‍Stacy London (00:08) Welcome, ladies. I'm so happy to have you on Hello Menopause today. Gaby, I'd like to start with you, if that's okay. I want to make sure I get the quote right: you said that nothing prepares you to break the news to yourself when you get a breast cancer diagnosis. Can you take us back to your mammogram?

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Gaby Natale (00:38) Absolutely. My background is journalism — I have decades of breaking news and telling stories. And then I was in that mammogram situation, and I was not connecting the dots. I had a mammogram and then a follow-up sonogram, and the radiologist said, "You're going to need a biopsy, Gaby."

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And I was like, okay, I'm going to need a biopsy — maybe I can also go visit my family in Argentina, kill two birds. I don't know where my mind was, because it's literally a moment where your life changes and the world stops for a second. And I'm so thankful, because the radiologist realized I was not connecting the dots. He told me, "Lady, you're not understanding. You are going to need a surgeon, you're going to need an oncologist, you're going to need a medical team for what's coming. You have to have the biopsy, but I can already tell you that you are going to need that medical team."

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The way I see it, it was like first breaking the news to myself — because even me, as a caregiver of my mother, who is a two-time breast cancer survivor, even knowing this can happen to great people, that you can take care of your health and it can still be part of your life — it takes a while to process. It's a lot of information. So for me, the first step was breaking the news to myself. The second was breaking the news to my world, because you know it's news that is going to break the hearts of the people you love. And the third was going public — breaking the news to the world, not just my world.

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The only one I didn't choose was the first one; it was the doctor telling me. The others, I chose. I broke the news to my world after surgery, in fact, because I wanted to say, "Hi, Mom, I have some good news and some bad news. The bad news is that I was diagnosed with breast cancer. The good news is I had surgery and we're fine." There were more steps involved, but I just wanted to protect my loved ones.

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Dr. Marisa Weiss (02:58) Of course you did.

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Stacy London (02:58) Yeah. And I'm wondering, what was the hardest of those three for you, if there was one that felt particularly difficult?

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Gaby Natale (03:07) I'm originally from Argentina and I'm based in Dallas, and my father came to Dallas to celebrate his 75th birthday with us. It was planned ahead of time, and I was in the phase of not telling my family yet. Do you remember that Italian movie, Life Is Beautiful, where they're pretending everything is beautiful and they're in the Holocaust? Of course I was not in the Holocaust, but that intention, that attitude of pretending everything is going fine and doing the happy birthday and everything. I was telling my father, "I'm going to a business meeting," when I was going to do the checkups before the surgery. And, Stacy — you're focused on fashion — I was going in my worst dress, my worst looks. And I would say, "I'm so happy this is my father visiting and not my mother," because not for one minute would I have gotten away with "I'm going to a business meeting" in some old leggings and tennis shoes.

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Stacy London (04:14) He would never — right. Mom would not have bought that.

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Gaby Natale (04:17) No, no, no. But my father was like, "Okay, you're going to a business meeting. See you later."

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Stacy London (04:23) And Monica, I'm so curious. You found out that you carried the BRCA gene at 40. Walk us through the decisions you had to come to after that diagnosis.

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Monica Molenaar (04:36) I was 39, actually. And it's one of those moments you never forget. I remember learning that I was a carrier — it was the first night of Hanukkah in 2013 when I got the call from the hospital. My mother and my grandmother had both had breast cancer very young, both twice. So, like you, Gaby, the result confirmed what I suspected, but it still came as a punch to the gut.

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In June 2014, about six months later, when I was 40, I had both of my ovaries and fallopian tubes removed. I went home the same day and woke up the next morning in full menopause. I had been told, "This will be an ambulatory surgery. It's non-cosmetic." My grandmother's breast cancer either spread to her ovaries or she also had ovarian cancer — it's unclear, I never got a straight answer about that. Neither my grandmother nor my mother died from the cancer. And the way I had been counseled at that young age was: this is non-cosmetic, no one will know. I already had two children, so it was all about fertility and whether I was going to have more kids. But no one told me that I was going to go into menopause the next day, or to expect that, or how I might feel. And that's really when the real drama started. They wouldn't put me on hormones. Every doctor I found after that gave me a different answer and said the last one was wrong, so I had no confidence in what I was taking. But the one thing I did know for sure, after I finally got a prescription six months later, was that I could not go on without HRT.

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Stacy London (06:22) I was going to say — it's not funny, it's tragic to hear this story: at 40, you were still told there was nothing wrong with having the surgery, that you'd be fine the next day. Dr. Weiss, I really have to defer to you here, because I feel like that kind of advice or information is so skewed, with no knowledge of female physiology and what it actually means to remove those vital organs from your body. What are your thoughts about that, and about what Monica had to cope with?

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Dr. Marisa Weiss (06:56) Well, you go through so much in such a short period of time that it's like "yada, yada, yada." You can hold on to some of what you've been told, and then they keep talking and it goes over your head. So it's so hard to know how to make all these decisions and be fully prepared in the short time you have before these big steps. But it's certainly a missed opportunity to help you avoid the expected huge symptoms that come from a cold-turkey menopause. When they yank out the ovaries and fallopian tubes, it's the removal of the ovaries that causes those symptoms — and there's a lot they could do to make you feel better. Not just feel better, but help you reduce the long-term health risks, like heart disease and osteoporosis, that come with experiencing menopause really early without being taken care of in a holistic way.

