Millions of Women Stopped Taking Hormones Because of a Misread Study with Dr. Sharon Malone

Mark Hyman, MD

Full Transcript

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Dr. Mark Hyman
When women need to start thinking about hormone therapy, can you help us frame how they should start thinking about it? The thing that maybe we should just unpack is this black box warning that came Mhmm. From the FDA because it's what got people really scared. So the black box warning for hormone therapy was what?

Dr. Sharon Malone
It will increase your risk of heart attack, of stroke, of dementia, breast cancer. You can't apply that same data from 79 year olds and 65 year olds to 45 year olds. Nice. They're not the same.

Dr. Mark Hyman
Overnight, I think fifty million women stopped hormones, which created a, you know, a catastrophe in their country. So let's talk about that. There's a survey that found that sixty six percent of women really are completely unprepared.

Dr. Sharon Malone
Estrogen affects every major organ system in your body, and it starts with your brain. The sooner you start it, the more benefit you get. But let me say this, when you're talking about libido issues, the first thing you should always address are

Dr. Mark Hyman
Doctor. Sharon Malone is a nationally recognized women's expert, board certified OBGYN, and certified menopause practitioner serving as chief medical adviser at Ally Health. With decades of clinical experience, she's become one of the leading voices advancing evidence based care for women in midlife and menopause. If you've been dealing with anxiety, low energy, or trouble focusing, and still feel like you're missing something, you're not alone. And that's why I created the Brain Shaping Academy, a new program that looks in places most people never think to check.

Like nutrient deficiencies, the health of your gut, metabolism, your immune system, and lots more. Alright, Sharon. Welcome to the podcast. So good to have you here.

Dr. Sharon Malone
Well, thank you so much for having me.

Dr. Mark Hyman
We're both here in San Francisco at a women's longevity health summit. And thank God because women have been a neglected species in medical research.

Dr. Sharon Malone
Forever. You

Dr. Mark Hyman
know, what's really striking to me as a doctor is and it's changing, thank God. But for most of the history of medical research, we've basically been studying seventy kilogram white men from Kansas, and they don't apply to everybody else. And so a lot of the research we have unfortunately doesn't really reflect what's happening in a broader population of women and women of color and women of different size, shapes, and ages. And it's really unfortunate because we we really have neglected women's health. I learned in medical school very little.

I mean, I learned all the diseases, obviously, but I didn't learn about women's, quote, health. How do we restore health and function and optimize women's health through their life cycles? And there are life cycles. There's, you know, pre prepubitive puberty. There's, you know, reproductive age, premenopause, perimenopause, menopause, post menopause, all these different stages.

Kind of different than a guy. I mean, guys go through this slowly.

Dr. Sharon Malone
Yeah. You're pretty basic. You know?

Dr. Mark Hyman
Pretty basic. And they go, you know, pretty trickled down, you know, with andropause, which is quite different. What's really interesting is that is that most women don't have any education about perimenopause or menopause. They don't know what to expect. There's a survey that found that sixty six percent of women really are completely unprepared.

And and even the women who go to see the doctor don't get good information and don't get good advice, and they want help for symptoms of of hormonal dysfunction or hormonal imbalance, and seventy five percent leave without a treatment. And I I would say probably the other twenty five percent leave with probably the wrong treatment. It's really a place where a lot a lot of women really feel ignored by the health care system, and they don't feel taken care of. It's unfortunate. And I think, you know, women are underserved, underinformed, and and I think this conversation we're gonna have really matters.

And we're gonna kind of dive into topic of how do we help women understand what's happening in their bodies throughout their life cycles. How do they get best prepared for the different stages? And how do they feel most vibrant, alive, and healthy not just treating disease. There's a difference between treating disease and optimizing health. And a lot of your work is really around understanding how do we optimize health for women through the life cycles.

And I think that's such an important thing. So why have women been so invisible? And why why why are are are women going through menopause, and and doctors are so ill equipped?

Dr. Sharon Malone
Well, you know, I I did a talk a couple of weeks ago, where I was we I did a deep dive into the history of medicine. You know? How did we get here?

Dr. Mark Hyman
Yeah.

Dr. Sharon Malone
And I think from its very inception, you know, the whole misogyny and racism is baked into the cake. It's not like that was an afterthought. I mean, all of it was looked at through the prism of the male body, and women were looked at as as inferior versions of men. Yeah. And that starts from the time of Hippocrates.

I mean, we all as doctors take a, you know, the Hippocratic Hippocratic oath. Oath. Yeah. Yeah. We never really knew.

What were we thinking at that time? Well, because women were considered not even just different. We were the lesser of the two. Yeah. And that's why we were never really given the consideration.

And that went on for almost two thousand years that that vision of what women were, we were not to be considered. We were looked at really only from our ability to reproduce. And if you couldn't do that, then what's the point?

Dr. Mark Hyman
True. There are also a few matriarchal societies in the world, but most were patriarchal.

Dr. Sharon Malone
Yeah. And Yes. Up to this very moment, we're still living in a patriarchal society. But, you know, it's changing, and it's changing because I think there's more awareness. And we can't change a system if we don't understand Mhmm.

How it started, how we got here. And I think that that's becoming more part of the conversation now. Why have women been left out of research? Well, it depends on who's making the decisions. Yeah.

You know? That's why I think that when we talk about diversity, we talk about diversity of opinions, diversity of curiosities.

Dr. Mark Hyman
Yeah.

Dr. Sharon Malone
And, you know, it matters who's in charge Yeah. What you're gonna study.

Dr. Mark Hyman
It's true. You know? And I I and you and I are sort of about the same demographic age. We we graduate residency around the same time, and it was in the kind of early nineties. And and during that time is when when we had a new NIH director that was the first woman, Bernadine Healy, who was an iconic thinker and said, hey.

Wait a minute. There's no research on women. We had some. Like, had the Nurses' Health Study, but this was not a randomized controlled trial. This was just a population study where they looked at trends over time.

They could improve cause and effect. We made a lot of inferences from that study, which was which was done out of Harvard with Walter Willett and, you know, really good scientists. But, you know, it's you cannot you cannot prove cause and effect. And and a lot of assumptions were made that ended up causing a real problem. You know, I always my joke is that, you know, if we did a study of 55 year old women who had sex, we would conclude that sex never leads to pregnancy.

Dr. Sharon Malone
Right.

Dr. Mark Hyman
Right?

Dr. Sharon Malone
Right. That's true.

Dr. Mark Hyman
But that's a 100% correct, but it doesn't it's not true. Right? And so that's that's kind of what an observational study does. It looks at patterns in a population, but they may not reflect actually the underlying truth or biology. Most

Dr. Sharon Malone
of what we know about women's health is really, as you say, from these observational studies or I think worse stills just sort of epidemiological studies where you, after the fact, have an observation and then go back and try to justify or figure out what the, you know, what the correlations were. And there's no way to prove anything from those types of studies. So I think that, doctor Healy really brought some academic rigor Yeah. To the conversation where she said, you know, if you're really gonna prove this, yes, we at that point, we'd had fifty years of data on hormones in women, but we didn't really have the ability to say, yes. This is indeed true because of our hormonal changes.

Dr. Mark Hyman
And can you just unpack for us how we got, you know, so confused? Because the nurse health study is just a great example of Mhmm. You know, a good study with the wrong conclusion. And in some ways, like Yeah. Right?

We we why why did this study show that women who took hormones did better, had less heart disease, had less cancer, had better brain health? There there was a lot of things that it showed that that made millions and millions and millions, tens of millions of women get on hormone replacement therapy. And in fact, when I was, you know, working in that time period, I I was I did a lecture, and this woman said my doctor said it's it's malpractice not to give, you know, hormone replacement therapy with permanent Provera, which is, you know, kind of what what was the current, prescriptions at that time.

Dr. Sharon Malone
Right. Well, the the biggest problem is that there's the healthy women bias.

Dr. Mark Hyman
There you go.

Dr. Sharon Malone
Because you had you were studying nurses, and you have to assume that nurses have a certain level of, attention to their health that perhaps another person may not. And so that was really what the Women's Health Initiative was trying to sort out. Were these women doing better? And they were. Yeah.

So, you know, that was the observation, but we didn't know why. Was it just the hormone therapy, or was it all the other health benefits that come from being a healthy person?

Dr. Mark Hyman
Yeah. They went to the doctor. They exercised more. They ate better. They took their vitamins.

They ate their fruits and vegetables. Right? They did they they were proactive about their health, and that's why they actually ended up on hormones because they went to the doctor and said, I I wanna get healthy. Right?

Dr. Sharon Malone
Exactly. But, you know, I I say this, that with a lot of these studies, you can say you know, you can prove the correlation, but you can't prove the cause Right. Unless you actually do the work and do the data. So that and collect the data. And that was what Bernadine Hayler and I and I have to say, you know, rest in peace, Bernadine Hayley, because she did it.

She was able to do it because she was a person that said, you know, I'm in charge here, and this is what

Dr. Mark Hyman
we're doing. And then they started the Women's Health Initiative, which was like a billion dollar study with a 160,000 women, and it was a randomized controlled trial. And there were some flaws within problems we'll talk about. But Mhmm. Before we get into that, I I kinda I had this thesis, and I wanted to sort of play it out with you because, you know, I I don't I don't believe that God screwed up and made a design flaw in women to have them suffer from all these hormonal dysfunctions.

