A roadmap to better health for women

Veteran physician Dr. Sharon Malone is on a mission to help women better manage their health in the American health care system.

Her number one tip? Be your best advocate.

Today, On Point: A roadmap to better health for women.

Dr. Sharon Malone, OB-GYN and chief medical advisor for Alloy Women’s Health. She’s also a certified national menopause practitioner. Author of "Grown Woman Talk: Your Guide to Getting and Staying Healthy."

Excerpt from "Grown Woman Talk" by Dr. Sharon Malone. Not to be reprinted without permission. All rights reserved.

Part I

DEBORAH BECKER: This is On Point. I'm Deborah Becker, in for Meghna Chakrabarti. It appears that women's health is having a moment, as they say. Last month, President Biden signed an executive order he called the most comprehensive action ever taken by a president on women's health research in America.

PRESIDENT JOE BIDEN [Tape]: We've launched the first-ever White House initiative on women's health research to pioneer the next generation of scientific research and discovery in women's health. Think of all the breakthroughs we've made in medicine across the board. But women have not been the focus.

BECKER: That executive order allocates $200 million to the National Institutes of Health to research women and health looking at topics such as menopause, endometriosis, arthritis, heart disease, and Alzheimer's disease.

Many of those disproportionately affect women, especially women of color. Despite women making up over half the population, medical research did not routinely include women in large scale clinical trials until 1993. Dr. Sharon Malone talks about this in her book where she details how the medical system in America often not only ignores women, but she says it was never really built for them in the first place.

Dr. Malone's debut book is called Grown Woman Talk: Your Guide to Getting and Staying Healthy. It came out earlier this month and she joins us from Washington, D.C.

Dr. Malone, welcome to On Point.

DR. SHARON MALONE: Thank you for having me.

BECKER: So let's get back to that statistic about women not being routinely included in large medical clinical trials. How do you think that that has affected the healthcare that women get?

MALONE: I think it has affected women's healthcare profoundly. I think the underlying assumption was that women were little men. And we are coming to the conclusion now that nothing could be farther from the truth.

Women were really not routinely even studied. I mean, you think about, the field of gynecology didn't really come about until the 1850s. And its start was rather problematic with Dr. J. Marion Sims, who experimented on enslaved women to really counter some of the obstetric injuries. And the problem with that is that before that women were, you know, considered contemptible and not really worthy of study. And with that unfortunate beginning, we still have not advanced very much beyond that because we still look at women as being just, you know, again, smaller versions of men. And most of the medical research that has been done has been done on men and sort of titrated down for us.

BECKER: And aside from research though, there are other reasons, right, that keep women, especially women of color, from even seeking medical help. In your book you write about your mom who unfortunately died of colon cancer at a young age. You were only 12 years old. So what about some of these other reasons and how have these reasons and this history influenced healthcare for women?

MALONE: Well, if you are interacting with a system that really was not built for you or with the thought of you in mind, we don't really have good, healthy relationships with medical professionals. And I think that was the reason that my mother lost her life. There is an education component, I think, for the conditions that affect us. We have to know what they are — what the early warning signs are and when to go for help and to whom to go for help. And those are the things that we're missing.

And I think that when you have very negative experiences interacting with medical professionals — and bear in mind, Deborah, my mother, you know, grew up in the Jim Crow South, where medical professionals were hard to access. She grew up in rural Alabama. So just the geographic inaccessibility was a problem. Then how you were treated within that system was a problem. So it didn't make for the basis of a very healthy, therapeutic relationship. And when you put that toxic mix together, I think that many women lost their lives because of not knowing what to look out for and what to do when they did encounter these things.

BECKER: And we're still, though, there's so much frustration with the U.S. healthcare system even now, especially for women. You know, we asked On Point listeners to tell us about their experiences and we heard from several of them, I'll tell you. And I'm going to play a little bit of tape from some of the voice messages we received.

On Point listener Tara Friedman. She's 46 years old. She's from Highlands Ranch, Colorado. And she said when it comes to navigating this system as a woman in the U.S., she feels like she's “flailing.” Let's listen:

TARA FRIEDMAN: I have long-haul COVID. I've had it now for two years, three months, 10 days. I'm perimenopausal. And I'm tired. I bounce around doctor to doctor. In fact, today I'm seeing three different doctors. Sometimes I'm listened to and cared for. Other times I'm ignored or dismissed or misunderstood. The guidance I get is oftentimes inconsistent or counters what other doctors have advised me. It's exhausting and I'm just tired.

