Sabtu, 29 April 2017

loss of libido

hello, i'm norman swan. welcome to this program on looking afterwomen around the time of menopause. menopause is a natural transition,or has it become overmedicalised? why do we need to manage it? at a time when a record numberof baby boomers in australia

loss of libido, are experiencing menopause, our experts will answer these andmany other questions of interest to you working in the primary-healthcare sectorin rural australia. we've got a number of resourcesavailable

on the rural education foundation'swebsite: but don't go there yet,as you've got to meet our panel. jenny bath is a clinical-nurseconsultant at women's health, based at tamworth communityhealth centre in nsw. welcome. thank you, norman. jenny provides clinical and informationservices to women of all ages. she's also secretary of the australianwomen's health nurses association. how many members have you got? - about 90 across australia.- you need more.

- particularly in rural areas.- absolutely. elizabeth gallagher is an obstetricianand gynaecologist in the act. she's got a special interest inmenopause and pelvic-floor disorders. - welcome, liz.- thank you. liz also has experience in thenorthern territory with indigenous women in outreach clinicsin remote communities. christine read is formerly a gp, butnow works as a sexual-health physician and independent consultantin family planning and reproductive and sexual healthin lismore, northern nsw.

- welcome, christine.- hello. christine is honorary secretaryof the australasian menopause society, and has manageda number of innovative projects to address the lack of servicesand information in country areas for rural women and aboriginal women. last but not least is dimitra tsucalas, who is a community pharmacistfrom ascot vale in victoria. - welcome, dimitra.- thank you. dimitra has done locum work for 13 yearsin country and metropolitan pharmacies

and both hospital and community sectors, and served in variousprofessional communities for the pharmaceutical societyof australia. she's sat on state and national boardsfor the psa. - welcome to you all.liz: thank you. jenny, you see women coming through,ordinary women, nothing special, just women coming through with issues. do you feel that their attitudestowards menopause or the symptoms they come in withare changing?

it's changed in that women are more likely to talk abouttheir menopause these days. and certainly, women can be expectedto live a lot longer after menopause. it has certainly changed over the years. what has changed? women's willingness to actually talkabout the symptoms and to seek help. christine, i've heard that womenhave stopped seeking help because they say,there's no hrt anymore, i might as well grin and bearthe hot flushes.

there's been quite a differencesince the whi... - the women's health initiative trial?- yes, that was in 2002. women got scared, and so did manydoctors and nurses, get scared of hrt. they are comingin fewer and fewer numbers, but that doesn't mean to saythat the problem has gone away. what's your take on that, liz? i agree with christine in that there are certainly still womenthat are having problems that are starting to seek help.

in some ways, over the last few years, as more evidence has come outafter the whi scare, showing a more positive light,or at least giving us more information so we know that in fact womenare perhaps coming back a bit to accepting hrt,at least in that perimenopausal time. what's the view from the pharmacy? we certainly see far fewerhrt prescriptions. there's a reluctance in the communityto take that up. that may be media influenced,i would think.

they're coming in forwhat i would call garbage, for stuff that doesn't work,aren't they, as well? sometimes they come in for other things. again, that's influenced by advertising. if that's on at night,they'll come in the next day. sometimes it's reading and the internet,that sort of resource. something that's naturaland, quote, safe. natural is interesting.personally, i don't subscribe to that. it conveys certain messages.

the marketing message is thatnatural is safe. poison ivy is natural, but it doesn'tmean you put it on your skin. norman: yes. is menopause drifting later, earlier? menarche is going earlier, isn't it? yes. norman: you'd expect the ovariesto get clapped out earlier and menopause to come earlierbut that's not happening or...? we're not cars. i don't think...

norman: you've only got so much fuelin the endocrine tank. that's true. i don't think that we areseeing an increasing number of women having natural menopause earlier. but there is a difference with prematureovarian failure and early menopause, in the sense that there are more womenwho have had breast cancer, had chemotherapy,surgery to remove their ovaries. there's beenquite a substantial increase in the numbers of very young womenexperiencing menopause. in terms of other issues, nutritionalstatus seems to be very important.

but because we are all very well fednow, we don't have menopause quite as earlyas in centuries past. given that fat cells produce estrogen, do you have fewer menopausal symptomsif you're fat? well, in fact,i think it's the opposite. from my understanding, obesity is one of the risk factorsfor symptoms in menopause. - really?- yes, but don't ask me why. it's counterintuitive metabolically,

given that there's more estrogencoursing around. what about the stages of menopause? my impression isthat's quite artificial, because this can be a prolonged projectfor women. what's your viewof the stages of menopause? it's interesting you should ask that. experts are now looking at stagesof menopause in a scientific sense. there has been, for some time,the straw staging, which is now being revised.

but that's quite artificial, really. in terms of practical usagefor clinicians, it's useful to think of premenopause - the time when your menstrual periodsare still regular, perimenopause - when they start tochange, which is average age about 47, and then postmenopause - when youhaven't had a period for 12 months. that's the definition, in a sense. of course that is retrospective,usually, unless you've had a surgical menopause.

what myths do you think there areamongst clinicians, particularlyprimary-healthcare clinicians still? that hrt still has quite a bad name in terms of prescribingat the general-practice level. i still think there areprimary-health physicians out there that are scared or too concerned to prescribe it, even to womenthat probably do need it. there are myths that every woman isgoing to have a horrible menopause. about 70% of women breeze throughmenopause without too much problem.

it's probably about 30%,that i call the vocal minority, that give menopause a bad name,not because they're not suffering, but because they tendto talk about it more because it's an unpleasant experiencefor them. but it is an unpleasant experiencefor those women. they probably do need more help. maybe they have to become vocalto overcome this reluctance to prescribe hrt. true, but for thosethat don't have the symptoms,

they're getting a bad message about it. what myths do you come acrossamongst women? the same as what liz was talking about. i also think a lot of women thinkthat it's going to be a bad time. i sometimes see women that havehad absolutely no symptoms at all. norman: they wonder what's wrong. yes. their periods have just stoppedand they've had no other symptoms. they're thinking, is this it?they're the good ones. from a pharmacy point of view,do you see many myths?

not so much myths,just a reluctance to take up hrt. i wonder whether there's a culturalinfluence in terms of what women expect. are they expecting to acceptthat part of their life? or are they just fed up telling somebodybecause nobody's listening? wasn't there studies in japan? of japanese women used to think...that's where the soy myth came from - that japanese womendidn't have menopause, they just got fed upcomplaining about it to male doctors. when you looked,they did have menopausal symptoms.

there is quite a cultural influencein managing menopause, or in women's acceptanceof menopause symptoms. in some cultures, there's no word formenopause, for instance. it's just accepted thatyou get to that point. i have worked with doctorsfrom thailand. a doctor from thailand worked with mefor a while and she said, 'i can't believe how manyaustralian women have libido problems. it's not a problem in thailand. women are very happythat their husbands are not interested,

or they're not interested.' i don't know if that was true,but there are cultural differences. do we know anything aboutindigenous women, how they're experiencing menopause? my experience is in the very,very remote communities. in all my time, i haven't had anybodycomplaining about menopausal symptoms. perimenopausal heavy periodsand a little irregular bleeding, but in terms of symptomatology,i really haven't come across that. i'm not sure whether that's becauseof the community perception

or because by that age, a lot of womenhave got other health problems. they've got other thingsto think about. in tamworth, jenny? from what i see of aboriginal women, it's very often that they justdon't report the symptoms. they often do have them, but unless you specifically ask themabout their symptoms, they very often just don't report it. i've had experience in dubboand coonamble,

where i was doing clinicswith aboriginal women. i agree with liz,they tend not to present. but if you put on a program designedaround reproductive and sexual health and maybe specificallyabout women's problems, they will come and talk about it. i did have a woman,who was 70 and an elder, who i was able to askabout her experience of menopause, and their experience of menopause. she told me that she had no ideaher periods would stop.

when they did stop,she thought she was going to die. norman: really?- yes. she had no idea. that was quite interesting, because i had askedabout bush medicines. in this particular area, she hadno knowledge of any bush medicines. i thought another myth wasthat there was a sudden uptake in the risk of cardiovascular diseasewith menopause, that british research had shown that

the rise in the risk of cardiovasculardisease is steady in women. there's no increased riskaround the menopause. what's your take on that? well, i haven't actually readthat particular information. where we're at at the momentas far as i can tell is that we know that womenpast menopause do have an increasing riskof cardiovascular disease. women tend to present differently to menwith more chronic illness. more recent information about hrtis that

there's probablya critical window of opportunity. if you keep the estrogen going... that's estrogen only,not estrogen plus progesterone. there's some data from the whi itself, when they've done subsetsof younger women that seems to indicate that that may betrue in combination therapy too. what are the symptoms that arerecognised to be pinned to menopause? hot flushes, vaginal dryness, tiredness, irritability.

periods can become irregular, heavy, lighter. night sweats are tied up often with hot flushes. irritability. one of the ones we didn't talk about before was muscle aches and pains. that's probably been underreported. norman: are muscle aches really

due to menopause? they seem to respond to estrogen. norman: that's a convincing sign?- exactly. if they get betterwhen they take estrogen, then they come back when they stopestrogen, that's good evidence. it has come up in at least one studyas being valid. that myalgia is a definite issue. we mentioned obesity a moment ago,but do we know what the factors are that make the experience of symptomsworse?

it's difficult to know exactly whysome people have really bad symptoms. we do know fromthe melbourne midlife women's study that symptoms usually lastfor about five years. but about 23% of women or sowill go on having flushes significantly for about 13 years. what makes it worse for some womenthan others? i don't think we know the answer. maybe in amongst that,coping mechanisms, problem-solving, anxiety and depression.

norman: other things going onin their lives? yes. elderly parents, childrenmoving out of home and back again. and the libido story? because hrtdoesn't do much for your libido. the libido story is a difficult one. that's really multifactorial. we now know from susan davies's work that testosterone levelsdon't significantly drop across the menopause transition. so, just replacing testosteroneprobably doesn't do anything.

it may do something,but it's not the answer. she did show in randomised trialsof women with low testosterone levels that you do get one or two extra sexualepisodes a month of higher quality. but if you look atthe fall in testosterone, that's linear from the mid-30s. there's no significant drop to accountfor that significant fall in libido. the closest association waswith the fall in estrogen. testosterone wasn't the answer,is what i'm saying. it does point totaking the whole-woman approach

rather than forcing on the hormones. and the couple, too. we've all met the womanwho had terrible libido and then lost her partner throughdivorce and found a new, younger model and suddenly libido is back again... norman: with a flatter abdomen.- and pecs. talk to me more about early menopause. how do we define that, liz? there's three definitions of menopause.

one is premature menopause, that is, women who are outsidethe normal range. some women become menopausalprior to the age of 40. the incidence of that is about 1%, of natural menopauseprior to the age of 40. then you have early menopause, which is defined as menopausebefore the age of 45, and late menopause after the age of 55. so women aged 40 to 55are still within a normal range

but just outlies within that. what are the causes for early menopause? for premature or early menopause? norman: apart from oophorectomy. premature menopause, there's a number of thingsyou need to exclude in women. one hypothesis is that there'san autoimmune-type cause for it, so that women who have autoimmunedisorders such as thyroid dysfunction, diabetes, may have a higher incidenceof premature ovarian failure.

