The Truth About Estrogen: What the Women's Health Initiative Got Wrong with Dr. Avrum Bluming & Dr. Carol Tavris

27:27So I was sitting in M &M, which in the hospital setting is Morbidity and Mortality Conference, basically a once a week meeting from our Department of Obstetrics and Gynecology, where we go through cases that week and, you know, our hits and misses and wins and some lectures and learning things when that press conference broke. And all the whispers, you know, going, this is before the internet, before cell phones, and everyone was so upset. And it was just like, I remember that lightning bolt moment. And the press conference said, estrogen increases the risk of heart disease, of death, of stroke, and of breast cancer.

28:07And the headline was in the New York Times, estrogen increases the risk of breast cancer. Breast cancer is the red flag here. Well, actually, that's not what their data said. So you've once said in the book, once they misinterpreted their own data, now you say they're misrepresenting it. That's correct. We have to talk about each one of these. Let me just dispense quickly with heart disease. They said it increased the risk of breast cancer. Actually, the median age of patients, the average age was 63, not between 45 and 51. when most women reach menopause. Half of the women were smokers. Many of them had hypercholesterolemia.

28:49Many were overweight and 25 % were obese. This wasn't a representative population, although at the time of the press conference, they said these data can be extrapolated to the general female population. But on breast cancer, what they said is it increases the risk of breast cancer. Actually, there are laws that allow us to determine the significance or validity of a result. So we're talking about statistics. We're talking about statistics. And the laws are kind of like basketball. In basketball, if you sink the ball through the basket, you get two points. If the ball bounces off the rim, you get zero points.

29:34Now, I don't have to argue the validity of that, but those are the rules. In statistics, in order for something to be called statistically significant, it has to have a likelihood of developing of less than one in 20. Right. Okay. And there are mathematical tests that determine that. The mathematical test for the increase that they saw in breast cancer, and this was only among the women who got the estrogen and progesterone, not the women who got estrogen alone. The mathematical test didn't add up. Hit the rim. Hit the rim. That's right. It hit the rim and bounced off. And in that article said the increased risk of breast cancer almost approached nominal statistical significance.

30:21I have never seen that statement before or since in any published medical article on any topic. Let me review this. So the average age of women in the study was 63. very different than the average age of women who would typically start hormone therapy at 50 or 51 when they hit full menopause. This group of women were 70 % overweight and then like 30 something percent obese. 40 % were smokers. They had several risk factors for cardiovascular disease being elevated much higher than ladies who would have been early in menopause taking the medications. And the outcome was cardiovascular disease. That was the primary outcome was, is she going to have a heart attack or not starting this medication?

31:08There's also problems, as you've talked about before, with the control group. It's worth saying so that we don't confuse people listening. What they said about heart disease, they have walked back. so that now what they say is actually estrogen or the combination decreases the risk of heart disease when started within 10 years of a woman's last menstrual period. The stroke, they've also now no longer stated. They said it increases the risk of death again, starting, they say, within 10 years of the last menstrual period. It actually prolongs life. It doesn't decrease lifespan. Estrogen, they now say, based on 20 years of follow-up, estrogen actually decreases the risk of breast cancer development among women who never had breast cancer by 23%, and that is a significant reduction.

32:05And here's a very important point, decreases the risk of death from breast cancer by 40%, also statistically significant. The one other thing they said, they said this the following year, they wrote it up, that estrogen has no effect on quality of life. Well, I'm sitting here with two women, of course, you smirk. But the question was, well, how is that possible? And if you read the article on quality of life that was published in 2003, they said, we knew that women who were symptomatic, who were randomized to placebo, would know within weeks that they were getting a placebo, not the hormones, and they would drop out of the study, which we didn't want.

32:50So we intentionally did not select symptomatic women to join the study. So symptomatic meaning severe hot flashes. Yeah, exactly. So women with severe hot flashes were largely excluded from the study. Correct. And so what they say in the article, but most people don't read the fine print, they said the symptoms that these women didn't have were not affected when they got hormones. You can't make this up, you know, but they did. And all of this has been walked back. So now they say that hormones are actually the best choice for symptomatic treatment. But following up on the question of breast cancer, the one thing they still hold on to, and this is now 23 years after that famous press conference, they say that the combination estrogen alone I said decreases the risk of breast cancer death from breast cancer but they say the combination increases the risk of breast cancer development but doesn't increase the risk of death from breast cancer and they still say that and Carol and I said well they misunderstood their own data well now having spoken with them having written with them having debated them having debated them in the medical literature everything I'm about to say, they know.