BECKER: And of course, this sort of dismissal on the part of the healthcare system can have health consequences. We also heard from On Point listener Jennifer Vernon of Salt Lake City, Utah. And she feels similarly. She said one doctor in particular stuck with her. She went on a week-long camping trip. She wasn't feeling well. She went to the doctor. He said she was likely just depressed and she had a bladder infection. So he did give her some medication, but it didn't seem to ease her symptoms.

JENNIFER VERNON: So a few weeks later, I went back. He said, "Go home and take your medicine. You're just depressed." About a few weeks later, I went back. And again, he said, "You're just depressed. Go home and take your medicine and maybe see a counselor." So after two months, I finally went back and I said, "I still don't feel well." And he finally did another test and I still had a bladder infection.

From that experience, it affected my mental health because I didn't trust what my body was telling me. And I know I should have gone to a different doctor. However, I didn't know better. So I would really like doctors to listen to women. We know our bodies. We know when something's not right. And please don't tell us we're just depressed and take our medicine.

BECKER: Dr. Sharon Malone, when you hear stories like that, those stories from our On Point listeners, I wonder what do you make of that? And what advice do you give women to try to get their voices heard?

MALONE: You know, when I hear stories like that, it really breaks my heart, simply because I think that we have a culture in medicine of not believing women. You know, there is this idea that women are hysterical or we're overly emotional or we're exaggerating symptoms for attention sometimes and that's the unfortunate thing. And we allow sometimes the people in the medical profession to tell us how we feel. And I talk about this in my book.

There is a sense called interoception, which is the innate sense that all of us have of what we feel like when we feel normal and balanced. And that's a sense that we should all get in touch with. Because when things are awry, it signals. Pain is a signal, not feeling well, feeling off. And no one, no one can tell you that you're okay if you feel differently. And I do encourage women, I said, if you are not getting the results that you really want from that interaction, it really is difficult, but sometimes you have to find another doctor. Because people that persistently put you off or minimize your symptoms sometimes can be doing your health a great disservice.

I think we should listen to our bodies and I think that we in the medical profession have got to start listening to women. And the other thing that really stuck out to me, if someone says, "Oh, you're just depressed," even if that were the case, being just depressed is not something to be brushed aside. If you are "just depressed," well then you should just make sure that those symptoms are addressed.

BECKER: You know, you give a lot of advice in your book about keeping your body healthy — finding a primary care doctor, having your medical records, understanding your family's medical history, you know, perhaps some genetic testing, right? And making sure you have an end of life plan. Basically saying, look, we're on new ground here. Everybody has to be an advocate. Would you say that's right? And how would you suggest that folks get into that mindset of making sure that they know how to advocate for themselves and prepare?

MALONE: Well, this is what I would say. I wrote this book with a very specific intention in mind. And I think that most women remember, and may even still have that book on their shelves, What to Expect When You're Expecting. And that was the book that women would go to, you know, you would read it and come back to it on specific sections to read about what you might be encountering.

Well, there's no equivalent of that for women over 40. And I wrote this book saying to myself, how about what to expect when you expect to live past 40? And I wrote it from the very beginning of explaining how to evaluate a medical system that has changed dramatically in the past 20 years. It is more confusing. The system is Byzantine. And I think even for the smartest of people, it is hard to figure out how to navigate the system.

So I start with that sort of concrete information. What is important? How do you find a doctor? How do you assemble a team? Because I think that the things that have changed in medicine happened in the background and most people were caught unawares.

You know, Deborah, I had the good fortune of being able to work in one practice for 30 years. So I knew my patients. I had seen them through, you know, through teenage years, through pregnancy, to perimenopause and beyond. And I had context for their symptoms and how to deal with them. But we are now living in a world where that is no longer going to be the case.

Every time you have an encounter with a medical professional, you may see a different person. You know, you go to urgent care, you see one person. You go to your doctor's office, you see a nurse practitioner. So, the only constant in that interaction is really you. And so what I want women to understand is that you have to be your own best advocate because no one is going to give you that consistent through line. But to be able to do that, you have to know how. You have to know what's important and what information that you are responsible for.\

Part II

BECKER: Dr. Malone, before the break, we were talking about women becoming better advocates for their health in a medical system that's become corporatized in many ways and impersonal. But I have to wonder: It's putting a lot on the patient, isn't it? To be able to say, you know, yes, you may not be listened to and you may be dismissed in a lot of ways, but learn how to advocate and perhaps the outcome will be better. And that may seem really daunting for some women.