if they've got prematureovarian failure, is that a sign you should be doinga test in blood glucose... - ..and a thyroxine level or tsh?- absolutely. and screening for otherautoimmune disorders as well. chemotherapy and radiotherapyare common causes in women that are diagnosed for breast cancerunder the age of 40. a rarer one is chromosomal abnormalities which may presentwith premature menopause. so, women who are fragile x carriers

and women who havemosaic turner syndrome are also at riskof developing premature menopause. mosaic turner? mosaic turner and... do you do chromosomes on people? with premature menopause, yeah, we do. norman: what difference will that maketo your management? it won't make any difference. but in terms of genetic counselling,certainly for a carrier of fragile x,

that may have some implicationsfor family. for turner syndrome, no, it won'tmake any difference to the treatment. but it's probably good for the womanto know. what other investigations would you do, if you've got a woman with menopauseearlier than you would expect? there's a number of issues to look at. firstly there's a psychological aspectto this, a psychosocial issue, where someone who is much younger thanthe normal menopause age will find it pretty difficult.

there's the issue of pregnancyand fertility, whether she has had children or not. as liz said, sometimes this isan autoimmune phenomenon. women do occasionally spontaneouslyovulate even a few years down the track. putting them on the pill,even if they haven't had a child, may treat their symptomsand preserve bone. norman: and prevent an unpleasant littlesurprise. or a pleasant one. yes, but if she still wants to havethe opportunity to conceive, hrt would be the way to go.

doesn't it increase the risk ofundescended testicle in the newborn? now you're telling me something. - we stop it when they become pregnant.- right. but bones would be a very important,and maybe cardiovascular disease too. you can get a dexa scan under medicare. if you're younger than 45when you have menopause, you can get a rebate for a bone density. there are emotional issues here. this could be a strong sense of lossfor some women.

we've got a question from paulfrom coffs harbour, who asks, 'has the increase in the useof fertility drugs...' and presumably we should askassisted reproduction here, '..had an influence on eitherthe onset of menopause or the experience of menopause,or confusion with menopause?' i don't work in that area at all,but from my knowledge, no. i'd have to say, though i'm not actuallyanswering paul's question, the issue with assistedreproductive technology and fertility is a challenging one,

because many womenare delaying childbirth now. they're not having a child at the agewe would have in the past. they're leaving it too late. there's this perception that artwill solve the dilemma for them. presumably you could have menopausestarting when you're having art and that confuses the situation. they just don't respond very well. women over 40who have ovulation induction, they don't get very many eggs,and those eggs that they do

don't necessarily creategood-quality embryos. those women are usually looking atdonor eggs. once you hit 42 or 43, the chancesof getting pregnant using ivf and ovulation induction is very low. can i ask what you would recommendfor women on the pill approaching menopause years? when should they stop? can they go through menopausewithout feeling anything? it can be quite a challenge.

we tend to keep taking the pill, or using contraceptionbut the pill in particular, until a woman is about the average ageof menopause, provided she hasn't got anycontraindications, so, about 51. but you don't know then whethershe's gone through menopause because the pill will mask that. you're left in a tricky situation. somebody who doesn't wantto get pregnant, in an ideal world, you move them to a barrier methodof contraception

and see what's happeningwith their menstrual cycles. a woman who's had a hysterectomywouldn't know when she's menopausal. sometimes they do becausethey can still become symptomatic. they get all the same symptoms. but they don't know the 365 dayssince the last period. and the causes of a late menopause? most of the time,i think it's hereditary. if women come inhaving menstrual problems or symptoms but are still menstruating,i usually ask them

at what stage their mother and sistershad menopause. that's often a good indicator. is there anythinga general practitioner should look for in a woman who's had late menopause? shehas an increased risk of breast cancer. yes, she does. that risk is about thesame as a woman who continued on hrt up until that time. i find that a useful fact to discusswith women who are anxious about hrt. so if you've got a womanwho is between the age of... norman: it's like an extra yearwith periods?

a year on hrt islike an extra year with periods? exactly. they're taking the same hormone that their ovarieswould normally produce. they've got the same riskof breast cancer as a woman who has a later menopause. that's good to say to women who haveearly menopause prior to the age of 45 but not under 40, who may be concernedabout going on hrt to get them through. let's go to our first case study. it's rebecca, who hasn't had children.

she's 40 years old, she's light-framed. she's pretty fit. she comes to your pharmacy, dimitra, and asks the pharmacist for something herbal for sleeplessness and day and night sweats. she's heard that valerian and black cohosh are absolutely terrific. some people believe they are, i'm sure.

she may see a pharmacy assistantand may see me. it depends who she hits first. if she sees a pharmacy assistant,they would be trained to triage, to obtain as much information for herabout her symptoms and her issue, any other medication she's on,any other conditions she has. she may have requested a product and they would refer to the pharmacistto see her. all pharmacy assistantsshould be trained in the first instance. they wouldn't necessarilytake that query on their own.

i would see her, then i would ascertain whethershe actually has menopause, because she sounds likeshe's come in with that preconception. she may or may not. she may have other issues going on,stress-related and otherwise. i might recommend the valerianto help her sleep in the interim until she sees her doctor. norman: does it work?- some people say it does. - some people say it doesn't.norman: what is it?

a herbal complimentaryto help you sleep. some people claim it's fantasticand some don't. i can't say i've tried itso i don't know. black cohosh has got a bad reputationfor liver damage. it depends on who you speak to. the reputation has come fromthe incidence of liver failure. there have been incidents that havehappened very immediately, within a week of taking it. some have happenedafter three years of taking it.

the tga has altered the requirementsfor the cmi for those products to include warnings on liver failure. it's incumbent on the pharmacistto warn people who buy that that it's a possible concern for them. there have been some studiesto indicate that it does work, but the consumer needs to be informed. there are also studies to showit doesn't work. with all these studies,there's always a huge placebo effect. my understanding is that cohosh is notmuch better than placebo, if anything.

there is a problem here in that peoplethink this is a natural product. that's why they're accessing it. there are severe adverse effectswith it. liz: that's irreversible liver failuretoo. time for transplants. so women are anxious about hrt, but they're prepared to go to somethingthey think is natural. it's one of those trickyand controversial areas. there are some pharmacistsand prescribers

who are pushing so-called bioidenticalsand tailored, personalised treatment for your hormonal symptoms, and women are deludedinto thinking they're safer too. that comes from the belief that it's the equivalentof what their body makes compared to havinga mare-equivalent estrogen. some of that may be marketing,some of that may be trial and error. isn't it just a money-making exerciseon the part of pharmacists? - it's a huge polarisation.christine: it's an industry.

but you can argue it's no differentto the industry of hrt. 15 years ago,i attended a lecture on hrt which advocated that every woman shouldbe on hrt for the rest of her life. i distinctly remember that. christine: that's true.we did talk like that. and stuff does change with new studiesand so on. we do now know a lot more about hrtand who's the best person to use it. one of the issuesaround the bioidenticals is that women are lulled into a false senseof security that this is safe.

if it's actively working,if it does contain the natural hormone, then it's got the same effectas the natural hormone. norman: you don't get onewithout the other. you can't get one without the other. and you're not tga protected.these are not registered products. no, they're not,and if a doctor is prescribing them... some people are very passionate about it and believe that they know exactlywhat they're doing. ok. that's what they're doing.

but other doctors get asked to writeprescriptions for patients because they don't go backto the first one. norman: because of the expense?- because of expense. the legal situation is that that doctor is responsible forwriting that recipe, which is what a prescription is. they take on the responsibilityfor the effect on the woman. if there is a very nasty,untoward effect, it's not a company that's liable.

have there been womendeveloping breast cancer and suing for these bioidenticals? not that i know of yet. but there have been casesof endometrial cancer that have been reported to the tga. these women have been givena bioidentical of unopposed estrogen? liz: or progesterone. all progesterone creamsare not as well absorbed. they don't know whatthe endometrial protective levels are.

progesterone becomes the issue - giving it in a form which is notnecessarily effective? you think you're giving opposed estrogenbut you're not? there's also the dosage factor,from what i understand. in instances where you massage it in,how much do you massage in? there are those things that needto be controlled, and they're not. they are controlledin commercial situations, where pharmaceutical companies areunder scrutiny and have quality control and we know what women are getting.

it doesn't mean to say thatthere aren't adverse effects, but at least we have a good conceptof what they are and a good evidence base about them. so, buyer beware. dimitra refers rebecca to you,christine, for further management. christine: thank you, dimitra.dimitra: my pleasure. you find out more, that she's excessively tired, she gets hot flushes,

she's not sleeping well at all. her mood is swinging around and she gets increasing anxiety. when you ask about her adolescence, she had an eating disorder. one of the most important things here is to assess whether she actually ismenopausal or not. rather than leaping in to do fsh, i would like to get a pictureof her menstrual periods

and whether she's had amenorrhea. it's equally important to get the story,for the woman to tell her story hopefully uninterrupted,if you've got the time, so that you can get a pictureof where she's at so you can validatewhat she's experienced and give her informationand normalise her. if she is truly somebodywho's had amenorrhea for a while and she's got these symptoms,she probably is early-menopausal. it may be useful to do an fshin this instance

because you need to prove to her,and possibly to yourself, that she is. - because she's young?- because she's young. you need to be aware, though,that fsh can vary. if she was about to ovulate again,she may have a normal one. you need to know where you arein the cycle, which is hard with irregular periods. sometimes you just need to repeat ita couple times. if you do it and it's high, then twoweeks later she gets a period, you know. norman: doing estrogen levelsis a waste of time?

christine: pretty much.we wouldn't normally do them. women come in asking for hormone levelsto be done. in her case, a young woman, you've got to look at thingslike prolactin, whether there are other causes for this. if we have got a straight caseof early menopause, it's important for us to look ather psychological profile, what's happening for her, because this is likely to cause grief,fear, anger.

fertility - has she had a child?does she still want a child? is she in a relationship? i do get a number of womenwho decide at the age of 40 that they're going to have a childwhatever happens. then bone. she's in the age groupwhere bone may be a problem. given that she had an adolescenceor early-20s anorexia or some eating disorder, she probably had amenorrheafor six months or more. that puts her at higher risk.

that's another rebatable-dexa story, if you've had hypogonadismfor six months or more. what about if she says,i was an elite athlete and played netball for the state and didn't have periods for three yearsin my adolescence. does that qualify you for a dexa? she by definition had hypogonadism, even though she wouldhave been exercising like mad. the thing i was going to say,coming back to hormone levels,

was, if this ladyhas normal hormone levels, that doesn't exclude thatshe's heading into the perimenopause. would you start to investigate herfor puos or hidden malignancy? i would, probably. unless she...yeah, no, i would. certainly thyroid functionand screens for diabetes, a full blood count,screens for chronic infections. norman: you might not doher bence-jones proteins just yet? i don't think i wouldif i had all of the other things.

but thyroid functionwould be worth checking. hot flushes, another rare cause wouldbe a hormonally active tumour, such as a pheo... pheochromocytoma, yeah. some people saythat premenstrual syndrome... some womenwho complain of symptoms around the time of menstruation do worse with their menopausal that true? that's been reported in a numberof studies when they've looked at it.

what the relationship isis difficult to define. it may just be that women who sufferfrom pms have a higher baseline anxietyand depression score and lower abilities to cope. it's difficult to generalisein that way. it may be that they've tippedover the edge with hormones too. they're more hormone sensitive. this is an areathat's so hard to understand. lorraine dennerstein has donemany studies on pmt.

she says that it's a hard area to study. she's the one who found out thata new partner sorts out your libido. watch out, you've got to perform. jenny, what do you doin this holistic sense for women? people talk about lifestyleand diet changes, nutrition, exercise. what's your practice with womenwho want a more holistic approach? i talk to themabout the sorts of things that might be increasingtheir hot flushes. i talk to them about cutting downon their alcohol intake, for instance.