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Stacy London (08:04) Holistic is sort of the key word, right? Nobody should feel like they have to walk into a breast cancer diagnosis without some supportive or ancillary information. Do you see that changing in oncology? Are we widening our network so that oncology talks to gynecology, gynecology talks with endocrinology — that we're opening up the conversation in a bigger way?

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Dr. Marisa Weiss (08:32) Yes — and thank you for the work you're doing that keeps the dialogue going, and hopefully creates a fertile conversation between specialties. We're usually very siloed. But it's good that we've finally gotten some studies done in people with a BRCA1 or BRCA2 abnormality who have these prophylactic surgeries to get to a safer place — but who still want quality of life. They want to feel like who they are: able to sleep, able to think, able to speak, able to enjoy intimacy, able to exercise without the risk of falling down and breaking a bone. There's a lot going on.

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So, for example, studies have been done in people with a BRCA1 or BRCA2 abnormality who have not had breast cancer, and those people can feel pretty comfortable that they can safely go on hormonal therapy — especially when they go through menopause at a young age, like you at 40. Under 40 is premature menopause; 40 to 45 is early menopause. It doesn't matter what you call it — it sucks.

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Stacy London (09:53) It sucks.

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Dr. Marisa Weiss (09:55) And then if you've been diagnosed with breast cancer and you find out you have an inherited genetic abnormality, you might be going through treatment. If you're BRCA1 positive, the cancer is more likely to be hormone receptor–negative, and maybe your doctor will feel a little more comfortable prescribing hormonal therapy to help you mitigate the symptoms you're experiencing and reduce your risk of long-term illness. But if you have a BRCA2 genetic abnormality — more likely to be associated with a hormone receptor–positive breast cancer — and you're on anti-estrogen therapies, most doctors would not feel comfortable prescribing systemic hormonal therapy to the whole system. But they might be more willing to prescribe local hormonal therapy, like low-dose vaginal estrogen, to manage painful intercourse, itching, frequent urination, burning when you urinate — all those symptoms I think all of us have had. I went through breast cancer 16 years ago. I know firsthand: it stinks. It really does. It's bad news.

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Gaby Natale (11:08) And that is such crucial information. My cancer was estrogen-positive. What Dr. Weiss is saying is crucial, because so many women get told no to everything — but there are nuances, there are details, there's different information. And as she said, systemic is not the same as local. At the same time, what I'm seeing in the medical community is that even for cases like mine, what used to be "hell no, everything is a no" is now "I want you to make an informed decision, so you decide about your own quality of life. You know your risk, your risk of recurrence, what's going to happen with this or that treatment" — the patient makes an informed decision. That was not the attitude of doctors five or ten years ago, but I'm seeing a change.

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Dr. Marisa Weiss (12:09) Right. That's great.

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Monica Molenaar (12:11) It's so important. Stacy, I don't even know if you know this — I'm 52 now, and I actually had two surgeries. When I was 40, I had my ovaries removed. But two years ago, when I was 50, I had my breasts removed. I had a prophylactic double mastectomy.

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Stacy London (12:28) I did not know that.

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Monica Molenaar (12:29) And the reason I did that — after taking HRT for 10 years to great effect, I have no menopausal symptoms. After the first six months following my ovarian surgery, I had a total meltdown and a complete crisis. No one had prescribed me anything, I didn't sleep through the night, I almost got divorced, I couldn't take care of my kids because I could hardly get out of bed. It was really a disaster. Then I got a prescription for HRT, and everything turned around. I started a business. I really got my life back together.

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And because my grandmother and my mother hadn't died from their breast cancer — looking back, I know how much my mother suffered after her chemotherapy and two rounds of breast cancer. We just didn't talk about that being menopause. I really didn't know. But after starting Alloy, diving deep into the science, and finally having access to doctors who understood the subject matter — which was so hard to find 12 years ago — I realized that if I did get breast cancer now, no matter what you think — like Gaby said, there's a really nuanced conversation that all women deserve to have. I firmly believe that after breast cancer, we are more than just our breasts, and we should be allowed to have an informed conversation and make decisions about our own body based on our own risk tolerance. But I realized that for the five to ten years I'd be treating breast cancer, I would go right back into surgical menopause, and I wouldn't be prescribed HRT during treatment. That was something I just couldn't face. I had a conversation with a doctor — I think a lot of us know and love Dr. Corinne Menn, who is herself a breast cancer survivor — and she said, "Monica, even I wouldn't prescribe HRT to you during treatment, and that's five to ten years." The next morning, I made an appointment to have a prophylactic mastectomy.

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Dr. Marisa Weiss (14:38) Wow. You are brave and courageous.

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Monica Molenaar (14:40) Thank you. It's been great.

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Stacy London (14:42) Absolutely brave and courageous — but also an informed decision, right? Gaby, you're bringing up an incredibly important point here. And Dr. Weiss, I'm so curious, because you're a survivor and a doctor as well. These kinds of informed choices have not been given to women, because we just didn't understand enough about female physiology to connect these dots in the first place. Is that right? It feels to me like there was so much missing in terms of understanding how the female body works, that we didn't make these important connections — that we didn't understand the true impact of menopause until we started looking at these very specific kinds of cases.

