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Alison Stewart: This is All Of It. I'm Alison Stewart, live from the WNYC studios in Soho. Thanks for spending part of your day with us. Whether you're listening on the radio, live streaming, or on-demand, I'm grateful you're here.

On today's show, we'll speak with author Tracy Kidder and Dr. Jim O'Connell about providing healthcare for unhoused and homeless people in Boston, we'll speak with the producer and director of a new showtime docu-series about missing and murdered indigenous women in Montana, and we'll continue our Silver Liner Notes series, looking at influential albums released in 1998 with a conversation about neutral milk hotels in the airplane over the sea. That's the plan, so let's get this started with the most recent issue of the New York Times Magazine.

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Alison Stewart: Today, we're talking about an experience half of the world's population will have. Menopause happens when the estrogen levels drop in female bodies, usually between the ages of 44 and 55, and menstruation begins to cease. Estrogen plays a key role in ovulation, and the lower levels can lead to some serious changes, including sleep disruption, memory fog, hair loss, mood issues, and sudden rushes of heat that can lead to profuse sweating.

For years, the "change of life" has been seen as inevitable and given a big medical shrug. My first guest today argues that the time has come to start taking treatment seriously and re-examine existing options, specifically one that's been around a while, menopausal hormone treatment, which her reporting suggests has gotten a bad rap. Joining me now is Susan Dominus, staff writer at the New York Times Magazine whose latest article is called Women Have Been Misled About Menopause. Susan, thank you for being with us to share your reporting.

Susan Dominus: Thank you so much for having me. It's a pleasure to be here.

Alison Stewart: Listeners, we want to hear your experience with menopause. Have you sought to treat your symptoms? Call in, share your stories. 212-433-9692, 212-433-WNYC. We're curious if you've considered menopausal hormone therapy. How did you weigh the risks versus the rewards? Anything else you want to share about your experience with menopause, our phone lines are open to you. 212-433-9692, 212-433-WNYC. You can also tweet to us or, if you want to remain anonymous, you can DM us on Instagram. The handle is the same for both, @allofitwnyc.

Susan, I want to start with this line from your article describing this time in a woman's life. You wrote, "The body is in a temporary state of adjustment. Even reinvention like a machine that once ran on gas trying to adjust to solar power challenge to find workarounds." First of all, how did you come to that metaphor, and why do you think it's useful to think about menopause that way?

Susan Dominus: When you think about the fact that estrogen regulates so many different important processes in the skeletal, the cardiovascular, the central nervous systems, the fact that there are estrogen receptors in our brain, in addition to our reproductive system, there are estrogen receptors rich in our bones, you think about this essential element that was so key for things to basically operate smoothly, and then really, it just disappears. To me, it's frankly a miracle that women's bodies continue to function as well as they do, given how radical that changes. As much as women do suffer, it also is a fascinating testament to how strong the human body is, that is able to keep going even in the absence of something that it's relied on for so long.

Alison Stewart: We'll talk about hormone treatment for menopause symptoms in a moment, but I do want to do a little bit of menopause 101. What are the first signs that menopause is happening?

Susan Dominus: I think for most women, basically, their periods start to become more irregular. Usually, there's more time passes in between them or it comes and it goes away for several months. Some women have much heavier periods than usual, although that can often be a sign of a cyst and it's not necessarily menopause. I think that's the first really tangible way women notice that their cycles are changing. Then there are often, not always, but there are often symptoms that come with that, such as hot flashes and night sweats and, for some people, new disruption. It's brain fog. [chuckles] These are things that are commonly experienced during perimenopause.

Alison Stewart: Do we know what's behind the hot flashes? I think that's probably the first thing that comes to people's minds.

Susan Dominus: What I find fascinating is how little we really understand about hot flashes and that we do understand so little about them really reflects just how much we have to learn about menopause itself since it's the most salient experience that most women do have of menopause. Basically, we know that there's a part of the brain called the hypothalamus that is connected to the reproductive system. It is rich in estrogen receptors and it is also regulated to temperature regulation in the body. It becomes almost hypersensitive in a way and it triggers this sense of rushing heat that women feel very much internally.

They feel that their core temperature is rising, and it's not. It's not actually happening. Their core temperature is not rising. This whole system also triggers the dilation of the veins and a rush of sweat in order to cool down the body, and you will feel heat rise on the surface of the skin as well. I almost think of it, it's not a perfect metaphor, but it's almost like phantom limb pain in the sense that there isn't something external that is something tangible that actually matches the feeling that you're having, if that makes sense.