Dr. Sharon Malone
I either. I don't either.

Dr. Mark Hyman
It's PMS, which affects seventy five percent of women, or whether it's painful menstrual cramps, or heavy periods, or PCOS, or severe menopausal, perimenopausal symptoms, I think there's there's drivers of those things that that are neglected in medicine. And basically, traditional doctors are trained only in two things. Give the pill before menopause and give, basically Premin and Provera after menopause or at menopause. And there's a lot of other options to to help people, and women particularly feel better. So can you kind of walk us through the life cycles of women?

There's four stages you talk about, premenopause, perimenopause, menopause, postmenopause, and help us understand what's actually happening in each of these.

Dr. Sharon Malone
Well, you know, I think that, you know, something that you said is that you don't think that women, you know, are are inferior versions of men and all this, and that is a relatively new thought. Yeah. Because, you know, you said God didn't create women to be inferior. But the reality is is that for forever, since we've been reading the bible, that was really how women came about. We were taken from the rib of Adam.

Dr. Mark Hyman
Mhmm.

Dr. Sharon Malone
We were punished. You know, the pain of childbirth was punishment for making Adam for tempting Adam into

Dr. Mark Hyman
Oh, jeez. I didn't know that. I guess I don't know my bible that well.

Dr. Sharon Malone
Yeah. I mean, that's why women you know, the a lot of the things that we believe are really biblically based. You know? Why are black people inferior? Why were they slaves?

Well, because it was the curse of ham curse of ham. You know? And that so a lot of that really like I said, it starts from the very beginning Mhmm. And it moves its way forward. And we are still trying to, you know, sort of lose some of that, you know, perspective about where women came from.

But we were we were punished. That's why. That's why women were always you know, felt that when you had your menstrual cycle, you had to be, you know, isolated from society. God forbid, you couldn't be touched. You were unclean.

All of these Yeah. Negative connotations about what, happens with women started very early on. But getting to your question.

Dr. Mark Hyman
But those were I think those were things that really related to more of, like, the menstrual cycle and seeing being as unclean and having to be ostracized from society. Those weren't necessarily the, like, like, true suffering of all these crazy things that are happening up for women, whether it's endometriosis or

Dr. Sharon Malone
Right.

Dr. Mark Hyman
PCOS or infertility or or, you know, bad menstrual cramps or, you know, all these different things that are going on that that that seem to be diseases that I don't think always were existing in in the female population at the level that we have now. And I think I'm just gonna be just straightforward with my opinion. I think it's because of our crappy diet, because of environmental toxins, and because change in our gut microbiome, all these things affect hormonal function.

Dr. Sharon Malone
Mhmm.

Dr. Mark Hyman
And they're not taught about, and they're not treated within traditional health care.

Dr. Sharon Malone
I I think they always existed. They just weren't recognized. And, again, I'm no biblical scholar. However

Dr. Mark Hyman
Yeah.

Dr. Sharon Malone
Yeah. Let's go back to Abraham and Sarah. Sarah was barren. You know, we talk about barren women all throughout bible. Well, why were they?

Oh, you know, endometriosis. I don't know. But I'm just saying. I'm just saying that that is these things that we know that women have suffered from for time immemorial, they had no names.

Dr. Mark Hyman
Mhmm.

Dr. Sharon Malone
They had no names. No one was paying attention to it. And whatever it was, there was also this prevailing notion that you were just being hysterical, or it's all in your head, or you're just, you know, being a woman.

Dr. Mark Hyman
By the way, hysterical for people listening, the root of hysterical hysteria is we call his hysterectomy is the uterus. So the it stimulates the female uterus is the word hysteria. Yeah.

Dr. Sharon Malone
And that was a thought. Our female organs, the things that that quintessentially made us female were the things that also made us crazy and suffering and all these things. So, yes, that's that's still there.

Dr. Mark Hyman
So take us through kind of these stages and and what's going on with women's health and and how they should think about it and what's happening and and, you know, you know, what what are the changes that that women should really be focusing on?

Dr. Sharon Malone
You know, we we have a pretty good understanding. I think the average woman in 2026 understands that that basic and first hormone hormonal change that we go through during puberty. Okay. So you go from being prepubertal before you get your first period, then you have your first period, and you but in before even before you get your first period, there is that transition. You know, that's not first sign of puberty.

Girls start to, you know, grow hair in, you know, pubic regions under their arms. They get breast buds. A transition from being a girl to being Yeah. Pubertal. Okay.

We understand that. But to give you some perspective on how little

Dr. Mark Hyman
But that's also happening a lot earlier too, so there's a lot of weird stuff going on with, you know, environmental estrogens Yeah. Toxins.

Dr. Sharon Malone
Yeah. So we understand that, but I want your listeners to know how recent that conversation was. Because a generation or two ago Yeah. Girls would go through puberty and have no idea what was happening. And imagine you're a little girl and you go to school one day, and then you just start bleeding.

Of course, you think, my god. I'm dying, or something's terrible. So that conversation

Dr. Mark Hyman
would never talk to them.

Dr. Sharon Malone
Never said a word. Didn't understand pregnancy. Didn't understand what led to what, and that's why you saw so many young girls who did not understand. Well, imagine that was how that phase of life was even dealt with. And, you know, we've said, you know, probably not a good idea.

And we've evolved, and we make sure that young girls understand the transition so they know how to prepare for it. They're not it's not something that's alarming. Okay? That's the good news. Yeah.

Then you make it through your your, what I call premenopausal years Yeah. Which really starts at puberty and goes for most women until their mid thirties, maybe early forties. That's premenopause. And your peak reproductive years are somewhere probably in your twenties and early thirties. Okay?

Then there's this thing called perimenopause. And if you think about it, it's that same transition. Like, you have to transition from being prepubertal to puberty. When you're perimenopause, you're transitioning from your reproductive years to your post reproductive years. And that process is what women have been left in the dark about.

Because you think you just go from one to the other. No. It's a years long process. And for some women, it can take as long as a decade. For black women, perimenopause starts earlier.

It lasts long Yeah. Up to a decade. And to not be prepared and when there's so many symptoms you can have during perimenopause, many of which we associate with menopause, but they start happening much

Dr. Mark Hyman
sooner. Misdiagnosed.

Dr. Sharon Malone
Right. And you think, oh, I'm depressed or I'm anxious. I can't sleep. Or, you know, I I changes in my libido. All of these things start to happen that really are divorced from what's going on with your period.

So you think that you know, everybody associates menopause with, okay. I'm not gonna get my period anymore. Well, what if all the symptoms of menopause can start showing up a decade before? You can see how there was confusion, and you get misdiagnosed. If you're depressed, here's an antidepressant.

Oh, I'm, you know, I can't sleep. Here's a sleeping pill. We sort of have been picking off women's symptoms one at a time without understanding that it all sort of falls under this rubric. And and women would be, I think, much more tolerant and I think much less distressed if they just understood it's a natural process going from one place to the other. And and once you get to menopause and so we've gone through premenopause.

Now we're in perimenopause, a transition of a years long transition. And then once you get to menopause, that just means that's the end of your fertile period. No more.

Dr. Mark Hyman
And, technically, it's defined as a year from your last period.

Dr. Sharon Malone
Yeah. And you know what? I don't that that

Dr. Mark Hyman
Isn't that what I learned?

Dr. Sharon Malone
Yeah. It is. That is that is what I learned as well. But in today's world, that definition is so woefully inadequate because it implies that you're not menopausal until you've gone three hundred sixty five days. And it's like, no.

You were menopausal at whatever moment it started.

Dr. Mark Hyman
Right. But

Dr. Sharon Malone
that is just the marker by which we divide and say Yeah. If you bleed more than a year after your last period

Dr. Mark Hyman
Yeah.

Dr. Sharon Malone
And you start, then that is the time that we should investigate that bleeding.

Dr. Mark Hyman
Right.

Dr. Sharon Malone
But it has no real

Dr. Mark Hyman
Because it could be uterine cancer or something else. Right?

Dr. Sharon Malone
But it has no biological significance, really.

Dr. Mark Hyman
That that

Dr. Sharon Malone
You know? It's just how we look at it. But there's so many ways to be menopausal that really don't tie to that at all. Well, a lot of women have IUDs. Guess what?

You have an IUD. You haven't had a period in years. How do you know? Women have had ablations. Women have had hysterectomies.

Dr. Mark Hyman
Is when they when they cauterize the inter side of the uterus if you have heavy bleeding so you don't keep bleeding.

Dr. Sharon Malone
So there are or you've been on birth control pills. There are a lot of different ways that, you know, you can go through that transition, and it has no bearing on what's going on with your menstrual cycle. So that's where I think we have to change that definition because it really doesn't work.

Dr. Mark Hyman
Also, like, medicalize a lot of things, so we we basically it it it changes the natural Yeah. History of these things.

Dr. Sharon Malone
Yeah. And then and then once you get to menopause, and this is just my little, you know, pet peeve. I don't like the term postmenopausal. I don't. Because once you're menopausal, and if we define that as, you know, no longer the end of your fertility, either naturally or otherwise Yeah.

