Redefining Womenâs Health: Menopause, Methodological Clarity
Author(s): Scott Douglas Jacobsen
Publication (Outlet/Website): The Good Men Project
Publication Date (yyyy/mm/dd): 2025/06/10
A Crash Course in Medical Myths: In Treating Menopause And Perimenopause and Throughout Our Medical Care
Award-winning science writer Amy Alkon exposes the systemic failures in womenâs health careâhighlighting how outdated guidelines, myth-based assumptions, and poorly trained doctors leave women misdiagnosed, dismissed, or untreated. In her new book, Going Menopostal, she helps readers cut through the noise, understand the science behind hormone therapy and metabolic health, and make informed, individualized decisions about aging. Her empowering message is to take charge of your body, question medical assumptions, and embrace aging with vitality, curiosity, and evidence-based action.
Why Most Doctors Canât Evaluate the Science
Scott Douglas Jacobsen: Letâs start with a core issue: Why arenât most doctors able to critically assess the science behind their recommendations?
Amy Alkon: They are not trained to read it critically. They donât have meaningful coursework in statistics and methodology assessment. I was incredibly fortunate to be informally mentored by Dr. Sander Greenland, one of the worldâs top epidemiologists and biostatisticians. He became my friend and would review my weekly science-based columns. Iâve got a long email from him on my wall that explains methodology and research flaws in beautiful, brutal clarity.
Jacobsen: How did this informal education shape your approach to writing Going Menopostal?
Alkon: Through him, I learned how to read studies criticallyâhow to spot fraud, bias, poor methodology, and unjustified conclusions. He also sent me literature on medical errors, misconduct, and statistical abuse. That education changed how I view all medical science.
It taught me that responsible scientific thinking means examining a body of workânot just one study. To draw firm conclusions, you need multiple well-conducted studies across different populations.
Iâm proud to say that in Going Menopostal, I donât make sweeping claims. When the research is heterogeneousâdifferent ages, drugs, study methodsâI explain my thinking. Iâm presenting my reasoning and encouraging readers to make their own decisions based on their health profiles.
Take heart disease, for example. Itâs already the leading killer of people. Itâs quickly becoming the leading killer of women, too. It will likely kill one in three women in the coming years. Itâs one in five right now, but that number is rising.
Competing Health Risks
Jacobsen: How do you weigh competing health risks when making treatment decisions?
Alkon: So when we talk about risksâlike the fear of breast cancer from taking hormone therapyâwe have to balance that against the far higher risk of dying from cardiovascular disease.
Some of the research is more conclusive than others, but I saw enough strong support to justify my choice. Iâm medically prudent. Iâm conservative about drugs. I donât want to take medication if I can avoid it. I donât wish for medical treatments unless theyâre necessary.
One of the things I include in Going Menopostalâto help people who donât have a nerd like me digging into their specific issueâis a set of six questions to ask your doctor.
Can you explain the reasoning behind your diagnosis and the treatment you recommend?Could other conditions be causing my symptoms?What are the risks of this treatmentâfor someone like me?Are there safer, less invasive alternatives?What can I expect during the treatment and recovery?Do I need this now, or could I waitâor possibly go without the treatment?If your doctor isnât explaining things clearly, ask them to explain until you understand. If needed, schedule another appointment or phone call. You canât give informed consent if you donât fully understand what youâre consenting to.
Informed consent is not optionalâitâs legally and ethically required in medicine. Doctors are obligated to explain things in plain language.
Advice for Unheard Women
Jacobsen: What advice do you have for women who feel dismissed or unheard by their doctors?
Alkon: But you owe it to yourself and your health to advocate for your body. That may involve some conflict. Some friction. So what? That moment of discomfort is worth it.
Can you do this? In Unfckology*âmy earlier bookâI say: your feelings are not the boss of you. You can have a feeling and still choose not to act on it. You donât have to say, âOkay, yes, Iâll do whatever you say. Iâll stay quiet.â No. You say, âF you, feeling.â
So what do you do? You focus on what you can control: yourself. Thatâs the growth. Yesterday, you may have stayed silent. But today? You spoke up. You were brave. Thatâs powerful. You need to give yourself credit, give yourself a big pat on the back, and say it out loud. I talk to myself and say, âGood job, self.â Itâs funny, makes me laugh, and snaps me out of whatever spiral Iâm in.
