"The Dismissal of Symptoms is Straight-Up Misogyny."

You’re listening to Burnt Toast! Today, my guest is Mara Gordon, MD.

Dr. Mara is a family physician on the faculty of Cooper Medical School of Rowan University, as well as a writer, journalist and contributor to NPR. She also writes the newsletter Your Doctor Friend by Mara Gordon about her efforts to make medicine more fat friendly.

Dr. Mara is back today with Part 2 of our conversation about weight, health, perimenopause and menopause!

As we discussed last time, finding menopause advice that doesn’t come with a side of diet culture is really difficult. Dr Mara is here to help, and she will not sell you a supplement sign or make you wear a weighted vest.

This episode is free but if you value this conversation, please consider supporting our work with a paid subscription. Burnt Toast is 100% reader- and listener-supported. We literally can’t do this without you.

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Episode 209 Transcript

Virginia

So today we’re going to move away from the weight stuff a little bit, into some of the other the wide constellation of things that can happen in menopause and perimenopause.

Before we get into some nitty gritty stuff, I want to do Laurie’s question about hormone replacement therapy, since that is still one of those topics that people are like, Is it good? Is it bad? I don’t know.

So Laurie asked:

Is there a reason why a doctor would not want to prescribe hormone replacement therapy? My doctor seems more willing to treat individual symptoms instead of using HRT. Is that maybe because I’m still getting my period?

Mara

I love this question. Now my professor hat can nerd out about interpretation of scientific research!

So first, I’ll just briefly say, Laurie, no big deal that you said HRT. But just so everyone’s aware, the preferred term is menopausal hormone therapy, MHT, or just hormone therapy, and it’s not a huge deal. But I think the North American Menopause Society now uses “menopausal hormone therapy.” The thinking is, hormones don’t necessarily need to be replaced. It comes back to that idea of, menopause is a natural part of life, and so the idea that they would need to be replaced is not totally accurate.

Virginia

We’re not trying to get you out of menopause, right? The goal isn’t to push you back into some pre-menopausal hormonal state.

Mara

But again, not a big deal. You’ll see HRT still used, and a lot of doctors still use that term.

So I graduated from medical school in 2015 and I remember one of the first times that a patient asked me about using menopausal hormone therapy, I was terrified. And I was still in training, so luckily, I had a mentor who guided me through it. But I had absorbed this very clear message from medical school, which is that menopausal hormone therapy will cause heart disease, cause pulmonary emboli, which are blood clots in the lungs, and cause breast cancer.

And I was like, “Ahhh! I’m gonna cause harm to my patients. This is scary.” I had also learned that hot flashes–they weren’t life threatening. So a patient could just use a fan and she’d be fine, right? She didn’t need medicine for it.

Virginia

Cool.

Mara

I think the dismissal of symptoms here is just straight up misogyny. That message of, oh, you should just live with this You’re tough, you’re a woman, you can do it. This is just the next stage of it. Is just misogyny, right?

But the fear of using menopausal hormone therapy has a specific historical context. There was a major study called the Women’s Health Initiative, and it was a randomized control trial, which is the gold standard in medical research. People were given estrogen and progestin to treat menopausal symptoms or they were given a placebo, and they didn’t know which pill they took. But WHI was actually halted early because they found an increased risk of breast cancer. This was on the front page of The New York Times. It was a really, really big deal. That was 2002 or 2003.

So even 15 years later, when I was starting out as a doctor, I was still absorbing its message. And I think a lot of doctors who are still in practice have just deeply absorbed this message.

But there’s a lot to consider here. The first issue is in the way that information about the Women’s Health Initiative was communicated. Nerd out with me for a second here: There is a big difference between absolute risk and relative risk. And this is a really subtle issue that’s often communicated poorly in the media.

So I looked it up in the initial paper that came out of the Women’s Health Initiative. There was a relative risk of 26 percent of invasive breast cancer, right? So that meant that the people who got the estrogen and progestin, as opposed to a placebo, had a relative increased risk of 26 percent compared to the placebo arm.

Virginia

Which sounds scary,

Mara

Sounds terrifying, right? But the absolute risk is the risk in comparison to one another. And they found that if you’re a patient taking the estrogen/progestin, your absolute risk was 8 people out of 10,000 women a year would get invasive breast cancer. So it’s very, very small.

