Millions of Women Stopped Taking Hormones Because of a Misread Study | Dr Sharon Malone

When women need to start thinking about hormone therapy, can you help us frame how they should start thinking about it? The thing that maybe we should just unpack is this black box warning that came from the FDA because it's what got people really scared. So the black box warning for hormone therapy was what?

It will increase your risk of heart attack, of stroke, of dementia, breast cancer. You can't apply that same data from 79-year-olds and 65-year-olds to 45-year-olds. They're not the same.

Overnight, I think 50 million women stopped hormones, which created a, you know, a catastrophe in the country.

So let's talk about that.

There's a survey that found that 66% of women really are completely unprepared.

Estrogen affects every major organ system in your body, and it starts with your brain. The sooner you start it, the more benefit you get. But let me say this. When you're talking about libido issues, the first thing you should always address Dr.

Sharon Malone is a nationally recognized women's health expert, board-certified OB-GYN, and certified menopause practitioner serving as chief medical advisor at Ally Health.

With decades of clinical experience, she's become one of the leading voices advancing evidence-based care for women in midlife and menopause.

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All right, Sharon, welcome to the podcast. So good to have you here.

Well, thank you so much for having me.

We're both here in San Francisco at a women's longevity health summit. And, uh, thank God, because women have been a neglected species in medical research forever. You know, what's really striking to me as a doctor is, and it's changing, thank God, but For most of the history of medical research, we've basically been studying 70-kilogram white men from Kansas, and they don't apply to everybody else. And so a lot of the research we have unfortunately doesn't really reflect what's happening in a broader population of women and women of color and women of different sizes, shapes, and ages. And it's really unfortunate because we, we really have neglected women's health. I learned in medical school very little. I mean, I learned all the diseases obviously, but I didn't learn about women's quote health. How do we restore health and function and optimize women's health through their life cycles. And there are life cycles. There's, you know, pre, prepubertal puberty. There's, you know, reproductive age, premenopause, perimenopause, menopause, postmenopause, all these different stages. Kind of different than a guy. I mean, guys go through this slower.

Yeah. You're pretty basic, you know, pretty basic.

And they go, yeah, pretty trickle down with andropause, which is not quite different. What's really interesting is that, is that most women don't have any education about perimenopause or menopause. They don't know what to expect. There's a survey that found that 66% of women really are completely unprepared. And, and even the women who go to see the doctor don't get good information and don't get good advice. And they want help for symptoms of, of hormonal dysfunction or hormonal imbalance. And 75% leave without a treatment. And I would say probably the other 25% leave with probably the wrong treatment. Or it's really, um, a place where a lot of women really feel ignored by the healthcare system and they don't feel taken care of.

And it's unfortunate.

And I think, you know, women are underserved, under-informed. And, and I think this conversation we're gonna have really matters. And we're gonna kind of dive into topic of how do we help women understand what's happening in their bodies throughout their life cycles? How do they get best prepared for the different stages? And how do they feel most vibrant, alive, and healthy? Not just treating disease. There's a difference between treating disease and optimizing health. And a lot of your work is really around understanding how do we optimize health for women through the life cycles. And I think that's such an important thing. So why have women been so invisible? And why, why, why are, are, are women going through menopause and, and doctors are so ill-equipped?

Well, you know, I, I did a talk a couple of weeks ago, um, where I was re— I did a deep dive into the history of medicine. You know, how did we get here?

Yeah.

And I think from its very inception, you know, the whole, misogyny and racism is baked into the cake. It's not like that was an afterthought. I mean, all of it was looked at through the prism of the male body and women were looked at as inferior versions of men. And that starts from the time of Hippocrates. I mean, we all as doctors take the Hippocratic oath, but we never really knew what were we thinking at that time. Well, because women were considered not even just different, we were the lesser of the two. And that's why we were never really given the consideration. And that went on for almost 2,000 years, that that vision of what women were, we were not to be considered. We were looked at really only from our ability to reproduce. And if you couldn't do that, then what's the point?

It's true. There were mostly a few matriarchal societies in the world, but most were patriarchal. Yes.

Yes. Up to this very moment, we are still living in a patriarchal society. But You know, it's changing, and it's changing because I think there's more awareness. And we can't change a system if we don't understand how it started, how we got here. And I think that that's becoming more part of the conversation now. Why have women been left out of research? Well, it depends on who's making the decisions. You know, that's why I think that when we talk about diversity, we talk about diversity of opinions, diversity of curiosities. And it matters who's in charge of what you're going to study.

It's true.

And you and I are sort of about the same demographic age.

We graduated residency around the same time. And it was in the kind of early '90s. And during that time is when we had a new NIH director that was the first woman, Bernadine Healy, who was an iconic thinker and said, hey, wait a minute. There's no research on women. We had some, like we had the Nurses Health Study, but this was not a randomized controlled trial. This was just a population study where they looked at trends over time. They couldn't prove cause and effect. And we made a lot of inferences from that study, which was done out of Harvard with Walter Willett and, you know, really good scientists. But, you know, you cannot prove cause and effect. And a lot of assumptions were made that ended up causing a real problem. And I always, my joke is that, you know, if we did a study of 55-year-old women who had sex, we would conclude that sex never leads to pregnancy.

Right? Right. That's true.

But that's 100% correct, but it doesn't, it's not true, right? And so that's what, that's kind of what an observational study does. It looks at patterns in a population, but they may not reflect actually the underlying truth or biology.

Most of what we know about women's health is really, as you say, from these observational studies, or I think worse still, just sort of epidemiological studies where you, after the fact, have an observation and then go back and try to justify or figure out what the correlations were. And there's no way to prove anything from those types of studies. So I think that Dr. Healy really brought some academic rigor to the conversation where she said, you know, if you're really gonna prove this, yes, we at that point, we'd had 50 years of data, on hormones in women, but we didn't really have the ability to say, "Yes, this is indeed true because of our hormonal changes." And can you just unpack for us how we got, you know, so confused?

Because the Nurse Health Study is just a great example of, you know, a good study with the wrong conclusion. And in some ways, like, right? Why did this study show that women who took hormones did better, had less heart disease, had less cancer, had better brain health. There, there was a lot of things that it showed that, that made millions and millions and millions, tens of millions of women get on hormone replacement therapy. And in fact, when I was, you know, working in that time period, I, I was giving a lecture and this woman said, my doctor said it's, it's malpractice not to give, you know, hormone replacement therapy. Mm-hmm. Uh, with Premarin and Provera, which is, you know, kind of what, what was the current, uh, prescriptions at that time.

Right. Well, the, the biggest problem is that there's the healthy women bias. There you go. Because you had— you were studying nurses, and you have to assume that nurses have a certain level of attention to their health that perhaps another person may not. And so that was really what the Women's Health Initiative was trying to sort out. Were these women doing better? And they were. So, you know, that was the observation. But we didn't know why. Was it just the hormone therapy, or was it all the other health benefits that come from being a healthy person.

Yeah, they went to the doctor, they exercised more, they ate better, they took their vitamins, they ate their fruits and vegetables, right? They did, they were proactive about their health, and that's why they actually ended up on hormones because they went to the doctor and said, I want to get healthy, right?

Exactly. But, you know, I say this, that with a lot of these studies, you can say, you know, you can prove the correlation, but You can't prove the cause, right? Unless you actually do the work and do the data so that, and collect the data. And that was what Bernadine Healy, and I, and I have to say, you know, rest in peace, Bernadine Healy, because she did it. She was able to do it because she was the person that said, you know, I'm in charge here.

Yeah.

And this is what we're gonna do.

