E119: The Financial Domain of Perimenopause

Katie: Follow the money. I'm just going to start with that. Follow the money. Welcome to the "7 Domains of Women's Health." I'm Katie Ward. I'm a professor in the College of Nursing and I'm a practicing nurse practitioner in women's health and menopause. And I'm joined by my co-host, Dr. Kirtly Jones. She's a professor of obstetrics and gynecology and a reproductive endocrinologist with the University of Utah.

We're on the financial domain of our seven-part series on perimenopause, and this might be the one I feel most passionate about right now.

So I want to go back in time a little to the 1960s when a book called "Feminine Forever" came out. Its author was promoting estrogen almost aggressively as it's being promoted today, and he had some choice words. He called menopausal women castrates, and he wrote about how much more attractive women on estrogen were than women who were not taking it.

And that book was all over in the grocery store. You could pick it up on the checkout. And it was instrumental in making estrogen prescribing almost routine back in the '60s.

It turned out that the author was actually being paid by the company that made the leading estrogen product on the market. And then, as now, I think the promotion was getting a little bit ahead of the research.

So as menopause treatment grew, there were women that were on estrogen and women who were not. And we thought we saw this phenomenon where the women on estrogen had fewer heart attacks. But that's the trouble with observational data. There's some bias baked into that.

It turns out that lifestyle was probably what made the difference then, as now. Women with healthier lifestyles also had more access to doctors and prescriptions and they had fewer heart attacks for lots of reasons.

So when we actually did the trials, estrogen wasn't protective for hearts. It actually might have promoted some heart disease. And early on in the '60s when we were prescribing all this estrogen, we also didn't know that women needed a progestin. And so sometimes we caused some endometrial cancer with it.

By the '70s, we actually saw what was probably some well-deserved backlash about menopause treatment. Not only was it causing the problems like endometrial cancer, but there was this feminist view that we were pathologizing a normal physiology and the observation that people promoting the treatment were the ones profiting from it.

So that brings me to the study that everyone's sort of up in arms about today, the study called the Women's Health Initiative. This was not a study for estrogen for menopause. We thought we knew everything we needed to know about that. This was a study about the heart disease question, really trying to unpack that observational data.

It had multiple arms. It had a low-fat diet arm, and that ran for years and years. And it turns out low fat diets don't protect against heart disease. It had a calcium arm, which also doesn't protect against heart disease. And it had a hormone therapy arm, and that's the one that's caused controversy for a long time now.

Kirtly, I bet you remember exactly where you were when that initiative came out.

Kirtly: Oh, boy. Yeah, I do. In the 2000s, when the first results of the Women's Health Initiative randomized trial came out . . . That's the one where some women were given conjugated estrogens and a synthetic progestin called medroxyprogesterone acetate, and the brand name was Provera. And some were given placebo.

The news, and it was national news, was that there was a 24% increased risk of breast cancer in women who took the combination of these two hormones compared to women who didn't. And there was an outcry to stop prescribing hormones in the menopause. I mean, it was big. And it was all over the news. Bad news is good press. People were making money and selling magazines.

And there were some questions here. Well, why did the WHI use conjugated estrogens and medroxyprogesterone acetate? This was the combination in a pill called Prempro, and it had a brand name of Premarin and Provera in it. Why didn't they use something different, something more like the hormones that women make?

It was a financial one, of course. The most commonly prescribed pill for menopausal hormone therapy was Prempro, and it was made by a large pharmaceutical company. And it probably was cheaper to do the study with. It's a financial decision as much as another one. And that's my take.

In Europe, they don't use this combination. They use other stuff, and the outcomes are a little different.

But the real result in terms that women and doctors could understand was about one extra breast cancer detected per thousand women per year.

And in fact, there was one extra blood clot per thousand women per year. But there was no decrease in heart disease, and there was about one fewer bone fracture per year. And in the wash, there were no extra deaths in the estrogen-taking group compared to placebo. But that didn't make the news, the fact that actually there just wasn't a big difference. But there was a lot of fear.

And women, except my patients, smartest ladies on the planet who knew how to do math and read "The New York Times" and were taking hormones because that made them feel better. But women other than my patients were scared, and doctors were scared, and major news organizations were scared.

