Four leading women's health experts discuss menstrual cycles, fertility, hormones, and menopause on The Diary of a CEO
Steven Bartlett hosts four women's health specialists for a wide-ranging conversation covering the female hormonal lifespan from menstruation through menopause.
Summary
Steven Bartlett hosts four women's health experts — exercise physiologist Dr. Stacy Sims, fertility specialist Dr. Natalie Crawford, OB/GYN and menopause specialist Dr. Mary Haver, and orthopedic sports surgeon Dr. Vonda Wright — for an in-depth conversation about women's health across the lifespan. The panel opens by establishing that women, despite being 51% of the population, receive less than 1% of health research funding after age 40, and that women were not required to be included in clinical studies until 1993. They argue that this research gap has produced systemic medical bias — including a documented culture of dismissing women's complaints as "whiny" — that continues to harm women today. The conversation moves through menstrual cycle physiology, PCOS, endometriosis (including a case study of a team member who suffered for 17 years before diagnosis), fertility and egg freezing, and concludes with an extended discussion of perimenopause and menopause, including the panel's argument that the standard medical definition of menopause forces women to suffer unnecessarily for up to a year before treatment is offered. All four panelists share personal accounts of pregnancy loss, disordered eating, overtraining, and their own hormone therapy decisions.
Key Takeaways
FULL TRANSCRIPT
Introduction and the case for a women's health conversation
Steven Bartlett: This might be one of the most important conversations we ever have on The Diary of a CEO, because women's health has long been a total mystery to so many people, and so many people are struggling with all of the issues that we're going to talk about today — with their menstrual cycles, PCOS, endometriosis, with diet, with understanding how to exercise as a woman. It's probably never going to be the case again that these four individuals, at the very top of women's health in their fields, will be in the same place at the same time having this conversation. We structured this conversation into two parts. They cover completely different subjects, but they're fundamentally interlinked. For me, the understanding that I got from this conversation at this table with these four women has fundamentally changed my life. It's going to change how I deal with my romantic partner, my sister, my team members that I work with every single day. And funnily enough, because it's a conversation I wouldn't have clicked on as a man, it turned out to be the conversation that I needed the most.
Ladies, we should start with some introductions. Could you give me a brief introduction, Stacy, as it relates to your perspective, your experience, and your sort of bias as it comes to this debate? When I say bias, I mean your experience and your research that you're lending to this conversation today.
Dr. Stacy Sims: I come from the exercise physiology and sports medicine background, so I'm always looking through the lens of activity and nutrition and how that has an impact on our stress and our stress outcomes, and how we can adapt to specific applied stressors, especially when we're looking at improving health span, improving mood, improving body composition, all of those things. I've worked with and still work with the subset of active women. I come from an endurance and high-performance sport background. That's where I've gotten my chops, and then brought it over into the general recreational female athlete perspective.
Natalie Crawford: I'm a fertility doctor and every day I help patients with IVF get pregnant because I have an IVF clinic. But my big passion has always been natural fertility, after I experienced my own pregnancy losses, trying to understand how we interact with the world and how that changes our hormones, and help women understand what their hormones are, what natural fertility is, what happens as we age to our bodies, our eggs and our hormones, and let them be better stewards of their own fertility and their own health decisions.
Dr. Mary Haver: I have a background in general OB/GYN, so I'm considered to be a women's health specialist. And it wasn't until I went through my own menopause that I realized there was a significant gap in my training. Watching Dr. Sims on your podcast talking about how women are not little men really struck such a chord with me and made me realize I was siloing women's health to the reproductive organs — the breast, the uterus, the ovaries, the vagina — and that if I really wanted to make a difference in a woman's whole health life, this last 30 to 40 years of her life, I needed to refocus what we were thinking about women's health for the long term. I come from a background in academics. I was a professor for 20 years. I was a residency program director. I stepped away from that so I could focus on the lack of my own education and knowledge in menopause care. And now I want to step back into the academic world to bring everything I've learned and change the way we educate our providers.
Dr. Vonda Wright: I am an orthopedic sports surgeon by training and I sit at the unique juxtaposition of orthopedics and performance, having taken care of elite athletes most of my life. Aging and longevity is the focus of most of my academic research. I too, as an academic, work on subjects of musculoskeletal aging, but many years ago added a third circle of the whole health of a woman. Sitting in this place fits directly into the mantra of my career, which has always been: I am going to change the way we age in this country and the world. Because the tool that I bring to the table is the fact that if I save your mobility, I'm going to save you from the ravages of chronic disease. So the work that I do is not only educational, it's research, and it's now education of the world about these subjects.
Why women's health needs its own conversation
Steven Bartlett: Explain this to me like I'm an idiot, ladies. Why do we need to have a conversation about women's health and not just health broadly?
Dr. Vonda Wright: I think the statistic that people don't realize on a day-to-day basis is that women are 51% of the population. We're actually not a minority. We're the majority. And yet often our health, our healthcare access, the research treats us as if we're a niche product, but we are the majority product. We have to have this conversation because data show that of the $450 billion dollars spent on research in this country alone, less than 1% is spent on women over 40. And yet we are nearly 90 million people. And we make 80% of all the healthcare decisions in this country for ourselves and everyone we touch. And so even though when you look at the long-term data, women are winning the longevity race here — we're living an average of 6 years longer than men — women suffer longer. We're living 20% more of our lives versus our male counterparts in poor health, with chronic disease or mental health disorders. McKenzie looked at the data for the Gates Foundation and what they found was yes, we live longer — we've all known that — however, we have twice as high mental health disorders. We're two times more likely to end up in a nursing home. We are much more likely to lose our long-term independence from frailty or dementia, much more than our age-matched male counterparts. And that's what we're all trying to fight here.
Dr. Natalie Crawford: Diseases that impact women specifically and only — things like PCOS, endometriosis — are extensively underfunded and not researched. It takes women 7 to 10 years to get a diagnosis of endometriosis after symptoms start. And we know this is a disease that impacts your entire body in addition to your fertility. But women are dismissed. They're not taken seriously, and there's not research guiding what we can do in a lot of these situations to try to help them the best.
Steven Bartlett: Why isn't the research there? Why don't they research women if women are the majority of the population? Why is all the funding going to researching men?
Dr. Stacy Sims: You have to think about who was in the room when medicine and science first started. If you think about back when the industrial revolution and the modernization of what we know as medicine, women were pushed out because they were believed to have smaller brains — thanks to Darwin — and not thought to have a seat at the table. So when you're thinking about designing studies, it was pretty much designed on the male physiology, on the male body, and then women were an afterthought. There wasn't any real in-depth look at the fact that XX is different from XY from in utero. So all the research has just been generalized to women. Even things like aspirin for heart attacks and blood thinning inhibitors — all of this was done on men and then just generalized to women. And now that we're having this global conversation on women's health, people are like, well, where is the information specific for women? And there's just a very small subset. We're looking and trying to expand that, but we have a lot of catching up to do.
Dr. Mary Haver: And that's primarily not only because of what you said, but the shocking statistic is that not until 1993 were women required to be represented in studies. 1993. We were all far into our lives in research by then. And there were still loopholes where people were finding ways to exclude women, and we're still not at 50%.
Dr. Natalie Crawford: It's not that we're harder to study. It just makes it presumed harder to study. There are more variables at play. It's more of a complexity to the research, but it's not more difficult. And this is where I bring it in — if a woman had had a seat at the table when all the study designs were started, it wouldn't be a question. It would just have been assimilated in. Because we've been so drawn into the one-week crossover design based on male physiology. When you add women's hormonal fluctuations, people say, "Oh, it's too complex." But it's not.
Physiological differences between men and women
Steven Bartlett: What is it that makes men and women different from a physiological standpoint? Because to understand why research would need to be done separately, we need to understand the differences.
Dr. Stacy Sims: We can look from a morphological standpoint where men have more fast-twitch fibers. Women are born with more endurance fibers — that's muscle. Men have more of the ability to do power and really fast energetic type activities, while women are more attuned to endurance type activities. And this affects metabolism. It affects blood glucose homeostasis. When we're talking about bone and bone density, men have stronger bones. They can acquire more load. They hold on to it better than women do. We see smaller lungs, smaller heart, less hemoglobin in women than men. And that's an offshoot of what testosterone does. So there are just basic physiological differences between XX and XY that people don't really assimilate and understand.
Dr. Mary Haver: Also, when we look at how we disease — cardiovascular disease, atherosclerotic disease, is the best example. Men tend to have their blockages right as those arteries exit the aorta and dive into the heart muscle. So we get what we call the widowmaker. It's called that for a reason because men die and they make a widow. That's the left anterior descending artery. Women by and large tend to not have these larger artery blockages, but their blockages are diffuse and microvascular, deeper into the heart muscle, which is why we present with a heart attack much differently than a man does. And we're not teaching our clinicians these differences. Women are considered to have atypical chest pain. When 51% of the population is female, why is my heart attack atypical and a man's typical?
Dr. Vonda Wright: This happens not only at the organ level. It makes sense that if we have a population with XX chromosomes and a population with XY, genetically the way we express those genes is different. But I think we miss the fact that down to a cellular level, every cell from an XX person expresses tissue changes and tissue manifestations differently than an XY. Our lab used to study what we called muscle-derived stem cells — now they're called satellite cells. When we harvested them and asked them to behave in different environments, satellite cells from XX people were better under the same experimental circumstances at making cartilage and muscle. XY males were better under the same circumstances at making bone. So down to a cellular level, we express our genes differently. It should be no mystery to us or anybody else that there are differences. And yet there is the propensity to just lump us all in the same basket. Of course they're different. We're genetically different down to every cell in our body. Every cell.
The "whiny woman" — systemic bias in medicine
Dr. Mary Haver: Because of this research gap and the bias in medicine, women have been misunderstood by their male counterparts in a number of ways. When I was in training, my first patient in gynecology clinic — I'm an intern, very excited, we have our stacks of charts, that's how old I am, we had paper charts — I pick up the chart, open it up. It's a 40-year-old woman with multiple vague complaints. She's gained some weight. She's a little bit depressed. Her libido is off. Her blood pressure is a little bit up. Her cholesterol is starting to rise. And she's seen family medicine. We're the third or fourth doctor at this point. And so my upper level, who happened to be male, walks down the hall in his cowboy boots — because Texas — and he's like, "What you got?" And I said, "Well, I have Miss Smith, she's a 40-year-old woman with..." and I list the complaints. And he goes, "Did you check her thyroid?" Family medicine did. "Did you check this?" A few simple labs. And he goes, "Hm, you got a WW." And I said, "What?" And he said, "Don't write this in the chart, but we call that a whiny woman around here." And I said, "Okay." He said, "Listen, women just tend to go through this at this age, and we're not really going to be able to help her. Pat her on the knee, tell her to have some wine, go on date night. She'll get better, but we're not going to be able to help her."
And that stayed with me. It took me 20 years of internalization to realize this. I don't want to blame him. He's not a bad guy. This was taught to him. But this kind of thinking — I saw this in the ER, I saw this in the OR, I saw this in every clinic. And so I've asked other clinicians around the country and I've heard "whiny gyne," "status Hispanicus," "total body dolor" — in different regional areas there was a name for this kind of vague complaints from this middle-aged woman. And I realized this was systemic bias built into the system. There's historical precedent for this — the wandering uterus, hysteria — these were real medical terms just until not even a generation ago.
Dr. Vonda Wright: They used to put women into asylums because of hysteria. It was hot flashes, all the things that are now known with perimenopause. They used to think it was some kind of insanity and lock women down.
Dr. Mary Haver: But this is pervasive. Not just in OB. It's every medical subspecialty that has some culture of, for lack of better words, blowing women off. We're not having the curiosity that defines medicine. We are supposed to be curious people. But yet when it comes to this, why do we stop at "seems to be something that happens to middle-aged women"?
Dr. Stacy Sims: In textbooks, you always had the Vitruvian man and all the angles of the male body, but there was never representation of women. The only time you heard about a female athlete was all the pathophysiology — the iron deficiency, the female athlete triad, which we now call relative energy deficiency in sport. And when you're looking at the historical idea of sport, the only way women were actually included and accepted is when they were anemic, because then they were quote more like men and then there wasn't a problem with training them. But we know that's not appropriate. That's a sign of illness and overtraining under-recovery.
Dr. Natalie Crawford: This is so systemic that women downplay their own complaints. They gaslight themselves. It takes them a long time to seek care because they're afraid of the response. They are not always honest with what's going on in their body. I'll say, "Do you have pain?" "Oh, no more than regular." They downplay everything. You have to really ask. And it's almost as if society has conditioned them — I don't want to be viewed as this way. I don't want to not be taken seriously. And it causes them to have an even harder time getting to a diagnosis because they don't feel comfortable sharing some of these symptoms, or they've downplayed them in their life so much.
Dr. Vonda Wright: They come to me almost to a woman, and before they even want to describe whatever musculoskeletal thing they have, they'll say, "But you know, I have a really high pain tolerance." Like it's a badge. Because we've been conditioned to not come for any pain. I've got such a high pain tolerance, but I couldn't take it anymore. I didn't want to come. And I feel like, why does it have to be that way?
Understanding hormones and the menstrual cycle
Steven Bartlett: Is that in part because we know very little about hormones as well? When I was speaking to our audience, we asked a thousand women to submit their questions ahead of this conversation. And one of the most asked questions related to understanding hormones. I think the conversation around hormones is quite a new one in society.
Dr. Mary Haver: I can right now draw from memory exactly what's going to happen in a normal menstrual cycle. We were taught that very well. But when I saw maybe three years ago an academic paper that showed all of the locations of the G-coupled estrogen receptors in the human body, I lost my mind. They're everywhere. The brain, the bones, the muscle, the gut, the endothelial lining of the individual blood vessels around our heart. It's really radical to me to think about how all these sex hormones — the progesterone, estrogen, testosterone — are everywhere.
Dr. Natalie Crawford: What is a hormone? They're not actually sex hormones. Hormones are your body's communication system. A hormone is dictating an action. And I think the most important thing to understand is that by definition, your hormones are dynamic. Your body is responding to the hormonal signal it sees and determining what next signal to send out. So there's constant fluctuation throughout the day in response to multiple stimuli. And that's how it's supposed to be. If we didn't do that, we'd all be dead. It's a symphony. But that makes it really hard for somebody to understand on the other end who's not in medicine and says, "Well, is it my hormones?" Because there's no one test that's going to give you one answer. You have to really interpret it in context of the full body. And it makes it really hard for practitioners who do not understand the hormones as well. We see a lot of mismanagement of hormonal scenarios and situations right now that are actually detrimental to patients.
Steven Bartlett: What is the most basic level that we have to start at to give people an understanding that we can then build on of what's going on here?
Dr. Stacy Sims: There is no real definition of normal because every woman's cycle is variable. So when we look at this, everyone thinks there's a standard cycle, but we don't actually know if that is the case, given that a woman's variation can change cycle to cycle. Sometimes we have anovulatory cycles. So until a woman can identify what her own normal is, we can't rely on a textbook graph to actually explain things to her.
Steven Bartlett: How does a woman know what their normal is? Because a lot of women are on birth control pills since a very young age. My partner Mel was on birth control for about a decade, so she didn't have her cycle, and then it came back and it was every 60 to 90 days. Then she changed her diet a little bit and it kind of went down to 30 days over time. But I don't think she knew what normal was. Is there such a thing as normal?
Dr. Natalie Crawford: There is what should be normal for you. You should have a regular predictable period, which means that you are having a menstrual bleed at a predictable interval. It can range person to person, but for you it really should be within a couple of days month to month. I always tell patients I should be able to give you a calendar. You should be able to take your finger, pick when your next period is coming, and within a few days be accurate. Now usually that range is somewhere between 25 and 35 days for the average person. When it starts to get shorter or longer, it can be a warning sign that something is going on.
When it comes to the menstrual cycle, let's give a one-minute explanation. From the brain, the brain is sending out pulses of hormones. FSH drives egg growth — it's called follicle stimulating hormone, and each egg is inside a follicle. So you have a group of follicles inside the ovary. FSH comes from the brain, grabs one of them and gets it to grow, and it makes estrogen. This estrogen from the ovary as the egg is growing is called estradiol, and it's the primary type of estrogen in your body. So it is rising, and when it gets to a peak level — the body is so fascinating because it's 200 picograms for 50 hours, a very exact amount — then the brain says we must have a mature egg, and it kicks out a surge of luteinizing hormone or LH. That is going to allow the follicle to rupture, the egg to be released, and the follicle to reform and then become a corpus luteum. And then the brain's going to send out pulses of LH giving you pulses of progesterone. Progesterone goes up and down the entire second half of the cycle, known as the luteal phase.
Steven Bartlett: What's progesterone?
Dr. Natalie Crawford: Progesterone is also made from the ovary. So the two main hormones when it comes to a premenopausal female are going to be estrogen and progesterone. Progesterone is the progestational hormone. It is going to change the endometrial lining and it is essential to get pregnant. It opens and closes the implantation window within the uterus and it completely changes the physiology of your body. That is why in the luteal phase your body works differently when you have progesterone. The luteal phase is after ovulation, when you have a corpus luteum — it makes progesterone. This is the second half of the cycle, known as the luteal phase. The first half, when you have estrogen only, is the follicular phase. So you have an estrogen-dominant phase, and then you have a phase where you have both estrogen and progesterone. Your body is made to function differently in these two phases because in the progesterone side, it's preparing you for a pregnancy. It thinks every month you might get pregnant and it starts to change how your body's going to work on a cellular level. But if you don't get pregnant, that progesterone level is going to drop and the cycle starts back over.
Dr. Stacy Sims: From an exercise and sports point of view, progesterone's job is to build this lush endometrial lining and it creates a lot of glycogen storage. So we often hear about glycogen in the muscle — that's what we're using for fuel. Progesterone has a way of shuttling a lot of the carbohydrate away and storing it into the endometrial lining, which is why we see differences in intensity and the way that a woman can respond to exercise if she has ovulated.
Dr. Natalie Crawford: In the second half of the cycle, your core body temperature increases, your resting heart rate is higher, your heart rate variability is lower, you have an increase in fatigue, you have an increased appetite. Your body is shifting function in case an embryo comes in, so that it can start to divert energy and change what it is doing, right down to your immune system changes. That's roughly from day 14 onwards, about three days after ovulation, until when you get your next period.
The menstrual cycle as a health marker
Steven Bartlett: You all talk about how our menstrual cycles can be a broader sign of whole body health. So should someone be concerned if their menstrual cycle is irregular?
Dr. Natalie Crawford: Yes. If your cycle is irregular, if the calendar trick doesn't work, if you're putting your finger and it's nowhere near when your cycle's coming, or if you have women who say, "Oh, there's no way I could predict it," or "I know it will come, but it'll come every four to six weeks" — your body is meant to work like clockwork when it comes to your hormones and your menstrual cycle. You can always have one abnormal month. But when you consistently are having irregularity, that is a sign that something else is going on. It's one of the biggest red flags that we have for early hormonal health or systemic problems. But we have a generation of women on contraceptive options who are not tracking their cycles. We have women who are not taught how to track their cycles. They don't know when ovulation occurs. They don't know how long their luteal phase is. If I say the first sign of ovulatory dysfunction or having a problem with your cycle is a short luteal phase, well, you only know that if you're tracking when ovulation occurs, because otherwise you could still have a regular cycle but not know that something's abnormal.
Dr. Mary Haver: The conversation that's happening now — not just at this table but in society — is that our monthly cycle is so much more than getting ready to have a baby. Because I think none of us knew this. At 17, I wasn't that interested in having a baby, so it didn't occur to me that I should care. And it's the only time, if you're thinking about it in that way, that you're worried about your period — if you don't have one and pregnancy, right? And so if we're shifting the conversation to this is physiology, this has to do with every part of female physiology, maybe it will be easier for people to know.
Dr. Stacy Sims: I often put it with my athletes that it's a marker of health. If you are able to take on the load of training, the load of travel, and maintain your normal menstrual cycle, then you are robust enough to be able to progress. But if there becomes a misstep in your menstrual cycle, then we need to look at all the stressors and the allostatic load, pull you back, and see what do we need to address. Do you need to eat more? Do you need to recover more? What are the things that are missing to bring you back to normal?
PCOS — causes, metabolic impact, and management
Dr. Mary Haver: I was diagnosed with polycystic ovarian syndrome in medical school. Like every medical student, of course, it was gloom and doom. I had a very serious boyfriend, quickly engaged, looking forward to starting a family with him, and the terror around my infertility and what the impact was. What was never taught to me and what I didn't understand until much later was the metabolic impact. PCOS is a symptom. There's nothing wrong with my ovaries. They're just responding to this high insulin level I was born with. And no one really sat me down and talked to me about it. My first research project was women with irregular periods and the risk of developing gestational diabetes. And I didn't even know what insulin resistance was at the time. And now we're coming to understand that when these young women are coming in with irregular cycles and we're making these diagnoses, immediately I was launching into the discussion about her metabolic health long term. It's a gift to know this. So now we can start making interventions — nutrition, diet, exercise — to give you a better system to deal with this thing that you were born with.