You're menopausal. Saying that someone is postmenopausal implies that whatever the whatever goes on in menopause stops after your symptoms stop, and they don't.

Dr. Mark Hyman
Well, let's talk about let's talk about this because I think I think there's I you're right. Like, I've seen women, you know, just go through with no symptoms and then

Dr. Sharon Malone
Mhmm.

Dr. Mark Hyman
Fine and everything's great. I've seen women start, you know, like ten years before and having, you know, all these disruptions and symptoms, hot flashes, vaginal dryness, libido changes, mood changes, sleep issues, and and irregular periods, heavy periods, you know, just every kind of symptom you might imagine. And and they're often, like you said, very dismissed, or they're medicalized and treated as something else, or they're not, I think, adequately sort of diagnosed or treated. So so can you talk about how how this whole process of menopause affects every organ system in the body, not just reproduction, and what the consequences are if it's not handled properly in terms of in terms of the long term risk of disease, in terms of the short term symptoms that women have to suffer from. I I personally believe it's criminal to not take care of women in a way that relieves their suffering because we have the tools.

We know what to do, and there's so many women walking around with so much suffering from all these hormonal dysfunctions that we know what to do with.

Dr. Sharon Malone
I think that you're right. Women have been, you know, like I said, in terms of neglected, in terms of their symptoms, minimized and dismissed. That's a given. But when you get to this point in life, we have looked at the hormones or lack thereof or even this transition as being just about reproduction, and it's not. You know, women make estrogen in a cyclical fashion throughout their lives once they once they finally get their periods.

And that estrogen affects every major organ system in your body, and it starts with your brain. Your brain, your skin, your hair, your eyes, your heart, your bones, you know, your vascular system. And we have not really looked at menopause through the wider lens. We've looked at it from a very narrow prism, you know, only as it, affects the reproductive system. And, oh, yeah, by the way, now we know that it that it affects bones, But we're kinda late to the game in term in terms of getting to the the real effects on what hap what's happening to women's brains.

And that goes back to what I was saying earlier is that people haven't been asking the questions. We just sort of accept that as, oh, well, is this getting older? And it's not just getting older. It's that change in your reproductive system.

Dr. Mark Hyman
So so kinda kinda highlight the, like, the major cyst symptoms that that women might experience.

Dr. Sharon Malone
Mhmm.

Dr. Mark Hyman
And then and then talk about, like, the consequences of of not adequately treating women with the right types of hormone therapy. We're get into what that looks like.

Dr. Sharon Malone
Well, let's let's start with the one that everyone knows, hot flashes. You know, hot flashes is the most common. Eighty percent of women will going through this perimenopause and menopausal transition will have hot flashes. Twenty percent don't. Lucky you.

But hot flashes themselves have been treated as, as jokes. Oh, here's a woman. She's flashing. You know? Look at her.

You know? And women were embarrassed

Dr. Mark Hyman
Yeah.

Dr. Sharon Malone
By hot flashes. Yep. This is why I say hot flashes are not benign. Because if you have hot flashes and night sweats, well, what does that mean?

Dr. Mark Hyman
Can't sleep.

Dr. Sharon Malone
You can't sleep. You can't sleep. Guess what's happening to you the next day? You're you're in a bad mood. Your brain is foggy.

We've been residents. We all know what it feels like to not have a night's sleep. You're not in your best frame of mind the next day.

Dr. Mark Hyman
Criggy. But

Dr. Sharon Malone
and then sleeplessness increases your risk of mood disorders. It increases your risk of hypertension. It increases the risk of of of maladaptive behaviors. Because when you feel bad, you self soothe or Medicaid.

Dr. Mark Hyman
Or how your relationships are.

Dr. Sharon Malone
You drink. You overeat. You do all of these things. It also people who have really, severe hot flashes, you know, these are things that increase your risk of cardiovascular disease down the road. Oh.

Oh, absolutely. Type two diabetes, sleeplessness, all of these things go up in women because of the the downstream effects of the hot flashes.

Dr. Mark Hyman
Don't sleep, you crave more carbon and sugar.

Dr. Sharon Malone
Exactly. I

Dr. Mark Hyman
know that one.

Dr. Sharon Malone
I was gonna say, we we understand that.

Dr. Mark Hyman
We're in the emergency room, like, 2AM, and the only opening is McDonald's. And I I would go and get the apple turnovers because I needed some sugar.

Dr. Sharon Malone
Because, you know, you get it. Because, you know, when I was a resident, I used to say the same thing. I can only I can't be hungry and sleepy. It's like one or the other. So you're gonna do something.

I'm gonna drink Coke. I'll drink whatever it is to to keep make myself feel better in the short term even though it's has not good effects later. But those are the kinds of things that we that we talk about when we're talking about cardiovascular disease in women and why it goes up. And it and the cardiovascular disease, risk does not go up for women until after menopause.

Dr. Mark Hyman
Mhmm. Mhmm.

Dr. Sharon Malone
Before that, that's why we've also lived with this notion that women don't, don't experience heart attacks and cardiovascular disease at the same rate as men. We do. It's just ten years later

Dr. Mark Hyman
Yeah.

Dr. Sharon Malone
Because of what is happening with menopause.

Dr. Mark Hyman
And so so women are having all these symptoms.

Dr. Sharon Malone
Mhmm.

Dr. Mark Hyman
And, you know, they get vaginal trinus. They get libido. They get mood changes. They have sleep issues, and it it really impacts their life. And, you know, my experience, you know, treating women more nutritionally with lifestyle is that those those modalities are so helpful.

Like, if women smoke, if they drink, if they don't exercise, if they eat tons of sugar, if they have so much stress, if they're, you know, exposed to a lot of environmental toxins, all these things disrupt hormonal function and balance, and they exacerbate symptoms. So there's a lot of even aside from just giving that hormone prescription, there's a lot of things that that women can do to reset their hormonal balance and feel better. Sometimes that's enough, sometimes it's not. Mhmm. And and so if we do all those things, and I've written a lot about that, and I'm sure you talk a lot about that as well.

When women need to start thinking about hormone therapy, can you help us kind of frame how they should start thinking about it? Because you know, my my this is, again, my understanding in looking at the literature is that the hormones that were were pushed on women, which is prescription Premarin, which is pregnant mare's urine, that's why they call Premarin pregnant mare's urine, which is conjugate estrogen, has very different biological effects than bioidentical hormones. It increases inflammation, increases triglycerides, it increases clotting risk more than than other forms of hormones that are what the body actually makes. And the same thing with the with the synthetic progesterone or progestins like Provera, which my joke was it makes women depressed and have facial hair and gain weight. So it makes them fat, hairy, and depressed.

So I don't like that. And and so I found that using using a very more a more nuanced approach to hormones where it's it's personalized, where it's often topical, not going through the liver, where it's as as low dose as possible to achieve the effect, where it's in the bio identical forms often works better. There's there's, you know, FDA approved versions of those, and there there are things that I tend to lean on more. And I'd love to hear your perspective on how you think about it because there's vaginal estrogens, there's topical estrogen, there's testosterone being used for women. There's so many people having questions about this.

I would really love to hear as an expert how how you think about this this approach. This is just a one size fits all. Okay. Your menopausal, permanent, primary, see you later. And if it doesn't work, good luck.

Dr. Sharon Malone
And, you know, I'm gonna take an unpopular position here because I'm gonna take the privilege of age. Because when when I started because, you know, I feel like I have seen every permutation of hormone therapy that there is.

Dr. Mark Hyman
Of course.

Dr. Sharon Malone
When I started, in 1992

Dr. Mark Hyman
Uh-huh.

Dr. Sharon Malone
I inherited a practice from two 70 year old men.

Dr. Mark Hyman
70?

Dr. Sharon Malone
70. Oh, yes. Yeah. They were they so they were prescribing hormones in the sixties. Imagine this.

So I'm a brand new resident, you know, and I know what I know, and, you know, you're never more sure of yourself

Dr. Mark Hyman
than Oh, yeah. You know everything when you finish residency.

Dr. Sharon Malone
I'm I'm good now. And I had these women day one Yeah. Who were 80 years old, who'd been on hormones since 1969.

Dr. Mark Hyman
Yeah.

Dr. Sharon Malone
And I was like and I was appalled because I was like, oh my god. Then we we had just sort of figured out that you can't give estrogen by itself to women who have a uterus. Remember that the add the addition Mhmm. Of the progestogen was a relatively recent, you know Yeah. Onset.

So that happened, like, in the eighties. And when I saw these women who had been on Premarin for thirty years, I was like, oh my god. They're, you know, they're all gonna die.

Dr. Mark Hyman
Well, because just for people listening who don't know, if you give what we call unopposed estrogen, unopposed by progesterone, it increases the risk of uterine cancer. Cancer.

Dr. Sharon Malone
Yeah. That's exactly right. And guess what? They were all fine. You know?

I came in, and I would say, oh my god. I'm the new doctor, and they've been seeing this doctor for thirty years. And I say, well, we've gotta add a progestin and you know? Right on. And they were quite reluctant, but I convinced most.

