I was sent a link to an opinion piece in MedPage Today titled “The Mainstream Menopause Narrative is Misleading Women”, in which the author takes issue with a recent podcast episode on menopause. Apparently someone in the mainstream is misleading women about menopause…

…and it seems that someone is me!

And Glennon and Amanda Doyle. And even the North American Menopause Society.

Apparently we’re well-intentioned, but a little misguided and overly influenced by Big Pharma. Like a group of Girl Guides, but way in over our heads.

I mean it’s funny. But also not.

For those who don’t know, MedPage Today is a health E-zine with a large readership of physicians and medical industry types (think Pharma, health tech etc) that seems to be funded by advertisements from pharmaceutical companies and possibly also by various connections with medical professional societies. Maybe they also sell data? Who knows? MedPage Today contains many articles written by respected journalists and physicians, but also junk pieces. Lots of newspapers feature both, so the junk along with the good stuff is par for the course. I didn’t have an issue with MedPage Today. At least not until now.

The author of the opinion piece “The Mainstream Menopause Narrative is Misleading Women” is a physician’s assistant whose byline states she is a “former assistant teaching professor in the Department of Family Medicine at the University of Washington” and whose last clinical job listed on her LinkedIn was a few years ago at a practice that lists itself as a health and wellness facility. I appreciate not everyone updates their LinkedIn page, but I felt it was worthwhile to investigate the author’s expertise in menopause.

The author uses an episode of We Can Do Hard Things (WCDHT) as a launching point for a poorly argued article about harmful narratives and menopause. However, in a strange twist the author doesn’t actually mention the podcast, the hosts, or the physician by name. Glennon and Amanda, are referred to as “The Host” in the article as they interviewed me (Abby Wambach was away), and I am referred to as “The Physician”.

Charming.

How do I know this about me and my appearance on We Can Do Hard Things (WCDHT)?

Yes, I know I can be hopelessly self-centered. But look at these two paragraphs, the top from the MedPage Today article and the bottom from the transcript of WCDHT. Identical phrases are highlighted in yellow.

And

This isn't grade school. Refer to me and WCDHT by name, or be clever enough to write about your topic without needing the signal boost from a popular podcast. I do this regularly, so trust me when I say it can be done. Look, there are plenty of people lying about hormones and calling menopause a disease, so there’s no shortage of material or people to call out. Whether it’s cowardice on the part of the author or MedPage Today or a sad stylistic attempt, I don’t know. And frankly don’t care to know. Although, MedPage Today and Shannon Casey PA-C you both now have my attention. If this were some personal blog, I wouldn’t care and I’d let it go. People write nasty or incorrect things about me all the time on social media and on personal blogs. But apparently some of my peers read MedPage Today and the publication holds itself up as a legitimate source of medical news, so buckle up.

And no, I have no interest in writing a rebuttal for MedPage Today. You don’t get page clicks as a reward for defaming me and you certainly don’t get page clicks from me for treating Glennon and Amanda Doyle poorly. They were using their large platform to raise menopause awareness and to their credit they asked an expert. Who should they have asked as a guest? Gwyneth Paltrow? A doctor shilling a line of supplements? Or perhaps the pandemic's worst woman, Dr. Christiane Northrup?

A Bit of a Defamatory Title

Leading with the title “Is The Mainstream Menopause Narrative Misleading Women?” and then centering the article on my appearance on WCDHT implies that the hosts of WCDHT and I are misleading women. And that, my friends, is not okay.

The article starts off explaining there is a growing interest in a discussion about menopause and the need for factual information and then makes reference to “a certain widely-disseminated podcast episode” raising awareness about menopause. And the author writes:

In an effort to share high-quality, accurate information, the podcast hosts interviewed a physician who is regarded as a menopause expert. (For simplicity, I'll refer to the podcast hosts as The Host and the physician they interviewed as The Physician.)

