A few months ago, I had the opportunity to interview Dr. Bethany Hays. We had lunch together and I was hoping to introduce the idea of the Sanity Papers and suggest an interview. Quickly dispensing with all that, she launched into a discussion of human sexuality and how hormones had shifted in the last few decades. I told her that I had not expected her to jump into a serious conversation so quickly. She laughed and the mutual friend we were with said, “Bethany is never not serious!”
Dr. Hays trained in OB/GYN but eventually integrated what she learned into a Functional Medicine practice. As opposed to talking to your GP for a few moments and being rushed out, clasping a prescription in your hand, Functional Medicine is about the physician inquiring into the well-being of the person as a whole. Listening is key. Often patients will reveal details in a longer story that can lead to a much better diagnosis and, consequently, a much more successful rate of care and cure. Dr. Hays is the former director of True North, in Falmouth, Maine. After practicing for over 32 years, Dr. Hays has retired—she says! This means that now she is mostly lecturing and training physicians to treat the whole patient.
She is simply one of the most intelligent people I have ever had the delight of speaking with—and one of the wisest on the issues addressed in the Sanity Papers: menopause, hormones, and women’s health. There’s a surprise at the end where she discusses what she is certain are the real causes of the rising numbers of children who develop autism.
Dr. Bethany Hays (BH): The issue about women changing their gender identity is interesting in a couple of ways. One, there’s gender identity and then there’s gender preference; in other words, there’s what you identify as, which is on a sliding scale, and then there’s your preference for a partner. Those two go together, so you can be way over on one side in your female identity and way over in another direction in preferring females. And I also think that what determines those two scales in men is very different than it is in women, partly because the default position for the brain is female, and it takes testosterone to make a female brain into a male brain. In a culture right now where there’s so much endocrine disruption, most of the chemicals in the environment that are detrimental to humans are pseudo-estrogens, which feminize the brains particularly of males and gives them a gender identity which slides to the female end of the spectrum. Then preference is often determined both by experience and level of desire; so, if you’re a person who has been sexually abused as a child, you have a much higher chance of choosing a lesbian lifestyle, because for women to feel good with sex they have to feel safe. I think what plays out with men is a much stronger desire for sex that has to do with high levels of testosterone; men want sex and want it a lot, and the people who also want it as much are other men, so you end up seeing more male/male encounters that are satisfying. What happens with menopause is the balance between male and female hormones shifts—before that, women have spikes of testosterone right at ovulation to get themselves pregnant and right before their periods to keep them married, and the rest of the time women are interested in sex for relationships, not for release of tension or the other kinds of things that men use it for. At menopause testosterone levels actually stay normal, but your estrogen levels drop off precipitously, so for a while you have a much more testosterone-dominant physiology that interacts with how your brain was formed, and what your life experiences were and currently are. I would think for many women in menopause it could flip in either direction, because if you’re extremely hard-pressed the stress hormones pull testosterone out of your system, and if you’re insulin resistant or diabetic then testosterone levels can go up. The sum of it is that there are many variations of what your hormone levels are doing at menopause, so it’s interesting to ask the question of what happens in utero, what happens in experience, what are the parameters that determine sexual identity, and what are the circumstances that determine sexual preference.
Madeleine Burnside (MB): I think we need to be asking many more questions about sexuality and sexual fluidity as they’ve traditionally been characterized, especially in cases where it’s not obvious what an individual may want to be in that way.
BH: That’s just the biological part, and then there’s the whole cultural overlay of belief systems.
MB: I’m sure I’m at the top of the bell curve, because I have distinct early memories as a child of being parked in my little stroller outside the grocery store and these ladies coming up to me saying oh, what an adorable little boy, and I thought to myself you have no idea that I’m a little girl. On the other hand, when I was told that I was definitely a girl my response was what do you mean? I want to be a policeman when I grow up! And of course I was told I couldn’t be a policeman because I was a girl. I thought sexuality was a choice, and I didn’t realize that it was in some way predetermined. I had no siblings so even from that fundamental point of view I hadn’t a clue. I thought people decided. I remember thinking how unfair, and it couldn’t be true…
BH: My message as a young girl was that you’re able to be anything you wish as long as you want it badly enough. So when I said I wanted to be a doctor that was fine, though what I didn’t understand were all the challenges I was going to encounter because I was a woman. The women in my generation of medicine had to do twice as much to get half as much credit.
