7 Leading Doctors Reveal The Truth About Hormone Therapy

Summary

The Tamsen Show

Episode Title: 7 Leading Doctors Reveal The Truth About Hormone Therapy
Host: Tamsen Fadal
Date: November 26, 2025

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Episode Overview

This episode delivers an in-depth, myth-busting exploration of hormone therapy for women, especially around perimenopause, menopause, and midlife health. Emmy-winning journalist and host Tamsen Fadal convenes a diverse panel of renowned doctors—including OB/GYNs, a cardiologist, a neuroscientist, an endocrinologist, and an orthopedic surgeon—to answer the most pressing and confusing questions about hormone therapy (HT/MHT/HRT). The experts clarify what hormone therapy really is, its safety profile, impacts on different aspects of women’s health (brain, heart, bones, body composition), and debunk lasting fears rooted in misunderstood research. With practical advice, lived experiences, and scientific evidence, the episode aims to empower women to make informed health decisions without stigma or unnecessary fear.

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Key Discussion Points and Insights

1. What Is Hormone Therapy? (04:12 – 06:53)

• Dr. Sharon Malone (OB/GYN) explains that “hormone replacement therapy,” “menopausal hormone therapy,” and “hormone therapy” are different labels for giving back lower doses of hormones (estrogen, and if needed, progestin) that the body stops making at menopause.
• HT is prescribed to address classical menopause symptoms: hot flashes, night sweats, mood swings, brain fog, sleep disruption, and more.
• She points out a major misconception: “Women are afraid of menopausal hormone therapy who've been on birth control pills for 20 years. And I just look at them and I’m like, girl, you’ve been on estrogen and progestin since you were 25...and you're going to be taking far less of it in menopause.” (Dr. Sharon Malone, 06:19)
• The MHT dose is often a third or quarter of what’s found in birth control pills.

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2. The 2002 Women's Health Initiative Study and the Roots of Fear (07:46 – 16:12)

• Tamsen shares her initial fears: “My mom had breast cancer and somewhere along the line, I absorbed this idea that hormones were dangerous... Estrogen equals breast cancer. That was all I knew.” (Tamsen, 00:54)
• Dr. Malone recounts the release of the 2002 Women's Health Initiative (WHI) study, which fundamentally altered public and medical opinion, conflating HRT with increased breast cancer risk and overshadowing other risks like heart disease.
• The WHI’s significant flaws:
  • Designed as a prevention study for heart disease, but included women with an average age of 63—far older than typical HT patients.
  • Results for older women were erroneously applied to younger women.
  • Only one medication, at one dose, was studied—ignoring nuance around drugs, dosing, timing.
  • “The increase in the risk of breast cancer did not reach the level of statistical significance that you could even call that a positive finding.” (Dr. Sharon Malone, 15:30)
• Fallout was dramatic: HT use plummeted from 38% of eligible women to under 6%, and that level has persisted.
• The misconception that estrogen is synonymous with breast cancer risk persists, even though cardiovascular disease remains the leading cause of death for women.

Notable Quote:
“It cemented this idea that doctors had been doing something really to the detriment of women’s health...And women abandoned hormone therapy in droves.”
– Dr. Sharon Malone, 10:36

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3. Impacts of Menopause and Hormone Therapy on the Brain (18:10 – 20:26)

• Dr. Lisa Moscone (Neuroscientist, Weill Cornell) summarizes robust findings that starting estrogen within 10 years of menopause is linked to a significant reduction in Alzheimer’s risk—32% in women without a uterus (estrogen-only), and a lesser, trending-reduction (23%) for women with a uterus (estrogen-plus-progestin).
• “For women who are using only estrogens and they take it at the right time... there is a significant risk reduction for Alzheimer's disease.” (Dr. Lisa Moscone, 19:02)
• The so-called ‘window of opportunity’—the decade after menopause—is critical; starting HT later appears neutral, rather than beneficial, for dementia prevention.

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4. Heart Health and Hormone Therapy (22:02 – 24:46)

• Dr. Jane Morgan (Cardiologist) discusses:
  • The evidence is evolving, but HT started near menopause may halt progression of heart disease; it likely does not reverse existing plaque, but could help prevent worsening.
  • New thinking suggests the '60/10 Year Rule' (no HT if past age 60 or 10 years post-menopause) shouldn't be absolute. Instead, consideration should be individualized, weighing medical history and health status.
  • “All 60-year-olds are not equal. All people who are 10 years post-menopause are not equal. And so the answer is, maybe have the conversation, but it’s no longer no.” (Dr. Jane Morgan, 24:25)

Memorable Moment:
Tamsen relates an anecdote: “Who here is afraid of heart disease? One or two hands went up. Then he asked, who is afraid of breast cancer? Every single hand in the room shot up...Heart disease is the number one killer of women. I want you to remember that.”
(Tamsen, 24:46)

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5. Bone Health, Longevity, and Hormone Therapy (25:48 – 29:45)

• Dr. Vonda Wright (Orthopedic Surgeon, Longevity Expert):
  • Estrogen is critical for bone health. “The data are so clear that estrogen can be used to prevent osteoporosis and bone death in women. It’s FDA approved for that. And yet it's never talked about.” (Dr. Vonda Wright, 26:39)
  • 70% of all hip fractures occur in women; after a hip fracture, risk of death and institutionalization skyrockets.
  • Bone loss is preventable and begins early; “I beseech people to build better bone while we still have hormones on board.”
  • Peak bone mass is reached by age 30. Early bone screening and awareness are vital.

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6. Visceral Fat, Body Composition, and Hormone Therapy (29:45 – 31:09)

• Dr. Rocio Salis Whelan (Endocrinologist, Obesity Medicine):
  • Estrogen decline in perimenopause increases visceral fat and reduces muscle mass.
  • “Hormone replacement therapy will help rechange body composition. We never promote estrogen as a weight loss hormone, but it will help change, recompensate your body again.” (Dr. Rocio Salis Whelan, 30:43)
  • HT aims to reduce visceral fat and preserve muscle, improving metabolic health even though it’s not a weight loss tool per se.

