Stacy London She/her (00:09.038)

Dr. Jill, I am so excited that you are here. There are so many things to talk about, but I was not familiar with your work. And I was so excited when I saw that we were going to talk about sort of menopause beyond the gender binary idea, simply because I think that there is, we're not talking about it enough, And two, there's just not a whole lot of information. We have been talking about menopause solely as this female physiological issue and in no other way. And it seems both narrow-minded and less fair to more marginalized groups, obviously, not to be studying medicine in every way that that is necessary. So I'd love to talk to you a little bit about all of your experience. And hold on, have my questions. It's a question also of opening my phone. But in your bio, it was really interesting. It said that you have a quote, particular interest in management of abnormal uterine bleeding, gender-affirming gynecology care and hysterectomy, menopause management, and contraception. Now, while those seem like big categories, they're actually quite specific. What made you decide to go into this particular area, not just of gynecology, but of menopause?

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Jill Liss MD (01:29.975)

Yeah, you know, I always tell people I focus on menopause and gender-affirming gynecology, and seemingly they seem maybe disconnected or different, but actually the overlaps are tremendous. And I feel really lucky to have landed here because both things complement one another. And a lot of the issues that people are struggling with, whether it be genitourinary syndrome of menopause or what I like to call genitourinary syndrome of estrogen deficiency,

because it may not be at a time of menopause. We do see in a lot of gender diverse individuals on testosterone that they share a lot of those same symptoms. You know, it ends up, I end up finding more commonality than I do differences. But I think what I am so grateful for as a clinician and what I love are being present for these really important transitions in someone's life, whether that be puberty, menopause, transitioning to motherhood. It's such a vulnerable time period and it's just, it's fraught with misinformation, it's fraught with shame and stigma, and it's just an honor for me to be a pillar of information and support that handles these really complex transitions.

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Stacy London She/her (02:47.384)

Sure, and you're talking about kind the complex transitions for female at birth individuals, right? How did you arrive at sort of an expansive understanding of gender and gender affirming care in gynecology? Because to me, I don't see many US doctors talking about that, whether that's something that's part of their practice or not.

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Jill Liss MD (03:12.897)

Yeah, so I started by just doing, we have an integrated transgender program at my institution. And so I am one of two representatives from gynecology. Yay, it's great. Yes. Yeah, and it's wonderful. It's a multi-specialty clinic. So we have endocrinologists, plastic surgeons, gynecologists, urologists, psychiatrists, social work, all sitting in one room. And it's really been one of the highlights of my career to work in that initiative.

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Stacy London She/her (03:22.414)

Can we just like, can we just applaud for that? Can we just say how amazing that is?

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Jill Liss MD (03:42.785)

interdisciplinary fashion. And so I started working there. And a lot of what I do there is gender affirming hysterectomy. You know, I don't typically manage the hormones because there's people who are ready and willing and able to do that. And I typically manage either abnormal uterine bleeding or hysterectomy for those individuals. And I have just found that this is such a segment of ignored. mean, you know, you've been in this space menopause itself for well resourced cis white women is still a challenge. We still don't have research or adequate physicians to see this population. You are absolutely correct. There are not a lot of people who are niche in this space and we don't have any research, but you have, you know, I find that a willingness to listen and acknowledge experiences is half the battle. And that, of course, people with uteruses who don't identify as women have abnormal bleeding, have menopause symptoms, and they need a space to feel comfortable talking about it and seek treatment when it's appropriate.

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Stacy London She/her (05:00.204)

Yeah, I mean, it actually almost brings tears to my eyes that, you know, this is something that we don't talk about that has such, think, as we've said, physical, but the psychological implications for somebody who feels that they are not in the right body to have to deal with that body's own mechanisms that run counter to their belief about their true self. I can't imagine anything more psychologically difficult to manage and not having many places to be able to discuss that is really quite something. I don't know, how long has your institution or your institution been around?

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Jill Liss MD (05:41.015)

Well, I'm at a large university, our practice has been around, I believe it was founded like mid 2010s.

