Perimenopause and Menopause Demystified: Hormones, Lifestyle and What Actually Works (with Dr Marianne Trevorrow)

Transcript

Kevin: Hey, Michelle, you brought a guest for us today again. That's amazing.

Michelle: We have an incredible guest. We have Dr. Marianne Travaro, and she is a naturopathic doctor. I found Dr. Marianne through the Canadian Lifestyle Medicine Group. And I, you know, just watching some really interesting conversation going on between professionals on that group. I got so excited and said, we have to have this woman on the podcast, because, you know, I have to say, there are two things when I was in nutrition training, that and even just as a as a woman, that were not I was not appropriately taught about, and I was not appropriately prepared for. And one, Marianne's gonna laugh when I say the first one, the one was the importance of Kegel exercises. The second one was perimenopause and menopause, I'm lumping those together. And I know it's it's a really important topic that you tend to as a female, hope I'm not making you blush here, Kev, it's as a female, you tend to not really worry about it until you start to become symptomatic. And then, at least in my experience with myself and my friends at my same age, and then when you become symptomatic, you're not really sure what it is like, it kind of takes a while before you figure out that's what's going on. And so maybe it's because I'm in that space. And that's the stage of life that myself and my friends are going through. And I've been getting a lot of questions about.

Kevin: And clearly, it sounds like I'm going to have a lot to contribute to this discussion.

Michelle: Well, how many women do you know, Kev?

Kevin: I do know quite a few. So right through secondhand news, sure.

Michelle: This will be very important for you just interacting with people in the world and with half the population of the world. Let me tell you about Dr. Marianne so we can dive right into this. All right. So Dr. Marianne Trevorrow has a private practice in Ottawa at Opal Wellness Pharmacy that focuses on care for patients at menopause, menstrual cycle disorders such as endometriosis, PCOS, two things that are also very, you know, are difficult situations to navigate for some women, as well as complex chronic disorders such as chronic fatigue, fibromyalgia, and long COVID. She practices with an evidence-based lifestyle medicine focus and also supports patients in implementing plant-based eating for individual and planetary health. I love that. Marianne's also the former editor-in-chief of the Canadian Naturopathic Doctors Association Journal, and a role that she just recently stepped down from after eight years. So I love the focus on evidence-based research and practice. That's just wonderful. She's currently a member of the Menopause Society, Plant-Based Canada, UK Plant-Based Health Professionals, the Canadian Coalition for Green Healthcare, and affiliated with the Canadian Association of Physicians for the Environment. What a resume, Marianne. Wow. It tells a lot about you, not only as a naturopathic doctor, but as a human being, and how you really see how we're not just this being on the planet, and it's all about us, the interconnectedness of things, and how we interact with the environment, how our environment interacts with us, and how we care for animals, and plants, and the earth, and how that matters to us as human beings. So thank you for the human being that you are, and for joining us today.

Kevin: Yes. Welcome, Marianne.

Dr Marianne Trevorrow: Thank you. A couple of points I think I should make here. One is that it's not only women that go through menopause. So I do have a number of patients in my practice. So I do support patients that are doing gender-affirming care. And that not all menstruators identify as women. So I do have non-binary and gender-queer patients in my practice, and try increasingly to use gender-neutral language. I mean, I'm not policing gender-neutral language, because I think it takes some time to sort of think differently about this. But there are a number of menstruators that may not necessarily identify as cis women. So that's an area that I'm increasingly doing in my practice, and hoping to get up to speed. There are courses now on working with non-binary and trans patients in menopause. And that's an area I find really interesting, because we really don't have a lot of good science and evidence to go on. But we're able to help these patients quite a bit. And I'll talk a little more later about some sex hormones are more feminizing and more masculinizing than others, and how we're changing a lot of our language about hormone therapy to be more gender-neutral, which I think is a very positive step. The second point I wanted to make was a little more about the environment. Because one of the things that I've found now, 20 years into practice, that I didn't have to think so much about 20 years ago, was the effect of climate change on my patient's health. Specifically, because I'm from out West, and I've spent most of my career in British Columbia, increasingly we're finding that extreme weather events, so flooding, heavy rains, are impacting patients' stress level, because we're having a lot of flooding problems. Especially on Vancouver Island, where I was practicing. And also, the increasing fires we're seeing out West are causing a lot of respiratory issues. So these issues are getting closer and closer to home, that the way we're practicing, we're having to think more about the choices that we make, like the exposure to microplastics in a lot of personal care products, for example. The exposure to a lot of toxins in the environment, I'm thinking specifically about particulate matter from forest fires and things like that, or if not the trauma of having to be evacuated. I wrote about this a couple of years ago in the journal, when there were large evacuations out of Northwest Territories and Northern Alberta, and people displaced for weeks and weeks at a time from their homes. So just some things that are changing. So the idea of eating more sustainably, of avoiding plastics, I mean, these things, minimizing the use of plastics in practice, I know that's something we talk about quite a bit at the Coalition for Green Health Care, and that I've changed my practice so that, for example, I use a lot fewer injections of vitamins because of the plastics in the syringes. And I recommend, I don't recommend vaginal estrogens anymore that come with plastic applicators, because we're throwing a lot of this stuff away and creating plastic pollution, which has become increasingly a problem. So I suppose that's a little technical to lead off with, but...

Kevin: No, but it's great for setting the context, honestly. These are some of the things that I've never even thought about, but the plastic wrapping of so many things used in a doctor's office makes perfect sense, and the average person, the average noob like me won't put two and two together like that. So thank you, that's interesting.

Michelle: Yeah, wow. You said so many important things in there, Marianne, and just mentioning, just going back to what you said about non-binary patients, I have to be honest with you, that's not something that I've thought about. I haven't thought about what we would normally call, quote unquote, women's health, but of course, there's a whole contingent of patients out there that don't identify as women, but are going to be experiencing all of those health issues, but need to have personalized care for them to navigate.

Dr Marianne Trevorrow: I just wanted to bring it up at the front, because if you hear me using gender-neutral language, that's what that's about.

Kevin: No, that makes sense.

Dr Marianne Trevorrow: Because there are menstruators who identify as non-binary, and there are menstruators who identify as trans, so I try as much as I can, when I remember, to use neutral language. This is one thing that we all, I mean, I have members of my family that identifies, my extended family that identifies trans, so I think this is something that we need to support and celebrate as family members, and talk about as if, and normalize it more than anything. I think one of the things that I find exciting about the way we're talking about hormone therapies over the last few years, is that we are now talking about hormone therapies in a little more of a spectrum of, again, more masculinizing and more feminizing hormones, rather than, oh, these are male hormones and these are female hormones, because women, as we are increasingly hearing about on the internet, women produce testosterone naturally before menopause and after menopause, and men naturally produce estrogens during their lifespan, so just a small sort of finger, keep on that point.