Steven Bartlett: You mentioned insulin resistance and metabolic dysfunction there, and gestational diabetes — diabetes in pregnancy. So someone who was non-diabetic before pregnancy and then develops diabetes. So her blood sugars have now reached a threshold where they are higher than normal and can cause problems for her pregnancy and herself long term. And up to 50% of those patients who develop diabetes in pregnancy will develop type 2 diabetes within 10 to 15 years after that gestation. So what we know now is we have warning signs of this well before pregnancy where we can set these women up for success.
Dr. Natalie Crawford: Having infertility predisposes you to many medical problems later in life, including an 80% higher chance of having a heart attack, a 75% higher chance of having metabolic syndrome, higher risk of cancer, and early death. It's not exactly that infertility is causing this, but it's that for many women, it's one of the first warning signs your body's giving you that there might be inflammation and insulin resistance or something impacting your hormones, your menstrual cycle, your ability to conceive, that if it is not corrected now is setting you up for many problems down the road.
PCOS is an example of this because in PCOS you have a lot of eggs inside the ovary. It's actually something that genetically runs in families. Likely there's something that happens when you're a baby inside your mom that predisposes your ovary to not lose as many eggs as it should, and it changes how they respond to insulin. So what happens is you end up having more eggs on average. Your brain doesn't know this and sends out the average signals, but that gets diluted amongst all the eggs and so you're not getting into these ovulatory stages. What happens from there is that you're actually in a relatively lower estrogen phase than you should be. You never see the progesterone. And what happens is you start to completely shift. The ovary itself actually becomes insulin resistant. And what this means is that throughout your entire body, you start to develop high glucose — that's your blood sugar. Your blood sugar is the fuel for all your cells. All your cells need glucose. Well, insulin is the hormone that helps that glucose go from the bloodstream into your cells. In insulin resistance, when your body sees high glucose all the time, it starts to send out more insulin saying, "Hey, we need to get this into cells," but the cells start to say, "I'm used to insulin being here, so I'm not going to respond." It's going to take a higher insulin signal to get the cell to open up the door and let glucose come in. This becomes very problematic, especially in PCOS, because that insulin is very inflammatory, causes you to get extra fat stored in different places, and completely changes your metabolic health in general but also your hormonal health and your brain. And so this resistance to insulin actually shifts how your brain's going to respond to hormones, therefore the hormones it's sending out. And it's a self-perpetuating cycle.
Steven Bartlett: My girlfriend's got PCOS. She's been very public about that. Is it something she did? Is it something she ate? Is this the way she was born?
Dr. Natalie Crawford: She was born with a predisposition of having too many eggs. You lose most of the eggs inside your body when you're a baby inside your mother's womb. You lose the next biggest set before you ever have your first period. Now, if you don't lose them for some reason, you're born with more and it interferes with how your hormones are supposed to communicate, leading to this metabolic issue and this insulin resistance. She did nothing to cause this. Nobody with PCOS caused it. However, choices you make can make it absolutely better or worse, just like any disease.
Dr. Natalie Crawford: When it comes to managing your PCOS, targeting insulin resistance and inflammation are really the key. The best way to decrease inflammation in your body is going to be to start by focusing on your gut. Your gut health controls a lot of the inflammatory burden that your body sees. The foods you choose to eat can be both helpful if they have a lot of fiber in them — they can feed your gut microbiome, which is important in estrogen metabolism — but they can also be very harmful if they are ultra-processed foods that are causing more inflammation and not feeding your gut microbiome at all. I always say it's like a scale. If you think every little food I eat can make my insulin or my inflammation better or worse — how we structure the food that we put in our body is one of the biggest changes the majority of people can make. That's going to be a very plant-forward diet. Doesn't mean it's plant only, but plants have fiber. Fruits and vegetables have fiber. So we have to make sure we're getting fiber as a big change.
I see a lot of patients with PCOS specifically being told they shouldn't eat fruit, they need to do keto. We see people avoiding certain food groups. And I always say it's not a really sexy diet, but it's a diet we all know. Lots of whole foods, fruits and vegetables, healthy fats, healthy sources of protein, avoiding the ultra-processed foods. That's going to be probably the biggest change most people can make. In addition, foundational changes of your day — sleep more, that is when your body fights inflammation and fights insulin resistance. Work on decreasing chronic stress. And then exercise — building and using skeletal muscle is one of the most effective ways to combat insulin resistance that exists. And since 80% of patients with PCOS have insulin resistance, a large portion of women with infertility, even without PCOS, have insulin resistance, that is a huge thing that people are missing.
Dr. Vonda Wright: Based on what you just said — I just took a phone call this morning from a patient, and it's just such a typical conversation. She doesn't like the way her body looks. Her solution is not to eat. We're having coffee for breakfast. We don't eat till midday. The gut reaction, because of the way many women are raised, is that we're going to starve ourselves, which is the opposite of good when it comes to physiologic wholeness. And then you don't have the energy to do the kind of exercise you need. Or on the other side, the response is I am going to work so hard every single day — there is overtraining. So you're just getting behind the eight ball with starving yourself and overtraining. None of which are going to solve either the core problem due to PCOS or the core problem in any stage of a woman's life.
Dr. Stacy Sims: This is where we look at the sociocultural effect of what a woman is supposed to look like. We want to think about how strong we can be and how much muscle we can build, because muscle is a massive metabolic help, as well as bone. And then when I get the pushback of, "Oh, I'm going to do fasted training," or "I'm going to fast till noon," I'm like, wait a second. Not only are we going to interfere with our circadian rhythm and our hormone pulses, we're also acutely interfering with our appetite hormones. If we're looking at ghrelin, which is our active form of appetite — it makes us hungry — it's elevated with cortisol. And so if we're thinking about that elevation and we're not doing anything to drop it and tell our body we have food, then it goes in and directly affects our neuropeptides, which then affects our hormone pulses. So when a woman's like, "I'm just having coffee for breakfast and I'm going to hold my fast" — okay, well, cortisol is going up. Ghrelin, you're going to get hungrier. Then you're going to learn not to respond to that hunger. You're going to hold your fast. And we see from the research that women who do that end up craving more simple carbohydrates in the afternoon, moving incidentally less, and contributing to poor sleep because they've now phase-shifted. So when we're talking about sleep and how important sleep is, we also have to think about the circadian rhythm and how it is affected by food intake, light, darkness, and all of these things. We need women to understand we want to build muscle, we want to sleep well, and that requires food.
Dr. Mary Haver: In the medical model of PCOS, when I'm talking about what we're taught and how we train our clinicians, we go into — we aren't taught a lot about disease prevention or root cause. Especially for PCOS, I was taught to give a patient birth control pills, or Clomid when she's ready to get pregnant. Nothing around nutrition, exercise, lowering inflammation. I was a program director until 2018 and there was nothing in the curriculum around this, which affects at least 10% of women — probably more — this condition, and how important lifestyle is. Patients, I'm sitting there thinking birth control pills, birth control pills. I mean, that was a knee-jerk reaction. I was treated for my own polycystic ovarian syndrome for 20 years with oral contraceptive agents. And I learned online through chat rooms about the nutrition end of it.
Dr. Stacy Sims: When I have athletes, because we see a higher percentage of PCOS in successful female athletes, we put them on more short, sharp, high intensity training to get that post-exercise response of anti-inflammatory, growth hormone response, all of these things that then bring down total body inflammation. And then we're very careful about food intake and when we're doing it and what kinds of food, so that they don't have to go down the route of oral contraceptive pills, because that has an effect on their performance.
The importance of having a period
Dr. Natalie Crawford: It's important to say at this table — you need to have a period if you're not preventing a period with hormonal contraception and you're in your reproductive years. Because very often women with PCOS or hypothalamic amenorrhea will say, "I don't have a period, but I didn't really like that anyway, so it doesn't bother me." But that's not fine by your body. That is a hypoestrogenic time. Very low estrogen. It's bad for your body for so many reasons to be low estrogen during these crucial bone-building years. It's very harmful to long-term health to have low estrogen at all — brain health, especially in young years when you're still developing.
Steven Bartlett: Why would a woman say that she didn't want to have her period? I understand it's painful, but —
Dr. Vonda Wright: I was a dancer and an athlete. I had very low body fat and I wouldn't have periods for six to nine months. And I'm like, yes.
Steven Bartlett: Do you know what's interesting? I was thinking of Mel. Because of what she's been through and also because she's listened to the conversations I've had with all of you and she understands the value and importance of her period, she now celebrates it. It's like a celebration in our house when it arrives. Because if you understand the importance that it has in full body health and the role it's playing, then the pain, the downside is weighed against your understanding of the upside, which to her means she's healthy, her hormonal health is working, things are great.
Dr. Stacy Sims: I remember sitting in a high-performance meeting just maybe three years ago and the leading athletics coach stood up and said, "I know when my athletes are ready to perform on the world stage when their periods stop." And all of us went, what? That's the time where we have to really look at your athlete — she is getting ready to crack and be injured. And it's still this pervasive idea, even in the fitness industry, that losing your period is okay because it means you're training harder. They actually are very resistant to getting it back. Like it's a sign of failure of their sport or their athletic endeavor. And I think that's why it's important to have these discussions.
Dr. Natalie Crawford: I think the other part of it is for women who have menorrhagia or heavy bleeding and heavy cramping — they don't realize that they can get help with that as well. And that's a conversation that isn't followed through when we're like, "Yes, get your period," but if you're someone who suffers from really bad cramps, we also have to educate that there are things we can do to help with that.
Steven Bartlett: Does the size of the bleed matter? Because she turned around to me the other day and she said with her last cycle she didn't bleed much and she seemed slightly concerned.
Dr. Natalie Crawford: It depends. Women know — your period should not cause you any stress in your life with modern period products. You should just roll with it. You shouldn't bleed through your clothes. You should be able to sleep through the night. You should be able to get through an athletic performance. You should not be anemic. Anemia is low red blood cell count to the point where your performance is affected. Your ability to carry oxygen is affected. So the red blood cells are what carry oxygen in our bodies. And women who have heavy periods, however that's defined, can lead to anemia. But the first thing that we notice is their ferritin is dropping. That's the first sign. My daughter — we just had some blood work done. She was feeling a little fatigued and her ferritin and iron saturations were really low. Turns out she's not eating a lot of iron-rich foods. So we're dealing with that. But we can get so far ahead of this by looking at these ferritin levels before she's actually anemic.
Is any change from what you consider normal concerning? We would all say yes. So if it gets heavier than that or less than that and it stays that way, that is concerning. You can always have a one-off.
Estrogen is the driver of growing the uterine lining. So if you have a lighter bleed one month, we are concerned that you did not grow as thick of a lining. Your body didn't see as much estrogen. Most of the time you ovulated earlier that cycle, your cycle came a little bit sooner than you're used to it coming, and it's not quite a big deal. But this can be concerning if we see consistently light periods, especially if we have a history of progesterone contraception, which thins out the lining. When you only see progesterone — like a progesterone IUD, the progesterone shot, even continuous birth control pills — your uterine lining gets thinner and thinner and thinner. And so we see it can take months to return to normal after coming off of hormonal contraception.
You also can get damage to the endometrial lining. There are stem cells in the endometrium that regenerate every month after you bleed. They regenerate so that the next group can grow in response to estrogen. And this can get damaged from typically anything inside the uterus — most commonly post-birth, a traumatic birth, a retained placenta, a D&C procedure, which is sometimes used after birth or in a miscarriage, or even IUDs or intrauterine surgery — and it can form scar tissue in the uterus that can cause a light period.
Steven Bartlett: What about pain? Two months ago she had excruciating pain that I've never seen before during her menstrual cycle.
Dr. Natalie Crawford: It's not pleasant to have your uterus contract and expel its contents in any form. But one time way above the norm is probably situational, based on other things that are contributing to inflammatory burden or response. Your body is also healing from the corpus luteum — it's a cyst on your ovary that can also feel painful. So there are multiple things that can cause pain. To Vonda's point, so many people say, "I have a high pain tolerance, this is okay," because we don't talk about our own pain, so I don't know if my pain is normal compared to somebody else's. Your pain should not keep you out of your activities of daily living. You shouldn't call in sick to school, call in sick to work, cancel dinner plans with friends consistently. Again, everybody can have a one-off month where something is off. But if this happens every month — that is a warning sign that something else could be going on. Endometriosis, adenomyosis, and uterine fibroids.
Iron deficiency and women's health
Steven Bartlett: You mentioned the word iron a second ago, Dr. Mary. What is iron got to do with this? And what is iron?
Dr. Mary Haver: Iron is an element that is in our diets and we do tend to store quite a bit of iron in our bodies. It's essential when we look at the structure of the red blood cell and of hemoglobin specifically. Hemoglobin is the actual molecule that is inside of the red blood cell that carries the oxygen. So iron is really critical to the formation of healthy iron-carrying red blood cells. We store iron in our bodies, a lot in the bone marrow, and it's stored in a particular molecule called ferritin. So when we're measuring ferritin levels in the blood, that is the first sign that your iron stores are getting low.
Steven Bartlett: Are women more iron deficient than one would think?
Dr. Mary Haver: A menstruating woman is often iron deficient. Yes. And I do see it in our post-menopausal patients as well. That's usually nutritional and inflammation related. Ferritin is also something that will decrease in times of chronic inflammation. So you're not able to utilize the iron that's coming in and store it because this inflammatory state is kind of inhibiting that. The World Health Organization estimates that roughly 30% of women aged 15 to 49 worldwide are anemic, with iron deficiency being the leading cause. And in some regions of South Asia and sub-Saharan Africa, prevalence can be up to 50% of women.
Dr. Stacy Sims: The norms have changed. When you're looking at male normative curves versus what we tend to accept for a female — now that we're looking at performance and other factors besides just what is this ferritin level, there's a lot of great new research coming out. In our clinic, we are looking for 60 to 100 for a ferritin level to be considered optimal. Very different than the baseline for keeping you out of a hospital versus you functioning at your absolute best.
Dr. Natalie Crawford: Because the norms that often get measured for us have shifted. If you were below 50, then we would look to get help. But now with the norms that have shifted with the sicker population, we can't get women help unless they are below 20. So when we say normal, I think this is important for everybody watching or listening — normal in medicine means common, not non-pathological. Not bad. Norms shifting means we're getting sicker as a population and we're willing to accept lower levels, although they're not optimal for health. The lab reference range is based on population averages. And so if the population is more anemic, this is going to accept lower levels as being normal even though they're by no means optimal. And that is one issue we do see with getting your own blood work drawn or these online companies when nobody's interpreting it on the other end. You see something that is in a normal range but it's not at all optimal for you.
Endometriosis — a case study and the diagnosis crisis
Steven Bartlett: I want to talk about endometriosis. We have a team member who's been with The Diary of a CEO since the very beginning called Liv. At age 13, she had her first period and she experienced agonizing pain with heavy bleeding. At age 14, she was put on the pill to manage the symptoms. Between age 15 and 24, she continued to have severe stomach pain which resulted in multiple A&E visits. She was often dismissed as having gastritis, and it led to having her appendix removed. At age 25, she came off the pill to see how she felt without it, but her periods worsened and she fainted from the pain. At age 26, she got an ultrasound which suggested endometriosis, but no NHS diagnosis was given. We ultimately had a conversation with you on the podcast, Natalie, and she felt very heard. Afterwards, Jemima in the team told Liv to come and speak to me. And Liv told me about her endometriosis — the first time I'd ever heard of it. We offered to help support her privately. She got an MRI scan privately which confirmed stage 4 infiltrating endometriosis. Liv then pushed on with her NHS appointments, but the pain was so much that she took me up on my offer to pay for it privately. By that point, the endometriosis had spread to her bowels and pelvis. There's a picture of this four-centimeter cyst from her operation. Her ovaries were stuck together and attached to her womb and her bowels. She then needed to book an appointment for surgery. And before the surgery, because of the scale of her endometriosis, she had her eggs frozen to protect her future fertility. This process took her 7 years and she was in pain for 17 years because she did not get a diagnosis.
Dr. Natalie Crawford: Her story is unfortunately not uncommon. This is a very typical story for somebody who suffers from endometriosis. Endometriosis is an inflammatory condition. The way I like to explain it is when your body responds abnormally to a normal process. You have immune dysfunction as well. So let's think of it as an autoimmune disease and a chronic inflammatory disease. When you have your period, you bleed out endometrial cells in your menstrual blood. In everybody, you also have some endometrial cells that will escape out the fallopian tubes. That's not a big deal. If you take out somebody's appendix while they're on their period, you'll actually see menstrual blood in their abdominal cavity. In the regular person without endo, your body says, "Oh, she's just on her period." In the person who has endometriosis, this creates a huge inflammatory response where your body starts to attack endometrial cells and you get these implants throughout the peritoneal cavity or the abdominal cavity of endometrial-like tissue that gets worse every time your body sees estrogen, because it's feeding the endometrium just like it would in the uterus. So it gets worse over time. The more ovulatory cycles you have, the disease gets worse. It's so inflammatory that it's not uncommon to get extensive organ scarring. You get anatomical distortion. These are some of the toughest surgical cases in addition to managing lifelong health but also fertility as well.
Dr. Vonda Wright: These implants will start growing into other organs because they'll find new blood supply. They'll steal blood supply from the bowel because all of our pelvic organs are just sitting there on top of each other — the bladder, the bowel, the cervix. Think of it like Velcro is what I say — almost these little patches of Velcro and they just start sticking together. And that's what inflammation and scarring does throughout your whole body.
Dr. Natalie Crawford: Because the primary symptom of endometriosis is pain — back to women's pain being taken seriously — that's one of the issues and why the average time to diagnosis is 7 to 10 years. Truly 17 years in this case from when she had pain. But the other symptoms do include sometimes pain with intercourse. You also see a lot of GI manifestations that we don't talk about. So if I have somebody who has painful periods and they say they have irritable bowel syndrome or a lot of vague GI complaints, that is a really big red flag to me because these little endometrial implants on the bowel, the intestine, this high inflammation that's happening, irritates your intestine and you get this GI response as well.
One of the hardest things about endometriosis is that it's a surgical diagnosis only. To be honest, we have to do surgery to fully see and diagnose that you have this. It's one of those "no meat, no treat" situations in medicine where you can't make the diagnosis until you have a tissue sample.
Steven Bartlett: Why don't we have a cure?
Dr. Natalie Crawford: Because it hasn't been studied is the primary answer. The secondary answer is that the goals are tough with endo because if estrogen feeds it, we all are going to sit at this table and talk about how important estrogen is for your body. And a lot of the treatments that exist for endometriosis take estrogen away to try to not feed these lesions. And that has a slew of other symptoms and long-term health implications as well. Truly, we don't even give women options to try to feel better. They are given birth control pills because, hey, I'm going to stop the ovulatory cycle, you're going to have less what we call unopposed estrogen days. We do have symptomatic relief. But it doesn't reverse disease. It doesn't cure it. It doesn't make anything better, but it can slow down the progression. Any of these treatments that do halt the ovulatory process severely impact fertility. Stage three or four disease, regardless of your age, you're going to have a less than a 20% chance of conceiving naturally over the course of your life if you have stage three or four disease. Every stage is impactful to your fertility because of the inflammation. Once you have anatomical distortion, an endometrioma or cyst inside the ovary, removing that cyst is going to decrease your egg count. That's why we froze eggs before we took the cyst out — so that we could get those eggs out of the body before we went and did something that was going to destroy part of the ovarian tissue.
Dr. Vonda Wright: I just think — I was a cancer nurse first before I did this — wait a minute, there's got to be a cell surface marker that's unique to the endometrium that we could make a monoclonal antibody against. And I will say that there are people now doing lovely and wonderful research on a cellular level of endometriosis trying to look at the endometrium itself, what cell markers are similar in endometrial implants. Can you diagnose this on an endometrial biopsy in somebody? We haven't seen it get to the point where it needs to, but at least people are paying attention. So I do think we might have emergent technology that will change the course of this for people.
Dr. Natalie Crawford: Right now, I think awareness is key. And one thing I always say is that especially as a teenager — because women adjust, you accommodate to the world around you — if you have pain every single month of your life, you are going to convince yourself this is normal for a degree of time because what other option do you have? But when you're a teenager, you don't know that. And so if when you are a teen you would stay home from school, you would not go to the football game or go out to dinner with friends, that to me is a huge red flag. It actually is a very high predictive marker that you do have endometriosis. Pain out of proportion to being able to complete your normal life as a teenager is a really big warning flag. I ask every patient about that when we talk about their periods because 50% of patients with unexplained infertility have endometriosis.
Dr. Stacy Sims: We have some pilot data looking at how to dampen inflammation and improve symptomology. We have some pilot data showing that when women do cold exposure, it dampens inflammation and improves their symptomology. So I'm always thinking on the outside — what other things can we do to dampen inflammation in a positive way to improve symptomology?
Steven Bartlett: How does that work?
Dr. Stacy Sims: If we're thinking about the responses to cold exposure — and we're not talking about ice, we're talking about cold water exposure — it creates a cascade of immune responses that kind of protects the body. So we're reducing inflammation, we're improving parasympathetic response, which reduces stress. If we're timing it and they know when their period is and they can go, okay, for the 10 to 14 days before my period starts, I'm going to have 10 minutes of cold water exposure — over the course of three to four months, that immune response becomes learned. So it reduces symptomology. So it becomes one of the treatment options that we have for some of our athletes that have endo and it interferes with their training.
Steven Bartlett: Someone wanting to do this at home — what temperature?