Going Menopostal does more than tackle the science of diagnosis and treatment for menopause and perimenopause. It shows how to live healthfully and fully in your later years. That means embracing evidence-based approaches to eating and exercising but making them doable.
As an advice columnist for all those years, Iâd offer options: âYou could do this, or you could try that.â And while writing, Iâd talk to myselfâlike, Amy, is anyone going to keep taking this advice? If the answer were no, Iâd call myself out: Youâre being a jerk, Alkon. Go think up something useful. Itâs the same with lifestyle advice, especially when it comes to eating and exercise. It has to be doable.
Navigating Nutritional Science
Jacobsen: How do you navigate nutritional science when so much of it seems contradictory?
Alkon: For many people, eating a low-carbohydrate, well-formulated dietâhigher in healthy fats and adequate proteinâis the most nutritious and sustainable way to eat across the lifespan. It helps prevent blood sugar spikes, excessive insulin secretion, and insulin resistance. That resistance contributes to a condition known as inflammation.
Chronic, low-grade inflammation builds up in the body over time. Itâs like thereâs always a slow fire burning. So, when your immune system needs to kick into gear, it is often tired, dysregulated, and weakened in response to a serious event. It canât mount a proper defence, and thatâs a huge problem.
These are foundational drivers of suffering and chronic illness. Cardiovascular disease, metabolic syndrome, and other severe conditions stem from this internal wear and tear. As for the old âlipid hypothesisââthat cholesterol alone causes heart disease? That has not been definitively proven. It is increasingly clear that the real culprits behind cardiometabolic disease are high blood sugar, elevated blood pressure, insulin resistance, and the constellation of risk factors known as Syndrome Xânow more commonly called metabolic syndrome.
One of the most disturbing aspects I cover in my book is that, while we all share basic anatomyâsuch as livers, kidneys, and heartsâthere are significant physiological differences across populations. In menopause and perimenopause research, most of the data is based on middle-class white women.
Black individuals tend to have lower triglycerides and higher HDL (the so-called âgoodâ cholesterol). That sounds greatâexcept that if you apply white-centred diagnostic standards to Black patients, they can appear metabolically healthy when they are not. That leads to underdiagnosis and undertreatment.
This is a tragedy because Black Americansâand other people of colour, including Hispanic populations and certain Indigenous groups like the Pimaâhave a significantly higher risk for diabetes, heart disease, and kidney failure. So when the guidelines are wrongâor not population-specificâthat is not just an oversight; it is dangerous.
Most doctors are just following the âpractice standardsâ theyâre given. But when those standards are built on flawed, non-inclusive research? The whole system fails. They donât know all this science. Remember, doctors are not trained to read and evaluate scientific research in medical school. So, they have to rely on practice guidelinesâstandards that may be outdated, incomplete, or based on flawed data.
LDL and Heart Disease Risk
Jacobsen: How can we ensure population-specific data guides treatment decisions?
Alkon: The real issue is that our institutions have failed. Medical education doesnât train doctors to read research critically. Doctors donât have the time to dig into studiesâand even if they did, most arenât taught how to evaluate study design, bias, or statistical flaws.
And the consequences are enormous. I see it. I recently had eye surgery, and sitting in that waiting room. I looked around at all the people around meâso many of them suffering from preventable conditions. It broke my heart. Theyâre old. They have diabetes. Theyâre obese. Theyâre weak.
The Key to Muscle Loading
Jacobsen: What about strength training?
Hereâs the reality: what you do for muscle, you do for bone. Bone responds to mechanical loadingâthe stress placed on it when muscles contract forcefully against resistance. That means lifting weights.
You must significantly challenge your muscles to build or maintain muscle and bone. Slow-speed weight training is the most effective, powerful, and efficient form of this. That means lifting weights that are heavy for you, using a controlled motionâabout five seconds up, five seconds downâwith no pumping or jerking. Pumping is how people get injured. The goal is not to fling your arm up; itâs to create deep muscular engagement.
