All your articles are so vitally important. It's so easy to be duped. A dear friend of mine, who is incredibly intelligent, said that I should listen to the recent menopause episode of the Armchair Expert because there was a menopause expert featured. My first question was "is she selling something?" And my friend replied, "her name is Dr Mary Claire Haver, and she is selling something, but it's because she realized that women's needs aren't being met." I nearly fell over and immediately started sharing your newsletter. Point being, I wish you were as famous as Oprah, and will do my little part to make this so.
Another excellent analysis. When I first heard about the recommendation for estriol for brain health, my immediate impulse was to pull up the slides from Dr. Maki's lecture, which, as you point out, substantiated that these claims are ...unsubstantiated. Then, I called Dr. Maki to make sure there wasn't any new data that I had missed. No new data. Just a new person fearmongering to make money.
That estriol study in MS is interesting to me *only* because I have MS *and* MT!
In my very specific case, MT made my MS sx (including cog fog) worse, and in my sample size of 1 MHT helped a ton! So, I certainly hope other people with MS and MT have knowledgeable primary/gyno clinicians on their team. (And to those people (something like a third of all pwMS), the research is coming!
Yes! The estriol study was looking at different mechanisms—specifically related to the sharp decline in relapses in pregnancy, but neither relapses nor pregnancy are the issue in MT cog fog! Lol! For me, the takeaway of that study is yet more indication that there’s *something* going on with estrogen and MS! The conclusion of the study certainly wasn’t to run out and purchase the latest snake oil!
I also have MS and taking MHT for a couple of years. I have always thought intuitively that estrogen was protective for my MS but try asking my neurologist about it, they are as clueless as some gynecologists are about menopause. I will continue to take my MHT with the belief that it is protective.
Absolutely! I wasn’t convinced until I abruptly lost access to hormonal birth control (insurance confusion). My MS symptoms kicked my a$$ so hard and fast we treated it like a relapse and started steroids. MRIs show zero new activity though.
I switched to the patch for my MT symptoms (because it wasn’t going to have the stupid insurance hiccup), and my MS symptoms immediately started recovering.
Until they get that research out, I’ll keep supporting my estrogen, tyvm!
That is great to know. My sister, who also has MS, is being convinced by her clueless gynecologist to stop hormones now that she is 60, and unfortunately, she is listening to her. I do not get it. I have asked her what her doctor's explanation is and she can't really say. We have no history of breast cancer in our family and even that would not be a convincing argument. I have tried to direct her to sites like this one but she's not listening...
I don't think we have the answer as estradiol and estrone can convert into each other. We do know that people with MS often have remissions during pregnancy, especially the third trimester. My understanding is that estrogens, and possibly other hormones, change the T helper (Th) cell profile from pro-inflammatory to anti-inflammatory. I'm certainly not an expert in the area, so full disclaimer. That is just from a brief review.
The premise will change the answer somewhat. If MS is thought of in the old way of being similar to cancer—relapses and remission—the analysis into estriol or estrone will get one line of reasoning. If MS is looked at as a “smoldering” disease—in brief (and over-simplified), progression in absence of relapses (PIRA)—the analysis will be very different, and I don’t personally know the conclusions.
What is known for sure is that naturally occurring estrogen provides neuro-immune protection. Much like it it known that naturally occurring Vitamin D levels influence numerous health outcomes for everyone. What is unsettled (yet) in both cases is what to do about that. Anecdotally, systemic MHT (FDA-approved) has a profoundly beneficial effect on MS symptoms in the MT. (I don’t know what the research says about relapse-specific effects, and estriol/estrone has not been supported for symptom management afaik)
Robust research is being done, and University of California at San Francisco has been a leader here.
Thank you so much for the time and care that go into these newsletters. I greatly appreciate having a reliable source of information on this subject; it was clear, at the time I entered perimenopause about 7 years ago, that my primary care doctor, an internist, had very little specific information about perimenopause, despite being roughly my age or slightly older (she's since retired). When I contacted her about my hot flashes (a truly interesting thing to experience as a middle school teacher - try explaining *that* to a room full of 7th graders), she prescribed standard birth control, which didn't work - and also caused some interesting issues with my insurance coverage, as I was taking it continuously, and not skipping the "placebo" week, so I needed refills every 3 weeks instead of every 4.
When that didn't work, she checked with an OB/GYN (although not MY OB/GYN; Kaiser is an interesting place), he suggested a combination of Depo Provera and daily estrogen, which worked well enough, until COVID hit and I couldn't get in to an office to get the next injection. By then, I'd talked to my gynecologist, who prescribed standard hormone replacement - medroxyprogesterone and estradiol - which has been completely effective since then.
