Menopause has gotten plenty of media attention. What it hasn't gotten is day-to-day direction, especially on the parts nobody likes to say out loud. This week I sat down with Dr. Cat Brown, a board-certified OB-GYN and the medical director at Winona, to talk about why a little dab of vaginal estrogen can protect you from recurring UTIs (and the urosepsis they can lead to), why the age-60 guideline doesn't mean what you think it means, and how one badly handled study cost a generation of women their care. If you've been told hormone therapy isn't for you, this episode is worth your 35 minutes. Who is Dr. Cat BrownBoard-certified OB-GYN and medical director at Winona, an online telemedicine platform created to bridge the gap for low-risk women who are good candidates for hormone therapy but don't have a doctor willing, or experienced enough, to prescribe it. She came to this personally, too: most of her own menopause education was self-directed after she hit roadblocks seeking care following her hysterectomy. What we actually talk aboutWhat Winona is, and what telemedicine can't do (00:38–02:19) — Winona was born during COVID, when nobody was prescribing hormone therapy by telemedicine. Dr. Cat is upfront that it's a bridge, not a replacement: you still need an in-person gynecologist, a breast exam, and a Pap smear if you have a cervix. You don't have to be a patient to use it (02:19–04:20) — A quiz, a library of free education on the long list of menopause symptoms, the Winona Women's app, and a Winona Women's Facebook group. Dr. Cat points to research showing that women with strong female friendships live healthier, longer lives, which is why community is part of the model. Why estrogen matters, and why it starts in perimenopause (04:21–09:05) — The Women's Health Initiative backstory, and why Dr. Cat says headlines reached the media before other doctors had peer reviewed the results. Then the case for estrogen as the hormone that fuels skin, joints, blood vessels, the heart, and the brain, plus why the goal isn't your 20-year-old hormone levels and why she says "hormone therapy," not "replacement." Her reframe: let menopause be the pause that makes you reevaluate what you're feeding your body and your soul. Why UTIs spike after menopause (09:06–11:43) — Estrogen loss thins the tissue around the urethral opening and weakens the barrier that keeps normal vaginal bacteria out of the bladder. That's the same reason we're taught to pee after sex. Left to recur, UTIs can lead to urosepsis, which Dr. Cat calls deadly for older women. Vaginal estrogen is not "taking hormones" (11:43–13:44) — Cream applied around the urethral opening treats the surface changes of menopause, with very little absorbed systemically. Dr. Cat says even women who can't take systemic hormones, including those with a history of breast cancer or blood clots, are safe to use it, and that menopause providers think it should be sold over the counter. Cream, tablets, rings, and painful sex (13:44–16:08) — Your options for vaginal estrogen, including a heads-up that some rings are designed to release hormone systemically. Plus the negative feedback loop of painful intercourse and what it does to long-term relationships. Dr. Cat's observation: every man gets the little blue pill, and most women get nothing for their own tissue. The estrogen face cream (16:09–18:36) — Estriol plus tretinoin, what it does for texture and fine lines, why it's controversial in the medical community, and why Dr. Cat says it's still a personal decision. I use it, and it feels great. The age-60 question (18:37–22:06) — Why 60 is Winona's line for starting hormone therapy by telemedicine, and what it is not: it isn't a deadline for stopping. Dr. Cat explains the window of opportunity (within 10 years of menopause), the slightly higher clotting risk when starting after 60, and why starting in early perimenopause, before your final period, gets you more heart and bone protection. Her analogy: don't wait for the gas tank to hit empty. If you're over 60 and curious (22:07–23:32, 29:29–29:47) — You're not locked out, you just need a different front door. Dr. Cat recommends an in-person menopause provider who can work with your other physicians and monitor you closely, and The Menopause Society has a zip code search to find one. The black box warning, birth control, and breast cancer risk (25:36–27:05) — Dr. Cat on why the warning never applied to topical estrogen, why she says birth control carries higher hormone doses and more clot risk than hormone therapy, and why she says daily alcohol is a much bigger breast cancer risk factor. (Yes, there goes the wine.) Patch, pill, or cream? (27:06–29:28) — Why Dr. Cat generally recommends transdermal, why she still prescribes pills, and her rule: the best method is the one you'll actually use consistently. Hormone therapy is like trying on jeans. Five women, five different cuts. Tell your doctor everything (30:12–31:22) — Even if they won't prescribe. Dr. Cat shares how patients' in-person doctors came around after seeing their labs and how much better they felt. "We've converted another doctor." The physician education gap (31:23–34:14) — Dr. Cat was taught in residency to learn this for the exams and never prescribe it. She mentions a large grant from Melinda Gates's foundation to The Menopause Society to educate physicians, why we should talk to younger women about menopause the way we talk about first periods, and why answering surveys and showing up is how the black box warning came off in the first place. Resources mentionedWinona, including the quiz and free education: bywinona.comWinona Women's app and Winona Women's Facebook groupFind an in-person menopause provider: The Menopause SocietyInstagram: Dr. Cat OBGYN (she's also on Facebook and TikTok) A note on the medical talkThis episode is education, not a prescription, and Dr. Cat's own point is that telemedicine doesn't replace in-person care. If you have a history of breast cancer or blood clots, or you're over 60 and thinking about starting, take these questions to your own doctor or an in-person menopause specialist. Use this episode to ask better questions. Enjoyed this one? Leave a review. It helps other women find the show. 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