The Truth About Your Brain in Your 40s
By Leslie Price
Dr. Louann Brizendine graduated from Yale School of Medicine, has a degree in Neurobiology from UC Berkeley, and did her internship and residency at Harvard Medical School. She also served on both the faculties of Harvard University and University of California at San Francisco, and is the founder of the Women’s Mood and Hormone Clinic at UCSF. She’s the author of The Female Brain and its follow-up, The Male Brain. Her new book, The Upgrade, is out in bookstores now.
I appreciate the way that you frame the book at the very beginning, when you say the terms used for this period in life – perimenopause and menopause – are really medical establishment terms. And as such, they focus on fertility.
That's all the medical profession focuses on. You go to your OB/GYN and that's it, that's what they do, you know?
When you’re going through puberty, there's a lot of information, and it’s the same with pregnancy. But there's really not a guide to this. And women want to know what's coming for them and what they should be doing now to prepare.
In school, they give you the class on all this stuff about your period. The Our Body, Ourselves book from back in the 1970s was so helpful in a lot of ways. I wrote this book with the idea that it was a modern kind of Our Body, Ourselves or What to Expect When You’re Expecting.
When you think about that, it really makes you understand why – if there's so much focus on fertility and we view this as the end of the fertility period – there's such a dearth of information. We even frame aging through fertility. It makes sense why society wouldn't value what's happening to us.
Which is only halfway through your life, or less. I think younger women are the ones that need to rattle the cage on that thing. Like, hell no, I won't go.
One of the things I took away from this book was that there are so many options for women, but they need to be tailored very specifically to each individual.
Having practiced medicine and having all these patients at The Women's Mood and Hormone Clinic, I've never seen one woman that was like another woman. Each one is so different; there are so many moving parts. Of course, there's a lot of overlap – it's got to do with mood, sleep, wellbeing, libido, and health. And how your brain functions in terms of your anxiety, depression, or outlook. It's not infinite, but it's quite different for each person.
You cover hormone therapy a lot in the book. I appreciated that you phrase it as “hormone therapy” instead of “hormone replacement therapy,” because when you say replacement, it's like, oh, you're deficient.
People get all crazy when you talk about hormones. You're not necessarily making up for a deficiency – sometimes you are – but you're adding and you're finding the right level. At age 35, you need a certain amount of estrogen. And then at 45, you may need to have some added back because you are getting a little bit low in your ovary tank.
It seems like hormones and hormone therapy are really important in a way that I didn't previously recognize – and that there’s an age where it's most beneficial.
Let's start with the bone piece, because bone strength for women is kind of maxed out at 35 years old, on average, and then you start to go on a decline. And so, for a lot of women that have osteoporosis in their family (typically white, athletic women without much body fat end up having more osteoporosis). Estrogen is the main thing in our bodies that keeps your bones strong.
Say you get a bone scan at age 35, and find that you're in the lowest 10 percentile. You want to top that up [with estrogen], because you want to preserve your bones. That's very well known in the bone-doctor world. But when the Women's Health Initiative came out, it was terribly flawed and got every doctor in the country to freak out and not be willing to prescribe [hormones]. A lot of women are still having trouble getting anybody to prescribe to them. In those days, they didn't have the test for the breast cancer gene. And so a lot of women in that study were not screened out who had the breast cancer gene. It was a mess.
So there are a lot of women who ended up having osteoporosis in the last 20 years.
And then, you get the issue of mood and anxiety disorders. Roughly 25% of women in their life will have a major depression or anxiety disorder. It’s not as if you can just take estrogen and it's like Prozac or anything, but it does help a lot of women to keep those levels consistent. The ratio of depression, male-to-female, is one-to-one during childhood. But by age 14, it's a two-to-one ratio, more female than male. It's clearly got to do with the fluctuations of hormones and the menstrual cycle. We don't like to hear that. That’s not fair. We have to bleed every month, and we have to have more depression and anxiety.
It can be quite disabling. We basically put women on a version of the birth control pill constantly for the whole year. That can balance a lot of people out. It's not done very often, because only 20% of doctors feel they know enough about hormones to even prescribe them. And in the OB/GYN field, some of them have had one, two, or even zero lectures in their whole residency on HRT. In the last 20 years, it's gone away. It's only the older doctors now, because they were practicing in the nineties. A lot of them are retiring. The younger doctors have had no education in it, which leaves you younger women in a horrible position.
What about the suggestion that hormone therapy could safeguard against dementia?