I not regarded as a menopause expert, I am a menopause expert. In the same way I am not regarded as an OB/GYN, I am an OB/GYN. I completed a five year residency in OB/GYN, am board certified in OB/GYN in two countries, have been in clinical practice for 30 years, prescribe the spectrum of evidenced-based therapies for menopause, am a certified menopause practitioner by the North American Menopause Society, and wrote a book on menopause that was favorably reviewed by the North American Menopause Society.

The author posits that this podcast episode is contributing to shaping the “narrative” of menopause in a concerning way. This is what was written:

However, in both this particular podcast episode and in the broader sociocultural conversation about menopause, some claims are shaping the narrative in concerning ways. As clinicians, we need to be aware of the messages influencing our patients. I'm not suggesting the messages are ill-intentioned -- in fact, quite the opposite. The push to demystify menopause and empower women are worthy goals that go hand-in-hand. But the history of medicine when it comes to menopause is incredibly fraught, and the subject warrants careful scrutiny.

So kind for the author to think that I am not ill-intentioned. If you read that dripping with sarcasm then you read it as written.

I am extremely mindful of not randomly supporting Pharma or femtech as well as providing evidence based information, so I take seriously any claim that I am somehow a tool of Big Pharma or that I am shaping the narrative about menopause “in concerning ways.” I have devoted a large part of my professional career to empowering women with facts, so the suggestion that I don’t quite get the importance of accurate messaging is galling. My quest to provide factual information should be clear to anyone who has spent any time on my social media pages, this blog, read any of my articles elsewhere, read my books, or listened to my podcast on TED. Or even listened fully to the podcast episode in question.

The article is centered about three claims the author felt were made in the podcast that are apparently false and symptomatic of mainstream medicine’s problem with menopause:

Claim: Concerns about breast cancer have unduly robbed women of the benefits of hormone therapy
Claim: Menopause is under treated
Claim: Seeking treatment for menopause is a feminist act

I acknowledge those are claims I have made and I stand behind them. But the author’s refutation of these claims is especially concerning because they are backed up by the evidence.

So let’s dive in a little, shall we?

Hormones are “Dangerous” with a capital D is apparently the author’s narrative?

Somehow the discussion that I had with Glennon and Amanda was “re-popularizing the use of hormone therapy at scale.”

I don’t quite know what that means, maybe “Estrogen for all my friends. Damn the science, full steam ahead!”

I’m sorry, but what the fuck show were you listening to?

The author cherry picks her points and acts as if she is refuting the podcast when she writes:

Some women experiencing intolerable menopausal symptoms may decide the benefits of hormone therapy outweigh the risks, and this could be a completely reasonable decision.

But seemed to ignore that I literally said this on the podcast:

“the risk is there, but it’s very, very low. I believe that people are intelligent enough to decide what is this doing for me, no medication is without side effects. And to say that it is, would be incorrect. But the risks are very, very, very low, and if people are suffering, there’s no reason that that is a risk that should hold them back.”

But that didn’t fit her narrative or her selective listening must have kicked in so she ignored that I ever said it.

But it’s not just breast cancer from menopausal hormone therapy (MHT) that women should fear. Although, before we move on to those other risks we should discuss the risk of breast cancer in terms that are easy to understand, as my equating the risk of breast cancer associated with MHT to be about the same as one glass of wine a day didn’t seem to work, so let’s try again. Overall, it seems the risk of breast cancer with combined MHT (an estrogen plus a progestin) is 1 additional case of breast cancer per 1,000 users/year. This is also the risk of breast cancer one incurs with low physical activity.

In support of the risks of stroke, heart disease, gallbladder disease, lung cancer and so many more bad things the author cites a Cochrane review, but it’s more nuanced than the abstract from that review presents. In addition, we can’t generalize risks for those starting MHT over age 60 with those starting it younger than that. What we do know is transdermal estrogen doesn’t appear to be associated with an increased risk of gallbladder disease or an increased risk of blood clots, stroke, or heart disease when started under the age of 60 or within 10 years of menopause. Also, the impact on lung cancer is neutral.

