The Hidden Link Between Postpartum and Perimenopause

Introduction and Welcome

Britta Bushnell: Hello folks, and welcome to Transformed by Birth, a podcast about the rite of passage of pregnancy, birth, and new parenthood. I'm your host, Britta Bushnell, author, mythologist, childbirth educator, and an all-around deep diver with a side of goofball. I'm so glad you're here. Today's episode explores the connection between postpartum and perimenopause and menopause. So grab your comfy beverage of choice or take us along for a walk as we connect with the midlife midwife Sarah Shealy. Before we begin, we start the way we always do, by lighting a candle. If you want to join me, please do, or take a breath as I light mine. Today's candle is in honor of the major life transitions — postpartum and menopause.

Britta Bushnell: Perhaps the last thing new parents are thinking about in a life transition is a life transition potentially decades away. Postpartum and menopause have both lived in the shadows for years. As a society, we love talking about the beauty and joy of pregnancy and new babies — do we love that — but talking about the bumps and valleys we navigate during postpartum? Well, it's often, "Oh, look at the cute baby," and avoid talking about the bumps. And perimenopause and menopause — while they're having a clear Renaissance — have also been relegated to understanding glances from others in our specific social club, when somebody suddenly turns red, glistens, and fans themselves rapidly. We recognize that. But up until recently, both postpartum and menopause have been conversational taboos. But their "we don't talk about that" status is not their only connection. What if how you're cared for in the postpartum period doesn't just affect the next six weeks or year, but the health decades from now? What if the exhaustion, brain fog, and depletion you feel as a new parent isn't just normal — it's a sign your body needs something it's not getting, and ignoring it now will show up in perimenopause and beyond?

My guest today is Sarah Shealy, a nurse midwife and menopause specialist with three decades of clinical experience caring for women across the entire reproductive lifespan. I love that — it's across the whole reproductive lifespan. Sarah founded a private menopause practice in California — note, she's my menopause specialist, folks — and created the Meno Learning Lab, an education platform for women navigating life transitions and clinicians seeking deeper expertise in midlife care. Sarah sees the through line. She understands that pregnancy, birth, postpartum, and midlife aren't separate chapters. They're physiologically connected rites of passage that shape long-term health. Working closely with Dr. Oscar Serrallach, whose groundbreaking work on postnatal depletion has reframed postpartum recovery, Sarah is making the case that postpartum care is not a luxury — it's preventative medicine. How you're supported, nourished, and allowed to recover after birth shapes your energy, hormone health, bone density, cognitive resilience, and vitality for decades to come. Sarah, welcome. I'm so glad you're here. Thank you for being here.

Sarah Shealy: Thank you so much for inviting me to your podcast, Britta. I'm so excited for us to have this conversation. I think you and I have had multiple conversations about this, and all the things that go around it, and I'm just excited to be here with you today.

Britta Bushnell: Oh, me too.

The Physiological Through Line: Connecting Postpartum to Midlife

Britta Bushnell: I feel like the intersection — first of all, "midlife midwife" is one of my favorite titles ever — and when I first started working with you, having midwifery care for my menopause midlife journey was exactly what I had been looking for, because the midwifery model of care in the childbearing era is so powerful. I utilized it, and I loved having midwives, whether it's hospital-based midwives or home birth midwives or birth center midwives. The midwifery model of care is so respectful that I was like, oh damn, yes — get me one of those for midlife. And then there was you. And I was like, oh good, I'm done. I found my person. So I have experienced firsthand how brilliant you are at helping people navigate the midlife transition. But I didn't know you when I was going through the postpartum period — we hadn't connected with you yet — and my audience is currently probably more interested in that period in life rather than midlife. And although some dance through postpartum and perimenopause simultaneously, which might be something we need to talk about, can you tell us how pregnancy, birth, postpartum, and midlife are physiologically connected, and why we don't talk about them that way?

Sarah Shealy: Well, thank you for that question. Once you see something, you can't really unsee it. And that's how this is for me. When I was very young, I lived in China, and in China there is a very clear understanding in traditional Chinese medicine, and just in the whole culture, that how you take care of yourself — or how you are cared for — in your postpartum time will impact the rest of your life. So before I ever became a midwife, I learned that, and it made sense to me. And so if we think of ourselves as being on a lifelong trajectory — and actually what happens to us as a newborn impacts the whole rest of our lives as well, right? The microbiome is set up when we are first born, and if we get to breastfeed and have the colostrum, we get the healthiest, most optimal microbiome that can actually carry us through our entire lives. Our microbiome is set up like in the first couple of weeks of life. So it makes sense to me that what happens in the postpartum time has an impact on the rest of the health trajectory as well.

But then if you layer into that the understanding that when we're pregnant, we are going through a time of enormous hormonal fluctuations — sort of like abundant hormones — so from the time that we start to have our cycles, we're having this really elegant dance between estrogen and progesterone during each cycle. And so as women, we are cyclic — this is our nature, right? And we become used to this. And there are very important things that happen when we have an estrogen surge and then we have a progesterone surge, and that impacts every cell in the body. Every organ system is filled with estrogen receptors. This estrogen peak that we have during regular cycling does a lot of really important things for us — for our immune system, for the microbiome, for our heart health, vascular health, bone density, all of these things. Then when we get to pregnancy, we have this enormous estrogen — it's a different type of estrogen than when we are cycling. It comes from the placenta. The placenta becomes our hormone factory, and that hormone factory produces enormous amounts of estrogen, progesterone, and many other hormones, right? We talk a lot about these two big ones, but there's lots of other things going on.

