Republican-sponsored bill would fine teachers $5,000 for telling the truth

AZ Central – The Arizona Republic

Republican-sponsored bill would fine teachers $5,000 for telling the truth

EJ Montini, Arizona Republic – February 2, 2023

Yes, there’s a bill in the Arizona House that, if made into law, would allow confused, disgruntled, ignorant or just plain unhinged individuals to file a complaint that could lead to a teacher or professor receiving a $5,000 fine for the offense of telling the truth.

About race.

Republican-sponsored House Bill 2458 is one of many misguided pieces of legislation being pushed in state legislatures around the country to prevent “critical race theory” from being taught in schools.

In essence, it’s a way of trying to whitewash history, as if our children would be better served by ignorance than knowledge. Beyond that, the only education level at which the theory has been discussed is college or above, so banning it for lower levels is a solution for a problem that does not exist.

Republican lawmakers are playacting

Not that any of this matters. HB 2458 will not become law. The sponsor knows it. The Republicans attempting to push it through the House know it. The opposition knows it. Those members of the legislative staff who do all the work know it.

Still, it proceeds. Why?

Is CRT being taught?How the state’s new superintendent views it

Because right now, your tax dollars and mine are funding a very elaborate, very calculated, very expensive game of political make-believe being played by grown-ups in elected office who are trying to convince us their charade is real. But it is not.

It’s playacting. A fairy tale. A sham.

It is happening in Washington, D.C., in the Republican-controlled House of Representatives, and it is happening here in the Republican-controlled Arizona Legislature.

It’s a performance that accomplishes nothing

The people behind HB 2458 know that if it makes it through the House and the Senate, both narrowly controlled by Republicans, it would not be signed by Gov. Katie Hobbs.

If they were interested in finding common ground about the issue and fashioning some form of legislation that would pass they would have contacted the governor’s office and tried to negotiate a compromise.

But bills like this are meant to promote fantasy, not serve reality.

They’re meant show constituents how vehement and committed the people they elected can be when they get into office. Even though it accomplishes … nothing.

And lawmakers here are simply mimicking their brothers and sisters in D.C.

Arizona House mimics the theater in D.C.

A while back, for example, Arizona Republican Rep. Andy Biggs tweeted, “Last night, my Republican colleagues and I defeated the Democrats’ 87,000-person IRS army. We are working quickly to reverse the Democrats’ negligent policies. This is already a very good start to the 118th Congress!”First, there is no “87,000-person IRS army.” Second, the Republicans who control the House defeated nothing.

Before becoming law, any legislation passed by the House must get through the Senate, and then be signed by the president.

Republican members of the House from all over the country are boasting to constituents about bills that will never become law. And that they know will never become law because they never bothered to find common ground about the issue and fashion some form of legislation that would pass.

Biggs also is among a group of House members who filed a resolution to impeach Homeland Security Secretary Alejandro Mayorkas for “high crimes and misdemeanors.”

There’s an adage about politics, show business

Again, pure show.

That we’re paying for.

Even if House members squeezed their impeachment through, Biggs knows the Constitution requires a two-thirds vote of the Senate to convict. And he knows that would never happen.

What’s going on within our divided government these days, here and in Washington, is not governing. It’s burlesque. It’s opera. It’s vaudeville.

It’s musical theater, melodrama, comedy, tragedy and farce, all rolled into one.

It’s proof of a political adage that’s been around for decades: Politics is show business for ugly people.

To Prevent Cancer, More Women Should Consider Removing Fallopian Tubes, Experts Say

The New York Times

To Prevent Cancer, More Women Should Consider Removing Fallopian Tubes, Experts Say

Roni Caryn Rabin – February 1, 2023

Monica Monfre Scantlebury, who discovered she had the BRCA1 genetic mutation in 2017, in St. Paul, Minn., on Jan. 27, 2022. (Jenn Ackerman/The New York Times)
Monica Monfre Scantlebury, who discovered she had the BRCA1 genetic mutation in 2017, in St. Paul, Minn., on Jan. 27, 2022. (Jenn Ackerman/The New York Times)

There is no reliable screening test for ovarian cancer, so doctors urge women at high genetic risk for the disease to have their ovaries and fallopian tubes removed once they are done having children, usually around the age of 40.

On Wednesday, a leading research and advocacy organization broadened that recommendation in ways that may surprise many women.

Building on evidence that most of these cancers originate in the fallopian tubes, not the ovaries, the Ovarian Cancer Research Alliance is urging even women who do not have mutations — that is, most women — to have their fallopian tubes surgically removed if they are finished having children and are planning a gynecologic operation anyway.

“Ovarian cancer is a relatively rare disease, and typically, we don’t message to the general population,” said Audra Moran, president of the alliance. “We want everyone with ovaries to know their risk level and know the actions they can take to help prevent ovarian cancer.”

To that end, the group also has begun offering free at-home testing kits to qualifying women who want to find out if they carry BRCA1 and BRCA2 genetic mutations, which confer an elevated risk for developing both ovarian and breast cancer.

Younger carriers of the mutations might consider removing only the fallopian tubes as an interim step to protect against ovarian cancer, and to avoid abrupt early menopause, Moran said, even though the gold-standard treatment for carriers is to remove the ovaries, too.

While women with BRCA1 and BRCA2 mutations have a very high risk for ovarian cancer, a majority of women with the disease do not carry the mutations.

The new advice is an acknowledgment that efforts to develop lifesaving screening tests for early detection of ovarian cancer have failed, and that women should consider more proactive measures.

Ever since a large clinical trial in Britain found that imaging scans and blood tests for early detection of ovarian cancer did not save lives, women have been told to heed vague symptoms, like bloating, that could indicate something amiss.

But experts say there is no evidence that vigilance about these symptoms prevents deaths.

The Society of Gynecologic Oncology, an organization of doctors who treat gynecologic cancers, has endorsed the new push to make genetic testing more accessible and to promote prophylactic removal of the fallopian tubes in women without genetic risks.

“It is considered experimental,” said Dr. Stephanie Blank, president of the society. But “it makes scientific sense and has a lot of appeal.”

“Removing the tubes is not as good as removing the tubes and the ovaries, but it’s better than screening, which doesn’t work,” she said.

Dr. Bill Dahut, chief scientific officer at the American Cancer Society, said, “There is a lot of good data behind what they’re suggesting, showing that for folks who had that surgery, the incidence rates of ovarian cancer are less.”

“If you look at the biology, maybe we should be calling it fallopian tube cancer and think of it differently, because that’s where it starts,” he said.

Ovarian cancer ranks fifth in cancer deaths among women, according to the American Cancer Society, and accounts for more deaths than any other cancer of the female reproductive system. Every year, some 19,710 women in the United States are diagnosed with ovarian cancer and about 13,000 women die of it.

The disease is a particularly stealthy malignancy, and it is often diagnosed at a very advanced stage as a result. Ovarian cancer is far less common than breast cancer, which is diagnosed in 264,000 women and 2,400 men each year in the U.S., but its survival rates are much lower.

In women with BRCA1 and BRCA2 genetic mutations, surgeons generally remove the ovaries as well as the fallopian tubes — at ages 35 to 40 in women with the BRCA1 mutation and ages 40 to 45 in women with the BRCA2 mutation, Blank said. Ideally, the women will have completed childbearing by then.

But women who don’t have a clear family history of ovarian or breast cancer may be unaware that they carry the mutations.

Monica Monfre Scantlebury, 45, of St. Paul, Minnesota, discovered she had the BRCA1 mutation in 2017, when her younger sister was diagnosed with metastatic breast cancer at age 27.

Their mother did not have the mutation, which means they inherited it from their deceased father. His mother, Scantlebury’s grandmother, had died in her 40s of breast and ovarian cancer.

While heart disease was discussed in the family, the women’s cancers were only whispered about, she recalled in an interview. After her sister died in 2020, Scantlebury had her tubes removed, along with an ovary that appeared to contain a growth.

“I was in my early 40s, and my doctors were less concerned about me getting breast cancer at that point and more concerned about my high risk of ovarian cancer,” she said.

A few days later she received a call from the doctors saying that cells believed to be precursors to high-grade serous ovarian cancer were found in one of her removed fallopian tubes. Scantlebury decided to have her uterus and cervix taken out, along with the remaining right ovary.

Those decisions were not easy. “I made the choice not to have any biological children, which was hard,” she said. “And I am still at risk for breast cancer.” But, she added, “I am named after my grandmother, and I believe the surgery prevented me from having the same obituary as her.”

The practice of removing the fallopian tubes while a patient is already having another pelvic surgery, called opportunistic salpingectomy, is already standard care in British Columbia, said Dr. Dianne Miller, who, until recently, was the leader of gynecologic cancer services there.

“Fifteen years ago, it became apparent that the most lethal and most common kinds of high-grade cancers actually had their origin in the fallopian tube rather than the ovary, and then spread very quickly,” Miller said.

By the time women experience symptoms like bloating or abdominal pain, she said, it is too late to do anything to save lives.

“I remember the light-bulb-going-off moment that many of these cancers are likely preventable, because a lot of women have a surgery at some point for hysterectomy, or removal of fibroids, or tubal ligation,” Miller said.

For women at average risk for ovarian cancer, removing only the tubes is a “win-win” situation, she said, because there are benefits to retaining the ovaries, which even after menopause continue to make small amounts of hormones that help keep the brain and heart healthy.

“As oncologists, we have our eyes set on curing cancer,” she said. “But if there’s one thing that’s absolutely better than curing cancer, it’s not getting it in the first place.”

While Ron DeSantis Is Fighting Culture Wars, Millions Of Floridians Are Losing Their Health Care


While Ron DeSantis Is Fighting Culture Wars, Millions Of Floridians Are Losing Their Health Care

Jonathan Cohn – January 31, 2023

Florida Gov. Ron DeSantis keeps making news with his self-described campaign to fight “woke” ideology. The latest headlines came about two weeks ago, when the Republican announced that he was prohibiting public high schools from offering a new Advanced Placement course in African American history. The course, his administration explained, “lacks significant educational value.” 

The announcement thrilled his supporters on the political right while infuriating his critics on the left. It’s safe to assume these were precisely the reactions that DeSantis wanted because they elevate his national profile and improve his chances of winning the 2024 Republican presidential nomination, which, as you may have heard, he is likely to seek.

But DeSantis has some other governing responsibilities, too. One of them is looking out for the health and economic well-being of Florida residents, including those who can’t pay for medical care on their own because they don’t have insurance. 

Florida has quite a lot of them ― nearly 2.6 million as of 2021, according to the most recent U.S. census figures. That’s about 12% of its population, which is well above the national average of 8.6%. It’s also more than all but four other states.

Floridians without insurance suffer because when they can’t pay for their medical care, they end up in debt or go without needed treatment or both. The state suffers, too, because it ends up with a sicker, less productive workforce as well as a higher charity care load for its hospitals, clinics and other pieces of the medical safety net.

