The Dr. Hyman Show - Millions of Women Stopped Taking Hormones Because of a Misread Study | Dr. Sharon Malone

Episode Date: May 27, 2026

For far too long, many women have been told their symptoms were normal, exaggerated, or simply something they had to live with—treated as isolated problems instead of part of a much larger hormonal transition happening inside the body. On this episode of The Dr. Hyman Show, I’m joined by Dr. Sharon Malone, host of The Second Opinion podcast and Chief Medical Advisor at Alloy Women’s Health. We discuss how menopause and hormone therapy became so misunderstood, the real story behind the Women’s Health Initiative study, and why a more individualized, prevention-focused approach to women’s health is long overdue. Watch the full conversation on YouTube, or listen wherever you get your podcasts. We explore: Why so many women enter perimenopause completely unprepared—and how symptoms can begin years before menopause officially starts What the Women’s Health Initiative actually found, and how one medical narrative reshaped women’s healthcare for decades How menopause affects far more than reproduction, including the brain, heart, sleep, metabolism, and bone health What you should know about hormone therapy today, including timing, individualized treatment, and understanding risk in context The daily habits that still matter most for healthy aging, whether or not you choose hormone therapy Midlife health should never be reduced to “just deal with it.” The more women understand what’s happening inside their bodies, the earlier they can take steps to protect their long-term health and quality of life. View Show Notes From This Episode Sign up for Dr. Hyman’s Brainshaping Academy to learn how to nourish the biological systems that support your mental, emotional, and cognitive health - ⁠Click Here⁠ Get Free Weekly Health Tips from Dr. Hyman https://drhyman.com/pages/picks?utm_campaign=shownotes&utm_medium=banner&utm_source=podcast Sign Up for Dr. Hyman’s Weekly Longevity Journal https://drhyman.com/pages/longevity?utm_campaign=shownotes&utm_medium=banner&utm_source=podcast Join the 10-Day Detox to Reset Your Health https://drhyman.com/pages/10-day-detox Join the Hyman Hive for Expert Support and Real Results https://drhyman.com/pages/hyman-hive This episode is brought to you by Paleovalley, Pique, Perfect Amino, Rho, Sunlighten and BIOptimizers. Head to paleovalley.com/hyman to save 15% off your first order today. Secure 20% off your order plus a free starter kit at piquelife.com/hyman. Go to bodyhealth.com and use code HYMAN20 to get 20% off your first order. Head over to rhonutrition.com and use code HYMAN to get 20% off their entire product line. Visit sunlighten.com and use code HYMAN to save up to $1600 today! Head to bioptimizers.com/hyman and use promo code HYMAN at checkout to save 15%. (0:00) Introduction, survey on hormone use, and Dr. Sharon Malone’s expertise   (4:04) Importance of women's health research and historical neglect   (5:35) Lack of education and preparation for menopause   (6:28) Societal and historical biases in women's health   (9:05) Observational studies vs. randomized controlled trials   (13:30) Life cycles, hormonal changes, and stages in women   (19:26) Detailed stages of hormonal changes and perimenopause   (23:00) Misdiagnosis and definition of menopause   (25:02) The term "postmenopausal" and its significance   (26:34) Impact of menopause on organ systems and major symptoms   (31:19) Lifestyle factors and hormone therapy options   (39:25) Black box warning, Women’s Health Initiative, and therapy timing   (45:00) Women's Health Initiative findings and breast cancer risk   (47:57) Reinterpreting breast cancer risk and black box warning   (53:21) Personalized hormone therapy and clinical diagnosis   (59:55) Importance of estrogen and bioidentical vs. synthetic hormones   (1:03:35) Addressing sexual health and testosterone use for women   (1:08:05) FDA-approved peptides for women’s arousal disorder   (1:09:57) Long-term benefits of hormone therapy   (1:12:43) Early menopause, hormone therapy, and health impacts   (1:15:07) Estrogen’s role in brain health and dementia prevention   (1:16:22) Alzheimer’s risk in women and hormonal 

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So the black box warning for hormone therapy was what? It will increase your risk of heart attack, of stroke, of dementia, breast cancer. You can't apply that same data from 79-year-olds and 65-year-olds to 45-year-olds. They're not the same. Over night, I think 50 million women stopped hormones, which created a catastrophe in the country. So let's talk about that. There's a survey that found that 66% of women really are completely unprepared. Estrogen affects every major organ system in your body, and it starts with your brain.

The sooner you start it, the more benefit you get. But let me say this. When you're talking about libido issues, the first thing you should always address are... Dr. Sharon Malone is a nationally recognized women's health expert, board-certified OBGYN, and certified menopause practitioner serving as chief medical advisor at Alli Health. With decades of clinical experience, she's become one of the leading voices advancing evidence-based care for women in midlife and menopause. you've been dealing with anxiety, low energy, or trouble focusing, and still feel like you're missing something, you're not alone. That's why I created the Brain Shaping Academy, a new program

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Right, Sharon, welcome to the podcast. So good to have you here. Well, thank you so much for having me. We're both here in San Francisco at a women's longevity health summit. And thank God, because women have been a neglected species in medical research. Or ever. You know, what's really striking to me as a doctor is, and it's changing, thank God. But for most of the history of medical research, we've basically been studying 70 kilogram

white men from Kansas. And they don't apply to everybody else. And so a lot of the research we have unfortunately doesn't really reflect what's happening in a broader population of women and women of color and women of different size, shapes, and ages. And it's really unfortunate because we really have neglected women's health.

I learned in medical school very little. I mean, I learned all the diseases, obviously, but I didn't learn about women's, quote, health. How do we restore health and function and optimize women's health through their life cycles. And there are life cycles. There's, you know, pre-puberated puberty. There's, you know, reproductive age, premenopause, perimenopause, menopause,

post-metapause, all these different stages, kind of different than a guy. I mean, guys go through this slowly. Yeah, you're pretty basic, you know. Pretty basic. And they go, yeah, pretty trickle down, you know, with andropause, which is not quite different. What's really interesting is that most women don't have any education

about perimenopause or menopause, they don't know what to expect. There's a survey that found that 66% of women really are completely unprepared. And even the women who go to see the doctor don't get good information and don't get good advice. And they want help for symptoms of hormonal dysfunction

or hormonal imbalance and 75% leave without a treatment. And I would say probably the other 25% leave with probably the wrong treatment. It's really a place. A lot of women really feel ignored by the health care system. they don't feel taking care of. And it's unfortunate.

And I think, you know, women are underserved, under-informed. And I think this conversation we're going to have really matters. And we're going to kind of dive into topic of how do we help women understand what's happening in their bodies throughout their life cycles? How do they get best prepared

for the different stages? And how do they feel most vibrant, alive, and healthy, not just treating disease. There's a difference between treating disease and optimizing health. And a lot of your work is really around understanding how do we optimize health for women through the life cycles? And I think that's such an important thing.

So why have women been so invisible? And why are women going through menopause and doctors are so ill-equipped? Well, you know, I did a talk a couple of weeks ago where I did a deep dive into the history of medicine. You know, how did we get here? And I think from its very inception, you know, the whole misogyny and racism, is baked into the cake. It's not like that was an afterthought. I mean, all of it was looked at through the prism of the male body. And women were looked at as inferior versions of men. And that starts from the time of Hippocrates. I mean, we all, as doctors, take a, you know, the Hippocratic oath. We never really knew. What were we thinking at that time? Well, because women were considered not even just different. We were the lesser of the two. Yeah. And that's why we were never really given the consideration.

And that went on for almost 2,000 years that that vision of what women were, we were not to be considered. We were looked at really only from our ability to reproduce. And if you couldn't do that, then what's the point? It's true. There were almost a few matriarchal societies in the world, but most were patriarchal. Yeah. Yes. Up to this very moment, we were still living in a patriarchal society.