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And then they started the Women's Health Initiative, which was like a billion-dollar study with 160,000 women, and it was a randomized controlled trial, and there were some flaws with it and problems we'll talk about. But before we get into that, I kind of, I had this thesis and I want to sort of play it out with you because, you know, I, I don't believe, I, I don't believe that God screwed up and made a design flaw in women to have them suffer from all these hormonal dysfunctions, whether it's, I don't know, whether it's PMS, which affects 75% of women, or whether it's painful menstrual cramps or heavy periods or PCOS or severe menopausal, perimenopausal symptoms. I think there's, there's drivers of those things that, that are neglected in medicine. And basically traditional doctors are trained only in two things: give the pill before menopause and give, you know, basically Premarin and Provera after menopause or at menopause. And there's a lot of other options to, to help people and women particularly feel better.

Mm-hmm.

So can you kind of walk us through the life cycles of women?

There's four stages. You talk about premenopause, perimenopause, menopause, postmenopause, and help us understand what's hap— actually happening in each of these.

Yeah. Well, you know, I think that, um, You know, something that you said is that you don't think that women, you know, are inferior versions of men and all this. And that is a relatively new thought.

Yeah.

Because, you know, you said God didn't create women to be inferior. But the reality is, is that for forever, since we've been reading the Bible, that was really how women came about. We were taken from the rib of Adam. We were punished You know, the pain of childbirth was punishment for making Adam, for tempting Adam into eating that apple.

Oh, geez, I didn't know that. I guess I don't know my Bible that well.

Yeah. I mean, that's why women, you know, a lot of the things that we believe are really biblically based. You know, why are Black people inferior? Why were they slaves? Well, because it was the curse of Ham. Curse of Ham. You know, and that, so a lot of that really, like I said, it starts from the very beginning and it moves its way forward. And we are still trying to, you know, sort of lose some of that, you know, perspective about where women came from. But we were punished, that's why. That's why women were always, you know, felt that when you had your menstrual cycle, you had to be, you know, isolated from society. God forbid you couldn't be touched, you were unclean. All of these negative connotations about what happens with women started very early on. But getting to your question.

But I think those were things that related to more of like the menstrual cycle and seeing being as unclean and having to be ostracized from society. Those weren't necessarily the like true suffering of all these crazy things that are happening now for women, whether it's endometriosis or PCOS or infertility or bad menstrual cramps or all these different things that are going on that It seemed to be diseases that I don't think always were existing in, in the female population at the level that we have now. And I think I'm just gonna be just straightforward with my opinion. I think it's because of our crappy diet, because of environmental toxins, and because change of our gut microbiome. All these things affect hormonal function.

Mm-hmm.

And they're not taught about and they're not treated within traditional healthcare.

I, I think they always existed, they just weren't recognized. And again, I'm no biblical scholar. However, let's go back to Abraham and Sarah. Sarah was barren. You know, we talk about barren women all throughout the Bible. Well, why were they? Oh, you know, endometriosis. I don't know, but I'm just saying that that is these things that we know that women have suffered from for time immemorial. They had no names. They had no names. No one was paying attention to it. And whatever it was, there was also this prevailing notion that you were just being hysterical or it's all in your head or you're just, you know, being a woman.

By the way, hysterical, for people listening, the root of hysterical, hysteria, is we call it hysterectomy is the uterus. So it's related to the female uterus is the word hysteria.

And that was a thought. Our female organs, the things that quintessentially made us female were the things that also made us crazy and suffering and all this thing. So yes, that's still there.

So take us through kind of these stages and what's going on with women's health and how they should think about it and what's happening and, you know, what are the changes that women should really be focusing on?

You know, we have a pretty good understanding. I think the average woman in 2026 understands that basic and first hormonal change that we go through during puberty. Okay, so you go from being prepubertal before you get your first period, then you have your first period and you, but in before you, even before you get your first period, there is that transition. You know, that's not the first sign of puberty. Girls start to, you know, grow hair in, you know, pubic regions, under their arms, they get breast buds, a transition from being a girl to being pubertal. Okay, we understand that. But to give you some perspective on how little—

But that's also happening a lot earlier too. So there's a lot of weird stuff going on with, you know, environmental estrogens, toxins. Yeah.

So we understand that, but I want your listeners to know how recent that conversation was because a generation or two ago, girls would go through puberty and have no idea what was happening. And imagine you're a little girl and you go to school one day and then you just start bleeding. Of course you think, my God, I'm dying or something's terrible. So that conversation—

Their mothers would never talk to them.

And never said a word. Didn't understand pregnancy, didn't understand what led to what. And that's why you saw so many young girls who did not understand. Well, imagine that was how that phase of life was even dealt with. And, you know, we've said, you know, probably not a good idea. And we've evolved and we make sure that young girls understand the transition so they know how to prepare for it. They're not— it's not something that's alarming. Okay, that's the good news.

Yeah.

Then you make it through your, your what I call premenopausal years, which really starts at puberty and goes for most women until their mid-30s, maybe early 40s. That's premenopause. And your peak reproductive years are somewhere probably in your 20s and early 30s. Okay, then there's this thing called perimenopause. And if you think about it, it's that same transition, like you have to transition from being prepubertal to puberty when you're perimenopausal. Perimenopause, you're transitioning from your reproductive years to your post-reproductive years. And that process is what women have been left in the dark about. Because you think you just go from one to the other. No, it's a years-long process. And for some women, it can take as long as a decade. For Black women, perimenopause starts earlier. It lasts longer, up to a decade. And to not be prepared. And when there's so many symptoms you can have during perimenopause, many of which we associate with menopause, but they start happening much sooner.

And they're often misdiagnosed.

Right. And you think, oh, I'm depressed or I'm anxious, I can't sleep, or, you know, I— changes in my libido. All of these things start to happen that really are divorced from what's going on with your period. So you think that, you know, everybody associates menopause with, okay, I'm not going to get my period anymore. Well, what if all the symptoms of menopause can start showing up a decade before? You can see how there was confusion and you get misdiagnosed. If you're depressed, here's an antidepressant. Oh, I'm, you know, I can't sleep. Here's a sleeping pill. We sort of have been picking off women's symptoms one at a time without understanding that it all sort of falls under this rubric. And, and women would be I think much more tolerant and I think much less distressed if they just understood it's a natural process going from one place to the other. And, and once you get to menopause, and so we've gone through premenopause, now we're in perimenopause, a transition of a years-long transition. And then once you get to menopause, that just means that's the end of your fertile period. No more.

And technically it's defined as a year from your last period, right?

And you know what, I don't, that, that, Isn't that what I learned? Yeah, it is. That is, that is what I learned as well. But in today's world, that definition is so woefully inadequate because it implies that you're not menopausal until you've gone 365 days. And it's like, no, you were menopausal at whatever moment it started. But that is just the marker by which we divide and say, yeah, if you bleed more than a year after your last period and you start, then that is the time that we should investigate that bleeding. But it It has no real—

Because it could be uterine cancer or something else, right?

But it has no biological significance really.

Yeah, yeah. That's true.

You know, it's just how we look at it. But there's so many ways to be menopausal that really don't tie to that at all. Well, a lot of women have IUDs. Guess what? You had IUD, you haven't had a period in years. How do you know? Right. Women have had ablations. Women have had hysterectomies.

And ablation is when they cauterize the inside of the uterus if you have heavy bleeding so you don't keep bleeding.

Right, exactly. So there are, or you've been on birth control pills. There are a lot of different ways that, you know, you can go through that transition and it has no bearing on what's going on with your menstrual cycle. So that's where I think we have to change that definition because it really doesn't.

