The Menopause Timeline Most Women Never Learn Until Midlife | Dr. Jessica Shepherd

Most women don't hear about perimenopause until they're already deep into it, sometimes a decade in. This week, guest host Karen Walrond talks with OB/GYN and Generation M https://amzn.to/4qepJp3 author Dr. Jessica Shepherd about the actual, gradual shape of that transition, the real math behind hormone therapy decisions, and why nearly 40% of a woman's life happens after menopause even begins. It's less a symptom checklist than a new starting point for the next several decades. What you'll explore: The gas-tank way to picture where you actually are between reproductive years and menopauseWhy symptom severity has almost nothing to do with how "together" you otherwise areThe difference between the "symptom bucket" and the "longevity bucket" in deciding on hormone therapyWhy perimenopause itself splits into an early, mid, and late phase, and why the late phase is the window with the most protective upside for starting hormonesWhat the SWAN study found about how menopause symptoms differ by race, and why that matters long-term If you've been treating menopause as a phase to survive rather than a stage to prepare for, this resets the starting point. You can find Jessica at: Website https://www.sanctumwell.com/ | Instagram https://www.instagram.com/sanctummedwellness/ | Episode Transcript https://www.goodlifeproject.com/podcast/perimenopause-symptoms-hormone-replacement-therapy-menopause-muscle-loss-jessica-shepherd Next week, we're sitting down with Priya Parker to talk about why conflict, handled well, might be one of the things that makes your closest relationships stronger instead of weaker, and what most of us get backwards about the moment right before it happens. Be sure to follow Good Life Project wherever you get your podcasts so you don't miss any upcoming episodes! Midlife Design Lab: I'm opening up an intimate retreat with me and a small, curated group in Boulder, CO (Oct 24-25, 2026), followed by 3 months of virtual group coaching. A few weeks back, I shared something I'd been building for myself, and the response blew me away, so spots are limited and I expect them to fill fast. If this calls to you, apply here https://jonathanfields.substack.com/p/midlife-design-lab-update-and-invitation?open=false#%C2%A7midlife-design-lab-immersion. Check out our sponsors and resources: Visit Our Sponsor Page https://www.goodlifeproject.com/sponsors/ Hosted on Acast. See acast.com/privacy https://acast.com/privacy for more information.

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:00Jonathan Fields?

  So here's a myth, menopause is something to survive quietly and get through as fast as possible. Turns out that myth might be more dangerous than the symptom it describes because it's exactly what keeps women from asking the right questions at the moment that they have the most leverage over the next several decades of health. In this conversation, you'll discover why perimenopause itself splits into an early, mid, and late phase, and why the late phase carries the most weight in hormone decisions. You'll learn how to build the kind of symptom storyline that gets a doctor to actually listen, the real risk versus benefit math behind hormone therapy beneath the headlines. You'll learn why the

• 0:41Jonathan Fields?

  data on menopause symptoms looks different by race and what that means long term, and why nearly half a woman's life happens after menopause even begins. Sitting in as my guest host is a dear friend, author, and leadership consultant, Karen Walrond, in conversation with board-certified OB-GYN and Generation M author, Dr. Jessica Shepherd. I'm Jonathan Fields, and this is Good Life Project. We'll jump right in after this short break.

• 1:14Speaker 01

  With no fees or minimums on checking accounts, it's no wonder the Capital One Bank guy is so passionate about banking with Capital One. If he were here, he wouldn't just tell you about no fees or minimums. He'd also talk about how most Capital One cafes are open seven days a week to assist with your banking needs. Yep, even on weekends, it's pretty much all he talks about, in a good way. What's in your wallet? Terms apply. See CapitalOne.com/Bank. Capital One, N.A., Member FDIC.

• 1:44Speaker 02

  Support comes from Wise, the smart way to manage the currencies you need around the globe. Fed up with losing out to hidden fees when you send money abroad with your everyday bank? Choose the smart way, Wise. You can count on the exchange rate you'd usually find on Google. No unwelcome surprises. Plus, ditch that "where's my money" feeling. Most transfers arrive in under 20 seconds. Join millions, saving billions on hidden fees. Be smart. Get Wise. Download the Wise app today. T's and C's apply.

• 2:17Jonathan Fields?

  This episode is brought to you by Choiceology, an original podcast from Charles Schwab, hosted by Katie Milkman, an award-winning behavioral scientist and author of the bestselling book, How to Change. Choiceology is a show about the psychology and economics behind our decisions. Hear true stories from Nobel laureates, authors, athletes, and everyday people about why we do the things we do. Listen to Choiceology at schwab.com/podcast or wherever you listen.

• 2:48Speaker 03

  I am so grateful that Jonathan asked me to do this. I'm just going to tell you, because I have so many questions. So it's like he knew that I was going to have all these questions for you. So I've read your book. I love the book. Thank you so much for writing the book. I'm going to start by sort of the myths of menopause. You argue that the most dangerous part of menopause isn't a single symptom. It's actually the myth. So can you talk a bit about what we have wrong about menopause and what that costs us by having that myth around menopause?

• 3:23Speaker 04

  Yeah, there are so many myths that are behind menopause. And that's really why I wrote Generation M was to kind of broaden the view. I think, one, there's a fear factor behind it, right? So it's been kind of categorized as something that we should be afraid of. So there's that, that I want to change that narrative. But also, we really look at estrogen, the worth of women, what their ovaries are worth in the context of what they do to the pelvis, right? So it's kind of like all this linear fashion of how we view women in who they are and what they're able to do. Outside of that, the context of menopause

• 4:04Speaker 04

  really is a whole body experience, right? So I'll tell you, like, from, you know, from the head to the toe is, we have brain changes, we have mood changes, but even going down to just our skin, we have changes in how our skin feels, itchy skin. So because women were not able to see it from that perspective, they were going through these symptoms of, you know, a whole laundry list, but not connecting the dots to, this is a midlife transition. That is biological, is going to happen. But what do I do in those moments where I feel, is it brain fog? You know, do I have ringing in my ears? Am I irritable? All of those play a part in it. And the more that we understand, the more that we're able to make better decisions

• 4:49Speaker 04

  on how we navigate through it, because we're all going to experience it differently.