MALONE: And I understand that. And that is exactly why I wrote that book, because this is the reality. You know, I wish we could go back and do it the old way, where, you know, you would have one nice family doctor who took care of you from cradle to grave. It's just not the way it is. And I think that we can — you know, I've practiced for 30 years, so I've seen the evolution of what's happened to medicine. And it doesn't necessarily mean that it's bad, but I do want you to understand that this is what it is. So it is going to require more of you. You know, it is going to require you to advocate for yourself. Because at the end of the day, no one cares more about your health than you do.

And so is it going to require a little bit more homework and a little bit more prep work for you before you see your doctor? Absolutely. Because here's the other reality: If you get that precious appointment with a doctor, you're going to have about five to seven minutes of face time. And if you have very specific issues that you want to address, then you have to be very efficient and organized about that face time. Otherwise you're going to leave that interaction and still not have gotten the answers that you wanted. So yes, it's going to require a little homework.

BECKER: Right. Let's talk about some of the specific ways that different health issues affect women. And one thing that you talk about in the book that I think is really interesting is stress and the effects of stress. I think most of us know that, you know, high levels of stress are unhealthy.  But can you talk about how that is a specific health issue for women and what women might be able to do to mitigate some of the effects of stress?

MALONE: Yes, stress. Everyone encounters stress in their life. We need the acute stress reaction. You know, as I said, you've got to be able to rescue that baby from a burning building. You know, you've got to activate. But that you can tolerate. What is not healthy is chronic stress, which means like activating your emergency system all day, every day. It grinds you down. It wears you out — not just mentally, but physically as well.

Those stress hormones, the adrenaline, the cortisol that get activated when in stressful situations, you know what they do? They raise your blood pressure. They raise your blood sugar. They make you feel on edge. These are things that give you higher risk factors for developing hypertension and diabetes. And when you activate these stress hormones all the time, what do you do? You eat more, you gain weight. All of it is sort of cyclical in terms of these stress reactions.

And the people that experience the most chronic stress is really African American women. There are so many things in our lives, be it, you know, work stress, family stress, financial stress, interpersonal relationships that are stressful. And that, if you tolerate that and don't deal with that, that stress, that level of feeling bad becomes your baseline. And remember that sense I told you about, interoception? Which means knowing what you feel like when you feel normal? Well, if you raise that baseline and being stressed is what you think is normal, then your body and you will ignore certain very serious warning signs for other diseases that may be problematic.

So yes, stress is a problem. And we have got to figure out ways. We can't always control the things in our lives that are stressful, but we can figure out ways to manage how we deal with that stress. And sometimes it involves seeing mental health professionals. Sometimes it's exercise. Sometimes it's as simple as getting a good night's sleep or eliminating the people and situations in your life which are stressful that you do have control over. And I think we all understand that there are certain toxic environments that we find ourselves in that we perhaps should not stay there.

BECKER: Because that can lead to some serious health issues that you write about in the book. And one of them that I found really surprising were the statistics about cardiovascular disease, right? You wrote, "In every decade of life after age 40, anywhere from two to seven times more women die of cardiovascular disease than die of breast cancer. And most of the risk factors for cardiovascular disease are known and avoidable." So I wonder — and of course, again, Black women are disproportionately represented here — what are some of the things that you think women should know about to protect their heart health?

MALONE: Well, I think that there are about five basic tenets that everyone should do. And it will decrease your risk of heart disease, it will decrease your risk of cancer, and decrease your risk of Alzheimer's disease as well. And these are basic things that we know, but we kind of go, "Oh yeah, yeah."

Exercise is very important. Eating a healthy diet with as few as many ultra-processed foods is important. Getting a good night's sleep. Eliminating smoking, simple thing to do. Cutting back on the alcohol in your life. And again, getting back to this notion of stress, sort of trying to minimize the stress in your life. This has health benefits that will pay off in every aspect of your health, not just cardiovascular disease.

