Reviewing "The M Factor" Menopause Documentary

Some Great Moments Marred by Misinformation

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I have finally had a chance to sit down and watch “The M Factor: Shredding the Silence on Menopause” on PBS. While not a professional entertainment critic, having done a docuseries, Jensplaining, I have some insight into the production that is involved. I understand that everything the team might want to include can’t make the cut and that some things an expert might feel are super important may be excluded because there isn’t time or it doesn’t fit a narrative. 

One aspect of the documentary that caught my eye was its promotion on social media as “the first ever menopause film to earn CME accreditation,” or credits for continuing medical education. To medical professionals, CME accreditation is supposed to mean the content has been vetted as accurate, any new or controversial claims have been clearly identified, and all conflicts of interest have been reported. To the public, the claim of CME accreditation adds a veneer of medical authenticity and credibility. If it’s good enough for doctors to learn from, it must be good enough for a layperson. 

I was mildly annoyed to find out that the film itself is not accredited, meaning a doctor can’t watch it at any time and then answer some questions and submit paperwork for credits. I was suspicious when watching the film the first time as I saw none of the typical disclosures needed for CME accreditation, such as conflicts of interest or identification of off-label use of products. Instead, the CME accreditation came from watching the film AND viewing a webinar discussion with two of the medical experts from the film. Only when you visit the site for the webinar do you finally get to see the financial disclosures and the declarations of off-label use of medications. This marketing bait-and-switch irritated me because there is a big difference between the film itself being certified and the film plus a webinar that includes more content and the disclosures being CME certified. 

The basic theme of the documentary is that menopause isn’t discussed enough, many aspects are under-researched, many doctors are unprepared to help women, and consequently, many women suffer in a variety of ways. All of this is important and handled well. There is a cursory review of the biology and the symptoms of menopause, which I felt could have been more in-depth. Throughout the documentary, we hear from several women who have suffered, either because they were told their symptoms weren't bad enough or would resolve, or because they struggled to get care, or both. These real-life stories are important and are effectively interspersed throughout the hour. 

There was excellent medical content from physicians Dr. Stephanie Faubion, Dr. Sharon Malone, Dr. Wen Shen, and Dr. Sherri-Ann Burnett-Bowie. Dr. Faubion accurately stated that menopause hormone therapy isn't a panacea, and for most women, the benefits outweigh the risks. Dr. Malone was clear that you get to decide what suffering and bothersome symptoms mean to you. We saw Dr. Shen with a patient who had been previously told that she wasn’t a candidate for MHT, but in actuality, she was, so there was an important discussion about a lack of education among providers. In addition, Dr. Lisa Mosconi, a neuroscientist, also provided insight into how the brain changes during menopause. 

There was an informative and outstanding discussion of racial and ethnic differences in the menopause experience, and it was great to see this important and neglected aspect of menopause get the attention it deserves. Dr. Burnett-Bowie and Dr. Malone discussed some of the differences in the menopause experience for Black women, Dr. Shen addressed experiences for Asian women, and Dr. Yamnia Cortés, PhD, discussed experiences for Latina women and the impact of stressors. Omisade Burney-Scott, creator of the Black Girl’s Guide to Menopause, also provided excellent information and insights and discussed the impact of adverse childhood experiences (ACEs) and racism. I loved her focus on a holistic approach and the space she creates for the spectrum of menopause experiences. There was also important information from Dr. Deirdre Cooper-Owens, PhD, and Omisade Burney-Scott about the terrible legacy of medical racism. 

The documentary also included an interesting discussion about menopause in the workplace. We heard how Genentech is thoughtfully considering menopause benefits. There was also mention of new funding for research courtesy of the Biden Administration, but we didn’t learn what might be funded. 

While there was a lot of good information, and I think many women will feel seen, which is important, unfortunately, the documentary also had some problematic content, so let’s get into it.

Breast Cancer

At the beginning, there is a news clip that says there were previous concerns that menopause hormone therapy caused breast cancer, but “new data being released now shows that isn’t the case.” In addition, we heard from two doctors that MHT doesn’t cause breast cancer.  

Here’s what we know. 