Kevin: Yeah, no, exactly, it seems like they're labels from probably like the 1930s or something, or maybe, and they've just stuck, yeah, and habits, old habits die hard.

Michelle: Yeah, wow, cool, all right, well, you've got me so excited, I'm going to dive in and start asking you some questions. Okay. So I just want to start for our noobs out there, how do you, just to level set, how do you define perimenopause and menopause in simple terms?

Dr Marianne Trevorrow: Well, in simple terms, menopause is the easier one, menopause is officially defined as the period that is 12 months after the permanent cessation of menses, so after the last bleed that any person has, you count 12 months, and then that is considered menopause, so perimenopause is, it has a number of different definitions, but I know that the Menopause Society defines it as the period starting when periods become irregular, and again, this is for regularly cycling people, not for patients with PCOS, but for regularly cycling people. This would be a variation in menses of more than seven days, and it starts at that point, and it finishes in that year after menopause, so perimenopause is the period before and after the menopausal transition, that's how it's officially defined. In common use, we tend to define perimenopause more as that seven to 10 year period leading up to the menopausal transition, but no, officially it includes menopause as well.

Michelle: I didn't appreciate that by definition, it also is a period after menopause.

Dr Marianne Trevorrow: Yes, yes, yes, exactly, but that's how, when doctors and researchers talk about perimenopause, they're including both the menopausal transition and the period immediately preceding and following the menopausal transition.

Michelle: So what are the earliest signs for a person that is entering perimenopause, and how would they likely know, and what are some of the ones that are probably the most overlooked?

Dr Marianne Trevorrow: Well, officially, we know that a person is entering perimenopause when cycles become irregular, so this would be for someone for whom they had regular cycles before that. So periods usually become shorter to begin with, usually we're going from 20, so a regular, believe it or not, a regular menstrual cycle can last anywhere from 25 to 34 days, so there is a fair bit of normal variability. Most people have a set period between menstrual cycles that is normal for them, meaning that they don't vary more than about three days, so people will be like a 27 day cycle or a 32 day cycle. But what happens at the beginning of the menopausal transition is that, because follicular stimulating hormone, this is a brain hormone that tells the ovaries to make estrogen and progesterone, it starts to increase because there's a signal that comes from the ovaries saying that follicles are starting to run out, so the brain sends a signal to the ovaries saying produce more estrogen, and you get cycles that are shorter and shorter because the estrogen starts to increase sometimes during the luteal phase, so this is sort of hormones 101. Follicular phase is the period of time after menses when a follicle is growing in the ovary, and luteal phase is the period after ovulation and before menses when the uterus is being prepared for potential pregnancy. So usually in follicular phase, estrogen levels are rising to the point where you have another hormone called luteinizing hormone that occurs. It surges when estrogen gets to a certain point and causes the follicle, though there'll be one follicle that grows, to excrete an egg into the tube to travel down to the uterus, and then afterwards that follicle becomes, it transitions into something called corpus luteum, which is a Latin term that actually secretes progesterone for the second half of the cycle, which prepares the uterine lining for pregnancy. And after a period of about 9 to 13 days, this is again in normally reproductive cycles, 9 to 13 days, if there's no signal from the uterus that a pregnancy has occurred, progesterone levels fall off, and that initiates bleeding. So it's a rather intricate balance system, and what happens is that when estrogen, so estrogen should rise in the first part of the cycle, but what happens is increasingly because follicular stimulating hormone from the brain is slowly rising in the later stages of the reproductive life of women and trans people. You'll see increases in estrogen early, so these are what they call luteal out-of-phase estrogen events. And what happens is increasingly cycles become shorter and shorter to the point where women or trans people aren't ovulating anymore. So typically I'd say, again I realize this is a rather technical argument, but typically you'll start to see cycles shorten. They'll shorten, they'll become lighter, and often the symptoms that you see with that would be associated with increases in estrogen. So you'll see sometimes heavy bleeding, you'll see often sore breasts, sometimes some mood changes, those are pretty typical. The ones that bring people into my office tend to be the ones that impact patients more. So insomnia would be one, hot flushes would be another, definitely irritability and anxiety would be symptoms that I see a lot in practice.

Michelle: Right, so for a stressed out middle-aged person, you know, working corporately, juggling the kids and the career and, you know, how would they know that the mood changes and the irritability are related to perimetopause?

Dr Marianne Trevorrow: Well, they wouldn't necessarily, and this is the thing that I explain to patients, is that sleep issues are often, sleep issues, heavy bleeding, irritability are what bring people into my office. And they may not necessarily connect them to hormonal changes, or they may have been told by another provider that, oh, it's too early for you to be in perimenopause. But they end up in my office because they are not functioning, or they feel like they're going to bite the heads off of the people around them, or the bleeding is so heavy that they're becoming anemic to the point where they can't really, they can't function well either, because we know anemia is probably the most common nutrient deficiency we see in people in their 40s that are menstruating. So it varies. I mean, people are coming into my office because they feel miserable, and they don't feel like they're getting answers to that. So that's often what they're telling me. And one of the things that I tell patients in turn is that hormones themselves, the hormone therapies, although they're a mainstay of my practice and something that I use every day when I'm treating patients, is that it often, they will help, but a lifestyle that is not balanced. I mean, and typically the thing that I'm seeing in a lot of my stressed out patients with corporate jobs, professional jobs, my teachers, my shift workers, my nurses, for example, is that they're not sleeping well, or they may be cutting into their sleep to juggle their family and professional responsibilities. So that's what's often bringing them into my office. They can't sleep. And one of the things we know is that if you're not sleeping well and regularly, it's common to feel exhausted, to put on weight, to start to have metabolic problems. So the ball rolls downhill after that.

Michelle: Yeah. So you have to kind of figure out, was it the chicken or was it the egg, right? Like you almost have to look at the whole, look at the group of symptomatology and try to figure out, is this your lifestyle or is this perimenopausal or is it a mixture of both?

Dr Marianne Trevorrow: Well, it's usually a combination of all of the above.

Michelle: So I'm just curious, to backtrack for one second, what led you to this area of interest in your practice? What led you to this topic?

