The Dr Louise Newson Podcast - 281 - Blind spots in modern medicine, with Dr Marty Makary

Episode Date: November 5, 2024

On this week’s episode Dr Louise is joined by Dr Marty Makary, Johns Hopkins professor, member of the National Academy of Medicine and bestselling author. Together they discuss the impact of the Women’s Health Initiative study on women’s hormone health, menopause education for healthcare professionals and the importance of patient-centred care that focuses on root causes, rather than just symptoms. Dr Marty talks about his new book Blind Spots, and the importance of asking big questions in medicine. You can follow Dr Marty on Instagram @martymakary, and TikTok @marty.makary For more information on Newson Health, click here. Dr Louise Newson’s first-ever live theatre tour, Hormones and Menopause – The Great Debate, runs until 12 November. For more information and tickets, click here.

Hello, I'm Dr Louise Newsom. I'm a GP and menopause specialist and I'm also the founder of the Newsom Health Menopause and Wellbeing Centre here in Stratford-Pon-Avon. I'm also the founder of the free balance app. Each week on my podcast, join me and my special guests where we discuss all things perimenopause and menopause. We talk about the latest research,

bust myths on menopause symptoms and treatments, and often share moving and, and always inspirational personal stories. This podcast is brought to you by the News and Health Group, which has clinics across the UK dedicated to providing individualised perimenopause and menopause care for all women. I'm very excited on my podcast today to introduce you a professor from America, John Hopkins University.

So I've got with me, Marty McCarrick, who I had just listened to at the weekend, with a great podcast with Peter Atier on the Drive. And I was listening and thinking, I want him on my podcast. And I don't always get what I want, but I have. My wishes come true. So welcome, Marty, to my podcast today. That's good talking with you, Louise.

You know, I was born in Liverpool, England, so I have a special place in my heart for England. Great. I love Liverpool. I trained in Manchester. And any excuse to go back in the Northwest. People are honest. They say it as it is. And I love doing medicine there because patients,

would just talk to you and you would learn so much so quickly. And what I've realized over being a doctor for 30-odd years is that most of my knowledge comes from my patients and a lot comes from actually basic science. And putting those two together is quite a skill that we don't always have. But how I practice medicine now is very different to 30 years ago because I've gained a lot more knowledge and experience. And so I'm keen to just for you to just tell the listeners a bit about your work and what you do because you've got lots of skills. And I feel like me, you've got so much experience that it's now coming together in a way that's making you want

to change other people's experiences in medicine. Well, thank you, Louise. You know, I have always been interested in the big questions. The questions we're not asking in medicine that we should be asking. For example, why has the age of puberty been going down in the United States every year by a week and a half? Years earlier now than it was just a century ago. Why are sperm counts down 50% in the last five decades? Why is autism in the United States going up by 14% every year for the last 23 consecutive years? Why are half of America's children obese or overweight? Type 2 diabetes is now common. A pediatrician just a generation ago would rarely see one case in their whole career.

Now it's one in four kids will have pre-diabetes or diabetes. In my field of pancreatic cancer rates have doubled in the last 20 years. What's going on? We don't ask these big questions in medicine. We've got to talk about our poison food supply. hormonal manipulation by toxins and pesticides and microplastics, the role of seed oils, and the engineered food additives that are put into our food supply. So I've always been interested in the big questions, I guess you might say.

And in terms of research, my research team has been focused on the big topics in medicine we're not talking about that we should be talking about. What I say are the topics that live in the blind spots of modern medicine. And it's so interesting because there are many blind spots. And in medicine, often it's very busy. You learn on the job. You learn from your immediate team around you. And it's quite hard to challenge more senior doctors sometimes as well.

