Below is a lightly edited, AI-generated transcript of the “First Opinion Podcast” interview with Patricia Bencivenga and Adriane Fugh-Berman. Be sure to sign up for the weekly “First Opinion Podcast” on Apple Podcasts, Spotify, or wherever you get your podcasts. Get alerts about each new episode by signing up for the “First Opinion Podcast” newsletter. And don’t forget to sign up for the First Opinion newsletter, delivered every Sunday. Torie Bosch: Brain fog and weight gain and hair loss and insomnia — those are the calling cards of perimenopause. At least that’s what the new perimenopause awareness movement claims. But what’s real and what’s just social media misinformation? Welcome to the “First Opinion Podcast.” I’m Torie Bosch, editor of First Opinion. First Opinion is STAT’s home for big, bold ideas from health care providers, researchers, patients, and others who have something to say about medicine’s most interesting and important topics. This season, we’re focused on the intersection of medicine and culture. Today, I’m speaking with Patricia Bencivenga and Adriane Fugh-Berman. Patricia is the special projects manager at Pharmed Out, a rational prescribing project at Georgetown University Medical Center. Adrienne is a professor at GMUC and director of Pharmed Out. After a quick break, I’ll bring you our conversation about perimenopause, menopause, and what happens when women are seen as victims of their hormones. Patricia Bencivenga and Adriane Fugh-Berman, welcome to the “First Opinion Podcast.” I’m going to start, Adriane, with a question for you that is extremely basic, which is: What exactly is perimenopause? Adriane Fugh-Berman: So “peri” just means “around.” And so perimenopause is the time, around the time of menopause. And usually people use it to mean the few years before menopausal, but it’s actually a pretty squidgy definition. And some people are saying that women are perimenopausal starting in their 30s. So there’s not really a very standard definition of it. Bosch: So when did you first realize that the conversation around perimenopause was starting to change? Fugh-Berman: Well, the concept of perimenopause has been around for 20 years and it’s always been sort of squidgy. We know that some of the symptoms of menopause start before menopause. Women may have changes in their periods that get longer, they’re more irregular, they might be heavier. That’s extremely common in the years before menopause. And some women have. Hot flashes and night sweats, or together they’re called vasomotor symptoms, before menopause starts as well. So that’s been known for a long time, but the medicalization of it, or the idea that women need to be treated with hormones or other things before menopause, does seem more recent. Bencivenga: I’d invite the audience to take a look at those Google search trends where you can put in a search term and see the interest over time. You’ll see right around 2023 a sharp rise and uptick in perimenopause. Bosch: And that absolutely jibes with my sense of it. So I’m 42. I think over the past two to three years, it seems like 75% of my friends between 35 and 45 has started to tell me that they are in perimenopause and it’s absolutely ruining their lives and blaming it for really everything, things that I chalk up to having a young child, for instance, or just being overworked. But there really is a sense, I think, among women in some certain demographics that perimenopause is absolutely this thing that’s sort of destroying the way they want to live. So Patty, can you explain the argument behind the provocative essay that you recently wrote for First Opinion? Bencivenga: Sure, sure. Really an issue I think we should all be concerned about is that women have been seen as erratic and unstable due to their hormone changes and their hormones for hundreds of years, right? You’re erratic, and untrustworthy when you’re pubescent, and then again your hormones are out of control when you’re PMSing, and then again, when you were having your period or you’re on the rag, or then again when you are pregnant, or then when you postpartum, or now perimenopausal or menopausal. So at what point are we going to be seen as fully stable and secure people? So is this narrative of erratic perimenopausal, everything’s in chaos, really good for women? That’s sort of what drove me to look more into this. Bosch: Yeah, and I found your article really persuasive in looking at the idea that a lot of these symptoms that women chalk up to being perimenopausal. So for instance, being tired, brain fog, which we can talk about in more detail later on, weight gain — as Adriane say, a lot them are maybe less about perimenopause than about simply aging. So Adriane, can you maybe talk a little bit about what the data say about the effects or side effects of perimenopause? Fugh-Berman: Yeah, well, it’s really difficult to separate out the symptoms that are attributed to perimenopause from symptoms of stress, symptoms of depression, and just symptoms of getting older. I mean, we’d all love to be able to blame weight gain on our hormones, by the way. That’s a common thing. Weight gain, thinning hair, and other issues are things that happen with aging. And midlife’s hard. Often women are stressed in their work life and trying to balance their home lives and maybe taking care of kids and taking care of aging elders. Like, there’s a lot that’s going on in midlife that can be difficult. But is it really helpful to women to be blaming their hormones? It almost really seems to be sort of taking away some