Well, 'cause we also like medicalize a lot of things. So we basically, it changes the natural history of these things.

Yeah. And then once you get to menopause, and this is just my little, you know, pet peeve, I don't like the term postmenopausal. I don't, because once you're menopausal, and if we define that as, you know, no longer the end of your fertility, either naturally or otherwise. Yeah. You're menopausal. Saying that someone is postmenopausal implies that whatever the, whatever goes on in menopause stops after your symptoms stop, and they don't.

Well, let's talk about, let's talk about this, cuz I think I think there's, I, you're right.

Like I've seen women, you know, just go through with no symptoms and then be fine and everything's great. I've seen women start, you know, like 10 years before and having, you know, all these disruptions and symptoms, hot flashes, vaginal dryness, libido changes, mood changes, sleep issues. And irregular periods, heavy periods, you know, just every kind of symptom you might imagine. And they're often, like you said, very dismissed or they're medicalized and treated as something else or they're not I don't think adequately sort of diagnosed or treated. So, so can you talk about how, how this whole process of menopause affects every organ system in the body, not just reproduction, and what the consequences are if it's not handled properly in terms of, in terms of the long-term risk of disease, in terms of the short-term symptoms that women have to suffer from. And I, I personally believe it's criminal to not take care of women in a way that relieves their suffering. 'Cause we have the tools, we know what to do. And there's so many women walking around with so much suffering from all these hormonal dysfunctions. That we know what to do with.

I think that you're right. Women have been, you know, like I said, in terms of neglected, in terms of their symptoms minimized and dismissed, that's a given. But when you get to this point in life, we have looked at the hormones or the lack thereof, or even this transition as being just about reproduction. And it's not, you know, women make estrogen in a cyclical fashion throughout their lives once they, once they finally get their periods. And that estrogen affects every major organ system in your body. And it starts with your brain, your brain, your skin, your hair, your eyes, your heart, your bones, you know, your vascular system. And we have not really looked at menopause through the wider lens. We've looked at it from a very narrow prism, you know, only as it affects the reproductive system. And oh, yeah, by the way, now we know that it that it affects bones, but we're kind of late to the game in terms of getting to the real effects on what's happening to women's brains. And that goes back to what I was saying earlier is that people haven't been asking the questions. We just sort of accept that as, oh, well, it's getting older. And it's not just getting older, it's that change in your reproductive system.

So kind of kind of highlight the, like, the major symptoms that, that women might experience. And then, and then talk about, like, the consequences of, of not adequately treating women with the right types of hormone therapy. We're going to get into what that looks like.

Well, let's, let's start with the one that everyone knows, hot flashes. You know, hot flashes is the most common. 80% of women will, going through this perimenopause and menopausal transition, will have hot flashes. 20% don't. Lucky you. But hot flashes themselves have been treated as jokes. Oh, here's a woman, she's flashing, you know, look at her, you know, and women were embarrassed by hot flashes. But this is why I say hot flashes are not benign. Because if you have hot flashes and night sweats, well, what does that mean?

Can't sleep.

You can't sleep. You can't sleep Guess what's happening to you the next day? You're in a bad mood. Your brain is foggy. We've been residents. We all know what it feels like to not have a night's sleep. You're not in your best frame of mind the next day.

No, cranky.

But, and then sleeplessness increases your risk of mood disorders. It increases your risk of hypertension. It increases the risk of maladaptive behaviors because when you feel bad, You self-soothe or medicate, or you come, you fix your relationships, or you drink, you overeat, you do all of these things. It also, people who have really severe hot flashes, you know, these are things that increase your risk of cardiovascular disease down the road. Oh, absolutely. Type 2 diabetes, sleeplessness, all of these things go up in women because of the downstream effects of the hot flashes.

If you don't sleep, you crave more carbs and sugar.

Exactly.

I know that one. Exactly.

I was gonna say, I'm just saying, we understand that.

We get to work in the emergency room like 2:00 AM and the only opening is McDonald's. And I would go and get the apple turnovers 'cause I needed some sugar.

Because, you know, you get it. Because, you know, when I was a resident, I used to say the same thing. I can't be hungry and sleepy. It's like one or the other. So you're gonna do something. I'm gonna drink Coke. I'll drink whatever it is to make myself feel better in the short term, even though it has not, good effects later on. But those are the kinds of things that we talk about when we are talking about cardiovascular disease in women and why it goes up. And the cardiovascular disease risk does not go up for women until after menopause. Before that, that's why we've also lived with this notion that women don't experience heart attacks and cardiovascular disease at the same rate as men. We do. It's just 10 years later.

Yeah.

Because of what is happening with menopause.

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And so, so women are having all these symptoms.

Mm-hmm.

And you know, they get vaginal dryness, they get libido, they get mood changes. Um, they have sleep issues and it, it really impacts her life. And you know, my experience. Treating women more nutritionally with lifestyle is that those, those modalities are so helpful. Like if women smoke, if they drink, if they don't exercise, if they eat tons of sugar, if they have so much stress, if they're, you know, exposed to a lot of environmental toxins, all these things disrupt hormonal function and balance and they exacerbate symptoms. So there's a lot of, even aside from just giving the hormone prescription, there's a lot of things that, that women can do to reset their hormonal balance and feel better. Sometimes that's enough, sometimes it's not. And, and so if we do all those things and, and, and I've written a lot about that, and I'm sure you, you talk a lot about that as well. When women need to start thinking about hormone therapy, can, can you help us kind of frame how, how they should start thinking about it? Because, you know, my, my, and this is again, my understanding and looking at the literature is that. That the hormones that were, were pushed on women, which is prescription Premarin, which is pregnant mare's urine. That's why they call Premarin pregnant mare's urine, which is conjugate estrogens, has very different biological effects than bioidentical hormones. It increases inflammation, increases triglycerides, it increases clotting risk more than, than other forms of hormones that are what the body actually makes. And the same thing with the, with the synthetic progesterone or progestins. Like Provera, which my joke was it makes women depressed and have facial hair and gain weight. So it makes them fat, hairy, and depressed. So I don't like that. And so I found that using a very more nuanced approach to hormones where it's personalized, where it's often topical, not going through the liver, where it's as low dose as possible to achieve the effect where It's in the bioidentical forms, often works better. And there's, there's, you know, FDA-approved versions of those in there. There are things that I tend to lean on more. And I'd love to hear your perspective on how you think about it. 'Cause there's vaginal estrogens, there's topical estrogens, there's testosterone now being used for women. There's so many people having questions about this. I would really love to hear as an expert how, how you think about this, this approach. It's not just a one-size-fits-all.

Okay.

You're menopausal, Premarin, Primera, see you later. And if it doesn't work, Good luck.

And, you know, I'm going to take an unpopular position here because I'm going to take the privilege of age. Because when, when I started, because, you know, I feel like I have seen every permutation of hormone therapy that there is. And when I started in 1992, I inherited a practice from two 70-year-old men.

70.

70. Oh, yeah. Yeah, they were. They are so they were prescribing hormones in the '60s. Imagine this. So I'm brand new resident, you know, and I know what I know. And, you know, you're never more sure of yourself.

Oh, yeah. You know everything when you finish residency.

I know everything. I'm good now. And I had these women day one who were 80 years old, who'd been on hormones since 1969.

Yeah.

And I was like, I was appalled because I was like, oh my God. Then we, we had just sort of figured out that you can't give estrogen by itself to women who have a uterus. Remember that the addition of the progestogen was a relatively recent, you know, onset. So that happened like in the '80s. And when I saw these women who had been on Premarin for 30 years, I was like, oh my God, they're, you know, they're all gonna die.