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Stacy London She/her (05:50.806)

Wow, so not even that old, which is what, you know, which was really what I was getting at. In 2010, we were barely talking about menopause, as you said, for, you know, females at birth, and there's still confusion and conflict around all of that. I know that you wrote a paper that was, or you co-wrote a paper entitled, Type and Age of Menopause, Potential Implications for Female Sexual Health, that focused on menopause effects in sexual function across women with different menopause experiences from natural age appropriate menopause to medically induced menopause? You know what, I want to go back to that question because I don't want to, sorry, Kirsten, here, I know she's going to cut this all out. I don't want to let go of the gender affirming care thing yet because there is a lot more to be said. And before we get into birth control and IUDs, which is like, can see where a lot of this is going and menopause related health risks, I do want to talk about, this idea of identity and you said yourself that there's such an overlap between just going through a female as, you know, at birth, chronological menopause experience still has huge overlap with gender affirming care and gender affirming care surrounding, you know, physiological mechanisms in the body that are rejected by that person and their authentic self. How do you deal with that on psychological level? Like when somebody comes to you and says, okay, you know, I am not living my truth and this is where I want to be affirmed in my identity. I want a hysterectomy. Let's say I want a radical hysterectomy. Do you caution about the effects of going into like straight on medical menopause? Is that something that's part of that discussion of all of those doctors sitting in that room? To be ready to encounter what those problems may cause for an individual who is not their actual sex at birth.

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Jill Liss MD (07:55.395)

What do I do? Mostly I just listen and affirm. I find that whether people are younger, and I don't mean pediatric, but early 20s to 40, people know how they feel about their body parts, whether they want them or not. It's not a wavering decision. That being said, we don't rush anything. I follow guidelines. Of course, we make sure that people have sound mind to make these decisions, but I believe people because people know themselves the best. And, you know, honestly, when people leave my office and they just say somebody, you know, this is the first time I ever felt taken seriously, that's the greatest gift that I can feel like I gave somebody. So I listen. But then when we talk about the menopause conversation as it relates to their ovaries, I do have a conversation with with them about potential health implications of removing ovaries. When somebody is on male level testosterone, cis male levels, meaning in the typical normal male range, they often will not experience any symptoms with removal of ovaries. so, yeah, so it's kind of nice to be able to say, you know, I can't say with certainty, but sex steroid hormones, whether that be estrogen or testosterone, are very important to your cardiovascular, bone health, brain health. And so if you were not on hormones, I would not feel comfortable to remove your ovaries because that could increase your chance of premature death as well as other health complications. But to our best knowledge, and of course we don't have robust longitudinal data, and I tell all of them, we have not studied trans males till they're 80 years old. We just don't know. But our best knowledge is that if you are on testosterone in this range, it is serving in a similar capacity to what your ovaries would be producing. And if we remove them, you're likely not going to feel any different. If you leave your ovaries, what is nice, and I do, you know, I say as someone who also practices a lot of menopause medicine, if you are not dysphoric about your ovaries, I would recommend keeping them. It's an insurance policy. If you lose access to testosterone, if you have dosing issues, if health complications arise that make you have a conversation around discontinuing testosterone, those ovaries can wake back up and usher you through your reproductive years and soften the blow. Because if you have your ovaries removed and your testosterone waivers, you will immediately start to feel symptoms of menopause and usually more abruptly when it's surgical.

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Stacy London She/her (10:47.84)

Yes, exactly. I which is what I have heard so many times that people who I and my mom herself had a radical hysterectomy, we had no idea the kind of mood that that was going to instill in her. mean, it was it was so difficult and she did not get HRT, which just made it, you know, I mean, we were we the depression was like suicidal ideation. I mean, it was not normal. You know, it was not on any range. So I really understand why. I mean, what a great way to explain it to people as an insurance policy. I'm sure if we had even heard that option just for somebody who needed a hysterectomy, that would have made a difference.