agency and also giving other people sort of a tool to minimize our thoughts and feelings. Bosch: I guess it’s one thing for people to say, “I have these problems, I’m perimenopausal,” and maybe that’s not actually accurate, but whatever gets us through the day, right? But you point out in your essay that there are also some sort of real-world consequences to this, namely in the form of this industry that’s popped up around perimenopause. So what does the industry of perimenopause look like right now? Fugh-Berman: Yes, we’ve done a lot of work on the pharmaceutical industry influence on medical information and there are certainly pharmaceutical companies that are involved in some of this. But what’s interesting about perimenopause and menopause is that there are many more parties involved than just pharmaceutical companies. So there’s telehealth companies and there’s compounders and there are influencers sometimes who are selling compounded hormones or selling supplements or selling expensive medical services. So there’s a whole industry that seems to have sprung up that has a lot of different parts to it in this area. Bosch: And so what sorts of things are women purchasing to try to ease these symptoms that they’re attributing to perimenopause? Bencivenga: Goops and creams and supplements as well as pharmaceutical hormones. Fugh-Berman: Compounded hormones, visits with health care providers, a lot of different things are being sold, books. Bencivenga: Books on perimenopause. There’s a movie. Weighted vests. Bosch: Right. There’s all these specific workouts that you’re supposed to do if [you’re in] perimenopause versus menopause. Bencivenga: It’s great to sort of tie into marketing for whatever you want to sell, because there is so much hype and there is so conversation around it right now. And you know, our experiences and our problems and our symptoms should absolutely be cared about and be respected and listened to. But there’s so much that we don’t know about perimenopause in midlife that we can kind of miss a lot if we just blame everything on it or if we say, “oh, this new supplement is probably going to help me.” You might end up spending a lot of time and energy and wasted money on something that might not have a whole lot of evidence backing it up. Bosch: I’m so glad you mentioned that because the idea here is not to say that people aren’t experiencing suffering, right, or experiencing symptoms that are making their life difficult. It’s figuring out exactly what the cause is. And perhaps, you know, I can imagine a world in which someone is blaming symptoms on perimenopause, but it’s actually something much more serious. And then they’re just delaying care, right? Bencivenga: Yeah, yeah, absolutely. That’s the example that struck me from the reporter at the Wall Street Journal, right? She had this itch that was nagging her for a while. And it was, “oh, it’s perimenopause. You’re in midlife. It’s probably perimenopause.” And it turned out to be a form of cancer, which is horrible, right. But there can be a cluster of different symptoms or things that might not even be symptoms, but we’re considering them to be symptoms that maybe don’t need medical intervention, but there are modifiable lifestyle things that we can do to address them to make people feel more supported in that midlife transition. So, the work by Martha Hickey and the empowerment model of menopause is really great and what I think we should be focusing on. Bosch: So I’m glad you mentioned menopause because it does not seem accidental that the rise in this discourse around perimenopause has coincided or maybe shortly followed a real change in the way people talk about menopause. Adriane, can you talk a little bit about how those movements intersect and maybe drive each other? Fugh-Berman: Yeah, sure. The concept that menopause is this horrible phase of life goes back some time. And we think there’s sort of been a 30-year cycle on this, that in the ’60s, hormones were pushed on women, that it was thought that it would keep them young forever. And then when it was linked to uterine cancer, they dropped out of favor and then came back in the ’80s and ’90s as health-promoting agents. And then when we finally, through women’s health activists, finally got a randomized controlled trial looking at hormones for chronic disease prevention, we found that the harms outweighed the benefits for chronic diseases. It was always true that hormones helped with hot flashes, night sweats, and vaginal dryness, painful sex. The only symptoms that have been proven to be associated with menopause are vasomotor symptoms, which are the hot flashes and night sweats and vaginal dryness. Possibly insomnia, although it can be hard to separate that from hot flashes at night. But those are the only symptoms that have proven to be associate with menopause. And it’s always been true that hormones have been helpful for those. And now we even have some non-hormonal pharmaceutical and non-pharmaceutical treatments as well. But the idea that hormones are good for whatever ails you and that there’s 30 or 50 or 100 symptoms of menopause or perimenopause and that hormones can help is absurd and may very well keep women from, you know, actually finding out what is causing a problem or concern. Bosch: And we should mention, and correct me if I’m wrong, that you have been a paid expert witness in litigation, including being an expert in litigation regarding menopausal hormone therapy. So just to disclose that. Fugh-Berman: Yes. Thank you for mentioning that. And