I'm William Brangham, and this is "Horizons."

It's a phase of life half of us will experience, but it's received little attention until now.

I just now call it out.

I'm like, "Hot flash, hot flash."

That's what's happening to me.

I did not sleep.

It's us who need the study.

It's us who need the research.

Brangham: More than a million women in the U .S.

will start menopause every year, yet this biological certainty is too often shrouded in secrecy or ignored by many mainstream medical researchers.

What we do and do not know about menopause, coming up next.

♪ Narrator: Support for "Horizons" has been provided by Steve and Marilyn Kerman and the Gordon and Betty Moore Foundation.

Additional support is provided by Friends of the News Hour.

♪ This program was made possible by contributions to your PBS station from viewers like you.

Thank you.

From the David M. Rubenstein Studio at WETA in Washington, here is William Brangham.

Welcome to "Horizons."

We are talking today about menopause, the natural process all women go through, but one that has been misunderstood by many, poorly studied, and is rife with misinformation.

Biologically, menopause is the time when a woman's ovaries permanently stop producing estrogen.

It's usually preceded by a phase called perimenopause, where a woman's hormone levels start to fluctuate, which can often trigger a whole series of emotional and physical symptoms.

But as most women who are in the midst of this or who have already been through it will tell you, this is not a simple time.

It can be a very difficult, disruptive, and uncomfortable period in their lives.

In a few minutes, we're going to talk with two doctors who have spent their careers studying menopause and guiding thousands of women through the confusing and contradictory guidance about how best to manage this period.

But first, we talk with a group of women who have been through it themselves about what it has been like for them.

Sandhya Garg, and I'm 60 years old.

Nicole Garrison, and I am 46.

My name is Michelle Pearles, and I am 54 years old.

Yes, my name is Melani Sanders, and I am 46 years old.

So I went into my OB, had a conversation with her, and she basically said, "Yeah, welcome to this phase of life."

And that was it.

And I walked away thinking, "Okay, am I going to have to live like this "the rest of my life?"

I just had a general ill at ease feeling.

That's really... I almost thought I was depressed, that I couldn't get it together.

Joint pain all over.

I had dry eyes, dry mouth, hair falling out, that it became obvious that this was not just "I'm busy and I'm tired."

There's something always wrong.

One day your shoulder, the next day your hip, the next day your brain fog, the next day your ear itching.

It's something all the time.

And it can sometimes be embarrassing.

But all of a sudden, I had real trouble falling asleep.

And then, when I would fall asleep, I would wake up multiple times throughout the night.

And that was... I was just exhausted.

It made working full time a real challenge.

I had young kids.

Honestly, I blamed myself.

I thought there was something I was doing wrong.

I really, I had to advocate for myself.

I had to, because I had reported symptoms a couple of years before, but they didn't offer hormones at that time.

Being a nurse, I knew more about it and I had talked to other nurses about it who had been through the similar process.

So I kind of was armed with some knowledge and basically demanded, you know, hormones.

And when you're in your perimenopausal, menopausal state, you often have children at home, you're working, you're balancing things.

So you're really not focusing on what could be happening.

You're just kind of managing it.

And it just got to the point where I felt like I couldn't manage it anymore.

We about to start a perimenopause-menopause club, And it's going to be called the We Do Not Care Club, okay?

My purpose for social media, of being on social media, is to strengthen, inspire, and encourage the everyday woman.

And so I hit record and I said, "I am at capacity."

And I shared a little bit about what I was going through.

And I said, "Let's start a club."

I'm in the thick of perimenopause and it is not easy.

I got this book and every time I open it up, I cry.

The response overwhelmingly has been, "Melani, thank you for saying what many of us "have not said or cannot say."

There's this liberation in it.

I didn't ask for help.

I didn't even share with my husband that I was having symptoms, you know?

And I said, "That's too isolating."

Since we all go through this, like why aren't we talking about it?

So I'm a contributing columnist for the Star Tribune and it covers everything from symptoms and how you go about getting care.

