Transcript
Speaker: Sometimes I don't know if anybody's listening. Is anybody out there? But then I hear that people are enjoying the podcast episodes I'm putting together. If you are one of those people, please like and subscribe. So I know that there are people out there listening. That keeps me continuing on. And then you'll get notifications when there's a new episode. Also, if you know someone who could use the information that I'm putting out there, please feel free to share and forward. I love your support. Thank you. Dr. James Simon is a DC-based physician providing patient-focused care for women across the reproductive life cycle. from adolescence to childbirth and through the menopause transition.
Speaker: His unique approach to care encourages women to be part of their own wellness, disease prevention, treatment, and recovery. And through his renowned clinical research efforts, he offers one-of-a-kind opportunities for patients to experience the latest innovations in women's sexual health. He has done so much research. He's been part of some major medication breakthroughs.
Speaker: Thank you, Dr. Simon. I'm so excited to have you on today. I've been wanting to have you on for a long time because from what I recall is I was pretty freshly postpartum with my last daughter and i saw you at a conference and we were kind of chatting about the joys of being postpartum in a low estrogen state. And you brought up this parallel to menopause and I thought it was fascinating and I want to share your theories with my listeners. So thank you so much for being here.
Speaker: It's really my pleasure, and I hope your listeners enjoy what might be a little bit of a brain teaser. Yes, definitely. So, you know, I studied anthropology as an undergraduate student. I'm by no means an expert, but I think it has shaped the way I see the world and the way I understand or try to make sense of health and politics. human existence, etc. And so your paper, The Evolutionary Origin and Significance of Menopause, is super interesting. And, you know, my first question for you is really about estrogen. It's the same hormone, but really a different job. Your paper makes this argument that low estrogen isn't inherently bad. It's useful during lactation or breastfeeding, but then it becomes
Speaker: not I don't know if I want to say harmful, but maybe not so helpful when a woman's in menopause. So I was wondering if you could kind of draw that parallel for us and explain the differences there. Sure. The the hypothesis here in this paper, which increasingly i am absolutely convinced it is true,
Speaker: which I came up with, and I should acknowledge our colleagues, Dr. Ricky Polico from San Francisco and Dr. Fred Naftalin from new York and Yale University.
Speaker: We came up with this idea from a singular observation, and all three of us noticed that women who were breastfeeding had hot flashes, just like menopausal women. And obviously they had very low estrogens and they were breastfeeding. And we all, because we're all gynecologists, knew that giving estrogen to women who are breastfeeding was bad for their milk supply. Right. And so putting that together, we started thinking and were wondering, That seems unusual. That seems weird.
Speaker: Why would Mother Nature have women who are breastfeeding also have hot flashes? Yeah. And then the whole idea came to us. If you look at... historically women never living long enough to get to menopause i and in many parts of the world even today the life expectancy even adjusting for infant mortality in many parts of the world is still less than the average age of menopause right
Speaker: put it together and came up with a unifying hypothesis of why low estrogen might be a good thing, a necessary thing, an important evolutionary stage for women who are breastfeeding.
Speaker: And you mentioned hot flashes. i thought that was really interesting. You know, I think we talked about sleep when I saw you in that conference, and I'd love to cover that too. But I thought the new thing that I learned from your paper was about hot flashes and how that warming sensation could actually be for a neonate or an infant. So for your audience, we need to get their brains in the right space. Okay.
Speaker: So even though you and I are people, adults in 2026, the right space for this entire conversation 50 130. thousand years ago when our very very, very, very, very early ancestors were making babies, breastfeeding babies, and living in a cave somewhere with no central heat, no central air conditioning,
Speaker: even before agriculture. And so how would a neonate, how would a newborn baby manage to stay warm yeah if it weren't for the mother's body temperature? And if you think about hot flashes, they typically start percolating up from about nipple level, chest level, and settle on a woman's cheeks and hands. So interesting. Yeah. And so what's at nipple level? hu And where is the baby when you're burping the baby? Right. And where are those women's hands when they're holding the baby at the breast or burping the baby.
