The NYT journalist who broke open the menopause conversation — on hormones, risk, and what we're still learning.
Susan Dominus wrote what many call the defining article of the modern menopause conversation. In Part 1 of this two-part episode, she and Stacy go deep: the cultural bias baked into "significant symptoms," how to actually think about hormone therapy risk, and why women spent 20 years without real answers.
Hello Menopause Season 4 Episode 6: The Menopause Information Gap
Susan Dominus, author of "Women Have Been Misled About Menopause"
Part 1 of 2: Hormones, risk, and the research behind the headlines
Stacy London: I think it frames our discussion in a different way. Susan, you potentially wrote the most famous piece about menopause that has happened in the last decade. How many years ago now since that article was published?
Susan Dominus: Thank you. Three — maybe more than three, around three.
Stacy London: Almost three, and here we are on a podcast today discussing the importance and the relevance of your work. There are not that many articles I can remember from three years ago that I read in the Times. But I think you did something really, really important with this article that is worth discussing at any phase of life.
What struck me was that we weren't just talking about symptoms. You were talking about how knowledge travels, how medicine makes decisions under uncertainty, and why so many high-functioning, multitasking women suddenly feel like they're falling apart — and why it's undeserved that they feel this way.
You also looked at the way the system responds to the way women feel. Earlier in the piece, you talk about painfully familiar moments — your doctor says they'll prescribe hormones for significant symptoms only, and then there's this internal math about whether you're being too melodramatic. Can you talk about what you learned about how to define "significant," and how much of that is medical judgment versus cultural bias?
Susan Dominus: I think there was a lot of cultural bias. There's this assumption that women are expected to just put up with a lot, and that the second they complain about anything, they're judged for it — seen as a problem, high strung. There was recently an article that found that women actually experience pain more acutely than men, that there are more neurons firing, that their experience of pain really is different. So if they are complaining more, maybe there's a reason for that.
The question of "significant symptoms" is really interesting because some doctors want that to mean you can't go on. But other doctors I interviewed — doctors who wanted women to consider menopausal hormone therapy but couldn't get through because women had been scared off of it — would say things like, "The fact that you're here complaining to me about it tells me it's significant. That's really all I need to know, so long as you understand this might not be entirely risk-free. I'm going to let you make that decision."
Stacy London: There is such a range when we talk about "significant." How would we know when we have so little understanding of menopause — especially when you were doing this article — that it was almost as if you didn't know what to ask, and doctors didn't know what to say?
Susan Dominus: There's also a distinction between aging and symptoms of aging that are "to be expected." But even if things happen with aging, if we could try treating them with hormone therapy and that might work, then maybe it's worth a try. I think it's not helpful when doctors dismiss menopausal symptoms as simply aging, because although there's a lot of overlap, one can be easily treated and for right now the other one can't. So let's try something.
One of the wisest things someone said to me was: if you've recently gone through menopause and you're having really uncomfortable symptoms that have only recently onset, try menopausal hormone therapy. Because if the thing goes away — the ringing in your ears, the dry mouth, the dry eyes, the joint pain — then you have a pretty good idea it's hormone related. And if not, you go off of it.
Stacy London: One of the most interesting things in all of my interviews was when Dr. Jen Gunter said we don't need panels of bloodwork. If you are in the range for perimenopause, we treat the symptoms. We already know these symptoms are specific to this time of life. We can start by treating them right away.
Did you interview any clinicians who had a framework for that discussion? Or did you feel, as a patient, there was language you wished you'd had to get a better understanding from your doctor?
Susan Dominus: In general, doctors were trained to ask: are you having severe hot flashes that interrupt your sleep and that you consider very bothersome? If the answer was yes, they might say you want to consider menopausal hormone therapy — although it raises your risk of breast cancer. People really trained in menopausal care would ask a broader range of questions and fold into the conversation a way of talking about risk.
The biggest problem with research conducted heretofore is that although the most well-known large-scale study is still the best randomized control trial we have measuring the effects of menopausal hormone therapy, it did find that being on menopausal hormone therapies after five years does seem to cause an uptick in breast cancer. But helping women understand the odds of getting breast cancer as a result is a complicated conversation about how to think about risk.
Some doctors would say things like, picture a stadium of 10,000 people. One of those people is going to have breast cancer they would not ordinarily have had because all 10,000 were on estrogen and progesterone. If you can live with those odds and you're really uncomfortable, try this — or try it for four years and go off before you reach the five-year mark.
But that's a pretty sophisticated conversation. Doctors, through no fault of their own, are trying to get in and out of appointments as quickly as possible. To help someone stop and think about their relationship to risk, their mother's breast cancer history, whether they smoke or drink — these are really complicated conversations, but women and doctors are finding more and more space to have them.
Stacy London: Your article was a huge driver in that direction. One of the things I find so interesting about that study is understanding the data — how to read it. The fact that these women were post-menopausal rather than perimenopausal or newly menopausal really makes for a different kind of conversation. And it was more about cardiovascular health, if I understand correctly, rather than the breast cancer uptick being the primary focus.