Well, because just for people listening who don't know, if you give what we call unopposed estrogen, unopposed by progesterone, it increases the risk of uterine cancer.

That's exactly right. You're exactly right. And guess what? They were all fine. You know, I came in and I would say, "Oh my God, I'm the new doctor," and they've been seeing this doctor for 30 years. And I say, "Well, we've gotta add a progestin," and you know, right on. And they were quite reluctant, but I convinced most. But the point is, I've seen women who've been on Premarin for 30 years and they were doing fine and they were great and didn't, you know, and weren't bent over. So yay for that. And then when we got to, by the time I started, we did have— we had bioidentical estrogens. Then it was another name brand. It was Estrace, which was estradiol.

Right.

And we had Premarin. Premarin had better name recognition. It was a bigger company and more marketing. Definitely better marketing. And so Premarin had been the hormone that we had been using for the longest since 1942. Okay, so my objections to Premarin have little to do with the effectiveness of Premarin.

It works.

It works. And—

For symptoms, but it causes other downstream problems.

No, not necessarily, because even the Women's Health Initiative, all of the positive things that we know—

Sure, bone health, brain health. Yeah, yeah.

—comes from Premarin. Yeah, for sure. That was the only medication used in that study. So, you know, I think before we say, oh, you know, Premarin's terrible. No, it's not. It's estrogen. It works. You know, it has different combinations of estrogen. It's not bioidentical. However, all of the good things that we know about what hormone therapy does really comes from Premarin, and we've extrapolated a lot of that data to estradiol because remember, there's not another big large-scale study after that. So that's one.

And that's my beef. I wish that the Women's Health Initiative used bioidentical hormones. I really wish it did. And there are some smaller studies that have, and they, and they actually are, do show benefit.

And I don't disagree because, you know, even then I didn't use Premarin nearly at the rate that my predecessors did simply because, and again, this is personal, has nothing to do with this. I didn't like the fact that it came from pregnant mare's urine. Right. You know, I'm like, well, okay, you can get one from horse's urine or one that's not. Okay. I would choose the one that's not. Yeah. Yeah. But that's the, that was my objection. And then also there's cost. You know, because Premarin is branded, it always has been and probably always will be. So it's much more expensive than others. And then when it comes to what we know about the Women's Health Initiative, when, when we look back and we look back now, we have 22, 23 years of data to look over. We found that, okay, it's not the estrogen. Oh, look at that. Estrogen doesn't cause breast cancer. Estrogen doesn't cause a lot of the negative things that we have been ascribing to hormone therapy. We said, well, then if it's not the estrogen, it must be the progestin. It must be that nasty little Provera that was in that pill that the women were taking. And to that, I would say yes and no. You know, I would say all things being equal, I would take the bioidentical. But what we also have to eliminate is some of the fear moving forward because micronized progesterone is great if it works for you. Some people don't tolerate micronized progesterone. So if you don't, I don't want women to sort of get into this notion or even doctors to feel like progesterone's bad. It's so bad. No, it's not. It's, you know, it's a different one. It works for some people. The majority of women should and probably could use bioidenticals. But don't take that off the table because if you do, you're sort of doing the same thing that— Well, you have a toolkit.

You have a toolkit. Kit, right? With a lot of different, a lot of different hormonal applications, variations in the formulations, the types of estrogens. You can use estriol, estradiol, estrone, all these different ones that are available for people. And there's, you know, obviously the synthetic progesterones or progestins and natural bioidentical progestins. But I, I think that, that the question is, um, when you're, when you're working with a woman, how do you, how do you start to think about when and what to do, because when, when you look at the data, they do seem to— there's some new data that seems to have fracked that it's better to start at different times if you want to get certain benefits. And you know, the, the thing that just maybe we should just unpack is this, this black box warning that came from the FDA, because it's what got people really scared. And I remember, cause you, I was practicing really heavily with women that, that during that time when, when that study came out and it stopped the study, they literally stopped the study because they were concerned about the harmful effect. So they had that, that's a big deal. And overnight, I think 50 million women stopped hormones, which created a, you know, a catastrophe in the country. How well I know. Yeah. Right. And so we kind of had a backlash. Yeah. Now we're kind of coming back to a more coherent way of thinking about it. And, and I'd like you to unpack, you know, how you think about, um, prescribing hormones and which hormones and for whom and what the benefits are because the Women's Health Initiative did show that increased stroke and increased heart attack. And there were some—

Did it though? Did it?

I mean, that's what they said, right?

That's what they said. Okay, and I'm gonna tell you it didn't really say that.

Because the effect sizes were small or the—

The effect sizes were small and they were as prescribed. Remember, the women entering the Women's Health Initiative, the average age was 63. Yeah. You could be anywhere from 50 to 79 years of age to be in that study. They didn't really even say, all right, these are women who've never had hormones before, and now we're going to give some hormones and some not. The criteria for entering and being randomized, you just had to not have taken hormones for 3 months. Yeah. Before entering the study. Do you see what I'm saying? So the population was really murky. They were too old. Yeah. That's not how we're prescribing today. We prescribe— what we do know is that The earlier you start treatment, the more long-term benefit you get.

I— And is it riskier to start it when you're older?

Well, yes, there are some— you get less benefit. And I don't think it takes any leap of faith to understand that if the purpose of the Women's Health Initiative was to sort of figure out whether or not the hormones really were the secret sauce in reducing the cardiovascular disease, because when the Women's the— when the Nurses Study, 50% decrease in the— in heart disease in, in the women who took estrogen. Yeah. Okay, is it that or is it something else? And to have women come into the study at 79 years old, I think we can all agree that it doesn't matter what I give you, the— that horse is out of the barn by then. And by having too many women who already had established heart disease. Well, how are you gonna prevent something that you already have? Yes.

It's like they didn't do angiograms on everybody and see what their hearts looked like.

Exactly. Exactly. So when you stratify, even the Women's Health Initiative, when you looked at the younger women who were in the minority, but the younger women did not have an increase in the risk of cardiovascular disease. All of the bad things, the only finding from the Women's Health Initiative that was statistically significant was there was an increase in the risk of blood clots.

Yeah, blood clots. But that does— a heart attack is a blood clot, right?

No, but, but we— yeah, but that's separate. And this is listed as separate in part because it's DVTs or deep vein thrombosis or pulmonary emboli. And that was reported separately.

But estrogen does mechanistically cause an increase in clotting risk. We know that.

Yes, yes, it does. However, again, perspective matters. You need to know to say some— to someone that it's a 50% increase or 100% increase. Well, what's the baseline? You know, and what we do know is that for women who start estrogen, even oral, earlier, when you're 40s or 50s, when you start, that increased risk of blood clotting, that we don't have it, we don't see it. It happens when you're older. And so a lot of the findings from the Women's Health Initiative that were negative, even the cardiovascular disease was elevated, but only in the first year and not after that, because again, you're probably giving something to women who already have fairly advanced heart disease.

And what about the breast cancer risk?

Ah, the breast cancer.

'Cause that's what freaks women out.

Yeah, that is the number one reason why women avoid hormone. Oh, cardiovascular risk, I don't care about that. It's the breast cancer. That was really the nail in the coffin.

Yeah, 'cause it did show some increased risk, right? That's what they reported at least. Okay, let me check that. I mean, that's what the public understood from this.

Oh, trust me, I've been in the weeds on this for so long.

I'm just framing it so people know. It's not like I'm not just saying I'm right. No, no, no, no.

