Stacy London She/her (00:00.462)

I'm so excited to meet with both of you and talk a lot about HRT, MHT and the preconceptions, misconceptions around hormone therapy. So let me start off by asking you, Dr. Bluming. in your book, Estrogen Matters, it challenges some of the prevailing fears about hormone replacement, HRT. And what do you think the biggest misconceptions around HRT are and why do they persist?

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Avrum Bluming (01:04.37)

Just that.

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Stacy London She/her (01:06.04)

Just that. I thought we'd open with something small and really easy to answer.

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Avrum Bluming (01:11.283)

Well, I think the biggest fear about hormone replacement therapy is its association with breast cancer. I think that fear is periodically stoked on a regular basis. If it isn't breast cancer, it's ovarian cancer. If it isn't ovarian cancer, there was even an article, a presentation relating hormones to lung cancer or lung cancer deaths, all of which are not true. But every time somebody waves that red flag in a theater, people pay attention. And in case you thought that there was a reason to take hormones, when the Women's Health Initiative first published their result, in July of 2002, they said, it really doesn't do anything good and it does a lot of bad things. It increases the risk of heart disease, it increases the risk of death, it increases the risk of strokes. And by the way, they said a little over a year and a half later, it has no effect on quality of life.

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Well, why would you want to take anything that's that bad without any redeeming characteristic? And every one of those statements has not only been shown to be false, the Women's Health Initiative has come around to agreeing that those statements aren't valid. And they now agree with everything, with one exception, that we wrote in the book. They agree.

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Stacy London She/her (02:59.918)

I mean, I think the bigger issue is, you why I've talked at length about that WHI study and how, you know, if it's bad data, you can still read bad data and give results, even if it's not the data that you were intentionally, you know, meaning to derive. From what I understand, that was not a test about hormones only. It was a test about cardiovascular health in women and even the subjects were in their 60s or 65 or post-menopause. Is that correct?

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Avrum Bluming (03:35.389)

Well, two things about that. First, yes, the median age of the women was 63 and half were overweight or obese and a significant number were smokers. It wasn't directly a population, but the data that they collected was fine. They misrepresented their own data. And that's the challenge we have put down.

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Stacy London She/her (04:06.254)

So they misrepresented it and you very wisely, I think, explain it as that they took that information, misread it and ran with it. But ever since that time, right, over 20 years ago, people are still holding on. Why is it, when you say something has no benefit and it's all dangerous, right? Of course people are going to run in the other direction. But now that we have consensus that hormone therapy, or at least the findings in that WHO study are almost all false. Why is it such a pernicious belief? Why are we still so afraid? And Carol, please feel free to pick up.

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Avrum Bluming (04:50.591)

That's right. Carol, you have to know, as you probably do, is a social psychologist. So Dr. Tavris is passionate and very well informed about that particular subject.

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Stacy London She/her (05:03.458)

And because I think the cultural pressure also around hormones and this idea of even talking about menopause does have an impact. mean, I certainly had an impact on my deciding whether to talk about menopause. I was terrified to tell people what I was experiencing. I mean, do you think that this idea that hormones are somehow bad for you has stuck with culture because it really just doesn't help women at all?

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Carol (05:31.286)