We agree there's nothing better we have right now. Even relative to risk, there was a period where clinicians didn't even talk about hormone therapy because it was considered unsafe.
Susan Dominus: Prior to that study, doctors really expected estrogen to turn out to be some kind of magical panacea. One doctor told me she had a slide in a presentation that said estrogen should be in the drinking water. The reason was that men have much higher rates of cardiovascular disease than women do until women hit menopause, so there was this assumption that estrogen was protective.
What is always forgotten is that women who did not have uteruses and therefore did not have to take progesterone — their breast cancer risks went down. Many doctors infer from this that it's actually the progesterone that was increasing the risk of breast cancer, not the estrogen.
But getting back to the psychological story: there were doctors who were really pushing hormone therapy on women. When there did appear to be some elevated risks, doctors were aghast — caught off guard. There was a lot of guilt and shame. It was a case of you don't know what you don't know. And it started with women famously flushing their menopausal hormone therapy down the toilet.
Stacy London: Which is interesting, because the hormones available to us today are not the same hormones — they're not identical to what was studied. And now we're talking about a completely new class of hormones and delivery systems, including testosterone. Once you do know, you change for the better.
Susan Dominus: Yes. There are so many doctors, including Sharon Malone, who say it's proven — that with new formulations it does not increase the risk of cancer. But I'm a stickler because so much of the history of science is about the failures of observational studies. You think you're controlling for everything, but it's very hard.
In an observational study, basically, people are asked after 20 years whether they were taking hormones. They answer yes or no. Then researchers look at how healthy they are and try to say the people on hormones are healthier. It's hard to tease out causation from correlation. There are statistical methods to control for income and other healthy habits, but you really don't know what you don't know. I'm pretty dubious about observational studies in general.
Stacy London: But we only have what we have, and hopefully there are new things coming. Now that testosterone has entered the chat, I would think that because of these potential risks we'd be trying to optimize those hormones to work as best as possible. I've also heard of research into ways to prevent the ovaries from declining — so that women never go through menopause.
Susan Dominus: That research is definitely happening and is super fascinating. The ovaries are actually the fastest aging organ in the human body, which is becoming a way of even studying what aging is. I wonder if people are studying even lower doses that would offset some symptoms. I don't know. And I think the really interesting thing will be in 10 years — if this larger movement toward helping women understand that there is treatment for these symptoms leads to changes we can actually measure.
Some people think that epidemiologically, there may indeed be a small uptick in breast cancer in women in this country as a result of more widespread hormone use. But people would still say overall it might be worth it — because so many fewer women are suffering day to day. They're having fewer hip fractures, they're not ending up in nursing homes, they're having better sex lives. When the WHI was studied, we didn't know how a breast cancer diagnosis would look. Nobody wants breast cancer, God forbid, but 90% of breast cancers are treatable. The whole calculation is very different now.
Stacy London: That's exactly what I wanted to come back to — our relationship to risk. How can we understand our relationship to risk if we're not given the full picture of risks and benefits? I don't know how to make that choice without it.
Susan Dominus: That's exactly right. And sometimes people can't really make the risk-benefit analysis unless they've personally tried it. If you're in the awful position of having a family history of breast cancer, but you're also thinking you might have to quit your job because your brain fog and depression is so intense you can't fulfill your duty to your clients — that was one friend's particular situation. The answer for her was: if it only makes you feel a little better, the benefit might not be worth it. But if it's game-changing, then maybe it is.
For her, once she experienced the benefit of the hormones, it was so clear to her that the risk was worth it. Cancer treatment has progressed, she wasn't guaranteed she was going to get it anyway, the formulations might indeed be safer — and she could live her life day to day as a thriving, healthy human being.
Stacy London: There was a Scientific American study about happiness in women showing that the lowest point is 40 to 50 — the highest rate of decreased earning potential, highest rate of divorce, highest rate of depression. And I keep thinking all of those things could be correlated with or caused by menopause.
Susan Dominus: Yes! I'm well aware of that finding. I also never made that connection, but I think you're absolutely right. It's also true for men, which is why it might be a little confusing — but for women, that certainly has to be a contributing factor. I never thought about that.
Stacy London: It's like perimenopause written all over it. We don't know the risk versus benefit of saying, "I would prefer treatment rather than break up with my partner just because my sex drive disappeared and now they think I don't love them." These are things I immediately understood to be the underlying cause. Of course there's a decrease in earning potential — aging women are not particularly adored by society. She's forgetting things, she's kooky, she's too emotional.
I'm also convinced — and I think we're one of three species that go through menopause — that women go through menopause so that they can rule the world. Not because our sole purpose is to have children or take care of our children's children. This idea of being out of flux, and getting to a place of different clarity, is a different space in time for life to be different things. We've been told here's your path — children, marriage, career, all three. And then this is when we actually get to take back and decide who we want to be instead.