34:11And what I am saying is their first conclusion wasn't statistically significant. In 2006, they published an article saying, you know, we hear that we've been challenged because, as you mentioned, the study was directed at heart disease, not at breast cancer. And in order to have a fair study, what we have to do is balance risk. And the risks for heart disease, cigarette smoking, high fat diet, high cholesterol levels are different than the risk for breast cancer development, family history of breast cancer, number of children. And so since our population was not selected on the basis of breast cancer risk, people have said that the increase we reported is not meaningful.

35:03And so Garnett Anderson, the chief biostatistician for the Women's Health Initiative, published an article in 2006 that said, okay, what I've done is I have retrospectively balanced for breast cancer risk, and I reanalyzed the data looking only at breast cancer risk factors for women. And she said it makes no difference, meaning I still see an increased risk. That's a lie. It makes a huge difference because we spoke about the basketball rules or the statistical rules. It went from being borderline statistically significant to statistically not significant. This is a biostatistician. And she said it made no difference.

35:51It made a huge difference. So why do you think that me, board certified OBGYN, on the front lines, counseling women day after day in menopause about the risk and benefits of hormone therapy, did not know any of this information? This all didn't come out in the last three years since I heard you guys speak or since I read the book. This has been coming out since the study was published, right? Trickling out over time. I do my recertification every year. I have articles put in front of me that are the latest, greatest updates, new guidelines. And none of this until recently was put in front of me.

36:30I was out there counseling patients based on 2002 erroneous data. I mean, why do you think that is? Well, first, it's still being reported. In 2025, they are still reporting an increased risk associated with the combination hormones. And the guidelines today from ACOG, American College of OBGYN, are lowest dose, shortest amount of time. Still. Still. For which there is no data. Yeah. See, that's the deadly compromise, which is we actually know that hormones are beneficial and helpful. But wait, the WHI says that they're dangerous. So what's the compromise that will allow us to use a little in the shortest time?

37:10Which is like, okay, smoking could kill you. So only smoke one pack instead of three packs. and only for a year instead of for 10 years. That would be stupid advice. Either it's not a risk, in which case take the drug, or it is a risk, in which case don't. But the shortest dose for the smallest amount of time represents a foolish compromise, I think. Let's take two steps back. What is the risk? It's not a risk of death. It's a risk of breast cancer development. Even if they're right and they're not, what is the risk? The risk is one extra case of breast cancer, non-fatal breast cancer, per thousand women taking hormones.

37:50If their data is correct. But their data is not correct. But even if their data were correct. So if we believe it. That's right. One per thousand. Well, you can't know that. In human beings, a one in a thousand increased risk is nothing. It's nothing. Human beings aren't genetically identical mice. Right. There are differences among us even in the best controlled studies. And there is no other study where this kind of a libel against the drug would stand for 30 plus years based on one extra non-fatal case of breast cancer per thousand. But even that one extra case is wrong. It's important to know, I said that there were four different groups in this.

38:40are the combination women against placebo and the estrogen alone women against placebo. And if you look at the combination against placebo, it does look on the graph as if there is a difference. In fact, the combination does have a higher risk of breast cancer than the placebo, but it's not because there's an increased risk among the women who got the combination. In fact, that risk is identical to the risk among the women who got estrogen alone. And I said that that showed a decreased risk. It's the placebo group against which the combination is measured that has a lower than expected risk. And that's been ignored, except for an article in 2004 that was ignored.

39:30an article in 2018 by Howard Hodes from USC and Phil Sorrell from Yale saying the placebo group is the problem. It isn't that there's an increased risk among the women getting the combination. And so one has to ask the question, why would the placebo group have a lower than expected risk? And the first answer is, I don't know. And the second answer is a significant number, 23 % of women who were randomized to placebo had taken hormones before they were randomized to the placebo group. And if the hormones decreased the risk of breast cancer and they were taking them, well, what would happen if we eliminated women who had taken hormones before they joined the study, both from the test group and the placebo group?

40:24And no surprise, the placebo group risk goes up and the graph for both the combination and the placebo group are now the same. Yeah. Proving in both groups that estrogen plus or minus a progestogen would be protective against breast cancer. Best we could tell. Yeah. It's so easy to accept data, especially now with media, trumpeting results because bad news sells. And again, the investigators here are respectable people. I have respect for them, even though I disagree with what they're writing. The first is the collaborative reanalysis. In 1997, a group of physicians from England put together, I think, 51 different studies and analyzed the studies to see if hormones increased the risk of breast cancer.