But, you know, it's changing. And it's changing because I think there's more awareness. And we can't change a system if we don't understand how it started, how we got here. And I think that that's becoming more part of the conversation now. Why have women been left out of research? Well, it depends on who's making the decisions. Yeah. You know, that's why I think that when we talk about diversity, we talk about diversity of opinion.

diversity of curiosities. And, you know, it matters who's in charge for what you're going to study. It's true. You know, and you and I are sort of about the same demographic age. We graduate residency around the same time. And it was in the kind of early 90s. And during that time is when we had a new NIH director that was the first woman, Bernie and Healy, who was an iconic thinker and said,

hey, wait a minute. There's no research on women. We had some, like we had the nurse's health study, but this was not a randomized controlled trial. This was just a population study where they looked at trends over time. They couldn't prove cause and effect. And we made a lot of inferences from that study,

which was done out of Harvard with Walter Willett and really good scientists, but you cannot prove cause and effect. And a lot of assumptions were made that ended up causing a real problem. My joke is that if we did a study of 55-year-old women who had sex, we would conclude that sex never leads to pregnancy. Right. Right. That's true. But that's 100% correct, but it doesn't, it's not true, right? And so

that's kind of what an observational study does. It looks at patterns in a population, but they may not reflect actually the underlying truth or biology. Most of what we know about women's health is really, as you say, from these observational studies or I think we're stills just sort of epidemiological studies where you after the fact have an observation and then go back and try to justify or figure out what the, you know, what the correlations were. And there's no way to prove anything from those types of studies. So I think that Dr. Healy really brought some academic rigor to the conversation where she said, you know, if you're really going to prove this, yes, we at that point, we had had 50 years of data on hormones and women, but we didn't really.

really have the ability to say, yes, this is indeed true because of our hormonal changes. And can you just unpack for us how we got, you know, so confused? Because the nurse health study is just a great example of, you know, a good study with the wrong conclusion. And in some ways, like, right? Why did this study show that women who took hormones did better, had less heart disease, had less cancer, had better brain health? There was a lot of things that it showed that made millions and millions and millions, tens of

millions women got on hormone replacement therapy. And in fact, when I was, you know, working in that time period, I was in giving a lecture and this woman said, my doctor said it's malpractice not to give, you know, hormone replacement therapy with permanent pro vera, which is, you know, kind of what was the current prescriptions at that time. Right. Well, the biggest problem is that there's the healthy women bias. There you go.

had, you were studying nurses and you have to assume that nurses have a certain level of attention to their health that perhaps another person may not. And so that was really what the women's health initiative was trying to sort out. Were these women doing better? And they were. So, you know, that was the observation. But we didn't know why. Was it just the hormone therapy or was it all the other health benefits that come from being a healthy person? Yeah, they went to the doctor. They ate better. They took their vitamins. They ate fruits and vegetables. They were proactive about their health. And that's why they actually ended up on hormones because they went to the doctor and said, I want to get healthy. Exactly. But, you know, I say this, that with a lot of these studies, you can say, you know, you can prove the correlation, but you can't prove the cause. unless you actually do the work and do the data. So that and collect the data.

And that was what Bernadine Healer, and I have to say, you know, rest in peace, Bernadine Healy, because she did it. She was able to do it because she was a person that said, you know, I'm in charge here. Yeah. And then they started the Women's Health Initiative, which was like a billion-dollar study with 160,000 women, and it was a randomized control trial. And there were some flaws within problems we'll talk about. But before we get into that, I kind of, I had this thesis, and I want to set it out with you because, you know, I, I don't believe that God screwed up and made a design flaw in women to have them suffer from all these hormonal dysfunctions.

I don't either. Whether it's PMS, which affects 75% of women, or whether it's painful menstrual cramps or heavy periods or PCOS or severe menopausal, paramedopausal symptoms, I think there's, there's drivers of those things that are neglected in medicine. And basically, traditional doctors are trained only in two things. Give the pill before menopause and give, you know, basically premen and probera after menopause or at menopause. And there's a lot of other options to help people and women particularly feel better.

So can you kind of walk us through the life cycles of women, this four stages you talk about premenopause, perimenopause, menopause, postmenopause, and help us understand what's actually happening in each of these? Well, you know, I think that, you know, something that you said is that you don't think that women, you know, are inferior versions of men and all this. And that is a relatively new thought. Yeah. Because, you know, you said God didn't create women to be inferior. But the reality is, is that for forever, since we've been reading the Bible, that was really how women came about. We were taken from the rib of Adam. We were punished. You know, the pain of childbirth was punishment for making Adam, for tempting Adam into, you know, even that apple. I guess I don't know my Bible that well. Yeah.

I mean, that's why women, you know, a lot of the things that we believe are really biblically based. You know, why are black people inferior? Why were they slaves? Well, because it was the curse of ham, you know, and that. So a lot of that really, like I said, it's. It starts from the very beginning, and it moves this way forward, and we are still trying to, you know, sort of lose some of that, you know, perspective about where women came from. But we were punished. That's why.

That's why women were always, you know, felt that when you had your menstrual cycle, you had to be, you know, isolated from society. God forbid, you couldn't be touched. You were unclean. All of these negative connotations about what happens with women started very early on. But getting to your question. But I think those were things that related to more of like the menstrual cycle and seeing being as unclean and having to be ostracized from society. Those aren't necessarily the like true suffering of all these crazy things that are

happening now for women, whether it's endometriosis or PCS or infertility or, you know, bad menstrual cramps or, you know, all these different things that are going on that seem to be diseases that I don't think always were existing in the people population at the level that we have now. And I think I'm just going to be just straightforward with my opinion. I think it's because of our crappy diet, because of environmental toxins, and because change the ribat microbiome, all these things affect hormonal function. And they're not taught about and they're not treated within traditional health care. I think they always existed. They just weren't recognized. And again, I'm no biblical scholar. However, let's go back to Abraham and Sarah. Sarah was barren. You know, we talk about barren women all throughout

the Bible. Why were they? Oh, you know, endometrials, I don't know, but I'm just saying. I'm just saying that that is these things that we know that women have suffered from for time and memorial, they had no names. They had no names. No one was paying attention to it. And whatever it was, there was also this prevailing notion that you were just being hysterical or it's all in your head or you're just, you know, being a woman. By the way, hysterical for people listening, the root of hysterical hysteria is, we call it.

hysterectomy is the uterus. So it's related to the female uterus is the word hysteria. And that was a thought. Our female organs, the things that quintessentially made us female, were the things that also made us crazy and suffering and all this thing. So, yes, that's still there. I wanted to share something personal about my own health journey. Now, while back, I went through a period where I was recovering physically and working hard

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I think the average woman in 2026 understands that basic and first hormonal change that we go through doing puberty. Okay, so you go from being pre-pubital before you get your first period, then you have your first period. But even before you get your first period, there is that transition. you know, that's not the first sign of puberty. Girls start to, you know, grow hair in, you know, pubic regions under their arms. They get breast butts.

A transition from being a girl to being puberal. Okay, we understand that. But to give you some perspective on how little. That's also happening a lot earlier, too. So there's a lot of weird stuff going on with, you know, environmental estrogens, toxins. Yeah. So we understand that. But I want your listeners to know how recently.

That conversation was because a generation or two ago, girls would go through puberty and have no idea what was happening. And imagine you're a little girl and you go to school one day and then you just start bleeding. Of course, you think, my God, I'm dying or something's terrible. So that conversation. And their mothers would never talk to them. Never said a word. Didn't understand pregnancy. Didn't understand what led to what.

And that's why you saw so many young girls who did not understand. Well, imagine that was how that phase of life was even dealt with. And, you know, we've said, you know, probably not a good idea. And we've evolved and we make sure that young girls understand the transition so they know how to prepare for it. They're not, it's not something that's alarming. Okay, that's the good news. Yeah. Then you make it through your, what I call premenopausal years, which really starts at puberty and goes for most women until their mid-30. maybe early 40s. That's pre-minopause. And your peak reproductive years are somewhere probably in your 20s and early 30s. Okay. Then there's this thing called perimenopause. And if you think about it, it's that same transition like you have to transition from being pre-puberal to puberty. When you're perimenopause, you're transitioning from your reproductive years to your post-reproductive years.

