Far too many menopausal and perimenopausal people find themselves mystified, blindsided and asking, "What's happening to me?" In this episode, author and sex educator Heather Corinna and Dr. Jewel Kling talk about what to know to get the care you need.
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Dr. Denise Millstine: Welcome to the “Read. Talk. Grow.” podcast, where we explore women’s health topics through books. In the same way that books can transport us to a different time, place or culture,”Read. Talk. Grow.” demonstrates how books can also give a new appreciation for health experiences and provide a platform from which women’s health can be discussed. At “Read. Talk. Grow.”we use books to learn about health conditions in the hopes that we can all lead happier, healthier lives.
I’m your host, Dr. Denise Millstine. I’m an assistant professor of medicine at Mayo Clinic in Arizona, where I practice women’s health, internal medicine and integrative medicine. I am always reading and I love discussing books with my patients, my professional colleagues, and now with you.
So excited about my guests and about the books we’ll be discussing today. My first guest is Heather Corinna, who is the author of “What Fresh Hell Is This: Perimenopause, Menopause, Other Indignities, and You,” as well as the author of “S-E-X: The All-You-Need-to-Know Sexuality Guide to Get You Through High School and College,” and the coauthor of “Wait, What?: A Comic Book Guide to Bodies, Relationships and Growing Up.” They’re also the founder and director of Scarlet Teen, the pioneering inclusive sexuality, relationships and health education resource for Young People, which was established in 1998, and they are currently the sexuality chair at Our Bodies, Ourselves. They’re based in Chicago and have been working as an educator, advocate and writer for over 30 years. Heather, welcome to the show.
Heather Corinna: Thanks for having me here.
Dr. Denise Millstine: My second guest is Dr. Jewel Kling, who’s a professor of medicine and chair of the Division of Women’s Health Internal Medicine at the Mayo Clinic in Arizona. She’s the assistant director of the Women’s Health Center for Mayo Clinic. And the associate chair of Equity, Inclusion and Diversity for the Department of Medicine at Mayo Clinic in Scottsdale. She completed medical school and a master’s in public health at the University of Arizona, Tucson and internal medicine residency and chief residency at Mayo Clinic in Arizona. Her clinical research interests are in menopause, sexual health and LGBT care. She’s a North American Menopause Society-certified menopause practitioner and (serves on the board of) the International Society for the Study of Women’s Sexual Health and the American Medical Women’s Association, Sex and Gender Health Collaborative. Dr. Kling, welcome to the show.
Dr. Jewel Kling: It’s such a pleasure. I’m so excited to be here.
Dr. Denise Millstine: Heather, Jewel and I have talked about your book back and forth and have both recommended it to several patients. The book we’re mostly focused on today is “What Fresh Hell Is This,” which is so incredible. The cover… Who were you thinking about when you started with this cover?
Heather Corinna: They got a designer to do the cover, but we did give them ideas and pretty much it was nothing but flames. I wrote the book both during pandemic and during the very worst part of my perimenopause. Everything in my brain that’s surrounded by flames. But they did an amazing job. I love love, love the cover.
Dr. Denise Millstine: I have a story for you that I think you’ll appreciate. A few years ago, I was frustrated because my periods were abnormal, they were changing… I work in women’s health, and my officemate came in and said, “Well, you’re perimenopausal.” I was like, “(Gasp) Bite your tongue!” Because, of course, I think I’m much younger than I am. But you are also an educator in this field. And as you were going through perimenopause, you too had the experience. What is going on? It felt like a huge mystery.
Heather Corinna: It’s one of those things where the more you find out, the more you find out you didn’t know. I really didn’t know jack. That’s after over 20 years of working very solidly in sexual and reproductive health and education around human beings and various life stages. All the things that you would think you would know, if not a lot, the basics. I feel like even the things that I thought were so basic, I was so often completely wrong about.
Dr. Denise Millstine: Jewel, just like Heather, you realize there were huge gaps in knowledge around perimenopause, the menopause transition, which now you’re a menopause expert and have focused your career on that. Tell us about how you made that decision.