41:20And what they reported is that they had no data on women who had taken hormones and stopped. They didn't see any increased risk among that group. But women who had taken hormones and continued to take them, and this is true for estrogen and the combination, have an increased risk of breast cancer. Really, how much of an increase? Well, it's about 6 per thousand women taking it for over 10 years. That is absurd, but that's what they reported, and because they're respected physicians, it's been published and it's still quoted. Interestingly, 80 % of the women in that study were on estrogen alone.

42:07The Women's Health Initiative cites the collaborative reanalysis as confirming what they said. Well, no, what the Women's Health Initiative said is that estrogen alone decreases the risk of breast cancer. Well, they sort of glide over that. They really can't explain that, but they use the collaborative reanalysis to support what they're saying. The second study, also out of England, is called the Million Women Study. Million Women Study is a very big name. Actually, a million women did get mail sent to them, and they were drawn from a list of women who got mammograms. Well, first, the list, women who got mammograms may have had a reason for getting the mammogram, so it may not be an unselected population.

42:52They're not all screening mammograms. That's right. But they sent a million, about 400 ,000 answered the two mailings. The mailings were separated by three years. Okay. And they reported an increased risk of breast cancer among women who took hormones, estrogen alone or estrogen and progesterone. First of all, they said women who had taken hormones in the past, even for more than 15 years, had no increased risk of breast cancer. Well, wait, wait, wait. Really? How do you explain that? No explanation. Second, the increase that they saw went from 1 in 100 women to 1.4 in 100 women. Yes, I mean, that's a 50 % increase, but it's 1 to 1.4.

43:45Come on, somebody. From crossing the street to having an aspirin has a risk. We hear women say things like, okay, so the risk is only one in a thousand, but I don't want to be that one. I hear that all the time. What if I'm the one? The one, exactly. So this in psychology is called risk aversion. If I'm thinking in terms of my risk of getting something, I don't want it. if I think in terms of my benefits of getting something, that's a different calculation. It's okay, one in a thousand of getting breast cancer, but how about 500 in a thousand of avoiding heart disease? Or I'm going to make up numbers here, but okay, so you have this one risk, but what if your benefits are greatly enhanced by your taking the drug?

44:27Most people don't think in terms of what they can gain. They worry more about what the risk is. That's a natural part of human thinking, I suppose, from our prehistoric tendency. We better look for that one tiger that might bite us, you know. But now the concern really is how to assess the overall risk versus benefits. And overwhelmingly, the benefits for women, how many things can we take in our lives that prolong our lives by three or four years? What do studies show? If you use this thing, you know, you'll live three months longer, you know, really? But years? I don't know of a single drug that will improve the quality of life of women over a certain age in on multiple levels than hormones, estrogen, estrogen, exactly.

45:10But that's left out of the conversation. It's only, how do we get to the point where the worst thing in the world is developing breast cancer? Fear of cells. I fear breast cancer. Trust me, I have a healthy respect for breast cancer, but not to the exclusion of osteoporosis and heart disease. Exactly. But breast cancer does get the attention. Every celebrity woman who gets breast cancer immediately makes a public announcement about it and then gets prayers and wishes from everybody that she doesn't die, even though, as Avram said, she has an extremely high likelihood of surviving. But it immediately gets sympathy and attention and publicity.

45:46And of course, it's our breasts. We worry about them. We love them. We want them. So of course, women are going to be distressed by this particular form of breast cancer, but it is unrelated to both probabilities of survival and the greater risks of what are the greater harms, right? And it's not just breast cancer. Okay. It's against hormones. Yeah. The Women's Health Initiative, now, they studied heart disease. They extrapolated to breast cancer. In 2009, they said hormones increase the risk of ovarian cancer. Around that same time, they said hormones increase the risk of lung cancer death. not increase the risk of lung cancer, but increase the risk of lung cancer death.

46:32There are now studies showing that's not true, that if anything, it may actually decrease the risk of lung cancer death, but it certainly doesn't increase it. They never retracted that. The ovarian cancer, Wolf Udian, who was the head of the North American Menopause Society, challenged the WHI authors in 2009 and said, wait, what you said about ovarian cancer is not statistically significant, they backed off. But there was no retraction in public media. It's an attempt to frighten people away from hormones. We came across an article that was published in JAMA Neurology last week that said that progesterone contraceptives increase the risk of brain tumors.