And that process is what women have been left in the dark about. Because you think you just go from one to the other. No, it's a years-long process. And for some women, it can take as long as a decade. For black women, perimenopause starts earlier. It lasts long up to a decade. And to not be prepared. And when there's so many symptoms you can have during perimenopause,

many of which we associate with menopause, but they start happening much sooner. And they're not misdiagnosed. Right. And you think, oh, I'm depressed or I'm anxious, I can't sleep, or, you know, changes in my libido. All of these things start to happen that really are divorced from what's going on with your period.

So you think that, you know, everybody associates menopause with, okay, I'm not going to get my period anymore. Well, what if all the symptoms of menopause can start showing up a decade before? You can see how there was confusion and you get misdiagnosed. If you're depressed, here's an antidepressant. Oh, I'm, you know, I can't sleep. Here's a sleeping pill. We sort of have been picking off women's symptoms one at a time without understanding that it all sort of falls under this rubric.

And women would be, I think, much more tolerant and I think much less distressed if they just understood it's a natural process going from one place to the other. And once you get to menopause, and so we've gone through premenopause, now we're in perimenopause, a transition of a years-long transition. And then once you get to menopause, that just means that's the end of your fertile period, no more. And technically it's defined as a year from your last period, right? And you know what? I don't, that definition. Yeah, it is.

That is what I learned as well. But in today's world, that definition is so woefully inadequate. Because it implies that you're not menopausal until you've gone 365 days. And it's like, no, you were menopausal at whatever moment it started. But that is just the marker by which we divide and say, if you bleed more than a year after your last period and you start, then that is the time that we should investigate that bleeding. Right. But it has no real. Because it could be uterine cancer or something else.

But it has no biological significance, really. You know, it's just how we look at it. But there's so many ways to be menopausal that really don't tie to that at all. Well, a lot of women have IUDs. Guess what? Yeah, IUD. You haven't had a period in years. How do you know?

Women have had ablations. Women have had hysterectomy. And ablation is when they, when they carterize the inside of the area, except you have heavy bleeding so you don't keep bleeding. So there are, or you've been on birth control pills. There are a lot of different ways that, you know, you can go through that transatlary. transition, and it has no bearing on what's going on with your menstrual cycle. So that's where I think we have to change that definition because it really doesn't.

Well, because we also, like, medicalized a lot of things. So basically it changes the natural history of these things. Yeah. And then once you get to menopause, and this is just my little, you know, pet peeve, I don't like the term postmenopausal. I don't. Because once you're menopausal, and if we define that as, you know, no longer, the end of your fertility, either naturally or otherwise, you're menopausal. Saying that someone is post-menopausal

implies that whatever the, whatever goes on in menopause stops after your symptoms stop. And they don't. Well, let's talk about, let's talk about this because I think, I think there's, you're right.

Like I've seen women, you know, just go through with no symptoms and then fine and everything's great. I've seen women start, you know, like 10 years before and having, you know, all these disruptions. and symptoms, hot flashes, vaginaldritis, libido changes, mood changes, sleep issues, and irregular periods, heavy periods, you know, just every kind of symptom you might imagine. And they're often, like you said, very dismissed or they're medicalized and treated as something else,

or they're not, I don't think, adequately sort of diagnosed or treated. So can you talk about how this whole process of menopause affects every organ system in the body, not just reproduction, and what the consequences are if it's not handled properly in terms of in terms of the long-term risk of disease, in terms of the short-term symptoms that women have to suffer from, and I personally believe it's criminal to not take care of women in a way that relieves their suffering. Because we have the tools. We know what to do. And there are so many women walking around with so much suffering from all these hormonal dysfunctions that we know what to do with.

I think that you're right. Women have been, you know, like I said, in terms of neglected, in terms of their symptoms, minimized and dismissed. That's a given. But when you get to this point in life, we have looked at the hormones or the lack thereof or even this transition as being just about reproduction. And it's not. You know, women make estrogen in a cyclical fashion throughout their lives once they finally get their periods. And that estrogen affects every major organ system in your body. And it starts with your brain, your brain, your skin, your hair, your eyes, your heart, your bones.

you know, your vascular system. And we have not really looked at menopause through the wider lens. We've looked at it from a very narrow prism, you know, only as it affects the reproductive system. And oh yeah, by the way, now we know that it affects bones. But we're kind of late to the game in terms of getting to the real effects on what's happening to women's brains. And that goes back. to what I was saying earlier is that people haven't been asking the questions. We just sort of accept that as, oh, well, it's getting older and it's not just getting older. It's that change in your reproductive system. So kind of highlight the major cyst symptoms that women might experience. And then talk about like the consequences of not adequately treating women with the right types of hormone therapy. We're going to get into what that looks like. Well, let's start with the one that everyone knows hot flashes. You know, hot flashes is the most common.

80% of women will, going through this perimenopause and menopausal transition will have hot flashes. 20% don't, lucky you. But hot flashes themselves have been treated as jokes. Oh, here's a woman. She's flashing. You know, look at her, you know, and women were embarrassed by hot flashes. But this is why I say hot flashes are not benign. because if you have hot flashes and night sweats,

what does that mean? Can't sleep. You can't sleep. You can't sleep. Guess what's happening to you the next day? You're in a bad mood. Your brain is foggy. We've been residents.

We all know what it feels like to not have a night's sleep. You're not in your best frame of mind the next day. No, cranky. And then sleeplessness increases your risk of mood disorders. It increases your risk of hypertension. It increases the risk of maladaptive behaviors because when you feel bad, you self-soothe or Medicaid. Or that's your relationships. Right.

You drink. You overeat. You do all of these things. It also, people who have really severe hot flashes, you know, these are things that increase your risk of cardiovascular disease down the road. Oh, absolutely. Type 2 diabetes. sleeplessness, all of these things go up in women because of the downstream effects of the hot flashes. If you don't sleep, you crave more carbs and sugar.

Exactly. I know that one. I was going to say, we understand that. They were in the emergency room like 2 a.m. And the only opening was McDonald's. And I would go and get the apple turnovers because I needed some sugar. Because, you know, you get it. Because, you know, when I was a resident, I used to say the same thing. I can only, I can't be hungry and sleepy.

It's like one of the other. So you're going to do something. I'm going to drink Coke. I'll drink whatever it is to make myself feel better in the short term, even though it has not good effects later on. But those are the kinds of things that we talk about when we're talking about cardiovascular disease and women and why it goes up. And the cardiovascular disease risk does not go up for women until after menopause.

Before that, that's why we've also lived with this notion that women don't, don't experience heart attacks and cardiovascular disease at the same rate as men. We do. It's just 10 years later. Yeah. Because of what is happening with menopause. And so women having all these symptoms, and, you know, they get vaginal trinous, they get libido, they get mood changes, they have sleep issues, and it really impacts her life. And, you know, my experience, treating women more nutritionally with lifestyle is that those modalities are so helpful like if women smoke if they drink if they don't exercise if they eat tons of sugar if they have so much stress if they're you know exposed to a lot of environmental toxins all these things disrupt hormonal

function and balance and they exacerbate symptoms so there's a lot of even aside from just giving that hormone prescription there's a lot of things that that women can do to reset their hormonal balance and feel better. Sometimes that's enough. Sometimes it's not. And so if we do all those things, and I've written a lot about that, and I'm sure you talk a lot about that as well, when women need to start thinking about hormone therapy, can you help us kind of frame how they should start thinking about it? Because, you know, my, this is, again, my understanding and looking at the literature, is that the hormones that were pushed on women, which is prescription, premen, which is pregnant mare's urine. That's why they call

