31: The Conversation Your Doctor Never Had with You | Dr. Sarah Berg, OB-GYN

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Mornings with MeganEpisode 31: The Conversation Your Doctor Never Had with YouGuest: Dr. Sarah Berg, MD, OB-GYN, Certified Menopause Practitioner, Founder of Selfority

INTRODUCTION

Megan Pfiffner (00:01) Dr. Sarah Berg is a board-certified OB-GYN and certified menopause practitioner who has spent over a decade caring for women and now focuses on transforming how menopause is understood through education. She is the founder of Selfority, a digital platform delivering evidence-based women’s health courses designed to feel as informative as a medical textbook, but far more engaging and accessible. She also leads Menopause at Work, an initiative helping organizations better support women in midlife by connecting menopause to performance, retention, and workplace culture. Dr. Berg writes for Katie Couric Media, STAT News, and Unbiased Science, and she has been featured on Parents.com. She speaks nationally on menopause, cardiovascular risk for women, and women’s health in the workplace, including at venues such as the Clinton Presidential Center. Known for her clear, honest, and relatable style, she is passionate about using education as a form of preventive care, helping women feel informed, supported, and not alone during the menopause transition. Hello, Dr. Berg, and welcome to Mornings with Megan.

Sarah Berg (01:06) Hi, thank you so much for having me. I am honored to be here.

Megan Pfiffner (01:11) It has been a long time coming. We met, we have chatted, we have done the things, and I feel like we had so much to talk about. I am very excited to continue the conversation on the podcast.

Sarah Berg (01:20) Absolutely. I felt like our initial conversations, I was like, we need to talk more, or maybe all the time, because this is fun.

Megan Pfiffner (01:27) All the time.

THE SLOPE SHOULDER MOMENT

Megan Pfiffner (01:29) I would love to dig in with a story from your practice. I read an article where you describe something happening in your exam room, and I would love to hear more about what you would call the slope shoulder moment. What was that, and why did it stop you in your tracks?

Sarah Berg (01:47) So I am an OB-GYN, so of course I see women at least once a year, multiple times a year often. So I get to know the people I am practicing and taking care of. There were these women that were amazing. They would come in, we would do the exam, but we would also have this conversation: tell me about what you were doing at work, or what was your latest fun vacation, or what triathlon are you running? They were just cool women that we had great conversations with, just because it was our time to connect.

They would come in year after year with straight backs, full of life, full of activity. And then all of a sudden, one year, I had to give it a name because that is exactly what it was. They came in with sloped shoulders. So they went from being these confident, excited, full-of-life women to almost having this physical appearance of: there is less of me, I do not want to take up space, something is not right. Because I was able to see them over multiple years, I knew this was a drastic change. And it was not just one woman. It was pretty much, along the line, most women when they hit a certain point in life.

So it was a lightbulb moment for me. As a gynecologist, I work with women from 12 years old having their first period to end of life, so I am learning and training across the full spectrum of women’s health. But what I was seeing was that this midlife moment, where they were coming in with the sloped shoulders, was something very dramatic and drastic, and it was happening across the board.

I wanted to dig in. I wanted to figure out what it was that universally seemed to put these women in the slope shoulder moment. But I also wanted to figure out what I was not doing, and what we were not doing, to prepare them. Because it was not a confidence issue. It was something else going on. And that was really my starting point for figuring out how I wanted to do something bigger to help women, not just individually in the room. Because that is powerful and that is wonderful. But I was afraid that we were having these individual moments, and how many women were not getting this information, were not allowed to have this opportunity. And so they were going to slope shoulder, and maybe they were never coming out of it. That was important to me. So that really was what got this ball rolling.

Megan Pfiffner (04:31) And tell me more: when you see this slope shoulder moment, is this something that you were able to work through with your patients? Did you have time to talk through that and to dig into what is actually causing it? Because there are so many things happening in the menopause transition.

Sarah Berg (04:47) Well, that was part of it too. We have all gone to the doctor’s office. I am a person, so I have been a patient as well. And there is not a lot of time in those office visits. So when I had these patients and I could tell there was a seismic change, first of all, I realized that I had not learned enough in my training to really fully grasp the range of things going on and how I could do my best as a physician. So that was a humbling but important moment: I saw there is more I need to learn to help them.

