Dr Louise Newson: Amy Alkon is a guest on my podcast today. She's an author and a scientific writer specializing in applied science. Her most recent book is Going Menopostal. And she's really unpacked a lot of the evidence. She's dispelling a lot of myths about the confusion between natural and synthetic hormones. And she really talks with a very personal experience as well. It's a really great book, and it's a brilliant conversation for you to listen to. So, Amy, I'm really excited to have you, even though you're over in the US. But I've been reading your book the last few days, and I just love it. I love the way you think. I love the way you write. I love your inquisitive nature. So just before we talk too much about the book, just tell me a bit about you and why you even wrote this book?

Amy Alkon: Well, I have had the luck...I've been an applied behavioral science writer. So my writing, I give advice, but it's informed by science. And in 2007, I met Sander Greenland, who's one of the top epidemiologists and bio statisticians in the world. And I was just desperate. I’m always desperate to be better at assessing research. And this guy is so generous. He coached me since 2007 on how to read and critically evaluate research. And he goes after methodological error and fraud and abuse in medicine. And so he sent me all these articles and papers about the horrible, horrible effects of, of care that is not based on good evidence. And, because of that, when I have an issue at the doctor, I don't go to the doctor and say, like with my hot flashes, I'm uncomfortable, what should I do? I go to the research base. I learn what you know, what the research says, and then I go to the doctor.

And that is very protective. And this is why I wrote the book for other women. Because most women can't do that. They're not these huge nerds. I read science day and night. And so we all deserve the evidence-based care that you, you know, that you're a source of. You're my hero. And, you know, you're one of the few people in this area that I actually just fully respect.

Dr Louise: Thank you. And it's interesting, because I am like you. I'm very scientific. I love reading papers. Quite meaty scientific papers, but I also really like evidence-based medicine. And medicine is an art and a science. You know, I feel very strongly that the art form is individualising care, but it has to be based on evidence. And many years ago, like 22 years ago, I wrote a book on evidence-based medicine for GPs actually, it was called Hot Topics for the MRCGP and the MRCGP is the membership of the Royal College of Physicians. So it's an exam that we take as GPs over here. But I realised that a lot of people are not quite so geeky as me. They have a better social life and they read other things. And so as busy doctors, you often read like the top line or the sort of highlights of guidelines and you never read the papers. Whereas when I read the papers, I'm not just reading the science. I'm learning about the authors, what conflicts they might have, what other agenda they might have, who's, who's paid them, is pharma behind them? Like, what sort of paper is it? And what are the numbers in the studies and all sorts of things, which is really builds up this picture. So I wrote the first book and then I did three more books after which were just like, you know, first edition, second edition, so that when people were like treating someone with diabetes, I would be unpicking all the papers and just just summarising what they were. And I've always worked like that and I really enjoy it. But I realise a lot of people don't. And it's not just the doctors. It's like you say, patients don't either. And then they go to a doctor. They don't know how much science they've read. They don't know how many papers they've read, they know they've got a medical qualification. But it's very difficult to know, isn't it? And, so to have access to information as a patient is really crucially important.

Amy: In our training here, in medical education in the US, it sounds like there's training in how to read and critically evaluate studies there. And I write about the three big myths in our medical care. And one is that doctors base your treatment according to evidence. And that's not true, because here in medical schools, it's more a moral failing. They do not teach doctors how to read and evaluate papers. So doctors don't read papers because they don't know how. And then, to be fair, at an HMO like mine they see patients every 20 minutes. And so I might read tonight, you're a nerd, too, but but, you know, people want to go home at night. And I can accept and understand that as much as I think it isa moral failing for doctors to not educate themselves in the ways medical schools have failed them.

Dr Louise: Yeah. And it's interesting. So I've worked, 25 years ago when I trained as a GP. I was in hospital medicine before and I worked full time and I didn't have time to read many papers then, but then I worked part time as a GP so I could be flexible around my children. But when I wasn't working as a GP, I was doing medical writing. So I was writing articles that was based on evidence for healthcare professionals, but also for people as well to learn more. So I've had a lot of blue sky thinking time. I've been really privileged with that. And then I when my I had my third child, I was only working one day a week as a GP and it was really hard, like I'd come home after seeing maybe 60 patients and I would literally my children would know not to go near me on a Monday night, you know, I was broken. But then the rest of the days I would be reading articles, guidelines and papers and then I would be summarising them. And if you're if you're writing about that, you have to know the evidence. You have to know it inside out, back to front. You can't write something unless you can support it by knowledge. And then I'd go back to the practice the following Monday and I'd say, oh, hi guys. What have you been doing all week? And then they would be just seeing patients. They would be having my Monday every single day. So of course they're not going to read. But medicine does advance and change and things that I learned to medical school very different. The drugs that are available are very different now. You know I qualified 30 years ago. So things have changed and some doctors just haven't advanced in the same way with their knowledge.