Alison Stewart: Let's take a call. Ali is calling from the Upper West Side. Hi, Ali.

Ali: Hi. Good afternoon. Thank you for bringing this topic forward. I work in investment banking, and I was recently at a executive leadership committee largely made up of my peers, directors, and managing directors. Overwhelmingly, the majority of women were in their 40s plus, and they actually invited a menopause expert to come and speak to the challenges that women in that age bracket face, as in the corporate environment, and how little is known and what an impact menopause has on their performance, on their mental health, on their emotional health, and what organizations can do about it to help support women as they go through that transition.

I just wanted to make sure that this was also being recognized still a way to go, still a lot of taboo conversation, but I certainly welcomed it, and it helped bring a lot of sensitivity, even as a woman who hasn't gone through it yet, appreciating what women really go through and how much little is known about it or how much misinformation is out there about it. Thank you.

Alison Stewart: Ali, thank you so much for calling in. Since you brought up so many interesting points, I'm going to tease out a few things from what Ali said. How many women, when you spoke to women who are going through menopause, felt comfortable talking about it in terms of how it has impacted their careers?

Susan Dominus: It's funny. I think I was mostly talking to women when I interviewed them for the piece about their emotional state. I do have one friend who I think, at times, almost felt concerned that she could not fulfill her fiduciary duty because of the extent of her sleeplessness, her brain fog, her depression. She was at her wit's end. There is a lot of research that does suggest that women miss work because of menopause.

Stephanie Faubion has done research finding that Black women miss more work because their symptoms tend to last longer and are more severe. There just needs to be a lot of recognition that this is a real phenomenon. In the UK, they're farther along in terms of activism around this issue. Hundreds of companies have signed a commitment letter of some kind committing, basically, to providing more resources and education and awareness for women in the workforce, and this includes many large corporations in the UK. It's kind of amazing.

Alison Stewart: My guest is Susan Dominus, staff writer for the New York Times Magazine. Her latest piece is Women Have Been Misled About Menopause. We are taking your calls. We want to hear your experience with menopause. What has it done to your life, to how you're walking through the world, how have you sought to treat your symptoms. If you want to share your stories, 212-433-9692, 212-433-WNYC. If you've considered menopausal hormone therapy, we'd like to hear from you as well. 212-433-9692, 212-433-WNYC.

I did want to point out one thing you talked about in the article because you have one of the best quotes, I think, a journalist has ever had. You know the one I'm going for. One of the women you talked to for the piece said that her gynecologist was not comfortable about talking about dryness and discomfort during sex. She told you, "I thought, hey, aren't you a vagina doctor? I use that thing for sex." Meanwhile, as someone on my team noted that there are ads for ED, erectile dysfunction, right on the subway and everywhere else on TV. What's behind the gender difference in the way that the medical community or at least the conversations we have approaching sexual health aging?

Susan Dominus: I think that we still have this idea that women's sexual health is just not that important, or maybe there's the idea that it's not that important to women. I just think it reflects on deep discomfort with female sexuality, mixed with ageism, and really mixed with discomfort about aging women's sexuality.

Alison Stewart: Forbes cites a study that found that 73% of women going through menopause don't treat their symptoms. Can you understand why not?

Susan Dominus: I think that there is a lot of misinformation out there. I think sometimes women don't even realize that there is a treatment, they just think this is what happens when you get older, the information is hard to access somehow, or there's a general mistrust of it. I sometimes think of it, it's almost akin to when we think back to how women used to accept sexual harassment in the workplace, this is terrible, and it's just our lot in life and to put up with it. I sometimes think that women felt that way about menopause like, this is terrible, and it's one more thing I just have to get through and endure.

Alison Stewart: Let's talk to Elizabeth calling in from Rockland County. Hi, Elizabeth, thank you so much for calling in.

Elizabeth: Hi, thank you for having me. I'm really excited that you're talking about this. I'm 54, and menopause was really challenging for me because it really diminished my sex life. My husband and I really enjoy our sex life, and it was very painful for me. The vaginal dryness is real, it was painful for him. It's a topic that was really difficult to talk to my gynecologist about, it looks to hit a dead end there.

Alison Stewart: Thank you for calling in, really appreciate you bringing this up. Yes, what age and gender discrimination people going through menopause had to deal with, Susan?