47:19Oh my God, brain tumors, that's terrible. So you read the article, It was published in JAMA Neurology. It's from the Cleveland Clinic. Again, respected people. And the increase doubles the risk of meningioma. That's the one brain tumor they looked at. The increase went from 3.5 to 7 per thousand women taking it for several years. Those are nothing numbers. Those aren't numbers that I would accept as an editor for a publication. I'd be ashamed to write an article with that conclusion, but it's there. We don't see that for when we talk about testosterone for men, you know, and hormone therapy for men.

48:07We don't see this demonization or this otherness or this somehow it's bad for you. So let's talk about the cost of fear. I want to say, by the way, about publication. As we know, in science, well, throughout the sciences, it's far easier to get a publication when you have a finding of alarm than when you have no results. And if you want to say something positive about hormones, forget JAMA, forget Lancet, forget the New England Journal of Medicine. For our listeners, these are the major, most well-respected publications in the world. They don't accept articles that are in favor of hormones. When I suggest to co-authors that I write a paper with, Why don't we try sending it to, they laugh and say, good luck.

48:48Menopause, which is a very good journal. Climacteric, which is a very good journal. There are three menopause-like journals and they publish the favorable articles. Yes. That's an imbalance that reverberates through social media and mainstream media that pick up the lead articles from the most reputable medical journals. I don't know why that is, but it is clearly a practice that's been going on for a long time. They will not dispute the Women's Health Initiative. They just will not permit anything that disagrees with them. And what's interesting is, I mean, it may be that their view is the Women's Health Initiative was so big, so powerful, such a governmentally supported project that it has to be right.

49:35It's too big to fail. It's too big to fail. And in the absence of the Women's Health Initiative, doing the right thing and calling another press conference. Here's where we are today in 2025. Isn't it important that we sort of review everything and reassure women that hormones are really safe, effective and healthy and prolong life? Let's do that. And by the way, along the way, correct what we've been saying about breast cancer. You want to get your backyard summer ready, but you don't want to break the bank? Wayfair gets it. Planning on dining alfresco or relaxing poolside? Wayfair has everything you need to prep your space.

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51:02Whichever you choose, delicious coffee awaits. Find Starbucks frappuccino drinks wherever you buy your groceries. But they haven't done that. So let's take it back to 2002. Press conference happens before the article's even published and we can read it. They're making all these claims. What happened on our end on the front line is we were getting calls because it was viral before there was the internet, right? It was the newspapers, magazines, Good Morning America. It was the number one medical news story of 2002. I want to make sure everybody realizes this. And women, by and large, threw their hormones in the trash and said, this will give me cancer.

51:37I can't do this. This is going to hurt me somehow. Doctors' offices were getting called. So here we have this, you know, 70-something percent of prescriptions are no longer being filled. What do you think this meant in real life? Do we see more broken bones? Do we see more heart disease? Are we seeing more dementia? Bill Sorrell, who we already mentioned, who's an OBGYN at Yale, who educates OBGYN physicians about hormones, who runs an organization called Improving Health After Hysterectomy, wrote an article in 2012 saying the best data they could get suggested that there was somewhere between 50 ,000 and 90 ,000 extra deaths in the United States from people who had been taking estrogen and weren't taking it.

52:20Now, in fairness, having said that, the numbers weren't statistically significant. Have to be fair on both sides. I've spoken to Phil numerous times. He believes the numbers are even better now, but there hasn't been a follow-up article on that. But there are unquestionably going to be more broken bones. We mentioned heart disease being the seven times as common as breast cancer as a cause of death. And I ought to mention when I say that, women respond by saying, well, old women die of heart disease and young women die of breast cancer. And I'd rather die when I'm old than die when I'm young. And in point of fact, in every decade of a woman's life, a risk of dying of heart disease is greater than her risk of dying of breast cancer.

53:08And that difference increases with every successive decade. One answer to your question comes from the Women's Health Initiative itself, which has concluded that estrogen is the best and safest thing to prevent osteoporosis. Yeah, it's FDA approved. Absolutely. For the prevention. For the prevention. For the prevention. So in that statement is the women who were not taking it in the 20 years that we told them it was not good for them did not get its protective benefits. So that is, in a way, one answer. So the boomers are really mad. The boomers that follow me, that generation who weren't given the option, told it was too dangerous, and then given sleeping pills, anxiety medications, they ended up on polypharmacy to treat all of their symptoms, are now really upset that they've been left out of the conversation.

53:56Good. Let's get mobilized. Yeah. Gen X isn't standing for it. They're not going to sit around and wait for the guidelines to all agree and catch up with each other. Which is why it is so important to have a doctor willing to sit down with you, educate himself or herself, and discuss with you what the risks for you are. Let's talk about who shouldn't take these hormones. Let's lay it out for the audience. What are the absolute contraindications? We started this whole discussion by talking about an open decision with your physician. In that open decision, there are no absolute contraindications.