Dr. Stacy Sims: 10 degrees Celsius. So about 40 Fahrenheit. It feels really cold but it's not an ice bath. Ice is not good — not ice baths that we see in all the popular media, because that is way too cold for a woman's body. It does the opposite. It's a severe stress and causes a stress response rather than a parasympathetic calming response that we want.
Dr. Natalie Crawford: Decreasing inflammation in an inflammatory disease is key to controlling the factors you can. And much like we talked about inflammation and PCOS, we heard the same word right here with endometriosis. Chronic inflammatory diseases are the number one thing that we see across the board impacting the population but especially women. And so these same strategies to work on decreasing your own inflammation — for endo it's a little different because you can target it for when you expect to have that high inflammatory burden. But that's really an important part that we don't talk about. I don't see that the NHS talked about an anti-inflammatory diet or getting more sleep or cold exposure.
The contraceptive pill — how it works and what it doesn't tell you
Steven Bartlett: On this point of birth control, one of the questions that came in from the audience was, "How terrible is birth control to female hormones?"
Dr. Natalie Crawford: The birth control pill shuts off the brain's desire to send the signal to the ovary to make hormones. So it is ethinyl estradiol, a synthetic estrogen, and a type of a synthetic progestine or progesterone. The brain thinks that you have estrogen and progesterone present. That's the luteal phase. And so your brain says we don't need an egg to grow. Ovulation starts in the brain. No FSH comes out and you're not going to get ovulation. So they're very effective for prevention of ovulation, which makes it a very effective contraceptive option. But as far as hormonal shifts, your brain's not sending out FSH and LH. Your ovaries are not going to be making estradiol or progesterone or testosterone. And so that is how they are sometimes helpful — if you have hemorrhagic cysts with ovulation, the birth control pill can prevent ovulation, therefore prevent some women from being in terrible pain. If you have PCOS, they're often handed out like candy. One reason is because it will regulate your cycle so that you don't have these prolonged irregular periods, but also will decrease testosterone levels, which is sometimes a good side effect of the pill for women who have PCOS.
But if you don't have PCOS, a lot of times your body's tissues are not responding to synthetic estrogen and progesterone the same way it does to natural. I think that's a very important point.
Dr. Mary Haver: My niece who competes at a national level started suffering from outrageous acne as she was going through her adolescence at 12 and a half. Of course she goes to the dermatologist and they're trying some topicals. And then finally, as you go down the algorithm for how we treat acne, one of the off-label uses is birth control pills — they will lower the testosterone and the skin can clear up. Her father, a little concerned, comes to me. Her mom had passed away. And for the first time, I immediately thought of her athletic performance. She wants to go to the Olympics. There's no way I'm going to let her testosterone levels drop. We're going to throw everything topical at this. And we finally found the right combination. Her skin looks great and she's super happy. But the next logical thing was to put this 14-year-old on a birth control pill to get her acne under control, and no one's thinking about her athletic performance. How is it going to affect her training years? This is critical for her.
Dr. Vonda Wright: I'm sitting here from a musculoskeletal standpoint thinking about the high percentage of women who have endometriosis and PCOS and the complete imbalance of natural hormones. Plus, for a lot of reasons now, girls are not cycling normally. And I'm sitting here terrified for their bones. We build bone from 15 to 25. And if we are so inflamed that we're producing all kinds of inflammatory cytokines — interleukin-6, C-reactive protein, tumor necrosis factor — which halt bone development, we don't have enough estrogen for whatever reason, we're going to shut off our testosterone because it makes us feel better, and we're not exercising and we're sitting around — no wonder I have 20 and 30-year-olds with no bone density that are then going to go into perimenopause and lose another 20%.
Dr. Natalie Crawford: I treat girls in their teen years when they come to me without their period much differently than a lot of other people do. Instead of just "you don't have a period, here's a birth control pill" — say you're not making estrogen and this is a crucial time for you. Let's give you estrogen. Let's talk about why you're not. What can we do to change it? And so this discussion is more than just disease state — it's truly important across the lifespan of a woman. The choices that are being made in her early reproductive timeline are going to impact her longevity.
What the experts would have done differently
Steven Bartlett: Can I ask all of you what you would have done differently for yourselves?
Dr. Stacy Sims: I was amenorrheic until I was 20 — didn't have periods — because of high stress, high sport, didn't care, didn't eat well, in the whole mindset of the '90s of calories in, calories out. If you're thinner, then you'll run better. If you're running better, then you're going to hit different metrics. I was a runner in high school and then joined the crew team. Same thing. So if I could go back and talk to my younger self, I would have been like, "You need to eat, you need to recover." Instead of the mantra of calories in, calories out, more cardio, lose weight, lose weight, lose weight. Because now I educate people: you want to take up space, you want to be strong, you want to look at not the idea of losing something, but gaining something — gaining that power, gaining that strength, gaining that bone, gaining that muscle, gaining your period. Those are the things that I'm trying to educate the younger generation, because that was not impressed upon me as a younger athlete, which then had a lot of repercussions later in life.
Dr. Mary Haver: I completely fell under the expectation of the aesthetics of it. When I did exercise, I exercised to look a certain way. And then in my 30s, I exercised for performance. I started running half marathons. I was doing baby triathlons, really short ones with my girlfriends. It was a social thing and it was super fun. Now I'm exercising for my old lady body. I'm exercising to be in a bigger body because I know my mother and my grandmother. My grandmother spent the last 10 years of her life in a bed, incontinent, with dementia and completely frail. And my mother is on the same course. My mother is 88, fell and broke her hip in January. She's just now walking on a walker. She's in an assisted living facility for Alzheimer's. I want to change that legacy for my children.
All of the things I would have done differently — I wanted to be thin. Thin was healthy. That is what I learned in medical school. And I kind of skirted that line because I stopped eating in medical school due to stress. I would have fed myself. I would have lifted weights. I would have stopped doing so much cardio because knowing what I know now, I was chipping away at my bone density. I was raising my inflammation levels. I was chipping away at my ability to resist the Alzheimer's and dementia that runs in my family. And that's what I'm trying to impress on my girls, who are 21 and 25. But that's the mentality that we grew up in, right? When you're looking at the supermodels of the '90s and Kate Moss and it was all heroin chic. Which is the worry now with the GLP-1s coming back and the ballerina body and all the things that we're seeing come back again. It is worrisome.
Dr. Natalie Crawford: I've already told the world about having low body fat, maybe being PCOS and not knowing it, not ever talking about that, having no periods. But then it didn't end in my youth. I went to college, same. I went to grad school, still same. I went to medical school and in medical school, four years of medical school, seven years of residency and fellowship — still didn't eat, still wasn't having periods. I didn't sleep for about 11 years, between call every third night and then I had a baby and then I was awake for two years. I think of all these things that I wish I knew then that I know now. I have four 30-year-old daughters and I have a 17-year-old, and they are not going to be allowed to hit a wall like some of us may have because we didn't know.
Dr. Mary Haver: I was on the birth control pill for probably 15 years continuously. And we have to give credit where credit's due because I was able to pursue medical training and not worry about what family building looked like for me, which was really important because I was not ready to have a child. So anytime we frame a discussion around birth control, I always want to say it's not ever going to fit into one bucket of all good or all bad. It's going to be different stages of life, different things are important. I didn't stop it soon enough to learn to track my cycle. I didn't recognize cycle abnormalities when I had recurrent miscarriages. I had a really hard time knowing — is this how my cycle's supposed to be or not? — because I never had the opportunity to just have periods and see what is my normal. I stopped it and started trying right away and got into a cycle of having a pregnancy and that would last for a while and then I would lose it. So I really lost the opportunity to say this is my baseline and oh there might be a problem here or to intervene.
I wish I'd advocated more when I had my own pregnancy losses. I was told over and over, "There's nothing you can do. This is nothing. Just keep trying." And even as somebody in the field, that felt very dismissive and is a fuel for a lot of what I do now. But on a personal level, 10 years after having those pregnancy losses, I was diagnosed with celiac disease because I had osteopenia on a DEXA scan. Celiac disease is essentially an allergic reaction to gluten. When I was eating gluten, which is in most of your carbohydrates — the good stuff like breads and pastas — it was causing an inflammatory reaction inside my body, making my gut unhealthy and creating a baseline level of chronic inflammation. And recurrent pregnancy loss can be one of the signs and symptoms of it, in addition to just some other what feel like very generalized symptoms — fatigue, low energy, headaches, GI distress. And when some of these symptoms finally got to a state where they were getting worse, probably with hormonal change with age, and my doctor ordered a bone scan, and it came back that I had osteopenia — very low density of my bones for my age — luckily I had somebody who was very committed to not labeling me a whiny woman and saying, "I think you're not absorbing something correctly." To get on this pathway to figure out that because of this autoimmune disease, celiac disease, I wasn't able to absorb the nutrients that I needed. But somebody had to be committed on the other end because these symptoms went on for so long. I just accepted them. I let them be.
But I also am scared because those critical bone-building years I was on the pill and I used it continuously, which means every single day. I know I was chronically inflamed. And so now I'm at a stage of my life at 43 saying I've got to try to catch up before it's too late. And that is scary.
Steven Bartlett: Can you catch up?
Dr. Vonda Wright: Yes. Yes, you can build bone. Age is the most natural thing we do from the minute of our birth. But men and women age at different rates, especially after perimenopause with the lack of estrogen. We age very differently from that point on. But your point being made is can we please maximize our bone density and our muscle mass and everything else frankly in our youth when we're probably not aware? When we're in college and doing all the things kids do, it's the last thing on our mind. And yet it's the most critical time because you want to start both your bone and your muscle from the highest possible level. Now, can you through lifestyle and hormones build bone again? Yes, actually you can. But wouldn't it have been better to start out with the maximum so that the natural decline doesn't take you into dangerous levels?
Contraception choices — what to tell daughters
Steven Bartlett: What are you saying to your daughters about the birth control pill that wasn't said to you? Are you recommending them to use it how you guys used it?
Dr. Natalie Crawford: I do see a trend towards not starting it as young as it was started in our generation, and I think that is important. Cycle awareness is one of the few early signs you have of your body's health as a young woman. And so to purposefully never get to know what that is is a detriment to saying, "I'm aware of what's healthy for me and I know what's happening in my body."
Dr. Vonda Wright: For my youngest daughter, she was a dancer, also teeny tiny. So tiny, even though she had great muscle mass, but like me she wasn't having periods. And so the advice was to put her on birth control to regulate periods. But I was always uncomfortable with that because she didn't have to be quite as tiny as she was. What we have done now is I've encouraged her to gain a little weight and get a little bit more body fat. She only had to gain five pounds and it has more regulated her and she's having her own periods now. I think what we should be telling our daughters is all the information so that they can make an educated decision, because I just did what I was told and I'm a doctor.
So my oldest — she wanted it for contraception. And so when we talk about contraception, it's not just the oral birth control pill. I did go through all of the options with her and then sent her to a trusted friend to let her go and make her own decision. She decided to have an IUD inserted, which I thought was a great choice for her because she had normal regular periods before we did this. There were no issues. And she had it inserted and then within a week she started having severe cramping, called me into the bathroom — and this is my daughter who has not let me see her unclothed since she was 7 years old, she's just very private — and she's writhing on the floor. She had expelled the IUD on her own. She had cramped it out. Her uterus pushed it out of her body and it was extraordinarily painful. So we basically delivered the IUD on her bathroom floor.
Steven Bartlett: Do you know what an IUD is?
Dr. Vonda Wright: It's birth control that is placed inside the uterus. It's shaped like a T. In the UK they use the coil still quite a bit, which is copper. There are different options for the IUD — some contain progestine, some contain just the copper. The way an IUD works is that it creates an inflammatory response in the uterus so that the cervical mucus thickens. So when we are fertile in our fertility window midcycle, the mucus of the cervix thins to the point where sperm can actually get through. Most of the month — probably 85 to 90% of the month — the sperm cannot traverse the cervix. So in our fertility window right at ovulation, the cervical mucus thins and then the sperm can transmit. The presence of the IUD creates an inflammatory environment that is basically toxic to sperm and thickens the cervical mucus where it becomes a plug. That's how it works. It works very, very well. Katherine within a week had her uterus eject it. She cramped so much that it pushed it through. And so that wasn't an option for her. She wasn't willing to go through that again. So then she had to go through the hormonal options, and she decided to have the implant — progesterone only, implanted in her arm. Quickly we realized she needed some estrogen. So she supplements estrogen on top of that.
Dr. Natalie Crawford: Stephen, I think the contraceptive discussion — we have to say that there are options that are highly effective at preventing pregnancy, and at some times in your life that is the number one most important goal and we need to choose a highly effective option. However, certain of those options have downstream impacts that have not been discussed. The typical contraceptive discussion says here are some side effects you may have. We're not talking about long-term implications of these. We're just talking about how you're going to feel, not exactly what is happening in your body.
A lot of these contraceptive options are progesterone only. And so by your new favorite graph, you don't see progesterone every single day. So when you have progesterone only, it is shifting your hormonal profile. And a lot of women — this progesterone is so high that it works by also preventing ovulation, making it highly effective. But if you're not ovulating, you're not going to be making those high estrogen levels. Dr. Haver and I have even talked about how we wish there was a contraceptive option that had estradiol in it so that your body could still have some estradiol.
Dr. Mary Haver: Ethinyl estradiol is very different than plain estradiol. They've put an ester group on the end which makes it bind to the estrogen receptor in the brain 300 times more powerfully than regular estradiol. That's why it's so effective. That's why we do it in a micro dose — versus estradiol which is dosed in milligrams, ethinyl estradiol is dosed in micrograms because it is that much more potent. Very, very different. Now in the UK and in other places in Europe there is a new form of contraception that has estetrol, which is the fetal estrogen. So we have four natural estrogens in the body. The ovary produces estradiol — that's the one we all know, it's really the biggest bang for our buck. The placenta produces something called estriol. Our fat cells and in the peripheral tissues can produce something called estrone. And then we have this fetal estrogen called estetrol. And they've been able to formulate that. So it is one of the natural estrogens and they've put it in a birth control pill that is available in the UK.
Steven Bartlett: If you were 18, what choice would you make for contraception?
Dr. Natalie Crawford: Studies have proven within a shadow of a doubt that relying on natural family planning at most ages is not a reliable form of contraception. So I would not recommend that. And relying on condoms alone. What I mean by natural family planning is timing your intercourse. So cycle tracking — we know that the fertile window is the five days before and the day of ovulation. Sperm can live for five days in the female reproductive tract. The egg lives for 24 hours. There are a few different ways you can do natural family planning and they have different degrees of effectiveness, but one of the main issues is that they have very large abstinence windows. So it's often not very sustainable. If this is all you're relying on for prevention of pregnancy, you have to really assure that you know when that ovulation is happening. It can be an effective way to prevent pregnancy if your cycles are very regular. But in my brain, I wish that's what you stop the birth control pill at least six months before you want to get pregnant, and then you start learning how to track your cycles and you're using some natural family planning if you're not quite ready then, because the margin of error — oopsies, it didn't work — the acceptance of "well we were going to try to get pregnant soon" is usually okay. It's not an effective contraception for most of the population.
We have to factor in that I was trained and taught to only look at birth control through the lens of contraception. We know that they might have some weird bleeding and maybe a few headaches. And for some, a DVT — deep venous thrombosis, you can have blood clots. It'll increase your risk, especially if you have a pre-genetic disposition to that. But what we didn't talk about were mental health, mood, and some of the long downstream libido effects of taking these. And so then I'm looking at it through the lens of — if I'm only looking through the lens of she doesn't want to be pregnant, younger patient, she's less likely to remember to do something every day. So then to take the impetus of remembering to take a pill every day or change a patch once a week, or we're looking at maybe a vaginal ring that she inserts for three weeks and removes for one for her period.
Pick one. If I had to pick one right now, if it was available in the US, I think I would go with the estetrol option. That's the one she's saying is in the UK — a newer option that we don't have. It's still a pill. And it's because so far, it's newer, it has less of the downstream effects. So you're not having that complete suppression, and it may also probably have less risk of DVT.
Dr. Vonda Wright: I do not love intrauterine devices for a patient who is 18 for a multitude of reasons. Now, I'm going to preface this to say it is a highly effective contraceptive choice. It's one of the most effective ones that we have. However, when we're putting IUDs in the uterus of women who are really young, sometimes the progesterone dose in them is so high that it is preventing ovulation. And we are seeing young women who are not ovulating and they are not making estrogen, and they don't even really realize it because that's not disclosed as one of the main mechanisms of a progesterone IUD — because it doesn't happen in enough people to effectively prevent conception that way. It works through the inflammation, the cervical mucus changes. And why does that matter? Because if you are not ovulating and you're not making estrogen, you are going to have low libido, low energy, you're not going to build your bones during critical years. Let's say the IUD lasts five to seven years. You're 18 to 25. These are some of the most critical years in your mental health, your bone health, your cardiac health. And being low estrogen during that time is going to set you up on a different risk trajectory for your entire life.
And the worst thing here about the progesterone IUD is that because of the progesterone, which will thin the lining, many women just say, "I don't have my period because my lining is so thin." And that's a side effect of the IUD. If that same woman was not ovulating and came to me and said, "I haven't had a period in seven years," and I knew she was low estrogen and not ovulating, we'd be highly concerned about her health. But because she has an IUD, what happens? Well, that's a side effect of the IUD. No big deal. So we're missing the moment to understand — are some of these symptoms just a side effect of the IUD, or are they having a much bigger role in what's going to happen to that woman's long-term trajectory for being low estrogen during crucial years?
Dr. Natalie Crawford: I'm very biased — I'm a fertility doctor. I see patients who have trouble getting pregnant. That is a narrow subset. That is not the majority of women who have IUDs. What would I suggest if you had to pick one contraceptive? Vasectomy. But I would still do the pill right now. The pill or the vaginal ring, depending on somebody's personal preference. I just think that it's really important if you're using the birth control pill to give your brain a break from the pill at times. Even if you're cycling it monthly, there are options now. I took an active pill every single day for a decade, meaning I suppressed my brain completely for that long. Now, your brain sends out hormone signals that impact your entire body. So even if you're going to take the pill at that young age, I would say take it so that you have the seven days of not taking a pill. Let your brain have a moment of release from the suppression and then take it again. That's still a very effective way to use the pill. But because women don't love having periods, we've offered these other options which are not wrong, but they just have a bigger consequence downstream than we're talking about. But the pill is very short acting. It only has a half-life of 28 hours, meaning it is out of your body very quickly. So you do want to stop the pill and see what is happening and track your cycles.
Mood, the luteal phase, and PMDD
Steven Bartlett: The question that came in from the audience was, is there any way to control hormonal mood swings during the luteal phase of the menstrual cycle?
Dr. Natalie Crawford: In the luteal phase, we do tend to see more mood changes and physical changes. And a lot of this is because we have an increase in estrogen and progesterone and then a decrease in both of these hormones. And what we find is that some women are simply more sensitive to these changes. They feel them quite profoundly. And there's even something called PMDD — premenstrual dysphoric disorder — which is when those hormones are dropping. You get these terrible mood swings, this terrible depression and anxiety, in addition to physical changes with terrible fatigue. You just feel like you can't accomplish any of your tasks, insomnia — quite similar to a lot of the things that we talk about anytime we talk about a low estrogen state. We see it in postpartum depression. It's a very similar state. And in the perimenopause transition, we have a 40% increase in mental health changes. What's happening is that our neurotransmitters — especially GABA, serotonin, and dopamine levels — are highly tied to what our hormone levels are doing.
Steven Bartlett: Is the mood swing — what's the right term to describe a mood when someone doesn't feel great?
Dr. Natalie Crawford: Dysphoria. It's often before the period. The estrogen is dropping before and it stays low through. So what happens is about the week before your period and then the week of your period, you are estrogen low. The rise of estrogen from that next egg being recruited is actually what stops you from bleeding and helps you start to feel better.
Because of this, a lot of people will throw a birth control pill at this situation because they will say, "I will give you constant hormone levels every day and now you will not have these PMDD symptoms anymore." However, a lot of women don't want to be on the pill for a variety of the different reasons we've talked about. I find that a low-dose estrogen in the luteal phase can be very effective — targeting after ovulation, I'm going to take some estrogen, helping alleviate these symptoms without interfering with ovulatory function. But I was trained to give them an SSRI for those seven to ten days. An antidepressant. Yes, an antidepressant only for those two weeks. And it does tend to help. But what no one taught me and what clinical experience has taught me is a low-dose estrogen — treating the root cause. Just give her estrogen back during that time period and she gets remarkably better. In some of the nutrition research, finding that low iron and low vitamin D are huge contributors to it. So there's that research to investigate too.
Steven Bartlett: With my partner, I should anticipate that her mood might drop in the lead-up to her having her period, and then after her period it might recover?
Dr. Natalie Crawford: It's very common. And whether or not that becomes clinically significant, whether or not it's life-disruptive for her rather than she just has a little bit of a low mood — most women can tolerate that. But for those who can't and it is disrupting their day-to-day activities and how they feel about the world, we have options.
Understanding the menstrual cycle week by week
Steven Bartlett: I want to understand her better. I'm looking at this little graph here which says the brain during the menstrual cycle. The menstrual cycle starts when her period starts by convention?