And this is an issue I see in medical journalism all the time. We talk about relative risk, like your risk compared to another group, but the absolute risk remains extremely low.

And just to round it out: I looked all this up about cardiovascular events too. Things like a heart attack, a stroke. So the absolute risk was 19. So there were 19 cases of a cardiovascular event out of 10,000 women in a year. People just freaked out about this because of the way that it was covered in the media.

Virginia

I was fresh out of college, doing women’s health journalism at the time. So I fully own having been part of that problem. We definitely reported on the relative risk, not the absolute risk. And I don’t understand why. I look back and I’m like, what were we all doing? We ended up taking this medication away from millions of women who could really benefit from it.

Mara

I found a paper that showed between 2002 and 2009 prescriptions for menopausal hormone therapy declined by more than 60 percent.

Virginia

I’m not surprised.

Mara

And then even up until the time I started my training, right in 2015, we’re just seeing a huge decline in hormone therapy prescriptions.

One other thing that’s also super important to acknowledge about the Women’s Health Initiative is that they enrolled women over 60, which is not really representative of women who want or need hormone therapy. So the average age of menopause is 51 and the vast majority of women who are experiencing symptoms that would respond well to hormone therapy are much younger. We’re talking here mostly about hot flashes. Which we call vasomotor symptoms of menopause, but it’s basically hot flashes. Women dealing with this are much younger, right? So they’re approaching menopause, late 40s, and right after the menopausal transition, early 50s, and then they don’t necessarily need it anymore, after their symptoms have improved.

Virginia

And it will also be true that with women in their 60s, you’re going to see more incidence of cancer and heart disease in that age group than in women in their 40s anyway, right?

Mara

Right

Virginia

So even the 19 cases, the eight cases—they were looking at a higher risk population in general.

Mara

Yeah. And so there have been all these subsequent analyses, which is why now we’re seeing menopausal hormone therapy sort of on the upswing. There’s a lot of increased interest in it.

The American College of Obstetricians and Gynecologists recommends it, the North American Menopause Society, the British Menopause Society; here’s a full run-down. It’s not that everybody needs it, and we’ll get to that in a second, but it is a totally safe and appropriate treatment for—specifically and most importantly—for vasomotor symptoms of menopause. Like hot flashes.

There’s been all these further analyses of the Women’s Health Initiative data and and then from other studies, too. And basically, it shows that when the hormone therapy is initiated before age 60, or within 10 years of menopause, there’s a reduced risk of heart disease and reduced mortality.

Virginia

Wow!

Mara

So the timing matters. Isn’t that so interesting? The timing matters.

Also, the route of administration matters. So what that means in English is that an estrogen patch seems to have a lower risk of blood clots. So one of those fears of the, you know, initial Women’s Health Initiative data was that you might have an increased risk of blood clots. But it’s something about the way that the estrogen is metabolized. It’s not metabolized through the liver when it’s absorbed through the skin, and something about that process seems to decrease the risk of blood clots.

So that’s why your doctor, if you’re interested in menopausal hormone therapy, might recommend an estrogen patch rather than a pill.

Virginia

Got it.

Mara

There’s a lot of ambiguity in all of this data, because, you know, we’re talking about just huge numbers of people, and it’s hard to sort of isolate variables when you’re studying just like massive cohorts of people and trying to understand what you know, what factors affect your risk for which diseases.

It’s not clear that taking hormones prevents heart disease. And that’s one of the big claims I see with menopause influencers, that every single person needs this.The data don’t support it at this point in time, and the major menopause organizations do not recommend it as a universal preventative treatment for everybody. But it seems like there might be some sort of association that may become clearer as research continues.

That said, now it seems like the pendulum is swinging in the opposite direction. I learned, “be afraid of menopausal hormone treatment.” And now all these menopause influencers are saying everyone should be on hormone therapy.

I don’t know the answer. And so the way that I try to parse through all of this noise is, you know, go to trusted sources, right? So I stick to society guidelines, like the North American menopause society, the British menopause society, they’re run by world experts in menopause.

Virginia

Okay, so we don’t need to be terrified of hormone therapy, and you can be on it if you’re still getting your period right? Just to finish Laurie’s question.