Speaker: Well, they're on the baby and the baby might get more heat from those hot flashes helping to keep him or her warm in a cave in the wintertime. So was the grandmother supposed to help? Like, say if you you don't get injured or die from cholera or like any of these things that took people out before they otherwise would have aged to lead to their death. do you feel like they were helping out with these same symptoms? Because I know, i mean, your paper addresses the grandmother hypothesis, but I don't know. I think it's kind of perplexing. Like, were they helping or were they just really not around for the most part, do you think? So our hypothesis does not agree or disagree with the grandmother hypothesis, but it asks a different kind of question. And that is, at the time of cave living, not contemporarily, at the time of cave living, there were either very few grandmothers because they had already died or they were actually a detriment to the living groups because they needed to eat and drink and consume calories at the time when the reproducing pairs had a very incredible limit on food. Yeah. Remember, before agriculture. yeah And so, you know, Mr. Caveman and the non-pregnant, non-breastfeeding females in the group, they would have to hunt and gather to get all of the food for...
Speaker: for The pregnant women who were too big and slow to hunt and gather for the breastfeeding women who had other responsibilities. And so grandma, while she may have been healthy enough to hunt and gather, was largely a caloric tax person.
Speaker: on the group. And so we kind of did not feel that the grandmother hypothesis applied back then. If I said that today, my wife, a grandmother of four grandsons would just kill me. after is But the answer is a grandmother today is both younger and much, much healthier than the time we're talking about. right And so right the circumstances are different. So just to lay it out there, basically, it seems like a lot of the symptoms of menopause and perimenopause, hot flashes, i mean, well, we didn't talk about sleep. I would love to go back into sleep, but those were happening because of a low estrogen state that actually might have come from a positive adaptation for a reproductive aged woman who has ah a young child or is in her postpartum stage, right? So it's this low estrogen state in general that then causes the issues later for those who manage to survive, which also kind of is sad, right? oh
Speaker: Congratulations, you're you're making it through and now you get to be miserable. Let's talk about sleep. What is happening with sleep and what are the parallels there? so let's flush it out a little bit, and I promise we'll get to sleep. So in a woman's normal life cycle, there are only two times when her estrogen is as low as it is during breastfeeding. When and when she's breastfeeding, and in the context we're talking about, she would be exclusively breastfeeding, meaning there were there was no supplements, there were no formula, there was no other source of food for that breastfeeding. our young baby than breast milk. right so
Speaker: that was one time in a woman's entire life when her estrogen was as low as it is. And then after menopause, and we've already said that most women never lived that long. So the adverse consequences of low estrogen in menopause wouldn't you know happen to most women because they wouldn't have been alive that long.
Speaker: But the low estrogen in breastfeeding has these tremendous parallels to the biology of the menopausal woman, but they're beneficial to that newborn baby. And one of them that you mentioned, sleep disturbance. would be beneficial to that baby because mom, breastfeeding mom, would be awakened easily to the baby moving, the baby crying, the baby needing to feed yeah an intruder into the cave.
Speaker: yeah any kind of disturbance in the cave. And so sleeplessness or very poor sleep would be a beneficial adaptation that would ultimately lead to survival of the mom and of the baby. And so sleep deprivation or sleep disturbance was a good thing in that context, not so good after menopause or any other time.
Speaker: Right. I mean, I hear my patients who are postpartum describe that, right? It's like a hypervigilance. They're sleeping, but they wake up very easily. And you mentioned your wife. i have to mention my husband. We've had three kids together and he's an awesome dad but I just couldn't rely on him to wake up when the baby would wake up because he would just keep sleeping and I would be awake. So like, just forget it. I'm going to take care of it. That's the point. The point is that the tolerance is different in a woman whose estrogen is very low and who is breastfeeding and who has her own internal signals to wake up. Right. You know, the breast is swollen. The breast gets tender. It's full of milk. Mom, wake up, feed the baby. It's time. Yeah. and
Speaker: Poor sleep is all part of that relatively straightforward advantage of low estrogen during breastfeeding. Well, you mentioned your husband. Yeah. will We always minimize or many people minimize the low estrogen effect on desire for sex and pain with sex or dryness with sex. Totally.