Okay, so you have you have to back up a step you said 22 years ago is like that's old times What's not old times a generation of doctors came of age in medical school? Learning that hormone therapy for women in menopause is going to cause cancer and many other dire things and it's not beneficial That's what they learned in medical school. It became the guidelines for their various specialties. We hear over and over from women going to their doctor saying, want to take estrogen. And the doctor says, no, it could kill you. And I can't harm my patient and I won't give you hormones. And they say, but look at the data, look at the Women's Health Initiative having changed its mind. No, I can't and won't. And so we hear over and over from women who are getting this message reinforced by the doctors who have not kept up with the Women's Health Initiative's own retractions or with the new contradictory evidence. Now that's not unusual in medicine. Doctors have a lot to do and they're very busy and da-da-da-da-da. And they don't want women swanning into their offices saying, hey, pay attention to me, which is cool, okay. But when you say, are women so frightened? So they're frightened for two reasons. First, because when the Women's Health Initiative launched this bombshell press conference, it scared the bejesus out of everyone, out of doctors, out of women. Prescriptions plummeted, nobody was worried about breast cancer before 2002. But once people are afraid of something, whether it's a vaccine or hormones, once the fear is in you, it leaves a kind of slimy trail behind, that emotional association rather than an informational or logical one. And so I think many women sort of still feel kind of, yeah, about hormones, okay? Even though the evidence is overwhelmingly reassuring and should be. And their doctors, many of their doctors have not changed their minds. One co-author of a book called Mistakes Were Made, but not by me. And that is with the Women's Health Initiative. They've never had a press conference saying, comparable to 2002, saying, by the way, everybody, sorry, we were so wrong in 2002. And let us tell you what we think now. No, they've not done it.

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Stacy London She/her (07:53.294)

And I do wonder when you talk about fear, I mean, I think that's absolutely right. Fear, whether it's a vaccine, whether it's a hormone, anything. I think also is this cultural implication, this sociobiological and cultural implication that we're sort of expired, right? This is our sell-by date. And one of the things that I find so interesting in speaking with women who, like myself, it took me seven years to fight to get on hormones. I fought with every doctor that I had. They said no, no your father died of heart disease. It's a bad idea Well, he died of a heart disease that was not genetic that was like absolutely out of nowhere. My mom had a stroke again for a very specific reason strokes do not run in our family We had no breast cancer in my family. But they told me because of those two things and because I had an autoimmune disease that I should not go on hormones and finally after seven years of sleeping four hours a night and literally driving almost every person out of my life with my insanity. I finally texted my doctor at four o'clock in the morning and I said, that's it. I'm going to a menopause specialist and whatever they say, I'm going to do. And lo and behold, I wound up on hormones. I sleep eight hours a night. I'm a much nicer person. I'm so glad you're meeting me now. You know, and I, but it took so much fighting and advocating on my own because I knew that something was wrong and I didn't know how to convince, you know, and I'm a people pleaser, certainly a medical people pleaser. So I would go in and say, you know more than me. If I'm, if you are not freaking out, why should I be freaking out? But I was crying all the time. I was angry all the time. I was having trouble focusing. I had brain fog and insomnia, night sweats, hot flashes, joint pain. And I really wondered why doesn't anybody say, Hey, even if hormones could cause breast cancer, what is the risk benefit analysis for the quality of my life? Because that I don't think was ever asked. And I honestly, to this day, think that if I had been explained, if everything had been explained to me, that I would have been able to, as an adult, make a reasonable choice. Look, at least there are treatments for breast cancer. Should that be the outside chance that that happens to me, we would be already looking for it, and I would be able to function in my daily life if I was on hormones.

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Carol (10:24.386)

So first of all, you know more than most doctors do who learned about zero in menopause when they're in medical school, as you will know. And by the way, the point that you've just made is also something most doctors don't know, which is the variety of symptoms associated with perimenopause and menopause. Women go to rheumatologist, and they go to cardiologists, and they go to psychotherapists, and they go to every other specialist because they've got these symptoms, all of which are related to the depletion of estrogen around this time. But do doctors know this? Cardiologists aren't thinking for the most part Gee, I've got this patient with heart palpitations, but her heart's completely fine. Gee, could she be in menopause? They aren't trained to look for that explanation, and that is indeed one of the concerns here.

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Stacy London She/her (11:09.88)

Well, I wonder also if, know, it seems to me like Gen X's legacy is really going to be about getting menopause into the mainstream. I feel that so strongly in the last five years, just the amount of articles and more discussion and companies that may or may not be helpful have all, you know, sprouted up. But what I think is so depressing, and I was talking to another doctor about this, is that, you know, like the boomers really suffered. You know, they really suffered without the help of understanding how important hormones are, particularly in female physiology. And am I right in saying that women were only required to be in medical studies since 1993 or 92? So we don't know that much about female physiology, right? Or at least you might, but the average person doesn't know how to connect the dots when it comes to heart palpitations and not being able to sleep and joint pain.