Britta Bushnell: Yeah, quite a cocktail.

Sarah Shealy: Yes, a huge cocktail — like when you go to the fancy party, you throw it all in there. Very, very — and then when we give birth, we birth the placenta after the baby comes out, and our hormone factory leaves. And so we're up here, and we go literally hormonally off a cliff.

Postpartum as a Mini Menopause: The Hormonal Cliff

Sarah Shealy: And that is the trigger for a lot of things that are good. It triggers milk making. It helps to trigger the uterus to clamp down and to stop bleeding. But hormonally, it can feel very disorienting, and it is kind of like a little mini menopause. And once you understand that postpartum is like a little mini menopause, then you start to be able to understand the connections between postpartum, perimenopause, and menopause. We now know that postnatal depression — we talk about depletion, depression, anxiety, they're all on a scale — and we now know that postpartum depression is actually a different type of depression than someone who is suffering from a regular chronic depression. Postpartum depression is very much linked to inflammation in the brain — neuroinflammation. Neuroinflammation is automatically triggered because of this huge loss of estrogen. The brain functions on estrogen. The brain loves estrogen. So when we're fueling the brain, we've got estrogen, and then of course we've got our nutrients — what we're eating. So when the brain is deprived of estrogen in that postpartum time after it goes off that cliff, we have rebound inflammation throughout the system, and specifically in the brain. And if someone has a vulnerability — a previous history of depression or anxiety, if they've had a traumatic birth experience, which unfortunately is way too common in our culture, if they don't have enough support at home, if they're in a difficult relationship — all of these things can contribute to even more inflammation in the brain, and then you have significant risk of anxiety and depression in the postpartum time.

Food as Medicine: Nutritional Wisdom Across Cultures

Sarah Shealy: The other piece of that is the food piece, and I say this because this all does translate into when we get to perimenopause. Our nutrient needs in the postpartum time are enormous, and a lot of people don't get fed well in the postpartum time because they're not prepared to take this on, and they don't realize that they won't have any capacity to make food for themselves. And so one of the biggest things, when you look around the globe at postpartum practices — every culture that has a postpartum cultural practice, food is at the center of it. And it's all very similar in that it's all cooked. It's all brothy. It's like soups and stews and broths, bone broth. It's high protein, high fat, and cooked vegetables, high in antioxidants, high in fiber, because you need help pooping. So all these things. And you can go to any culture that has a traditional postpartum culture, and while the foods in particular might be different depending on the culture, those few basic things are going to be consistent — and of course, rest and care, right? So in America, we're often missing these pieces, because people don't prepare for postpartum, unfortunately.

A Generational Shift in Talking About Perimenopause

Sarah Shealy: So then if we take that out to perimenopause — we get to perimenopause. Your listeners will probably be in our sort of millennial generation, right? You and I are more Gen X, I think.

Britta Bushnell: Very much.

Sarah Shealy: And so we as Gen Xers are the last generation who will not know about perimenopause before we got there.

Britta Bushnell: Yeah.

Sarah Shealy: And that part is done. People will now know, yeah.

Britta Bushnell: We broke it out of hiding for sure, as we do.

Sarah Shealy: Talk about it, let us talk about it, yeah. But also the millennials will talk about anything — they will share and share their stories online, and then Gen Z is coming in.

Britta Bushnell: And then Gen Z is coming in.

Sarah Shealy: And we never really did, because our mothers said, "Oh, don't talk about that," right? Yeah. So the fact that we can talk about periods and tampons and pads and discs and birth control and vulvas — the fact that you and I do that, it's not of the Gen X way. Like, that was not how it was done. But I'm sure that you probably, like me, taught your friends how to use tampons, right? Because their mothers never did.

Britta Bushnell: Yep. And I was the one that had all the contraceptives in my dorm room, and everybody knew they could come and get contraceptives from me, right?

Sarah Shealy: Passing it on, yes. Well, my mom did work at Planned Parenthood when I was growing up, so — and my mom was a nurse at the Student Health Center — exactly, exactly. So yeah, see what happened. So when we take that kind of through line — if postpartum is a little mini menopause, and then we can understand the importance of this cycling, like the elegant dance of estrogen and progesterone — throughout our 20s and 30s it really becomes a guiding force that actually helps with so many things. When we get to perimenopause, which can be two to ten years, sometimes people even say fourteen years, prior to the final menstrual period, which is the last period — and then you don't get called officially menopausal until you're twelve months with no period, right? So if we look at this perimenopause time, what's happening is different from the postpartum time. Because postpartum is like up, and then a cliff. But perimenopause is like my elegant dance has become rather discoordinated. There's like the partners are bumping into each other. They're stepping on each other's toes. They are sometimes not even showing up. And so this is when the ovaries are kind of thinking about, you know, maybe I'm going to retire soon.

Britta Bushnell: Am I ready? Am I not ready?