You continue the set until you reach muscle failure, where you cannot do one more rep with proper form. Thatâs key. When you hit failure with good form, youâve created microtears in the muscle. That sounds bad, but it is the foundation of muscle repair and growth. Over the next day or two, your body rebuilds the muscle stronger.
And hereâs why that matters: bone and muscle are metabolically active tissues. They help regulate insulin sensitivity, reduce inflammation, and fight off the effects of agingâincluding that creepy visceral fat, which wraps around your organs and tries to kill you. Strength training helps you fight that.
So again, as I was writing the book, I asked myself, âWhatâs doable?â Because the average person isnât a saint. Weâre lazy chimps. We need something realistic and repeatable. Thatâs why I recommend just one set of muscle failures per movement. Thatâs it. I do eight of these a weekâtwo on Sunday. Thatâs all. And Iâve got visible muscles. You should feel my arms. Itâs wild.
I use what I call my Barbie gym. Iâve got this graveyard of weights on the living room floorâdifferent dumbbells in a pile. You donât need fancy machines or 37 different exercises.
When you do these full-body movementsâlike squats or rowsâyou send a systemic signal throughout your body. Youâre not just working your biceps and ignoring everything else. Even without gym equipment, Iâm the healthiest Iâve ever been. And to be honest, Iâd been scared. Iâm a slow writer and have spent years sitting in a sedentary chair. Iâd get up occasionally, but it wasnât consistent activity.
I used to run seven miles three times a week, but I wasnât putting weight on my bones as I needed to. At some point, I went to walk to the office supply store near meâabout half a mile away. I walked one long block, and my back was killing me. I thought, âOh my god, youâve ruined your body. You sat in your chair for years and are now destroyed.â
But noâI hadnât ruined it. I caught it in time. Once I started strength training with weights, I rebuilt my strength. All of this is vital. The two key things you need to do are:
Eat a low-carb, adequate-protein, sufficient-fat diet.Lift weights with intensity.For protein specifically, you need at least 1.2 grams per kilogram of body weight per day. Thatâs the minimum for preserving muscle as you age. The U.S. government recommends 0.8 grams per kilogram, which is outdated and too lowâespecially for older adults. If you donât get enough protein, it does not matter how much calcium you takeâyou could eat a dairy aisleâs worthâand it still wonât build bone properly. Protein is required for calcium to be incorporated into bone.
Whatâs so terrible is that if youâre not an obsessive science nerd like meâif youâre not someone who stayed home on every holiday, including Christmas and Thanksgiving, to read medical studies and write a bookâyouâre left without recourse. I poured every molecule into this project because the science had to be right.
Be careful. With my other books, if I got something wrong, maybe youâd have a bad date. But if I get something wrong in this bookâon medicineâyou could die. I felt that weight. Writing this book was a terrible responsibility.
Iâve called it the most critical and stupidest thing Iâve ever done because it was terrifying. I joke that I forgot to take endocrinology when I didnât attend medical school, but I had to teach it anyway. Hereâs what happens in med school: Youâre taught to believe things because someone important at an expensive institution said them. The information ends in textbooks, and youâre expected to accept it.
But as an outsider, Iâm constantly asking, âWhatâs the process here?â I look deeply. I cut up endocrinology textbooks and taped them to the walls of my house. My shower? Itâs a giant study space. Iâve got a clawfoot tub, and the bathroom walls are papered with medical diagrams and citations.
Thatâs how I work.
Jacobsen: Can you give us an example of this?
Alkon: And thatâs how I discover things that even major researchers in the field missâbecause theyâve been taught to believe. Theyâre not always looking critically. One of the most dangerous, persistent confusions I found is between medroxyprogesterone acetate (MPA)âa synthetic progestin used in older birth control pillsâand real, bioidentical progesterone.
