Neha Pathak, MD, FACP, DipABLM: Welcome to the WebMD Health Discovered Podcast. I'm Dr Neha Pathak, WebMD’s Chief Physician Editor for Health and Lifestyle Medicine. Today, we're picking up where we left off last week in our conversation with Dr Sharon Malone about myths and misinformation around perimenopause, menopause, and HRT.

In today's episode, we're taking a closer look at perimenopause. If you're in your thirties, forties, or early fifties, and you feel like you're experiencing new symptoms — whether it's brain fog, disrupted sleep, mood swings, hot flashes, weight changes, palpitations, and even joint aches — and every appointment seems to end with a new prescription for a single symptom, you are not alone.

A lot of women are being treated in pieces. This can look like being prescribed an antidepressant for mood, a sleep aid for insomnia, perhaps even hormone therapy for traditional perimenopausal symptoms like hot flashes. Is anyone zooming out to ask the most important question? Could many of these symptoms be tied to the menopausal transition?

Today's episode is important because it brings the conversation back into the exam room and gets practical. We're talking about how perimenopause is diagnosed — specifically how it's a clinical diagnosis. It can be really confusing because there aren't really confirmatory lab tests. We'll talk about what kinds of symptoms should raise your suspicion and how hormone therapy is not a one-size-fits-all, yes-or-no decision.

It's really important not to attribute everything to perimenopause, but it's equally important to recognize when this pattern of symptoms that travel together might benefit from addressing perimenopause with your healthcare provider.

First, let me introduce my guest, Dr Sharon Malone. Dr Malone is the Chief Medical Advisor for Alloy Women’s Health. She brings decades of clinical and real-life experience to her treatment of women in the menopausal transition and their post-reproductive years. She’s the author of Grown Woman Talk and podcast host of The Second Opinion.

This is really helpful, and I think what you have done is really laid out the landscape of the research, the understandings that have come from the research, and the advocacy. And so I really want to now bring it back into that exam room. So let's talk about the types of symptomatology and that window that someone would come into the exam room with, where you would say, let's talk about hormone therapy.

Sharon Malone, MD: I'll say this first: blood work isn't helpful. Periods aren't always helpful because we've got too many other things that will interfere with knowing what's going on with our menstrual cycles. Even though menstrual irregularity is a sign of being in perimenopause, it's a clinical diagnosis, which means if you are between the ages of 35 and 50 and you are having any one of those 34 symptoms that we associate with perimenopause — brain fog, hot flashes, night sweats, rage, irritability, depression, weight gain, all of those things, joint pain — the list gets longer every day.

But if you have any of those symptoms, regardless of really what's going on with your period, and you're within that age range, that's how you make it — it's a clinical diagnosis. So this is a diagnosis that's arrived at between you and the patient. And the patient will sometimes come in and they will tell you these things.

And if you know that these are all signs of perimenopause, you don't treat the symptoms individually, because this is what has traditionally happened. I'm depressed — here's an antidepressant. I'm gaining weight — okay, well, you know, go see an endocrinologist; it must be my thyroid. You know, I can't sleep — here's a sleeping pill. And we have been treating women in midlife individually for their symptoms. Palpitations? Oh, go see a cardiologist. You know?

So we have not really had the understanding that all of these symptoms hang together. If you look at where this woman is in her reproductive life — so again, don't need a blood test, don't need a sonogram, doesn't know what's going on with your period because you’ve got an IUD and you haven't had a period in 10 years — those are the things that should pop into your mind first, not last, because there's an easy way to figure it out.

And these are women who I think you can offer one of the — and again, there are many options. Remember I told you hormone therapy is a lot of things. It may be birth control pills, it may be estrogen, it may be progestin, depending upon whether you have a uterus or not. And there are even options within all of those categories.

So picking the best one for that particular patient depends on what symptoms are we trying to address? What's the cost of the medication? Transdermals cost more than oral medications. Orals are not bad, you know. And that's the other thing I want to say. People think, oh, well, it's got to be bioidentical hormones, and it can only be this, and it can only be transdermal. Maybe, you know? I mean, it depends.

And if you are not at risk for the things that oral hormones increase your risk for — because oral hormones do slightly increase your risk of blood clotting, far less than birth control pills and an order of magnitude less than what pregnancy increases your risk of blood clots for — so if you don't have any of those things, you're a healthy, active person, you don't have any other issues, could you take oral? Of course.

It's just a matter of understanding that it is never a binary choice: this is good, this is bad. It depends. But that depends on having someone prescribing for you who understands. And it's no disrespect, because I understand that there are doctors who weren't trained in how to prescribe.