But the other side of it was, was I able to undo that in 15 minutes? The answer is no. And I kept feeling like there is not enough time in this office to really explain something that is so significant. Just like when you hit puberty and you have videos and classes to tell you what is happening, there was none of that for what is essentially the same hormonal shift happening on the other side. No one is talking about it ahead of time. There is no prep course for it. You feel like you are just dropped in.

And a lot of times, by the time I was seeing them with the sloped shoulders, they had been trying to manage their symptoms for so long on their own. You do not get to the slope shoulder until you have kind of given up. So they had probably been dealing with this longer than they let anyone know. It was only when they were so far in the hole that they were starting to show physical signs of it. So it was not just about undoing that moment. It was about looking back and figuring out all the things they had thought were self-problems, that were really biology problems. Not problems per se, but transitions they were not aware of. And transitions that the people around them were not expecting either, so no one understood why this person was not acting the same way she had for the past ten years.

And it is just like when you have a preteen who is starting to go through changes. You give them grace because you know something is going on. No one is giving these women that same grace.

Megan Pfiffner (06:55) So common.

Sarah Berg (07:06) Even when things are not hitting the same way, we understand something is going on and we give them grace. No one is giving women in this transition that same grace.

WHAT PERIMENOPAUSE ACTUALLY FEELS LIKE

Megan Pfiffner (07:19) No, and the expectations are always that women keep carrying the load they have been carrying. And then there is this internal shame or guilt that I see with a lot of women, where they feel like they have somehow failed themselves, failed their family, failed the workplace because they are not able to carry on the way they were. And what I hear you saying is that this is not about a lack of ability or a personal failure. It is about the actual biological changes happening in the body. The biology changed, not them. It may not be a problem, but it is a transition. So tell us more: what might someone experience if they are new to the perimenopause space and starting to say, there are some weird things happening in my body, but I cannot figure it out? What are some things you would commonly see?

Sarah Berg (08:18) I think the most important are the first symptoms that we often overlook as a self-issue. Estrogen, which goes up, down, and all around during perimenopause, is a hormone that travels all over the body. And I think this is very misunderstood. People think of estrogen as a reproductive hormone. They think of it as something that lives only in the ovaries and uterus. But it goes almost everywhere. And one of the main areas it goes, that people do not expect, is the brain.

So a lot of the first symptoms that people think are something wrong with them are actually the result of estrogen fluctuating in the brain. The brain is an organ that is very important to who you are, and when estrogen is going up, down, and all around there, it affects almost every area of the brain, but especially the prefrontal cortex at the front. That is where we are used to being the multitaskers of the world.

Women are great at what I call keeping the tabs open. You can have 16 tabs open and flip through them, no problem: office brain, dog-needs-to-go-to-the-vet brain, what-are-we-doing-for-dinner brain. That is easy normally. But when your body is doing this estrogen buffering, your prefrontal cortex is not getting the signal it is used to. So you go from being a really great multitasker to being adequate. But you are not used to being adequate. You are used to being fabulous. And just so you know: your multitasking ability during this buffering stage is still better than most of your male counterparts. You are just now feeling how they normally feel. But it feels like you are not doing your best, so you feel like you are not doing well.

So your prefrontal cortex is disrupted, and you are thinking: I am losing my mind, my brain is not working the way it should. And then you start having these spiral thoughts: is this early dementia? Am I having early cognitive decline? I have heard women have more Alzheimer’s than men. Is this my slippery slope? That is scary.

And then another area that gets hit hard is the emotional center, the amygdala, where your emotions are processed. Something that would not have triggered you five years before can now send you off in a way you do not even recognize in yourself. And people make fun of that. Comedians joke about it. That is so unfair. Your receptors are literally changing.

Megan Pfiffner (11:03) Thank you.

Sarah Berg (11:19) So you are feeling like you might be going down some sort of mental disease spiral. And then the brain is also where your heat and temperature receptors are, and those are getting disrupted too. Hot flashes, night sweats. And then word finding. That one gets people, too. Words that were right there before are now gone. Memories that were right there before are long gone.

And here is the important part: these symptoms often show up before the classic signs people associate with menopause, like very irregular periods or no periods at all. Usually these brain and mood symptoms are already happening before the hot flashes and night sweats arrive. But because we have not talked about them, women do not recognize them as perimenopause. They think they are not dealing with this transition yet.