Mara

If you’re still getting a period regularly, you’re more in perimenopause than past the menopausal transition. And we will often use contraception to help and that you can have a lot of the same benefits from using contraception in that stage. It’s also useful just because unintended pregnancy still can be totally a thing in your 40s. But yes, you can absolutely use traditional regimens of menopausal hormone therapy while you’re still getting a period too. Just know it won’t prevent pregnancy.

Virginia

Since we talked a little bit about hot flashes, I’m gonna jump to Judy’s question so we can kind of round that piece out:

One of the things I am really struggling with is the way I have lost all ability to regulate temperature. I am boiling hot almost all the time, and the slightest thing makes me break out into a full sweat, which makes me not want to move at all.

My doctor has not been super helpful in navigating this. What can I do to mitigate this issue? If anything, it is so very hard for me not to blame the size of my body for this, since the correlation seems so clear, smaller body less sweating, larger body sweating all the dang time.

Mara

Judy, I empathize first of all. Just one caveat I can’t really give medical advice to Judy. There are a lot of things that could be going on, and it’s really important that you see a doctor and get a full history and physical exam.

But I will say that this is one of the things that menopausal hormone therapy is extremely helpful for, is hot flashes.

Virginia

That was my first thought!

Mara

There are a lot of influencers who really overstate the benefits of hormone therapy, right? Hormone therapy is not really going to cause significant weight loss or prevent weight gain. It’s not totally clear that it helps with mood symptoms or even sleep is a little more ambiguous. But the one thing it really works for is hot flashes. So that would be my thought: Start there.

Virginia

And on the feeling like you want to blame your body for it: I don’t know if Judy identifies as fat, but as someone who identifies as fat, I often feel like I’m sweatier now than when I was thinner. I run warmer. All my skinny friends will be bundled up in coats, and I still won’t be wearing one in October. I do notice that. And I think that this is a situation where that is, even if those two things correlate— you’re larger and you’re sweatier—is that worth putting yourself through the hell of weight loss?

You may decide yes, it is, if hormone therapy doesn’t work for you.But that’s one of those times where I bring it back to “What would actually make my daily life miserable?” I can drink water, I can be in AC, I’m gonna find a link to this nighttime cooling bed thing that my friend Claire Zulkey really loves.

Mara

I’ve heard of those!

Virginia

I think there are options to mitigate your suffering with this. Medicine is definitely an option. Before you go to “okay, my body size has to be the thing that changes.”

Mara

I totally agree. I just deal with this all the time where people tell me in my clinic that they want to lose weight. And when I sort of gently ask, what are you hoping to achieve? What are your goals? They’re often things that can be achieved through other means. Like, people say my clothes don’t fit, right? And most of my patients are low-income, right? I’m not trying to be flippant about the idea that everyone can just go and purchase a new, you know, multi $1,000 wardrobe at the drop of a hat. But it is possible to get new clothes in affordable ways. Don’t torture yourself with clothes that don’t fit because you feel like weight gain is a moral failing.

And I think that there are things that we can do to help keep us at a comfortable temperature, right wear clothes that feel, you know, that feel good. Air conditioning is an amazing modern invention. And, you know, cool beverages, ice cream.

Virginia

Popsicle O’Clock is very important in my summer right now, very important.

Mara

Wait, what’s a popsicle clock?

Virginia

Oh, Popsicle O’Clock. It’s just the time of day where you eat popsicles. It could be 9am it could be 4pm just whenever I feel like we need to add popsicles to a situation.

Mara

I think we all need more popsicles in our life, that is absolutely for sure.

So I think what I’m hearing from Judy’s question is once again, shame about body size, and also this myopic zooming in on weight loss as the only possible solution. Which I blame doctors for in many ways!

Some people do benefit from weight loss, right? I’m not opposed to the idea that anybody would ever want to lose weight. I don’t think that that’s a betrayal of fat solidarity, necessarily. But that there are other things you can do just to make your life feel better in the meantime, or even if you choose to never pursue weight loss. There are things you can do to feel better, and we shouldn’t deprive ourselves of those things.

Virginia

And you don’t know that it is the weight gain. It could be age and hormones, and those coincided with the weight gain for you personally. But there are lots of thin women getting hot flashes all the time too.

Okay, this next question is from Michaela:

I am super curious about the connection between perimenopause, menopause and mental health symptoms, specifically, an uptick in anxiety and depression. Is this a thing?

