Your Menopause Questions, Answered, With Dr. Sharon Malone

This webinar is SUPER special because our guest is our very own Dr. Sharon Malone! If you don’t know her, she’s our Chief Medical Advisor with three decades of experience as an OBGYN. She helps shape so much of what we do here at Alloy with her philosophy that all women should be able to make decisions regarding their health and quality of life based on facts, not fear.

And now she’s an author! Her book Grown Woman Talk: Your Guide to Getting and Staying Healthy is now available wherever books are sold! Grown Woman Talk is for every woman who has felt marginalized or overwhelmed by a healthcare system that has become more impersonal, complex, and difficult to navigate than ever. You’ll come away more informed about your own health and about how to advocate for yourself, and honestly, we think you’ll really enjoy the book. It’s a great read.

Dr. Malone recently chatted with our community manager Rachel Hughes about, what else, menopause and MHT! We recommend you watch the whole interview on our YouTube, but we also want to share some highlights with you here.

This interview has been edited for brevity and clarity. Please note that the webinar is for educational purposes only and is not medical advice. 

Rachel Hughes: Welcome Dr. Sharon Malone. First, we have to mention your book, Grown Woman Talk: Your Guide to Getting and Staying Healthy. My first question to you is why this book and why now?

Dr. Sharon Malone: Thank you Rachel. I wrote this book for a couple of reasons. One, I realized that there's not really much out there that is a resource that addresses the whole of a grown woman's experience. We spend a lot of time talking about perimenopause and menopause, and we should, but I wanted you to have the totality of it. I want you to learn how to pick a doctor and how to write your will. I think that there are not enough conversations about women's health in general, and I think that we spend too much time, perhaps an inordinate amount of time, in our reproductive years. But what about everything else? What about after 40? And this book really came from a lot of the conversations I've had with my friends and my family members about very basic things that I realized that they didn't understand about this changing medical environment that we find ourselves in.

Rachel Hughes:

Thank you so much. I want to ground us in a few questions that come up a lot around perimenopause and menopause. First, if you could talk about the various forms of estrogen and how you might decide which one is for you and what might not be for you. 

Dr. Sharon Malone: Well, estrogen has various forms. You can take it as a pill, as a patch, as a spray, as a vaginal cream, etc. But, there are really two broad categories. You’re either taking oral estrogen or transdermal estrogen. Transdermal means that it goes directly into your bloodstream via the skin. And for the most part, it’s not important which you take. There may be certain special circumstances where a transdermal estrogen would be preferable, but I think the overarching sentiment is that estrogen, however you take it, works. And for the most part, when you’re deciding, the question is going to be about which form you’re most likely to be compliant with. Is it a daily pill? A spray? A patch you change twice weekly? The one that works is the one that works for you.

Another factor you’ll want to consider is cost. There’s some price point variation. The least expensive option is usually the pill. But at the end of the day, you know you better than anyone else. 

Rachel Hughes: Terrific; thank you so much. As the conversation around menopause has just gotten brighter and louder over the last few years, I'm noticing now women over 60 questioning if it's safe, if it's effective to take MHT. And I wonder if you can speak to that.

Dr. Sharon Malone: Sure. First, I want to say that while a lot of things that happened with the Women’s Health Initiative (WHI) were terrible. But, on the other hand, we did learn some important things and I don’t think we can lose sight of that. The majority of women who were in the study were over the age of 60, with the average age being 63. And we learned that if you are looking to achieve the greatest benefit, you should start hormone treatment around when you start menopause, around age 50, or within 10 years of when you’ve had your last period. The risk to benefit ratio just changes as you get older. You won’t get all of the cardiovascular benefit, or all of the osteoporosis prevention benefit if you start late. But there is not really a hard and fast parameter. If you’re over age 60 or more than 10 years from your last period, it just requires a bit more conversation about your treatment goals and your particular risk factors. And all of this only applies to systemic estrogen. Everybody, regardless of age, can use topical vaginal estrogen, and probably should. 

Rachel Hughes: To piggyback off of that question a little bit, when should you stop taking hormones? 

Dr. Sharon Malone: I don’t like the word should. You should do whatever it is you want to do. How about that? 