Dr Marianne Trevorrow: Well, I think, I mean, I started out, interestingly, the first few years of my practice, I worked, I had a, I was on Vancouver Island and I worked mostly with kids and teenagers with developmental disorders. So a lot of kids on the autism spectrum with ADHD, kids, teenagers with a lot of behavior issues, food issues, various things. And almost universally, they had stressed out parents and the stressed out parents would ask me for help with sleep issues or menopausal issues. And I was curious because at the time when I was new in practice, I was actually going through perimenopause myself and having some symptoms. And I started to be interested in, this was the period I started in practice goodness in 2000, 2007. And so this is almost 20 years ago. And this was right after the Women's Health Initiative trial, back when we were told that hormones, I mean, I was taught during my naturopathic training in the United States, that hormone therapy was dangerous, that it would cause strokes and breast cancer. And I was taught to use- I was taught the same thing. I was taught to use herbal medicines for this. And what I found in practice, it didn't really work. So I started to be- this was on Vancouver Island. I had relationships with a few compounding pharmacists, and they led me to some courses on bioidentical hormones. And I thought they were- they were fascinating. I just- over time, however, I discovered that the whole idea of bioidentical hormones is not really that evidence-based. So I started digging into what really is effective and evidence-based. And this was a time when our thinking about hormone therapy, about menopause was evolving. And gradually, over the next decade, I would say my practice started shifting more and more to working with midlife patients, because there was just such a need for good integrative care for those patients. And it just wasn't- there was still- I would say until four or five years ago, we really- I mean, it was half the time patients would be coming in to see me and being told that they would like to discuss or consider hormone therapy, and they were told that this was dangerous, or they were told that they would get breast cancer, or things like that. And I found in my practice that- and then taking the course in the Menopause Society, that really hormone therapy is safe and effective in the vast majority of patients that use it. So that's- slowly over time, I've sort of been shifting my focus, and now I pretty much exclusively work with patients at midlife.

Michelle: Maryann, I love that you brought up the Women's Health Initiative study, because I think it's still hanging out there in people's memories.

Dr Marianne Trevorrow: Oh, sure. Yeah.

Michelle: As the pervasive narrative that these hormone therapies are dangerous. Just for the benefit of our listeners, can you just kind of encapsulate that issue?

Dr Marianne Trevorrow: So the important thing to remember, it started- it was a study- there was, I think, about 68,000 women in the interventional arm. There was also an observational arm, so it's a huge study. Over 100,000 women total. I think there were 30 academic centers involved in the United States. This study- so the interventional study, they were studying whether hormone therapy- and it was a specific form. They were giving Premarin, which is conjugated equine estrogen. So these are estrogens derived from pregnant horse's urine, which was the standard form of estrogen given in the 90s and early 2000s for hormone replacement therapy. And they had one arm where they were giving women this therapy specifically, and one arm where they were giving women another therapy called Prempro, which was Premarin and Prevero, and a specific patented drug. And they were comparing them both to placebo. And the reason the study was- so an important thing to know as well is they were recruiting women in the study between the ages 40 and 79. So there was a large- so these were post-menopausal patients, potentially right at the menopausal transition, and potentially up to a decade to a decade and a half after. So if you're looking at patients at 79, you could be talking a couple of decades after menopause. So they were casting a broad net, and the question they were asking- and this is the important thing that I think is often forgotten in the discussions of that study. The most important question they were looking at in the interventional trial is, can hormone therapies after menopause prevent heart disease in women? And they were looking for, is there specific- can we give women these hormones specifically to prevent cardiovascular events? And what they discovered is that that is not true. They actually stopped the wing. And again, this is important to know, that there was a wing of the trial that was stopped in 2002 because they saw an increased incidence in breast cancer and strokes. That was the wing with the Premerin and the Prevera wings. So that was the wing with the equine estrogen. So these are both oral hormones, and in much higher doses than we would give now. So this was that specific wing. So they stopped the trial in 2002 because they said that the evidence for harm was greater than the evidence for benefit, which is what you do in a large trial like that. When you find evidence for harm in your statistics. So the trial functioned the way it was supposed to. Was it answered the question, should we give hormones specifically to prevent heart disease or prevent breast cancer necessarily? And the answer was for estrogens and progesterones given to women between 40 and 75. The answer is no. The thing that happened with the study, though, when it became part of the mass media and the way it was reported, was it became hormones are dangerous. And that was not at all what they were saying. Since that time, there have been a number of studies, because remember, this is a lot of data. This is over 100,000 women in these trials. So they were also looking at things like does calcium prevent osteoporosis? Are there other factors that contribute to heart disease and breast cancer in mature women? So there has been a number of restudies of that original material. And each time it seems that they do a new trial, they discover new information. The latest position statement the North American Menopause Society said, which was from 2023, is that there is likely a benefit from hormone therapy for women with symptoms in the 10 year period after menopause. So now we're looking at guidelines that say as long as you initiate hormone therapy before age 60 or 10 years after menopause, that you're likely going to have a benefit for certain kinds of conditions. These are called unlabeled conditions. So these would be things like prevention of osteoporosis, treatment of vasomotor symptoms, and other symptoms of menopause. And this is systemic hormone therapy. So we're talking estrogen and progesterone for those patients. We give progesterone as part of menopausal hormone therapy with estrogens to prevent a buildup of the uterine lining and prevent abnormal bleeding. Because one of the things that we do know that is a risk of hormone replacement therapy, and one that we have to manage with hormone replacement therapy, is that bleeding that is abnormal, so bleeding that is heavy during perimenopause or bleeding that occurs after menopause, can be an early sign of the development of uterine cancer. So we give progesterone to inhibit that bleeding. And we know now that oral micronized progesterone does that very effectively. So now oral micronized progesterone, which I must add, is not currently part of Naturopathic Doctors' Scope in Ontario. But it has been asked for by our association. It was applied for. Our regulator has approved it. We understand it's right now being considered at the Ministry of Health. We are being told that the association is being fast-tracked. But we give progesterone with estrogen for that specific reason, is that you must, to manage those risk factors. So we don't give Prevera, really at all, with hormone replacement therapy. I haven't seen a prescription for that in many, many years. It is very unusual to see a prescription for Premarin these days as an oral agent. We're giving, almost 100% of the time, conventional providers, so this is family docs and specialists as well as myself, are giving estrogen as a topical formula of one kind or another. So we're giving lower doses. We've discovered we can manage symptoms with lower doses. But we're giving gels and patches now. And that's something that the Menopause Society has said in their latest physician statement from 2023, is that those are preferred for a few reasons. One is that we understand now, again from research, that estrogens given topically don't carry an increased risk of formation of clots the way that oral estrogens do. And that was one of the other big concerns that came out of the large Women's Health Initiative trial. And it was actually very helpful to have that research question answered, is that they do increasingly, oral estrogens, as well as oral progestogens, become a risk concern in patients over 40 to 45 because of this risk of clots. And clots can, you think, well, what's the issue with clots? Well, clots can potentially become things like, can cause a heart attack in the form of a clot that stops a coronary artery, or it could enter the brain and cause a stroke. So these aren't minor things. I mean, these are potentially major risks we could be causing that we are no longer causing because we're not using these forms of hormones anymore.