Talks a lot about kind of the system, the healthcare system and where we're at in terms of supporting women.

Once the symptoms are controlled, once you're not having the abnormal bleeding, it's just then you can appreciate that this is a cycle of life.

You know, there's other things other than having children.

So it's not a taboo topic.

It's not something we should be embarrassed to talk about.

And I think that the world is shifting in a positive way to make that more so the case.

If you feel as though something is not right, follow your instincts and just know that you are not alone and that you are enough.

Keep going.

Our big thanks to all of those women for sharing their stories with us.

Joining us now is Dr.

Sharon Malone.

She's a former OB-GYN and certified menopause practitioner.

She's now the chief medical advisor at Alloy Health, which is a digital health company focused on perimenopause and menopause.

And Dr.

Lauren Streicher.

She's a clinical professor in obstetrics and gynecology at Northwestern University's Feinberg School of Medicine.

She too is a certified menopause practitioner and the founding medical director of the Northwestern Medicine Center for Sexual Medicine and Menopause.

Thank you both so much for being here.

So great to have you.

Just reflecting on those women that we heard from, I was watching the two of you.

You were both nodding along as they were talking.

And I just wonder what you would add.

Sharon, what would you add to their experience so that people understand a little bit about what women are going through?

You know, I wish that all women knew that this is a phase of life that will take years long to transition into when you get to menopause.

And I think that I want them to know that it's normal.

Every woman will go through this, but suffering is not your only option.

You know, this is where I think that we sometimes in the medical community have not, have sort of failed our patients in not preparing them for this.

Because the time to talk about menopause and perimenopause is not when you're in the middle of it.

It's when you're 30, when you're 35.

So you're prepared so you don't think that there's something horribly wrong when you start to experience these symptoms.

Brangham: But Lauren, the thing that was so striking to me is that we are in 2026 and there are still these women all over the country saying they felt alone, they felt this was their fault, they felt that no one was talking about this, they felt that they couldn't share it with their partner.

How is that possible?

Well, not only is it possible, but this is the reality for most women.

And in addition to all those feelings, these women really focused on how they were blindsided.

They were so unprepared.

Because I think a lot of women say, "Okay, well, maybe I'll have some hot flashes, "I won't be able to sleep."

But no one is telling them that there's estrogen in every single part of your body.

So when a woman's talking about, "Wait, dry mouth, "my hair, all of these other symptoms," so no one is talking about it.

And they just don't know what to do with this information.

But what also struck me about what these women were talking about is they were talking about the here and now.

And what we forget is that yes, hot flashes, insomnia, vaginal dryness, all of these not only impact on quality of life, but they are also impacting on length of life.

And no one is talking about that.

That the choices... meaning the choices that you make midlife as you are going through this menopause transition are going to impact the chance that you're going to have bone problems, osteoporosis down the road, that you're going to have cardiovascular disease, that you're going to have a stroke.

Because there's this idea that while inconvenient and unpleasant, hot flashes aren't harmful.

And we now know that's not the case.

We've learned so much that there is a very high association with what women are experiencing now and how that is going to have repercussions years down the road.

And we're not hearing that in these women who are just dealing with the, "Are you kidding?

"Oh my God, no one told me, no one's helping me."

But again, to your point of why is it that no one's talking about it?

Well, first of all, we have ageism.

People saying you're in menopause is admitting that you're old.

And people think of menopause as grandma as opposed to in your 40s.

And let's face it, there are women who are much younger when they enter menopause as a consequence of maybe chemotherapy or radiation or surgery.

So we are talking typically, yes, women in their mid-40s and older, but even younger than that.

But nobody wants to be menopausal because it makes them feel old.

It makes them feel old.

And also just the idea of, "Am I sexy anymore?"

"My partner, my husband, I'm out there single."

30% of women in this age group are single.

"If I'm menopausal, oh my God.

"What is that going to say about me "as being a sexy, desirable woman?"