Estrogen-only menopause hormone therapy may or may not be associated with a very rare increased risk of breast cancer, and Premarin by itself without a progestogen has no risk at all and likely reduces the risk. However, most women do not take estrogen-only MHT; they take estrogen plus a progestogen, which is associated with a risk of breast cancer. While observational data suggests progesterone might pose a lower risk than a progestin, this is not based on clinical trial data, so we must be careful when discussing this. 

The 2022 Hormone Therapy Position Statement of The North American Menopause Society states that estrogen plus progestogen or combination therapy has a “rare increased risk” for breast cancer, where rare is defined as between 1-10 out of 10,000 women per year. Most people quote 6 out of 10,000 women per year for the risk of breast cancer with combination menopause hormone therapy. This does not mean that women should be afraid of hormone therapy, and if you have symptoms that hormone therapy can treat, then the benefit-to-risk ratio is almost certainly favorable, but it also means that saying there is no risk is false. Zero and rare are not the same thing. 

Hormone Levels

There was what I can only describe as a baffling section about hormone levels. We heard that because estradiol levels could be as high as 500 before menopause and that they are less than 20 after menopause (I am assuming she means pg/ml), estrogen-wise, going from the menstrual cycle to menopause is like going from 6 cups of coffee a day to none. This analogy is head-scratching because women don’t walk around with daily estradiol levels of 500 pg/ml and then all of a sudden drop below 20 pg/ml with menopause. To a layperson, going from an estrogen level of 500 pg/ml and then abruptly to less than 20 pg/ml sounds scary, and based on this information, menopause sounds biologically problematic and then perhaps hormone therapy might be essential because who can go from 6 cups of coffee a day to zero? Isn’t one cup of coffee a day a reasonable option?

So much context is missing. While estradiol levels may be as high as 500 pg/ml right before ovulation, that’s temporary. In addition, during the menopause transition, hormone levels are erratic, and symptoms during this time are often not due to low estrogen but rather the hormonal chaos. In addition, estrogen levels are almost as low as menopause at the start of the menstrual cycle. If I were to cherry-pick another point in time of the menstrual cycle, I could just as easily argue that no woman should ever have hormone therapy because they do fine with low levels of estradiol on day one of the cycle, and that would be just as incorrect as the point presented in the film.

This concept of your body being used to estrogen so it is safe is a natural fallacy; just because women have estrogen before menopause does not mean it is safe to take a pharmaceutical estrogen; what tells us that pharmaceutical estrogen in menopause is safe is research. And really, that distinction matters. 

Dr. Somi Javaid claimed that after menopause, the goal for estrogen levels is “greater than 20 and less than 100” (again, I am assuming pg/ml). No menopause society recommends measuring hormone levels to manage MHT. However, I was not surprised by Dr. Javaid’s recommendation as she founded HerMD, and when I interviewed a physician there last year, I was told it was their practice to check blood levels to manage MHT (click here to read my previous review of this non-evidence-based practice at HerMD).   

Was this part about checking levels not fact-checked, or was this a bad edit? I don’t have the answer, but the end result is that this does the women who are watching and every evidence-based menopause provider a massive disservice because women are going to think hormone levels matter, and this sets them up for disappointing conversations in the office or the possibility of getting substandard care.

Overhyped Benefits of Menopause Hormone Therapy for Prevention of Cardiovascular Disease and Dementia

We heard from a couple of providers that menopause hormone therapy is important for the prevention of cardiovascular disease and dementia, but the current menopause society guidelines do not support this indication. Dr. Mary Claire Haver was particularly emphatic, stating, “We know that it is protective against cardiovascular disease. We know it's protective against neuro dementia.”

The same 2022 Menopause Guidelines that Dr. Haver referenced in a correct claim that the benefits of MHT outweigh the risks do not recommend MHT for primary prevention of heart disease and dementia. I am always annoyed by this kind of cherry-picking. If we “knew” that MHT protected the heart and brain, the guidelines from several medical societies would clearly recommend MHT for the primary prevention of heart disease and dementia, but they do not. 