it also means that I’ve seen thousands of pages of internal company documents actually spelling out the marketing campaigns that were used and how the pharmaceutical industry really changed how physicians and patients viewed menopause. And this was really all a public relations campaign to get women onto hormones and to promote hormones for chronic disease prevention without evidence in the 1990s. And some of those documents have been disclosed at the Drug [Industry] Document Archive. If people want to dive into email correspondence and marketing plans, it can be fun. Bosch: Did anything from those marketing plans really stick out at you? Fugh-Berman: Wow. Well, the idea that pharmaceutical companies, this is really a lot of the work that we do now, that they don’t just control information on drugs, they control information on diseases, on conditions, is really very scary and was very well documented in these documents that came up during the trial. ... One of our publications is on how ghostwritten articles in the medical literature changed perceptions of physicians about, for example, hormones causing breast cancer, that there’s a whole spate of articles in medical literature saying, “oh, hormones don’t really cause breast cancer, they expose breast cancer” or “the breast cancers that they cause aren’t bad breast cancers, they’re good breast cancers.” And just these absurd things that appeared in medical literature that doctors believed, that women believed. And unfortunately, these claims are coming back. These claims that, “oh, we used to think that hormones caused breast cancer, but now we realize that that’s not really true.” Like, that’s just wrong. There has not been new evidence from randomized controlled trials that have contradicted any of the findings of the Women’s Health Initiative, which was a large, long-term, federally funded study of estrogen/progesterone in women with a uterus and estrogen alone in women without a uterus, because the only purpose of the progestins is to protect the uterus from uterine cancer that’s caused by estrogen alone. Anyway, this was a large, long- term study. We got so much information out of it. And that and other studies have found quite consistent results about the harms outweighing the benefits for chronic disease. It does prevent osteoporosis, but the fact that the estrogen/progesterone increases the risk of stroke and pulmonary embolism and breast cancer and estrogen alone increases the risk of strokes and ovarian cancer, the harms, outweigh the benefits of this. I think it’s really interesting to note that after the Women’s Health Initiative millions of people, after the results came out, millions of women all over the world stopped taking hormones on the same day, essentially, because they’d just been taking them because their doctors told them it was good for their health. And breast cancer rates dropped in every cancer registry in the world that was looking at it over the next few years. Bosch: In your First Opinion essays, both in January on menopause and more recently on perimenopause, you wrote about a couple of documentaries that have kind of helped propagate some of these ideas. Can you talk a little bit about those documentaries and what you think they have to do with the narratives coming out around perimenopause and menopause now? And these, I should say too, that these are PBS documentaries, I believe. Is that correct? I know they’re streaming on PBS. Bencivenga: I think they’re contributing to the medicalization of menopause and perimenopause, and I think they might be worrying a lot of women to be concerned about their health through midlife, which in and of itself can be OK. It’s great to engage in more healthful behaviors, you know, lowering on drinking, stopping smoking, all of these things, but I do not like the take of medicalizing a very normal transition and a very normal phase of life that is perimenopause or menopause. Fugh-Berman: Regarding “The M Factor,” which was the film on menopause, there was a lot of misinformation in there. There were a lot of claims that were made that were completely wrong and against the evidence. And that film was actually accredited for continuing medical education by the Federation of State Medical Boards. And we got that accreditation yanked by getting a group of menopause researchers together to sign a letter documenting just a portion of the misinformation and non-evidence-based claims that were made in that film. So they actually lost accreditation for that film. Nonetheless years later they came up with a film on perimenopause, which made fewer claims but had some scary stories in it about a woman who couldn’t remember her own name, for example, and attributed that to perimenopause. So, sort of scaremongering about this. You know, most women do not have a problem with perimenopause. Most women do not have a problem with menopause Some women have mild symptoms. Some women around the time of perimenopause do have some issues with focus and attention, for example, but it goes away. It’s temporary. It may be due to sleep disturbances, whatever. But like how reassuring it should be to know that like, OK, this is just a transitional period and that these symptoms are going to go away, which by the way, really does in that theory of estrogen deprivation, right? ’Cause your hormones are just going down after that. So your focus and attention and memory get better. So there may be, you know, some of these changes, it’s transitional. You hear a lot about, “well, you know, it’s been shown