Women in our country are under tremendous stress. Our healthcare system, it is really failing certain parts of our population. Let's demand that our health system is built for us and not somebody else.
It took me 20 years of practice to sit back and realize women are not crazy. They're actually hurting.
We should expect our national health institutes to put far more funding into women's health.
Billions and billions and billions.
Yes. Our healthcare should not be determined by politics. It should be determined by science. I want women to step into their full power because when they do, we do change the world.
The views and opinions expressed on Unpaused are those of the talent and guests alone and are provided for informational and entertainment purposes only. No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis, or treatment. My guest today, Melinda French Gates, opened a recent essay in The New York Times with an image I cannot shake. A 100 years ago, American women gave birth under twilight sleep, drugged unconscious, tied to the bed if they thrashed. No voice in the room, no memory of their own child being born. We shudder at that now, at the idea that women had no agency over their bodies at this incredibly important moment of their lives. And in her essay, Melinda asks a question I want us all to sit with. Will our granddaughters one day look back on how we treat menopause right now and feel exactly the same way?
Nearly one in three women over the age of 40 has menopause symptoms that are severe enough to disrupt her life. Only about one in four actually gets treated. The rate of women on hormone therapy, the most effective tool we have, has collapsed to under 5%. Fewer than a third of OB-GYN training programs teach about menopause at all. And on top of that, McKinsey found that for every dollar the world spends on medical research, only five cents goes to women's health. In her essay, Melinda announced that she is giving $215 million in new funding, including a major grant to train the clinicians who keep missing the menopause symptoms in their patients. That brings her total investment in women's health to more than $600 million in two years with menopause and midlife a priority for the first time. I applaud every dollar of it, but I didn't ask her here today to walk through a press release. I want to go deeper. Why is this happening at all? How can we meaningfully affect change at a policy level as well as in the patient-clinician relationship? Can more training fix a system that was never built for women's bodies in the first place? Philanthropist Melinda French Gates has spent more than two decades fighting for women and girls. Today, she leads her own organization, Pivotal, and she is aiming her resources at women's health areas that are notoriously underfunded, including initiatives aimed at menopause and midlife care for women. I'm Dr. Mary Claire Haver, a board-certified obstetrician and gynecologist and certified menopause practitioner. I'm also an adjunct professor of obstetrics and gynecology at the University of Texas Medical Branch. Welcome to Unpaused, the podcast where we cut through the silence and talk about what it really takes for women to thrive in the second half of life.
Melinda French Gates, welcome to Unpaused.
Thank you for having me. I'm so glad to be here.
So, you wrote an essay The New York Times published called "Women Deserve Better Than This." And you called for a menopause revolution. The day that dropped, I didn't know it was coming. My menopausity group chat exploded, you know, and it was just—we have about 50, 60 researchers, PhDs, MDs, DOs together, and we talk about everything that's popping up on social media or in the news. So, you were the topic of conversation. The same day, my Google Alerts went off because it was being picked up across multiple outlets and my favorite podcast. All of a sudden, your face was popping up everywhere. So I thought, this is big. It spurred so much positive conversation, so much advocacy, so many people who were so excited that you had jumped into this discussion. You have focused on women's health for over 20 years when I started digging around in the research. What's made you drawn to this especially? I know you're a mother of two daughters.
I'm a mother of two daughters and a son. And my team and I for a long time have focused on women's health because only if a woman's healthy can she step into her full power, right? And I know that when women step into their full power, it changes their family, their community, their society. We have good research on this. So we had been focusing on the earlier stages of women's health over the last 20 years. But this perimenopause, menopause phase, it just was so chronically underfunded and under-researched. It's like it was a glaring hole. People are talking about it. We're starting to see a little bit of change, and we thought, this just doesn't make any sense. We are half the population and we all go through this. So it's just time.
It's time. I agree 100%. The first year the National Institutes of Health, the NIH, tracked menopause research was 2023.
