Beyond the Prescription

By Lucy McBride MD

Join Dr. Lucy McBride for honest conversations about what it really takes to be healthy. Each episode goes beyond quick fixes and conflicting health advice to explore the questions that matter: How do... more

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The podcast currently has 113 episodes available.

Best of Beyond the Prescription

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Number 1: Can People Actually Change?
Dr. Lucy McBride sits down with Benoit Denizet-Lewis, longtime writer for the New York Times Magazine and bestselling author of You’ve Changed: The Promise and Price of Self-Transformation, for a wide-ranging conversation about how people actually transform. What Transformation Actually Means—and How It Happens * The self-help industry focuses on habit change and optimization; Denizet-Lewis was interested in something deeper: shifts in identity, perspective, and personality that make people feel genuinely different * Change happens in multiple ways: sometimes it’s intentional and goal-directed, sometimes it arrives uninvited through illness, aging, or a moment of unexpected awe * People are deeply conflicted about change: they want it for themselves and are simultaneously threatened by it in the people they love * The narrative of transformation is almost always tidier in retrospect than it was in the living of it Identifying What is Fixed vs. What Is Dynamic * Core personality traits can be tweaked with real effort, but wholesale personality transformation is rare * Genetics and childhood shape us in ways that are largely fixed, but how we relate to those things is not * Trauma can be repaired; relationships fractured by the past can, with sustained work, become the closest ones we have * The serenity prayer captures something clinically true: distinguishing between what is fixed and what is dynamic is the definition of wisdom Self-Compassion as the Engine of Change * The transformation Denizet-Lewis describes most personally wasn’t a dramatic identity shift: it was learning gentleness toward himself * Ram Dass’s approach to jealousy—welcoming it in, naming it, refusing to let it run the show—illustrates what it looks like to observe a feeling without being consumed by it * Honest self-observation is essential to change, but it has to be paired with compassion; without it, the mirror is too painful to look into * An apology that ends with a period is one of the clearest expressions of self-awareness and change Shame vs. Guilt—and Why the Difference Matters * Guilt says “I did something bad”; shame says “I am bad”—and the distinction has real consequences for whether change is possible * Research on young people who committed crimes found that guilt was a positive predictor of rehabilitation; shame, counterintuitively, increased the likelihood of reoffending * The shame of failing to change—of breaking a resolution, relapsing, or falling short of a goal—is under-appreciated and causes many people to stop trying altogether * Shining a light on shame, naming it, and normalizing it is often the first step toward dismantling it; living in it while organizing behaviors around it is one of the most reliable ways to stay stuck Change as a Social Act * We like to think of transformation as private and interior, but it happens in community—getting buy-in from others, having change witnessed and reflected back, is part of how it becomes real * Social media has complicated this: performing transformation publicly creates skepticism, making it harder for genuine change to be legible to others * Asking people close to you whether they’ve noticed a change—awkward as it is—can be one of the most grounding forms of accountability Technology, Distractions, and Reclaiming Space * The phone has become the first place most people go when anxiety surfaces — which means it’s both a cause of anxiety and the default coping mechanism for it * Denizet-Lewis and McBride argue that the best thinking—in writing, in medicine, in life—tends to happen in stillness Upshot Transformation is messier, slower, and more social than many before-and-after stories suggest. The question isn’t whether change is possible—it is—but whether we’re willing to do the unglamorous work of honest self-observation, shame reduction, and showing up differently over time. 📣 HELLO READERS! Please join me this summer for the official Beyond the Prescription Book Club! It’s open exclusively to Substack readers and gives you early access to the book, pre-publication. 👀 We’ll get into the nitty gritty of health and wellness and what it all means for YOU. Sign-ups are open in May only. Get full access to Are You Okay? at lucymcbride.substack.com/subscribe
May 13, 202650min
