The Daily - Menopause Is Having a Moment

Episode Date: July 28, 2023

Some of the worst symptoms of menopause — including hot flashes, sleeplessness and pain during sex — have an established treatment. Why aren’t more women offered it?Susan Dominus, a writer for The New York Times Magazine, explains how menopause has been misunderstood both by doctors and society for years, and tells us what happened when her article about it went viral.Guest: Susan Dominus is a writer for The New York Times Magazine.Background reading: From The New York Times Magazine: Women have been misled about menopause.A selection of seven books to guide you through menopause.For more information on today’s episode, visit nytimes.com/thedaily. Transcripts of each episode will be made available by the next workday.

From The New York Times, I'm Brussels Bureau Chief Matina Stevis-Gridneff. This is The Daily. Today, New York Times Magazine writer Susan Dominus on menopause. She tells the story of how it's been misunderstood for years, both in society and by doctors, and what happened when her story about it went viral. It's Friday, July 28th. Okay, we're recording now. So I'm going to ask you a couple of questions.

And one of them is just if you could describe to me some of the symptoms that you experienced. Okay. So when I first started, am I going to say menopause journey? I think I'm actually going to. When I first started the menopause journey. The first thing that I noticed were incredibly heavy periods. Night sweats. Consistent, recurring.

Literally every two or three minutes. Uncomfortable. Hot flashes. I'd wake up in the middle of the night with my hair, my pajamas, the pillow and sheets soaked. I would just lie in bed awake all night, sweating with my heart racing. And I had small children, and what I really noticed was that things that normally wouldn't bother me that they were doing would send me into orbit. I also did notice I would get actual migraines during my cycles.

I'd also get high anxiety, so that was really affecting me. My first sign was definitely hot flashes, but then there was something that I hadn't heard about, which is all of the moisture in my body left the building. Like my eyes were dry. My scalp was dry. My nose was dry. My mouth was dry. And then just keep on moving down the body and just know that every single place that was once moist was now dry. I was born in the 70s and no one talked about menopause. It's not really spoken about. You know, I had told my doctors what I was experiencing and they just didn't really say anything about it. The doctor I saw was a younger woman, probably in her 30s.

She offered me supplements or anti-anxiety medication. I think for myself, I thought I just kind of pushed through it. Yeah, I would say it took me seven years before I got help. Treatment options. Did I have any treatment options? I talked to my doctor and I got the same whole kind of, there's cancer in your family, you're high risk. So there's nothing you can do except, you know, basically wear cardigans because they're the quickest sweater to take off.

So, yeah. Susan, you wrote a story for the New York Times Magazine this year that became one of the most read stories of the year. It got more than 3,000 comments on the article page, which is huge. And it ignited a really big, open conversation, which you yourself became a figure in. It was about menopause. Can you tell us why you wrote that story? I was interested in writing about menopause because even some of the smartest, most can-do women I knew, women who have tremendous agency and are great at research and are extremely efficient,

were completely baffled by the subject. They were confused about their symptoms. They were confused about how menopause works. And they were absolutely searching for anything that would help them with the symptoms in ways that were very rarely successful. And then I myself started experiencing some of those symptoms. I was having hot flashes that woke me up in the middle of the night and often sent me into kind of an anxious spiral. I was having strange discomfort in my abdomen. I felt sort of strained. My body didn't feel familiar to me. And I was really having problems with my abdomen. I felt sort of strained. My body didn't feel familiar to me. And I was

really having problems with my memory. Like what? So I started having trouble recalling names, sometimes words. It was bad enough that my friends, well, really my sister was commenting on it. And I also thought it was a real thing. And I started thinking about a conversation I'd once had with a writer I really admire, someone who I knew had retired pretty young. When I saw her at a party at some point, I said to her, why did you stop writing? And she said, because of menopause. The words just weren't coming.

And I honestly think I got like almost like a little chill at the time. And I've, you know, I've thought about it ever since. So what did you do? So it was time for me to see my OBGYN anyway. And I thought, you know what, I'm going to bring these issues up with her. They're enough of an issue in my life that I think it's worth talking about. And I sort of described what I was going through, which was, I would say, on my mind, but they weren't dramatic. I wasn't having 17 hot flashes a day. Some women do. But when I

mentioned them to her, I remember she said, we only treat significant symptoms. And I definitely felt a little ashamed that I had, you know, dared to complain about these issues. And I just was wondering to myself, like, well, all right, were they significant? What does significant mean exactly? I mean, they were significant enough to me that I brought them up, you know, that they were on my mind. And how did this doctor's appointment end? Like, did you end up asking for treatment? Did you push back on this concept of significant symptoms? No.