Premarin pregnant mare's urine, which is conjugate estricians, has very different biological effects than bioidentical hormones. It increases inflammation, increases triglysteryase, it increases clotting risk more than other forms of hormones that are what the body actually makes. And the same thing with the

synthetic progesterone or progestins like Provera, which my joke was it makes women depressed and have facial hair and gain weight. So it makes them fat hair and depressed. So I don't like that. And so I found that using using a very more, more nuanced approach to hormones, where it's personalized, where it's often topical, not going through the liver, where it's as low dose as possible to achieve the effect, or it's in the bio-identical forms, often works better. And there's, there's, you know, FDA-approved versions of those, and there are things

that I tend to lean on more. And I'd love to hear your perspective on how you think about it, because there's vaginal estrogens, there's top of estrogen, there's testosterone, unbiased for women, and so many people having questions about this. I would really love to hear as an expert how you think about this approach. So it's just a one-size-face-all, okay, you're pentapausal, permanent pervarice you later, and if it doesn't work, good luck. And, you know, I'm going to take an unpopular position here because I'm going to take the privilege of age, because when I started, because, you know, I feel like I have seen every permutation of hormone therapy,

that there is. And when I started in 1992, I inherited a practice from two 70-year-old men. 70. 70. Oh, yeah. Yes. They were, they were prescribing hormones in the 60s. Imagine this. So I'm a brand new resident, you know, and I know what I know.

And, you know, you're never more sure of yourself than right after you. I know everything. I know everything. I'm good now. And I had these women day one. who were 80 years old who'd been on hormones since 1969. Yeah. And I was like, and I was appalled because I was like, oh, my God. Then we had just sort of figured out that you can't give estrogen by itself to women who have a uterus.

Remember that the addition of the progestogen was a relatively recent, you know, onset. So that happened like in the 80s. And when I saw these women who had been on primord for 30 years, I was like, oh, my God, they're, you know, they're all going to die. Well, because just for people listening, you don't know, if you give what we call unopposed estrogen, unopposed by progesterone, it increases the risk of uterine cancer. That's exactly right. And guess what? They were all fine. You know, I came in and I would say, oh, my God, I'm the new doctor and they've been seeing this doctor for 30 years.

And I say, well, we've got to add a progestin and, you know, right on. and they were quite reluctant, but I convinced most. But the point is, I've seen women who've been on primarin for 30 years, and they were doing fine and they were great and didn't, you know, and weren't bent over. So yay for that. And then when we got to, by the time I started, we did have, we had bioidentical estrogens then. It was another name brand. It was estrace, which was estradiol.

Right. And we had primarin. Primarin had better name recognition. It was a bigger company. More marketing. Definitely better marketing. And so Primarin had been the hormone that we had been using for the longest since 1942.

Okay. So my objections to Primarin have little to do with the effectiveness of Primarin. It works. It works. For symptoms, but it causes other downstream problems. No, not necessarily. because even the women's health initiative, all of the positive things that we know. Sure, bone health and brain health.

Yeah, yeah. All that comes from Premarin. Yeah, for sure. That was the only medication used in that study. So, you know, I think before we say, oh, you know, Primerin's terrible. No, it's not. It's estrogen. It works, you know, it has different combinations of estrogen.

It's not bioidentical. However, all of the good things that we know about what hormone therapy does really comes from Perman. And we've extrapolated a lot of that data to Estradial because remember, there's not another big, large-scale study after that. So that's one. And that's my beef. I wish that the Women's Health Initiative used by identical hormones. I really wish it did. And there are some smaller studies that have. And they actually do so benefit. And I don't disagree. Because, you know, even then, I didn't use Permanent nearly at the rate that my predecessors did simply because, and again, this is personal, has nothing to do.

with this. I didn't like the fact that it came from pregnant mayor's urine. Right. You know, I'm like, well, okay, you can get one from horse's urine or one that's not. Okay, I would choose the one that's not. But that's the, that was my objection. And then also there's cost. You know, because Primarin is branded. It always has been and probably always will be. So it's much more expensive than others. And then when it comes to what we know about the women's health initiative. When we look back and we look back now, we have 22, 23 years of data to look over, we found that, okay, it's not the estrogen. Oh, look at that. Estrogen doesn't cause breast cancer. Estrogen doesn't cause a lot of the negative things that we have been ascribing to hormone therapy.

We said, well, then if it's not the estrogen, it must be the progestin. It must be that nasty little provera that was in that pill that the women were taking. And to that, I would say yes and no. You know, I would say all things being equal, I would take the bioidentical. But what we also have to eliminate is some of the fear moving forward because micronized progesterone is great if it works for you. Some people don't tolerate micronized progesterone. So if you don't, I don't want women to sort of get into this notion or even doctors to feel like, progestin's bad. It's so bad.

No, it's not. It's, you know, it's a different one. It works for some people. The majority of women should and probably could use bioidenticals. But don't take that off the table because if you do, you're sort of doing the same thing that. Well, you have a toolkit. You have a toolkit, right, with a lot of different tools. A lot of different hormonal applications, right.

Variations in the formulations, the types of estrogens. You can use estriol, estradial, astrond. as drone, all these different ones that are available for people. And there's, you know, obviously, the synthetic progesterones or progestions and natural bioidentical progestions. But I think that the question is, when you're working with a woman, how do you start to think about when and what to do? Because when you look at the data, they do seem to,

there's some new data that seem to affect that it's better to start. It's different times if you want to get certain benefits. And, you know, the thing that just maybe we should just, unpack is this black box warning that came from the FDA because it's what got people really scared. And I remember, because I was practicing really heavily with women that during that time, when that study came out and that stopped the study, they literally stopped the study because they were concerned about the harmful effects. So they had, that's a big deal. And overnight, I think 50 million women stopped hormones, which created a, you know, a catastrophe in the country.

How well I know. Yeah. Right. And so we kind of had a back. Now we're kind of coming back to a more coherent way of thinking about it. And I'd like you to unpack, you know, how you think about prescribing hormones and which hormones and for whom and what the benefits are. Because the women's health initiative did show that increased stroke and it increased heart attack. And there were some... Did it, though? Did it? I mean, that's what they said, right?

Okay. And I'm going to tell you it didn't really say that. Because the effect sizes were small or the... The effect sizes were small, and they were as prescribed. Remember, the women entering the Women's Health Initiative, the average age was 63. You could be anywhere from 50 to 79 years of age to be in that study. They didn't really even say, all right,

these are women who've never had hormones before, and now we're going to give some hormones and some not. The criteria for entering and being randomized you just had to not have taken hormones for three months before entering the study. Do you see what I'm saying? So the population was really murky. They were too old. That's not how we're prescribing today.

We prescribe what we do know is that the earlier you start treatment, the more long-term benefit you get. And is it riskier to start it when you're older? Well, yes, there are some. You get less benefit. And I don't think it takes any leap of faith to understand that if the, the, purpose of the women's health initiative was to sort of figure out whether or not the hormones really were the secret sauce in reducing the cardiovascular disease. Because when the women's, when the nurses study, 50% decrease in the heart disease in the women who took estrogen.

Okay. Is it that or is it something else? And to have women come into the study at 79 years old, I think we can all agree that it doesn't matter what I give you. That horse is out of the barn by then. And by having too many women who already had established heart disease, well, how are you going to prevent something that you already have? Yes, it's like they didn't do angiograms on everybody and see what the hearts look like. Exactly. Exactly.

So when you stratify, even the women's health initiative, when you looked at the younger women who were in the minority, but the younger women did not have an increase in the risk of cardiovascular disease. All of the bad things, the only finding from the women's health initiative that was statistically significant was there was an increase in the risk of blood clots. Yeah, blood clots. But there's a heart attack as a blood clot, right? No, but yeah, but that's separate.

This is listed as separate in part because it's DVTs or deviant thrombosis or pulmonary embolite. And that was reported separately. But estrogen does mechanistically cause an increase in clotting risk. We know that. Yes, yes, it does. However, again, perspective matters. You need to know to say to someone that it's a 50% increase or 100% increase, well, what's the baseline? You know, and what we do know is that for women who start estrogen, even oral, earlier, when you're 40s or 50s, when you start, that increased risk of blood clotting that we don't have it.