Amy: I have to tell you, you'll know how horrible this is. Better than anyone. The head of gynecology at the big, massive West L.A. facility had an appointment with me about two months ago because my gynaecologist, who's great, is off. She told me the circa 2002 advice from the discredited Women's Health Initiative study that I should taper off estrogen at 60 because it causes, and I'm 61, it causes breast cancer and Alzheimer's and all this. And, I was so shocked. You know, here's this woman. She told me she read the science. Yeah. No you haven't. And you not only that, you haven't even read the practice bulletins from the Menopause Society from 2017, 2022 that say we don't have a stopping role. We have what you said individualised care, so important. You know, we look at a woman's health and then monitor her. And that's why you can if you initiate estrogen right at menopause or within six years, you know, for cardiology, for cardiovascular health, you know, you can take it throughout your lifetime if you remain healthy. And so you have it in your body protecting your bones at 79 when you're likely to fracture. And then you're not left for years from 60 to 80without this, while your bones, you know, become more and more fragile.

Dr Louise: I think, what I'm going to ask you is really important based on your book as well. So I've got teenage children who are girls, and I've got an elderly mother, and my younger children can get hormones very easily. They can go and ask for contraception, whether they need it or not. They might just want it for their skin or their mood or whatever. They can go and ask it, and I can pretty much guarantee if they wanted it, they'd come out the same day with a prescription of hormones. My elderly mother has been on HRT for, about 30 odd years now, maybe a bit longer. She has been phoned up by her GP last week to tell her she needs to stop it. Now, they're on different hormones, so the hormones of contraception are not the same as the hormones. My mother's, So just tell me with your knowledge and research, which hormones are safer?

Amy: Oh, okay. So transdermal estradiol, that's, basically an estrogen sticker. That is the that is the safest form of estrogen to take. And it again, you need to initiate it, as close to menopause as possible. So menopause being 12 months without a period. And this is healthier than the oral estradiol and you needless of it. So oral estradiol can do all sorts of bad things like raising clotting factors because it goes straight to your liver. It's called first pass hepatic effect. That's fancy, fancy talk for it, you know, you take it orally, goes to your liver. Your liver is very good at getting rid of stuff from your body. So you need a huge amount. And then transdermal estradiol, because it goes to your bloodstream, there's a negligible amount, trace amount that gets to your liver. And so it can't elevate those clotting factors. This is very important, and doctors don't know this I know because one of the other substitute gynaecologists just told me transdermal could cause me to have a heart attack or stroke, and it, okay, that's physiologically implausible to impossible. You know, and, you know, and the stroke thing, my blood pressure is99 over 62. You know, I'm not going to have a stroke. Okay. Let's look at our whole health. And this is something I appreciate that you do where doctors don't, looking at the patient as the system and being the creativity, the art of medicine you're talking about, you need to have the deep transdisciplinary knowledge to be able to look at what is the actual underlying effect. And of course, one of the other myths of medicine I bring out is that doctors are not trained in diagnostic reasoning. So this is a big problem, because what they do is that you come in with the symptom. Now we're empathetic as humans. We evolve that way. And so the doctor wants to ease your suffering. Doctors are not terrible people. There's a sociopath in every profession, but they want to help you. They just don't know how. You know, and so if you treat a patient the way doctors do with their fear, their unwarranted fear of hormones, give a patient antidepressants, you know, and there are patients who need that, like, you know, who who can't take hormones. But if you give the patient antidepressants, what you're doing is leaving their breasts and uterus unprotected, their endometrium, their uterine lining, they're being under, they're not being protected against, cancer, breast cancer, uterine cancer. They're not having their, you know, their bones helped. So you're treating the symptom of hot flashes. And these do, the antidepressants do. But you're not. You're leaving so much of them not protected not helped. And it's just terrible. And it comes out of the lack of science, you know, in our medical care and the fact that our practice standards, they're not science based and doctors don't know. And and I want to bring out one thing because since you you're the antithesis of this, in America, almost none of the gynaecologists have any training whatsoever in menopause and perimenopause. They treat patients anyway, which is a violation of medical ethics. And then there are some experts, and they've been trained by the Menopause Society. And the training is a joke. 45 hours required of continuing medical ed in women's health in general, 15 of which must be in menopause and perimenopause. And then they take an online test and then they're experts. They're absolutely not. And I know this because I'm like a medical lie detector for science. They say things to me. And these appointments I had ten,ten gynaecologists deny me the increased dose of estrogen I needed. And, they just say all these things that are not scientific and I have to not come off like the irritating know it all, because that doesn't help you get the drug you need.

