Episode Summary

Dr. Lucy McBride discusses hormone replacement therapy (HRT) and menopause, breaking through the noise of conflicting medical information. She explains the science behind menopause, addresses common misconceptions about HRT risks, and examines the recent FDA announcement about removing black box warnings on estrogen products. Throughout the episode, she advocates for evidence-based, individualized decision-making that considers a woman’s complete health profile rather than fear-based restrictions.

Key Concepts

Understanding Menopause and Perimenopause

* Menopause occurs when the ovaries stop producing consistent, robust amounts of estrogen and progesterone

* Perimenopause is the 7-10 year lead-up to menopause, characterized by irregular periods, hot flashes, night sweats, mood instability, sleep interruption, and vaginal dryness

* The average age of menopause in the United States is 51, but symptoms and experiences vary dramatically among women

* Testosterone decline in women is age-related rather than menopause-related, beginning in a woman’s 20s and 30s (Listen to Dr. McBride’s conversation on testosterone for women with New York Times journalist Susan Dominus here.)

* Every woman who lives long enough will experience menopause, affecting 50% of the population

The WHI Study and Its Lasting Impact

* The Women’s Health Initiative (WHI) study was the largest-ever randomized controlled trial studying menopause and hormone therapy. It was halted abruptly in 2002 and created widespread fear about HRT by linking it to increased breast cancer and cardiovascular disease risks

* The study had significant design flaws: participants were older (average age 63), used synthetic hormones (Premarin and Provera), and the timing hypothesis wasn’t considered

* McBride argues the study measured “harm of late initiation” rather than harm of HRT itself

* The study led to black box warnings on estrogen products that persisted for over two decades

* These warnings resulted in generations of women being denied information and treatment options for menopausal symptoms

Health Implications of Estrogen Deficiency

* Estrogen deficiency increases cardiovascular disease risk, with women losing their protective advantage over men after menopause

* Bone density loss accelerates during perimenopause and menopause, increasing osteoporosis and fracture risk

* Genitourinary syndrome of menopause causes vaginal dryness, painful intercourse, and increased urinary tract infection risk (Listen to Dr. McBride’s conversation on sexual health with Dr. Rachel Rubin here.)

* Cognitive changes and dementia risk may be associated with long-term estrogen deficiency

* Quality of life impacts include disrupted sleep, mood changes, and diminished sexual function that shouldn’t be dismissed as “just part of aging”

The Science of HRT Benefits

* Transdermal estrogen (patches, creams, gels) carries lower risks than oral estrogen by avoiding first-pass liver metabolism

* Micronized progesterone is preferred over synthetic progestins for women with a uterus to protect the uterine lining

* Early initiation of HRT (within 10 years of menopause onset) shows cardiovascular benefits rather than risks

* HRT can reduce fracture risk, improve genitourinary health, and potentially offer cognitive protection

* Local vaginal estrogen is topical (i.e, not the same as systemic hormone therapy) and is highly effective for genitourinary symptoms with minimal absorption into the bloodstream

Breast Cancer Risk in Perspective

* One in eight women will develop breast cancer over the course of their life; most breast cancers are sporadic (i.e., not hereditary or due to an inherited genetic mutation)

* The absolute risk increase of breast cancer from HRT is approximately 1 additional case per 1,000 women per year; data from the WHI showed that women who took estrogen-only HRT had a reduced risk for breast cancer

* Alcohol consumption (one drink per day) carries comparable or higher breast cancer risk than HRT

* Obesity presents a significantly higher breast cancer risk than HRT

* Having a family history of breast cancer doesn’t preclude HRT use

* Dr. McBride emphasizes viewing women’s health holistically rather than solely through the lens of breast cancer risk

Reframing Medical Decision-Making

* The question to ask your doctors isn’t “Can I take HRT?”; it’s “What are the potential risks and benefits of taking hormone therapy given my unique health profile?”

* Doctors should provide evidence-based information and guidance that honors patients’ unique health issues, tolerance for risk, and ability to understand tradeoffs inherent in any medical decision

* Risk exists on a continuum; it’s not monolithic. Risk cannot be reduced to zero—it’s about weighing competing risks and benefits which will very person to person

* Fear is real and valid, but shouldn’t be the sole driver of medical decisions

* Women deserve comprehensive information about their bodies and treatment options, regardless of age or time since menopause onset

* Read more of Dr. McBride’s article on vaginal hormone therapy and importance of empowering women to make informed decisions about their own health here.

Upshot

The conversation challenges decades of gatekeeping around hormone replacement therapy by emphasizing evidence-based, individualized care. Dr. McBride advocates for removing the stigma and fear surrounding HRT, encouraging women to ask better questions and doctors to provide evidence-based guidance that considers the whole person. Her central message: HRT isn’t right for every woman, but every woman deserves comprehensive information about her body and the right to make informed decisions.

In this conversation, Dr. Lucy McBride sits down with New York Times journalist Susan Dominus to discuss her recent article “‘I’m on Fire’: Testosterone Is Giving Women Back Their Sex Drive—and Then Some” on testosterone supplementation in women. With testosterone use surging among midlife women, they explore the gap between recommendations from the medical establishment and the wellness industry, examining why women are turning to testosterone for sexual health, energy, and vitality—and what the limited evidence really tells us about risks and benefits.