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Jill Liss MD (11:28.225)

Yes. And I want to make one quick important distinction on language with radical hysterectomy. when we, radical is actually a different procedure related to cancer, cervical cancer. So you want to say total hysterectomy includes the uterus and cervix, and then BSO or bilateral salpingo-uh-phorectomy, it's obviously a mouthful, is the ovaries. And I really think of them as two separate procedures because just because somebody had a hysterectomy doesn't mean that their ovaries removed and you could also have your ovaries removed and still have a uterus. So it does get important when we think about the hormones. Yeah.

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Stacy London She/her (12:09.024)

No, absolutely. my God. And this is way more information than I had. thought, you know, a hysterectomy was just your uterus and then an oophorectomy was just your ovaries and that a radical hysterectomy was both, but that's a total. again, you know, and this is interesting because I think that language is important. As you're saying, I've heard that term thrown around for the last five years that I've been, you know, advocating around menopause. So it is interesting that people, even doctors finally had to explain that perimenopause and menopause are not the same thing and that you're really talking about perimenopause, right? All of these funny distinctions, but how important they become in relationship to hormones. And I think that's very important for people to understand. mean, whether they're going through this, you know, just chronologically, and I said as they're, you know, as sex at birth, but or not. And I can imagine that, I mean, just talking to you, I really understand obviously that you are clearly empathic and compassionate. It's not an area of gynecology that like everybody's rushing to get into. and, and it's not, and certainly under, would think that under this administration that it, you know, we were already talking about the problems with bodily autonomy in physiologically female women. And I feel like we are, we are watching the country and this attitude towards

gender dysphoria as something that is like a disease rather than something that can be treated and taken care of. And people can go on to live incredibly happy lives.

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Jill Liss MD (13:47.231)

Incredibly full lives. And I'm getting chills as you say that because what I, really, you know, I don't do a lot of obstetrics or really any anymore, but you know, there's a lot of life or death, you know, and I've saved lives in obstetrics and the stakes seem so high, but every time I leave my gender diverse clinic, I actually think per capita, I am in a way that feels so easy to me, right? It's like not that hard. Sure, like I'll listen and then we schedule you a hysterectomy. I actually feel that per capita I am saving more lives in that clinic than doing these acute hemorrhages on a labor floor. And that is, I mean, what a gift. Like it feels to be able to do something that feels easy and change lives in that way. I mean, what more could I ask for?

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Stacy London She/her (14:42.23)

Yes, and there are just not enough people doing it. So, you know, we're already talking about like finding somebody like you, Dr. Liss, is not the easiest thing in the world for most people. And that's what's so unbelievable is that, you know, I'm curious if we if we change this whole conversation a little bit and talk a little bit about those who are scared right now, right, those who are seeing what's happening in our country, who are gender dysphoric or non binary or trans, what are some of the, what would be some of the advice that you would give them? Like, I think that this is so important when you just said about ovaries being an insurance policy, right? Particularly for trans men. And I think that we, know, there isn't, there's no guidebook that drops out of the sky. I see, you there are eight books being written about menopause this year in 2025 alone that are being published. What Fresh Hell Is This is the only book that I can think of by Heather Corina that was a non-binary guide to menopause. There are very, you know, I know Dr. Jen Gunter talks about it a little bit, but are there places that you recommend where people who are having to experience both these things, whether it is, you know, just non-binary or dysphoric or trans and experiencing menopause one way or another, whether it's surgical or chronological, which is fascinating to me because one thing that I've noticed in culture a little bit is that Gen X is so much freer with gender, right? This is where this real conversation has started and the language around it has just transformed exponentially. I didn't know about LGBTQIA +, right? Until this younger generation, but what I found so fascinating was that while 12 year olds were coming out and identifying as pan, my 57 year old friend came out as asexual. I was like, what? Having all of this new terminology and having a young generation that is just accepting of it has allowed my generation, Gen X, to be like, I wasn't gay, I was this.  I wonder if you're seeing that reflected in the kind of patient population that you talk to. And if this is something that we can, how do we improve that conversation? How do we improve that so we're including more people more of the time?

