One of the things that I'm sitting here thinking about is the fact that my friends and I all talk about menopause, right? Because we're all in the thick of it. But more than half of the women that I know are scared of HRT. I know it's because of the fact that I think it was 1991 when there was that huge study that was released. I think it was the Women's Health Initiative that cast HRT in a negative light. If I really think about it, it was 1991. I was just out of college, and my mom was going through menopause. I remember the huge debate was that HRT causes cancer, and it cast such a negative light on this therapy that's available for women to treat menopause symptoms. I understand that the study has been harshly criticized. It's now 30 years later, but it's very clear to me that the fear that it created, it's still lingering, and it's keeping a lot of women from even exploring hormone replacement therapy as a safe option for them. Can you tell us more about this study and how you think about it as a medical doctor?

Well, the Women's Health Initiative was the largest clinical trial. I think that's ever been done. It was designed to tell whether hormone therapy, menopausal hormone therapy, was going to actually reduce the risk of heart disease and without increasing the risk of breast cancer. It was also there were other arms that looked at exercise, that looked at calcium, so the calcium replacement. So there are quite a few different arms of the women's health initiative. The arm with estrogen plus... So when it was p remarin, that was used. P remarin plus a progestin. That was stopped early because they reached the threshold of concern about breast cancer. Now, going into the Women's Health Initiative, we knew that there was a very low risk of breast cancer associated with menopausal hormone therapy. So this wasn't like a surprise. It was the threshold that was reached. And it was communicated to the public in a way that is typically not done. Usually, there aren't press releases when a study is halted. Usually, we wait, we get the data, the article is published. So it's peer reviewed, and we have all of that. And that didn't happen. That created this big hoopla, where lots of things got taken out of context, lots of things accelerated in ways that were uncontrollable because fear sells.

I I don't know how many major news stories were dedicated to the WHI, but it was really out of proportion. Then when more information came out and when there were more studies that came out, that never gets the same attention. We know that estrogen plus a progestin is associated with an increased risk of breast cancer. But those aren't the hormones that we typically prescribe now. That's the difference. We believe that the progestins, which are slightly different different molecules than progesterone, carry the higher breast cancer risk. It's still acceptable and in the safe range to take that the hormone progesterone is lower risk, and that if you don't need a progesterone or a progestin, that that risk is the lowest. So I would say to people, if you're taking a transdermal estrogen and oral progesterone, which is our standard starting therapy, we believe that the risk of breast cancer is very low. It's not probably zero, but that it is very, very low. We believe that if you're taking estrogen alone, that risk is even lower. Some people believe it's zero, other people believe it may be a little bit higher. And again, it depends how you look at the data.

So absolutes are very difficult. And so the risks are very low. So if you're somebody suffering with hot flashes, if you're somebody who is at high risk for osteoporosis, if you're someone who's struggling with depression in the menopause transition, if you have things that estrogen can treat, then those risks are likely very small in comparison. However, if you're at someone at very high risk for cardiovascular disease, then estrogen may not be the best therapy for you. And so it really comes down to an individualization. But I would say for the majority of people who are suffering with symptoms related to menopause, who have things that hormone therapy can treat, that menopausal hormone therapy appears to be a very, very safe option. And you just have to look at it in context. If you're somebody who is at higher risk for cardiovascular disease, but not super high risk, then transdermal is probably okay, but oral isn't because there's a higher risk of blood clots associated with oral. So you just have to look at what is it going to do for you. I'm very high risk for osteoporosis. My mother died from osteoporosis. I have quite a high FRAX score, which is a risk calculator.

And so that's the main reason that I'm on menopausal hormone therapy, because my risk of osteoporosis is pretty significant, and I'm already getting closer and closer to osteoporosis and osteopenia. It's a concern for me from a health standpoint. That's why I'm taking it. People always want us to say zero risk. Getting in a car has a risk. I always like to not talk in those kinds of absolutes and say, What's the reason you're on it? And what is the risk-benefit ratio for you? And for the majority of people, the risk-benefit ratio is absolutely going to be in the favor of benefit. But there are some situations where it might not be. So for example, somebody at very high risk for cardiovascular disease, someone who's previously had a blood clot, someone who's previously had a heart attack. So you have to put it in perspective.