Michelle: So, if you're with a group of women, or a group of other individuals around this age where these are a concern, inevitably, there's chatter about, oh, well, you should talk to your doctor. This is what I do, and this really worked for me, and for the next person, it'll be something different. Some person will be getting a topical progesterone, and then there's another one that will be using an estrogen cream, and the other will have a transdermal patch, and others will have a vaginal capsule. I don't know if it's possible, Marianne, but can you kind of walk us through the different approaches and how you would know what's right for you, or why their different primary care practitioners are treating different things? I think there's a bit of skepticism with a certain segment of the public that it's whatever the pharma rep came by with that day, or how would the average noob kind of understand this complex situation, because what you've described, like, there really isn't a one-size-fits-all approach here.

Dr Marianne Trevorrow: Oh, absolutely not. Absolutely not.

Michelle: And I don't know how helpful it is that we have these conversations of, oh, this is what I have. Well, maybe I should ask my doctor about that, you know?

Dr Marianne Trevorrow: Well, and this is the thing that I think is the complexity with this, and definitely for patients in perimenopause. And as I brought up initially, and it's something I've been increasingly learning with my non-binary patients with estrogens, is that estrogens are often... So estrogens are very feminizing hormones. So many patients on estrogen therapy will find that they get symptoms of... They will get estrogen-pneumonic symptoms, so breast tenderness may be one of them. They find that their skin changes. For many of my patients, the rejuvenation aspect of increased collagen formation with estrogens is very welcome. For some of my non-binary patients, the feminizing effects, so the breast tenderness or the potential feeling of fullness in the breast, is very distressing. So that's one factor that enters into how is it... And one of the things we're learning about transdermal hormones is that patients' ability to absorb these vary quite extensively. Now this is something we probably should have known beforehand because it's one of the things in the testosterone literature that we know with trans patients and cis men is that men vary in their ability to absorb topical hormones, but we're starting to... We're learning that people really do... So I have patients, for example, on sometimes twice as much topical estrogen patches than others, and it can be difficult to predict who will absorb well as opposed to who will absorb poorly. That can be a challenge. In terms of the different... And this is also true for progesterone, and I do have to add the caveat that right now in Ontario, naturopathic doctors can only prescribe suppository and topical forms of progesterone. If we're going to have the ability to prescribe, we need to have the forms that are standard of care and are safe. So a rule of thumb is that when I have a patient coming in to me for hormone therapy, the first thing I establish is, in what phase of menopause are we? So for a patient who still has regular cycling, estrogen may not be appropriate for them in this phase of perimenopause because what it would likely do is cause bleeding to increase, and we may not want that. In fact, we usually don't want that. So we may be leading off if a patient has significant insomnia or significant mood changes or anxiety. We may start with progesterone as a monotherapy, and I use that quite a bit in my practice. I have great success with that. My patients often report significant changes in mood. We do have to be careful with progesterone because some patients have a paradoxical reaction that they have actually depressed mood from progesterone. And so we have to, I start conservatively with dosing, and I check to see if they've had adverse reactions, say, to oral contraceptives in the past. That sort of gives me a hint that there might be just the same, I mean, the same as we would do with any antidepressant medications. Again, as an ND who has translocated from BC to Ontario, I don't, those medications are not in my scope here, but if they were in British Columbia and I have considerable experience with antidepressant therapy, and sometimes patients don't respond the way you think they should to the medicines. So what I do in practice with hormones is I start with fairly conservative dosing, start in early perimenopause with progesterone, and later perimenopause, if I have a patient that is a candidate for estrogen therapy, start with a conservative dose of estrogen. And then I walk patients through the various forms. So there are, there are patches, and there are gels, there are two different kinds of gels on the market, and this is for systemic therapy. So this is to manage hot flashes. I don't manage heavy bleeding in my practice because standard of care for heavy perimenopausal bleeding is either an oral contraceptive like Nistellas or Slend, so one of the new generation of oral contraceptives, or IUDs. And so I'm honest with patients, I tell them that progesterone that I prescribe won't work for that. So I refer them back to often their primary provider or to a menopause clinic specifically. But yeah, in later perimenopause, I walk them through, these are different forms. Do you have a preference? There is, like for example, with the gels, there is a gel called Estrogel that a lot of patients use, it comes in a pump. Some patients don't like the fragrance that's put in it. This is different than a cream? So creams, most of, so all of the medicines that I know that are made by pharmaceutical companies that are estrogens or gels, so they come in a pump or a packet. So some patients don't like the packets because they don't like opening all the little packets and some patients don't like the smell of the estrogen, the estrogen gel in the pump. So creams, when you're talking about creams, that's going to be a compounded progesterone that will be made by the pharmacist. So the creams would be progesterone, although you can also make it in a gel. But it really comes down to patient preference. Some patients like the gels, some patients like the creams, some patients like the patches. I would say in my practice, which is interesting because I have an MD colleague who has a menopause clinic out in Carling, who is, I want to give a shout out to my good friend, Dr. Keiko Chan, who I work with a lot and who we talk a lot about challenging cases. Her patients by and large like the estrogen, like estrogel in the pump. My patients by and large like the estrogen in a patch. We have no idea why that is. Both of us have no, we have absolutely no idea why it seems that her patients like one and my patients like the other. But it seems to, and I think this is important, that women do and trans patients do have options for hormone therapy. And individualizing, I mean, you can't just sort of slap a patch on it and call it good. It's often a process of try a conservative dose, see if that manages it. In my practice, I'm starting with sort of the minimum dose that I think will be effective in most patients. And then I see the patient six weeks later to see how they responded to it. And then if we're fine, then we sail along for another few months. If we're not, then we try a small, depending on if they've had symptoms of hormonal excess. So that one's easy. Symptom of hormonal excess with estrogen is that you will feel, your breasts will be sore and you may have headaches. Like the headaches are a big one. And so we have to back it off, or they may feel dizzy. With progesterone, if you give a patient too much progesterone, which is hard to do with a topical, but can happen, they'll feel very, very sleepy. Like just can't get out of bed sort of sleepy. So you have to back off.