Sarah Shealy: Am I ready? Am I not ready? Yeah, it's like a little bloop, bloop, bloop. And then the brain makes a hormone called follicle-stimulating hormone that calls down to the ovaries and says, "Get to work," because the brain is always monitoring, "Do we have enough estrogen?" And during this time, the onset of perimenopause often is unnoticed, because it can often start as a cognitive change, and the cognitive change is very frequently increased anxiety or low mood, irritability. It might feel for many of us like a loss of resilience or a loss of patience — that things that we used to just be fine with now are so annoying, and rather than responding to things, we're reacting. And so a lot of that can start also at a time when we often have — and in these days, often have — small children, big jobs, careers that are really demanding, relationships that have gone through whatever chapters relationships do. And women often find themselves in a place where they already feel quite overwhelmed and overstimulated, and then this little thing comes in, and it can be very hard to recognize that it's not necessarily you — it's your hormones. Because also it's still you too. But then a lot of people say, "I don't feel like myself." And I think we hear this a lot in postpartum as well, because ultimately — so you know, our noise canceling is working, okay — you might feel like, "Who am I? Where did I go? What have I been doing?"

Britta Bushnell: Which is what we also hear in the postpartum period — exactly: "Where am I? Where did I go? What's happening?"

Sarah Shealy: Yeah.

Postpartum and Perimenopause as Rites of Passage

Sarah Shealy: And so this is why for me, now that I'm able to be working with midlife women every day — which I adore — we're often listening to the stories of postpartum and connecting this trajectory to this perimenopause time. And I know that one of your things is rites of passage, and a rite of passage, as I'm sure your listeners know, has three kind of main parts. It's first where you get separated from everything you thought you knew to be true, and then you're in the liminal space — which is, who knows how long — and there's no roadmap. And it might be like a maze where you get to a dead end. It's not necessarily a labyrinth, because you don't really have a clear path to follow. And it can feel just lost — like a place where you just feel lost. That liminal is —

Britta Bushnell: — often referred to also as the messy middle. Yep. So that feeling of, I don't know what's going on, it's just a mess. Or, in Bruce Lincoln's model, he calls it metamorphosis — it's the place of the enclosed, the part of the caterpillar's journey to butterfly that happens in the dark and involves the dissolving as well as the rebuilding. Yeah, the mush, the goo — the goo of imaginal cells. And yeah, so that middle, absolutely. I mean, that's such an important — and that is also really connected to identity transformation.

Sarah Shealy: Well, it is, right. And this is how I explain it to my clients — you are already in this, and you're changing from one identity to the next identity. And it's not for the faint of heart. No, it's a big gig, you know? And this is why Oscar has a program that he does online called Mother Morphosis. And it's for mothers, and it's almost an entire year-long program that he and his wife and his team in Australia created. Because I think in Australia, the experience of time is a little different than here — I feel like we're really in a big hurry here. And being in a big hurry is not really helpful for the female nervous system. And I think — I was listening to your podcast interview with the woman talking about the different types of time, Kairos and — okay, wait — Kairos and what's the other one?

Britta Bushnell: Chronos and Kairos?

Sarah Shealy: Chronos and Kairos time, and how babies are on Kairos time, right? I have to re-listen — I know, I have to — I'm trying to remember right now. And one kind of time is like the time of all the universe, and babies, and they don't care. And the other one is like, we've got to get out the house, we've got to get our shoes on, we've got to get going, we don't want to be late. And when we think about this for the postpartum time and babies, I also see that in perimenopause — we have less capacity to be so much on someone else's time. And I feel like a big urge that I felt when I was in perimenopause, and I still feel very much now that I am post, is that I do not want to be rushed. And I think that that's a big thing with giving this kind of care and thinking about what the nervous system needs to have the capacity to feel well-resourced. And this is like — it's a different time. The slowing down needs to be very intentional, and it needs to be a practice. And in the world that we live in now, it's harder and harder to do this. So I think that was a long wandering answer to your question, but hopefully that sort of pulls those threads together — they're all little rites of passage. And the other thing that I see a lot is that this happens for women outside of their hormonal health, but it's happening in their relationships, it's happening in their career — like, all at once, everything is going to shift. It's sort of like the universe kind of picks you up, shakes you up, and then you're going to come back down over here, and it might look completely different.

Identity Transformation: Matrescence, Metamorphosis, and Midlife

Britta Bushnell: Yeah, yeah. Even the way you look out through your own eyes — the world looks different. You don't just look different, but the way you see through yourself is different. And there's so much about that in the journey into parenthood, motherhood, through that metamorphosis of the postpartum period. And I do — it is a complete reshaping. And I love the caterpillar as a metaphor, and the cocoon, the chrysalis, because it is that aspect that nothing is left of the former self except — and I love this — the imaginal cells, the little aspects of the nervous system that remain. And I find that really interesting, because there is that piece of what we recognize — the smells, the tastes, the touch that still feels and rings true from our former identity, but we've changed entirely. And now where I am in my post-menopausal period, it does feel really similar. I mean, I had a session with my coach-therapist recently, and I've had all kinds of things happening in my life — I have a child getting married, I have, you know, a grandkid, I have some medical things happening in my sphere. And my coach-therapist looked at me and she goes, "Oh, well, good thing you know how to help somebody through postpartum, because you're basically going through postpartum right now." Because these things are of a different type, but I do think the similarity between the perimenopause, menopause, midlife journey, and the postpartum period — there's a way in which postpartum is a preparation or a sample run for another one that's coming. But you also talk about it not just from a rites of passage place, but also about the depletion playing in. So can you unpack some of that — what is the role of postnatal depletion in the journey of midlife?