It is an iterative process. You can't just say, here, bye, see you next year. There may be adjustments that have to be made along the way. Oh, this one didn't work — well, let's try this, or let's increase your dose. There are a lot of subtleties about how to bind to — and if you don't feel comfortable with it, and if you are coming into this conversation with the same misconceptions about hormone therapy that an entire generation of doctors and patients have come into, then yeah, it's going to be problematic.

And that's why I say the problem — we've got two problems now. One is awareness, and I think that we are doing very well on awareness. So yay for that. Women know more about it. But when you're immersed in menopause world, you think everybody knows. I'm like, don't you know that already? And every time I go in a room, I'm always like, oh, you didn't hear me say that? And they're like, no, we don't even know who you are. No, we don't hear it.

But it's a conversation that needs to be had over and over and over again, and you can't say it enough times. So that's one — educating patients — and that's good. But educating physicians is going to take a while, because then you have to have not only education about it, but also the experience of knowing how to adjust and how to bob and weave for some of these things.

It also means being able to have a longitudinal relationship with your doctor, which a lot of patients don't have. It also means having access. Access is a problem because in a world where 50% of the counties in the United States don't have a functioning OB-GYN — that's worse in certain areas; it's even worse than that.

And there was just an article in The Green Journal, the OB-GYN journal, that said that projected for 2030, only six states in the United States will have an adequate number of OB-GYNs to meet the population needs. Six. So, you know, it's a problem.

So we have to figure out, okay, now that we've gotten people educated and they know that this is what they want to do, and they come in, where are they going to go? And I think that this is where I'm hopeful, because I think that moving forward, the next generation of doctors won't be in the position that you were — having trained without it — because it will now be part of the conversation.

But we still can't fix the fact that there are no doctors. Okay? So they're trained, but — or 10 years from now they'll be great — but where are they? And that is where we have to be a little bit more innovative.

And that is why I do what I do. When I left clinical practice, and I'm the medical advisor at Alloy Health, we do perimenopause and menopausal care in the digital environment. And we don't just say, oh, here's your prescription, you know, type it in and we'll mail it to you. Yes, we do that. But we have doctors that are trained specifically in perimenopause and menopause, and they're available to you.

You have that same doctor that you'll see over the course of your treatment, such that you can text back and forth and say, this happened, that happened. And so you do get that ongoing care, because I think that what we understand is not everything works for everybody. It's not one — again, know what your toolbox is, know what options are available, and know how to tweak when tweaking is necessary.

And that's where I think so much of medicine — not just what we do in women’s reproductive health — so much of it is going to change to the digital environment, because we can't clone doctors. And that's for everything, not just what we do.

Pathak: Right. And I mean, to your point also about personalizing medicine — we hear a lot about personalized medicine, but that's really what medicine always has to be in order to optimally treat. It's always a little bit of a dance and a titration.

You know, even if we're thinking about blood pressure, it's not like you're just going to get a pill and that's it — same dose for everyone. You have to adjust based on your personal risk factors, other conditions that might be going on. Do you have a history of breast cancer? Do you have a history of blood clots?

A question that I get asked a lot is about migraine with aura. There's still a lot of concern among women who have been diagnosed with migraine, who are like, oh, well, I can never take hormone therapy because of that. Can you talk a little bit about that?

Malone: And you know what the answer to that is? You know, there are a lot of things that women will take themselves out of the conversation over because they think they can’t. And here come the migraines with aura. Oh, it increases your risk of stroke. I had a blood clot after a car accident 20 years ago. I can’t take hormone therapy. I have a family history of breast cancer. I can’t take hormone therapy. None of those are true.

And the reality is that even with those things—like, say, let’s take migraines with aura—most women in perimenopause who have had migraines, and a lot of migraines, or menstrual migraines, which the hormonal flux is the trigger for the migraines. So evening out hormones for a lot of women will make their migraines better. That’s number one.

But that would be a case where that woman would be a better candidate for a transdermal estrogen as opposed to an oral, because the oral estrogens, yes, they do slightly increase your blood clotting factors, so you don’t have to use that one. But a transdermal that bypasses the liver doesn’t affect your clotting factors. There’s no reason why you cannot take that. And that is the same thing that would be true even for someone that had a blood clot 20 years ago. Well, then do the transdermal, and then it does not appear to have the same effect on clotting factors.

So again, it’s just knowing little stuff like that—knowing which one to choose for which patient. A family history of breast cancer. And this has come out in the most recent guidelines about prescribing for HRT. So many women think they can’t have hormones because they have a family history of breast cancer. What they have said is this: your risk for developing breast cancer is your risk. Family history is one of those risk factors. However, taking hormone therapy does not increase whatever your baseline risk is.