DeSantis could do something about this. He has refused. In fact, as of this moment, his administration is embarking on a plan that some analysts worry could make the problem worse.

This story probably deserves some national attention as well.

DeSantis Has A Clear Record On Health Care

The simple, straightforward reason so many Floridians have no health insurance is that its elected officials won’t sign on to the Affordable Care Act’s Medicaid expansion, which offers states extra federal matching funds if they make the program available to everybody with incomes below or just above the poverty line.

Most states have now done just that. It’s the single biggest reason that the uninsured rate nationwide is at a record low. But eleven states have held out, leaving in place the much more limited eligibility standards they had established before the Affordable Care Act took effect. 

Florida is one of them. Childless adults in the Sunshine State can’t get Medicaid unless they fall into a special eligibility category, like having a disability. And even adults with kids have a hard time getting onto the program because the standard income guidelines are so low ― about 30% of the poverty line, which last year worked out to less than $7,000 for a family of three. That’s not enough to cover rent, food and other essentials, let alone buy a health insurance policy.

The non-expansion states all have Republican governors or legislatures or both, and are nearly all in the Deep South. They represent the last line of resistance against Obamacare, which Republicans have spent more than a decade fighting and, famously, came very close to repealing in 2017.

Gov. Ron DeSantis, shown at a recent appearance in Daytona Beach, doesn't have much to say about Medicaid expansion -- or why he's opposed it.
Gov. Ron DeSantis, shown at a recent appearance in Daytona Beach, doesn’t have much to say about Medicaid expansion — or why he’s opposed it.

Gov. Ron DeSantis, shown at a recent appearance in Daytona Beach, doesn’t have much to say about Medicaid expansion — or why he’s opposed it.

DeSantis was no mere bystander to that effort. As a Republican serving in the U.S. House, he was part of a far-right caucus that voted against the first ACA repeal bill that leadership brought to the floor because, DeSantis and his allies said, it didn’t undo enough of the law’s protections for people with pre-existing conditions. 

GOP leaders eventually put forward a more aggressive repeal. DeSantis and his colleagues voted yes on that one, but it failed in the Senate.

With repeal now off the political agenda, the main question about the Affordable Care Act is whether states like Florida will follow the lead of all the others and finally open up its Medicaid program to everybody living at or just above the poverty line.

If it did, several hundred thousand currently uninsured residents would become eligible for the program, according to independent estimates. 

End of a Pandemic Relief Effort And Its Impact

Florida’s refusal to expand Medicaid is not a new story. But it is newly relevant because of an expiring federal pandemic measure and its likely effect on access to health care for low-income residents.

When COVID-19 hit, the federal government offered states extra money to fund Medicaid as long as states agreed not to disenroll anybody who joined or was already on the program ― on the theory that in the midst of a public health emergency, the overwhelming priority was maximizing the number of people with insurance. 

That arrangement is about to end. States will have a year to go through their Medicaid enrollment files, removing anybody who cannot reestablish their eligibility. And in every state, significant numbers of people are likely to lose coverage ― in some cases simply because they aren’t aware their coverage is in jeopardy or because they can’t make their way through a complex, confusing process their state has put in place. 

Officials in some states are going out of their way to minimize coverage losses. Oregon, for example, will be letting all children younger than 6 stay on Medicaid automatically. Illinois is making it easier for adults to stay on the program while taking more time to go through the process of reestablishing eligibility.

Florida just announced its plan and, according to Joan Alker, executive director of Georgetown University’s Center for Children and Families, the state seems intent on pushing ahead quickly even though its own projections suggest 1.75 million Floridians could lose insurance as a result. 

“They’re very anxious to get almost 2 million people off of Medicaid, which is scary,” Alker told HuffPost. She added that she is especially worried about children, who represent a disproportionate number of Florida’s Medicaid population because the income guidelines for young people are looser than they are for adults.

Alker was careful to say that it was impossible to be sure how Florida will ultimately handle the process of reviewing Medicaid enrollment. She also said she was pleased that state officials made statements acknowledging the special predicament of children. 

A spokesperson for the Florida Policy Institute, a nonprofit organization that has been tracking the state’s plans, offered a similarly mixed assessment ― crediting state officials with an “intentional” plan that stressed communicating with parents clearly about their options while stating that it’s “too soon to tell whether the efforts outlined in the plans will be enough to make sure that Medicaid-eligible Floridians keep their coverage.”

But however Florida officials decide to handle this process, and however it works out, one thing is clear: If Florida were part of the Medicaid expansion, the number of people losing health coverage would be a lot lower.

The Uninsured In Florida Have A Difficult Time

Frederick Anderson, a family medicine physician, knows better than most what a difference health insurance can make for people in Florida. He oversees medical operations at a Miami-area clinic focusing on underserved populations, where large numbers of people have no insurance. He thinks a lot about one woman in particular. 

She’s the primary caregiver for a son with autism, Anderson told HuffPost, and she has no insurance because her below-poverty income is too high for the state’s Medicaid threshold. She’s been suffering from serious, debilitating headaches, but she can’t pay for the MRI she needs or find a neurologist with an open appointment.

It’s a problem he sees all the time, Anderson explained, because there just aren’t enough safety net providers to meet the demand. Patients end up waiting for the care they need or skipping it altogether. “We do the best we can,” Anderson said, “but many of our patients will need to see orthopedists, or neurologists or you name it, and these individuals have no easy access to those services. Or they would benefit from certain medications that I would like to prescribe for them, but … it’s just unaffordable.”

Anderson lives and works in Miami-Dade County, where the uninsured rate is among the highest in Florida. But rural areas of Florida face their own, special challenges.

The economics of health care make it more difficult for rural hospitals to survive without help from Medicaid, which is why in states like Florida that haven’t expanded eligibility, rural hospitals are struggling and in some cases closing, depriving communities of more than just acute care.

“We think of hospitals as places to go when you have something major that is wrong,” Scott Darius, executive director of the advocacy group Florida Voices for Health Care, told HuffPost. “But in those rural areas, we’ve learned, hospitals are the primary care location for large portions of the population.”

DeSantis Hasn’t Had Much To Say On Medicaid

These accounts are consistent stories reporters covering health care hear all the time. They also echo some of the anecdotes that an organization called the Florida Health Justice Project has collected on its website as part of an ongoing campaign, in conjunction with other advocacy groups, to bring expansion to Florida.

“Florida ranks [near the bottom] for the rate of uninsured residents,” Alison Yager, executive director at the Health Justice project, told HuffPost. “Expanding Medicaid, as all but 11 of our sister states have done, would surely boost our shameful showing.”

But the cause has been a tough sell in Tallahassee, where Republicans have had nearly uninterrupted control of the Florida’s lawmaking process since 1999. Two previous efforts to get expansion through the state legislature failed. DeSantis’ spokesperson confirmed in 2021 that he remained opposed to it.

That was two years ago, and since then he’s managed to avoid saying much about the issue, including to HuffPost, despite several inquiries to his office over the past three weeks. Medicaid expansion got only sporadic attention in the 2022 gubernatorial campaign, although Democrats tried initially to make it an issue, and it didn’t draw so much as a mention in the lone debate DeSantis had with Democratic nominee Charlie Crist.

A year before that, DeSantis signed a much narrower measure: a 2021 bipartisan bill increasing Medicaid’s postpartum coverage from 60 days to a year. It was a priority for the outgoing GOP House speaker, and it’s always possible political circumstances will align and lead to more legislation like that in the future.

But DeSantis’ hostility to government health care programs runs deep.

Protesters rally near the U.S. Capitol after House Republicans voted to repeal the Affordable Care Act in 2017. DeSantis was one of those House Republicans.
Protesters rally near the U.S. Capitol after House Republicans voted to repeal the Affordable Care Act in 2017. DeSantis was one of those House Republicans.

Protesters rally near the U.S. Capitol after House Republicans voted to repeal the Affordable Care Act in 2017. DeSantis was one of those House Republicans.

Long before he was attacking “critical race theory” lessons and supposed sexual brainwashing in the schools, he was railing against Obama-era programs generally (as New York magazine’s Jonathan Chait has explained) and the Affordable Care Act specifically (as The New York Times’ Jamelle Bouie has written) as fundamentally incompatible with American principles of freedom and private property.

DeSantis may also have more practical objections to expanding Medicaid. Maybe he thinks it’s too big a drain on state finances or too wasteful a program, as many conservatives and libertarians argue. Maybe he thinks Medicaid does more harm than good for beneficiaries or that people on the program could find insurance on their own if only they were more industrious and got paying jobs. 

Those latter claims don’t hold up well under scrutiny. The majority of Floridians missing out on Medicaid expansion are in families with at least one worker, according to the Center on Budget and Policy Priorities. And when the uninsured get Medicaid, their access to care and financial security improves, according to a large and still-growing pile of research

Their health outcomes also seem to improve, though the evidence on how the Medicaid expansion has affected mortality specifically remains the subject of some debate.

The Politics of Medicaid May Be Different Nationally

Advocates today have their eyes on trying to expand Medicaid through a ballot initiative, which is the way it’s happened in Idaho, Missouri and several other states where Republican lawmakers had blocked it. 

But Florida Republicans are already working to make that process more difficult because it’s a way for voters to circumvent GOP opposition to popular causes. And it’s not like waging a ballot campaign is easy now. Organizers recently told the Tampa Bay Times that 2026 is the earliest they could realistically get a Medicaid measure on the ballot.

As for DeSantis, his record on health care could become a key point of contrast in a hypothetical 2024 White House campaign. President Joe Biden, after all, is the guy who called Obamacare a “big fucking deal” and just signed into law reforms that make the program’s financial assistance more generous. Any conceivable replacement on the Democratic ticket would have a similar record of votes in Congress or state actions to support coverage expansions

There’s no way to be sure how an issue will play out in the next election ― or whether it will even matter at all. But it’s not hard to imagine the contrast on health care working to the Democrats’ advantage. The Affordable Care Act is relatively popular these days, and Medicaid expansion tends to poll well even among Republican voters

That may help explain why DeSantis and his spokespeople have so little to say on the subject. But that silence doesn’t change the real-world impact of his posture ― or what it reveals about his priorities.

DeSantis Takes On the Education Establishment, and Builds His Brand

The New York Times

DeSantis Takes On the Education Establishment, and Builds His Brand

Stephanie Saul, Patricia Mazzei and Trip Gabriel – February 1, 2023

Patricia Okker, facing camera, president of New College of Florida in Sarasota, is embraced by a supporter on Tuesday, Jan. 31, 2023.  (Todd Anderson/The New York Times)
Patricia Okker, facing camera, president of New College of Florida in Sarasota, is embraced by a supporter on Tuesday, Jan. 31, 2023. (Todd Anderson/The New York Times)

Gov. Ron DeSantis of Florida, as he positions himself for a run for president next year, has become an increasingly vocal culture warrior, vowing to take on liberal orthodoxy and its champions, whether they are at Disney, on Martha’s Vineyard or in the state’s public libraries.