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7. Testosterone and Women’s Health (31:51 – 35:02)

• Dr. Kelly Casperson (Urologist, Sexual Health Expert):
  • Testosterone is not just a “male” hormone; it is actually the dominant sex hormone in women and essential for numerous body functions, including libido and brain health.
  • “Testosterone is actually women’s dominant sex hormone. It is wrong when people say estrogen is our main hormone. Our main hormone is testosterone.” (Dr. Kelly Casperson, 33:12)
  • All sex/steroid hormones are made from cholesterol—progesterone leads to testosterone, which leads to estrogen.
  • Many clinicians and patients are unaware of the close interplay of these hormones.

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8. Who Can and Cannot Take Hormone Therapy? (38:09 – 43:20)

• Dr. Sharon Malone reviews FDA-approved indications and true contraindications:
  • Indications: Vasomotor symptoms, genitourinary syndrome of menopause, osteoporosis prevention, and early/premature menopause.
  • Absolute contraindications: Personal history of breast or estrogen-dependent cancer, personal history of heart attack or stroke, liver disease (for oral formulations), undiagnosed vaginal bleeding, and personal history of blood clots.
  • Many commonly cited reasons for denying HT (e.g., family history of breast cancer, treated hypertension, migraines) are not valid per current evidence.
  • Delivery method matters: Transdermal estrogen has lower clot risk than oral.
  • Mortality is not increased for women on HT, even in WHI; estrogen-only users had decreased incidence and mortality from breast cancer.
  • “For the women who took estrogen only in the Women’s Health Initiative… not only had a 23% decrease in the incidence of breast cancer, but they had a 40% decrease in the risk of dying if they took estrogen than if they did not.” (Dr. Sharon Malone, 43:07)

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9. Vaginal Estrogen: A Neglected Solution (43:20 – 45:50)

• Dr. Corrine Min (OB/GYN, Menopause Specialist, Breast Cancer Survivor):
  • Low-dose vaginal estrogens (or DHEA) are highly effective for local symptoms (dryness, painful sex, UTIs), are well-tolerated, and are not significantly systemically absorbed.
  • New AUI guidelines confirm safety for most women, including estrogen receptor–positive breast cancer survivors.
  • Lubricants and moisturizers help, but do not treat the underlying tissue changes—only hormones can do that.
  • “Even breast cancer survivors, even ER-positive breast cancer survivors, women who are on estrogen blockers or lowering estrogen, can safely use vaginal hormones. And it's really important.” (Dr. Corrine Min, 44:24)

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Notable Quotes & Memorable Moments

• Tamsen Fadal (00:54):
  “Estrogen equals breast cancer. That was all I knew. But when my own symptoms hit and I started digging for real answers, I realized I didn’t actually know what hormone therapy was. I only knew the fear. And once I learned that most of that fear came from one misunderstood study in 2002...everything changed.”

• Dr. Sharon Malone (10:36):
  “It cemented this idea that doctors had been doing something really to the detriment of women’s health...And women abandoned hormone therapy in droves.”

• Dr. Lisa Moscone (19:02, 19:54):
  “These women have on average 32% reduced risk of Alzheimer’s disease and dementia in old age relative to those who don’t take hormones... For the other type of formulation...there’s still a 23% reduction in Alzheimer’s risk...However, a trend level...”

• Dr. Jane Morgan (24:25):
  “All 60-year-olds are not equal. All people who are 10 years post-menopause are not equal. And so the answer is, maybe have the conversation, but it’s no longer no.”

• Dr. Vonda Wright (28:35):
  “I repeatedly beseech people to build better bone while we still have hormones on board. Because the number one way to get control of bone health is to have estrogen on board.”

• Dr. Kelly Casperson (33:12):
  “Testosterone is actually women’s dominant sex hormone. It is wrong when people say estrogen is our main hormone. Our main hormone is testosterone.”

• Dr. Corrine Min (44:24):
  “Even breast cancer survivors, even ER-positive breast cancer survivors, women who are on estrogen blockers or lowering estrogen, can safely use vaginal hormones. And it’s really important.”

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Timestamps for Important Segments

• What is hormone therapy? – 04:12 – 06:53
• The 2002 WHI Study and Fear of Estrogen – 07:46 – 16:12
• Menopause, Hormones, and the Brain (Alzheimer’s) – 18:10 – 20:26
• Heart Disease, the “Window” for Therapy – 22:02 – 24:46
• Bone Loss and Estrogen – 25:48 – 29:45
• Belly Fat, Body Composition, and HT – 29:45 – 31:09
• Testosterone’s Role in Women – 31:51 – 35:02
• Eligibility and Safety for Hormone Therapy – 38:09 – 43:20
• Vaginal Estrogen for Local Symptoms – 43:20 – 45:50

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Final Thoughts & Resources

• Tamsen emphasizes: "You do not have to suffer. You do not have to wait until your symptoms are unbearable. There is no medal for powering through." (Tamsen, 02:40)
• The episode directs listeners to practical tools like the Menopause Map (symptoms, options, doctor questions) and Tamsen’s new book, How to Menopause, for a comprehensive resource.
• All references, time codes, and resources mentioned are linked in the show notes for easy navigation.

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Summary Tone and Takeaway

The tone is conversational, candid, myth-busting, and supportive—matching Tamsen’s mission of women’s health empowerment. Each expert breaks down complex, emotionally charged topics into actionable insights, aiming to replace fear with facts and guide women in reclaiming their midlife health. Women are encouraged to ask questions, seek individualized care, and challenge outdated medical dogma.

“You’re not supposed to navigate this stage by yourself. We can break down the things that no one ever taught us.”
— Tamsen Fadal (46:18)

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For more details, chapter breakdowns, and links to referenced guides and experts, see the show notes.

Transcript

[Tamsen]

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[Dr. Kelly Casperson]

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[Tamsen]

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[Dr. Sharon Malone]

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[Tamsen]

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[Host/Interviewer]

Today's podcast is sponsored by Midi Health. I walked in with real symptoms. Brain fog, exhaustion, anxiety and walked out with nothing but a suggestion to wait it out. That's why MIDI matters. They actually listen and they treat what others ignore. This is midlife care that finally makes sense. Ready to feel your best and write your second act script? Visit joinmitty.comtamsen today to book your personalized insurance covered virtual visit. That's joinmitte.com Tamsen Midi the care Women.