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Avrum Bluming (12:08.443)

One of the things we've discovered is less than 25 % of OB-GYN fellowships, less than 25 % spend any time on menopause. And the ones that teach anything about menopause often teach for a few hours about menopause over a several year training period. So that many doctors walk into that situation not well prepared to deal with it. And it's easier to say no than to say, I'll look into it.

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Stacy London She/her (12:47.276)

And I'm also looking at my notes as well, because there were things that I did want to make sure that we hit. But I also found this to be true just in the messaging. mean, the messaging around menopause needs a lot of work. It needs a lot of help, right? I used to say things like, well, the only thing I want dry in menopause is a good martini. You know, I was like, we need to lead with humor, people. Otherwise, this is not really, we're not getting anywhere. But I, sorry, say that again, Carol.

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Carol (13:11.342)

You're speaking my language. Speaking my language, of course.

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Stacy London She/her (13:15.542)

Yes, exactly. These are hard things to talk about. We're finally bringing them out into the open for the first time. And I think that a lot of this may be my perception of it, but because this is more about female physiology, it's gotten less attention because there is a gender gap in medicine. Yes.

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Carol (13:34.926)

Okay, so, Stacy, let me interrupt you for just one moment. I'm charmed, amused, and delighted. But here's the thing. Every generation of women that reaches menopause thinks they have discovered menopause for the first time in the entire history. You mean there's a stigma about being in menopause? What? You mean there are symptoms? Why didn't anyone tell me?

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Stacy London She/her (13:38.936)

Please.

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Carol (13:57.486)

Why didn't anyone tell you? Well, who's going to tell you? Your mother's going to tell you? Yeah, she tells you what her experience was. The stigma for women of being older and being post-reproductive age and the change of their lives, and now they have older parents to take care of and teenage kids to take care of. Every damn generation, Stacy, thinks that this was the first time. But this is why it's good for you to be talking to an old woman like me, because when

feminism began to emerge in the 1970s with our bodies, ourselves, and the women's liberation movement that said, hey, no one is studying the female body in the ways that it's different from the male body. We're generalizing from male, the normal male to females. And what can we do about this? But the kind of feminism at that time endorsed the healthy woman notion. We don't want to pathologize menopause. It's not a sickness. It's not a disease. It's a normal change in life, just as the onset of menstruation is. There's nothing, you're not sick. And so you'll get through this the way you got through menstruation to begin with. they were, many of these women were opposed to medication of any kind. They endorsed natural products. Okay, you have sleeplessness, suck it up honey, it'll only last 10 years. That's women's burden, just get on with it, you know. So women today have two legacies to contend with really. One is the ignorance of the medical establishment about menopause. And the other is the strand of feminism that is really opposed to medication instead of natural products. And in our book, at the end of every chapter on brain or the heart or whatever the issue might be, we look at all of the alternatives that are being sold to women and promoted to women as ways of dealing with that problem, osteoporosis or dementia or heart, okay? We have examined all of them. Hoping against hope that we will find that ginkgo is really the thing for your bones. So we've looked at all of this, understanding why so many women would prefer natural products, quote, natural products. Yeah, as a natural product, too, by the way. So that's what today's generation of women is confronting.

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Stacy London She/her (16:36.898)

So that's fascinating to me on so many levels. First of all, Carol, thank you so much. Put me in my place because I do agree with you that every generation has been through this.

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Carol (16:48.526)

That's the question, Stacy, you don't know this.

