search and that is the best shortcut to getting good information.
 
Caroline Ford: I think that’s really helpful. And then I guess the flip of that is when people see things online or their dear friend gives them a recommendation that they should proceed with the Wim Hoff method for the endometriosis pain as we were talking earlier, how do people deal with that? How can you fact check these types of things which sound appealing and perhaps are communicated incredibly well to you? So, if you see something online, how do you find out if it is true?
 
Jennifer Gunter: You have to fact check everything and you need to not go into the comments to look. You need to really step out and that is really difficult in our 24/7 news society. But also when you look at Instagram and TikTok, the sort of advent of reels or videos, I think it has really changed the way people get sucked into the content on social media. For me, all of a sudden, I look up and it has been one hour. My greatest fear is shark videos and I have been watching an hour of shark attacks. It knows what you are scared of, it really knows. It is scary. So, you have to step out and fact check these things. It is difficult because the algorithm is not designed to do that. Whether it is your friend or something online, you really need to have a resource and check it.
 
Caroline Ford: Thank you for kicking us off, please ask your question.
 
Audience question 1: I am wondering what responsibility you think medics have in terms of fact checking other doctors. Because when you talk about kind of charlatans, there are definitely many who are completely unqualified wellness influencers.
 
But I see medical practitioners peddling things like the g-shot which is an auto-hemoglobin injection into your vagina to help you orgasm better.
 
Jennifer Gunter: Right
 
Audience question 1: Many doctors…which doesn’t work.
 
Laughter
 
Many doctors seem to be quite nervous about calling each other out and I'm wondering what your perspective on like when doctors see other doctors doing things that are sketchy, what should they be doing?
 
Jennifer Gunter: Yeah. So, first of all, I think we should be asking it – is a great question. The guy who invented the g-shot temporarily lost his license and he came up with that idea by practicing on his sex partner. Wow. He is also an internal medicine doctor, not a gynecologist. So, when I see colleagues doing that, I think, you think that little of your patients? That you would trust that person whose only publication is in a predatory journal? Right? Everybody here knows a predatory journal, they’re junk journals, you can get anything published you want. You could write whatever, you give them the money and they will publish it.
 
So, I think that we need to demand our medical professional societies do better. Like, I personally think if you do that, you shouldn't be allowed to be in a medical professional society. Professional societies should have a standard. You should meet a standard. I don't have a problem of calling people out in person, but I try to really give people the information.
 
What is really problematic with these things is the people who do these procedures are so good at search engine optimisation. So, I have written quite a lot about how the g-shot is a scam and it is terrible, and I still get direct messages from people all the time who are like, "I had this done, I’ve had these complications and when I googled it I didn't find anything bad."
 
So, they know exactly how to do the search engine optimisation so nothing comes up. It brings up a really good point of these what are called data voids. So, when you have something that is a scam, well nobody has written about it because it is a scam. Right? So, you go to google it, the only things that come up are the positive things. So, I think we need to be better at calling people out. I absolutely do because our patients deserve that. Like people get harmed.
 
And what like, you want to make money that badly that you don't care how much you hurt somebody? I think that is terrible behavior, that is not professional behavior. So, I agree and I think people should and you know fortunately, I live somewhere that we have a strong first amendment. So, I am allowed to, you know, we have very protected free speech, but if you live somewhere like England for example, you have to be incredibly careful what you say because you can be sued for libel and slander very easily.
 
So, it can be challenging depending on where you live. I don't know what the laws are like here for that.
 
Caroline Ford: Oh, we can talk about defamation laws and what is happening in Australia another time. We might take our next question from over here.
 
Audience question 2: Hi there, thank you for your generosity of time tonight, it has been really fantastic. I have got a HRT question actually, it is sort of linked to what you said earlier about if you are symptom-free versus not. What are your thoughts about long-term HRT use for prevention of dementia and osteoporosis and heart disease?
 