During the podcast we discussed some of the risks of MHT, and you can read the transcript or listen to the episode here. But it’s an hour-long podcast, not a consensus statement on hormones and there was a lot to talk about. That said, if there wasn’t enough detail for the author, once again there is a lot more information and nuance in my book which was offered up as a reference by the hosts as were the 2017 NAMS guidelines on hormones, knowing that one hour isn’t nearly enough time to cover everything and there are many individual factors to consider.

As for the specific claim that the author feels it’s wrong to say fears about breast cancer have unduly robbed women of the benefits of hormone therapy? Research says that 70% of women in Europe, 69% in the United States, and 52% in Japan decided against using hormones due to safety concerns. Concerns about breast cancer is one of the major reasons cited for not starting MHT and this fear has resulted in more women suffering from hot flashes, insomnia, and fractures related to osteoporosis.

So yes, concerns about hormones have robbed many women of therapy that could help them. That doesn’t mean all women should take hormones and no one on the podcast ever made that claim or even came close to it.

Menopause is under treated

The author of the article apparently has issues with how the hosts, Glennon and Amanda Doyle, set the stage for the podcast. The point of the podcast was to have an expert on to educate about menopause, and Glennon and Amanda opened by saying things that represent what many women report they have heard or read.

For example, the author is concerned there is no science to back up the claim made by one of the hosts that "73% of women are never treated for their menopause symptoms." The hosts aren’t writing menopause guidelines for a medical society, they are reflecting what the “everywoman” has heard. Furthermore, this 73% number was taken out of context as it was used to make the argument that we spend a shit ton more money on research and drugs for erectile disfunction as opposed to treating menopause. It wasn't in the context that all women should be taking MHT.

Anyone who has spent any time treating women in menopause would know that many are under treated. I just partially made the case above that it is. But let me build on it some more.

Use of MHT dropped by 80% in the years after the WHI. This was due not only to the results of the WHI, but the frenzy of articles about it. There were over 130 news articles about the dangers of MHT in 2002. I practiced before and after the WHI, and it was a media frenzy.

In one survey 76% of OB/GYN residents who did not have a formal menopause curriculum (only 21% did at the time of publication) felt "barely comfortable" and 8% felt "not at all comfortable" with menopause. Knowing this it’s not a stretch that many women don’t have their symptoms adequately treated.

So how there is anything to quibble about this statement is beyond me. It doesn’t matter if the 73% was pulled from a survey that was not in a peer reviewed journal because it was brought up by the host (not the expert) to launch the discussion and represent the broader zeitgeist. The reality that many OB/GYNs are poorly trained in menopause and the fact that many people are unnecessarily scared of hormones are two massive points of evidence as to how menopause is under treated.

Seeking treatment for menopause is a feminist act (Issues with Penile Winter? Not me)

The author apparently isn’t a fan of comparing the advertising and overall care and societal treatment of erectile dysfunction with the way it treats menopause. I’m sorry, what planet do you live on? We have textbooks and doctors that refer to menopause as ovarian failure and call it a disease, and yet erectile dysfunction has a nice euphemism? Why don’t we call it penile failure or penile winter? And drugs for erectile dysfunction seem to always be covered by drug plans and are affordable. The same cannot be said about hormones.

The author of the MedPage Today article is most concerned about this scenario (I shit you not)

The Host has a point here, but framing menopause in this way runs the risk of undermining the patient/provider relationship. Consider a typical scenario: a woman presents to the clinic, tells her doctor about the menopausal symptoms she's experiencing, and lets him* know she'd like to start HT. He's reluctant due to the risks, and he uses the rest of the short 15-minute appointment to explain that, in her case, the risks of HT actually outweigh the benefits. Although the patient understands what he's saying, she mostly feels like he isn't taking her symptoms seriously. When she leaves without the prescription she came in for, she feels frustrated. In her mind, she didn't get the treatment she needed and deserved.