Susan Dominus: I just think a general, just as this person is saying, that the discrimination comes out in subtle ways, which is just not recognizing the importance of it, and not wanting to engage in the conversation and not offering very low-risk treatments such as vaginal estrogen cream to people who are having genital urinary symptoms. I don't totally understand it myself. There was research suggesting that doctors wait for women to bring up the symptoms, maybe they've done an exam, maybe they didn't notice that there's vaginal dryness, but they don't actually say, "I'm observing some vaginal dryness, would you like to treat that?"

In doctors' defense, they have these very short windows, they have a lot to cover. There are matters of life and death at stake as well that they need to check those boxes, they need to do a breast exam and maybe do a pap smear. Talking about sex is always going to be sensitive, and it takes time. It's not easy. I think it's easy to overlook those questions, but I do think given that there is such a low-risk treatment for that, it is shocking that more doctors don't bring it up themselves.

Alison Stewart: Let's talk to Judith calling in from the Upper West Side. Hi, Judith, thank you so much for calling All Of It.

Judith: Hi. I had no problem with my menopause because I went to a Chinese herbalist. The herbs that he gave me, I just had no problems. I was scared I would have dizziness because my mother experienced dizziness when she went into menopause. I went to him, and I said everything, and he assigned me the herbs and they were terrific. I never had any problem. I recommend the herbs. There were no side effects, there's no danger because some of that hormone stuff can be dangerous.

Alison Stewart: Ah, we're going to get into that, whether or not that's actually true. Judith, I want to ask your question, you said something about your mom. Did you and your mom have this conversation, or did you have to approach your mom, or did your mom come to you with it?

Judith: She died by the time I was old enough to get the menopause, but I remember when she went into menopause, all those pills for dizziness on the cabinet shelf, and I said, "Oh, I don't want to get the dizziness, so I'm going to go to the Chinese herbalist."

Alison Stewart: Judith, thank you so much for calling in. Our phone lines are full for our conversation about menopause. My guest is Susan Dominus, staff writer at The New York Times Magazine, her piece is Women Have Been Misled About Menopause. After the break, we'll get into the subject of hormone treatment after the break.

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Alison Stewart: This is All Of It. I'm Alison Stewart. My guest is Susan Dominus, staff writer at The New York Times Magazine, her recent piece of the cover story, Women Have Been Misled About Menopause. What have women been misled about, Susan?

Susan Dominus: I think there is the general feeling that menopausal hormone therapy is just dangerous, scary, you will definitely get cancer if you try it. We know that it's just bad and scary and to be avoided. Why would you ever do it if it was going to elevate any of your risks? Really, that had to do with the rollout of a 2002 study from the Women's Health Initiative that was an incredibly important, well-funded, randomized controlled trial that studied the effects of hormone therapy, and it was trying to decide, should all wouldn't be taking hormones, because it's going to be good for their heart and good for their health in general?

To their surprise, what they found out was, no, no, absolutely not. There are elevated risks here, and there's no reason that everybody should take it for preventive care. That's not what hormones are for, and they found real risks. What was never really explained to women was how low those risks are in context, especially for women who are 50 to 60, and that if you are really symptomatic, and you were suffering, you should have those risks put in context for you, and be able to make that decision for yourself rather than have doctors just telling you it's bad and/or the belief from the way that it was rolled out that these risks are too high to even consider. It should be a conversation people are having and a decision that they're making in consultation with their doctors.

Alison Stewart: Yes, I remember when that study came out, and it felt like the brakes just went on.

Susan Dominus: The brakes did go on. The brakes to go on. Prescriptions dropped precipitously within a year-long period, and then ongoing, it continued. Prescription rates continue to drop as the years went on. I suspect that they had been swinging upwards more recently, but there's still a lot of fear among women, there's still a lot of fear among doctors, or just reservations, or they move the conversation on very quickly if the patient has any reservations.

I think specialists also are just not even aware necessarily that these hormones could be an option for somebody, let's say, who comes to a neurologist and is complaining of migraine or mood swings. Well, not migraine, that's not a good example, I apologize. There's no suggestion that hormones do actually treat brain fog, research hasn't proven that, but even to have a neurologist affirmed for one part of what you could be going through if you're 52 could be perimenopause, not to discount the symptoms, they're real, but just to even consider that as a possibility.

Alison Stewart: Let's take some calls. Cheryl calling in from Astoria. Hi, Cheryl, thanks for calling All Of It.