So when you're told something, you often do think it's right. And you might not have the time and privilege to go and check the evidence. But when you look at the bigger topics, that's when you can take a step back and lose the emotion with an individual. or patient, things are different. But it's interesting you're talking about cancer and obviously with my work, everyone's scared about breast cancer for the wrong reasons with hormones, which we can talk about in a bit. But when I trained as a medical student as an undergraduate, breast cancer affected around one in 12 women. At a graduate, it was one in 11. And now it's around one in seven women. Now, people always associate HRT incorrectly with breast cancer, but I often say to people,

even if you knew nothing about the WHO, the Women's Health Initiative study, you knew nothing about hormone treatment. Now, when the incidence of breast cancer was one in 11 women, 30% of women in the UK and 40% of women in the US were taking HRT. That's gone to. down to about 14% of menopals of women in the UK and less than 2% in the US. But breast cancer, I've said, has gone from one in 11 women to one in seven. So we can't blame HRT for that, can we, Marty? No. Look, they initially tried to claim when the Women's Health Initiative study was announced in 2002 that breast cancer rates had gone down after the announcement, as if they had rescued these women from the perils of HRT.

But a deeper analysis revealed those were decreases in breast cancer deaths started just before the announcement. And you wouldn't see an effect within months if people stopped taking their hormone replacement therapy. So that was debunked. And there's been many false claims about hormone replacement therapy. the, perhaps the dogma that taking hormone replacement therapy at the time of menopause causes breast cancer is probably the biggest screw-up in modern medicine. There's probably no medication that improves the health outcomes of a population more than hormone replacement therapy for women who started within 10 years at the onset of menopause,

arguably with the exception of antibiotics. Women live longer, feel better, the benefits are overwhelming. This is something I'm sure you've covered many times. But when I took a deep dive into the data on the incredible health benefits, reducing cardiovascular disease, preventing Alzheimer's, avoiding cognitive decline, making bones healthier, maybe even reducing the risk of diabetes and cancer in some studies, the benefits are overwhelming. If hormone therapy did increase the risk of breast cancer, as they had claimed,

the risk would be far eclipsed by the overwhelming health benefits. Now, I don't believe that claim that it causes breast cancer. And in the book, Blindspots that I just am putting out now, I did a deep investigative journalism sort of review of what happened when they made announcement. It turns out they had deceived their co-investigators. They had bamboozled the general public. They had played the media by not releasing their data until long after the announcement. And they had even crushed dissenters trying to ruin their careers. So it's a very incredible backstory of how basically a small group of people decided to,

call hormone replacement therapy a carcinogen, when in fact, for the vast majority of women going through metapause, it is a miracle. I absolutely agree. And it's very interesting when you look back at the history because obviously hormones were discovered really in the 1920s. But in 1941, so a long time ago, Professor Albright discovered that it can help with bone density. The hormones will improve bone density and reduce osteoporosis. And then I was reading some notes, actually, from a conference from 1972. So I was only two then, long time ago.

And it was all about aging and menopause and talking about how hormones reduce diseases related to aging. So all the diseases you've just said, Marty, so heart disease, diabetes, dementia, you know, it was all there. And everyone was really, and we'd come. I can't forget there's a reason why it was the number one selling drug in the US in the 90s. And it was for many reasons. People were feeling better.

And actually I went into medicine to help people feel better. And every day in my clinic, people say, thank you. I'm happier. I'm enjoying my life. Very hard to measure on a study, but I think that is really important. But it's not just feeling better. It's preventing disease, which is another reason of going into medicine, keeping people healthy. So the biggest risks for women for our mortality are actually heart

disease and dementia. And these hormones reduce that. But then it's interesting because you're saying quite rightly the study starting within 10 years, but that is still the synthetic hormones. We've moved on so much in 20 years. So we now can have our own hormones back. So biochemically and structurally they are exactly the same as our own hormones. So they have even better biological effects. I can't think of a safer medication that I've ever prescribed to a patient and a more effective medication. But it's still denied to the majority of women

and it feels so wrong that we're medicalizing symptoms of the menopause with other medicines as well. There's some data that we cannot ignore, some data that we have to examine. You can't just dismiss data. that you don't like. And there's some pretty compelling studies that the risk of cardiovascular disease,

that is fatal heart attacks, is cut in half among women who start hormone therapy early after menopause. So what do you do with that? Do you just say, oh, well, we're going to ignore that research? No, there's a mechanism. It's not just data in isolation. It's known that estrogen increases nitric oxide,