The Clinical Reality of Postnatal Depletion

Sarah Shealy: Yeah, thank you. Because at the heart of all of it, I am very much a clinician. And as a clinician, I spent a long time wondering what I could do to help these women who were coming to me postpartum who weren't fully recovered — not just like six weeks, but I'm talking six months or even two years. And they would say things like, "I don't really feel like I ever fully recovered from having my baby. I just don't feel back to myself." And you know, as a young midwife, I wouldn't necessarily know what to say — "Well, your hemoglobin looks okay, right?" I didn't really know. And it was really when I first read Oscar's book that it became very clear — all the threads got pulled together. And then I was like, okay, I see — so we have the hormonal piece, but then we have the nutrient piece, the micronutrient piece, and then there's a macronutrient piece.

So we have the micronutrients and the macronutrients. And when we think about the status of the physiology — listen, we are hardwired to survive, right? As women, our bodies are made to go the distance. You look at all kinds of stories of women and mothers who are facing hardship of all kinds, and there's so much survival and perseverance. So we know that we're hardwired to be able to do this thing despite all odds. But when we look a little bit closer at what toll that takes on our bodies, it is very clear that the biggest metabolic lift is in the postpartum time. Your body has gone through this enormous transformation to grow a human plus all the physiologic changes that have to go into the mother's body to grow a baby and a placenta. Once that baby and placenta are born, the recovery phase is not just six weeks — that's such a falsehood.

Britta Bushnell: It's such a misnomer. Such a false —

Sarah Shealy: So when we look at the individual organ systems, some of the organ systems don't come back to baseline for almost an entire year. And I think that's just not well understood and not really talked about. But we can see it — and if there were, you can think of pregnancy as like a stress test on the body. And especially if we had a high-risk situation, like if someone had high blood pressure or if they had diabetes — those are the big ones, metabolic and cardiovascular — then we know they actually have increased risk of those complications lasting later in life or returning later in life. A gestational diabetic has increased risk of being diabetic early. High blood pressure, high risk of cardiovascular disease early. There's inflammatory load that happens during this time in pregnancy that is good — it's there intentionally so that we can grow a baby — but it's a test, kind of, to see what's up with the physiology. So there's already that question mark, and then in the postpartum time, because you're in this vulnerable window — and we think about vulnerable windows when we have big hormonal shifts — vulnerable windows are good for opportunities for learning and shifting and changing, but they're very vulnerable in that small insults can have outsized effects. So we talk about how one unit of stress will have more than one unit of effect on the body when we're in one of those vulnerable windows.

Britta Bushnell: When we're in a vulnerable window, yeah?

Sarah Shealy: Same — one unit of support, outside effect. So when we think about the nutritional piece in the postpartum time — it's like, you might have been able to, in your early 30s or whatever, gone for periods where you eat like crap, you don't sleep enough, you're not taking good care of yourself, but you're young enough and you have enough resilience, and it's not a vulnerable window. So you just bounce back. You can't do that in postpartum, because you don't have that resilience — you're in a vulnerable window. Same in perimenopause — it's another vulnerable window.

Micronutrient Deficiencies: What Gets Depleted and Why It Matters

Sarah Shealy: So when we look at the depletions that can happen — the most common ones are iron. I mean, they're really basic. You had a huge blood loss. So where's the iron level? And not just the hematocrit and hemoglobin, but where's the ferritin? The ferritin is the iron stores — that's like what you have in the bank. And that can be masked, because often it's not assessed in a normal visit. So iron is a big one. Omegas are a big one. Protein — just, are you eating enough protein? Zinc and magnesium can be other depletions, especially in the postpartum time. Vitamin D, vitamin B12 — these are our collection of postnatal depletion micronutrient deficiencies that are very, very common. If we don't put those back in, we're missing an opportunity to really help someone feel better faster. And a lot of these affect every single organ system. So if you are low ferritin, low iron, you're just not going to have enough energy, and your blood is not going to have capacity to carry enough oxygen, and your mitochondria don't get fed the way that they need to for you to just feel better and recover. When you add the sleep deprivation into that —

Britta Bushnell: — which often shows up in the postpartum period and can also show up in perimenopause.

Sarah Shealy: Yes. So then if we take that and we understand — there's some really interesting data about perimenopause and who perimenopause is really different for. Who has a more severe, earlier onset of perimenopause? Folks who have had previous traumatic life experiences. So someone that has a higher childhood ACE score — adverse childhood events — they have earlier and more severe perimenopause symptoms. People who already have inflammation in the system, from whatever. And so these are not only nutritional deficiencies, but they also might be trauma and stress.

Inflammation, Lifestyle, and Perimenopause Symptoms

Sarah Shealy: And so we also see that perimenopause symptoms can be mitigated by a lot of lifestyle things — like yoga, more protein, more fiber, more exercise. And so if we can have relief from the perimenopause symptoms through lifestyle changes, it tells us that underlying inflammation is a huge driver of perimenopause symptoms. Now this doesn't mean that you don't need to have, at some point, or might choose to have, hormone therapy. But hormone therapy is not like some magic pill that's going to take everything away, just like the way that an epidural doesn't mean that you're not going to have to do some work to have a baby in labor, right? And I think people still live in a culture of a pill for every ill. And the reality is that I could give you all the hormone therapy in the world, but if you are not eating correctly, and if you're not focusing on trying to get your sleep organized, and if you're not willing to start lifting the weights and doing the movement, then you're not going to feel optimally better. You might feel a little bit better, but — that's the same thing for postpartum and perimenopause. But in perimenopause, now that we have labs we can look at, we can look for these micronutrient depletions. And I find that many people coming into perimenopause are extremely deficient in vitamin D, vitamin B12, and in their ferritin. And you know what — when your B12 is in the basement, you're not going to feel good. That's not a hormonal thing, that's a micronutrient depletion. So when we fix that, you might go, "Oh wow, I feel so much better."