Michelle: So is there a difference between, I think I heard you say that there's a variability with the transdermal patch that a person may or may not absorb. Does the same variability exist with the gels?

Dr Marianne Trevorrow: Yes. Yes, absolutely. Absolutely.

Michelle: So that would just be an individualized issue, not the particular prescription?

Dr Marianne Trevorrow: Yes. And one of the things you learn, and I think this is actually, I think this is a welcome change in practice, is we no longer test hormones at baseline for menopausal patients. Because one of the things that we understand from large clinical trials, particularly two trials, one was called SWAN, Study of Women Across the Nation, the other was called the STRAW trial. So the STRAW trials actually helped us stage the various phases of perimenopause. And one of the things that we learned from these blood tests that were done in these large trials was that there is a tremendous variability, even within the same patient for the same point in the cycle, cycle after cycle. And it was one of the ways that we learned about that we no longer use the term estrogen dominance, we now use the term luteal out-of-phase estrogen events. And so I know, and this is when I give talks, I throw a slide up often where I think it was from the STRAW trial where it showed the same point in the cycle in six different patients and you had six different, completely different levels of estrogen and progesterone. So there's really, and one of the things we learned as well is that we used to test a lot of follicle stimulating hormone because we know it goes up in perimenopause, but it doesn't just, it's not just an on-ramp, it goes up, but sometimes it'll go up and then come down because of the effects of a luteal out-of-phase estrogen event. So really we're wasting time, energy, and money by doing blood tests in the perimenopausal period. Wow. So, I have so many questions.

Michelle: A little while back there, you mentioned between on-label and off-label. Can you just break that down for our new listeners?

Dr Marianne Trevorrow: So on-label means that a drug therapy has been approved as an indication by Health Canada. So that means it is considered standard of care and usually a best practice. So standard of care means that it has sufficient support in research to beat Health Canada's standards for that therapy. So for example, estrogen therapy in menopause is considered on-label for a hot flashes and on-label for the prevention of osteoporosis. There are other menopausal symptoms, increasingly there's discussion in the literature, and I think this is something that I see a lot in practice, that estrogen can be a benefit for many patients with a lot of joint pain and soft tissue pain that arises in menopause. It's called the musculoskeletal syndrome of menopause. We used to think of that as, I know in the addition of the Menopause Society textbook that I had when I took the course, it said that well over half of women have arthritic symptoms so we don't consider that a separate syndrome. Well now we do because we have studies, but that is not considered on-label. So that's considered, well that might benefit that, but it hasn't risen to the point of sufficient evidence. It can be a challenging conversation to negotiate because I agree that the idea of on-label and off-label drugs really has to do with what's been studied and what hasn't been studied. And that has to do with things like what kind of grants people can get, what kind of industry support there might be for a specific therapy, what it will cost to get it approved. I mean those are challenging conversations to have. I'm trying to translate that into things that make sense to patients, but they are important to know behind the scenes that not every effective prescribed therapy is a non-label therapy and often off-label therapies can be, assuming there's no potential high level of risk, that they can be quite valid. It is challenging to, if you're not an established researcher, to get grant funding to study a lot of these menopausal issues. Even though they're hot topics, it can be difficult because it costs a lot of money doing interventional trials. You're looking at hundreds of thousands of dollars to do all these things. And I think that's another thing that's important to know.

Michelle: Well, just on that, I don't know what the statistic is, but I remember reading it somewhere about the amount of study that is actually done in this space in the spectrum of all scientific literature. And it's very small, even though it impacts such a large percentage of the population. Do you know what that stat is?

Dr Marianne Trevorrow: Well, the latest stat that I saw from Canadian Institute for Health Research, or CIHR, is that approximately 12% of research studies go on areas that pertain only to women. So we're talking about, and that went like wildfire through a lot of my colleagues on social media, that's a pretty small percentage. And I think there's been some bias and misogyny against these issues for mature women's health. There's been a sea change in the way we're looking at these issues. And we're starting to understand that a lot of this affects like half of the population and some places more than half. And it affects women and non-binary people in the prime of their working careers. And it is affecting, again, we're in a system where productivity matters, so it is affecting productivity, and I would say in practice, impacting quality of life, which to me is as or more important. But I think that now that thought decision leaders, people that are prominent, now that I mean, I'm just in my, I've just turned 60. So I was at the leading edge of women having, prioritizing professional careers. I mean, the boomers in the beginning of Gen X, and now we're seeing a number of women in senior governmental, senior corporate, senior academic roles, we're not willing to put up with being told, oh, there, there, there, you're just getting older, you just need to accept that. And so that's why I think, I think it's the late boomers and early Gen X, women that are not willing to put up with, with this anymore.

Michelle: Right on.

Dr Marianne Trevorrow: Yeah, exactly.

Michelle: So I'm so glad that you brought up nutrition, lifestyle medicine, because I think that's what that's what binds you and I together in the communities that we belong to. And certainly it's the reason we started this podcast. And I want to, I want to get you to talk a little bit about your experience in that space. And just to open this part of it, I have to tell you a little bit about my own experience. And that is my, I'm adopted, but my biological mother, I watched her go through, you know, probably what was perimenopause and menopause, because we met when I was 26, and she would have been 40 in her mid 40s. And I experienced her struggling with hot flashes and mood swings. And, you know, I don't know about the more intimate symptoms that, you know, that, that, that, that plague a person at that stage of life.

Dr Marianne Trevorrow: Oh, because we didn't talk about that.