which keeps the blood vessel wall healthy and soft and may help with it. perfusion. And a finished study showed that among women who stopped taking hormone replacement therapy, they had a 26% increased risk of a fatal heart attack in the first year after stopping it. So you cannot ignore these data just because somebody doesn't like them. And I think there's been a narrative. There's been a group think on hormone replacement therapy. I discovered that the few doctors who declared that it causes breast cancer, without supporting data had already really kind of made up their mind. The lead investigator who made

the announcement had said on record prior, years prior, that quote unquote, we have to stop the HRT bandwagon. Yeah. Well, you're leading the largest study ever done in the history of medicine, a clinical trial. You're supposed to wait for the results, not declare, we got to stop this H-R-T bandwagon. So we have not had good leaders with this study. They've deceived the public, deceived. I interviewed the lead guy who made this announcement in my book, Blind Spots, and it was unbelievable what I had discovered. But, you know, if you don't like data, it doesn't mean you dismiss it. It means you've got to discuss it, and we have to have a civil discourse. You're absolutely right. And I think it's also, if you don't understand something or it

doesn't fit with what you expect, then in my mind, you go back to the basics. I'm like an annoying two-year-old and think, but why, but why? So then you go back and think, well, hormones we have in our body anyway. So when we talk about hormone replacement, we're obviously replacing missing hormones. So if you look back about how these hormones, estradiol, progester, and testosterone work in the body, they're actually derived from cholesterol, as you know, which is irony in itself and we've been told cholesterol is bad for so long. But some cholesterol is good, of course. But these hormones are very anti-inflammatory, like you say, Easterdial can affect nitric oxide. It helps mitochondrial function. It helps all our inflammatory immune cells to work

better. So it makes sense as well that you've got these results for decades showing reduction risk of osteoporosis, helping also brain as well. And I think we should be relayed menopause is a brain condition, not an ovarian condition, and I'm not sure why it's landed literally in the lapse of gynecologists, because it's a multi-system disorder that we should all, every clinician, every medical student, should think about it in a very different way. You know, you're so right. Almost every cell in the body has an estrogen receptor, and it affects so many aspects of health. And what I have seen as sort of a public health researcher is that when we have interventions in medicine that affect multiple different systems, sometimes those

interventions get lost in our sub-specialization. Take gut health, for example. Gut health is central to so many different aspects of overall health, but there's no specialty for it. And what journal does that research get published in? And which center of the government is funding that type of research? So it gets lost. But every cell in the body is connected. And one thing we've lost in our modern siloed era of medicine is that there's an incredible connectedness at the level of insulin and glucose metabolism, mitochondrial health, and hormonal health. And so I think it's pretty amazing how the medical establishment got this wrong. The group think, the sort of intellectual laziness where people will, to this day, cite the 2002

Women's Health Initiative saying that's the reason why they believe hormone therapy causes breast cancer. And now I'm telling some of those doctors, well, it's amazing that you think that's the reason why it causes breast cancer because I interviewed the lead author of that study, showed him his own data, and he acknowledged to me that hormone therapy did not increase the risk of breast cancer mortality. So people believe it. And he didn't, you know, he didn't even acknowledge. Well, I think the other thing is, even using that data from WHOI, when they looked at the estrogen-only arm, so women that only took estrogen and followed them up, there was a 22% lower incidence of breast cancer. But the other thing I think about all of this is coming back to the patients, like we were saying at the beginning, the people that we're trying to help as individuals. If you look at the sort of worst analysis, if you like, of WHOI showing this increase incidence, it's still not statistically significant.

But again, as an individual person, I'm allowed to choose what's worrying me most. And actually, I've said it before on this podcast, I'm really scared of osteoporosis because I've seen so many people, especially of osteoporosis of the spine. They're in so much pain. They can't digest properly. They can't breathe properly because they've got curvature. They're dependent on others. I'm quite an independent person.