We also got many questions about whether perimenopause and menopause exacerbate ADHD symptoms.

Mara

So this is a question I get a lot from my patients, and I’ve seen a lot of discourse about online. And the short answer is: There is probably a connection between the hormonal changes of perimenopause and the menopausal transition and mental health. Do we understand it? No.

So I mean, with ADHD specifically, I will say: This is really not my area of expertise. It’s a very complex mental health condition, and our medical understanding of it is really rapidly evolving. I have many patients who have a diagnosis of ADHD but I’m typically not the one who diagnoses them.

That being said: Estrogen affects neurotransmitters. Neurotransmitters are implicated in ADHD. Declining estrogen does seem to affect dopamine, in particular, which is implicated in ADHD. And anecdotally, I’ve had many of my patients say that they feel like their ability to focus and sustain attention decreases. And they experience brain fog as they enter perimenopause and menopause. So it’s there’s probably something going on, and a lot of researchers are really actively studying it, but we don’t know yet.

Virginia

Do we know if this is something that hormone therapy can help with?

Mara

So I think the answer is, I don’t know.

Virginia

What about anxiety and depression?

Mara

I don’t think the data are there, right? Hormone therapy is usually not considered a first line treatment for the mental health conditions that are often associated with the menopausal transition. But we have great medicines for those conditions. We have good treatments for ADHD, we have good treatments for anxiety and depression. And sometimes during the menopausal transition, patients might need an increase of those treatments. And that could mean going back into therapy, if you’ve been out of therapy, increasing your medications or restarting a med that you may have stopped years ago. Those are all totally valid approaches during this phase.

And I guess what I’d say, is that it’s okay to trust your body. And if you notice changes in your mental health associated with perimenopause or menopause itself, ask about it. Don’t be afraid to advocate for yourself. And while hormone therapy doesn’t look like it is an effective treatment specifically for those symptoms, there are other treatments, and you should feel empowered to ask about them.

Virginia

The next question goes back to some of the diet and exercise stuff we’ve touched on. This person writes:

Since recently reaching menopause, my cholesterol has become high. I understand there is a proven link between menopause and increased cholesterol, and that weight is part of the picture. I’m trying to lower my cholesterol with focus on nutrition and exercise. But it is f*****g with my head because it feels like a very restrictive diet. I’d love any thoughts on the menopause cholesterol connection and keeping cholesterol low with nutrition and exercise without falling into the abyss of obsessing about how many almonds I’ve eaten.

Mara

Oh, that is such a good question!

Virginia

The almond of it all.

Mara

Almonds are really good in some scenarios, but also just like, kind of a sad snack. I always think about President Obama eating those, like, eight almonds, or whatever.

Virginia

It turns out that was a joke and he wasn’t doing that. But just the fact that everybody assumed he would says a lot!

Mara

That is hilarious, and I didn’t know! And it just shows how with information online, the initial story sticks. Like to this day, 10 years later, I still thought that Barack Obama ate eight almonds as his indulgent midnight snack every single night. I hope the man is eating some ice cream and living his best life.

Okay, so there is absolutely a link between menopause and elevated risk of cardiovascular disease. But even within the term cholesterol, there are different types. I wouldn’t really say to a patient, “Your cholesterol is high.” One thing you might hear is “your LDL cholesterol is high,” which is known popularly as, the “bad” cholesterol. Which, again, moral language alert.

But LDL cholesterol is a proxy for risk of cardiovascular disease. I will say it’s not a great one; it’s kind of a blunt instrument. We measure and we treat it, because we don’t have other great ways of predicting cardiovascular risk. But it is not the full portrait, although it’s certainly a risk factor for developing cardiovascular disease. And the transition of menopause seems to impact LDL, cholesterol, other biomarkers of cardiovascular disease, and increases your risk for cardiovascular disease.

And what’s interesting–I think we talked about this a little bit already, is that this happens, this this risk happens independent of normal aging.

So, for example, women who go through menopause early start developing this increased risk earlier than women who go through menopause slightly later. And overall, we see that women develop cardiovascular disease, at rates lower than men, and at later in life than men. And there’s a hypothesis that this has to do with menopause, right? That there’s a protective effect of estrogen, but then when your estrogen starts to decline in menopause, it puts women at an increased risk compared to where they were pre-menopause.