Well, first of all, we discussed the major scenarios where hormones may not be appropriate as well as the reasons to take MHT. But as many women are told inappropriately that hormones are too risky, of course if they don’t feel they have the right information, they should go elsewhere. But I also advised people to look up the guidelines so they can advocate for themselves and to bring those guidelines with them to their visit. In this hypothetical 15 minute scenario our doctor can either say, “Wow, you are right, you are 50 and having hot flashes, so transdermal hormones are a reasonable option” or say, “I am so glad you brought in the guidelines, because your risk of heart disease means hormones are not the best option. NAMS says so right here in the document that you brought, so let’s talk about non hormonal options.”

If every patient brought in the guidelines from medical professional societies and wanted to follow them I think that would be awesome.

Yet somehow Glennon’s, Amanda’s and my conversation is going to send women into the arms of Big Pharma and snake oil and scammy femtech? Except you know where I explicitly said women should go if they aren’t getting help? A NAMS certified provider.

But the North American Menopause Society (NAMS) is bad or something

Me saying that women should use the NAMS 2017 guidelines or seek out a NAMS provider so they can make sure they are getting the right information is apparently not good advice. This is what was written in MedPage Today:

…what most podcast listeners don't realize is that these kinds of guidelines are often heavily influenced by pharmaceutical companies' interests. Of the 20 clinicians and researchers recruited to be on the NAMS 2017 Hormone Therapy Position Statement Advisory Panel, 10 of them reported financial conflicts of interest. More generally, the NAMS website concedes that the organization's funding comes in part from "charitable contributions from corporations" -- i.e. pharmaceutical companies.

It’s pretty clear the author is not intimately familiar with the NAMS 2017 Hormone Therapy Position Statement, which has been endorsed or supported by the following:

This NAMS position statement has been endorsed by Academy of Women’s Health, American Association of Clinical Endocrinologists, American Association of Nurse Practitioners, American Medical Women’s Association, American Society for Reproductive Medicine, Asociacio´n Mexicana para el Estudio del Climaterio, Association of Reproductive Health Professionals, Australasian Menopause Society, Chinese Menopause Society, Colegio Mexicano de Especialistas en Ginecologia y Obstetricia, Czech Menopause and Andropause Society, Dominican Menopause Society, European Menopause and Andropause Society, German Menopause Society, Groupe d’e´tudes de la me´nopause et du vieillissement Hormonal, HealthyWomen, Indian Menopause Society, International Menopause Society, International Osteoporosis Foundation, International Society for the Study of Women’s Sexual Health, Israeli Menopause Society, Japan Society of Menopause and Women’s Health, Korean Society of Menopause, Menopause Research Society of Singapore, National Association of Nurse Practitioners in Women’s Health, SOBRAC and FEBRASGO, SIGMA Canadian Menopause Society, Societa`Italiana della Menopausa, Society of Obstetricians and Gynaecologists of Canada, South African Menopause Society, Taiwanese Menopause Society, and the Thai Menopause Society. The American College of Obstetricians and Gynecologists supports the value of this clinical document as an educational tool, June 2017. The British Menopause Society supports this Position Statement.

When does NAMS recommend MHT?

Hot flashes and night sweats
Prevention of osteoporosis.
Genitourinary syndrome of menopause

That’s it! That’s the entire list. If this was some big Pharma contaminated cluster fuck there would be a hell of a lot more recommendations. Of course COIs should be listed, but guidelines like the one from NAMS that don’t push hormones enthusiastically and that are supported by professional societies all around the world are unlikely to be suspect.

Look, there are plenty of people with lucrative private practices making wild claims about hormones being essential to prevent dementia and diabetes and to lose weight, so it’s not like there aren’t valid places to punch. But maybe that is only known to someone who actually is regarded as a menopause expert?

So where are women supposed to turn if it isn't to experts like me and NAMS?

Who knows? No answer is provided. I guess a 15 minute visit with a provider who had a 21% chance of receiving a menopause curriculum in training? Or I guess women should turn to Google? That is guaranteed to get exactly the result the author is arguing against. Lots of hot-takes, no constructive suggestions.