Megan Pfiffner (12:28) That is such an interesting segmenting out of early perimenopause versus later perimenopause. Because that early stage you are describing, feeling like you might be going down some sort of mental disease spiral, that is actually what I see in the Regulate pillar of the Perimenopause Matrix. The nervous system calibration that women in midlife start to lose, and it shows up as rage, as shutdown, or as that sense of not recognizing yourself. It is like when you have a toddler and you have to help regulate them. When we get older, our own calibration is disrupted. We are raging, we want to move away from our family for a week, we do not want to talk to anybody.

And I work with women who do exactly what you say: they have seen the neurologist, they have had a consult about dementia, they have talked to everyone, and everyone says you are fine. Because no one is looking for this pattern. Women are getting lost in the shuffle. You mentioned earlier that you did not feel you got enough education around this as an OB-GYN, and everyone assumes that if you are an OB-GYN, you know everything about reproductive hormones. But as you mentioned, this is not just a reproductive transition. So tell us more about why it was challenging to find that information, and what made you feel you needed to go further.

THE TRAINING GAP AND WHY YOUR DOCTOR MAY NOT KNOW

Sarah Berg (13:54) A major reason it is challenging is that there is not enough research. We are woefully behind on all of women’s health research, but especially this stage. And some of it is because of a study done almost 30 years ago that really put a halt on women thinking that hormonal medication was a good idea. When you have a study that says something is really bad, no one is going to keep studying it. They will take that at face value.

That study, the WHI study, if you have heard of it, really turned people off from hormonal treatment during this time. And when everyone said hormones are not good for women, it stopped medical education too. If you cannot give someone something for a condition, it starts to feel like there is nothing to do. So doctors trained after the WHI study, so after 2002, which is most of the physicians practicing today, received maybe one to two hours of lecture on menopause in their entire training. Comparing that to the fact that I have made a course for women on menopause that is six hours, and that is just a fun overview. It is a massive topic.

As a trained OB-GYN, spending four years only learning about women’s health, 80 hours a week, I received maybe four lectures on menopause total. I came out thinking I was well-trained. But when you meet patients over and over again, if you have any ability to self-reflect, you realize: I am not prepared for this. And that feels really bad when you have committed your life to caring for others.

So that was my pivot point. These women have 30 to 40 percent of their life ahead of them. We are treating them as an afterthought and telling them to just deal with it. That is an unfair way to care for women. There is a menopause certification. I stepped away. I completely immersed myself in learning. And that certification was almost like opening a door. It just showed me how much I had been missing. It has been overwhelming and amazing to see how many ways we can care for women when we open our eyes to this stage. But also: give your doctor grace. They came through this time period without the education. And if it is really difficult for them to go where I went, because they are caring for the full spectrum from a 12-year-old to end of life, maybe this is the time to find one of those doctors who has decided this is their focus, at least for this part of your care.

SELFORITY: EDUCATION AS PREVENTIVE CARE

Megan Pfiffner (18:32) So with that period of time when you decided to extend your education, really open that door and dive deeper into menopause, you eventually started building a foundation that you turned into a business. You left your clinical practice, which is not a small thing. Most doctors do not do that. But you did, to build something. It sounds like what you kept seeing in the exam room made you decide the solution was education, not more appointments. Can you tell us more about that, and about Selfority?

Sarah Berg (19:06) Yes, absolutely. Selfority is my youngest child. It takes a lot of my time in the best way possible, and I love it so much. Selfority is my education platform. The name is the way I want women to think about themselves: Selfority means self-priority. My tagline is “female health prioritized,” because what I know women have always done, and what I have done myself, is not even put themselves on the list of things they care about. I want women to get on that list.

Education is preventive care. If you can learn, naming something takes away a lot of the stigma. If we can give you education in a way that is interesting and worth engaging with, it may change not only your baseline knowledge, but your entire ability to transition, and what the last third or fourth of your life will look like.

My desire is to bring women education earlier rather than later. I hear this all the time: I wish I had learned this in my 30s. When you think about preventive care, you are thinking about something that has not happened yet. So bringing you education so you know what is going to happen, or what is happening, and what you can do to manage it. Always evidence-based, never one-size-fits-all. If anyone ever tells you this is the only way to do something, they do not know you, and they do not know enough about this area.