We don't see it. It happens when you're older. And so a lot of the findings from the women's health initiative that were negative, even the cardiovascular disease was elevated, but only in the first year and not after that. Because, again, you're probably giving something to women who already have fairly advanced heart disease. What about the breast cancer risk? Ah, the breast cancer. Because that's what freaks them out. That is the number one reason why women avoid hormone.

Oh, cardiovascular risk. I don't care about that. It's the breast cancer. That was the, that was really the nail in the coffin. Yeah. Because it did show some increased risk, right? That's what they reported at least. Okay. Let me tell you. That's what the public said. Oh, trust me. I've been in the weeds on this for so long. I'm just framing it so people know. It's like I'm not just saying. No, no, no, no. That was what they held press conference. That was the headline. That was the press conference. Oh, not only does this, you know, they held a press conference. when they stop the Women's Health Initiative to say, oh, not only does it not help your heart, it increases your risk of blood clots and heart disease and strokes and it went on and on and on.

Well, that's very scary. And I would challenge anyone to give me another example of when the NIH, the regulars of NIH, held a press conference to announce a study. I mean, that's how big of a deal they thought that was. And I'll also mention that Bernadine Healy was not there at that time. So we're going to give her a pass on that. Okay. But here's the breast cancer story.

And I will say this. The data is the data. You don't get to change the data because you don't like it. Okay. You can change your interpretation of the data, but it is what it is. But let's take it at face value. What did the women's health initiative say about women who took estrogen, the primarin, and the provera?

All right. They reported there was a 26%. increase in the risk of breast cancer in estrogen and progestion users versus non-users. 26%. That sounds terrible. Who wants that? That's relative risk. Living a long and healthy life isn't about chasing shortcuts. It's about focusing on small daily habits that support the body at the cellular level, circulation, recovery, repair of your cells, which are the foundation of long-term health. And one ritual I built into my own routine is using an infrared sauna. Infrared works differently than a traditional sauna instead of just

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research is starting to look at how certain forms of magnesium may support brain health and sleep quality. Now, one randomized clinical study, adults who took a brain-available form of magnesium reported improvements in sleep quality and daytime functioning compared to placebo. Now, magnesium is one of the most common nutrient deficiencies I see and low levels can contribute to stress, poor sleep, muscle, tension, and low energy. And the challenge is that most magnesium supplements only contain one or two forms, and they're not always well absorbed. And that's why I recommend magnesium breakthrough by bioptimizers. It's a full spectrum formula that includes seven different forms of magnesium, designed to support your brain, your muscles, your stress response, and your

sleep. I take it as part of my evening routine. Try today and go to bioptimizers. dot com slash hymen and use the code hymen at checkout to say 15% off your order. That's B-I-O-P-T-I-Z-E-R-S dot com slash Hyman and use the code hymen. But what did that mean in real terms? That means for women who did not take estrogen and progestin, 30, the natural incidence is about 30 per 10,000 women per year will be diagnosed with breast cancer, living long enough to get it. In the estrogen and progestin, user group, it went from 30 per 10,000 women per year to 38 per 10,000 per year with no increase in the risk of dying from your breast cancer, even if you were diagnosed on hormone therapy. So let's make that sound a little better. All right, eight per 10,000 additional cases of breast cancer.

And that's 26%. That's 26% with no increased risk of dying from it and then make it even better. less than one and a thousand additional cases of breast cancer in the women who took estrogen and progestin. Now, that doesn't sound nearly as scary as 26%. Correct. But that was never really put into perspective. I think Mark Twain said there's lies or damn lies and there's statisticians. Exactly. And, you know, and there is, and when you put it that way, you say, oh, okay, well, eight and a thousand, but I'm no more likely to die from it, even if I'm, I'm taking hormone therapy. And even that statistic itself, and you and I know in a medical study, if you were going to report a finding, to call it a finding, it has to be statistically significant.

It was not statistically significant. But that stuck like glue. It's still with us today because doctors and patients still believe that a family history of breast cancer is a reason not to take hormone therapy. So that's just said, worst case scenario, let's, you know, put it on, blame the old bad, primarin and provera. Even that did not statistically increase your risk of breast cancer. And that is what has taken a long time for people to really understand those numbers. And because I remember the day that came out, it was 1992, and I had been prescribing for 10 years, well, 2002, and I had been prescribing for 10 years before that.

Yeah, me too. And patients were horrified. Oh, doctor, I can't believe you're trying to kill me with this stuff. And when I read the study, I said, wait a minute, it's not as bad as what they said. Yeah. And again, remember, applying that data, again, take it as it is, you can't apply that the same data from 79-year-olds and 65-year-olds to 45-year-olds. They're not the same. So let's talk about that because I think that I want to really help women understand our

newer thinking and what the newer data is around what to start and when because it has implications for brain health, for bone health, for heart health, for overall symptom reduction. The black box warning I want to talk about before we dive into all that. That's recent. It's a black box warning for people learning what that is. The FDA puts a black box on the drug label that says, if you're taking this, beware because it can cause X, Y, or Z. So the black box warning for hormone therapy was what? Warning, Will Robinson. It will increase your risk.

See, only you and I get that. Lost in space. But it will increase your risk of heart attack, of stroke, of dementia, breast cancer. Now, if you picked up your medication from the pharmacy and it said, wow, my doctor didn't say that to me, even for the patients who had an adequate discussion about it, they would read that warning.

go take it home and not use it. So the black box has heart attack, strokes, cancer, and dementia. Dementia, yeah. That sounds fun. That's, that's pretty, that's pretty discouraging, I would say. And, and as I said, going back to the original study, it never, they, remember, I told you, the only statistical finding that was significant was blood clots. Yeah. So how can you say all those things? So my point is that that was removed just in 2025. Well, I think it may be just off now because I think, you know, they had to go through all the inventory, the stuff that already added on there. Yeah. But now it's off.

And it's in the regular package insert. You know, every drug has, you know, risks and side effects that are listed in that long. Yeah. It's like thin paper that you could fold out. It's like a fourth million words on it. Right. With very, very small print. Yeah.

So it's in that part now. It's not on the box. Yeah. And that's what we're like, it took an act. I don't know, whatever, to get people to realize it's like, no, don't say that because you can't. That's not science. Given that's true, let's talk about the plus side here because I don't, I said earlier, I don't think women should have to suffer from hormonal dysregulation and symptoms.

We have a lot of understanding about what causes it from a lifestyle perspective, including things that are not really being well addressed in medicine, whether it's the microbiome or environmental toxins, because those do play a role. We know nutrition plays a role, exercise. sleep, stress, all those things, smoking, alcohol, people understand those. But, you know, what are we thinking about now is the right way to approach hormone replacement therapy? When should we start it? How long should it be given? What are the right formulations that work best? What are the options for women out there? I want to sort of dig into all this with you. Okay, well, this is the... Like kind of where the rubber meets the

the road. So perimenopause does not have a bright line that signals when it begins. A lot of it depends on, again, style, it's genetics, it's, you know, personal to you. So someone may be perimenopausal at 35, someone else may be perimenopausal starting that process at 45. And there's no blood test that's going to tell you, yes or no, you're in perimenopause. Perimenopause is a clinical diagnosis. So remember all those symptoms that we said, hot flashes, mood swings, night sweats, sleeplessness, you know, weight gain, all of those things that we associate with menopause can start in perimenopause even while women's periods are relatively regular. And perimenopause actually has three stages itself, early, mid, late perimenopause. Now, the question is, if I can't