Britta Bushnell: And is there a connection between those things that you're seeing in the perimenopause and menopause phase, with that postpartum phase? Are those micronutrients that are often also depleted during that time? Is there a link there?

Sarah Shealy: I think so. But I also see it in my clients who've never had children, so I think it's more population-based. The thing that's happening in perimenopause that a lot of people don't understand is that the microbiome — mouth, gut, vagina, skin — all have microbiome, but they're not the same, though they do communicate with each other.

The Microbiome and the Estrobolome

Sarah Shealy: And the microbiome has a part of it called the estrobolome. And the estrobolome is supported by estrogen and also helps to metabolize estrogen and either recycle it or flush it out through the system — that's in the gut. But when we start to go through perimenopause, the microbiome changes and it becomes less diverse. That's literally the terminology in the scholarly articles — it becomes less diverse. And what I say is, we all know that anytime something becomes less diverse, it's just not good. It basically dies off — some of our healthy microbiome has died off because we're starting to not have enough estrogen. And that can lead to poor absorption of our nutrition, that can lead to new onset of GI symptoms, like gut symptoms — people are like, "I used to be able to eat everything, now I can't eat this, this, and this." They've got new-onset sensitivities to foods. They might have constipation, or if they've already had constipation, it's worse. That's a sign that your microbiome is not well-organized.

Britta Bushnell: Right, yeah — I mean, it's a good sign that it's not working.

Sarah Shealy: It's good news-bad news. Good news is now you know. Bad news is, now you know. But now you know, and now you can do something about it. So I do a lot of helping people restore their microbiome and then helping them learn how to take care of their microbiome. Because again, I could give you all the hormones in the world, but if you're not pooping, that's not going to work out for you. Because hormones get processed — our endogenous hormones come from cholesterol through the liver, and that's how they get into the digestive system. And some of them should get pooped out, and some of them should get recycled and kept. And if that whole system is not working, then you're not getting the optimal effect of your hormone therapy.

Vaginal Estrogen, Pelvic Floor Health, and Preventive Care

Sarah Shealy: And it also puts a lot of pressure on the pelvic floor. So this is the other piece that's a connection between the postpartum time and perimenopause and menopause — is the vulva is full of estrogen receptors, both estrogen and testosterone receptors. And when estrogen is low, the vulvar tissue will suffer. So we have our friends in perimenopause and our friends in postpartum both will probably benefit from vaginal estrogen. And vaginal estrogen helps to restore estrogen to the vulvar tissues, which is not only good for comfort just in general, but it's also good for the microbiome up inside the vagina. Because when the microbiome inside the vagina is normal and healthy, it's very acidic — and that's why, if you remember back to when you used to get your periods, you would sometimes stain your panties not from blood, but just from discharge in between. It would be like a little white bleach stain, right? That's because that vaginal discharge is acidic, and that's normal and healthy. And that helps to protect us from urinary tract infections and other infections, and helps to keep the tissue nice and healthy and robust.

When we lose that estrogen from the vulva — same happens to our face, we lose collagen, the skin gets thinner, it gets easier to get damaged — the microbiome is not robust enough to give us that regular sort of vaginal lubrication or just moisture inside the vagina. And so that can be very uncomfortable with any kind of sexual activity, but it can be beyond that too — it can lead to increased risk of UTIs. And then there's also another piece, which is the pelvic floor itself. All the muscles rely on estrogen to hold strength. And so the pelvic floor in postpartum is very vulnerable, because it's just done this huge job of opening to have a baby — or even if you had a C-section —

Britta Bushnell: I was going to say, if you weren't going to say that, I was going to say that part. Yes, yeah.

Sarah Shealy: But this is where people get confused. They think, "Well, because I didn't push the baby out, my pelvic floor is fine." But it's not only because of the big stretch that's done — it's because of all the hormones that have come in, the relaxin, that really changes the whole orientation of the pelvis. And then the pelvic floor muscles with low estrogen don't have the same strength, and it takes time for this to recover. And during that time, if we can put some vaginal estrogen back in the region, it helps the muscles as well. But of course, in this country, we don't do regular pelvic floor physical therapy recovery from postpartum —

Britta Bushnell: — although I highly recommend it.

Sarah Shealy: Yes, everybody should, right. But of course, it's hard to find, it's expensive, blah, blah, blah. But there are more options available now than there ever have been. So I think anybody that is postpartum, once all your healing is complete — usually by six, eight, twelve weeks — it's a good time to connect with a pelvic floor physical therapist.

Britta Bushnell: Yeah, I've had pelvic floor physical therapists on here, and they've even said, "Come see us while you're pregnant."

Sarah Shealy: Oh yeah, well — that's ideal, right?

Britta Bushnell: Come see us while you're pregnant, and then carry it through, so that you've got continuity of care, as well as things you can do to support the pelvic floor.