Given that I also developed cancer around that time (follicular lymphoma - a treatable but incurable form of blood cancer for which one of the standard symptoms is badly described as "night sweats", as mine were most common mid-afternoon), so avoiding hot flashes and the fear that it was the cancer becoming active again is rather important to me.
This is of course anecdotal, N of 1 example but for me the systemic use was the one that completely alleviated UTIs. I only saw a slight improvement with the cream. GSM is a localized problem caused by a systemic drop off in estrogen.
Thank you! These articles are so incredibly helpful. Would you be willing to speak to this recent Armchair Expert podcast episode with Dr. Mary Claire Haver? I understand issues with her supplement company, but curious aside from that if any red flags came up for you during interview. This podcast is wildly popular, and Dr. Haver was specifically picked by listeners as their “favorite” expert on menopause transition and menopause.
Time and time again I find that people with products to promote are not reliable sources of information. Messages get twisted. And sometimes what they do is make fantastical claims, which then helps drive people to their website. Dr. Haver has falsely claimed that "we know" estrogen protects the brain against dementia (in the M Factor Documentary). She has a free menopause guide you can download, but there are photos of her supplements in the guide. So all of her information seems brought to you courtesy of her supplement company. I choose to look for people unencumbered with that bias. Also, Dr. Haver uses mice studies to support her turmeric supplement. When people do that, it makes me question how they read the literature.
Yet to read the attached article, however maybe you could return home 🤗
You can remain a positive influence to your many reading & no potential 'retribution' from the current administration.
Consider it a sabbatical just until the the bully, buffoon is religate to a bad memory & your neighbours can rebuild.
Dr. Sophia Halassy couldn't be happier. The 32-year old bilingual obstetrician-gynecologist is settling into a new job at the Dr. Georges-L.-Dumont University Hospital Centre in Moncton, helping to tackle a years-long waiting list of patients.
Thank you once again for all the research you put into debunking nonsense with celebrities and on social media! You are my first line of defense in the menopause world :) I have many smart friends buzzing right now about this Oprah special and it's because women want a glossy, shiny object wrapped up in a pretty celebrity to tell them what to do, which is amazing to me. Who cares about mouse studies? Oprah said it was okay...
The newest headlines are now trying to capitalize on this it seems saying the more symptoms of perimenopause you have the more risk of cognitive decline and dementia as you get older, but not to worry, all is ameliorated with hormones. Not sure what to make of this study…me thinks if it waddles like a duck it must be bullshit.
Thank you as always for the comprehensive and clear analysis. Sigh. It does seem like everyone speaking up in the menopause space is involved in selling supplements or a degree removed from someone or a brand that is. Like Dr. Maki who has partnered with Halle Berry and Midi’s medical advisors for ex.
There are so many "experts" in the field of menopause (peri and post) that have data that has been presented. Dr. Wendy Wolfman (Mt. Sinai, Toronto) presented at the menopause society general meeting in Sept. 2024 regarding MHT in women over 65 which seems to have been discounted by many practitioners. I would agree that people who are in the public eye and have no background in medicine should be very careful presenting information that is not based on science. Dr. Davis disagrees with some information that the Menopause Society states in the 2022 position statement especially in regards to treating (starting and continuing) MHT over 60 (webcast interview 2024). Perhaps the cognitive issues women have is due to the night sweats which interferes with quality and duration of sleep. The Menopause Society does state in the 2022 statement that compounded formulations can be considered if standard treatment is not effective.
There might not *yet* be studies supporting estrogen for brain fog but directionally the evidence is mounting. Surely any menopause clinician will attest to not an insignificant effect of estrogen for those suffering from brain fog. Additionally, women are twice as likely to die from Alzheimer's disease than men and a plausible hypothesis posits that it is due to a sharp drop off in hormones in women. Here's one study showing that prior HRT use reduced the incidence of AD in women https://pubmed.ncbi.nlm.nih.gov/12413371/
We look at the wealth of data. That is a relatively small uncontrolled observational study from 2002 and not something we would use to make treatment decisions. One of the slides above shows several much larger observational studies that suggest a possibility of harm, but we still don't use those to make treatment decisions.
Let me put it this way. It would be disappointing and wrong at this point of our medical knowledge to deny a woman estrogen therapy for brain fog (provided she was premenopausal or menopausal) because we don’t have enough data. The clinical and observational data coupled with the well studied risk of HRT would make it a compelling use case.