Thank you for that because, Dr. Gunther, I've been really surprised by the number of my friends who are suffering through menopause and perimenopause and just completely the quality of their life is impacted, who have been afraid to try hormone replacement therapy or even talk to their doctor about it because somewhere in the back of their head, they think it causes breast cancer, and that's why they're not even considering it. And so I appreciate you just clearing the air a little bit so that people know that you should at least go talk to your doctor about it.

Yeah. And there are calculators that can help you determine your breast cancer risk. I would recommend, I think we heard it was Olivia Munn who was talking about, I believe that's who it was recently talked about. She had a breast cancer risk assessment, which led to her having an MRI, which led to an early diagnosis of a breast cancer. And so there's all kinds of... There's several easy tools that we can do to help explain things more in context for So if somebody comes to me and they have something that menopausal hormone therapy can help, I do something called an ASCVD score. It calculates your cardiovascular risk. And we need your lipids, and we need to know your blood sugar and your blood pressure, a few other things. And so we can calculate that. I need to see a mammogram, and I need to ask you some questions about your breast cancer history risk. And that's important because at a certain level, when your breast cancer risk is higher based on other factors, there's also a conversation to be had about medications that lower your risk of breast cancer. So there's bigger discussions to have.

But so you can do these risk calculators and you say, look, well, I'm somebody who's got hot flashes. Menopausal hormone therapy is a gold standard. I have low risk for this other reasons, so there would be no reason not to go on it. But again, everybody weighs risks differently. And so versus you're somebody that, oh, you've got a pretty high cardiovascular risk. So can we talk about one of these other treatments for your hot flashes? Or you're somebody who's got a history of breast cancer. So can we talk about one of these other medications for hot flashes?

I want to ask a couple more questions about HRT. So someone listens to this episode. They feel very seen and validated. They go into their OB-Gyn. They say, I want to assess the risks. And let's just say you try it. Okay, you make the personal decision with the recommendation of your doctor to go on the standard protocol. How do you know if it's working?

Well, so are your symptoms improving? So it's really... Except for- And how long does it take? Pretty quick. So unless you're someone like me taking it for osteoporosis prevention, because I don't feel any different, right? And that's, again, a really important reason to take an FDA-approved medication because I wanted to protect my bones. I need to know what I'm absorbing, right? So if you have hot flashes, most people see a pretty significant improvement within four weeks. Depending on how much better people feel, sometimes we might give an eight-week try before switching doses. And it just depends on how people feel on the medication. So usually with something like hot flashes, you're going to see an improvement pretty quickly. With depression, usually within a couple of months as well. So I always like to talk about with menopausal hormone therapy, there's green light indications, meaning these are like the FDA approved solid reasons. Hot flashes, night sweats, gold standard. Osteoporosis prevention, FDA-approved. If you have We didn't talk about this, but if you have menopause before the age of 45, we do recommend everybody take hormones regardless of symptoms until at least the average age of menopause.

And then at that average age, you can decide if you want to stay on or not like everybody else.

What is the average age of menopause?

Fifty-one. But so say you're starting it for... So you've got these green light indications, great. Everybody believes that the benefits outweigh the risks as long as you're in the right category for that. Then there are more yellow light indications, things where it hasn't broached, where it's recommended in the guidelines, but there's pretty good data to support it. So for example, depression in the menopause transition can be very helpful for that. Many of us would try it if somebody's got a sleep disturbance, even if they don't think they're waking up with hot flashes, because sometimes people don't wake up. But what it's doing is it's disrupting your sleep architecture, so you don't have as much deep sleep. So it might be worth a try to see. For example, I still get the occasional hot flash, but even when I was, I don't wake up, but I'm so hot, I wake my partner up. I'm just a super deep sleeper, right? But I've still had disrupted sleep. So you might not realize that. So it might be worth a try to see. The data for joint pain, it's not really that great. I mean, maybe it's going to help 20 % of people with joint pain, so it wouldn't mean it would be wrong to try, but it would be, you just want to...