I want to be able to use my zimma frame and get out of the bath on my own. I want good muscle strength. I'm scared of this osteosarcopenia that occurs, it's loss of bone and muscle mass. I'm more scared about having an osteoporite hip fracture which has a higher mortality than breast cancer. So as an individual, I have a risk of breast cancer because I'm a woman with breasts. I've already said it's a one in seven risk. But taking HRT, even if I was taking the awful synthetic hormones, which I don't, it might increase my risk a bit.

You've already said it won't increase my risk of mortality if I'm diagnosed. But actually, I really don't want osteoporosis. And thank you very much. I don't really want heart disease, or type of diabetes or dementia, or other inflammatory conditions, or autoimmune diseases. You know, all these diseases that increase. And we know that even the WHO study, bowel cancer, was lower incidence by a significant amount.

But we don't talk about it preventing bowel cancer. It's about causing breast cancer. And isn't that because it's an emotive thing for women and for us to stop prescribing and stop helping women feel better. I don't really know what these people's agenda is, but it's not about giving people choice and autonomy. You know, it's amazing. We all spend so much time talking about how to prevent bone fractures and osteoporosis and ignore this giant, obvious, incredible intervention right in front of our faces. And just to touch on something you mentioned, having a hip fracture

has a high mortality. One in five people do not survive the first year. year after a hip fracture. That's a high mortality. That is a risk. And so when you have an intervention like HRT, that reduces the risk of a fracture by up to 60%. Now, that's according to our randomized trial in the New England Journal. That should tell us. That's something we should focus on. And when there was a big international convention on osteoporosis, guess what the number one thing was that they put out there as a way to prevent osteoporosis, hormone replacement therapy, orthopedic surgeon. have noticed the difference for a long time. And we can talk about vitamin D and calcium all we want,

but it's not going to help prevent osteos. It's not going to make your bones stronger if there's no estrogen in one's body. So I think we sometimes we can't see the forest from the trees. Same thing with the cognitive decline. We've got these billion-dollar Alzheimer's drugs now that barely work, and they have high complication rates, 19% rate of cerebral edema or hemorrhage.

They barely work. They supposedly slow. the progression slightly with early mild Alzheimer's. Well, here's a drug that in a study reduced the risk of Alzheimer's by 35 percent, hormone replacement therapy. And no one talks about it. I mean, it is like we are only interested sometimes in letting big pharma run the narrative on the most expensive drugs. And we are sometimes just cannot see the forest from the trees. It's like we don't need a randomized trial to tell us to use some more common sense. The data are overwhelming.

They're right in front of us. And I try to summarize all that data in basically one chapter of this book on health called Blindspots. And it's so important because, you know, as I admit it, we want to treat the underlying cause. You know, if someone was bleeding because a knife was stuck in their finger, I could put a plaster on, but I don't need to take the knife out first. You have to see what's causing the problem and then you can be more direct in your approach. But we're sort of worried so much. And most women we see in the clinic are already on or have been offered antidepressants. That is not going to help the hormonal imbalance.

And, you know, when I say to some doctors and gynecologists, you know our hormones and neurosteeroids, they are produced in the brain. They work as neurotransmitters so they can help regulate serotonin, dopamine levels. It's like you can see this glazed look over their face, but no, it's about periods, Louise. Actually, most women, yeah, we have periods or we don't have periods, but that's not what defines us. What does define us is whether our brain's working or not. And it's really scary, and I know from personal experience, but I know from treating thousands of women, that it's the brain fog, it's the memory problems, it's the mood changes,

that are affecting women far more than any hot flush or sweat. and also leading us not only often to have relationship breakdowns, but to affect our jobs. And we've got this choice taken away from us when we've got very simplistic medicine. And of course we can live without hormones. But why should we? I don't know. It doesn't make sense to me. You know, tragically, because of this women's health initiative, Dogba 22 years ago,

medical schools just kind of concluded, well, there's nothing you can do for menopause. So why teach it? And so menopause itself got ignored in medical school curricula and residencies, which still had a very strong paternalistic male-dominated origin. And so these curricula decided there's no need to teach about menopause. We were, I remember, occasionally told in passing, yeah, menopause is when a woman stops producing hormones and some women experience symptoms, but they're usually mild and they last a few years. Well, that's total misinformation. It's not true.