But his crusade has perhaps played out most dramatically in classrooms and on university campuses. He has banned instruction about gender identity and sexual orientation in kindergarten through third grade; limited what schools and employers can teach about racism and other aspects of history; and rejected math textbooks en masse for what the state called “indoctrination.” Most recently, he banned the College Board’s Advanced Placement courses in African American studies for high school students.

On Tuesday, DeSantis, a Republican, took his most aggressive swing yet at the education establishment, announcing a proposed overhaul of the state’s higher education system that would eliminate what he called “ideological conformity.” If enacted, courses in Western civilization would be mandated; diversity and equity programs would be eliminated; and the protections of tenure would be reduced.

His plan for the state’s education system is in lockstep with other recent moves — banning abortions after 15 weeks of pregnancy, shipping a planeload of Venezuelan migrants to Martha’s Vineyard in Massachusetts and stripping Disney, a once politically untouchable corporate giant in Florida, of favors it has enjoyed for half a century.

His pugilistic approach was rewarded by voters, who reelected him by a 19 percentage-point margin in November.

Appearing on Tuesday at the State College of Florida, Manatee-Sarasota, one of the state’s 28 publicly funded state and community colleges, DeSantis vowed to turn the page on agendas that he said were “hostile to academic freedom” in Florida’s higher education system. The programs “impose ideological conformity to try to provoke political activism,” DeSantis said. “That’s not what we believe is appropriate for the state of Florida.”

He had already moved to overhaul the leadership of the New College of Florida, a small liberal arts school in Sarasota that has struggled with enrollment but calls itself a place for “freethinkers.” It is regarded as among the most progressive of Florida’s 12 public universities.

DeSantis pointed to low enrollment and test scores at New College as part of the justification for seeking change there.

“If it was a private school, making those choices, that’s fine, I mean, what are you going to do,” he said. “But this is paid for by your tax dollars.”

The college’s board of trustees, with six new conservative members appointed by DeSantis, voted in a raucous meeting Tuesday afternoon to replace the president and agreed to appoint Richard Corcoran, a former state education commissioner, as the interim president beginning in March.

Corcoran will replace Patricia Okker, a longtime English professor and college administrator who was appointed in 2021.

While expressing her love for the college and its students, Okker called the move a hostile takeover. “I do not believe that students are being indoctrinated here at New College,” she said. “They are taught. They read Marx and they argue with Marx. They take world religions. They do not become Buddhists in February and turn into Christians in March.”

DeSantis also announced Tuesday that he had asked the Legislature to immediately free up $15 million to recruit new faculty and provide scholarships for New College.

In all, he requested from the Legislature $100 million a year for state universities.

“We’re putting our money where our mouth is,” he said.

New College is small, with nearly 700 students, but the shake-up reverberated throughout Florida, as did DeSantis’ proposed overhaul.

Andrew Gothard, president of the state’s faculty union, said the governor’s statements on the state’s system of higher education were perhaps his most aggressive yet.

“There’s this idea that Ron DeSantis thinks he and the Legislature have the right to tell Florida students what classes they can take and what degree programs,” said Gothard, who is on leave from his faculty job at Florida Atlantic University. “He says out of one side of his mouth that he believes in freedom and then he passes and proposes legislation and policies that are the exact opposite.”

At the board meeting, students, parents and professors defended the school and criticized the board members for acting unilaterally without their input.

Betsy Braden, who identified herself as the parent of a transgender student, said her daughter had thrived at the school.

“It seems many of the students that come here have determined that they don’t necessarily fit into other schools,” Braden said. “They embrace their differences and exhibit incredible bravery in staking a path forward. They thrive, they blossom, they go out into the world for the betterment of society. This is well documented. Why would you take this away from us?”

Corcoran, a DeSantis ally, had been mentioned as a possible president of Florida State University, but his candidacy was dropped following questions about whether he had a conflict of interest or the appropriate academic background.

A letter from Carlos Trujillo, the president of Continental Strategy, a consulting firm where Corcoran is a partner, said the firm hoped that his title at New College would become permanent.

Not since George W. Bush ran in 2000 to be “the education president” has a Republican seeking the Oval Office made school reform a central agenda item. That may have been because, for years, Democrats had a double-digit advantage in polling on education.

But since the pandemic started in 2020, when many Democratic-led states kept schools closed longer than Republican states did, often under pressure from teachers unions, some polling has suggested that education now plays better for Republicans. And Glenn Youngkin’s 2021 victory in the Virginia governor’s race, after a campaign focused on “parents’ rights” in public schools, was seen as a signal of the political potency of education with voters.

DeSantis’ attack on diversity, equity and inclusion programs coincides with the recent criticisms of such programs by conservative organizations and think tanks.

Examples of such initiatives include campus sessions on “microaggressions” — subtle slights usually based on race or gender — as well as requirements that candidates for faculty jobs submit statements describing their commitment to diversity.

“That’s basically like making people take a political oath,” DeSantis said Tuesday. He also attacked the programs for placing a “drain on resources and contributing to higher costs.”

Supporters of diversity, equity and inclusion programs and diverse curricula say they help students understand the broader world as well as their own biases and beliefs, improving their ability to engage in personal relationships as well as in the workplace.

DeSantis’ embrace of civics education, as well as the establishment of special civics programs at several of the state’s 12 public universities, dovetails with the growth of similar programs around the country, some partially funded by conservative donors.

The programs emphasize the study of Western civilization and economics, as well as the thinking of Western philosophers, frequently focusing on the Greeks and Romans. Critics of the programs say they sometimes gloss over the pitfalls of Western thinking and ignore the philosophies of non-Western civilizations.

“The core curriculum must be grounded in actual history, the actual philosophy that has shaped Western civilization,” DeSantis said. “We don’t want students to go through, at taxpayer expense, and graduate with a degree in zombie studies.”

The shake-up of New College, which also included the election of a new board chair, may be ongoing and dramatic, given the six new board members appointed by DeSantis.

They include Christopher Rufo, a senior fellow at Manhattan Institute who is known for his vigorous attacks on “critical race theory,” an academic concept that historical patterns of racism are ingrained in law and other modern institutions.

At the time of his appointment, Rufo, who lives and works in Washington state, tweeted that he was “recapturing” higher education.

Another new board member is Eddie Speir, who runs a Christian private school in Florida. He had recommended in a Substack posting before the meeting that the contracts of all the school’s faculty and staff be canceled.

The other new appointees include Matthew Spalding, dean of the Washington, D.C., campus of Hillsdale College, a private college in Michigan known for its conservative and Christian orientations. An aide to the governor has said that Hillsdale, which says it offers a classical education, is widely regarded as the governor’s model for remaking New College.

In addition to the governor’s six new appointees, the university system’s board of governors recently named a seventh member, Ryan T. Anderson, the head of a conservative think tank, the Ethics and Public Policy Center, which applies the Judeo-Christian tradition to contemporary questions of law, culture and politics. His selection was viewed as giving DeSantis a majority vote on the 13-member board.

Valley fever could be spreading across the U.S. Here are the symptoms and what you need to know


Valley fever could be spreading across the U.S. Here are the symptoms and what you need to know

L’Oreal Thompson Payton – January 31, 2023

Kateryna Kon—Science Photo Library/Getty Images

Valley fever, a fungal infection most notably found in the Southwestern United States, is now likely to spread east, throughout the Great Plains and even north to the Canadian border because of climate change, according to a study in GeoHealth.

“As the temperatures warm up, and the western half of the U.S. stays quite dry, our desert-like soils will kind of expand and these drier conditions could allow coccidioides to live in new places,” Morgan Gorris, who led the GeoHealth study while at the University of California, Irvine, told

As the infection continues to be diagnosed outside the Southwest, here’s what you need to know about valley fever.

What is valley fever?

Valley fever, which commonly occurs in the Southwest due to the region’s hot, dry soil, is an infection caused by inhaling microscopic spores of the fungus coccidioides. About 20,000 cases of valley fever were reported in 2019, according to the Centers for Disease Control and Prevention, and 97% of cases were reported in Arizona and California. Rates are usually highest among people 60 years of age and older.

While most people who breathe in the spores don’t get sick, those who do typically feel better on their own within weeks or months; however, some will require antifungal medication.

What are the symptoms of valley fever?

Symptoms of valley fever may appear anywhere from one to three weeks after breathing in the fungal spores and typically last for a few weeks to a few months. About 5% to 10% of people who get valley fever will develop serious or long-term lung problems. Symptoms include:

  • Fatigue
  • Cough
  • Fever
  • Shortness of breath
  • Headache
  • Night sweats
  • Muscle aches or joint pain
  • Rash on upper body or legs
How is valley fever diagnosed?

Valley fever is most commonly diagnosed through a blood test; however, health care providers may also run imaging tests, such as chest X-rays or CT scans, to check for valley fever pneumonia.

Who is most likely to get valley fever?

People who are at higher risk for becoming severely ill, such as those with weakened immune systems, pregnant people, people with diabetes, and Black or Filipino people, are advised to avoid breathing in large amounts of dust if they live in or are traveling to places where valley fever is common.

Is valley fever contagious?

No. “The fungus that causes valley fever, coccidioides, can’t spread from the lungs between people or between people and animals,” according to the CDC. “However, in extremely rare instances, a wound infection with coccidioides can spread valley fever to someone else, or the infection can be spread through an organ transplant with an infected organ.”

How can I prevent valley fever?

While it’s nearly impossible to avoid breathing in the fungus coccidioides in places where it’s common, the CDC recommends avoiding spending time in dusty places as much as possible, especially for people who are at higher risk. You can also:

  • Wear a face mask, such as a N95 respirator
  • Stay inside during dust storms
  • Avoid outdoor activities, such as yard work and gardening, that require close contact with dirt or dust
  • Use air filtration systems while indoors
  • Clean skin injuries with soap and water
  • Take preventive antifungal medication as recommended by your doctor
Is there a cure or vaccine for valley fever?

Not yet. According to the CDC, scientists have been working on a vaccine to prevent valley fever since the 1960s. However, researchers at the University of Arizona College of Medicine in Tucson have created a two-dose vaccine that’s been proved effective in dogs.

“I’m really quite hopeful,” Dr. John Galgiani, director of the Valley Fever Center for Excellence at the University of Arizona College of Medicine, told Today. “In my view, right now, we do have a candidate that deserves to be evaluated and I think will probably be effective, and we’ll be using it.”

These jobs are most likely to be replaced by ChatGPT and AI

CBS News

These jobs are most likely to be replaced by ChatGPT and AI

Megan Cerullo – February 1, 2023

Chatbots and artificial intelligence tools like ChatGPT that can almost instantly produce increasingly sophisticated written content are already being used to perform a variety of tasks, from writing high school assignments to generating legal documents and even authoring legislation.

As in every major cycle of technological innovation, some workers will be displaced, with artificial intelligence taking over their roles. At the same time, entirely new activities — and potential opportunities for employment — will emerge.