[Tamsen]

Deserve When I first started hearing the words hormone therapy, I honestly wanted nothing to do with it. My mom had breast cancer, and somewhere along the line I absorbed this idea that hormones were dangerous. I couldn't even tell you who told me that. It was just something that lived in the back of my mind for years. Estrogen equals breast cancer. That was all I knew. But when my own symptoms hit and I started digging for real answers, I realized I didn't actually know what hormone therapy was. I only knew the fear. And once I learned that most of that fear came from one misunderstood study in 2002 that we're going to talk about, everything changed. And this is where the journalists in me took over. I've spent my career asking hard questions, chasing down facts, making complicated stories understandable. So when menopause didn't add up, I treated it like any other big story. I started calling the experts. And I'm lucky, really lucky, that through this show we have access to some of the best minds in women's health. Today you're going to hear from top OB gyns who specialize in menopause. A cardiologist, a neuroscientist, an endocrinologist, even an orthopedic surgeon. All breaking down hormone therapy through their expert lens. If you're new here, welcome to the TAM Fam. If you're coming back, I'm really glad you're here. This is a community. We learn together, we support each other, and we talk honestly about what women go through because not enough people do. And at the heart of this is one goal to help you understand your body, make smarter choices, and support your health for the long run. Before we jump in, I wanna say something that every single doctor I've interviewed has told me in one way or another. And I really want you to hear it. You do not have to suffer. You do not have to wait until your symptoms are unbearable. There is no metal for powering through. And we do that as women. We minimize and push through. We try to make everything look easy. I want you to let go of that while you're listening to this episode today. Whether you're in perimenopause, menopause, post menopause, or just trying to make sense of it all, this episode isn't meant to be every single thing there is to know about hormone therapy. But it is a clear practical breakdown of the questions I hear every single day. Is hormone therapy safe for me?

[Host/Interviewer]

What does it really do?

[Tamsen]

How long should I be on it? Today you're going to learn how it can impact your brain, your heart, your bones and that visceral fat around your belly. Your sleep and your long term health. At any time you can go into the show notes and you'll see clear time codes for every chapter. So if you want to jump ahead to a certain topic, it's all laid out for you. And because I know how overwhelming this stage can feel, I made something to help you navigate it. It's called the Menopause Map, a free guide you can download anytime. It walks you through symptoms, treatment options and the exact questions to bring to your doctor's appointment. I I'll link it for you in the show notes so it's always right there when you need it. Now, to get us started, I want to introduce you to Dr. Sharon Malone. She's a board certified OB GYN, a nationally recognized menopause expert, and truly one of the most trusted voices in Women's Health. Dr. Sharon has been helping women navigate midlife for decades. She's a legend and I've turned to her more times than I can count. Her conversation was one of the first episodes we recorded and one of our most listened to episodes. When we talked earlier this year, she gave me one of the clearest explanations I've ever heard of what hormone therapy actually is. And I think it's a perfect place for us to start.

[Host/Interviewer]

I want to break down HRT and hormone therapy and menopause hormone therapy. And there's a lot of things going around, there's a lot of confusion right now. There's a lot of information. You can go to Instagram. You know, everybody's now hearing the word perimenopause and menopause and so what is hormone therapy?

[Dr. Sharon Malone]

Okay, so I want to make it clear, because I, I still use the old term. I say hormone replacement therapy. I don't think replacement is a bad word, but obviously someone objected to it.

[Host/Interviewer]

Sharon tells it like it is, and that's what I love about it.

[Dr. Sharon Malone]

Yeah, I'm like, what's wrong with that? I don't have a problem. But hormone replacement therapy, menopausal hormone therapy. Same, same. Yes. And all it means is that when you reach either perimenopause or menopause, then you are using hormones to treat hormones hormonal problem. And you know, because we know at menopause, the. It is, it is really defined by a persistently low lack of estrogen and lack of ovulation into fertility forever and on. So you are just giving back, not at the same levels that you had when you were ovulating and you were premenstrual, but. But you are giving back just enough to take care of the symptoms. All those gnarly symptoms that come up with menopause. Hot flashes, mood swings, night sweats, sleeplessness, brain fog, the list goes on and on, and we know it. So you are giving back a smaller dose of estrogen and progestin for women who have a uterus. And if you've had a hysterectomy, then you can be treated with estrogen only because estrogen is really the secret in the secret sauce that controls the symptoms that women have during menopause. So that simply is all menopausal hormone therapy is. But to give you an idea, women are so afraid of menopausal hormone therapy. Women are afraid of menopausal hormone therapy who've been on birth control pills for 20 years. And I just look at them and I'm like, girl, you've been on estrogen and progestin since you were 25. Why do you. And you're going to be taking far less of it in menopause than you did before. And somehow, you know, again, it's a perception problem.

[Tamsen]

Of course it is.

[Host/Interviewer]

And it's a branding problem.

[Dr. Sharon Malone]

Menopausal hormone therapy is anywhere from a third to a quarter of the dose of what's in a standard birth control pill. It is, yes. Same components. The components are different because they have different missions, but there are still estrogen and a progestogen, estrogen and a progestogen, just different types and different, smaller amounts.

[Host/Interviewer]

Before we move on, I want to.

[Tamsen]

Point out something that's happened recently. The FDA announced they're removing the black box warning from menopausal hormone therapy.

[Host/Interviewer]

Products.

[Tamsen]

It's a sign that the conversation around hormone therapy is changing. And since we're talking about how fast this space is evolving, I just want to take a second to say thank you for listening and for supporting this show. If you haven't already, make sure you hit subscribe and leave a review. I read every single one. And they really do help us keep bringing you the experts, the science, and the straight answers you deserve. Now, even with this FDA update, a lot of women still see the word estrogen and immediately think breast cancer. That reaction is so common, I had it myself and it didn't come out of nowhere. So let's talk about why hormone therapy got such a scary reputation in the first place. Because once you understand where that fear started, everything else you're about to hear is gonna make so much more sense. That study was set out for people.

