Menopause is the most ubiquitous experience nobody talks about. Pain, hot flashes, mental clouding — they’re a constellation of symptoms that women are routinely told are “normal.” Abdul reflects on the costs, to individuals and society. Then he sits down with Susan Dominus, a staff writer at the New York Times Magazine, whose recent piece on menopause treatment has forced doctors to rethink their recommendations.

TRANSCRIPT

[AD BREAK] [music break] 

Dr. Abdul El-Sayed, narrating: The FDA approves an RSV vaccine. The W.H.O. officially ended the COVID global health emergency as the U.S. public health emergency expires this week. A new CDC report shows that overdose deaths among Black folks skyrocketed in 2020, driven largely by fentanyl. This is America Dissected. I’m your host, Dr. Abdul El-Sayed. [music break] Friends. Before we get started, a quick call. If you’re graduating from a public health program this year, we want to hear from you. We’re putting together an episode about the future of public health. And you, well, you’re that future. If you’re graduating in 2023 and want to talk. Send us an email at AmericaDissected@crooked.com. That’s Americadissected@Crooked.com. And our producers will be in touch. Now on to the show. Today we’re talking about menopause and the general disservice wrought upon people who are going through it by a scientific establishment that fundamentally discounts the suffering that comes with the experience. If you haven’t caught on by now, there are a lot of ways that our health care system discounts the experiences of women. We talked a few weeks back about the differential experience of puberty, particularly early puberty, and the ways that our silence on the matter has done way more harm than good. We’ve talked about our failure to take the experience of birth seriously, particularly among Black women. We’ve talked about the ways that society has full on discounted the dangers of pregnancy and dismissed the many other reasons women seek abortions. So much so that national policy favors allowing people to force it on you, which 24 states have now gone ahead and done. Now look, I don’t think I need to put my cards on the table in this one. But menopause. It’s not something I’ve had to think much about. I’m a 38 year old cis man. I’m never going to face menopause. And while plenty of women I know and love have experienced it, the script they’ve been taught discounts their pain and discomfort as something to suffer silently, and certainly not to speak to a young man about. Of course, menopause was part of my medical school curriculum. But like most things we’d talk about in medical school, it was sterilized into science speak as if the physiological phenomenon was all I needed to know about. Ovaries run out of ova and with them stop producing the monthly pulses of estrogen and progesterone that animate the ovulatory cycle. Never mind the ways that estrogen withdrawal leads to a host of painful symptoms, from hot flashes to pain with sex to dry skin. And we absolutely did not talk about the ways that the constellation of symptoms experienced and the parts of the bodies they affected targeted the fundamental way someone perceives a core part of their identity. Nope, none of that. But we did talk about the Women’s Health Initiative. It’s a landmark study that fundamentally altered the course of menopause treatment in the early aughts. There was a before Women’s Health initiative, menopause symptoms were treated with hormone replacement therapy. This should make sense. Menopause symptoms, well they stem from the body’s abrupt ceasing to produce the hormones, estrogen and progesterone. Simply replacing it well, it allays those symptoms. And then there was a after Women’s Health initiative. See, in the study, researchers thought that the hormone replacement therapy would have secondary benefits, particularly around preventing heart disease, too. So they embarked on the largest known study of its kind, enrolling 160,000 women to test that hypothesis. But then one of the key arms of the study was abruptly halted. 

[clip of unspecified doctor] Women should not start or continue this therapy to prevent heart disease. The findings show it doesn’t work. In fact, the therapy increases the risk for heart attack or stroke. 

Dr. Abdul El-Sayed, narrating: It was the shot heard round the world. Researchers found that estrogen and progesterone therapy increased the risk of a number of maladies, including stroke and breast cancer. For example, hormone replacement therapy increased breast cancer risk by 26%. But a note here, those numbers can be tricky. See, the baseline risk of breast cancer between 50 and 60 is about 2.33%. That means 2.33% of women in that age group will develop breast cancer. So when we say that number increased by 26%, it means that that baseline risk, it jumped from 2.33% to 2.94%. So out of 10,000 women, the number of cancer cases would go from 233 to 294, an increase of 61 cases in 10,000. But that was enough to have them cancel the study altogether and warn the world. Now, look, I’m not discounting those 61 cases, but I am saying that 61 in 10,000 may force us to think about, well, all the costs of untreated menopause. See a recent study from the Mayo Clinic of more than 4000 women in four states found that the symptoms of menopause cost nearly $1.8 billion dollars. Yes, billion with a B dollars through missed workdays, cutbacks in hours or frank resignations or worse, layoffs. And that doesn’t even include the pain, discomfort and dysfunction of the symptoms of the people experiencing them. Since the Women’s Health Initiative, hormone replacement therapy has been reserved for only the most extreme symptoms, and folks have been told that menopause is just a part of life, that they just need to grit and bear it like childbirth or menses, early puberty and all the other things women go through and are routinely told to ignore. See as a man, I would have gone on ignoring menopause if it weren’t for a breakthrough article in the New York Times Magazine written by our guest today, Susan Dominus. In which she goes back to the moment our understanding of menopause flipped and asks why. I wanted to have her on the show to dig in. Here’s my conversation with Susan Dominus. 

Dr. Abdul El-Sayed: Can you introduce yourself for the tape? 

Susan Dominus: Sure. My name is Susan Dominus and I’m a staff writer at the New York Times Magazine. 