Read on to learn what experts say are the kinds of workplace tasks that are most vulnerable to being taken over by ChatGPT and other AI tools in the near term.

Computer programming

ChatGPT can write computer code to program applications and software. It can check human coders’ language for errors and convert ideas from plain English into programming language.

“In terms of jobs, I think it’s primarily an enhancer than full replacement of jobs,” Columbia Business School professor Oded Netzer told CBS MoneyWatch. “Coding and programming is a good example of that. It actually can write code quite well.”

That could mean performing basic programming work currently done by humans.

“If you are writing a code where really all you do is convert an idea to a code, the machine can do that. To the extent we would need fewer programmers, it could take away jobs. But it would also help those who program to find mistakes in codes and write code more efficiently,” Netzer said.

Basic email

Writing simple administrative or scheduling emails for things like setting up or canceling appointments could also easily be outsourced to a tool like ChatGPT, according to Netzer.

“There’s hardly any creativity involved, so why would we write the whole thing instead of saying to the machine, ‘I need to set a meeting on this date,'” he said.

Mid-level writing

David Autor, an MIT economist who specializes in labor, pointed to some mid-level white-collar jobs as functions that can be handled by AI, including work like writing human resources letters, producing advertising copy and drafting press releases.

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“Bots will be much more in the realm of people who do a mixture of intuitive and mundane tasks like writing basic advertising copy, first drafts of legal documents. Those are expert skills, and there is no question that software will make them cheaper and therefore devalue human labor,” Autor said.

Media planning and buying

Creative industries are likely to be affected, too. Noted advertising executive Sir Martin Sorrell, founder of WPP, the world’s largest ad and PR group, said on a recent panel that he expects the way companies buy ad space will become automated “in a highly effective way” within five years.

“So you will not be dependent as a client on a 25-year old media planner or buyer, who has limited experience, but you’ll be able to pool the data. That’s the big change,” he said.

Legal functions

ChatGPT’s abilities translate well to the legal profession, according to AI experts as well as legal professionals. In fact, ChatGPT’s bot recently passed a law school exam and earned a passing grade after writing essays on topics ranging from constitutional law to taxation and torts.

“The dynamic that happens to lawyers now is there is way too much work to possibly get done, so they make an artificial distinction between what they will work on and what will be left to the wayside,” said Jason Boehmig, co-founder and CEO of Ironclad, a legal software company.

Common legal forms and documents including home lease agreements, wills and nondisclosure agreements are fairly standard and can be drafted by a an advanced bot.

“There are parts of a legal document that humans need to adapt to a particular situation, but 90% of the document is copy pasted,” Netzer of Columbia Business School said. “There is no reason why we would not have the machine write these kinds of legal documents. You may need to explain first in English the parameters, then the machine should be able to write it very well. The less creative you need to be, the more it should be replaced.”

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“There aren’t enough lawyers to do all the legal work corporations have,” Boehmig added. “The way attorneys work will be dramatically different. If I had to put a stake down around jobs that won’t be there, I think it’s attorneys who don’t adapt to new ways of working over the next decade. There seem to be dividing lines around folks who don’t want to change and folks who realize they have to.”

U.S. woman detained in Russia after walking calf on Red Square


U.S. woman detained in Russia after walking calf on Red Square

February 1, 2023

U.S. citizen Alicia Day, detained for walking a calf in Red Square, attends a court hearing in Moscow

(Reuters) – A U.S. woman was detained and fined by a Russian court on Wednesday for walking a calf on Moscow’s Red Square that she said she had bought to save from slaughter, Russian state media reported.

Alicia Day, 34, was fined 20,000 roubles ($285) for obstructing pedestrians in an unauthorised protest and sentenced to 13 days of “administrative arrest” on a separate charge of disobeying police orders.

“I bought the calf so that it wouldn’t be eaten,” TASS news agency quoted her as saying.

Video shared by state media showed Day explaining that she had got a driver to bring the calf to Red Square by car. “I wanted to show it a beautiful place in our beautiful country,” she said.

The U.S. embassy did not immediately comment when asked about the case.

Day had been living in a suburb of Moscow on a tourist visa, the RIA news agency said, and had carried out similar acts of protest before in other countries.

In 2019, the Daily Mail newspaper reported that she had “rescued” a pig she named Jixy Pixy from slaughter in western England, brought it to London by taxi and taken it for walks and restaurant meals, but had to hand it to an animal welfare charity after her landlord discovered she was keeping it in a small apartment.

($1 = 70.15 roubles)

(Reporting by Caleb Davis; Editing by Raissa Kasolowsky)

War’s longest battle exacts high price in ‘heart of Ukraine’

Associated Press

War’s longest battle exacts high price in ‘heart of Ukraine’

Hanna Arhirova – February 1, 2023

FILE - Ukrainian soldiers ride in a Humvee in Bakhmut, Donetsk region, Ukraine, Wednesday, Dec. 21, 2022. (AP Photo/Libkos, File)
Ukrainian soldiers ride in a Humvee in Bakhmut, Donetsk region, Ukraine, Wednesday, Dec. 21, 2022. (AP Photo/Libkos, File)
FILE - Rescuers carry the body of a civilian at a site of an apartment building destroyed by Russian shelling in Bakhmut, Donetsk region, Ukraine, Wednesday, May 18, 2022. (AP Photo/Andriy Andriyenko, File)
Rescuers carry the body of a civilian at a site of an apartment building destroyed by Russian shelling in Bakhmut, Donetsk region, Ukraine, Wednesday, May 18, 2022. (AP Photo/Andriy Andriyenko, File)
FILE - Local residents stand in line waiting for free bread from volunteers in Bakhmut, the site of the heaviest battle against the Russian troops in the Donetsk region, Ukraine, Friday, Oct. 28, 2022. (AP Photo/Efrem Lukatsky, File)
Local residents stand in line waiting for free bread from volunteers in Bakhmut, the site of the heaviest battle against the Russian troops in the Donetsk region, Ukraine, Friday, Oct. 28, 2022. (AP Photo/Efrem Lukatsky, File)
FILE Smoke billows after Russian attacks in the outskirts of Bakhmut, Ukraine, Tuesday, Dec. 27, 2022. (AP Photo/LIBKOS, File)
Smoke billows after Russian attacks in the outskirts of Bakhmut, Ukraine, Tuesday, Dec. 27, 2022. (AP Photo/LIBKOS, File)
FILE - Ukrainian soldiers rest near their position in Bakhmut, Donetsk region, Ukraine, Saturday, Dec. 17, 2022. (AP Photo/LIBKOS, File)
Ukrainian soldiers rest near their position in Bakhmut, Donetsk region, Ukraine, Saturday, Dec. 17, 2022. (AP Photo/LIBKOS, File)
FILE - Ukrainian soldiers fire a Pion artillery system at Russian positions near Bakhmut, Donetsk region, Ukraine, Friday, Dec. 16, 2022. (AP Photo/LIBKOS, File)
Ukrainian soldiers fire a Pion artillery system at Russian positions near Bakhmut, Donetsk region, Ukraine, Friday, Dec. 16, 2022. (AP Photo/LIBKOS, File)
FILE Ukrainian servicemen prepare to fire at Russian positions in the frontline near Bakhmut, Donetsk region, Ukraine, Thursday, Nov. 24, 2022. (AP Photo/LIBKOS, File)
Ukrainian servicemen prepare to fire at Russian positions in the frontline near Bakhmut, Donetsk region, Ukraine, Thursday, Nov. 24, 2022. (AP Photo/LIBKOS, File)

KYIV, Ukraine (AP) — Visitors used to browse through Bakhmut’s late 19th century buildings, enjoy walks in its rose-lined lakeside park and revel in the sparkling wines produced in historic underground caves. That was when the city in eastern Ukraine was a popular tourist destination.

No more. The longest battle of Russia’s war has turned this city of salt and gypsum mines into a ghost town. Despite bombing, shelling and attempts to encircle Bakhmut for six months, Russia’s forces have not conquered it.

But their scorched-earth tactics have made it impossible for civilians to have any semblance of a life there.

“It’s hell on earth right now; I can’t find enough words to describe it,” said Ukrainian soldier Petro Voloschenko, who is known on the battlefield as Stone, his voice rising with emotion and resentment.

Voloschenko, who is originally from Kyiv, arrived in the area in August when the Russian assault started and has since celebrated his birthday, Christmas and New Year’s there.

The 44-year-old saw the city, located around 100 kilometers (60 miles) from Russia’s border, gradually turned into a wasteland of ruins. Most of the houses are crushed, without roofs, ceilings, windows or doors, making them uninhabitable, he said.

Out of a prewar population of 80,000, a few thousand residents remain. They rarely see daylight because they spend most of their time in basements sheltering from the ferocious fighting around and above them. The city constantly shudders with the muffled sound of explosions, the whizzing of mortars and a constant soundtrack of artillery. Anywhere is a potential target.

Bakhmut lies in Donetsk province, one of four that Russia illegally annexed in the fall — but Moscow only controls about half of it. To take the remaining half, Russian forces have no choice but to go through Bakhmut, which offers the only approach to bigger Ukrainian-held cities since Ukrainian troops took back Izium in Kharkiv province in September, according to Mykola Bielieskov, a research fellow at Ukraine’s National Institute for Strategic Studies.

“Without seizure of these cities, the Russian army won’t be able to accomplish the political task it was given,” Bielieskov said.

The deterioration in Bakhmut started during the summer after Russia took the last major city in neighboring Luhansk province. It then poured troops and equipment into capturing Bakhmut, and Ukraine did the same to defend it. For Russia, the city was one stepping stone toward its goal of seizing the remaining Ukrainian-held territory in Donetsk.

From trenches outside the city, the two sides dug in for what turned into an exhausting standoff as Ukraine clawed back territory to the north and south and Russian airstrikes across the country targeted power plants and other infrastructure.

The months of battle exhausted both armies. In the fall, Russia changed tactics and sent in foot soldiers instead of probing the front line mainly with artillery, according to Voloschenko.

Bielieskov, the research fellow, said the least-trained Russians go first to force the Ukrainians to open fire and expose the strengths and weaknesses of their defense.

More trained units or mercenaries from the Wagner Group, a private Russian military company led by a rogue millionaire and known for its brutality, make up the rear guard, Bielieskov said.

Bielieskov said that Ukraine compensates for its lack of heavy equipment with people who are ready to stand to the last.

“Lightly armed, without sufficient artillery support, which they cannot always be provided, they stand and hold off attacks as long as possible,” he said.

The result is that the battle is believed to have produced horrific troop losses for both Ukraine and Russia. Quite how deadly isn’t known: Neither side is saying.

“Manpower is less of a Russian problem and, in some ways, more of a Ukrainian problem, not only because the casualties are painful, but they’re often … Ukraine’s best troops,” said Lawrence Freedman, a professor emeritus of war studies at King’s College London.