You know, in her defense, you know, doctors have such short windows. She had things to do, pap smears to take. I just, you know, felt a little bad and left, basically. mirrors to take. I just, you know, felt a little bad and left basically. So after that, I really wanted to start to get a handle on the material or at least to try to. I was confused. My friends were confused and I really wanted answers. And when I started researching the topic, I realized pretty quickly that the history of menopause in this country is sort of a history of misinformation or lack of information, lack of research. It's a topic that has just been so shrouded in ignorance, really, that it took a lot of work to unearth facts that are well-known to the medical community, but somehow haven't really translated into information for everyday women. Okay, so what is the history of menopause?

And how did you arrive at that conclusion? So far as I know, women have been reaching menopause since time immemorial. But we basically say that a woman is menopausal when a year has gone by and she has not had her period for that period of time. Perimenopause is the time leading up to that, which is a time of a lot of kind of intense hormonal fluctuations. It can last anywhere from four months to a decade. And interestingly, there's research that suggests that for Latina women and Black women, it can last even longer and start earlier.

But for a very long time, it was just something that women had to deal with. And menopause was not exactly part of the mainstream conversation until 1966 when a British gynecologist named Robert Wilson published a book called Feminine Forever. And it shifted the conversation around menopause and what could be done about it and suggested that hormone treatment which had been around for a few years but wasn't widely used could keep women young and beautiful and sexual and the book was also sort of empowering in that way but it was also a little bit promising that maybe they'd be easier on their husbands and they'd also be more

desirable and there was this idea, you know, take estrogen because it'll make your husband's life better too. So for example, he writes, quote, all postmenopausal women are castrates, end quote. But he said that if a woman were to use estrogen, quote, her breasts and genital organs will not shrivel. She will be much more pleasant to live with and will not become dull and unattractive, end quote. Wow. So it's like, here's this thing that will help alleviate women's suffering, but basically we're just

going to package it with men in mind. I think he was doing something complicated, which is he was genuinely helping women feel empowered about their sex lives. But it was, I think, at a moment in time when you couldn't just empower women. You also needed to reassure their husbands, maybe that there was something in it for them as well. But women seem convinced and they start taking it in droves, frankly. There was a brief blip in the mid-70s when doctors realized that taking estrogen alone increased the risk of endometrial cancer.

So then they started adding in progesterone, which helped address that concern. And after that, I would say hormone use resumed full force. By the way, Glenn Miller played Songs that made the hit parade resumed full force. You know, over the years, it became, you know, part of popular culture. There's a famous episode of the classic TV show from the 1970s, All in the Family, in which poor Edith, the mother of the family, is really suffering from menopausal symptoms.

Hey, Edith, there you are. Gee, we're waiting here. We're starving. Don't rush me, Archie Bunker. You get your dinner on time. You always get your dinner on time. And they show her being unusually irritable and angry with everyone. What's the matter with Ma?

I was going to ask you. You know, she's going through these mood swings. You know, she starts taking these little pills to help her that the doctor prescribes. Ah, she'll be all right. These are these hormones, which by the way, the hormones are pretty hot stuff, you know. And so the culture really was reflecting the reality of just how commonly prescribed hormones were at that time. I've taken control of my life and I keep up on things that affect my health, like estrogen loss and menopause. Lauren Hutton, who was at the time a very admired

former model turned actress, was featured on a commercial for hormone therapy. Ask your doctor what you can do to protect your health during and after menopause. Believe me, the time to protect your future is now. You know, one doctor said that people believed it was so great for women's health that this one doctor told me she had it in one of the slides she would present saying that estrogen should be in the water. Oh, wow. Meanwhile, as menopausal treatment is becoming incredibly popular, there was a faction of activists who were really concerned that we really didn't know what the health benefits were or the risks because there had never been a large randomized controlled trial to study that. And so in the mid-90s, the National Institutes of Health, led by Bernadine Healy, the first female leader of the NIH, started this massive, massive randomized controlled trial

that would include research on the health benefits and risks of estrogen and progestogen. on the health benefits and risks of estrogen and progestogen. So this is a significant investment in researching this basically critical stage in every woman's life that so far just hadn't really been understood all that well. Yes, there's no doubt that this was a really important moment in women's health history, I would say. So they recruit these thousands of women. They randomize the users of the hormone. They have control group.