Theyâre not the same thing, but a famous researcher conflated them in a significant paper. Then, everyone else copied her. They didnât even check the citations. They just assumed, âSheâs important; she must be right.â
But I went to the citations. And what did I find? Those scary side effects she blamed on progesterone were from MPAânot real progesterone. So hereâs this beautiful, natural hormoneâprogesteroneâbeing falsely accused of harming women when, in fact, itâs essential for our well-being. During pregnancy, a womanâs body produces ten times the amount of progesterone she makes during a typical menstrual cycle. If it were dangerous, pregnancy would be lethal.
But itâs not. Progesterone is a hormone that promotes calmness and supports sleep. And when I finally got access to itâafter fighting tooth and nail to get oral micronized progesterone, the FDA-approved formâI got my sleep back.
And that was huge. Before perimenopause, I could put my head on the pillow at night and fall asleep instantly. Iâd wake up at 6 a.m. feeling rested and wonderful. No effort. But in perimenopauseâthat transition phase to menopauseâI started waking up five or six times a night. It was not very good.
It was so horrible. I had terrible brain fogâbecause I wasnât getting sleep. And hereâs why that matters: thereâs excellent research. Your brain shrinks during deep sleep, allowing cerebrospinal fluid to wash through and clear out metabolic waste.
Without sleep, that cleanup doesnât happen. That fog you feel? Thatâs real. And over time, it contributes to severe neurological decline. In the U.S., doctors typically donât prescribe the 300 mg dose of oral micronized progesterone. Thatâs the dose used in France since 1980, and it is effective and safe. But here? Itâs rarely given. Why? Not because of any rigorous trial showing that 200 mg is better than 300 mg. No, itâs based on inertia, cost, hearsay, and outdated studies that arbitrarily tested lower doses.
Letâs be clear: progesteroneâthe real thing, not synthetic progestins like medroxyprogesterone acetate (MPA)âis a very safe hormone. Unless you have rare conditions like liver ascites (fluid buildup in the abdomen) or extremely low blood pressure, it has fewer side effects than aspirin.
The FDA-approved formâPrometrium, or its genericsâis delivered in peanut oil, so if youâre allergic, youâll need it compounded in another base. But compounded medications can be the Wild West. Thatâs why I recommend using only accredited compounding pharmaciesâthe ones certified by the Pharmacy Compounding Accreditation Board (PCAB). Those are your best bet for getting the correct dose and an uncontaminated product.
Hereâs another problem: Most people do not know how their body metabolizes drugs. Are you a rapid metabolizer? A slow metabolizer? Most doctors do not test for that. So you donât know how much progesterone you need to protect the endometriumâthe uterine liningâespecially during perimenopause, when estrogen levels are spiking and crashing, and youâre often not ovulating. That means youâre not producing progesterone naturally.
So, how much do you need to replace it? We donât know exactly, but we do know that 300 mg is safe and effective, benefiting bones, cardiovascular health, sleep, mood, and other aspects of overall well-being. In France, it is even used as a mild anesthetic. It is that safe.
Fighting for Evidence-Based Therapies
Jacobsen: Why do you think patients need to fight so hard for evidence-based hormone therapy?
Alkon: Most gynecologists are trained in maternity and reproductive health, not menopause medicine. Thatâs starting to change, slowly, because menopause is finally entering public discourse. But right now? Most women are undiagnosed, misdiagnosed, or dismissed altogether.
They donât recognize that what theyâre experiencing is perimenopause. The rage. Insomnia. The brain fog. I got horrible motion sickness in my 40sâI couldnât ride in a car without wanting to throw up my shoes. Thatâs a symptom of hormonal imbalance. I know this from reading the research. Most women donât. And thatâs terrifying.
Why? Because no one properly diagnosed them. Because the science is not driving the conversation. This area is riddled with so many mythsâit breaks my heart. Thatâs why I wrote this book. I fought three major battles with the Kaiser:
To get FDA-approved progesteroneânot medroxyprogesterone acetate, which is on their formulary.To obtain the correct dosage, 300 mg has been used effectively in France for a long time.To get it covered by my insurance.Those were serious fights. Most other patients are not in a position to fight like that. So theyâre being misled, mistreated, or left untreatedâand theyâre at risk. Thatâs devastating.