Sarah Shealy: Yeah, absolutely. So these are just a few little things of how you can see how postpartum care could be preventive medicine for the future. Like, even just these things — vaginal estrogen, pelvic floor physical therapy, adequate nutrition, replacing the lost nutrients, getting enough rest. But then when we look even bigger, into things like bone density — I know that a lot of times postpartum people are not really thinking about bone density. But when you get to where we are, we start talking about bone density and we're like —

Bone Density, Death Rehearsal, and the Midlife Crossroads

Britta Bushnell: — about bone density, we're like — what's going to happen to my bones?

Sarah Shealy: Because — you know, and this is where the rite of passage pieces come in too. I know that some people even talk about postpartum and labor and birth as like a death rehearsal, right? It's like — you really come — there are very few times in a person's life that you come very close to death. And a lot of people don't really want to talk about this, but I'm going to talk about it, because I think you see this mimicked again in the perimenopause time. Because you start to feel like everything's kind of falling apart, and you start to get oriented to how it was for your mother, how it was for your aunties — the generation before you. And especially for us in Gen X, we can look at that generation and we can go, "Wow. Well, they never exercised. They all smoked." Just right there, those two things, you know. And I think they probably ate fairly well because there wasn't so much processed food back then when they were our age. But that exercise and smoking — those are huge in terms of health outcomes. And then we see them — because they never exercised, there's — and they did a lot of dieting, there's a lot of diet culture — they end up very, very frail. So maybe they did live to be in their 80s and 90s, but they were very frail. Like, you could — I know that before my mother passed away, she was very frail, and I would watch her and I would kind of want to hold a little bubble wrap protector around her, because she also didn't have very good balance, because she never went to the gym.

So when we think about — if birth is a death rehearsal, perimenopause is another death rehearsal. It's really like a crossroads. It's like a choice. It's like a time to decide. It is a rite of passage, but it's important for people to understand that while a rite of passage isn't like something we can fully control — we do get pulled into them through our hormones — it's not like we have no control. We can make choices inside of that liminal space that will change the trajectory of the next integration phase — when we've kind of come into who we are now. How do we want to be as the next chapter of wherever that rite of passage happens to be, whether it's postpartum or perimenopause?

And even once we get to menopause — what I think is also so interesting, and very similar to postpartum, is that just because you're now in menopause — just because you went twelve months without a period — it doesn't mean you're now set as who you're going to be forever. God no, right? And physiologically, when you look at what's happening hormonally, it's not done yet even at twelve months — the hormones continue to adjust and change. We actually have a definition of early post-menopause, mid post-menopause, and late post-menopause. Early post-menopause is the first five to seven years past the last menstrual period, and the hormones are still doing some stuff in the background — it's not a total flat line, some people say it is, but it's not. Which is the same thing as — just because you now have a baby on the outside and you're called a mother, it takes years to embody and sort of put on that new identity. And physiologically, it takes years to fully recover from what you just did. And so I just find it so fascinating that our physiology really is at the heart of our rites of passage as we live this life. It's fascinating. And I think the hormones — we don't — we're just at the very beginning of figuring out what is optimal hormone therapy. We don't know yet. Yeah, we don't even know yet.

Rites of Passage Theory: The Long Goodbye and New Beginnings

Britta Bushnell: When I'm thinking about what you're talking about — about the different stages, and also the death rehearsal piece — it brings me back to rites of passage theory. And I've been loving the exploration of it in really layperson's terminology. That separation phase, you know, from van Gennep, is also can be thought of as the long goodbye — that is the goodbye to a former version of ourselves, that has with it grief, has with it death, has with it letting go. And we often fight that.

Sarah Shealy: Oh yeah, we certainly often —

Britta Bushnell: — are like, "No, I don't want to say goodbye." And that long goodbye, the long process of being willing to say this piece — which is a grief piece in it — and when you said we can't control it, I want to just caveat: I mean, we can control aspects of it. We can control aspects of it, but we can't control all of it. Like, you can't zip through the long goodbye without any grief. Grief belongs. It's not something to avoid or to optimize out of. There's a lot we can optimize, there's a lot we can do, there's so much support we can have — and there is still letting go. There is still letting go. And then if that's the long goodbye, and then the messy middle, and then the third stage — which in Bruce Lincoln's model is emergence, or reincorporation, which is from van Gennep — in this other model it's talked about as new beginnings. And it does feel like on that other side of metamorphosis, on that other side of the mess, is a new beginning. And a new beginning is also kind of messy — we don't have it all figured out. One of my mentors and my dissertation advisor, Chris Downing — I interviewed her for my former podcast, and I think she was around 92 at the time, and her mother was still alive. And she spoke about how, with her mother living so long, she never felt like she kind of got into cronedom early. So she referred to herself for a long time as a baby crone. And I loved the idea of being a baby crone.

Baby Crone: The Micro-Steps of Becoming

Britta Bushnell: When you're talking about multiple stages and you're talking about hormonal changes, but even that identity piece — the reason I spoke about this, about what Chris was talking about, is that I think we think once we come through a transformation, we arrive done. And we don't. No. It's like baby crone, and then mid-crone, and Crone Crone — she had all these different stages of cronedom in her archetypal understanding of things. And I think there are a lot of micro-steps in our becoming.

Sarah Shealy: Well, I feel the same way with motherhood, like — absolutely. Because you might be feeling, a couple of years in, like, "Okay, I got this." But the reality is, until you're the mother of a four-year-old, you have never been the mother of a four-year-old. And then a five-year-old, and a six-year-old. And now, for us, we have kids in their 20s, and like — I've never been the mother of a kid this particular age before, you know, well — with the first one, right? So with the second one you're like, "Okay, I've been here before," but not to you — to this particular kid, you know.