Women should not be lied to about the data, meaning it is wrong to tell them that brain fog is a sign of neurodegeneration and that it can be treated with estriol. It is absolutely reasonable to try estrogen for brain fog as women may have disrupted sleep that they don't appreciate and brain fog is ill defined. But telling women you have a special drug for it that is "clinically tested" is predatory.
Wow - very helpful article - thank you! I'm 71, still having hot flashes, so your comment about the spinal block piqued my curiosity and I googled it - not sure I'd want to risk the side effects. But that search led me to the Equelle site, and I'm wondering if you're familiar with that product, if you'd be willing to comment on whether you think it's worth a try or a waste of money? Thanks for all you do!
I hope you speak to your doctor because there are options for treating hot flashes, hormonal and non-hormonal. Dr. Gunter has probably written about it and Dr. Lauren Streicher talks about it on her podcast, episodes from 7/12/2023, 7/19/2023 and 7/26/2023. Her episode 77 from 5/14/2023 is about Fezolinetant, or Veozah, a non-hormonal FDA approved treatment for hot flashes.
Thank you - I have talked with my doc. The prescription treatments are generally pretty heavy duty medications with serious potential side effects. For example, Veozah side effects can include stomach pain, dizziness, difficulty sleeping, back pain, and surprise: hot flashes! In December 2024 the FDA issued a black box warning due to potential tho rare serious liver damage. So, no thanks to that. I appreciate your reply!
Black box warning was due to one case of liver failure which reversed when the drug was stopped which is why it is we now monitor liver function tests. Side effects are quite rare. Biggest issue is coverage. And it only gets rid of flashes. None of the other benefits of estrogen . Another similar drug is about to get approved without liver issues. And no I have no financial relationship with the company.
All your articles are so vitally important. It's so easy to be duped. A dear friend of mine, who is incredibly intelligent, said that I should listen to the recent menopause episode of the Armchair Expert because there was a menopause expert featured. My first question was "is she selling something?" And my friend replied, "her name is Dr Mary Claire Haver, and she is selling something, but it's because she realized that women's needs aren't being met." I nearly fell over and immediately started sharing your newsletter. Point being, I wish you were as famous as Oprah, and will do my little part to make this so.
Another excellent analysis. When I first heard about the recommendation for estriol for brain health, my immediate impulse was to pull up the slides from Dr. Maki's lecture, which, as you point out, substantiated that these claims are ...unsubstantiated. Then, I called Dr. Maki to make sure there wasn't any new data that I had missed. No new data. Just a new person fearmongering to make money.
Thank you for staying on top off and sharing this misinformation.
That estriol study in MS is interesting to me *only* because I have MS *and* MT!
In my very specific case, MT made my MS sx (including cog fog) worse, and in my sample size of 1 MHT helped a ton! So, I certainly hope other people with MS and MT have knowledgeable primary/gyno clinicians on their team. (And to those people (something like a third of all pwMS), the research is coming!
It is interesting for MS! I definitely prescribe MHT for people with MS. But not compounded estriol!
Yes! The estriol study was looking at different mechanisms—specifically related to the sharp decline in relapses in pregnancy, but neither relapses nor pregnancy are the issue in MT cog fog! Lol! For me, the takeaway of that study is yet more indication that there’s *something* going on with estrogen and MS! The conclusion of the study certainly wasn’t to run out and purchase the latest snake oil!
I also have MS and taking MHT for a couple of years. I have always thought intuitively that estrogen was protective for my MS but try asking my neurologist about it, they are as clueless as some gynecologists are about menopause. I will continue to take my MHT with the belief that it is protective.
Absolutely! I wasn’t convinced until I abruptly lost access to hormonal birth control (insurance confusion). My MS symptoms kicked my a$$ so hard and fast we treated it like a relapse and started steroids. MRIs show zero new activity though.
I switched to the patch for my MT symptoms (because it wasn’t going to have the stupid insurance hiccup), and my MS symptoms immediately started recovering.
Until they get that research out, I’ll keep supporting my estrogen, tyvm!
That is great to know. My sister, who also has MS, is being convinced by her clueless gynecologist to stop hormones now that she is 60, and unfortunately, she is listening to her. I do not get it. I have asked her what her doctor's explanation is and she can't really say. We have no history of breast cancer in our family and even that would not be a convincing argument. I have tried to direct her to sites like this one but she's not listening...
Oof! Whatever she does, I hope it’s done gradually. MS brains aren’t great at sudden changes.
This was a great conversation, and I hope she will maybe watch and take some of it to her gyno and neuro.
https://youtu.be/EXeUUijqiI4?si=2DQzPscFhLNscfPi
Isn’t it estrone that has the benefit for MS?