The Institute for the Study of War recently reported that Wagner forces have seen more than 4,100 die and 10,000 wounded, including over 1,000 killed between late November and early December near Bakhmut. The numbers are impossible to verify.

Ukrainian President Volodymyr Zelenskyy, in a recent address, described the situation in Bakhmut as “very tough.”

“These are constant Russian assaults. Constant attempts to break through our defenses” he said,

Like Mariupol — the port city in the same province that Russia eventually captured after an 82-day siege that eventually came down to a mammoth steel mill where determined Ukrainian fighters held out along with civilians — Bakhmut has taken on almost mythic importance to its defenders.

“Bakhmut has already become a symbol of Ukrainian invincibility,” Voloschenko said. “Bakhmut is the heart of Ukraine, and the future peace of those cities that are no longer under occupation depends on the rhythm with which it beats.”

For now, Bakhmut remains completely under the control of the Ukrainian army, albeit more as a fortress than a place where people would visit, work or play. In January, the Russians seized the town of Soledar, located less than 20 kilometers (some 12 miles) away, but their advance is very slow, according to military analysts.

“These are rates of advancement that do not allow us to talk about serious offensive actions. It’s a slow pushing out at a very high price,” Bielieskov said.

Along the front line on the Ukrainian side, emergency medical units provide urgent care to battlefield casualties. From 50 to 170 wounded Ukrainian soldiers pass daily through just one of the several stabilization points along the Donetsk front line, according to Tetiana Ivanchenko, who has volunteered in eastern Ukraine since a Russia-backed separatist conflict started there in 2014.

After its setbacks in Kharkiv in the northeast and Kherson province in the south, the Kremlin is hungry for any success, even if it is just seizing a town or two that have been pounded into rubble. Freedman, the King’s College London professor emeritus, said the loss of Bakhmut would be a blow for Ukraine and offer tactical advantages to Russian forces, but wouldn’t prove decisive to the outcome of the war.

There would have been more value for Russia if it could have captured a populated and intact Bakhmut early on in the war, but now the capture would just give its forces options on how to seize more of Donetsk, said Freedman.

A 22-year-old Ukrainian soldier who is known as Desiatyi, or Tenth, joined the army on the day that Russia started the full-scale war in Ukraine. After months spent defending the Bakhmut area, losing many comrades, he said he has no regrets.

“It is not about comparing the price and losses on both sides. It’s about the fact that, yes, Ukrainians are dying, but they are dying because of a specific goal,” said Desiatyi, who did not give his real name for security reasons.

“Ukraine has no choice but to defend every inch of its land. The country must defend itself, especially now, so zealously, so firmly, and desperately. This is what will help us liberate our occupied territories in the future.”

Follow AP’s coverage of the war in Ukraine:

What is Valley fever? Fungal infection from the Southwest may spread with climate change.

USA Today

What is Valley fever? Fungal infection from the Southwest may spread with climate change.

Adrianna Rodriguez, USA TODAY – February 1, 2023

The HBO series “The Last of Us” has brought awareness to the growing threat of fungal infections. While there’s no known fungus that turns humans into sporous zombies, health experts say one pathogen may become more prevalent due to climate change.

Valley fever is an infection caused by coccidioides, a fungus that generally prefers warm, arid climates and predominately lives in soil in the southwestern United States, according to the Centers for Disease Control and Prevention.

The CDC reported about 20,000 cases of Valley fever in 2019. Although most cases are mild, the fungus spreads in a fraction of patients causing severe disease and death.

Studies show variable weather caused by climate change could spread the fungus to other parts of the country, said Dr. Paris Salazar-Hamm, a researcher at the University of New Mexico School of Medicine.

A 2019 study found Valley fever endemicity could spread from 12 to 17 states and the number of cases could increase by 50% by 2100 in a “high warming scenario.”

“Fungal pathogens are a group that get vastly overlooked and Valley fever is an interesting model because it’s associated with the climate,” Salazar-Hamm said.

Here’s what we know about Valley fever.

How do you catch Valley fever?

A person gets Valley fever by inhaling fungal spores from soil that’s typically kicked up in the air, according to the University of Arizona’s Valley Fever Center for Excellence.

What are symptoms of Valley fever?

Symptoms typically occur within three weeks exposure, according to the Valley Fever Center for Excellence.

The CDC says symptoms include:

  • Fatigue
  • Cough
  • Fever
  • Shortness of breath
  • Headache
  • Night sweats
  • Muscle aches or joint pain
  • Rash on the upper body or legs.

‘A tipping point’: Arizona universities join forces to map the deadly Valley fever

Valley fever: Why the CDC calls this little-known disease a ‘silent epidemic’

Is Valley fever a serious disease? What is the survival rate?

The fungal infection is endemic in the southwest, with most people experiencing mild to no symptoms, said Dr. Manish Butte, professor and division chief of immunology, allergy and rheumatology in the department of pediatrics at the University of California, Los Angeles.

But there is a small subset of people where the fungus “spreads rapidly and destructively throughout the body,” eating flesh for nutrition, he said.

“If it spreads to the brain or spinal cord, about 40% of the people die,” he said. This process can take up to two weeks from exposure. About 200 people die from Valley fever each year, the CDC reports.

It’s unclear why only a fraction of people exposed to the fungal spores develop severe disease but Butte’s research suggests it may have something to do with an individual’s immune system.

“We still find a number of patients where we don’t have a good clue for them, and that’s where immunologists like me try to get involved and try to understand from genetic tests,” he said.

‘We have to find a cure’: Fungus lands US bat species on the endangered list

Can you be cured of Valley fever?

Most acute infections can be treated with antifungal medications, most commonly fluconazole, Butte said, but the tricky part is knowing when to use it.

Fungal infections are difficult to catch through simple x-rays, he said, and the only diagnostic testing available is a blood test that detects antibodies.

Some clinicians mistake fungal infections for a viral or bacterial infections and use antibiotics to treat patients, Salazar-Hamm said.

“You wipe out the bacterial flora (with the antibiotic), allowing the fungal infection to grow and it makes it worse,” she said.

Antifungal drugs are also “intense,” Salazar-Hamm said, and may have bad side effects. The Mayo Clinic says some rare side effects include:

  • Fever
  • Headache
  • Hives, chills
  • Chest tightness
  • Fast heartbeat, among others

“Fungi are more closely related to humans than they are to bacteria,” she said. “Targets for fungal drugs have negative side effects for human cells.”

About 1% of patients where the fungus spreads throughout the body are also given another antifungal called AmBisome, but Butte said many patients still die. His research focuses on how immunomodulation – or manipulating the immune system – could help these select patients fight the fungus.

Is Valley fever high contagious?

Multiple people in a household can get the fungal disease by inhaling the spores airborne in their environment, but Valley fever is not “contagious” in that it cannot be passed from person to person.

Health and patient safety coverage at USA TODAY is made possible in part by a grant from the Masimo Foundation for Ethics, Innovation and Competition in Healthcare. The Masimo Foundation does not provide editorial input.

Women Have Been Misled About Menopause

By Susan Dominus – February 1, 2023

Hot flashes, sleeplessness, pain during sex: For some of menopause’s worst symptoms, there’s an established treatment. Why aren’t more women offered it?

Photo Credit…Marta Blue for The New York Times

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For the past two or three years, many of my friends, women mostly in their early 50s, have found themselves in an unexpected state of suffering. The cause of their suffering was something they had in common, but that did not make it easier for them to figure out what to do about it, even though they knew it was coming: It was menopause.

The symptoms they experienced were varied and intrusive. Some lost hours of sleep every night, disruptions that chipped away at their mood, their energy, the vast resources of good will that it takes to parent and to partner. One friend endured weeklong stretches of menstrual bleeding so heavy that she had to miss work. Another friend was plagued by as many as 10 hot flashes a day; a third was so troubled by her flights of anger, their intensity new to her, that she sat her 12-year-old son down to explain that she was not feeling right — that there was this thing called menopause and that she was going through it. Another felt a pervasive dryness in her skin, her nails, her throat, even her eyes — as if she were slowly calcifying.

Then last year, I reached the same state of transition. Technically, it is known as peri-menopause, the biologically chaotic phase leading up to a woman’s last period, when her reproductive cycle makes its final, faltering runs. The shift, which lasts, on average, four years, typically starts when women reach their late 40s, the point at which the egg-producing sacs of the ovaries start to plummet in number. In response, some hormones — among them estrogen and progesterone — spike and dip erratically, their usual signaling systems failing. During this time, a woman’s period may be much heavier or lighter than usual. As levels of estrogen, a crucial chemical messenger, trend downward, women are at higher risk for severe depressive symptoms. Bone loss accelerates. In women who have a genetic risk for Alzheimer’s disease, the first plaques are thought to form in the brain during this period. Women often gain weight quickly, or see it shift to their middles, as the body fights to hold onto the estrogen that abdominal fat cells produce. The body is in a temporary state of adjustment, even reinvention, like a machine that once ran on gas trying to adjust to solar power, challenged to find workarounds.

I knew I was in perimenopause because my period disappeared for months at a time, only to return with no explanation. In the weeks leading up to each period, I experienced abdominal discomfort so extreme that I went for an ultrasound to make sure I didn’t have some ever-growing cyst. At times, hot flashes woke me at night, forcing me straight into the kinds of anxious thoughts that take on ferocious life in the early hours of morning. Even more distressing was the hard turn my memory took for the worse: I was forever blanking on something I said as soon as I’d said it, chronically groping for words or names — a development apparent enough that people close to me commented on it. I was haunted by a conversation I had with a writer I admired, someone who quit relatively young. At a small party, I asked her why. “Menopause,” she told me without hesitation. “I couldn’t think of the words.”

‘It suggests that we have a high cultural tolerance for women’s suffering. It’s not regarded as important.’

My friends’ reports of their recent doctors’ visits suggested that there was no obvious recourse for these symptoms. When one friend mentioned that she was waking once nightly because of hot flashes, her gynecologist waved it off as hardly worth discussing. A colleague of mine seeking relief from hot flashes was prescribed bee-pollen extract, which she dutifully took with no result. Another friend who expressed concerns about a lower libido and vaginal dryness could tell that her gynecologist was uncomfortable talking about both. (“I thought, hey, aren’t you a vagina doctor?” she told me. “I use that thing for sex!”)

Their doctors’ responses prompted me to contemplate a thought experiment, one that is not exactly original but is nevertheless striking. Imagine that some significant portion of the male population started regularly waking in the middle of the night drenched in sweat, a problem that endured for several years. Imagine that those men stumbled to work, exhausted, their morale low, frequently tearing off their jackets or hoodies during meetings and excusing themselves to gulp for air by a window. Imagine that many of them suddenly found sex to be painful, that they were newly prone to urinary-tract infections, with their penises becoming dry and irritable, even showing signs of what their doctors called “atrophy.” Imagine that many of their doctors had received little to no training on how to manage these symptoms — and when the subject arose, sometimes reassured their patients that this process was natural, as if that should be consolation enough.