I can never tell you whether or not you will get breast cancer. The overwhelming majority of women in this country who get breast cancer are not on hormone therapy. And since the use of hormone therapy has gone down, guess what’s happened? The risk of breast cancer has gone up. So you can’t blame the hormones.

So that’s why I said knowing that and sort of being sometimes reassuring—but I think that the reassurance should come from the fact that if you say, you know what, I don’t know if you’re gonna get breast cancer, but this I do know: if you take hormone therapy—remember I told you the women who were taking estrogen alone—those women had a 40% decrease in the risk of dying from breast cancer, even if they developed it.

But even for women—and this is directly from the Women’s Health Initiative, not anything I’m making up—but for women who took the estrogen and progestin, where there was that one in a thousand—and that’s another conversation, to say whether or not that’s even true—but the reality is that even from that study, the women who got breast cancer on estrogen and progestin had no increase in the risk of dying from breast cancer. You didn’t get a worse breast cancer. Your prognosis wasn’t worse. It was the same.

So again, if people understand that, they wouldn’t be so fearful of hormone therapy, because remember all that suffering, remember all those things that we talk about that really decrease the quality of your life and, in some instances, will decrease longevity factors because of those things that increase your risk.

And what we do know—and a lot of doctors, I think, are unaware of, and this is even OB-GYNs—suppose you have your ovaries out and you’re 40 years old, for whatever reason. What we also know is that for women who have either an early or a premature menopause—early means being menopausal before 45, premature means being menopausal before age 40—those women will have an increased risk of cardiovascular disease, increased risk of dementia, increased risk of osteoporosis if they are not treated with HRT.

So the current recommendation is for if you have an early or premature menopause—and this is in the FDA guidelines, not interpretation—those women not only can take hormone therapy, they should take hormone therapy. And too many women have not been offered the same. And I’m gonna put our OB-GYN colleagues in this—women who’ve had hysterectomies or had ovaries out. And you don’t tell a patient, oh, by the way, you’re gonna be in menopause tomorrow. You know, not next week—when your ovaries come out, immediately, those women need to be protected.

So unless you have a serious contraindication, those are women who should be treated. And in addition to everything else, we’ve got a lot of women across the country who have been seriously undertreated. And I think that there’s been a lot of suffering unnecessarily.

And I practice what I preach. You know, I’m 67 years old. I’ve been on hormones since I was 50, and I have no intention of stopping unless I have one of the reasons why I should stop. But in terms of how I feel—how I feel at 67 versus how I don’t know what—I’ve seen a lot of 67-year-olds. But in terms of being able to maintain your vitality, your ability, and sexual function—let’s talk about that.

All women, regardless of how old you are, everybody can use vaginal estrogen. Even if you think, oh, I’m 75, I missed the window. Okay, we can’t do the prevention stuff on you when you’re 75, but we can do prevention of urinary tract infections and the discomfort and everything that comes with painful sex. Because the amount of estrogen that’s in a vaginal estrogen is so small, and it is not systemically absorbed.

So at a minimum, everybody can and should be offered vaginal estrogen as we age. Because I know you know this, but people don’t think about it—what’s one of the most common causes for hospitalizations for elderly women? Urinary tract infections. That can lead to all kinds of things—sepsis, mental status changes—that can be problematic. What will help with that? Vaginal estrogen. It’s simple. It’s cheap. But people just have to know that that is something that every woman should be offered.

And here’s the thing, too—and I will go on here, as you can see, this is something I feel passionately about—but when women get to be a certain age, let’s say 65, 70, a lot of women stop going to their gynecologist. So you don’t go to a gynecologist. You see your internist, and you see your cardiologist, and whoever else you see. If you never get undressed in that doctor’s office, and no one knows what your vagina and vulva look like, then I can tell you that 90% of women at that age will have signs of the genitourinary syndrome of menopause—whether they complain about it to you or not—because most women just don’t. Urinary incontinence and leakage—they don’t complain about it.

But if you don’t see it, you don’t realize that it’s there. And I can tell you, as a gynecologist, I made everybody—everybody’s gotta get undressed. Let me look. Let’s see what it looks like down there. And if you do, then you’ll have an understanding. When your patients are showing up in your office and they keep coming in and they have recurrent UTIs, the answer isn’t, let’s give you more and more and more antibiotics, or let’s put you on this. How about let’s do some vaginal estrogen, particularly in women who are over 60.