Key Concepts

Women Actually Make Testosterone (And More Than Estrogen)

* The common misconception is that testosterone is purely a male hormone

* Most women don’t realize they naturally produce testosterone—and in higher quantities than estrogen

* Women’s bodies produce testosterone from three sources: 25% from ovaries, 25% from adrenal glands, and 50% from peripheral tissues

* Testosterone plays a role in libido, energy, metabolic health, and muscle tone throughout women’s lives, however the role of supplemental testosterone for issues other than low sexual desire remains unclear

The Decline in Testosterone Levels Starts Earlier Than You Think

* Testosterone levels in women begin declining around age 30, dropping to approximately 50% by age 60

* This is a gradual, age-related process, not a sudden menopausal crash

* Menopause doesn’t cause testosterone to plummet; it coincides with the end of a depletion that’s been happening all along

* Women in their mid-40s can feel the effects of low testosterone long before they’re perimenopausal

* Understanding this timeline challenges the narrative that testosterone issues are specifically about menopause

The Testosterone Surge: From UK Trend to US Phenomenon

* Just a few years ago, testosterone therapy for women was primarily a UK conversation; the US medical establishment was dismissive

* In the past six to eight months, testosterone use has exploded across the US

* Women are discussing it on streaming feeds, social networks, and with their friends, indicating a cultural moment

* The treatment has moved from relative obscurity to mainstream conversation at remarkable speed, and the wellness industry is seizing the moment

The Evidence Gap: What We Know and What We Don’t

* The medical establishment has been cautious about testosterone in women due to limited research and because supplemental testosterone is not currently approved by the FDA

* Existing studies support the use of supplemental testosterone in women only for libido and sexual function (i.e., hypoactive sexual desire disorder)

* Anecdotal evidence suggest that testosterone can help women with energy, muscle mass, metabolic health, cognitive “clarity,” and overall wellbeing; however more research is needed to understand where these are true effects versus placebo

* The potential downsides are real (especially if given at high doses): voice changes, irritability, hair loss, hyper-arousal

* Long-term effects remain unknown, particularly regarding cardiovascular health, metabolic changes, and other systemic impacts

* Doctors face the challenge of counseling patients when definitive evidence is lacking, creating tension between patient demand and evidence-based medicine

* This uncertainty leaves both physicians and patients navigating uncharted territory

Navigating the Gray Zone Between Medicine and Wellness

* Women find themselves caught between traditional medical systems that historically have not made space to discuss sexual health and wellness practitioners who proselytize products without adequate evidence

* This dynamic mirrors other areas of women’s health where quality-of-life concerns have been historically undervalued compared to longevity metrics

* The conversation reflects a broader cultural shift toward prioritizing women’s subjective experiences as legitimate healthcare goals

* There’s a growing concern about polypharmacy: using multiple pharmaceutical interventions to address interconnected symptoms, then needing additional treatments for side effects

* The question remains whether people are reaching for pharmaceutical solutions too quickly instead of evidence-based lifestyle interventions like exercise, sleep, and stress management

* Both Dr. McBride and Ms. Dominus stress the importance of seeking care from practitioners who are well versed in medical evidence—for example those who are certified by the Menopause Society—and addressing testosterone levels in context, ruling out other causes for issues like fatigue and brain fog before jumping to testosterone as a quick fix, while acknowledging the lack of access to evidence-based care to address the nuances of patients’ health

Upshot

The conversation about supplemental testosterone represents a pivotal moment in women’s health—where patient demand for quality-of-life improvements collides with limited evidence. This moment underscores the need for nuanced, individualized discussions between patients and providers that honor women’s subjective experiences while acknowledging medical uncertainties, a challenge that extends far beyond testosterone to many aspects of midlife women’s healthcare.

Episode Summary

In this conversation, Dr. Lucy McBride sits down with psychiatrist Dr. Jessi Gold to discuss how to manage emotional wellbeing during times of political upheaval. With the country feeling unsettled by ongoing violence and crisis, they explore practical strategies for emotional regulation, the importance of naming feelings without judgment, and why small daily acts of self-care aren't indulgent—they're essential for functioning in a chaotic world.

Key Concepts

The Importance of Naming What's Really Happening

* Pretending the external world doesn't affect you is both unrealistic and counterproductive

* Avoiding the "grief Olympics"—comparing your struggles to others' and dismissing your own feelings

* Everyone exists in the same messy world, and acknowledging its impact creates space for authentic connection

* Naming feelings reduces the underlying current of stress that affects work performance and relationships

* You don't have to fix the world's problems to acknowledge they're affecting you

Feelings as Information, Not Pathology

* Social media makes it easy to conflate normal human emotions with clinical diagnoses

* All emotions serve a purpose and provide valuable information about your needs and circumstances

* The continuum approach: you don't need to meet clinical criteria to deserve self-compassion and support

* Feelings are temporary and meant to be experienced, not immediately eliminated or "fixed"

Acceptance vs. Resignation: Reallocating Your Resources

* True acceptance means redirecting energy from things you can't control to areas where you have agency

* The serenity prayer framework: identifying what you can and cannot change provides clarity and reduces helplessness

* Acceptance isn't giving up—it's strategic resource allocation of time, energy, and mental bandwidth

* Small acts of self-efficacy can counter overwhelming feelings of powerlessness

* Control-seeking behaviors often increase anxiety rather than providing the relief we're seeking

Dialectical Thinking: Holding Two Truths Simultaneously

* Both difficult realities and moments of joy can coexist without negating each other