Dr. Jewel Kling: Well, I was going to say to Heather’s comment and Heather, thank you for this book. Beyond it being great, it’s just honest and personal. For you to share your experience of going through perimenopause to help other people is just such a gift. But as you spoke about being in this field, being somebody that maybe should know this information and not knowing and then going through it, what has surprised me is how little the medical practitioners that we expect that should know this information, don’t know. I can even see people turning to your book to get that information, because they might not get that accurately from their physician or their advanced practitioner. That’s not a fault of theirs. We could talk about the history or the contributors, and there’s many that have factored into the fact that we really need to do a better job of educating professionals so that they can help women and people navigate their journey through perimenopause and menopause.
Heather Corinna: I think one of the things is that the lack of knowledge about this is so universal. You can be whatever kind of expert that you want to be. But the other thing is people will say “Why didn’t my doctor tell me about this? Why didn’t my mother tell me about this?” Not only are everyone’s experiences with this, who actually have them for themselves, so divergent, but we’re all by and large, as a culture, missing so much information.
Dr. Denise Millstine: I love how you start just at the very beginning of the book with simple definitions about perimenopause, the menopause transition. I’m about to give a talk later this afternoon to medical professionals, and I’m going to use the same definitions because people make mistakes about them all the time. Premenopause is when you start having your period while you can have babies until you become perimenopausal. Yet people will come and say, I think I’m premenopausal and they’re in their thirties. Obviously they’ve been premenopausal for 20 plus years. So it’s a mystery to a lot of people.
Heather Corinna: When even coming up with how to explain that, for something that takes up relatively small amounts of space, that’s the stuff that matters. When you’re thinking about it particularly, you have to think about it in a way where, like teaching sex-ed, it’s actually factual and accurate to the best of our knowledge at this time, all of this stuff, as with sexual health, 10 years from now, I’m sure that we’ll have to make changes because we’ll actually know things that change our understanding of how this all works. But then also, it has to be accessible. Everybody needs to be able to use it.
A lot of people don’t like the term menopause, which is understandable. But then you also have to ask yourself a question, especially when someone goes to a health care provider, if everybody doesn’t have somewhere where we can meet and speak the same language, it makes it even a million times harder to try and get the care that you need and the information that you need and for everybody to be on the same page. That stuff is really tricky and I feel like even with that, we always want to be reevaluating to be like, “Does this still work? Does it work for us? Okay.”
Dr. Jewel Kling: What I really learned and like how you did those presentations, they were evidence based, factual. It makes sense in the clinic how we communicate, but also patient centric. I learned something reading your book about how we approach or call things like “normal” or “natural menopause” and how that leaves people out by just using those terms. So there’s other ways that we could converse about menopause. It’s more inclusive and engages with people, so it’s more inviting than we can navigate that journey with them together.
Dr. Denise Millstine: Well, you talk a lot about all the different symptoms that come with perimenopause and talk about journaling and tracking those symptoms because they can be caused by other things. They can be confusing. You don’t know you’re in menopause until 12 months after you stop having your period. So there’s this long time period of perimenopause where you’re experiencing symptoms. Dr. Kling, you’ve been working on some projects to help women track their symptoms a little more consistently. Can you tell us a little bit about that?
Dr. Jewel Kling: There’s twofold. The goal of our research here in women’s health is both to answer more questions because just like the information about perimenopause and menopause has little infiltrated medical training and even pop culture, when we look at the research there’s so much that needs to be done, particularly as it relates to people that identify with other genders apart from cisgender people. But even for just cisgender women, there’s such a lack of data, particularly for people of marginalized groups and populations. Our research efforts are twofold. It’s really to explore some of those outcomes associations.
Looking to see how things like adverse childhood experiences impact the menopause experience? How does somebody’s skin color impact the bioavailability of the hormone therapy that they use if we’re recommending it transdermal? We’d love to answer those questions, but then also use those indirectly, translate them in our clinical practice and beyond using forums like this to make sure that people know what to expect and how that may or may not apply to them so that they can benefit from both the research, but then the clinical practice.