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Jill Liss MD (17:18.271)

Yeah, I think, you know, it's simple things like normalizing pronouns of it's with everything that's stigmatized talking about it, having conversations, including folks in the conversation, making sure people are at the table where key decisions are made. Unfortunately, when it comes to resources, it is such a, you know, medicine lags behind culture. And I wish I could give you a great robust list. I think that really people need to lean on one another. The communities can be very strong. I know my local trans and gender diverse community is really strong so doctor recommendations circulate, support groups are really key. But I think medicine has a long way to go, but looking in states that are friendlier for these integrated programs. I know, you know, access is really challenging, making sure that you find a state and a program that supports you is really key. And there are several of programs like mine across the country.

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Jill Liss MD (22:04.513)

And I'd love to summarize, you know, for your listeners, some who may identify it as gender diverse. And first of all, acknowledge that this is just menopause transition is really challenging no matter what. And then when you are faced with dysphoric feelings about your body, because it once again highlights things that are unpleasant to begin with, it's especially challenging. Now the good news is the testosterone folks tend to fare really well and may never know that it happened. But those on intermediate doses of testosterone or no testosterone are likely to feel it the way that you may expect. But there is a range of treatment options, many of which are not contradictory to gender affirming goals, like maybe someone really wants to avoid estrogen, we can do that. There are still ways to treat hot flashes that are hormonal and non-hormonal. There are ways to treat mood disturbances. So, you know, it is, I will not lie and say that you, it's potentially easy to find someone, but I think anybody who's familiar with menopause and trans-informed can help you navigate this and to not just suffer because these are really, really complex feelings and symptoms to deal with, especially for those who feel uncomfortable in their body.

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Stacy London She/her (23:34.062)

I can't imagine, but I also can imagine knowing just physically sort of my own experience with menopause was so severe. If I was up against that and my core identity, I don't know if I would have been able to handle it. I actually don't know. That feels overwhelming. And it is just great to know that there are places to go and look for and that somebody who really bisects this area, while there may not be many of you, there are. And we should talk about some of the other stuff that I did want to ask you about because you co-wrote this paper entitled, Type and Age of Menopause, Potential Implications for Female Sexual Health, that focused on how menopause affects sexual function across women with different menopause experiences. From natural age appropriate menopause to medically induced menopause, can you tell, is it surgically induced or is it medically induced?

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Jill Liss MD (24:28.953)

Surgically, so it's all three. So natural menopause, meaning you just go through it, surgical, meaning the ovaries were removed, and medical, there's some medications particularly used like in breast cancer treatment that do medicinally induce menopause.

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Stacy London She/her (24:44.098)

Right. I understood that is that different in the trans community when we're talking about? Just because I know you were writing this paper on women female at birth, but I'm just curious if there was a difference in medical menopause, like being on testosterone. Does that shrink ovaries? Does that do anything in particular to female physiology?

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Jill Liss MD (25:09.815)

Yeah, so it does, we didn't address that in this paper, but it does, being on testosterone does, I'll oversimplify it, but essentially creates somewhat of a dormant state of the ovary. And that's because the testosterone is flooding the reproductive system. And so they're like, okay, I don't need to work very hard. And so there's probably a slight volume reduction of the ovaries themselves, but again, it's temporary in that if you remove the testosterone, they wake up again.

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Stacy London She/her (25:39.17)

What were the findings of that paper and can you talk a little bit about that?

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Jill Liss MD (25:43.723)

Yeah, absolutely. So in general, this was a review of the existing literature. And as you can imagine, there's literature. It's not robust or as robust as I would like, because I really firmly believe sexual function and sexual matters are our health. And what we found in this literature review essentially is that there are definitely shifts in the natural transition. Desire tends to go down approaching menopause and then pelvic concerns like pelvic pain and burning do go up post menopause. But the most important thing is that, and of course there are impacts of surgical menopause and medical menopause and those can be more significant than natural.