Susan Dominus: If you think about it in evolutionary terms — when you're in your reproductive years, you have value. You are sought, cherished, desired. After menopause, you're no longer fertile, which can coincide with no longer being desired in the same way. You have to look out for yourself. You are now your own protector. And so potentially you have to be a little tougher, a little stronger, a little more fearless.
Stacy London: That makes sense with the way hormones kind of decrease — that "don't give a fuck" feeling also comes from having less estrogen. I really felt that shift after menopause.
Susan Dominus: Yes. We're starting to understand that when you put women on very high doses of testosterone, they change dramatically. Who they are inside feels different. We don't totally understand the way that menopause and that shift in hormones will change women across the board, but whatever is happening is probably more subtle and has more ramifications than we can easily grasp, measure, or discern.
Stacy London: So one of the things I find so interesting in everything you've said is that it's not black and white. There is so much nuance to this conversation. Our hormonal health is finally getting some spotlight. But we didn't even talk about it before, unless we were talking about hormonal teenage boys.
Dr. Jen Gunter talks about in The Menopause Manifesto that adverse childhood events — ACEs — can have an effect on menopause 40 or 50 years later. There's so much we still don't understand. I do hope you'll continue writing on this.
Susan Dominus: I don't think I'm going to do a book — so many were already in the works, including Tamsin Fadal's and Jen Gunter's, which is wonderful and a classic. I admire her so much.
But just to tell you how little I knew going into this article: I got a nice education at a fancy college, I like to think I'm no dummy. And I went for a walk at the beginning, just after getting the assignment, and told a colleague at the Times what I was working on. She said, "I have a question — if you're about to go through menopause and then you go on menopausal hormone therapy, does it delay menopause? Does your body actually not change the way it would be changing?" And I said, I don't know. I couldn't even answer that question. The answer is no — your body goes through menopause and then you treat the symptoms. But I couldn't answer it. And we were both people who consider ourselves fairly well resourced and educated. I've covered women's health on and off for years.
Part of the problem is that so many women got their information about women's health from women's magazines for years. But magazine advertisers hated menopause — any reference to it. They always wanted their readers to skew younger because of the way buying patterns get set earlier. So there was this huge vacuum for so long.
Stacy London: And isn't that amazing. Now, look, magazines are essentially a different medium, but that vacuum is what made your article land the way it did.
Susan Dominus: What blows my mind is that women have found a way to make an issue that has to do with their own aging somehow hot. That's the great miracle of the 21st century. You can say the words "vaginal dryness" out loud in a sentence — I would have died rather than said that five years ago.
Stacy London: I always used to say the only thing you want dry in menopause is a good martini. We've been made to feel so ashamed of aging. That's what women associate with menopause — not that it's a biological rite of passage, but that you're old. You're old and you're worthless in our culture.
Susan Dominus: You're old, you're worthless, and you're sexually revolting. There's an Adam Sandler movie I remember watching in which the whole joke is that one of the men has a girlfriend who's in her 60s. The shot of this young man kissing this older woman was a sight gag. To me, that movie — made by a very mainstream star — really speaks to just how permissible it was to revile older women who tried to be sexual.
Stacy London: The values of our youth have an expiration date. And when those values are done, they are what expire — not us. We just no longer choose to subscribe to that belief system. We're no longer saying my value is how many kids I have, or the corner office, or how much men want to have sex with me.
I'm also convinced this is why a lot of women wind up dating other women after menopause. Women are just much cooler.
Susan Dominus: They no longer feel obligated to subscribe to the conventions of society.
Stacy London: And women generally have such a better understanding of each other in such a more intimate way, even in friendship, that it makes more sense. After talking to a coach who told me that post-menopause, the way your hormone profile changes also shifts your psychological profile — the way we've gendered feminine and masculine gets very blurred after post-menopause, post-andropause. Women's hormones are constantly up and down — pregnant, postpartum, always seemingly not on an even keel. And going through menopause kind of gives you that less emotionally reactive mindset that society has always attributed to rationality.
Susan Dominus: Any rational woman would prefer to be with a woman.
Stacy London: So one of the things I think is so interesting in literally everything you've said is that there is so much nuance here. And our hormonal health is finally getting some of the spotlight. But these are much more complicated conversations than we've been allowed to have. Since we have so much more to cover — including testosterone — I'd love to do a Part 2 with you.
Susan Dominus: I would love that. Thank you for all the good work you're doing educating women about this.
Stacy London: It's funny how it came all the way back around for me. I really focus now on the fact that there is an identity transformation going on in menopause and post-menopause. My style went out the window. My body changed. I talk to women now not just about what menopause has brought in terms of how they feel about themselves, but about helping them rediscover who they want to be. We don't give women the grace to figure out who they want to be next. We're so busy mourning what we've lost that we don't see the real opportunity. And that's what I want to do more of.
Hello Menopause is hosted by Stacy London and produced by Let's Talk Menopause in partnership with Studio Kairos. This transcript has been lightly edited for clarity. This podcast is for informational purposes only and does not constitute medical advice. Please consult a qualified healthcare provider about your individual care.
Part 1 of 2.