Dr. Natalie Crawford: Yes. Day one is the first day you start bleeding. Her brain starts by sending out FSH, follicle stimulating hormone, which is going to get her ovary to start growing an egg which lives inside a follicle and making estrogen. And that rise in estrogen as it's growing will stop her from bleeding. So the beginning of that cycle, day one, the bleeding that she's experiencing is because she didn't get pregnant in the month before. So it's getting rid of that endometrial lining, cleaning the slate. She's estrogen and progesterone low during that time period. And then once her bleeding stops, it's because an egg has been chosen. Estrogen is then going to rise until it gets to that peak level. During that time, she's going to feel her best for most women.
So is that the first 14 days? By convention, if you had a 28-day cycle — which only about 13% of women actually do, but all of these graphs usually use 28 days because it's easy to go week by week and that's the lunar calendar — it is roughly the first two weeks for most women to get up to that ovulatory time period. So the time from I have started bleeding until I am now ovulating — that is all considered the follicular phase.
In those first 14 days, she's going to have better spatial skills and be more focused. Once you get to your estrogen-dominant phase — so you have a lot of estrogen and you don't have progesterone — most women have increased concentration, more focus, they actually can sleep better, they have higher libido. Performance tends to be improved — aggression, concentration — during what we call the late follicular phase. So that means the time period when you're really making that estrogen, let's call it days 7 to 14 for ease. So I'm now done bleeding, a follicle is growing, meaning an egg is making enough estrogen to stop that bleeding, I've not yet ovulated and seen progesterone. This is where we typically have our best performance overall from how our body is functioning.
And then from day 14 onwards, progesterone slows your body's metabolism down. It's preparing you for that pregnancy. Many women actually have fatigue. They're hungry. Specifically in the brain, progesterone levels as they rise, we see an increase in GABA, which is a neurotransmitter, and that is more of a calming hormone. So women tend to see sleep changes — deeper sleep, longer sleep in that luteal phase.
Steven Bartlett: And on this it says she's going to be — she's going to have peak libido around day 14?
Dr. Natalie Crawford: Because she has an egg available. That peak estrogen level of 200 picograms is heightening everything. To have peak libido when an egg is released — the body is made that way on purpose.
Wearables and women's physiology
Steven Bartlett: This is a bit off script, but my girlfriend always talks about her HRV being very different. She has really great HRV scores and then once every month for a period of time they're terrible and she can't explain it.
Dr. Stacy Sims: Wearables are not designed to capture women's physiology. What happens after ovulation is your respiratory rate goes up, your resting heart rate goes up, and your HRV plummets. So on the wearables, most women about five days before their periods start will never be in the clear, so to speak. They will never look recovered. They will never look like they can take on a lot of stress. They're not stress resilient because of the way the algorithms are reading this change that is natural, that is produced by progesterone to alter our respiratory rate and our heart rate. It doesn't mean that she's not stress resilient — that's what the wearable is saying.
Steven Bartlett: She came downstairs and she said, "Oh god, my recovery is so bad." And then a couple of days later she had a period. She was shocked that she had done everything right, but her recovery on her wearable said that she was in a terrible state.
Dr. Stacy Sims: This is why we do not let athletes use wearables leading up to a peak event, because they feed into what the wearable is telling them and it's not true data with regards to how their body can actually perform. Wearable data masters then need to segregate populations and make new norms for women and maybe new norms for different fitness levels of women. I've always been pushing for the past five or six years interacting with wearable companies — if you want to capture it well, then you need to be able to compare follicular to follicular and luteal to luteal. So comparing like — we know your HRV is going to be different in your follicular phase. This is not a bad thing. People could theoretically do that on their wearables and look at the previous month and see the level you're at then. Obviously the wearable companies could do a lot more here. But then it comes back again on the woman trying to understand and interpret the data herself, which can be a little bit problematic, because there are so many women out there like "my wearable told me that I'm in the red, I can't do anything today," when in fact physically and psychologically they can do what they set out to do. It's just now they have this little seed saying that no, you can't do it, because of an improper algorithm on their wearable.
Fertility — the five non-negotiables
Steven Bartlett: I want to close off on the subject of fertility because it was heavily asked by our audience and I guess I'm well placed to ask some of these questions because I'm in that journey myself of trying to have a child at the moment. Natalie, you have five fertility non-negotiables that you talk about.
Dr. Natalie Crawford: I think it's really important to think about — for too long we've been told your fertility is luck. It's good luck if you get pregnant. It's bad luck if it's not. And that's this narrative that gets propagated. And fertility is certainly not fair, meaning people will have infertility and do everything right. But there are things that we do that will inherently also harm our fertility and our hormonal health and make it harder to get pregnant. And that's even when we are doing treatments. So a lot of times people say, "I'm doing IVF so I don't need to worry about these non-negotiables." And that's also not true.
We need to get more sleep — that's going to be number one. We need to actively work to decrease stress. That is not "I'm just going to live a stress-free life," but all these things — I'm going to not take call, I'm going to set some boundaries and not have late meetings, I'm going to see morning light, I'm going to take a walk outside. We live in a stressful world and chronic stress itself can impact your fertility, your natural fertility, and IVF success rates. We're going to work on exercise to build muscle and try to improve our muscular health since it's part of our metabolism. We're going to eat an anti-inflammatory diet — that's definitely key, high in fiber. And we're going to look at the world around us and work on pulling toxins out of our world. We haven't even entered the discussion about how environmental toxins are harming our body, our hormonal health, our fertility, our ovaries, our organs. And so these are all things that we make active choices on that we have to start paying attention to and changing.
Egg count, age, and fertility decline
Steven Bartlett: I've always been quite shocked by this graph showing the egg count by age. What do men and women need to understand about egg counts in order to make better family planning and fertility decisions?
Dr. Natalie Crawford: Stephen, how many sperm do you make a second?
Steven Bartlett: Millions.
Dr. Natalie Crawford: You make 1,500 a second. You make millions every day. You make sperm every single day. You have germ cells that create sperm. Women are born with all the eggs you're ever going to have. I like to imagine that this is a vault inside your ovary that is storing all of your eggs. And every single month, since before you are born, eggs come out of this vault. And what happens is that when the vault is more full, more eggs come out every month. And as the vault starts to get emptier, fewer come out. And this means that we lose the majority of our eggs well before our reproductive years even start. So you lose the most before you're born. From being a five-month baby to birth, your egg count goes from six to seven million to one to two million. Millions of eggs lost before you're even born. From birth to puberty, let's say you go from one to two million to half a million to simplify numbers. So the second biggest drop before you're ever ovulating, before you ever have a chance to get pregnant. And then you only ovulate around 400 eggs over the course of your reproductive lifespan.
As that egg count starts to drop over time, the other really, really big important factor is that our eggs have been in our body our whole life. Two different things are happening at the same time. One is that our chromosomes start to leave their perfect position. They absorb the wear and tear of years. So we see more chromosome abnormalities as we get older. It's why it's harder to get pregnant and why we see an increase in miscarriage as we age. But also concurrently our metabolic health is poorer as we are older too. And mitochondrial function in eggs — the metabolic capacity becomes less capable. And so we see that it's harder to get pregnant not because women are running out of eggs but because the quality of the eggs declines.
But everybody will run out of eggs. You'll have a period of time where you have a very low egg count. We call it diminished ovarian reserve in the fertility world. We call it perimenopause more globally. And these are two words to describe the same thing. As your egg count starts to get very low, you start to have an unpredictable response from your ovary and your brain is trying to compensate for that. And so you see various hormone changes, but these start before you might recognize even menstrual cycle changes. But everybody will run out of eggs. Every woman will. Your ovaries will go into what we call ovarian failure and no longer respond to hormonal signals from the brain or artificial signals that we give.
Steven Bartlett: Shouldn't we then be freezing our eggs?
Dr. Natalie Crawford: As a society, if we are purposely delaying childbearing, we know that it gets harder to get pregnant with age. And if having kids is a life goal, putting eggs into the freezer earlier is a way to save that opportunity. It's not an insurance plan. It's not a guarantee, but it is a smart game plan, especially as we are waiting longer. Because even with IVF, we can't always overcome age-related infertility if we have fewer eggs and more genetic abnormalities. The technology helps us identify healthy eggs, helps us have more eggs able to grow in a certain month and take them out and test embryos in a lab, but I'm working with the eggs and sperm that you're giving me. Meaning if there's not many of them, if there's a lot of chromosomal damage, if there's a lot of mitochondrial dysfunction, if the sperm quality is not great, that doesn't mean we're going to be able to have success. So what you're doing on a daily basis to impact egg and sperm quality is still crucial.
Egg freezing has gotten a lot of bad rap. It's still a new technology. It's only been around about 10 years off experimental purposes. Meaning that women who froze their eggs 10 years ago have much poorer egg survival rates. They were older at the time. Their experience is very different than the modern woman who is freezing her eggs now, maybe in her upper 20s or early 30s.
Steven Bartlett: What is the optimal age?
Dr. Natalie Crawford: If you want to have a child as a life goal and you're not ready to conceive by age 32, that is when there's a clear delineation that it makes smarter financial sense as well as likelihood sense. The shorter answer — my daughter will freeze her eggs in her 20s. The younger you are, the more eggs that you have. If she says, "I want to have kids as a life goal," then that will be something that we will do in order to help her keep that, because there are so many other variables which impact your ability to get pregnant or your egg count. Endometriosis decreases your egg count. People will develop an ovarian cyst and they'll have surgery. A twisting of their ovary and maybe they'll lose an ovary. Smoking, chemo, radiation, marijuana, any abdominal surgery. So many things can impact your eggs because you only have this group. You're born with them.
I always wanted to be a mom. Yet I already told you I took a birth control pill every single day and I didn't even think about it until that moment was in front of me. And that's the part of the discussion that we do have to start to have earlier — if this is a life goal for you, what do we need to do? Understand our body better, our fertility better, and maybe that does include freezing eggs because it does give many women an opportunity that time would eliminate.
Fertility journeys and the emotional weight of infertility
Steven Bartlett: I had a conversation with you, Natalie, on the podcast, but then many other women over the course of the last two to three years. And one of the things that I learned from that was that we don't family plan, and then we have to deal with the consequences of not family planning. As an interviewer, when I do life story episodes, I go through a woman's life story. And obviously the women sitting in front of me are typically high performers, high achievers in some capacity. And then we arrive at the end of the conversation when we talk about family and kids and all those kinds of things. And there's often a lot of tears. The straw that broke the camel's back was the UFC fighter Ronda Rousey. It just so happened that when I interviewed her, she had just found out that her seventh round of IVF had failed. And so she was very, very emotional. I left that interview and had a conversation with my girlfriend. I was like, "Listen, I've seen too many women over the age of 35, maybe sort of under the age of 45, in tears in front of me. I think we should have a conversation about this. Should we freeze our eggs?" Me and my partner are both 33 now. And at first — I don't know, maybe it was the way I worded it — she was offended. She was like, "You don't want to have a baby with me?" I didn't really think about the emotions surrounding it. And there's this prevailing narrative in society that if something's not quote unquote natural, then it's not good. And that IVF or egg freezing is not natural. And that torments people's brains because they want to live a natural life. After honestly five minutes of that conversation, I think the framing that flipped her mood was that wouldn't we want to give ourselves the option? And it's actually about having options.
I don't think people family plan. I think as you said, we focus on our careers, then we pop up at 35, 36, 37 and assume that we can.
Dr. Natalie Crawford: Especially if you live a healthy life, you think, "Oh, this will be easy for me." Or if you're a high achiever and you've achieved other things, many women are really taken aback by not being able to achieve this or not having control over infertility and what is a natural process — to run out of eggs and to go into menopause. If you are lucky to live long enough, this is going to happen.
I got my diagnosis of PCOS in medical school before I was ready to start family planning. And I knew I was probably going to struggle. And so it took us about three years to successfully conceive the first time. And you can't — even though I'm working in the business, running between patients to go and have another ultrasound or go get a shot or go do all the things that it took — you can't remove the emotion from it. And I can't tell you how many times I cried. And of course, all of my co-residents, my four best friends, all got pregnant in succession with no trouble. And even crying to my mother about the struggles I was having, she's like, "I just got pregnant eight times with no trouble." And then my first pregnancy resulted in a miscarriage, in the middle of work, and all my friends were there and they were cheering, they were so excited I was finally pregnant, and then we lost the baby. And having to push through and work through it — it's like it was yesterday. I have two healthy kids, thank God. And we were never — after those two, we tried again, we were never able to get pregnant again. But it is impossible to remove the emotion because in the mindset it's luck, or it's something we did, we caused this. And as a high-performing someone who's like, you check all the boxes and you make all the good grades and you do everything right — and this is the one thing that suddenly you didn't think much about, and then it becomes everything when that becomes hard or it's taken away from you.
Dr. Vonda Wright: I'm in awe of this story that four of your residents got pregnant immediately because in orthopedics that does not happen. Every orthopedic surgeon in my generation that I know — if we got pregnant, we miscarried. And maybe that was lifestyle and maybe that was not eating for 40 hours. Maybe it's all the radiation that we undertake. I think it's better now for the younger generation. We encourage all of them — if you are not partnered and wanting to have a child now, then please consider freezing your eggs if that's a goal, because we can't predict our futures and our residencies extend into our 40s.
Dr. Natalie Crawford: I am one of the ones who sat here and cried in front of Steven myself when talking about my own pregnancy loss journey. I see it every day and I tell patients every day news that they do not want to hear. 50% of infertility is due to male factor. 50% is due to female factors. One of the most important things I want to convey on this topic is that IVF is an amazing technology that has helped 13 million babies be born. It has been life-changing and world-changing. And things don't have to be natural. Sometimes the natural progression of disease is death. So we have technology and science that exists to optimize and improve life and to help life exist. And that's part of what IVF is. And I think that's important because we do see a narrative right now that IVF is inherently bad and natural fertility approaches are inherently good. And we truly need to say both things are good. Do women need to learn about their bodies earlier? Talk about cycle tracking, take better care of themselves, get an earlier investigation when things aren't going well? Absolutely true. But also, needing to have fertility treatments is not a failure. Needing to see a fertility doctor is not a failure. If you need IVF, that is okay. All the other stuff is still really important to the outcome of your journey. But this narrative of IVF isn't natural so it's bad, or egg freezing isn't natural so we shouldn't do it — that's harmful to society and to women who do carry the burden of family planning for the future.
Dr. Vonda Wright: Hearing you talk about that is very interesting to me because in other parts of medicine, in my own medicine — we were talking outside about how I now do knee surgery through needles. It's an advancement of technology. We celebrate that. We like better things for people. It's not natural. But I'm capable of helping you live a better life. So it's interesting to me — it's the stigma of women's health. This is women's health, so we're going to control it, we're going to protect these gals, we're not going to apply the vast knowledge. I'm a little offended by it, actually. If you want to know the truth, why can I be so encouraged and be considered top of my field when I adopt new technologies? But in your field, 13 million parents — or 26 million parents — would be told that technology is not okay.
Dr. Natalie Crawford: I agree. It's a terrible narrative that is happening right now in the political landscape. And I think it's important to say scientific advancement is good and it changes the lives of so many people. I think as scientists and people in medicine, there's also been a disservice to not trying to get to the root cause and not working on preventive medicine. And so going towards treatments and technology has made the lay person feel like half of the picture wasn't discovered or talked about. And so we can do better on both ends of it. And that comes to women's health more than anything because there is stigma when it comes to infertility — there's isolation, you know, being left behind your peer group. Questioning a life goal will make you question who you are, your life meaning, your purpose. And that is an extremely stressful and challenging state for somebody to go through. And we should be giving more support to that.
Spontaneous fertility rates by age
Steven Bartlett: So Dr. Crawford, what is the spontaneous fertility rate by age in general?
Dr. Natalie Crawford: If you are 30, your odds of getting pregnant monthly — we use a monthly rate called fecundability. It's going to be at best 20% per month. When you're in your 20s, it's a little bit higher. Can get up to 25% per month if you're having sex regularly and have regular periods. So if you're having unprotected intercourse and you have regular cycles, your best odds in a given month are going to be about 20% at age 30.
Steven Bartlett: How much sex do you have to be having?
Dr. Natalie Crawford: Really just have to have it in that fertile window. Just once? Yeah, sex solely on the day of ovulation would be the ideal time, but you just need to have intercourse at least once in that fertile window. But that number drops quite significantly. At age 35, if you're trying to get pregnant, it's going to be 10 to 12% per month odds of getting pregnant. At age 38, it's going to be 5% per month. At age 40, it's going to be 3%. These are a little bit higher if you've had a child already because there's some proven fertility factors. But if we look at that, you say, "I'm chasing these dreams, I'm going to try to have my first baby at age 38." You have a 5% chance per month. That's not zero, but that means the greatest probability is that by the six-month time frame, you won't be pregnant. And then you're going to start a pathway of trying to investigate why that is happening. And if you do need intervention, you're further down this graph too. You're going to have less eggs to work with, and their quality is going to be less good. That's why those numbers drop rapidly.
Natural fertility rates are not about being out of eggs because you ovulate just one egg at a time. It doesn't matter if you have 20 eggs outside that vault or five eggs. You're ovulating one egg at a time. So natural fertility is all about egg and sperm quality. This huge drop we see from 20% to 5% is because of the change of our egg quality as we get older during our 30s, which most of us feel like is really young.
Steven Bartlett: Is there anything that has a really pertinent impact on the quality of my eggs?
Dr. Natalie Crawford: We have two factors. Age, which you can't control to an extent — chromosome damage is going to happen even if you are exceptionally healthy because tincture of time. They've been sitting inside your body. Chromosome damage builds up. But the variables that you can control is everything that impacts cellular health. Chronic inflammation and insulin resistance are the two things that are going to most dramatically harm your eggs' metabolic function. It's going to harm your mitochondria. You're going to get mitochondrial damage. We know that when we start looking at older women, they have more dysfunctional mitochondria. They're shaped abnormally. The products inside their follicular fluid show higher levels of inflammation just based on age — that happens — but also if they start having infertility versus not having infertility. So we know that inflammation and insulin resistance are key players even in patients without known PCOS or endometriosis, but they play a role in aging and specifically your egg health as you age.
So if you say getting pregnant is a life goal, I'm tracking my cycles, I don't want to freeze my eggs right now, but what should I do? All these things that we talk about to decrease inflammation inside our body. That's it. And from a young age, because these changes build up over time.
Steven Bartlett: And if I have PCOS, do I have less eggs?
Dr. Natalie Crawford: You're going to run out of eggs around the same time. You're born with a little bit more, but because you lose eggs based on how many you have, essentially you're going to catch up. So during your reproductive years, you tend to have more eggs out of the vault, which interferes with normal hormonal signaling, making all of the hormonal metabolic changes worse. Very interesting thing — as women with PCOS tend to get older and their egg count starts to drop, and they have fewer eggs coming out of the vault, they'll often start naturally ovulating even if they didn't earlier. And so I'm always a little concerned when somebody says, "I used to never have periods, but now I do. Did I cure my PCOS?" Maybe they did make some good lifestyle changes along the way, but honestly, that's a red flag for me that she's now more rapidly declining in her egg count, approaching what will be perimenopause for her, because her egg count is low enough to then respond to the brain signals.
Male fertility factors
Steven Bartlett: As a man, is there anything I can do to increase the odds that I'm going to impregnate Mel?
Dr. Natalie Crawford: You can stop using cannabis and smoking cigarettes, drinking alcohol. We need to avoid heat. The testicles are outside the body for a reason — they need to be at a lower body temperature in order to adequately make normally functioning sperm. So hot tubs, saunas, those should be off limits if you're wanting to get pregnant. Same with high-intensity exercise and compression of the testicles. So this is notably cycling for long periods of time — an hour on the bike or more routinely can actually compress the testicles and increase their heat.
We also see diet playing a big role. The great thing about men — you're making sperm every single second. The sperm lifespan is 90 days: 72 days to make a sperm, 18 days to get out the ejaculatory system. But that means you could make a singular change in your health and see a different outcome in your sperm. That is so rare — that doesn't exist in women's health — that one variable can move the needle so much.
Marijuana is a huge one. Marijuana use works at the brain to prevent those FSH and LH signals which are crucial to tell your testicles to make sperm, and they also impact the inflammatory environment. So sperm are not as motile. They are not shaped as well. The DNA inside their heads is more fragmented. In fact, men who use marijuana — their partners have a higher rate of pregnancy loss, even if their partners are not around it at all.
Steven Bartlett: You're using the word pregnancy loss versus the word that we're aware of in the UK called miscarriage. Is that intentional?
Dr. Natalie Crawford: Miscarriage can mean a lot of different things to people. A pregnancy loss, an unsuccessful pregnancy — depending on when you medically lose a pregnancy, or if a pregnancy is in the fallopian tube and it's an ectopic pregnancy, that's still a pregnancy loss, meaning you had a positive pregnancy test that did not end up in a baby. So it's a little more inclusive for a variety of different stages of when and how loss can occur. Miscarriage kind of infers that the pregnancy was in the uterus and now it's self-evacuating or we have to evacuate it.
Dr. Vonda Wright: And you were saying a second ago that from your experience, pregnancy loss is much higher with women who have high-stress careers and jobs.
I don't know the real statistics, but in my experience as a high-capacity, high-stress, not sleeping for 11 or 22 years person, I have seen it a lot and it happened to me. Chronic stress is associated with a higher rate of pregnancy loss.
Pregnancy loss — the silence and the return to work
Steven Bartlett: Is there anything else that people misunderstand about pregnancy loss and miscarriage that is worth talking about?