[Host/Interviewer]

Who are just hearing about this 2002.

[Tamsen]

Study that we've heard over.

[Host/Interviewer]

We just, we know that year, right. Over and over again. And that was set out to say that, hey, there are some long term benefits of this when it comes to cardiovascular health.

[Dr. Sharon Malone]

That was it exactly. It was designed as a prevention study. It was going to. It was to ask the question, does the use of hormone therapy decrease the risk of cardiovascular disease, which we know is the number one cause of death for women in this country and around the world. Imagine what that would do and how that would change everybody's behavior. If you knew that I could give a medication that was readily available, been around for 50 years, and we could do decrease the risk of cardiovascular disease by 50%, that would be huge.

[Tamsen]

Huge.

[Host/Interviewer]

And you and I were in that same room when Dr. Avram blooming said out loud, in a room we were at, he is a world renowned doctor that I know that you and he have done many, many talks together, said, is anybody worried about cardiovascular disease? Few hands went up. Is anybody worried about breast cancer?

[Dr. Sharon Malone]

Right.

[Host/Interviewer]

The entire room raised their hand.

[Dr. Sharon Malone]

Exactly. And, you know, and that's the good news and bad news, I think, really about the public education effort about breast cancer. Because we're in a very different place now than we were 50 years ago in terms of awareness and screening. That's, of course. But it is so sort of elevated that in women's minds that we think that that is the only and most important thing that women are dying from. And it is not. It is still was then and is now still cardiovascular disease.

[Tamsen]

The study shows.

[Host/Interviewer]

To look at that. And then what happens that, that fateful day that I know you remember, well, Actually, the morning after, I feel like, is what you remember best.

[Dr. Sharon Malone]

I do. I do. I remember it because, remember, at this point, I've been practicing for 10 years.

[Dr. Lisa Moscone]

Yes.

[Dr. Sharon Malone]

All right, so 10 years is two. I've been telling patients one on one every day, oh, you've got to take this hormone. This is great. And investigators at NIH held a press conference at the National Press Club, invited everybody to come listen, and they said, by the way, you know that everything that we've been telling you about hormones and how great it is, it's not. It not only doesn't decrease the risk of cardiovascular disease, it increases the risk of breast cancer. And when they said the words it increases the risk of breast cancer, I mean, I wish I could tell you what a seismic effect it was, because this really flew in the face of everything we had been saying about estrogen for time immemorial, and just poof, it went away. Women were angry. They were upset. It was picked up on every major news outlet in this country and around the world. And it cemented this idea that doctors had been doing something really to the detriment of women's health, not to the benefit, and that if you took these awful hormones, you were going to get breast cancer. And women abandoned hormone therapy in droves.

[Host/Interviewer]

From a large percent.

[Tamsen]

Right.

[Host/Interviewer]

And it just.

[Dr. Sharon Malone]

From about 38% of women who were eligible to take HRT, it went from about 38% to less than 6%. And it has persisted. It is still in about the 5% range even today, 22 years after that study came out. And, you know, that's never the end of the story because, you know, it's hard for people to realize, but there was a time before the Internet and before we had instant access to information. And when they held that press conference, even the investigators who were participating in 40 centers around the country had no say in the stoppage of that study. In the article that came out that made these claims about increased risk of breast cancer, it's sort of a group, a small group of regulators at NIH came up with this. They put it out, and immediately it wasn't like it was years later. The doctors who were involved in the clinical trials protested because they were like, wait, wait, wait. That's not really what it said. But again, 22 years later, we are still trying to put that genie back in the bottle. Undo. And it's been difficult.

[Host/Interviewer]

They cemented that idea that estrogen causes breast cancer. What did they find in that study?

[Dr. Sharon Malone]

We did learn some things from the women's Health Initiative. It was a large study. But here is what the basic flaw was. Oh, the basic misinterpretation of the data. If you were going to construct a study and say, we're trying to prove that it decreases the risk of cardiovascular disease and we're gonna do it with healthy women and we're gonna follow you over years to find out. Well, the reason, one of the reasons why they didn't choose younger women in the study was because women don't, you don't see the uptick in cardiovascular disease until about 10 years after menopause. So they can't start a study and say, all right, we're gonna start it at 50 and I'll come back and check you out when you're 70.

[Host/Interviewer]

Right.

[Dr. Sharon Malone]

So they skewed it such that the women were much older at the start of the study. So the average age of the woman entering the Women's health initiative was 63, and you could be anywhere from 50 to 79 and still be in the study. Well, that may have sounded, you know, I understand their reasoning. Sure. However, that was not typical of who we normally prescribed hormones for. We prescribed hormones for symptomatic women around the time of menopause, and that's sort of more typical of our population. But when you start it that far out, I don't think it takes a rocket scientist for anyone to see that. How are you gonna do a prevention study on a 79 year old? She either has heart disease or she doesn't. And it doesn't matter what you give her at that point, you're probably not going to affect that. That was the flaw number one. And I think flaw number two was that they took that data from older women who were more than 10 years on average after menopause, and generalized it to everybody. So the same data that they got from a 63 year old, they applied it to a 50 year old. And they also only looked at one medication, one dose and nothing else. So all of the other nuance, you know, about dosing and, you know, timing, we didn't know. So it, it took a very specific finding. And maybe if they had said, wow, if you give it to women 10 years after menopause and the average age of 63, you don't impact their cardiovascular disease.

[Host/Interviewer]

Right, right.

[Dr. Sharon Malone]

If you had said that, but it didn't say that said everybody. But that wasn't really the thing that, that really turned women off. As I said, what, what really got them was the breast cancer, of course, and the breast cancer study. That part of it was confusing as well, because even though there was a slight increase in the risk of breast cancer for women who in the women who took estrogen and progestin, not the women who took estrogen only. Even though there was a slight increase, there's this thing in medical studies. When you do a study, your results are either significant or they're not statistically right. You can't be like it's kind of or it's almost sort of, sort of sort of significant. I bet it's kind of inching towards that. And that's what they did even at the beginning. The increase in the risk of breast cancer, even in that the first pass did not reach the level of statistical significance that you could even call that a positive finding.