There’s also some data to suggest that the severity of menopause symptoms—particularly vasomotor symptoms like hot flashes or sleep disturbances—may indicate risk for developing cardiovascular disease. So this is not to scare everyone, but it’s good to have knowledge. If you’re having really severe hot flashes, it may indicate that you are at slightly higher risk for developing cardiovascular disease than somebody who is not.

The intention of having this knowledge is not to make you feel shame, and not to berate you for your belly fat or whatever. It’s to have knowledge so that you can help mitigate risk factors in ways that feel aligned with your values and ways that feel aligned with the way that you want to pursue health in your life.

And so I would approach this reader’s or this listener’s question with smy same approach to all of my patients questions. “I have hypertension, does that mean I need to lose weight?” “I have diabetes, does that mean I need to lose weight?” The answer is that we have many treatments that can help you address these concerns independent of weight loss. But this is not to say that you cannot pursue weight loss too, right? And if using a GLP-1 agonist to reduce your visceral adiposity is aligned with your values, and you can tolerate the side effects, and you feel good about it, and it’s covered by your insurance….that’s totally a reasonable approach. But it’s not the only one.

So I think what I’m hearing from this patient is the menopause flavor of what I do every single day in my work as a size inclusive doctor. Which is: How can we disentangle weight stigma and body shame from these questions of how to lead a healthy life? And the idea of giving you more information, I hope, is not to shame you or make you feel guilt for the relationship between body size and risk of cardiovascular disease, but instead, to give you information that might help you take proactive care of your body, right?

And proactive care might mean committing to an exercise routine. Proactive care might mean taking a statin. A statin is a very common cholesterol medicine like Lipitor. It might mean getting your blood pressure under control and taking an antihypertensive.

Virginia

I also want to say on cholesterol, specifically, I did a piece that I’ll link to digging into the connection between nutrition and cholesterol. And the data is not as strong as I think a lot of doctors are telling folks.

And I think the benefit of making dietary changes—the amount it could lower cholesterol—was not huge. It was like three points or six points or something in one of the studies we looked at. So if it’s making you crazy to count almonds, it’s possible that medication might be a more health promoting strategy for you. Because it will be less stressful and it will have a bigger benefit on your cholesterol than just trying to control it through diet and exercise.

Mara

Yeah, I totally agree. I think there’s a really strong genetic component that we haven’t fully understood and medication is a totally reasonable approach and very safe approach. Honestly, statins are pretty benign medications. They’re pretty inexpensive, pretty minimal side effects, which is not to say– nobody’s paying me from the statin companies, I swear to God!–but yeah, like they’re, they’re pretty benign as medications go. And I think it’s a totally reasonable way to approach this issue.

Virginia

I just think it’s one of those times where this is shame coming in, where it’s like, “You should be able to fix this with how you eat and exercise, and so you don’t get the medication unless you fail at that!” This is a framing that I’ve encountered from doctors. But what if we gave the medication, what if we also consider diet and exercise, but don’t make that a pass/fail situation in order to earn the medication?

Mara

Yeah, that’s really interesting.

And even the language you’re using Virginia is what we use in the medical record, and I’ve tried to stop it. But the way we’re taught to describe patients, is “patient failed XYZ treatment,” right? And I feel like we’re both at once, overly invested in pharmaceutical treatments, right and underinvested. They’re a very useful tool. And we moralize it, both pro and con? Sometimes, like, we moralize in favor of it. So if your BMI is 26 or above, you need to be on a GLP one agonist, which is just false, right?

But on the other hand, I think we often underutilize medications because there’s this sense that you’re getting at —that you have to exhaust all of your like willpower options first, and it’s somehow failing to use a med. And that is really false too. They’re really useful tools. Science is really useful, and we shouldn’t feel ashamed to use it.

Virginia

All right. And our last question, I like because it just will give us a chance to kind of sum up some key points:

As a post menopausal woman, I feel like I’m swimming in information, and I’m overwhelmed by it all. What are Dr Gordon’s top three pieces of advice out of all of the WHO meaning, if women at this time only did these three things, it would make the biggest difference, and then they just had it. You know, is, does it need to be different for perimenopause versus post menopause? Or maybe not.

So what are your top three? Top three tips for surviving this life stage?

