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Menopause is not aging

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it is an energy crisis in the brain

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You are forty five

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sitting in your office

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staring at the computer screen

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and suddenly you forget what you were about to do

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and lately this keeps happening more and more

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Last week you stood in the supermarket for five minutes

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unable to remember what you came in to buy

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Yesterday in a meeting

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a technical term you had used for ten years

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suddenly vanished from your mind

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as if someone tore a page out of your dictionary

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You start secretly searching for early onset dementia

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Nights are worse

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At two in the morning

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you wake up with no warning

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your back drenched in sweat

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your heart pounding in your chest

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You toss and turn

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and your mind starts playing disaster movies will I lose my job

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is something seriously wrong with my body

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why does my husband annoy me more and more

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You know these thoughts are irrational

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but you cannot control them

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You go to see a doctor

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the doctor looks at your age

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asks a few questions

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and writes you a prescription for antidepressants

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You go home holding the box of pills

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and a voice inside you says

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I am not depressed

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I just feel like I am disappearing bit by bit

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If these descriptions feel like looking in a mirror

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I need to tell you one thing

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You are not disappearing

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Your brain is going through a decade long energy switchover

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Hello

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everyone

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I am Leo Wang

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I have done several episodes about the brain and mental health

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depression

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anxiety

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panic attacks

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bipolar disorder

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postpartum depression

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and every episode makes the same core point it is not a flaw in your character

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it is something going wrong with your brain chemistry

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In today's episode

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I want to talk about something with a wider reach and a longer duration

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but the most deeply misunderstood topic

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perimenopause

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commonly called menopause

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You might think menopause just means getting old

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your periods stop

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you get a few hot flashes and it passes

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This understanding is wrong

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Perimenopause is not an outcome

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it is a process

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It begins around age forty to forty five

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and lasts until well after you fully stop menstruating

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The whole process averages four to seven years

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and for some people up to fourteen years

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For Chinese women perimenopause starts on average at forty six

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with menopause occurring between forty eight and fifty two

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But the most crucial point is this

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the core of this process is not in the uterus

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it is in the brain

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In 2015

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Professor Brinton at the University of Arizona

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published in Nature Reviews Endocrinology

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an extremely important paper

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and her core argument is just one sentence

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perimenopause is essentially a neurological transition state

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not a retirement ceremony for the reproductive system

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it is a system level energy overhaul of the brain

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What does this mean

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Let me unpack it layer by layer

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Layer one

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your brain is losing its main fuel

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Your brain is only two percent of your body weight

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but it consumes twenty percent of your body's energy

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and the brain's favorite fuel is glucose

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What role does estrogen play in this

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It is the master dispatcher of the brain's glucose supply chain

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Estrogen regulates the expression of glucose transporter proteins

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letting glucose enter brain cells efficiently

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It also drives mitochondrial oxidative phosphorylation

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the core operation of the brain cell's power plant

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Put simply

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estrogen is the plant manager of the brain's power station

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What happens in perimenopause is

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this manager does not suddenly quit

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but starts showing up only now and then

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Some days it comes to work

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full of energy

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and estrogen spikes even higher than normal

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Other days it is absent for days on end

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and estrogen crashes to rock bottom

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This is completely different from postpartum depression

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postpartum is a cliff edge drop within forty eight hours

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progesterone and estrogen plunge from their peak to near zero

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that is a chemical tsunami

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it hits hard

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and passes relatively quickly too

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But perimenopause is a different kind of torment

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it is a hormonal roller coaster that swings high and low erratically for years

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Every day your brain wakes up not knowing

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whether today's fuel supply will be plentiful or cut off

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Professor Brinton calls this state the brain's bioenergetic crisis

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In 2024

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Professor Mosconi at Cornell University

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using a radioactive tracer called fluoroestradiol

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did a brain imaging study

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and she found something shocking

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on the surface of brain cells in perimenopausal women

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the density of estrogen receptors was significantly increasing

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What does this mean

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Your brain cells are frantically growing more antennas

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trying to catch the increasingly scarce estrogen signal

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just like the worse your phone signal gets

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the harder you hold your phone up high

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And Mosconi found

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that women with higher receptor density

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had worse memory

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and more severe emotional symptoms

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Your brain is not degenerating