• 4:53Speaker 03

  Yeah, you know, it's so funny, as, you know, I said at the top, like, so I'm in post-menopause, and I want to talk a little bit about that. But I feel like so much of the experience that I've had in midlife, like, the symptoms are things that I've remembered or figured out after the fact, like, oh, that was probably perimenopause, you know, that kind of thing. So let's just, let's just start from sort of the beginning, right? Like, menopause isn't one event. There's three different stages of menopause. So can you talk a little bit about, like, what is menopause and what are the three stages that we go through?

• 5:28Speaker 04

  The full range of it is hormonal, in the sense of hormonal shifts, when they start, when they end, or when the decline is pretty significant. And so in our pre-menopause phase, I guess would be more of our reproductive years, when our body is in default to get pregnant, right? The ability to get pregnant is there. Now, when we go into perimenopause, is really where, I use the gas tank analogy, it's the easiest to remember, is where your gas tank is not at full, you know, estrogen in this reproductive phase. And it's not any better. It's just where our hormones are. Starts to go more into like, three-quarter tank, half tank, because as estrogen and progesterone start fluctuating, even as early

• 6:10Speaker 04

  as the age of 35, carrying on, it's going through this shift, preparing for menopause. And so that shift can be anywhere from 10 years, 12 years, from when you start, all the way up until that menopausal shift, which is where estrogen has completely declined, and now it is not giving off enough estrogen to elicit a possibility of pregnancy, right? So see how it kind of reverts back to, the body is going through pregnancy, it can get pregnant. Perimenopause is where it could, but it's less likely because of the shift into menopause, where it's not. So that's on a pregnancy hormonal level. But during all of those times is where we start to have symptoms. And the moment you start to have

• 6:55Speaker 04

  fluctuations in hormones is where women will start to exhibit symptoms. Granted, that can be differences in severity, intensity, frequency, duration. And so that really is the struggle of figuring out, oh, this is the symptom that I'm going to go through. And it might be more severe and frequent than my, you know, sister or the colleague that I work with. And that is where the conversation really needs to build into, I'm having this happen, what can I do to navigate it? And it should be no blame or shame behind it.

• 7:27Speaker 03

  Yeah. You know, it's, I remember at one point, and having like, heart palpitations, right? And like, really sort of freaking out about it. And this was way before I thought I was in perimenopause, right? I was probably in my 40s. And like, can you just talk a little bit of like, what are some of the symptoms? Because I feel like that might have been a symptom of it. Like, the symptoms are really wide-ranging, right?

• 7:56Speaker 04

  Oh, yeah. And the reason is because estrogen receptors, and testosterone and progesterone, I want to show them love as well. But estrogen really is our kind of predominant, I guess you can say, hormone when we speak in the context of menopause and perimenopause, are all over the body. So the best place to think of how I have these symptoms, why am I having these symptoms, are because there are estrogen receptors all over the body, brain, muscle, heart, bone. And so a hormone, all it is, is a chemical messenger. It's really just sending out a signal every day, and usually it follows a very tight schedule. But when you go through perimenopause and menopause, that schedule gets very jolted, shifted,

• 8:40Speaker 04

  it shows up one day, doesn't. So if it's sending a message to a part of your body, brain, heart, all the things I mentioned before, and all of a sudden that message is not as clear, not as frequent, not as consistent, then the organ that receives a message to do what it needs to do, whether that's with cognition, or my bone being strong, or my muscle mass being strong, then it can't do that. And that's what is happening over time, is we are feeling the symptoms of something that is deficient, not as often, declining, et cetera.

• 9:13Speaker 03

  So, okay, so this is so interesting to me. How can you discern whether or not what's happening, the brain fog, whatever else is happening? Like, I feel like a lot of times we're like, is it, is it menopause? Is it perimenopause? How do we get to a point where we can be like, oh, this is probably what that is. I need to go talk to my doctor about it?

• 9:33Speaker 04

  Well, I think panic mode, granted, most people get there. And it's more of an art of, I'm aware of what's going on. How severe is it? Is it impacting my daily life? Is it something that I felt three months ago, and now I feel it now? And I can maybe give it some pause to see if it's going to happen again? Those are moments that people can have. And then also finding a provider that will actually listen. And I know that sounds...

• 10:01Speaker 03

  I mean, that's cute.

• 10:05Speaker 04

  Even being a physician myself, you know, I understand how we were trained and not excusing it, but we were there to like fix a problem and you know, the hierarchy of medicine of we really know everything and you're coming in and we're going to fix you.

• 10:18Speaker 03

  Right.

• 10:18Speaker 04

  That is, you know, in, kind of in the culture of how we practice medicine. What we are starting to see now, you know, very small numbers and it's growing, is this experiential part of perimenopause and menopause that was really never addressed before. Before we were addressing it for the context of, is your hormone here? Is your hormone here?

• 10:39Speaker 03

  Okay.

• 10:39Speaker 04

  That's what we need to find a lab.

• 10:40Speaker 03

  Yep.

• 10:41Speaker 04

  What we were not bringing into the conversation was, how do you feel? How was your experience different than the lady who came to me before with the same numbers? Right? The labs can be all the same for a group of 10 women, but they all experience it differently. And that's where we need to shift the conversation into, how are you actually experiencing it? And where can I meet you there?

• 11:03Speaker 03

  Okay. So if I'm, so imagine I'm, I'm in my 40s or something and things are feeling weird, right? I'm getting those things like, and I start to think, you know what? Maybe, maybe I'm starting to enter into perimenopause or something like that. Like, what do I need to do? Like, how do I prepare myself to go to the doctor? What do I, what do I need to do in order to prepare for that?

• 11:24Speaker 04

  Like any visit, I would say, even outside of menopause is to really have a good story behind it. Like, we work well with data, right? So it doesn't help us when a patient comes in, it's like, I'm having a hot flash. And we're like, oh my goodness, how long have you been having it? How often? How does it feel? And people are like, I don't know. I just know I have a hot flash. We're like.

• 11:44Speaker 03

  Yeah, guilty.

• 11:44Speaker 04

  So.

• 11:48Speaker 04

  Being like, no, I noticed it six months ago is very slight. Now I noticed that I have to stop what I'm doing. Now it wakes me up at night. I'm also having some anxiety, which I never had before. And that's how we can like discourse and being like, okay, I'm going to bring in my medical perspective and ask you questions that are going to help the story evolve.

• 12:10Speaker 03

  Yeah.

• 12:10Speaker 04

  And that's where we can have a good starting point into what is really going on with you? Cause it's going to be different than the lady who walks in behind you. What's your story? There are some good apps out there, actually. One is Natural Cycles.