But here's the other thing about cardiovascular disease that is interesting to me. That statistic that you cited that, you know, at every decade in life, anywhere from two to seven times more women will die of heart disease than die of breast cancer. And yet we are not fearful of cardiovascular disease. Because I think that we sort of think of cardiovascular disease as an inevitable consequence of growing older. You know, "Old people get cardiovascular disease." Well, no, they don't.

But the breast cancer story is, I think, something that we find ourselves victims of our own success in the breast cancer story. Because undoubtedly the awareness campaign, early diagnosis, and better treatment has really raised the issue of breast cancer in every woman's mind. And that's a good thing. But — and here's the but — I want you to understand that more women die of cardiovascular disease every year than from all cancers combined. And it's just a matter of having some perspective on that. And we don't have to be fearful of cardiovascular disease because there's so many things we can do to avoid it if we are careful and mindful --

BECKER: And should there be screening, like there are regular mammograms? Could that help?

MALONE: Absolutely. There can be screening. But I think more importantly, there should be more public education around cardiovascular disease, so women understand the importance of cardiovascular disease and how it can affect not only the length of your life, but the quality of your life. And I think we also have this misconception that men have more heart attacks than women, and it's sort of a men or an old person disease. Not true. And there's also not really fully understanding that cardiovascular disease and heart attacks in particular present differently in women, which is why the symptoms and early warning signs are often ignored.

Again, gets back to this feeling. If you're chronically fatigued, sometimes chronic fatigue is a sign of heart disease. And we don't really recognize that as such. One of my dear friends is a cardiologist, Dr. Jane Morgan, who says when we talk about heart disease in women, we say that women have "atypical symptoms," which think about that language. No, women don't have a typical symptoms. Women have symptoms that are typical for women. They're only atypical when you're comparing them to men.

And I want women to understand that in those 10 years, the 10 years after you've finished menopause, so after age 60, the risk of heart disease for women equals or exceeds that of men. Fewer women are going to survive their first heart attack. And the extent of disease goes on for much longer, often undiagnosed.

BECKER: I wonder if you think it helps to have more women as physicians? And I'm going to play another piece of tape from one of our listeners about this. This is On Point listener Margaret Racine. She's from Northern California. And she said she actually had a positive experience with one of her doctors. Here she is.

MARGARET RACINE: My first pregnancy, my doctor listened very well. It was a woman doctor, which I think has made a big difference in my medical care. I felt very well cared for each session. She answered any questions from the biggest to kind of the silliest about what skin care I could be doing. And she was really a huge advocate for me, I felt by the end of my pregnancy, being a high risk, obese, geriatric pregnancy.

BECKER: So, Dr. Malone, encouraging story there from Margaret of Northern California. But I just wonder, you know, there are many, many more women who are doctors. Is it getting better?

MALONE: Yes. I think that there is a component of empathy that most women, particularly in the field of OB GYN have. Because, needless to say, there are a lot of things that happen to women and they are explaining to me. And if I'm a female physician, I get it. I understand it. I know what cramps feel like. I know what being pregnant is like. So there is that component that I think that we as women can relate to. But does that mean that men can't? No. I think it's just a little easier for women.

But here is what, you know, I said, we get back to the beginning, even for women in medicine these days, you're still sometimes going to be faced with that five to seven minutes of face time. And that's the hard stop against which we have to sort of make the best of this interaction.

I think that men need to be a little bit more sensitive and aware. But I also want you to understand that for most women of a certain age — and that will be those of us who trained, you know, in the 80s and 90s — we were very much trained in a a male-dominated medical field. So a lot of the things that we were told and the ways we were taught actually were things that were not benefiting women.

And we were told many things about women, and particularly women of color, that turned out now that you look back on it and you're like, "Oh, well, okay, why did we say that?" The myths, the things that we attribute to Black women that we attributed to just being Black. And the reality is no, that's because they have a predominance of certain risk factors and socioeconomic and what we call the social determinants of health, which are the circumstances around where people live and work and that have nothing to do with the race of the person involved, but where they live in their environment, the things that are outside their control.

So, you know, we've got a lot of unlearning to do. Not just males. Because I'm not going to male-bash. There are plenty of good male doctors out there. But there is a natural inherent tendency for women to understand certain things. And particularly when it comes to things like perimenopause and menopause. I have to tell you, you get way more interested in it when you have actually experienced it. (LAUGHS)

BECKER: (LAUGHS) Yeah, well, we will get to perimenopause and menopause in just a couple of minutes. But I do want to, you know, it was fascinating to me when you said when you were trained in the 80s and 90s, and many medical professionals were trained, and, you know, now you're at the peak of your career, or maybe slowly winding down and you've acquired all of this experience, there may be some unlearning to do.