It's going along. And then in 2002, the people in charge of the trial call this huge press conference. For the millions of women taking or considering the combination hormone therapy estrogen and progestin. Finally, some conclusive answers. And they announced that they are abruptly stopping the trial because they had found they had reached a certain threshold of risk for women who are using the hormones such that they had no choice but ethically to stop the trial. Wow. The government is shutting down a major study of hormone replacement therapy in women because of serious health concerns. The combination of estrogen with progestin does not improve long-term health because there's increased risk of breast cancer, of heart attacks, stroke, blood clots. They found

increased rates of heart disease, of clotting, of stroke, and of breast cancer. In the study, compared to women taking placebo, those on estrogen and progestin together had a 22% higher risk of heart disease, 26% higher risk of breast cancer, and a 41% higher risk of stroke. And as you can imagine, this was very, very big news. Tonight, the wonder has come out of hormone replacement therapy. percent higher risk of stroke. And as you can imagine, this was very, very big news. Tonight, the wonder has come out of hormone replacement therapy. I think the majority of women taking this combination therapy will be told by their physicians to stop. There's just this sense of dire concern that these risks were elevated and women responded in droves to this fear. And they were calling their doctors,

they were throwing their hormones, you know, flushing them down the toilet. So it sets off basically a panic. Yes. One doctor I interviewed said that she remembered when JFK was shot, she remembered 9-11, and she remembered the day of the WHI press conference because she had never received that many calls in one day. So clearly this is a huge shift for women. And I have to imagine it comes with some anger that women were sort of given this treatment that was supposed to help them. But now they're thinking it's actually putting them in danger of grave disease like cancer.

Yes, I think that's exactly right. And I also think a lot of doctors felt a lot of guilt that they had been prescribing this so aggressively to women of all ages under the assumption that it was going to be this kind of miracle cure. Right. And so because of this press conference and the huge impact that it had, women really stopped asking their doctors about it. Doctors, not all, but many,

kind of stopped prescribing it or recommending it and started discouraging women from using menopausal hormone therapy. And medical schools pretty much stopped teaching it. Oh, wow. And menopausal hormone therapy basically just fell off the map. But here's the thing. There's a way of looking at all that information that is much more nuanced and allows much more for women's agency. And because of the way the information was delivered and the way it was

interpreted by the medical community, millions of women probably have suffered needlessly over the decades since. We'll be right back. So Susan, you said that the findings from that big study and the risks of hormone therapy, that the way they were presented led to a misinterpretation. How exactly was the study misinterpreted? So there were several ways. One thing we do know is that the public has a pretty poor understanding of how to think about risk statistics. So, you know, if a woman's risk of having breast cancer between the ages of 50 and 60 is around 2.33%, If you increase that risk by 26%, which is what the study did fine for the

women who were on those hormones, then you get something like 2.94%. And that is an increase, but it might be small enough of an increase that for some women, it would be a risk they'd be willing to take. And it's a risk level that only kicks in after five years of use or so, by the way. So I think there was not a lot of context. And when people hear something like a 26% increased risk, maybe they think, oh, that means I have a 26% chance now of getting this cancer, or they don't know what the starting point is. So it's hard to interpret it without really getting into the nitty gritty, but those things are really important. And there were a lot of good things that came out that were overlooked in the aftermath of this huge news story about how dangerous they were. So there was research

that suggests that for women who start hormones in their 50s, you know, before the age of 60 or within 10 years of going through menopause, that there actually could be cardiovascular benefits if they started taking the hormone earlier rather than later. And there was another arm of the trial that only studied women who had had hysterectomies who did not need to take progestogen. And those women actually had a decreased risk of breast cancer and overall better long-term health outcomes, which is meaningful because something like a third of women by the age of 50 have had hysterectomies. Other research came out that found that using hormones

could lower the risk of diabetes, and we certainly knew it lowered the risk of osteoporosis, which for many women is really important in terms of quality of life, in terms of mobility. But it wasn't the job of the people conducting these trials to of quality of life, in terms of mobility. But it wasn't the job of the people conducting these trials to evaluate quality of life issues. That's not what they intended to do, and it really wouldn't have been appropriate. But because that countervailing issue wasn't ever presented, I think it got lost in this larger dialogue. So actually, a better version of