Jennifer Gunter: It is absolutely not indicated for dementia at all and that is a recommendation of every Menopause Society around the world. It is also not indicated for prevention of cardiovascular disease, the data isn't good and all the prospective trials we have don't show benefit. If you need it for osteoporosis, then it is fine to take long-term for that. It would depend on somebody's family history and their own personal history and what their bone density would be.
 
We think based on only observational data that long-term use is probably fine for people who need it, but people shouldn't be led to believe that they can prevent dementia or heart disease because the guidelines support that currently.
Audience question 2: What does the data show in addition to potentially osteoporosis prevention if you need it if you are in that category. Any other long-term benefits that the data is showing?
 
Jennifer Gunter: That would be the only beside symptom control.
 
Audience question 2: Thank you
 
Jennifer Gunter: You’re welcome
 
Caroline Ford: Thanks, we’ll go back to this microphone.
 
Audience question 3: Hi, I wondered what areas of research you are most excited about and any gaps you wish people were going to research?
 
Jennifer Gunter: So, I am really excited actually about the whole neurokinin 3 receptor antagonist research and basically that’s the area of your brain that is involved in lots of different things. It is involved in thermoregulation and many different coordinated centres. But it’s new drugs that have been very effective for hot flashes. The research has taught us a lot about how the hot flash works and the brain and once you get a whole new class of drugs, because this is a brand-new class, it opens up all different other kinds of research avenues. So, I think that’s really exciting.
 
The thing that I wish we knew more about, was and we were talking about this earlier, is the basic biology of endometriosis. We still do not really understand the basic biology. We don't know if this is a bunch of different diseases, is this one disease, why does one person get full of endometriosis and another person doesn’t? Why does one person have terrible pain, and the other person has no symptoms at all? So, I feel that that’s a very, very understudied area and I wish that, if I was Melinda Gates and I had more money than God, I would give it to that.
 
Audience question 4: You said a lot of women come into your practice with preventable endometrial cancer because they didn't know what to look out for. What should we look out for?
 
Jennifer Gunter: Yeah, so, one of the biggest risks is obesity, being overweight. It is a significant risk factor. And that might change how we would screen somebody. It would change maybe medications we will talk to you about for prevention. The progestin medications can be very effective at prevention. You can take those medications every single day or have a progestin IUD put in. For some people we are seeing people decide if they want to go on medications like Ozempic[SW3] [SW4] [NE5]  to help reduce their risk of cancer.
 
So, you know, these are there may be other health implications as well, reducing the risk of diabetes. And then it would also change how we might manage if you have irregular bleeding or other things. So being aware that if you have any bleeding after menopause, it really needs to be evaluated. But even if you're not menopausal, you know if you’re having an abnormal bleeding pattern, not having it pushed off, have somebody really look at your risk factors and decide based on your risk factors whether you should be screened or not.
 
Audience question 4: I actually had three questions.
 
Caroline Ford: Well, you can only ask one.
 
Audience question 4: Trying to figure out which is the most important. There is a doctor called Lisa Mosconi and she showed some brain scans of women going through menopause over time. They showed that the brain was shrinking. She is a neurologist and an expert in menopause. I wondered if you knew anything about female brain scans and how they change when women come into menopause? And I do have another important question about HRT, if I may.
 
Caroline Ford: You may not. I’m sorry. There’s lots of other people who want to ask so we will stick with the first one.
 
Jennifer Gunter: I know Lisa Mosconi very well and her work is excellent. But what she is showing is that the brain changes and that it actually recovers. So, you see changes in glucose metabolism, and you see that reversing. And on Dr Mosconi’s latest book, she actually says HRT is not indicated for dementia prevention. So, your brain changes and responds to all kinds of stimulus. It changes after pregnancy, it changes in response to being on different medications, it changes in response to many things.
 
And so, we don’t really understand what all of the implications of these scans are yet and so it’s really exciting that we have this new area of research.  
 
Audience question 5: So, I’m from Asia where women's health is highly stigmatised. Herpes is seen as a death sentence, but I just wanted to ask you, what are your favourite resources for people who want to educate themselves?
 