MB: Another point I’d like to hear your thoughts on has to do with interviews I’ve had with many women who’ve had hysterectomies at 38 or 40.
BH: Yes, and there was a time in the United States where half of women had had hysterectomies by the age of 40, and that’s the group they looked at when they did the women’s health studies. And though that’s no longer the case it’s still more than it should be. If you take a woman’s ovaries out before the age of 50 you take eight years off her life, unless you replace the hormones, which they’re not doing anymore. Those high hysterectomy rates came out of the early-20th century, when mental illness in women was considered to be a form of hysteria, and they did quite horrifying things to women to rid them of that. Or they got the rest cure, where they were put into a dark room for months at a time and fed nothing but gruel, which of course did not help their mental health because they became nutritionally deficient as well. They were basically incarcerated until they agreed to stop complaining.
MB: One of the stories that got me started on the Sanity Papers project was Mary Todd Lincoln’s, who of course was institutionalized because her son couldn’t tolerate the fact that she cried all the time. He had her put away, but she was fairly quickly able to argue her way out because she had powerful friends who took her seriously. But she was 56, and her husband had died in her arms, two of her sons had died, one in 1850 and another in 1862, and she was going through menopause. Now, do you think she might be suffering with major depression? What else was there for her to do except be horribly depressed and take opiate drugs, which she did. One of the museums where I worked actually purchased what they called The Insanity Papers, which were all the clinical and legal records around her forced confinement. Although I don’t find her to be an interesting person for most of her life, the institutionalization piece so clearly had menopausal elements of some sort, even if it wasn’t the whole picture. I’ve certainly had interviewees who’ve told me they sat around crying for months, and that’s one of the ways it takes people. I remember reading that in nineteenth-century France, for instance, neurological and anatomical pathology clinicians like Jean-Martin Charcot were big on this whole idea of identifying the origins and stages of hysteria, pinpointing it from as early as the age of 20. Among numerous other studies and hypotheses, he performed surgical experiments on prostitutes to see what he could discover and record about the condition; and they were prostitutes, so nobody was going to complain.
BH: At Baylor, where I trained, we saw one woman after the other with heavy periods and heavy cramps and pain, and there wasn’t really pathology so we called it dysmenorrhea menorrhagia syndrome; that’s what you do in medicine when you don’t have a diagnosis, you classify it as a syndrome, which is important to know when they tell you that you have a syndrome. It was an excuse to take uteruses out. There were several guys who, after graduating from Baylor, went down to the Rio Grande Valley, where the story was they took out every uterus they could find. They were throwbacks, just making money by performing surgeries, which they loved to do; the rumor came back that there were no uteruses left in the Valley. What happened to women was determined also by where they lived and who their doctors were and who trained them. In my case I loved surgery and was good at it. When I decided to go into OB/GYN, the head guy said well, you can’t go into OB/GYN because it’s not a subspecialty for women. I said wait a minute, it’s all about women, and his response was, well, but it’s a surgical subspecialty, and my reply was, so, you don’t think women can sew? That kind of stopped him in his tracks. I went ahead and became the first female resident in my OB/GYN program and the first woman to become chief resident. They had to change their minds about me more than once.
MB: Well, it’s amazing the number of women I’m seeing who’ve had their menopause precipitated by a hysterectomy. It’s incredible.
BH: Yes, even if they didn’t have their ovaries out. If you do a hysterectomy and leave the ovaries in, you have to cut between the ovaries and the uterus; there’s a ligament there that has a blood supply in it, so about half of the blood supply to the ovaries comes through the uterus. When you chop that off and if the other side can’t take over the ovary becomes dysfunctional. In fact we knew it became dysfunctional, because one of the reasons we’d do a hysterectomy was to get women to quit ovulating and having PMS and ovulatory hormone-fluctuation types of symptoms. We knew if we took their uterus out and left their ovaries in they didn’t go through menopause, at least not right away. But then they stop ovulating and as a result have an imbalance of estrogen and progesterone, and not ovulating means they don’t get the progesterone that counteracts the estrogen, which increases all kinds of estrogen-related problems. Until women discovered that they could take progesterone orally or trans-dermally there were a great number who had hysterectomies or even tubal ligations. Some women who’ve had tubal ligations have damage to the blood supply bad enough that they stop ovulating, or they don’t make enough progesterone and become estrogen-dominant, which increases bleeding and fibrosis and endometriosis, and probably the chances of getting breast cancer.