the coverage could have been something like hormone therapy could mean increased risk of breast cancer and other things like stroke or blood clots. But that risk is still limited and most importantly should be weighed against the benefits that we know that women experience through this treatment. But instead, it was conveyed as representing this huge risk. And so no wonder everyone basically stopped taking it. I think that's really accurate. It was understood to be a really dramatic, really scary risk. And epidemiologically across a population, it's not nothing. It is a thing. But just there was no context and there was no opportunity for women to have the agency to think in an informed way about what that risk was. So when you begin to engage in this question

for yourself and you look at what your options are, you're basically walking into a world that's sort of still dealing with the aftermath of this misinterpretation and misunderstanding. Yeah, I was walking into a world in which, although there were always doctors who did prescribe menopausal hormone therapy, it was really not well understood by doctors who were coming up. There were plenty of doctors who just were like, yeah, you've reached menopause, nothing we can do about it. I do think that there was a lot of sort of casual suck it up tone, you know, that took over. And to me, it sort of merges with the general misogynistic ageist reality that older women are the last group. It's agreed can be the target of

insensitive jokes, jokes about their undesirability, for example. It's just this feeling that older women are not treated with respect and care. What do you think, Blanche? Am I through with my cycle? with respect and care. What do you think, Blanche? Am I through with my cycle? Well, I'd say menopause is a pretty good guess. You're about as puffy as the Pillsbury Doughboy. Especially dealing with menopause or breast.

Oh, forget it. Men just die. Call her Hot Flash Drew. I am so hot. We even age out of the bad things, like being fetishized or diminished or talked down to. It's even worse. You're invisible. And this must be your mother.

My wife. You're shamed. You're unseen. Oh, grody. Then, menopause. A 67-year-old woman in China gave birth this week. The birth set a record for most friction. You and I, I have to be honest that Jake Silverstein came to me,

my editor at the New York Times Magazine, the editor-in-chief, wanting me to write a big story about menopause. And it's fascinating to me now that I actually hesitated. I actually wasn't sure that it was a topic that I wanted to be too closely associated with. You know, my college friends, when I told them that, they said, but that's why you have to write the article is because it needs to be destigmatized. And of course, they were 100% right. And I'm glad that I did because not only was it a pretty fascinating

inquiry to me, at least, but it also brought me up to speed on the range of options that are now available to women who are seeking relief for menopausal suffering. Like what kind of options? So there's really been a lot of development of other kinds of ways of administering hormones for women who need care. There are patches that are lower doses. There's a micronized progesterone that it's hoped that that's closer to women's own progesterone such that perhaps the risk of breast cancer might be lowered. And for women with a cancer history who are not strong candidates for menopausal hormone therapy,

now there's a drug on the market, hopefully insurance will eventually cover it, called Vioza that is a non-hormonal option for treating hot flashes. And there are new ways of getting good care from doctors trained in menopausal health, by telemedicine, there are new ways of getting good care from doctors trained in menopausal health, by telemedicine. There are online subscription services that make it extremely easy to get access to the hormones. And obviously, these things take time. I think it's going to be a big learning curve, both for doctors and how to make this information

available in a way that is both concise but nuanced and for patients to learn that this is something that they have the right at least to consider. Right. But also in the culture, especially in the past few years, there's been a new conversation about menopause itself. We're talking about what my friend Maria Shriver and I call the Big M.

You know, Oprah has talked about it. I, too, am a hormone taker. Michelle Obama has talked openly about it. Just hot flashes. I mean, I had a few before I started taking hormones. I remember having one on Marine One. So I do think there's really positive change in all of this. You cannot outrun. You cannot out-earn. You cannot out-exercise. You cannot out-yoga.

You cannot out-fox the Big M. You cannot. The menopause train is coming no matter what. So by the time my article was published... This article just came out in the New York Times. I think what I wrote really kind of hit a nerve. Women have been misled about menopause. But that was a nerve that was already a little bit live before I got there. Susan, let's start with you because I've even had friends who've asked me about it as recently.