• 12:23Speaker 03

  Okay.

• 12:24Speaker 04

  And it actually helps you kind of like, put less work in, build more efficiency into building that story of hot flashes, night sweats. Not only does it help you identify them, but then it will track it for you. So that when you do go to a doctor, you're like, look at my spreadsheet and storyboard.

• 12:42Speaker 03

  Right.

• 12:42Speaker 04

  And that's, that leads into a better conversation, especially since in medicine, we don't really give time, right? We're like, tell me in 30 seconds, your whole life.

• 12:52Speaker 03

  Right, right, right, right, right. So like, should we, like, do you want a month of data? Do you want six months of data? Like if things, because what sort of panics me about that is like, if I sit there and I think it's perimenopause, but it's actually something serious, and I should be in an emergency room because it's, it's something different. Like, I don't want to feel like, oh, you should be keeping track of things for a year, right? And something's deteriorating or something like that. So what's the most helpful?

• 13:22Speaker 04

  I think what is most helpful, and this is actually a harder question to answer is because everyone walks in at different intensities.

• 13:29Speaker 03

  Yeah.

• 13:29Speaker 04

  So even outside of the menopause experiencing, like we see that in heart disease. People will be like, oh my gosh, I've had this pain in my chest for two years. We're like, why didn't you come see us?

• 13:38Speaker 03

  Right, right, right, right.

• 13:40Speaker 04

  Different, just with their acuity, their awareness. They're like, I had, so then you have the other extreme of that. I had a pain at lunchtime today and I'm here to see you. And we're like, is that the first?

• 13:50Speaker 03

  Right, right.

• 13:52Speaker 04

  You know, so that's, that is really going to go down to the person of them evaluating, how long do I typically, that usually is a very personal thing. Like people will either procrastinate, or they'll be like, I had it done today and I need it done and fixed right now, immediately.

• 14:10Speaker 03

  Right.

• 14:10Speaker 04

  So that's where, you know, I don't know if I have a correct answer, but what I will say is, you know, for anyone who's listening, when we are just speaking about perimenopause and menopause, is the attunement of awareness in your body is always helpful.

• 14:25Speaker 03

  Yep.

• 14:25Speaker 04

  Not letting it go too long before you address it, because it can always be monitored. It could always maybe go away and not come back for some time, maybe years. But the goal really is to kind of get some eyes on it.

• 14:38Speaker 03

  Yep.

• 14:39Speaker 04

  And the more that we can do that, the more that I've had patients, for example, come to me and they're like, you know, they're annual. So they're not even there for perimenopause, menopause. I typically will bring it up because I know that, you know, not everyone is aware of it. And they'll be like, you know what? Now that you've said that, I have noticed them hot flashes or sleep disturbances. And I'll be like, great, how long have you been having that? And they're like, you know, maybe three months. I'll be like, okay, let's even bring in, does it disrupt you three nights a week, seven? And they're like, no, it's not that significant. I'm like, that's okay. If it starts to now get worse, or you're noticing that it does these things and disrupting your sleep, I need you to come back to me. And they're like, got it.

• 15:23Speaker 03

  Yeah.

• 15:23Speaker 04

  So those are, you know, ways of, of creating storyboards and enhancing this conversation. Cause before it was just very, I've hit a wall.

• 15:32Speaker 03

  Yep.

• 15:32Speaker 04

  Or I don't have a symptom.

• 15:34Speaker 03

  Yeah. I mean, I think what's really been helpful about what you're saying here is also that you can start having symptoms as early as 35 or 40. And so I think just by us talking, sort of having that cognition that, oh, you know, if something is weird happening, just note it and be able to talk to your doctor about it the next time that you, you see it. So that's, that's really helpful. Okay. We don't get into the big stuff now. All right. HRT, hormone replacement therapy. I want to talk a little bit about that. And I'm going to admit to myself, I mean, I admit to you, like, not that I'm skeptical, I'm not skeptical. I believe, you know, hormone replacement therapy definitely helps women and stuff like that. But I will say that I've been very wary about it. And sort

• 16:15Speaker 03

  of my thinking is, if my body is naturally supposed to be getting rid of estrogen and all this other stuff, is it really healthy for me to be putting it back in? Or am I supposed to just sort of like, this is life and just like getting my period was life? Like this is sort of a life cycle. So can you talk a little bit about like, what is HRT? What are the options? Who should get it? Like, just sort of demystify it for me?

• 16:47Jonathan Fields?

  And we'll be right back after a word from our sponsors. Good Life Project is sponsored by FAIR. So you know the feeling when you wander into a little shop that you've never been in and within about 30 seconds, you can just tell somebody actually cares. Every candle, every notebook, every odd little thing on the shelf was chosen by a real human with a point of view and taste that you just love. It's less a store and more of a person. And it's a big part of what makes a place feel like home. That's why I love what FAIR is doing. So FAIR is a wholesale marketplace, connecting independent retailers with over a hundred thousand unique brands worldwide across home, apparel, beauty, food, and more. It's the thoughtful distinctive stuff that makes a

• 17:30Jonathan Fields?

  shop stand out and keeps regulars coming back, which matters as you plan for the holidays. Eligible retailers get 60 day interest free payment terms, plus free returns on first orders with every brand. So trying something new doesn't feel like a gamble. So sign up today and get 50% off your first wholesale order, up to a hundred dollars at F A I R E dot com slash good life. That's F A I R E dot com slash good life. Terms may apply. Good Life Project is sponsored by Ernesta rugs. So if you ever had a space that was almost right, not wrong, just close enough. For me, that's our front porch. It's where I go to think and have my coffee. But every rug we put out there has been whatever size

• 18:14Jonathan Fields?

  was available. So it just kind of floats. And I kept putting off fixing it because getting the right size felt like a whole project. Then I found Ernesta. They make designer quality rugs, custom cut to the exact size of your space. So it actually fits instead of almost fits. Their design team even helps you nail the size completely free. And you can order five oversized samples to set right next to your furniture, plus get $50 towards any rug you choose. Our porch rug is on its way and I can't wait to step outside and think, yep, that one feels like ours. Visit ernesta.com and order five samples for only $10 and you'll get $50 toward any rug of your choice. That's E R N E S T A dot com.