If it doesn't work, you're not going to keep pushing the dose higher and higher and higher because you're like, Oh, well, it was a chance, and maybe it's going to work, maybe it's not. There is some evidence to show that it may reduce your risk of type 2 diabetes. So again, if you're somebody at very high risk, that might be a conversation to have. Those are like these yellow light indications. And then So if you have brain fog. So brain fog, specifically, there aren't studies to tell us that estrogen treats brain fog. And in fact, people perform better than they think when they have brain fog. So on cognitive testing. So it's this symptom that we don't really understand. So you could certainly have brain fog from depression, right? You could have brain fog because you're not sleeping well. So all of these other things could come into play. But if you're only symptom were brain fog, then I might be like, it's less clear you're going to get a benefit from that. And maybe there's a discussion to have about what might be the other factors. But if you've also, we've done a depression questionnaire, you're scoring higher for depression, well, brain fog is a symptom of depression, too.

So let's get that treated and let's see. And then let's also work on the other foundations, like exercise and eating healthy, because there is one study that looks at the healthy things you're supposed to do in menopause, get your right exercise, eat a fiber-rich healthy diet and not smoke. I think it was only 8% of women did all three.

Wow. He wrote this unbelievable article that went crazy viral. Dr. Gunther, you say, Don't use menopause to excuse mediocre men. What does that mean?

I think everybody knows exactly what I mean. But yeah. So there's this edge of a knife, I think, when you're a woman, right? So we like to... Women are too hormonal to this, to that. But you can also have symptoms related to that. So it's just really important to make sure that because of this history of calling women hysterical, calling them the mad woman in the attic, all of that stuff. Because of that history, I think it's super important to be accurate when we're assigning fault as to what the fault is. So yeah, there was this advice voice column in The Guardian, and this woman had written in, and I can't remember the specifics now, but her and her husband had had a contract or a verbal agreement about how they would be raising their children. And he was clearly not living up to what they'd agreed upon. And he was basically whatever, her third child. And I think a lot of women out there know exactly what I'm talking. Anyway, he was her third child, and she wanted to leave him because she was like, I don't want to be a mother to him.

And I hear this from a lot of women. And she was writing in for advice because he wasn't vacuuming. He wasn't doing any of the stuff. She was basically doing it all. And the answer was, maybe it's menopause. Maybe you're intolerant because of your hormones.

Really? Yeah.

Maybe she should go on hormone therapy. She didn't say she'd have hot flashes. She didn't say she was sleeping poorly at night. She clearly laid out that they had agreed to be equal partners. And here she was now in this relationship that we talked about earlier, where she was doing all the grunt work, all the nasty stuff. And he was out at the pub. It was the most obvious, pull the plug, get divorced, save yourself, run, don't look, back, run. And no, maybe it was your hormones, because I know that when I was going through menopause, I had a shorter temper. So I think it's really important that when When we're talking about depression and menopause, when we're talking about how women feel, that we are not excusing the bad ways that society treats women and saying that, Oh, if you just took hormones, it would be better. Because the answer to being mistreated is not taking hormones. The answer to being mistreated is to be treated correctly. And so I just think that it's really important that we're clear about these things. Now, if somebody comes to me and says, Oh, my I had the perfect relationship, and my husband does everything.

And now that I'm not sleeping at night and I'm soaked in sweat all the time, I've got a super short temper. Yeah, your hormones might be having something to do with that. Maybe if you actually had a good night's If you were to sleep, this would be better. I think most people can agree with that, right? But that wasn't the situation that was being presented. So I just think that it's really important, especially in the workplace, too, right? That many women in the workplace are treated terribly, especially as they age, that there's so many glass ceilings, right? And while it's super important that workplaces accommodate menopause, we also don't want to use that as lip service, so then we can excuse all the bad policies that are keeping women from advancing, right? Oh, look, we're letting you control the temperature, when really there's also a massive glass ceiling. So I just think accuracy in all things.

Everything you need to know about menopause.

Just like you went through puberty, which might have and had some symptoms, menopause is in many ways the same thing. You can think about it as puberty in reverse.