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Stacy London She/her (16:51.246)

I just, I know, just turned 40. No, what I was gonna say is that what's so funny about it is that we do think, I do think you're absolutely right. I think women get to this phase, whether it's the physiological signs of menopause or the midlife reckoning, whatever you wanna call it, because as you just said, there are so many cultural issues going on at the same time. One doctor said to me, when you're dealing 45 to 55, highest rated, divorce, depression, decreased earning potential in women. This does not surprise me. This doesn't feel like it's by accident. It also seems like this is when we're sort of least physiologically able to manage all this pressure, including elder care or kids leaving home or whatever it is. But I wonder if Gen X, and this is also cultural in the sense that we kind of got to, know, we're the beneficiaries of cosmetic dermatology and, you know, shots and things like that different haircuts where we're not cutting our hair at 45, that give us this feeling of not just a longevity difference, but a youth span difference that we consider ourselves to be more culturally relevant at 50 than women in generations before us. And the reason that I say that is because I think that we, Gen X is sort of this scrappy generation, latchkey kids, whatever. I mean, I'm making generalizations here, obviously. But the idea being that we got to menopause and said, no, no, no, no, no. We don't think of ourselves as old. We don't want to be culturally associated with aging. So how are we going to turn this ship around and make it something culturally relevant, medically important? know, we're like little bit, we're like spin masters. know, we like to say like, we still drink a martini every once in while, we might steal a puff off somebody's cigarette we're not old. And so we had to change the messaging around menopause to satisfy our needs culturally, which I think is kind of hysterical. Do you disagree?

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Carol (19:02.156)

Well, yes and no. The American market has always sought potions for youthfulness. We're a young country. We value the young. We don't value the wisdom and lessons of the old. The great anthropologist Margaret Mead used to say menopause is no big deal. I love my menopausal zest afterward. Fighting stereotypes of age has been an issue for women more or less forever, yeah, in the sense that, I mean, there've been so many demographic changes in our history. People are living longer and better and healthier. And so the question women face,

hitting 50 is how do I deal with the next half of my life that will allow me to be functioning and healthy and respected and active? You know, those are the great questions that every generation has to face. And they're influenced by the workforce, whether jobs are available to women, whether jobs whether the workforce accommodates the issues and needs of women, whether it's childcare or menopausal symptom care. I think that women in middle age will do better to confront these social economic concerns in their workplaces and lives than to just think about another beauty infusion.

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Stacy London She/her (20:38.606)

Well, I couldn't agree more.

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Carol (20:42.668)

You know, that's what organization accomplishes is doing the best for all of us. We cite in our book this study done in England of the huge number of women doctors in England leaving the National Health Service or cutting back their hours because the demands on them would not accommodate their...menopausal symptoms, hot flushes and sleeplessness, and you can't be a doctor if you're sleeping.

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Stacy London She/her (21:14.624)

Right, exactly. Yeah. so I'm curious, just taking off from that, let's just talk about the use value of HRT. I mean, you've got women saying, look, we can't work these hours. We've already started that menopause in the workplace conversation. How can we be helpful? What is insurance going to do to help us? But what is the actual benefit? When we talk about this, and I'm curious. I remember one doctor said to me, look, think of it as like, if you started a savings account at 20, you'd have more money in the bank than if you started saving at 60. But that doesn't mean there's no benefit to saving money at any age, right? Is that the way it works with hormones?

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Carol (21:58.08)

Yeah, Avrum, is for you. This is the great question that I was asked at that meeting by the 50-year-old woman who said, well, I have no symptoms. Should I be taking hormones now?

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Avrum Bluming (22:08.169)

Well, let's talk about what we know about hormones. We know that seven times as many women die of heart disease as die of breast cancer in the United States every year. The leading cause of death among women with breast cancer is heart disease, not breast cancer. Newly diagnosed breast cancer today carries between a 95 and a 98 % cure rate. And that doesn't mean we shouldn't fear breast cancer. Some people do die of it. 42,000 a year in the United States. It's a serious issue and being an oncologist, I recognize it as a serious issue, but it's dwarfed by heart disease, infirmity and heart disease death. And we and the Women's Health Initiative team agree, as do cardiologists around the world, that estrogen decreases the risk of serious heart disease by 50%. and decreases the risk of death from serious heart disease by approximately that amount. Osteoporotic hip fracture kills almost as many women in this country each year as heart disease, as breast cancer does. And the best treatment to prevent osteoporotic hip fracture is estrogen, which decreases that risk by 50%. If there's one thing women are more worried about than cancer, it's cognitive decline, Alzheimer's disease. There is no treatment for Alzheimer's disease. Two thirds of Alzheimer's disease patients are women. And there are numerous reports in the medical literature that show that hormone therapy started around the age of menopause will decrease the incidence of cognitive decline by between 25 % and 65%, depending upon which study you want to cite. And on all of these, the Women's Health Initiative agrees with those data that I've just mentioned. In addition, longevity is improved by taking hormones. And they agree with that and have published that as well.