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[Tamsen]

Now we're going to get into how menopause and menopausal hormone therapy can impact your brain, your Your heart, your bones, all of it. And we're starting with the brain because when Dr. Lisa Moscone joined me earlier this year, she broke down the connection between hormones and cognition in a way I'd never heard it before. She's a neuroscientist, the director of the Women's Brain Initiative at Weill Cornell, and she ranks in the top 1% of scientists in the world over the last 20 years. She's also leading a massive groundbreaking program with welcome leap that's redefining what we know about women's brains. So let's start there with your brain. And Dr. Lisa Moscone, when it comes.

[Dr. Lisa Moscone]

To Alzheimer's is that it's impractical to start a clinical trial that looks at using hormone therapy now for menopause and then wait 20 years for some women to develop Alzheimer's dementia to have a diagnosis of dementia. That's never going to happen. It's just not possible. So we don't have any.

[Host/Interviewer]

So we don't have that research.

[Dr. Lisa Moscone]

We don't have any. What we do have is observational evidence, including really well done studies, very large scale. What you need to do with observational evidence is called a meta analysis. It's a statistical integration of all available data with any data you want to do, but especially with observational evidence. This is our meta analysis includes more than 6 million women. It shows something that I think is quite clear. This is women without a uterus who are taking only estrogen. These are the women who have a uterus and take estrogen with any type of progesterone, progestin. Now, for women who are using only estrogens and they take it at the right time. Within 10 years of the final menstrual period, there is a significant risk reduction for Alzheimer's disease. So these women have on average 32% reduced risk of Alzheimer's disease and dementia in old age relative to those who don't take hormones. If you start taking hormones in those studies at least more than 10 years after menopause, then there is no protective effect, it's neutral.

[Host/Interviewer]

So that's where that 10 year window after you've hit menopause comes into play.

[Dr. Lisa Moscone]

And for the other type of formulation, estrogen for women with the uterus, it started in midlife or within 10 years, the final menstrual period, there's still a 23% reduction in Alzheimer's risk, which is however, a trend level, which means that some studies show a protective effect, but other studies do not. They may even show a harmful effect. And what we have found just recently that is published, so I can talk about it, is that all the studies reporting a negative effect are from northern Europe, which is very interesting. Not the U.S. not the U.S. so I wonder what was happening in northern Europe in, you know, a long time ago when these women were on hormones.

[Tamsen]

Next, I think it's important to get into the heart. Heart disease is still the number one killer of women, yet so many of us are far more afraid of breast cancer. I sat down with Dr. Jane Morgan, one of the most respected cardiologists in the country, to ask her exactly what hormone therapy means for our hearts and, and whether or not it could help protect them. Before we get into it, I also want to quickly mention something else I'm really excited about, my book, how to Menopause. It's on sale right now for Black Friday. If you're looking for a clear, no nonsense guide that you can reference anytime, or if you just want to take a deeper dive into everything we're talking about today, I'll link it in the show notes. It's a great time to grab it for yourself or for a friend who might need it, too. Okay, let's talk more about the Heart with Dr. Jane Morgan. Could it be as easy as getting.

[Host/Interviewer]

On hormone therapy to help reduce any risk of heart disease? Or do we have that correlation yet?

[Dr. Lisa Moscone]

Yeah.

[Dr. Jane Morgan]

And can it be that easy? And that's really a big question because we go back to the paper and the information that was presented at the American College of Cardiology. The question that isn't answered, which may be when we have the next session coming up, is if these women started hormone replacement therapy, do we see a regression or an opening of their carotid arteries? So, in other words, do they have fewer symptoms? And now we actually see these, the plaque going away. Now, very few, there have been very few drugs that we have that actually cause a regression of plaque formation. The plaque can actually decrease. Statins are one of them. So the medications that we often use to treat cholesterol can actually make your plaque smaller, but we don't actually have a lot of them. So that's the question that we need to answer. I think what, what we think now is that it certainly can keep it from progressing and getting worse because ultimately what we want to do is decrease your risk of heart disease and stroke.

[Host/Interviewer]

I have a lot of women that are now listening and hearing this information and coming up and asking on the show, I passed this window of I'm past 60 or, oh, gosh, I went into menopause 12 years ago. Is it too late for me to do something now to protect my heart, my bones, my brain? When it comes to hormone therapy, what is the answer to them?

[Dr. Jane Morgan]

So the old answer, at the age of 60 or 10 years after menopause, we think, oh, you know, the window has closed. You've missed your window of opportunity. But new age thinking is maybe not. And the reason we said that is that the data shows that in the first year of starting hormone therapy, after you're 10 years or more beyond menopause, you do have an increased risk of heart disease, an increased risk of effects. Mostly that happens in the first four months. After that, however, your risk drops back down to normal. And so it was thought it's not worth taking that risk. When we take a look at it, that risk is actually quite small. And everyone's history and their physical activity level and physical being is different. However many chronic medical conditions you have, what are you managing? That kind of thing. And so now we say it's an individual conversation that you will have with your physician. All 60 year olds are not equal. All people who are 10 years post menopause are not equal. And so the answer is, maybe have the conversation, but it's no longer no.

[Tamsen]

I was at an event about a year ago with Dr. Avram blooming. He is a leading oncologist and author of the book Estrogen Matters. He asked the room, who here is afraid of heart disease? One or two hands went up. Then he asked, who is afraid of breast cancer? Every single hand in the room shot up. And here's a part that still hits me today. Heart disease is the number one killer of women. I want you to remember that taking care of your heart is not optional. It's essential, and we don't talk about it enough. But it really matters so much. Your heart, though, is not the only part of your body that's impacted by estrogen. Next, we're going to discuss something most of us don't even think about until it's too late. Our bones. For this, I turn to someone who is a true force in this space, Dr. Vonda Wright. She's an orthopedic surgeon, a researcher and author, and one of the most respected voices in longevity. She spent her career teaching women how to build stronger, healthier bodies at every age. And the way she explains bone loss in midlife made me realize this is something we all have to understand much earlier. So let's get into it.