Dr. Denise Millstine: My practice focus is in integrative medicine. Heather, you start talking about the basics in terms of approaches to perimenopause that seem so simple and yet are so powerful when we give them time and space, things like stress management, sleep, hydration, smoking, if you’re a smoker, building community. Talk a little bit about those basic strategies.
Heather Corinna: Again, it’s almost one size fits all wellbeing advice. It’s so easy to blow off because we’re all sick of hearing about the same stuff. If there’s anything that we have challenges with, knowing that it would benefit us doesn’t necessarily help us manage those challenges or get any better at it if we’re not good at it, or be able to change things that necessarily will always be a challenge for us. It can be easy, especially in a capitalistic society, to be like I’m going to buy stuff and then I’m going to get some medications and then that’s going to do it.
That’s not to say that there aren’t both things you could buy and medications that can often help with this. But if you’re not nourishing yourself when it comes to eating and nutrition and you’re not getting enough rest and everybody won’t stop crawling up your back to leave you alone so you cannot be so stressed out all of the time, if you’re isolated… I smoked for 35 years, so my heart goes out to everyone who’s had a hard time not smoking. That’s one of those things where we can only in this world do so well with our nutrition, especially depending on who we are and what our privileges are. If we have an addiction, we have an addiction. It’s harder to get support like really supported, not just paid lip service, to actually working on those things because for us, for instance, to be under less stress, more people have to start taking care of themselves and asking less of us.
For us to be well nourished, especially if we’re marginalized, we actually need some equality and some equity when it comes to our food availability. All of these kinds of things, in order for us to get more movement, if especially we have disabilities that mostly nobody’s going to make that work for us at a gym or anything else, we need actual support in doing those things not just somebody doing the usual which is telling us that it’s good for us and we’re just going to go do it.
It’s also one of those things where this is a time of life where so many more things are often being asked of you that it seems like a real conflict to figure out how this could also be the time of life that you center yourself better, and take care of yourself better. How do you do that when more and more things keep going wrong with everybody else and your responsibility in them is bigger? And the way that everybody gets there is going to be a different way, but I think the big message to kind of walk around with at this point of life is almost like, well, if not now, when? Time is running out.
Dr. Denise Millstine: Not get any younger. It’s a really good point. It’s a very interesting time period, though, that historically has been really portrayed as this time of pulling back and sort of shriveling up, no longer fertile. We had a great conversation with Kirsten Miller, who wrote “The Change” about changing the narrative around menopause and the menopause transition that women actually, in her fiction, get these superpowers. I want to talk to you a little bit about that in terms of sex.
Obviously we can’t talk to the founder of Scarleteen and not talk about sex in the episode, but you obviously talk about it in your book as well. But you make some comments about how important the sexual experience is, to embrace that it’s an individual experience, that your body is changing, but that doesn’t necessarily mean it’s changing for the worse. You can often be more in touch with who you are, more empowered, more wise from your prior experiences. Talk a little bit about sex at this age.
Heather Corinna: I think a lot of that happens where people say, “Oh, no, this thing doesn’t work anymore.” More times than not, the biggest hurdles around now are if people are still trying to stick to and make their bodies stick to the super limited, heteronormative script about sex that probably, for most people, was never all that great to begin with. But you could do it right, like you could physically do it in a way that with menopause and post menopause, some of this stuff, you can’t. Your body’s just not going to have it anymore. It’s so different when we’re queer and we’re gender expansive because we’ve always known that those scripts, most of us, don’t work for us. It’s kind of like we’re already in the habit of being a little bit better about adopting because we can exempt ourselves more from those scripts. Not completely. Alas, a lot of it is realizing that that never really worked. Again, now you’re hitting a wall where it’s just not going to happen at all.
And it’s almost like you’re forced to make a kind of change that probably you would have been benefiting from all along. I think one way of thinking about that is that for some people that really just have not felt able to give themselves permission to that, there’s something that if your body just won’t let you anymore, there’s kind of a built in permission. Maybe you couldn’t give it to you, but now that’s just what has to happen, which especially also for people that might have had a harder time talking to partners about changes like that, sometimes it can be a little easier for that person rather than saying, “I just don’t like this,” to be like, “My body just won’t do this anymore.”