Michelle: Right, absolutely. But I know I, you know, she used to always comment, oh, you just wait, you just wait, right? Like, this is going to be your experience. And I became primarily whole food plant based, like very close to 100%, about a good three or four years, I think, before the onset of perimenopause for me from, from when I noticed it anyway. And I didn't experience any of that. Like, I very rarely ever had a hot flash. And, you know, there were times actually when I would say, where are these hot flashes people talk about, because I'm freezing cold here in Ontario in January. I could use a hot flash right now. But I did experience the sleep disturbances, the dryness, the things, things like that, and noticing the differences in the skin. And that, you know, where estrogen in, in my case, has been a very welcomed therapy. And it's, you know, only a couple of times a week. It's some sort of a capsule. And, you know, a lot of those, I think, I think probably the biggest problem that myself and even friends of mine have discussed, it's like, where did these UTIs come from out of the blue, never had this problem before. And that that's probably the most essential reason why I was really interested in this topic of hormone therapies, because estrogen seemed to be the magic bullet for that one. So, but then, but I would like to know from your experience, like, I feel so fortunate that I, for a whole bunch of reasons, was drawn to whole food plant-based nutrition. And I think that it has been, by and large, my saving grace for some of those other symptoms. But what, like, talk to us about what you see in the experience of your patients and what you know from the literature in terms of the importance of that and how it can benefit a person in this stage of life.

Dr Marianne Trevorrow: Absolutely. And I do want to, so I want to put a finger in the, in the discussion about pelvic estrogens and circle back around to it, because the dryness, so vulvar dryness with people with vulvas, this again would be, would be cis women, trans women, and non-binary patients, about, so a majority of us will have issues post-menopausally with dryness. There are shifts in the microbiome in, in the vagina and in the vulva that can create the, can set people up for urinary tract infections. And for those patients, local use of estrogen is tremendously beneficial. And we're talking about actually a majority of patients there. Right. So that is something that, and that should be thought of separately. Like we give low dose estrogens as, sometimes as a compounded cream, sometimes as a suppository and that, and it goes to patient preference. But those are, I would say that, that is a separate syndrome called the genitourinary syndrome of menopause. And that has, that is completely separate from, from menopausal hormone, systemic menopausal hormone therapy. But circling back to lifestyle, I would say probably one of the, one of the top three or four concerns that patients come into my office in midlife and with menopausal symptoms are, I am gaining weight. I'm gaining weight specifically around my abdomen. I don't know what I'm doing differently. And I really want this to stop. And they may or may not have heard that hormone therapy will fix that. And that is something that's actually a myth that I dispel right away, is that hormone therapy will not, will not change the way our fat is deposited at midlife, because we're not replacing the hormones that we had in our reproductive years. We're actually giving a much lower dose to sort of cushion the fall. But more importantly, what we're understanding about metabolism and the way that fat deposition changes at midlife, and this goes for women, men, and non-binary people, that we do, the fat that we deposit at midlife and later tends to be either visceral fat, so that's fat that's under our top layer of muscle around the abdomen, or abdominal fat, and that we do need to think differently, if we haven't been, about the diets that we're eating, and about potentially are we eating too much animal protein, for example? Are we eating too much saturated fat? We know that in North America, I know there's a big, big push right now, again, on social media around protein intake, but in North America, we know that even patients on vegetarian and vegan diets have more than adequate levels of protein. And the big problem in North America is our diet that is heavy, still with saturated fats, with calorically dense foods, and a lot of those come in processed foods. And we know that there is increasing, as the protective effect of estrogens in our reproductive years begin to wane, that we are more susceptible to insulin resistance, we're more susceptible to cardiovascular disease, although people are presenting with, well, I have this weight and I don't like it, the bigger risk and concern, and the one that I say is the most important thing to pay attention to, is that insulin resistance actually raises our risk of cardiovascular disease, specifically heart disease. And the diet, you know, focusing really on a diet that's high in phytonutrients, so this would be antioxidants from plant-based foods, and plant-based proteins, in fact, we know one of the most successful diets for lowering cholesterol is a diet known as the Portfolio Diet that was studied at the University of Toronto, Cardiometabolic Lab, lots and lots and lots of good research on it. Dr. Jenkins, right? Dr. Jenkins Lab, and the original platform was that it contained overwhelmingly plant-based protein. And so that's one of the things that I talk to patients about, you don't necessarily have to, you know, is they have a misconception that a plant-based diet is a vegan diet, and I tell them that there is a spectrum of plant-based eating, and that plant-forward diets and eating a diet that's higher in plant proteins and fiber will make people feel, they will increase satiety, so people will not feel as hungry, they will help the gut microbiome, so if patients have any irritable bowel symptoms, so bloating, gas, diarrhea, that sort of thing, that will help that over time. It will improve the state of your skin because we know that collagen formation, collagen is instead of swallowing expensive collagen supplements, I tell patients that eating a diet that's predominantly fruits and vegetables create the, these are easily absorbed, easily digested building blocks of collagen, and that makes your skin look healthier and younger. Exactly. So, and it improves, and more importantly, by improving collagen formation, it helps with blood flow into vessels, it helps lower blood pressure, I mean, there's a lot to like about eating a plant-forward or plant-predominant diet. I mean, leaving aside the issues of animal protein and its effect on the environment and its effect on climate change and the resources that we need to create, like the intense resources that we put into things like intensive animal agriculture, I mean, even leaving all of that, all of those climate impacts aside, on the individual level, moving towards these more sustainable diets is more sustainable for people in general, just on an individual level, but it is definitely, it requires motivation and often a change in habits, and that's where stress management and sleep come in because when I'm talking to patients who are exhausted and running on fumes a lot of the time, even the thought of trying to create meals, you know, dinner at the end of a working day when you've got, you know, kids coming into the kitchen saying, what's for dinner? Your phone's buzzing and you haven't had enough sleep, I mean, we have to, we have to be realistic about what, you know, what would be a logical first and second step for patients and how I think we can get small changes in diet, small improvements, and one of the things that I do, that I do tell patients is important to think about is think about the cost of eating this way because it's actually cheaper to eat plant-based proteins by and large than the cost of animal proteins. It is. It will save money, yes, it's sometimes a little more time to prepare food, but you can, there are ways you can do it, and that's often where working with dietitians, I know there is a local dietitian that Dr. Chan and I work quite a bit with in Ontario by the name of Catherine Pouliot, she is actually on the faculty of the University of Ottawa Med School, fantastic dietitian, works with a lot of our patients to sort of, and she's doing something that I think is an increasing trend in lifestyle medicine, which I think is very helpful, she's doing cooking classes because I think that learning skills, I mean, just like in couple therapy, we're learning communication skills, in dietetics we're learning cooking classes, I think learning a lot of these helpful lifestyle habits is, it gets people on the road instead of feeling like, oh, now I got to do this, now I got to do that, now I'm going to do this, I'm already exhausted. Hormones don't fix somebody who's exhausted all the time because they're doing more than well over half of the household tasks. The amount of domestic work that women with professional jobs do in families, and we do need to, I mean, this is something that I think is being renegotiated in our generation is now that couples are working often as many hours as each other, why is it that the domestic responsibilities of what we call kin keeping, why does this always seem to fall on the shoulders? Again, I'm talking about heterosexual, but it falls on the shoulders of wives and mothers, so there's a good reason why women are tired, and that's leaving aside the whole issue of single parenting, which can often feel overwhelming because you're looking at trying to be in the workplaces if you don't have kids and then trying to parent if you don't have a full-time job.

