The Vajenda: 2023 in Review

What Interested You, What Interested Me, and More

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Before turning the proverbial page on the calendar, I wanted to recap some of this year’s highlights and also revisit the five most popular posts of 2023 here at The Vajenda to see what I could learn.

As an aside, this is a great introductory post to The Vajenda, so if you have a friend who you think could benefit from some science-based medical content with a large serving of feminism, this is a great e-mail to forward. And if you are that friend, Hi, and welcome! I’ve also taken the paywall down for a few posts until January 1st, so read on to find out which ones and why and to get access.

A Community of more than 50,000 Strong…and Growing!

In December, The Vajenda passed 50,000 subscribers! Wow. Considering the rise of misinformation online, I am truly excited to see the number of people who want evidence-based medical content. Time and e-mail space are precious, so I do not take your support lightly. It’s also wonderful to see that The Vajenda has become a community, and I love seeing messages of support and people sharing tips and tricks in the comments. 

2023’s Most Important Moment in Menopause: Approval of Fezolinetant for Hot Flashes

I thought quite a bit about the “biggest” moment in menopause this year, and for me, it’s the approval of fezolinetant, a neurokinin-3 receptor antagonist (trade name Veozah), for hot flashes. You can read more about the drug in this post. The fact that pharmaceutical companies are looking at novel therapies for symptoms of menopause is not just exciting because more therapies are a good thing, but in the case of fezolinetant, it opened up a whole new understanding of the biology of hot flashes. How cool is that?

While estrogen is still the gold standard for hot flashes, not everyone can safely take estrogen, and for some people, the side effects aren’t worth it. And there are also people who don’t want to take hormones. More therapies mean more options. And who knows, with more research, in time, there may be more non-hormonal medications that are as good or even better than estrogen. Or perhaps another non-hormonal drug that researchers thought would be good for hot lashes might turn out to help joint pain or another symptom. That’s one of the great things about science; it’s simply exploration, and you don’t know where it might lead. 

The Most WTF Moment in Menopause: Anger About Fezolinetant

There are some people who hold themselves out as menopause experts who are upset about fezolinetant. I was shocked at some of the posts over on Instagram–a lot of “only estrogen is a worthy therapy” and thinly veiled “you are nothing without estrogen” messaging, which I find offensive and disturbing. I initially saw these posts months ago after the Super Bowl ad about hot flashes from the company that makes Veozah and again a week or so ago when it was approved in the UK. The idea that a medical provider would want fewer options for their patients is truly mind-boggling, and honestly, it’s a slap in the face to everyone who can’t take estrogen as well as for science and all women, because hey, aren’t we worthy of medical exploration? I wonder if these people have built a following and/or a profitable practice around the concept that menopause is a disease caused by low estrogen and that estrogen solves every health issue in menopause, so admitting fezolinetant has a place means their underlying message that you are doomed without estrogen isn’t correct. 

It’s true that fezolinetant is incredibly expensive (in the United States, anyway), and it’s valid to be upset about that, but every new pharmaceutical product is initially a cash grab. What has happened price-wise with fezolinetant is no different than with Brexafemme, a new medication for yeast infections. It’s possible to be angry about the cost and still think the drug is great and has a place in menopause care. 

Tuck “shitting on medical therapies for menopause that aren’t hormones” away as a red flag for disinformation about menopause care. It’s not whether a therapy is a hormone or not that matters; it’s whether we have rigorous data to show us it is effective and safe. And being upset about fezolinetant means someone is upset about menopause research, and I just can’t even… 

The Most Common Questions on The Vajenda and Over on My Instagram

By far, the most common questions here this year were about menopause hormone therapy or MHT. When to start, what to take, who should take it, troubleshooting side effects, etc. I found myself answering many of the same questions repeatedly in the comments, and not in a satisfactory way because these kinds of answers almost always require much more than just a paragraph or two. This prompted me to create a “Hormone Therapy Guide” for paid subscribers that I also affectionately refer to as a guide to the Hormone Menoverse. Each post is very in-depth (basically, a book chapter), and the guide starts with basic introductory content and then builds out, following the structure I use when discussing MHT with patients in the office. Unlike a book, it’s a living document where you can ask questions, and I can respond in the comments or sometimes with a new post/chapter. I am also updating posts as new, relevant studies are published. You can find all the posts and links in the Table of Contents, which also shows upcoming topics that I have yet to address. Keep asking questions because they give me ideas about which sections need subsections for deeper dives into specifics. While your question may seem oddly specific to you, in my experience, many others do as well when one person has a concern or question. To give you an idea of the content here, I’ve taken the paywall down until the end of the year for a couple of the most popular posts: Six Steps Before Starting MHT and Getting Started on Menopausal Hormone Therapy. 