Dr. Natalie Crawford: It's not talked about, I think. That's one of the things. People still think it's taboo and rare, but I think all of us around the table had pregnancy loss.
Dr. Vonda Wright: When I had mine, I was in training and I didn't want to call my attending and tell them because he was a man. And I didn't think I could take any time off. I went back the next day. I would have gone back the same day, but I could barely move. I was running labor and delivery at night. I got discharged, IV pulled out in my hand, and went back on the ward. So I think hopefully part of this international conversation about women's health — not just gynecological health but health in general — will give women grace. Because there's no way that I should have been expected to go back to an orthopedic surgery residency the day after I lost a child. I went back to work less than five weeks after delivering a child. I think other European countries have it right. New Zealand is a year.
Dr. Natalie Crawford: Six weeks with one and three weeks with the other, because if I wanted to leave my fellowship on time, I wanted to graduate on time, I couldn't exceed the total vacation. These internships and fellowships were all developed for men who had a family, had a wife, had someone at home to take care of that business. I went back before my body was ready. Before that baby was ready. And my milk supply dropped immediately the minute I went back to work. I tried to pump but you get called for a crash C-section or emergency surgery and you're pulling the pump off the breast and running down the hall hooking your nursing bra back on trying to get to the OR. All that cortisol — my milk, you know. So I was able to breastfeed while I was home with the baby, but once I went back to work my milk production just shattered.
Dr. Mary Haver: I have a picture of a day in the hospital. It was a day after I gave birth. My laptop is open. I'm trying to breastfeed. Because we launched a company the month before I gave birth, and instead of my male co-workers going, "Okay, we'll give you some grace," no — I had a week and then they were at my house having meetings.
Dr. Natalie Crawford: There's such a different discussion about miscarriage now than when I went through it. I told nobody. I didn't either. It was so secretive. I didn't feel like I could. And we are seeing a different generation where I do think talking about women's health and Stephen you having these discussions on a bigger stage are lessening the stigma for what is something that people go through. One out of four pregnancies will end in a pregnancy loss. That is not a low percentage of people. In the same breath, most people should not have two in a row. And if you do, you should go get an evaluation because there are medical things that can contribute to pregnancy loss that we would love to identify a lot earlier and see if there's something we can do to make that different.
Supporting women in the workplace
Steven Bartlett: What do I need to understand about what a woman goes through either in the wake of pregnancy loss or in the wake of a pregnancy and a birth — physiologically, psychologically — as an employer, to be able to create a better environment for the women that are going through either of those two things?
Dr. Natalie Crawford: One of the simplest things to say that's going on is that pregnancy is one of the most hormone-robust times you have, even just momentarily pregnant. If you have a placenta starting to implant, you are now making levels of estrogen and progesterone that you will not ever make at any other time period of your life. When you lose that pregnancy or when you're postpartum, you have this huge hormone crash. Suddenly you go from this very high level of these hormones dropping off immediately. And in addition to all the physical changes, the emotional changes — that has a huge impact. We've talked a lot about low estrogen and how that feels. The very interesting thing most studies about estrogen show is that the hardest time for women is when estrogen is changing. So going from high to low is actually when your body and your brain can't keep up. And the higher you were and the faster you come down — even in IVF, when we go do an egg retrieval and somebody had many eggs, they have a much higher estrogen than they naturally would. I go and put a needle in each one and drain the eggs out and destroy those cells and their estrogen plummets. And they expect to go the next day and feel normal. And I always say, you're actually going to feel worse when I'm done with you. It's going to be that week after the egg retrieval where your hormones go from the highest they've ever been very quickly down low. It's that delta, that change. And that happens anytime you have that. But pregnancy and loss and postpartum are some of the most profound times that you experience this.
And one of the other things is the identity shift. If you're working, we are all very highly motivated and became parents. But it's that whole identity shift of now how do I interact in my life and how do I interact with my peers? I'm a mom. How am I being identified? What are the implications? So there's a complete identity shift that also isn't discussed and that can also perpetuate some of the postpartum that we see as well. And anxiety and lack of control, right? Because you don't know what you're supposed to do, especially if you're a mother for the first time. That can be very anxiety-provoking in addition to hormone changes and not getting sleep. But lack of control — you don't control your schedule, you don't control when you sleep, you don't control if your child gets sick. And so I would say from an employer standpoint: grace, support, and flexibility.
Steven Bartlett: If you could design their working month around their menstrual cycle, around potentially a pregnancy, whatever — how would you redesign their month? Because we've inherited this sort of industrial revolution 9-to-5 working hours. What would you change?
Dr. Stacy Sims: There are a couple of companies in New Zealand who are pretty flexible, especially after the pandemic, where they have allocated certain hours that are free to work at home. You just have to get the work done. To the point where they have four-day working weeks. And then they're also putting into the annual leave what they call menstrual leave or menopause leave. And it's — you just say, you know, I can't come today. Some people are using it for childcare. Some people are using it for really bad cramping days. Other people are using it for mental health days. But it's there to be used for however. And you don't have to identify it as being a menstrual cycle day or menopause. It's just extra leave. And people don't care as long as you get the work done. And I think that having that flexibility greatly benefits productivity as well as the feeling of empowerment and inclusivity, which then feeds forward to better productivity.
Steven Bartlett: If I've got an extremely high-stress job, is there any part of the cycle where I should theoretically be avoiding stress?
Dr. Stacy Sims: Well, that's an individual thing. It's about understanding your own responses to your own hormone flux. For most people, it's peak luteal — when your progesterone is the highest — that tends to be when people have a harder time focusing and concentrating or getting tasks done. That's going to be the middle of the luteal phase, the middle of this second half of the cycle, when you have that progesterone really high. Your body might be ready to implant an embryo if there was one. That tends to be when people say they feel more fatigue and less energy and less focus and concentration. So if you are looking at your month and you have the flexibility to say, okay, I'm going to try to write this paper, get this study done, do these tasks that call for increased focus in my follicular phase when I'm estrogen dominant — for the average person, that is typically when they have an easier time achieving those tasks. Which is the first couple of weeks, the time period before ovulation. But there is an individual response and I definitely will see some people who feel immensely better when progesterone's present and not so great the other time. So I think we use generalizations just as a rule of thumb because that's what it is for most people, but hormones specifically, there's always an individualized response and learning to listen to your own body is key.
Dr. Natalie Crawford: I think every woman wants to do a really good job and she is going to frontload those tasks on a time that she feels better and offload in a time where she's not feeling as well, but she's going to get it done for sure. And so giving her the flexibility is going to allow her to be her most productive rather than demanding she have a fixed amount every single day.
Dr. Vonda Wright: I think support can come in a lot of ways, but the financial burden to a large corporation of having a stop-gap childcare at work — maybe if you're not going to offer full childcare because you're getting a lot of productivity out of women if they know their children are on campus and can go at lunchtime. But if you're not willing to do that, if you have a stop-gap where instead of calling your attending — one day my nanny didn't show up and I had to find some way — just for those emergencies within the corporation, that breeds loyalty that will increase productivity. And so I think it's money well spent. Offering those things to make her mothering easier while she's trying to work — I think you would have the most competitive workforce.
Dr. Stacy Sims: What happens in New Zealand? You have 20 hours free daycare a week. So it's 20 hours funded, and then it's a very small nominal fee for hours over that for up to year five or when they're five years old, because then they start school on the first day that they turn five. It does help significantly keep productivity and a little bit of the worry off.
Perimenopause — the transition nobody talks about
Steven Bartlett: What does this conversation around eggs and fertility dovetail into menopause and specifically perimenopause?
Dr. Natalie Crawford: You can't have one without the other. Perimenopause is basically in this fertility decline area. You don't want to ever have a baby — you're still going to go through perimenopause. Perimenopause is defined medically in the worst way as the transition from normal menstrual cycles to no menstrual cycle ever again. Menopause is defined as one year after the final menstrual period. What it really means is ovarian failure. And that offends people, but that's actually medically what it is. You have run out of eggs and you run out of the ability of the ovary to produce hormones.
Perimenopause begins medically — a lot of it is based on menstrual cycle irregularity — but hormonally what's happening starts well before our periods become irregular. So as those egg levels decline and the ability to respond to the stimulus coming from the brain — remember ovulation starts in the brain — when estrogen levels normally get low during the cycle, the brain doesn't like it. The hypothalamus, the gland in our brain, starts looking for estrogen. It likes estrogen. And when the estrogen levels are high, it's happy. And so when estrogen levels decline naturally in a cycle, it says, "Where's my estrogen?" And it sends a signal to a second gland in the brain called the pituitary. And that makes the LH and the FSH.
So what causes perimenopause? What causes menopause? Lack of eggs. So it's the loss of eggs and the loss of the group of eggs to respond to these signals. We're beginning perimenopause. We've reached a critical threshold level where our ovaries cannot respond. If menopause is going to be, for simplicity, the jar is empty — when the jar gets lower, the ovary doesn't want to be out of eggs. So the brain is working harder to get an egg to grow because the ovary becomes more stubborn. It wants to hold on to them. It doesn't want to lose them. The brain has to send out stronger signals to get an egg to grow. Because there's not as many, we don't lose as many per month. So that's great, but that means we have years of being at this low, unreliable ovary stage where the brain is working really hard.
What happens is that the hormone changes start shifting in the brain. The ovarian response starts shifting, and before you have irregular cycles, you will first see a shortening of your cycles very predictably. The brain will send out a stronger signal. An egg will ovulate faster. You'll start to get shorter cycles. And then there are hormone fluctuations, but they're still regular. And so what will happen is a woman will start to feel these hormone shifts. It's less predictable. She is having some change, but it's still a regular cycle. And so she is often told, "Your hormones are fine. You have a regular cycle."
And in the brain, as we talked about those neurotransmitters — not only is estrogen changing and the amount that we're producing, actually in perimenopause quite often we'll have much higher estradiol levels than we did in our premenopausal years. There are also independent FSH receptors outside of the ovaries, so these hormones that are pumping out to talk to the ovaries are also back-talking to different parts of the brain. So the first symptoms that patients feel — and they've done a great study on this — is "I don't feel like myself." And they even call it IDFM. And so you can't put your finger on it. Periods are regular, but your environment hasn't changed. Your normal stressors haven't changed. The life you built that you could manage — you're suddenly losing resilience. And that's because of a hormone fluctuation that is hard to pin down.
So we see sleep disruptions, mental health challenges increase — 40% increase across the perimenopause transition — and the cognitive changes. And that is what really scares my patients the most. And they come in and most of them are high functioning in some degree. And suddenly she can't remember all the things she used to remember. Where are her keys? Word salad. You're struggling to find words.
Dr. Vonda Wright: I cannot remember their names or I can't remember — I get in the car and I can't remember where I'm going or what my purpose of getting in the vehicle was. You have to think for a second. And so all of that is related to the hormonal changes.
Steven Bartlett: At what age?
Dr. Vonda Wright: I think that there's a tendency in medicine to want to have definitions. I personally think that this random 366 days after your last period — that's your menopause day — I think that's pretty random. And I don't know who made that up. When I have patients come in to me for their musculoskeletal things and they're of a certain age, and I don't just focus on whatever the musculoskeletal body part is, but we start talking about their whole health and they start talking about these things — I am often the first one to say to them, "You know what, you are probably in perimenopause." And they're like, "But my cycles are regular." I'm like, "But you are beginning this transition." I would propose that most people don't seek out a lot of help earlier. But they should just assume that they're perimenopausal anytime after 35 they don't feel like themselves, and start down a road of learning or investigating or let's feel better and what do I need to do about it?
Dr. Mary Haver: It's frustrating to all of us. The people who kind of make the rules, the institutions that make the guidelines, the academic ivory tower — they are like, "Whoa, back off, slow down. We shouldn't be blaming everything on menopause." And I don't think that's what we're saying. But completely dismissing the female experience and not at all including this cataclysmic hormonal change is hurting women.
Dr. Natalie Crawford: The average age of menopause is 51 to 52. And so let's say that is when your ovaries are in failure. They will no longer make eggs, make hormones, or respond to brain signals. For most women, about 7 to 10 years before that they will start to enter into what we will call perimenopause — the unpredictable response of the ovary and the brain. Their communication system — their best friends who aren't communicating well. Their signals are getting interfered. They're not responding appropriately. The ovary is getting more stubborn. The brain is trying to work harder. You get these higher peaks, these lower troughs. And essentially that is the time period. So it is unique to an individual because everybody's born with a different number. They lose them at a different rate. Your mom's age of menopause is a predictive factor. If you've had a first-degree relative go through menopause at 46 or sooner, you have a six times likelihood of going into early menopause. So knowing that information is really important — if you have a mom or older sisters, what age is normal for your family, so that you can be a little more in tune if there's some genetic predisposition for you?
Dr. Stacy Sims: We do have a generation of women that were on contraception and then went through childbearing and then on contraception again until now they're suddenly entering this transitional period and they don't know what their own normal is, making it even worse.
Dr. Mary Haver: The average age of menopause, if we look at the math, is 51, but under that 90th percentile curve with 5% on each end, it's about 45 to 55. That's menopause. Now let's just do math and back it up 7 to 10 years. So we're looking at the mid to late 30s to 40. So when I have a 46, 47, 48-year-old patient come in who's still cycling, she has almost 100% chance of being in perimenopause just based on her age alone, knowing the statistics around that.
Steven Bartlett: So with my partner, between the age of sort of 35 to 45 is when I can expect her to go through perimenopause, where there are very few marbles left in the jar, and her hormones might be less predictable. One of the questions we had in from the audience was how can I manage the symptoms of perimenopause, and they use the word naturally.
Dr. Mary Haver: We don't have a single large-scale study done on the treatment of perimenopause. So let me break it down for you. When we look at funding in women's health, it's horrible. If I go into PubMed, which is the database I go to look up medical journal articles, and I type in the word pregnancy, I will get today 1.2 million articles. Amazing. So important. We need healthy pregnancies. If I type in the word menopause right now, I think it's about 99,000. So those numbers represent time, brain power, funding, what is important in women's health. If I type in the word perimenopause, we are about at 8,000. Very, very small. Your name's on a couple of those. So the last third of my life — from an academic standpoint, from funding, from brain power, from where we focus — is not as important as when I had the ability to be pregnant. More women will go through perimenopause than menopause because we're going to lose a few to accidents and cancers and early deaths. More women will go through perimenopause than get pregnant. Yet in my training, in medical school, I got one one-hour lecture on menopause, nothing on perimenopause. And in my OB/GYN training, as part of our reproductive endocrinology blocks, I had one block of that my second year. In those six weeks, I got one one-hour lecture each week. No clinics, no focus, nothing. And then as a program director, where I was in charge of the education of over 100 residents over about 10 years, I knew exactly what the curriculum required, and menopause just gets shoved into a tiny box.
Menopause — what happens when the eggs run out
Steven Bartlett: And then what happens when we run out of marbles in the glass there?
Dr. Natalie Crawford: What's really interesting is this happens — this is ovarian failure. You're going to go into a state of low estrogen because the ovaries no longer have the ability to make eggs. Therefore, they are not going to make estrogen or progesterone. Estrogen is low, but the brain is sending out all the FSH it has. FSH is very high in menopause and the ovary cannot respond because there's no more eggs. There's nothing left to respond.
Steven Bartlett: I need to understand again why estrogen drops when the eggs disappear.
Dr. Natalie Crawford: The estrogen is made from the cells that surround each egg. So when there's no more eggs, there's no more cells that make estrogen. The follicle goes away too. So estrogen is made in the ovaries — the primary type of estrogen that we're talking about is made from the cells that surround each follicle, called the granulosa cells. And as the follicle gets bigger, as the egg matures, more of those cells become more active and you make more estrogen. So even when you have a little bit left, when you're on your period, some eggs here, you're still making some estrogen. It's not as high as when you're ovulating, but these little eggs will each make a little bit.
Steven Bartlett: Do I make estrogen at times?
Dr. Mary Haver: You do, but you make it somewhere else. It gets converted over from testosterone. We have enzymes in our body that convert estrogen and testosterone back and forth.
Dr. Natalie Crawford: So there are no more eggs. This is menopause. This is ovarian failure. And we're calling it ovarian failure on purpose because at this moment, you're not going to make estrogen. The brain is sending out all the signals it can — very high FSH trying to get estrogen to be made. There's no eggs, so there is no estrogen. What Dr. Haver has said, which is correct, is our friends in the medical world do not define this moment as menopause. They make you sit here and be estrogen low for a year and have no period for a year before they will say you're in menopause. If they even decide to treat or offer treatment. You must thou shalt go without one year. So we're absolutely sure that the ovaries have moved on before we would even consider.
Dr. Mary Haver: But what is the point of that? We've made estrogen our entire lives. I don't think that people, the medical community, have recognized estrogen's effects outside of reproduction until very recently. There's been isolated pockets, but no one owns menopause. Like no one — you think it would be OB/GYN, but there's no one in charge of women's health after reproduction ends. There's no czar.
Dr. Vonda Wright: So what's the harm of waiting a year before people take it seriously? What happens?
Dr. Mary Haver: Suicide, mental health changes, rapidly declining bone density. Your brain, your bones, your heart, your blood vessels, your vagina — your body has estrogen receptors everywhere that we've already established. And suddenly you've lost the ability to make your primary source of estrogen.
The suicide peak and mental health in perimenopause
Steven Bartlett: I'm looking at this chart here about suicide rates. The most likely time for a woman to commit suicide is between the ages of 45 and 55. Do you think that's linked to menopause?
Dr. Mary Haver: 100%. We know that mental health — we have an increase in mental health disorders, either pre-existing getting worse or new onset, of about 40% across the transition. And we look at SSRI prescriptions, which are antidepressants. They double across the menopause transition. Now there are a couple of reasons for that. One is we weren't treating menopause with hormones. SSRIs can actually help a hot flash — certain types. Paxil is one of the ones that has been proven to decrease hot flashes some. It's not great, but it works a little bit. And with all of the mental health changes, a lot of women are ending up on these antidepressant medications.
So we don't want to go a year without estrogen. We know that some of the new data coming out — when I was researching for the new perimenopause work — there's a really great window of using hormones to treat mental health disorders and seeing improvement in mood and also some in cognition by giving estrogen, or estrogen plus the progestine, early in perimenopause before the periods actually stop. And that actually works better than an SSRI. So say she's on an SSRI and has done well. She's had a long history
of depression. Suddenly she's not controlled. Suddenly her symptoms are back and she's on the same medication. Rather than doubling or adding a second agent, we really should be giving these women hormonal therapy. Now, that doesn't hold postmenopause. So this is really a perimenopausal window of opportunity. In postmenopause, they aren't responding as well, and probably because the oestrogen levels have stabilised. So when we give a woman back — she adapts. So postmenopause, that's why the suicide rates kind of peak in this key perimenopause area. And in postmenopause, the hormone levels stabilise, so women tend to get better, and they do respond better to SSRIs for new-onset anxiety and depression in those patients.
Dr. Vonda Wright: And I want to do a randomised control trial where we add some creatine.
Dr. Mary Haver: Oh, that would be amazing.
Dr. Vonda Wright: Well, no, it's 3–8 grams per kilogram of body weight.
Steven Bartlett: So you're saying if I'm a 45-year-old woman and I've still got my menstrual cycle — at that time, before I've hit menopause — I should be considering some type of hormonal therapy?
Dr. Natalie Crawford: So when we give someone menopausal-dosed menopause hormone therapy in the form of oestradiol — usually in a patch, because you have that nice steady state — it is enough to feed back to the hypothalamus, to that brain, to calm it down, but not enough to suppress ovulation. So she's often given oestrogen support in very low doses, and menopause hormone therapy is basically micro-dosing compared to what we do naturally. We're giving enough to calm the brain down and stabilise what's happening without suppressing her natural ovulation.
Steven Bartlett: Giving enough what?
Dr. Natalie Crawford: To raise you back to maybe what that baseline would be. Giving enough oestrogen. Correct. Giving enough oestrogen to raise the baseline level so it's not as low. It's not so high that it's preventing ovulation, but it's going to alleviate some of these drastic highs and lows that you're having and create a more stable hormone environment. It's the delta that we were talking about post-pregnancy — the delta, the chaos. The space is what bothers us, not the high nor the low eventually.
Steven Bartlett: So I run out of eggs and then I'm by definition menopausal at this stage, and my body adapts. So there's going to be a drop and then —
Dr. Mary Haver: We're specifically talking about mental health because you brought up the suicide chart. So postmenopause — once everything calms down and you're fully menopausal — you're out of the zone of chaos. The hormones have just — your bones continue to deteriorate, a lot of other things are happening, but our mental health, our brain tends to calm down and things get better.
Steven Bartlett: When do I become postmenopausal instead of menopausal?
Dr. Mary Haver: Menopause is a day, right? Medically, menopause is one day in your life — one day exactly after your final menstrual period.
Dr. Natalie Crawford: That's the point of that random — agree, right? Because what if it's a leap year? Do we go 366 days? What if you've had an IUD? What if you've had all these things? It's really an antiquated definition and we really need to modernise.
Dr. Mary Haver: So it's really you're perimenopausal, then you're postmenopausal.
Dr. Natalie Crawford: Correct.
Steven Bartlett: And when I'm postmenopausal —
Dr. Mary Haver: Forever. That's your new biological state.