Michelle: Yeah, you know, you're so right because I think a lot of people are starting their families later than they used to in my parents' generation.

Dr Marianne Trevorrow: Absolutely, for financial reasons often.

Michelle: Right, they're dealing with this while they're still raising young kids. Oh, yeah.

Kevin: And their parents are living longer as well, so they're sandwiched between the generations as well, yeah.

Michelle: Yeah, yeah, so well, you know, you've echoed a lot of things that I found doing nutritional coaching and consultation around the visceral fat is usually the biggest concern. Always, yeah, always. And I found the same thing, just from my perspective, to echo what you said, that it's really around the metabolic adaptations and changes that have been happening in their body and making them understand that, you know, that biodiversity is going to have a big part. Most people are not consuming enough fiber, they're not drinking enough water, they're not moving enough, they don't realize as they age that the importance of doing more resistance training and getting some exercise snacks in during their very, very busy day, like, and not only cardio, cardio is really important, but making sure that they're doing, you know, more of that muscle mass.

Dr Marianne Trevorrow: Oh, yes, strength, preserving strength and mobility, absolutely, you know, doing mobility exercises, you know, yoga, tai chi and that sort of thing. Yeah, absolutely. I think too, Michelle, in our generation, definitely, you know, I have an unusual background as in my younger years, I was a high performance track cyclist. So I was someone that did strength training as part of what I did. But in definitely my generation there, you know, it was, you know, you didn't see a lot of women in the weight room. And it definitely there's been a sea change with that, with a lot of and I think this is a good change that women, women, again, and non binary patients, being able accessing strength training, the idea that, you know, amongst my cohort was that this was feminine that you would create, you would make yourself into a more masculine physical shape. I think it's sort of gone out the window in a way that I think is is healthy and life affirming, that strength as we get older is is such a crucial, it's one of the one of the crucial reasons why we see so many broken hips and osteoporosis in older women as much disability is that they were taught to only do a very limited, very limited forms of exercise. And now, you know, people I think are blowing that up. And I think that's a healthy change. So yeah, I'm, I think that the pillars, what they call the pillars of lifestyle medicine, so definitely diet looking at plant forward diets, diets that have a lot of fruits and vegetables and are, and that are pleasurable and that people like to eat. I mean, that's just, you know, I'm from, again, I moved here in 2019 from Vancouver Island, and where which is the land of the, you know, the tofu and broccoli vegans where I had a lot of patients early in my career, who had, you know, who were very, very, I don't know what I use the word strict, but very, you know, they were very, you know, they were sincere vegans. And I certainly supported them in practice, supported them in, in removing all forms of animal protein in their diet and tried to help them maintain a sustainable, successful diet. But we didn't have, I think one of the things that I'm excited about is we have an explosion of resources and cookbooks and diets that are more varied and that people can enjoy. I mean, when we look across the world, I mean, one of the things, again, that I think is very promising is the explosion of different ethnic cuisines that incorporate plant-based eating. Because once you get, I mean, I have this conversation a lot with my patients from the African diaspora, from South American diaspora, from South Asian diaspora. These are cultures that historically ate a lot of pulses or soy or other foods, and that only transitioned to this unhealthy North American diet when they became diaspora or immigrated here. So I, you know, I tell them that, you know, this, this is, I think we're getting away from this idea that, oh, the Mediterranean diet is really the solution to cardiometabolic disease. And we're talking more about the folio diet and about diets from different, from different areas of the world. And I know that I have, like, I have a selection of plant-forward cookbooks from, from many different countries. And I think that there's now, there's now many more resources for people to try this way of eating and a lot of interest in it. And a lot, the products are less expensive and they're easier to find. I know typically, historically, for example, it was thought that vegans are people that ate a plant-based diet. So they're getting maybe 80 to 90% of their proteins as plants were deficient in B12. I don't see that very much anymore. And this is patients that aren't supplementing, but we get, we can get vegan B12 sources from a lot of plant milks now. A lot of our milks are fortified with vitamin D and B12 and calcium in, in North America, by and large, you know, not so much from American products, but definitely in Canada, they are pretty much all fortified. And I'm not seeing those deficiencies as much anymore in practice. The deficiency I do see that I do caution patients about is iron. Iron is, is, can be tricky to, to digest. And that goes for, for meat eaters as well as non-meat eaters. And that, a lot of that I'm seeing in my patients that are still menstruating. And I know that we've recently changed the criteria for what we consider to be iron deficiency, but it's, it's number one over and above. That's the deficiency that I'm seeing more than anything else is iron deficiency.

Michelle: I would echo that. And, you know, I have to say for my, my tea drinking friends out there, because what you don't know about me, Marianne, is I'm also a professional tea sommelier in part of my life.

Dr Marianne Trevorrow: That's fun.

Michelle: But what I didn't before going through perimenopause and menopause, I didn't have any issue at all with my iron absorption, even, even being a plant-based eater. But what I did find once I was full blown through menopause, I found that my iron level, I found out through blood tests with my primary care that my, I'm anemic, that my, my iron was low. Now I didn't experience feeling, you know, low iron, like fatigue or anything like that. It was just, it became, came up as a biomarker. I didn't feel like anything was wrong, but I had to pay attention to that. And then I've had to manage my tea drinking with my meals because it's weird for me to not always have a cup of tea. But as you know, those, those compounds actually block.

Dr Marianne Trevorrow: The tannins in the tea. Yeah, they do.

Michelle: They block the absorption of non-team iron. And, and, and so it's, I'm totally fine as long as I make sure that I'm not drinking tea with my meal or I'm like making sure there's a good 45 minutes or an hour away from when I'm digesting that food, which has been, I have to say a huge behavior change for me, because it's very weird for me to not drink tea with my meal. And once I, I had to reason myself through why this was happening to me, because we, we also, if you know too much about nutrition, you also become a little bit arrogant and go like, what me? How can I have low iron?

Dr Marianne Trevorrow: How can I? Yeah, I'm vegan. How is it that my cholesterol is high? Yeah, I've seen.