That was what they held.

That was the headline.

That was the press conference. Oh, not only does this, you know, they held a press conference when they stopped the Women's Health Initiative to say, oh, not only does it not help your heart, it increases your risk of blood clots and heart disease and strokes. And it went on and on and on. Well, that's very scary. And I would challenge anyone to give me another example of when the NIH, the regulators at NIH, held a press conference to announce a study. I mean, that's how big of a deal they thought that was. And I'll also mention that Bernadine Healy was not there at that time. So we're going to give her a pass on that. But here's the breast cancer story. And I will say this, the data is the data. You don't get to change the data because you don't like it. It. Okay, you can change your interpretation of the data, but it is what it is. But let's take it at face value. What did the Women's Health Initiative say about women who took estrogen, the Premarin and the Provera? All right. They reported there was a 26% increase in the risk of breast cancer in estrogen and progestin users versus non-users. 26%. That sounds terrible.

Who wants that? It's relative risk.

But what did that mean in real terms? That means for women who did not take estrogen and progestin, 30— the natural incidence is about 30 per 10,000 women per year will be diagnosed with breast cancer, living long enough to get it. In the estrogen and progestin user group, it went from 30 per 10,000 women per year to 38 per 10,000 per year with no increase in the risk of dying from your breast cancer, even if you were diagnosed on hormone therapy. So let's make that sound a little better. All right. 8 per 10,000 additional cases of breast cancer.

And that's 26%. That's 26%.

Right. With no increased risk of dying from it. And then make it even better, less than 1 in 1,000 additional cases of breast cancer. Yeah. In the women who took estrogen and progestin. Now that doesn't sound nearly as scary as 26%. Correct. But that was never really put into perspective.

I think Mark Twain said, "There's lies, there's damn lies, and there's statisticians." Exactly.

And, you know, and there is, and when you put it that way, you say, "Oh, okay, well, 8 in 1,000, but I'm no more likely to die from it even if I'm taking hormone therapy." And even that statistic itself, and you and I know in a medical study, if you were going to report a finding, to call it a finding, it has to be statistically significant. It was not statistically significant. But that stuck like glue. It's still with us today because doctors and patients still believe that it— that a family history of breast cancer is a reason not to take hormone therapy. So that's just that worst-case scenario. Let's, you know, put it on— blame the old bad Premarin and Provera. Even that did does not statistically increase your risk of breast cancer. And that is what has taken a long time for people to, to really understand those numbers. And because I remember the day that came out, it was 1992, and I had been prescribing for 10 years. Well, 2002. And I had been prescribing for 10 years before that. Yeah, me too. And patients were horrified. Oh, doctor, I can't believe you're trying to kill me with this stuff. And when I read the study, I was like, wait a minute, it's not as bad as what they said. Yeah. And again, remember, applying that data— again, take it as it is— you can't apply that, the same data from 79-year-olds and 65-year-olds to 45-year-olds. They're not the same.

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So let's talk about that because I think that I want to really help women understand our newer thinking and what the newer data is around what to start and when, because it has implications for brain health, for bone health, for heart health. For overall, you know, symptom reduction. The black box warning I want to talk about before we dive into all that. Mm-hmm. Because that, that's recent. It's a black box warning for people who don't know what that is. The FDA puts a black box on the drug label that says, if you're taking this, beware because it can cause X, Y, or Z. So the black box warning for hormone therapy was what?

Warning, Will Robinson, it will increase your your risk. See, only you and I get that joke. Lost in space. But it will increase your risk of heart attack, of stroke, of dementia, breast cancer. Now, if you picked up your medication from the pharmacy and it said, wow, my doctor didn't say that to me. Even for the patients who had an adequate discussion about it, they would read that warning, go take it home and not use it.

So the black box has heart attack, strokes, cancer, and dementia.

Dementia. Yeah, that sounds fun. That's pretty discouraging, I would say. And as I said, going back to the original study, it never— they— remember I told you the only statistical finding that was significant was blood clots. Yeah. So how can you say all those things? So my point is that—

And that was removed just in 2025.

Well, I think it may be just off now because I think, you know, they had to go through all the inventory of the stuff that already had it on there. But now it's off. And it's in the regular package insert. You know, every drug has, you know, risks and side effects that are listed in that long insert page.

It's like thin paper that you could fold out that's like got 40 million words on it.

Very, very small print. So it's in that part now. It's not on the box. And that's what we're like, it took an act of, I don't know, whatever to get people to realize this. It's like, no, don't say that because you can't. That's not science.

Given that's true, um, let's talk about the, the plus side here because I don't— I, I said earlier, I don't think women should have to suffer from hormonal dysregulation and symptoms. We have a lot of understanding about what causes it from a lifestyle perspective, including things that are not really being well addressed in medicine, whether it's the microbiome or environmental toxins, because those do play a role. We know nutrition plays a role, exercise, sleep, stress, all those things, smoking, alcohol, people understand those. But, you know, what, what are we thinking about now is the right way to approach hormone replacement therapy? When should we start it? How long should it be given? What are the right formulations that work best? What are the options for women out there? I want to sort of dig into all this with you. Okay, well, this is the, like, kind of where the rubber meets the road.

So perimenopause does not have a bright line that signals when it begins. A lot of it depends on, again, lifestyle, it's genetics, it's, you know, personal to you. So someone may be perimenopausal at 35, someone else may be perimenopausal starting that process at 45. And there's no blood test that's going to tell you yes or no, you're in perimenopause. Perimenopause is a clinical diagnosis. So remember all those symptoms that we said, hot flashes, mood swings, night sweats, sleeplessness, you know, weight gain, all of those things that we associate with menopause can start in perimenopause even while All women's periods are relatively regular. And perimenopause actually has 3 stages itself, early, mid, and late perimenopause. Now the question is, if I can't diagnose it by blood tests and I can't really use periods as a, you know, as the defining factor of when to start, then how do you decide? History, history, history. The patient will tell you. When she's perimenopausal. If she, if you're having any combination of those symptoms and they are bothersome to you, then that is the time you start treatment. And we do have fairly robust data that says, even from the Women's Health Initiative and some other studies that say to get the maximum benefit, the earlier you start in this process, the more long-term benefit you're gonna get. Get. But how we choose to treat those symptoms during perimenopause, well, again, it will depend. It depends on what your other symptoms are. It may be you have bleeding issues. Maybe you're— someone else has more sleep issues. In that case, maybe I'll start with progesterone. So that is where this is the art of how to prescribe. There is no one way to do it. You know, the basic components, there's estrogen and there's a progesterone, but the mix It depends on what your symptoms are, how old you are, and what we are trying to fix. Maybe you're 37 years old and you're having these things and you need birth control. Well, that's a case where we might use a birth control pill. Yeah. Because it has estrogen and progestin in it. But that's why I said it depends. But remember, I want, uh, women to understand that it's a clinical diagnosis. If you are feeling that way, a lot of women will go to the doctor doctor, get a blood test and be asked the question, when was your last period? And you'll say last month. And they'll go, oh, well, it's not perimenopause. Come back 365 days after you haven't had a period. Right.

Because they don't— because we're not really trained well in this in medical school. Right. And in residency, even, even OB-GYNs, I don't think really have the right understanding of it.

A lot of what I learned about this was really through not just what I learned in residency. We were taught more about it in OB-GYN But it also is trial and error process. The experience of say, oh, well, that didn't work. Well, let's try this. But knowing that you have the full complement of estrogens and progestins. Okay.