Britta Bushnell: I don't know what it's like to be the mother of my firstborn getting married, right? It's happening right now. And so there is a whole thing with that. And I know you've already done —

Sarah Shealy: — yeah, I got to do that not that long ago. But you know, I have a mentor, and I remember her — she's about fifteen years older than me — and I remember her saying, when she got to probably a little bit older than I am now, she said, "You know, I'm not that interested in much else other than I just am ready to be a grandmother. The things that used to really excite me or that I would be really curious about — I'm just not that curious about it anymore, and I really just want to be a grandmother." And I remember listening to her being like, "Wow, can't imagine that." And then the time passes and the kids get older, and then it's like, "Oh, actually, yeah, you could do that."

Britta Bushnell: Yeah, I just spent five days with my grandbaby and I freaking loved it.

Sarah Shealy: Yes.

Future-Proofing Your Postpartum

Britta Bushnell: Yeah, so, which kind of pivots me back. Let's — before we wrap up, I want to talk more about supportive postpartum practices and what's needed in that postpartum period, not only to support them through that rite of passage, but to set them up for the next rite of passage that's coming down the road.

Sarah Shealy: Yeah. Well, actually Oscar and I got together and created a whole course. It's called Postpartum Essentials, because as clinicians, we really had a shared experience of just feeling like you're arriving to the train wreck after it's already happened, and then you're trying to pick up the pieces and put these people back together after they've really had a big — whether it's a breakdown or a crisis or whatnot. And we were really aligned with this experience of, how can we get people to get ready before it happens? And it really goes to like, future-proofing your postpartum. It's really about trying to think about your postpartum before you get there, because too many people are like — "What's your postpartum plan?" — "Oh, we're just going to wing it." That's the —

Britta Bushnell: — the number one response is, "I'm going to wing it."

Sarah Shealy: And so we know how that goes. And no one in business would ever suggest that you have a big launch and don't make a plan for what's going to happen after. It's kind of like a really weird blind spot in our culture. And so we put together a course, and it has a beautiful workbook with checklists. It's very practical — very, very practical — because there are a lot of things that you can do to be ready, and a lot of conversations you can have so you can make sure you're on the same page with your partner, and that you can set yourself up for success. And that doesn't mean that everything goes perfectly to plan, but at least you have a plan, and at least you have set yourself up with food — number one — supplies, and then the people piece. But also just with the mindset that you're going to do the thirty to forty days where you're going to stay home, cocoon in, don't let too many visitors come in, don't make any plans. And during that time, you're not going to be cooking, cleaning, laundry, shopping, or exercising — that's off the table for this first period. Because if you can take care of yourself well in the first month, you're really setting yourself up well for the whole first year.

And I learned that as a midwife, from one of my midwife mentors — the conversation about postpartum needs to start happening as soon as they're pregnant. And in today's traditional medicine care, there's very little time for any conversation. People are seeing their practitioners for ten minutes, maybe fifteen if they're lucky. So there's no conversation happening visit to visit to visit. And so this Postpartum Essentials course kind of replaces what you would get if you were seeing a midwife for home birth visits, which is like an hour-long visit throughout your pregnancy — you would have these leisurely conversations. And so we've broken up all the video content into nice, little, short snippets. It's beautifully edited, and it's conversational and it's really easy to understand.

And my dream would be that people would say, "Who are you going to see for your postpartum care? Did you do your postpartum planning session yet? When are you going to do your postpartum planning session?" And that postpartum planning sessions would be something that people would do with their childbirth educators, with their postpartum doulas, with their lactation consultants, so that they know who are going to be their support people in the postpartum time. So just like your pelvic floor physical therapist — wouldn't it be great if you already knew them? But also your postpartum therapist — wouldn't it be great? Especially anyone that has a vulnerability, you know, like a previous history of anxiety, depression, OCD — these are the big postnatal mood disorders that can show up. All these folks should have a postpartum therapist already that they know and have a connection to, so that when the time comes, they're not struggling —

Britta Bushnell: — you don't have the energy to do that after the fact. You need it set up ahead of time. Yeah, 100%. So — where can people find that course?

Sarah Shealy: So that course is up and available on Oscar's website. So droscarserrallach.com, and I will have a link up on my website as well.

Britta Bushnell: And we'll put it in the show notes too. And then where can people find out about you and your work, if they want to know more?

Sarah Shealy: Yeah, I have a website — it's just sarahshealy.com — and I have Instagram and TikTok that I post on occasionally. And sometimes I get really excited and do a bunch and then take a break. So I'm there, and I'm happy to follow up with anybody that feels like this is something that they need. Because I also offer postnatal depletion care for folks who are in the postpartum time and who would like to just have some labs done and an assessment and a conversation — that can be very, very helpful for people to have a full, true recovery. And I mostly see folks who have gone down the path without having that, so I look forward to having more folks who are kind of doing preventive medicine, checking in to make sure they're doing the things they can do to take care of themselves so that they can have a better health trajectory in their recovery.

When Postpartum and Perimenopause Overlap

Britta Bushnell: I love that — have that ahead of time. And then we didn't get to it, but there are some folks who are navigating a postpartum period and perimenopause simultaneously. I have people close to me who had a baby and never had another cycle, never had another period.