• 19:01Speaker 01

  With no fees or minimums on checking accounts, it's no wonder the Capital One Bank guy is so passionate about banking with Capital One. If he were here, he wouldn't just tell you about no fees or minimums. He'd also talk about how most Capital One cafes are open seven days a week to assist with your banking needs. Yep. Even on weekends, it's pretty much all he talks about, in a good way. What's in your wallet? Terms apply. See CapitalOne.com slash bank. Capital One, N A, Member FDIC.

• 19:35Speaker 04

  Yeah, I love you framed it that way and brought in your own personal experience so that I can fire back and you can be like, oh, I did.

• 19:43Speaker 04

  Where I, I, I will challenge you on a few things. This is, this is why we have these conversations. Yeah, is to bring awareness, curiosity and challenge into it is, one, you said something, and I'm glad you just like were like really honest about how you asked the question, is why would I want to put it back if it's naturally going away?

• 20:03Speaker 03

  Right.

• 20:04Speaker 04

  What I always phrase, or you know, or give a storyline behind is the advancement of life in women, right? So in the early 1900s, the life expectancy was about 59.

• 20:16Speaker 03

  Okay.

• 20:17Speaker 04

  Right. And a lot of that from the science I'll talk about later is it's pretty much if you think of reproductive kind of, you know, cavemen, we reproduce, right? And then we're like, oh, okay. Well, we're done with that. And life expectancy.

• 20:35Speaker 03

  Right.

• 20:35Speaker 04

  Now, what we have done in science and technology and innovation for both men and women is advanced life expectancy. So now it's about 79 for women.

• 20:45Speaker 03

  Right.

• 20:45Speaker 04

  Right?

• 20:45Speaker 03

  Right, right.

• 20:46Speaker 04

  So 20 years, say, we've expanded that. What we haven't done for those 20 years of being like, you can live longer, whether that's antibiotic use or just like how we have our food, all of that.

• 20:59Speaker 03

  Yep.

• 20:59Speaker 04

  We did not account for the loss of estrogen at the end of reproductive years. And now that the science clearly shows us that estrogen really is a proponent of longevity and how our organs function from head to toe, it makes sense that for 20 year gap, without estrogen, we really haven't done much for how our organs preserve or function for that timeframe, which is why women, we did well because women live longer than men. But there is about a 10 year to 12 year gap at that end of life stage where women live poorer health than men.

• 21:40Speaker 03

  Oh, wow.

• 21:42Speaker 04

  So that is where, you know, when you kind of like demystified and look at it from, you know, a broad lenses, you don't actually do not have to take estrogen.

• 21:52Speaker 03

  Okay.

• 21:53Speaker 04

  Or any hormone.

• 21:54Speaker 03

  Right.

• 21:54Speaker 04

  That is a personal choice.

• 21:56Speaker 03

  Okay.

• 21:56Speaker 04

  What we do know now is, you know, from the WHO study 20 years ago, which was the worst PR campaign for women, is that hormones, even if, you know, what people's mind usually go to is the risk associated with it.

• 22:10Speaker 03

  Yeah.

• 22:10Speaker 04

  Whether that's cancer, whatever it is.

• 22:12Speaker 03

  Yep.

• 22:13Speaker 04

  Is we now know the benefits clearly outweigh all of the risk that could ever come with taking hormones.

• 22:20Speaker 03

  Okay.

• 22:20Speaker 04

  Why is that? Because it's such a vital part of how our body functions and the ability for us to give it its best opportunity to do its good work. And I'm not shaming anyone if they don't take it. But here's another question I pose to you. When we have thyroid disruption, decline, not functioning, what do people not have a problem with doing?

• 22:42Speaker 03

  Taking thyroid medicine, taking medication. Yeah.

• 22:46Speaker 04

  Thyroid is a hormone.

• 22:48Speaker 03

  What?

• 22:49Speaker 04

  Yeah. Thyroid hormone.

• 22:50Speaker 03

  Thyroid stimulating hormone.

• 22:51Speaker 04

  Thyroid secretes hormone. It's the same thing. It secretes that messenger that I was talking about earlier to tell the body what to do. It's our metabolism hormone.

• 23:03Speaker 04

  But we don't treat the ovary like that. It gets such a bad rap. It's still cute. I do a lot of, when I look at the ovary, I'm like, you're just so cute hanging out there by yourself, just dangling, cute little one. And we will find it. And we're like, you are dead and we will not help you. So you know, the thyroid's like, give me all the meds you want.

• 23:24Speaker 03

  So, okay, so, so wait, so are you saying that we should all be taking HRT?

• 23:30Speaker 04

  Like, if I wanted to get on a soapbox and be that type of advocate, I would be like, I am a complete advocate for hormones and see the benefit and feel that women get really good bang for their buck.

• 23:43Speaker 03

  Okay.

• 23:43Speaker 04

  When they aren't HRT, not only for symptoms, but for longevity and improvement in how our bodies are long term. Do I think that everyone should, has to be, needs to be on it? No, because it's a personal choice. That's where I kind of let you decide what journey would you like to take? What adventure do you pick? Up to you.

• 24:03Speaker 03

  So what are the options? Like, what are the different types of HRT that we can look into?

• 24:08Speaker 04

  Well, the three hormones, which I mentioned earlier, estrogen, progesterone and testosterone, all start to ship decline from the age of 35. Progesterone's actually the first hormone that starts to decline. And then we have testosterone, which, you know, kind of for both men and women steadily over the decades, start to decline. And then estrogen does take a pretty good hit in the 40s and then completely declines by 50. All of those can be taken by women with careful discussion, obviously.

• 24:36Speaker 03

  Yeah.

• 24:37Speaker 04

  In what I want to take, what modality I want to take it in, which I'll go over, and which combination of it, right? Some, some of my patients are on all three. Some patients are just on testosterone. Some people aren't just progesterone and testosterone. Some people aren't estrogen and progesterone. Like it really is like a menu of options and how you can take it. Estrogen typically has most of the modalities because it's our most kind of vital joie de vivre hormone. So you can take it in oral, patch, pellet, sublingual, cream, like.

• 25:09Speaker 03

  What?

• 25:09Speaker 04

  It's so, it's so full of variety. And that's why I love being able to have these discussions because most women are like, what? I didn't know that. And that's the beauty of picking your own adventure. But we have to give, I think, you know, just society and doctors have to be, build so much more foundational education around questions that you ask. Why would I take it? What does it mean? Am I replacing something that really should not be there? Those are great questions.