we know that red wine can make flushesworse, particularly at night-time. we know that higher anxietyand depression levels can make symptoms a lot worse. so, looking at general lifestyle things. stopping smoking if they haven'talready, and hopefully they have. a lot, unfortunately, don't. that is a risk factorfor increased symptomatology, isn't it? i don't know so much about the symptoms. christine: yes. and also bone density.

we know with earlier menopauseand bone density and cardiovascular risk,smoking is obviously way up there. i wasn't aware whetherit makes your symptoms worse or not. because it vasodilates to some extent,you do get worse vasomotor symptoms, a bit like taking alcohol. have there been studies of exercise,diet? do we know whetherthey make a difference? one of the things that seemsto be fairly well known is spicy foods. that's one of the things that causeshot flushes. not 'cause' but it makes...

norman: it causes hot flushes in me, sowhy wouldn't it in a menopausal woman? another thing we would say to them,as well as cutting down red wine, is maybe looking at their foodand moving back from spicy food. christine: taking all the funout of life. what about exercise? there have been studies that have lookedat all aspects of menopause - exercise, acupuncture, meditation,mindfulness. it's hard to come up witha randomised control trial that provesthat they actually do anything.

they probably do more good than harm. norman: exercise wouldhelp your depression. exactly. my approach to managing menopause is to try and empower womenas far as possible to deal with it themselves, with some help from meand from the nurse i work with and maybe the counsellor. but looking at the whole woman,and encouraging her to take charge.

so yes, i'll get down on the floorand show her some exercises if she thinks thatit all takes too long. get her out and about looking atwhat she can do with her brain. many women have put their lives on holdbecause of children. i had a woman the other daywho had lots of problems to deal with - a husband with cancer and an elderlymother and children in high school. once we unpackaged that a bitand dealt with some of her problems, she started to think forward. she was planning ontaking up a university course

and doing some dance classes. all that's important. suddenly there was more to think aboutthan symptoms and more to do. what merits hrt in this day and age,liz? women whose symptoms arequality of life-impairing. that is, women that find thatthe symptoms they're getting are interfering to the point where theycannot undertake normal activities in a good frame of mind. what's available now?

some has gone off the market,some is not available on the pbs. some gps, i'm thinking rural gps,who haven't prescribed for a while, might be feeling deskilledabout prescribing hrt. if they go to the australasianmenopause society website, there's a list on the pbs of the different forms of hrtthat are available. that's a very good resource. the biggest change that's happenedover the last few years is a number of particularlyoral preparations

have been taken off the pbs. especially for women on the pension,the hormones now available to them are really quite limited. norman: it's patches? it's patches.well, estradiol implants... merck sharp & dohme worldwide have just stopped productionof estradiol implants. they're no longer available. a number of oral preparationshave been taken off the market.

and then,those removed from the oral tablets. so yes,we're down to patches and creams. tell me about dose-finding.that's been an issue in the past. you haven't had a hysterectomy,you're going on a combined hrt. there are some combined patchesavailable, but that very much limits youto the dose. there's only a fixed doseof 50 micrograms of estradiol in those combined patches, whereas if you use estradiol patcheswithout the progesterone cover,

you have a range of 25, 37.5, 50, 75and 100 micrograms patches, so it's easier to tyre-trackthe estrogen. if you do that, you've still got totake an oral progesterone or have a mirenaor look at something else to give them endometrial protection. if a woman is coming up to menopauseand is getting symptoms that she feelsshe would like to take hrt for, usually just start her onan average dose, and that would be, middle of the range,

usually 50 micrograms of estrogenwith appropriate progesterone. is the progesterone tethered tothe estrogen, or is it a standard dose? with the patches, there are two doses. there's 140 and 250. it's already sorted out in patches? if you wanted to customise it, you'dgive an oral progesterone or a mirena. if you lower the estrogen dose,you can drop the progesterone dose. the other thing is about starting womenwhen they're close to menopause. we generally use sequentialor cyclical therapy.

norman: what does that mean? it means that they'll get a periodevery month. it's like the pill but it's hrt? christine: similar. there's one where you getestrogen/progesterone the whole time. every day, or every patch,contains both estrogen and progesterone. then there's ones whereyou use estrogen only for two weeks, then progesterone for two weeks. those women will get a period whenthey get progesterone withdrawal.

- does evidence support that?- absolutely. if you start women on hrtwhen they're still perimenopausal and their ovaries are still producingestrogen on their own, hrt is not strong enoughto suppress that and they'll get a lotof breakthrough bleeding. if a woman is not 12 monthsafter her last period, you should start her on cyclical hrt. norman: and side effects? - periods.- so, breakthrough bleeding.

breast soreness. if you start them on cyclical estrogen, that usually controlsbreakthrough bleeding. - what about weight gain?- the evidence is, when you hit middle age,you put on weight. women on hrt blame the hrt. women off the hrtblame the lack of hormones. in fact, it's just an age thingand a change in your metabolism. if a woman has had a hysterectomyand is on unopposed estrogen,

the story is good. there's no increased riskof breast cancer, i understand. that has been supportedby the estrogen-only whi trial. and i believe there's been another trialor two after that. there's quite robust evidence that women on estrogen alone arein the good group as far as that goes. we've got some questions here - 'is there any connectionbetween early-onset diabetes and early menopause?'

adult-onset diabetes? you would say it's type-1 diabetes,not early-onset? yes, type-1, the autoimmune one. we've already covered a questionfrom rural nsw about high level of alcoholand severe symptoms. you were saying that is an issue. another gp from south australia asking, 'should we routinely advise againstthe use of bioidenticals?' we're saying yes,because you don't know the dose,

and it's also informed consentbecause it's not safer. yes. the other thing i notice with womenthat have been using those is they're really not gettingthat good follow-up through their gp. it's not being monitored at all. the jean hailes foundationhas an algorithm. they do. this is the jean hailesfoundation algorithm. it's been endorsed by the ams and it's in the family-planningliterature as well. norman: there's patient-educationmaterial as well?

christine: there are patient-educationmaterials. dimitra: we have menopauseinformation leaflets for patients and that's put out by the psa. there's resources on the back of that - the jean hailes foundation contacts,menopause society and other resources are on there,and phone numbers. norman: the australian familyphysician's got quite a good... christine: yes. australian family physician hasa whole edition on menopause,

a very good resource for gps. there's been a bit of controversyabout vitamin d and calcium, with a new zealand researcher suggestingan increased risk of heart disease. but the evidence is strong for vitamin dand calcium. the heart disease one is in womentaking calcium alone, not with vitamin d. my understanding is that vitamin dnegated that effect. anybody else? if people are concerned, they can goto the osteoporosis australia website. they've got a statement about calcium.

although their guideline is about tobe finalised in a month or two's time. learning about your symptoms and knowing how to look after themyourself is critical here. definitely. most definitely. the other thingi would suggest to women is, a lot of women these days have accessto the internet. the jean hailes foundation,for instance, has got some really good fact sheetsspecifically for those women. i always direct them to those websites.

- the australasian menopause society.- absolutely. they are the only two websitesi recommend women go to to get good information. the jean hailes foundation also puts outa quarterly magazine free of charge. women can phone in or write inand subscribe for free. it's got really good basic informationaround menopause. it's worth mentioning, we did talk aboutearly, premature menopause a bit. jean hailes does have a support group. norman: an online support group?

i'm not sure exactly how it works,but they have a newsletter too. let's go to our next case study, sophie, a married woman of 54 living on a farmin western queensland. she's menopausal,she's still sexually active but upset becauseshe's experienced loss of libido. she complains of vaginal drynessand some pain with intercourse. she has signs of weakening bladdercontrol, a bit of urinary incontinence. her adolescent children are growing upand leaving home. she's caring part-timefor an aged parent.

she's becoming anxious, depressed,mood changes, complains of feeling unappreciatedand unloved. she comes to see you to begin with,jenny. it's a very common presentation. this woman has a lot of things going onin her life. she needs to have a holistic approachto what's happening. obviously her symptomsneed to be controlled, but i would be looking at heras a whole. as christine says,i'd be listening to her story

and not trying to solve all her problemsat once, but taking it bit by bit and hopefully making things better. what would you doabout her bladder problems, liz? i thinkyou need to get a history off her. there's two sorts of incontinence -urgency and urge incontinence, that is, the got to go,race-to-the-toilet problem versus stress incontinence,weakness of the pelvic floor. does that often come on at menopause? it's more common at menopause.

vaginal prolapse more commonly presentsin women as they hit menopause and beyond. that's because as you getthe fall in estrogen, you get vaginal atrophy,ligamentous laxity. any weakness that was held upby the good tissue, as the tissue becomes weaker,tends to sag and give way. parts of the urethra and the bladdertrigone are also estrogen-dependent, so as estrogen levels fall, sometimesthat can become more sensitive. hrt wasn't very good at that,from memory.

my understanding is, results were mixed. in a lady like this, if she did haveurinary urgency and frequency as her main presenting problem,i would try her on hrt. sometimes that makes it worse,but sometimes it makes it better. presumably not instead of bladderor pelvic-floor training? i would still do that,but she's also got the dyspareunia. that will help with bothof those problems, but... the difficulty for her is going to bethat she's out in western queensland. if you're going todo pelvic-floor exercises,

there's good evidence that working witha good women's pelvic-floor physio is better than doing it on your own. the question is access for her. while i live in canberra, i've gota few really good women's-health physios with a particular interest inpelvic floor, once i deal with women from thesouth coast or inland new south wales, where they've just gotthe generic physio that does ankles and arms and backs... often they're men, and notthat interested in pelvic floors.

it becomes very difficult. if she can possiblyget to a women's-health physio, she will be better off. as she gets olderpelvic floor gets weaker, and it's best to keep it healthyfrom as early as you can. can i just saythat i agree with you absolutely. norman: but nowyou're about to disagree. no, i'm about to say thatwhat i do in a practical sense, because i'm not a superspecialistlike you are,

is to get women to use vaginal estrogen,to do their pelvic floors, and if they are overweight,to try and lose weight. i give them a three-month windowof doing this fairly consistently and hopefully get a nurse or a physioto show them the exercises so they do them correctly. then get them back in three monthsto see. we don't always expect perfection, but i often do find that women thenhave it better under control. they feel more in control.

you'd go straight to vaginal estrogenfor her vaginal dryness? - in somebody like that i would.liz: i would too. is there a risk of endometrialhyperplasia with vaginal estrogen? studies that have been doneover at least a year indicate not, although i have had some women, andprobably some gps will say the same, who have used it according to directionsand have had a bit of bleeding. clearly from time to timethere is a bit of absorption. do you think that's bleedingfrom the uterus or from traumafrom pushing the thing in?

sometimes they scratch themselves. i think there are women who genuinelyhave a bit of bleeding. they describe a heavinessa bit like a period bleed. is there truth to the assertion thatif they continue being sexually active, vaginal drynesstends to sort itself out? vaginal dryness comes on oftenfour to five years after menopause. it can be quite progressiveand very distressing for a couple who have had a good, healthy sex lifeall their lives. using lubricants and moisturisersis important,

but sometimes vaginal estrogens arethe only way, and they will needto use them long-term. but i generally try and get womento use them for a couple of weeks to prime the vagina,then twice a week as directed. then you might get away with once a weekor even once every ten days. try and monitor it yourself. is there an issue in termsof cervical-cancer screening? it really helps to do a pap smear? if women are getting atrophic smears,then yes, that helps.