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Dr. Marisa Weiss (15:22) Well, there's no question: there's only one of each person. There's no one-size-fits-all. Everyone deserves a personal conversation with a doctor who listens to you, takes you seriously, and has the patience to work through various options. And these conversations are not a one-time thing — it's an ongoing conversation. Over time, as new treatment options become available, we have more options, so the conversation gets richer. For example, the median age of menopause is around 51, and the average age of getting breast cancer is about 61, 62. So these two things happen around the same time, and there are a lot of things to consider.

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There are non-hormonal therapies that can be tried first — new ones that can be very effective. But if they don't do the trick and you're still suffering, you deserve more relief, and to continue the conversation: okay, tried that, box checked — what's next? Increase the dose, decrease the dose, take it away, add something in instead? We have more non-hormonal therapies that can help — like a medicine you take by pill that can help with genitourinary symptoms, for people who don't want to apply a cream directly to the vaginal area.

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Stacy London (16:53) And even though you're taking it orally, that's not systemic — or it's just not hormonal, so it doesn't matter?

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Dr. Marisa Weiss (16:59) It's a medicine that helps with genitourinary symptoms. It's not estrogen in the usual way people are concerned about. There are other medicines helping people with hypoactive sexual desire disorder that are non-hormonal. So we have more and more tools that we never used to have.

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We've also learned that some medications don't get along together. For example, if you've been diagnosed with a hormone receptor–positive breast cancer and you're on tamoxifen, and you experience vasomotor symptoms like hot flashes or night sweats, taking Paxil — a medicine that can help with those symptoms — is not a good idea, because it can get in the way of tamoxifen doing its job. So we have to make sure we listen to you, take you seriously, and learn each thing about each person: What's going on for you? What are the symptoms? What are the concerns? What are the challenges?

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Stacy London (18:08) And Monica, I'm curious, because you did a lot of prophylactic care. When you went through surgical menopause, what were some of the most difficult symptoms for you? Why did you realize, risk-benefit, you were not going to go through it again?

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Monica Molenaar (18:30) I've had all the symptoms.

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Stacy London (18:31) Me too.

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Monica Molenaar (18:34) But the biggest one, when I first went into it, was that I stopped sleeping. I literally couldn't sleep through the night for six months — and then all the follow-on effects of that. My kids were young. I hope he's not listening, but I was really resentful of my husband.

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Stacy London (18:54) How could you not be?

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Monica Molenaar (18:56) There was just so much going on, and I felt so dismissed and deleted from the system. Nobody was helping me. I couldn't get the same answer twice from different doctors. I had so many questions, and one doctor — in the middle of New York City — flat out said to me, "You know there's no money in menopause. The research hasn't been done. I cannot answer your questions. Period." I walked out of there. I've never felt so deflated. How is this possible? I'm in the middle of New York City, I have tons of resources, I had my surgery at one of the biggest cancer centers in the world — and they wouldn't treat me because I didn't have breast cancer. I couldn't have follow-on care from them because I wasn't a cancer patient. So I was really just told, "Great, you're good to go."

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Stacy London (19:48) Hanging.

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Monica Molenaar (19:48) The surgeon did say, "You can get hormones when you need them." But I didn't have hot flashes, and that was the only symptom I knew of at the time. So I was waiting for the hot flashes. I didn't know I needed HRT. And then one day, truly after six months — I lived in an apartment in New York City with a shared building roof deck, and I was sitting there trying to calm myself down. A neighbor from across the hall, who I was friendly with and who's 15 years older than me, saw me practically in a puddle of tears. She said, "You don't really look like yourself. Are you okay?" I broke down and told her what had happened. She put her arm around me and said, "I can help you. I have somebody who can help you." And she made me an appointment with her menopause provider.

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Stacy London (20:46) I actually get teary hearing that story, because I wish every woman would do that for one other woman. That's all I wish in the world.

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Monica Molenaar (20:52) She really changed my life. But the person she sent me to — whose career had been treating menopause — wasn't an MD, so that was already looked at askance by the other doctors I was going to. She prescribed compounded estradiol cream — compounded HRT — which I didn't know anything about at the time. I'm not saying anything bad about it: it worked, it did the trick, and in fact it really helped me. But it led to this vortex of misinformation. When I finally went back to the doctor at Sloan Kettering, she said, "You have to stop taking this. It's compounded. You need something FDA-approved. We don't know what's in there." And I was like, oh my gosh. She put me on a path that made me feel worse. So for five years I went to doctor after doctor after doctor. I've had compounded, I've taken pills, patches, pellets, gels, sprays — I've tried every type of estrogen out there. So I've really lived the experience.

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And to your point, Stacy, what I've tried to do with my career as a result is be that person who can put their arm around women and say, "We will help you. Here's the information. Here's access to doctors who know what they're talking about and are willing to have the conversation with you. Here's the array of treatments you can choose — let's make this personalized for you so you get what you need." I've become an accidental estrogen activist.