80% of women plus experience symptoms, they can last on average 7 to 8 years and they can be severe. And so we ignored menopause altogether in medical education. So today, tragically, at least in the United States, a woman is more likely to be prescribed in antidepressant for menopause than they are hormone replacement. And that's the same here. But actually, I'm quite provocative, as you can probably guess, but I actually want to bin the word menopause, Marty,

because it's too late when it's menopause. Menopause, as you know, is stopping periods for at least a year. But the biggest problem often with symptoms is in the peri-menopause, is state of flux, because we don't have this homeostasis in our brain. We have chaos because the hormones are going up and down. And that can last a decade or so. And quite rightly you say menopause symptoms can last seven years or so. but then I see and speak to a lot of women who have premenstrual syndrome, premenstrual

dysphoric disorder, PMDD, that's a hormonal change. But it's happening every month for them. So I see women who for three days a month have very dark intrusive thoughts. They can't go out of the house. They can't go to work. They have physical symptoms. They have palpitations. They have urinary tract infections. The period comes and wow, they feel great again. So, but these women, it's, you could say it's only effective. them a few days a month. You build that up from a year. That's a lot of time that they're really struggling. And these women say the days that I feel well, I'm so worried about the time it's going to happen. And if I'm a professional athlete, I can't perform on those three days. And all I'm being

offered is a contraceptive pen or antidepressants, whereas giving those natural hormones for those days. So if we're waiting and waiting for menopause, we're missing populations of women who are struggling or thinking about it as a midlife condition. You know, I've got patients who are as young as 14 who became menopausal because they either had cancer treatment or their ovaries didn't develop well. So they're in school with symptoms. But who do they talk to? How do they know? And often there's a delayed diagnosis, as you know, with huge health risks because the longer without hormones, the more the health risks. So thinking about it as a hormonal problem with health risks. And I don't care whether someone's got perimenopause, menopause, PMD, they're just labels.

We have to again think about it being a hormonal issue that needs treating. Yeah, we've got to get back to treating the whole person. I think so often we are glamorizing in the medical field subspecialization. And then everyone has a hammer and everyone's going after one thing. The Alzheimer's doctors are using these billion-dollar Alzheimer's drugs that barely work and have high complications. The psychologists and primary care doctors may be throwing antidepressants at menopause. The endocrinologists may be treating people for prediabetes or giving them obesity drugs for the weight gain. And nobody is recognizing that the body is one whole organism.

Every cell is connected. And we've got a central organ system in the gut, which even metabolizes estrogen. We've seen how it deconjugates to make the active form. So I think, unfortunately, we're a bit of a victim of a modern era of hyper-specialization. Look, I'm a subspecialist. I believe in subspecialties. We can do amazing things. I have a subspecialty expertise in pancreatic disease. But we've got to also remember that we're talking to a human being, and we've got to restore the human connection.

And that is so important. and I think it's been lost a lot. I mean, you're probably a similar age to me, but I spent a lot of time about how to take a really good history. And the diagnosis, 90, 95% is in the history. It was really hard to access MRI scans, CT scans, even ultrasounds when I was a junior doctor. And I worked for some amazing doctors and professors

who would strip me apart if I hadn't done a full examination and really got into the depths. And that's the art of medicine, whereas now it's so easy to just order us, test, order a test, and then the test results come back normal, usually, in hormonal women, and then they're made, oh, it's all in your brain, it must be because you're stressed, it must be because you have a difficult job or whatever. And then it's sort of medical gaslighting that goes on, which I find very sad. Like, it's fine in medicine to say, I don't

know what's causing it, but there is something, because you're telling me. But somehow, I don't know, sometimes doctors don't want to admit that they don't know, and I think it's fine to not know all the answers, isn't it? Well, I think right now there's, a lot of mistrust in doctors and hospitals. We just had a study come out in JAMA that showed that trust in doctors and hospitals went from 71% before the COVID pandemic to 40% today, a 31 point drop. What's causing this mistrust? Well, people feel like they've been lied to. They feel like there's been no apologies for some of the bad policies during COVID. They feel that there's no accountability. They feel that they've been lied to about the food pyramid. And so much,