But the point is, I've seen women who've been on Premarin for thirty years, and they were doing fine, and they were great and didn't you know, and weren't bent over. So yay for that. And then when we got to by the time I started, we did have we had bioidentical estrogens then. It was another name brand. It was Estrace, which was estradiol.

Dr. Mark Hyman
Right.

Dr. Sharon Malone
And we had Premarin. Premarin had a better name recognition. It was a bigger company. And

Dr. Mark Hyman
More marketing.

Dr. Sharon Malone
Yeah. Definitely better marketing. And so Premarin had been the hormone that we had been using for the longest since 1942. Okay. So my objections to Premarin, have little to do with the effectiveness of

Dr. Mark Hyman
Premarin. It

Dr. Sharon Malone
works. It works. And For symptoms,

Dr. Mark Hyman
but it causes other downstream problems.

Dr. Sharon Malone
No. No. Not necessarily. Because even the women's health initiative, all of the positive things that we know

Dr. Mark Hyman
Sure. Bone health

Dr. Sharon Malone
Yeah. Brain

Dr. Mark Hyman
health. Yeah.

Dr. Sharon Malone
Comes from Premarin.

Dr. Mark Hyman
Yeah. For sure.

Dr. Sharon Malone
That was the only medication used in that study. So, you know, I think before we say, oh, you know, Premarin's terrible. No. It's not. It's estrogen.

It works you know, it has different combinations of estrogen. It's not bioidentical. However, all of the good things that we know about what hormone therapy does really comes from Premarin, And we've extrapolated a lot of that data to estradiol because remember, there's not another big large scale study after that. Right. So that's one.

And

Dr. Mark Hyman
that that's my beef. I wish that the Women's Health Initiative used bioidentical hormones.

Dr. Sharon Malone
I I

Dr. Mark Hyman
really wish it did. And there are some smaller studies that have. Right. And they and they actually are

Dr. Sharon Malone
Right.

Dr. Mark Hyman
Do show benefit.

Dr. Sharon Malone
And I don't disagree because, you know, even then, I didn't use Premarin nearly at the rate that my predecessors did simply because and, again, this is personal. It has nothing to do with this. I didn't like the fact that it came from pregnant mayor's urine.

Dr. Mark Hyman
Right.

Dr. Sharon Malone
You know, I'm like, well, okay. You can get one from horse's urine or one that's not. Okay. I would choose the one that's not.

Dr. Mark Hyman
Yeah. Yeah.

Dr. Sharon Malone
But that's the that was my objection. And then also there's cost. You know, because Premarin is branded. It always has been and probably always will be, so it's much more expensive than others. Mhmm.

And then when it comes to, what we know about the, the women's health initiative, When when we look back and we look back now, we have twenty two, twenty three years Mhmm. Of of data to look over, we found that, okay, it's not the estrogen. Oh, look at that. Estrogen doesn't cause breast cancer. Estrogen doesn't cause a lot of the negative things that we have been ascribing to hormone therapy.

We said, well, then if it's not the estrogen, it must be the progestin. It must be that nasty little Provera that was in that pill that the women were taking. Mhmm. And to that, I would say, yes and no. You know, I I would say all things being equal, I would take the bioidentical.

But what we also have to eliminate is some of the fear moving forward because micronized progesterone is great if it works for you. Mhmm. Some people don't tolerate Mhmm. Micronized progesterone. So if you don't, I don't want women to sort of get into this notion or even doctors to feel like progestin's bad.

It's so bad. No. It's not. It's, you know, it's a different one. It works for some people.

The majority of women will should and probably could use bioidenticals. But don't take that off the table, because if you do, you're sort of doing the same thing that

Dr. Mark Hyman
Well, you have a tool kit. You have a tool kit, right, with a lot of different tools.

Dr. Sharon Malone
A lot

Dr. Mark Hyman
of different hormonal applications Right. Variations in the formulations, the types of estrogens. Exactly. You can use estriol, estradiol, know, estrone, all these different ones that are available for people. And there's, you know, obviously, the synthetic progesterone or progestins and natural or bioidentical progestins.

But I I think that that the question is when you're when you're working with a woman, how do you how do you start to think about when and what to do? Because when when you look at the data, they do seem to there's some new data that seem to have that it's better to start at different times if you wanna get certain benefits. And, you know, the the thing that just maybe we should just unpack is this this black box warning that came from the FDA because it's what what got people really scared. And I remember because you I was practicing really heavily with women that that during that time when when that study came out, and it stopped the study. They literally stopped the study because they were concerned about the harmful effects, so they had that's a that's a big deal.

And overnight, I think fifty million women stopped hormones, which created a, you know, a catastrophe in the country.

Dr. Sharon Malone
How well I know.

Dr. Mark Hyman
Yeah. Right? And so we kinda had a backlash.

Dr. Sharon Malone
Yeah.

Dr. Mark Hyman
Now we're kind of coming back to a more coherent way of thinking about it. And and I'd like you to unpack, you know, how you think about prescribing hormones and which hormones and for whom and what the benefits are because the Women's Health Initiative did show that increased stroke and increased heart attack. And and there were some

Dr. Sharon Malone
Did it, though? Did it?

Dr. Mark Hyman
I mean, that's what they said. Right?

Dr. Sharon Malone
That's that's what gonna tell you it didn't really say that.

Dr. Mark Hyman
Because the the the effect sizes were small or the

Dr. Sharon Malone
The effect sizes were small, and they were as prescribed. Remember, the women entering the the, women's health initiative, the average age was 63. Yeah. You could be anywhere from 50 to 79 years of age to be in that study.

Dr. Mark Hyman
Mhmm.

Dr. Sharon Malone
They didn't really even say, alright. These are women who've never had hormones before, and now we're gonna give some hormones and some not. The criteria for entering and being randomized, you just had to not have taken hormones for three months Yeah. Before entering the study. Do you see what I'm saying?

So the population was really murky. They were too old.

Dr. Mark Hyman
Yeah.

Dr. Sharon Malone
That's not how we're prescribing today. We prescribe what we do know is that the earlier you start treatment, the more long term benefit you get. I I

Dr. Mark Hyman
riskier to start it when you're older?

Dr. Sharon Malone
Well, yes. There are some you get less benefit. And I and I don't think it takes any leap of faith to understand that if the the purpose of the women's health initiative was to sort of sort of figure out whether or not the hormones really were the the secret sauce in reducing the cardiovascular disease. Because when the women's the when the nurses study, fifty percent decrease in the in the heart disease in in the women who took estrogen. Yeah.

Okay. Is it that, or is it something else? And to have women come into the study at 79 years old, I think we can all agree that it doesn't matter what I give you. The that horse is out of the barn by then. Right.

And by having too many women who already had established heart disease, well, how are you gonna prevent something that you already have?

Dr. Mark Hyman
Yes. Like, they it's like they didn't they didn't do angiograms on everybody and see what their hearts look like. Yeah.

Dr. Sharon Malone
Exactly. So when you stratify even the women's health initiative, when you looked at the younger women who were in the minority, but the younger women did not have an increase in the risk of cardiovascular disease. All of the bad things the only finding from the Women's Health Initiative that was statistically significant was there was an increase in the risk of blood clots.

Dr. Mark Hyman
Yeah. Blood clots. But that doesn't a heart attack is a blood clot. Right? In the heart.

Dr. Sharon Malone
But but we yeah. But that's separate this is listed as separate in part because it's DVTs or deviant thrombosis or pulmonary emboli, and that was reported separately.

Dr. Mark Hyman
But estrogen does mechanistically cause an increase in clotting risk. We know that.

Dr. Sharon Malone
Yes. Yes. It does. However, again, perspective matters. You need to know to say some to someone that it's a 50% increase or a 100% increase, well, what's the baseline?

Mhmm. You know? And what we do know is that for women who start estrogen, even oral earlier, when you're forties or fifties when you start, that increased risk of blood clotting that we don't have it. We don't see it. It happens when you're older.

And so a lot of the findings from the women's health initiative that were negative, even the the the cardiovascular disease was elevated, but only in the first year and not after that. Because, again, you're probably giving something to women who already have fairly advanced

Dr. Mark Hyman
heart disease. Breast cancer risk?

Dr. Sharon Malone
The breast cancer.

Dr. Mark Hyman
Because that's what that's what frees men out.

Dr. Sharon Malone
That is the number one reason why women avoid hormone. They the oh, cardiovascular risk. I don't care about that.

Dr. Mark Hyman
Yeah.

Dr. Sharon Malone
It's the breast cancer. That was the that was really the nail in the coffin.

Dr. Mark Hyman
Yeah. Because it did show some increased risk. Right? That's what they reported at

Dr. Sharon Malone
least. Let me let me

Dr. Mark Hyman
tell you. Right. That's what the that's what the public said understood for this year.

Dr. Sharon Malone
Trust me. I've been in this I've been in the weeds on this for

Dr. Mark Hyman
so long. I'm just I'm just framing it so people know it's not like I'm Right. I'm not just saying I'm

Dr. Sharon Malone
like No. No. No. No. It's That was that was what they held.

Dr. Mark Hyman
That was the headline.