I don't think we have the answer as estradiol and estrone can convert into each other. We do know that people with MS often have remissions during pregnancy, especially the third trimester. My understanding is that estrogens, and possibly other hormones, change the T helper (Th) cell profile from pro-inflammatory to anti-inflammatory. I'm certainly not an expert in the area, so full disclaimer. That is just from a brief review.
The premise will change the answer somewhat. If MS is thought of in the old way of being similar to cancer—relapses and remission—the analysis into estriol or estrone will get one line of reasoning. If MS is looked at as a “smoldering” disease—in brief (and over-simplified), progression in absence of relapses (PIRA)—the analysis will be very different, and I don’t personally know the conclusions.
What is known for sure is that naturally occurring estrogen provides neuro-immune protection. Much like it it known that naturally occurring Vitamin D levels influence numerous health outcomes for everyone. What is unsettled (yet) in both cases is what to do about that. Anecdotally, systemic MHT (FDA-approved) has a profoundly beneficial effect on MS symptoms in the MT. (I don’t know what the research says about relapse-specific effects, and estriol/estrone has not been supported for symptom management afaik)
Robust research is being done, and University of California at San Francisco has been a leader here.
Thank you so much for the time and care that go into these newsletters. I greatly appreciate having a reliable source of information on this subject; it was clear, at the time I entered perimenopause about 7 years ago, that my primary care doctor, an internist, had very little specific information about perimenopause, despite being roughly my age or slightly older (she's since retired). When I contacted her about my hot flashes (a truly interesting thing to experience as a middle school teacher - try explaining *that* to a room full of 7th graders), she prescribed standard birth control, which didn't work - and also caused some interesting issues with my insurance coverage, as I was taking it continuously, and not skipping the "placebo" week, so I needed refills every 3 weeks instead of every 4.
When that didn't work, she checked with an OB/GYN (although not MY OB/GYN; Kaiser is an interesting place), he suggested a combination of Depo Provera and daily estrogen, which worked well enough, until COVID hit and I couldn't get in to an office to get the next injection. By then, I'd talked to my gynecologist, who prescribed standard hormone replacement - medroxyprogesterone and estradiol - which has been completely effective since then.
Given that I also developed cancer around that time (follicular lymphoma - a treatable but incurable form of blood cancer for which one of the standard symptoms is badly described as "night sweats", as mine were most common mid-afternoon), so avoiding hot flashes and the fear that it was the cancer becoming active again is rather important to me.
Another one to bookmark and pull out when patients ask about brain fog and hormones. Thanks again for confirming there is no new data
So yet another snake oil seller to fleece the marks, and having success because of Oprah.
I do appreciate all the diligent work you do on behalf of women. I have a question about MHT. Is MHT effective in treating chronic UTIs?
Not systemic, only vaginal
This is of course anecdotal, N of 1 example but for me the systemic use was the one that completely alleviated UTIs. I only saw a slight improvement with the cream. GSM is a localized problem caused by a systemic drop off in estrogen.
Thank you! These articles are so incredibly helpful. Would you be willing to speak to this recent Armchair Expert podcast episode with Dr. Mary Claire Haver? I understand issues with her supplement company, but curious aside from that if any red flags came up for you during interview. This podcast is wildly popular, and Dr. Haver was specifically picked by listeners as their “favorite” expert on menopause transition and menopause.
https://open.spotify.com/episode/4ukytAV4aik2DDjVvROikt?si=4nLag0mVSiiX22rOyQQQNw
Time and time again I find that people with products to promote are not reliable sources of information. Messages get twisted. And sometimes what they do is make fantastical claims, which then helps drive people to their website. Dr. Haver has falsely claimed that "we know" estrogen protects the brain against dementia (in the M Factor Documentary). She has a free menopause guide you can download, but there are photos of her supplements in the guide. So all of her information seems brought to you courtesy of her supplement company. I choose to look for people unencumbered with that bias. Also, Dr. Haver uses mice studies to support her turmeric supplement. When people do that, it makes me question how they read the literature.
Dr. Jen
Yet to read the attached article, however maybe you could return home 🤗
You can remain a positive influence to your many reading & no potential 'retribution' from the current administration.
Consider it a sabbatical just until the the bully, buffoon is religate to a bad memory & your neighbours can rebuild.
Dr. Sophia Halassy couldn't be happier. The 32-year old bilingual obstetrician-gynecologist is settling into a new job at the Dr. Georges-L.-Dumont University Hospital Centre in Moncton, helping to tackle a years-long waiting list of patients.