Well, let's, let's bifurcate this into symptoms and disease prevention. Because on the other side of menopause is heart disease, breast cancer, osteoporosis, osteoporosis, and dementia, because women experience that at far higher rate. So I want, I want to bifurcate it just for, okay, for making people understand a little bit. How do we, how do we really understand this perimenopausal period? Because when I, you know, when I've been treating women, I, I find that, you know, the, the lab test, you're right, could be all over the place. Like one day they look like they are, one day they're not. And, but I do often see this, this interesting phenomena that I want you to talk about, which is, is this sort of reduction in the progesterone in the second phase of the menstrual cycle. We call this the luteal phase. So we see higher levels of estrogen and we see lower levels of progesterone. And then you get this imbalance. And when you have high levels of estrogen, it causes more body fat, it causes more heavy bleeding. And when you have, for example, if you're overweight, if you're eating a lot of sugar, it causes a lot of estrogen in the body. I've seen this over and over. And so you get this sort of imbalance and that causes a lot of these heavy feeding symptoms and really heavy, heavy cycles and things that we often see. So I would love you to sort of talk about that, that phenomenon, or if you, if you think it's not a thing, cuz I, I think it's a thing.

No, I, I think that you, you're right. What's happening is, is not that—

'cause you're having anovulatory cycles, right?

If you're looking at cycles, you're saying that the, the reason why when you're in perimenopause that the estrogen levels will sometimes overshoot. Yeah. Is because normally it's limited. Limited by the amount of estrogen you make is limited by ovulation. So since so many of perimenopausal cycles are anovulatory, which means they get started but you don't ovulate— that's also why your fertility is not good— but you have too much estrogen in the first half of the cycle, and the progestin, the progesterone that happens in the second half of the cycle only happens after you ovulate. That's right, that's what I'm getting at. So when you don't ovulate, your estrogen keeps going, and then now you don't have that. That's why Having someone who understands that says, well, if this person— maybe giving them additional estrogen at this point is not helpful. Maybe we need to supplement with progesterone.

Lab tests can help because you can see if you do it in day 18 to 23 in that luteal phase or the second half of the cycle, you see, oh, God, their estrogen is really high, but their progesterone is kind of low. But you know where it should be, right?

But you know what? This is what I would say. An experienced doctor doesn't even need lab work. If I can tell by your history, if you come in and you say, God, my periods are going on for 2 weeks and I'm heavy bleeding, Okay. Or are they longer? Right. Whatever the, whatever the blood test shows me, ultimately what I'm going to do is I'm going to treat the patient and her symptoms. Right. I'm not going to alter it based upon what her blood results were. I can't— you, you know, you can figure that out. Yeah. So that's why I said it depends on what symptoms you're trying to treat. If you got hot flashes and sleeplessness, the one thing that I will say, estrogen is the secret sauce. This, because it will— estrogen is the most effective treatment for that symptomatic menopause. Vaginal dryness, you know, irritation, the mood swings. That's the estrogen that is most effective. So it's a matter of playing with that and saying, okay, if someone only has one thing to give you and they're going to prescribe the same thing if you're perimenopausal and the same thing You're menopausal and the same thing 20 years down the road. That sort of lets you know that they haven't really, what should I say? They haven't had experience with all of the things and you just need to know what you need at that particular point.

Right. This is such an important point. It's personalized, it's customized, it changes at different periods of that transition. That's really helpful for women to understand. You need to work with someone who really understands the nuance of how to understand your symptoms and what you're doing and what's going on and how to properly address that and what the right combo toys of different hormones. And I'd love to sort of hear your perspective on, on whether people should be using it orally, topically, if it makes a difference, if it should be bioidentical, not bioidentical, how much that matters, how much we know about it.

Okay. So let's, let's start from this place that I think more than certainly more than 50 years ago, most clinicians are going to start with the bioidentical. You're going to use a bioidentical estradiol, Not one of the synthetic ones. Okay. That being what it is, and I even hate the term synthetic. They're all synthetic. It's just a matter of—

it's just, it's just, it's just, it's the same molecule as your body makes. Exactly. Bioidentical. Bioidentical. As opposed to pregnant mare's urine.

Yeah. Let's not use synthetic. So you're gonna start there. Yeah. Okay. So once you say, okay, estradiol, it can come as a pill, a patch, a spray, a gel, or even a vaginal ring. Mm-hmm. There's a vaginal ring you can put in, I think it leaves, leave it in for 3 months. Yeah. Change it. Those are your options. Those are your— those are just modes of delivery. There are certain people, um, that a transdermal may be preferable. If I were giving estradiol, if I were giving hormone therapy to someone who's a smoker, I would say, yes, let's do a transdermal because we don't need the extra first pass in the liver effect. If, um, If I have someone who is not particularly compliant or they don't like to take pills or whatever, then I'll say, "Yeah, put a patch on once or twice a week. We'll do a patch." But again, don't take oral off the table because the overwhelming majority of women who take oral do just fine. And even though the blood clot risk is higher, It's higher of a very small number. You know what increases your risk of blood clotting the most of anything you'll ever do? Pregnancy. Oh yeah. Pregnancy, oral contraceptives. The amount of hormone that you take in hormone therapy after menopause pales in comparison to those two things.

I was telling you about my daughter's about 26 weeks pregnant now. And she called me the other night and she's like, "Dad, I have like chest pain, shortness of breath." I'm like, "Oh." She's an orthopedic surgery resident. I'm like, "Oh my God." She's like, Maybe you have a PE or pulmonary embolism. Thank God she just had heartburn. Yeah, yeah.

But see, she knows to at least be alerted to that possibility. Right. You know, so that's why I said oral versus transdermal. And there are other things, there are other non-medical considerations. And, you know, and I think they're legitimate. Let's talk about sex.

Okay, sure. 'Cause I think this is a big thing. Libido goes down, vaginal dryness goes up. It's a big thing.

And, and you read a lot about it now.

We're talking about estrogen, we're talking about progesterone. Let's talk about testosterone and what your view is on that, how to use it, if it should be used, when it should be used. Because I personally found it extremely helpful for women and has also another side benefits. It increases, you know, bone health and other things. So can you talk about your perspective on testosterone for women? Okay. It's just one of those things that's out there in the, in the ether right now.

I, I, I will because I'm a little bit outside the, the general conversation. Conversation on that too, in terms of what I think about testosterone. But let me say this. What— when you're talking about libido issues, the first thing you should always address are the woman's menopausal symptoms. Because if you're hot, sweaty, sleepless, you've got vaginal dryness, and every time you have sex, you have a urinary tract infection, guess what you don't want to do? Have sex. There you go. You know, that So fix that first.

Yeah. So vaginal dryness, super easy to fix. Even if you don't take oral, you can do vaginal estrogen. There's pills that you can stick in there. There's rings, there's creams.

Yeah. Yeah. So everybody—

so once we— by the way, by the way, that doesn't really get it systemically absorbed that much. So people are worried about—

right, right. No, no systemic absorption from the amount of estrogen that's in vaginal estrogen. It's minuscule. So it works where you put it. So it work in the vagina near the urethra because the urinary system is close, right there next door. So it'll fix both of those, but you don't have to worry about overdosing. You don't have to worry about, oh my goodness, I've had breast cancer, I can't use vaginal estrogen.

And you mean to use a progesterone or progesterone?

No, no. You don't? Because there's no systemic absorption. Unless you are taking systemic estrogen, you don't need to take a progesterone. Okay, so that being said.

I know that, I just want everyone else to know.