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Dr. Marisa Weiss (22:44) Amazing. The other point is that if you still have your uterus — because you mentioned having your ovaries and fallopian tubes removed, but the uterus is still there — and you're taking estrogen, you still need a progestogen to protect the lining.

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Monica Molenaar (22:56) Absolutely. Of course. I definitely take it.

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Stacy London (23:00) And Gaby — I'm so sorry to interrupt, because I love this conversation. Monica, first of all, you are that person. You are that person for so many of us — as are you, Dr. Weiss, as are you, Gaby. This is why we have you on the podcast.

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Gaby Natale (23:12) I love that, because I also use the word "accidental" — I say I'm an accidental femtech founder. This was never in my plans. I was doing my career as a speaker, author, and journalist — I'm still doing it — and then life happened to me. And I said, if I'm not finding the resources — and in English it's confusing, and in Spanish—

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Stacy London (23:43) This was my next question for you.

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Gaby Natale (23:45) Tell me your question.

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Stacy London (23:47) Well, I was going to say, I feel like a lot of women in Latin and Hispanic communities don't get a diagnosis as early as they could. We're told that diagnoses for different races can come later compared to white women, let's say — which I assume is incredibly difficult. I met one woman very recently who spoke very little English. She told me she went in to have her ovaries removed, and they took out her uterus without asking her.

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Gaby Natale (24:28) The situation is very complex because it's very layered. There are problems of access, problems of language barriers, problems of economic barriers — and then there are the cultural taboos. It's still taboo in the Hispanic community to talk about menopause. Of course, we have amazing leaders who are changing the conversation, but we still find so many women who wouldn't even say their age out loud.

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Stacy London (24:59) Right.

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Gaby Natale (25:00) I'm proud — I'm 48, I say it out loud. But so many women still feel they're going to be discriminated against, or so much of a woman's value has been tied either to her fertility years or to an idea of beauty associated with youth — and I believe we can be beautiful at every stage of our life.

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In my case, when I first became an official Susan G. Komen ambassador and started doing interviews to raise awareness about early detection, we made the announcement on Univision's morning show, Despierta América. I was fresh out of chemo and still didn't have hair, but I had a cute turban — I was compensating with all my fashion for the fact that I was having a lot of transitions in my body. We were doing the interview live, in Miami, in summer, and I started feeling the hot flashes and realizing I was having all these symptoms. When you're going through breast cancer treatment — I understand oncologists, their number one job is to save a life. Let's keep this woman alive.

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Stacy London (26:19) Yeah — and let's get rid of the cancer.

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Gaby Natale (26:21) Yes. Let's keep this person alive — and they succeed. But they're overwhelmed, and there aren't many conversations around quality of life. So I started doing the research, and I said: if I, an educated woman, bilingual, a journalist trained to research, still cannot find this information — culturally relevant, bilingual — there must be millions of women out there looking for menopause information and not finding it. I looked up the domain Menopausia.com. It was not cheap, but it was available. And I said, this is a testament to the neglect we're facing as women, because I'm sure if you look for cars.com, travel.com, sandwich.com, erectiledysfunction.com — you name it — it's not available.

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Dr. Marisa Weiss (27:17) Hair loss.

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Gaby Natale (27:18) Yes — not available. But Menopausia was available.

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Stacy London (27:21) So what have you built with Menopausia.com, and what do you hope to keep building?

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Gaby Natale (27:29) We built the first bilingual digital platform for all things menopause and perimenopause, taught in our culture, in our language, for our community. We realized we have to meet people where they are, so we need to educate from the basics — what is menopause 101, what is perimenopause 101 — because sometimes on our Instagram we get questions like, "What is estrogen?" You cannot address what you don't know is happening to you. These women are going through so many symptoms; some don't have the information, and others are in denial, because so many of us think, "It's not happening to me, it's not happening to me" — but it's happening.

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Stacy London (28:15) "It's not going to happen to me" — exactly. I remember when I first read the word "perimenopause." It was in a book called Moody Bitches: the sleep you're not getting, the weight you're still gaining, the sex you're not having. I was like, oh my god, this is me. It was the first time I'd ever seen anybody mention the word perimenopause. And I remember thinking, I can't talk about this. Nobody's going to want to date me. If I mention this, it's going to mean I'm old and I'm being put out to pasture.

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Gaby Natale (28:49) And that you're a has-been — because professionally, too, you may be considered a has-been, in the dating world, in Hollywood, in so many places. It's still such a big taboo. That's why I feel this movement has such a beautiful mission: to challenge the status quo, to change the conversation, to be a little more rebellious and tell women, you know what? Aging gracefully is whatever the F you want to make of it. It can be having your silver hair, like you, beautifully, Stacy. For somebody else, it could be dyeing their hair. It could be loving your wrinkles. It could be getting a butt lift. It's whatever you want to do — because for me, the definition of aging gracefully is doing it on your own terms.

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Stacy London (29:42) Amen. The funny thing is, aging on your own terms does require knowledge, right, Doctor? When we talk about all the prophylactic steps Monica took — what should we be thinking about in midlife? When we're talking about mammograms, when do we get them? I'm told once a year unless you have dense breasts, but I'm curious what you see as the best protocol for women 40 to 60 as they experience this. For me, the toughest things were the anxiety, the depression, the rage — I felt like I was going to jump off a bridge. And sometimes we forget that this is both biological and cultural — things happening at the same time that get ignored when we need the most attention. So what can we do to know we're taking care of ourselves? What do we need to look out for after menopause? You started to mention them — osteoporosis, painful sex — things we can fix if we know. But what do we need to know?