but it's hard to do the actual speculumexamination in a woman with dry vagina? when i was at family planning,deborah bateson ran a study on that and found that five days of estradiol starting seven days priorto the pap smear was perfect. we had pathologists look atthe specimens and that was the dose. did that reduce the pain associatedwith having the pap smear as well? yes. we did acceptability and pathology. but you've got to starttwo or three days beforehand ideally? liz: why is that?- that was the dose-finding study.

there's no particular reason? ok. we're happy to provide some educationfor you here, dr gallagher. this was just totally practical stuff. professor davis,who we've had on the program before, would say,why wouldn't you consider testosterone? her randomised trial would suggestthere is some benefit here. i know it's not approved in australia. from my perspective, testosterone, as you say,is not approved for women in australia

and it has some issues with safety. the fda didn't approve itin the united states either. it has been shown in some trialsto help to some extent. i see libidoas a far more multidimensional problem than as a hormonal problem. i would rather spend the timein unpacking it. however,i accept that there will be some women for whom testosteroneseems to be a necessary thing. let's go to our next case study.

katrina, she's 55 years old. she presents with heavy periodson and off for the past six months. she has three or four sweats a day,and chills. she's been feeling emotionally labileover the past three months. she recently slipped on a stair, andshe was surprised to break her ankle. she's feeling anxiousabout the whole thing. christine? i'd be worried about this. having a fracture is... norman: she's got osteoporosisuntil proven otherwise.

virtually, yes.we need a dexa on her for sure. it's important to get a good history, and to look at reasons whythat might be the case. if she does have a poor t-score... below -2.5 is defined as osteoporosisby the who, but it's not the only reasonfor fractures, of course. in this woman, there is also this issueof heavy periods. a woman who's having very heavy periods sometimes completely underestimatesthe amount of blood she's losing.

it's very important to knowwhat her haemoglobin is, what her iron stores are. you see women who are quite anaemic. norman: this is a woman you'd wantto do a pap smear on, isn't it? jenny: she should have been havinga pap smear every two years. you've made a very good point, norman. when we do a menopause consultationand managing menopause, we mustn't forget about preventive care. as jenny has said, doing a pap smearevery two years until somebody is 70,

then breast examinationthrough breast screen, and of course looking at holistic thingslike we've already discussed. how are you going tomanage her heavy periods? it's importantto get a good history off her. when they're saying on and off, my experience with womenheading into perimenopause is one month might be heavy,the next month might be light. you look at whether they're manageablefor her. some women find that they can managea heavy period every now and then.

look at her iron levels and haemoglobin. multiple pads a day. multiple pads every few hours, actually,would be my definition. my test is to ask them whether theyhave to put a towel on the bed at night. or how often they get up to change padsat night and how often they change padsduring the day. is she a candidate for hysterectomy? absolutely not. there's lots of goodmedical management of heavy periods, especially in a woman of 55

who is likely to become menopausalor postmenopausal some time in the next year or two. norman: you'd put her on the pill? no, i'd put it into perspectivewith them and say, if you're reaching menopausein another year, you'll have 12 more periodsin your life. can you manage that? and often they can. in looking at management, there's medical managementand surgical management.

medical management would includethings like the pill but i wouldn't put a 55-year-old on it. drugs such as tranexamic acid,they can use every six hours when the bleeding is heavy. it will reduce menstrual blood lossby about 40% and bring thatinto a more manageable time frame. the mirena has revolutionisedthe treatment of heavy periods in perimenopausal women. norman: just remind us what that is.

it's a progesterone-containing iud. that works by, over time,thinning the lining of the uterus down so that it reduces menstrual blood losson average by about 94%. that lasts for five years,and will do if she ever needs hrt for progesterone cover. so she can just useestrogen-only patches. if you're looking at the surgicalmanagement of heavy periods, there's a number of different formsof endometrial ablations, which are day proceduresthat work very quickly.

they have a good effectwithin six weeks of having it. then move on to hysterectomy. in somebody like her,i'd do a pelvic ultrasound as well. we've had a questionfrom rural new south wales. what would you do with her husband? i'd try and get him in to talk. as often i can, when i have womenwho have emotional issues as well as other important things, i like to ask themif they'd bring their husbands along

so that i can get his perspectiveand get a couple perspective. in rural areas, and across the board, there are often a lot of issuesgoing on in a relationship. i'd be talking with him and with her. in fact, men are very interestedin menopause. they often don't say a great dealto start with, but once you get into the flow of it,they'll offer quite good insights. one time i was invitedto talk to a group of vietnam veterans about menopause, which intrigued me.

they were very interested. let's go to our last case study,who's ann. she's 52 years old, postmenopausal. two years ago, she was diagnosed withbreast cancer. she comes to you with hot flushes,irritability, sleep problems, vaginal dryness, dyspareunia that isn'trelieved by lubricants. she had chemo and radiation for breast cancer, a lumpectomy

and chemoradiation, adjuvant therapy. she's estrogen-receptor positive, and she's on tamoxifen following initial diagnosis and management. liz? you've got to tease outall the different symptoms. there is some evidencein women like this, who are estrogen/progesteronereceptor-positive, that if you give them hrt there isa higher chance of recurrence rates.

there were two studies that showed that. this is a contraindication to hrt? it's a contraindicationto hormonal therapy, that's right. there are a numberof non-hormonal treatments for hot flushes and irritability. norman: like nifedipine,calcium-channel blockers? no, not nifedipine. clonidine. christine: yes, clonidine. clonidine, snris and ssrisand gabapentin

are the four groups of drugsthat seem to help with hot flushes. they're not quite as effectiveas estrogen, but in a woman like this, probably managing rather than curingwould be enough. and if she's on raloxifenefor chemo prevention, does that cause the same issues? both tamoxifen and raloxifene are serms. that's a selectiveestrogen-receptor modulator. while they are useful in managingsome estrogen-related issues,

they're agonists. they're also antagonists. they do tend to cause hot flushes. raloxifene will have the same problemas tamoxifen. i agree with liz that the ssriset cetera are probably the way to go. you get an interaction, don't you? there is an interaction with tamoxifen. the cytochrome p-450 enzymecan be affected with paroxetineand also with fluoxetine.

so it's probably wisestto stay away from them. but an snri like venlafaxinecan be quite useful. about 60% of the time,they help with flushing. there is the issue with this womanabout her vagina and her discomfort. a lot of oncologists wouldbe reluctant to use vaginal estrogens. we've already said that systemic hrtis contraindicated. but there may be a place for usinga weak estrogen, like oestriol, in some cases. of course you've got to go throughthe issue with women

and get informed consent. there is no data that sayswe can safely use it. liz: there is also no datato say it's unsafe. i would always talk with the oncologist to see if we can make this woman... there's a quality-of-life issue here. with the adventof regional cancer centres, there will be more local expertiseavailable to general practitioners in rural areas.

what are your take-home messages?dimitra? about that time of life, women shouldconsider an overall check-up, where they are with the pill,if they're on the pill, if they're suffering symptoms, do they need to see their gpto evaluate what options they have? are the symptoms bad enoughthat they need to do anything? norman: christine? i'd take an individual-woman approachwith a holistic management process, looking at all of the elementsof her life

and seeing what it isthat i can help her with, but on an individual basis. gps and family practitionersshould not be afraid to prescribe hrt in women who need it around the timeof perimenopause. it's definitely the best treatment. we've got good data now about the risksand benefits. short-term in women,it's the treatment of choice. norman: jenny? i would agree mainlywith what christine said.

but also to remind women that it is a natural and normal part of their lives and that there is something that can be done and they need not suffer in silence. Thank you very much. This has become an interesting program. I've learned a lot, and I hope you also love this program, feeling the heat: managing menopause. Here are some useful sites for your partner like

and of course, the commonwealth's healthinsite. if you're interested in obtaining more information, there are a number of resourcesavailable on the rural health educationfoundation's website: there's also limited dvd distributionof this program available. check the rural health educationfoundation's website for details. thanks to the australia government'sdepartment of health and ageing

for making this program possible,

loss of libido
and thanks to you for taking the timeto watch and participate. don't forget to completeand send in your evaluation forms to register for cpd points. i'm norman swan. i'll see you next time�

Jumat, 28 April 2017

in women

female speaker: thank you alot for coming to our talk. it's my pleasure to introducetoday's distinguished guest speaker, dr. john gray, a greatauthor of the book "men are from mars, women are venus,"the best-selling relationship book of all years.

in women, he wrote 18 other books,and you can read about them on his website and his[inaudible] publications. and i won't keepyou longer, and i'll let john gray tospeak for himself

and share with youthe differences between the genders. thank you, john, for coming. john gray: thank youfor having me here. well, it's really funfor me to be at google, since i live on google. it's a researcher's dream tobe able to google everything instantly. you don't understandsomething, google it.

understand something, google it. i remember one of mymentors a long time ago was saying that if, whenyou're speaking, if you use one word that somebodycan't understand, then they tend to blank outon everything else you say. and one of the greatthings for google for me is i'll be readingresearch and this and this, and if a word comesalong i don't understand, i can immediately googlethat and come back.

because to trulyunderstand something, you have to actuallyunderstand every word. but we intuitively think we'regoing to get it at the end, but we don't. so in my message on"men are from mars, women are from venus," what's somuch fun for me is, typically, people can relateto the examples from your ownpersonal experience. so just to know you alittle bit as my audience

so i give the right talk, whohas read "men are from mars, women are from venus"? how many of you read it? so a lot of you haven't. ok, now, how many of you whohaven't have heard of it? so your parents read it, right? that was when i knewi was getting old, when people wouldcome up and they'd go, oh, i love your book,and my parents read it.

they started goingon walks together. they actually are somuch happier afterwards, so they thank me. and i said, well,when you get ready, you'll probably wantto read the book, too. so i'm going to give-- for thoseof you haven't read "men are from mars"-- some of the basicideas of that in our short presentation, and we'llalso have room for question and answers, if youlike to ask questions.

i'll also briefly talk aboutmy most recent book, which is called "work with me,"which is about 25 books later. i've applied theprinciples of understanding gender differencesin a positive way. because so much of thetime, when men and women show up differentlyin a relationship, we often have an intuitivereaction, which is wrong. how many of you have read thebook called "slow thinker, fast thinker"?

it was a good book,but it talks about most of our interpretationof reality is automatic, kind of like i know that thatbuilding's quite far away, and you're closer to me. and when we're in relationships,when our partners say or do things, we have anautomatic interpretation, which is oftenwrong, particularly when it's the opposite sex. so a lot of my ideas,i think the popularity

of "men are from mars"was that you really don't have to doanything to change your relationship to the better. because so many of theproblems that couples have in relationshipsis misinterpretation. and so if you can startto interpret a situation correctly, you findout the problem is not as big asyou thought it was. there's an oldeastern indian story

of the person who sees a snakeon the ground, and it's dark, and they start yelling andscreaming, snake, snake. and somebody turns on thelight, and it's a stick. so so many of the problemsi see with my couples as a marriage counselorare big problems to them, and then i explain it tothem, and it's a stick, and then you canwork with the stick. so in "work with me"--that's the second book i'll be briefly talking about.

that's my most recentpublished book. it talks about genderdifferences in the workplace, and how are these basic blindspots between men and women. and we teach throughhuman resources in different companies. we go in, and we do theseworkshops sometimes. and we did a survey ofover 100,000 men and women from workshops. so they filled out this surveybefore they took the course.