Dr. Natalie Crawford: For now. I'm sure someone's working on something to change that.
Dr. Mary Haver: I do wonder that. I do wonder if they're going to figure out a way to extend fertility.
Dr. Natalie Crawford: They're trying.
Dr. Mary Haver: But then I think about it — if you're a 60-year-old woman, would you still want to be worried about that?
Dr. Natalie Crawford: So what they're doing is looking at whether there's a way to extend ovarian function — with a low enough baseline to keep you out of osteoporosis, to slow that down, to protect your heart — without pregnancy.
Steven Bartlett: I'm now postmenopausal. Lots of things change in my body, I'm guessing, because I no longer have the same levels of oestrogen. Do the levels of oestrogen ever go up again naturally, or do I then need to start considering — outside of a tumour —
Dr. Mary Haver: No.
Steven Bartlett: — hormone replacement therapies and things like that?
Dr. Mary Haver: You might. And that will help you fend off — the sleep issues, it'll slow the rate of change. But it doesn't stop it. You still have to put in your lifestyle modifications to improve and/or stop the sarcopaenia and the bone density loss and all the things that people associate with postmenopause.
Steven Bartlett: Did any of you have menopause hormone therapy?
Dr. Mary Haver: Yes.
Dr. Natalie Crawford: Yeah.
Dr. Vonda Wright: Mm-hm.
Steven Bartlett: And what was the decision, and what impact has it had?
Dr. Vonda Wright: So I think what was just said in framing where we're going with this conversation is important. We're now perimenopausal — it's a new physiology. What used to work for all of our exercising — if we even did, because we know that at least in this country, 60 to 80% of people aren't intentional with their lifestyle — so to frame this next part of the conversation, I'm sure we're going to talk a lot about hormones, and I'll tell you my hormone decision-making, but I think it's important to all of us: it's only one of the building blocks to rebuilding a great life. It's interesting that the five steps of fertility that you went over are actually exactly the same.
Dr. Natalie Crawford: Curious, isn't it?
Dr. Vonda Wright: It is. It's great protein and anti-inflammatory nutrition. It's a cardiovascular fitness life. It's a lifting life. It's a stress detox, whether it's environmental or relational. And sleep, sleep, sleep. And then yes, hormones are really a critical building block. But as we enter the conversation, women are sentient beings and we get to decide and we get to make the changes because we have agency. So what we're going to describe is not a one-size-fits-all. It's all the tools on the table. So I choose — if I'm going to work my proverbial rear end off to be the best I can be for the rest of my life — I choose to use all the tools. Not everybody does that. But to choose one tool and think that's going to be enough — it never is.
So when I decided to — and I've been pretty public about my journey in this, because you'd think I would have known after 22 years of formal education and all this, and being an ageing musculoskeletal ageing researcher, you would have thought I would have known. But I honestly, looking back, maybe thought I was never going to age because I was so healthy. So I had a baby at 40. I breastfed until almost 41 and a half, 42. And then I was back — very quickly, five weeks — at my high-power, high-capacity career. But things were getting really different around 45 for me, and I think I went right from postpartum to perimenopause with very little downtime. So chaotic hormones to almost — and so I suffered for a while. At 47, I talk about it like — I went from this really high capacity to thinking I was going to die, not only because of night sweats, brain fog, the things that lots of women have, but I started having heart palpitations. And I called my cardiology friend, because I worked at a university. I'm like, "Ricky, Ricky, I think I'm dying." So he did put me on a stress test and my heart was perfect right at that point. And then I had arthralgia, which is total body pain. It's part of the inflammatory response of not having oestrogen. It's part of the musculoskeletal syndrome of menopause — an assembly of symptoms — so much that I went from training to almost not being able to get out of bed. And my experience of not knowing what was coming and hitting a wall is not uncommon.
So I started educating myself and becoming an acquired expert. I read what I consider the world's data on the safety of hormone optimisation, as I like to call it, and I made the decision that I was going to use all the tools. I was going to learn to lift heavy again — which I hadn't done since high school, because I was a runner — and I changed the way I do my cardio, and I changed my diet, and I am so committed to sleep. Do not call me after 9:30 at night because I am going to be in bed. And just the quiet times of de-stressing. But I also decided to augment — or to optimise — my hormones with oestradiol, with progesterone, because I have a uterus, and after I felt comfortable with those, with very small doses of testosterone. And that makes me feel like myself again — not just one, because I think sometimes people think that you can just make a hormone decision and feel like yourself again. It takes lifestyle plus or minus this decision.
Steven Bartlett: Is there a stigma associated with that decision? Taking hormones. But also, I guess, just more broadly with entering menopause.
Dr. Vonda Wright: There is absolutely — I mean, you can just look at popular media, you can look at their representation. Go right now and give me an image.
Dr. Mary Haver: It's decreasing because of you, though. Like, we have to acknowledge you are decreasing the stigma.
Dr. Vonda Wright: True.
Steven Bartlett: And you're sitting at the table with us. I say that because there's a woman in my life who was telling me about her decision to start taking menopause hormone therapy, and she described the moment with her husband when she was looking at the box. And she was staring at the box and staring at the box and staring at the box and mulling it, and there was clearly something emotional going on there — that this decision to take this marks something. Which is interesting, because no one really questions the oral contraceptive pill.
Dr. Mary Haver: Exactly.
Dr. Vonda Wright: I treat both men and women, and when a man comes into my clinic with low energy, popping all the tendons all over his body, everything hurts, we very quickly test his testosterone and send him on his way with no judgement, because he's trying to be vital. And I think it goes with the general conversation about ageing women. When men talk about living longer, it's called longevity and we celebrate that, and we take pictures of movie stars in the south of France — very distinguished, with their greying temples. When women — when we talk about women living longer, until right now, because we're all screaming about it — it's under the guise of anti-ageing, a superficial, "Oh my God, don't let her age." So I think part of that is the stigma of menopause — somehow, because we're no longer able to have — there's not a value. We've aged out of the game. Which hopefully we're pivoting this narrative, because as I said earlier, women are winning the longevity battle. We already live longer, but it's how we're living that we're trying to course correct.
Dr. Mary Haver: And it's not just humans that go through this. I like using the whale analogy, because whales go through it, and then the whales that are no longer reproductive become like the senior — everyone, all the other little whales, listen to them.
Dr. Vonda Wright: Like, I want to be like a whale, where you have this seniority and respect —
Dr. Mary Haver: Wisdom keepers. Yeah, exactly.
Dr. Vonda Wright: I love this part of my life.
Steven Bartlett: You love this part of your life?
Dr. Vonda Wright: Yes.
Steven Bartlett: Why?
Dr. Mary Haver: I have never felt like I've been in exactly where I'm supposed to be. In this moment, I feel like I'm helping more people. I have better relationships. I'm having better sex. Everything in my life pretty much is better. And I don't know if menopause and life circumstances have just given me permission to cut out the crap and focus on what's really important — don't sweat the small stuff. Something kind of switches in our brain. No filters. It's amazing. And I don't think I could have done this ten years ago. I was too worried about what people thought. I was too worried about being a good girl and following the rules and checking the boxes and never stepping outside of the guidelines. But until I realised that I wasn't really serving the population that I trained for x amount of years to serve — that they were being left behind — that's really what allowed me to be where I am today.
Dr. Vonda Wright: I think most of us describe this as the most authentic — we're actually who we were made to be. And the confidence we feel comes from our memories of success. I think that's where confidence comes from. We remember everything that we have learned to fix over time. We could probably figure anything out. And so that comes with experience, and frankly it comes with ageing. The price of ageing — or the price of having wisdom and experience — is ageing. And so you get to this place and you're like, "I'm going to figure this out. We're going to figure this out." And I don't want the younger generations to have to go through the stuff that we've gone through. So if I can share my experiences to help them navigate, then that is a good thing.
Dr. Natalie Crawford: Yeah. I'm in perimenopause, so I'm at a slightly different stage. And I know this because my cycles are shorter, but they're still very regular. They used to be 28 to 29 days. Now they're 25 to 26. I know that means I have fewer eggs coming out of my vault every month, and that's why I'm ovulating sooner. But I can feel all the hormonal shifts much more profoundly than before. Now, as a reproductive endocrinologist — what we call a fertility doctor — most fertility doctors now do IVF day in and day out, and there are a lot of corporate reasons why that is. But we're also trained in puberty, premature ovarian failure, and hormones. So I'm more of a cowboy and quite cavalier at giving oestrogen. I even told these ladies last night — because I see people who are in low oestrogen states every single day, and how it impacts their life. So I am on low-dose oestrogen right now, even though I'm still cycling. I'm still making my own progesterone, so I don't have to take progesterone right now. But it clearly makes a difference in my day-to-day function and how I feel. And most REIs like me will jokingly say, "You'll put me in the ground on oestrogen," because it has such a profound impact on how you're able to function. And specifically, if we're not forcing you to go through this empty-glass period for years and years of your life, there's more opportunity to slow down part of the process that we all know is going to happen with ageing — but to live, as Vonda says, a healthier health span. How are you going to live healthy longer, not just live longer?
Dr. Vonda Wright: And I think your approach — I think it's part of the decision-making that is critical — because 35 to 45 and early perimenopause are prime times for prevention. It's to get our standards set. You don't have to lose your bone like you're going to get — but it's hard for women to get care. And we also have to acknowledge that if you go into — if you do what we're recommending, and I also do the same thing for my patients — it's very hard for somebody to get care for this. This is not happening in 99% of doctors' offices. There is no birth control pill or nothing — which is all they were taught — given that even in menopause, only 4% of women have chosen or have been educated on the pros and cons of hormone optimisation.
Steven Bartlett: 4%?
Dr. Mary Haver: They did a study in the US in 2023. I'm not sure about other countries, and that's on FDA-approved prescriptions. So when we add in compounding, it's maybe a little bit higher. But when you look at FDA prescriptions only, 4% of eligible women — meaning no risk factors, right age — are utilising, are going to get their prescriptions filled. Evidently this is going to change with the education that you guys — we hope, at least — are providing. They're being offered it and having a discussion, so that each one may choose not to — and that's their right.
Steven Bartlett: But are there side effects worth noting? I know a lot of people are quite scared of taking synthetic hormones.
Dr. Natalie Crawford: So there are risks and then there are side effects. When we look at the side effect profile — any time we give a woman oestrogen, progesterone — and we'll have to look at them individually — but oestrogen: you can have headaches, you can have irregular bleeding. About 50% of patients, and more on the patch than on oral. There's a patch and there's oral.
Vonda, you take the patch, right?
Dr. Vonda Wright: I do. And that's on your stomach. Yeah, it's right here actually.
Dr. Natalie Crawford: And how often do you have to replace that?
Dr. Vonda Wright: Twice a week.
Dr. Natalie Crawford: Okay, fine. So when we look at menopause hormone therapy, we have oestrogen, we have progestogens, and then we have testosterone, basically. And there are different ways to get it into your body — there's oral and non-oral, roughly. So oral is a pill, you take it. Non-oral, we're looking at through the skin or through the mucosa. Mucosa could be under the tongue, it could be in the vagina. The gastrointestinal tract is lined with mucosa and it's a nice way to absorb medication, and in the rectum to absorb medication. We don't have a rectal form of oestrogen yet. And then there are also injectables, so you can inject it straight into the muscle or subcutaneous tissues. So most commercially available, FDA-approved options — we're looking at a ring for the mucosa, a patch for transdermal, or pills for oral.
Steven Bartlett: And what do you take?
Dr. Mary Haver: Yes. So I am on a patch. And I've just been — I'm not a great absorber through my skin, and I couldn't get my oestradiol levels high enough where studies are looking at the best bone protection. So I've added about half a milligram of oral oestradiol at night. I'm on oral micronised progesterone, which is probably the best way to get it into our system, and I tolerate progesterone very well. And testosterone.
Dr. Natalie Crawford: And I am on a gel that is FDA approved. I'm borrowing the men's version because we don't have an FDA-approved version for women in this country.
Dr. Mary Haver: I borrow my husband's.
Dr. Vonda Wright: Australia has one.
Dr. Natalie Crawford: And I think the UK just approved one — this is news from like the last month.
Steven Bartlett: So it's broadly advisable, after a doctor's consultation, to take some form of hormone therapy?
Dr. Natalie Crawford: Definitely if you're symptomatic, if you have the classic vasomotor symptoms, it's absolutely the gold standard. But can I comment on that?
Dr. Vonda Wright: Women say to me all the time either, "I don't feel that bad," or, "I want to do this naturally." And those are the things that make me say, "Okay, fine, do it naturally." But brain fog, night sweats, and hot flashes are not the only things going on. And so if you're making this decision fully informed — well, you're a sentient being, make the decision. But you cannot feel your bones crumbling until they're broken. You cannot feel your muscle going away. You cannot feel your brain starving. You can't detect microvascular disease of your heart. So you may think you're getting away with something, and maybe you don't have night sweats or brain fog, but it doesn't mean you're not having a different physiology. And if you are fully aware of that and make a decision that you don't want to optimise your hormones, that's your decision, and I'm fine with that. But what I'm not fine with is people thinking they're getting away with something when they're not.
Dr. Mary Haver: You're making the decision based on fear and not facts.
Dr. Vonda Wright: Correct.
Love, sex, and relationships through menopause
Steven Bartlett: My last question is about love and sex in menopause. You said you're having the best sex of your life, Mary. And I've also heard you talk about how several people in this season of life end up getting divorced — you said they throw the trash out. So when we talk about menopause — it can spur, for some women, this moment of empowerment. They realise they have to circle the wagons, because the only way they're going to survive through this cataclysmic upheaval is to get rid of relationships that aren't working, put up boundaries, and sometimes that's going to be the end of a marriage. Other times it's going to strengthen a relationship because you're cutting out things that were getting in the way. So I see many marriages or many relationships really improve through the transition. But it does take two.
Dr. Mary Haver: You know, sex is biopsychosocial. So when I look at sex, it's not — I think of the entire experience. And as far as my desire for frequency, testosterone does seem to have given that an uptick. So it is — we have lots of studies done on libido for women, which in medicine we call hypoactive sexual desire disorder, and it has to bother you. So a lot of women are like, "I don't want to have sex ever again. I don't care." There's nothing wrong with that, right? Unless it affects your relationship and it bothers you — it has to bother you. But I have a lot of patients who come in and say, "I love him. I used to want to do it. We used to have a really great frequency and everybody was happy about it. It was something I looked forward to and enjoyed, and now there's nothing. I have nothing." And for those patients, testosterone can be helpful. Not for everyone.
And so there's other emerging data on looking at the musculoskeletal system. I am naturally thin. I was not an athlete growing up — at best, I was a dancer — and I didn't do anything to protect my muscles and bones as I was coming up through the ranks. And so here I am in my 50s, just getting out of recreational endurance training, thinking, "What have I done to my bones and muscles?" I lay on that DEXA scan as nervous as I've ever been in my life — like getting my board scores nervous — like, "What have I done?" And it wasn't bad, okay? But I like to be perfect. So I'm like, "What can I do?" I'm eating the protein, I'm lifting the weights, I'm starting to do all these things. And we know that women who have naturally higher testosterone levels, from genetics or whatever, have less frailty as they age — and that's my focus. If I run the cancer gauntlet — and probably 80% of my aunts and uncles have died of cancer — and if I run that gauntlet and I'm doing everything lifestyle and preventative screening to address that, and then women end up with dementia and frailty like my mother and grandmother — I'm like, "Okay, I want to have as much bone and muscle strength as I can. So I'm going to add some testosterone and see what happens."
At the time, I would not have said I had any sexual dysfunction. I did not qualify medically for HSDD. I go on testosterone and there's definitely an uptick in that area, and everyone is happier — my interest has improved, my initiation has improved, and that had kind of waned with time and stress and kids and whatever. The other thing is we were empty-nesting at the same time, so that probably helped — no more kids busting in our door at 2 in the morning letting us know they're home from whatever experience. And our communication is better. My husband's retired from Chevron and we are building this company together — our menopause company. And so our relationship has actually improved through all of that. So all of the things that feed into what we know is female desire are just better all the way around. And I think testosterone had a little bit to do with it. My ability to focus and my ability to prioritise and put up the right boundaries has really helped with that. And we're just having a lot more fun with it.
Dr. Vonda Wright: But I think we would be remiss in this part of the conversation — and I'll say it, I'm the orthopaedist, but I'm going to say it anyway. Many men — I just talked to my husband publicly about this because we're trying to educate men — most men don't realise that in perimenopause, as oestrogen wanes, it affects all tissues. And there is an entity called the genitourinary syndrome of menopause, where the vagina will actually atrophy and all the external soft tissues that are usually used to engorging will become dry like a desert. And Steven, sex can feel like razor blades. And men don't know that. And women are afraid to tell their partners. So the men feel rejected — like, "Why doesn't she love me or desire me anymore?" And it may be that, but it's probably not that. It hurts, and she bleeds. And women don't know that this is normal when your oestrogen is low — not that it's okay, it shouldn't be normal — but when you're in a low oestrogen state, regardless of whether it's menopause, birth control pills, postpartum breastfeeding, or even a progesterone IUD, these can all cause time periods where your oestrogen levels are low enough that the vaginal tissue is not having the right collagen and elasticity that it should.
Steven Bartlett: So what's the solution?
Dr. Vonda Wright: Not lubricant. Lubricant can sometimes aid, but that's not addressing the root cause. It'll help with symptoms, but if part of the problem is that the tissue can't respond as it should — that it's frail, that it delays orgasm — then we really want to get to the root cause, which is that oestrogen is crucial for skin elasticity. It's like men going on testosterone, right? If he's not having an erection, there are 29 solutions for that right now, primarily funded solutions as well.
Dr. Natalie Crawford: But for women, it's not just desire — it's physiological. And so vaginal oestrogen — putting something in your vagina — and what you put in your vagina: there are several options. We have creams, we have pills, there's a ring specifically designed just for that. So we have different methods of getting oestrogen into the vagina. There's also something called prasterone, which is DHEA basically, which is a pre-hormone that the vagina miraculously will convert to oestrogen and testosterone. But it's expensive and tends not to be covered by insurance. But for our sexual medicine friends who specialise in female sexual function, they love it because you're not only getting a boost of oestrogen to the vagina, you're also getting testosterone — and there are testosterone receptors in the vulva, in the lower vagina, and around the skin around the vagina as well.
But here's the bonus: all of this, plus vaginal oestrogen, will help prevent chronic UTIs — which kill older women — and it will help support the pelvic floor and the uterus from prolapsing. So it has all these added benefits. And here's another bonus: it is such a low dose that it is not systemic. So any risk that you could think of that might make you not want to do systemic oestrogen — including breast cancer — is unaffected by vaginal oestrogen. And so it is a huge solution. And there's no age at which a woman can't go on it.
Dr. Mary Haver: She'll kill me — she'll never know this — but I put my 86-year-old mother on it so that we could prevent UTIs and failure of tissue so she didn't get sores and infections. Isn't that a miracle?
Dr. Natalie Crawford: And we should say that vaginal oestrogen in preparations made for vaginal oestrogen — or low-dose oestrogen preparations — you can give oral oestradiol vaginally and it will be systemically absorbed, because the vagina is highly absorptive. So I don't want somebody to hear this and think — just to be clear, we often prescribe or recommend a local treatment of vaginal oestrogen products, which are in very low dose, and they really impact the local tissues of the pelvic floor, the urinary system, the vulva, and the vagina, and they improve your wellbeing and your health without some of the risk that might come from systemic hormones in somebody who may not want to take them.
Closing reflections
Steven Bartlett: I am all out of questions. So I wanted to conclude this segment by asking you: what is the most important thing that I have missed on the subjects we've talked about — menstrual cycles, menopause, everything in between? What is the most important subject you think we might have missed?
Dr. Natalie Crawford: I think we covered it, but to restate it: you control a large part. We said over and over — inflammation and insulin resistance. We touched on different lifestyle factors that impact this, because when your body is having hormone change, there's a lot of the external world around you, or the choices you're making, that can make some of that better or worse or influence what is happening. And I know we're going to go over more of this, but I think this idea that "I have no control over what's happening to me" isn't 100% true. I mean, you don't have control over when some of this stuff happens, but you can take control of a situation by understanding your body, knowing what's happening, knowing how to advocate for yourself, and making active decisions to live a healthier, better life.
Dr. Mary Haver: Yes. That's the goal — to empower women to understand, to ask the questions, so they don't feel like something is happening to them and they have no control or options. Which is what our mothers' generation had. They were always gaslit, told, "It's all in your head. There's nothing we can do." My mother was put on — it was called Butisol. It's basically a sedative. It was "mother's little helper." And I found an old magazine article — if you look at the magazine articles from the 50s and 60s on these medications, mostly sedatives that were given to women, it's like, "Now she can do the laundry again." She's flipping a pancake in the ad, in the apron, in the 1950s. "Get your mum back, get your wife back." And it was a combination of oestrogen plus a sedative. And I was just absolutely floored. And I remember Mum's little bottle — it was called Butisol — and it would sit on her counter and she would talk about it like it was her talisman. "I need my Butisol. Oh, this happened — where's my Butisol?" And when I was researching and reading about these sedatives that were given to women, I was like, "Wait, Mama — I remember the bottle. I remember what it was called, because she talked about it all the time." I went and looked it up and it's a derivative of phenobarbitol.