Now imagine that there was a treatment for all these symptoms that doctors often overlooked. The scenario seems unlikely, and yet it’s a depressingly accurate picture of menopausal care for women. There is a treatment, hardly obscure, known as menopausal hormone therapy, that eases hot flashes and sleep disruption and possibly depression and aching joints. It decreases the risk of diabetes and protects against osteoporosis. It also helps prevent and treat menopausal genitourinary syndrome, a collection of symptoms, including urinary-tract infections and pain during sex, that affects nearly half of postmenopausal women.

A posed photograph of a middle-aged woman, cropped tightly to show her ear and part of her face, with drops of sweat visible on her face.
Credit…Marta Blue for The New York Times

Menopausal hormone therapy was once the most commonly prescribed treatment in the United States. In the late 1990s, some 15 million women a year were receiving a prescription for it. But in 2002, a single study, its design imperfect, found links between hormone therapy and elevated health risks for women of all ages. Panic set in; in one year, the number of prescriptions plummeted. Hormone therapy carries risks, to be sure, as do many medications that people take to relieve serious discomfort, but dozens of studies since 2002 have provided reassurance that for healthy women under 60 whose hot flashes are troubling them, the benefits of taking hormones outweigh the risks. The treatment’s reputation, however, has never fully recovered, and the consequences have been wide-reaching. It is painful to contemplate the sheer number of indignities unnecessarily endured over the past 20 years: the embarrassing flights to the bathroom, the loss of precious sleep, the promotions that seemed no longer in reach, the changing of all those drenched sheets in the early morning, the depression that fell like a dark curtain over so many women’s days.

About 85 percent of women experience menopausal symptoms. Rebecca Thurston, a professor of psychiatry at the University of Pittsburgh who studies menopause, believes that, in general, menopausal women have been underserved — an oversight that she considers one of the great blind spots of medicine. “It suggests that we have a high cultural tolerance for women’s suffering,” Thurston says. “It’s not regarded as important.”

Even hormone therapy, the single best option that is available to women, has a history that reflects the medical culture’s challenges in keeping up with science; it also represents a lost opportunity to improve women’s lives.

“Every woman has the right — indeed the duty — to counteract the chemical castration that befalls her during her middle years,” the gynecologist Robert Wilson wrote in 1966. The U.S. Food and Drug Administration approved the first hormone-therapy drug in 1942, but Wilson’s blockbuster book, “Feminine Forever,” can be considered a kind of historical landmark — the start of a vexed relationship for women and hormone therapy. The book was bold for its time, in that it recognized sexual pleasure as a priority for women. But it also displayed a frank contempt for aging women’s bodies and pitched hormones in the service of men’s desires: Women on hormones would be “more generous” sexually and “easier to live with.” They would even be less likely to cheat. Within a decade of the book’s publication, Premarin — a mix of estrogens derived from the urine of pregnant horses — was the fifth-most-prescribed drug in the United States. (Decades later, it was revealed that Wilson received funding from the pharmaceutical company that sold Premarin.)

Your Questions About Menopause, Answered

What are perimenopause and menopause? Perimenopause is the final years of a woman’s reproductive years that leads up to menopause, the end of a woman’s menstrual cycle. Menopause begins after a woman’s final menstrual period.

What are the symptoms of menopause? The symptoms of menopause can begin during perimenopause and continue for years. Among the most common are hot flashes, depression and anxiety, genital and urinary symptoms, brain fog, and skin and hair issues.

How can I find some relief from these symptoms? A low-dose birth control pill can control bleeding issues and ease night sweats during perimenopause. Avoiding alcohol and caffeine can reduce hot flashes, while cognitive behavioral therapy and meditation can make them more tolerable.

How long does perimenopause last? Perimenopause usually begins in a woman’s 40s and can last for four to eight years. The average age of menopause is 51, but for some it starts a few years before or later. The symptoms can last for a decade or more, and at least one symptom — vaginal dryness — may never get better.

What can I do about vaginal dryness? There are several things to try to help mitigate the discomfort: lubricants, to apply just before sexual intercourse; moisturizers, used about three times a week; and/or estrogen, which can plump the vaginal wall lining. Unfortunately, most women will not get 100 percent relief from these treatments.

What is primary ovarian insufficiency? The condition refers to when their ovaries stop functioning before the age of 40; it can affect women in their teens and 20s. In some cases the ovaries may intermittently “wake up” and ovulate, meaning that some women with primary ovarian insufficiency may still get pregnant.

In 1975, alarming research halted the rise of the drug’s popularity. Menopausal women who took estrogen had a significantly increased risk of endometrial cancer. Prescriptions dropped, but researchers soon realized that they could all but eliminate the increased risk by prescribing progesterone, a hormone that inhibits the growth of cells in the uterus lining. The number of women taking hormones started rising once again, and continued rising over the next two decades, especially as increasing numbers of doctors came to believe that estrogen protected women from cardiovascular disease. Women’s heart health was known to be superior to men’s until they hit menopause, at which point their risk for cardiovascular disease quickly skyrocketed to meet that of age-matched men. In 1991, an observational study of 48,000 postmenopausal nurses found that those who took hormones had a 50 percent lower risk of heart disease than those who did not. The same year, an advisory committee suggested to the F.D.A. that “virtually all” menopausal women might be candidates for hormone therapy. “When I started out, I had a slide that said estrogen should be in the water,” recalls Hadine Joffe, a psychiatry professor at Harvard Medical School who studies menopause and mood disorders. “We thought it was like fluoride.”

Feminist perspectives on hormone therapy varied. Some perceived it as a way for women to control their own bodies; others saw it as an unnecessary medicalization of a natural process, a superfluous product designed to keep women sexually available and conventionally attractive. For many, the issue lay with its safety: Hormone therapy had already been aggressively marketed to women in the 1960s without sufficient research, and many women’s health advocates believed that history was repeating itself. The research supporting its health benefits came from observational studies, which meant that the subjects were not randomly assigned to the drug or a placebo. That made it difficult to know if healthier women were choosing hormones or if hormones were making women healthier. Women’s health advocates, with the support of the feminist congresswoman Patricia Schroeder, called on the National Institutes of Health to run long-term, randomized, controlled trials to determine, once and for all, whether hormones improved women’s cardiovascular health.

In 1991, Bernadine Healy, the first woman to serve as director of the N.I.H., started the Women’s Health Initiative, which remains the largest randomized clinical trial in history to involve only women, studying health outcomes for 160,000 postmenopausal women, some of them over the course of 15 years. Costs for just one aspect of its research, the hormone trial, would eventually run to $260 million. The hormone trial was expected to last about eight years, but in June 2002, word started spreading that one arm of the trial — in which women were given a combination of estrogen and progestin, a synthetic form of progesterone — had been stopped prematurely. Nanette Santoro, a reproductive endocrinologist who had high hopes for hormones’ benefit on heart health, told me she was so anxious to know why the study was halted that she could barely sleep. “I kept waking my husband up in the middle of the night to say, ‘What do you think?’” she recalled. Alas, her husband, an optometrist, could scarcely illuminate the situation.

‘When I started out, I had a slide that said estrogen should be in the water. We thought it was like fluoride.’

Santoro did not have to wait long. On July 9, the Women’s Health Initiative’s steering committee organized a major news conference in the ballroom of the National Press Club in Washington to announce both the halting of the study and its findings, a week before the results would be publicly available for doctors to read and interpret. Jaques Rossouw, an epidemiologist who was the acting director of the W.H.I., told the gathered press that the study had found both adverse effects and benefits of hormone therapy, but that “the adverse effects outweigh and outnumber the benefits.” The trial, Rossouw said, did not find that taking hormones protected women from heart disease, as many had hoped; on the contrary, it found that hormone therapy carried a small but statistically significant increased risk of cardiac events, strokes and clots — as well as an increased risk of breast cancer. He described the increased risk of breast cancer as “very small,” or more precisely: “less than a tenth of 1 percent per year” for an individual woman.

What happened next was an exercise in poor communication that would have profound repercussions for decades to come. Over the next several weeks, researchers and news anchors presented the data in a way that caused panic. On the “Today” show, Ann Curry interviewed Sylvia Wassertheil-Smoller, an epidemiologist who was one of the chief investigators for the W.H.I. “What made it ethically impossible to continue the study?” Curry asked her. Wassertheil-Smoller responded, “Well, in the interest of safety, we found there was an excess risk of breast cancer.” Curry rattled off some startling numbers: “And to be very specific here, you actually found that heart disease, the risk increased by 29 percent. The risks of strokes increased by 41 percent. It doubled the risk of blood clots. Invasive breast cancer risk increased by 26 percent.”

All of those statistics were accurate, but for a lay audience, they were difficult to interpret and inevitably sounded more alarming than was appropriate. The increase in the risk of breast cancer, for example, could also be presented this way: A woman’s risk of having breast cancer between the ages of 50 and 60 is around 2.33 percent. Increasing that risk by 26 percent would mean elevating it to 2.94 percent. (Smoking, by contrast, increases cancer risk by 2,600 percent.) Another way to think about it is that for every 10,000 women who take hormones, an additional eight will develop breast cancer. Avrum Bluming, a co-author of the 2018 book “Estrogen Matters,” emphasized the importance of putting that risk and others in context. “There is a reported risk of pulmonary embolism among postmenopausal women taking estrogen,” Bluming says. “But what is ‘risk’? The risk of embolism is similar to the risk of being on oral contraceptives or being pregnant.”

The study itself was designed with what would come to be seen as a major flaw. W.H.I. researchers wanted to be able to measure health outcomes — how many women ended up having strokes, heart attacks or cancer — but those ailments may not show up until women are in their 70s or 80s. The study was scheduled to run for only 8½ years. So they weighted the participants toward women who were already 60 or older. That choice meant that women in their 50s, who tended to be healthier and have more menopausal symptoms, were underrepresented in the study. At the news conference, Rossouw started out by saying that the findings had “broad applicability,” emphasizing that the trial found no difference in risk by age. It would be years before researchers appreciated just how wrong that was.

A posed photograph of a middle-aged woman, cropped tightly to show part of her head and face, with her eyes closed and her hands cradling her forehead.
Credit…Marta Blue for The New York Times

The “Today” segment was just one of several media moments that triggered an onslaught of panicked phone calls from women to their doctors. Mary Jane Minkin, a practicing OB-GYN and a clinical professor at Yale School of Medicine, told me she was apoplectic with frustration; she couldn’t reassure her patients, if reassurance was even in order (she came to think it was), because the findings were not yet publicly available. “I remember where I was when John Kennedy was shot,” Minkin says. “I remember where I was on 9/11. And I remember where I was when the W.H.I. findings came out. I got more calls that day than I’ve ever gotten before or since in my life.” She believes she spoke to at least 50 patients on the day of the “Today” interview, but she also knows that countless other patients did not bother to call, simply quitting their hormone therapy overnight.