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it is struggling

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it is using every possible means to keep running normally

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Layer two

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it is not just an energy problem

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your emotional regulation system is also being dismantled

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Estrogen does not only manage energy

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it also directly regulates the three most important mood chemicals in your brain

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The first

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serotonin

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serotonin is the neurotransmitter that makes you feel life is bearable

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Estrogen regulates the activity of the serotonin synthesizing enzyme

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in other words

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estrogen is the quality inspector of the serotonin production line

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when the inspector only shows up now and then

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the production line falls into chaos

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The second

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GABA

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GABA is the brain's braking system

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Remember the allopregnanolone I mentioned when talking about postpartum depression

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its chemical structure is almost identical to sedatives

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it acts directly on GABA receptors

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it is a natural tranquilizer

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In perimenopause

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progesterone drops

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and the supply of allopregnanolone becomes intermittent too

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your braking system works on and off

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The third

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brain derived neurotrophic factor

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this name is too long

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you just need to know it is fertilizer for brain cells

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without it

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the connections between neurons become fragile

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new memories are hard to form

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and old memories are easily lost

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Estrogen fluctuations directly affect the secretion of this neurotrophic factor

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Three production lines break down at the same time

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serotonin is disrupted

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and your mood sinks

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GABA fails

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and you get anxious and sleepless

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the neurotrophic factor drops

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and your memory gets worse

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These are not three separate symptoms

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this is one unified neurochemical event

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with a single source the chaotic swings of estrogen

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Layer three

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is a reality that makes me very angry

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One survey found

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that when women see a doctor for perimenopause symptoms

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thirty nine percent of them

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get antidepressants as their first prescription

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rather than hormone replacement therapy

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More than a third

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What does this mean

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It means that a huge number of women

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whose problem is clearly a broken estrogen supply chain

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are treated by doctors as psychiatric patients

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In 2024

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The Lancet published a very important review

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a team led by Professor Brown

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analyzed twelve prospective studies and concluded

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there is no convincing evidence

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that menopause universally increases the risk of depression

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the raised risk mainly occurs in specific subgroups

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women with severe hot flashes badly disrupted sleep

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or a history of depression

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More importantly

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this paper clearly warns

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that wrongly attributing psychological distress to menopause

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can harm women

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because it delays accurate diagnosis

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and delays effective psychotherapy

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And the reverse is also true

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treating an emotional breakdown clearly caused by hormones as depression

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using antidepressants for a problem they cannot solve

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is also a form of delay

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This diagnostic dilemma

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is the most overlooked trap of perimenopause

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its symptoms overlap heavily with depression

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insomnia low mood declining concentration

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social withdrawal loss of interest in life

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but the causes are completely different

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one is a primary failure of the neurotransmitter system

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the other is a secondary chain reaction triggered by hormone swings

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and the treatments are completely different too

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If you are a woman between forty five and fifty five

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and you have recently started having these symptoms

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and your doctor has not asked you one basic question

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have there been any changes in your menstrual cycle lately

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then you need to find a different doctor

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Layer four

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is about brain fog

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the cognitive symptom perimenopausal women report most often is brain fog

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feeling like your head is filled with paste

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thinking feels like walking through water

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In 2023

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a research review by the Metcalf team found

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the cognitive functions most affected in perimenopause

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are verbal learning and verbal memory

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that is the word on the tip of your tongue that will not come out

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the experience of forgetting what you just read

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At the same time

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processing speed attention and working memory can also be affected

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But this study also found a very important fact

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the cognitive performance of perimenopausal women is heterogeneous

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some people actually get stronger in certain cognitive areas

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while others get weaker

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This is not a uniform pattern of decline

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it is more like the brain reallocating computing resources

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Remember Professor Hoekzema's research I mentioned when talking about postpartum depression

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pregnancy causes large scale structural changes in a woman's gray matter

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just like synaptic pruning in adolescence

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the perimenopausal brain is doing something similar it is not damage

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it is reorganization

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Your brain is adapting to a whole new hormonal environment

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and this adaptation process is chaotic and painful

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but it is not a one way street

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Professor Mosconi's brain imaging research also supports this

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she found that the brains of perimenopausal women do change in structure

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connectivity and energy metabolism

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but some of these changes gradually stabilize after menopause