Steven Bartlett: Oh my gosh.
Dr. Mary Haver: And it was heavily prescribed to women. It's a barbiturate — a class of drug that is basically a sedative. We use it in surgery, we use it for seizures. And they were sedating my mother on the daily through her perimenopause. Now, she had eight kids. She was running a restaurant. She was very high functioning. And I just refused for that to be — that was her reality. And here she lies in a bed with Alzheimer's and a fractured hip, and she hasn't walked in eight months. She's just now getting on a walker eight months after her hip fracture, from osteoporosis — she's never had a bone density scan in her life. And our children deserve better. It's not going to be my future, because I have the means and the access. But I want every young girl, all of our children, to have a better future than what was offered to our mothers.
Dr. Vonda Wright: Exactly. I think ending this, I would want every woman to approach her midlife — her new life — with the same vigour and the same curiosity and the same demanding of care that she would do for one of her children if her child is sick. She's not going to take no. She's not going to take being blown off. She's going to keep searching to the ends of the earth until she finds an answer. And that's the same kind of taking control that I want women to do about this time in their lives.
Steven Bartlett: Thank you so much. We're going to continue this conversation — for the viewers and listeners at home, I've been through all of these wonderful books that I have in front of me, and there are so many lifestyle, nutrition, and exercise-related solutions to many of the things we've talked about today, to be a truly optimised, hormone-healthy, menstrual-cycle-healthy woman — which I want to talk about in our part two of this conversation.
Fertility non-negotiables
Steven Bartlett: It was heavily requested by our audience, and I guess I'm well placed to ask some of these questions because I'm on that journey myself of trying to have a child at the moment. Natalie, you have five fertility non-negotiables that you talk about.
Dr. Natalie Crawford: I do, and I think it's really important to think about. For too long we've been told, "Your fertility is luck — it's good luck if you get pregnant, it's bad luck if it's not." And that's this narrative that gets propagated. Fertility is certainly not fair, meaning people will have infertility and do everything right. But there are things that we do that will inherently harm our fertility and our hormonal health and make it harder to get pregnant — and that's even when we are doing treatments. So a lot of times people say, "I'm doing IVF, so I don't need to worry about these non-negotiables." And that's also not true.
So, things that we need to do: we need to, as we've all said, get more sleep — that's going to be number one. We need to actively work to decrease stress. That is not "I'm just going to live a stress-free life," but all these things — I'm not going to take call, I'm going to set some boundaries and not have late meetings, I'm going to see morning light, I'm going to take a walk outside. We live in a stressful world, and chronic stress itself can impact your fertility, your natural fertility, and IVF success rates. We're going to work on exercise to build muscle and try to improve our muscular health, since it's part of our metabolism. We're going to eat an anti-inflammatory diet — that's definitely key, high in fibre. And we're going to look at the world around us and work on pulling toxins out of our world. We haven't even entered the discussion about how environmental toxins are harming our bodies, our hormonal health, our fertility, our ovaries, our organs. And so these are all things that we make active choices on, that we have to start paying attention to and changing. We'll go into detail on the lifestyle factors and the environmental toxins in our second episode together.
Egg count, age, and fertility planning
Steven Bartlett: I've always been quite shocked by this graph, because it's quite significant. This is just showing the egg count by age. What do men and women need to understand about egg counts in order to make better family planning and fertility decisions?
Dr. Natalie Crawford: Okay. Well, I've asked you this before, Steven — how many sperm do you make a second?
Steven Bartlett: Millions.
Dr. Natalie Crawford: You make 1,500 a second. You make millions every day. But still, you make a ton of sperm. You make sperm every single day — you have germ cells that create sperm. Women are born with all the eggs they're ever going to have. And yes — my favourite vault analogy. So I like to imagine that this is a vault inside your ovary that is storing all of your eggs. And we'll use this cup with all of the beads as that analogy. Every single month, since before you are born, eggs come out of this vault. And what happens is that when the vault is more full, more eggs come out every month. And as the vault starts to get emptier, fewer come out. This means that we lose the majority of our eggs — you can see the line — well before our reproductive years even start.
So you lose the most before you're born. From being a five-month foetus to birth, your egg count goes from 6 to 7 million down to 1 to 2 million. Millions of eggs lost before you're even born. From birth to puberty, let's say you go from 1 to 2 million to half a million — to simplify the numbers. So the second biggest drop happens before you're ever ovulating, before you ever have a chance to get pregnant. And then you only ovulate around 400 eggs over the course of your reproductive lifespan.
As that egg count starts to drop over time, the other really important factor is that our eggs have been in our body our whole life. Two different things are happening at the same time. One is that our chromosomes start to leave their perfect position — they absorb the wear and tear of years. So we see more chromosome abnormalities as we get older. It's why it's harder to get pregnant and why we see an increase in miscarriage as we age. But also concurrently, our metabolic health is poorer as we get older, and mitochondrial function in eggs — the metabolic capacity — becomes less capable. So we see that it's harder to get pregnant not because women are running out of eggs, but because the quality of the eggs declines.
But everybody will run out of eggs. You'll have a period of time where you have a very low egg count. We call it diminished ovarian reserve in the fertility world. We call it perimenopause more globally. And these are two words to describe the same thing. As your egg count starts to get very low, you start to have an unpredictable response from your ovary, and your brain is trying to compensate for that. So you see various hormone changes, but these start before you might even recognise menstrual cycle changes. But everybody will run out of eggs — every woman will. Your ovaries will go into what we call ovarian failure and no longer respond to hormonal signals from the brain or artificial signals that we give. Meaning, I will see older women come in thinking that I have magic medicines with IVF that can still help them get pregnant, but I can only get the eggs outside the vault to grow in IVF.
Steven Bartlett: And so shouldn't we then be freezing our eggs?
Dr. Natalie Crawford: You're right. As a society, if we are purposely delaying childbearing, we know that it gets harder to get pregnant with age. And if having kids is a life goal, putting eggs into the freezer earlier is a way to save that opportunity. It's not an insurance plan — it's not a guarantee — but it is a smart game plan, especially as we are waiting longer. Because even with IVF, we can't always overcome age-related infertility if we have fewer eggs and more genetic abnormalities. The technology helps us identify healthy eggs, helps us have more eggs able to grow in a certain month, and allows us to take them out and test embryos in a lab. But I'm working with the eggs and sperm that you're giving me. Meaning, if there aren't many of them, if there's a lot of chromosomal damage, if there's a lot of mitochondrial dysfunction, if the sperm quality is not great — that doesn't mean we're going to be able to have success. So what you're doing on a daily basis to impact egg and sperm quality is still crucial.
But egg freezing has gotten a lot of bad press. It's still a new technology — it's only been around about ten years off experimental status. Women who froze their eggs ten years ago had much poorer egg survival rates, they were older at the time, and their experience is very different from the modern woman who is freezing her eggs now, maybe in her upper 20s or early 30s.
Steven Bartlett: What is the optimal age?
Dr. Natalie Crawford: If you want to have a child as a life goal and you're not ready to conceive by age 32, that is when there's a clear delineation — it makes smarter financial sense as well as likelihood sense. The short answer is: my daughter will freeze her eggs in her 20s. The younger you are, the more eggs you have. If she says, "I want to have kids as a life goal," then that will be something that we will do in order to help her keep that option, because there are so many other variables which impact your ability to get pregnant or your egg count. Endometriosis decreases your egg count. People will develop an ovarian cyst and have surgery. They'll have a twisting of their ovary and maybe lose an ovary. Smoking, chemo, radiation, marijuana, any abdominal surgery — so many things can impact your eggs, because you only have this group. You're born with them.
So we plan for life goals differently. And we've never really talked about our fertility life goals until more recently. When we went into our professional careers, we knew what we had to do — to get into medical school, to get into residency, to get your PhD. You had this list of things and you set goals and you worked to achieve them. But I always wanted to be a mum. Yet I already told you I took a birth control pill every single day and I didn't even think about it until that moment was in front of me. And that's the part of the discussion that we do have to start having earlier — if this is a life goal for you, what do we need to do? Understand our body better, our fertility better. And maybe that does include freezing eggs, because it does give many women an opportunity that time would eliminate.
Steven Bartlett: I had a conversation with you, Natalie, on the podcast, but then with many other women over the course of the last two to three years, and one of the things I learned was that — as you say — we don't family plan, and then we have to deal with the consequences of not family planning. As an interviewer, when I do life story episodes, I go through a woman's life story. And obviously the women sitting in front of me are typically high performers, high achievers in some capacity. And then we arrive at the end of the conversation when we talk about family and kids and all those kinds of things, and there's often a lot of tears.
It was in those conversations sitting here with several women that were on the show — what was the straw that broke the camel's back? It was the UFC fighter Ronda Rousey. It just so happened that when I interviewed her, she had just found out that her seventh round of IVF had failed. And so she was very, very emotional. I left that interview and had a conversation with my girlfriend. I was like, "Listen, I've seen too many women over the age of 35 — maybe under the age of 50, but really under the age of 45 — in tears in front of me. I think we should have a conversation about this. Should we freeze our eggs?" I mean, me and my partner are both 33 now. And at first — I don't know, maybe it was the way I worded it — she was offended. She was like, "You don't want to have a baby with me?"
Dr. Natalie Crawford: Yeah.
Steven Bartlett: It was like, "You don't want to have sex with me?" Like, I didn't word it well. I didn't really think about the emotions surrounding it. I think that was really what it was — you were trying to make a pragmatic decision.
Dr. Natalie Crawford: Yeah.
Steven Bartlett: As men often do. Like, I was just like, "We should freeze —" but I didn't think about what that meant. And there's this prevailing narrative in society that if something's not quote-unquote natural, then it's not good — that IVF or egg freezing is not natural. And that torments people's brains, because they want to live a natural life, even though they're in planes and on iPhones. We want this one area of our life to be natural. And after honestly five minutes of that conversation, I think the framing that flipped her mood was: wouldn't we want to give ourselves the option? And it's actually about having options. But I wanted to throw that out there because I don't think people family plan. I think, as you said, we focus on our careers, then we pop up at 35, 36, 37 and assume that we can.
Dr. Natalie Crawford: Mm-hm. But that is not the case. Especially if you live a healthy life, you think, "Oh, this will be easy for me." Or if you're a high achiever and you've achieved other things, many women are really taken aback by not being able to achieve this, or not having control over infertility and what is a natural process — to run out of eggs and to go into menopause. If you are lucky enough to live long enough, this is going to happen.
I got my diagnosis of PCOS in medical school, before I was ready to start family planning. And I knew I was probably going to struggle. And so it took us about three years to successfully conceive the first time. And even though I'm working in the business — running between patients to go and have another ultrasound or go get a shot or go do all the things that it took — you can't remove the emotion from it. And I can't tell you how many times I cried. And of course, all of my co-residents, my four best friends, all got pregnant in succession — our poor chief residents — with no trouble. And even crying to my mother about the struggles I was having, she's like, "I just got pregnant eight times with no trouble." And then my first pregnancy resulted in a miscarriage, in the middle of work, and all my friends were there and they were cheering — they were so excited I was finally pregnant — and then we lost the baby. And having to push through and work through it — it's like it was yesterday. I have two healthy kids, thank God. And after those two, we tried again — we were never able to get pregnant again. Which, you know, I had two kids and put a bow on it and we're done. But it is impossible to remove the emotion, because in the mindset, it's luck, or it's something we did, we caused this. And as a high-performing person who checks all the boxes and makes all the good grades and does everything right, this is the one thing that you suddenly didn't think much about, and then it becomes everything when it becomes hard or it's taken away from you.
Steven Bartlett: But I think women assume that it's their burden, because we assume that if we can't conceive, it's just us or something. But I think I heard you say this — it's a two-way street, and the issue is not always the woman. A high percentage of the time it's her partner. And so I don't think we absorb that information upfront either, until we start investigating it.
Dr. Vonda Wright: But I'm in awe of this story that four of your residents got pregnant immediately, because in orthopaedics that does not happen. Every orthopaedic surgeon in my generation that I know — if we got pregnant, we miscarried. And maybe that was lifestyle, and maybe that was not eating for 40 hours. Maybe it's all the radiation that we undertake. I think it's better now for the younger generation, and we — as the — I'm not that old, but I am older than the current residents — we encourage all of them: if you are not partnered and wanting to have a child now, then please consider freezing your eggs if that's a goal, because we can't predict our futures, and our residencies extend into our 40s.
Dr. Natalie Crawford: Well, I love that you're helping facilitate that discussion, because that certainly wasn't the culture back when we were in training.
Dr. Mary Haver: I am one of the ones who sat here and cried in front of Steven myself, when talking about my own pregnancy loss journey, just because — you know, I see it every day, and I tell patients every day news that they do not want to hear. 50% of infertility is due to male factor, 50% is due to female factors. One of the most important things I want to convey on this topic is that IVF is an amazing technology that has helped 13 million babies be born. It has been life-changing and world-changing. And things don't have to be natural. Sometimes the natural progression of disease is death. So we have technology and science that exists to optimise and improve life and to help life exist. And that's part of what IVF is. And I think that's important, because we do see a narrative right now that IVF is inherently bad and natural fertility approaches are inherently good. And we truly need to say both things are good.
Do women need to learn about their bodies earlier? Talk about cycle tracking, take better care of themselves, get an earlier investigation when things aren't going well? Absolutely true. But also, needing to have fertility treatments is not a failure. Needing to see a fertility doctor is not a failure. If you need IVF, that is okay. All the other stuff is still really important to the outcome of your journey. But this narrative of "IVF isn't natural, so it's bad" or "egg freezing isn't natural, so we shouldn't do it" — that's harmful to society and to women, who do carry the burden, whether they need to or not.
Dr. Vonda Wright: Hearing you talk about that is very interesting to me, because in other parts of medicine — in my own medicine — we were talking outside about how I now do knee surgery through needles. It's an advancement of technology. We celebrate that. We like better things for people. It's not natural. "Live with your thing," right? But I'm capable of helping you live a better life. So it's interesting to me — it's the stigma of women's health work. Because this is women's health, we're going to control it, we're going to protect these gals, we're not going to apply the vast knowledge. I'm a little offended by it, actually. If you want to know the truth — why can I be so encouraged and considered top of my field when I adopt new technologies? But in your field, 13 million parents — or 26 million parents — would be told that technology is not okay?
Dr. Mary Haver: I agree. It's a terrible narrative that is happening right now in the political landscape. And I think it's important to say scientific advancement is good, and it changes the lives of so many people. Natural doesn't always mean better.
Dr. Natalie Crawford: I think, as scientists and people in medicine, there's also been a disservice in not trying to get to the root cause and not working on preventive medicine. So going towards treatments and technology has made the lay person feel like half of the picture wasn't discovered or talked about. And so we can do better on both ends of it. And that comes to women's health more than anything, because there is stigma — when it comes to infertility, there's isolation. Being left behind your peer group, questioning a life goal, will make you question who you are, your life meaning, your purpose. And that is an extremely stressful and challenging state for somebody to go through. And we should be giving more support to that. We should be saying, "Freeze your eggs. You're at a stressful life stage," instead of the narrative that we are seeing right now.
Steven Bartlett: So would the message be to young men and women who want to have kids at some point in their life — to freeze their eggs in their 20s? Is that what you would advise?
Dr. Natalie Crawford: Most people in their 20s maybe don't have good awareness of these goals, but certainly your later 20s and early 30s are the prime opportunity where, for the average person, you're going to have a high number of eggs. You're still high on the graph and your egg quality is still going to be high — meaning it's going to be easier to get the outcome that you want. Certainly your 20s would be ideal, but it's expensive. A lot of people don't have the financial resources to freeze their eggs in their 20s — they're in training or they're starting their career. So to have an extra $10,000 lying around isn't always realistic. And I think that's why people are often waiting, because that feels elective — "Oh, that's extra money, I don't know that I have that right now."
When we see insurance that starts to cover egg freezing as an option, we see huge uptake in women going to freeze their eggs. You will see that at companies where almost less than 5% of women would freeze their eggs before age 35 — and then they introduced a health plan that would cover egg freezing, and up to 50% of them would. So you can see that financial access and awareness all go hand in hand. But that's a big player in being able to do that, because it is an expensive process.
Spontaneous fertility rates by age
Steven Bartlett: So Dr. Crawford, I think what most people don't understand — what is the spontaneous fertility rate by age in general?
Dr. Natalie Crawford: So if you are 30, your odds of getting pregnant monthly — we use a monthly rate called fecundability — it's going to be at best 20% per month. When you're in your 20s, it's a little bit higher, can get up to 25% per month if you're having sex regularly and have regular periods. So if you're having unprotected intercourse and you have regular cycles, your best odds in a given month are going to be about 20% at age 30.
Steven Bartlett: How much sex do you have to be having?
Dr. Natalie Crawford: Well, you really just have to have it in that fertile window.
Steven Bartlett: Just once?
Dr. Natalie Crawford: Really just once. Sex solely on the day of ovulation would be the ideal time, but you just need to have intercourse at least once in that fertile window.
But that number drops quite significantly. At age 35, if you're trying to get pregnant, it's going to be 10 to 12% per month. At age 38, it's going to be 5% per month. At age 40, it's going to be 3%. These are if you're trying for the first time — they're a little bit higher if you've had a child already, because there are some proven fertility factors. But if we look at that, you say, "I'm chasing these dreams. I'm going to try to have my first baby at age 38." You have a 5% chance per month. That's not zero, but that means the greatest probability is that within a six-month time frame, you won't be pregnant. And then you're going to start a pathway of trying to investigate why that is happening. And if you do need intervention, you're further down this graph too — you're going to have fewer eggs to work with, and their quality is going to be less good.
That's why those numbers drop rapidly. Natural fertility rates are not about being out of eggs, because you ovulate just one egg at a time. It doesn't matter if you have 20 eggs outside that vault or five eggs — you're ovulating one egg at a time. So natural fertility is all about egg and sperm quality. This huge drop we see from 20% to 5% is because of the change in our egg quality as we get older during our 30s, which most of us feel like is really young.
Steven Bartlett: And what can I do — because I know weight has a role in egg quality, right? If you're underweight or overweight — is there anything else that has a really pertinent impact on the quality of my eggs?
Dr. Natalie Crawford: Yes. So we have two factors. We'll say age, which you can't control to an extent — chromosome damage is going to happen even if you are exceptionally healthy, because tincture of time. They've been sitting inside your body and chromosome damage builds up. But the variables that you can control are everything that impacts cellular health. So chronic inflammation and insulin resistance are the two things that are going to most dramatically harm your eggs' metabolic function. It's going to harm your mitochondria — you're going to get mitochondrial damage. We know that when we start looking at older women, they have more dysfunctional mitochondria. They're shaped abnormally. The products inside their follicular fluid show higher levels of inflammation just based on age — that happens — but also if they start having infertility versus not having infertility. So we know that inflammation and insulin resistance are key players, even in patients without known PCOS or endometriosis, but they play a role in ageing and specifically your egg health as you age.
So if you say getting pregnant is a life goal, I'm tracking my cycles, I don't want to freeze my eggs right now — but what should I do? All these things that we talk about, and we're going to talk more about, to decrease inflammation inside our body. That's it. And from a young age, because these changes build up over time. And if you have PCOS, it's even more important, because you're at a higher predisposition to have insulin resistance — your cells are more sensitive to how they're going to respond.
Steven Bartlett: But do I have fewer eggs if I have PCOS?
Dr. Natalie Crawford: So you're going to run out of eggs around the same time. You're born with a little bit more, but because you lose eggs based on how many you have, essentially you're going to catch up. So during your reproductive years, you tend to have more eggs out of the vault, which interferes with normal hormonal signalling, making all of the hormonal and metabolic changes worse. A very interesting thing: as women with PCOS get older and their egg count starts to drop, and they have fewer eggs coming out of the vault, they'll often start naturally ovulating, even if they didn't earlier. And so I'm always a little concerned when somebody says, "I used to never have periods, but now I do. Did I cure my PCOS?" Maybe they did make some good lifestyle changes along the way, but honestly, that's a red flag for me — that she's now more rapidly declining in her egg count, approaching what will be perimenopause for her, because her egg count is low enough to then respond to the brain signals.
Dr. Vonda Wright: Like, nodding your head over here.
Male fertility factors
Steven Bartlett: And as a man, is there anything I can do to increase the odds that I'm going to impregnate?
Dr. Natalie Crawford: You can stop using cannabis and smoking cigarettes, drinking alcohol. We need to avoid heat. So the testicles are outside the body for a reason — they need to be at a lower body temperature in order to adequately make normally functioning sperm. So hot tubs, saunas — those should be off limits if you're wanting to get pregnant. Same with high-intensity exercise and compression of the testicles. So this is notably cycling for long periods of time — an hour on the bike or more, routinely, can actually compress the testicles and increase their heat.
Steven Bartlett: What about sitting in a chair for five hours?
Dr. Natalie Crawford: She'll be fine. I want to — same thing. Sitting in a chair, boxers breathe, being in a room that's hot — those things aren't quite enough to truly raise that core testicular temperature quite like some of these other things.
We also see diet playing a big role. The great thing about men is you're making sperm every single second. The sperm lifespan is 90 days — 72 days to make a sperm, 18 days to get out through the ejaculatory system. But that means you could make a singular change in your health and see a different outcome in your sperm. That is so rare — that doesn't exist in women's health — that one variable can move the needle so much.