Within six months, insurance claims for hormone therapy had dropped by 30 percent, and by 2009, they were down by more than 70 percent. JoAnn Manson, chief of the division of preventive medicine at Brigham and Women’s Hospital and one of the chief investigators in the study, described the fallout as “the most dramatic sea change in clinical medicine that I have ever seen.” Newsweek characterized the response as “near panic.” The message that took hold then, and has persisted ever since, was a warped understanding of the research that became a cudgel of a warning: Hormone therapy is dangerous for women.

The full picture of hormone therapy is now known to be far more nuanced and reassuring. When patients tell Stephanie Faubion, the director of the Mayo Clinic Center for Women’s Health, that they’ve heard that hormones are dangerous, she has a fairly consistent response. “I sigh,” Faubion told me. She knows she has some serious clarifying to do.

Faubion, who is also the medical director of the North American Menopause Society (NAMS), an association of menopause specialists, says the first question patients usually ask her is about breast-cancer risk. She explains that in the W.H.I. trial, women who were given a combination of estrogen and progestin saw an increased risk emerge only after five years on hormones — and even after 20 years, the mortality rate of women who took those hormones was no higher than that of the control group. (Some researchers have hope that new formulations of hormone therapy will lessen the risk of breast cancer. One major observational study published last year suggested so, but that research is not conclusive.)

The biggest takeaway from the last two decades of research is that age matters: For women who go through early menopause, before age 45, hormone therapy is recommended because they’re at greater risk for osteoporosis if they don’t receive hormones up until the typical age of menopause. For healthy women in their 50s, life-threatening events like clots or stroke are rare, and so the increased risks from hormone therapy are also quite low. When Manson, along with Rossouw, did a reanalysis of the W.H.I. findings, she found that women under 60 in the trial had no elevated risk of heart disease.

‘I remember where I was when John Kennedy was shot. I remember where I was on 9/11. And I remember where I was when the W.H.I. findings came out.’

The findings, however, did reveal greater risks for women who start hormone therapy after age 60. Manson’s analyses found that women had a small elevated risk of coronary heart disease if they started taking hormones after age 60 and a significant elevated risk if they started after age 70. It was possible, researchers have hypothesized, that hormones may be most effective within a certain window, perpetuating the well-being of systems that are still healthy but accelerating damage in those already in decline. (No research has yet followed women who start in their 50s and stay on continuously into their 60s.)

Researchers also now have a better appreciation of the benefits of hormone therapy. Even at the time that the W.H.I. findings were released, the data showed at least one clear improvement resulting from hormone therapy: Women had 24 percent fewer fractures. Since then, other positive results have emerged. The incidence of diabetes, for instance, was found to be 20 percent lower in women who took hormones, compared with those who took a placebo. In the W.H.I. trial, women who had hysterectomies — 30 percent of American women by age 60 — were given estrogen alone because they did not need progesterone to protect them from endometrial cancer, and that group had lower rates of breast cancer than the placebo group. “Nonetheless,” Bluming and his co-author, Carol Tavris, write in “Estrogen Matters,” “we have yet to see an N.I.H. press conference convened to reassure women of the benefits of estrogen.” Anything short of that, they argue, allows misrepresentations and fears to persist.

Positive reports about hormone therapy for women in their 50s started emerging as early as 2003, and they have never really slowed. But the revelations have come in a trickle, with no one story gaining the kind of exposure or momentum of the W.H.I. news conference. In 2016, Manson tried to rectify the problem in an article for The New England Journal of Medicine, issuing a clear course correction of the W.H.I. findings as they pertained to women in their 40s and 50s. Since she published that paper, she feels, attitudes have changed, but too slowly. Manson frequently speaks to the press, and as the years passed — and more data accumulated that suggested the risks were not as alarming as they were first presented — you can almost track her increasing frustration in her public comments. “Women who would be appropriate candidates are being denied hormone therapy for the treatment of their symptoms,” she told me in a recent interview. She was dismayed that some doctors were not offering relief to women in their 50s on the basis of a study whose average subject age was 63 — and in which the risk assessments were largely driven by women in their 70s. “We’re talking about literally tens of thousands of clinicians who are reluctant to prescribe hormones.”

Even with new information, doctors still find themselves in a difficult position. If they rely on the W.H.I., they have the benefit of a gold-standard trial, but one that focused on mostly older women and relied on higher doses and different formulations of hormones from those most often prescribed today. New formulations more closely mimic the natural hormones in a woman’s body. There are also new methods of delivery: Taking hormones via transdermal patch, rather than a pill, allows the medication to bypass the liver, which seems to eliminate the risk of clots. But the studies supporting the safety of newer options are observational; they have not been studied in long-term, randomized, controlled trials.

The NAMS guidelines emphasize that doctors should make hormone-therapy recommendations based on the personal health history and risk factors of each patient. Many women under 60, or within 10 years of menopause, already have increased baseline risks for chronic disease, because they are already trying to manage their obesity, hypertension, diabetes or high cholesterol. Even so, Faubion says that “there are few women who have absolute contraindications,” meaning that for them, hormones would be off the table. At highest risk from hormone use are women who have already had a heart attack, breast cancer or a stroke or a blood clot, or women with a cluster of significant health problems. “For everyone else,” Faubion says, “the decision has to do with the severity of symptoms as well as personal preferences and level of risk tolerance.”

For high-risk women, other sources of relief exist: The selective serotonin reuptake inhibitor paroxetine is approved for the relief of hot flashes, although it is not as effective as hormone therapy. Cognitive-behavioral therapy has also been shown to help women with how much hot flashes bother them. Doctors who treat menopause are waiting for the F.D.A.’s review of a drug up for approval this month: a nonhormonal drug that would target the complex of neurons thought to be involved in triggering hot flashes.

Conversations about the risks and benefits of these various treatments often require more time than the usual 15-minute slot that health insurance will typically reimburse for a routine medical visit. “If I weren’t my own chair, I would be called to task for not doing stuff that would make more money, like delivering babies and I.V.F.,” says Santoro, now the department chair of obstetrics and gynecology at the University of Colorado School of Medicine, who frequently takes on complex cases of menopausal women. “Family medicine generally doesn’t want to deal with this, because who wants to have a 45-minute-long conversation with somebody about the risks and benefits of hormone therapy? Because it’s nuanced and complicated.” Some of those conversations entail explaining that hormones are not a cure-all. “When women come in and tell me they’re taking hormones for anti-aging or general prevention, or because they have some vague sense it’ll return them to their premenopausal self — and they’re not even having hot flashes — I say, ‘Hormone therapy is not a fountain of youth and shouldn’t be used for that purpose,’” Faubion says.

Too many doctors are not equipped to parse these intricate pros and cons, even if they wanted to. Medical schools, in response to the W.H.I., were quick to abandon menopausal education. “There was no treatment considered safe and effective, so they decided there was nothing to teach,” says Minkin, the Yale OB-GYN. About half of all practicing gynecologists are under 50, which means that they started their residencies after the publication of the W.H.I. trial and might never have received meaningful education about menopause. “When my younger partners see patients with menopausal symptoms, they refer them to me,” says Audrey Buxbaum, a 60-year-old gynecologist with a practice in New York. Buxbaum, like many doctors over 50, prescribed menopausal hormone therapy before the W.H.I. and never stopped.

A posed photograph of a middle-aged woman, cropped tightly to show her neck and part of her face, with her hands kneading the back of her neck.
Credit…Marta Blue for The New York Times

Education on a stage of life that affects half the world’s population is still wildly overlooked at medical schools. A 2017 survey sent to residents across the country found that 20 percent of them had not heard a single lecture on the subject of menopause, and a third of the respondents said they would not prescribe hormone therapy to a symptomatic woman, even if she had no clear medical conditions that would elevate the risk of doing so. “I was quizzing my daughter a few years ago when she was studying for the board exams, and whoever writes the board questions, the answer is never, ‘Give them hormones,’” Santoro says. In recent years, there has been some progress: The University of Pennsylvania has established a menopause clinic, and Johns Hopkins now offers a two-year curriculum on the subject to its medical students. But the field of gynecology will, most likely for decades to come, be populated by many doctors who left medical school unprepared to offer guidance to menopausal women who need their help.

I didn’t know all of this when I went to see my gynecologist. I knew only what my friends had told me, and that hormone therapy was an option. The meeting was only my second with this gynecologist, a woman who struck me as chic, professional and in a bit of a hurry, which was to be expected, as she is part of a large health care group — the kind that makes you think you’d rather die from whatever’s ailing you than try to navigate its phone tree one more time. Something about the quick pace of the meeting — the not-so-frequent eye contact — made me hesitate before bringing up my concerns: They felt whiny, even inappropriate. But I forged on. I was having hot flashes, I told her — not constantly, but enough that it was bothering me. I had other concerns, but since memory issues were troubling me the most, I brought that up next. “But that could also just be normal aging,” she said. She paused and fixed a doubtful gaze in my direction. “We only prescribe hormones for significant symptoms,” she told me. I felt rebuffed, startled by how quickly the conversation seemed to have ended, and I was second-guessing myself. Were my symptoms, after all, “significant”? By whose definition?

The NAMS guidelines suggest that the benefits of hormone therapy outweigh the risks for women under 60 who have “bothersome” hot flashes and no contraindications. When I left my doctor’s office (without a prescription), I spent a lot of time thinking about whether my symptoms were troubling me enough to take on any additional risk, no matter how small. On the one hand, I was at a healthy weight and active, at relatively low risk for cardiovascular disease; on the other hand, because of family history and other factors, I was at higher risk for breast cancer than many of my same-age peers. I felt caught between the promises and, yes, risks of hormone therapy, the remaining gaps in our knowledge and my own aversion, common if illogical, to embarking on a new and indefinitely lasting medical regimen.

‘Menopause has the worst P.R. campaign in the history of the universe, because it’s not just hot flashes and night sweats.’

Menopause could represent a time when women feel maximum control of our bodies, free at last from the risk of being forced to carry an unwanted pregnancy. And yet for many women, menopause becomes a new struggle to control our bodies, not because of legislation or religion but because of a lack of knowledge on our part, and also on the part of our doctors. Menopause presents not just a new stage of life but also a state of confusion. At a time when we have the right to feel seasoned, women are thrust into the role of newbie, or worse, medical detective, in charge of solving our own problems.

Even the most resourceful women I know, the kind of people you call when you desperately need something done fast and well, described themselves as “baffled” by this stage of their lives. A recent national poll found that 35 percent of menopausal women reported that they had experienced four or more symptoms, but only 44 percent said they had discussed their symptoms with a doctor. Women often feel awkward initiating those conversations, and they may not even identify their symptoms as menopausal. “Menopause has the worst P.R. campaign in the history of the universe, because it’s not just hot flashes and night sweats,” says Rachel Rubin, a sexual-health expert and assistant clinical professor in urology at Georgetown University. “How many times do I get a 56-year-old woman who comes to me, who says, Oh, yeah, I don’t have hot flashes and night sweats, but I have depression and osteoporosis and low libido and pain with sex? These can all be menopausal symptoms.” In an ideal world, Rubin says, more gynecologists, internists and urologists would run through a list of hormonal symptoms with their middle-aged patients rather than waiting to see if those women have the knowledge and wherewithal to bring them up on their own.