Dr. Sharon Malone
Conference. That was the press conference. Oh, not only does this you know, they held a press conference just when they stopped the Women's Health Initiative to say, oh, not only does it not help your heart, it increases your risk of blood clots and heart disease and strokes, and it went on and on and on. Well, that's very scary. And I would challenge anyone to, to give me another example of when the NIH the regulators of NIH held a press conference to announce a study.

I mean, that's how big of a deal they thought that was. And I'll also mention that Bernadine Healy was not there at that time, so we're gonna give her a pass on that. Okay. But but here's the breast cancer story. And I will I will say this.

The data is the data. You don't get to change the data because you don't like it. Okay? You can change your interpretation of the data, but it is what it is. But let's take it at face value.

What did the Women's Health Initiative say about women who took estrogen, the Premarin, and the Provera? Alright. They reported there was a twenty six percent increase in the risk of breast cancer in estrogen and progestin users versus nonusers. Twenty six percent. That sounds terrible.

Yep. Who wants that?

Dr. Mark Hyman
It's relative risk.

Dr. Sharon Malone
Right. But what did that mean in real terms? That means for women who did not take estrogen and progestin, thirty the natural incidence is about thirty per ten thousand women per year will be diagnosed with breast cancer, living long enough to get it. In the estrogen and progestin user group, it went from thirty per ten thousand women per year to thirty eight per ten thousand per year with no increase in the risk of dying from your breast cancer even if you were diagnosed on hormone therapy. So let's make that sound a little better.

Alright. Eight per ten thousand additional cases of breast cancer.

Dr. Mark Hyman
Six percent.

Dr. Sharon Malone
That's twenty six percent. Right. With no increased risk of dying from it. And then make it even better. Less than one in a thousand additional cases of breast cancer Yeah.

In the women who took estrogen and progestin. Now that doesn't sound nearly as scary as twenty six percent.

Dr. Mark Hyman
Correct.

Dr. Sharon Malone
But that was never really put into perspective.

Dr. Mark Hyman
Like, what was I think Mark Twain said there's lies or damn lies or the statisticians.

Dr. Sharon Malone
Exactly. And, you know, and there is, and and when you put it that way, you say, oh, okay. Well, eight in a thousand, but I'm no like no more likely to die from it even if I'm taking hormone therapy. And even that statistic itself and you and I know in a medical study, if you were going to report a finding, to call it a finding, it has to be statistically significant. It was not statistically significant.

Yeah. But that stuck like glue. It's still with us today because doctors and patients still believe that it that a family history of breast cancer is a reason not to take hormone therapy. So that's just said, worst case scenario, let's, you know, put it on blame the old bad Premarin and Provera. Even that did not statistically increase your risk of breast cancer.

And that is what has taken a long time for people to to really understand those numbers. And because I remember the day that came out, it was 1992, and I had been prescribing for ten years well, 2002. And I had been prescribing for ten years before that.

Dr. Mark Hyman
Yeah. Me too.

Dr. Sharon Malone
And patients were horrified. Oh, doctor. I can't believe you're trying to kill me with this stuff. And when I read the study, I said, wait a minute. It's not as bad as what they said.

Yeah. And, again, remember, applying that data again, take it as it is. You can't apply that the same data from 79 year olds and 65 year olds to 45 year olds. They're not the same.

Dr. Mark Hyman
So let's talk about that because I think that I wanna really help women understand our newer thinking and what the newer data is around what to start and when because it has implications for brain health, for bone health, for heart health, for overall symptom reduction. The black box warning I wanna talk about before we dive into all that.

Dr. Sharon Malone
Mhmm.

Dr. Mark Hyman
Because that that's recent. It's a black box warning for people who don't know what that is. The FDA puts a black box on the drug label that says, if you're taking this, beware because it can cause x, y, or z. So the black box warning for hormone therapy was what?

Dr. Sharon Malone
Warning, Will Robinson. It will increase your risk. See, only you and I get that.

Dr. Mark Hyman
Lost his face.

Dr. Sharon Malone
But it will increase your risk of heart attack, of stroke, of dementia, breast cancer. Now if you picked up your medication from the pharmacy and they said, wow. My doctor didn't say that to me. Even for the patients who had an adequate discussion about it Yeah. They would read that warning, go take it home, and not use

Dr. Mark Hyman
black box says heart attacks, strokes, cancer, and dementia.

Dr. Sharon Malone
Dementia. Yeah.

Dr. Mark Hyman
That sounds fun.

Dr. Sharon Malone
That's that's pretty that's pretty discouraging, I would say. And and as I said, going back to the original study, it never it they remember I told you the only statistical finding that was significant was blood clots. Yep. Yep. So how can you say all those things?

So my point is

Dr. Mark Hyman
that And that was removed just in 2025.

Dr. Sharon Malone
Well, I think it may be just off now because I think, you know, they had to go through all the inventory, the stuff they already added on there. Yep. But now it's off, and it's in the regular package insert. You know, every drug has, you know, risks and and and and side effects that are listed in that long Yeah.

Dr. Mark Hyman
Like it's like thin paper that you could fold out, and it's, like, got 40,000,000 words

Dr. Sharon Malone
on it. Very small print.

Dr. Mark Hyman
Yeah. Yeah.

Dr. Sharon Malone
So it's in that part now. It's not on the box. Yeah. And that's what we're like it it took an act of, I don't know, whatever, to get people to to realize it's like, no. Don't say that because you can't.

That's not science.

Dr. Mark Hyman
Given that's true, let's talk about the the plus side here.

Dr. Sharon Malone
Mhmm.

Dr. Mark Hyman
Because I don't I said earlier, I don't think women should have to suffer from hormonal dysregulation and symptoms. We have a lot of understanding about what causes it from a lifestyle perspective, including things that are not really being well addressed in medicine, whether it's the microbiome or environmental toxins, because those do play a role. We know nutrition plays a role, exercise, sleep, stress, all those things, smoking, alcohol. People understand those. But, you know, what are what are we thinking about now as the right way to approach hormone replacement therapy?

When should we start it? How long should it be given? What are the right formulations that work best? What are the options for women out there? I wanna sort of dig into all this with you.

Dr. Sharon Malone
Okay. Well, this is the

Dr. Mark Hyman
Like, kind of where the rubber meets the road.

Dr. Sharon Malone
So perimenopause does not have a bright line that signals when it begins. A lot of it depends on, again, lifestyle. It's genetics. It's, you know, personal to you. So someone may be perimenopausal at 35.

Someone else may be perimenopausal starting that process at 45. And there's no blood test that's going to tell you yes or no, you're in perimenopause. Perimenopause is a clinical diagnosis. So remember all those symptoms that we said, hot flashes, mood swings, night sweats, sleeplessness, you know, weight gain, all of those things that we associate with menopause Mhmm. Can start in perimenopause even while women's periods are relatively regular.

And perimenopause actually has three stages itself, early, mid, and late perimenopause.

Dr. Mark Hyman
Yep.

Dr. Sharon Malone
Now the question is, if I can't diagnose it by blood tests and I can't really use periods as a you know, as the defining factor of when to start, then how do you decide?

Dr. Mark Hyman
History. History. History.

Dr. Sharon Malone
The patient will tell you when she's perimenopausal. If she if you're having any combination of those symptoms and they are bothersome to you, then that is the time you start treatment. And we do have fairly robust data that says, even from the Women's Health Initiative and some other studies, that say to get the maximum benefit, the earlier you start in this process, the more long term benefit you're gonna get. But how we choose to treat those symptoms during perimenopause, well, again, it will depend. It depends on what your other symptoms are.

It may be you have bleeding issues. Maybe your someone else has more sleep issues. In that case, maybe I'll start with progesterone. So that is where Right. This is the art of how to prescribe.

There is no one way to do it. You know the basic components. There's estrogen, and there's a progestogen. But the mix depends on what your symptoms are, how old you are, and what we're trying to fix. Maybe you're 37 years old, and you're having these things, and you need birth control.

Well, that's a case where we might use a birth control pill because it has estrogen and progestin in it. But that's why I said, it depends. But remember, I want, women to understand that it's a clinical diagnosis. If you are feeling that way, a lot of women will go to the doctor, get a blood test, and be asked the question, when was your last period? And you'll say last month, and they'll go, oh, well, it's not perimenopause.

Come back three hundred and sixty five days after you have an adenocarcinoma.

Dr. Mark Hyman
Right. Because they don't because we're not really trained well in this in medical school

Dr. Sharon Malone
Right.

Dr. Mark Hyman
And in residency. Even even OBGs, my end side, I don't think really have the right understanding of it.

Dr. Sharon Malone
A lot of what I learned, about this was really through not just what I learned in residency. We were taught more about it in OBGYN, but it also is trial and error process. The experience of say, oh, well, that didn't work. Well, let's try this. But knowing that you have the full complement of estrogens and progestins.

Okay.

Dr. Mark Hyman
Well, let's let's bifurcate this into symptoms Mhmm. And disease prevention.

Dr. Sharon Malone
Mhmm.

Dr. Mark Hyman
Because on the other side of menopause, it is heart disease, breast cancer

Dr. Sharon Malone
Osteoporosis.

Dr. Mark Hyman
Osteoporosis Mhmm. And dementia. Mhmm. Because women experience that at a far higher rate. Mhmm.

So I wanna I wanna bifurcate it just

Dr. Sharon Malone
for Okay.