Why women have more Alzheimer’s than men is under a lot of research right now. One of the big things that women have that men don't is: Our hormones fall off the cliff basically at age 50, while in men, testosterone gets metabolized in the brain into estrogen by aromatase. A 60-year-old man has four times the estrogen in his brain than a 60-year-old woman.
That's why they are thinking that estrogen may be protective for brains, including male brains, against developing dementia and Alzheimer’s. That’s another reason that, if a woman is having lots of symptoms in her mid-forties, she should know that she can start on estrogen at that time.
In the book, you talk about how our brain shifts away from multitasking, and how disorienting that is. As someone who loses track of my thoughts so easily when I’m distracted by someone, I know this feeling. It’s frightening.
A lot of women 40+ have the experience you're describing. They are terrified that they may be getting dementia. That’s why I talked about increased focus and there’s a story of a woman [in the book] who was saying, “please email it to me.” You're finding a workaround.
I was used to holding many things in my head at once when I was younger and I would just say, well, I’ll do it later. Now that I'm older, I realize if something needs to be done, I'm going to do it right away because I don't want to forget it. It's a very common change, part of “the natural aging process.”
A portion of the book tackles a phenomenon that a lot of my friends have experienced, which is that all of a sudden, your menstrual cycle is different and you're just dumping blood.
We call it flooding. You're flooding.
That’s obviously hormone-related. Can you explain that? Because it’s another thing that no one explains to you.
Flooding can happen. It's not anything abnormal. I mean, obviously if you’ve got unexpected bleeding, you should get it checked out to make sure you don't have some kind of tumor growing or something like that.
But the thing that can happen is we have our eggs and our ovaries are developing during that follicular cycle, when the follicles are developing. And then you have an eggless cycle where you don't ovulate. If you ovulate, there's that little shell, that little casing, that's left behind. That's the thing that makes the progesterone. That’s the progesterone manufacturing organ, that little shell that's left behind once the egg pops out, but it doesn't pop out. It doesn't convert that shell into progesterone formation. So you don't get any progesterone that cycle.
And what does progesterone usually do? Well, the progesterone usually starts to increase after ovulation, which means that it makes sure your uterus holds on to that nice cushion of blood in case there's a fertilized egg. And then, in those last two days before the bleeding starts, the progesterone all of a sudden crashes down – it disappears really quickly. That's what causes the shedding, which stimulates the whole cascade of events that causes the shedding of the blood starting your period. If you have a cycle where you don't have that progesterone, you might just shed a little bit of blood, but then the second month, all of a sudden you have a whole egg cycle that's coming, and you have almost two months worth of buildup.
Between the ages of 40 and 50, women can get a lot of flooding and even get big clots that plop into the toilet that really freak people out. They think, did I just have a miscarriage?
That's why doctors often put you on progesterone, or the mini pill, or the Mirena. That will keep the lining of your uterus low. If you're going on the pill, then it totally regulates your cycle. It’s normal that happens during that stage of your ovaries running out of eggs, where you’ll have an eggless cycle.
The book also covers SSRIs, which is obviously a big topic for women in this age group. Specifically, you mention microdosing liquid Prozac. Is this a common treatment?
I've been doing it at my clinic for about 20 years. I still have women that come back and say, “Thank God I had that little bottle in my refrigerator for those two or three years when I was going through it; it saved my life.” The reason I started using liquid Prozac is because when I started prescribing it, it was the only SSRI that was made in liquid.
Let's be clear: If it's full-on clinical depression, you're probably going to need a regular dose. The microdosing gives a little bit of a cushion for people's mood and anxiety. The typical starting dose with Prozac is 10 milligrams. With the liquid, I often start women on one milligram.
Some of my patients need to be on two milligrams or even five, and some take half a milligram. It's very tailored. As a doctor, I want to give my patients all the information and the toolkit, and then together, we can test drive things to see what works for them because each person's body is different. This is very, very individualized treatment. And right now, the doctors who do that are more in the concierge-medicine type practices. It's wealthy women who see these doctors. Because your Kaisers and your HMOs don't have the doctors who are trying to do this.
We have to get this information out there so that women can really push their own healthcare systems to get with the program.
Okay, so say we know we're going to go through this period of time – which could be two years, or 14 years – that could be turbulent. What's on the other side? Stability?
Yeah. That's why I call this The Upgrade. There are no more periods, which means a whole lot of things. It's not just about the blood; you're basically able to feel an increased sense of fluidity and not have the rug pulled out from under you every few weeks.