I am a writer at heart, so I love storytelling. I try to bring stories and imagery so you can attach something to the information. My brain imagery in the course: I call it the New York bureaus. Each area of the brain is a bureau, and we talk through what is happening in each bureau as we go. We talk about the brain, the bones, the heart, all the things you do not even realize estrogen is touching, because we have been taught estrogen is only about making babies or not making babies. When we learn that estrogen is everywhere, it will help you feel less like you are losing yourself. You will realize this is a transition, there is another side. And if you can do these things, you can weather the transition better. You may come out the other side into what I truly think is the best third of our lives: past the stage of having to justify ourselves to others, into the “this is me, take it or leave it” side of ourselves.

I want to get women there, feeling like their best selves, rather than feeling like they are irrelevant. A lot of women start to feel: society does not care about me anymore. That is bull. That is simply not true. And when people are taught how to manage this stage, they do not feel like they have lost part of themselves. They feel like they have gained something.

Megan Pfiffner (23:03) I love the idea of putting yourself on the priority list, because that is also something I speak with a lot of women about. You have to take care of you. When you are trying to juggle everything and your bandwidth is stretched, you start dropping balls. If you are not on that list, you are not going to be able to do all the things. So with Selfority and this course, what are some of the aha moments that women experience when you are talking about estrogen touching every part of the body? You talked about the brain already. What are some other places estrogen goes that women might not be aware of?

WHERE ESTROGEN GOES THAT NOBODY TELLS YOU ABOUT

Sarah Berg (24:56) A big one is joints. I see this a lot. Someone is talking about frozen shoulder, or they have gone to every specialist under the sun and no one thinks they have arthritis. That could be perimenopause. Estrogen receptors are in your joints, in your bones, in all your tissues. When the transition happens, you get achy. But there is no medical diagnosis. No orthopedic finding. Sometimes you feel dismissed. You spend a lot of money getting dismissed: different specialists, different imaging, different labs. And if you understand that estrogen is in those joints, a lot of people go, oh, that is why I literally could not move my shoulder above my head for a long time.

The frozen shoulder connection is shockingly common at this stage. I have decided I need to make a menopause sports bra because imagine trying to get a sports bra on when your shoulder will not work, or off when it is sweaty.

Megan Pfiffner (26:10) How are you getting that over your head?

Sarah Berg (26:15) More people need to be talking about this. Another one is sexual health. People are very uncomfortable talking about it. Coming in hot: I have a whole section on the genitourinary changes in the course, and understanding the changes happening in that area.

One of my favorite analogies, one that used to crack people up in the office: I call it the cat on the carpet. Because I do not care if you are having sex or not. There are changes happening that are simply irritating. And when it is happening in an area we do not talk about, you are not going to do anything about it. You can itch your arm in public. You cannot itch your vagina in public. Or you can, but you are going to get looks.

Megan Pfiffner (26:43) You are going to get looks. Yes.

Sarah Berg (27:05) When we do not have estrogen flowing to that area, it gets dry and irritated. It can make sex painful, which becomes a whole rabbit hole that affects relationships and self-worth. But even if you are not having sex, it is really uncomfortable to sit all day on a very dry area of your body and feel like you would love to be that cat on the carpet, just rubbing back and forth. But you cannot, because you are in a meeting.

There are so many things people think they just have to deal with because it is just age-related. There are amazing things we can do, and we should be doing them. If you want to do whole-body estrogen or not, that is 100 percent a personal choice. But I strongly recommend vaginal estrogen regardless. Vaginal estrogen goes only to the vaginal tissue. It does not travel systemically. This was a key reason so many doctors pushed for that black box warning to go away, because the framing on vaginal estrogen was the same as for whole-body systemic estrogen, which made it unnecessarily scary. Vaginal estrogen should be for every woman. It is like the smallest bandage on the smallest cut.