and we found that there arethese basic blind spots. there's eight that i focuson, but i'll mention one right now, which iswe asked the women, do you feel appreciatedin the workplace? and over half of thewomen felt they were not being appreciated by men. and then we ask the men,do you appreciate women in the workplace? and over 90% of mensaid, of course.

so that's a blind spot. men think that they'recommunicating appreciation, but women often notfeeling appreciated. and this gives rise to oneof the basic differences between men and women, whichis that women feel valued and appreciated whenyou know what they do. when a man gets paid, getacknowledged for the result-- good job, you did this, now youget this promotion or whatever. that makes a man feelvalued and appreciated.

acknowledge what i do. but for a woman, she wants to beacknowledged for what she does, but she also wants to be seen. she wants to be heard. she wants to be understood. and this was my first insightinto the world of "men are from mars, women are fromvenus"-- what was it-- over 30 years ago. before i realized it, beforei was even married to my wife.

we've been married 28 years. but helen is myassistant 30 years ago. and helen comes to me andsays she wants to quit. and i said, why wouldyou want to quit? you're the best. i just gave you a raise. you make as muchas me, basically. and she said, it'snot about the money. i just don't feel appreciated.

and i said, all right. well, hold on. why don't you feel appreciated? because i thought shewas a gift from heaven. and she said, well, john, youdon't even know what i do. and my reaction asa man was, that's why i appreciate you so much. and we laugh because wecan see the logic of that. of course.

i don't have to think. i don't have to plan. i don't have to do anything. she made all the arrangements. she put the money in the bank. she paid my bills. she organized my seminars. she handled all my clients. i just showed up at work andcounseled eight women today.

which, by the way, when "menare from mars" came out, everybody was so upset at me. some people still are. how do you know this? i said, well, mycredentials, basically, as a counselor-- how manymen have sat in a room and listened to women talk foreight hours a day for 10 years? you have to get paid a lotof money to do that job. so i said to her, justlet me-- she said,

you don't even know what i do. and so i caught on very quickly. i said, well, give mea week, and let's see. so helen continued towork for me for years. i just celebrated her birthdaywith her just recently. and all i did differently--and helen stayed with me and felt valuedand appreciated-- was i took five extra minutesa day to find out what she did. and once i knew what she did,then she felt part of a team.

very important for womento feel part of a team, not to feel isolated. second thing is shefelt seen, and that i come in and actuallylook at her. if you're a programmer, anengineer brain, you're a guy, eye contact is notso important for you. but to women, it is. watch women talk, they'llbe looking at each other, whereas guys could be lookingoff or looking down or looking

around, sometimeslooking at each other, but always when there's a point. if you're talkingsocial talk with guys, we have to be looking at afootball game or a computer screen. it was just the othernight, i was at a party with one of my old friendswho was sitting next to me. and my wife issitting over here. actually, it washelen's birthday,

and she's sitting in front. and i'm talking tomartin, his name is, and my wife points outto me 3/4 of the way into the evening,john, you're not looking at martin when you talk. you need to look at him. i said, ok, honey. i looked at martin. he didn't even notice either.

so what i focus on isthe little differences between men and women. it's not like a womancan't do what a man does. it's not that a man can'tdo what a woman does. and it's not that all men andall women fit into these slots so neatly. generally, about10% of men will tend to relate more thefemale examples. 10% of women will relatemore to the male examples.

women often come upto me and say, gee, i feel like i'm from mars. and i say, well,that's conditioning, to a great extent. women today areconditioned to be like men, and there's nosafety to acknowledge feminine aspects of who you are. and part of my messageis to validate that, but not to negate if you'remore on your masculine side.

that's great. that allows you tooften fit into the work world much better. and women will say to meafter they read my book, they say, yeah, i feellike i've become a man to become successful, and i'mvery confused when i get home. it's like i feel split. so i wrote a book, which iscalled "why mars and venus collide" before iwrote this book.

and "why mars andvenus collide" is-- what's happening today is thatwomen go into the workplace. the workplace stimulatescertain hormones. now, that hormone is thehormone is the hormone that gets produced whenyou're solving problems and particularly when youhave a responsibility, and it's all up to you, andyou're solving a problem. now, what hormone would that be? that hormone iscalled testosterone.

it's the emergency hormone. it's the hormone whenyou feel pressured, when you feel a senseof got to go fast. got to get this done. it's up to me. nobody else is going to do it. or you sacrifice becauseit's a difficult thing, but you say, i can handleit, because i'm getting paid, and that's my job.

that's the hormoneonly gets produced. it's testosterone. well, the difference between awoman's body and a man's body is hormonal. these are realphysiological differences. the average maleneeds 30 times more testosterone tobe in a good mood. the number one causeof heart disease in men is a low testosterone.

there's no man that hasa heart attack unless he has low testosterone,high estrogen, estrogen being the feminine hormone. as men get older, they startthinking, i want to quit. that's because faulty diet,lack of exercise, too many estrogens in our environment. what happens isestrogen levels star rising, pushingtestosterone levels down. that is number onecause of heart disease.

as soon as theman retires, which means he doesn't havework, which means, i have to get upand do something. i have to solve problems. a man has one year beforehis first heart attack. this is a statistical fact. so a statistical fact. not every man. but men need to work.

men need to go out thereand solve problems, because solving problemsreleases testosterone, and testosterone a hormonethat lowers stress for men. does testosteronelower stress for women? no. does testosterone beingreleased feel good to women? yes. it feels good. so women can lovetheir testosterone job,

but their stress levelsrise and rise and rise. and this is shownin a study that was done in scandinaviancountries of several hundred thousand women andmen being tested, and they foundthat-- and this is one of the areas whereyou have the greatest equality betweenmen and women-- i get frustrated when i go there,because they call it equality. i call it blindness.

we're all the same,which we're not the same. but at least there'sequal respect for everybody, whichis a good thing. but real equality iswhen you can recognize the differences in thespirit of equality, equal opportunity, equalrespect, regardless of man, woman, culture,race, whatever. so what they found in thisstudy in scandinavia-- huge four-country study-- isthat women in the workplace,

their stress levels weretwice as high as men's. when women came homefrom the workplace, their stress levels werefour times higher than men. these are averages. and that basically means theirhappiness level is dramatically declining. university studies inamerica have repeatedly shown that, in the '70s, women'shappiness level was way up here, and men's was down here.

men has pretty muchstayed the same, and women hasdramatically dropped. so what you get, as womenmove more into the workplace, as an average, theirhappiness goes down. so what's going on there? when i say this, i'mnot saying, oh, women shouldn't be in the workplace. i have three daughters. they all have jobs and careers.

i've supported that completely. but they're happy. their stress levels are low. they're educated to understand--they have two parts. we all have two parts. the masculine sideis solving problems, releasing testosterone. if you're a man, thatwill lower your stress. but what lowersstress for women?

well, this was ahuge breakthrough that happened in 2002 at ucla. they discovered that the hormoneoxytocin, which is generally associated childbirth and femaleorgasm, the hormone oxytocin is the hormone thatactually directly lowers stress for women. and without an abundanceof oxytocin in your body, your brain does not havean off switch, which means when you haveproblems, if a woman's upset,

she's upset for daysand days and days. she's still thinking aboutthis, thinking about this. i was just counseling a couple,and they were in their 80s. and they haven't seenme in about a month, and she brings up an issuethat happened six weeks ago or a month ago. he says, i can't believe she'sstill thinking about this. i said, you don't understand. women don't have an off switch.

they keep going aroundand around and around. now, how many women in thisroom can relate to that? you're not on camera, butyou can relate to that? i'm getting some nods. can i get some arms up? let me just see. they've actually put menand women on computer scans when the sun sets, and whathappens for a man and a woman is very different.

unless there's an emergency,you say to the man and woman, you say, sit down and relax. and you put your brainscans on to measure blood flow in the brain. and for the woman, assoon as she sits down, blood flow increasesto the brain. brain activity increases. you ask her, whatis she thinking? what is she thinking?

she's thinkingabout all the things she needs to do thatshe's not doing it while she's sittinghere on this couch. that's her braingoing like this. you look at the man's brain,blood flow literally stops. it just goes backhere to where he can keep his body temperatureand breathing and so forth. and you ask him, whatare you thinking? and what does he say?

nothing. and if you didn't havethat test, the woman says, you must be thinkingof something. you must be thinkingof something. and this is the difference. and so what's going onthere, which i talked about in "men are from mars" longbefore all this research came about, i just observed it. is that mentypically go to work.

they're solvingproblems all day. they're releasingtestosterone, particularly if a man is successful, whichmeans he feels confident, i know how to solve problems. so if i get in my car, andi'm driving 100 miles an hour, if i feel like i'm in a goodcar, and i'm a good driver, actually my stresslevel goes down. how many men can relate to that? you're doing something whichis extremely dangerous,

by the way. because if you were to letgo of the steering wheel, you would die. or if a deer ran out infront of your car, which you have no controlover, you would die. but your brain,basically, you're producing huge amounts oftestosterone, releasing it, and dopamine. dopamine is thebrain chemical focus,

so you're going right into focuszone because there's danger. so dopamine and testosteronego hand in hand. so your stress levelsare going down. so quite often, i noticedthat if i got in an argument with my wife, or somethingwas stressing me out, i'd want to go fora drive in my car. and i would just drive alittle faster than usual, so i have to look front andbackwards for the police. and i would start to relax.

now, of course, if mywife was in the car, that would raise herstress levels hugely. so there's huge differenceshere in how we cope with stress. that's just one little example. but, typically, whati would see happening, what i still see happening,which a lot of men don't do now, and this ispart of my message to men, is that we would go to work,and we would solve problems, and we'd come home from work,and we'd forget problems.

you have to realize,for thousands of years, hundreds ofthousands of years-- i've gone 18 timesaround the world, been with indigenoustribes around the world, when the sun sets,the men sit around, because their job isin the jungle doing what they do whenthere's sunshine. now they're sittingaround, or they're a guard sitting arounddoing nothing, as well.

so they don't movewhen the sun sets. they actually need to relax. and when they relax, theirbrain, in order to relax, their brain literallyhas the ability to forget stressful messages. so the way men cope withstress is you solve problems, and at the end of the day,you forget your problems. and we have a shut off. we can turn them off.

and when you turn offyour problems, you relax. and when you relax, yourbody rebuilds testosterone. that's how yourebuild testosterone is to do anything awoman would consider to be a complete waste of time. so he'll come home from work. he'll sit around, maybe watchthe news, sit on his computer, do something, play avideo game, anything. and she's going, but we'vegot this, and we've got this,

and we've got this. and there's this. and you forgot this. you're not doing this. and she can'tunderstand why he's not attending to all those things. but he's doing what he has todo to cope with stress, which is to turn off allresponsibilities for a little me time.

and she's going, well, why doeshe get me time, and i don't? because you can't. you should be admiring that. you should be going, iwish i could do that. and, of course, women, youdo subconsciously admire it. this is all the spa magazines,all the upper level gold watch magazines. they always show somebeautiful spa resort place, and a woman issitting in meditation.

and she seems to be sobeatifically calm and peaceful. you have no idea she'sworrying about 50 things. but the illusion is thatshe can turn off her brain and be completelyhappy like that, which is an illusionfor women today. they can't. but what this research in1992 showed is how you can. and you can do it. the hormone that allowsyou to relax is oxytocin.