And I know you don't want to male-bash, but I do want to include a comment from an On Point listener that I think sort of shows what is in the system still, what kind of thinking might be in the medical system and what some women have to deal with. This is Janet Gaddy of Browns Summit, North Carolina, and she left us this message about an experience she had with a male doctor. Let's listen.

JANET GADDY: I was scheduled for a colon resectioning and the surgeon actually took my husband aside and told him that I wouldn't look like I did before the surgery, I guess an implication that I would be scarred. It really stuck with me when he told me about it. It was even disturbing to him.

BECKER: Dr. Sharon Malone, is there still a lot of that going on?

MALONE: I hope not. I would sincerely hope that that is that is the exception and not the rule. However, is there still some insensitivity out there in the medical profession? Yes, there is. I think the biggest problem is when women are interacting with doctors, I don't think we give women the same amount of respect for their own agency. You know, I think that a lot of times women are often told what to do and told what they can and cannot have, as if we're living in the 1900s where, you know, "There there, dear, just do this and don't question me."

And let me say, being in a position as a patient, it's intimidating generally, because, you know, a lot of times you're not feeling well or you're anxious about whatever your complaint is. And it's very difficult to advocate for yourself, particularly when the interaction with the physician doesn't allow that or doesn't encourage that. So these are the kinds of things that I think are more problematic that we've got to step away from is to get physicians — we've got to do it on both sides.

We've got to get physicians to be comfortable with the fact that yes, we are dealing with grown women who have their own agency and who might have questions. And to not feel threatened because someone challenges or asks you a question. And I think those are the kind of interactions that are probably pretty common. Because, you know, doctors are pressed for time and I think they mean well, but the execution sometimes is poor.

BECKER: Right. Right. And it's still being taught to patients in books like yours and also to doctors, you would say, right?

MALONE: Yeah. I want patients to know. And the reason — again, it gets back to the reason I wrote this book — sometimes you may know that something is wrong, but you don't know what is wrong about it or what to do about it. And that's what I want you to have. A little bit of data.

Part III

BECKER: We want to talk now about all of the attention that has been recently placed on the topic of menopause. And Dr. Malone is a certified national menopause practitioner.

We should also say back in February, we did a full hour on the show about menopause, looking specifically at what happens in the brain during this life transition. We sat down with neuroscientist Dr. Lisa Mosconi to talk about her latest book called The Menopause Brain.

In your book, Dr. Malone, you write that women spend a third of their lives in menopause and yet there's not a lot of openness about this. So why don't you tell us: Is this just part of the continuing lack of information about women-specific issues? Or why do you think there's this lack of attention and information about the effects of menopause?

MALONE: I think it's the perfect storm. I think it is, you know, menopause sort of hits right at the time where we are dealing with issues of ageism. We are dealing with issues of sexism. And I think it intersects with our attitudes about what women should expect as they age. And let me say this: We have really sort of normalized the experience of suffering in women's existence.

Because think about it: We have, you know, as women, we have grown up, we have suffered through cramps, through pregnancy, through childbirth, through bad relationships, everything about the language of how we describe our experiences through health is usually through the language of suffering. So when we get to perimenopause and menopause, we just think that's just the normal end experience of this lifetime of suffering that women must endure. And I think that when you get to the point where you normalize suffering, then you don't look for solutions.

And let me say this: Women have been going through menopause for as long as we have lived long enough to experience menopause. And the reasons why we've paid so little attention to it? Now that to me is perplexing. Because you know, menopause is the one universal experience that all women born with ovaries will experience. I mean, you may or may not get pregnant. You may or may not have cancer or endometriosis. You will be menopausal. And so we have known what the symptoms are. We have known what some of the long-term complications and issues of perimenopause and menopause. And yet, we allow women in 2024 to enter this phase of life with almost no information.

And the problem is, is that when they start to encounter some of the symptoms that we typically associate with menopause, such as hot flashes and mood swings and sleeplessness and lack of sex drive, and the list goes on and on, women have no idea what's happening to them. And they also have no idea what to do about it, and again, to whom to go for help. And that is the conversation we're trying to have now is to sort of get women out of the mindset that suffering should always be your default space. And also let you know what the implications are and what treatments are available for menopause and for perimenopause.