And then of course, the most important part is that this comes at a very inconvenient time of life.

Brangham: Right, we heard that from one of the women.

Exactly, and they're like, "Wait a minute, "I've got to work, I have to think, "I have to take care of my family.

"I cannot even begin to deal with the fact "that I'm functioning on four hours of sleep "and I have brain fog "and I'm going to the bathroom every 10 minutes "because my bladder has not gotten the memo "that this shouldn't be happening."

Dr.

Malone, let's do a little bit of medical breakdown here.

Menopause and perimenopause.

Walk us through just some definitional understanding of what those two stages are.

Okay, well, menopause is a little bit easier to define because it does have a bright line.

And that is the time at which either your ovaries stop functioning naturally as a result of age or you may have had surgery, you may have had chemotherapy, things that prematurely plunge you into menopause.

So that's easy.

It also marks the end of your reproductive years.

So that's menopause.

Perimenopause is I think where people start to get confused because they kind of know what menopause is, but the phase beforehand, which can go on anywhere from four to 10 years before you get to menopause is where the confusion lies.

And I think that a lot of doctors don't understand that this is a years-long process that needs to be dealt with.

A lot of the symptoms that we associate with menopause, such as hot flashes and mood swings and night sweats and sleeplessness happen during perimenopause and oftentimes are worse doing perimenopause than after you've... Oh, interesting, so it can be more volatile.

Oh, yes, yes, because what's happening, you know, there are two different things going on hormonally.

And when you're in perimenopause, it's not that your hormones are low and completely gone, they're fluctuating wildly, and that is having effects throughout your body, you know, mentally, physically, the all that... Brangham: Hormonal rollercoaster.

All of that hormonal change.

So some days your hormones are too high, some days it's too low.

And that is what you are constantly feeling sort of out of sorts because you're not in the normal balance that you would have been in your premenopausal years.

And then once you get to menopause, until you, four to 10 years, well, how do you know how long it's going to be?

- You don't.

- You don't get a telegram in the mail saying, bingo.

No one gives you an expiration date.

And I think that the experience of menopause differs for different ethnicities.

You know, black women in this country, even though we say that menopause average four to seven years, for black women, that perimenopausal transition takes as long as 10 years.

And it starts earlier and their symptoms are more severe as they go through this transition.

And yet they are the women who are least likely to have a discussion and to be prescribed hormones even when they're symptomatic.

I want to ask you, Dr.

Streicher, about this, what I have come to learn as a sort of seminal moment in the treatment of menopause.

And this was in the early 2000s when a decade long study that was being run by the NIH about the effects of hormone replacement therapy was suddenly stopped because the study's authors said, "Well, we have detected a signal "of real health implications."

So I'm going to just put this graphic up and say, this was the Women's Health Initiative study.

And it said, quote, "Long-term use increases the risk "of breast cancer by 26%, "stroke by 41%, "and heart attacks by 29%."

I know you were both treating women back at the time.

Tell me a little bit about what the impact of that.

We'll talk about the study in a moment, but the impact of that study must have been like a thunderclap.

Streicher: It was, I call it the flush that you ___ around the world.

Because every single woman took their hormone therapy, flushed it down the toilet and not only were they terrified, they were angry.

They were angry that "I have been sold "a bill of goods."

And quite frankly, first of all, I just want to be very clear.

The study was an excellent study.

A lot of people say, "Oh, this study "was a flawed study, was a bad study."

It was a very good study.

The problem is that women in the study were not reflective of most women when they're going through perimenopause and menopause today.

70% of the women in this study were over the age of 60, completely different population.

They were given a form of hormone therapy that we do not routinely use today.

And it was the progestogen, the synthetic progesterone that was actually the culprit in terms of increasing the risk of breast cancer.

It was not the estrogen, the conjugated equine estrogens, which we know actually is protective when it comes to the breast.

The biggest issue though is your folks.

It was the media.