Cheryl: Hi. I'm 51, and I started experiencing menopause as soon as I went off birth control a year ago. I kept going back to my gynecologist because I was in pain, my joints hurt, everything hurt, and I didn't think that was a symptom of menopause until I started reading a lot. I tried natural treatments, but I still was really in pain. I decided to go on the hormones. I was scared at first, but then it's really similar to taking birth control. It's been a game-changer. I'm no longer in pain. I have my quality of life back. I'm really glad I had the discussion with my gynecologist to make that decision, but no one talks about it. We're no longer silent and hidden anymore.

Alison Stewart: Cheryl, thanks for calling in. Let's talk to Julie from Sullivan County. Hi, Julie, thank you so much for calling in.

Julie: Hi, Alison, thanks so much for covering this topic. I was really glad to see the article in The Times. I have a few things I wanted to say about this. I know people close to me. I'm about to be 53. I'm going through perimenopause. I actually thought I was done, but it seems it's back. [chuckles]

I know a bunch of women in my life who are from the generation above me who've been on hormone replacement therapy and do so much better than their counterparts. They just have so much energy, mental and physical, which is such a big issue. Never mind looking at it, that's a whole other thing. Once I started going into perimenopause and having hot flashes and all the crazy symptoms that have been really changing my life, I was looking for doctors who might be hormone replacement friendly, and it was very hard to find one.

I finally found one that seemed like maybe she would be willing to prescribe hormone replacement therapy. She was, and is, but there's just so little information that I was able to get. Everything has been through research, and my research, it's all been very contradictory. Anyway, I've talked to--sorry.

Alison Stewart: Susan, dive in there. You seem like you want to respond.

Susan Dominus: Yes, I do think it is hard to find doctors who have really taken the time to specialize in this. There is the North America Menopause Society. On their website, you can type in your ZIP code and they will offer you practitioners in your area who have been certified by this organization as menopause experts. There are increasingly telemedicine options as well. There's something called Midi Health that now offers menopause-trained doctors here in New York, as well as in other states who are available, they are ready, they will meet with you one-on-one to discuss your symptoms and your personalized risks and benefits.

There are also sites that sell prescriptions that have other relationships to business arrangements with doctors and who provide counseling and advice. There's sites like Evernow, Gennev, Alloy. It's different from going into a doctor's office, but I know certainly, with Midi, the appointment comes, I think it's telemedicine, but it feels much like any other doctor who's been trained in this kind of care.

Alison Stewart: Let's talk to Yara from Queens who had a different experience in her family. Hi, Yara. Thanks for calling in.

Yara: Hi. How you doing?

Alison Stewart: Great.

Yara: From my experience, I remember my mother when she was menopausal and she took HRT, and she had a terrible time with it. She was moody, the hot sweats, whatever you expect with menopause and postmenopause, she had it. When I turned 50 and began menopause, I decided not to do anything about it. I was always very fit and active, and I thought, I'm going to continue in that vein, and now, postmenopausal, I'm 59 now, I felt that with regular exercises, drinking lots of water with going to bed at a regular time, the worst that has happened to me was I asked my husband, he may say I'm really really bad, but I don't think so.

I think the worst that I could say about the menopause is that you get hair where you don't want hair. There's hair on your chin or your grown hair somewhere where you're not expecting them. Yes, I have night sweats, but they're not so bad that they stop me sleeping. If I'm talking to somebody, I would say the opposite. Don't take therapy, just have a diet, exercise, sleep, have a regular sleep pattern, and see what happens.

Alison Stewart: Yara, thank you for calling in. It was interesting to hear a different point of view, but I wanted to follow up that call with the idea that female bodies, it's not a monolith. What works for one person isn't going to work for another person, and I think that's important to acknowledge, Susan.

Susan Dominus: Yes. The range of people's symptoms is vast. For sure, there are women who sail through, there are women who don't even have hot flashes. That is a not insignificant number of women, but then there are women whose systems really do seem to break down. It's not something that losing a few pounds or meditating is going to help. There are women who are depressed, who are really just having a hard time functioning, who are hot flashing 10, 15, 20 times a day, who are waking up numerous times in the middle of the night because they're having night sweats.

That is very hard on the body. We know how bad it is to lose sleep. We know what kind of bad outcomes come down the road for women who don't get adequate sleep. Certainly, everybody has to weigh their risks and their own personal risks and benefits, but what works for one person, just as you say, Alison, will not work for everyone.