BECKER: You know, in your book, you mention that perimenopause can actually start much earlier than I thought. Can you explain — on average, of course, there's like an age range. And I wonder if you can describe that age range and what some of those symptoms are? There are a lot of symptoms. Maybe that's part of the reason why there's confusion, right?

MALONE: Well, there is confusion. And for those listeners who don't know about what perimenopause actually is, you know, we have sort of three distinct phases in our reproductive lives. Your pre-menopause, which starts from puberty through your peak reproductive years. Perimenopause is that change between, usually happens for women in their early forties to their early fifties, and that's the transition to menopause. And menopause, the time, the age at which you've had your last menstrual period, and it is confirmed by having 12 months of no additional periods. That's how you know you're done.

But those 10 years — or sometimes even more — in between does not have a bright signal that says, "Okay, perimenopause has begun." Sometimes it starts with menstrual irregularities that women will start to notice, but sometimes you can have completely regular periods and start having, again, hot flashes, mood swings, night sweats. You can have changes in libido, vaginal dryness, itchy skin, itchy eyes, brain fog, which is a huge one that happens. And what is happening in that transition is that your hormones are fluctuating wildly. And those wildly fluctuating hormones are really registering in your body physically and also in your mental state. Because the one thing that people don't realize is that menopause is not just a reproductive phenomenon, menopause and perimenopause affects your entire body as well as your mind. And so the symptoms being as varied as they are, a lot of times you don't think of it because you might be 41 years old. You're not thinking of menopause because you don't have an idea of what the entire spectrum is, or time frame over which this occurs.

And, you know, it gets in the way of women seeking help, thinking that there are other things wrong. You might go to an endocrinologist because you're gaining weight, or you think that you have a thyroid problem or you're depressed or anxious and you're going to see a psychiatrist. And someone needs to — and usually that someone is your gynecologist — should be able to make sense of those symptoms and actually connect the dots so women understand, "No, I'm not sick. No, I'm not crazy. These are very typical signs of perimenopause." And that person should also be able to explain to you what your treatment options are, such that if you don't want to feel this way, and it's getting in the way of how you're functioning, then you need to know to seek treatment and care.

BECKER: Yeah, well, let's talk about treatment. Because treatment's been controversial hormone replacement therapy to try to get some of those hormones stabilized and alleviate some of those symptoms. You know, there was a big study done that said that hormone replacement therapy increased the risk of cancer. So where are we now with that as a potential therapy for some of these symptoms?

MALONE: Well, where we are now is we have been trying to re-educate not just women, but doctors as well. Because the source of this bad information is not just coming from the press and the internet, it is coming directly from doctors who are still giving information out to women that says, "Oh dear, you can't have those hormones because they increase your risk of breast cancer."

And let me just say in short that most of the findings from the Women's Health Initiative, which was the study that was done 22 years ago now that put that out there in the universe that estrogen therapy, or hormone replacement therapy, increases the risk of breast cancer, a lot of that has been walked back. It was never as bad as initially purported.

And what we also know and are coming around to the fact that there are many, many benefits to hormone therapy in addition to just relief of menopausal symptoms. Taking hormone therapy also decreases the risk of osteoporosis. It decreases the risk of type 2 diabetes. If you take estrogen and progestin, it decreases the risk of colon cancer. So the list goes on and on, and that message has not gotten out there. And we are really desperately trying to get women to understand that you should not feel as if, if you were taking hormone therapy, that you were somehow compromising your health either in the short term or the long term. Because that's just not true. It's been a hard message to walk back because, you know, it's sticky. It's a very sticky message.

BECKER: Right and frightening, right?

MALONE: Yes.

BECKER: I mean, I think a lot of people are probably afraid to experiment with something like that. You also say that most women should use some type of vaginal estrogen too, right?

MALONE: Absolutely. Because, and let me make this distinction because when we talk about hormone replacement therapy, we're talking about either systemic hormones, which means that you are taking estrogen and/or estrogen and progestin. You take progestin if you have a uterus. Estrogen is the actual secret sauce in all of this. But what you're taking systemic estrogen for is for relief of menopausal symptoms and for the decrease in cardiovascular disease and decrease in the risk of osteoporosis. And that is really what women are taking systemic estrogen for.