* Social media algorithms push people toward emotional extremes

* You can care deeply about global suffering while still finding meaning in daily life

* Examples like Viktor Frankl demonstrate that hope can survive even in the most dire circumstances

* Dialectical thinking protects against all-or-nothing emotional spirals

Practical Micro-Strategies for Daily Emotional Regulation

* Small, discrete coping tools work better than major lifestyle overhauls for most people

* Fidget tools, breathing exercises, and physical grounding techniques provide in-the-moment relief

* Gratitude practices counter the brain's evolutionary bias toward remembering negative experiences

* Body awareness (like noticing jaw clenching while scrolling) provides early warning signals for stress

Digital Boundaries and Media Consumption

* "Mindless scrolling" is actually highly stimulating and often traumatic content consumption

* Watching repeated footage of traumatic events creates secondary trauma, especially for vulnerable populations

* Moving phones out of bedrooms and avoiding immediate morning phone checking reduces anxiety activation

* Setting specific times and limits for news consumption prevents information overwhelm

* Parallel activities with friends (working quietly together) can provide connection without amplifying distress

Upshot

Dr. McBride and Dr. Gold emphasize that managing anxiety during chaotic times requires both self-compassion and practical action. Their message: you don't need to be clinically depressed or anxious to deserve support, and tiny daily interventions can make a significant difference in emotional resilience.

Episode Summary

In this episode, Dr. Lucy McBride sits down with Dr. Shira Doron, Chief Infection Control Officer and Hospital Epidemiologist at Tufts Medical Center, to cut through the confusion surrounding COVID vaccines and public health policy. With the CDC in upheaval and patients calling with urgent questions about protecting their families this winter, they tackle the messy reality of vaccine access, institutional breakdown, and what it all means for your health decisions. Dr. Doron explains why getting clear answers feels impossible right now—and offers practical guidance for navigating the chaos.

Key Concepts

The Regulatory Meltdown

* FDA approved new COVID vaccines but only for high-risk groups, creating access barriers at major pharmacies

* Entire ACIP advisory committee was gutted—all 17 members replaced at once—leaving no clear decision-making authority

* CDC leadership departures and delayed meetings mean the usual vaccine rollout process has completely broken down

* Retail pharmacies like CVS can't administer vaccines without ACIP recommendations, forcing patients to get prescriptions

* The dust may settle by late September, but institutional trust has been severely damaged

The Backstory Nobody's Talking About

* A little known fact: the Biden-era ACIP was already planning to shift away from universal annual vaccines toward risk-based recommendations

* Internal polling of that committee showed 76% support for targeting high-risk groups rather than everyone over six months old

* Current policy direction mirrors what the previous committee intended, but the chaotic process has destroyed confidence

* Medical and scientific community feels betrayed by political interference in normal advisory processes

* Reform was needed, but "slash and burn" approach leaves the country vulnerable to future health crises

Making Sense of Who Should Get Vaccinated

* Dr. Doron suggests talking with your doctor but in general she recommends waiting for the new formulation rather than rushing to get the current vaccine during this summer's wave

* Dr. Doron notes that “high risk” for COVID is broadly defined—and includes sedentary lifestyle, history of smoking, anxiety, ADHD—such that most Americans will qualify for a shot. Plus, self-attestation of risk is likely to continue (rather than requiring medical documentation at pharmacies), and she predicts it will not be difficult to get a shot if you want one (though cannot be sure, and insurance coverage is up in the air)

* Professional medical societies are creating their own guidelines to fill the regulatory void

* Individual risk assessment with your doctor beats one-size-fits-all recommendations

What Vaccines Actually Do (And Don't Do)

* Modest protection against any infection for 2-3 months, more like "wearing a raincoat in a rainstorm" than a force field

* Strong, durable protection against severe disease (due to cellular immunity i.e., T cells) is the real benefit for high-risk individuals

* Limited impact on transmission, so getting vaccinated to protect others isn't particularly effective

* Timing matters: Dr. Doron suggests waiting 6 months to get vaccinated after a COVID infection, 3 months after previous vaccine for most people

* Novavax may offer better side effect profile and longer-lasting protection than mRNA options

Beyond Vaccines: Testing and Treatment

* Paxlovid remains effective for high risk patients when started within 5 days for people at risk of severe disease but is not a standard recommendation for healthy, vaccinated people; we live in a data-free zone on the degree of benefit (if any) for lower risk individuals

* Test for COVID or flu only when results would change your management—mainly for those who might benefit from antivirals

* Home rapid tests can help gauge contagiousness as you recover

* Basic rule: stay home until fever-free for 24 hours without medication

* Early testing and treatment of high-risk household members beats trying to prevent transmission through vaccination

Trust, Messaging, and Moving Forward

* Current chaos represents backlash against heavy-handed pandemic messaging that ignored individual risk differences

* Public health authorities lost credibility by overpromising vaccine effectiveness and dismissing legitimate concerns

* Acknowledging uncertainty and meeting people where they are builds trust better than blanket mandates

* Need institutional reform, not destruction of essential public health infrastructure

Upshot

Dr. McBride and Dr. Doron emphasize that navigating this regulatory chaos requires working closely with your healthcare provider for individualized risk assessment rather than relying on one-size-fits-all guidance. They stress that while patients must advocate for themselves in the current fragmented system, the real solution lies in rebuilding trustworthy public health institutions that prioritize transparent communication and evidence-based recommendations over political interference.