Alison Stewart: We talked about when hormone therapy first came out, that up to 15 million women had prescriptions, and then the 90s, and then that changed in 2002 after this study. Something that does seem to be persistent is people's, women's, females' interest in knowing about hormone treatment, menopause, and breast cancer. Why is this? This is one of the pieces of information women wanted the most, females wanted the most about the relationship between breast cancer and hormone therapy.

Susan Dominus: Because that is a real statistic. They find that really after about four or five years of hormone therapy, your risk of breast cancer does increase by 26%. That is true for women who have uteruses, I should say. Women who do not have uteruses do not need oppositional progesterone to counter effects of the effects of the estrogen. Women without uteruses and women who've had hysterectomies, they take estrogen alone, and they actually have a lower incidence of breast cancer than placebo. Just to speak about the majority of women, which is women who do need to take progesterone along with estrogen. So far as we know, there is a 26% increased risk.

People often use a different kind of progesterone now. It's supposed to be closer to the-- these are FDA-approved progesterones that are supposed to be closer to the body's own progesterone, and those are thought to be lower risk based on observational studies, but we don't have long randomized control trials to confirm that. If you're going with the WHO findings, what that amounts to is for every 10,000 women who use hormones, an additional eight will get breast cancer, and across a population, that is a very big number.

What women have to decide for themselves is how do I feel about my own personal additional 8 out of 10,000, how that applies to me, and how I interpret that. I think some women will hear 8 of 10,000 and think, "Those odds look okay to me. I'm really suffering, and I can't go without." I think some people will say, "8 out of 10,000, no, that's just too much for me." People have very individualized levels of risk, and I think all these responses are reasonable. It's very personal, and it is a thing. It is a real risk.

Alison Stewart: Let's talk to Deborah from Monmouth County, New Jersey. Hi, Deborah.

Deborah: Hi. How are you?

Alison Stewart: Doing Great. You're on the air.

Deborah: Hello?

Alison Stewart: Yes, you're on the air.

Deborah: Oh, great. I had a couple very different experiences. I had a gynecologist who I really loved, I'd gone to for about 30 years, and he was wonderful. I've nothing bad to say about him except he was really not open to prescribing any kind of hormonal thing to help with low libido. Basically, when he found out how often my husband and I were having sex, he said, "Basically, you're fine. Tell your husband he just needs to get over it."

Alison Stewart: Wow.

Deborah: Which was really not helpful.

Susan Dominus: No, I'll say this. In his defense, I'll say this, there's no defending that was very dismissive, and I'm sorry that happened to you. My understanding is that estrogen and progesterone will not enhance your libido, but it will help with vaginal dryness, which leads to painful sex, which usually lowers women's libido. There are sexual health experts who may have other options for libido itself, but the real way that hormones can help with women's libido is by treating the vaginal dryness and other genital urinary symptoms that can lead to painful or uncomfortable sex, but I don't think these issues or questions should be dismissed ever. I'm sorry that that's what the doctor's response was.

Deborah: In your article, you mentioned a number of non-hormonal therapies that are either in use or nearing FDA approval that would be more targeted in the symptoms they treat. Are there any that you find particularly hopeful?

Susan Dominus: I know that a lot of menopause experts are very excited about this new drug coming out. Hopefully, that they're hoping that the FDA will approve it maybe within the next couple of months, even. That is a non-hormonal option of targeting the neurons that are associated with hot flashes. There are people who would say, "Okay, sure, you're going to take that," but it hasn't been subject to long randomized controlled trials. Hormones, at least are whatever their flaws, we know what they are, but I do know that, as I said, a lot of menopause experts are very, very, very excited about this option.

There is also an antidepressant, paroxetine, that does is effectively reduces hot flashes, not as effectively, generally as hormone therapy, but it's definitely an option that doctors prescribe. I'm super interested in the way that cognitive behavioral therapy has been shown to help women, not so much reduce the number of hot flashes they have, but reduce how much they bother them, which I find interesting. It's a very non-invasive way to at least change your experience of them.

Alison Stewart: The name of the piece is Women have Been Misled about Menopause. There's so much more in the piece. You should definitely check it out and follow Susan on Twitter. Susan, really appreciate all the resources that you've been tweeting out for people. It's been really, really helpful. You've been doing really good work on that front as well.

Susan Dominus: Thank you. It's my pleasure. I do think those resources are treasure chests of information, and that's what we can tell women are star for, based on the response to this article. It's been this collective cluelessness that women deserve to have remedies. Thank you for having me on the show to talk about it.

Alison Stewart: Susan Domino, thanks so much, and thanks to everyone who called in.

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