• 25:38Speaker 03

  So two questions. One is, um, if I feel generally fine, is there any reason to do it? Like if I feel okay, um, I'll use me as an example. Yes, I get hot flashes. Yes, I've woken up in the middle of the night. Um, but, but I sleep fine. Like I sleep, I actually sleep eight hours a day, right? And if I wake up, I go right back to sleep. And hot flashes, yeah, they're annoying, but you know, they're fine. Like if I feel generally okay, should I still be talking to my doctor about it? Or, um, is it really for people who are being impacted negatively by the symptoms? Is it too late for me? Like, when is too late to start? Like, talk a little bit about that.

• 26:24Speaker 04

  All great questions because I have most women, you know, typically asking those questions of, my symptoms are not that bad.

• 26:31Speaker 03

  Yeah.

• 26:31Speaker 04

  Do we need to go on it? And I'm like, guess what? You have choice because even if they're not that bad, you could minimize them a little bit more if you wanted to. You could actually not go on hormones and being like, I, I'm okay.

• 26:44Speaker 03

  Yep.

• 26:44Speaker 04

  That's choice. The other part of that, so that's like in a symptom bucket. I put them in two buckets. Symptom bucket.

• 26:50Speaker 03

  Yeah.

• 26:50Speaker 04

  Longevity bucket.

• 26:52Speaker 03

  Right.

• 26:52Speaker 04

  So the symptom bucket is like, oh my God, I cannot even go to work, finish my day.

• 26:57Speaker 03

  It's debilitating.

• 26:58Speaker 04

  Correct.

• 26:59Speaker 03

  Yeah.

• 26:59Speaker 04

  That where, and I still have women who have that debilitating and still choose not to. Their choice.

• 27:05Speaker 03

  Yeah, yeah.

• 27:06Speaker 04

  So that's symptoms. Now, when I was talking about that 20 year gap.

• 27:10Speaker 03

  Yeah.

• 27:10Speaker 04

  What our organs can do, brain function, we know it's cardio protective. Estrogen is cardio protective.

• 27:16Speaker 03

  Wow, okay.

• 27:17Speaker 04

  You know that it does not cause breast cancer. We know that our bones are stronger when we're on estrogen, right? So when we get older, do I particularly want to maybe give my bones the best ability to be strong? Testosterone, when we're trying to look at muscle mass and building muscle, so we're strong later and we have better metabolism older, do I want to give myself testosterone to help with that, to aid with that? So that's a longevity discussion on, do you want to be on it for internal things that may not even be symptomatic and not impacting your daily, like how we see life and how we experience it? How do you want to show up at 70, 80 and 90? A lot of times to me is determined in

• 28:02Speaker 04

  mid-age on what you do with nutrition, exercise and considering hormones.

• 28:06Speaker 03

  Wow. And is it ever too late to start HRT?

• 28:10Speaker 04

  That is a beautiful question. So what we typically have heard is, uh, you can only go on it for a certain amount of time. And it, if it's past a certain time, it's too late. We are changing that conversation because of the longevity piece, which I just spoke to. But when women are older, I have a different conversation with them because they usually have gone now a portion of time without hormones. What happens in that timeframe is acceleration of disease, um, plaque in the arteries, decline in bone, right? So we kind of have to have a different conversation.

• 28:46Speaker 03

  This is terrifying.

• 28:47Speaker 04

  Where are you now? And what can we still offer you? Because most of my patients who start later, I do not say not have it. We just have to maybe do more testing, do more maybe cardiac tests to see what are you still, not, I don't want to use the word eligible, but what can still benefit you? What are you, everything I say when a person walks in a doctor's office is risk and benefit.

• 29:15Speaker 03

  Yep.

• 29:15Speaker 04

  Accepting personal risk and benefit is really how people make decisions. Because I have people who have had breast cancer. And even if I'm like, you know, is it estrogen or progesterone receptor positive or not, we have that discussion, how bad are your symptoms? And what are you willing to risk if you want to start hormones? And I have had women who have like, my quality of life is so bad. And even if there's a risk of maybe having breast cancer, because I'm on estrogen, I'm willing to take that risk.

• 29:47Speaker 03

  Yeah, wow.

• 29:48Speaker 04

  Who have not had breast cancer ever, or even in their family history, will be like, I just, I just don't want any risk of getting breast cancer that might be associated if I took estrogen, I'm not going on hormones. I'm like, okay.

• 30:02Speaker 03

  Wow. So, you know, you've talked about earlier and later, like, when is the right time to at least, even if you choose that you're never going to do hormone replacement, like, is there a specific age? Is there like, is it as soon as you're expecting, experiencing perimenopause system? Is it, is it like, just, you know, like how they do with, with breast exams or anything else? Like, at age 43, you should be talking to your doctor about HRT? Is there any sort of guidance you can give to listeners about when to have that?

• 30:32Speaker 04

  And, and the good, the good thing is, we have data behind that. So when we look at a timing perspective, you know, timing really is, what can I do before the gas tank is depleted, which would be menopause? And what we do from a perspective of what's going to give us our best cardio protection, bone protection, uh, brain protection, is before the hormone is completely depleted. So actually, in that late perimenopausal phase, if we were to kind of cut perimenopause into three stages, early, mid, and late, latter mid into late perimenopause is actually, from a timing perspective, when we're looking at organ functionality and being protective, is the best time to start.

• 31:13Speaker 03

  Okay.

• 31:14Speaker 04

  But that does not mean that someone who's outside of that phase cannot be on hormones. That's two different statements.

• 31:19Speaker 03

  Okay. And so, so we're having, so I come into your office and I'm like, okay, it's time, it's time to have, start having this conversation. Like, what kind of tests are there, labs that I should get? Like, what kinds of things should I be getting tested in order to figure out, like, where I am and what I might need?

• 31:36Speaker 04

  Labs typically, in the perimenopausal phase, like, once you're still having a cycle, whether it's regular or irregular, labs really don't tell us much, because we know you're cycling, right?

• 31:47Speaker 03

  Yeah.

• 31:48Speaker 04

  The hormones say, yeah, you're having a cycle, it's a regular, regular, it can still produce an egg, which then makes your uterus shed.

• 31:54Speaker 03

  Yep.

• 31:55Speaker 04

  I know this.

• 31:56Speaker 03

  Right.

• 31:57Speaker 04

  So, the lab is not going to tell me if you're in perimenopause, I already know you are, usually based on age. Now, what I will say is, I, you know, for my personal, uh, practice, and, and a few other physicians practice this way, is we will still run labs, because it still gives us a really nice foundation for what you're going to experience later, and things that we can compare later. The most important part, when you think of labs, is not always just the hormones. I actually want to look at your metabolic profile.