Dr Louise: But it's very difficult. But also like what I was trying to tease out with my children, if they if they did, they don't, but if they did want contraceptive then that's synthetic hormones, it's not even the same as my mother who takes body identical estradiol, progesterone, testosterone, are the same structure as the hormones we produce. Whereas in the book, you're very clear. So talking about the synthetic progestins, but also ethinylestradiol, the conjugated equine estrogen. So the estrogens that we use in older types of hormones, but they're still used in contraception. So I find it's like double standards. It's fine to have a contraceptive that’s synthetic with risks, but people don't talk about those risks, they're younger people. Whereas any type of natural hormone everyone always presumes has got risks associated with, even though they haven't.

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Amy: It's the irony of this, and this is where the art of medicine comes in. So you have the deep transdisciplinary knowledge and you see that this is ludicrous. You know, I always tell women, you know, that, you know, I had the copper IUD, which is just copper blocking the little sperm from reaching the egg, you know, and, and so and this is so important because, you know, okay, there can be risks, perforation, everything. But those risks to me, if you look at the actual trade offs, those risks are preferable to the risks of taking these synthetics. You know, we talk about the Mirena mustache, women who have the Mirena IUD. There are all these viralising, you know, male side effects that can happen to you. And, you know, why would you take something that has health risks when you can use the copper IUD that has no chemicals in it, that just has a reaction that kills the sperm?

Dr Louise: Yeah, I think because people don't know and often it's the patients don't know, but also the doctors haven't been educated the difference, and and I didn't know for many years because no one sat down and spoke to me. And if you don't really know, you're not really understanding the difference in the chemistry. So I think this is where your book is so good and interesting because it talks about the science, but weave through it you've got your own personal journey as well, and we all change when we experience something that's definitely for sure, whether we're doctors or patients, we become more knowledgeable and we also know how hard it is sometimes to access the medical system. So your book does a lot, but it must have taken you a long time to write the book and research it didn't it?

Amy: Eight-year deep dive. I did this thing you're not supposed to do as an author, I live. I'm still living off my savings. I'm running out because this was such a mission. What had happened was I went to my healthcare provider, to my gynaecologist, you know, and I wanted to get oral micronised progesterone, the amount you need, per the wonderful work of Jerilyn Prior, MD, the endocrinologist and clinician. And they were on the formulary only had proxyprogesterone acetate, the synthetic knock off that raises your risk of breast cancer. It is harmful to the brain. It's harmful to the cardiovascular system. And so I fought three battles with the woman who's now the associate director of the hospital, former head of gynecology. They treated me with respect. Instead of blowing me off, they listened. And they allowed the the progesterone, the dose. I wanted, which they don't give in the U.S. for no scientific reason. And then, also they covered it in the US. So you need to have because we don't know how we metabolise steroid hormones. And so you need to make sure you have enough to protect your uterus and breasts against cancer. And it's also very helpful healthy drug that promotes GABA and sleep and mental wellness. And so this is not a drug where you're in danger. It goes up ten times the amount in the menstrual cycle, in pregnancy women are not dropping dead from progesterone. Quite the contrary. And so when I did this because I'm naive, I'm from the Midwest and we're kind of like Pollyanna. And I said, okay, so now I've showed you the science, and now will you put this on the formulary and give this to all women? I think there's almost a laugh. No, they wouldn't. And to me, this was like the equivalent of, you know, I got the care. And it would be like watching a stream of women, an endless stream, walk into an open manhole and say nothing. And so I did this book. I call it the stupidest, most horrible, and most important thing I've ever done. Because my joke is that I forgot to take endocrinology when I forgot to go to med school. I had to learn all this, but I did this book as a mission because I thought, how dare you leave women unprotected when you know this? You've been trained by Sander Greenland. You have the capacity to write this book in a way others don't. You know. And I include all this stuff and dietary science and everything, the most efficient and powerful ways to eat and exercise, doable by mere mortals. And and so I put this all together, but it was really, really horrible because you have to do what you're saying. You verify the science. What I love about you is that, you know, you look at, you know, you look at the the are people are this who are the scientists? And I look at that. And what I see basically is that every scientist, the ones I respect, they're there's some way in which they are selling their point of view a little too unscientifically. And it is it depresses me. But I understand that we're human and people do this, but I look for it always in everybody, and I look for also big famous researchers. This woman, J.Julie Kim, not to call her out particularly, but she's famous. She has a paper on how progesterone causes breast cancer. You know what? Okay, wait a second. This doesn't make physiological sense. So I go and I read her paper and I look I always look at the citations in the back. So the citations for this, they all say medroxyprogesterone acetate and that's what those papers are about. And so this gets spread. It's like a game of toxic telephone. So in our, when you get a prescription here for progesterone you get this, this scary sheet with it, this is going to kill you. Here's how. Because it's for medroxyprogesterone acetate, not progesterone. That's how big the confusion is and how terrible it is.