diagnose it by blood tests and I can't really use periods as a, you know, as the defining factor of when to start, then how do you decide? History, history, history. The patient will tell you when she's perimenopause. If you're having any combination of those symptoms, and they are bothersome to you, then that is the time you start treatment. And we do have fairly robust data that says, even from the Women's Health Initiative and some other studies, that say to get the maximum benefit, the earlier you start in this process, the more long-term benefit you're going to get. But how we choose to treat those symptoms during perimenopause. Well, again, it will depend. It depends on what your other symptoms are. It maybe you have bleeding issues. Maybe someone else has more sleep issues. In that case, maybe I'll start with progesterone. So that is where, this is the art of how to prescribe. There is no one way to do it. You know the basic components. There's estrogen and there's a progestogen. But the mix depends on what your symptoms. are, how old you are, and what we're trying to fix. Maybe you're 37 years old and you're having

these things and you need birth control. Well, that's a case where we might use a birth control pills because it has estrogen and progestin in it. But that's why I said it depends. But remember, I want women to understand that it's a clinical diagnosis. If you're feeling that way, a lot of women will go to the doctor, get a blood test, and be asked the question, when was your last period? And you'll say last month and they'll go, oh, well, it's not perimenopause. Come back 365 days after you haven't had appeared. Right. Because we're not really trained well in this in medical school. Right. And in residency. Even OBGs, I don't think really have the right understanding of it. A lot of what I learned about this was really through not just what I learned in residency. We were taught more about it

and OBGYN, but it also is trial and error process. The experience of say, oh, well, that didn't work. Well, let's try this, but knowing that you have the full complement of estrogens and progestants. Okay. Well, let's bifurcate this into symptoms and disease prevention. Because on the other side of menopause is heart disease, breast cancer, osteoporosis, and dementia. As women experience that at a far higher rate. So I want to bifurcate it just for making people understand a little bit. How do we really understand this parametopausal period?

Because when I, you know, when I've been treating women, I find that, you know, the lab test you're right, can be all over the place. Like one day they're, look like they are, one day they're not. But I do often see this interesting phenomena that I want you to talk about, which is, is this sort of reduction in the progesterone in the second phase of the menstrual cycle. We call this a ludial phase. So we see higher levels of estrogen. and we see lower levels of progesterone.

Then you get this imbalance. And when you have high levels of estrogen, it causes more body fat, it causes more heavy bleeding. And when you have, for example, if you're overweight, if you're not a sugar, it causes a lot of estrogen in the body. I've seen this over and over. And so you get this sort of imbalance, and that causes a lot of these heavy bleeding symptoms

and really heavy cycles and things that we often see. So I would love me to sort of talk about that phenomenon or if you think it's not a thing because I think it's a thing. No, I think that you're right. What's happening is not that. Because you're having in obviatory cycles. Right. If you're looking at cycles, you're saying that the reason why when you're in perimenopause that the estrogen levels will sometimes overshoot is because normally it's limited by the amount of estrogen you make is limited by ovulation.

So since so many of perimenopausal cycles are in ovulatory, which means they get started, but you don't ovulate. That's also why your fertility is not good. But you'll have too much estrogen in the first half of the cycle, and the progestin, the progesterone that happens in the second half of the cycle only happens after you ovulate. That's right. That's what I'm getting at. So when you don't ovulate, your estrogen keeps going and then now you don't have that. That's why having someone who understands that says, well, if. this person, maybe giving them additional estrogen at this point is not helpful.

Maybe we need to supplement with progester. And lab tests can help because you can see if you do it in day 18 to 23 in that ludial phase of the second half of the cycle, you see, oh, God, their estrogen's really high, but their progesterone's kind of low from where it should be. Right, but you know what? This is what I would say. An experienced doctor doesn't even need lab work. I can tell by your history, if you come in and you say, God, my periods are going on for two

weeks and I'm heavy bleeding. Okay. Or are there longer? Right. Whatever the blood test shows me, ultimately what I'm going to do is I'm going to treat the patient and her symptoms. Right. I'm not going to alter it based upon what her blood results were. I can't, you know you can figure that out.

Yeah. So that's why I said it depends on what symptoms you're trying to treat. If you've got hot flashes and sleeplessness, the one thing that I will say, estrogen is the secret sauce. because it will, estrogen is the most effective treatment for that symptomatic prepose, vaginal dryness, you know, irritation, the mood swings. That's the estrogen that is most effective. So it's a matter of playing with that and saying, okay, if someone only has one thing to give you and they're going to prescribe the same thing if you're perimenopausal and the same

thing if you're menopausal and the same thing 20 years down the road, that sort of lets you know that they haven't really, what should I say? They haven't had experience with all of the things, and you just need to know what you need at that particular. Right. This is such an important point. It's personalized, it's customized, it changes at different periods of that transition. That's really helpful for a human understanding. You need to work with someone who really understands the nuance of how to understand your symptoms and what you're doing, what's going on, and how to properly address that and what the right combo is of different hormones. And I'd love to sort of of hear your perspective on whether people should be using it orally, topically, if it makes a

difference, if it should be bio-identical, not bi-identical, how much that matters, how much we know about it. Okay, so let's start from this place that I think more than, certainly more than 50 years ago, most clinicians are going to start with the bio-identical. You're going to use a bio-identical estradial, not one of the synthetic ones. That being what it is. And I even hate the term synthetic. They're all synthetic. It's just a matter of...

It's just the same molecule as your body makes. Exactly. Bioidentica means. As opposed to pregnant, urine, estrogen. Let's not use synthetic. So you're going to start there. Yeah.

Okay, so once you say, okay, estradial, it can come in as a pill, a patch, a spray, a gel, or even a vaginal ring. As a vaginal ring, you can put in, I think it leaves, leave it in for three months change. Those are your options. Those are your, those are just modes of delivery.

There are certain people that a transdermal may be preferable. If I were giving estradei, if I were giving hormone therapy to someone who's a smoker, I would say yes, let's do a transdermal because we don't need the extra first pass and the liver effect. If

I have someone who is not particularly compliant or they don't like to take pills or whatever, then I'll say, yeah, put a patch on once or twice a week, we'll do a patch. But again, don't take oral off the table because the overwhelming majority of women who take oral do just fine. And even though the blood clot risk is higher, it's higher of a very small number. You know what increases your risk of blood clotting the most of anything you'll ever do, pregnancy. Oh, yeah. Pregnancy, oral contraceptives, the amount of hormone that you take in hormone therapy after menopause pales in comparison to those two things. My daughter's about 26 weeks pregnant now,

and she called me the night and she's like, Dad, I have like chest pain, shortness of breath. I'm like, oh, she's an orthopedic surgery resident. I'm like, oh, my God. She's like, maybe I have a P. or pulmonarymism. Then God, she just had heartburn. Yeah. But see, she knows to at least be alerted to that possibility. Right. You know, so that's why I said oral versus transdermal, and there are other things, there are other non-medical considerations. And, you know, and I think they're legitimate.

Let's talk about sex. Okay, sure. Because I think this is a big thing. Lebeda goes down, vaginal trinous goes up. It's a big thing. And you read a lot about it now. we're talking about estrogen, we're talking about progesterone. Let's talk about testosterone and what your view is on that, how to use it, if it should be used, when it should be used, because

I personally found it extremely helpful for women and has also the side benefits. It increases bone health and other things. So can you talk about your perspective on testosterone for women? Okay. It's just one of those things that's out there in the ether right now? I will because I'm a little bit outside the general conversation on that, too, in terms of what I think about testosterone. But let me say this. When you're talking about libido issues, the first thing you should always address are the woman's menopausal symptoms, because if you're hot, sweaty, sleepless, you've got

vaginal dryness, and every time you have sex, you have a urinary tract infection, guess what you don't want to do? Have sex. There you go. So fix that first. So vaginaldrine is super easy to fix, even if you don't want to take oral. you can do vaginal estrogen, there's pills that you can stick in there,

there's rings, there's creams. Yes. Yeah, yeah. So everybody. So once we... And by the way, by the way, that doesn't really get it systematically absorbed that much. So people are worried about breast cancer.