Dr. Abdul El-Sayed: Susan, I really appreciate you making the time to chat with us today. You wrote a fantastic article, a really important article uh for the Times magazine about menopause. And um this is a an experience in life that upwards of 50%, if not more than 50% of people uh are on pace to have or have had. And um I’m not one of those 50%. And so I’ll be honest with you, before I read the article, my understanding of menopause and menopausal treatment was what came out of um the Women’s Health study. And um and you write very movingly and convincingly about how um this represents a sort of failure to take into account or to fully account for the full lived experience of menopause. I want to ask you, stepping back, you know, you talk about it a little bit in the article, but what led you to to write about this or to take it up as a reporting project? 

Susan Dominus: Um. I actually love this question because it’s not what you’d think. Um. My uh male editor in chief, Jake Silverstein, thought it was an important topic, and I love uh and respect the fact that that was this was his idea. He brought the idea to me right around the same time that I went away for a small reunion with some of my closest women friends from college. And if we were away for, you know, four days, I feel like all told, we spent like 20% of the whole trip just talking about menopause because each of us was having some interesting or troubling um or really upsetting experience of it. It was a spectrum, but everybody wanted to talk about it and everybody was baffled by how little we knew. We didn’t even know, you know, what is the difference between perimenopause and menopause and are we in it? And do you have symptoms before you’re actually in menopause? And how do you treat them and why isn’t there more? And is it safe to treat menopausal symptoms? And, you know, we were pretty um well well-educated, well resourced women, and we were baffled. And um I was sort of hesitating. I wasn’t sure. It seemed like a very big topic to take on. I ended up focusing a lot on um menopausal hormone therapy, but my friends really felt like this is such an important topic and that there is a stigma attached and people need to write about it to reduce the stigma. 

Dr. Abdul El-Sayed: I, I can’t imagine the experience of living your life and you’re in your uh early fifties, and then all of a sudden your hormones just completely go out of rhythm. And this causes all kinds of disturbances, a set of symptoms that um you don’t see coming that are not quite the same for everyone experiencing them and don’t have a defined end point. And it’s like it’s almost like you end up having this sort of new onset chronic disease that everyone just says is normal, right? 

Susan Dominus: Yeah. 

Dr. Abdul El-Sayed: What is that experience like? 

Susan Dominus: Well, first of all, I do feel it’s important to say that not all women do experience menopause or the menopausal transition as um a real hardship. You know, there is some percentage of women who who take it um very easily. Uh. Those women, I think, are, in fact, in the minority. [laugh] But um, you know, I think it’s a little bit of the frog in boiling water syndrome um combined with uh women’s um sense that they’re not really supposed to complain anyway, you know, it’s sort of gradual. And, you know, you start waking up in the middle of the night and, you know, you’re you’re sweaty and you’re hot and you know you think like, okay, I guess I’ll open the window now or I’ll try to take a nap, you know, during the day or um and then, you know, it’s very hard to know. Okay, well, I’m feeling these things, but are these things that are happening because I’m going through menopause or is it just that I’m stressed or is it that I can’t remember anything anymore because I’m not sleeping well? And am I not sleeping well because I’m worried about my kids? I’m worried about my parents. I’ve got so much on my mind. Or is it menopause? Is it hormones? You don’t really know and no one’s really talking about it. Nobody’s telling you there’s anything you can do about it. And so you just kind of deal with it. It is also an intense moment because I think when you realize you’re going through menopause, like every time you have a hot flash, frankly, you’re kind of reckoning with the inexorability of mortality. I mean, I don’t think I’m exaggerating to say that that’s part of it. Or at least you’re being confronted by your own aging. And um for some women, even more than that, I think a sense of like not universally, but I think for some women, it can be interpreted as there can be a fear of losing one’s femininity, one’s womanhood. It’s and there are a lot of things going on in the lives of women who are in their fifties who are, you know, maybe they’re in the prime of their careers, maybe they have children, maybe they have older parents they’re dealing with. You know, everybody is facing a lot of uh existential stress right now. So I think I think it’s it is an unfortunate um time in your life to be hit with a new set of symptoms. You know, for some women, it’s even joint pain. Like you want to exercise, you want to feel fit. But if everything creaks and aches all of the sudden, you know, that can be it can be um a hindrance for sure to your feeling like your best self, right when you need to be your best self. Right? 

Dr. Abdul El-Sayed: You you you mentioned something that I really appreciate and I want to pull on a little bit, which is that, you know, women are expected to experience things and not complain about them. And we just did a recent episode about early puberty uh in girls. And, you know, we were talking about the experience of going through puberty and the way that that gets stigmatized and the fact that we we do not have or the conversation that we do have if we have one, doesn’t necessarily empower um the folks who are experiencing this. It is sort of a conversation had um quietly between people so as not to interrupt all the folks who are not going through this. Like that’s kind of the nature of the conversation. And I just feel like there’s so many parallels and they all sort of point back to, you know, gender norms and assumption about gender norms um to to what do you degree do you feel like the failure to have taken the question of menopause as seriously as we ought to, given how many people this affects, how profoundly is centered in a ongoing, um you know, frankly, misogynistic approach to the way that we think about women’s health? 

Susan Dominus: You know, there’s a there’s a quote that I think about a lot in the article from a woman named Rebecca Thurston, who’s done a lot of really important and groundbreaking research on menopause and menopausal symptoms. And, you know, she basically believes that menopause and the lack of um more treatments and the lack of more discussion about it represents one of the great blind spots of medicine. And I asked her, you know, what she made of that? And she said, I think that it suggests that we have a high tolerance for women’s suffering and especially probably older women’s suffering, which is a way of saying that they are, um you know, not as highly valued as they should be in a society and– 

Dr. Abdul El-Sayed: Disposable. 