• 32:30Speaker 03

  Okay.

• 32:31Speaker 04

  I want to look at your hemoglobin A1C. How are you metabolizing glucose? And what is your fasting insulin like? What do your cardio protective labs look like? Because I know, once you decline estrogen, you're going to see an increase in cardiovascular kind of disease progression. What does your thyroid look like? So I actually run a whole slew of other things outside of the, how are your ovaries looking?

• 32:56Speaker 03

  Right.

• 32:57Speaker 04

  Into being, what is your whole body experience? Because that's your starting point. That's your starting, that estrogen, once it declines, is actually going to come back and impact those other labs as well. And we can now do some work in preparation, in a preventative mode, than waiting for everything to fail, or start to kind of like, being like, now I'm having a symptom. A symptom really is, your body's already been depleted, it's just telling you outwardly now. Trends are very helpful, but we don't, we should not chase trends, when I mean, it should not be every three months, six months.

• 33:30Speaker 03

  Okay.

• 33:31Speaker 04

  This can be something that's annual, maybe every other year.

• 33:33Speaker 03

  Okay.

• 33:34Speaker 04

  Um, because then, then we start chasing numbers, and that's not a good thing as well, right? But trends are really helpful, so we can say, oh my, you know, maybe in the last year, I've noticed that your hemoglobin A1C has started to creep up, maybe your cardiovascular markers are starting to showcase something that they didn't last year. I do believe that trends help us give a better picture and lay a better protective layer.

• 33:57Jonathan Fields?

  And we'll be right back after a word from our sponsors. Good Life Project is sponsored by Whatnot. So, I love buying books, and for some reason, I especially love buying used books. I just had so much fun, literally minutes ago, I picked up the entire Hunger Games trilogy of books for only $11, and also got this beautiful thank you from the seller, and a welcome from all the others in the chat. Whatnot is the largest dedicated live shopping platform, from beauty to luxury fashion, even cookies, and you almost never pay full price. Plus, what really gets me is the other side of the screen. On Whatnot, anyone can sell, whether your business is big or small, or doesn't even exist yet.

• 34:38Jonathan Fields?

  You go live, share what you love, and build relationships with people who come back for you, not a logo. According to Whatnot, people selling there sell 10 times more than on other major marketplaces. It's a real path to building something that lasts. Search Whatnot, W-H-A-T-N-O-T, in the App Store, download, and you can start selling right away. This message is brought to you by Apple Card. Ah, fall, that cozy season where we swap the swimwear for sweaters and sunnies for scarves. But before the Halloween decorations are put away, or Thanksgiving table has been set, there's already holly jolly music playing in the grocery store, reminding you that the year is coming to a close.

• 35:22Jonathan Fields?

  Time to kick end of year into high gear. When you use Apple Card with Apple Pay, you earn 2% daily cash back on all purchases, including food, decorations, gifts, and more. Get a head start on your end of year purchases. Apply for your Apple Card in the Wallet app on your iPhone today, and start using it right away with Apple Pay. Subject to credit approval, Apple Card is issued by Goldman Sachs Bank USA, Salt Lake City Branch. Terms and more at applecard.com.

• 35:51Speaker 01

  With no fees or minimums on checking accounts, it's no wonder the Capital One Bank guy is so passionate about banking with Capital One. If he were here, he wouldn't just tell you about no fees or minimums. He'd also talk about how most Capital One cafes are open seven days a week to assist with your banking needs. Yep. Even on weekends, it's pretty much all he talks about, in a good way. What's in your wallet? Terms apply. See CapitalOne.com/Bank. Capital One, N.A., Member FDIC.

• 36:28Speaker 03

  So this is great. Let, I mean, let's be clear, you're a great doctor, and you are interested in this, and you're an expert at this. But if I'm going to my GP, or even if I'm going to, like, they may not be as well-trained as you, one, um, or may think that it's a silly thing to even worry about, right? And, oh, that's cute, little woman, you're in menopause, just deal with it, move along. So, um, what do you, like, what are the things that you say in order to advocate for yourself with your doctor, to say, no, no, I, I know my body, this is something, how do you pursue it? So what is, what's like, the best thing to say to them?

• 37:11Speaker 04

  That is a very important question, because that is more of what we're seeing now than not, right?

• 37:17Speaker 03

  Okay.

• 37:18Speaker 04

  Because, yes, in the menopause landscape of curriculum, what we're taught, how the experiential medicine part that I talked about early on, is not there.

• 37:26Speaker 03

  Mm-hmm.

• 37:27Speaker 04

  Uh, will we get there? I'm very hopeful, and I think that I'm, you know, seeing shifts in how we train, and how we bring up menopause in midlife. But this is the opportunity for patients to advocate for themselves in a way that says, like you said, no, I really am feeling this way.

• 37:44Speaker 03

  Yep.

• 37:45Speaker 04

  And listening to my body, and I'm, I'm staying, you know, in tune with it. The response is going to tell you, do I stay here, or do I now go elsewhere to find care?

• 37:57Speaker 03

  Right.

• 37:58Speaker 04

  The answer, maybe I'm not as well-versed in menopause, but I can refer you somewhere. Tell me more about that experience, so I can see what, what else we can look into.

• 38:07Speaker 03

  Okay.

• 38:08Speaker 04

  And if not in that family of answers, that's when, without having, you know, like, you know, angry attack, maybe, a fight from the office, is being like, our time has ended here, I need to find relationship with a provider who is really going to address the experiential portion of what I am going through.

• 38:32Speaker 03

  Yeah.

• 38:33Speaker 04

  And that actually can be done in, in various ways. Like, there are websites that showcase doctors, and, you know, nurse practitioners that are, uh, trained in menopause. And I will say that there are GPs, there are internal medicine doctors, neurologists, that actually have started, and even cardiologists, to change their focus in midlife in women. So there's that, which I'm grateful for. Then there's telehealth platforms. So, for example, you know, I'm the chief medical officer at hers. We implemented a perimenopause and menopause platform, because we realized there is a need. There are other ones as well, there's about four or five other telehealth platforms that address this, right? So now, we're kind of seeing the, you know, extensions of what this looks like, but it is not widespread.