Jennifer Gunter: So, I think that it would depend on the subject that you wanted to learn about. So, for example, if it was something about sexually transmitted infections, the WHO has actually a ton, if we are trying to think about it on a global perspective. The WHO has really good information about tons of different things on their webpage. And I know they got slammed a lot during COVID but actually they have some really good information. So that would be a good place to start.
 
I would say medical librarians are also a great place to start. If you have access to a library. Go talk to a librarian, they are the most amazing people. Librarians at universities are like superstars of science. So, if you have a question and you're not sure whether start, I’d actually say talk with a librarian as well, especially if you are a student at a university. You have these people who know how to find information. So, think about talking to them as well.
 
Caroline Ford: Oh my god, Jen, my mother is a librarian, and she is in the audience, and you have just made her night.
 
Laughter
 
Jennifer Gunter: Seriously, I love librarians. I love librarians. I think every single time I've sent someone to talk to a librarian, they are like, I had no idea they are so amazing! and I’m like, I know.
 
Laughter
 
Caroline Ford: She also threw me a red themed party when I got my period. So, we’ll talk about that later.

We are very short on time. So, I’m going to take two last questions.
 
Audience question 6: Oh hi, so you talked about estrogen in relation to HRT. And I’m just wondering what your opinion is about adding testosterone into that mix. There’s not as much information about it. What typically the sort of symptoms that someone would be experiencing in order to consider that?
 
Jennifer Gunter: So, there’s actually a fair bit of research. The world expert is actually Professor Susan Davis from Australia. The only indication for testosterone is for problems with libido that haven't responded to cognitive behavioral therapy and other things. The data absolutely does not support it any other indication.
 
Audience question 6: Ah okay, because there is quite a lot of information around brain fog and brain related symptoms.
 
Jennifer Gunter: Quite a lot of people making money off of that because that’s how you make money. When you prescribe testosterone you have to do levels to make sure they don’t go too high. You don’t have to do with anything else. How to make money from people? Having them to levels and charge them so that you can explain the levels. So, it's a massive moneymaker. Until Professor Susan Davis says we can use it for anything else, she knows more about testosterone in women than anybody else. None of these people on Instagram. What they are all doing is misquoting her work. So, until she says it, she is all for the science and she believes women deserve the science. She’s doing all kinds of research with it. She’s the person who has co-authored many of the guidelines and she is, you know, has no financial stake in it.
 
Caroline Ford: Thank you, our last question.
 
Audience question 7: Hi, so I’m late diagnosed autism and ADHD. So, I was diagnosed at about 46. I am now going through perimenopause/menopause. I had lots of issues of the medication with my ADHD and I’ve got endometriosis so have lots of issues with hormone medication. I am taking some of the natural things like evening primrose oil and that sort of thing.  It is kind of helping a bit with the hot flushes and things like the brain fog. But I’m just wanting to know if it's even worth bothering trying any of the normal pharmaceutical medications? Or if there is anything else that I can try to help with that?
 
Jennifer Gunter: I don’t think I can really answer that question in this kind of format. There is just so much other information to know. I was so the best thing to do would be to sit down with your healthcare provider and write down your whole list of symptoms, the symptoms that are bothering you. And they can go through the toolbox about what can treat what and can hopefully come up with a combination that works best for you.
 
Caroline Ford: Thank you. And for all of the people that didn’t get a chance to ask your questions, I’ve had a good read of the ones on Slide. I can assure you that the answers are in Jen’s book. 
Laughter
 
And so, as I said, she will be signing books in the foyer and they will be available to buy and I strongly recommend it. So, I’m going to draw this evening's conversation to close, thank you so much everybody for joining us tonight.
 
Applause
 
Please thank Jen.
 
Applause
 
Thank you for listening. This event is presented by the UNSW Centre for Ideas and UNSW Medicine and Health a part of national Science Week. For more information visit UNSW Centre for Ideas .com and don’t’ forget to subscribe wherever you get your podcasts.
 
Music plays