Susan Dominus: Yeah disposable, invisible. Um. You know, the other thing I will say in defense of the, you know, the research industrial complex is that, you know, menopause, it affects your quality of life, but it’s the rare thing that affects your quality of life that actually doesn’t really um endanger you, you know what I mean? So I think it’s it’s you’re not going to die of menopause. You’re going to die of something. But it’s unlikely to be. I mean, it is true that you have higher you know, it’s possible that if you have good menopausal care, you are less likely, for example, to get a fracture. And like that’s really important. Um. But but otherwise, it’s not a fatal disease. It’s just a quality of life issue, hot flashes. You know, there is some research that suggests there’s an association between more than four hot flashes a day and high rates of cardiovascular disease. But it’s unclear whether the hot flashes are causing that or whether they’re just um a reflection of the fact that there is cardiovascular disease. But for the most part, the hot flashes don’t we don’t think that they do any damage. Right. They’re not dangerous. They’re just really, really uncomfortable and disruptive. So I think that that is a less compelling um you know symptom for um doctors and researchers to like, you know, throw money at. 

Dr. Abdul El-Sayed: But but here’s where I’m gonna I’m gonna push back. And and, you know, I’m not one to defend uh medical industry or the research industrial complex. Having been a part of both of them um and I think about how much money is made treating erectile dysfunction. 

Susan Dominus: Yes. Correct. 

Dr. Abdul El-Sayed: Which, you know, if you think about it, this is sort of the male analog, which is not nearly as painful. Right? 

Susan Dominus: Yes. 

Dr. Abdul El-Sayed: It’s just it’s just not it’s the lack of pleasure. It’s not the presence of pain. 

Susan Dominus: Correct. 

Dr. Abdul El-Sayed: And we spend huge amounts of money on um on both researching and treating erectile dysfunction because there’s a market for it, but also because it affects men. And a lot of the folks who’ve been in positions of power identified this as this is a serious problem that we both can monetize, but also that we can treat. And a higher [?] of our nature, we can take care of some people here who are experiencing this awful thing, um and we just haven’t done that with menopause. And I’ll be honest with you. Like, you know, as as when we were talking about the about puberty a couple of weeks back, you know, the same parallel sort of came up our our experience for the most part of um of puberty as as males doesn’t involve one day as a child bleeding from your genitalia. 

Susan Dominus: Yeah yeah no right. Yeah. 

Dr. Abdul El-Sayed: Uh. 

Susan Dominus: It’s really interesting. 

Dr. Abdul El-Sayed: And we don’t we don’t, you know, require products. And the fact that we don’t offer products universally, right, I think is a function of the fact that it was always expected that uh women and girls would go on and take care of that situation without without making a fuss about it for everybody else. Whereas, you know, these these challenges both at the beginning uh of our um pubescent period and then toward the end of our um of our of our sexual lives, we’ll call it, um you know, any time there is uh there’s the risk of a male being nonplussed. Um. There is a ready response from the medical industry. Um. And when it comes to women and girls, where that involves pain and discomfort um and sometimes loss of function, we just don’t do anything about it. Right. You know sort of the simple way I think about health is, is it does one of three things. It either causes you pain or discomfort. It it takes away your function or it has the potential to shorten your life. Um. And and menopause ticks two of the three. And um you know, erectile dysfunction only ticks one. 

Susan Dominus: Yeah, I think the difference there between um helping um men with their sexual pleasure and ignoring the actual pain that women experience during sex, just as you say, when they have what’s now what’s now called genital urinary syndrome, which is um, you know, a series of changes to women’s, you know, frankly, their genital urinary system um that happens to, you know, happens to 50% of women. They experience some sort of dryness or thinning of the vaginal walls or discomfort during sex, you know, pain, burning, itching, um you know, increase in urinary tract infections. [laugh] I mean, it affects 50% of women. And as they as they go, you know, after they go through menopause and reluctance to really talk about it more openly and aggressively, even in doctor’s offices, has to do with a deep discomfort with the sexuality of older women. I mean, it’s not just that it’s not a crisis that women who are in their sixties you know might be um having painful sex, but it’s like the idea that they would even want to be having sex, I think is an uncomfortable idea for many people. I mean, I think there’s noth– there’s this whole brand of humor around how you know um appalling it would be for a younger man to have sex with an older woman. You know, there’s a real almost like visceral revulsion that people have around that idea. It’s a trope that you certainly see in comedy. And um and I think it reflects a a larger um societal discomfort with the with very idea of a woman’s sexual value um once she’s of a certain age. 

Dr. Abdul El-Sayed: We’ll be back with more with Susan Dominus after this break. [music break]. 

[AD BREAK]

Dr. Abdul El-Sayed: You know, we talked about puberty and we’re talking about menopause. We have a three month old at home. And having just uh watched my spouse go through a second pregnancy and we don’t even talk about that. Right. Um. And it’s just it’s at every level of a life course where the pain, the frustration, um the discomfort of women is taken for granted. And, you know, obviously, there’s there’s a whole field of women’s health, and yet it’s been underfunded, under-resourced um we don’t have a big, broad public conversation about it. So, uh you know, and as as someone who’s I’ve never I’ve never had to deal with these things, but as someone who thinks a lot about um these questions of what do we choose to treat and what don’t we choose to treat. It’s it’s rather astounding to me um that the the sort of biases, the the structural bias of the past, we’ve just sort of carried forward in terms of what we choose to invest in, what we choose not to. Um. I want to jump now just to the sort of state of of medical management of um of menopause. And can you can you walk us through how menopause was managed before the Women’s Heart Initiative study? 