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Dr. Marisa Weiss (30:53) Well, you need to know that there's only one you, and you are unique. You need to find your voice and use it to get the best care possible. That means letting your doctor know what you're experiencing. Are you unable to sleep? Are you unable to have intercourse, and you want to have it? Are you unable to get through a business meeting without wanting to take your clothes off, because you feel claustrophobic from hot flashes? Do you have night sweats? Are you moody and unpredictable, and you surprise yourself with the thoughts you have?

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Stacy London (31:33) That was me.

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Dr. Marisa Weiss (31:38) So you have to communicate what's going on for you.

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Stacy London (31:41) And I'm curious — this is a question for all of you — because I had to fight my own sense of shame around menopause. I imagine there's also a huge related issue with illness and shame. Menopause is not an illness, and yet the shame associated with both feels like it's somehow about weakness or being vulnerable, instead of allowing other people to help and creating a network that's going to help you. We have to be vocal about that. Have you all experienced—

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Monica Molenaar (32:17) It's so interesting that you say that, because as I've been listening to everybody, I've been reflecting back on when I had my ovaries removed and went into menopause at 40. It wasn't so much — I mean, I really was kind of deleted and considered much older. I also hadn't worked in a few years and wanted to go back to work, and now I was a 40-year-old woman who wanted to re-enter the workforce and do something different, and I couldn't fit in — which is also how I ended up an entrepreneur. But I felt so ashamed. Am I a woman anymore, without my estrogen, without my ovaries? Who am I? It was such a confusing time. And because I was so young, I didn't have anyone to talk to about it. That was another one of the symptoms — this feeling of true isolation. I couldn't get answers from doctors that made sense to me. I didn't have many older friends, except, thank goodness, for this neighbor who was 15 years older. I really didn't know how to even have the conversation. I felt so embarrassed, like I had done this.

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That has been such a driving force behind what I've done for the last eight years: opening up the conversation and having more discussions like this. I'm sure the rest of you have the same experience — now, when you walk into a room full of women, or even men, and they know what you do, that's all the conversation at the party. It's like bees to honey. People want to have this conversation. And giving women the opportunity to talk about it has been such an important part of the cultural progression. It's almost become a badge of honor at this point to be in perimenopause or menopause.

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Stacy London (34:24) Right. But I credit all of you with the reason we've been able to transmute shame into something powerful. Gaby, go ahead — I feel like I was about to cut you off.

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Gaby Natale (34:42) Coming from media, I know how important images are, and how important words are — they shape the way we see the world. So we are very intentional about smashing stereotypes. So many times I see women in menopause portrayed in articles and on platforms as losing in life. They're always fanning themselves. They're never active. They're holding their heads, pinching their midsection fat. We are so much more than that. And it's actually not true, because menopause coincides with our highest leadership capabilities and our highest earning potential. So why are we showing women as if they're losing in life, when this is the moment they're shining the most in leadership and earning potential?

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For me, it was very important at Menopausia to show women that we are active, that this can be the best time of your life. Because here's the thing: what's the point of addressing all the symptoms — no hot flashes, sleeping through the night, everything perfect — if in your mind you're still thinking that your happiest days, your most productive days, your most creative, prosperous days, your best romances are all behind you? What's the point in not having hot flashes if you have nothing to look forward to?

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Dr. Marisa Weiss (36:17) Right. And you know, 30 percent of a woman's life is after menopause, so this is really important. My mother had breast cancer at 75 — a mastectomy, no reconstruction — was widowed at 83, and met the love of her life, not my father, when she was 83 and he was 90. And they were totally into the whole package — sex and this and that.

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Gaby Natale (36:43) Why not?

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Dr. Marisa Weiss (36:44) Why not? She died a year and a half ago at 95. But we have to lead by example — and all of you are opening up this conversation, that it's a natural, normal thing. Most of us experience it privately, internally. It's sort of secretive; we don't necessarily share it. So the fact that more people are sharing it will lead to more solutions.

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Stacy London (37:14) Well, and Alloy is one of those solutions. Monica — we talked about Menopausia.com, and I want to talk about Breastcancer.org, but I want to talk about Alloy specifically for a second. I feel like I was there at the very beginning when you were building this company, and I don't think I knew your entire backstory. You're the living embodiment of what you want to see in somebody who goes out and builds what didn't exist. I also think women are great at that, by the way — we're so good at building what's necessary when we've been ignored, dismissed, erased. What can we expect at Alloy? What do you hear from your patients who've had breast cancer? How are they finding the experience of working with Alloy and your doctors?

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Monica Molenaar (38:03) First of all, as we've all established, breast cancer and menopause after breast cancer is one of the most confusing and misunderstood topics. After all these years of studying it and being in the conversation, I still have so many questions. The vast majority of survivors are told no estrogen, ever — and there's no conversation about other hormones, like testosterone, which could be helpful and important. They think no hormones means no relief, and those two things are not the same. At Alloy, vaginal estrogen is definitely on the table. I don't prescribe — I'm not a doctor — but the doctors on the platform will prescribe vaginal estrogen to breast cancer survivors. And we have other non-hormonal options that can help with specific symptoms.