that the benefits of hormones outweigh the risks in younger women.” And I think that is something that we should talk about. In women who are severely symptomatic — it’s only women who were severely symptomatic who should be considering hormones in the first place. But of course, women in their 50s are going to have fewer heart attacks, strokes, and other diseases simply because they’re in their 50s. These are conditions that are more common among women in their 70s and their 80s. So the fact that there are not a lot of incidents of strokes in women in their 50s should not necessarily be reassuring. And by the way, in the Women’s Health Initiative, there was an increase in breast cancer among women taking estrogen/progesterone, not estrogen alone. But that increased risk lasted for decades beyond when women stopped. So even if the risks for women in their 50s are not very high while they’re in their 50s, what is that doing to their risks when they’re their 70s? Bosch: One thing that’s interesting about this is because it has become such a sort of, it’s just something so popular among groups of women, right? I’m sure you both are among groups of women talking about, well, maybe, maybe not Patty who is quite young, but once you’re a certain age, you just seem to talk about perimenopause and menopause all the time. And I’m curious, are you often among women who are talking about perimenopause or menopause socially? And if they say something incorrect, do you jump in and say, “Well, actually the research says something different”? Fugh-Berman: Always. It’s hard for me to let misinformation slide. It seems from media and social media and from some communications that we’ve gotten from people that there definitely is a lot of pushback. But I will say that actually we also get a lot of support from health care providers who have women in their offices demanding hormones for things for which hormones are an inappropriate treatment for. And we get positive feedback from women who have not had a problem with menopause and think that this is a really overblown thing. Bosch: Is there anything else you wish that people understood about perimenopause and menopause? Bencivenga: I really worry with the current narratives and the conversations that we’re seeing that we aren’t taking into account a very long history that we’ve had with hormones and all the work that’s been done to sort of get us to this point. There’s been a lot of work by feminists and women’s health activists to understand the effect that hormones and menopausal hormone therapy has on our bodies. And so I worry that current narratives and the oversimplification of all of these symptoms are due to your perimenopause are going to take us back a few steps. You know, even taking into account the decision by the FDA to remove the black box warning on hormones, you had [Marty] Makary, our [then] commissioner of food and drugs saying that hormone replacement therapy has saved marriages, rescued women from depression, and prevented children from going without a mother. I mean, that’s just a wild thing for our [FDA] commissioner to be saying. And even the fact that he’s saying “hormone replacement therapy” shows that we’re taking a few steps back, right? As you transition into menopause, you don’t need to replace anything that you’re missing that’s going to harm you, right? Menopause is totally natural transition and a totally normal phase of life. You don’t even need to be using the term HRT anymore, but here we are. Fugh-Berman: So the accurate term is MHT or menopausal hormone therapy. And the fact that, well, we support changes in the label on vaginal estrogen because the risks are different with vaginal estrogens, although they are not nonexistent. The harms of hormone therapy still exist even if they’ve taken the black box warning off the label. And in fact, the harms are still in the level. They’re just harder to find, which it’s hard to see how that is a benefit to either women or their physicians to hide the harms further down in the label rather than highlighting them. Bencivenga: And I would just say that we’re kind of in uncharted territory with using, you know, hormones in younger women, in perimenopausal women. And we’re substituting, you know, wishful thinking or hope that these are going to lead to a number of better health outcomes in the absence of evidence and data. And so that’s a really big issue. Bosch: And so now as we start to wrap up, I guess my last question is if a woman is saying, you know what, maybe it’s not perimenopause, maybe it’s just aging, but this cream I bought from an influencer makes me feel better. So does it really matter? What would you say to her? Fugh-Berman: It depends on what the harms of that cream are or that supplement or that compounded hormone prescription or that, or what it is. So if something is harmless and makes you feel better then maybe the only hit is to your wallet. But if something harmful, it’s really important for women to be aware of the risks. Bosch: Well, Patricia Bencivenga and Adriane Fugh-Berman, thank you so much for coming on the “First Opinion Podcast” today. And thank you for listening to the “First Opinion Podcast.” It’s produced by Hyacinth Empinado. Alissa Ambrose is the senior producer, and Rick Berke is the executive producer. You can share your opinion about the show by emailing me at [email protected]. And please leave a review or rating on whatever platform you use to get your podcasts. Until next time, I’m Torie Bosch and please don’t keep your opinions to yourself.