Marijuana is a huge one. Marijuana use works at the brain to prevent those FSH and LH signals, which are crucial to tell your testicles to make sperm, and they also impact the inflammatory environment. So sperm are not as motile, they are not shaped as well, and the DNA inside their heads is more fragmented. In fact, men who use marijuana — their partners have a higher rate of pregnancy loss, even if their partners are not around it at all.
Steven Bartlett: You're using the word "pregnancy loss" versus the word that we're aware of in the UK — "miscarriage." Is that intentional?
Dr. Natalie Crawford: Miscarriage can mean a lot of different things to people. A pregnancy loss — an unsuccessful pregnancy, depending on when you medically lose a pregnancy — or if a pregnancy is in the fallopian tube and it's an ectopic pregnancy, that's still a pregnancy loss, meaning you had a positive pregnancy test that did not end up in a baby. So it's a little more inclusive for a variety of different stages of when and how loss can occur. Miscarriage kind of infers, when we say it, that the pregnancy was in the uterus and now it's either self-evacuating or we have to evacuate it.
Steven Bartlett: And you were saying a second ago, Vonda, that from your experience, pregnancy loss and miscarriage are much higher with women who have high-stress careers and jobs.
Dr. Vonda Wright: Well, I don't know the real statistics, but I'm sure they exist. But in my experience as a high-capacity, high-stress, not-sleeping-for-11-or-22-years person, I have seen it a lot, and it happened to me.
Dr. Natalie Crawford: Yeah, chronic stress is associated with a higher rate of pregnancy loss.
Pregnancy loss and miscarriage
Steven Bartlett: Is there anything else that people misunderstand about pregnancy loss and miscarriage that is worth talking about?
Dr. Mary Haver: Well, it's not talked about, I think. That's one of the things — people still think it's taboo and rare. But I think all of us around the table have had pregnancy loss.
Dr. Vonda Wright: Yep. Two, at least two.
Dr. Mary Haver: And when I had mine, I was in training, and I didn't want to call my attending and tell him, because he was a man. And I didn't think I could take any time off.
Dr. Vonda Wright: Same. I went back the next day. I would have gone back the same day, but I could barely move. I was running labour and delivery at night. I got discharged, IV pulled out in my hand, and went back on the ward.
Dr. Mary Haver: Yeah. So I think, hopefully, part of this international conversation about women's health — not just gynaecological health, but health in general — will give women grace. Because there's no way that I should have been expected to go back to an orthopaedic surgery residency the day after I lost a child. Or frankly — I don't know what your experiences were — but in my generation of doctors, and I'm sure it happens everywhere, I went back to work less than five weeks after delivering a child. And I think other countries have it right — oh yeah, New Zealand is a year.
Steven Bartlett: A year?
Dr. Vonda Wright: Yeah. So it's 20 hours — yeah. Six weeks. I did six weeks with one and three weeks with the other, because if I wanted to leave my fellowship on time, I wanted to graduate on time, I couldn't exceed the total vacation. So these internships and fellowships — and I'm sure that built into these programmes we sign up for, they were all developed for men who had a family, had a wife, had someone at home to take care of that business. And we're all in supportive relationships, and that wasn't the issue, but I went back before my body was ready. Before that baby was ready to unlatch, and my milk supply dropped immediately the minute I went back to work. And I tried to pump, but you get called for a crash C-section or emergency surgery and you're pulling the pump off the breast and running down the hall hooking your nursing bra back on trying to get to the OR. All that cortisol — my milk just — so I was able to breastfeed while I was home with the baby, but once I went back to work, my milk production just shattered.
Steven Bartlett: I have a picture of a day in the hospital — it was a day after I gave birth. My laptop is open, I'm trying to breastfeed, because we launched a company the month before I gave birth. And instead of my male co-workers going, "Okay, we'll give you some grace" — no. I had a week, and then they were at my house having meetings.
Dr. Mary Haver: There's such a different discussion about miscarriage now than when I went through it. I told nobody.
Dr. Natalie Crawford: I didn't either. I mean, it was so secretive. I didn't feel like I could.
Dr. Mary Haver: And we are seeing a different generation where I do think talking about women's health — and Steven, you having these discussions on a bigger stage — are lessening the stigma for what is something that people go through. One out of four pregnancies will end in a pregnancy loss. That is not a low percentage of people. In the same breath, most people should not have two in a row. And if you do, you should go get an evaluation, because there are medical things that can contribute to pregnancy loss that we would love to identify earlier and see if there's something we can do to make that different.
What employers need to understand about women's health
Steven Bartlett: What do I need to understand about what a woman goes through either in the wake of pregnancy loss, or in the wake of a pregnancy and a birth — physiologically, psychologically — as an employer, to be able to create a better environment for the women going through either of those two things? What's going on inside the body?
Dr. Natalie Crawford: One of the simplest things to say is that pregnancy is one of the most hormonally robust times you have — even just momentarily pregnant. If you have a placenta starting to implant, you are now making levels of oestrogen and progesterone that you will not ever make at any other time period of your life. When you lose that pregnancy, or when you're postpartum — let's say you're having this huge hormone crash. Suddenly you go from this very high level of these hormones dropping off immediately. And in addition to all the physical changes, the emotional changes — that has a huge impact. You've heard us talk a lot about low oestrogen and how that feels. The very interesting thing most studies about oestrogen show is that the hardest time for women is when oestrogen is changing. So going from high to low is actually when your body — your brain — can't keep up.
Dr. Mary Haver: Can't keep up. Doesn't know what's happening.
Dr. Natalie Crawford: And the higher you were and the faster you come down — we'll use this analogy too. Even in IVF, when we do an egg retrieval and somebody had many eggs, they have a much higher oestrogen than they naturally would. I go and put a needle in each one and drain the eggs out and destroy those cells, and their oestrogen plummets. And they expect to go the next day and feel normal, or they expect to feel worse during the stimulation process when they're using hormone shots. And I always say, "You're actually going to feel worse when I'm done with you. It's going to be that week after the egg retrieval where your hormones go from the highest they've ever been, very quickly down low." It's that delta, that change. And that happens any time you have that. But pregnancy and loss and postpartum are some of the most profound times that you experience this.
Dr. Mary Haver: And one of the other things is the identity shift. So if you're working — we are all very highly motivated and became parents. But it's that whole identity shift of: now how do I interact in my life and how do I interact with my peers? I'm a mum. How am I being identified? What are the implications? So there's a complete identity shift that also isn't discussed, and that can also perpetuate some of the postpartum challenges that we see as well.
Dr. Natalie Crawford: And anxiety and lack of control, right? Because you don't know what you're supposed to do, especially if you're a mother for the first time. That can be very anxiety-provoking in addition to hormone changes and not getting sleep. But lack of control — you don't control your schedule, you don't control when you sleep, you don't control if your child gets sick. And so I would say from an employer standpoint: grace, support, and flexibility. If I had had better support structures — to say, "When your child is sick, it's not the end of the world if you are not here physically at the office" — that didn't exist. Meaning that my child getting sick became this extremely stressful situation.
Steven Bartlett: But for the average woman working a nine-to-five job, whether it's in medicine or other fields — if you could design their working month around their menstrual cycle, around potentially a pregnancy, whatever — how would you redesign their month? Because we've inherited, I think from the industrial revolution, this nine-to-five working hours, we don't work Saturday and Sunday, we do that four times across a month. What would you change? What should women change? Because I've heard some countries or systems are trying to give women time off around certain parts of their cycle, for example.
Dr. Vonda Wright: Well, there are a couple of companies in New Zealand who are pretty flexible, especially after the pandemic, where they have allocated certain hours that are free to work at home — you just have to get the work done — to the point where they have four-day working weeks. And then they're also putting into the annual leave what they call menstrual leave or menopause leave. And it's — you just say, "I can't come today." Some people are using it for childcare. Some people are using it for really bad cramping days. Other people are using it for mental health days. But it's there to be used for however you need it. And you don't have to identify it as being a menstrual cycle day or menopause — it's just extra leave. And people don't care as long as you get the work done. And I think having that flexibility — if you have the ability to have more flex hours or shared time space or something like that — greatly benefits productivity as well as the feeling of empowerment and inclusivity, which then feeds forward to better productivity.
Steven Bartlett: If I've got an extremely high-stress job, is there any part of the cycle where I should theoretically be avoiding stress?
Dr. Vonda Wright: Well, that's an individual thing, because it's about understanding your own responses to your own hormone flux. My partner says to me that she needs to not do work — there are like a couple of days a month where she's like, "I'm just going to nest." That could be her response. She's like, "I just don't have the stress tolerance to be able to do XYZ." And understanding that in her own cycle is great, because then she can allocate tasks that take more stress for other days.
Dr. Natalie Crawford: For most people, it's peak luteal — also when your progesterone is the highest — that tends to be when people have a harder time focusing and concentrating or getting tasks done. Which is going to be the middle of the luteal phase, the middle of this second half of the cycle. So when you have that progesterone really high, your body might be ready to implant an embryo if there was one. That tends to be when people say they feel more fatigue and less energy and less focus and concentration. So if you are looking at your month and you have the flexibility to say, "Okay, I'm going to try to write this paper, get this study done, do these tasks that call for an increased focus in my follicular phase" — when you're oestrogen-dominant, have high oestrogen and no progesterone — for the average person, that is typically when they have an easier time achieving those tasks. Which is the first couple of weeks, the time period before ovulation.
But there is an individual response, and I will definitely see some people who feel immensely better when progesterone's present and not so great the other time. So I think we use generalisations just as a rule of thumb, because that's what it is for most people. But with hormones specifically, there's always an individualised response, and learning to listen to your own body is key.
Steven Bartlett: I want to close off on this point about how employers and the way that we work can be better suited to a woman's health. Is there anything else we missed there?
Dr. Natalie Crawford: Flexibility. I think we mentioned before the ability to make a decision for yourself — "This is a day that I can do these tasks." I think every woman wants to do a really good job, and she is going to frontload those tasks on a time that she feels better and offload in a time where she's not feeling as well, but she's going to get it done for sure. And so giving her the flexibility is going to allow her to be her most productive, rather than demanding she have a fixed output every single day.
Dr. Mary Haver: And I think support can come in a lot of ways, but the financial burden to a large corporation of having a stop-gap childcare at work — so maybe if you're not going to offer full childcare because you're getting a lot of productivity out of women — if they know their children are on campus and can go at lunchtime. But if you're not willing to do that, if you have a stop-gap where — instead of calling your attending, one day my nanny didn't show up and I had to find some way — just for those emergencies within the corporation — that breeds loyalty, that will increase productivity. And so I think it's money well spent. Talk about having a competitive woman — she would probably want to work for you. And offering those things to make her mothering easier while she's trying to work — I think you would have the most competitive workforce.
Steven Bartlett: And what does that mean — having a nanny on site, or childcare on site?
Dr. Mary Haver: Childcare on site. Whether it's full-time — bring your children full-time there — or that's a big corporate commitment. But a smaller corporate commitment would be this emergency childcare, so that your kids aren't there all the time, but maybe they're sick or maybe somebody didn't show up, and then you have a licensed childcare provider available. Which is a fault of the US system, because —
Dr. Vonda Wright: What happens in New Zealand?
Dr. Natalie Crawford: You have 20 hours free daycare a week.
Dr. Vonda Wright: A week?
Dr. Natalie Crawford: Yeah. So it's 20 hours funded, and then it's a very small nominal fee for hours over that, for up to year five — or when they're five years old, because then they start school on the first day that they turn five. It's like, you turn five, happy birthday. But it does help significantly to keep productivity and take a little bit of the worry off — "What am I going to do with my child?"
Steven Bartlett: Amazing.
Perimenopause: the transition explained
Steven Bartlett: What does this conversation around eggs and fertility dovetail into menopause, and specifically perimenopause?
Dr. Natalie Crawford: You can't have one without the other, right? So perimenopause is basically in this fertility decline area. You don't — fertility is not an issue, you don't ever want to have a baby — you're still going to go through perimenopause. And so perimenopause is defined medically in the worst way as the transition from normal menstrual cycles to no menstrual cycle ever again. So when we look at definitions, menopause is defined as one year after the final menstrual period. What it really means is ovarian failure. And that offends people, but that's actually medically what it is — you have run out of eggs and you've run out of the ability of the ovary to produce hormones.
And so perimenopause begins — medically, the STRAW staging is the very complicated methodology to define the stages of perimenopause, and a lot of it is based on menstrual cycle irregularity. But hormonally, what's happening starts well before our periods become irregular. So as those egg levels decline and the ability to respond to the stimulus coming from the brain — remember, ovulation starts in the brain. So when oestrogen levels normally get low during the cycle, the brain doesn't like it. The hypothalamus — the gland in our brain — starts looking for oestrogen. It likes oestrogen. And when the oestrogen levels are high, it's happy. And so when oestrogen levels decline naturally in a cycle, it says, "Whoop, where's my oestrogen?" And it sends a signal to a second gland in the brain called the pituitary. And that makes the LH and the FSH.
So I'm trying to figure out — what causes perimenopause? What causes menopause? Lack of eggs. So it's the loss of eggs and the loss of the group of eggs to respond to these signals. So here we go — we're beginning perimenopause. We've reached a critical threshold level where our ovaries cannot respond. And that might be — I don't know — millimetre. So when you're not out of eggs but just the count is low, right?
Dr. Mary Haver: Let's use the jar. Yeah.
Dr. Natalie Crawford: So if menopause is going to be, for simplicity, the jar is empty — when the jar gets like this — so we'll say if you had a full jar, the jar is not empty, but it's gotten lower. And what is happening is the ovary doesn't want to be out of eggs. So what Dr. Haver is saying is the brain is working harder to get an egg to grow, because the ovary becomes more stubborn — it wants to hold on to them, it doesn't want to lose them. The brain has to send out stronger signals to get an egg to grow. Because there's not as many, we don't lose as many per month. So that's great, but that means we have years of being at this low, unreliable ovary stage where the brain is working really hard. There's not as many eggs here. They will still ovulate, but it starts to happen at a less predictable rate.
Steven Bartlett: So is that perimenopause — when there's —
Dr. Natalie Crawford: Yes. And there's not a definition — which makes it the hardest — of, say, what number of eggs equals perimenopause. There is a unique response to each person at what level your ovary gets to where it will start to respond dysfunctionally. But what happens is that the hormone changes start shifting in the brain. The ovarian response starts shifting. And before you have irregular cycles, you will first see a shortening of your cycles very predictably. The brain will send out a stronger signal, an egg will ovulate faster, you'll start to get shorter cycles. And then there are hormone fluctuations, but they're still regular. And so what will happen is a woman will start to feel these hormone shifts — it's less predictable, she is having some change, but it's still a regular cycle. And so she is often told, "Your hormones are fine. You have a regular cycle."
Dr. Mary Haver: So in the brain, as we talked about those neurotransmitters — not only is oestrogen changing and the amount that we're producing, but actually in perimenopause, quite often we'll have much higher oestradiol levels than we did in our premenopausal years, where we had that kind of predictable ebb and flow of our monthly hormones. There are also independent FSH receptors outside of — so these hormones that are pumping out to talk to the ovaries are also back-talking to different parts of the brain. So the first symptoms that patients feel — and they've done a great study on this — is "I don't feel like myself." And they even call it IDFM. And so you can't put your finger on it. Periods are regular, but your environment hasn't changed, your normal stressors haven't changed. The life you built that you could manage — you're suddenly losing resilience. And that's because of a hormone fluctuation that is hard to —
So we see sleep disruptions, mental health challenges increase — a 40% increase across the perimenopause transition — and the cognitive changes. And that is what really scares my patients the most. And they come in, and most of them are high-functioning in some degree — some of us in academia, some of us in the OR, some of us — but most women are high-functioning because they're juggling so many jobs. Even if she didn't choose to go the routes that we've chosen, she is managing children, school drop-offs, all the things that women tend to put on their plates. And suddenly she can't remember all the things she used to remember. Where are her keys? Word salad — you're struggling to find —
Dr. Vonda Wright: I can't tell you how many times I am like — I see people and I cannot remember their names. Or I can't remember — I get in the car and I can't remember where I'm going or what my purpose of getting in the vehicle was. You have to think for a second.
Dr. Mary Haver: And so all of that is related to the hormonal changes.
Steven Bartlett: At what age?
Dr. Vonda Wright: Well, I think there's a tendency in medicine to want to have definitions. So I personally — and I know a lot of us who talk all the time — think that this random 366 days after your last period, "that's your menopause day" — I think that's pretty random. And I don't know who made that up. But when I have patients come in to me for their musculoskeletal things, and they're of a certain age, and I don't just focus on whatever the musculoskeletal body part is, but we start talking about their whole health and they start talking about these things — I am often the first one to say to them, "You know what, you are probably in perimenopause." And they're like, "But my cycles are regular." I'm like, "But you are beginning this transition" — which I call menoladolescence — but it's this — I would propose that most people don't seek out a lot of help earlier. But they should just assume that they're perimenopausal any time after 35 they don't feel like themselves, and start down a road of learning or investigating or "let's feel better — what do I need to do about it?"
Dr. Mary Haver: You know, it's frustrating to all of us. We talked a little bit about this last night — the people who kind of make the rules, the institutions that make the guidelines, the academic ivory tower — they are like, "Whoa, back off, slow down. We shouldn't be blaming everything on menopause." And I don't think that's what we're saying. We're not trying to — but completely dismissing the female experience and not at all including this cataclysmic hormonal change is hurting women.
Dr. Natalie Crawford: So the average age of menopause is 51 to 52. And so let's say that is when your ovaries are in failure — they will no longer make eggs, make hormones, or respond to brain signals. So all the eggs, all the little marbles, are all the way gone at 51 to 52. For most women, about 7 to 10 years before that, they will start to enter into what we will call perimenopause — or the unpredictable response of the ovary and the brain. I say their communication system — their best friends who aren't communicating well. Their signals are getting interfered. They're not responding appropriately. The ovary is getting more stubborn. The brain is trying to work harder. You get these higher peaks, these lower troughs. And essentially that is the time period.
So it is unique to an individual because everybody's born with a different number. They lose them at a different rate. Some factors that we control impact that rate, but some things that we do not. Your mum's age of menopause is a predictive factor. If you've had a first-degree relative go through menopause at 46 or sooner, you have a six times likelihood of going into early menopause. So knowing — having this conversation — almost every patient I ask, "What age did your mum go through menopause?" They do not know the answer.
Dr. Mary Haver: Because the mums haven't talked about it. There's so much stigma about reproductive health. So knowing that information is really important — if you have a mum or older sisters, what age is normal for your family, so that you can be a little more in tune if there's some genetic predisposition for you?
Dr. Natalie Crawford: The general idea of what Dr. Haver is saying is that in these last 7 to 10 years of ovarian lifespan, it becomes more stubborn and less predictable, and it does cause hormonal shifts that most women can't detect with their cycles. We do know that if you are actively tracking when ovulation's actually happening and looking at your follicular and luteal phase and you know what's normal for you, you will most likely be able to detect these hormone shifts in that time period. But that's not what women are taught. Their tracking is just that it's coming regularly. And we do have a generation of women who were on contraception, then went through childbearing, then on contraception again, until now they're suddenly entering this transitional period and they don't know what their own normal is — making it even worse.
Dr. Mary Haver: Correct. So, as she said, the average age of menopause — if we look at the math — is 51, but under that 90th percentile curve, with 5% on each end, it's about 45 to 55. That's menopause, right? That's full menopause. Now let's just do the maths and back it up 7 to 10 years. So we're looking at the mid to late 30s to 40. So when I have a 46, 47, 48-year-old patient come in who's still cycling, she has almost 100% chance of being in perimenopause just based on her age alone, knowing the statistics around that.
Steven Bartlett: Okay. So with my partner, between the age of sort of 35 to 45 is when I can expect her to go through perimenopause — where there are very few marbles left in the jar — and her hormones might be less predictable. And one of the questions we had in from the audience was: how can I manage the symptoms of perimenopause, and they use the word "naturally"?
Dr. Mary Haver: Well, we don't have a single large-scale study done on the treatment of perimenopause. So let me break it down for you. When we look at funding in women's health, it's horrible. But if I go into PubMed — which is the database that I go to look up medical journal articles — and I type in the word "pregnancy," I will get today 1.2-ish million articles for pregnancy. Amazing. So important. We need healthy pregnancies. If I type in the word "menopause" right now, I think it's about 99,000. So those numbers represent time, brain power, funding — what is important in women's health. If I type in the word "perimenopause," we are at about 8,000.
Dr. Natalie Crawford: Yep. Very, very, very small. Your name's on a couple.
Dr. Mary Haver: Thanks. So is the last third of my life — from an academic standpoint, from funding, from brain power, from where we focus — not as important as when I had the ability to be pregnant? More women will go through perimenopause than menopause, because we're going to lose a few to accidents and cancers and early deaths. More women will go through perimenopause than get pregnant. Yet in my training — in medical school — I got one one-hour lecture on menopause, nothing on perimenopause. And in my OB/GYN training, as part of our reproductive endocrinology blocks, I had one block in my second year. In those six weeks, I got one one-hour lecture each week. No clinics, no focus, nothing. And then as a programme director, where I was in charge of the education of over 100 residents over about ten years, I knew exactly what the curriculum required, and menopause just gets shoved into a tiny box.