Mara

Oh, my God, if only I knew! I’m flattered that you’re asking, and I will do my best to answer, but I don’t think there’s a right answer at all.

So I’ve thought about a couple things. I will say that, you know, longevity and wellness and health span is extremely complicated, but it’s also kind of simple, right?

So sometimes the advice that we’ve just heard over and over again is actually really, really good, right? So, sleep. Are we sleeping enough?

Staying engaged with social relationships, that seems to be extremely important for longevity. And it’s kind of amazing, actually. When they do these long-term studies on people who are thriving into old age, like they have really strong relationships. And that is so important.

Moving our bodies and it does not need to be punishing. Workouts can be gardening. I know Virginia, I love receiving your gardening content online. Gardening is an amazing form of exercise, and can be very life affirming, and does not need to feel like punishment. Just getting up, moving our bodies, sleeping enough, maintaining relationships, cultivating a sense of purpose and meaning in our lives. It’s actually been really studied right, that people who have a sense of meaning and have a sense of purpose in their lives tend to live longer and live longer, healthier lives.

So all of this is to say that like it’s complicated, but sometimes it’s not. And there are a million people on the Internet who want to sell you a miracle drug, a miracle supplement, a miracle weighted vest, whatever. But sometimes simple, Simple is good. Easier said than done, right?

Virginia

Yeah, but start simple. That’s wonderful.

Mara

Can I ask? Virginia, what would your advice be?

Virginia

I love the three areas you hit on: Sleep, social relations and exercise or moving your body. None of those are about weight loss or dieting. I think that’s really helpful for us to keep in mind that the things that might protect our health the most can also be very joyful as well. The idea that doing things that makes you happy and reduce your stress can be health-promoting is great. And I think that’s something especially in midlife. We are all incredibly busy. We’re holding a lot of things together. A lot of us are caregivers, maybe sandwich generation caregivers. So prioritizing your own joy in that feels really wonderful.

Butter

Virginia

All right, so speaking of joy, let’s do some Butter! Dr. Mara, what do you have for

us?

Mara

I have a Philadelphia-specific one, but hopefully it can be extrapolated to our listeners in different locations. So I have recently been really craving soft serve ice cream. And so I googled best soft serve in Philadelphia, and I found this Vietnamese coffee shop called Càphê Roasters, which is in North Philly. In a neighborhood called Kensington. And it has condensed milk soft serve ice cream. So good.

And so I recently, I had to give a lecture at a medical school in the north part of the city early in the morning. It was like, 8am and I was like, “Oh, I’m never up in this neighborhood. I gotta get over there.” And I went after I gave my lecture, and I bought myself ice cream at 10:30 in the morning. And I ate it in my car, and it was so good. Condensed milk. So good. But soft serve in general, is my Butter. But for those of you in Philly, go to Càphê Roasters in Kensington and get the condensed milk. It is chef’s kiss, delicious.

Virginia

Amazing. I’m gonna double your Butter and say ice cream in general is my Butter right now. We have a spare fridge freezer that I have just been loading up with all of the popsicles to get us through summer.

But also: Ice cream dates. Something that comes up a lot for me as a co-parent is figuring out how to have one on one time with my kids. Since we have joint custody, they move as a package. So I get kid-free time, which is wonderful, but when they’re with me, it’s just me. So one thing I’ve been figuring out is pockets of time when I can take one kid out for ice cream. It’s usually when a sibling is at another activity, and so we have an hour to kill, and often we would just like, wait for the activity, or go home and come back, and then you’re just driving.

And now I’m like, No, that will be our ice cream break!

Mara

I love that.

Virginia

So one kid’s at the library doing her book trivia team stuff, and the other kid and I are getting ice cream while we wait for her. And it’s great one on one time with kids. Obviously, the ice cream is delicious. The other thing I’ve realized, especially if you have younger kids who are still building restaurant skills, ice cream is a great practice run at being a person in a restaurant, which is really hard for kids understandably. It is one food thing that they’re excited to go do. And you do have to sit and practice eating it somewhat neatly. There’s a high mess potential. My pro-move for that is, always have wipes in your car, bring a pack of wipes in.

Mara

I love that, and it’s so intentional about sort of creating traditions with kids. That feels really special. But I will say I had my ice cream solo, and that was also really good solo ice cream too.

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