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Your brain is not aging

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it is crossing an extremely long threshold

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But the cost of crossing it is real

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forty to sixty percent of perimenopausal women experience insomnia

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And what is insomnia

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it is the only window for the brain to repair itself being blocked

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I said in the anxiety episode

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that sleep deprivation makes the amygdala's response to negative stimuli

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increase by more than sixty percent

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while prefrontal function declines

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It is another vicious cycle hormone swings cause insomnia

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insomnia worsens cognitive and emotional problems

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cognitive and emotional problems worsen anxiety

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and anxiety worsens insomnia

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Layer five

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is the cultural layer

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the word menopause

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in the Chinese context has become an insult

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are you going through menopause

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the subtext being you are irrational you are irritable you are unreasonable you are old

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This label does more damage than the condition itself

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China has about two hundred and ten million women currently in perimenopause

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but survey data shows

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about seventy percent of women

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attribute their symptoms to being run down

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or just getting old

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which leaves intervention seriously delayed

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Your body is going through a system level neurochemical reorganization

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and your culture is telling you this is called getting old

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just tough it out

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This is the same as postpartum depression being called being dramatic

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anxiety being called overthinking

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depression being called not being strong enough

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it is exactly the same pattern

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society replaces a diagnosis with a label

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and replaces treatment with a throwaway line

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Every episode I make in this series

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hits the same wall your suffering is not a character flaw

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it is a physiological event that can be scientifically measured and medically treated

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Having said all this

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I should talk about what to do

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First

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see a doctor

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but not just any doctor

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a gynecological endocrinologist who understands perimenopause

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the first thing you need to do is test your hormone levels

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Second

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learn about hormone replacement therapy

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the guidelines from Britain's NICE clearly state

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that hormone replacement therapy is the first line treatment for perimenopausal mood problems

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A 2022 review by the Herson team noted

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that estrogen in perimenopause note

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perimenopause not postmenopause has a significant effect on depressive symptoms

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There is a key concept here of a time window

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starting too early or too late

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gives different results

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so the sooner you recognize perimenopause

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and the sooner you discuss a treatment plan with your doctor

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the better the outcome

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Third

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exercise

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I know this sounds like a cliche

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but the mechanism of exercise in this context is very specific

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aerobic exercise can directly stimulate the secretion of brain derived neurotrophic factor

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that brain cell fertilizer

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the things your estrogen can no longer manage

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exercise can partly take over

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Fourth

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protect your sleep as the highest priority

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perimenopausal sleep problems are not just being older and sleeping badly

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it is not that simple

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your brain is undergoing a system level overhaul

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and deep sleep is the only construction window for that overhaul

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block this window

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and the overhaul fails

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If your sleep problems are severe

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see a sleep specialist

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Fifth

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tell the people around you what is happening

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your partner

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your children

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your colleagues

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not to win sympathy

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but to help them understand

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you are not being unreasonable

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your brain is going through an energy system switchover lasting years

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what you need is not stop overthinking

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but I know you are really uncomfortable

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I am here

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Finally

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I want to say something that moves me deeply

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when I talked about postpartum depression I said

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humans are the only primate on earth

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that lets a mother raise a child alone

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today I want to add one more line

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humans are also the only species that lets women cross menopause alone

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In traditional societies

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older women were the center of wisdom for the whole community

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after they no longer bore the task of reproduction

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they became the tribe's mentors mediators and keepers of knowledge

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anthropologists call this the grandmother hypothesis

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the reason women evolved a lifespan far beyond their reproductive years

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is that after menopause

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they held irreplaceable value for the survival of the whole group

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But what has modern society done

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it has redefined this stage into a derogatory term

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from the moment a woman's reproductive value is drained

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she is labeled as expired

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This is not a verdict of biology

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this is cultural violence

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Your brain is not aging

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it is switching to a new mode of operation

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This switching process is painful

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it is chaotic

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but its endpoint is not decline

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it is another steady state

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You are not becoming a worse version of yourself

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you are crossing a storm

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toward a brain no longer held hostage by the hormonal roller coaster

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If you are going through perimenopause

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or someone around you is going through it

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how are you facing it

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what experiences what confusions

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what have you always wanted to say but no one has ever asked you

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tell me in the comments

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I am Leo Wang and I will see you next time