The article ends with this statement

Unfortunately, the messages our patients end up hearing about menopause are often carefully crafted by companies that are prioritizing their own best interests -- whether pharmaceutical companies or health tech companies. Although the narrative presented sounds empowering, it's only part of the story.
As clinicians, we need to equip our patients with a more well-rounded understanding of the various factors and forces that are shaping these messages. Knowing the whole story is what's truly empowering.

This is offensive. No one who actually listened to the podcast would have heard a carefully crafted Pharma or health tech message from me or from Glennon or Amanda Doyle. And if the author had bothered to read my blogs, my instagram, my twitter, or my books she would know how ridiculous her implication is given how many companies I have personally gone after for making false and indefensible claims.

I don’t care about whether this piece stays up or is pulled from MedPage Today, but I do care that my peers might read this and I do care what you say about Glennon and Amanda Doyle, because that podcast episode helped a lot of people. And we should be thanking people with big reaches for using their privilege thoughtfully.

If you don’t think an hour-long podcast that covered the Grandmother Hypothesis, the Feminine Forever fiasco, what actually happened with the WHI, provided evidence-based guidelines for MHT, that put the risks of MHT in perspective, plus gave practical tips for navigating a doctor’s appointment isn’t well-rounded, then I will suggest that perhaps you don’t have the expertise to write about menopause.

Because right now it does take an act of feminism for many women to get help and advocate for themselves when they are suffering. And for a clinician to say otherwise? Well, it leaves me wondering how many women they’ve actually listened to in the office.

If you want to attack me, use my name. But you better come prepared.

And MedPage Today, so fucking disappointed. You owe Glennon Doyle, Amanda Doyle, and me a public apology.

References

The NAMS 2017 Hormone Therapy Position Statement Advisory Panel. The 2017 hormone therapy position statement of The North American Menopause Society. Menopause 2017; 24:728–753.

Homoda H, Panay N, Pedder H et. al. The British Menopause Society & Women’s Health Concern 2020 recommendations on hormone replacement therapy in menopausal women. Post Reproductive Health 2020, Vol. 26(4) 181–208

Nappi RE, Kroll R, Siddiqui E, et al. Global cross-sectional survey of women with vasomotor symptoms associated with menopause: prevalence and quality of life burden. Menopause 2021; 28:875–882.

Stuenkel CA, Davis SR, Gompel A, et al. Treatment of symptoms of the menopause: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2015;100:3975–4011.

Santen RJ, Stuenkel CA, Burger HG, et al. Competency in menopause management: whither goest the internist? J Womens Health (Larchmt). 2014;23:281–285.

Christianson MS, Washington CI, Stewart KI, Shen W. Effectiveness of a 2-year menopause medicine curriculum for obstetrics and gynecology residents. Menopause 2016 Mar;23(3):275-9.

Rossouw JE, Anderson GL, Prentice RL, et al. Writing Group for the Women's Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women's Health Initiative randomized controlled trial. JAMA 2002; 288:321–333.

Thaung Zaw JJ, Howe PRC, Wong RHX. Postmenopausal health interventions: time to move on from the Women's Health Initiative? Ageing Res Rev 2018; 48:79–86.

Sarrel P, Portman D, Lefebvre P, et al. Incremental direct and indirect costs of untreated vasomotor symptoms. Menopause 2015 Mar;22(3):260-6.

Crawford SL, Crandall CJ, Derby CA, et al. Menopausal hormone therapy trends before versus after 2002: impact of the Women's Health Initiative Study Results. Menopause 2018; 26:588–597.

Monteleone P, Mascagni G, Giannini A, Genazzani AR, Simoncini T. Symptoms of menopause—global prevalence, physiology and implications. Nat Rev Endocrinol 2018; 14:199–215.

Baber RJ, Panay N, Fenton A. IMS Writing Group. 2016 IMS Recommendations on women's midlife health and menopause hormone therapy. Climacteric 2016; 19:109–150.

The Vajenda

MedPage disses me, Glennon Doyle’s podcast…