Michelle: Yeah. So, so that's just a caution out there. Like you have to understand it's not about what you eat. It's about what you absorb. And yes, you are doing something in your behavior that's inhibiting absorption that there's paying attention to.

Dr Marianne Trevorrow: Irritable bowel syndrome is a thing that we see over and over and over and over again in practice. And patients like getting patients to move to a higher fiber diet is not something you can do overnight. It often takes a process of months of getting the gut to adapt to being able to digest all these fibers and not create a lot of gas and discomfort.

Michelle: Yeah.

Dr Marianne Trevorrow: But eating, eating lentils of various kinds, we know they're an excellent source of non heme iron. So it's just a lot of North Americans, for example, don't know how to cook with them. I mean, my South Asian patients, they, I mean, I don't even need to tell them how to cook with lentils. They know all the gamut of lentils and all the different things you can make with them. So it really, I try to ask, well, you know, what, which diet did you grow up with? What are you comfortable with? What are you, you know, what is your, like, what would a daily diet look for you? So before making assumptions about what it is that people, you know, what is a comfort food for them? Because I've found that comfort foods vary tremendously.

Michelle: Wow. You've such a wealth of knowledge, and I can think of half a dozen topics that we need to get you back to discuss. Well, there's no way we could fully explore this topic in one podcast because it's so spacious, but I think we've laid down a really great primer for our listeners. I think it might be appropriate just as we go to close this out, talk to me a little bit about how a patient would distill between when they should talk to their primary care MD versus a naturopathic doctor.

Dr Marianne Trevorrow: A lot of patients that are seeing me for hormone therapy have found that either they're not having a productive discussion with their primary care provider for a variety of reasons, or they can't get in to see their primary provider, or they have kind of an atypical presentation. They may be, like, postpartum, but getting perimenopausal symptoms and are kind of concerned about, well, what do I, I mean, I've just weaned my kid, and now I'm having hot flashes, and it's somewhat confusing in the context of a 10-minute appointment to try and unpack that. So that's where having the longer intakes is really helpful. I think that for basic hormone therapy, I mean, for basic management of heavy bleeding, any primary care doctor and nurse practitioner can do that. They don't need to come see us. Where patients, I know where it works well is that I know my colleague who has a menopausal clinic on Carling has said that she finds it's sometimes a struggle with new menopausal hormone intakes to get all the questions answered in the time that she's paid to do it. And so she likes that patients can come to see me when they have more questions. And then if we need to, for example, have, you know, if there's heavy bleeding, I can walk them through why the hormones that I can prescribe are not the most effective therapy for that, and then I can send them back. So I think it varies. I think the most important thing if you're looking for hormonal therapy at midlife is to look for a provider that is certified by the Menopause Society, because we have the training in what is considered evidence-based care and best practices in that area. It's a fairly rigorous course to go through. There is an exam. And so if you want to work with an ND and find our, like you need that kind of care where, you know, you have a bunch of different things going on and you need someone to help unpack some of these lifestyle factors. Definitely, we have the ability to do that. In our longer, and we're able to use the benefit system because benefits allow us to bill for time, which is a luxury my conventional colleagues often don't have. We're able to unpack more complicated situations more than our conventional colleagues. I think that especially when patients are struggling to sort of put things together, I mean, they may have tried a hormone therapy and it's not exactly working for them. I can help them troubleshoot in a way that's difficult to do in the context of a 10-minute follow-up appointment.

Michelle: So talk to us about how people can connect with you. Do you do virtual care?

Dr Marianne Trevorrow: I do virtual care. So I am, my regulator allows me to do virtual care within Ontario. But within Ontario, you can contract me at my, on my website, which is drmarianne.ca and that has my website, my online booking site, email, and all the ways that you can reach out to me from there. But yeah, that's how you get a hold of me. I'm Dr. Marianne T. So DR, my first name and the letter T on Instagram and on Facebook. And I do tell patients that I don't respond to DMs about care. You have to go through my website because I have to maintain confidentiality. Okay.

Michelle: Well, Kevin, now it is your time.

Kevin: It's my turn. Your moment of fame. We always have a couple of dad jokes at the end. So Marianne, are you ready? Are you strapped in?

Dr Marianne Trevorrow: I am ready for your dad joke. Bring it on.

Kevin: Okay. So a flight attendant was showing me to my seat on a plane and she asked me window or aisle? And I said, window or you'll what? Oh, no. Shh, hear the canned applause. Of course, I do nothing but. And I've got another one just for fun. You know, two for one special. Why do lobsters never give to charity?

Michelle: Why is that? Why do lobsters never give to charity?

Kevin: Because they're shellfish. And on that note, Marianne, you're welcome to come back anytime, but you might not after hearing those.

Dr Marianne Trevorrow: It's all right. I've heard worse.

Kevin: Oh, okay. Oh, good. Okay. That makes me feel better then. Good. So I still have a ways to fall. Amazing. Well, thank you for joining us. And of course, if you have any questions for us, you can reach out to us, email n the number four noobs at gmail.com or on Facebook or Instagram at nutrition, the number four noobs. And thank you for joining us and we will catch you next time. And until then. Eat your greens. And be real, everyone. This has been nutrition for noobs. We hope you're a bit more enlightened about how your fantastic and complicated body works with the food you put into it. If you have a question or a topic you'd like Michelle to discuss, drop us a line at n for noobs at gmail.com. That's the letter n the number four n o o b s at gmail.com. If you haven't already, you can subscribe to the podcast on whatever your favorite platform might be. Also, please consider leaving a review or telling your friends. That's the best way to spread the word. We'll see you next time with another interesting topic. The views and opinions expressed on nutrition for noobs are those of the hosts. It is not intended to be a substitute for medical, nutritional or health advice. Listeners should seek a personal consultation with a qualified practitioner if they have any concerns or before commencing any actions mentioned in the podcast.

Michelle: So if a woman is entering perimenopause, how will she know? What are the what are the part of me? If a person, if a person is entering menopause, I won't police this.

Dr Marianne Trevorrow: We all are learning about neutralizing language.

Kevin: Kevin will edit that. I'll put a buzzer in and I'll buzz you every time.

Michelle: Turn it into a drinking game if it's me.

Kevin: Exactly.

Dr Marianne Trevorrow: But the thing is what happened to it when the press got a hold of it. And I don't mean to be, you know, I don't mean to be overly critical of journalism.

Kevin: Wait till you see what we do with this podcast.