We’d ideally want the person in a relationship with anybody to be able to be more honest, but everybody’s circumstances are different. But it’s another one of these things, and it’s really interlinked with self-care, about learning how to center yourself if you haven’t already. All of these things that you learn to center yourself and sex, to center yourself when it comes to the kind of care that you need, are only going to benefit us more and more as we get older and older. Just like they would have benefitted us a lot when we were younger.
When people really kind of push against it and try so hard to keep things the same, when it’s just not happening, the outcomes are so different with people that just lean in to learn to be adaptive around this with themselves, with their partners, in their relationships, all of these things. It gets a lot easier. For some people it’s bigger than that. For some people, this is really, really liberating these particular times because they haven’t had them before, or it’s been a while.
Dr. Jewel Kling: That’s just so important and so exciting and it kind of goes back to what we were talking about with how we talk about the definitions of menopause, that we link things often to these terms of “normal” or “natural,” and just keep thinking about many of my patients faces when I talk to them about sexual functioning, especially at midlife, and say, “Hey, there is no normal,” and what a relief it is to know that they don’t have to meet some expectation. The next challenge may be then explaining that to their partner, who may think that there’s this “normal” that they have to be meeting to, but having permission to live in your body, explore your body and express it. It feels good. One of the things — Denise may be able to acknowledge this too — that we also, at least as a sexual medicine provider, want to make sure that women know that sex should not be painful.
So many patients come into our office that have been having painful sex and just say, “I thought that was how it was supposed to be.” As part of that, too, that first of all you shouldn’t be having sex if it’s painful. If it is, there are things that we can do, at least from a medical perspective, oftentimes in combination with amazing physical therapists and sex therapists, probably things, Heather, that you know a lot about and talk to patients about, or women about, but just making sure of those two things. That’s not normal and it shouldn’t be painful.
Heather Corinna: And that “it’s okay for it to be painful,” or it’s even “supposed to be painful” is anybody who was raised with the vulva or vagina, it’s somewhere in there to some level or another, depending on what communities and cultures you were raised in. So once again, it’s interesting to me starting to really work the whole age gap when it comes to sexuality. But for sure, if somebody already had a very formed idea when they started to have sex, that pain was normal or even was something that was supposed to be happening, or like “It’s not really sex unless something hurts,” then yeah. You hear how they can be — younger people go through their life this way thinking if it’s intercourse it’s painful. Then people get in the middle and think, “Well, you’re not supposed to need the lube,” which is so weird, which is like saying, you’re not supposed to need frosting on cake. It’s like who cares if you need it or not? It’s frosting. Why not have them? And then again, it comes through now here, especially for somebody who this is how it’s always been. How do they know then that it never was supposed to be like this? There’s always whatever the cause, whether you fix it again with medicine or you fix it with consent or you fix it with getting more relaxed, there’s always a fix for it.
Dr. Denise Millstine: You talked about lube and the frosting on the cake. The normalization of talking about products for sexual health, and then Dr. Kling and the Women’s Health Center have really done a good job of making that available through the Mayo Clinic store as an example. Not that you can’t buy it from many other sources, but sometimes people need permission to find these things in places that they feel comfortable shopping.
Heather Corinna: Yeah, I didn’t know that. That’s a really big deal. And it’s the same thing when so many doctors don’t talk about sex, period. And that silence alone really speaks volumes. If a patient has to start these conversations on their own, that is a whole different thing than, again, somebody introducing the conversation. Even in the office being really just normalizing everything. Then, yes, you can leave your appointment and you can get what you need in the clinic store the same way that you would with a certain supplement or anything else, that’s amazing. That’s fantastic.
Dr. Denise Millstine: We have to talk about hormone therapy because Heather, your book is such an amazing distillation of the science behind hormone therapy, which is not for everyone. There’s no single answer for everyone, but it’s such an important topic that can be really difficult to navigate through. I know Jewel and I both feel that your presentation of the topic was spot on in terms of it should be considered and then you need to think about the risks to benefits and that there are a variety of ways to do it that make it safer or more effective. It must have taken you a year to go through all that information.