Speaker: which is very common and like very popular to talk about in the menopause context. But in the context of a woman who's breastfeeding, no sex drive, low sex drive, pain with sex, not wanting to have sex, That was a good thing for that baby who's breastfeeding because the worst thing that could happen in the context of low calorie availability in that environment would be to get pregnant again with another baby yeah when you're breastfeeding the current baby. Yeah, that is super interesting and I think makes a lot of sense.
Speaker: It's so fascinating. And it's all right. It's all about survival and then the ability to reproduce and then keep that new offspring alive and potentiate survival. Right. That's the framework of evolutionary anthropology for people who are listening and have never thought of things in this context. It's very difficult for a contemporary person, man or woman, to think about what their lives, their partner's lives, and their children's lives would have been like 50,000 years ago, living in a cave with no running water, you know. sanitation, no heat, no air conditioning, and no grocery store. It's very true. And i think we talked previously about anxiety too, because personally, I had never really experienced anxiety until I was postpartum. And it's like, what is this? But it kind of goes with the sleeplessness and this hypervigilance and anxiety.
Speaker: I hear my patients now. I mean, it allows me to relate to my patients in menopause now because I feel like i I got a pretty good preview of menopause with each of those three children. But anxiety is also potentially helpful if you think about that context, right? if you think about anxiety in general, it's very... helpful as an adaptation up to a point.
Speaker: yeah You and I see patients who use their anxiety, use their adh d symptoms, use their ability to multitask to their benefit and advantage at home with their children in the workplace to their advantage until it gets to be too much and then it crashes and burns. And there it is this nice balance that I think Mother Nature intended for women to have in the context of breastfeeding and rearing children that men don't have. And I'm not saying it's bad or it's good, but it is different from Women can organize and keep a lot of balls in the air. Men are more likely to be straight ahead, hunt, keep your eye on the prize, et cetera. Whereas women seem to have a better ability to appoint, balance kids, life, husband, work. And it's just a different approach that, again, i think is evolutionarily important.
Speaker: advantageous if you're living in a cave, breastfeeding and keeping your baby alive. Yeah. One thing that we're missing, you know, I feel like in so many ways we have evolved and developed as a society to find treatments for these things, to help women through these different stages. But if we think about postpartum anxiety and then even, i don't want to compare them, but it can be really devastating depression. The thing that we're missing today is the village. Right. Like even in that time pre-agriculture, there was still this sense of community and a village in a sense. Right. and we don't have that now to help a new mom who might be experiencing anxiety or depression. If you, for better or worse, and there will be people who will discount this versus those that will embrace it remember that our concept of primitive life evolved from our experience and view of non-human primates in the wild. And in general, there were multiple females in the group, all either breastfeeding, pregnant, or mating.
Speaker: And there were very few males with a group of females, and thereby the women would be able to help each other. That was the community, yeah even if it was just one male and four, five, six, even eight females. Mm-hmm.
Speaker: We see this in many other species. For example, elephants. The group of females tend to group raise the young elephants, whereas the males are off doing whatever the males are doing. and you have these long-lived females who...
Speaker: bring with them ah generations of information about child rearing, about where the resources are out in the wild, et cetera. And so, yes, this idea of group or community yeah raising of children kind of is not part of our contemporary ah society, at least in the first world. Yeah, it' I think it's kind of too bad. And i mean, you do see groups of women that help each other and are there for each other. But I do feel like in American culture, it's really about doing things on your own and getting through on your own. And sometimes that's not possible. Yeah, exactly. Okay, this is kind of going off in a different direction, but related. the bone density topic was a new one for me too, because I had not put together that parallel. Actually, I'm not even sure I was aware that there was, I knew there's calcium leaching from the bones during lactation, but I didn't realize how much it affects bone density and how women in their reproductive yours can bounce back from that. But obviously in menopause, as women are starting to experience lack of bone density or bone loss, there is no bouncing back. There's just preserving what you have. So let's think about that a little more globally. Okay. So again, focusing on that newborn baby at the mother's breast, Mother's biology, mom's biology in the face of very low estrogen.