Sarah Shealy: Very, very common these days, and it's very confusing to figure out. So really, anyone who's mid-30s and beyond giving birth — you very well may be overlapping postpartum and perimenopause. And this is a particular — my heart — I love all my clients, I really do, but this particular demographic, I feel a lot of compassion for, because it's so, so much to manage. And I really do love caring for these types of folks so that they can really thrive. Because also, if you're having a baby and you are in perimenopause and menopause — we didn't really talk about how perimenopause and menopause is a very high-risk, vulnerable window especially for bone density, but also muscle mass and cognitive health. And so having the right kind of support around that transition physiologically is quite important for your lifelong health trajectory. And I especially feel like — look, if you're having a baby, you've got to be as strong as you possibly can be, to be able to do all the things that you need to do as a mom for as long as you possibly can, so that you don't miss stuff. Like, to me, this work is about helping women have the resilience to not miss the moments in their lives, you know? Like the sweet, beautiful moments — whether that's in nature or with their kids or with partners or grandkids, lovers — really, all of it. I just feel passionately that women, before this generation, missed a lot of moments because they just didn't feel well. And if you don't feel well and you don't get help to feel better, you're just going to feel worse and worse and worse. And this vulnerable window in midlife is really in that sort of late 30s through the 40s. And the more that we can really help women understand — it's a time to do an honest check-in with your health status, and to really have a good understanding of where am I with my cardiovascular health, my metabolic health, my physical strength, my cognitive health. Like, how am I doing with my social connections? Because longevity is not just about your blood pressure and your blood sugar — it's also about your vitality and your social connections. That's your first circle, but then also the wider circle. And so we really think a lot about community, and that loneliness is an epidemic. It's just like there are so many pieces, so many pieces.

Britta Bushnell: And community matters in the postpartum period, it matters in the perimenopause and midlife period. And one of the things I'm pondering as I'm hearing you talk is how vitally important — or helpful — it is to have somebody in the childbearing era who's also got glasses on looking at the future with you, so you're not just looking at this moment and how you're doing in this moment, but how are you setting yourself up for the long term, for the midlife, for everything that's coming down the road. And it's one of the things that I think is really special about what you do — you've had this existence in work with being a midwife, a birth midwife, an academic, I know all those things, and now being really focused on the midlife transition. But the connection between those is something that I want more people to know about, and I just love it.

Women's Healthcare Gaps and the Call for Comprehensive Care

Sarah Shealy: Yeah, it's — we're in, I don't think we've ever had such a fragmented healthcare system as what we have right now. And women are getting bounced around from provider to provider, and then they lose insurance, and then they get their insurance back. And a lot of times, this is a place where women fall out of care — because they're in postpartum, and also if they had a traumatic birth experience, they're probably not circling back. Forty percent of women don't go back for their postpartum visit. And then they've become disconnected from their primary care because they've been just doing prenatal care, and then they're too busy with the baby, and so they don't prioritize their own care — which we know, as mothers, we will always put everyone else first. And so we've got a lot of women who have lost trust or just fallen away from care, and then we are entering the most vulnerable chapter of perimenopause, where the health trajectory really can go one way or the other, and they're not getting a comprehensive assessment of full midlife health risk factors in all those categories. We're just kind of leaving it to chance — same like, no postpartum planning. And I think that that's why, as a clinician, I created the practice that I have. Because I feel like — I didn't get it from any of my providers in the regular medical system. Nobody ever asked me about my perimenopause symptoms. Not a one. Yeah, and I had to go every single year to get checkups because I was teaching in the hospital. And in an annual exam for a woman in their 40s, they should be assessed for perimenopause symptoms. And they should be given a tube of vaginal estrogen and told, "This is something you get — if you don't need it now, you will need it, and here's how you use it, and here's what it's for." As a teaching moment. There are so many missed opportunities.

Britta Bushnell: And siloed care —

Sarah Shealy: Well, it's not only siloed care — it's that we have a clinician population that hasn't been educated. And so we're not doing preventive care for women. We don't know how to do women's health care. We do sick care only, and we only screen for the things that are mandated, and we're not doing health like health. So there's a lot of work to be done, and that much work to be done. And I'm really grateful for this time to get to chat with you.

Closing Reflection and Outro

Britta Bushnell: Thank you. I know we're way past our time, and I just want to keep talking and talking and talking. And we're also talking about two different, very important, interesting, juicy periods of time, so it's a lot to cover in one episode. And I do want to ask my final question that I ask all of my guests, which is: what's one thing you feel passionately about that you want new and/or expectant parents to see, hear, feel, or know about this unique and profound period in their lives?

Sarah Shealy: Postpartum is an incredible time for learning. It's an incredible opportunity for growth and connection. And if you prepare yourself for the other sort of mundane, practical logistics, then you can really enjoy your postpartum. And that's what I want for everyone. I want people to be able to really sink into it, relax and enjoy it, and have it be an experience where the partners and the baby really nest in and get connected, and that there's as little stress and as little distractions as possible.

Britta Bushnell: I love that. Thank you so much, Sarah. And thank you, listeners, for sharing this time with us. If something shared today impacted, supported, or moved you, please share this episode with a friend. I produce this podcast myself, and your support makes it possible. To show a little love for the podcast and these conversations, please follow, rate, and review. If you'd like to continue the conversation, please join us on Instagram at Transformed by Birth. I look forward to being with you again on the next episode of Transformed by Birth. Now let's gather what we want to take away from this episode. With an inhale — and with our exhale, I'll blow out the candle. Until next time, bye friends.