Heather Corinna: Literally, I wrote this entire book pretty much inside a year, inside a very small room, in a pandemic, in perimenopause, which has its pros and its cons. There’s some things that make that harder. There probably were some things that made it a little bit easier, actually.
It’s really freaking complicated. It’s very, very fraught. It’s interesting the conversations that people will have, will have or want to have and concerns about hormonal medications. It’s so weird to me that they’re so different from everything else. If it was normalized for us, with any medication we’re offered being like: “Well, I want to hear a conversation. What does it offer me? What do I risk? What are my other options? What are the different ways that I can take this? How long do I have to take it to know if it’s working? How do I stop it if I don’t like it?”
Ideally the health care system, especially in the United States as it is right now, is how do you even make this happen? But we should be doing this with everything. If and when you get to the point where whether you’re looking at hormonal medications for gender affirmation or you’re looking at them for menopause, separate from that, it should be the same thing.
But I think a lot like you see with certain psychiatric medications and vaccines, there are pressures from different sides to do it. Don’t do it. Then you have the history that people don’t fully know and it gets so tricky. I think, for whatever reason, too, culturally, people think of hormone therapy as necessarily not reversible. Like it does things that once it does those things, you’re forever stuck in whatever that is. It’s medication. You can be using it and then you can stop using it. And the things that happen when you’re using it only happen when you’re using it.
But again, it’s one of those things where especially with this, you get that political intersection of it having mostly been about women and now it is also about trans people and then it is about how this has always worked when it came to misapplication of the FDA and everything like that, it’s just so thorny that I think the hardest part was making sure that I wanted everyone to leave that chapter being like here are a range of options. No one is better or worse than the last or required or not required. It’s just here for you. If you want it, you could try it. You could not try it. There’s different ways to do it. Because that’s really the other big thing is that I think that one of the most gendering things about the medical treatment of menopause is that hormone therapy has only almost ever been estrogen based.
A lot of that has been around presenting it as people having and keeping their femininity and this weird binary view of hormones and gendering hormones and everything else. But I think that’s also another thing that especially when you’re talking to trans and queer populations, that’s a factor in thinking about hormone therapy. If all that you’ve seen is, “This is to help you be or stay feminine,” and there’s nothing in there being like, “This has nothing to do with any of that and maybe you don’t want a lot of urinary tract infections or maybe you want to sleep better.” All of these barriers are built into this. It’s really something else.
Dr. Denise Millstine: We use a ton of hormone therapy to help with all those symptoms we were talking about at the beginning. Certainly hot flashes are disruptive. They can impede your professional life, they can impede your ability to sleep, they can be unpleasant. That’s just kind of the tip of the iceberg.
Dr. Jewel Kling: Absolutely. So many symptoms and having access to options for treatment is important. I’m pausing because I’m just digesting the idea of how estrogen-based therapies are also part of this gendered binary and how they’re presented. It’s so interesting from a research perspective, we think about the 17 beta estradiol and how it influences all the receptors and all the different parts of the body, but that doesn’t address that question for somebody that’s coming in that maybe is excited about their menopause transition means that they’re not going to have to ascribe or continue to hit these societal norms of femininity.
I love that idea. Just making sure to have that conversation with patients about the difference between the goals of treatment and really, what you’re saying, Denise is addressing those quality of life impacting symptoms. I think in my maybe biased view as a women’s health internist, what I see more often than not, is people being told they shouldn’t use hormone therapy, or they can’t use hormone therapy for reasons that I don’t understand that aren’t evidence based.
I feel very strongly I want to make sure everybody has access to that because hot flash is just not an annoying symptom that you have. As you lay out in your book so beautifully, Heather, they impact so much part of your life that having access to something to address those is so important. The other thing you said, Heather, that I think is so important and I hope listeners also hear too, is this higher threshold for talking about the risks and the benefits for hormone therapy than we do with any other medication, as you said nicely, Heather, probably influenced by gender stereotypes or sexism or all these different things that fuel that discussion.