oxytocin is stimulatedin a variety of ways. i've written wholebooks on oxytocin, how to simulate it,how you lose it, how you get in, and so forth. we'll go a littlebit over it today. and with oxytocin, when awomen is giving love-- ok, if you're nurturing others,if you're caring about others, if you're thinking about others,if you're helping others-- basically, if you're taking careof your kids-- because women,

for thousands andthousands of years, if you go to anindigenous tribe, you'll see the babies arebeing born every year. women are just pregnantmost of the time. they're taking care of the kids. when the sun sets,the men are all sitting around doing nothing,sharpening their tools or whatever, telling stories,or not talking at all. women are completely busy.

they're nonstop action,nonstop busy, busy, busy. but their stress levelsare dramatically low. what is lowering their stress? when you feel you'rein an environment where there's no time pressure. the number one inhibitorof oxytocin production is feeling not enough time. the number one complainti hear from women today is not enough time.

there's too much to do, andthere's not enough time. and when you feel, as a woman,there's not enough time for me to do what i'd liketo do, to do what i enjoy doing-- it's a huge,perplexing thing for men when we see women say, ihave no time for me. he'll take a deep breath andgo, how is that even possible? because if a guy runs out oftime for me, he just takes it. but when a woman isfeeling stressed, your mechanism tolower stress is

to nurture othersand release oxytocin. oxytocin, when you'regiving to other people, caring for others, beingconcerned for others, doing for others-- notnecessarily solving problems-- being in a social relationship,listening to someone, helping them, whatever. it's not so much solvingproblems as nurturing. see, here's the differencebetween nurturing, which is oxytocin-releasing,and problem solving

is testosterone-producing. so my wife is a gardener. when she's plantingher seeds, when she's caring for herseeds, that's nurturing. when the irrigationsystem is broken, and water is spurting up,that's solving a problem. so you see how solving a problemis the illusion that i'll solve it, and it's done forever. and then, of course,they come back.

so men make greatemergency workers. a big problem comes,i'm going to solve it. then you feel like,ah, now i can rest. relax. forget about that. but women are designed tonot forget about things. this is the bigcomplaint men have, is 30 years in-- i'll justdo a funny story here. my wife and i were inthe galapagos islands.

you know, the galapagosturtles live long lives. there's a t-shirtthey're selling there, it's these two oldturtles talking, and the husband's saying tothe female turtle, honey, the affair was 97 years ago. can we let it go? when she's under stress,all of her memories come up. see, this is howwomen cope with stress is talking about what'sstressing you out.

so the memories come up. men cope with stress byforgetting those things. forget it. so a woman's busy talkingabout stressful things, and a man goes, just forget it. don't worry about it. it's not a big deal. just do this and this and this. don't take that exit next time.

and the worst is the man willlisten to you complaining about your job, he'llsay, just quit that job. you can get another job. as if you're going to say,gee, i hadn't thought of that. what a brilliant idea. no wonder i'm married to you. you're so smart. but, see, when a man hears aproblem, he wants to kill it. basically, it's runfrom it or kill it.

solve it. fix it. because that releasestestosterone. then he relaxes. for a woman, testosterone doesnot lower her cortisol levels. it doesn't raise them. it just doesn't lower them. so what lowers stress levelsfor women is oxytocin. ah.

so now when you're in apersonal relationship, and you're nurturing others,you're releasing your oxytocin. your stress levels goes down. but guess what? giving doesn'trebuild your oxytocin. what rebuilds oxytocinso you have it to give is when you feel you'rereceiving support. so, for women, everythingis about reciprocity. it's i give, and i get back.

i give-- if you're my friend,i do something for you, and now you're obligatedto do something back. if we're two girlfriends,and i call you up, with the first thingi'll do is a woman is say, tell me about your kids. or tell me about this. it's like i remembereverything about you, and i ask lots ofquestions, get you talking, and now you owe me fiveminutes of listening.

women can't believe when aguy will talk about himself and then not ask her questions. it's like, how can hejust talk about himself? and he's over here thinking, whydoes she have nothing to say? because women eagerly askquestions to draw somebody out because they so muchvalue being heard. see me, hear me, touch me. all of these thingsare oxytocin producers. so that if you feelseen and heard,

and you feel backedup, if you're part of a team-- andthis is women in tribes. women have alwaysbeen in tribes. you go to indigenous cultures. they're doing everythingtogether, all the time. and there's never anyrushing, by the way. there's a sense of support. it's that you feel that youhave support at all times. it's not like you needthat support all the time.

it's not i like you'rethis needy person. it's just that youalways have backup. and so women, becausetheir instinct is always to be giving, becausegiving releases oxytocin, and you have a rewardssystem to make you feel good. women are busy alwaysgiving, but if it's all women you're working with,all day long, everybody's giving, soeverybody's receiving. and suddenly, you take awomen and put them in hand

with men, who don'tlive in that world. or in a corporate environment,it isn't structured that way. see, the whole difference ofmars world and venus world, we have to blend them together. one is not bad. one's not better. but to make sense of it,you look at the two worlds. in the mars world,the strong survive. the better you are, thebigger result you get.

the harder you work, the smarteryou are, the bigger result. you get paid more. gee, he didn't get paidmuch, but look what you did. you got more. at home, in the personal world,the child who is the sickest gets more. they get more attention. they get more help. they get more support.

and everybody getswhat they need. it's not what you earn,it's what you need. but you don't go into yourboss and say, you know, i really need that job. your chances ofgetting it go down. it's like, i'veearned this role. look what i've done. i do this and this and this. therefore, i shouldget this reward.

these are two differentworlds of thinking that blend together, and thisis the male female relationship, which is a new experimenton planet earth. if you go to any theindigenous tribes-- we're talking thousands andthousands of years of history. go visit in africa, you'llsee two fires at night. women around one,men around another. go to the amazon. i was just in yourgoogle maps area

where you can seethe whole world, and i was going allthese places i've been. go down to the amazon. you'll see, at night,men are sitting around. women are behind awall, and they're all busy with the children andcooking and cleaning and making alcoholic beveragesto give to the men. how do they make thosealcoholic beverages? just little trivia here.

they chew these roots. they masticate them,chew them, and spit them into this bowl with alittle heat under it. and if they go forthree or four days, it becomes very alcoholic. so the men are alljust sitting around. the women come outwith their bowls occasionally and handit to their husbands. and there i am with thechief, so the chief's wife

gave me his bowl. it was this big on--just tasted terrible. that chief, by theway, [inaudible] chief, he was also very proud ofhis seven shrunken heads. they do exist. and through my two translatorsasking him, why do you do that? he says, oh, very clear. i have seven children. i said, well,explain that to me.

he says, well, the jungleonly has so much food, and you can only get so muchfrom your grocery store. and if you're going to bringa child into this world, you have to eliminate somebodyfrom a neighboring tribe. otherwise, there willbe a shortage of food. that was theirsustainability program. i think we've come a long way. it's tribal thinking versusglobal consciousness. now we're movinginto the world where

if i hurt someone outthere, i'm hurting myself. and the history oftribal consciousness is i don't care about them. i care about my children. that's a mafia family. mafia fathers are veryloving to their kids as long as they say yes,but not to anybody else. so this, we're tryingto get out to see, and that's the experienceof the heart opening.

and, ultimately, this happensthrough this great experiment of romance, men andwomen coming together in romantic relationships. you seek out, you find someonethat your heart opens to. and can you keep your heartopen to the same person who's not perfect? say, for the firstthree years, it seems as though they're perfect,and then reality sets in. and reality sets in becausewhen you meet someone new,

and there's sexualattraction, your brain produces massiveamounts of dopamine. how many are familiarwith the term dopamine? that's when you'redriving your car fast. that's when you're reallyfocused on a project. that's when you'regetting a reward. that's when there's danger. that's when there's sex. that's when you're doing--any addictive substances goes

into the nucleusaccumbens, where dopamine produces lots of pleasure. so anything that's pleasurablefor you is producing dopamine. so in the firstthree years, one of the major dopaminesimulators is newness. newness stimulates dopamine. now, what is theopposite of newness? not newness. and what happensafter three years?

it's not new. and then to makethings worse, when you have an argument, whatdoes she generally do? she brings up the past. so there's definitely not new. it's the worst thingcouples can do. and i'm not putting it onher, because she'll start it, but then he'll comeback, and now he'll start going into the past, too.

and now you're bothliving in the past. as soon as you can'tbe in present time, dopamine levels startdecreasing, decreasing, decreasing. all that passion youfelt in the beginning dissipates afterthree years unless you have relationship skills. you have to understandthe software. with so many ofyou into software--

that's how i got into thiswhole relationship thing. i used to work asa programmer back in the days of stanfordresearch institute and cobol. so i used to programthe computers. at a certain point, i realizedi should program people. so i had that veryanalytical perspective that men are like this,women are like this. if we do this, then this. if we do this, then that.

and we can see it predictively. a man comes home-- hedoesn't know anything about men and womendifferences-- he says, hi, honey. and he goes and sitsdown and reads a book. and she's going, is that it? he used to be excited to see me. matter of fact, what she'll doif they're married in a house is he comes home,she'll test them.

she'll go to another partof the house and wonder, does he even miss me? does he care about me? she's playing hide ad seek,venusian hide and seek. i'm hiding, and you'resupposed to find me. so she's going, i could bedead, and he wouldn't even care. and he's from mars-- he hashis own little hide and seek. men come home-- hegoes, she's not around. good.

he just wants to be alone, nointerference, nobody calling on, nobody asking for anything. just give me abreak for a while. so he's playinghide and go seek, but the rules are,don't find me. he doesn't want to be found. she wants to be found. men solve problems to feelbetter and then forget them. the easiest way to solvea problem is forget it.

manana. tomorrow. i don't have todeal with it now. and that's what we'retrying to help you with, but it doesn't work for her. and she'll betalking about things and just blows himout of the water. he goes, oh, my gosh. i'll make $1 million on a book.

we'll be doing a bunchof fun stuff together. i'll come home oneday a week later, and i'll leave a glassout on the counter. and she'll lose itand go, ugh, is it that hard to put yourglass this far over to here and put in the dishwasher? i mean, can't you atleast put it there? and i'm like, what isshe, nuts or something? we're, like, the luckiestpeople in the world.

we're having an argument overa glass, which is right here? how could she do that? but when you understandher world-- and part of the craziness,from my perspective, is two days before,it was a big bunch of all these disheswere everywhere. it was piling up and piling up. it was some partywe had, and nothing had been done for a couple days.

so she had spent muchof the day cleaning up. so it was completely clear--so you have to imagine this. you've been livingwith trash, and women see this 10 times more than men. they actually have morecells in their eyes. they see it. they can't ignore it. guy comes home. he sees his tv set.

that's it. doesn't see anything. she sees everything,and it's hard to relax if it's not in order, organized. so here it is. it's been cleaned up. she spent all daycleaning it up. and from her point,can't there just be a moment where itstays so pretty and nice?

so it just triggered a button. she had an emotional reaction. and when women haveemotional reactions, see, men think that thatemotional reaction is just about the glass. but it's never about just thefirst thing she talks about. that's just the warm up. that's the foreplay for thebig story that's about to come. she's got all kinds ofthings that are bothering her

that have been building up. it's like, for women,it's like the straw that breaks the camel's back. women hold this stress up,this stress up, this stress up. and finally something happens,and it starts to come out. and when it comes out, aguy thinks you're nuts. but here's a way to help, ,again interpret each other correctly. she's not nuts at all.