The very first year. Yeah. So before then, we had to scramble and go and Google or do a search on the word menopause to see if it was in an article and then hand-count each one. There wasn't even in ACOG, American College of OB-GYN, which I'm boarded—there's not a menopause subset when we do our yearly board recertification. It's kind of buried under office practice along with gonorrhea and lots of important things, but there's not a focus on this even from the American College of Obstetrics and Gynecology. So I think spreading knowledge and awareness and advocacy is absolutely huge. It's a pivotal point in our health trajectory where so many of us are not functioning, like you say, at our full power. And when women are well, everything gets better, right? They reinvest in their community, they take care of the younger generation, they provide a source of wisdom. But when we look at the data, at least in the data of work and how women are functioning in the office, I see it in clinic. When a woman comes to me in clinic, she's usually seen five, six doctors before she was able to put it together for herself, comes to me, and she's struggling. A lot of these women have very high-powered careers or they were so involved in their community, right? Even if they didn't get paid in a traditional job, they were running things at the kids' school or in their community, and suddenly they are losing resilience. They're not able to function at the level that they were. And being able to restore that for someone is one of the greatest gifts I think I've ever done. I practiced medicine for a long time, delivered a lot of babies, done a lot of surgery, super proud of all that. But now that I just focus on taking care of women after reproduction ends, it's like the greatest medicine I've ever practiced in my life. And watching those women go back to these careers that they've built, these lives that they've built, and being able to function—I think if we could give that gift to all women and have our medical community focus back on that, I think is huge. But what kills me is I'm a product of the system and super proud of the stuff I learned, but I didn't even realize it was a problem till I went through it. And that's a little embarrassing, right? I thought menopause was what they told me it was: the end of your periods, a few hot flashes, and then you just get on with it.
No, not cardiovascular disease increase, brain fog, the road to Alzheimer's opens up wide and steep, and osteoporosis fracture. I didn't even know the percentage of women who would have an osteoporotic fracture, like that kind of information. We've siloed so much of health into, okay, the orthopedists are going to take care of this, the cardiologists are going to take care of this, OB is just going to take care of the breast and pelvis. And no one, what I realize now, is looking after our health because we disease differently than men do. It's like once we get rid of the bikini area, what do we have left? And so I saw in Pivotal—
So what is Pivotal first?
So Pivotal Ventures is a company that I formed that does investments, but it's also now a philanthropic arm and it's an advocacy arm to try and move forward the key issues in society that I think are not being well-represented. And as you said, for a woman, in my opinion, a woman has to be well to do well. And so over the course of my career, both when I was at the Gates Foundation and now with Pivotal Ventures, we've been investing in these stages of women's life—reproductive, maternal healthcare—and there's still so much more to be done there. So I've doubled down on my investments there. And now we're adding on this new stage for exactly the reasons you say: it is chronically underfunded, which means it's chronically under-researched. We just sort of neglected it and expected women to go through it and go through it well. Are you kidding me?
And so if I think of even just one issue that people go through and that I went through in perimenopause and menopause—okay, the chronic insomnia, and then what it does to your brain, as you said, long-term, but even in the moment. I will say, because of the chronic insomnia, I started to have brain fog and I doubted myself. I would be going in to meet with a world leader or CEO somewhere and feel like, "Am I going to be able to do this? Do I have the facts and figures? Do I have the convincing argument I want to make?" To doubt yourself right when you're in the peak of your career, this is happening. I will say it's happening to so many women. One of the things that surprised me when I put out that New York Times article about menopause and having a revolution is, one, the number of women that wrote in and shared their stories and said, "I finally feel seen." But the number of women that wrote in and said, "I had to take a day off from work. I had to take a week off from work." I have friends where many of them are stepping back from their careers right when they're in their prime. And the research now shows that we know that one in 10 women takes at least—and this is a minimum and I wish we had better data—one day off because of menopause. But the truth is, what I saw in these New York Times comments and anecdotally my friends who talked to me, women are really having to take days off and step back to go seek the care they need, but also because they feel so unwell, right? That's just tragic.
And that's only tracking, Melinda, the data we know. That's only tracking hot flashes. You know, that's not tracking the things that are not commonly recognized as menopause, like brain fog, like anxiety, like depression, the mental health changes.
And you know, I think the numbers are probably a lot bigger.
And I see it clinically where they're coming in—CEOs, COOs—and like, "I'm struggling to do my job and doubting myself and can I do this?" being passed over for promotions. And if we don't have a seat at the table—
People tend to not look after you.
You have to look after yourself at work, right? And both at work, but also this is why, to use your point, we need a seat at the table to change this. And we can change this. When you look back at the history of breast cancer and what was known 40 years ago and what's known today, that changed because of the Susan G. Komen Foundation, right? And the advocacy they created and the walks for cancer and breast cancer. And so now today, a woman knows how to screen herself. She knows she should get a mammogram. She should advocate for a mammogram, get early treatment if she has it. I mean, we have come a long way, but it's because of that start. And so that's why I called for a menopause revolution. Let's really start now. You've been doing a lot of work, others have, but we need to all come together and make change, demand that the system meets our needs, not that it's created for somebody else.