• 39:16Speaker 04

  So, in science, what we are guilty of, for good and bad, good, because we want to make sure that we are giving good care, and we are not harming patients.

• 39:26Speaker 03

  Sure.

• 39:27Speaker 04

  In order to do that, typically, we were like, what is the study? What did the study show? Did the study confirm the other study? To make sure that what we're advocating for is correct.

• 39:36Speaker 03

  Yep.

• 39:37Speaker 04

  And in menopause, we're so early in this kind of timeframe, it's very hard to be certain, right?

• 39:42Speaker 03

  Yeah.

• 39:43Speaker 04

  And that's what medicine do. And so guidelines are typically made on certainty. So because we're not all the way there of 1,000% certainty, it is very hard to train physicians who historically have been like, we are, the science tells us where we go.

• 40:00Speaker 03

  Yeah. Yeah. And, you know, and also, as I'm listening to you talk, and, and, and talking about, you know, some people, some doctors are well-versed, some doctors are getting well-versed, one of the things in your book that really...

• 40:14Speaker 03

  I don't think I, I, I got it until I read it was the idea that menopause can affect you differently, not just as individual people, obviously, we're all different people. So it will affect us differently, but also there's different impacts statistically based on race that certain, that some people, and that it didn't even dawn on me that that could be a case, right?

• 40:37Speaker 04

  Yeah.

• 40:38Speaker 03

  So, so how, um, like I, I think, I, I don't want to quote you back to you, but I feel like sometimes they, that, that black women have more severe symptoms than people who are Asian or white, uh, which I, can you talk a little bit about that? Cause that was really, really surprising to me.

• 40:56Speaker 04

  Yeah, it's, it's surprising to a lot of people, even, you know, physicians, as we start to see the literature, but there is a great study that was done, the SWAN study, that really kind of parsed out experience based on ethnicity. And it was great to see, you know, for me, for a provider, that that is helpful to know contextually from data, what my patient might experience different to another. And obviously our biologies are, you know, function different, our DNA allows us to experience, so you will see in every ethnicity, an increase in one disease versus another.

• 41:35Speaker 03

  Yeah.

• 41:36Speaker 04

  Now, what that study showed is when we look at, just take hot flashes in intensity and duration, meaning how many years women typically will experience it, were lowest for Japanese women and highest for African-American, black, Afro-Caribbean women. And what this shows is, one, differences in experience, but now even linking that further is we do know that the more severe, and as, as far as increase in duration of hot flashes that a woman experiences, actually increases their risk for cardiovascular disease.

• 42:11Speaker 03

  What?

• 42:12Speaker 04

  So, and also later on in life, dementia. So when you have this kind of science behind, even as much as ethnicity.

• 42:23Speaker 03

  Yeah.

• 42:24Speaker 04

  That allows us to address women's health so much more intricately and allowing women the space and time to sit with it.

• 42:33Speaker 03

  Yep.

• 42:34Speaker 04

  And being like, now what do I want to do when I hear these numbers?

• 42:37Speaker 03

  Yeah. And obviously, I mean, as you, I think, point out in the book, like every person, every person, even with that, with those statistics, every person is different. Okay. Let's, let's move off from HRT and stuff like this. One of the things I think you said is that, um, after menopause, like most of us have almost 40% of our life still yet to live, right? So can we talk a little bit about the things, especially now that you've talked to me about the fact that not only is the, um, are the symptoms, things like whether or not in the moment that they're debilitating, but it also has, um, knock on effects on how well you live in, in later years? Like what are some of the non-HRT things that we should be doing to help sort of survive

• 43:20Speaker 03

  symptoms, to help us, prepare us for longevity? Like what are some of the things that, that we should all be doing for that?

• 43:26Speaker 04

  Yeah, that question is very important because what we typically see when something's new, you know, to culture or society, it seems like it's kind of like the foghorn alert, right? So most people are like only hearing about hormones right now. And so there's a lot of fixation on it for good reason, because it was so kind of negated in the past. So now we're seeing, oh my gosh, we need to talk about it. We're going to speak about it loudly. But the fact really remains, when we look at aging, especially for women, I'm going to like exclude men for this, both men and women age, and with that comes disease progression and the ability to, you know, as far as when we get older, what that really means as far as age-related disease.

• 44:08Speaker 03

  Yep.

• 44:09Speaker 04

  And for women, we see that menopause is inextricably intertwined with aging and how we live that last third of our lives.

• 44:18Speaker 03

  Okay.

• 44:19Speaker 04

  So this will show up in the form of, when we think of cardiovascular disease, still the number one killer of women and men, but for women. But when we look at this sharp decline, typically after the age of 65, 70 for women, where now we have this consequence of frailty, uh, decrease in physical mobility, Alzheimer's disease, which is, you know, part of the, the dementia kind of umbrella, but specifically for Alzheimer's is more in women than men.

• 44:48Speaker 03

  Okay.

• 44:49Speaker 04

  Three times more.

• 44:51Speaker 03

  Oh, okay.

• 44:52Speaker 04

  Yes. So when we look at age-related disease later on in life for women, most women are admitted or not admitted, but transitioned to a long-term care facility or aging facility because of UTI and urinary incontinence.

• 45:09Speaker 03

  Yep.

• 45:10Speaker 04

  Right? So when you put all of this together, there is kind of like this model, which we have already seen, it happens, it's pretty true to number. What do we get to do in order to increase awareness and recognition of what's happening? Is that timeframe in midlife where we kind of get to turn the cruise ship in a different direction?

• 45:33Speaker 03

  Okay.

• 45:34Speaker 04

  And that's why I think it's imperative, and I call it the magic of midlife, is to look at aging for what it is. It happens to all of us, but what can we do early on to be preventative in order to have better longevity? And longevity does not mean increasing life expectancy. It means that as we age, for as long as we're going to live, how do we improve our well span?

• 45:59Speaker 03

  Right.

• 46:00Speaker 04

  And the ability for us to live those later years, strong cognition.

• 46:05Speaker 03

  Yep.

• 46:06Speaker 04

  Not having urinary incontinence, being able to still travel, function, it's functionality more so than just, I lived long, great.

• 46:13Speaker 03

  Right, right.

• 46:14Speaker 04

  Did you live long, great?

• 46:15Speaker 03

  Yeah, exactly. So what do you do? Like, what are some of the things we can do to, to make that happen?

• 46:20Speaker 04

  Exercise and nutrition, I think, are some of the most fundamental things outside of hormones that someone could start to change in midlife.