it's just that shehas a greater need to talk about what'sbothering her. men have a greater need toforget what's bothering them. so our job is toforget about it. her job is to talk about it. so here's a little difference. we come into some physiology. the emotional partof the brain called the limbic system is twiceas big in a woman than a man.

big difference. twice as big. under moderate stress, a womanwill experience eight times more blood flow to theemotional part of the brain. under moderate stress. under extreme stress, a manwill experience that blood flow, but the problem hasto be really big. women will experiencean emotional reaction to small problems.

and so a man misinterpretsher emotional reaction as if she's sayingthe problem is big, and she doesn't knowwhat to do about it. so we're constantly seeingwomen, when they get emotional, it's like, what, shecan't handle that? she's not saying, ican't handle that. she's just having anemotional response to it as a way to let go of stress. and man's way tolet go stress is

to detach, to separatefrom his emotions. and you can seethis in brain scans. the amygdala ina man is wired up to go right to the part ofthe brain-- fight or flight is the amygdala-- intosolving the problem. you know what freuddid-- it totally different from modern therapy. 90% of the people who seemodern therapists are women. why?

it's changed. it's eye contact. it's how do you feel? how do you feel? what else do you feel? what else happened? how does that make you feel? it's all this personalnurturing interaction. freud did none of that.

he had mostly men. you go into a dark roomwhere you had no eye contact. you lie down on a couch,which every man loves to do. he'd sit behind you, and allhe would do is take notes. he'd ask you questions. and you would solve problems. why do you think this? and why you think that? and why do you think this?

he could have just been saying,and what is 23 times 17? and you would have tocalculate these problems. just solving problems andrelaxing lowers a man's stress. it wasn't somebig, magical thing. but for women, it did nothing. so, gradually, itevolved for women. and usually it wasjust very wealthy men they did therapy, becauseonce you're a man, and you have lots ofwealth, you go crazy.

and by crazy, i mean, lookat the "national enquirer" and see all the wealthysuperstar people. they get divorced. they have battles. they take drugs. they're going through rehab. what's going on is that theydon't have to work anymore. these are men whodon't have to work, so they get to dowhat they like to do.

when you do what you like todo, oxytocin gets produced. oxytocin doesn'tlower stress in men. doing anything thatwomen like to do does not lower stress in men. that's why in thebeginning, men are so happy to do things with you. and after a while, they'reready to sit on the couch. and what you'll sayto them things like, hey, what would you like to do?

he'll say, i'd like to justsit here and have you make me dinner. or you might want to goout to dinner tonight, and you say to him,hey, john, would you like to go out todinner tonight? and what does every womaninterpret that to mean? what she's reallysaying is, i'd like to go out to dinner tonight. wouldn't you liketo go out to dinner?

let's go out to dinner tonight. but she doesn't say that. she says, hey,john, would you like to go out to dinner tonight? if he's not initiated intothe venusian language-- which is very convoluted andchanging all the time, depending on hermood-- would you no, i'd rather just stay home. you could make me this dinner.

because he actuallythinks you're asking what he'd like to do. the flip side of this isfriday night comes along. and this is where we havethis experiment of romance. marriage is based upon loveand affection and romance, which is magnificent. i've been marriedto my wife 28 years. to experience passion withsomebody that you know, it's like amiraculous experience.

very few people haveever experienced it. they have to have somebodynew, somebody different. to actually experience passionwith somebody you know. it was like sevenyears into our marriage is when i woke up tohow great my life was. not that i wasn'thaving a good time, but making love with mywife, it was fireworks. it was spectacular. it was one of those timeswhere, afterward, you

just laugh at howfantastic it was. and i said to her,wow, that was as good as it was in the beginning. and she goes, oh,that was better. i said, what do you mean? she says, well, in thebeginning, the sex was great, but you didn't really know me. now, you've seen thebest of me, and you've seen the worst of me, andyou still love and adore me.

that's real love. in the beginning, its aglimpse of what it feels like. it's the brainchemicals of love. but you don't even knowwho you're reacting to. it's mostly fantasy. in order to keepyour heart open, we need to have these advancedcommunication insights. because what do you do? if a guy needs togo to his cave--

one of the big insightsof "men are from mars"-- now it's pretty muchgone into the culture. man cave. he needs his man cave. he goes to his man cave, exceptmen typically don't come out. so i teach women how to bringhim out of the man cave. he's got to havethat, but he also needs a littleincentive to come out. if you say to him, what wouldyou like for dinner tonight,

or what would you like to do? he'll say, justsit in my man cave and continue doing what i'mdoing, as opposed to you have to know what you'dlike, what you want, learning how to ask for support. these are all like new skills. women have never hadto do that in the past. and for thousands andthousands of years in indigenous cultures, womendon't ask men for anything.

they don't even talk to men. men learned a man'srole from his father. women learned to do from mother. that was it. there's very littleconnection and communication. so it's learning to takethe time that we need. and for men, it'soften alone time, and for women, it'sconnection time. if you want to keep theconnection open with a man,

and you want to keephim connected to you, your role is to, in asense, draw him out. and one of the bestmetaphors for this is when i was going toplaces in indigenous india. you go to these temples thatare 5,000-year-old temple, and you'll see allaround the temple, men are sitting in meditation,not the women at the spa. men are all sitting inmeditation, because they can more quickly--it's not automatic,

but a man has the abilityto shut the world out, and that is the mostpowerful way for him to rebuild his testosteroneand regenerate his body. so men are allmeditating at the temple, and women are all dancingaround naked with little bells in their waist. and their job? to get men out of meditation. you're supposed to drawus out of the cave.

their whole mythologyis shiva would meditate 10,000 years or a millionyears or whatever, and his wife has to dancearound him until finally they make love and create the world. but it's the womanthat draws the man out. and women today, they don't evencare about drawing the man out. they just like goingon with their life, and then they misinterprethe's sitting in his cave. what you start to think is,well, he doesn't love me.

he didn't used to goto the cave before. and that's because he had thenewness in the relationship that would produce hugeamounts of dopamine, and then thatproduces testosterone, so he wasn't needingto rebuild it as much. so now you're inthe relationship. he's taking more time away. he doesn't have thatsame attraction to you he had before.

he's starting to pull away. and women go, oh, ihave to get it back. i have to get back. and you run after him,and he runs away more. that was one of the bigthemes in "men are from mars, women are from venus" ismen are like rubber bands. they want to get close toyou, and then they pull out. when they pull out, like arubber band, they stretch. and when it reaches its lengthof how much space do i need,

then he springs back, and hefalls in love with you again. and then he pullsaway-- he misses you-- and he springs back. now, i'm going to go ona trip to china next week or so for three weeks. i haven't been away from my wifein eight years for three weeks. but what i know is i'llhave the best sex of my life when i come home. that other time i was ona tour for three weeks,

and it was the bestsex of my life then. because i have pulled back. and when i pull back, ihave a chance to miss her. i have a chance torebuild my focus on her. i have a chance for mytestosterone levels to rise. and when i come back, itwill just be super stud land. i'm really lookingforward to it much more than how much i'm gettingpaid, which is a lot as well. but that is reallyan exciting thing.

so when men pull away, theyspring back like a rubber band. and then once they're in,the rubber band gets soft. it's just a metaphor for sex. imagine a man justwent in and stayed. you'd be wantingto push him away. he pulls out. he goes in. it's that dance of comingcloser, pulling apart. and that's his role togo in and pull back.

he has the hormones for it. testosterone is thein and out urge. this is testosterone. when women don't understandthe hormonal differences between men, when he pullsaway, what do you do? you run after him. and so if you'rerunning after him, does that rubber bandever get to stretch? and how do you run after him?

i go into all the detailsin the books, but you say, what's the matter? is there something wrong? or let me do something for you. or let's do this together. or what would you like to do? and now you'reconcerned about him. when he pulls away,that's when you have to come back to beingself-sufficient, self-reliant.

i have a life, and you'relucky to be part of it. if you can stand in yourplace without getting insecure and running afterhim, that causes him to want to come back. because, see, men reallyneed women to be happier. we can only get to acertain level of happiness. then we have to be able tomake a woman happy to take us to a higher level. the illusion weall have as men--

we get caught in thistrap-- is that we think we can make her happy. you can't make a woman happy. you can only makea woman happier. you're not responsiblefor her happiness. because in the beginning,all that newness stimulates hugeamounts of dopamine, just like winning thelottery, just like superhero. that's why theycall heroin, heroin.

you get to be a hero andsit down and do nothing. it makes you feel like a hero. a woman makes you feel like ahero, makes you feel fantastic. look what i did. she's so happy. the problem is,when you take credit for all of her happiness,when she's not happy, look what you feel. you feel like you've failed.

you shut down. you get bent out of shape. you get pouty. you get feminine. see, what peopledon't understand is this feminizationof men is when men become allnegative emotions. if you're in yourmasculine side, you have healthy testosterone,you don't get afraid.

you don't get angry. you don't cry unless theproblem is really big, and there's nothing you can doabout it, like grieving a loss. there's places for feelingsbut not in arguments. men used to be taughtthis stuff, how to endure pain withouttalking about it. in initiation foran american indian, they'd stick sticksthrough the breast in front of the wholevillage at 13 years old.

they'd tie ropes to itand slowly raise you. throw the rope over a limb,slowly raise you in the air, and you hang therethe whole day. and you're notallowed to cry out. you have to learn todeal with that pain. you have to containit inside yourself. and now do we needthese initiations today? we have a moreadvanced initiation. try listening to your wifewithout saying anything

for 10 minutes. without reacting back. see, you have tolearn as men how to contain thefemale side of you inside and not becomea female and start whining and complaining back. this destroys marriages. a woman will complain. a man has 10 more back.

he says, i can beat that. i'm a man. i got testosterone. i can do more. and now you get this littletit for tat argument. nobody's taught men today. you don't do that. that's not what men do. what women need mostis to feel heard,

and then a magic trick happens. she feels better, andnothing has changed. this is like a revelation. i have women coming intomy office so unhappy, and when they leave,they're so happy. and after a while,i point out, do you realize that you cometo my office unhappy, and you leave happy,and nothing has changed? nothing has changedin your life.

it's all inside ourselveshow we look at the world. as a couple, men can learnhow to support a woman. women can learn how toreceive that support. that's the whole newdance, is women learning, how do i motivate him togive me the support i need? because he wants to do it,but it's very hard to start. when he goes to hiscave, you misinterpret, thinking, he must not love me. so how can you goand ask for support

to somebody you thinkdoesn't love you? or ask for helparound the house? women need way more help. how can you ask? you look at him witheyes of resentment. aren't you helping? aren't you joining in? why aren't you helping me? well, he needs ajob description,

and he needs to be paid. paid is your happiness. so let's say you needhim to do something. would you move that box? and it's the thirdtime you've asked him. he moves the box,and you glare at him, like, finally you did it. as opposed to, oh,you moved the box. then, next, you're traininghim to do little things

to make you happy. because in a man'smind, big things make you happy,not little things. he's dating you. he's only doing little stuff. and he figures if littlestuff makes you happy, wait until i do the bigstuff like commitment, and marriage, orsharing my income. that's the big stuff.

then i don't need todo the little stuff. but it's the littlestuff that actually generates the oxytocin. so if i give onerose to a woman, she gets a surge of oxytocin. if i give her 24 roses, inmy mind, that's at least 24 surges, right? it's just the same surge. so think of it interms of points.

in a man's mind, i'm givingher 24 roses, 36 roses. that 36 points. that should lastme half the year. it's one point. and why are roses sosymbolic of romance? because they die in a week. you have to keep nurturing it. so once menunderstand this stuff, women are not so complicated.