Episode Summary

In this episode, Dr. Lucy McBride tackles the crisis facing American healthcare and provides practical strategies for navigating a broken system. She explores a fundamental disconnect between what patients need and what the current system delivers: while patients require comprehensive, relationship-based healthcare that addresses their whole story, the system provides fragmented, rushed medical care that focuses solely on immediate symptoms.

Key Concepts

The Systemic Breakdown of Primary Care

* Root causes: Pressures from insurance companies and large hospital systems force doctors to see high patient volumes in brief increments, creating unsustainable working conditions and suboptimal care

* Consequences: Primary care has evolved from comprehensive problem-solving into rapid referrals and prescription writing, leaving doctors feeling burned out and unable to provide the care they trained to give

* Scale of crisis: Millions of Americans currently lack access to a primary care provider, with shortages expected to worsen significantly in coming years

* Financial reality: Only 5% of U.S. healthcare spending goes toward primary care, while the vast majority addresses damage control rather than prevention

* Professional exodus: Primary care physicians are leaving medicine due to burnout, time constraints, and inability to practice the comprehensive care they were trained to provide

Medical Care vs. Healthcare: Understanding the Critical Distinction

* Medical care defined: Problem-specific, episodic, transactional treatment focused on immediate symptoms (what urgent care and emergency rooms provide)

* Healthcare defined: Patient-centered, relationship-based care involving shared decision-making, understanding of individual health risks and goals, and comprehensive whole-person treatment

* The integration challenge: True healthcare requires connecting physical symptoms with biographical data, social determinants of health, and emotional well-being

* Relationship foundation: Healthcare depends on trust, rapport, and a provider's understanding of the patient's complete story and context

* Access inequality: While medical care is available through urgent care and ERs, comprehensive healthcare is increasingly accessible only to those who can afford it

Primary Care Options in the Current System

* Insurance-based care: Traditional approach using provider networks, though often limited by short appointment times and restricted access

* Federally Qualified Health Centers (FQHCs): Community-based centers providing comprehensive care regardless of ability to pay, often with shorter wait times (findahealthcenter.hrsa.gov)

* Direct Primary Care (DPC): Membership-based model allowing doctors smaller patient panels and longer appointment times to provide more comprehensive care, though not universally accessible due to cost

* Nurse practitioners and physician assistants: Can provide excellent primary care when well-trained and aware of their knowledge limitations

* Telehealth services: Options like One Medical and MD Live meet specific needs but have limitations in providing comprehensive relationship-based care

How to Evaluate & Select a Primary Care Provider

* Access assessment: Inquire about wait times for routine appointments, same-day sick visits, and between-visit communication methods

* Care philosophy evaluation: Understand appointment lengths, approach to preventive and whole-person care, mental health integration, and specialist coordination methods

* Logistical considerations: Verify insurance acceptance, understand membership details for DPC practices, and clarify after-hours coverage and prescription refill processes

* Red flags to avoid: Providers who lack time for building relationships, demonstrate defensive behavior when questioned, or fail to provide adequate access when needed

* Fit assessment: Recognize that doctor-patient relationships require mutual trust and respect; switching providers when the relationship isn't working is acceptable and necessary

Self-Advocacy Strategies & Appointment Preparation

* Priority setting: Prepare the most urgent issues for each appointment, understanding that comprehensive care may require multiple visits

* Rapport building techniques: Acknowledge providers' time constraints, share personal details to establish connection, and express understanding of systemic pressures while maintaining care standards

* Documentation responsibility: Keep personal medical records since electronic health records are fragmented across different healthcare systems and make sure they are updated with medications, dosages, allergies, family history, vaccination records, and specialist information

* Follow-up planning: Schedule subsequent appointments proactively rather than waiting for problems to arise, ensuring continuity of care

The Future of Healthcare Technology and Innovation

* Electronic health record limitations: Current systems serve primarily as billing tools rather than patient-centered care coordination platforms, with each healthcare system maintaining separate, incompatible records

* Technology's potential: AI and digital innovation (if done well) could create centralized, real-time health records shared across all providers, improving care coordination and reducing redundancy

* Innovation priorities: Successful healthcare technology must elevate—not eliminate—the patient-doctor relationship. Tech entrepreneurs who understand this principle are most likely to achieve meaningful reform

* Patient empowerment through data: Individuals must maintain their own comprehensive health records until systems improve, including all provider visits, medication changes, and test results

* Systemic reform needs: Long-term solutions require centering primary care in the healthcare system, ensuring universal access to medical homes, and prioritizing prevention over damage control

The Upshot

Dr. McBride encourages everyone to advocate fiercely for comprehensive relationship-based care rather than settling for episodic medical transactions. She emphasizes that while individual self-advocacy is essential for navigating current realities, true reform requires investing in primary care and ensuring universal access to medical homes that address the whole person.

Episode Summary

In this episode, Dr. Lucy McBride welcomes cognitive neuroscientist Dr. Julie Fratantoni to discuss practical strategies for protecting and improving cognition. There’s a fundamental disconnect between modern lifestyle patterns and optimal brain health: while our culture celebrates multitasking, passive consumption, and constant stimulation, the neuroscience reveals that our brains thrive on focused attention, active engagement, and purposeful challenge.