MB: Obviously I’m very interested in the variety of experiences, but I’m also interested in what makes them happen. Part of my historian’s perspective is looking at the factors that go into a person’s self-description of their own experience, whether it’s cultural bias or things that happened they don’t understand or they do understand. I’ll never interview a sufficient sample because I’m not going to speak to thousands of people, but I’m attentive to the underpinnings as well as the narrative; otherwise stories are just stories and there’s no real context for them.
BH: The other overlay that’s affecting us more and more, and will be until the guys figure out that it’s affecting them too, is the effect of the contamination of the environment, which primarily implicates women. It also affects men, but the difference is that men have such a reserve in terms of their fertility, and we’re only now beginning to see the impact on sperm counts. When I trained the normal sperm count was sixty million, and now it’s twenty million. Normal is what gets most women pregnant, so when it was sixty million there was a far larger reserve and men could get a lot of marginal women pregnant. But as women begin to have more trouble, the lower sperm count has raised the infertility rate in couples dramatically over the time of my medical career. The sneaky thing that these environmental pseudo-estrogens do is change women’s estrogen signaling, but it’s not changing their lab work because nobody’s testing for it; so the lab work looks normal or low because the body’s trying to compensate for all this exogenous estrogen, but women are getting breast and uterine and brain cancers and all kinds of neurological and immune system imbalances. The second big overlay is immune system dysfunction, because estrogen is a huge affecter of the immune system. Autoimmunity is where your immune system mistakes some tissue in your body for a foreign invader. It has to do with damage to the system itself and the gastro-intestinal barrier that keeps pouring things out, and how your immune system interprets the foreign invader and then searches for anything that looks like that; and if it sees tissue that belongs to you, if it looks like part of what the immune system is trained to make antibodies to, you make antibodies. The big one that women have is autoimmune thyroid disease, which is so common now they just put you on thyroid hormone if your TSH [thyroid-stimulating hormone] is elevated. Women have this at something like a ten-to-one ratio versus men. Women also get all the autoimmune diseases more often, and attacks on their endocrine organs including the adrenals, which leads to lowered resistance and inflammatory problems like cancer—breast cancer, for example, is an inflammatory disease. And if affects the production of cortisol, which in turn affects sleep and increases fatigue and depression. All these sort of track together Here’s an interesting fact: one article I read said that the incidence of autoimmune attack on the ovary at age 20 is one in ten thousand, at 30 one in a thousand, at 40 one in a hundred, and at 50 one in ten, which I guess would mean that by 60 every woman who’s lived long enough has an autoimmune attack on their ovary. And that’s the incidence of premature ovarian failure. They stop at 40 in this model, but I kept going and thought wait a minute, is menopause autoimmune related? Nobody has a test for incidence of autoimmune attack on the ovary because it has so many proteins that you can become isoimmunized, so the only people looking at antibodies to the ovary are researchers. No one’s paying attention to any of this and asking the question is this what causes menopause, or how often does it affect menopause.
MB: Well, most animals don’t survive menopause, with the exception of killer whales and pilot whales. So is that because autoimmune disease has taken over and essentially killed them?
MB: That’s interesting.
BH: Well, we don’t know if we have autoimmune ovarian disease because we know the ovaries don’t do anything after menopause, which also happens to be not true, because what they do primarily after menopause is create testosterone, which they continue doing for the rest of your life. So if you have autoimmune attack on the ovary it disrupts not only the production of estrogen but testosterone too. When you have not enough testosterone, the binding globulin that keeps estrogen and testosterone bound up and out of trouble goes up; then, what little estrogen you have which is being made in fat cells to keep your brain and bones healthy after menopause gets bound up and now you really are castrated. Super castrated, because you’re both not making what the ovary makes and you’re not able to use what the rest of the body cells that make estrogen are producing. So, you would think controlling testosterone in older women would be extremely important, right? There are no bio-identical testosterone products for women; well, the one product that is available is an oral methyl-testosterone, which was taken off the market for men because it caused liver cancer, but is still on the market because it’s the sole FDA-approved product for women containing testosterone.