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Stacy London She/her (26:24.067)

Isn't it?

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Jill Liss MD (26:37.775)

But that really the most important variable is related to somebody's attitudes around sex prior to menopause and relationship satisfaction. And so if you have great sex and positive feelings about it beforehand, that is more protective against having good sex after menopause than following a hormone level. And that feeds into what we know that sex is not just a testosterone issue. It's much more complicated. The brain is such an important part of the physiology of sex and desire. you know, the biopsychosocial model is at play here. And so the research at this point says that is paramount, but those other factors do matter. And of course, if somebody's having vaginal dryness due to lack of estrogen and pain, then we've got to treat that for sex to be good again. But if all the other features are in place, then chances are you can have very satisfying sex in menopause.

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Stacy London She/her (27:37.286)

Well, I did not find that to be the case at all. So it's very interesting to hear that. And I've never heard the finding that your attitude about sex prior to menopause would have any effect on sex in menopause. That is the first time I've heard that. it's interesting because you said, you know, sex is about the brain. And I have heard that cognitive behavioral therapy is sometimes helpful.

that, you know, obviously there are now drugs on the market for female arousal too, as far as I know, more that less than the eight that are definitely out for men. And that there's also a big difference between desire and arousal, and that they don't necessarily both get activated at the same time for you to have good sex or, you know, that there are different ways to activate them.

It's really interesting. I just basically fell dead inside. Like I don't even remember. don't know if we're going to put this in the podcast or not, but as a young person, I loved sex. I loved it. I had the best time. I turned 52 and I was like, couldn't make me have sex if you tried. Like if you forced me and like, filled me with liquor and tied me down, I would scream and yell because one, it was incredibly painful, but much more than the physical aspect of it, which I know has so many remedies, I could not muster arousal. Like I could not muster, not arousal, desire. And there's really been no sort of longer term understanding as far as I understand it, to explain that kind of deadening of feeling, like not even attracted to people anymore, which I find very weird.

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Jill Liss MD (29:34.603)

Yeah, you're right. Like these findings, of course, do not encompass every person's experience. But I think the key is that it's pretty easy to blame, like, my estrogen's down and my testosterone's down. It's just even when we, yeah, and this is the reason, it's just cause and effect. And it's just more complicated than that. And of course, hormones are at play here.

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Stacy London She/her (29:43.694)

Well of course, yeah.

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Jill Liss MD (30:13.935)

It's a good paper. I think one other fun fact we found was that masturbation actually increases in the early menopause transition.

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Stacy London She/her (30:25.428)

That I feel like is also, I feel like that's just anecdotally true because look at all of these like wonderful vibrator companies or sex toy companies or lube companies that are now, you know, they're, you know, they're just like going gangbusters because Gen X is like, we want to have sex. So I think that's kind of amazing. What are the most common misconceptions that you encounter about menopause regarding fertility and contraception?

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Jill Liss MD (30:56.983)

This is an issue I'm pretty passionate about because most people let their guard down, those who are at risk of pregnancy having sex that would result in pregnancy. I think there is this lowering of the guard around, I'm over 40, I'm probably not fertile, but actually it's...an incredibly high risk group for unintended pregnancies. So up to 50 % of pregnancies in women over 40 are unintended. And I think people are like, I'm done with birth control, I'm done with having kids. But even as cycles become irregular, there's still ovulation occurring. And that's what makes perimenopause so challenging is that the ovaries are functioning, meaning you are releasing an egg, maybe the majority of the time or gradually less and less, but that provides opportunities for fertilization. So if you are not desiring to be pregnant, it's really important to keep that top of mind and even, and I love how this conversation around menopause and perimenopause is becoming, I don't know, I'm in a bubble, but for me it's everywhere. And it's so great. But like, I don't hear risk of pregnancy coming into that conversation very often. And it's just important to think about. mean, we are in the reproductive years, again, for those at risk of pregnancy for like 40 years. It's a long time to have to think about it. But it is important to think about. And also hormone therapy, if somebody's starting menopause hormone therapy, that is not contraception. It does not stop ovulation. And so it's important for people to know that that distinction exists and that they could still be at risk of pregnancy.