THE BLACK BOX WARNING: WHAT IT WAS AND WHY IT IS GONE

Megan Pfiffner (29:20) And we have so many options. One of the things you mentioned is the black box warning. I actually brought mine. For anyone watching, I am holding up the insert from my vaginal estrogen, because I know all of these things: I know about the Women’s Health Initiative, I understand that this warning is not based on current science. But even knowing that, when you open this up and it says serious side effects include stroke, blood clot, breast cancer, severe allergic reactions, heart disease, cancer of the ovaries, cancer of the uterus, it is scary. Even knowing it is wrong, I opened this box, excited about my vaginal estrogen, and this little insert gave me pause. So I can only imagine how women who did not have a doctor to explain it, or had not read about the WHI, felt when they opened this and thought they were making the right choice, and then got that paper.

Can you tell us more about the November 2025 FDA announcement removing that warning, and what it means for vaginal estrogen versus systemic estrogen?

Sarah Berg (30:41) Truthfully, removing it from all estrogen is, I believe, the right answer. There are definitely different perspectives on that, but for vaginal estrogen at least, that black box warning was an overstatement. It is a complicated story.

The WHI study was done in 2002. And it was actually done because at that point we thought estrogen was the answer to everything. We were giving it to every woman for everything, and this particular arm of the study was trying to prove estrogen would improve heart health. So the setup was not about hot flashes or perimenopause symptoms. It was about preventing heart attacks. And they chose older women, specifically, because older women are more likely to have heart issues. The average age in that study was over 60.

Most women starting hormone therapy today are starting because they are having symptoms, so they are typically in their 40s or 50s. This was women not even necessarily having symptoms, on old-school medicines at old-school doses.

Megan Pfiffner (32:24) Premarin, and all that. Horse urine.

Sarah Berg (32:28) Yes. Premarin, from horse urine. That was the medicine they were using. It is not what most women are getting prescribed today. So they started the study with these older women, specifically for heart health, and then they stopped it early and made a big announcement before they had fully presented the study.

They came out and said: we need to stop this because we are giving women breast cancer and hurting their hearts. When you actually look at the data and look at which age ranges were having problems, it was the older women who were started later, which is still why we are really careful about starting hormone therapy too late. When estrogen has been gone for a while, your blood vessels have gotten stiffer, and then you give it back, all that plaque can dislodge. That is when scary things happen. So yes, it was harmful in older women who started late, and we are still conscientious about that. But when you look at the younger end of the study population, the women we actually prescribe to now, we were seeing protective effects. When you average everything together, it looks terrible. But when you look at real clinical practice, they are two different stories.

The breast cancer finding was especially overblown. The absolute risk versus relative risk calculation was not even statistically significant in the relevant age group. It is the same increased risk as drinking a glass of wine per day. No one is putting a black box warning on your wine glass.

Megan Pfiffner (38:20) They did great PR for that study. They had it published in JAMA, they called a press conference, and the cat was out of the bag before anyone could pull it back. And just so our listeners know: normally when you complete a big study and release results, there is a peer review process. The investigators write everything up and send it to peers and colleagues to review before anything is published or shared. They broke those protocols. They went directly to the public through JAMA and a press conference, which was very backwards to how science is normally done. We have since re-investigated and reanalyzed all of this.

And I wanted to share an important statistic: since the FDA removed that warning on November 10th, 2025, there has been a 72 percent surge in estrogen prescriptions. Source: FDA labeling change 2026 and ISSWSH 2026 data. That tells us women are getting the message. People are prescribing. Doctors are feeling it is okay. And one of the things I wanted to talk about, something you have written about, is that even with this good news, there is now a patch shortage following it. It feels like the story of a system that never actually believed women were going to say yes to this. So what is happening?

THE PATCH SHORTAGE AND WHAT IT SAYS ABOUT WOMEN’S HEALTH

Sarah Berg (39:53) Oh my goodness. Yes. I wrote an article about this in February, and it is still a major issue in April. So this has been going on for a while. Companies knew, before any of us knew, that this change was coming. But just like you said, they did not believe people were going to make this big major surge in demand. These companies are trying to make a profit. They hedge their bets on how much they need to make versus how much is going to sit on a shelf. So they did not ramp up production, and there are not enough companies making these patches to begin with.

If you want to know how many companies make erectile dysfunction medicines, it is a very long list.

Megan Pfiffner (40:41) A lot.

Sarah Berg (40:43) There are multiple safeguards. When one company does not have enough, there are multiple others that can fill the gap. That is not the case for the estrogen patch. And looking back, you can understand why: when there is a big black box warning on something, that makes it very scary for companies to invest money in it. So even the companies that did take the chance and make the patch before all this happened, they did not scale up production, because they did not believe demand was going to surge this way. And it has not caught up yet.