Susan Dominus: So for for many years leading up to 2002, when the National Institutes of Health launched the Women’s Health Initiative, um hormones were actually prescribed pretty readily um to women who have a uterus. They were given um estrogen and progesterone. The progesterone is basically to counteract the increased risk of endometrial cancer. For women who don’t have a uterus, they were readily given um estrogen alone. And there was the thinking that it was going to um be great, that these hormones, that estrogen would be great for preventive care, for heart disease and cardiovascular disease. Um. And it was, you know, one of the most commonly prescribed medications um that there was. And doctors also did regularly prescribe it um to much older women, which is now something that I think with good reason doctors do still do, but with more caution. 

Dr. Abdul El-Sayed: Just, you know, for context for folks. The a lot of the experience of menopause from a from a physiological standpoint is estrogen withdrawal, whether it is the genital urinary symptoms, whether it is the hot flashes, it’s all of a sudden, you know, the the the production of estrogen in the ovaries um happens uh with the production or the maturation of ova. And when that stops, right, a lot of that estrogen production goes away. And so it makes sense that the treatment would be um to continue to give somebody the hormones that their body is no longer making. Um and–

Susan Dominus: Because there’s estrogen receptors in so many parts of the body. Right. Like your skin, your hair, your brain. Yeah.

Dr. Abdul El-Sayed: Exactly. 

Susan Dominus: Your breasts. Yeah. 

Dr. Abdul El-Sayed: And um you know, that that sort of change in estrogen is also what explains a lot of the experience of pregnancy. Right. Is that you all of a sudden estrogen levels go sky high um and uh and it’s a lot of the same sort of parts of the body that are targeted. And when you have a regular dosing, that’s that’s what um maintains and sustains the physiological aspects that we um tend to tie to feminine bodies. Right. That that’s that’s what does that. And when that starts to go away, the experience is extremely uncomfortable. And um and that’s what sort of explains menopause. And so we used to treat that, that we used to treat with with hormones until this 2002 study. And I’d love to hear a little bit more about what the study did and maybe maybe not just what the study did, but also how the study landed. 

Susan Dominus: Well, the study was intended to see if indeed um hormone therapy did improve women’s cardiovascular health. The question was, would it be good to use hormones for preventive care? And it was so commonly believed that um estrogen would be great for cardiovascular health, for women of any age and any heart condition. That one doctor I interviewed for this piece told me that she used to have a slide that she would give in presentations that said estrogen should be like fluoride, it should be in the water. That’s that’s what a cure all people thought it was going to be. So the um National Institutes of Health launched this um major randomized controlled trial still to date, the largest randomized controlled trial of um women only that has been conducted. And contrary to the idea that um it was going to lower the risk of cardiovascular disease, it actually found increased incidence of um coronary heart disease, of um strokes, of clots. And um this was this was in the estrogen and progesterone group, the women who still have uteruses. Um. And that was really shocking to the researchers. Um. They also saw increased incidence of breast cancer. Um. And basically they did something that was pretty unusual. That was pretty unusual is they called a huge press conference. Um. Where they announced that they were bringing the um the estrogen and progesterone arm of this of this trial to a crashing halt because it was deemed to be you know, they had they had passed a threshold of risk that was unacceptable for a trial. And even though they emphasized in this press conference that the risk to each individual woman was extremely small, that it was sort of an epidemiological, um you know, that you would see these numbers across a population. But for the individual woman, it was going to be a really small risk. They emphasized that. But all anybody really heard is we’re stopping the trial. And I think it’s pretty clear that people thought, how people interpreted that news was they stopped the trial because hormones are dangerous to women. Um. Now, the threshold of risk that a, you know, a trial can tolerate is much lower than an individual might decide is okay for her. And also, you know, the trial wasn’t um it wasn’t factoring in quality of life issues for women. So the doctor who held the press conference actually said we have found that the risks outweigh the benefits. What he meant was we found the medical risks outweigh the medical benefits. But that’s not the same thing as saying these risks outweigh whatever lifestyle or risks exist in having hot flashes five times a night. So um it wasn’t measuring quality of life. It wasn’t measuring um anyway. So the researchers went on the talk shows and they gave all these interviews. And, you know, they they rattled off all these statistics That sounded really alarming. Good God. You know, after five years, we saw a 26% increased risk in women. Um. Now, they didn’t break it down by age. Um. And, you know, if you’re in your fifties, you know, your your breast cancer risk is actually quite low. It’s something like 2.1% risk, it might be a little higher than that. I’m not sure I’m getting the number exactly right. But, you know, 26% um on top of a risk that low is is is really quite small. You’re still not going to get to 3% even, you know, so with those it wasn’t presented that way. It was just I think a lot of women hear, oh, my God, I have a 26% increased risk of breast cancer. You know, I imagine many women heard that as you have a 26% increased you know risk of breast cancer or maybe your risk is 26 times higher. I think people just don’t know how to interpret those statistics. But if you don’t know what the base number is, then you don’t know how to factor in what that 26% increase really is. So the– 

Dr. Abdul El-Sayed: Yeah. 