It was a finance thing. Doctors stopped prescribing because they thought they might get sued, and women stopped taking it because they thought they might get cancer.

But the WHI was never intended to be a quality-of-life study, and 63,000 women got randomized. It's not the WHI's fault. It wasn't a bad study, and it answered the question, sort of, of "Does Prempro, that particular product, protect your heart?" And it didn't.

But I didn't change my practice. I just spent a lot more time doing stats with my patients on that sheet that you put over the table that patients sit on. So when patients would see me, I'd get my pen out and I'd start doing numbers and graphs so that people who were frightened, but were symptomatic . . . They wanted to continue hormones because they felt better, but they didn't want to be scared.

I'm upset, still upset, because it felt like big media was getting a lot of press and something out of it, and my individual patients were getting scared. I wasn't happy.

Katie: Right. And I think the same thing happens now. This was more a media problem than it was a medical problem, but specialists in various parts of medicine, that's what they see. They're reading the press too.

And I think that the mirror, the inverse is happening now where people are picking up on the benefits of hormone therapy, but kind of overhyping that as well.

Kirtly: We're kind of in a numbers-free zone now. At least WHI had numbers that you could explain on the white sheet on the table. You're going to sit on this table later, but let me write on it first.

Katie: My practice didn't change either. I think I've been practicing pretty much the same through that whole time. I always knew that the menopause therapies helped people with the symptoms of menopause, and it protected bones, and that seems like a good reason to use it if you're a good candidate.

I felt like the risks that the WH identified could be managed with a healthy lifestyle, and we could help people improve their risk for heart disease by changing their lifestyle and cancer screening for the breasts. So I didn't do anything different either.

But you're right. For a while, I was really trying to convince people this was safe. And now it feels a little bit different, that I'm trying to remind people that it's not for everyone.

So I think the hard part is that our healthcare system is pretty fragmented. And for people that aren't in this specialty and maybe aren't really reading the statistics as carefully as we were, they just heard the headlines and they denied women prescriptions for hormone therapy, and those patients that had real symptoms didn't really have anywhere to turn.

I did see this kind of shadow industry rise up, these kind of hormone balancing clinics and med spas and naturopaths. They've always been out there, I've been aware of them, but I feel like that kind of practice has really accelerated in the last five years.

And honestly, I think what's happened is that people have discovered kind of for the second time around that you can really monetize perimenopause and menopause and . . .

Kirtly: Stop, stop, stop. Remember Suzanne Somers?

Katie: Oh.

Kirtly: So when we scared everybody out of their hormones, this wonderful, beautiful woman named Suzanne Somers, who's had breast cancer . . . And bless her heart, she's passed away of breast cancer. But she wrote a book and she said, "Oh, no, don't listen to this. You should take this particular hormone, this particular estrogen, and you'll be feminine forever." It was a "Feminine Forever" all over again by this gorgeous woman who had a lot of work done.

That was early in the five or ten years after WHI, but she got rich on it. And my patients wanted a different kind of hormone, and I was fine with it. I said, "Sure, we can get you this one." But it's fine. It's money, money, money. All of the money.

Katie: Yep. And here's the thing that drives me crazy. My patients come in and they're angry that the WHI got things wrong. So they're angry about that now, and they're upset that we haven't studied women enough. And they're right about that history, I think, but they're willing to spend a lot of money on testing and treatments that have not been studied at all.

So the thing that they believe that they're buying is the remedy for bad science. And in fact, it's more of the exact same thing. It's now the absence of science.

Kirtly: Right. We're in a science-free zone right now.

Katie: Yeah. I mean, I think the thing about menopause is if you're going to make money on it, the best thing to do is to test numbers that fluctuate. And that's the thing with hormones, is that hormone numbers fluctuate across a menstrual cycle. They fluctuate from month to month wildly during perimenopause. They fluctuate again in response to treatment. And so if you're charging by the blood draw, it's a great business model, but it's absolutely not evidence-based.

Kirtly: Yeah. Well, it was a little discouraging when women would come in with a hormone panel that I didn't order. They paid for it, and they may have paid hundreds of dollars, but it didn't tell me anything I didn't already know. They were really worried that their progesterone was low, and I said, "Well, it's supposed to be low right now." It didn't help me know what they were doing right now as much as their symptoms did.