I think there’s no absolute time at which a woman should stop taking hormones. I’ll be honest: I’ve been on hormone therapy since I was menopausal. I’ve been on it for 15 years, and I have no plans to stop. If you have a contraindication or a reason to stop, or if you want to stop, by all means, stop. But otherwise, you can take hormones for as long as you want to take hormones as long as you have no contraindications. And if you’re at risk for osteoporosis, you might not want to stop, because you’ll start to lose all that bone density you’ve preserved in the five or six years after you stop your hormones.

So there’s really no should. But you might have a preference. And really, what we’re trying to do at Alloy is give women agency and information so that they can make healthcare decisions based on what’s right for them. 

Rachel Hughes: I’m reminded of the several times I’ve heard you mention the release of the WHI study and the conversations you had with patients in your practice. A lot of women said “I’m just going to keep going.” I would love to hear from some of them someday, but can we talk about the people who decided to keep taking their MHT?

Dr. Sharon Malone: I had patients who kept going, and also, I started hormone therapy after the Women’s Health Initiative came out. Because I read the study. In real time. And I understood it, and the results actually weren’t bad. But there was all this fear mongering going on.

Rachel Hughes: Thank you. Now we’ll start with some questions that have been sent to me. Why are oral birth control pills still the go-to for symptomatic perimenopausal women, when the hormones are synthetic, it’s a higher dose, and the side effects are lower testosterone and low libido?

Dr. Sharon Malone: I’m going to start by saying this: I don't know what's going on, but there's a lot of birth control pill bashing going on out there in cyberspace.

And for womankind, there has probably not been a medication that has been as important as the birth control pill in terms of changing the course of our lives. Giving women reliable birth control and giving them control of their own fertility has been seismic.

And for most women, it’s great. There are people who can’t tolerate it, and we do have alternatives, but right now I’m going to stick with things that are applicable to most women. 

The reason we use birth control pills in perimenopause is that by definition, when you’re in perimenopause, you’re still getting your period. And for a lot of women, it’s the periods and the bleeding that becomes a problem. It’s too long, it’s too often, it’s too heavy. And birth control pills give you cycle control, not just symptom relief. MHT doesn’t offer cycle control. 

The second reason we use birth control pills in perimenopausal women is that when you’re in perimenopause, you’re on the way to the end of your fertility. But it’s not gone. And for those of you who think you can’t get pregnant during perimenopause, my mother had yours truly when she was almost 45 years old. It happens! So, the birth control pill gives you reliable birth control. And it’s not forever. You’re only going to be on a low-dose birth control pill until you get to menopause. And then once you get to menopause, you can seamlessly transition from birth control pills to MHT. 

Rachel Hughes: Can we talk about the science of the hormones in birth control vs MHT? About synthetic vs natural hormones? 

Dr. Sharon Malone: Other than Premarin, all estrogen products, be they birth control pills, be they menopausal hormone therapy, are synthetic. Synthetic is not a medical term. It just means that it's made in a laboratory. Natural means it's naturally occurring. The only naturally occurring estrogen that we use is in Premarin. And why is that naturally occurring? Because it comes from pregnant mare’s urine. Now, in my personal opinion, getting something from a pregnant mare’s urine is not preferable to getting something that’s made in a lab. And physiologically, it does not make any difference. So don’t get caught up in the language of synthetic and natural. Bioidentical does not mean “natural.” It just means that when the company makes estradiol in the lab, it is bioidentical. 

Rachel Hughes: Terrific. Thank you. I love this next question. “What is the best way to handle a PCP appointment to be sure that you are able to make an informed choice around MHT?” This is another great reason to get your book!

Dr. Sharon Malone: I do think you need to plan for this, and the first thing you do is ask your PCP, “Do you treat menopause?” A lot of them don’t. So that’s the first place to start. And if they say no, you don’t need to spend time there. And that’s why Alloy exists. We’re here for the women who cannot and do not have access to menopause-trained physicians. Menopause treatment is something that works really well. It’s not like we don’t understand it. The North American Menopause Society revised their guidelines in 2022, and everybody agrees the most effective treatment for the symptoms of menopause is Menopausal Hormone Therapy. End of sentence.