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Stacy London She/her (33:26.326)

I want to just go back to the, were the long-term findings or what were the findings of the paper that you did? Like, why was that information about what you were doing in your, the, before the common misconception about the age and potential implications for female sexual health? You said that started in the brain. So why were these outcomes important for research?

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Jill Liss MD (34:06.957)

I think because it's important to realize, I think what's helpful about this paper is that there are different implications for menopause depending on how one arrives at it. And that are at least within medicine, we need to be talking about it perhaps slightly differently to folks who are at risk of having higher levels of sexual dysfunction, being on the lookout if somebody's had an early menopause due to ovarian removal, talking about it, asking about it. I mean, the thing is what we need to be doing is so basic, but drawing attention to these differences allows us to provide more of that individualized care.

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Stacy London She/her (34:52.682)

And then just to go back to the question that we were getting into about, about, birth control, when is it important if you are still in peri-menopause and you are spotting or bleeding and you have not done that, done that entire one year without a period, then you should be aware that contraception might be necessary.

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Jill Liss MD (35:16.023)

It's super important. And like until the last hurrah, every time you bleed, you know, that usually, you do get into what's called an ovulatory or disordered bleeding in perimenopause where not every bleed is associated with ovulation, but in general, a period follows ovulation. So until the last one.

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Stacy London She/her (35:39.59)

It's so funny. I really want people to start throwing menopause parties, but then you never know when your last period is going to be until you realize it's your last period. So I was like, so we have to have them like maybe two years out from your actual, you know, one day of menopause in order to be able to celebrate for sure. And I laugh about this because I had spine surgery at the end of 2016. I got my period twice in January of 2017, never saw it again. But I was about, I don't even know how old I was then, 46, maybe 46. I started to have perimenopausal symptoms after my period stopped. And which was also, was like, thought it was all done when your period stopped. It didn't even start for me until after my period was so fascinating.

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Jill Liss MD (36:30.473)

It is really interesting. The SWAN study, which is one of the most important studies from which we gather observational data about people going through the transition, they do define the year. They mapped the stages of reproductive aging and they do map, and again, this is generalized and not everybody's experience, but the year following the last period is the time most likely to have symptoms.

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Stacy London She/her (36:59.328)

That's when my symptoms were most severe, most severe. Wow. Okay. So, my God, I feel so much better. Listen, if this conversation isn't helping anybody, right, if it isn't helping anybody who's listening to it, it has helped me significantly. yes. And then if someone no longer gets a period due to an IUD or birth control pills or certain medical conditions, how can they tell if they've entered menopause other than let's say like, something obvious like a hot flash. How do they know?

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Jill Liss MD (37:31.117)

Yeah, this is such a common question. Like 30% of people don't get periods for whatever reason, about 30%, whether that be hysterectomy, IUD, And I think it's really frustrating for people because people want to know, am I in menopause? And our definition is not perfect by any means. The definition of menopause is 12 months of not having a period. But again, that doesn't work for 30 % of the people. So there are ways to know. mean, the truth of the matter is, nobody knows the day they finished puberty either. And so I do try to de-emphasize that the exact moment in time is so, so important, because it's not going to change how I treat you. Like, generally speaking, if you're about the average age and you have symptoms, then that's really

what matters. But there are ways to tell. And one of them would be, there's ways to tell that you're not in menopause. And that can be blood work. It's not something I frequently use because I find that between age and symptoms and history, that gives me the information I need. But if you do have blood work that's not in the menopausal range, then you're not in menopause. If you do get blood work in the menopausal range, it doesn't necessarily mean that you're in menopause. It means we caught you on a low day because by definition, things are so erratic. And again, I think our menopause definition is lacking, but conceptually, what I really like to think about is erratic ovarian function in perimenopause and then no ovarian function in menopause. So the bleeding is a proxy for that, but it's really coming back to the ovaries.