it's easier to makethe relationship work. but it is an art. it is like learninga new program. it's a new system. and once you learn the newsystem, it's really easy. but when you turnover to a new system, it's really hard for a while. that's what we're goingthrough right now. so we have about 10 minutesfor questions and answers.

i see one right over here. go right ahead. audience: [inaudible]? john gray: ok. so you'd like to know how womensabotage communication at work? because that is probablyone of the things that i write aboutin "work with me." i have 10 minutes totalk, so i'll give you one way women sabotagecommunication at work

is they simply use the phrase,bob, could you do this for me? and bob will say, sure,and then forget to do it. and you'll think,how could he forget? and this is something youexperiment with this week. instead of using,could you do this? can you do this? say, bob, wouldyou do this for me? and you'll see he willremember to do it. it's linguistics.

if you say would, a manfeels he's making a promise. if you say, could you do it? yeah, i could do it. it doesn't even go into thefront part of his brain. it literally doesn't go there. the next one, another way is notgiving enough feedback to a man that you value him. because women just assume thatif you're interacting with him, he must feel valued.

so one of the ways a womancan communicate value to man, that you valuehim-- three phrases. you start doing thisthis week, you'll see a huge difference inthe men you work with. he's talking. when he pauses, say,that makes sense. and just brighten up,like, that makes sense. you'll see. he'll take a double take.

what did i say? somebody acknowledgedi make sense. that makes sense. another one is, with a littlefemale enthusiasm, good idea. you'll see hismood will changed. and at least a couple timesa week, go, brilliant. he says, yes, yes. what else can i do for you? now, i know the flip side ofthis-- how do men sabotage?

well, i'll do acouple on men, which is how men could sabotagerelationships in the workplace. same thing at home, whichis, ask more questions. whenever you think you're readyto give a solution or a point of view, ask another question. if you show interest ina woman's point of view, you start buildinga bond of trust, as opposed to justbeing interested in solving the problem.

men are just interestedin solving the problem. but if you can justask another question, it take your interestinto her point of view if a man can askthat extra question. here is the next one, as amale manager, particularly, but working on ateam with women. when there's a problem, and awoman's presenting the problem, don't immediately give whatyou think is the answer. instead, pause, andsay to her, and what

do you think weshould do about this? and listen to her answer. because so much ofthe time, men just-- if you talk about aproblem, men jump in there with 30 times moretestosterone, which gives you faster reaction time. i got the answer! i'll solve that problem. and he doesn't realize thatyou have the answer, too.

so you're sabotagingyour success by not letting him knowyou have an answer-- that would be another topic onhow women sabotage-- but men sabotage building trustand a sense of cooperation when they're working with womenby jumping in with solutions, rather than asking afew questions first. but, for men, it's likeplaying basketball. i want to grab the balland dunk it myself. women are all, ona certain level,

let's all take turns, andlet's all take credit together. we're a team. we did it all ourselves. and a man's overhere, but i did this. anyway, a lot on that. that's from thebook "work with me." well, i'm askingthe question where you hear i mentioned ihad a study of 100,000 men and women that wetook their evidence

right from the book, which isanother one of the blind spots was the number onecomplaint women have-- we asked this question, itjust happened to be the highest one-- is, do you experiencethat men listen to you? and over 70% of womensaid men don't listen. they asked the men, domen listen to women? and 90% of the mensaid, of course. so in his world, he'slistening, but in her world, she doesn't feel heard.

that's a gap. and, yes, we've donethe research on that. i did that bookjust because people would say what you just said. well, where's yourresearch on this? i probably talked to morepeople about relationships than anybody in history,than the whole planet history of the world. that's all i dois talk to people

about relationship experiences. not in a scientific studywith 18 men and women, with thousands of people, with50 people, again and again and again. and what i see is these themes. but i wrote thatbook just so people who like to look at the digitscould actually see the digits and how many women truly see theworld through different eyes. but i appreciate the comment.

it's a force thatwe have to overcome, because there's ahuge force which wants to say we shouldall be the same. we should all think the same. we should all react the same. and if we can alljust become one, then the world willbe a better place. it will be fairer for people. it'll be fairer for people.

we'll be able toappreciate our differences, appreciate ourdifferent strengths, and create room forpeople to be different. that is what will makethis world a better place. yeah, women have a lot moreadrenaline going on than men. what happens withadrenaline is adrenaline is produced from dopamine. so i'll give you anexample you can relate to. as a man, you're driving acar around 80 miles an hour,

you feel very relaxed, right? easy going. and then you hit it up-- there'sa certain point between 80 and 120 where most men willstart to feel the adrenaline. it's like, rrrr. there's like thisrrrr energy inside. that's the shifting of dopamine,which you're confident, you're capable, you're online. that's dopamine.

lots of testosteronebeing produced. now your concernsstart to increase. that a dropping of yourserotonin, your optimism. you're starting to thinkof what could go wrong. that's serotonin dropping. so when your serotoninlevels start to drop, your dopamine convertsinto adrenaline. and adrenaline gives you evenmore ability to react fast, so you get spikes intestosterone at that point,

maybe 10 times more. but then youdeplete, so then you need more recoverytime afterwards. and this is all about howmuch adrenaline gets produced. for women, yourvulnerability in your brain is that because your limbicsystem is so much more active than men's,you tend to run out of serotonin muchfaster than men. this is why womenhave depression

four times more than men. they run out of serotoninfaster under moderate stress as opposed to men. canadian researchshows that men actually make serotonin 50%more efficiently. that's because wehave more muscle mass. men store 50% more of residueserotonin, which is probably an evolutionary development,because you're in danger. your life is indanger, and you have

to stay cool,calm, and collected to prevent your dopamine fromconverting into adrenaline. but adrenaline, particularly,once you feel adrenalin, as a man, you really need tophysically move your body. if you don't burnthe adrenalin off through physical movement ofthe muscles, then what occurs is cortisol levelswill start to rise. and cortisol levels don'tgo away very quickly. adrenaline canburn off like that.

but once your cortisol levelsrise, it's sort of a slow rise, and it stays in there. it's the worst thingfor your health. cortisol inhibits digestion,inhibits your immune system, inhibits your detoxificationsystem, causes brain injury. all those thingsare directly related to chronically elevatedcortisol levels. and this is the world that'shappening for women today. so women's health issuesare dropping down.

more women have heartattacks than men today. and this can allbe remedied-- not by saying women should be home. it's by saying women should havea balanced personal life where they schedule theirlives so that they're doing their testosteronestimulating activities balanced by personal, fulfilling, homeexperiences in a personal life to balance the work life. and it's understandingall those dynamics

of what createsoxytocin in your body because our world has becomeway too testosterone oriented. and ultimately, for men, love isvery important to men, as well. and if he comes home, anda woman can't be loving, then you get a man whodoesn't come out of his cave. so there's a hugebalance and upset. so many of the problemswe experience today with all of the mass shootingsand all that stuff that's going on.

we see the kids goingand shooting people. these kids are alwayson antidepressants or antipsychotics. they're always on drugs. since we started usingdrugs for mental illness, there's now, since 1980, 35times more mental illness in america. 35 times more. people, once they start takingmedications, don't go off.

they do not heal the brain. they change the brain, andthe brain-- the problem goes worse and worse. that whole story is writtenin my most recent book, which you can all get afree-- for right now-- free pre-publicationcopy, just doing a free downloadat it's called the "mars venuswellness solution for focus," so focus is-- thechallenge for our children

today is one out of fiveboys with adhd being drugged. and what parentsdon't realize is adhd drugs cause stuntedgrowth for young children. they cause heart disease. some of them are againstthe law in canada, because actually you getheart attacks from it. but long beforeheart attacks, you're getting arteriosclerosis. it also causesbrain changes that

don't disappear as teenagersbut just turn into addictions to caffeine, addictionsto internet porn, and the inability to committo a long-term relationship. these are all the more adultstages of add and adhd. and in the new book, imap at every stage of life how, when we getadhd as children, and what causesit-- which they all say we don't know-- we do know. it's all there inall the literature.

i just quote pubmed againand again, all the causes of adhd, the rampantimbalance today. and as we move throughstages of life, people don't recognizeas your brain develops, adhd turns into something else. one of the consistentingredients that goes along with adhd in an autisticchild, asperger's child, adhd child is dramatically lowglutathione levels in the body. glutathione protects thebrain from brain energy

or free radical damage. in all those cases, dramaticallylow glutathione levels. every person who has dementiaand alzheimer's-- it is now predicted that one out ofthree people over 70 will have dementia and alzheimer's. my younger sisterhas alzheimer's. my older brother hasdementia and early stages of alzheimer's. this is becoming anotherrampant epidemic in america.

the cause is so clear. they keep saying wedon't know the cause. go right to thephysiology, and you'll find that-- i can't gointo all the causes. that's a whole other book--but i talk about the causes. i talk about the remedies,natural remedies. but natural remediesdon't work if you don't eliminate the causes. say you have aheadache, and i actually

have a natural pill that willtake away your headache-- which i don't, by the way--but if i had a pill to give you to takeaway your headache, but you keep hitting yourselfin the head with a hammer, will that pill work? but for people thatdon't hit themselves in the head with ahammer, it will work. well, there are 10,000 studieson natural solutions for add and adhd all over the place.

they just don'twork all the time, as drugs don't work,because people don't know, how am i creating this everyday by my lifestyle choices and decisions? so, anyway, more on thatsubject is at just get a freedownload of the book. for now, it's free. soon it will be on amazon. you can order it and buyit, but it's an easy read.

and, particularly, as a techie,for some techie guys here-- because they don't realize thatthey have huge amounts of add, because they think, ihave no problem focusing. i can focus on mycomputer for 10 hours. and i remember talking to oneof the world's experts on adhd, and i looked at him, and isaid, you know, you have adhd. he said, that's ridiculous. i have total focus. i'm so focused, mywife can talk to me,

and i don't hear aword she says while i'm thinking about something. that's also adhd. that's a problemwith attention where you can't shiftyour attention here, but you become overlyfocused on one thing. and i'll finishedmy talk by talking about how add is creatinghuge problems in relationships today, is that it causesmen to become hyperfocused

on one thing. in the beginning, they canbe hyperfocused on her, but once the newnessgoes away, he becomes hyperfocusedon his work, and he doesn't take the timeto rebuild his testosterone. the average for a man at 50 hashalf the testosterone levels he had as a younger man. i have 25% more. and i know exactly how i did it.

i explain it in my books, soi'll live a long, healthy life. this is why men die, istheir testosterone levels start dropping. dopamine levels drop. but, anyway, focus-- for men,they become hyperfocused. and for women, they becomehyperfocused on the things that would, theoretically, releaseoxytocin-- other people's needs. so they're overwhelmed.

so overwhelm, the adult symptomof adhd, is so common in women, it's unbelievable. it's like, i haveno time for me. i have to do thisfor this person. who says? it's your brain takingon more than you can do. this is adhd. and it can be corrected. these are simple solutionsfor all these things.

i have people writingit to me, it's like, my child is nowtaking your vitamin c and grapeseed extractthat you recommended, and he suddenly changed. and he says, daddy, i like thisso much more than the medicine. this makes me feel so good. just simple anti-inflammatoriesfor the brain rather than taking a drugthat does not cure anything, nor do they claimto cure anything.

it only creates more of thesame problem that caused adhd in the first place, verysimilar to any drug addiction.

in women

anyway, you've been a greataudience here at google. thanks for inviting me,and thanks for the great work that you do. appreciate it.

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