The media completely misrepresented the data that was frightening both to women and to physicians, quite frankly, who did not read it correctly and analyze it.

And the truth of the matter is, is the study was actually reassuring.

98% of the women in this study did very, very well.

And once we realized that it was really the progestogen that was the culprit and changed that out to do something else, estrogen therapy, hormone therapy is very, very safe.

But unlike any other study, I think, that we've ever dealt with in our lifetime, in our careers as physicians, it just doesn't go away.

The repercussions of this keep on going on and on and on, and we're still explaining it away today.

Malone: I think what's a little bit unfair is to sort of blame it all on the media.

Streicher: I don't blame it all on the media.

Brangham: I give you permission, blame it on us.

No, because the media was reporting what they were told.

And there was, I cannot think of another study before nor since that required a press conference at the National Press Club and bringing in every media outlet to announce this big finding.

And when you say things like breast cancer, it increased your risk of breast cancer, increased your risk of heart disease, that's what they were told.

Brangham: And everything after that, every caveat after that first clause kind of is ruined.

Exactly, you say breast cancer to women and it's game, set, and match.

Not doing it.

Listen, you go in for your mammogram, what's the first thing they have you fill out on the form?

"Do you take estrogen?"

Well, if that doesn't wake you up and say, "Gee, if they want to know, that must be bad for you."

So this messaging goes on and on.

And when a woman does get breast cancer, the first thing people say is, "Well, were you taking estrogen?

"Were you taking estrogen?"

So it's just, in our society right now, it has become such a buzzword.

Hormone therapy equals risk, equals breast cancer.

And as I point out all the time, what happened to breast cancer rates when we stopped prescribing estrogen?

After the WHI?

They did not go down.

They have continued to go up.

If estrogen was really the culprit, we would have seen those rates precipitously drop because a lot of women were using estrogen back then.

So how do you talk to your patients now, Dr.

Malone, about this, given that they are still, in their minds, they remember those headlines.

It was the 2000s, not that long ago.

What do you tell them?

Women are smart.

If you give them the right data and if you explain it in a way that's just very straightforward, just as we explained it right now, they go, "Oh, okay, okay."

Malone: But you know what I think happened, and I think there were two things that happened after the Women's Health Initiative that were incredibly detrimental to the whole conversation about women's health in midlife.

One is that it disadvantaged an entire generation of women because they, when you heard it, you didn't want to take hormone therapy.

And also, it disadvantaged the research that we could have collected in these 25 plus years, all the studies that didn't get done, short-term, long-term, that we would have had way more information about it.

But most of the women in the Women's Health Initiative, the study participants, when the results came out, they stopped taking their hormones.

So imagine if we had those, if we could get those 20 years back and those women had stayed on their hormones, we'd have the answers to a lot more questions that we still have today.

Well, there's one other piece to add on to that.

The doctors didn't learn about hormone therapy.

You know, we studied... Brangham: The doctors who are ostensibly tasked... Streicher: Who were in training.

So just to be clear, though, just to be honest, when I did my residency, we didn't learn anything about hormone therapy either.

I learned all that after the fact because I had to.

I was doing a lot of surgery.

My patient population happened to be older, so I took it upon myself to learn about menopause and hormone therapy.

But it became a topic that was not only not addressed, but with the explanation of, "Oh, you don't need to learn about that because we don't prescribe hormone therapy anymore.

Brangham: We know it's... - We know, we know.

So don't bother learning that, which was a very different message than what we got.

Malone: Right.

You know, and the one thing I want your listeners and viewers to know is this, is that the conversation that I had about hormones in 2002 with a few minor tweaks here and there is not different than the conversation that I'm having about hormones in 2026.

Because it required doctors, and I will say doctors, to actually have read the study when it came out.

Because if you read it, you would understand what the limitations were of the study.

I get it, I understand why the study was constructed that way.

But you were answering a question that the study itself was not equipped to answer.

That's the problem.

Streicher: Exactly.