[Host/Interviewer]

Can you explain why, as an orthopedic surgeon, and longevity. Doctor, Hormone therapy is such an important topic for you.

[Dr. Vonda Wright]

First, I want to frame what I say by the fact that I believe that every woman is a sentient being with agency. So even though I do come across very strongly and I see very little reason not to make this decision, I recognize that it's still every woman's decision. While everyone wants to continue to argue about brain health, does estrogen replacement replace fill the estrogen receptors that coat our brain? Obviously. But people still want to argue about the clear evidence that started within 10 years. Most guidelines now talk about using menopause hormone therapy to prevent heart disease to the tune of 40%.

[Dr. Corrine Min]

Okay.

[Dr. Vonda Wright]

There is no argument. The data are so clear that estrogen can be used to prevent osteoporosis and bone death in women. It's FDA approved for that. And yet it's never talked about. Now in the last year, I see people picking up bone as a subject while I'm screaming it from the mountaintops. 70% of all hip fractures occur in women. 70%. The minute snap my fingers, the minute you fall and break your femur, you have a 30% chance of dying. 50% of the time you will never go home. And your family is left to make the decision. Because you can't take care of yourself anymore. Your family is left to make the decision. Do you hire somebody full time to live with you and take care of you? Well, that's cost prohibitive. Do you move in with your child or your niece or nephew? Most people say to me, I don't want to be a burden to my family. Do you move into assisted living? Two thirds of all people in assisted living are women. Do you know how much that costs a month? 7 to $15,000. So what you have to do is use your life savings down to the point where you're a pauper and get Medicaid all because you broke your hip. Osteoporosis, it literally from the Latin means holy bones. Loss of bone strength is entirely preventable, but it doesn't start when we're 65, when the US insurance industry will finally pay for a DEXA scan. It starts when we're teenagers. It continues when we're 30. And I repeatedly beseech people to build better bone while we still have hormones on board. Because the number one way to get control of bone health is to have estrogen on board.

[Tamsen]

If we have a woman who's in.

[Host/Interviewer]

Her 30s right now listening, is she in an incredible place to be?

[Dr. Vonda Wright]

Oh, my God. Ideally. So it is estimated that we reach peak Bone mass, the most bone we're going to build between 15 and 25 extends up to 30. So I personally think that we should all be getting some kind of bone measurement, whether it's a DEXA scan or an ultrasound REM scan for bone quality as a baseline then because I kid you not, every woman coming into my orthopedic office, no matter what her age, gets a DEXA scan. And I have 20 year olds and 24 year olds and 30 year olds who come come in with poor bone density and they don't even know it and they've never built enough bone. As a young woman, if you carry that, you just assume you're fine, you're young. But if you come in with low bone density and it levels off, declines about 1% a year like a man, until you reach perimenopause. Within the five to seven years of perimenopause, you're going to lose 15 to 20% of your bone density because of the mismatch that comes when we don't have estrogen. Omg.

[Tamsen]

Okay, now we're going to talk about something that really hit me hard and that most of us first notice in perimenopause, and that's belly fat. I don't know about you, but what I had felt like a tire around my middle for years. And I thought if I worked out harder, put in more time on the elliptical or ate less, I could get rid of it. But what worked for me before stopped working for me. And it was so frustrating. It's like it happened overnight. What I've learned and what the doctors on this show have taught me is that visceral fat isn't just about how our clothes fit. It has real health consequences as we age. So the big question I had was, is hormone therapy actually a tool that can help with this? To break it down, I went to endocrinologist Rocio Salis Whelan. She's a triple board certified doctor, an expert in obesity medicine, and the person I went to when I was doing everything right and still wasn't seeing the changes. And in our conversation, she made it so clear. So let's get into it.

[Host/Interviewer]

What are some of the ways you can do that with meds?

[Nutrafol Representative]

Definitely hormone replacement therapy will help rechange body composition. We never promote estrogen as a weight loss hormone, but it will help change, recompensate your body again. Right. So remember, in perimenopause there's a drop of estradiol and an increase in visceral fat, decrease in Muscle mass. So by giving you back what you're not making, we intend to see less visceral fat and more muscle mass.

[Tamsen]

If you listen to the original episode with Dr. Rocio, you know, a big part of it was also about GLP1s. So if you've been curious about those two along with hormone therapy, the full episode is a must. Listen, she is great explaining it all. I'll link that in the show notes for you as well. Now we're going to go into something I never expected to have conversations about in midlife, and that's testosterone. Most of my life, I assume testosterone was strictly a men's hormone. I think we were all taught that, but it turns out women need it too, and the science around it's fascinating. Dr. Kelly Casperson is a urologist, a sexual health expert, and someone who has been leading this discussion for years. And she broke it down in a way that made everything finally click.

[Dr. Kelly Casperson]

We really gendered the hormones. One of my sayings is like, hormones aren't gendered. Yeah, right. But we, you know, for better, better for worse, probably for worse, we said estrogens for women, testosterone is for men. We, we discovered estrogen in cow ovaries and we discovered testosterone in rooster testicles. Like, we've never been more nuanced ever since then. So we gender these, these hormones. And what are hormones? Hormones are chemical messengers in our body that travel to other places in our body that tell our cells how to function and how to communicate. They actually help the health of our cells, our mitochondria, like the lining of nerves. Right. So to even call these hormones sex hormones is very dismissive because most of us aren't reproducing for our entire life and it kind of makes them extra. Right? Like, oh, it's just about sexual health.

[Dr. Sharon Malone]

That's.

[Dr. Kelly Casperson]

That's not life or death, but really, these are neuro hormones. And when you dig into the whole sexual function, like libido, I'm always like, where's, where's your libido? It's in your brain, right? Oh, okay. It's in your brain. And so these hormones work in your brain as well as other places. And so testosterone is actually women's dominant sex hormone. It is wrong when people say estrogen is our main hormone. Our main hormone is testosterone. And if you convert, if you were to a normal cycling woman, not a post menopause woman, if you convert her testosterone, which is measured in deciliters, it's like deciliters. And then estrogen's measured in something else. And if you do the math, you will see that testosterone is higher than estrogen in your average woman.