Pathak: You mentioned there’s a window—a sweet spot. Can you talk about what that window looks like with regard to ending? So we’ve talked about what the window looks like for starting. Is there a time when one should be tapered off or that discussion should happen? Or can you be on hormone therapy indefinitely?

Malone: Two things. One, about the window of opportunity—and that window comes in, you know, again, depending upon when you go through menopause, when you start, when you end. Two things I’ll say about that. There is no time limit.

So what happens to a lot of women is they’ll say, well, I can only take it for 10 years, or I can only take it for five years, so I’m just gonna wait until my symptoms get so bad, and then I’m gonna start. No advantage to that whatsoever. You treat when you are symptomatic. So if you’re symptomatic in perimenopause, treat in perimenopause. You don’t have to wait until that theoretical 365 days past your last period, whenever that might be.

So that’s number one: treat when symptomatic. And there is mounting evidence that says that the earlier you treat, the more benefit you get on the prevention point.

So that’s number one. Number two, even though we say within 10 years or less than 60, that’s a relative number. Sixty is not a hard stop. Suppose you had your last period when you were 55. Well then at 60, you’re still five years in. The point is that all of it has to be taken in context.

And even someone who’s 62, 63, 64, who is still symptomatic—why would I tell you, sorry, you’re over 60, you can’t have it? If you are symptomatic, then we sort of do a better assessment of what those other risk factors are. And if you are otherwise healthy and symptomatic, then yes. And then this, again, may be someone where we say, all right, let’s do transdermal as opposed to an oral. There’s a lot of leeway about that.

And we have to remember, guidelines are just that. They’re not meant to be applied to every individual. And that’s why you said you have to really know why it’s important.

And the other thing—and the question you asked first of all—is there a time limit? No. You can take it for as long as you would like to take it, as long as you are symptomatic. I think that even after long-term use of hormone therapy, women will come off, and a lot of them will get their symptoms back again. They’re like, whoa, hot flashes. I thought they were gone. No—you hit pause on hot flashes. You didn’t hit erase. So they’re gonna come back when you stop.

And they might say, yeah, maybe I’m gonna stop, because you stop for a reason or a personal reason. That’s okay. But the people who should continue indefinitely are women who are at risk for osteoporosis, because we know that hormone therapy—estrogen particularly—is the only medication that has an FDA-approved indication for the prevention of osteoporosis.

So we know that right after menopause, within the first five or six years after menopause, women will lose a considerable amount of bone rapidly, and then they will continue—albeit at a slower rate—for the rest of their lives. But if you take hormone therapy from 50 to 60 and you have a low bone density, and your mother had a hip fracture, and you say, oh, I’ve had 10 years and I’m 60, I’m gonna stop—well, guess what happens? Between 60 and 65, you’ll lose that bone that you just preserved rapidly, and you’ll be right back where you were at 65 than if you had never taken it.

So that’s why we say for women who are taking it for the indication of prevention of osteoporosis, continue, because when you stop, you are gonna start losing that bone again. It’s like Rogaine and hair loss. You put it in and it’s great, but you stop—it’s like Cinderella. It’s gone. And the same thing happens with your bone density.

So that’s where I want to sort of alleviate some of that concern. Your risk does not elevate with years of use.

Pathak: Really, really helpful. And you know, my final question for you is really help us understand how to find a healthcare professional, someone on your medical team who really is going to give you this type of information and help you make these personalized choices. What’s your best advice for finding the right person on your team?