54:32This isn't cyanide. that's a great way to put it this isn't cyanide this is a medicine that's got pros and cons and in your individual situation you must weigh the pros against the cons and together with your physician decide whether it's worth it to you gynecologic cancer survivors specifically breast ovarian even uterine are being told by oncologists you cannot have this medication you will die you You know what the only prophylactic medicine we know of that helps prevent ovarian cancer is estrogen. Estrogen, taken as contraceptive estrogen, which there now seems to be some movement against, but estrogen will decrease the risk of ovarian cancer by somewhere between 4 % and 10 % for each decade that a woman takes it.

55:29Nothing else does that. And the data do not support that estrogen increases the risk of ovarian cancer. They do support that it increases the risk of uterine cancer, an increase that's eliminated by the use of progesterone. That's correct. I would add one other element because I was one of the 37 women in America who had no symptoms at all in menopause. Neither did my mother for that matter. And a woman asked me after a lecture, she said, well, I'm 50 and I have no symptoms. Should I take HRT? I get this question. Yeah. It's a great question. So I said, you know what, when you're my age, you'll have a different answer than the answer that you have right then, you know?

56:08And because the answer has to again involve in conversation with your doctor, what are your risk factors going forward? My father and three of his brothers died of sudden heart disease when they were 50. What about osteoporosis? What about dementia? What about other risk factors in your family that you might like not to have when you are in your 70s and 80s? And of course, when you're 50, you're not thinking about when you're 80. You're thinking about what is my health benefits right now for this decade? When my patients come to me in clinic, it's number one to put out the fire, like get them to a functional status again.

56:39Usually they're coming in very symptomatic. They've been to several different clinicians before they end up with me and they saw something I said on social media and it drives them to my office. So we get them back their functionality, usually some combination of hormone therapy. Then the conversation about the next 30 years begins and the prevention. And we talk about how's your mom? How's your grandmother? How are your aunts? How are the women in your family aging? And of course, it's a package. It's not just hormone therapy. And we talk about what the data is showing for cardiovascular protection, definitely for her bones, possibly for dementia prevention, but also the lifestyle factors that are going going to play into that as well.

57:16Because with all the bro science, you know, forgive me, Dr. Blooming, you know, all the men on social media squawking about how they want to live to 120. No woman I know wants to live that long. She just wants to stay out of a nursing home and to maintain her independence and functional life and her brain power for as long as she possibly can so that she doesn't burden her children or her husband. You know, she kind of is like buying into she's going to be his caretaker, but like who's going to take care of her? Exactly right. Exactly right. Okay. Let's break down risk communication. And estrogen matters.

57:50You both say statistics can terrify or clarify depending on how they're used. Let's put that in plain English for me, for our listeners. Well, it's really what we were talking about before, about whether you want to see yourself as the one person in 10 ,000 who's at risk of something, or if you want to see yourself as part of the 500 who will benefit. The communications researcher George Gerbner once said, human beings are the only species to distinguish us from all other species. We are the only species that tells stories. And then he added, and lives by the stories we tell. And that is why the power of one anecdote, one story, my mother had a really bad time on estrogen when she was taking birth control pills.

58:30I'm never going to do it myself. Or my beloved fill-in-the-blank person got breast cancer because she had been taking hormones. One compelling story often drives the narrative, drives the fear or the optimism. My friend is drinking kumquat juice every morning and swears that it's made her skin better, whatever it might be. And the reason this matters, a friend of mine told me that she had been at her oncologist and women were there, were all dealing with breast cancer in one way or the other. And she said some of us had been on HRT and we were sure that hormones had caused our breast cancer. And then she paused and said, all of us had had coffee that morning too, right?

59:06Yeah. If you're looking for a cause, as we all do, when something... We are really seeing this amplified on social media right now. Oh yeah. Oh yeah, yeah. It's this looking backward fallacy. If A comes before B, A must have caused B. There are a lot of things can cause B. And we might want to select one, but it behooves us to think further and see if it's really a logical cause or not. You know, one of the things I think that women don't understand about estrogen is that it is a hormone that affects every damn part of our bodies. I didn't realize this. I thought when I went into menopause, I thought estrogen declined gently the way it declines gently in men.