Dr. Mark Hyman
For making people understand a little bit. How do we how do we really understand this perimenopausal period? Because when I, you know, when I've been treating women, I I find that, you know, the the lab tests you're right can be all over the place. Like, one day they're look like they are, and one day they're not. And but I do often see this this interesting phenomena that I want you to talk about, which is is this this sort of reduction in the progesterone in the second phase of the menstrual cycle.

We call this the luteal phase. Mhmm. So we see higher levels of estrogen Mhmm. And we see lower levels of progesterone. Then you get this imbalance.

Dr. Sharon Malone
Mhmm.

Dr. Mark Hyman
And when you have high levels of estrogen, it causes more body fat. It causes more heavy bleeding. In in in in when you have for example, if you're overweight, if you eat a lot of sugar, it it causes a lot of estrogen in the body. I've seen this over and over.

Dr. Sharon Malone
Mhmm.

Dr. Mark Hyman
And and so you get this sort of imbalance, and that causes a lot of these heavy bleeding symptoms and really heavy heavy cycles and things that we often see. So I would love you to sort of talk about that that phenomena or if you if you think it's not a thing, because I I think it's a thing.

Dr. Sharon Malone
No. I I think that you you're right. What's happening is is not inaudible cycles. Right. If you're looking at cycles, you're saying that the the reason why when you're in perimenopause that the estrogen levels will sometimes overshoot Yeah.

Is because normally, it's limited by the amount of estrogen you make is limited by ovulation. So since so many of perimenopausal cycles are anovulatory, which means they get started, but you don't ovulate. That's also why your fertility is not good. Yeah. But you'll have too much estrogen in the first half of the cycle, and the progestin the progesterone that happens in the second half of the cycle only happens after you ovulate.

Dr. Mark Hyman
That's right. That's what I'm getting at.

Dr. Sharon Malone
So when you don't ovulate, you your estrogen keeps going, and then now you don't have that. That's why having someone who understands that says, well, if this person maybe giving them additional estrogen at this point is not helpful. Maybe we need to supplement with progesterone.

Dr. Mark Hyman
Test can help because you can see if you do it in day eighteen to twenty three in that luteal phase of the second half of the cycle, you see, oh, god. Their estrogen's really high, but their progesterone's kinda low

Dr. Sharon Malone
But you know what?

Dr. Mark Hyman
Should be.

Dr. Sharon Malone
Right. But you know what? This is what I would say. An experienced doctor doesn't even need lab If I can tell by your history, if you come in and you say, god, my periods are going on for two weeks, and I'm heavy bleeding. Okay.

Dr. Mark Hyman
Or they're longer.

Dr. Sharon Malone
Right. Right. Whatever the whatever the blood test Right. Shows me, ultimately, what I'm gonna do is I'm gonna treat the patient and her symptoms.

Dr. Mark Hyman
Right.

Dr. Sharon Malone
I'm not gonna alter it based upon what her blood results were. I can't you you know you can figure that out. Yeah. So that's why I said it depends on what symptoms you're trying to treat. If you've got hot flashes and sleeplessness, the one thing that I will say, estrogen is the secret sauce because it will estrogen is the most effective treatment for that symptomatic menopause, vaginal dryness, you know, irritation, the mood swings.

That's that's the estrogen that is most effective. So it's a matter of playing with that and saying, okay. If someone only has one thing to give you and they're gonna prescribe the same thing if you're perimenopausal and the same thing if you're menopausal and the same thing twenty years down the road, that sort of lets you know that they haven't really, what should I say? They haven't had experience with all of the things, and you just need to know Right. What you need at that particular

Dr. Mark Hyman
Right. It's it's such an important point. It's it's personalized. It's customized. It changes at the periods of that transition.

That's really helpful for me to understand. You need to work with someone who really understands the nuance of how to understand your symptoms and what you're doing, what's going on, and how to properly address that, and and what the right combo is of of different hormones. And I'd love to sort of hear your perspective on on whether people should be using it orally, topically, if it makes a difference, if it should be bioidentical, not bioidentical, how how much that matters, how much we know about it.

Dr. Sharon Malone
Okay. So let's let's start from this place that I think more than certainly more than, fifty years ago, most clinicians are gonna start with the bioidentical. You're gonna use a bioidentical estradiol, not one of the synthetic ones. Okay? That being what it is.

And I even hate the term synthetic. They're all synthetic. It's just a matter.

Dr. Mark Hyman
It just it just it just the same molecule as your body makes. Exactly.

Dr. Sharon Malone
And bioidentical.

Dr. Mark Hyman
As opposed to pregnant nurse urine

Dr. Sharon Malone
and estrogen. Let's know you're synthetic. So you're gonna start there. Yeah. Okay.

So once you say, okay. Estradiol, it can come as a pill, a patch, a spray, a gel, or even a vaginal ring. Because a vaginal ring, can put in I think it leaves leave in for three months. No change. Those are your ops those are your those are just modes of delivery.

Mhmm. There are certain people, that a a transdermal may be preferable. If I were giving estradi if I were giving hormone therapy to someone who's a smoker, I would say, yes. Let's do a transdermal because we don't need the extra first pass in the liver effect. If, if I have someone who is not particularly compliant or they don't like to take pills or whatever, then I'll say, yeah.

Put a patch on. Once or twice a week, we'll do a patch. But, again, don't take oral off the table. Mhmm. Because the overwhelming majority of women who take oral do just fine.

Yeah. And even though the the blood clot risk is higher Mhmm. It's higher of a very small number. You know what increases your risk of blood clotting the most of anything you'll ever do? Pregnancy.

Dr. Mark Hyman
Oh, yeah.

Dr. Sharon Malone
Pregnancy, oral contraceptives, the amount of hormone that you take in in hormone therapy after menopause pales in comparison to those

Dr. Mark Hyman
two things. My daughter's about twenty six weeks pregnant now, and she called me the other night, she's like, dad, I have, like, chest pain, shortness of breath. I'm like, oh, she's an orthopedic surgery resident. I'm like, oh my god. She's like, maybe I have a PE or pulmonary embolism.

Thank god she just had heartburn.

Dr. Sharon Malone
Yeah. Yeah. And and but see, she knows to at least be alerted to that possibility.

Dr. Mark Hyman
Right.

Dr. Sharon Malone
You know? So that's why I said oral versus transdermal. And there are other things. There are other nonmedical considerations. And, you know, and I think they're legitimate.

Dr. Mark Hyman
Let's talk about sex.

Dr. Sharon Malone
Okay. Sure.

Dr. Mark Hyman
Because I think this is a big thing. Libido goes down. Vaginal dryness goes up. It's a big thing. And and you read a lot about it now.

We're talking about estrogen. We're talking about progesterone. Let's talk about testosterone and what your view is on that, how to use it, if it should be used, when it should be used. Because I personally found it extremely helpful for women. And has also another side benefits.

It increases, you know, bone health and other things. So can you talk about your perspective on testosterone for women? Because

Dr. Sharon Malone
I Okay.

Dr. Mark Hyman
It's just one of those things that's out there in the in the right now.

Dr. Sharon Malone
I I I will because I'm a little bit outside the the general conversation on that too in terms of what I think about testosterone. But let me say this. What when you're talking about libido issues, the first thing you should always address are the woman's menopausal symptoms. Because if you're hot, sweaty, sleepless, you've got vaginal dryness, and every time you have sex, have a urinary tract infection, guess what you don't wanna do?

Dr. Mark Hyman
Have sex.

Dr. Sharon Malone
There you go. You know? That so fix that first.

Dr. Mark Hyman
Yeah. So vaginal dry is super easy to fix. Even if you don't wanna take oral, you can do vaginal estrogen. There's pills that you can stick in there. There's rings.

There's creams.

Dr. Sharon Malone
That's yeah. Yeah. So everybody there. So once we

Dr. Mark Hyman
By the way by the way, that doesn't really get it systemically absorbed that much. So people are worried about Right. Breast

Dr. Sharon Malone
cancer. No systemic absorption from the amount of estrogen that's in vaginal estrogen. It's minuscule. So it works where you put it. So it will work in the vagina, near the urethra, because the urinary system is close right there next door.

Yeah. So it'll fix both of those, but you don't have to worry about overdosing. You don't have to worry about, oh my goodness. I've had breast cancer. I can't use that.

Dr. Mark Hyman
And you need to use a progesterone or progesterone?

Dr. Sharon Malone
No. No. It because there's no systemic absorption. Unless you are taking systemic estrogen Okay. You don't need to take a progesterone.

Okay. So that being said

Dr. Mark Hyman
I know that. I just want everybody else to know.

Dr. Sharon Malone
So so let's get to that. So now I have a patient, and I have addressed all of her symptoms. She's sleeping well.

Dr. Mark Hyman
She's just high.

Dr. Sharon Malone
Yeah. Yeah. No dryness. And she's just, ugh, libido still in the toilet. Yeah.

That would be an instance where some point in the future, then I would say, well, let's give it a try. Let's try some testosterone. And, again, what I want everybody to understand is the testosterone conversation is not new either. Testosterone, we had it compounded, but that's been around forever. This was you know, I was prescribing testosterone for women with low libido back in the nineties.