Susan Dominus: –risk was still super duper low for women in their fifties. Now, you know, by the way, totally reasonable to decide to decide. One of the other ways that people describe it, it’s like for every 10,000 women who take hormones, an additional um eight would have um would have breast cancer. Now, you can listen to that statistic and think like eight, you know, 10,000. That’s not for me. That’s too high. I respect that. But I just don’t think that most women heard it that way. And I think many women, if they did understand it that way, would um be perfectly comfortable with it. 

Dr. Abdul El-Sayed: Mm hmm. I I really appreciate you walking us through all of the ways that that study got interpreted, um because it highlights a couple of cardinal uh issues with the way science is done and communicated. The first is that, you know, scientists love to talk about themselves as if they’re are super unbiased or we are super unbiased. And the problem is, is that this study was designed expecting or testing the opposite hypothesis to the one that it identified. 

Susan Dominus: Yeah. 

Dr. Abdul El-Sayed: Which for that reason it created a level of alarm that probably was not justified by the data simply because it was contrary to the hypothesis. Right. And to illustrate again, the the the contrast here, men on average die about two years earlier than women do. We have higher rates of cardiovascular disease, which largely accounts for that difference. Increasingly, now um you’re seeing suicidality and uh drug overdose account for some of that difference. But right that is because men don’t go through a thing called menopause. So testosterone on its own likely accounts, right, for a big part of the difference. And testosterone, estrogen, if you look at them chemically, are really, really quite similar. Obviously, they do what we consider the opposite thing, but both of them are uh what we call steroid hormones. And whenever you hear steroid um think cholesterol, Right, that’s the S-T-E-R that’s the same route. Um. And so our bodies just sort of, you know, it’s a small little difference. Um. And we all have receptors for both of them. But their impact in the rest of our tissue, independent of, you know, the tissue that are primed to look for testosterone or uh or or uh estrogen, the impact on our tissue is probably quite similar, but we don’t have a menopause. And so we’re dosed on steroid hormone right for much longer in our lives, right. Particularly uh after the age of 50. And so, you know, if you think about it, you step back and you think about the the um hypothesis that was being tested. Right. If you if you sort of thought about this for a second, you say, well, if you were in a situation where you really wanted to test the endpoint of cardiovascular disease and that’s all you cared about, you might propose testosterone blockers in men. 

Susan Dominus: Hmm. That’s really interesting. 

Dr. Abdul El-Sayed: But nobody would ever right say, yeah, yeah, that’s definitely worth it. You’re like, what, but it’s a two year life expectancy increase? Right? 

Susan Dominus: Yeah. 

Dr. Abdul El-Sayed: And nobody would ever say, yep, that’s that’s definitely worth doing. And so–

Susan Dominus: Well it’s because it’s so interventional also, right? I mean. 

Dr. Abdul El-Sayed: That’s right. So it shows us how biased we are to what’s, quote, “normal or natural,” A and B, that we’re not very good at thinking about the difference between the endpoint that we’re measuring and what we think holistically about a person’s experience. Right? 

Susan Dominus: Mm hmm. 

Dr. Abdul El-Sayed: Um. So, like, if you could if you could give somebody a a a um uh a hormone blocker and say this is going to give, increase your life expectancy two years, because you’re right, it would be an intervention, nobody would propose it. And very, very few men over the age of 50 I know would be like, yeah, that’s that’s worth it right? Um.

Susan Dominus: No. Definitely not. 

Dr. Abdul El-Sayed: Yeah. So it just shows you how like we got the we were so biased or scientists, the scientists who did this study were so biased by what their hypothesis had been going in and by the fact that uh they were the laser focused on their end point, that they forgot to ask bigger picture questions. So they failed to contextualize their findings within the broader question of alright what does this mean for women on the study? And then they let their alarm take over, right? You don’t usually hear a press conferences about the outcomes of studies, but they let their alarm take over almost, you know, as a self-protection mechanism, um which is fundamentally about bias. Like alarm is not a thing scientists usually think about. It’s, you know, we pride ourselves on being calm, cool, collected observers of the evidence. But that clearly isn’t what happened here. 

Susan Dominus: Well, it’s just very strange just because they could do the math. I mean, they they even did do the math, you know, and talked about it in the um in the press conference. I will say I think some of the hype had to do with the press. Um. And I think uh also so many women were fearful based on what they were hearing about how it was being presented in the press that they were coming to their doctors in a panic. Um. One doctor said to me that doctors were so, as you say, sort of stricken by having been proven wrong, that they felt and they some of them felt guilty, that they had been prescribing it you know all across the board, including to older women. And so they couldn’t kind of deal with it. And they just stopped cold turkey prescribing it because it was almost as if they were overcompensating for whatever they had done before. But like, you know, again, 26% increased risk of breast cancer. It’s not nothing, but it’s you know, I think for, you know, many people take all kinds of medications that entail that kind of elevated risk for various um bad outcomes because they know it will offset some serious lifestyle impairing symptoms. So it is it is really I think you’re right, there was a huge psychological component to the way the trial uh trial’s findings were announced and to the way that doctors responded and certainly to the way that women responded. I think women were sort of almost primed to think that, like, surely this is too good to be true. Like, really, I can just take hormones and it’ll you know it’ll offset so many of the symptoms of aging and menopause that you know plagued women for you know generations before me. Maybe it just seems maybe it just seems, quote unquote, “unnatural” to you know, I still have friends who had unbelievably um terrible uh perimenopause and menopause, just terrible sleep problems, terrible hot flashes, real like real misery. And and we would talk about menopausal hormone therapy. And, you know, some people just want their lives to be very natural. You know, they just that’s there’s a they valorize that I guess they privilege that and you can’t persuade them otherwise. But I think you’re right that the um there was an irrationality that took over and an infantilizing that came of it. In other words, women weren’t even really given the choice to think about about the risks and whether they um were willing to take them to stop suffering. 