So, so let's get to that. So now I have a patient and I have addressed all of her symptoms. She's sleeping well. She's not hot. Yeah, yeah, yeah. No dryness. And she says, "Eh, libido still in the toilet." Yeah. That would be an instance where some point in the future, then I would say, well, let's give it a try. Let's try some testosterone. And again, what I want everybody to understand is the testosterone conversation is not new either. Either. Testosterone, we had it compounded, but that's been around forever. This was, you know, I was prescribing testosterone for women with low libido back in the '90s. So this isn't like, oh, we just discovered testosterone. But here's what I have found. And again, this is the experience part of it. When you are treating libido, it works really well for women and not so much for us.

Testosterone.

Yeah. Testosterone.

And how do you, how do you, I mean, the problem is for men, there's a lot of FDA sort of approved formulations that you can use that are pumps, that are patches, that are, you know, injections. There's all sorts of stuff. For women, it's kind of not, it just, it's not available and you have to kind of, it's the wild west out there. Right. Right.

It's, it's been up, uh, it's been in front of the FDA a couple of times. To get a female-approved version of testosterone. And it's the same testosterone. It's just that a women's dose is a tenth of what the men's is. So it's difficult sometimes to take the male version and get a tenth of the dose.

Compounding pharmacies and yeah.

That's a case where sometimes we're generally speaking, I don't love compounded, but if you can't get it, Yeah, yeah, I've used compounded.

And I've had even topically, like I've had clitoral testosterone drops and they work really well.

Yeah. I, you know, and I would argue with no one who says I've tried testosterone and it works really great. And I'm saying yes, then of course. But again, that's the phase-in process. I would never start all three at once. Even if decreased libido was one of your symptoms that you presented with, because we fix one thing and we all know that libido libido with women is much more complicated. It's not a plumbing issue necessarily.

It's a lot of things that go into it. Well, people say women's greatest sex organ is between their ears. Exactly.

Exactly.

The other thing I want to just touch on briefly is, you know, we're in the world of Ozempic and peptides, and there's actually an FDA-approved peptide for women's arousal disorder, right? By Lissi. By Lissi. Never used it. Never prescribed it. Never prescribed it. Because you don't think it works or because? You don't know about it? It might take place. You know what?

No, it was, you know, when I was practicing, we had two options. We had Addyi and we had Vyleesi. And it's the same sort of situation. I'm one of those people that I'm like, show me, okay? And you know, I have prescribed Addyi to a couple patients. Vyleesi, when you, this was, now remember, this was pre—

That's a pill. I mean, Vyleesi is an injection. That's a pill.

It's an everyday pill. Yeah, and Vyleesi is an injection. Injection. So this is pre-Ozempic. Most people were not sold on that idea, and you could— it's on an as-needed basis, but every time you have to say, well, 30 minutes before you're going to have sex, go get this, take this shot, and women are like, no thank you. So it was less, you know, that's why I've had—

it does work though, it does work.

And I, you know what, and I—

it works for men too, actually, it works for men too.

That's great if it does, but like I said, I was never able to convince someone that that was a good option.

By the way, I've tried it and I'm telling you it works. But I don't know how it works for women because I'm not a woman.

I will take your word for it. I've never used it. But I think that the libido issue for women, again, is something that's been sorely unaddressed. I think we can all agree that men's libido and their ability to perform has been an outsized conversation. And we've not really paid attention to women's libido in the same, with the same level of importance and the the same level of distress that it causes for women. No, it is.

And we should, and we should, we should do better. So we've talked about all the vasomotor symptoms, the, the, the irregular bleeding symptoms, the sleep symptoms, all those can be addressed with combinations of various estrogen, progesterone, topical, oral, vaginal. Let's talk about the, the importance of understanding the timing of starting hormone therapy for disease prevention, particularly dementia. And let's also talk about osteoporosis because, you know, people don't realize this, but, you know, if you have a hip fracture and women get more than men because they're less testosterone, lower bone density, it's a 50% mortality in a year. I mean, if you get, it's like cancer. Like if you get a hip fracture, you're likely to be dead in a year, 50% of the time.

I think that when we start talking about things like the long-term benefits, I think that We have fairly decent data on the cardiovascular benefit of hormone therapy, you know, that it decreases the risk of cardiovascular disease. And that's not, you know, we have a lot of different, not just observational studies, but we even have things with, there's the Danish Osteoporosis Study that started around the same time as the Women's Health Initiative. And when the Women's Health Initiative shut down, they shut down. Just go, oh, well, no need in finishing that. By the time it shut down, it had 10 years of data and it was with bioidentical. Yeah, right. So yay on that. And that, and that showed— it showed a decrease in the risk they had even 16 years out. They showed that the women who were on hormone therapy had a decreased risk of cardiovascular disease. So I think that that is— we've got, we've got fairly good data on cardiovascular disease. Okay. We've always had data on osteoporosis that was is one of the indications for hormone therapy. If you are at risk for osteoporosis, yes, take it. Sure. Now let's go to the dementia part of this. What we do know about dementia, I'll tell you what I, I'll, I'll do it in two parts. I'll tell you what I know and I'll tell you what I think. Okay. Right now in the current indications for hormone therapy, FDA approved, Hormone therapy is approved for women who have a premature or early menopause. However you get to that place, and some women naturally have an early menopause, and early, I mean before age 45, premature if you're menopausal before age 40. Well, how does that happen naturally? Sometimes you've had your ovaries out, sometimes you've had chemo or radiation, things that sort of shut down prematurely and prematurely. Right. Estrogen therapy and hormone replacement therapy is indicated for those women because what happens if you have an early menopause or premature menopause? You're at increased risk for cardiovascular disease, dementia, and osteoporosis. So the recommendation is not can you, but, but you probably should. And it would be, you know, it would It would be considered a major misstep if someone takes your ovaries out and you're 38 years old and they do not give you hormone therapy. So, yeah, with that we know. So let's go back to the dementia issue because there seems to be a lot of controversy about it. Yeah. Do you know how long it would take to do a study to— even if you did a randomized double-blind? 30 years.

We'd all be dead.

Okay. Sometimes you have to go with the data you have. And we infer all the time in medicine. We don't— there are very few things that we have, like, I have gold standard absolute proof that this is the case. And I don't think it's a great leap of faith to say, well, if it prevents dementia and osteoporosis and heart disease if you're 42, why would it not if you're 46? Yeah. You know, you have to look at it from that point, from that perspective. I think that we have some really interesting ways of looking at this now, which I think is going to help give us some data before we are all dead and gone. And that is now we have Dr. Lisa Mosconi, who is looking at— she's imaging women's brains. And she has been able to demonstrate that your brain looks different in premenopausal perimenopause, and postmenopause. She and I think it's Dr. Rebecca Brenton are the two neuroscientists that have really delved into this to say, we can do this. We can follow one person through perimenopause, menopause, and menopause and image that same brain. So I don't have to wait 30 years to get that data. And so there is now concrete evidence that estrogen plays an important role in how women's brains function and what the structure of their brain looks like.

Yeah, but clearly brain fog and all that. Yeah. It's better with hormones. We know that. That's symptomatically true.

So, you know, I think that, you know, if you were— but, but it gets back and I'll get to this, the same thing that I was saying before in that it matters when you take it. That's right. You can't prevent or slow down osteoporosis when you're 70, too. And that's why timing matters. And we've got a lot of the stuff that we talk about hormone therapy. The sooner you start it, the more benefit you get. There is no benefit in waiting 5 years down the road before you start.