59:45No, it's a plummet. It's a damn plummet off a cliff down to, you know, 1 % of what it had been. And since every organ in our bodies is affected by estrogen, what are we depleting our bodies of? If you have a thyroid removed and you need Synthroid to stay alive, no one thinks that's somehow unfeminist or inappropriate or unmedically sound. It's replacing what you lack. Protecting us from male levels of heart disease was estrogen. And talking about prevention, it's worth noting that estrogen's benefits, especially in areas that we can measure easily, last as long as you take it. And they stop when you stop.

1:00:25so that a woman who takes estrogen will decrease her risk of an osteoporotic hip fracture, around which about as many women die each year as they have breast cancer. Say that again, because I don't think people realize that. Osteoporotic hip fracture is associated with the same number of deaths in this country, close to the same number, as breast cancer. And that can be prevented in half by women who take estrogen. But if you stop taking the estrogen within six or seven years, measuring your risk of osteoporotic hip fracture reaches a point where your bones will look as if you had never taken it.

1:01:08So you've both been really clear. It's not enough just to critique the Women's Health Initiative that, you know, I've heard the critiques. Millions of women have heard the critiques. Physicians are starting to hear the critiques. But we're not really shifting practice patterns. What do you think it's going to take to make that happen? I'm so glad. Carol and I, for the last eight years, have been talking to women all over the world, really. And it's easy to get them riled up. Hey, sister, let's fight this. You're not changing much. How can we change? She walks into her doctor's office, locked and loaded, ready for this discussion, and is met with 94 % of the time a brick wall.

1:01:51That's right. I don't want to talk about it. So first, I don't want to talk about it. Doctor, that is not an acceptable response. I am your patient. If you don't want me to be your patient, I understand. But as long as I am here as your patient, I need a discussion. By the way, I came armed with information and I don't accept everything I read, even by these two people as gospel, but I need feedback from you. And the doctor must respond in an open way. But we need more than that. And in discussions that we've had many, many times, we decided there are two main reasons why doctors aren't keeping up with women's desire for estrogen by giving estrogen.

1:02:39One is the fear of legal culpability. Some women who take hormones that, doctor, you may prescribe will come down with breast cancer and who wants to be sued. And we live in a litiginous society. What we've decided is let's put together an informed consent form. Doctor, I understand your concern about legal culpability. I want to spare you that aggravation. And so this informed consent form goes over the benefits referenced and the risks, including the risk of breast cancer development. And I will sign consent saying, I won't hold you legally liable should I come down with breast cancer. I think that's a wonderful first step.

1:03:26It's a fantastic tool. And for our listeners, we're going to have this on our website at thepawslife.com. click a button, easy to download that you can take to clinic, and it'll be linked in the show notes as well. That's great. Okay. The second thing that we put together is a quality of life questionnaire. Most people aren't aware that there are many symptoms associated with menopause, not just hot flushes and night sweats. There are palpitations, there are joint aches, there are frozen shoulder. Bloating, fatigue, problems, concentrating or remembering. I'm reading right off the list. Mood swings, headaches, bloating, swelling of hands or feet, muscle or joint pains, breast tenderness, palpitations, chest pain with exertion or with exercise.

1:04:07These are the ones that stopped me in my tracks. Fear of heart disease, fear of osteoporosis, fear of breast cancer recurrence. Right. And what we suggest is that you download this quality of life questionnaire. And each one of these complaints is in a column where you can grade the symptom as either tolerable, unbearable, or not at all. Right. And on the second column, how much it interferes with the quality of your life. And you fill that out before you start the hormone therapy and fill it out once a month or twice a month until you get tired of it and share it with the doctor treating you.

1:04:49I remember when we were talking about lumpectomy as a possible alternative to the radical mastectomy and surgeons refused. They said it would be malpractice not to do the radical mastectomy. And I remember the first time a doctor in our community in Los Angeles did a lumpectomy and he walked to the patient's bedside after the surgery. And after of the conversation, he said to me, he was so overwhelmed by the patient's gratitude, he said, I'll never do another mastectomy. And it has spread around the world. It's standard of care now that the slumpectomy radiation is now the standard of care. It's certainly as good as, and it's much less toxic than the mastectomy, even the modified radical mastectomy.

1:05:38I want to add to the quality of life questionnaire. It's a fabulous document to bring to the doctor even on your first visit. And the reason is that we all know the experience of, I have all these symptoms I want to discuss with the doctor, and then seven of them go out of your mind when you actually arrive. Like you forget to mention the heart palpitations, which are driving you crazy. So by filling out this list of symptoms associated with menopause and seeing where you are on them and how you are responding to them, it's a great document for the doctor to have as well. And let me add what you can't see, you know, our listeners can't see, is on the informed consent form, There is about two full pages of medical references, of journal articles that is attached to this in case the doctor has any questions or wants to read up on their own.