Unless you live under a rock, you most likely have seen it or been sent it by a friend. It seemed to really connect with women who wanted a lot of information in one place. One of the best things as a woman in menopause I have ever read. You are going to see yourself in the stories. And a lot of, I think, frankly, voicing of what they had been going through. I just think it was a quick way to convey to people around them that menopause is no joke, you know, that it is a real thing in women's lives and it needs to be taken seriously. And it's shocking, frankly,

that it hasn't been talked about from the rooftops for longer than it has. So your article clearly struck this nerve, but I'm wondering if you know whether things have actually shifted inside the doctor's office for women who are literally going through this right now. So I do think for women who are going through this now, I'd like to think that the door has been open for more of those conversations by the work that's been collectively done. I mean, just, you know, some doctors have told me that they have a QR code that they give to women so that they can read the article. Doctors have told me they now have waiting lists because so many people are

coming in to talk about something that they didn't realize was even a topic of conversation they should be engaging in. I don't know. I personally found it very moving that my friend's daughter, a college student, read this article. To me, the idea that she's going to go through life feeling like this is not a mystery, that she has some answers, that she knows the range of things that she might expect. For me, it always just felt like this wave that was eventually going to come at me and I would just have to kind of figure out how to ride it whenever I got there. Was it going to mean I would stop writing? Was it going to mean that I felt nothing as many women do? Many women have minimal symptoms. It's my hope that the information is out there and that women going through it don't just feel more empowered, but like, you know, all women who are going to get there eventually.

Well, this woman has definitely been thinking about it in this conversation. And yeah, I do feel more confident and more informed to face what will happen to me. Yeah, I think what's exciting about this moment, and I do think that, you know, as the media says, like, menopause is having a moment. I don't think it's really just about menopause, and I don't think it's just about the symptoms, and I don't think it's just about the treatment, although all of that is really important. I think it's a moment of women who are older saying, we are important, and the things that we care about are important. And the things that we are talking about among ourselves, that's important not just to us, or at least it should be important to people other than us. will feed back into the doctor's office and will feed back into those appointments where women go to find solutions and discuss menopause and their symptoms. And their care in general. Yeah, I like

to think that there could be a kind of virtuous cycle in which, you know, older women feel that they are being heard in the doctor's office, which is, of course, not divorced from culture itself. They do interact and that their care in general might even improve. heard in the doctor's office, which is, of course, not divorced from culture itself, they do interact and that their care in general might even improve. Right. Like maybe they won't be just offhand rebuffed. Yeah. Like you were. That would be a good outcome for sure. You know, I want to be clear, like I'm really not here to advocate for menopausal

hormone therapy for women because every woman's health condition is different. Everybody's risk benefit analysis is different. Everybody's profile is different, but every woman should have the right to feel that there is time and space for the conversation and to have their symptoms taken seriously, whatever they decide to do. Susan, thank you. Oh, thanks so much for having me on. So, I'm curious, what did you end up doing? What did you decide for yourself? I am on... I'm taking estrogen and progesterone, pretty low dose.

And I have to say that my hot flashes have completely gone away. And I think I hadn't really appreciated how much they were bothering me until they did go away. But I probably won't stay on them for more than five years at most because I do have a slightly elevated risk of breast cancer given my family history. But I know that in five years, I will probably have to do some real thinking and having some conversations and gather information and, you know, make the best choice that I think I can make. We'll be right back.

Here's what else you need to know today. On Thursday, federal prosecutors added major accusations to an indictment charging former President Trump with mishandling classified documents after he left office, saying he told a maintenance worker at Mar-a-Lago to delete potentially incriminating footage from a security camera. delete potentially incriminating footage from a security camera. The charges appear to strengthen prosecutors' case against Trump in the classified documents case, as they prepare to charge him in a second case over his effort to overturn the 2020 election. That indictment is expected to come in the next few days.

And in the latest evidence of global warming, the month of July is now on track to be the hottest month in recorded history, according to climate experts. Last month was the world's hottest June, and so far 2023 is likely to be the world's hottest year, displacing 2016. At the moment, the eight warmest years in recorded history are the last eight years. Today's episode was produced by Lindsay Garrison, Sydney Harper, Olivia Nat, and Diana Nguyen, with help from Shannon Lin. It was edited by Paige Cowett, with help from Patricia Willans. Contains original music by Marion Lozano, Daniel Powell, Elisheba Etup, and was engineered by Chris Wood. Our theme music is by Jim Brunberg and Ben Lansberg of Wonderly. That's it for The Daily. I'm Matina Stevis-Gritneff. See you on Monday.