No systemic absorption from the amount of estrogen that's in vaginal estrogen. It's minuscule. So it works where you put it. So it will work in the vagina, near the urethrin, because the urinary system is close right there next door. So it'll fix both of those, but you don't have to worry about overdosing. You don't have to worry about, oh, my goodness, I've had breast cancer.

I can't use vasiosis. And you need to use a progesterone or progester? No, no. Because there's no systemic absorption, unless you are taking systemic estrogen, you don't need to take a progestin. Okay, so that being said. I know that. I just want everybody else knows. So let's get to that.

So now I have a patient and I have addressed all of her symptoms. She's sleeping well. She's getting high. Yeah, yeah, yeah. No dryness. And she says, libido still in the toilet. Yeah.

That would be an instance where some point in the future, then I would say, well, let's give it a try. Let's try some testosterone. And again, what I want everybody to understand is the testosterone conversation is not new either. Testosterone, we had it compounded, but that's been around forever. This was, you know, I was prescribing. testosterone for women with low libido back in the 90s. So this isn't like, we just discovered testosterone.

But here's what I have found. And again, this is the experience part of it. When you are treating libido, it works really well for some women and not so much for us. Testosterone, yeah. And how do you, how do you? The problem is for men, there's a lot of FDAPR's sort of approved formulations that you can use that are pumps, that are patches, that are, you know, injections, it's all sorts of stuff.

For women, it's kind of not, it just, it's not available. And you have to kind of, it's the Wild West out there. Right. Well, it's, it's been up, it's been in front of the FDA a couple of times to get a female approved version of testosterone. And it's the same testosterone. It's just that a women's dose is a tenth of what the men is. So it's difficult sometimes to take the male version and get a tenth of pump. So you're compounding pharmacies and yeah. That's a case where sometimes we're generally speaking, I don't love compounded, but if you can't get it. Yeah, yeah. I've used compounded.

And I've not even topically, like I've had clitoral testosterone drops and they work really well. Yeah. You know, and I would argue with no one who says I've tried testosterone and it works really great. And I'd say yes, then of course. But again, that's the phase-in process. I would never start all three at once, even if decreased libido was one of your symptoms that you presented with. Because we fix one thing.

And we all know that libido with women is much more complicated. It's not a plumbing issue necessarily. It's a lot of things that go into. People say women's greatest sex organ is between their ears. Exactly. Exactly. The other thing I want to just touch on briefly is, you know, we're in the world of OZempec and peptides.

And there's actually an FDA-approved peptide for women's arousal disorder, right, by Lisi. By-le-Ci. Never used it. Never prescribed it. Never prescribed it. Because you don't think it works or because you don't know about it much? You know what? No, it was, you know, when I was practicing, we had two options.

We had Addie and we had Bileisi. And it's the same sort of situation. I'm one of those people that I'm like, show me, okay? And, you know, I have prescribed Adi to a couple of patients. Vileisi, when you, this was, now remember, this was pre. That's a pill. I mean, bylisi is an injection. It's an everyday pill.

Yeah, and Raleisi is an injection. So this is pre-Ozimic. Most people were not sold on that idea. And you could, it's on an as needed basis, but every time you have to say, well, 30 minutes before you're going to have sex, go get this, take this shot. And women are like, no, thank you. So it was less, you know, that's why I've had this experience. It does work, though. It does work.

And I, you know what? It works for men too, actually. It works for men too. That's great if it does. But like I said, I was never able to convince someone that that was a good option. By the way, I've tried it. I'm telling you it works. Okay.

But I don't know how it works for women because I'm not a woman, right? I will take you work for it. I've never used it. But I think that the libido issue for women, again, is something that's been sorely unaddressed. I think we can all agree that men's libido and their ability to perform has been an outsized conversation. And we've not really paid attention to women's libido and the same, with the same level of importance and the same level of distress that it causes for. No, it is. And we should. Yeah. And we should do better.

So we've talked about all the vaso motor symptoms, the irregular bleeding symptoms, the sleep symptoms, all those can be addressed with those combinations of, various estrogen, progesterous, topical, oral, vaginal. Let's talk about the importance of understanding the timing of starting hormone therapy for disease prevention, particularly dementia. And let's also talk about osteoporosis because, you know, people don't realize this, but, you know, if you have a hip fracture and women get more than men because they're less testosterone and lower bone density, it's a 50% mortality of a year. I mean, if you get, it's like cancer.

Like, if you get a hip fracture, you're like, likely to be dead in a year, 50% of the time. I think that when we start talking about things, like the long-term benefits, I think that we have fairly decent data on the cardiovascular benefit of hormone therapy, you know, that it decreases the risk of cardiovascular disease. And that's not, you know, we have a lot of different, not just observational studies, but we even have things with, there's the Danish osteoporosis study that started around the same time as the women's health initiative. And when the women's health initiative shut down, they shut down.

Just go, oh, well, no need in finishing that. But by the time it shut down, it had 10 years of data. And it was with bioidentical. Yeah, right. So yay on that. And that showed. It showed a decrease in the risk. They had even 16 years out, they showed that the women who were on hormone therapy had a

decreased risk of cardiovascular disease. So I think that that is, we've got, we've got fairly good data on cardiovascular disease. Okay. We've always had data on osteoporosis. That was one of the indications for hormone therapy. If you're at risk for osteoporosis, yes, take it. Now, let's go to the dementia part of this. What we do know about dementia, I'll tell you what I, I'll, I'll, I'll do in two parts. I'll tell you what I know and I'll tell you what I think. Okay. Right now in the current indications for hormone therapy, FDA approved, hormone therapy is approved for women who have a premature or early menopause,

however you get to that place. And some women naturally have an early menopause, and early, I mean before age 45, premature if you're menopausal before age 40. Well, how does that happen? naturally. Sometimes you've had your ovaries out. Sometimes you've had chemo or radiation, things that sort of shut down prematurely. Prematurally, right. Estrogen therapy and hormone replacement therapy is indicated for those women because what happens if you have an early menopause or premature menopause? You're at increased risk for cardiovascular disease, dementia, and osteoporosis. So the recommendation is not, can you, but, but you, but you

you probably should. And it would be, you know, it would be considered a major misstep if someone takes your ovaries out and you're 38 years old and they do not give you hormone therapy. So that we know. So let's go back to the dementia issue because there seems to be a lot of controversy about it. Yeah. Do you know how long it would take to do a study to, even if you did a randomized double-duty? We'd all be dead. Okay, so sometimes you have to go with the data you have.

Yeah. And we infer all the time in medicine. We don't, we, there are very few things that we have. Like I have gold standard, absolute proof that this is the case. And I don't think it's a great leap of faith to say, well, if it, if it prevents dementia and osteoporosis and heart disease if you're 42, why would it not if you're 46? Yeah. You know, you have to look at it from that point, from that perspective. I think that we have some really interesting ways of looking at this now, which I think is going to help give us some data before we are all dead and gone.

And that is now we have Dr. Lisa Moscone, who is looking at, she's imaging women's brains. And she has been able to demonstrate that your brain looks different in premenopause. perimenopause and postmenopause. She and I think is Dr. Rebecca Brenton are the two neuroscientists that have really delved into this to say, we can do this, we can follow one person through perimenopause, menopause, and menopause, and image that same brain. So I don't have to wait 30 years to get that data.

And so there is now concrete evidence that estrogen plays an important role in how women's brains function and what the structure of their brain looks like. Yeah, well, clearly brain fog and all that gets better with hormones. We know that. That's symptomatically true. So, you know, I think that, you know,

if you were, but, but it gets back, and I'll get to this. The same thing that I was saying before in that it matters when you take it. That's right. You can't prevent or slow down osteoporosis when you're 72. And that's why timing matters. And we've got a lot of the stuff that we talk about,

hormone therapy, the sooner you start it, the more benefit you get. There's no benefit in waiting five years down the road before you start. Yeah, I mean, you really talk a lot about proactive medicine. And I mean, I think the guidelines for a Dexas scan is like when you're 60, which is insane to me. Totally. I mean, you should do when you're 40, which is a bone density scan. And I think, you know, even now we're having ways of tracking brain health through brain imaging. I co-founded a company called Function Health, and we can do quantitative brain imaging. We can do all kinds of biomarkers that tell you what your brain health is. What I'm curious about is if, and I think at this point, it's a conjecture opinion

because the question is still out there is, why are women so disproportionately affected by Alzheimer's? And could it be because of this sudden drop in estrogen after menopause? And does the data show that women who take hormones and have taken them starting early? Because if you start when you're 60, it doesn't seem to do anything. So you got to start like early when you're right and when you're metapausal. Right. Right. That's kind of the take home message.