Malone: See, that’s where it gets hard again because I told you we’re, we’re trying to find someone who actually has an interest in treating midlife women and midlife. Generally speaking, I would say nine times outta 10 it’s going to be an OB-GYN who has a particular practice. You’re probably going to find someone who has more of an interest who’s doing gynecology only, as opposed to someone who’s doing OB and GYN.
And it’s because, I mean, it’s time constraints. Let’s be serious about this. For women who are doing OB and GYN, it’s a lot. It’s a lot. And I think that that’s another front to work on, is trying to separate those specialties because it’s too much to ask of one particular doctor to try to do so many things in the course of a day, and it’s time-consuming.
So that’s why a lot of people don’t like to do it, or they kind of put it off because it’s like, ugh. And now I gotta go read something, and now I gotta figure this out. But there is a place that you can go. There is the Menopause Society, which is menopause.org, that you can go to and put in your zip code, and it will tell you if there are menopause-certified practitioners who are in your area.
Okay? So what if there’s not one in your area? What are you supposed to do? Well then that’s where a digital health company like Alloy can be helpful because we want you to be able to have information and access. And so that’s another option for you. But it’s a problem finding a provider.
And even when you do—and I tell you this is the politics of it, not the medicine of it—because gynecology, and you know this as being a primary care doctor, reimbursements are not great for things that we do on the prevention front. You get paid for procedures. You don’t get paid for a lot of the talking and the counseling, excellent counseling that you do. That’s just the nature of the beast.
And that’s a policy and political decision that they’ve made about where women’s health falls in the big scheme of things. So what happens is that even sometimes when you find a menopause practitioner in your area, it is not uncommon that that doctor has opted out of the insurance market. And now you have a concierge doctor.
And again, I understand it, and there’s no shade on people who decide to do that, because you realize that your time is valuable. And if I’m doing a certain amount of work, I deserve to be paid for that work. But that also disadvantages patients because now you can get it if you can afford it.
And that’s where we, as a society, have got to reorder some things. That’s going to take a while, you know—if ever. But it also means that we’ve got to be smarter about how we deliver care. And that’s why the digital health space is really a great opportunity for women to go in and just say, I can log on, I can read, I can educate through webinars. There are all these things that I can learn about myself. Now I can connect with the doctor and get the prescription and get the treatment that I need.
And that is going to be the wave of the future because there’re just not physically enough providers. But in summary: menopause.org—check to see if there’s a doctor in your area. Second, see if that doctor takes your insurance or if you can afford seeing a concierge doctor. And if not, then certainly that’s the service that we provide.
’Cause that’s been my mission, is to make sure that the information shouldn’t just go to a few. Every woman should have the information that she needs, and she can choose to do it or not do it. That’s not the point here, because I’m not trying to sell anybody anything other than information.
And I think that women are quite capable. We make decisions all the time. We make health decisions for ourselves, for our families. And I think that when we get good information, we can make even better decisions about how we choose to feel, how we choose to age, and how we choose to move about in the world.
Because if there’s one final message I wanna leave your listeners with, it’s this: menopause is a great phase of life. It is probably the first time in your life that you’re not preoccupied with something else or someone else. It’s an opportunity for you to reinvent, to reinvigorate, to go do something else now that you’re relieved of a lot of these other things.
But to be able to really take advantage of that means you’ve gotta feel well enough to be able to do it. You gotta be able to get outta your chair. You gotta be able to do all these things that preserve not just your lifespan, but your health span. ’Cause we wanna be good at 80. We don’t wanna be just, you know, sitting in a chair somewhere. No, we wanna be doing stuff. That’s what I plan, anyway.

Pathak: Well, I am just looking forward to all the things that you do and all of the education and knowledge that you impart to everyone. And I just want to thank you so much for taking the time to do that with us today.

Malone: It is always a pleasure, and as you can tell, it’s something I kind of like talking about.

Pathak: We’ll have to have you again and again and again, so thank you so much.

Malone: You are so welcome.

Pathak: Thank you so much for being with us today as we wrap up our two-part podcast series on perimenopause, menopause, and hormone therapy. I’d like to close with three key takeaways from this conversation.
First, perimenopause is a clinical diagnosis, and many symptoms often travel together. Blood work is usually not helpful because hormone levels fluctuate widely, and periods aren’t always a reliable marker for perimenopause, especially if you have an IUD or take hormonal contraception.
But if you are between the ages of 35 and 50 and develop classic symptoms like hot flashes, night sweats, brain fog, mood changes, sleep disruption, and weight changes, along with other symptoms like new palpitations or joint pain, it’s important to find a healthcare provider who can work with you to connect the dots instead of simply treating every symptom in isolation.
Second, hormone therapy is not a one-size-fits-all or good-versus-bad choice. It’s a toolbox. The right approach depends on your symptoms, goals, cost, and risk profile. Treatment requires follow-up, and dose or formulation adjustments over time. So it’s really important to make sure the healthcare provider that you are working with for hormone therapy is asking a lot of these questions and really figuring out what is the best option for you.
Lastly, determining whether you’re a candidate for treatment is a discussion to have with your healthcare provider, as there are so many myths and misconceptions.

Pathak: You don’t automatically have to rule out hormone therapy based on your medical history. Talk with your healthcare provider and figure out what your risks might be, and work together to understand what might be better, safer options—whether that’s a different route of administration or a different type of dosing that might be beneficial in your situation.
We hope this two-part series has helped to affirm your experience and provide language and clarity for shared decision-making with your provider. To find out more information about Dr Sharon Malone, perimenopause, menopause, and HRT, make sure to check out our show notes. Thank you so much for listening.
Please take a moment to follow, rate, and review this podcast on your favorite listening platform. If you’d like to send me an email about topics you are interested in or questions for future guests, please send me a note at [email protected]. This is Dr Neha Pathak for the WebMD Health Discovered Podcast.