The most common question I get asked on Instagram is about intermittent fasting and menopause. I receive a direct message about this at least once a day. If you aren’t interested in reading about weight or if this topic is triggering, please skip the next three paragraphs.

Intermittent fasting (time-restricted eating) is heavily promoted by some people as “the answer” for weight gain in menopause and/or around the middle. There are targeted ads, special diets, and even books that tell you that intermittent fasting is THE WAY. And, of course, there are seemingly endless Instagram posts on the subject. If you are looking at any menopause content on Instagram, you are almost certainly going to be exposed to miraculous-sounding claims about intermittent fasting, hence the questions I receive. 

Here’s what we know: weight gain in menopause is more related to age than hormone changes. Often, the promotion of intermittent fasting (and meal plans and supplements to support intermittent fasting) is associated with messaging about “hacking” hormones to “blast” belly fat (it’s always hacking and blasting, for some reason, which I find very cringe). Nothing hacks hormones…what does that even mean? Like the nebulous but fear-inducing toxins, it is never explained. It’s true that in menopause, the weight we gain does concentrate around the middle, but science doesn’t actually understand the biology, so making a claim that you have the one diet to rule them all is ridiculous. You can read more about it here in this post. 

We also don’t have studies that tell us intermittent fasting is a superior approach for weight loss in general or if weight around the middle is the concern. If we did, that would be in the guidelines from professional societies, and it isn’t. In fact, there was a lecture this year at the annual Menopause Society meeting on weight loss, and I specifically asked about intermittent fasting and/or ketogenic diets. The speaker confirmed what I have read in the literature, that these two strategies don’t provide any specific benefits, and any weight loss is the result of calorie restriction. If intermittent fasting or a ketogenic diet helps someone achieve calorie restriction, that means for that person it may be a good approach (as long as their LDL isn’t rising, which can be an issue with some ketogenic diets), but it is not THE approach, and if weight loss is your goal, you are not missing out on THE WAY by passing on intermittent fasting and/or a ketogenic diet.   

The Top Five Articles from 2023

The top five posts from 2023 are a good sampling of the range of content that you will find here at The Vajenda. One of the articles is paid subscriber-only content, but I will make it available through January 1.

1. Don’t Use Menopause to Excuse Mediocre Men. I wrote this piece after reading an atrocious advice column in the Guardian. A woman was stuck with a lump of a man for a husband and was getting rightfully very angry about his inability to participate in his own fucking household. The grand advice? It’s your hormones! Take estrogen.
   
   No, really, the answer to a man not doing laundry or helping with his own children was to take hormones. The woman asking the question wasn’t sleeping poorly because of hot flashes; she was rightfully enraged. The idea that a woman should take medication so she can continue to suck up living with a man-baby is enraging because A) he should be a functioning member of his household and B) the advice boils down to, no, it isn’t that he is as useful as a broken sofa, you are being too hormonal. And that advice came from a psychotherapist. Talk about gaslighting. I believe this post resonated with people because we are burdened by a lifetime of messages telling women their job is to make the world easier for mediocre men. I hear women tell me about their anger, and as they describe their burdensome home life, I can barely contain my rage for them. It’s true that some people can have mood issues in menopause, but sometimes anger at age 45, 50, or 55 (or any age) is simply appropriate rage. There is a trend of blaming everything on menopause, but sometimes it’s just that you are partnered with a mediocre man. 

2. The Daily Show’s OB/GYN Expert Had Sex With His Patient. This was a recent post, as in earlier this month, and yet it resonated so much that it made the top five. Michelle Wolf was guest hosting The Daily Show and displayed a clear bias about home deliveries. She interviewed an OB/GYN, Dr. Stuart James Fischbein, who thinks women should have the same medical care as animals because you see if a giraffe can drop her baby and keep walking, you can too! But that was far from the most enraging thing about the interview. Dr. Fischbein had previously been on medical probation for having sex with a patient less than two weeks after he had cut her abdomen open for big surgery for endometriosis. And then, a few days later, he had sex with her again. HE WAS GROOMING HER WHEN SHE WAS JUST A DAY OR TWO OUT FROM SURGERY AND IN THE HOSPITAL ON PAIN MEDICATIONS (yes, I am shouting). And then he made a movie trailer claiming that he was a victim (????) and called it…Bedside Man. Oh, and he lost his board certification for OB/GYN because of this. If this is the only doctor you can get to support your views, your position might need some rethinking (understatement of the year). Also, elevating him as an expert is misogyny. What was even more disturbing was the number of women defending this man on my Instagram. Internalized misogyny is a real mind fuck. 