MB: I think this conversation is going to have a great deal of relevance. I sometimes send these materials to my doctor, who is a man.
BH: If your doctor didn’t get it in medical school and the drug reps don’t give it to him he won’t have it, unless the materials you give to him, or what you as a patient say or do, trigger him to find out on his own. But it’s all there in the literature. He’s not going to find it in the North American Menopause Society, which until recently has been run by men.
MB: Well, Dr Lynnette Leidy Sievert, a biological anthropologist who’s done extensive fieldwork and writing around the evolution of menopause and post-reproductive ageing and with whom I’ve spoken at some length, has recently come off the NAMS board. And I personally would hope to be able to consult professionally and on a personal level with you about some of my recent health issues and concerns.
BH: There are important things that women need to know about breast cancer, and most recently it’s been figured out that there are essentially two peaks of breast cancer: there are the early ones in your fifties and early-sixties, and those are hormone-related, and then there’s the increase that happens with growing older, and those are age-related. We really shouldn’t be talking about them in the same sentence. Hormone-related cancers often go away of their own accord if you don’t provide estrogen. They are generally easier cancers to deal with because they’re hormone-receptor positive, unless you’ve got the BRCA gene, which is much worse because it gives you old-age cancer very young. The HER-2 positive cancers are actually old-age cancers. But aside from that, the hump that happens in your fifties didn’t used to happen. I’ve got one slide that shows the incidence of cancer at different ages in five-year increments from 1950 to 1985 and beyond, and what we’ve seen is a gradual but steady increase in these hormone-related cancers.
MB: I’m the only woman in my family on either side who’s had breast cancer at this age; we all have longevity, and the one other person who got it was my aunt when she was 80. She totally dealt with it and she’s still fine. But I had a relatively minor case, it was DCIS [ductal carcinoma in situ] a couple of years ago, and now I’ve got something going on with a large lump that they haven’t yet been able to diagnose. My doctor said it might be lobular cancer, which is hard to detect but easy to treat, but I’m having a procedure in a few weeks time that will give us all a better idea of what’s going on. I’ve had a mammogram and then a sonogram and then an MRI, all of which weren’t determinative, so now they’re going to take it out and go from there.
BH: You mentioned that you had radiation, and though I would think it’s too soon for that to have caused another cancer in you, radiation can further harm cells that are already damaged. But whatever brought you to the first cancer has not been addressed. If you get another cancer and it looks like the first they call it a recurrence. If you had a cancer and the lymph nodes were negative, suggesting that it hadn’t spread, and nothing shows up in a distant location in the next two years, then if you get it again that’s a new cancer. No one should get a second cancer regardless, but nobody’s telling you how to keep that from happening. There are five things you need to look at: inflammation; insulin resistance and diabetes; infections; toxins; and hormone levels and metabolites. And all of those can be addressed from a functional medicine point of view. There are also nutritional, dietary and lifestyle approaches, most of which come back to what your grandmother told you. And there are some supplements that can move matters along; for example, methylation is critically important for preventing cancers. Most cancers start with a demethylation process, because as we age we have more and more trouble making methyl groups, which are useable carbon atoms. As a carbon-based life form you can imagine that might be important. A growing part of the population is having trouble making methyl groups because we started putting folic acid into pregnant women. Back in the 1970s they discovered that babies with neural tube defects were often born of mothers who were folic deficient, so they started giving high doses of folic acid. That put an end to most of the neural tube defects, but it also got rid of the miscarriages of women who were genetically unable to activate folate. And if you can’t activate folate you can’t activate methyl groups, so a whole bunch of babies who would have aborted, who had those genetics, got through and were born massively folate deficient, which leads to autism. And now we have a much higher incidence of folate metabolism genetics in the population, so there’s a far greater need for B vitamins, which is what makes methyl groups. If you don’t make those groups your DNA gradually becomes demethylated and accidentally opens up cancer programs, or rather some of the same kinds of embryonic programs that grow and divide before birth but have no good use thereafter.