Thank you once again for all the research you put into debunking nonsense with celebrities and on social media! You are my first line of defense in the menopause world :) I have many smart friends buzzing right now about this Oprah special and it's because women want a glossy, shiny object wrapped up in a pretty celebrity to tell them what to do, which is amazing to me. Who cares about mouse studies? Oprah said it was okay...
The newest headlines are now trying to capitalize on this it seems saying the more symptoms of perimenopause you have the more risk of cognitive decline and dementia as you get older, but not to worry, all is ameliorated with hormones. Not sure what to make of this study…me thinks if it waddles like a duck it must be bullshit.
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0301165
Thank you as always for the comprehensive and clear analysis. Sigh. It does seem like everyone speaking up in the menopause space is involved in selling supplements or a degree removed from someone or a brand that is. Like Dr. Maki who has partnered with Halle Berry and Midi’s medical advisors for ex.
Dr. Maki NO financial renumeration from MIDI or Halle Berry. She is 100% evidence based.
There are so many "experts" in the field of menopause (peri and post) that have data that has been presented. Dr. Wendy Wolfman (Mt. Sinai, Toronto) presented at the menopause society general meeting in Sept. 2024 regarding MHT in women over 65 which seems to have been discounted by many practitioners. I would agree that people who are in the public eye and have no background in medicine should be very careful presenting information that is not based on science. Dr. Davis disagrees with some information that the Menopause Society states in the 2022 position statement especially in regards to treating (starting and continuing) MHT over 60 (webcast interview 2024). Perhaps the cognitive issues women have is due to the night sweats which interferes with quality and duration of sleep. The Menopause Society does state in the 2022 statement that compounded formulations can be considered if standard treatment is not effective.
There might not *yet* be studies supporting estrogen for brain fog but directionally the evidence is mounting. Surely any menopause clinician will attest to not an insignificant effect of estrogen for those suffering from brain fog. Additionally, women are twice as likely to die from Alzheimer's disease than men and a plausible hypothesis posits that it is due to a sharp drop off in hormones in women. Here's one study showing that prior HRT use reduced the incidence of AD in women https://pubmed.ncbi.nlm.nih.gov/12413371/
We look at the wealth of data. That is a relatively small uncontrolled observational study from 2002 and not something we would use to make treatment decisions. One of the slides above shows several much larger observational studies that suggest a possibility of harm, but we still don't use those to make treatment decisions.
I think the wealth of data is coming but probably not fast enough to help women. Here's a new study showing "correlation" https://pubmed.ncbi.nlm.nih.gov/40067757/
That is a study of high risk women and is not a clinical trial so cannot inform us what pharmaceutical estrogen can do.
Let me put it this way. It would be disappointing and wrong at this point of our medical knowledge to deny a woman estrogen therapy for brain fog (provided she was premenopausal or menopausal) because we don’t have enough data. The clinical and observational data coupled with the well studied risk of HRT would make it a compelling use case.
Women should not be lied to about the data, meaning it is wrong to tell them that brain fog is a sign of neurodegeneration and that it can be treated with estriol. It is absolutely reasonable to try estrogen for brain fog as women may have disrupted sleep that they don't appreciate and brain fog is ill defined. But telling women you have a special drug for it that is "clinically tested" is predatory.
Completely agree
Wow - very helpful article - thank you! I'm 71, still having hot flashes, so your comment about the spinal block piqued my curiosity and I googled it - not sure I'd want to risk the side effects. But that search led me to the Equelle site, and I'm wondering if you're familiar with that product, if you'd be willing to comment on whether you think it's worth a try or a waste of money? Thanks for all you do!
Stellate ganglion blocks are effective, but not likely a long term stratgy.
I hope you speak to your doctor because there are options for treating hot flashes, hormonal and non-hormonal. Dr. Gunter has probably written about it and Dr. Lauren Streicher talks about it on her podcast, episodes from 7/12/2023, 7/19/2023 and 7/26/2023. Her episode 77 from 5/14/2023 is about Fezolinetant, or Veozah, a non-hormonal FDA approved treatment for hot flashes.
Thank you - I have talked with my doc. The prescription treatments are generally pretty heavy duty medications with serious potential side effects. For example, Veozah side effects can include stomach pain, dizziness, difficulty sleeping, back pain, and surprise: hot flashes! In December 2024 the FDA issued a black box warning due to potential tho rare serious liver damage. So, no thanks to that. I appreciate your reply!
Black box warning was due to one case of liver failure which reversed when the drug was stopped which is why it is we now monitor liver function tests. Side effects are quite rare. Biggest issue is coverage. And it only gets rid of flashes. None of the other benefits of estrogen . Another similar drug is about to get approved without liver issues. And no I have no financial relationship with the company.
i get that and good luck!