On the page for the CME certification, there is a disclosure by Dr. Haver for unlabeled use of estrogen and progesterone, which I am guessing refers to her claims about the heart and the brain:

We had an entire session at the 2024 Menopause Society Meeting about how the 2022 Guidelines don’t recommend MHT to prevent dementia (I wrote about that information here), and it was reinforced that those guidelines are current. And just last month, misinformation on social media about claims that hormone therapy protects the heart and the brain reached such a fever pitch online that the Menopause Society issued a statement about it, which states:

Based on existing science and clinical evidence, estrogen-containing hormone therapy is not recommended for primary prevention of cardiovascular disease or dementia in women who experience menopause at the average age.

It’s disappointing to see emphatic statements about dementia included in the documentary, given the above statement and the research that has been published to date. 

While there is a possibility that some types of MHT might be protective for the heart, the data is far from certain here, which is why MHT is not recommended for primary prevention of heart disease. The typical, evidence-based discussion is to tell women at low cardiac risk that the data reassures us that hormones are safe and it’s possible they may derive some cardiac benefit, but the studies are conflicting. For people interested in knowing more about menopause hormone therapy and heart disease, I have a detailed post here.  

Testosterone

Testosterone therapy was presented as being beneficial for mood, muscle, bone health, and depression. I found this section highly problematic, as prescribing testosterone for these reasons deviates from every menopause society guideline, but this was not mentioned, which is, in my opinion, an unacceptable choice by the production team. 

Dr. Kelly Casperson was the sole provider interviewed for this section, and we heard how two of her patients benefited from testosterone, with no discussion of the placebo response rate with testosterone that is seen in studies. We also heard from a woman who was seeing Dr. Casperson because she had felt unwell and asked a previous provider to check her testosterone levels, which were low. The answer, of course, was testosterone, except guidelines don’t recommend checking testosterone levels due to symptoms or replacing it when it is low, so this segment could mislead both the providers who were watching to learn more about menopause as well as the public. 

Dr. Casperson also leaned into the “natural” fallacy, stating, “I think one of the most damaging things we did to women is that we made them afraid of something their body naturally makes. I think it's devastating.”

Sigh. Because the body makes testosterone or estrogen or thyroid hormone or growth hormone, for that matter, it does not mean these hormones are safe when administered pharmaceuticals; rigorous science does. And the best science that we have currently does not support the claims made here about testosterone. 

Sadly, there was no mention here of cognitive behavioral therapy (CBT) or mindfulness-based therapies for low libido, which are highly effective.

There Is No Discussion of Non-hormone Therapies, except for a General Comment that “Supplements are Good” 

It was disappointing to see estrogen and especially testosterone offered as the only medical therapies for symptoms of menopause. There was no mention of accepted nonhormonal therapies, such as neurokinin-3 receptor antagonists or gabapentin, or CBT. I don’t think I missed it because I watched the documentary three times and did a word search of the transcript. Thankfully, neurokinin-3 receptor antagonists and CBT were mentioned in the webinar, but sadly that won’t be seen by women watching at home. I don't know what was left on the cutting room floor, but it was a choice to spend precious minutes on prescribing testosterone outside of the recommendations and not on valid nonhormonal options. The cynic in me knows that testosterone gets a ton of attention on social media while non-hormonal therapies get almost none, so I know which content makes for better reels to share. 

Unfortunately, the only nonhormonal options we heard about were supplements. Gerianne Tringali DiPiano, the President and CEO of FemmePharma, said, “But there are also a number of products that have emerged that are what we would refer to as more natural products and supplements. There is good information in the scientific literature about some of these supplements and the way in which they can support women who are in the menopause transition.”

The specific supplements are not mentioned, just, I guess, you know, supplements. This makes it impossible to assess the veracity of the claim. Also, once again, we hear the natural fallacy with “more natural products.” Supplements are not picked from a supplement tree; they are made in a lab, and taking a pharmaceutical dose of a vitamin is not natural. Sigh. 

I found this general “supplements can be great” narrative especially troubling as several people involved with the documentary profit from the sale of supplements:

• Dr. Denise Pines, a producer, owns a menopause tea company.

• Dr. Mary Claire Haver owns “Pause Life supplements. I laughed out loud when I saw her products displayed on her desk but turned around so the label wasn't showing. 

• Dr. Malone has an ownership interest in Alloy, which sells a synbiotic supplement.