Key Concepts

Active vs. Passive Engagement with Information & Technology

* Dr. Fratantoni discusses recent research showing passive AI use creates "cognitive debt" by bypassing memory encoding and reducing creativity

* Study found 15 of 18 participants who used ChatGPT couldn't recall a single sentence from essays they'd just written with AI assistance

* Using your brain first before incorporating tools requires engaging through critical thinking and connecting new knowledge to existing information

* Always close down and repeat back what you learned, either aloud or in writing, to consolidate information

Emotion Regulation & Stress Recovery

* Dr. Fratantoni advocates for stress “recovery" rather than stress management, focusing on bouncing back to keep the prefrontal cortex online

* The “physiological sigh” involves one full inhale, pause, extra sip of air, then full exhale through mouth to activate parasympathetic nervous system

* Reappraisal strategies include reframing anxiety as excitement or considering alternative explanations for ambiguous social situations

* Studies show reappraisal reduces amygdala activity, increases prefrontal cortex activity, and improves heart rate variability and telomere length

* Breathing patterns directly affect blood oxygen/carbon dioxide ratios, modulating norepinephrine production and focus levels

Focus & Attention Training in a Distracted World

* Modern digital environments work against natural attention patterns, requiring strategies to rebuild focus capacity

* Multitasking is actually rapid task-switching that increases brain stress and reduces performance

* Simple tally systems to track interruptions build consciousness of attention patterns and reduce their frequency through awareness

* Start with 5-10 minutes of focused work without distractions, then incrementally build this "focus muscle" over time

* Memory formation requires both attention and encoding time, so constant busyness prevents proper memory consolidation

“Hormesis” & Finding the Right Level of Challenge

* Dr. Frattantoni introduces hormesis for cognitive health—moderate stress benefits the brain while extremes become detrimental

* Research with 12,000+ people found low to moderate stress induces cognitive benefits that promote resilience

* The right challenge level varies by individual interests, capabilities, and circumstances, requiring self-assessment over universal prescriptions

* Examples include learning languages, dance classes, martial arts, or hobbies requiring ongoing skill development

* Neither overwhelming stress nor complete lack of challenge serves cognitive health

Flexible Thinking & Perspective-Taking

* This executive function involves shifting between viewpoints, adapting to circumstances, and maintaining curiosity about others' experiences

* Cognitive flexibility functions like physical flexibility—enough structure to be sturdy but adaptable enough to avoid breakage

* Taking different perspectives activates multiple brain regions and reduces inflammation in healthcare interactions

* Learning to disagree while maintaining emotional regulation and curiosity strengthens multiple cognitive systems simultaneously

* Having difficult conversations while disagreeing represents one of the most challenging tasks for the brain

Purpose and Meaning as Cognitive Protection

* Longitudinal research shows having life purpose provides significant protection against cognitive decline

* Study of 11,000+ older adults found purpose protective against cognitive decline regardless of other health variables

* Purpose doesn't require grand accomplishments—can be simple as tending gardens or contributing to community

* Dr. Fratantoni suggests a two-minute "personal manifesto" exercise to clarify core values and life direction

The Upshot

Dr. McBride and Dr. Fratantoni make the case that conscious attention to cognitive health isn't just personally beneficial—it's essential for redefining how we age and challenging the assumption that cognitive decline is inevitable.

Episode Summary

In this episode, Dr. Lucy McBride welcomes Dr. Sunita Puri for an intimate conversation about death, dying, and what it means to have a "good death." Dr. Puri, author of the critically acclaimed memoir "That Good Night: Life and Medicine in the 11th Hour," shares her expertise on palliative care while addressing the critical gap in how modern medicine approaches end-of-life conversations. The discussion explores the historical context of dying well, the problematic medicalization of death in contemporary healthcare, and practical guidance for both patients and families navigating end-of-life decisions. Dr. McBride brings a personal dimension to the conversation, sharing how Dr. Puri supported her through the sudden loss of her brother the previous year, illustrating the profound impact of compassionate end-of-life care.

Key Concepts

Redefining "Good Death" Beyond Idealized Visions

* The concept of "good death" has historical roots dating back to medieval Europe's "Ars Moriendi" (The Art of Dying) and ancient Buddhist and Hindu contemplations of impermanence

* Modern expectations often center on dying at home surrounded by loved ones, but this idealized vision can create unnecessary guilt and stress for families

* Financial and practical constraints make home death unrealistic for many families, as hospice doesn't provide 24-hour caregivers

* Good deaths are possible in hospitals, ICUs, and nursing homes when focused on dignity, comfort, and honoring the patient's values

* Flexibility and acceptance of circumstances, rather than rigid adherence to a "perfect" death plan, leads to better outcomes for patients and families

The Crisis of Medicalized Dying in Modern Healthcare

* The 1960s explosion of medical technology (iron lungs, CPR, ventilators) shifted medicine toward extending life at all costs, regardless of quality

* Healthcare systems default to aggressive interventions without adequate discussion of alternatives or patient values

* The "conveyor belt of technology" operates independently of what patients actually want or what would serve their best interests

* Medical training fails to prepare doctors for honest end-of-life conversations, leading to inherited patterns of avoidance and euphemism

* The gap between cure-focused medicine and compassionate end-of-life care leaves patients and families without adequate support for decision-making

Transforming Medical Communication Through Radical Honesty

* Traditional medical communication often provides facts without explaining their significance or implications for the patient's life