And you struggled as well with finding a clinician that would recognize what was happening. Do you feel comfortable talking about that?
I do. Luckily I have older friends, so when I started going through some of these symptoms, I could recognize what they likely were because I went through menopause much earlier than I expected. And so I'm in my 40s, but it took me three doctors to get the right healthcare for my symptoms. And here I am—I'm unbelievably privileged. I have access to the best healthcare in the world, right? But to have three doctors who could really go through, and finally the last one say, "Okay, this is specifically what I think we should do." And you have to be in good dialogue with your doctor because it's not always clear even when you find a—
Well, it's not a cookie-cutter solution for everyone.
And that's why even for my first investment in this area, we are focusing on training OB-GYNs. You're one of them, right? You have the right information, but we're only training a third of OB-GYNs.
A third. I was a former program director, so I can speak at least until 2018. So at least until then, I knew the curriculum backwards and forwards, and menopause was basically an afterthought. Obstetrician-gynecologists are busy. We are delivering babies, doing surgeries, kind of tasked with so much, and there's a lot of political pressure in different states on the obstetrics part of the world, and that's a whole separate conversation. But menopause was like, "Oh yeah, make sure she gets her mammogram, make sure she gets her bone density at 65, and don't give her hormones because of the Women's Health Initiative unless..." I trained—my residency was '98 to 2002. Right as I was graduating was when the WHI broke. So I was trained to give menopause hormone therapy. We probably had 40% of patients who were on it of who were eligible who were on it. And that seemed like a reasonable number at the time. And then when the study broke, it was like stop, stop everything. And all meaningful education also stopped. All meaningful research outside of alternatives to HRT stopped. And so when we look at the data now, depending on who you read, 7% at best are being offered and electing to utilize menopause hormone therapy. And not that it's going to cure everyone or it's a panacea for everyone, but that's just over 90% of the population not even being given the option or the conversation. And that's a systemic problem.
That's right. And you're making several amazing points here. One is, why did we have one study? There should have been 30 studies. Again, had we started this back when we started breast cancer, there would have been 30 studies. And so we could have compared—instead of misreading that piece of research, we could have done some comparisons to then say, "Oh, no, no. This actually is effective." And the problem is, as you said, things stopped. But now that we finally have come back to that piece of research, as you said, so few women are getting the right information. I have two sisters-in-law who have been going through this more recently. One's quite a bit younger than me. And again, she has a very good doctor, but getting all the right information about HRT—the moms in my mom's book club who are younger than me are all saying, "Yeah, I went to my doctor, but he's not sure, she's not quite sure. What are you doing? How are you thinking about this?" Right?
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It's elective. It's not mandatory. The American College of OB-GYN doesn't recognize the Menopause Society guidelines. So ACOG, which is what I'm boarded at, has not changed their menopause guidelines since 2014.
Well, that seems like a fantastic place. I know you are all about advocacy, which we need. Would you not train an OB-GYN how to deliver a baby?
We expect our OB-GYN to know what they're doing, right? So why would you not—that's a stage of a woman's life. Why would you not expect them to be fully trained in menopause and it to be mandatory? And as you go get—you have to go back and do medical training over time to stay licensed. Absolutely that should be part of it.
They're getting there. It's a very slow attrition for ACOG, but I think we need to mandate this. I think it needs to be bigger than OB-GYN. We're busy.
It needs to be health providers. It needs to be any clinician who touches—
You bet. And look, let's demand that our health system is built for us and not somebody else. If we're going to speak the truth here, the health system was built for men. And you've talked about a woman's body was assumed to be a default of a man's. No, we need to demand that the health system is built for the other half of us, right?
One of the things I see which I'm excited about—I'm a nerd and I get an alert on PubMed every day when the word menopause or perimenopause is mentioned in a research article. So I read every abstract just to see where we're heading with this, and it's not really the OB-GYN literature, at least not in the US. NIH funding is a little tricky right now, but there's a lot of good worldwide stuff happening. It's the cardiovascular literature. It's the urology literature. It is the rheumatologists. They are starting really to do a deeper dive on sex-based differences in disease.
And I think menopause is more than reproduction. This is truly the health of women and how we are going to allow women to age in this last 30 years. We have so much room to go. But I am seeing every day just more and more and more articles coming out showing our heart disease. And I think your Pivotal is really investing.