• 46:27Speaker 03

  Okay.

• 46:28Speaker 04

  Our body just takes on fuel differently. It metabolizes food differently. It stores food differently, and that's how we get what our outcome is. So that is not easy to do. I would say lifestyle changes, you know, even for my patients are some of the hardest things to do, because it sounds so easy.

• 46:44Speaker 03

  Yeah, yeah.

• 46:45Speaker 04

  We're like, yeah, we're going to pay attention to our fiber intake, increase our protein, you know, increase some of our supplementation in vitamin D, creatine, vitamin B12 complex.

• 46:55Speaker 03

  Okay.

• 46:56Speaker 04

  And I'm going to do it overnight. No, usually lifestyle changes, I would say, take three to five years.

• 47:01Speaker 03

  Yeah.

• 47:02Speaker 04

  Then with exercise, we were typically taught, you know, do cardiovascular exercise, which is still very important, but we were never understanding the muscle and muscle building and how it contributes to strength and metabolism later on in life. So women were like, oh, I don't want to build muscle. I don't want to get big. Your muscle's already on its way out. So either you help it.

• 47:26Speaker 03

  You might as well build muscle.

• 47:29Speaker 04

  Or you're literally like, bye-bye.

• 47:33Speaker 03

  Yeah.

• 47:34Speaker 04

  You know, muscle, because it's already on its way out. And muscle really is the ability for women to maximize their longevity and improve their life, even from the beginning stages in mid-age. So I would say, you know, the kind of the pyramid or trifecta of what we see in aging is specific to menopause is underlying with nutrition and exercise, specifically resistance training and weight training, and then kind of funneling up to the cherry on top with hormones and deciding how you want to do that, how long you want to do that. And that's what I would say is the building blocks and tools, when we think of magic of midlife and longevity.

• 48:16Speaker 03

  Jessica, this has been so informative and so helpful for me. I feel like I've learned so much. So, you know, just to kind of wrap everything up, can you just, I'm going to ask you the question that Jonathan always asks every guest, what do you think it means to live a good life?

• 48:33Speaker 04

  You know, what really comes up when I think about that is this ability to strategize and change our lives at a very strategic moment that we never have been given the opportunity to do that. And so I hope that this conversation has enlightened and encouraged, uh, women to take their lives into their own hands and having the curiosity to keep going so that we can create more wellbeing in all of our lives.

• 49:01Speaker 03

  Dr. Jessica, this has been an amazing, amazing conversation. I am so grateful to Jonathan for asking me to, to be the guest host on this episode. Thank you so, so much for your time and your generosity and all your wisdom. Really, really appreciate it.

• 49:15Jonathan Fields?

  So let's talk about some of the big actionable takeaways from Karen and Dr. Shepherd's conversation. One thing that I've been sitting with after reviewing it is the gas tank, Dr. Shepherd's image for perimenopause, hormones not broken, just slowly draining over years, not overnight, sometimes starting as early as your mid 30s. And right alongside that, the symptom bucket versus the longevity bucket, this idea that whether or not you ever go near hormone therapy, there's a decision buried in there about not just how you feel today, but about how you want the next 40 years to go. And that line about how, will Medicaid a tired thyroid without a second thought, but somehow treat it declining ovary like it's already done?

• 50:00Jonathan Fields?

  That one really stuck too. If you take one thing into your week, let it be this, start writing down what your body is actually doing, not to panic, just to start noticing. And hey, before you leave next week, we're sitting down with Priya Parker to talk about why conflict handled well, fighting, might be one of the things that makes your closest relationships stronger instead of weaker, and what most of us get backwards about the moment right before it happens. So be sure to follow Good Life Project wherever you get your podcasts, so you don't miss that or any upcoming episodes. And do me a quick favor, a seven second favor, share this conversation with just one person or leave us a review wherever you get your podcasts.

• 50:43Jonathan Fields?

  It really helps us get discovered and reach more people. This episode of Good Life Project was produced by executive producers Lindsay Fox and me, Jonathan Fields, guest hosted by Karen Walgren, editing help by Troy Young, Chris Carter, crafted our singing music. And of course, if you haven't already, follow us wherever you get your podcasts, so you never miss a conversation. Until next time, I'm Jonathan Fields, signing off for Good Life Project.

• 51:08Speaker 01

  With no fees or minimums on checking accounts, it's no wonder the Capital One Bank guy is so passionate about banking with Capital One. If he were here, he wouldn't just tell you about no fees or minimums. He'd also talk about how most Capital One cafes are open seven days a week to assist with your banking needs. Yep. Even on weekends, it's pretty much all he talks about, in a good way. What's in your wallet? Terms apply. See capitalone.com/bank. Capital One, N A, Member FDIC.

• 51:46Speaker 05

  This message is brought to you by Apple Card. Ah, fall. That cozy season where we swap the swimwear for sweaters and sunnies for scarves. But before the Halloween decorations are put away or Thanksgiving table's been set, there's already holly jolly music playing in the grocery store, reminding you that the year is coming to a close. Time to kick end of year into high gear. When you use Apple Card with Apple Pay, you earn 2% daily cash back on all purchases, including food, decorations, gifts, and more. Get a head start on your end of year purchases. Apply for your Apple Card in the Wallet app on your iPhone today and start using it right away with Apple Pay. Subject to credit approval, Apple Card is issued by Goldman Sachs Bank, USA, Salt Lake City Branch. Terms and more at applecard.com.

• 52:27Speaker 06

  There's one thing that will forever change the way you sleep, and it's the softest 100% organic cotton sheets from Bowlin Branch. You'll fall asleep faster, wrapped in the most luxurious comfort. You'll never sleep hot again with sheets that feel breathable to sleep in. You'll experience the purest softness on night one and feel your sheets get even softer with every wash. Discover the difference with 15% off your first set of sheets at bowlinbranch.com with code BUTTERY. Exclusions apply. See site for details.

• 52:57Speaker 07

  Network freedom and flexibility, that's what you want in a healthcare plan. With a Humana Medicare Advantage PPO plan, you can see any doctor in the country who accepts Medicare, including specialists. No referrals, no kidding. Learn more at gethumana.com. See any doctor who accepts Medicare and is willing to build Humana. Humana PPOs may not be available in all areas. Benefits and costs share may vary. Humana is a Medicare Advantage PPO organization with a Medicare contract. Enrollment in any Humana plan depends on contract renewal.