And so, as a practicing clinician, I wanted to have information that they could use but not use a lot of needless money for the system or for them personally. I wanted to know how they were feeling and what they were hoping to get better and do it in a cost-efficient way. Some of my patients had money, but a lot of my patients did not, and it mattered what we chose to do.

Katie: And almost never do those labs tell me what I need to do in terms of prescribing. I'm much more interested in my patients' history.

I mean, this is sort of like a case of history rhyming in my mind. So back in the '60s, we monetized menopause without science and maybe caused some problems.

Kirtly: Now, we didn't hurt very much. Most of our patients felt better, and the risks were tiny, a couple per thousand of women with blood clots. There was a little bit of harm, but it was for people who felt better. It was a great deal of good, and their bones were great.

Katie: Yes. But then we kind of overcorrected and abandoned menopause entirely when we got some bad news, and that definitely hurt women. And now, I think the current menopause market is doing exactly what "Feminine Forever" did originally and Suzanne Somers the next time around, is selling solutions to normal physiology.

And I do think that hurts women, even if it's only hurting them in their wallet. I think that there are way better uses of your money than these . . . A lot of these clinics now sell you a subscription, so you pay some couple thousands of dollars and you can have your blood drawn as often as you want, and somebody tells you a story about it for that.

But I think the new tool in the toolkit is the marketing juggernaut that's social media. If you are in the perimenopausal demographic, you cannot escape menopause influencers on your social media feed unless you're totally off of social media, which would probably be a good idea.

But as someone who sees menopausal women every week, I can tell you that there are internet trends that come and go. For example, a while back, somebody was discussing itchy ears as a menopausal symptom. And in the next few weeks, the number of women that came in that had itchy ears was just off the charts. Everybody's ears itch once in a while, but if someone . . .

Kirtly: I'm watching you. You're scratching your ear right now, Katie.

Katie: I just thought of that.

Kirtly: I'm watching you on my video. Sorry, ladies listening, or men listening. She's scratching her ear on our video.

Katie: But if you've just heard recently that that's a menopause symptom and then your ear itches, you are certainly primed to pay attention to it and come in and tell your doctor, "And I have itchy ears."

Kirtly: I have itching. Just talking about itchy ears now, my ear itches.

Katie: Right. So that clip has sort of gone out of circulation, and lately I'm back down to seeing a normal number of itchy ears.

Currently, everyone is worried, I think, about not getting enough protein and out buying weighted vests. So the number of weighted vests I see on any given walk is . . . I almost kind of laugh. There's no evidence that it builds bones. Maybe you burn a tiny number of more calories carrying around that extra weight, but it can also lead to back pain and plantar fasciitis and change your gait. And really, there's no good data that the vests do anything at all. I guess if it gets you out walking, that's a good thing. And maybe those people look cooler than I do with my backpack and a water bladder in it.

Kirtly: Weighted vest, huh? That's a thing? It's not really a thing in my old lady world, so maybe I won't lose that extra 20 pounds. I'll just walk around with my own biologically devised weighted vest that's kind of coating my whole body.

Katie: Better distributed.

Kirtly: It's beautifully distributed. Sort of.

But you remember the trick when you stood in the door and pressed the back of your hands against the door frames as hard as you could for a count of 15, and when you stepped away from the door, your arms just floated up like they were weightless?

Katie: Can that be our million-dollar idea, Kirtly?

Kirtly: That's our idea. I used to do that all the time when I was a kid, and I'd make other kids do it. I guess if you march around with 15 pounds of weighted vest, you must feel weightless when you take it off.

Wait, I actually did that. I worked for a month doing cardiac catheterization, just helping. I wasn't a cardiologist. But I had to wear a weighted vest with lead to protect me from the X-rays all day. It was a 20-pound weighted vest, and I felt weightless when I took it off. And it made me so happy to take it off. So maybe I'll get one. I'll feel terrible all day, but when I take it off . . . Anyway. Sorry. I digress.

Katie: Then you'll need a weighted blanket at night just to stay on your mattress.

Kirtly: I'm just trying to save you money.

Katie: Selling stuff is one part of social media. There's another sort of more insidious thing from my perspective, and that is selling you mistrust.