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The problem, in a way, is that because of the litigious society we live in — because of all the misinformation, doctors' liability, and malpractice — our doctors at the moment don't prescribe systemic estrogen to breast cancer survivors. It's such a loaded topic, so difficult. And we're a newer business; we couldn't start there.

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Stacy London (39:35) Right, of course. I mean, you couldn't start with testosterone, for sure.

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Monica Molenaar (39:39) Absolutely — advocate. As I said, I've truly become an activist around this, and I would love for every woman to have the conversation. The doctors are certainly available for that conversation, to give women advice and offer the options we have that are safe — and also advice on how to speak to their team. As Gaby said, when you've been through breast cancer, you usually have a medical team — a lot of different people. To go deeper, I'd really encourage everyone to read Estrogen Matters by Dr. Avrum Bluming and Carol Tavris.

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Stacy London (40:20) I interviewed them, and I was like, first of all, I wish you guys were married and could adopt me — but if not, they're an incredible, incredible resource. And Dr. Weiss, I do want to ask you: if somebody comes to you and says, "I've been diagnosed with breast cancer," are there three questions worth asking before any choice of treatment is made — around menopause, around its sort of intimate relationship with breast cancer?

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Dr. Marisa Weiss (40:55) As everyone has described, they're very commingled. The very treatments you use to reduce the risk of breast cancer coming back — or of getting it in the first place — can cause menopausal-like symptoms, and anti-estrogen therapies have side effects that can be additive with the others. The key thing is to let your doctors know who you are, what's going on in your life, what's working for you, what hasn't worked, and what your goals are — what's important. For example, low libido depends on whether libido is important to you. If it's not important to you, it's not a problem. But if it is important—

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Stacy London (41:44) To you. Right.

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Dr. Marisa Weiss (41:48) Like my mother — it wasn't important to her when she was married to my father, but as soon as he was out, she was like, "Okay, I'm ready. Where is he?" And I was schlepping her to synagogues and hitting on these guys for her. I was her wingwoman for a period. There's a book about this.

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Gaby Natale (42:06) I wish I had met your mother so bad now.

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Dr. Marisa Weiss (42:10) You also need to know from your oncologist what your treatment plan is and what you can expect. Are you going to be on anti-estrogen therapies for three years? For example, if you have DCIS, some people are using low-dose tamoxifen for just three years. Or do you have an invasive hormone receptor–positive breast cancer with lymph nodes involved, in which case you're looking at more like 10 years of anti-estrogen therapy? It's a different scenario.

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You also want to create a baseline — not just of the symptoms you're experiencing, but of what your bone health looks like. Get that DEXA scan. Make sure your vitamin D level is in a therapeutic range, make sure your diet includes enough calcium, make sure you're physically active and holding on to your lean muscle mass, and that you're doing strength training and balance exercises, so you're more likely to keep your bones strong and reduce the risk of falling down, breaking a hip, and having issues with that. It's time to do an audit of what's going on for you, what matters to you, and where you want to see your life going.

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When I was diagnosed 15 years ago, I was right at the median age of menopause, diagnosed with a hormone receptor–positive breast cancer that required anti-estrogen therapy, in a family with a gene abnormality. So — layer it on fast, right? And I suffered in silence. Sleeping has been an issue. I wanted to see my kids grow up. I wanted to hopefully see grandkids one day. Fast-forward: all three of my kids are "under new management," and I have a few young grandchildren and five grand-dogs. I wish I'd known then that I would be here now, having this conversation. But I also know how important it is for doctors to stay informed and educated about what's coming down the pike. That's why — I'm an oncologist, but I'm also certified in lifestyle medicine and obesity medicine, and I'm preparing for my Menopause Society boards next week.

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Stacy London (44:31) Woo!

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Dr. Marisa Weiss (44:32) Women today bear the burden of the world on their shoulders, between home, work, and community, and they need to bring it all to their lives. It's our responsibility and privilege as doctors to take care of people like that — never to be dismissive, to make sure you listen and take things seriously, and to know it's part of an ongoing conversation that has to be built on trust. You can't have your hand on the doorknob about to leave the room if you expect someone to share something very intimate, very private, that can be embarrassing — shameful, like you were saying.

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And depending on what culture you're from, that can be a heavy burden. When we did a program for Latina women — a very diverse group, of course — no one wanted to identify themselves as having had breast cancer. You mentioned that. No one wants to talk about menopause, and God forbid you talk about breast cancer — everyone's running away. And there are cultures where, if you get breast cancer, it means you did something wrong, that it was your fault, that it's shameful. So one message today: it's never your fault. Most people diagnosed with breast cancer — about 85 percent — don't have it running in their families: no family history, no inherited genetic alteration. It's the most common cancer to affect women, and even if there's nothing in your family, no inherited genetic abnormality, no one's off the hook.

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Stacy London (46:10) That's right. And no one — sorry, Doctor, I didn't mean to step on you.

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Dr. Marisa Weiss (46:15) No—

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Stacy London (46:16) No one is off the hook, and no one is off the hook for menopause. To have these conversations feels incredibly important. At Breastcancer.org, what kind of information can we find?