And so for our listeners—
When we look at a heart attack, men tend to have the big widowmaker, the LAD, the left anterior descending artery that comes—one of the coronary arteries. It gets a big clot and then a plaque way up high right as it exits the aorta. Women—I didn't know this, no one taught me this, I learned this two years ago—tend to have diffuse microvascular disease, which is why we show up in the ER with atypical chest pain, though we're 51% of the population and our heart attack is atypical. And then we're misdiagnosed 50% of the time. We have a much higher chance of dying from a first heart attack than a male. And the medications don't work as well on us as they do on our male counterparts. And the data is not stratified by sex, meaning male versus female. It's just like, "Oh, this particular drug worked great for this group." But when you look at the data and tease out the women versus the men, the women don't do as well.
And talk to me about where you want to see this investment going for heart disease.
So, I'm invested with an organization called Wellcome Leap through a model—Regina Dugan, who's an amazing scientist, I've known her a long time. And she's taking a model that came out of DARPA to help us. The model helps you get things much more quickly—three to five years as opposed to 10 or 20. And that is exactly what they're looking at. They're looking at this plumbing around a woman's heart to say, "Okay, where are these places coming in microvasculature, and how could we come up with a better diagnostic?" Because even to go to the right place to get the right diagnostic for women is expensive and available in very few places. So we're looking at could you come up with a diagnostic that catches this much, much sooner. So the research is specifically focused on a woman's heart and the vasculature around it, not a typical heart, which is assumed to be the male heart.
That's really groundbreaking to me. Lisa Mosconi, are you familiar with her work? So she's with Wellcome Leap as well with the CARE program, where they're using the same model to see what is this connection with Alzheimer's and dementia and menopause, because we just see that acceleration.
Well, and as you said, again, if a woman gets chronic insomnia and we see the symptom which is brain fog, the chronic insomnia can lead to so many things, right? And so there are just so many issues here. And for me, it's actually also exciting to see that we're finally going to be on the brink of this. We need so much more funding, though. I mean, so much more funding. We should expect our national health institutes to put far more funding into women's health of all the types you mentioned—
Billions and billions and billions.
Yes, because that is how research moves forward. It has been our government funding through the NIH that then goes to all the researchers around the world in the US. Again, to think that women live nine years unhealthy in life—we've misthought, "Oh well, that's at the end of their life because they live longer." No, half of it is those most productive years. And to me, it's just tragic. It just shouldn't be. I think of these stages of women's life—they can either be off-ramps or they can be continued on-ramps into the life that they want. Right.
So, how do you think that and the advocacy arm for Pivotal—and literally today I testified this morning for a congressional hearing on menopause.
What is the best way—you've lived this life in business and advocacy to make this happen. I was doing Pap smears and delivering babies back in the day, but I do think this needs to be mandated. What do you think the best path to that is?
Well, I don't have a perfect answer for that. Our government is very tricky right now in particular. But I would say this: I think there is absolutely room at the state level to make sure that we demand—and I say this to all women and men who care about their wives and their sisters and their daughters—we should demand that we get women's health services on the agenda of insurance and Medicaid and Medicare, right? Because when a woman can take time off for menopause if she needs it, but also be able to hook up to good insurance covering those menopause symptoms, it makes a difference. There are many women in this country who can't afford to go to the doctor to even begin to explore their menopause symptoms. That just shouldn't be. So that's a great place to advocate. I don't know, what else would you say? You're more on this issue than I am. So we have an advocacy arm through my company and we—
track state-by-state all the legislation associated with menopause. Some are educational initiatives, some are mandating training initiatives, and so we take it all the way to see what dies in committee, but it is really bipartisan. I'm not seeing a clear red state or blue state. It is really across the board.
The one in Texas sadly died in committee, but at least we got something to the table. And I think women realizing that their vote really matters here. I end almost every stage that people always ask me, "What can we do?" And I'm like, "Vote."
Vote for someone who cares about your health. Vote for someone who wants to see you healthy for your entire life.
That's right, because everyone does well. Because women tend to—not all women—give back
and tend to reinvest in their community. They want to see the next generation do well. And certainly there are men who do that as well. But we just see that when women do well in their 60s, 70s, and 80s, those communities thrive.
They do, because they are investing in the next generation. They're investing in the community. As they get a bit older, they often have a little more time on their hands, right? Or they may have built a little bit of wealth and say, "I'm going to give back to my community." So absolutely people should vote and should pay very close attention to who their state representative is and even at the federal level to say, "Okay, I want to make sure that we have the right administration or people on the Hill who are going to advocate for the things we need in our lives," whether that is good child care or good paid leave policies
and women's health. These don't have to be either/or. These should be ands.
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The World Economic Forum report—