The issue with breast cancer, and let's just put it on the table and get it off the table, a year after the July 2002 publication of the Women's Health Initiative, a black box warning was ordered by the FDA to be inserted in every estrogen-containing medication. And yet, the Women's Health Initiative, after continued follow-up, has shown that estrogen decreases the risk of breast cancer development by 23 % and decreases the risk of death from breast cancer by 40%. The only area where we still disagree, and the Women's Health Initiative keeps putting this in to almost every article they write, and it's almost a subliminal message, is they say the combination of estrogen and progesterone given to women with a uterus because estrogen does increase the risk of uterine cancer and adding progesterone to the combination eliminates that increased risk. And they say that what they found is that the increase, that there is an increased risk of breast cancer development, not breast cancer death, by the combination. What does that increase amount to? It amounts to between one and seven new breast cancer patients for 10,000 women taking hormones for a year. That's a meaningless number. You can't do a study that comes up with that number, but even that number is misrepresenting the Women's Health Initiative's own data. What they say, and they've published this, is women who start hormone replacement therapy, even the combination, within 10 years of menopause, meaning somewhere between 45 and 55, have no increased risk of breast cancer. Even their data say that. And that includes women with a family history of breast cancer. Now most people don't realize that. Their report that this small number of increase is seen among women who took the combination, if it's controlled for breast cancer risk factors disappears, disappears. Now the study was done for heart disease, not for breast cancer. And the risk factors for heart disease are different than the risk factors for breast cancer. And if you control for the risk factors for breast cancer, and this was an article published in 2006 by the Women's Health Initiative, there is no increased risk of breast cancer development, even among women who had been randomized to the combination. And yet you'd never know that without going through their articles carefully and holding them to account.

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Stacy London She/her (27:31.446)

Right. I, you know, I mean, that is amazing. Thank you for the incredibly detailed explanation. I think that's where some of my confusion comes from. When people talk about that WHI study and they talk about the bad data, they weren't talking about bad data as you said, it's that they were testing for cardiac health and not menopause that, that sort of skewed and not breast cancer, excuse me, that skewed these results in a way that to make them, you know, send everybody in a panic. I know one of the bills in front of Congress right now is to take the black box off of estrogen. Is that something that you would agree with?

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Carol (28:10.328)

We started it, that's Avrum's.

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Stacy London She/her (28:12.43)

That's you! I didn't know that was you who started it!

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Avrum Bluming (28:17.183)

Well, it's the whole menopause that started it. And we generated a letter to the head of the FDA saying it's time that that black box warning was removed. Yes.

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Stacy London She/her (28:31.446)

Yes. I've spoken at length with Dr. Sharon Malone about that and you know that that has been something that I know she has been involved in as well. Maria Shriver, I know, I mean, there's a big, you guys are a bunch of heavy hitters out there. So I'm really hoping that this is something that we can get done because just from my own personal experience, I would never have gone on suffering if I didn't - if I was told I didn't have to. And basically everybody said, it up, buttercup. You know, this is the way it is.

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Carol (29:06.061)

Well, you know, we get letters all the time. this sweet couple wrote to us and said, she said, well, you know, so I thought I would use vaginal estrogen because I really like having sex with my husband. then we got that we've OK, finally a grudging OBGYN said, OK, you can have the vaginal estrogen tablets. And she said, we read the black box warning. And my husband said, honey, I'd rather have you alive without sex than dead. I am. so, you know, and it what it's even on the vaginal tablets of course because it has estrogen in it. Now let me just be clear, the women's health initiative, it took them 16 years but they finally said you know what it's perfectly safe to take vaginal estrogen.