3. Genitourinary Syndrome of Menopause is a recent post and an entry in the Hormone Menoverse series and is available for everyone until January 1, 2024. I think this post was popular because genitourinary syndrome of menopause is still woefully under-treated, and inexcusably, not every provider understands the nuances of the therapies. For many people, the information in this post should be enough to get started on therapy, but there is a deeper dive into the estrogen products and more posts to come in this section. 

4. Misinformation about Bioidentical Hormones, the Complicated Legacy of Suzanne Somers. While many people, myself included, have fond memories of Suzanne Somers in Three’s Company, for many OB/GYNs, she leaves another legacy that is not laughter but the genesis of harmful misinformation about so-called bioidentical hormones. Somers was the OG of hormone grifting, gleefully promoting poorly constructed hypotheses as medical empowerment. One of Somers’s experts, Dr. Prudence Hall, was put on probation by the Medical Board of California for unprofessional conduct, gross negligence, and repeated acts of negligence regarding her prescribing of so-called bioidentical hormones. So, there’s that.

You can read the full report here. 

Interesting side note, GOOP currently recommends Dr. Prudence Hall as an “integrative and functional” OB/GYN.

This is not a recognized medical specialty or subspecialty. I could call myself an integrative and functional OB/GYN or certify people in it if I so choose. There is no accredited training or exams; rather, the idea is to create the illusion of scholarly work. Regardless, it’s an interesting choice to recommend someone as an expert on “bioidentical hormones” who has been in trouble with the medical board and caused very real harm by prescribing those exact medications.

Here’s my #1 tip when researching any medical expert: check to see if they have ever been put on probation by their licensing body. This doesn’t happen often (it should really happen more), but when it does, the full report from the medical board is often startling, and it’s something you should know if you are to be fully informed. 

5. My Open-Minded Approach to Alternative Medicine. I’m often accused on Instagram of not being open-minded about alternative medicine, so I wrote a post about how I think women deserve science-backed therapies, not fairy tales. In this post, I make the case that we should be calling alternative medicine what it really is: under-studied or unproven therapies, which, of course, makes it sound way different. If you haven’t read this piece, please do. It’s my personal favorite from the year.  I really like this quote from the article:

Being open-minded means being open to the evidence, it doesn’t mean accepting an understudied or unstudied therapy because someone who profits from it says so. And it’s not just the companies that profit, every naturopath, functional medicine doctor, or functional nutritionist that charges you for the privilege of getting this care is also profiting from the appeal to natural and ancient therapies and conspiracy theories about Big Pharma. The real question should be, why aren’t people promoting so-called alternative medicine doing better research?”

Personal Achievements and the Year to Come

I was asked by The Menopause Society to write a Practice Pearl on laser therapy for Genitourinary Syndrome of Menopause. The short take is that it doesn't seem to be effective, but there is a high placebo response rate, so studies that don’t include a placebo or sham arm are essentially worthless. You can find the Practice Pearl here.

I also finished my latest book, Blood: The Science, Medicine, and Mythology of Menstruation! It is my longest and most in-depth book, and it is a response to the explosion of menstrual profiteering on Instagram and in the office, from naturopaths, functional nutritionists, menstrual coaches, chiropractors, influencers, and so-called functional and integrative doctors. As always, my answer to misinformation, disinformation, and the gaps in medical care is medical empowerment through facts. I am proud of this book and can’t wait to share it with you. It’s received starred reviews from both Publisher’s Weekly and the Library Journal (which is a big deal in the book world). Check them out:

“Gynecologist Gunter (The Menopause Manifesto) delivers a superb overview of “the menstrual cycle and the medical conditions and therapies with” it. …Gunter is a sharp critic of the ways in which menstrual complications have been dismissed by the medical establishment (she notes that despite painful periods affecting a majority of women, they are often dismissed as “exaggerated and a sign of weakness” while “billions of dollars of funding” are showered on erectile dysfunction), and her talent for explicating the biology of periods will engage even the scientifically uninclined. Filled with piercing social analysis and enlightening science, this one’s a winner.”—Publishers Weekly STARRED Review.

“Requisite reading. A no-nonsense, educational, science-backed, in-depth title about menstruation and the impact it can have on one’s body. This title will empower readers to better understand their bodies and to advocate for themselves in medical situations.”  - Library Journal STARRED Review.

Blood will be available on January 23, 2024, but you can pre-order here. And there will be a Blood book tour (which sounds very metal, and I am here for it). I will be in several cities across the U.S. and Canada and will also be heading over to the U.K. Come and ask a question, get a book signed, and hang with an evidence-based crowd. 

Final Thoughts

Thank you for subscribing, sharing, commenting, and asking questions! I have some great posts coming up, and I hope to squeeze in one more (about an interesting new study on hormonal contraception and mood) before the end of the year. 

Happy New Year!