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Stacy London She/her (39:17.07)

Which makes so much sense to me. I everything that I've heard, and again, now that menopause has become so popular, she's like the popular cheerleader on the team, I laugh because I remember in the beginning when I started doing my own research, every doctor said to me, have to have an FSH test. You have to have a Dutch test. You have to have all these tests. And I remember the first doctor was Jen Gunter, who said to me, if you are of age and you are experiencing symptoms, do not get roped into blood tests that you don't need, right? Like if it's obvious, if you're 12 or 13 and you start getting pimples, you're in puberty. We don't need to over test for things that are quite obvious. And there are all these doctors that are pushing and pushing and pushing every blood panel you can get. But even in a situation like this, they're not doing it because they don't know what protocol is or that you're not accepting it and spending all this extra money for things that you don't need. But that definition really does explain why you don't have to have all those blood tests because you're making a differentiation between bleeding and hormones. And I think that is very, very important for people to understand.

And I actually think that was part of my next question, what role do hormone levels play in determining menopause status? So we kind of answered two questions in one. But I do wonder, there, yeah, like the, is there a standard threshold for estrogen or FSH levels that indicate menopause? But I don't think there is, but please tell me if I'm wrong.

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Jill Liss MD (41:04.383)

There are. So it can vary slightly lab to lab, but a high FSH typically above 70 or 80 is menopause with a low estrogen, like below 20 is consistent with menopause. But again, if you're going to make the diagnosis, particularly like, let's say you're making it in a young individual less than 40, and that's a very high stakes diagnosis, you would not make the diagnosis based on one assessment. You would retest and make sure over time because again these are such dynamic day-to-day hour-by-hour hormones that one snapshot is not enough to to hang your

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Stacy London She/her (41:50.382)

And that also makes a lot of sense even in talking about doing any kind of blood test that you're not going to get a definitive answer necessarily from one test. Also really important for people to know, I think, so that they.

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Jill Liss MD (41:59.673)

I think with ordering these tests, it's really important, you know, anytime I order a test, I as a steward of healthcare dollars, trying to do my part, you want to think about will I, what will I do with this information? And will this information change how I take care of somebody or provide insights? And if you are fitting the bill for perimenopause or menopause, I don't really care what the number is, because if it says you're not in menopause or in menopause, I don't treat you differently and I'm not going to withhold therapies. So why put you through getting a poke in your arm to not change anything?

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Stacy London She/her (42:41.044)

Right, exactly. And have to pay for that poke, sometimes out of pocket, right? So I mean, all of these things, I think are, and again, I still feel, just generally speaking, the healthcare industry is not, you know, weighted towards women. So it makes it that much harder, and certainly not weighted at all towards gender dysphoria, or non binary folks, or, you know, anybody different. So let's talk a little bit about some of the myths. What are some of the biggest myths when menopause related health in terms of weight gain, heart disease, osteoporosis, and what preventative steps should women in their 40s and 50s be taking, thinking about what the post-menopausal experience will be like for them? I will tell you on this podcast, we have talked a lot about strength training and we have talked a lot about sleep and we've talked a lot about nutrition. and you know, those are things that I think when we talk about the bedrocks, it's very interesting. I spoke with Dr. Shelby Harris, who said, you know, we always think of it as like the triangle, right? It's nutrition, it's sleep and it's exercise, but she's, she argued that sleep would probably be the bedrock and then food and nutrition would be on top of that.

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Jill Liss MD (43:57.368)

I agree.