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Stacy London She/her (29:48.024)

Vaginal estrogen just as like a lotion is non systemic to the body anyway. So you're not even you're not putting estrogen inside your bloodstream.

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Avrum Bluming (29:59.081)

We have to address that right now, which is different. So if we just finished saying, if we're not laughing at you at all, if we just finished saying that estrogen given systemically, either as a pill or a patch, but given systemically decreases the risk of breast cancer by 23%, decreases the risk of death from breast cancer by 40%, why in God's name do we care if vaginal estrogen is absorbed or not.

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Stacy London She/her (30:36.0)

It is systemic or not, right? Okay, fair, absolutely fair. But I am curious what you think. This I just need to know from your particular perspective, how you feel about estrogen skin cream.

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Avrum Bluming (30:51.583)

Skin cream, you mean for making women look younger and more beautiful.

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Stacy London She/her (30:55.354)

Look plumper. Yeah. Well, I guess that estrogen, there's a new prescription estrogen skin cream that when you put it on is apparently helpful in making your skin look plumper, softer. I don't know, but I'm asking you because I, don't understand that theory. And I was curious.

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Avrum Bluming (31:12.575)

We, Carol and I are very careful not to market products without supportive scientific data that we can cite. That's the best answer I can give you to that.

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Stacy London She/her (31:26.616)

Sure, I understand. I guess I'm also curious about all of the things that you must have seen popping up. mean, menopause has become such an interesting topic. And Carol, as you said, it's come up before. do not, I'm not taking it as ours. But what I am wondering about is like, I have never seen the amount of like grifters that are now really taking advantage, particularly of women this stage when, or even gender non-binary folks, I mean, we're talking about a very vulnerable physiological moment in time. I call it a, yes.

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Carol (32:05.622)

Okay, Stacy. I'm sorry for interrupting it. We call this the ABE approach, anything for estrogen. meaning, here you have a generation of women who are scared of estrogen because it's going to cause all these terrible things. But we actually secretly know that estrogen is beneficial for all of our tissues that as we age, for the inevitable thinning of the genitourinary system. That's inevitable. The skin will get thinner and drier. Those are normal changes in aging strongly influenced by the depletion of estrogen. Okay. But if estrogen could kill me, then what am I going to do? I will try an estrogen product that isn't systemic estrogen, which is what would help patch the dryness in my skin and my bones and my head and my heart and every other part of me. Maybe I could just pat it gently on my nose and that will solve the problem for me. No, you know, it's an effort to use estrogen without using estrogen. Avrum, would you agree with that? that?

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Avrum Bluming (33:15.593)

Well, sure. And as you know, it's projected to be a $26 billion industry in the very near future. Well, that's going to attract all kinds of people, good and bad. What I'd like to focus on, sure, we can talk about how people have been misled and we're all angry and let's change the culture. But I'd like to mention three steps that we can actually do to make a difference. One step is right to the Food and Drug Administration. And let's get that black box warning off of estrogen products. It never should have been put in. It is now 23 years later. It should be discontinued. And this is what Sharon Malone, whom you mentioned, has said is low hanging fruit.

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Stacy London She/her (33:51.288)

Well, that's that is what I care about - action items.

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Avrum Bluming (34:14.611)

That's so true. This is so clear. Let's do that to show that we can do something besides complain.

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Carol (34:22.966)

And we have a letter to the FDA.

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Stacy London She/her (34:23.094)

Right. Wonderful!

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Avrum Bluming (34:28.595)

The second thing that is important is education. And that's why we're talking. That's why we wrote the book. That's why there are many people. We aren't lone voices in the wilderness. There are many people participating in this. Mary Claire Haver has called us the menopause, which are people, most of whom are women, but there are some men as well, who are working to inform the culture, not to berate it, but to inform them. Be open to information and be critical of the information you get. And the one warning is there is a rallying cry that says we're going to make a difference, let's have more studies on women's issues. Well, you know, the Women's Health Initiative was a billion dollar study that was done specifically on women's issues. And it set us back a quarter of a century. Just saying let's have more studies is not an answer. Let's collect data. We have computerized medical records.