Dr. Abdul El-Sayed: I mean, I think there is a um a fundamental paternalism uh in medicine where what you know, what doctor says goes, and this has been lorded over women in particular to great detriment. When I hear about the ways that uh that that childbirth and pregnancy were treated back in the day, back when OBGYNs were were mainly male, I mean, it was sort of a we’re going to do this thing to your body because all your body is is a vessel for this infant and you’re just going to take it and not not second guess anything we say or do. Um. And I think some of you know, part of it is also if you if you think through the generational impact, this study came out in 2002, and effected people who are over the age of 50 by definition, so you’re talking about people who were born in 1950 were probably young women in the 60s, 70s, 80s. Right. And so I do think there was a generational or like a cohort effect there um that, you know, there was a culture of, like what doctor says goes and you’re going to listen. And if you dare step up and second guess what we’re saying. Right. Who are you to to ask us uh these questions? Um. And uh, you know, and I think the press decidedly I was I was going back and preparing for this, watching some of the the coverage. And it just was it was I mean it was so profoundly alarmist. The other thing I wanted to tease out there is the lies that can be told by way of relative risk communication. What do I mean by that? When you say this increased the probability of X threefold and you’re like, okay, it went from one case in 10000 to 3 cases in 10,000. 

Susan Dominus: Mm hmm mm hmm. 

Dr. Abdul El-Sayed: And it’s not that you’re lying per se, but you are using the way you communicate that number to aggrandize in effect that’s not very grand, right? And in that respect, it is um it is it is attaching an emotion that’s not necessarily deserved. 

Susan Dominus: Right. It’s something that journalists lean on also, I think, by the way, when they’re trying to bolster an argument, uh they will stop and break down that that absolute number and the, you know, the absolute risk and the way that it’s really helpful. And that was definitely a huge part of the phenomenon here. You know, they also just didn’t emphasize the good news when it came. So they did find a 26% you know reduction in fractures. That was what, you know, when the W.H.I. 2002 findings were released, that didn’t really get a lot of attention. Um. Basically, they you know, they eventually found that being on menopausal hormone therapy if you start it young enough really reduces your risk of diabetes. Um. And then they found that for women who were on estrogen alone, the women who didn’t have uteruses, they kept going with that arm of the study. And when they finally concluded that arm of the study, after eight and a half years or so, what they found was that the women who were on estrogen alone had lower rates of breast cancer. So this is like incred– I mean, it’s you know, it’s not easy to lower rates of breast cancer. 

Dr. Abdul El-Sayed: No. 

Susan Dominus: Um. And yet it got very little attention. It was very little known. And uh it you know there wasn’t a press conference held to tell women like, we have good news for you. If you are one of the 30% of women who’ve had a hysterectomy before the age of 60, which is, you know, an incredible number, but it speaks to how much of the menopausal population does not have a uterus. Um. Great news. We can lower your risk of breast cancer. You know, you can go on menopausal hormone therapy and um you know, those things, that stuff somehow the good news that came out over the years never really garnered the same amount of attention. And there’s also research to suggest that, you know, one of the things that really alarmed people was this increased incidence of cardiovascular disease. You know, there has been research since to suggest that if you take hormones between the age of 50 and 60, um that it actually reduces the kind of the markers for cardiovascular disease you know when they examine women’s arteries, that they see healthier looking, um you know, less plaque and healthier vascular systems. So um none of this uh this these distinctions you know. It’s much more uh safe to take hormones between the age of 50 and 60 because your baseline risk is lower. So whatever incidence risk you have, an increased percentage risk is much lower. But also there’s some thought that if you start the meni– the hormones as you’re going through perimenopause or soon after you’re menopausal, it’s much better for your system than if your system, your body starts to go through all these changes. It’s made some changes. And now you introduce hormones, you know, ten years out that is thought to not necessarily be um as safe as starting when you’re young. 

Dr. Abdul El-Sayed: Yeah. Um. Sort of the difference between bridging versus stopping and restarting. Uh. 

Susan Dominus: Exactly. Yeah, that’s exactly right. 

Dr. Abdul El-Sayed: We’ll be back with more with Susan Dominus after this break. [music break]. 

[AD BREAK] 

Dr. Abdul El-Sayed: Couple questions, 20 years on from the Women’s Health Initiative, um how have, have doctors become a bit more nuanced in treating menopause? 

Susan Dominus: I mean, not in my experience. I mean at the risk of um tooting the New York Times’s um horn. [laugh] I cannot tell you how many doctors have told me that this this article has changed the conversation. I mean, many doctors literally are giving it out in their office or they’re like sort of they have the QR code posted in their OB-GYNs I’m talking about. But um women are coming to them and saying, did you see that New York Times magazine article? Like I mean, I cannot tell you. Like their like just as their phones were ringing off the hook when the WHI study came out and suggested that hormones were unsafe for women. Um. You know, doctors are telling me that their practices are, OB-GYNs, that their practices have been like be– crazy busy lately because women want to talk about this, women who were too shy to bring it up or who felt awkward or who brought it up and felt like the doctor kind of hinted it wasn’t a great idea. Now they really want to hash it out. And it’s not to say that this article suggested to them, like you should definitely be on menopausal hormone therapy, because I think we made it clear in this article um that it requires a conversation and it’s not for everyone it might it might not be for you if you’re over 60 and you haven’t started and you’re at high risk for breast cancer, or if you’ve had breast cancer, it’s it’s almost certainly not right for you. But women want to have the conversations now with their doctors. And that’s I think it’s inspired a lot of um a lot of a lot of discussion and a lot of appointments. It’s rare that you actually get to feel like something you publish moves the needle on the conversation. I am hearing from OB-GYNs that it has moved the needle on the conversation. 