Now, local or vaginal estrogen is used for the symptoms of vaginal dryness, urinary, tract infections, frequency, urgency, painful sex, that is what vaginal estrogen is used for. And even if you choose not to do systemic hormones, just about every woman should use vaginal estrogen because of the effects of the vaginal thinning and dryness that happens as we age. Even if you've had not one hot flash, almost 85 percent of women will experience the vaginal dryness, urinary tract infections, and urinary issues.

BECKER: I read that you said that some women, it's not uncommon for some women to become perimenopausal in their 30s.

MALONE: Yes. Now imagine this. Remember if I told you that the average age for menopause, which means just having had your last period, and that's where we mark it. Now you'll be menopausal for the rest of your life, which is why I said that a third of your life you'll spend in that menopausal state. But if the average age is 51 — and it's a little earlier than that for Black women, because they tend to enter menopause earlier and experience symptoms that are more severe and last longer. But if you say average age is 51, and I tell you that that process can take anywhere from four to 10 years, that means that on average, women are entering perimenopause in their forties, usually in their early forties.

However, suppose you're going to be menopausal at 45. Well, then that means that you can back that up another 10 years and you might experience perimenopausal symptoms that we're talking about in your 30s. And this is where it gets really confusing because a 35- or 36-year-old woman may go to her doctor and say, "Oh my God, I can't sleep. I have hot flashes. I'm anxious. I'm depressed." More often than not, your doctor won't even be thinking about menopause because they go, "Well, you're 35." And I'm here to tell you, you are perimenopausal when you are having symptoms. You do not have to wait until a particular age to age into this because we are all going to experience our last menstrual period at different ages.

BECKER: Another one of those, "Oh, I don't have to worry about that until I'm really old" kind of things, right? (LAUGHS)

MALONE: (LAUGHS) Right!

BECKER: So, you know, if so many patients are doing their homework because they have to, Dr. Google can be quite a rabbit hole. And there can be a lot of business opportunities for folks who might think that the neglect of some of these issues, the lack of time by doctors really can open up some opportunities for folks to offer their own alternatives and supplements to help all of these things, especially for women, might help their health issues. What do you say to women about, you know, sort of trying to figure out if some of these things that you see online that will guarantee that you're going to feel better and your symptoms will be alleviated. How should women evaluate some of those health claims that are being made all over the place really by some of these businesses?

MALONE: Well, this is what I would say to you, because I think bottom line is this, particularly if we're talking about perimenopause and menopause: The most effective treatment for the symptoms of perimenopause and menopause is hormone therapy. And that is period, end of sentence. That is a million different organizations — the North American Menopause Society, which is now the Menopause Society, and 30 or 40 other medical organizations have agreed that that is the case.

Now, when you are out there looking at supplements and things and people are selling you things. I usually say the good rule of thumb is that if it looks too good to be true, it's either not that good or it's not true. So do a little bit of homework. And if someone is making these miracle claims, then take a moment to say, okay, well where's the data behind that?

And a good clue for you is that if you are looking at supplements or things on the internet and they say it "supports" this or it "supports" that, because you can't say it "treats" it because then you'd be a medicine. That is the language that they use to get around having actual data behind their claims. So be a wary consumer.

I don't think that the internet is a good place to go to look for a diagnosis. I think that the internet is a good place to go for information, not just data points. And to know that there are trusted people that you can follow on the internet that do give solid information. And I give some of those resources in the back of my book because how do you know? I mean, people, you know, people can say anything, it doesn't have to be true. And it's just a matter of knowing your source. Doing a little bit of homework. And I know I'm asking a lot of you, but it's important. Because I think your health is important. And I think that I have the same goal that you have. And that is to make sure that you navigate this thing called midlife and beyond being as happy and as healthy as you can possibly be.

And I want you to have the message that you do have some control over that. And I want to change the face of what aging and what midlife and what a 60-year-old, what a 70-year-old looks like and what you should be able to do. Now, it's going to require a little bit of work on the front end, but it is doable and it is not difficult.

BECKER: All right. Dr. Sharon Malone, longtime OB GYN and chief medical advisor for Alloy Women's Health. She's also author of Grown Woman Talk: Your Guide to Getting and Staying Healthy. That book came out earlier this month. Thanks so much for being with us.

MALONE: Thank you, Deborah.