other topics, saying opioids were not addictive for 30 years, saying that you could avoid a peanut allergy with the golden rule to avoid peanut butter in the first three years of life. Well, it didn't prevent peanut allergies. That rule caused peanut allergies, and it ignited the modern-day peanut allergy epidemic that really affects the UK and the U.S. worse than any countries in the world. They don't even have peanut allergies in Africa. So I go into all these topics in the book, But we need some fresh new ideas. We need big thinking. We need to look at the body as one organ system.

Maybe we need to treat more diabetes with cooking classes instead of just throwing insulin at people. Maybe we need to recognize menopausal symptoms with good physical examination and history taking so we can help women who are candidates for HRT. Maybe we need to talk about school lunch programs, not just putting overweight children on OZempic. And maybe we need to talk about. about environmental exposures that have hormonal effects,

not just scratching our head saying, we don't know what's causing the decline in fertility and the decline in puberty. We know that pesticides, for example, have hormone-like binding properties. And we can't just ignore that. I think we dismiss things so often in the medical culture because we're so busy doing our job.

You know, we're told just bill and code and we measure doctors by throughput. But we've got to stop and ask, what are we doing? Can we look at our food supply, our environment, and the toxins that have hormonal like properties? And are we open to looking at the body holistically and treating a person, not just a disease? It's so important.

I was talking to my husband this morning, who's a surgeon, he's on corn, he's an NHS doctor, he's got a full list. He says to me, Louis, stop thinking about preventing disease. The NHS is a nightmare. It's a car crash. We can't look after the people that are ill. People are sicker.

They're more ill. It's hard enough to look after those that are ill. And I feel like we're just sort of putting sandbags up in a tsunami because we're not actually, it's going to get worse if we don't look at the root cause and preventing. Like you say, right from children, because it's not their fault they're obese. It's not therefore they've got type 2 diabetes. But then you've got this sort of no blame kind of.

And of course, we shouldn't be blaming the targets. We should be thinking about what's going on. And you're absolutely right. This big thinking has got to do more than thinking, though. It's got to act as well with the right people. Because it's a global problem. You know, your country, our country is really struggling with health. And it's really sad because it's some very simple things that would make a big difference, I think.

Yeah. Very well put, Louise. No, I agree with everything you're saying. here. And so thank you for your work. It's really good. Oh, thank you so much. What a lovely podcast. But before I finish, I can't let you go without asking for three take-home tips. So if you were running global health, Marcy, and you were allowed three things that you think would make the biggest difference to the most people globally, no mean feat, what three things do you think have got the biggest chance of improving our future health? Well, I think.

releasing doctors from the captivity of billing and coding and seeing patients in short visits, allowing them to be creative, to address the root causes. So I would change the whole structure by which doctors are measured and being paid. I would change our research priorities to focus on food and the food supply. And I would try to do what we can to change our medical school curricula and teach not just the technical skills, but the non-technical skills of being a great physician. Humility, knowing your limits, working as a team, listening to patients, and communicating effectively with other individuals. Those are the qualities, I think, that are lost in the modern era of medicine. So those are some thoughts, but I think we are making good changes. I think

thanks to people who are now getting the good word out on health. We're not just focusing on playing whack-a-mole with sickness, but we're talking about health for the first time. That's why I wrote the book Blind Spots. I wanted to go directly to the public and educate them about the latest scientific research about health so they can make better decisions every day on a whole series of topics,

from cancer prevention to allergy prevention, to food choices, and including hormone replacement therapy. So thank you for your work, Louise. Oh, thanks, Martin. Thanks for being such a great guest, and I hope we can meet in real life at some stage. I'd love that.

Thank you. You can find out more about Newsome Health Group by visiting www.newsonhealth.com. And you can download the free balance app on the App Store or Google Play.