So, for example, there's an influencer who publishes a list of labs that you should request from your provider. She, of course, presents herself as an expert, and she is, but she presents herself as somebody who figured out menopause when no one else was doing this.

She publishes this list of labs, and my patients come in with that exact list as a screenshot or written down on a piece of paper, and they're already sort of primed to believe her and not believe me. They've never met her, but they see her a lot on the phone. She's never examined them and she's not going to be responsible for any outcomes, but she has somehow earned their trust before they've come in physical contact.

And the thing that's frustrating for me is the list is actually designed to cause a problem. The labs on it are chosen so that I, as a responsible clinician trying to not blow up healthcare costs for everybody, am going to turn down some of them as not being necessary. And when I do that, when I say, "A random cortisol doesn't help," or, "The lab panels that we talked about aren't needed right now," the patient feels like I'm being dismissive and I don't understand what's happening and I'm not up to date like the person on the internet is.

That failure is actually the point of the list. It positions her as an authority and discredits me when I'm actually the one trying to provide evidence-based care. But the patient goes home and she goes back to her app, and she finds the influencer, and there's the influencer ready to sell her own supplement line or get her in for a $1,500 consultation.

The list was always designed to get patients to return back to her site to buy her products. And to think I'm behind the times.

Kirtly: I get upset because it makes women feel like they're less, they're in danger, they're at risk, they're not enough. And I'd say I like to save people in the system money when it doesn't make much sense to do a test.

But if someone has their fears hanging on a test, I would usually order it in a way that was actually . . . Because sometimes they order tests, like an estrogen test, that are really ridiculous. In fact, our labs don't even do. So I'd order one that our labs do and hopefully their insurance would pay for it.

Of course, there are women who are so financially privileged that money isn't an issue. But for my patients, they weren't mostly like that, and it did matter. I didn't want them frightened. I wanted a number that they could use.

Katie: Yeah. And I always just feel like I have a responsibility to be a good steward of the healthcare dollar and everybody downstream that has to run the labs, interpret the labs, give the feedback when it's not something that's actually needed. Yeah, it's tricky.

And I don't want to leave my patients frustrated, but it's hard to be told I need to order a lab test based on some influencer on social media when I know that no decision is going to be made based on that result.

Anyway, there's the influencer layer. And then I do want to talk about the med spa layer because I think that's an important thing for people to know. A med spa is not exactly a medical practice. The people staffing it don't necessarily have a background in menopause and they're usually not menopause certified.

The training that they get from their employer is more how to keep you coming back, because that's what they're getting paid for. So that model runs on retention, the subscriptions we talked about, or upselling you some vitamins or some supplements, and a lot of unnecessary lab testing.

And because it's primarily a spa and not a medical home, there's a whole lot of care that people there don't get. So nobody there orders a mammogram or does a Pap smear or a pelvic exam or looks for other things like lichen sclerosus. And so when something does go wrong, like abnormal bleeding, for instance, the med spa doesn't actually work it up. They tell you to go see your doctor.

This has happened to me more times than I care to think about. I see people who do actually end up with endometrial cancer, and sometimes it is caused by inappropriate hormone prescribing and it's being done in a system that does not offer that kind of follow-up testing that patients need.

Kirtly: Yeah. Well, I do think that women have autonomy over their own lives, even if their autonomy has been hijacked by marketing. When do you really have autonomy as a human being when the message that you get points you in a certain way?

If a woman wants to go to a med spa and we are their gynecologists, when they have difficulties, I want them to continue to come to us. Meaning if they have blood clots or breast cancer or . . . They should be getting mammograms anyway. But they have adverse symptoms from excessive male hormones, that's currently a big thing, or abnormal uterine bleeding, I want them to feel confident to come.

We want to keep them safe and solve problems with them. I don't want to judge them. I'm not a judge. I just want them healthy and to feel good and feel good about themselves, and not have them in an environment where they're not enough, they're just not good enough, and they need something else to make them better. That makes me so sad, Katie.

Katie: It does, doesn't it?

Kirtly: It makes me sad.

Katie: It really does. And then there's another new player in the market, and these are kind of interesting. They're these telehealth kind of startup companies. I think they started out with a really good intention, because in 2023, there was a big article in "The New York Times" that Susan Dominus wrote about how women had been misled about menopause. And she went back through the whole thing that we just talked about the WHI and how that scared women unnecessarily.