* Effective palliative care requires moving beyond "checklist" approaches (Do you want CPR? Feeding tube?) to understanding what gives the patient's life meaning

* Dr. Puri's approach involves explaining that "reversing a death is not the same as restoring a life," helping patients understand the reality of interventions like CPR

* Doctors must learn to sit with discomfort, witness suffering, and acknowledge uncertainty rather than defaulting to medical interventions

* Authentic communication requires doctors to examine their own reactions and fears about death, as "95% of doctoring is an inside job"

Practical Framework for Advance Care Planning

* Individuals should reflect on deaths they've witnessed, considering what seemed acceptable or unacceptable about those experiences

* Choosing a surrogate decision-maker requires careful consideration beyond automatic family hierarchies - sometimes friends understand one's values better than spouses or children

* The MOLST (Medical Orders for Life-Sustaining Treatment) form provides a concrete starting point for documenting wishes and should be displayed prominently for emergency responders

* Advance directives should be revisited after major health events, hospitalizations, or significant life changes rather than treated as one-time documents

* Effective planning requires honest conversations with primary care doctors, not just legal documentation, and patients should specifically request these discussions

Embracing Uncertainty and Impermanence as Spiritual Practice

* Buddhist and Hindu concepts of impermanence offer frameworks for accepting life's inevitable changes, including death

* Learning to "sit with uncertainty" becomes essential for both patients and healthcare providers in end-of-life situations

* Death anxiety can be addressed through traditional therapy, medications, and emerging research on psychedelics such psilocybin

* The practice of observing impermanence in everyday life (seasonal changes, relationship evolution) builds capacity for accepting larger uncertainties

* Healthcare providers must model comfort with uncertainty rather than promising false certainty or avoiding difficult conversations

Mercy and Dignity as Core Medical Values

* The concept of "mercy" encompasses both aggressive curative care when appropriate and allowing natural death when intervention would cause suffering

* Modern medicine must balance technological capabilities with recognition of human dignity and individual values

* The phrasing "allow natural death" reframes end-of-life care as supporting a natural process rather than withholding treatment

* Psychedelic-assisted therapy shows promising results for death anxiety in terminal patients, offering profound spiritual experiences that reduce fear

* Healthcare encounters become acts of love when providers center patient values and offer their authentic presence during vulnerable moments

About Dr. Sunita Puri

Dr. Sunita Puri is an Associate Professor of Medicine at the University of California, Irvine School of Medicine, where she serves as Director of the Inpatient Palliative Care Service. A Rhodes Scholar and Yale University graduate, she is the author of the critically acclaimed memoir "That Good Night: Life and Medicine in the Eleventh Hour," which examines her journey into palliative medicine and quest to help patients and families redefine what it means to live and die well. Her writing has appeared in publications including the New Yorker, Atlantic, New York Times, and Wall Street Journal. A sought-after international speaker, she has delivered lectures around the world on compassionate end-of-life care. In 2019, the Guardian created a mini-documentary about her work that has been viewed over 3.5 million times. You can follow her on Instagram and Twitter, and you can hear her previous conversation with Dr. Lucy McBride here.

Episode Summary

In this conversation, Dr. Lucy McBride speaks with author and journalist Debbie Weil about the surprising truths of aging. Weil, who writes the [B]old Age newsletter on Substack, shares insights from her journey of self-discovery in her 70s, challenging common narratives about aging as inevitably terrible. The conversation explores the unexpected freedoms that come with age and the importance of vulnerability in building community—plus the broken healthcare system's impact on trust, and practical health topics including GLP-1 medications. Both women discuss how authentic storytelling creates meaningful connections and how aging can be a time of continued growth rather than just loss.

Key Concepts

The Surprising Gift of Self-Discovery in Aging

* Weil describes discovering that aging involves getting to know your essential self better, rather than losing yourself

* Contrary to anti-aging messaging that suggests everything goes downhill, she found increased self-acceptance and authenticity

* The process involves recognizing you're fundamentally the same person while becoming more comfortable with who you are

* This self-knowledge becomes a foundation for making better decisions about health, relationships, and life choices

Freedom from Others' Opinions and Social Expectations

* Many older adults experience liberation from constantly seeking approval or worrying about others' judgments

* Weil notes the common refrain among older women: "I don't give a s**t anymore" about trivial social pressures

* This freedom manifests in practical ways: not wearing makeup if you don't want to, saying no to obligations that don't serve you

* The shift allows for more authentic relationships and choices aligned with personal values rather than external expectations

The Power of Vulnerability in Building Community

* Weil's most popular writing pieces are those where she shares personal struggles and physical challenges

* Vulnerability creates connection by allowing readers to feel seen and understood in their own experiences

* Both women discuss how sharing imperfections and uncertainties makes them more relatable and trustworthy as voices in health and aging

Healthcare System Failures and the Crisis of Trust

* Dr. McBride explains that only a small percentage of healthcare spending goes to primary care, with the vast majority focused on disease management and hospitalizations

* The average patient has just seven minutes with their doctor, creating transactional rather than relationship-based care

* This broken system has given rise to the wellness industry, which attempts to fill gaps but cannot replace proper medical care

* Trust in healthcare providers requires authentic listening, understanding of individual circumstances, and collaborative decision-making

GLP-1 Medications: Sophisticated Weight Management Tools

* Dr. McBride describes GLP-1 medications (like Ozempic) as the most sophisticated medical technology in her lifetime for weight management