Yeah. I mean, you really talk a lot about proactive medicine. And I mean, I think the guidelines for a DEXA scan is like when you're 60, which is insane to me. Totally. I mean, you should do when you're 40. Yeah. Yeah. Which is a bone density scan. I agree. And I think, you know, even, even now we're having ways of, of tracking brain health through brain imaging. I co-founded a company called Function Health and we can do quantitative brain imaging. We can do all kinds of biomarkers that tell you what your brain health is. What, what I'm curious about is if, and this, I think at this point it's a conjecture opinion cuz the question's still out there is why are women so disproportionately affected by Alzheimer's? And could it be because of this sudden drop in estrogen after, after menopause? And, and does the data show that women who take hormones bones and have taken them starting early. Because if you start when you're 60, it doesn't seem to do anything. So you gotta start like early when you're right. And when you're menopausal, right. That's, that's kind of the take-home message. It's like, don't wait.

I think that is definitely the take-home message because, you know, one of the things that, that the central question is why do, you know, Why are two-thirds of the people with Alzheimer's in this country women? That's right. Why are Black women two times more likely to be diagnosed with dementia than white women? Why is that? That's where you've gotta start. And if you look at just the basic things, you say, well, what happens to women in that same time period? And that is the only— and it has something to do with menopause, probably something to do with estrogen. And that's what really what we're trying to pin down on that because that's really the big difference between how men age versus how women age. Yeah. A lot of things start to us because when we get to menopause, our estrogen levels fall off the table.

It's like a boom. It's a boom. Gone.

Yeah. It's not a smooth— As opposed to guys, it's kind of like— Gradual decline. No, it's gone. It's gone. It's never coming back. Right.

So, but by the way, but just so people understand, even after menopause, women still make estrogen and progesterone. It's not that it goes away. Not much. No.

We don't make as much. It's not zero. But it's, we don't make estrogen. Estradiol, we make estrone. Estrone. Estrone. Right. But that is, that is something that's metabolized in peripheral fat. Yeah. So if you are a very thin, lean person, you probably don't have a lot of estrone.

Correct. Correct. And then, yeah, skinny old ladies are the ones who get the fractures.

And it's much weaker. Yeah. It's a much weaker estrogen than estradiol. Yeah. Fair enough. So, you know, there's that. But what I was saying, getting back to, this brain health part of it is that I'm willing to make the inference. Maybe I'm right, maybe I'm wrong. It will not be the first nor the last time in medicine that we've made decisions— On incomplete data. On incomplete data. You know, sometimes we do. And I hope and I pray that I'm right, but at a minimum, I don't think you're doing harm.

At a minimum. And I would just add that, you know, we now now have, which we never had, you know, when you and I were starting training, tools and diagnostics to really track cardiovascular risk and breast cancer risk and things that matter. So if people are concerned about heart disease risk or breast cancer risk with hormone replacement therapy, we now have, you know, deep diagnostics for cardiovascular risk that we do with functional health. For example, we look at ApoB, lipoprotein A, lipid fractionation, CRP. We look at metabolic health in a deep way, insulin. These things are really important because they, aside from all the hormone issues, these are the things that drive cardiovascular disease. And then the same thing with breast cancer. Now we have tools that, you know, whether it's mammograms or breast MRIs or even new liquid biopsy tests, there's more tests emerging that are, you know, proteomic testing for cancer and other, you know, DNA kind of fragment testing that's available through liquid biopsy. So all this is iterating really fast. So I think, you know, it's important for women to sort of track it, not just go, oh, it's fine, but to track their health over time and to see longitudinally what's happening. And even I think when they get their GYN exam to get a uterine ultrasound and make sure the uterus is okay and everything's okay. Because like, you know, these things like uterine cancer and even ovarian cancer now with some of these, you know, liquid biopsies and other tests, we can start to, start to track these things. So I think given the kind of constellation of advanced diagnostics that are here now and that are coming soon, it gives me a lot more, I would say, peace of mind to kind of even move forward with this set of incomplete data that we have.

We can't wait to, you know, to give people the information. But you know what you and I agree on most is the idea of prevention. Yeah. You know, I think that, you know, I wrote a book called Grown Woman Talk. It's not just about menopause, but it's about all the things that affect women in midlife. Yeah, yeah, yeah. And at the end of every chapter, I'll give a list of things that these are things you do. I talk about cardiovascular disease, I talk about cancer, I talk about Breast cancer and the chronic stresses and hypertension and diabetes. At the end of each chapter, it's almost the same thing. Don't smoke, limit your alcohol, exercise, eat a healthy diet, and get a good night's sleep. Duh. Whether you are, it doesn't matter what you're trying to prevent, breast cancer, colon cancer, dementia, the same basic things go into that because that's just a recipe for healthy living. And quality living, we hope, as we age. And—

Yeah, it's not like you're going to take hormone therapy and everything's going to be fine. You can live a crappy lifestyle. You got to do it all.

Right. It's a both/and. You know, that's not going to, you know, and you can have all the great, you know, molecular genetic testing in the world and something else will still come up and bite you. So you got to just be able to say, you know, there is a limit to what we can predict. And I use my mother as an example. My mother grew up in rural Alabama. She grew up on a farm. Okay? I don't think my mother ever ate a non-organic thing in her life. That's right. In her life. That's right. That's right. My father grew vegetables. That's right. We, you know, that's how we ate growing up. My mother died of colon cancer, but my mother died of colon cancer, not because of something she did that was wrong. It was, she died of colon cancer because colonoscopies weren't a thing. Right, right. You know, in today's world, yes. So we have to take the two together. We take the technology and the science and the knowledge that we've acquired with healthy living. Because I don't want people to think that you have, you don't have complete control over anything as far as your health. You can minimize your risk. You can never eliminate it.

Well, this is such a great conversation, Sharon. I appreciate all your dedications over the years. People, you know, can learn more about your work. You have a podcast, Second Opinion, right? Second Opinion. And that can be found wherever podcasts are found. Wherever podcasts are found. And you're an advisor, a channel provider to Ally Health. Ally Health. Ally Health. Tell us a little bit about what that is. Because I think as women are listening and men are listening who are in relationships with women, they're like, well, what do I do and where do I go? And yeah, the average doctor may not be able to kind of have the nuances here. You know, there are now online platforms and tools that are much more sophisticated, understand these things, and you're an advisor to one of them called Alloy Health. Can you just share a little bit about that?

And Alloy, I've been with them for 5 and a half years now. So I was there from the very beginning. And when I stopped clinical practice, I, you know, I'd accumulated all this, you know, I've got not just the medical background, but I've got the experience of having done this for a while. And what I realized is that you can educate women all you want, but if they don't have access, then what difference does it make? You can't find a doctor, you can't find someone that will prescribe for you or that even knows what to do. And that's why it was important when I joined Alloy, I was able to take my expertise, train the doctors that work for us, many of whom are, you know, they're all board certified and then now they are menopause trained so we can leverage average the expertise of a few over hundreds of patients, not just the one-on-one that you're going to be able to see in the course of a day. And menopause and perimenopause treatment lends itself well to dealing in the, uh, in the digital health platform. And that's how a lot of care is going to be delivered in the future. And so, you know, I think that people should feel confident that this is not an inferior version of what you're going to get in a doctor's office.

In many cases, it's a superior version. It's the better option. Yeah. Yeah. Well, thank you for doing that work and thank you for your dedication to this field and writing your books. And where can they find more about you beside your podcast? You have a website?

Yes, I have a website and it's easy. drsharonmalone.com.

And your social media is?

@smaloneMD on Instagram and Threads. Amazing. Wonderful.

Well, thanks for your work. Thanks for being a voice out there for reason and coherence in a very complicated, confusing space.

We need more of you. Well, thank you for having me.

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