I now eat a carnivore dietâfish, meat, eggs, butter, and ghee. I do this because it reduces inflammation. I avoid sugar and flour, which provoke inflammation and drive insulin resistance, a broken insulin response that leads to chronic inflammation and, eventually, the inability of our immune system to muster adequate defences.
This way of eating helps me maintain a metabolically healthy lifestyle. I take supplements to compensate for any nutritional deficiencies that the carnivore diet might leave behind. It was sadâbut I gave up bacon and pork rinds. I love pork rindsâtheyâre so delicious. But I had eye surgery, and I needed to go with the whole SWAT team on any source of inflammation. I had to bring it as low as possible.
Hereâs something interesting about forming habits: the first time you donât eat your beloved greasy three strips of bacon for breakfast, it sucks. But then you adapt. I started eating smoked herring heated up with butter on top. People might find that gross, but itâs high in omega-3s and low in omega-6s (unlike hamburger, which is higher in omega-6).
I had been eating sardines until I discovered they were weirdly high in omega-6s. So I cut them. I also cut out chicken thighs, which I loved but also have high omega-6s. Nina Teicholz brilliantly wrote about this in her book The Big Fat Surprise. She explains why industrial seed oils are harmfulâthey promote inflammation and are a significant contributor to the problems in the modern diet.
This is how Iâve found a way to be healthy as I age. Because aging is this gradual erosion, itâs inevitable. So, I want to minimize the impact as much as possible. Iâll be honestâIâm a big weenie. Iâm not good at suffering. A cold? I act like Iâve been diagnosed with a terminal disease. Iâm not brave compared to othersâI know that about myself.
So itâs important to me to do what I can now. Thatâs where habit formation comes in. That first dayâskipping the bacon, not eating the pork rindsâit sucked. But then I had the herring. How I prepare itâmicrowaved, lightly heatedâis delicious when you donât overcook it.
Everything I make is fast. I donât cook; I heat. If it takes more than two steps, Iâm out. Salmon? Throw it in a pan with gheeâwhich has a high smoke pointâflop-flop, sear it, and itâs done. Hamburger? I cook it in the air fryer because itâs even faster. And this stuff is delicious. That matters. I eat fatty food because itâs satiating. I recently ordered trout because it was on saleâbut it turned out to be super low in fat. I was hungry all day. I thought, âWeâre gonna eat thisâŠand then weâre gonna eat something else.â
So when I help peopleâand do medical coaching for friends (Iâm not a licensed professional, to be clear)âI always start with this question: What are you willing to do? You canât just say, âHereâs what Iâd do.â That doesnât work. The question is: What will YOU do, based on your life, your habits, and your self-discipline? Thatâs how I approach it.
In fact, in 2020, the American College of Cardiology finally acknowledgedâafter years of pushing harmful, outdated adviceâthat the claims against saturated fat are not supported by high-quality evidence. They did not say it bluntly, but science shows that the real culprit behind metabolic disease is not saturated fat but refined carbohydrates.
Sugary and starchy carbsâbread, desserts, pasta, potatoes, juiceâdrive excess insulin secretion, which leads to fat gain and inflammation. A low-carb dietâis called ketogenic because it refers to ketosis, the state where your body burns fat for fuel instead of glucose (blood sugar). You must consume 30 grams of carbohydrates or less daily to maintain ketosis. You track this through blood testing and by monitoring your physical signals.
Now, some people canât do this alone. If you have diabetes or another serious condition, you need a doctor. But hereâs the challenge: You must find someone who understands nutrition science. That is rare. And itâs expensive.
The same applies to resistance training: safety is paramount. Maintaining healthy muscle is vital for healthy aging. Even one day of sedentary behaviour can negatively impact your metabolic and immune systems. I try never to be sedentary. After my eye surgeryâa corneal endothelium transplantâI wasnât allowed to lift weights, and that worried me. So I asked my doctor, âHow soon can I walk?â
Running was off-limits, and Iâm a fast runner. I usually do 20-minute sprints in the morning, often in front of the TV, or I go out early to get morning light exposure on my retinas, which helps regulate my circadian rhythm. So, while I recovered, I walked. Back and forth across my living roomâhundreds of times a dayâas fast as was safe for my healing eye.