Our research studies might as well. The Women’s Health Initiative, which has influenced how we talk about hormone therapy. Oftentimes breast cancer tends to be one of the fears that women have when they come in to talk about hormone therapy. What’s interesting is if you look at some really common medications we use as internists all the time, like calcium channel blockers, which is a blood pressure medication, or statins, which is a medication to lower your cholesterol, both of those have been shown to increase your risk of breast cancer.
Some of them in some studies at a higher rate than hormone therapy. But I bet those conversations aren’t being held when we’re talking about starting statins or blood pressure medication. So it goes to show really the importance of having the discussions like we’re having right now. The importance of Heather’s book is really to dispel some of those and give people the information they need to make those decisions.
Dr. Denise Millstine: I was presenting at a general medicine conference last week and talking about integrative medicine and menopause, but talked very briefly about hormone therapy because it is the most effective for people who are candidates for it. One of the audience questions was whether or not I had the patient sign a consent form before I prescribed hormone therapy. I thought, do you sign consent forms for your blood pressure medications?
No. You document that you had the conversation. It’s a shared decision. Everything has pros and cons, no matter what you decide to do. You obviously have to have those conversations. But there’s nothing special that requires a consent form for menopausal hormone therapy.
Heather Corinna: It really does, though, when you think back to it, starting with birth control pills. The thread that goes through most well-recognized hormones just ticks all the little boxes of sexism, transphobia, and misogyny — and it’s all there. But of course, also within the Western medical system, it’s baked in. You don’t see it on the face of it. People just learn it as they come up. It’s quite something. It’s interesting right now, having a foot in both worlds, to see what’s happening with MHT and then what’s happening with anti-trans initiatives around other kinds of hormone therapy.
Dr. Denise Millstine: That’s a whole other topic. I mean, that is just enormous.
Heather Corinna: It is. We don’t even have to ask ourselves the question of saying, well, if this were about cisgender men, would it be different? Because we know that it would from seeing what happened with Viagra versus everything else. You bet your answer would be different. It would be absolutely, completely different. Completely different. None of this stuff would be issues.
Dr. Denise Millstine: Well, your book ends with a fantastic appendix from Joanne Mason called “Menopause. For the Rest Of Us,” a.k.a. “People Born With Testicular Systems,” and to my knowledge, I don’t think there are books that address that so directly as yours.
Heather Corinna: That’s the first time that we think it’s been anywhere. Even doing it together was a little tricky because Joanne is considerably older than I am. Joanne is a trans woman a couple of decades older than me, so we don’t use the same nomenclature and hers is no more or less valid than mine. Mine is more, no more or less valid than hers. So even kind of figuring out how to do that, and again, especially in this climate, where getting people to be inclusive of menopause with those of us who are A-gender or are trans masculine is hard enough. But then in anti-trans land it’s transgender women are kicked the most.
Getting people to also realize that many trans women go through menopause several times just within decades is really tricky. I’m very glad I was a little kind of worried out there, especially when you have a guest writer and who’s vulnerable to be like, “Please, everybody be cool,” and so far we’ve pretty much, I think, only heard people be really appreciative, which is great. It’s a real gift that she gave to the end of the book there.
Dr. Denise Millstine: Well, you both are so amazing. The work that you do is so incredible. The world needs more people who are willing to have honest conversations about these topics and these components of people’s health. Heather, “What Fresh Hell Is This” is just such a phenomenal book. I hope so many of our listeners pick it up and read it through and maybe educate their friends and even their health care professionals from what they learn from it. I know we learned a lot from it.
Heather Corinna: Thanks so much and thanks for having me. It was really great to talk with both of you.
Dr. Denise Millstine: Thank you for joining us to talk books and health today on “Read. Talk. Grow.” To continue the conversation and send comments, visit the show notes or email us at readtalkgrow@mayo.edu.
“Read. Talk. Grow.” is a production of Mayo Clinic Press. Our Producer is Lisa Speckhard-Pasque and our recording engineer is Rick Andresen.
The podcast is for informational purposes only and is not designed to replace the physician’s medical assessment and judgment. Information presented is not intended as medical advice. Please contact a health care professional for medical assistance with specific questions pertaining to your own health if needed. Keep reading everyone.