1:06:21So you and other members in our menopause have published criticisms in peer-reviewed journals and spoken at leading institutions, myself included. I spoke at ACOG. Yet prescribing practices are resistant. As a matter of fact, the most up-to-date guidelines are the Menopause Society guidelines. and they were changed in 2022, like stepping away from the smallest dose for the shortest time possible. Yet, you know, the American College of OB-GYN still hasn't updated their guidelines in I think 14 years at last count. You know, why do you think change is so slow here? You have to admit you were wrong.

1:06:55That's just a starter. Mistakes were made, but not by me. Not by them. So that's your, another book. Well, that's another book, exactly. No, why no change? Well, who are we to criticize the Women's Health Initiative? But once a practice is established, I mean, look how long the radical mastectomy existed. Many medical practices sort of get into the system and changing them is like, I'm fond of saying, it's like turning a battleship around in a tiny river. You need a lot of tugboats, I guess. And even then, it's not going to be an easy process because the new guidelines become so entrenched that turning them around, it requires people to change their minds, change their practices.

1:07:35They have to actually read and learn why the original assumptions were wrong. I read a study that said specifically on this subject of from new research to clinical guidelines being updated to clinical practice change. 212 years. 17. Yeah. So that's about as long as the WHI has been. Oh, good. It's only 17? So we're going to skip a whole generation of women. But what I love about social media and podcasts now is we are out there. I think the tide is turning. and women are realizing that they have power here and that they need to be the CEO of their own healthcare and that they can go in with these tools that we're arming them with to speed this process up.

1:08:16Because I think by and large, clinicians are good people. They want to do well. They care deeply, but we're busy, especially in menopause care. I mean, as a former program director in obstetrics and gynecology, we had six hours of menopause built in hours in a four-year curriculum. So if you want to do up-to-date menopause care, you have to go seek outside training because they're not giving it to you in your CME. This is something you have to like really want to do. So I want women to realize you really right now cannot expect to walk into your regular doctor's office. You might get lucky, but more than likely they're not prepared to help you here.

1:08:49But like I graduated from my training the year the study hit and I was terrified of it. You know, I was sitting in your lecture three years ago, reluctantly myself on hormone therapy because I thought, well, if I get breast cancer, or at least I'll have a better quality of life. Knowing my chances of surviving breast cancer were good, but I couldn't live like that. So realizing that I wasn't hurting myself and I had left a lot of patients bereft because I didn't know. And that's what we have to change. Well, and we have to understand too, the dilemmas for so many women going to see a doctor who has a tiny amount of time to devote to them.

1:09:23Yeah, 15 minutes at least. The 15 minutes, exactly. So to have this complicated conversation in 15 minutes is right away daunting for women. And because of the sad long history of women not being listened to by their doctors when they do come in, the concern I would raise for women, women have always been good at getting information from other women. But your best friend and your mother may not have the best answers for you. And that's really something to keep in mind because this whole movement about this isn't natural and it's unhealthy for you and so forth, that comes from the women's - That's not what I did.

1:09:57No, yeah, it's not what I did. You don't really need this. It's adding something to your body that isn't natural and so forth. That is all from the women's whisper network of a bias, some superstition, some anti-medication, anti-medicalizing of menopause, anti-pathologizing of menopause. It's not pathologizing menopause to say you will benefit by restoring the you that was. That's the difference. If you were going to design, I have very strong thoughts here, a menopause curriculum from both from the psychological standpoint and from the medical standpoint, what are the top three things you would want your trainees to walk away with?

1:10:35Trainees, physicians. Physicians, yeah. Well, first, listen to the patient. The patient is an important part of the care team, probably the most important part. Second, you must keep up with the literature. What we're talking about now is what we understand today. One of the exciting but sometimes frightening things is we never know enough. We are learning all the time. So keep an open mind. Data accumulates and criteria change and stay abreast of that. Yes. Yes. I would say this. It's kind of interesting to me that for a very long time when women say to their doctors, you know, all of the symptoms of menopause, and they say, well, but you know, midlife is a very difficult time for women.

1:11:24Women are anxious because I don't look the way I did at 25 and because I'm taking care of my parents who are in trouble. I'm taking care of my teenagers who are in trouble. I have so many social, economic, and personal concerns. My husband and I are quarreling all the time. There are so many midlife emotional and psychological concerns for women about their changing bodies, about work, about family. So for a very long time, the intervention was, well, let's just solve those problems, dear. Let's get you an antidepressant for your unhappiness, a little cosmetic surgery, all of which might be appropriate or timely in certain circumstances.