[Host/Interviewer]

So wait, we have more test. We actually have more testosterone than we do estrogen, Is that right?

[Tamsen]

That's correct. Yes.

[Dr. Sharon Malone]

So.

[Host/Interviewer]

So that's why. So let's go back a little bit. So let's talk about what is testosterone, first of all, and why women need it.

[Dr. Kelly Casperson]

Yeah. So testosterone is considered a neuro or steroid. And steroid just means the. The way the carbons are arranged in rings. Steroid itself has gotten a very bad reputation for bodybuilders and overdosing. All steroid means is what it looks like. Right. So vitamin D is a steroid and a hormone and cholesterol. Right. And so cholesterol is the steroid pathway. Cholesterol will lead to progesterone, to testosterone, to estrogen. And you can't make estrogen in your body without it coming from testosterone.

[Host/Interviewer]

See, I don't think.

[Tamsen]

I think I even wrong that.

[Host/Interviewer]

I don't. I don't think I realized that's how closely aligned it is.

[Dr. Kelly Casperson]

I went to med school. I didn't know that.

[Host/Interviewer]

Okay, good.

[Tamsen]

I feel. I feel better.

[Dr. Kelly Casperson]

You made me feel a little bit better. Don't feel bad.

[Host/Interviewer]

Okay, so.

[Dr. Kelly Casperson]

And I think a lot of menopause experts don't know that.

[Host/Interviewer]

Well, I think it's very confusing because when we talk about hrt, we talk about estrogen and progesterone. Right. And then testosterone is this third thing that maybe you might want to do or not.

[Dr. Kelly Casperson]

Dr. Again, it's extra instead of, like, it's the dominant hormone. We were at this talk together in Dallas, which was awesome.

[Host/Interviewer]

Yes.

[Dr. Kelly Casperson]

But every time this is like, what makes me cringe so much when somebody's like, I can't take hormones because of X, Y, and Z, which, number one, that's usually wrong. But number two, what about testosterone? What about progesterone? Like, when they say they can't take hormones, what they mean is estrogen. And it drives me nuts because I'm like, that's one type of hormone, and you can usually always take the other one.

[Tamsen]

Every time I talk to Dr. Kelly, I walk away thinking, like, okay, why did no one tell us this 10 years ago? She cuts through the confusion so fast. So I hope you guys are learning as much as I am with this, because I think every time I hear one of these conversations and even re. Listen to them, more of it actually sinks in. If you're loving this episode and this conversation, take a second to leave a review I read all of them. They mean so much. It helps me figure out what we want to talk about next on this show. And I love hearing what you're thinking.

[Host/Interviewer]

I talk a lot about small habits that make a big difference and AG1 has become one of mine. Every morning before my day starts, I mix a scoop of AG1. It's one simple ritual that supports whole body health in one easy step. I travel a lot. I have long days and it can throw everything off. AG1 gives me steady energy and fills nutrition gaps with antioxidants, probiotics and 75 high quality ingredients from real food sources. And I love that. I love that I don't have to juggle a dozen supplements anymore. Just one scoop and I'm set. And I feel good knowing I've already done something solid for myself before my day gets chaotic.

[Tamsen]

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[Host/Interviewer]

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[Dr. Sharon Malone]

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[Host/Interviewer]

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[Tamsen]

Now, I know hormone therapy is not right for everybody and we're all different. Some of you may be feeling scared or maybe a doctor told you it wasn't right for you. But there has been a lot of confusion around who can and cannot take it, and there's a lot of nuance. So I want to bring back Dr. Sharon Malone to clear up any fears you may have.

[Host/Interviewer]

Who can and who cannot take hormone therapy. If we can just.

[Dr. Sharon Malone]

In a nutshell, let me tell you what, what the FDA has, you know, and we all know, but the FDA indicate, has indicated that hormone therapy can be used for vasomotor symptoms. The genital urinary syndrome of menopause, the things that we talked about. It can be used for the prevention of osteoporosis and it can and should be used for women who have either early or premature menopause. And early menopause means you're menopausal before age 45. Premature menopause means you're menopausal before the age 40. Those are the four indications for hormone therapy by the FDA. Now they also give you some guidance on who can't or what are the contraindications to taking hormone therapy. One is a personal history of breast cancer or an estrogen dependent cancer like endometrial cancer. If you personally have had a heart attack or stroke, if you have liver disease because the oral medications are passed through and metabolizing the liver. And the fourth thing is undiagnosed vaginal bleeding because that's a sign could be of endometrial cancer. So we need to know what that's about. That's it. Notice what's not on the list of contraindications. Hypertension, obesity, smoking. A lot of things that we use to not give women hormone therapy are not in the contraindications. And I think that we can all agree that the FDA is amongst the most conservative, you know, organizations that will tell you if they knew for a fact that you couldn't do it if you had these other things. But we are, we are denying hormones to women who have a family history of breast cancer. We are denying hormones to women who have hypertension even though that hypertension may be treated. We are denying, when, oh, migraines. Oh, you can't have it. There's no, it's not in there.

[Host/Interviewer]

Why are we doing it? Why are we denying hormones to women who are asking for them or want to take them?

[Dr. Sharon Malone]

And I'll tell you why. And I think some of it is extrapolating some of the contraindications to birth control pills.

[Host/Interviewer]

Okay.

[Dr. Sharon Malone]

To hormone therapy. You shouldn't smoke and take birth control pills. Right? Right. But remember I told you that's three to four times the amount not true for hormone therapy. So we are, in addition to women, not really seeking out and being afraid. Then that's where this sort of gatekeeping comes in with physicians, because physicians are not offering, because they are thinking that the same contraindications for MHT or HRT are the same ones for birth control pills, and they are not. So there are all these women who are out there who are not being treated, and there's no real data to support that. So when you look at the four reasons why they can't. Oh, and the other thing I forgot, there was one more, and that was about blood clots. You know, if you've had a blood clot in your legs or lungs, but even the breast cancer and the blood clot issue, we've come back and we've revisited that because that was all based on oral estrogen only.

[Host/Interviewer]

Okay.