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It would be so easy to put into computerized medical records the relevant data necessary and let's get the people who analyze data to look at this on a continuing basis. And if what Carol and I are saying is not borne out by future data accumulation, we certainly want to know that. I don't think that will be the case, but we'd want to know that those three things could make a difference.

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Stacy London She/her (36:23.374)

And those are three things that require both doctors and you need politicians on your side. What about the people, what about the consumer, right? I mean, or the patient, however you wanna see this, because I agree, Carol, this is not like, I don't like to medicalize menopause as if it's some sort of disease, right? I really, I'm post-menopausal now. I keep saying like, it was the reckoning of my life. I like got in the ring, it was like David and Goliath and I won. But it took hormones and therapy and friends and normalizing this conversation and de-stigmatizing it and democratizing it for all of that to happen. And I'm a very privileged person to be able to do that. How do we do this for the masses, especially, and we don't have to put this in the recording at all, but under this new administration, I so worry about anything of this kind of importance, this necessary clinical research being done.

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What do we do as consumers? What do we fight for? Do we write to our representatives? What can we do just as citizens to do better around medical information? Is it demanding it? Is it going in and advocating for it? Is it knowing the questions to ask? How do we do our part?

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Avrum Bluming (37:45.043)

While you are thinking Carol, let me just interject that Eric Weiner is a former president of the American Society of Clinical Oncology, which is the largest group of oncologists in the world. And his operative phrase is partnering with patients, which is don't tell patients just what to do and have them absorb it and either follow or disregard your advice, work with the patient.

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Carol (38:16.406)

I will add to this what women can do. Writing for your congressperson is not going to do very much at the moment. And we need to wait and see how things settle down. It may be that the new head of the FDA is going to be more sympathetic to removing the black box warning, for example. What individual women can do, and this is in fact a big difference for your generation, Stacy, is that women are more vocal and more active and more demanding. I mean, this happens, of course, for any group when they suddenly realize there's a problem that's not just affecting them, but all of us in this boat. We want to get in the boat together and steer it in the right direction. What individual women can do, need to do, and are doing is getting noisier about what they're entitled to from their doctors. I'm entitled to respect. I'm entitled to your listening to me. I'm entitled to my telling you my symptoms and you're discussing a treatment program between us. These are, this is across the medical system, of course, and a system when doctors don't have any time, you know, they have seven minutes to talk to you and so forth. But one of the reasons that women go to so many alternative doctors and so forth is they want to be listened to, they want to be heard, they want their complaints known. But if women can inform themselves,

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Carol (39:44.96)

I mean, starting with what menopause is and what hormones do and why the depletion of estrogen is causing the symptoms you're feeling, that right away I think is the most energizing and the word Avrum and I laugh about often empowering, but it is the word because once you understand why your body is reacting this way, you realize it's all in your head and you're not crazy. It's your body's natural reaction to a depletion of estrogen. So women need to inform themselves and not with the easiest answers, but get the good basic information and then demand your doctors listen to you.

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Stacy London She/her (40:28.718)

Listen, and I guess I want to end more with a very specific conversation. know, obviously, know, estrogen matters. It's the name of the book, but, even more important than that, what, and you hit on this a little bit, but I just want to go back to it. So people really do understand. It's not just that you're taking hormones while you're in perimenopause or you're, you menopause is one day. What are we talking about post menopausal? That depleted hormones are actually doing for our body as we age. I think people don't really understand what we gain from continuing to take estrogen and progesterone and perhaps testosterone. I have no idea. I leave that to you to discuss.