The corneal endothelium is a single-cell layer that regulates fluid in the eye. I had a genetic diseaseâthanks, Momâcalled Fuchsâ dystrophy (Fuchsâ with an apostrophe S). These cells die off and turn into trash cells called guttate, which sounds too much like frittataâwhich is excellent if you donât overcook it, and most people do.
If untreated, you go progressively blind. I was grateful to get the transplant. But I also wanted to preserve it. I couldnât lift weights or runâbut I could walk. So I did.
Jacobsen: How did you handle that emotionally?
Alkon: Now, I was worried. Iâd been doing resistance training every day. What will happen to my muscles and bones during this period of inactivity?â A study shows how quickly you lose muscle and strength when you stop training.
There is a study on this phenomenon, known as detraining. If you stop lifting weights for a while but start again within a specific periodâmaybe ten weeks, I thinkâyou can build your strength back faster than if you were starting from scratch. I do not remember the exact timeline, but thatâs the general idea.
At first, I was weak. I could not lift the weight I usually do. However, you must be patient with yourself. Thatâs one of the most significant aspects of any health journey: self-compassion. And Iâm not great at that. My family are Jews from Michiganâpure Ashkenazi Jews. We have a brutal work ethic. I will drag myself to the computer and work if Iâm not dying. Coffee, determinationâwhatever it takes.
But during my recovery, when I was not feeling well, I had to rethink that. Iâd say, âOkay, your goal today is to get to the computer and do this one thing.â And sometimes, I was too sick to do that. So Iâd remind myself, âYouâre a hard worker. You need to rest.â
Jacobsen: What about age and the average personâs dietary habits?
Alkon: When weâre younger, our bodies are robust. We can get away with eating the Standard American Dietâall those processed foods high in sugar and refined carbs. But over time, your body stops being able to amortize the damage. And then? You get sick.
You gain fat. Your blood sugar goes up. Your blood pressure follows. And once cardiovascular disease sets in, thatâs itâyou canât get your old health back. You canât reverse the arterial plaque that forms from years of high blood pressure and chronic inflammation driven by diet.
So, prevention matters. Look at older people who are sufferingâobese, dealing with diabetes, with other metabolic diseasesâand realize: That is the Ghost of Christmas Future. That is your possible outcome. Thatâs why Iâm taking the steps Iâm taking.
Hereâs the thing: You donât need to adopt someone elseâs rules if you do not have issues in a particular area. For example, do you sleep fine after eating before bed? Then eat. Do what works for you. The rule should always be: listen to your body, not someone elseâs fear-based checklist.
Jacobsen: Now, what about intermittent fasting? Like 16:8 or 18:6 fasting windows?
Alkon: I do not know enough about it to give an informed opinion. I try to model what doctors should do, which is to say âI donât knowâ when I genuinely donât know. Iâve read some about fasting, which may have benefits and downsides, depending on the individual. However, I havenât conducted a thorough enough review of the research to speak confidently or publicly about it. So, for now? I donât know. I also donât skip meals. Iâm too much of a hedonist. Fasting may be beneficial, but Iâll need to investigate it further before I weigh in.
Jacobsen: What is your vision of empowered aging, especially for women?
Alkon: The goal is to stay you, just with some wrinkles. And I see that now. I see these vital older women lifting weights and doing pull-ups at 80âliving active and meaningful lives. Theyâre not just grandmas in aprons anymore. Theyâre strong, sharp, and visible. These days, grandma is me. But I feel like the same me I was at 8, or 20, or whatever. Thatâs the goal: to be youâas much as possibleâwith the robust health you had when you were younger. You do that through protective measures: a smart diet and adequate exercise.
Jacobsen: Amy, thank you very much for your time today, your expertise, and your honesty. It was a pleasure to meet you.
Alkon: It was great. Youâre interesting and innovative.
Jacobsen: Excellent. Thanks so much, Amy. Take care.
Alkon: You too. Bye.
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