So this isn't like, we just discovered testosterone. But here's what I have found. And, again, this is the experience part of it. When you are treating libido, it works really well for some women and not so much

Dr. Mark Hyman
for others.

Dr. Sharon Malone
Yeah. Testosterone.

Dr. Mark Hyman
And how do you how do I mean, the problem is for men, there's a lot of FDA sort of approved Right. Formulations that you can use that are pumps, that are patches, that are, you know, injections. There's all sorts of stuff. For women, it's kinda not it just it's not not available, and you have to kinda it's the Wild West out there.

Dr. Sharon Malone
Right. Right? It's it's been up. It's been in front of the FDA a couple of times to get a female approved version of testosterone, and it's the same testosterone. It's just that a woman's dose is a tenth of what the

Dr. Mark Hyman
men's does.

Dr. Sharon Malone
So it's difficult sometimes to take the male version and tight get

Dr. Mark Hyman
a tenth of pharmacies. And yeah.

Dr. Sharon Malone
That would that's a case where sometimes we're generally speaking, I don't love compounded, but if you can't get it

Dr. Mark Hyman
Yeah. Yeah. I've used I've used compounded. And I've had even topically. Like, I've had the Yeah.

Clitoral testosterone drops, and they work really well.

Dr. Sharon Malone
Yeah. I you know, and I would argue with no one who says, I've tried testosterone, and it works really great. And I'm saying yes, then, of course. But, again, that's the phase in process. I would never start all three at once even if Yeah.

Decreased libido was one of your symptoms that you presented with because we fix one thing. And we all know that libido with women is much more complicated. It's not a plumbing issue Yeah. Necessarily. It's a lot of things that

Dr. Mark Hyman
don't People say women's greatest sex organ is between their ears.

Dr. Sharon Malone
Exactly. Exactly.

Dr. Mark Hyman
The the other thing I wanna just touch on briefly is, you know, we're in the world of Ozempic and peptides. And there's actually an FDA approved peptide for women's arousal disorder. Right? Vyleesi.

Dr. Sharon Malone
Vyleesi. And Never used it.

Dr. Mark Hyman
Never never prescribed it.

Dr. Sharon Malone
Never prescribed it.

Dr. Mark Hyman
Mhmm. Because you don't think it works or because you don't know about it

Dr. Sharon Malone
much or less. I it was you know, I when, I was practicing, we had two options. We had Addy, and we had Vyleesi. And it's the same sort of situation. I'm I'm one of those people that I'm like, show me.

Okay? And, you know, I pres I have prescribed Addi to a couple of patients. Vyleesi, when you this was now remember, this was pre

Dr. Mark Hyman
That's a pill. I mean, Vyleesi is an

Dr. Sharon Malone
injection. Everyday pill.

Dr. Mark Hyman
Yeah. And Vyleesi is an injection.

Dr. Sharon Malone
So this is pre Ozempic.

Dr. Mark Hyman
Mhmm. Mhmm. Most

Dr. Sharon Malone
people were not sold on that idea. And you could it's on an as needed basis, but every time you have to say, well, thirty minutes before you're gonna have sex, go get this take this shot, and women were like, no. Thank you. Right. So it was less you know, that's why I've had

Dr. Mark Hyman
to this, though. It does work.

Dr. Sharon Malone
And I you know what? And I

Dr. Mark Hyman
It works for men too, actually. It works for men too.

Dr. Sharon Malone
That's great if it does, but like I said, I was never able to convince someone that that was a good option.

Dr. Mark Hyman
But I have to By way, I've tried it, and I'm telling you it works. Okay. But it but I don't know how it works for women because I'm not a woman. Right?

Dr. Sharon Malone
Will take your word for it. I've I've never used it. But I I think that the libido issue for women, again, is something that's been sorely unaddressed. I think we can all agree that men's libido and their ability to perform has been an outsized conversation. And we've not really paid attention to women's libido in the same Mhmm.

With the same level of importance and the same level of distress that it causes for

Dr. Mark Hyman
No. It is. And we should. And we should.

Dr. Sharon Malone
We should do better.

Dr. Mark Hyman
So we've talked about all the vasomotor symptoms, the the the irregular bleeding symptoms, the sleep symptoms. All those can be addressed with combinations of various estrogen, progesterone, topical, oral, vaginal. Let's talk about the the the importance of understanding the timing of starting hormone therapy for disease prevention, particularly dementia. And and let's also talk about osteoporosis because, you know, people don't realize this, but, you know, if you have a hip fracture, and women get more than men because they're less testosterone, lower bone density, it's a fifty percent mortality in a year. I mean, if you get it's like cancer.

Like, if you get a hip fracture, you're likely to be dead in a year Right. Fifty percent of the time.

Dr. Sharon Malone
I I think that when we start talking about things like the long term benefits Mhmm. I think that we have fairly decent data on the cardiovascular benefit of hormone therapy, you know, that it decreases the risk of cardiovascular disease. And that's not you know, we have a lot of different not just observational studies, but we even have things with, there's the, Danish osteoporosis study was that started around the same time as the Women's Health Initiative. And when the women's health initiative shut down, they shut down.

Dr. Mark Hyman
Mhmm.

Dr. Sharon Malone
Just to go, oh, well, no need in finishing that. But we but by the time it shut down, it had ten years of data. Mhmm. And it was with bio identical.

Dr. Mark Hyman
Yeah. Right.

Dr. Sharon Malone
So yay on that. And that and that showed. It showed a decrease in the risk they had even sixteen years out, they showed that the women who were on hormone therapy had a decreased risk of cardiovascular disease. So I think that that is we've got we've got fairly good data on cardiovascular disease. Okay.

We've always had data on osteoporosis. That was one of the indications for hormone therapy. If you're at risk for osteoporosis, yes, take it. Now let's go to the dementia part of this. What we do know about dementia I'll tell you what I I'll I'll in two parts.

I'll tell you what I know, I'll tell you what I think. Okay? Right now in the current indications for hormone therapy, FDA approved, hormone therapy is approved for women who have a premature or early menopause, however you get to that place. And some women naturally have an early menopause and early, I mean, before age 45. Premature if you're menopausal before age 40.

Well, how does that happen? Naturally, sometimes you've had your ovaries out. Sometimes you've had chemo or radiation, things that sort of shut down.

Dr. Mark Hyman
Prematuring.

Dr. Sharon Malone
Prematuring. Right. Estrogen therapy and hormone replacement therapy is indicated for those women because what happens if you have an early menopause or premature menopause? You're at increased risk for cardiovascular disease, dementia, and osteoporosis. So the recommendation is not can you, but but you probably should.

Yeah. And it would be, you know, it would be considered a major misstep if someone takes your ovaries out and you're 38 years old and they do not give you hormone therapy. So Yeah. With that, we know. So let's go back to the dementia issue because there seems to be a lot of controversy about it.

Yeah. Do you know how long it would take to do a study to even if you did a randomized double

Dr. Mark Hyman
trial years.

Dr. Sharon Malone
We'd all be dead. Okay? So sometimes you have to go with the data you have. Yeah. And we infer all the time in medicine.

Mhmm. We don't we there are very few things that we have. Like, I have gold standard absolute proof that this is the case. And I don't think it's a great leap of faith to say, well, if it if it prevents dementia and osteoporosis and heart disease if you're 42, why would it not if you're 46? Yeah.

You know, you have to look at it from that point from that perspective. I think that we have some really interesting ways of looking at this now, which I think is going to help give us some data before we are all dead and gone. And that is now we have doctor Lisa Moscone who is looking at she's imaging women's brains. And she has been able to demonstrate that your brain looks different in premenopause, perimenopause, and postmenopause. She and, I think, it's doctor Rebecca Brenton are the two neuroscientists that have really delved into this to say, we can do this.

We can follow one person through perimenopause menopause and and, menopause and image that same brain so I don't have to wait Yeah. Thirty years to get that data. And so there is now concrete evidence that estrogen plays an important role in how women's brains function and what the structure of their brain looks like.

Dr. Mark Hyman
Yeah. Well, clearly, brain fog and all that Yeah. Gets better with hormones. We know that. That's symptomatically true.

Dr. Sharon Malone
So, you know, I think that, you know, if you were but but it gets back, and I'll I'll get to this. The same thing that I was saying before in that it matters when you take it.

Dr. Mark Hyman
That's right.

Dr. Sharon Malone
You can't prevent or slow down osteoporosis when you're 72, and that's why timing matters. And we've got a lot of the stuff that we talk about hormone therapy. The sooner you start it, the more benefit you get. There's no benefit in waiting five years down the road before

Dr. Mark Hyman
you start. I mean, you really talk a lot about proactive medicine. And I I I mean, I I think the guidelines for a DEXA scan is, like, when you're 60, which is insane to

Dr. Sharon Malone
me. Totally.

Dr. Mark Hyman
I mean, you should do when you're 40. Yeah. Yeah. Which is a bone density scan. I And I think, you know, even even now we're having ways of of tracking brain health through brain imaging.

I I cofound a company called Function Health, and we can do quantitative brain imaging. We can do all kinds of biomarkers that tell you what your brain health is. What what I'm curious about is if and this I think at this point, it's a conjecture opinion because the question is still out there, is why are women so disproportionately affected by Alzheimer's, and could it be because of this sudden drop in estrogen after after menopause? And and does the data show that women who take hormones and have taken them starting early? Because because if you start when you're 60, it doesn't seem to do anything.