* These medications work through multiple mechanisms: improving insulin efficiency, suppressing appetite, reducing "food noise," and slowing digestion

* Contrary to popular belief, not everyone who stops the medication regains all weight, especially when properly tapered with medical supervision

* The medications can help people break cycles of food restriction and emotional eating, leading to healthier long-term eating patterns

Creating Authentic Communities Through Shared Stories

* Both women have built engaged communities by sharing personal experiences rather than just dispensing advice

* Weil is launching a "No Guilt [B]old Women Book Club" featuring memoirs by older women writers

* The power of storytelling lies in helping people feel less alone in their experiences of aging, health challenges, and life transitions

* Writing and sharing stories becomes a way to process personal experiences while creating connection with others facing similar challenges

Episode Summary

In this conversation, host Dr. Lucy McBride sits down with Shannon Watts, founder of Moms Demand Action and author of NYT bestselling book, Fired Up, to explore how women can break free from societal pressures and pursue their authentic desires. Watts shares insights from her 11 years leading the largest grassroots gun safety organization and her interviews with 70 women for her new book. The discussion covers the psychological barriers that prevent women from "living on fire," the inevitable blowback that comes with stepping outside traditional roles, and the transformative power of female community. Both women examine how age can become a superpower for authenticity, the importance of redefining success beyond traditional metrics, and practical strategies for identifying and pursuing one's values, abilities, and desires.

Key Concepts

The "Living on Fire" Formula: Values + Abilities + Desires

* Living on fire is a metaphor for combining your core values, unique abilities, and authentic desires in meaningful action

* Most women are taught to fulfill obligations rather than desires, creating a fundamental barrier to authentic living

* The formula requires ongoing practice - sometimes it leads to big changes, sometimes small ones, but all matter equally

* Women often underestimate their abilities and need exercises to catalog their skills and seek outside perspective on their strengths

* Values evolve throughout life stages - Watts' values of protecting family and community when starting Moms Demand Action at 41 have shifted now that she's an empty nester

Blowback: The Primary Barrier to Women's Authentic Expression

* Fear of blowback (criticism, social disapproval) emerged as the number one limiting factor for women across all demographics

* Women are socialized to be people-pleasers, making criticism particularly painful and likely to trigger retreat behaviors

* Three strategies for managing blowback: evaluate the source, reframe the temporary nature of uncomfortable feelings, and remember you're modeling courage for others

* Blowback is predictable but not personal - it's a systemic response to women challenging traditional roles

* Learning to endure difficult emotions without numbing behaviors (alcohol, social media, isolation) builds resilience and agency

The “Deathbed Regret” Paradox: Motherhood vs. Authentic Living

* While the most common deathbed regret globally is "not living authentically," mothers in the study feared their regret would be "pursuing desires at the expense of children"

* This internalized guilt prevents women from recognizing that pursuing their own fulfillment actually benefits their children

* Children need to see mothers as whole people with interests beyond parenting to avoid unhealthy pressure and learn healthy life modeling

* Experts consistently affirm that children benefit when mothers pursue meaningful work and interests outside the family

* The fear reflects deep societal conditioning around women's roles and self-sacrifice expectations

Community and Female Friendship as Essential Infrastructure

* Watts discovered at 50 that despite leading a large women's organization, she lacked close personal friendships

* Female friendship requires intentional cultivation and vulnerability - it doesn't happen automatically in midlife

* The "five people you can call at 3 AM" test revealed how many accomplished women lack deep support networks

* Women's collaborative approach differs fundamentally from male competitive patterns, creating opportunities for mutual elevation

* Building authentic community requires moving beyond scarcity mindset and embracing the belief that supporting other women strengthens everyone

Avoiding "False Fires": Redefining Success and Fulfillment

* False fires include the commodification of purpose (turning every passion into profit), chasing ephemeral happiness, and equating busyness with fulfillment

* Society pressures women to monetize their interests rather than allowing pure pleasure and personal satisfaction

* The pursuit of perfection and the fear of public failure keep women from taking necessary risks

* True success means pursuing fulfillment over external validation, allowing for pleasure without productivity requirements

* Understanding the difference between temporary emotions and lasting values helps distinguish authentic desires from societal expectations

Age as Superpower: Wisdom, Self-Awareness, and Fearlessness

* Women over 50 develop crucial abilities: wisdom, self-awareness, and reduced concern about others' opinions

* The Serenity Prayer concept - knowing what you can and cannot control - becomes more accessible with age and experience

* Acceptance becomes a superpower when women learn to focus energy on areas where they have agency

* Later-life authenticity allows women to challenge the narrative that their productive years end when children leave home

* Generation X is rewriting rules around aging, menopause, and post-maternal identity, creating new possibilities for older women

The Upshot

This conversation illuminates a fundamental tension in women's lives: the conflict between societal expectations to prioritize others' needs and the human necessity of pursuing authentic desires. Watts and McBride make the case that women's liberation isn't just personally beneficial - it's essential for modeling healthy adulthood to the next generation and addressing society's most pressing challenges.