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Stacy London She/her (43:57.774)

And exercise, food and nutrition, nutrition and exercise. Yeah, because I don't count food as nutrition. That's just teasing. But so you agree with that. But are there other things that we should be thinking about, like, again, weight gain, heart disease? There are bigger risks that I've heard for heart disease as women age. And particularly, we don't understand the definitive connection between estrogen and cardiac health. But we know that there's some kind of connection and that if you are not strength training, let's say you're at a higher risk for osteopenia or osteoporosis, but are there other things that we have been, you I haven't been talking, I don't want to talk supplements for a second, because, you know, when I think of supplements like black cohosh or evening primrose, we know there's no data around that. But what about things like calcium, magnesium, vitamin D, like actual, you know, when we talk about taking a multivitamin,

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Those things actually seem more important to me now than they ever did when I was growing up. And it was like, take vitamin C if you have a cold, or whatever it is. None of that stuff ever made any difference to me. And I had a long talk with my doctor, not just about bone health and cardiac health and cognitive health, but mood. Vitamin D was so important for mood. And calcium and magnesium make that easier to digest and all of these other things that I didn't know. So is there anything that you would recommend aside from food as nutrition and exercise and sleep that you find to be most helpful at this period or before when we're trying to be preventative of extreme menopausal symptoms?

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Jill Liss MD (45:44.139)

I have a pretty minimalistic philosophy and that is to try to get everything you can from your diet and knowing that that's really hard for most Americans to achieve. But based on evidence-based guidelines, the most critical supplementation would be around calcium and vitamin D. And so for postmenopausal women, that's about 1200 milligrams of calcium and 800 milligrams of vitamin D daily. A lot of people actually do get enough calcium in their diet. And so if you're someone who consumes dairy, even almond milk, a lot of greens, you may not need to supplement that. Most people do need some vitamin D, but maybe not the super high doses that you hear about. But that is an example where having levels checked and making sure you're within range can be helpful for your bone health. I also am a huge believer in fiber.

25 grams a day. There are multiple benefits to it. So I believe that's come up before, but I'll just reiterate that 25 grams. That's about the benchmark. So it's a little confusing because you're like protein about 25 grams a meal, but 25 grams a day for fiber. Legumes are like a superfood. So anything in the bean family gets you to that goal relatively quickly. And so if I had one takeaway, which I know you like to have, it would be increased lentils in your diet. It's such an easy way to get protein and fiber and has tons of great nutrition densely packed in.

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Stacy London She/her (47:49.492)

So I guess, you know, really one last question, because, you know, what is it that you wish knowing all that you know now and really in this very expansive range of human experience, what do you think more people need to know about managing the menopause transition and perimenopause in particular.

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Jill Liss MD (48:27.789)

I'm very hopeful about what's to come with the young Gen Xers and millennials in the pipeline. This is the most educated, wealthy, informed group of consumers that has ever existed. And the culture shift is palpable to me. I I truly carry a grief around the boomers, 60s, 70s, who just like completely didn't get their needs met. But I think that's changing. And so what I would say is no, like awareness is actually everything. So know about it, talk about it, have friends that you feel comfortable talking with. know, we talk about nutrition and sleep. believe that friendships, especially, you know, female friendships or non-partner relationships are such a critical cornerstone of your health. And this is a time where sometimes they can fall to the wayside, but I would say is the time to double down on your non-partner relationships so that you have a village. These experiences were meant to be experienced as a village. so band together and seek good resources. I think the one concern I have around this rising generation, who again, I have full confidence in, but is that there's never been so much information and there is some bad information out there. There are a lot of people trying to make money on this generation. So pause, make sure you're consuming good content, make sure if you're putting something in your body, just because something's natural doesn't mean that it's healthy. So be a good consumer, talk to your friends, talk to your doctors, don't take shortcuts, but advocate for your health and well-being. You do not need to suffer. This is a time that actually can be very fruitful and productive if you're proactive about it.

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Stacy London She/her (50:27.369)

Wonderful. Oh, Dr. Liss, I can't thank you enough. This was such a lovely conversation. Thank you. I mean, I really I'm so interested in all your work. And this is this is really incredible.

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Jill Liss MD (50:30.145)

Yeah, it was great. I'm so pleased. Thank you.

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