Dr Louise: And it is confusing because if you use the word estrogen, it can include ethinylestradiol, it can include equine estrogens and estradiol and estriol and estrone so there's lots of different types of estrogen under the word estrogen. But the word progesterone is only progesterone. That's where we're really careful usingthe word. In the US it's more progestins. We say progestogens but it's not progesterone. And there is this big confusion. And like you say, Prior's work is amazing because she has worked so hard for so many years. And I was reading the other day that she, applied for so many universities. I think it was nine times to try and get into medical school. And like her determination was huge. But she's still, people like raise their eyebrows and don't want to think about progesterone. So the WHO have got the list of essential medicines and obviously there's antibiotics on there, there's really important drugs. There's insulin. But when you look at hormones they only list, the contraceptives and medroxyprogesterone. They don't have progesterone. They don't have estradiol. They certainly don't have testosterone. And you know, I think this is a real omission because it shows this sort of ignorance between these different hormones. And we've got to understand the difference because some are associated with risks, the synthetic ones, the natural hormones are associated with lots of benefits. And as you say in your book, the benefits to symptom control, but more importantly, the benefits to future health as well.

Amy: Exactly. And then another thing in my book, I wrote the book and the the longitudinal research was not out on testosterone. I now am taking it. I had to write my own prescription and the pharmacokinetics for somebody very high up in gynaecology because they don't know this. They have the male, the androgel on their formulary. And men have 20 to 25% thicker skin, more sebum. And because I know how to take this, I have I have to take it twice a day, you know, every 12 hours I have to divide this, get it in a little, you know a little container within 30 seconds because it evaporates. And I put it on with the back of it like an eye dropper, the individual eye drop thing that I use, you know, and then, I mean, I'm not I'm not going to get an exact dose, you know, this is so terrible. And this is the how deep the lack of evidence in, in our medical care goes where, you know, they don't even know that you need to have cream. You know, they should have cream and they're called oral syringes which is they're not oral and you don't inject them. But it's a precise dose for women. Cream is better with women's skin and I know because I've read your research and I've read your papers on testosterone. I was looking at one the other day when I was writing the pharmacokinetics up. And I mean, this is egregious we don't even know a form approved in, in, here in America. And you have to have hypoactive sexual desire disorder. And by the way, before I did the medical stuff, I read the papers on this because I'm an evolutionary psychology expert, and it doesn't really seem to work for that. But you have to make up this story about your sad sex life in order to get it, you know, because you have to get you have to look at what is it allowed to be prescribed for by the Menopause Society. And, you know, I'm not a dishonest person, but I'm going to lie for my for the benefit of my health if I have to, to get the prescriptions I need.

Dr Louise: I have a real issue with HSDD which is hypoactive sexual desire disorder because it says that women have to be severely psychologically distressed for at least six months before being able to make that, you know, have that diagnosis. Now, as a doctor, I don't let my patients become severely psychologically distressed with anything. So, and our guidelines and a lot of other guidelines say that if women have reduced sexual desire, we can consider testosterone, which is a lot nicer, and it's a lot better. But it it's not all just about having sex with a partner. So many of my patients are told by doctors, well, you haven't got a partner. Therefore you don't need a libido, therefore you don't need testosterone. And I also think as a doctor, I shouldn't be judgmental. If people want to improve their libido, I'm not going to ask them, like what they're doing with their improved sexual desire. It's up to them and it feels really like going back in time to have these very rigid criteria to say whether someone can or cannot have a hormone that affects every cell in our body. It just seems weird.