Speaker: We talked about symptoms like vaginal dryness, pain with sex, loss of libido, hot flashes and disturbed sleep. Those are symptoms. But if we think about the biology, the underlying biology, when there is low estrogen, whether it's a 20 something or 30 something or 40 something breastfeeding herbaceous or a 50-something who's menopausal, the biology changes. And the biology changes are, regardless of the age of that person, typical of what happens in a breastfeeding woman. Several examples. You mentioned loss of bone or decreased bone density. Well, in breastfeeding, the calcium that's coming out of the bones of that mom are going into the breast milk to help form the baby who's breastfeeding his or her bone. Yeah. So it's mom is being the host
Speaker: of this perfect parasite that's sucking out the calcium for his or her bones. And it's not only that. yeah When there's very low estrogen during breastfeeding or menacee,
Speaker: And in fact, the bad cholesterol and triglycerides, a form of fat in the circulation, they go up pretty dramatically to the detriment of that mother's cardiovascular system. But increasing the fat in the breast milk, making it, you know, full fat breast milk as opposed to skin, And helping again the baby. So you have a number of these biological changes, good for the baby, bad for the mom, and then repeated nearly exactly in menopause where there's no time yeah When she recovers, yeah like that younger woman, gets her menstrual cycles back, and puts calcium back into her bones, reduces her bad cholesterol, has an increase in her fertility, her sex drive, a decrease in her vaginal dryness and pain. Starts to get some sleep. Thank you, Mother Nature. And the cycle starts again until she's pregnant again and breastfeeding again.
Speaker: Those cycles never start again after menopause. She is stuck in perpetual breastfeeding mode. after menopause, even though there's no baby. And those are all detrimental physiologies for her. Bad sleep, hot flashes, low sex drive.
Speaker: Now, these are all things that are all very popular to talk about on the internet, but we don't really consider them in this evolutionary context.
Speaker: Yeah. I just have to say as little tangent is that we were living in Africa when we conceived our first daughter. And so I told my parents as a way of announcing our pregnancy, you know, I think I got a parasite. And then I showed them the ultrasound scan. We're so confused. But I've always kind of joked that they are little parasites that are growing inside of us, taking all of our nutrients. It's just a tangent. But if you think sort of the treatment for menopause and you think of these correlations and then sort of the detriments that happen to women, do you feel like all women should be on hormone therapy? What's your thought in the prevention of some of that detriment?
Speaker: But this is a very complicated question that takes more than a 90-second answer. yeah But I will go on record, and I've been on record in writing, in speaking, etc., that I think the overwhelming majority of women...
Speaker: who are otherwise healthy, and that's an important distinction, who are otherwise healthy, get benefit from being on physiologic menopausal hormone therapy.
Speaker: It's very easy to document for hot flashes and for sleep disturbance and for vaginal dryness and for libido and for bones. It's more difficult to document for brain health and cardiovascular health, but there are pieces of those puzzles also that suggest benefits for hormone therapy.
Speaker: yeah We got sidelined a little bit in the Women's Health Initiative back 20 plus years ago. But in fact, in the women who we're talking about, the young women who are healthy, yeah they did get benefit from those organ systems and well-being. from being on hormone therapy. yeah The detriment and the reason that we came to this really challenging view of hormone therapy risk and benefit came mostly from women who were much older, up to age 79, starting on hormones, and from women who were not all that healthy. Yeah. So when we talk about bringing my comments into a contemporary context, we need to separate out those women who are generally healthy at menopause from those who are not and avoid making a generally unhealthy problem worse by giving those women hormone therapy.