Dr. Abdul El-Sayed: I was going to say, you’ve got to give yourself your flowers here. [laughter] Uh it’s not just the New York Times. Um.

Susan Dominus: I mean it’s if it weren’t what I was hearing so often, I would not say it. But from my article it was clear that I was like a little bit I had kind of an awkward experience with my own OB and I switched and when I went in it was almost like they were so lovely. But even like even the [lauhging] even the assistant who worked there was you know commenting on how much it’d affected the practice and there was like a lot of excitement. And for some OB-GYNs, the effort of overcoming the reservations that women have about menopausal hormone therapy because of years of bad press, the effort was more than they could put in with each patient, even though they often thought that these women should consider it. So there are many OBs who I think think this makes their job much easier because they want women to consider this as an option. But there was so much um hesitation because of just misinformation, just flat out misinformation, that um it takes a long time to actually unpack. Well, what is the risk? And like? Well, we’re using different formulations now. Are they safer than the ones that were used in the W.H.I.? Well, they look safer from tons of observational studies, but they’re not randomized controlled trials. So the research isn’t as good you know, these things are complicated. And you know I wish that doctors could say to women, we have three 10 year long randomized controlled trials that all confirm that menopausal hormone therapy is, you know, flat out safe. Um. There’s lots of reasons to think that the new formulations are safer based on really good observational studies. And that this particularly that the issue is not that the estrogen was causing um whatever adverse health effects they were seeing, but that it was the progestin because the women who were on estrogen alone had better health outcomes than placebo. Right. So clearly, it seems likely that it was really the progestin that was causing the health problems. So do we have a better, safer formulation now um in micronized progesterone? A lot of observational um research suggests yes, but you as a doctor know that’s not quite as good as a randomized controlled trial. 

Dr. Abdul El-Sayed: Yeah. Do you know of any studies in the works? 

Susan Dominus: Um. Randomized controlled trials? No, um not not for that. Um. Not that would be as exhaustive as certainly what the WHI did I mean the WHI study, which was also studying things like are low fat diets healthier for women or vitamins you know, did they improve outcomes? It was like a billion dollar project at the end of the day. 

Dr. Abdul El-Sayed: Yeah. 

Susan Dominus: It was in fact, one person told me it was so big that some hospitals actually it was the first time that they integrated like um networked computer systems because they had to do that in order to be part of this massive project. 

Dr. Abdul El-Sayed: Wow. I mean, you wouldn’t need a study that big. And to be fair, a lot’s changed in the last 20 years. We can get much better inference from smaller studies than we could in the past. So, you know, NIH, if you’re listening, uh this this might be um something to fund somebody to do. I want to ask you, going back to that trip that you took with your uh friends. If you had taken that trip after you reported your article, what would the conversation have been? 

Susan Dominus: I think there would have been a lot less agita over whether or not to go on menopausal hormone therapy, because we all knew it existed, but we all weren’t sure whether it was like a good idea. It seemed like it probably wasn’t a good idea. I have one friend who um, you know, had really, really heavy, heavy bleeding during perimenopause, so much so that she had to miss work at times. This was a friend on the trip with me. And um some of the women who were away that weekend were already on menopausal hormone therapy, one of whom had gone into um menopause very early. But none of us felt like in a position to be like, this is ridiculous. Just go on the menopausal hormone therapy, it’s important and it’s safe. And you can also go off of it in a couple of years and there will be no harm. I mean, they didn’t even see any increased risk of breast cancer until after five years. It’s not that menopausal hormone therapy is the answer for everyone. But we didn’t even know how to think about it during that conversation. So I think that’s the main thing is the idea that there is recourse. And this friend eventually did make that choice. But many, many months of suffering went by you know that of needless suffering um before she did. And it pains me to think about that. I actually have a lot of I get very upset when I think about the collective amount of suffering over the past 20 years that women endured simply because of misinformation that snowballed and snowballed and took on a life of its own and became kind of like the sort of general accepted dogma, that like there was something fishy about this particular um treatment. And I mean, I if you read the comments to the New York Times Magazine article, there are women who say, I think that my marriage ended over how depressed I got. Um. I took myself out of the workforce because I could not function my my word recall, my memory, my general energy just plummeted. I mean, it’s really, really deeply, deeply sad how much suffering happened um for, you know, in the WHI’s defense. Probably women in their seventies shouldn’t start menopausal hormone therapy. That’s we now know that’s not a good idea. And and women were doing that not all the time but it was something that doctors did with some regularity. So, you know, there was a lot of important information that obviously came from this um from this trial. But collectively, when you consider the amount of suffering, even just women thinking that they were having autoimmune diseases because they were suffering joint pain and not knowing that it could be remedied by hormones or neurologists um never considering that, well, you know, you’re 52. Like, is it possible that this could be related to menopause? It’s just [sigh] it is very upsetting, I have to say. 