That one article, I think all of a sudden, people really wanted to get in and see a menopause specialist. And there are not enough of those, right? We're booked out for months at a time.

And so there were a couple of these telehealth companies that realized that they could really provide some help by doing telehealth menopause care. They hired a lot of certified menopause clinicians via telehealth so they didn't have to have offices and rent, and you could see anybody across the country if you were licensed appropriately and take their insurance. They really were trying to meet a need of getting access to people for menopause care quickly.

But the problem with being telemedicine that I think maybe we didn't see in the very beginning is that eventually you're going to send people back to a doctor in their community. And so they only get to see patients for a few visits until that person gets back to a clinician that can actually put their hands on them.

And so that has created another problem within these telemedicine companies, is they've had big investments by venture capitalists who put a lot of money into this great idea, but investment capital is not philanthropy. They're not just there for the cause because women can't get menopause care. They want to make money, and they want to make a lot and in a big hurry.

So these telemedicine companies that started out with a good idea are now sort of forced by how the market works to try to sell other things to get their patients coming back. And so they're selling a lot of products that women probably don't need and probably don't work, like compounded hormone face cream and arousal cream and compounded GLP-1s and these new longevity products that we have no research on. 

And then they're also really sort of extending who needs hormones, people trying to get them started before they actually need it or maybe after it's no longer safe.

And they're paying a lot for celebrity spokespeople to push out content and the social media people to sort of influence folks towards their platform. And so they've gone from being a thing that we needed to something that's really . . . I think they need to make capital, they need to make a return on their investment, selling a lot of things that people don't need.

So my honest advice about the big telemedicine companies is to use them, but carefully. If you're suffering and you can't get to another certified menopause provider or for the perimenopause, they can get you in quickly and they can get you started on legitimate hormone therapy and they can use your insurance, and I think that's really worthwhile.

But then find a clinician who can examine you and transfer your care there. Most of us are happy to continue people on a prescription if it's working, but skip the face creams and the supplements and the compounded GLP-1s. Telemedicine is a bridge, but not your end destination.

Kirtly: I completely agree. We don't get people for primary care or for midlife women's care or for perimenopause care in a timely fashion. It's a long, hot summer and people are having hot flushes or having more hot flushes, and it makes them crabby. They should be able to be seen in a timely manner by a competent clinician who's going to listen to their concerns.

And if it ends up being telehealth, then you keep that appointment right away. But follow up with us, with somebody who can follow up and take care of you in real time.

Katie: Yeah. And I think the same if you start out at a med spa. Great, start there, but come see a certified menopause provider as soon as you can.

The Menopause Society keeps a directory of certified providers and you can search by zip code. So I'd encourage people to do that. And look for someone who's in a system who can take your insurance and do all the things, order your mammogram, do your exam, and be invested in your health, not just in a profit. You want somebody who's going to be responsible for your health, not just somebody with a following.

So I think that's what I wanted to talk about really, is just this picture of all these different forces that are changing the way menopause care is being provided. I feel like right at this moment, anything menopausal hormone has this halo around it, and anything hormonal contraception does not. And I get it. Perimenopause is real, it's frustrating, it's confusing.

Kirtly: Oh, yeah. But remember, the majority of women do just fine. So you are not broken. Chances are you will ride this little horse on its journey just fine. There are seriously women who struggle, bleeding, associated symptoms, hot flushes. So that's what we're here for. But don't be frightened that this is coming at you, because chances are you're going to be okay.

Katie: Yeah. And if you need treatment, it's available and it doesn't need to cost a fortune. Your insurance covers it. There are people doing the hard work to treat women and to advance the science, and they're doing this in exactly the way science should work. It's slow and it's careful and it's quiet.

The people doing this work are not trying to sell you a supplement line, but your social media feed is designed very carefully to steal your attention and to make you angry and to sell you things. So use that with caution.

And keep coming back here. We're going to be doing more episodes on the environmental domain of the perimenopause and the spiritual domain of the perimenopause. And if you're just jumping in now, you can go back and get the physical, social, emotional, and intellectual domains.

We are happy you're here with us. You can follow the "7 Domains of Women's Health" wherever you get your podcasts, or at womens7.com.