Amy: It's paternalistic to use that word. And the thing is, the real reason I wanted it. I have, attention deficit disorder, which I hate. I don't have a deficit of attention. I have too much, you know, all over the place. And I need to focus. Adderall helps me with that. But, you know, in menopause, you have a decrease in norepinephrine and dopamine. And these are some of the things that are already, you know, not not in sufficient quantity in those of us who have this and so in menopause, I had, you know, really terrible memory problems, other problems and estradiol helped. But the testosterone I've just been taking it for, maybe it's been three weeks. Oh my God, I'm back to being myself again. I saw that, and I had to make up this story about how I, like my sad sex life. And, along the lines of what you said, I want to point something out to women. You know, I have a whole section on vibrators in my book. You know, that women, you know, to tell them, you know, it is wonderful, give yourself pleasure. You know that if you have, sort of stigma against that in your head, here's why you might rethink that, you know, and to get the pleasure throughout your life that you can have, you know, from the marvelous little, you guys say clitoris, clitoris here. And, you know, this is stopping women from having the full, rich lives they can, all this, this sort of prejudice against, you know, the drugs that comes from a lack of scientific evidence and fear, defensive medicine, the practice of medicine to defend a doctor's license, avoid getting complaints and prioritising that over the patients. And the reason you have to do that is if you're ignorant, if you know the medicine that you can confidently prescribe for your patient and let them know what the risks are, and you know the risks. If there are risks, that's, that's, that's real, that that's doctoring how it should be. And it's not what we get for the most part.

Dr Louise: Yeah, for sure. And actually there's a lot of risks in a lot of other medicines that I prescribe as a doctor compared to hormones, you know, and there's not nearly as much discussion out in the public about risks of antidepressants or risk because of antibiotics or risk of blood pressure treatment. It's just maddening how it's been shoehorned into the space of hormones. So show me your book, I know you've got the book there, just hold it up so we can see it.

Amy: Oh yes, I should have done I forgot, I was so excited to be on here that I forgot to sell my book. This is Going Menopostal what you and your doctor need to know about the real science of menopause and perimenopause. And it's written in this everyday language because I needed to tell women the science without being in this medicalese that where it's impenetrable. So what's been happening? This this is so, I have joy every time I get these messages. Women are going to their doctors and sometimes screenshotting science in the book and using it to get the evidence based medicine where they're getting the hormones and sufficient amount, the right kind and that that's just so beautiful. It's so beautiful.

Dr Louise: I think it's giving people more confidence, actually, because your book is based on evidence as well as opinion, that's really important. So people can learn from it. And you write in such an easy way for people to understand. So and I always ask for three take home tips, but what three reasons are there whypeople should buy your book? What are the three things you hope that people will then and be able to act on from your book?

Amy: Well, I tell them, you know the actual science in contrast to what they prescribe here. So I tell you why you need that and give you justification for it. So you can go to your doctor with that. And so the other two things would be, that you get for my book. I also tell you, beyond hormones, because I'm transdisciplinary, I know there's evidence across many areas from decades since 1995 of reading and dietary science and exercise, the most powerful and efficient ways to exercise. And they are not based on nutrition research, which is the crapfest of research where they ask you did you have a donut? What did you eat last month? I can't tell you what I had yesterday, and so these are doable by mere mortals. I exercise, you can see my muscles. I'm a lazy, hedonistic pig. And so, you know, I exercise 16 minutes a week with weights to get like this, you know, and, and so you can do that. I have weights on my floor. I'm not going to go to a gym, you know, regular people, you'd get a gym membership, you don't go, then you feel bad because you don't go. Then you eat cookies because you feel bad. So we're not going to have that cycle. And then the other thing that I do in the book is to talk about ageing at the very end, and how women are stigmatised as we age and how ludicrous this is. We're powerhouses. I'm so much better as a human being at 61 than I ever was. And note that I talk about my age all the time. I will tell you my age insistently as somebody who went to Harvard will let you know that before you’ve licked your martini olive at a cocktail party, because I don't accept the stigma. And if you're healthy, if you take the right hormones, use the right hormones, eating and exercise this way, protect your bones through eating and exercising this way, you can live, be old, and be fabulous and have a new career and a new you. Menopause can be a beginning rather than a sad oh the change, we're not going to talk about it. And that's why, by the way, my cover, I designed my cover and the title and everything. This is bold. It's like we're not going to be all like ladies bathroom colours here. You know, the pink and the flower. No, no no, no. Broken fan. This is about the inexplicable rage as women feel in perimenopause when they're not getting progesterone through cycles when they don't ovulate. And it's also about my outrage, the Going Menopostal at women being denied the care. And so this is all about bold. See my earrings? These are they're like $2 the size of coffee tables. I wear red lipstick. Here I am. I'm 61. I'm fabulous. You're not going to ignore me. And that's how I'd like to see women go out into the world, you know, because we're all, we're old and powerful and fabulous and if you have your health, you're more able to do that than anybody.

Dr Louise: Brilliant. What a great way to end. So thank you so much. It's been really enjoyable.

Amy: Thank you.