I think that is definitely the take home message. Because, you know, one of the things that the central question is why do, you know, why are two-thirds of the people with Alzheimer's in this country women? That's right. Why are black women two times more likely to be diagnosed with dementia than? than white women. Why is that? That's where you've got to start. And if you look at just the basic things, you say, well, what happens to women in that same time period? And that is the, and it has something to do with menopause, probably something to do with estrogen. And that's

what really what we're trying to pin down on that. Because that's really the big difference between how men age versus how women age. A lot of things start to us because when we get to menopause, our estrogen levels fall off the table. Gone. It's not a slow, gradual decline. No, it's gone, it's gone. It's never coming back. Right. So. But by the way, just so people understand, even after menopause, women still make estrogen and progesterone. It's not that it goes away.

It's not zero. But it's, we don't make estradiol. We make estrogel. We make estrone. Estrone, right. But that is, that is something that's metabolized in peripheral fat. Yeah. So if you're a very thin, lean person, you probably don't have a lot of estro. Correct. And then, yeah,

the skinny old ladies are the ones who get the fractures. And it's much weaker. Yeah. It's a much weaker estrogen than estrogen. Yeah, fair enough. So, you know, there's that. But what I was saying, getting back to this brain health part of it,

is that I'm willing to make, I'm willing to make the inference. Maybe I'm right, maybe I'm wrong. It will not be the first, nor the last time in medicine that we've made decisions on incomplete data. On incomplete data. You know, sometimes we do. And I hope and I pray that I'm right,

but at a minimum, I don't think you're doing harm. And I would just add that, you know, we now have, which we never had, you know, when you and I were starting training, tools and diagnostics to really track cardiovascular risk and breast cancer risk and things that matter. So if people are concerned about heart disease risk or breast cancer risk with hormone replacement therapy, we now have deep diagnostics for cardiovascular risks

that we do at function health. For example, we look at APOB, lipoprotein A, lipid fractionation, CRP, we look at metabolic health in a deep way, insulin. These things are really important because aside from all the hormone issues, these are the things that drive cardiovascularies. And then the same thing with breast cancer. Now we have tools that, you know, whether it's mammograms or breast MRIs or even new liquid biopsy tests,

there's more tests emerging that are, you know, proteomic testing for cancer and other, you know, DNA kind of fragment testing that's available through liquid biopsy. So all this is iterating really fast. So I think, you know, it's important for women to sort of track it, not just go, oh, it's fine, but to track their health over time and to see long-gidum is happening. And even I think when they get their GYN exam to get a uterine ultrasound and make sure the uterus is okay and everything's okay because like, you know, these things like uterine cancer

and even ovarian cancer now with some of these, you know, liquid biopsy, so they can't start to start to track these things. So I think given the kind of constellation of advanced diagnostics that are here now and that are coming soon, it gives me a lot more, I would say, a piece of mind to kind of even move forward with the set of incomplete data that we have. We can't wait to give people the information. But, you know, what you and I agree on most is the idea of prevention. Yeah. You know, I think that, you know, I wrote a book called Grown Woman Talk. It's not just about menopause, but it's about all the things that affect women in menaces.

And at the end of every chapter, I'll give a list of things that these are things you do. I talk about cardiovascular disease. I talk about, you know, breast cancer and the chronic stresses and hypertension and diabetes. At the end of each chapter, it's almost the same thing. Don't smoke, limit your alcohol, exercise, eat a healthy diet. and get a good night's sleep. Duh, whether you are, it doesn't matter what you're trying to prevent,

breast cancer, colon cancer, dementia. The same basic things go into that, you know, because that's just the recipe for healthy living. Yeah. And quality living, we hope, as we age.

Yeah, it's not like you're going to take hormone therapy and everything's going to be buying. You can live a crappy lifestyle. You got to do it all. Right. It's of both and, you know, that's not going to, you know, and you can have all the great, you know, molecular genetic testing in the world, and something else will still come up and bite you.

So you've got to just be able to say, you know, there is a limit to what we can predict. And I use my mother as an example. My mother grew up in rural Alabama. She grew up on a farm. Okay. I don't think my mother ever ate a non-organic thing in her life. That's right. In her life.

That's right. That's right. My father grew vegetables. That's right. That's how we ate growing up. My mother died of colon cancer. But my mother died of colon cancer, not because of something she did that was wrong. It was, she died of colonoscopy's worn a thing.

Right, right. In today's world, yes. So we have to take the two together. We take the technology. in the science and the knowledge that we've acquired with healthy living. Because I don't want people to think that you have, you don't have complete control over anything as far as your health. You can minimize your risk.

You can never eliminate it. Well, this is such a great conversation, Sharon. I appreciate all your dedications over the years. People, you know, can learn more about your work. You have a podcast, second opinion, right? Second opinion. And that can be, well, wherever podcasts are found. every podcast.

And your advisor to Alloy Health. Tell us a little bit about what that is. Because I think as as women are listening and men are listening who are in relationships with women,

they're like, well, what do I do and where do I go? And yeah, the average doctor may not be able to kind of have the nuances here. You know, there are now online platforms and tools that are much more sophisticated,

understand these things, and you're an advisor to one of them called Ally Health. Can you just share a little bit about that? And at Alloy, I've been with them, for five and a half years now. So I was there from the very beginning. And when I stopped clinical practice, I, you know, I'd accumulated all this, you know, I've got not just the medical background, but I've got the experience of having done this for a while. And what I realize is that you can

educate women all you want, but if they don't have access, then what difference is it make? You can't find a doctor. You can't find someone that will prescribe for you or that even knows what to do. And that's why it was important. When I joined Alloy, I was able to take my expertise, train the doctors that work for us, many of whom are, you know, they're all board certified, and then now they are menopause trained. So we can leverage the expertise of a few over hundreds of patients, not just the one-on-one that you're going to be able to see in the course of day. And menopause and perimenopause treatment lends itself well to dealing in the in the digital health platform. And that's how a lot of care is going to be delivered in the future. And so, you know, I think that people should feel confident

that this is not an inferior version of what you're going to get in a doctor's office. In many cases, it's a superior version. It's the better option. Yeah, yeah. Well, thank you for doing that work and thank you for your dedication to this field and writing your books and where can they find more about you beside your podcast. You have a website? Yes, I have a website. And it's easy, Dr. Sharon Malone.com. And your social media is S. Malone MD on Instagram and threads.

Amazing, wonderful. Well, thanks for your work and thanks for being a voice out there for reason and coherence in a very complicated, confusing space. We need more of you. Well, thank you for having me. If you love this podcast, please share it with someone else you think would also enjoy it. You can find me on all social media channels at Dr. Mark Hyman. Please reach out. I'd love to hear your comments and questions. Don't forget to rate, review, and subscribe to the Dr. Hyman show

wherever you get your podcasts. And don't forget to check out my YouTube channel at Dr. Mark Hyman for video versions of this podcast and more. Thank you so much again for tuning in. We'll see you next time on the Dr. Hyman Show. This podcast is separate from my clinical practice at the Ultra Wellness Center, my work at Cleveland Clinic and Function Health, where I am chief medical officer. This podcast represents my opinions and my guest's opinions. Neither myself nor the podcast endorses the views or statements of my guests. This podcast is for educational purposes only and is not a substitute for professional care by a doctor or other qualified medical professional.

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