So, finding someone who knows how to prescribe it is important because if you have someone who doesn’t know what they’re doing, then you’re going to waste time on a visit or waste time trying to convince someone to give you something that you’ve already done the homework on. So start with that phone call. If the person does not treat menopause, go to menopause.org to see if there’s a menopause-trained practitioner in your area. And go to that person.

Rachel Hughes:

Thank you so much. Someone asked why, in their post early menopause years, do the hot flashes continue? 

Dr. Sharon Malone:

So, everyone’s journey is different. But there are commonalities. It’s not the same, but it rhymes. Most women will have hot flashes starting in perimenopause, and it will continue for a few months or years or even decades after your last menstrual period. And you can’t know how long that will be. My advice to you, is that if you have hot flashes, treat them, because hot flashes are not benign. We make fun of them on TV. Everybody is like, “oh, here’s a woman with a fan.” But the reality is that hot flashes have implications for cardiovascular disease. They disrupt your sleep. We know that women who have persistent hot flashes have more hypertension, and are more likely to develop lesions in their brains. So, if you have hot flashes, don’t think that the solution is to suffer through them until they go away. They may eventually go away. But hot flashes are not just annoying. 

Rachel Hughes:

Let’s go now to questions in the chat. “I started transdermal estrogen in 2019 at age 51 after consultation with a menopause-trained OBGYN for severe perimenopausal symptoms. No progesterone needed, because I have no uterus. However, in July of 2023, a mammogram showed increasing bilateral breast calcifications with suspicious groupings. I had a biopsy on my right breast and it showed intraductal papilloma without atypia. It was recommended I see a breast surgeon because this benign tumor can upgrade. I had a consultation with three breast surgeons and all said I should stop transdermal estrogen. Please understand that the breast surgeons are not certified by The Menopause Society. So out of fear, I stopped ERT (estrogen replacement therapy) about eight months ago and am miserable. I reached out to my original provider who prescribed ERT in 2019, and she said she could no longer help me due to complicated breast health and told me to listen to the breast surgeons who are not menopause-trained. I then reached out to another menopause-trained provider and she said it was okay to restart, despite all of this.”

Dr. Sharon Malone:

Okay. Now, without giving specific medical advice, I'm going to tell you what the current state of the recommendations are. The only current contraindication regarding breasts and estrogen therapy is whether or not you personally have an estrogen-dependent breast cancer. And even that's debatable. So we're not going to get into that. 

But I will say this. The Women’s Health Initiative actually told us something about women who have had hysterectomies and who take estrogen only for menopause (no progesterone), and the study found that there is actually a 23% decrease in the incidence of breast cancer, and a 40% decrease in the risk of dying from breast cancer if you use hormone therapy. And that never made it out there. 

Generally, estrogen does not cause breast cancer. And I can’t say whether or not you are going to get breast cancer, because your risk is your risk. Maybe you will, and maybe you won’t. Plus, the biggest risk factor for developing breast cancer is age; it’s living long enough to get it. So the longer you live, the more likely you are to get breast cancer.

Rachel Hughes: Great. Thank you. Next question: “Can anyone take vaginal estrogen? My doctor said that she doesn't recommend it and that I should use a moisturizer.”

Dr. Sharon Malone:

The answer is yes. Moisturizer does not suffice. All of us should be using vaginal estrogen. Start in perimenopause. Use it forever. Go ahead. I was just going to say, I was thinking of some of the conversations I've had with urologists who've spoken about vaginal estrogen. These are the terms they put it in. It is preventative medicine helping with UTIs, painful sex, urinary tract infections, prolapse, and more.

Vaginal moisturizers are treating symptoms, not the cause. Vaginal estrogen goes to the cause. 

Rachel Hughes: Finally, Dr. Malone, what do you want for all of us here today to walk away with? 

Dr. Sharon Malone: What I really want women to know is that you’re not going to be ill-served by having more information. Get information. And use it so you can make better decisions about your healthcare. You have more power than you think, and if you’re not being served by your current provider, you should exercise your other options. That’s why Alloy exists, and it’s why I wrote my book. We don't have to just accept the inevitable.

Rachel Hughes: Yeah. Thank you so much, Dr. Malone. A pleasure.

Dr. Sharon Malone: Thank you.

For more of Dr. Malone and Rachel’s conversation, head to our YouTube. To learn about upcoming webinars, follow us on Instagram @myalloy.