Speaker: Makes sense. And, you know, my theory is that we really should be starting hormone therapy earlier. I feel like our science is still catching up with this, but for so long, we've been talking about this 10 years from menopause of starting, but I honestly think we should be starting in perimenopause when those fluctuations begin to happen. Maybe we could do more prevention, but still, still yet to be established. So I agree with you in the biologic context, but the perimenopause
Speaker: that trying to intervene medically is really challenging. yeah And your audience should hear those words very clearly.
Speaker: It's not that Dr. Pope or Dr. Simon don't care. we do. It's not that we don't want to intervene. We do. But it's trying to hit a moving target that seems to change day-to-day, week-to-week, month-to-month, and do so without causing new and different problems. Yeah. It is the real challenge. and That challenge has not yet been completely addressed, but it will be. Yeah. I have one last question for you What do you think about the role of progesterone?
Speaker: Because, I mean, you have been doing reproductive endocrinology for years and years, and I feel like I have always thought of progesterone as the necessary component of hormone therapy with estrogen. but there is so much talk about progesterone's benefits in and of itself. And to be honest, I'm skeptical, but I wonder if you have some thoughts about it, especially given this context of looking at the postpartum to menopause parallel.
Speaker: So I think it's an unanswered question. So let's start with that yeah There is good information on both sides of the, yes, you should be on progesterone and no, you shouldn't be on progesterone.
Speaker: Here's my thoughts. In the same context that we discuss, some women utilize their benefits, their anxiety, their sleep disturbance, et cetera, to the benefit of their child or even to their own benefit in their work of life or their real life. yeah There are those who can't compensate, can't bring their anxiety down to a level that's beneficial. cannot bring their sleep down to a level that is beneficial and they need help. And progesterone, when delivered orally, as opposed to vaginally or intramuscularly, as we do frequently in reproductive medicine, but when delivered orally, it breaks down to some very active
Speaker: what we call neurosheroids or neurologically active hormones that improve anxiety and improve sleep and improve sleep in many different ways.
Speaker: But it's not been studied well enough for me to say any woman after menopause with sleep disturbance should be on progesterone or any woman after menopause who has heightened anxiety should be on progesterone. These are early preliminary findings that suggest that maybe there's a subgroup of women who really get benefit from being on progesterone, whether they need it or not. That's important.
Speaker: And then there are others who you see in your clinic, as do i who think the progesterone is the tool of the devil. It makes them sleepy, grumpy, loopy, dizzy, let out unable, bloated, unable to function. yeah And your audience needs to remember that progesterone is actually the hormone of pregnancy.
Speaker: It's the hormone of pregnancy. Going back to our pregnancy and lactation story, it's the hormone of pregnancy. It's the hormone of premenstrual symptoms. It's the hormone of premenstrual dysphoric disorder, mood changes right before the period. I've yet to find a woman who wants more of that. no So also remember that weight gain in the perimenopause and menopause is a big concern of women and a big problem societally. And what does progesterone do during pregnancy?
Speaker: It makes us eat more and hold on to calories more. And so we have this circumstance where there's clearly a benefit and a liability to progesterone that might be highly individual where we need to really try and find the balance between the risks and the benefits woman specifically.
Speaker: And helps to make sense of things that people see online because, you know, you hear one person's experience and then people are wondering, is that for me? Should I be doing that? Am I doing something wrong? It's great to put that into perspective. It's really individualized and people respond differently. to hormones. And it's great to have a framework of ah why this has come to be. But it's also wonderful that we are back in the road of helping to treat women and get them the relief of their symptoms, both during the postpartum stages of life and during menopause. So yeah, thank you so much for your time. This has been super interesting for me. I'm sure others will agree. And it's been a pleasure chatting with you and picking your brain. It's lovely to see you, Dr. Pope. Thanks for having me. And I hope that your audience will have a chance to look back at that paper, think about what it might have been like to live in a cave years ago. We have come away since then. Thank God. Yeah, exactly. Yeah, I will post the paper for people to reference so they can find it on the link. And yeah, thank you so much. I hope you have a wonderful rest of your day. Thank you.
Speaker: You too.
