Myths and facts on menopause with Dr. Lucy McBride

Part 2 of my Q&A with primary care doctor, Dr. Lucy McBride

If you missed part one of my conversation with Dr. Lucy McBride, click here to read more about protecting women’s health.

Discover more from Lucy on her Substack, Are You Okay?, and on her website.

Lucy McBride, MD, is a Harvard- and Johns Hopkins-trained primary care doctor in Washington, DC. During the pandemic, she became a nationally recognized voice on the importance of addressing mental and physical health in tandem. She is the author of a medical newsletter, Are You Okay?, now reaching over 28 thousand people a week, and she is the author of a forthcoming book about whole-person health with Simon & Schuster. She hosts a top-rated podcast called Beyond the Prescription where she interviews guests like she does her patients, pulling the curtain back on what it means to be healthy. She has published numerous opinion pieces in The Atlantic and the Washington Post (among others(, and she has appeared on CNN, MSNBC, NPR and PBS, advocating for a data-driven, holistic approach to health care, helping redefine health as more than our cholesterol and weight. Health, she argues, is a process, not an outcome. Health is about more than our cholesterol and weight: it’s about awareness of our medical facts, acceptance of the things we cannot control, and agency over what we can change. 

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Before we get into menopause, tell us a bit about perimenopause - signs of it, what to expect, and when women should see their doctors to talk more about it.

Perimenopause is defined as the stretch of time—usually seven to ten years—leading up to menopause. The symptoms of perimenopause vary widely. The most common symptom of perimenopause is irregular periods (i.e., periods that are longer or shorter in duration and/or periods with a longer or shorter interval between them.) Other common symptoms include a low libido, vaginal dryness, hot flashes, joint pains, urinary tract infections, pain with sex, fatigue, moodiness, irritability, heart palpitations, and dry skin—among others. 

Note that some women don’t experience any of these symptoms; others will be debilitated by them. This is due to the variable production of hormones by a woman’s ovaries as they gradually slow down.

My advice is that all women, particularly in their 40s, report symptoms of menstrual irregularities and other hormonal symptoms to their doctor. Of course we don’t want to over-treat a normal biological process; it’s also important for women to understand the various hormonal, behavioral and lifestyle treatment options for bothersome perimenopausal symptoms.

How do women know when they actually are in menopause, and what should women ask their doctors about this next phase of their lives?

Menopause is defined as having done a full year without a menstrual period. In the case of non-menstruating women (e.g., women who have had a hysterectomy), menopause is defined as having symptoms and/or laboratory testing to suggest that the ovaries are no longer producing robust amounts of estrogen and progesterone. As per the previous question, women who are in perimenopause and menopause may experience a range of symptoms, and to varying degrees. 

My best advice for women at this phase is to ask their doctor about hormone replacement therapy (HRT). Specifically, I suggest asking how HRT might help 1) ameliorate any current menopausal symptoms and 2) prevent the long-term effects of the absence of estrogen and progesterone in the body. Imagine yourself when you’re 80, I tell my middle-aged patients. Ask about the specific risks and benefits of HRT for your body, using the latest medical evidence about HRT to guide the conversation. Know that biased, anecdotal and fear-based messaging about HRT is everywhere! It can be difficult to cut through the noise, so be sure to find someone who has access to the facts and the humility to know what they don’t know.

Again, HRT isn’t right for every woman, but every woman has a right to the facts about their unique risks and benefits of HRT.

There are so many misconceptions about hormone replacement therapy (HRT) due to flawed or outdated science. Tell us a bit more about hormone replacement therapy - why is it important, what misconceptions are being told, and what do women most need to know?

When a woman experiences symptoms that interfere with her quality of life and when the benefits of hormone therapy outweigh the risks, the most effective way to treat symptoms caused by declining or absent hormones is by taking hormone therapy. Just like any medical intervention, however, hormone replacement therapy carries risk.

So, the question of how to treat your particular symptoms hinges on the potential risks and the likely benefits of hormone therapy for you (and only you). Because some of the symptoms are subjective (i.e. quantifying stiff joints, hot flashes, or irritability is more difficult than, say, measuring cholesterol), a decision about hormones should include quality of life issues in addition to measurable data.

It’s also important to remember that there are long-term benefits of hormone replacement therapy, beyond simply treating immediate symptoms. HRT has been shown to reduce the risk for osteoporosis, premature heart disease, and early cognitive decline—among other things. 

In other words, there are risks of taking hormones; there also are risks of not taking hormones. (Click here for the most recent expert guidelines that nicely capture the risk-benefit ratio of hormone replacement therapy. And be sure to talk with your doctor.)

Too many women needlessly suffer through menopause because of false narratives about the safety of HRT and because discussions about quality of life often aren’t prioritized.

What should women do if her doctor tells her she shouldn’t take or isn’t a candidate for HRT? 

The first thing I suggest is to make sure that your doctor’s advice stems from a careful appraisal of current medical evidence. Even in my own medical training, I was taught not to prescribe HRT unless a woman was absolutely miserable—and, if prescribed, it should be only in the smallest doses and for the least amount of time. 

It’s important to note that for women who are appropriately advised not to take HRT or for those who decide not to, there are some non-hormonal remedies for menopausal symptoms. Examples: 

• For stiff joints: The combination of strength training and stretching is critical. Our joints have to work harder when the surrounding muscles are weak or tight. For example, our knees absorb more wear-and-tear if our quadricep (thigh) muscles are weak and/or stiff. Particularly as we age, women should aim to include muscle tone and elasticity in their exercise routines.

• For hot flashes: Behavioral changes such as limiting alcohol, caffeine, and spicy foods; wearing light clothing; and turning on fans can help reduce hot flashes and night sweats. So can managing your stress and other activities, such as public speaking, that tend to spike adrenaline levels. You can also consider natural supplements (e.g., black cohosh, evening primrose, and vitamin E) or prescription medications (e.g., Gabapentin or an SSRI medication like Effexor) which can provide some relief. The upshot? These treatment recommendations are nuanced and depend on the patient. It’s always best to talk with your primary care provider about your specific needs and tolerance for symptoms versus side effects from different therapies.

• For insomnia: I wrote a longer post on SLEEP here.

Can women who aren’t candidates for systemic HRT use vaginal estrogen? 

Yes! Vaginal estrogen has been shown to improve symptoms of genitourinary syndrome of menopause (GSM) which includes vaginal dryness and the increased risk of urinary infections as a result of thin, atrophic vaginal tissue. Vaginal estrogen is typically safe for women, even those with a family or personal history of breast cancer. Vaginal estrogen can significantly improve the quality of life for women who are prone to UTIs. The North American Menopause Society’s expert guidelines on HRT are here. My friend and sexual medicine expert Dr. Rachel Rubin’s advice about vaginal estrogen is here.