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Dr. Marisa Weiss (46:30) We have expert medical information and personal support, 24/7, on reducing your risk, prevention, diagnosis, treatment, recovery, moving beyond, recurrence, and metastatic disease — for people who have inherited a genetic alteration that may be moderate or high risk, people who are in a relationship or not in a relationship, wherever you are. There's only one of each person who comes to us, and our resources are in English and in Spanish. We're trying to make sure all of our expert information is accessible to everyone, at no cost. We're a nonprofit organization.

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Monica Molenaar (47:11) What you said really rings true, and it's the point I'm also trying to advocate for: everyone deserves to have their own conversation about their own goals, how they want to live their lives, and what's important to them. We are more than our breasts. We are whole women, whole people. And what I hear from women day in and day out — it's so tragic — is that they go to the doctor and the doctor says, "No, you cannot have that," and that's the end of the conversation.

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Stacy London (47:43) Right. Just no.

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Monica Molenaar (47:45) It's not "Who are you and what's important to you in your life? How do you want to live? What are you afraid of? What are you not afraid of? What's the accurate information?" What's also been unfortunate to watch is that a lot of doctors aren't staying current on the information. If it's a reproductive-age woman with breast cancer, a lot of energy goes into maintaining her fertility. Once you're out of that — once fertility isn't on the table — a lot of times there's no more conversation. That's how I felt, certainly: there was nothing more to talk about, because what did it matter? I wasn't having more kids.

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Stacy London (48:41) Right. What does it matter?

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Dr. Marisa Weiss (48:42) Or "You're lucky to be alive" — like, "What are you talking about? You're lucky to be alive." I'd also say that the conversation you're talking about is iterative over time. There's no magic bullet. Even if you're someone with no contraindications to hormonal therapy in the perimenopausal or early menopausal years, you try one thing and see if it works. If it doesn't, you play with it a little before you toss it, or you find something else and layer it in. It's an ongoing conversation. And what worked for you in the past may no longer work for you now, because life changes. So you need a relationship with your doctor so you can have these conversations.

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I went to my primary care doctor and asked if she had a gynecologist she could refer me to, and she said, "At your age, you don't need to see anybody anymore."

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Stacy London (49:46) Wow.

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Dr. Marisa Weiss (49:47) She didn't stop and ask, "Why are you asking me? Is there something going on in your life that's not happening the way you want it to? Is that why you're asking? Is there something that would help me lead you in the right direction?" I felt so shut down and dismissed. And I learned from that — we always learn — to make sure I never say anything like that, and that if anyone reports their doctor said something like that, I help them get to someone who will listen carefully.

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Now, there are a lot of people who live in places with very few doctors and very few options — not in a big city, but in rural America or some remote place — or whose insurance plan limits what they can do. So you might have to work iteratively with the doctor who was dismissive and try to get things back to where you can have a therapeutic relationship. That's a reality for a lot of people.

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Stacy London (50:49) I'm actually very curious about that, because what we're talking about—

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Monica Molenaar (50:50) I think that's where Alloy comes in. And what's interesting about what you just said, Dr. Weiss, is that all of it is true — the iterative conversation and the changing of your body — whether you've had breast cancer or not.

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Stacy London (51:09) Or not.

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Monica Molenaar (51:09) For me, for example, twelve years into menopause, I'm still — and this is really why I developed what I did, to get the care I needed myself — which I know is evolving. I have symptoms. There was a period when I had a cessation of care: I didn't have a doctor to go to, I stopped getting a prescription for HRT, and all the other symptoms came in, and eventually I did get the hot flashes. Even while on HRT, I developed genitourinary syndrome of menopause and all the vaginal symptoms I hadn't had before. After eight years, I accidentally took half my normal dose of estrogen because I got the wrong prescription — and I got incontinent. I peed in my pants.

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So we ended up developing topical estrogen for your skin, because I realized, my goodness, this works so well for my vagina — what would it do for my face? I started putting the vaginal cream on my face, and it worked unbelievably well, because skin is skin. So things change. Your body changes. We are evolving organisms, and what used to work may not work tomorrow. You always have to be engaged in what's going on in your body, being proactive and advocating for yourself to get the information and the treatments you need. That's where, hopefully, these types of conversations help women understand—

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Stacy London (52:46) Yeah — you're co-creating your care.

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Monica Molenaar (52:50) Yes.

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Stacy London (52:51) Sorry, Gaby, go ahead.

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Gaby Natale (52:52) No problem. I think when menopause is induced, it's good news and bad news at the same time. The bad news is that you're having all the symptoms at once, and unfortunately they may be more severe than for other women. The good news is that you cannot pretend it's not happening. You have to own it. There's no other way — you have to own it and say, "Okay, all of this is happening to me."

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And I think the key word for us in menopause — whether you come to this stage gradually or it's medically induced — the key word for the quality of life you're going to have is agency. If we don't have agency, it's going to be very difficult to have a great quality of life. Of course there's access, there's knowledge, there's science. But it all starts with agency, because too many times women have to go to multiple medical consultations and knock on many doors until they find the information they're looking for. If they don't have agency — especially in certain cultures where we worship doctors, and if the doctor says "this is all that can happen to you and these are all the solutions available," you're not going to challenge that — then we need to become our own best advocates for our health.