• Ms. Tringali DiPiano, is the CEO of FemmePharma, and I am sure it shocks you to learn that FemmePharma sells, yes, you guessed it, supplements. The person with a supplement store was allowed to make an unsupported claim about the benefits of supplements. I mean, come on. 

While we’re on disclosures, Tamsen Fadel, a producer, has an ownership interest in MIDI Health. Although the company doesn't appear to sell its own supplements, its website recommends many different supplements, and it offers compounded semaglutide, which was specifically advised against at the Menopause Society 2024 meeting. Sigh. 

Dental Health

Close to the beginning of the documentary, we heard from Dr. Teri Barichello, DMD, VP and Chief Dental Officer for Delta Dental of Oregon/Alaska, that “Nearly 30% of women in menopause will lose a tooth within the first five years of menopause,” but we learn little else about it. My concern here isn’t that we’re getting bad information; it’s more that this was a scary sound bite with no follow-up or context. Hearing that tooth loss could happen in the “first five years” left me thinking this was largely hormonal and something to perhaps act on urgently around menopause. Based on what I saw on Twitter, this statement frightened a lot of women, so I think it would have been good to expand upon it. For example, I wanted to know the rate of tooth loss for age-matched men, how investigators controlled for hormone status in evaluating tooth loss for women, and how other health-related concerns might be involved. I have no idea of the breadth and scope of the interview, so it’s possible all of my questions were answered but were ultimately cut, and it’s also possible that information doesn’t exist because of the lack of studies and everyone just needs to be better about brushing and flossing until we learn more.

The oral microbiome can change in menopause, the production of saliva can decrease, and a change in bone health can affect the jaw, so there are legitimate hypotheses to explore regarding dental health and menopause. However, I couldn't find a study specifically looking at tooth loss in the first five years of menopause, but I will contact the dentist who provided that information and will report back as I am really curious.

I did find the Buffalo OsteoPerio Study, an arm of the Women’s Health Initiative (WHI), and 28.7% of women who were menopausal lost at least one tooth over five years, but this study is not limited to the first five years of menopause; rather, the average age at the first visit was 65.88 years. Smoking, diabetes, baseline dental health, elevated BMI, and previous tooth loss were significant risk factors for tooth loss. In this study, hormone therapy was associated with a lower rate of tooth loss, and while statistically significant, it wasn’t as significant a predictor as other factors, such as diabetes, BMI, gum health, or previous tooth loss. It seems that over 5 years, with an average age of 65.88, 25% of women on MHT lost at least one tooth versus 32% of those not taking MHT. 

Dental health, it turns out, has a complicated intersection with hormonal health. There is apparently a popular saying that “pregnancy costs women a tooth,’ and a study from 2008 suggests that isn't an adage but is factual and independent of physical or dental care. On average, a woman will likely lose one tooth for each birth. There are various physiological reasons, but suffice it to say this is complicated, and I am super eager to learn more.  

Conclusions

Sadly, the documentary's many good points were marred by some significant misinformation, and I believe it’s unacceptable and unfair to put women in a position where good science and helpful information is presented alongside information not supported by the guidelines, especially when we know that the first piece of information people hear is the one they are likely to keep believing. Given the silence around menopause, this documentary may be the first piece of information many women and even healthcare providers receive. 

After watching the webinar, I felt the documentary would have been far stronger had Dr. Faubion and Dr. Shen had a bigger role in discussing the medicine. However, they don’t have a massive social media presence like some of the other doctors. 

A lot of the documentary is very good, and I’d hate for people to miss those parts. If you plan on watching, keep in mind my concerns and/or open a copy of the 2022 Menopause Society Guidelines or the Menopause Society Statement on Misinformation and the 2019 Global Consensus Position Statement on the Use of Testosterone Therapy for Women so you can fact-check for yourself. And remember, a documentary is a storytelling experience, not journalism.

References

Menopause Society 2024 Statement on Misinformation Surrounding Hormone Therapy https://menopause.org/wp-content/uploads/2024/09/TMS-statement-on-HT-Misinformation.pdf

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The 2022 Hormone Therapy Position Statement of The North American Menopause Society. Menopause: The Journal of The North American Menopause Society. Vol. 29, No. 7, pp. 767-794

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