Dr. Abdul El-Sayed: Yeah. Well, we appreciate you writing on it and um and igniting a conversation about the therapy that is available. Our guest today was Susan Dominus. She’s a staff writer at the New York Times magazine and author of a groundbreaking new article, Rethinking How We Treat Menopause. Thank you so much for making the time. I really appreciate it. 

Susan Dominus: Thanks. I really enjoyed hearing what you had to say. It was a pleasure to hear your thoughts. [music break]

Dr. Abdul El-Sayed, narrating: As usual, here’s what I’m watching right now. This winter saw a major bump in a number of common respiratory viruses. One of them was RSV. But next winter, for the first time, there will be an RSV vaccine available. The vaccine is available for adults aged 60 and older. One of the groups hardest hit by the virus, which makes sense given the fact that while kids are the most likely to transmit RSV. Seniors are most likely to die of it. It’s unquestionably good news that we have a vaccine for RSV for seniors. My worry, well, it’s about uptake. Only about 40% of seniors have had the shingles vaccine, which prevents varicella zoster the virus responsible for chickenpox that hangs out in the nerve roots only to reappear after your immune system weakens in older age as shingles. And the disinformation around the COVID vaccines throughout the pandemic, well, it’s primed folks against new vaccines in ways that may prevent seniors from taking these, too. Notice how I said during the pandemic? Well, according to the W.H.O., the COVID global health emergency is officially over. It ended last Friday, and the U.S. public health emergency is set to sunset this Thursday. First, let me explain what ending a global public health emergency actually means. It means that the W.H.O. has determined that the number of cases is no longer more than we expect, though it remains high. That there’s no way to stop cross-border transmission and therefore that we no longer need a coordinated international response. Look, whether you want those things to be true or not, they are particularly as cases, hospitalizations and deaths are at an all time low. But there’s something more here I want you to understand. It does not mean that COVID is gone. In fact, COVID is going to continue to evolve and we’re going to continue to have to evolve with it. And we’re likely to see new waves, particularly in the fall, every year. But I want to step back and look, I don’t mean to beat a dead horse. To be honest, I don’t know why people beat horses in the first place, but you get what I’m saying. There is a gigantic lesson, particularly for those of us in the United States on this pandemic. For three years, every single public health agency around the world experienced the deepest and broadest mobilization in its history. It meant that the federal government showed what was possible. More people had health care than ever before. We invested billions in basic science, public health program implementation and public health awareness. And though here in the U.S., we still lost over a million people. Public health from distancing to masking to vaccines, to testing to treatment saved millions more. Don’t get me wrong, there are parts of the pandemic I never want to go back to. But the part that had government investing in the basic health care resources that for so long in this country we were told we couldn’t afford, that we were told could not be done. Well they were. To draw all that down begs the question, what was the real emergency? Look a super transmissible, super deadly virus spreading all over the country is certainly an emergency unto itself. But isn’t millions of people dying because they don’t have basic health care an emergency too? Or the shocking level of homelessness, poverty, and mental illness? Or our failure to invest in basic prevention across our communities. So while the COVID emergency may be ending, the public health emergency in this country is not. And I think we all ought to be asking whether it’ll take for us to address all of those other causes of death too. On that note, a new report from the CDC showed that while opioid overdose jumped across the board in the first year of the pandemic, it jumped particularly highly among Black Americans, among whom overdose attributable to fentanyl, accounted for the highest increase in overall overdose deaths. I raise this because since the beginning of the opioid crisis, it’s been characterized as a disease of low income, rural white folks. And that’s meant that we’ve moved the bulk of our available resources into those communities to tackle it. But as with almost all diseases, they follow poverty and marginalization. And it’s always only been a matter of time until structural racism opened the floodgates of our national opioid crises into predominantly Black communities. But it’s not just substance use. It’s about treatment, too. And that’s where racism has also reared its ugly head. It’s about access to substance use treatment. Because Black Americans are far less likely to access buprenorphine, a lifesaving medication that reduces the risk of overdose owing to a constellation of factors, including, well, frank racism among doctors who prescribe it, and the exact lack of health care at baseline in this country I just talked about. Meanwhile, rather than invest in harm reduction, that actually saves lives. Conservatives are too busy blaming the border for our fentanyl crisis because, well, fentanyl can be manufactured nearly everywhere. But isn’t it convenient to blame the border, meaning immigrants on this? [laugh] Well, if you’re conservative, you bet it is. So let’s be clear about something. You could seal the border tomorrow and it would do absolutely nothing for the millions of Americans currently living with substance use disorder. So can we please stop demagoguing Brown folks over this? That’s it for today. On your way out. Don’t forget to rate and review. It really does go a long way. And if you love the show and want to rep us, I hope you’ll drop by the Crooked store for some America Dissected merch. [music break] America Dissected is a product of Crooked Media. Our producer is Austin Fisher. Our associate producers are Tara Terpstra and Emma Illic-Frank. Vasilis Fotopoulos mixes and masters the show. Production Support from Ari Schwartz. Our theme song is by Taka Yasuzawa and Alex Sugiura. Our executive producers are Leo Duran, Sarah Geismer, Michael Martinez, and me. Dr. Abdul El-Sayed, your host. Thanks for listening. [music break] This show is for general information and entertainment purposes only. It’s not intended to provide specific health care or medical advice and should not be construed as providing health care or medical advice. Please consult your physician with any questions related to your own health. The views expressed in this podcast reflect those of the host and his guests and do not necessarily represent the view and opinion of Wayne County, Michigan, or its Department of Health, Human and Veterans Services.