Number 2: Rethinking Hormone Therapy, Hot Flashes & Sexual Health with Dr. Lauren Streicher, MD
Episode Summary Dr. Lucy McBride sits down with Dr. Lauren Streicher, Northwestern University professor and sexual medicine expert, to untangle two decades of fear-based messaging about hormone therapy in the wake of the Women’s Health Initiative. They revisit what the WHI actually showed (and didn’t show) and make the case for individualized, evidence-based menopause care across hot flashes, sleep, bone health, genitourinary symptoms, and sexual health. The WHI: A High-Quality Study That Was Badly Misread * The WHI was the first randomized controlled trial on menopausal women and hormone therapy — well-designed, but its early termination generated fear-based messaging clinicians are still undoing * The women who took estrogen only showed a reduced risk of breast cancer; the combined arm showed an increase of one case per thousand women, with breast cancer mortality still reduced Hot Flashes Are Not Harmless * The average duration of hot flashes is seven years — 10 years in Black women, lifelong for 10% * Each hot flash triggers a spike in heart rate, blood pressure, cortisol, and inflammation that accumulates real cardiovascular damage over time * Chronic sleep disruption from menopause compounds that cardiovascular risk significantly Local Vaginal Estrogen: Safe and Woefully Underused * Genitourinary syndrome of menopause — urgency, recurrent UTIs, pain with intercourse, pelvic floor dysfunction — is treatable at any age, including in women on aromatase inhibitors * The FDA recently removed the black box warning from vaginal estrogen; it was never warranted and existed only due to blanket class labeling tied to oral estrogens (listen to more discussion about the removal of the FDA black box warning here) The 10-Year Window Is Not a Stop Sign * Women who start hormone therapy within 10 years of their last period tend to do better at a population level — it does not mean therapy must stop after 10 years * A woman still symptomatic at 62 is a very different conversation than a symptom-free woman who feels she missed the boat (read about options you may have after the 10 year window here) Hormone Therapy and Breast Cancer: What the Science Actually Shows * For women with BRCA mutations, multiple studies — including a large 2025 prospective analysis — show no increased breast cancer risk on hormone therapy after oophorectomy. Breast cancer incidence was actually significantly lower in HRT users, with the protective effect concentrated in estrogen-only formulations. * For women with a prior breast cancer diagnosis, the evidence on HRT risk is limited and formulation-specific: older trials showed increased recurrence risk with combined estrogen-progestin (particularly in ER+ disease), but modern formulations are understudied, vaginal estrogen appears safe, and a 2025 expert consensus endorsed shared decision-making for women with severe symptoms. Existing data are too outdated and heterogeneous to apply universally. Perimenopause Requires a Different Playbook * During perimenopause, estrogen levels surge and crash erratically — standard menopause-dose hormone therapy often does nothing; a low-dose birth control pill is frequently the better tool * The decision to start, continue, or stop hormone therapy should be driven by symptoms and medical history — not arbitrary rules or influencers Upshot The fear that followed the WHI left generations of women under-treated and misinformed, and many are still paying the price. Hormone therapy is not right for everyone, but the decision should be driven by symptoms, history, and honest risk-benefit conversation, not by outdated warnings, arbitrary timelines, or wellness culture overcorrections. Women deserve accurate information about their own bodies, and that starts with clinicians who know the evidence and are willing to have a nuanced conversation. Get full access to Are You Okay? at lucymcbride.substack.com/subscribe
March 10, 202647min
Number 3: Making Sense of Hormone Therapy & the FDA’s Removal of the Black Box Warning ⛔️
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. Get full access to Are You Okay? at lucymcbride.substack.com/subscribe
November 12, 20251h 5min
Number 4: Testosterone for Women: What You Need to Know with NYT Journalist Susan Dominus
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. Get full access to Are You Okay? at lucymcbride.substack.com/subscribe
November 04, 202547min
Number 5: How to Manage Anxiety When It Feels Like the World is Falling Apart with Dr. Jessi Gold
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. Get full access to Are You Okay? at lucymcbride.substack.com/subscribe
September 17, 202546min