But I remember even you told me before, when we were talking, that even you with your expertise and your knowledge, amongst your friends, they were saying, "Come on, Sharon, I'm not taking that."

Okay, so this is a true story.

My best friend, and she's just a couple of years older than I am, and when she went through menopause, she said, you know, having all classic symptoms, she went to see her doctor, doctor put her on hormones, they were great, she felt wonderful, and she took them for a year, and she stopped.

And I said, "Why'd you stop?"

And she said, "Oh, no, I can't continue with these," because again, it's the smallest dose for the shortest amount of time, and I kind of felt good for a year, and I couldn't convince my best friend, sitting there knowing what I know and trying to explain what the study actually said, and she was like, "No, thank you."

Now, if I can't convince someone who's known me for 30 years, imagine how difficult it is to have that conversation in a room, and you've got 15 minutes.

Streicher: And there was another factor.

I would have the same conversation with my patients and with my friends, and they would go on hormone therapy, and they would be doing great, and then they would go to their internist for their annual exam, and what would happen?

The internist would look at them in horror and say, "You have to stop that, "you have to stop that right now."

And when they would tell me that, I'd say, "Would I stop your internist's antihypertensive medication "without checking with him?"

No, but yet, that's what was happening.

Just the last few minutes we have, I don't want to amplify any of the misinformation that is out there, but let's just acknowledge that there is a great deal of it out there.

For people who are scanning the internet, seeing all of these different bits of advice coming at you, Dr.

Streicher, what would you counsel people to do?

Streicher: What I would tell them is, there's some very good information out there, and there's very bad information, and women are very often told, "Do your own research," and they should do their own research, but they should do their own research on who's giving the information.

The idea that they're going to figure out on their own how to treat their hot flashes, how to prevent them from losing bone, what are they going to do about their vaginal dryness, what are they going to do about their bladder.

That's what we're here for.

That's what the experts are here for.

This is nuanced, this is individualized.

This takes years and years of study and experience.

So no, you shouldn't be researching what you should be doing.

You should be doing research on who's giving that information.

Do they have an academic appointment?

Have they published?

Have they been out there in practice?

Are they selling something?

There are a lot of things you can look at to determine, is this the person you should be trusting?

Dr.

Malone, what about the other thing?

Lifestyle, diet, exercise, things that women can do to help this entire process?

Malone: That's a given.

Whether you're talking about hormonal issues during perimenopause or cancer prevention or heart disease.

You know, at a baseline, everyone should be observing a healthy lifestyle.

So yes, but it's a both-and because we have both seen women who have done everything humanly possible and they still get to this phase of life and they are floored by it.

And so, you know, it is an adjunct to your actual treatment.

It is not the answer, the total answer.

Streicher: Yeah, a smoothie's not going to make your vaginal dryness go away.

I'm just saying.

But, no, but to add to that, I think it's also important to acknowledge that not every single woman has to take hormone therapy.

You know, there's a message out there that, "Well, if you're 60-something years old "and you miss the boat, you are doomed.

"You are doomed to an early, horrible death."

Nothing could be further than the truth.

We know that all of the things that Sharon just talked about are just as important, if not more important.

I mean, we haven't talked much about dementia.

We know that 60% of what determines whether someone gets Alzheimer's or dementia are things that you control.

You know, your activity, your social interactions, doing things that are good for heart health.

And that's what helps your brain.

If you didn't take hormone therapy, it's okay.

It's okay, you'll be fine.

You just need to do all those other important things.

Brangham: It's such an important conversation.

I can't believe we're out of time.

I know we could talk for another hour about this.

Dr.

Lauren Streicher, Dr.

Sharon Malone, thank you both so much for being here and for having this conversation with us.

- And thank you.

- Thank you.

And that is it for this episode of "Horizons."

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We'll see you next week.

Narrator: Support for "Horizons" has been provided by Steve and Marilyn Kerman and the Gordon and Betty Moore Foundation.

Additional support is provided by Friends of the News Hour.

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