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Avrum Bluming (41:14.151)

As you know, Stacy, the term premenopause is before your periods stop. Perimenopause is during the year after your last menstrual period, and everything after that is menopause. Menopause is menopause, it's menopause. That's really what it is. When people say, how long should I take hormones, the standard incorrect answer is the lowest dose for the shortest period of time. What we say repeatedly in the book is there is no support for that oft-repeated statement. That, in fact, once you stop taking hormones, the benefits leave your body relatively quickly so that while estrogen will decrease the risk of an osteoporotic fracture by 50 % while you're taking it, within five years of stopping estrogen, your risk of that fracture is as if you had never taken it at all. And so like thyroid hormone, which once you're put on, you take for the rest of your life,

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The default position should be once you're taking it, don't stop. And there's no strong indication to stop unless something comes up. And that's why we don't give advice to a broad population of people we haven't evaluated individually. This has to be discussed with your doctor. But once you start it, hold on to it unless there's a very good reason to stop and you're allowed to challenge your doctor's initial refusal to start it or your doctor's insistence that it be stopped or your doctor's efforts to get you off it for some abstract reason that isn't spelled out. And if the doctor does spell it out, can often be deflected by data, by good data.

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Carol (44:22.272)

Exactly. You know, this is back to the word replacement, Stacy, which I hate that term, hormone replacement therapy. You know, what gas tank and you're filling up my gas tank with refilling my, but replacement is actually the right word because in many women estrogen levels really do plummet. It's not like a small decline the way testosterone is a slow decline. No, it's a plummet. It's a real plummet. And that's why thyroid, if you don't have a thyroid, you need to take Synthroid. it was so known before the Women's Health Initiative that women were so much less vulnerable to heart disease and heart attack before menopause than men.

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And the reason was they were protected by estrogen. And as Bernadine Healy, who was the head of the National Institutes of Health at the time, she said, why would I give up this benefit just because I get menopause, to become more risk of heart disease as men are? Forget that. So it is interesting because many women, not many, but a significant minority of women like me have no menopausal symptoms of hot flashes.

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Avrum Bluming (45:13.627)

NIH.

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Stacy London She/her (45:38.318)

That doesn't mean you don't have them.

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Carol (45:40.078)

Exactly. What women aren't thinking of it when they're 50 is what will how healthy will I be at 70 75 80 85 brain work? my bones work?

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Stacy London She/her (45:50.958)

Well, that's what I asked myself, right? Once I realized that I could maintain, that I could manage my symptoms with hormones, the next question was, well, right, how long do I stay on them? I don't go to the gym anymore thinking about being skinny. I go to the gym because I want to be able to walk when I'm 85 because I'm strong. So I do stability and mobility and strength training. It's interesting. I went and had a head to toe MRI scan. And the two things that I was looking for, right? I just, you I was like, I want to know up there. And he's kind of white plaque on my brain. And I want to know how my heart is doing because I'm thinking 30 years ahead. And what I find so interesting is that menopause put me in a place to be more proactive about my health than any other time in my life.

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Carol (46:38.094)

Yeah, that does it. Good for you. Absolutely. Yep. Yep.

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Stacy London She/her (46:41.556)

It has been such a pleasure to talk to you. Now, I just want to make sure everybody knows where they can find you. Not everybody can be friends with you or come to lunch like I can, but I do want people to know where they can find your work and where to find you on social media. So Carol, why don't you go first?

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Carol (46:56.846)

Okay, well the website estrogenmatters.com, they'll get basic stuff, also how to contact us, and we will reply always, and our Instagram account also @estrogenmatters.

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Avrum Bluming (47:10.751)

Well, if you write to info at estrogenmatters.com, we respond to every mail that we get, every single one. And we have for the last nine years from all over the world, unless it's something that simply doesn't warrant a response, but that's a decision we make.

Stacy London She/her (47:38.312)

Right. And you're like, is it cancerous? Because I don't know. That's for a podiatrist. Exactly. I hear you. I feel like I get questions all the time that are not about menopause or fashion. And I was like, I don't know what to tell you. Absolutely not sure.

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I want to thank you so much for your time and your knowledge and expertise. Thank you for talking to our listeners. It's going to make such a huge difference.

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Carol (48:02.36)

Thank you, Stacy.

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Avrum Bluming (48:03.423)

It's a pleasure, Stacy.

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