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Stacy London (54:24) No question. Sorry — one thing I want to ask the three of you. I agree: all of this we're talking about, agency and knowledge, to me it all falls under the umbrella of bodily autonomy. The same way we talk about abortion is the same way we should be talking about all care — we need to understand what's happening, the risks, the benefits. But this can feel overwhelming when we tell women, "You've got to do all this work or it's not going to work out." Has each of you figured out your own system for gaming the system? I understand we're responsible for getting as much information as we can. We should go to our doctors armed with our biggest complaints and tell them what's going on in our lives. But as you said, Dr. Weiss, doctors have, what, maybe eleven minutes at most for some of these visits? And we get crushed in terms of time and attention. It's very easy to give up — to say, "I don't know who to choose or what to do." When you sit quietly and think about it, are there three things — any of you can answer — that made it easier to start gaining knowledge, mining information, and finding trusted people, in a way that didn't feel like the weight of the world was on your shoulders? Is there a way to do this that feels easier?

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Dr. Marisa Weiss (56:04) At Breastcancer.org, the whole reason I started it was to give people the expert medical information and support they need to prepare for these important meetings with their doctor. And then bring it up soon after you get into the appointment — don't bring it up at the end. People are embarrassed, ashamed, it's private, so they may not bring it up until the doctor is halfway out the door. That's not a good way to start an important conversation.

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Stacy London (56:27) That's not a good plan.

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Dr. Marisa Weiss (56:28) So let them know ahead of time that you're coming in with sensitive questions about these topics, and maybe even submit the questions ahead of time, so they become part of your record. And always thank your doctor for listening — or thank them ahead of time. You could say, "I'm so grateful we have this time together to talk about the symptoms I'm experiencing. I really depend on your expertise, or on you referring me to somebody else if need be, to manage them better, because I'm suffering."

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I'd also add, following up on what others have said: we take care of so many issues outside the doctor's office. People are managing a lot of this outside the doctor's office, and the doctor may be clueless about what you're doing, because none of it may show up in your electronic medical record. The doctor may legitimately be out of the loop.

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Stacy London (57:30) Right.

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Dr. Marisa Weiss (57:30) For example, with vaginal estrogen — what we're talking about for genitourinary symptoms of menopause is local, low-dose vaginal estrogen. You can also take systemic estrogen through the vagina; that's a different preparation, usually not what we're talking about, but it happens. And if you put estrogen on your skin or other places, it can be absorbed systemically. We can assume that if it's fine down there, it can help up here — but people might be using a lot of different preparations at once and have systemic estrogen on board without endometrial protection, without knowing that their levels may have crossed the line from low or undetectable to right in the middle of the range.

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Stacy London (58:25) To detectable. Yeah. I appreciate that so much. Ladies, I want to thank you so much for your time today. You've all had such legitimately different experiences, but together you're building this unbelievable tome of knowledge for the women who come after us. And might I also say, I give our generation huge props. We got nothing — no education, we didn't know anything about anything. Gen X, woo-hoo — I'm so proud of us, and I'm so proud that this is the legacy we leave for the women who come after us.

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Monica Molenaar (59:01) Stacy, you asked what we do in a quiet moment — looking at the three of us, I don't think any of us ever actually sits down and has a really quiet moment.

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Stacy London (59:10) Not anymore. You can't. You're too busy.

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Monica Molenaar (59:13) I have so many thoughts now with Dr. Weiss — I think there are some really great seeds of collaboration here between Alloy and—

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Dr. Marisa Weiss (59:24) Love that.

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Monica Molenaar (59:26) It's such an important conversation. What we built was to address those women and provide the ongoing, long-term relationship with a doctor that most women don't get — in particular, a lot of women in areas around the United States who don't have access to doctors, exactly as you just said. Giving information is important, but the next step — how do you get the treatment, how do you have a relationship with somebody who can follow you over time and help manage your symptoms as they change — is what's absolutely critical going forward, because without treatment, it's not helpful.

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Dr. Marisa Weiss (1:00:10) Amen.

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Gaby Natale (1:00:13) And if I may add: for us at Menopausia, what's important is being in language and in culture, so you feel it's built for you. And also really separating what is science-backed from what's out there — online and on social media there are so many charlatans targeting different communities. So it's very important to us that whatever we offer is science-backed. And we make the most of technology. When I was going through treatment as a breast cancer patient, there was a breast cancer navigator. She didn't replace the doctor or anybody else. Now, with technology, we have Mina, our own AI menopause navigator, because sometimes you're overwhelmed. It doesn't replace doctors, but it can help you with next steps in terms of information when you're feeling overwhelmed. It would be a shame for our generation not to take advantage of something that can personalize at scale, as AI can.

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Stacy London (1:01:21) Ladies, thank you so much. I hope you stay in touch with me — but I also hope you stay in touch with each other, and that wonderful, fruitful, helpful relationships come out of this, because it's such a service to everyone who needs you. Thank you.

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Gaby Natale, Dr. Marisa Weiss & Monica Molenaar (1:01:37) Thank you.

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[End of episode]

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