1:12:03But the number one line of issue for the doctor is, how are you medically? How is your estrogen? That is, I mean, in so many of the cases in our book that we describe where women told, well, you better quit your job. It's obviously too stressful for you. And how can you manage such a high, powerful job with all of these symptoms, you better cut back. You better get out of the workforce. Well, no. How about helping me do my job better? And so on. So I think it would be useful in my menopause class for physicians to understand that these patronizing views of just quit working, spend more time baking.

1:12:41Drink more wine. They're not what we're talking about is the first line of issue for women in menopause. So my mother is 88 and is in a memory care facility with Alzheimer's. And in January 1st, she thought she heard my father. She was hallucinating. And she got out of bed in the middle of the night without her walker and she fell and broke her hip. And so she survived. She was well enough to have the hip replacement and survived the surgery. And it's just now eight months later walking with her walker again, And some. It's been a lot. I want a different legacy. And my grandmother had a very similar course.

1:13:17And she's incontinent. She's in a diaper. And so her quality of life is terrible. It's as good as it can be given the situation. I'm refusing for that to be my inevitable. And I think estrogen matters and is going to have a huge part, along with lifestyle and all the things that we're working towards. And, Dr. Blooming, you've said, my patients are my teachers. After decades in oncology and women's health, I mean, I'm assuming, I don't know how old you are, I'm assuming you could retire. You know, I know you've retired from clinical practice, but you are always working. You are always lecturing.

1:13:51You are always teaching. What keeps you going here? First, passion. And second, I love what I do. There are very few ways to spend your life where you can go to bed every night and think how you made a difference. Now, you want that difference to be for good, but physicians are blessed with that as a built-in part of their job. And what about you? What keeps me going? What keeps you going? I'm assuming you could retire and just read and knit or do what we expect women of a certain age to be doing. But you are always working, teaching, giving back. That's what keeps me going. A mentor of mine said to me years ago, I said, don't you feel sometimes, certainly for the movement for women's equality and rights, that we're Sisyphus, you know?

1:14:47We're just, how do you keep going, pushing that rock up the hill, up the hill, up the hill? and he said, think how much further down the hill it would be if we did not keep going. And, you know, I mean, the path toward education and change is slow. The forces of reaction will always stand in your path. The people who don't want to change will stand in your path. They will call you cranks, outsiders, but, you know, enough outsiders becomes a movement and that's exactly what's being created here. And it is exhilarating and motivating to be a part of it. For both of you, for the women listening right now who have been told by their doctors usually that hormones aren't safe, what do you want her to know?

1:15:29There is a place where she can get information that is sitting right in front of us. The reason we wrote the book is I can't say it in a sentence. There are no absolute answers, but the balance has to be correct. and this book gives you the information to help achieve that balance in your own situation. What would I say to such a woman? Learn, read, share, become angry as the first reaction often is. You know, I've been lied to. I've been lied to by a massive enterprise that has not given me the full truth. And then once you get through being really angry, do something with it. Tell your sisters, tell everyone you can that they have been misled and there is a better path.

1:16:22Well, I want to thank you both for writing this incredible book, for joining me today, for changing my life and the lives of my followers and, of course, my patients. And for all of you listening, welcome to Unpaused. We are just getting started. We want to thank you for your wonderful support, your enthusiasm, your efforts, not just for our book, but for the cause for women and for the work you do. It's been just magnificent. Thank you. Thank you. Thank you. Your opinion obviously matters because it's informed, because you're open to learning new things and you're honest in the way you evaluate the new things.

1:17:03And we are very grateful for that. Very glad. Thank you. I'd love to hear from you about this topic and anything else that's on your mind. You can find me on Instagram at Dr. Mary Claire and get honest and accurate information on health, fitness, and navigating midlife at thepawslife.com. If you're loving this podcast, be sure to click follow on your favorite podcast app so you never miss an episode. While you're there, leave us a review and be sure to share the show with the women you love. We would be so grateful. You can also find full episodes on YouTube at Dr. Mary Claire. As a reminder to our audience, you can follow Dr.

1:17:43Tavaris and Dr. Blooming on Instagram at estrogen underscore matters. For more information or to contact Avra McCarroll, go to their website at www.estrogenmatters.com. Unpaused is presented by Odyssey in conjunction with Pod People. I'm your host, Dr. Mary Claire Haver. The views and opinions expressed on Unpaused are those of the talent and guests alone and are provided for informational and entertainment purposes. No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis, or treatment. The most memorable gifts aren't found, they're made.

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