Women who were already on the patch, who had found one that worked perfectly for them, are now being told it is unavailable. Or they get a different formulation from a different manufacturer. They are all dosed similarly, but they are not the same. We are not one-size-fits-all. Even on the same dose from a different manufacturer, it may not work the same for you. So it can feel like starting over. That is not good for you medically, and it is not good for you mentally, or socioeconomically. Some women are going from paying $20 every three months to paying $300 a month, because their insurance only covers the one brand that is currently available. That is not okay.

Women are having to pay that because they know what it felt like without it, and they need it. If we had the number of companies making estrogen patches that we have making erectile dysfunction medications, this would not feel this bad for this long. But we do not. And that is because there is less investment in women’s health. And that makes me very sad.

Megan Pfiffner (43:30) It makes me sad too. And thinking about what you were talking about at the beginning: women were not even required to be included in NIH-funded research until 1993, when Congress passed a law requiring it. So we are very behind. But it feels like we are making progress. And there are doctors and practitioners out in the world, like you, who are menopause-trained and certified, sharing the message and building the programming and education that women need.

If a woman listening right now has been putting off dealing with her perimenopause symptoms because of fear, because of the old warning, because her doctor has been dismissing her, or because she just does not know where to start, what are three things you want her to walk away knowing?

THREE THINGS EVERY WOMAN NEEDS TO HEAR

Sarah Berg (44:13) First: it is not all in your head. Even though estrogen receptors are changing what is going on in your brain, this is not a you issue. This is a transition issue. It happens universally to every woman who lives long enough to go through the menopause transition. You are not alone. And if you feel comfortable talking to others about it, you will be shocked how many women say, that is me too. I thought I was alone. So do not be afraid to say: this is what is going on with me. You will find so many lightbulb moments with other women.

Second: you do not have to grit and bear it. There are so many options. It is not one-size-fits-all. There is what I call a toolbox of different options. Some may work for more people than others, but just because something worked for someone else, or someone tells you this is the only way, you will be shocked how many options there are, and how personalized it can be. It is not rocket science to personalize it; it is just trial and error. Do not feel like you are stuck.

Third: your doctor usually wants to help. Come in with your story. Do not be afraid to tell them. Do not make them pull it out of you. That can help you get the best care possible. But if you are hitting roadblock after roadblock, it may be time to transition this part of your care to a practitioner who is certified in menopause. They may have more up-to-date knowledge. And if you live somewhere a menopause specialist is not readily available, that is what telehealth is for. This kind of care is mostly about hearing your story to understand the best way to treat it. It is not the physical exam you need with your gynecologist.

Start journaling. Write down when things are happening and how you are feeling. That helps you move from “I just do not feel great,” which is not an effective starting point for care, to: “four nights a week I am waking up three times for night sweats, and I notice it more after a glass of wine or a certain food.” That kind of information helps direct your care. Track what is going on in your body. Prioritize yourself so you can get the best care. And if that still does not get you there, find the right kind of care.

Megan Pfiffner (47:32) Okay. So we are remembering that we are not alone. We are 51 percent of the population, friends. Every person you know who also has a vagina will also go through the menopause transition. Two: we do not have to grit and bear it. There is help, there is support, and as Dr. Berg said, there is a toolbox of options your doctor can work with, both hormonal and non-hormonal, to support your symptoms. And three: give your doctor some compassion by providing them with the information you have. Know yourself and share that with them, because you know the most about your own body. And as Dr. Berg pointed out, not all doctors receive the same training. So if your doctor is no longer able to support you in the way you need, it might be time to seek out a menopause-specific practitioner who has taken the time to further educate themselves.

Dr. Berg, it has been such a pleasure. Thank you so much for joining us and for everything you have done to support women’s health with Selfority. Are there any parting words you would like to leave with the audience?

Sarah Berg (48:38) I just want to say thank you for having me. I really appreciate this time. I have loved getting to know you and talking with you. And to everyone listening: you are not alone. This is a transition stage to get you to the best part of your life. This is not an ending. This is a transition.

Megan Pfiffner (48:58) I love that. Not an ending. This is a transition. Thank you so much for listening. We will see you next Wednesday.