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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And don’t miss these:

• Dr. Mara Will Not Sell You a Weighted Vest

• Healthcare is Ground Zero for Fatphobia

• Is Dr. Mary Claire Haver Making Menopause

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 tha