Dr. Sharon Malone
Doesn't

Dr. Mark Hyman
You gotta start, like, early when you're right when you're menopausal. Right. Right? That's that's kind of the take home message. Like, don't wait.

Dr. Sharon Malone
I think that is definitely the take home message. Because, you know, one of the things that that the central question is, why do you know, two why are two thirds of the people with Alzheimer's in this country women?

Dr. Mark Hyman
That's right.

Dr. Sharon Malone
Why are black women two times more likely to be diagnosed with dementia than white women? Why is that? That's where you've gotta start. And if you look at just the basic things, you say, well, what happens to women in that same time period? And that is the old and it has something to do with menopause, probably something to do with estrogen, and that's what really what we're trying to pin down on that.

Because that's really the big difference between how men age versus how women age. Yeah. A lot of things start to us because when we get to menopause, our estrogen levels fall

Dr. Mark Hyman
It's like a boom. It's a boom. Gone.

Dr. Sharon Malone
Yeah. It's not a

Dr. Mark Hyman
small guys. It's kinda like

Dr. Sharon Malone
Gradual decline. No. It's gone. It's gone. It's never coming back.

Dr. Mark Hyman
Right.

Dr. Sharon Malone
So But

Dr. Mark Hyman
by the way, but just so people understand, even after menopause, women still make estrogen and progesterone. It's not that No. It goes No. We don't make Not zero.

Dr. Sharon Malone
It but it's we don't make estradiol. We make

Dr. Mark Hyman
estrone. Estrone. Right.

Dr. Sharon Malone
But that is that is something that's metabolized in peripheral fat. Yeah. So if you're a very thin, lean person, you probably don't have a lot of estrogen.

Dr. Mark Hyman
Correct. And then yeah.

Dr. Sharon Malone
Yes. Skinny old

Dr. Mark Hyman
ladies are the ones who get the fractures.

Dr. Sharon Malone
And it's much weaker. Yeah. It's a much weaker estrogen than estradiol. Yeah. Fair enough.

So, you know, there's that. But what I was saying, getting back to this brain health part of it, is that I'm willing to make I'm I'm willing to make the inference. Maybe I'm right. Maybe I'm wrong. It will not be the first nor the last time in medicine Right.

That we've made decisions

Dr. Mark Hyman
On incomplete data.

Dr. Sharon Malone
On incomplete data. You know? Sometimes we do. And I hope and I pray that I'm right, but at at a minimum, I don't think you're doing harm.

Dr. Mark Hyman
Yeah. And I now At

Dr. Sharon Malone
a minimum.

Dr. Mark Hyman
And I would just add that, you know, we now have, which we never had, you know, when you and I were starting training, tools and diagnostics to really track cardiovascular risk and breast cancer risk and things that matter. So if people are concerned about heart disease risk or breast cancer risk with hormone replacement therapy, we now have deep diagnostics for cardiovascular risk that we do at function health. For example, we look at APOB, lipoprotein A, lipid fractionation, CRP. We look at metabolic health, in a deep way insulin. These things are really important because they aside from all the hormone issues, these are the things that drive cardiovascular And then the same thing with with breast cancer.

Now we have tools that, you know, whether it's mammograms or breast MRIs or even new liquid biopsy tests, there's more more tests emerging that are, you know, proteomic testing for cancer and other, you know, DNA kind of fragment testing that's available through liquid biopsy. So all this is iterating really fast. So I I think, you know, it's it's important for women to sort of track it, not just go, oh, it's fine, but to track their health over time and to see longitudinals happening. And even I think when they get their GYN exam to get a uterine ultrasound and make sure the uterus is okay and everything's okay because, like, you know, these things like uterine cancer and even ovarian cancer now with some of these, you know, liquid biopsies and other tests, we can start to start to track these things. So I think given the kind of constellation of advanced diagnostics that are here now and that are coming soon, it it gives me a lot more, I would say, peace of mind

Dr. Sharon Malone
Mhmm.

Dr. Mark Hyman
To to kind of even move forward with with with the set of incomplete data that we have.

Dr. Sharon Malone
We can't wait to

Dr. Mark Hyman
I agree. I agree.

Dr. Sharon Malone
To to give people the information. But, you know, what you and I agree on most is the idea of prevention. Yeah. You know, I I think that, you know, I I I wrote a book called Grown Woman Talk. It's not just about menopause, but it's about all the things that affect women in

Dr. Mark Hyman
men's lives.

Dr. Sharon Malone
Yeah. And at the end of every chapter, I'll give a list of things that these are things you do. I talk about cardiovascular disease. I talk about cancer. I talk about, you know, breast cancer and the chronic stresses and hypertension and diabetes.

At the end of each chapter, it's almost the same thing. Don't smoke. Limit your alcohol. Exercise. Eat a healthy diet.

Mhmm. And get a good night's sleep. Mhmm. Duh. Whether you are it doesn't matter what you're trying to prevent.

Breast cancer, colon cancer, dementia Exactly. The same basic things go into that. Exactly. You know, because that's just a recipe for healthy living Yeah. And quality living, we hope, as we age.

Dr. Mark Hyman
And Yeah. It's not like you're gonna take hormone therapy and everything's gonna be mine. You can live a crappy lifestyle. You gotta do it all.

Dr. Sharon Malone
Right. It's a both and. You know? That's not gonna you know? And you can have all the the the great, you know, molecular genetic testing in the world, and something else will still come up and bite you.

So you gotta just be able to say, you know, there is a limit to what we can predict. And I I use my mother as an example. My mother grew up in rural Alabama. She grew up on a farm. Okay?

I don't think my mother ever ate a nonorganic thing in her life. In her life.

Dr. Mark Hyman
That's right. That's right.

Dr. Sharon Malone
My father grew vegetables.

Dr. Mark Hyman
That's right.

Dr. Sharon Malone
We you know, that's how we ate growing up. My mother died of colon cancer. But my mother died of colon cancer not because of something she did that was wrong. It was she died of colon cancer because colonoscopies weren't a thing.

Dr. Mark Hyman
Right. Right.

Dr. Sharon Malone
You know? To in today's world yes. So we have to take the the two together. We take the technology and the science and the knowledge that we've acquired with healthy living. Because I don't want people to think that that you have you don't have complete control over anything as far as your health.

You can minimize your risk. Yeah. You can never eliminate it. No.

Dr. Mark Hyman
Well, it's such a great conversation, Sharon. I I appreciate all your dedication over the years. People, you know, can learn more about your work. They you have a podcast, Second Opinion. Right?

Dr. Sharon Malone
Second Opinion.

Dr. Mark Hyman
And that can be found wherever podcasts are found.

Dr. Sharon Malone
Wherever podcasts

Dr. Mark Hyman
are found. And you're an adviser to Ally Health. To Ally Health. Just tell us a little bit about what that is. Because I think as as women are listening and men are listening who are in relationships with women, they're like, well, what do I do, and where do I go?

And, yeah, the average doctor may not be able to kinda have the nuances here. You know, there are now online platforms and tools that are much more sophisticated, understand these things, and you're an adviser to one of them called Ally Health. Can you just share a little bit about that?

Dr. Sharon Malone
And at Ally, I've been with them for five and a half years now. So I was there from the very beginning. And when I stopped clinical practice, I you know, I'd accumulated all this. You know? I've got not just the the medical background, but I've got the experience of having done this for a while.

Dr. Mark Hyman
Yeah.

Dr. Sharon Malone
And what I realized is that you can educate women all you want, but if they don't have access Yeah. Then what difference does it make? You can't find a doctor. You can't find someone that will prescribe for you or that even knows what to do. And that's why it was important.

When I joined Alloy, I was able to take my expertise, train the doctors that work for us, many of whom are you know, they're all board certified, and then now they are menopause trained. So we can leverage the expertise of

Dr. Mark Hyman
a

Dr. Sharon Malone
few over hundreds of patients, not just the one on one that you're gonna be able to see in the course of the day. And menopause and perimenopause treatment lends itself well to dealing in the, in the digital health platform. And that's how a lot of care is gonna be delivered Yeah. In the future. Yeah.

And so, you know, I think that people should feel confident that this is not an inferior version of what you're going to get in a doctor's office. In many cases

Dr. Mark Hyman
Just a superior version.

Dr. Sharon Malone
It's the better option.

Dr. Mark Hyman
Yeah. Yeah. Well, thank you for doing that work, and thank you for your dedication in this field and writing your books. And and and and where can they find more about you beside your podcast? You have a website?

Dr. Sharon Malone
Yes. I have a website, and it's easy, Doctor Sharon Malone dot com.

Dr. Mark Hyman
And your social media is?

Dr. Sharon Malone
S Malone MD on Instagram and threads.

Dr. Mark Hyman
Amazing. Wonderful. Well, thanks for your work, and thanks for being a voice out there for reason and coherence in a very complicated, confusing space. We need more of you.

Dr. Sharon Malone
Well, thank you for having me.

Dr. Mark Hyman
If you love that last video, you're gonna love the next one. Check it out here.