Episode Summary

In this conversation, Dr. Lucy McBride hosts Dr. Mary Claire Haver, the renowned board-certified OBGYN from Galveston, Texas. Dr. Haver, author of the bestselling book The New Menopause, discusses the current menopause moment, the complexities of hormone replacement therapy, and why women have been deprived of essential information about their hormonal health for decades. The conversation covers everything from the misinterpretation of the Women's Health Initiative study to practical prescribing guidelines for estrogen, progesterone, and testosterone. Both doctors emphasize that menopause care requires a nuanced, individualized approach that treats the patient, not just the symptoms or lab values.

Key Concepts

The Current "Menopause Moment"

* Social media as catalyst: Dr. Haver explains that social media has become a powerful platform where women share their menopause experiences, creating unprecedented awareness and demand for better care

* Generational shift: Gen X women are refusing to "quietly suffer" through symptoms like vaginal atrophy, bone deterioration, and cognitive decline

* Health span focus: Patients are increasingly concerned with quality of life and preventing the trajectory of decline they witnessed in their mothers and grandmothers

* Caregiver burden awareness: Women are motivated by not wanting to burden their children with preventable chronic illnesses and disabilities

The Women's Health Initiative Legacy and Medical Education Gaps

* Flawed interpretation: The 2002 Women's Health Initiative study wasn't inherently flawed, but its interpretation and media coverage created decades of fear around hormone replacement therapy

* Medical school inadequacy: Both doctors received minimal menopause education—Dr. Haver recalls just one hour in medical school with outdated information

* "Bikini medicine" concept: Dr. Haver describes OB-GYN as focusing primarily on "breast, uterus, vagina" rather than comprehensive women's health

* Guideline conflicts: Current conflicting guidelines between ACOG and the North American Menopause Society create confusion for practitioners

* Systemic healthcare bias: The medical system struggles to address symptoms that can't be measured in blood tests or imaging

Hormone Replacement Therapy: Estrogen Formulations and Prescribing

* Oral vs. transdermal delivery: Oral estrogen carries a small increased risk of blood clots (7 in 10,000) due to first-pass liver metabolism, while transdermal forms (patches, gels, sprays) avoid this risk entirely

* Cardiovascular benefits: Oral estrogen may offer slightly better cardiovascular protection and LDL reduction due to liver metabolism

* Bone protection thresholds: Different estrogen levels provide different benefits—some stop bone degradation while higher levels can actually build bone

* Individual absorption variability: Patients absorb hormones differently, requiring personalized dosing and monitoring

* Cost considerations: Generic patches are often the most affordable option, while newer formulations like gels and rings can be expensive

Progesterone: Beyond Endometrial Protection

* Mandatory for uterus owners: Women with a uterus must take progesterone with estrogen to prevent endometrial overgrowth and cancer risk

* Sleep and anxiety benefits: Progesterone converts to allopregnenolone, which binds to GABA receptors and provides sedative effects

* Multiple delivery options: IUDs can provide local progesterone for endometrial protection while oral progesterone can be added for sleep benefits

* Individual tolerance: Some women experience paradoxical stimulation or next-day grogginess from progesterone

* Newer options: Duavee combines conjugated estrogen with bazedoxifene, a SERM that blocks estrogen receptors in breast and uterine tissue

Testosterone: The Overlooked Hormone

* Age-related decline: Testosterone levels begin declining at age 30 in women, reaching about 50% of peak levels by age 50

* FDA approval gap: Despite multiple medical societies supporting testosterone for low libido treatment, the FDA has not approved any testosterone products specifically for women

* Evidence for libido: Strong evidence supports testosterone use for hypoactive sexual desire disorder in women

* Potential broader benefits: While not definitively proven, observational data suggests women with higher natural testosterone levels have better bone density, muscle strength, and lower frailty scores

* Dosing challenges: Women must use compounded or modified men's formulations due to lack of FDA-approved options

The Zone of Chaos: Understanding Perimenopause

* Clinical diagnosis: Perimenopause is diagnosed based on symptoms and patient history, not blood tests, due to wildly fluctuating hormone levels

* 7-10 year process: The transition from regular cycles to menopause typically takes 7-10 years as egg supply dwindles

* Unpredictable patterns: Unlike the predictable monthly cycle of reproductive years, perimenopause involves erratic hormone fluctuations

* Multiple system effects: Estrogen affects every body system—brain, bones, heart, vagina, mood—making perimenopause symptoms diverse and complex

* Treatment complexity: Managing perimenopause often requires different approaches than treating postmenopausal women, including considerations about contraception needs

The Upshot

This conversation illuminates why menopause care represents one of medicine's most significant gaps in women's health. The combination of inadequate medical education, misinterpreted research, conflicting guidelines, and time-constrained healthcare visits has left millions of women without access to evidence-based treatment. Dr. Haver's work, along with other menopause advocates, is helping to change this narrative by emphasizing that menopause is not just about hot flashes—it's about optimizing health span and preventing the cascade of age-related diseases that disproportionately affect women after menopause.

The key takeaway is that menopause care requires a toolkit approach where hormone replacement therapy is one important tool among many, including nutrition, exercise, stress management, and sleep optimization.

For women who missed the opportunity for hormone therapy during their menopause transition, it's never too late to focus on building better health through lifestyle interventions and appropriate medical care. The goal isn't just living longer—it's about maintaining vitality, independence, and quality of life throughout the aging process.

Most importantly, this conversation underscores the need for women to become educated advocates for their own health, to seek out menopause-knowledgeable providers, and to make decisions based on current evidence rather than outdated fears. As Dr. Haver emphasizes, women armed with good information make great decisions for themselves.