[Dr. Sharon Malone]

And we now know that there are other modes of delivery, such as a transdermal estrogen that you can use that does not affect the blood clotting factors as much as oral. And you can also look at the issues with women who have had breast cancer and women who are breast cancer survivors who are years out from their diagnosis and are probably cured. Then that is a more nuanced conversation where women get to be involved in that conversation. It shouldn't ever be someone that tells you absolutely no, never. It's a matter of your quality of life, what your risk tolerance is and what your treatment goals are.

[Host/Interviewer]

And family history of breast cancer is not a reason to say it's not.

[Dr. Sharon Malone]

I have two sisters with breast cancer. And that gives me not the slightest pause. Because the other part of that study that never really got out there was that even, even if you took the Women's Health Initiative at face value, where there was a, almost significant risk of, you know, increased risk of breast cancer, there was no difference, no difference in the mortality rate. So even of the women who took hormone therapy, you are no more likely to die of it, whether you took it or you didn't take it. But here's the part that never got the, the, the real, the press that it should have gotten, and that is for the women who took estrogen only in the Women's Health Initiative, the women who took estrogen only in that study not only had a 23% decrease in the incidence of breast cancer, but they had a 40% decrease in the risk of dying if they took estrogen than if they did not if they got breast cancer.

[Tamsen]

Now I want to shift into a topic that does not get talked about enough. That's vaginal estrogen. This is one of the most effective, most underrated options out there and it's safe for the vast majority of women, including many women who can't take systemic hormones. Dr. Corrine Min not only is an OB GYN and a menopause specialist, but also a breast cancer survivor herself. And she broke it down beautifully in our conversation earlier this year.

[Host/Interviewer]

The loss of estrogen can make your vagina disappear. Essentially, yes.

[Dr. Corrine Min]

Well, I don't want people to think that it's going to disappear, but the canal, the length can be shortened, right? And so, you know, we can get that back, you know, with dilator therapy. So, you know, but first we've got to treat the root problem is the loss of hormones so you can give estrogen. So when people say, I want this to be like, clear. Vaginal moisturizers help restore some moisture, but it's not treating the root problem of the activity. Vaginal lubricants decrease friction with sexual activity, but neither a moisturizer or lubricant are going to change atrophy.

[Dr. Sharon Malone]

Got it.

[Host/Interviewer]

Go to the most recent guidelines that came out that talk about vaginal estrogen because I think it's really important and we'll just do a quick to understand the difference between the two. So when a woman says, I don't want to do hormone therapy, that is different than what we're talking about with vaginal estrogen, correct?

[Dr. Corrine Min]

Yeah, we're talking about low dose local hormones, vaginal estrogen, or there's a product that is an FDA approved vaginal DHA which works on both estrogen and testosterone receptors. And they, you know, both estradiol or DHA work by, you know, improving the tissue but not being systemically absorbed. Right. So if someone says, I either can't use hormone therapy systemically or I don't want to, you can use local estrogen therapy. In the AUI guidelines, it's the American Urologic association just put out these excellent, excellent guidelines on the genitourinary syndrome of menopause and make it very clear, clear that yes, even breast cancer survivors, even er, positive breast cancer survivors, women who are on estrogen blockers or lowering estrogen, can safely use vaginal hormones. And it's really important. And they also make it very clear that it's more than just dryness. It's urinary tract infections. Urosepsis, urinary urgency and frequency. Right. So there's, you know, it's a lot more than just this dryness kind of idea.

[Dr. Sharon Malone]

Sure.

[Host/Interviewer]

Yeah. I mean, I think sometimes we're like, oh, that's a luxury issue to be dealing with. And that's not what that is. That is a health risk and a health issue to be dealing with.

[Dr. Vonda Wright]

Yes.

[Dr. Corrine Min]

And, you know, I see patients who are in the midst of, say, cancer treatment. They're like, you know, sex is not really on my mind right now. And I get that you're in the midst of all this stuff, but I think it's really important if they know that they can be proactive and do something preventatively so that four years down the line, 10 years down the line, things haven't changed so much that if they want to be intimate, they want to protect that part of their health that we don't have to, you know, be doing all this catch up.

[Tamsen]

Okay, so take a breath with me for a second. I know that was a lot of information, but I hope you're feeling a little more clear, a little more empowered, and a lot less alone. I always say this, and I really mean it. You're not supposed to navigate the stage by yourself. We can't do that. This community exists because we learn from each other, because we share what's working, and we can break down the things that no one ever taught us. If you have learned something new or if something just clicked, I would love to hear about it. Leave me a comment or review and tell me, what did you learn? What do you want more of? And maybe what's still confusing. I read every single one of the messages you sent, and I try to respond to as many as possible. They really help me figure out what guests we're going to bring on next. And don't forget everything we talked about today, plus all the doctors, the time codes, the resources. They're sitting right there for you in the the show notes. I tried to make it as easy as possible. I also included my free menopause map. You can download at any time and bring it straight to your next doctor's appointment. And if you even want more support, my book, how to Menopause. It's on sale right now for Black Friday, so gift it to a woman you love. It doesn't just cover hormone therapy. It's a 360 holistic look at the entire stage of life, perimenopause, menopause, and postmenopause. It features 42 of the top experts in the world and covers everything from symptoms and treatment options to relationships, the workplace, your confidence, and more. It's really the book I wish I had, and I hope it supports you in the way these experts have supported me. Thank you so much for listening, thank you for your reviews, and thank you for being part of this growing community of women who are done being left in the dark. I'll see you in the next episode, and until then, live your someday today.

[Host/Interviewer]

Today's podcast is sponsored by Midi Health. So many of you know this, but I was dismissed over and over again when I was struggling with perimenopause symptoms. I didn't even know I was in perimenopause. It is so important you're getting care from someone that specializes in women in midlife and that they're willing to have the hormone therapy conversation with you. I get questions from you every single day about where to go for support and I'm always suggesting Midi Health. It's covered by insurance and you don't.

[Tamsen]

Even have to leave your house ready.

[Host/Interviewer]

To feel your best and write your second act script, visit joinmitty.comtamsen today to book your personalized insurance covered virtual visit. That's joinmitty.com Tamsen Midi the care Women Deserve.

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