The W.H.I. trial measured the most severe, life-threatening outcomes: breast cancer, heart disease, stroke and clots, among others. But for a woman who is steadily losing hair, who has joint pain, who suddenly realizes her very smell has changed (and not for the better) or who is depressed or exhausted — for many of those women, the net benefits of taking hormones, of experiencing an improved quality of life day to day, may be worth facing down whatever incremental risks hormone therapy entails, even after age 60. Even for women like me, whose symptoms are not as drastic but whose risks are low, hormones can make sense. “I’m not saying every woman needs hormones,” Rubin says, “but I’m a big believer in your body, your choice.”

Conversations about menopause lack, among so many other things, the language to help us make these choices. Some women sail blissfully into motherhood, but there is a term for the extreme anxiety and depression that other women endure following delivery: postpartum depression. Some women menstruate every month without major upheaval; others experience mood changes that disrupt their daily functioning, suffering what we call premenstrual syndrome (PMS), or in more serious cases, premenstrual dysphoric disorder. A significant portion of women suffer no symptoms whatsoever as they sail into menopause. Others suffer near-systemic breakdowns, with brain fog, recurring hot flashes and exhaustion. Others feel different enough to know they don’t like what they feel, but they are hardly incapacitated. Menopause — that baggy term — is too big, too overdetermined, generating a confusion that makes it especially hard to talk about.

No symptom is more closely associated with menopause than the hot flash, a phenomenon that’s often reduced to a comedic trope — the middle-aged woman furiously waving a fan at her face and throwing ice cubes down her shirt. Seventy to 80 percent of women have hot flashes, yet they are nearly as mysterious to researchers as they are to the women experiencing them — a reflection of just how much we still have to learn about the biology of menopause. Scientists are now trying to figure out whether hot flashes are merely a symptom or whether they trigger other changes in the body.

Strangely, the searing heat a woman feels roaring within is not reflected in any significant rise in her core body temperature. Hot flashes originate in the hypothalamus, an area of the brain rich in estrogen receptors that is both crucial in the reproductive cycle and also functions as a thermostat. Deprived of estrogen, its thermostat now wonky, the hypothalamus is more likely to misread small increases in core body temperature as too hot, triggering a rush of sweat and widespread dilation of the blood vessels in an attempt to cool the body. This also drives up the temperature on the skin. Some women experience these misfirings once a day, others 10 or more, with each one lasting anywhere from seconds to five minutes. On average, women experience them for seven to 10 years.

What hot flashes might mean for a woman’s health is one of the main questions that Rebecca Thurston, the director of the Women’s Biobehavioral Health Laboratory at the University of Pittsburgh, has been trying to answer. Thurston helped lead a study that followed a diverse cohort of 3,000 women over 22 years and found that about 25 percent of them were what she called superflashers: Their hot flashes started long before their periods became irregular, and the women continued to experience them for as many as 14 years, upending the idea that, for most women, hot flashes are an irritating but short-lived inconvenience. Of the five racial and ethnic groups Thurston studied, Black women were found to experience the most hot flashes, to experience them as the most bothersome and to endure them the longest. In addition to race, low socioeconomic status was associated with the duration of women’s hot flashes, suggesting that the conditions of life, even years later, can affect a body’s management of menopause. Women who experienced childhood abuse were 70 percent more likely to report night sweats and hot flashes.

Might those symptoms also signal harm beyond the impact on a woman’s quality of life? In 2016, Thurston published a study in the journal Stroke showing that women who had more hot flashes — at least four a day — tended to have more signs of cardiovascular disease. The link was even stronger than the association between cardiovascular risk and obesity, or cardiovascular risk and high blood pressure. “We don’t know if it’s causal,” Thurston cautions, “or in which direction. We need more research.” There might even be some women for whom the hot flashes do accelerate physical harm and others not, Thurston told me. At a minimum, she says, reports of severe and frequent hot flashes should cue doctors to look more closely at a woman’s cardiac health.

As Thurston was trying to determine the effects of hot flashes on vascular health, Pauline Maki, a professor of psychiatry at the University of Illinois at Chicago, was establishing associations between hot flashes and mild cognitive changes during menopause. Maki had already found a clear correlation between the number of a woman’s hot flashes and her memory performance. Maki and Thurston wondered if they would be able to detect some physical representation of that association in the brain. They embarked on research, published last October, that found a strong correlation between the number of hot flashes a woman has during sleep and signs of damage to the tiny vessels of the brain. At a lab in Pittsburgh, which has one the most powerful M.R.I. machines in the world, Thurston showed me an image of a brain with tiny lesions represented as white dots, ghostlike absences on the scan. Both their number and placement, she said, were different in women with high numbers of hot flashes. But whether the hot flashes were causing the damage or the changes in the cerebral vessels were causing the hot flashes, she could not say.

About 20 percent of women experience cognitive decline during perimenopause and in the first years after menopause, mostly in the realm of verbal learning, the acquisition and synthesis of new information. But the mechanisms of that decline are varied. As estrogen levels drop, the region of the brain associated with verbal learning is thought to recruit others to support its functioning. It’s possible that this period of transition, when the brain is forming new pathways, accounts for the cognitive dip that some women experience. For most of them, it’s short-lived, a temporary neurological confusion. A woman’s gray matter — the cells that process information — also seems to shrink in volume before stabilizing in most women, according to Lisa Mosconi, an associate professor of neurology at Weill Cornell Medicine and director of its Women’s Brain Initiative. She compares the process the brain undergoes during those years of transition to a kind of “remodeling.” But the tiny brain lesions that Thurston and Maki detected don’t resolve — they remain, contributing incrementally, over many years, to an increased risk of cognitive decline and dementia.

In the past 15 years, four randomized, controlled trials found that taking estrogen had no effect on cognitive performance. But those four studies, Maki points out, did not look specifically at women with moderate to severe hot flashes. She believes that might be the key factor: Treat the hot flashes with estrogen, Maki theorizes, and researchers might see an improvement in cognitive health. In one small trial Maki conducted of about 36 women, all of whom had moderate to severe hot flashes, half of the group received a kind of anesthesia procedure that reduced their hot flashes, and the other half received a placebo treatment. She measured the cognitive function of both groups before the treatment and then three months after and found that as hot flashes improved, memory improved. The trial was small but “hypothesis generating,” she says.

Even adjusting for greater longevity in women, Alzheimer’s disease is more frequent in women than men, one of many brain-health discrepancies that have led researchers to wonder about the role that estrogen — and possibly hormone therapy — might play in the pathways of cognitive decline. But the research on hormone therapy and Alzheimer’s disease has proved inconclusive so far.

Whatever research exists on hormones and the brain focuses on postmenopausal women, which means it’s impossible to know, for now, whether perimenopausal women could conceivably benefit from taking estrogen and progesterone during the temporary dip in their cognitive function. “There hasn’t been a single randomized trial of hormone therapy for women in perimenopause,” Maki says. “Egregious, right?”

What’s also unclear, Thurston says, is how the various phenomena of cognitive change during menopause — the temporary setbacks that resolve, the progress toward Alzheimer’s in women with high genetic risk and the onset of those markers of small-vessel brain disease — interact or reflect on one another. “We haven’t followed women long enough to know,” says Thurston, who believes that menopause care begins and ends with one crucial dictum: “We need more research.”

A posed photograph of a middle-aged woman, cropped tightly to show her neck and part of her torso, with her hands in sharp focus in front of her chest and her fingers winding together.
Credit…Marta Blue for The New York Times

In the information void, a vast menopausal-wellness industry has developed, flush with products that Faubion dismisses as mostly “lotions and potions.” But a new crop of companies has also come to market to provide F.D.A.-approved treatments, including hormone therapy. Midi Health offers virtual face-to-face access to menopause-trained doctors and nurse practitioners who can prescribe hormones that some insurances will cover; other sites, like Evernow and Alloy, sell prescriptions directly to the patient. (Maki serves on the medical advisory boards of both Midi and Alloy.)

On the Alloy website, a woman answers a series of questions about her symptoms, family and medical history, and the company’s algorithm recommends a prescription (or doesn’t). A prescribing doctor reviews the case and answers questions by text or phone, and if the woman decides to complete the order, she has access to that prescribing doctor by text for as long as the prescription is active.

Alloy holds online support groups where women, clearly of varying socioeconomic backgrounds, often vent — about how hard it was for them to find relief, how much they are still suffering or how traumatized they still are by the lack of compassion and concern they encountered when seeking help for distressing symptoms. On one call in July, a middle-aged woman described severe vaginal dryness. “When I was walking or trying just to exercise, I would be in such agony,” she said. “It’s painful just to move.” She was trying to buy vaginal estradiol cream, an extremely low-risk treatment for genitourinary syndrome; she said there was a shortage of it in her small town. Until she stumbled on Alloy, she’d been relying on antibacterial creams to soothe the pain she felt.

The space was clearly a no-judgment zone, a place where women could talk about how they personally felt about the risks and benefits of taking hormones. At one meeting, a woman said that she’d been on hormone therapy, which she said “changed my life” during perimenopause, but that she and her sisters both had worrying mammograms at the same time. Her sister was diagnosed with breast cancer and had her lymph nodes removed; the woman on the call was diagnosed with atypical hyperplasia, which is not cancer but is considered a precursor that puts a woman at high risk. The NAMS guidelines do not indicate that hormone therapy is contraindicated for a woman at high risk of breast cancer, leaving it up to the woman and her practitioner to decide. “My new OB-GYN and my cancer doc won’t put me on hormones,” the woman said. She bought them from Alloy instead. “So I’m kind of under the radar.”

No one at the meeting questioned the woman’s decision to go against the advice of two doctors. I mentioned the case to Faubion. “It sounds to me like she felt she wasn’t being heard by her doctors and had to go somewhere else,” she said. Faubion told me that in certain circumstances, higher-risk women who are fully informed of the risks but suffer terrible symptoms might reasonably make the decision to opt for hormones. But, she said, those decisions require nuanced, thoughtful conversations with health care professionals, and she wondered whether Alloy and other online providers were set up to allow for them. Anne Fulenwider, one of Alloy’s founders, said the patient in the support group had not disclosed her full medical history when seeking a prescription. After that came to light, an Alloy doctor reached out to her to have a more informed follow-up conversation about the risks and benefits of hormone therapy.

As I weighed my own options, I sometimes asked the doctors I interviewed outright for their advice. For women in perimenopause, who are still at risk of pregnancy, I learned, a low-dose birth control can “even things out,” suppressing key parts of the reproductive system and supplying a steadier dose of hormones. Another alternative is an intrauterine device (IUD) to provide birth control, along with a low-dose estrogen patch, which is less potent than even a low-dose birth-control pill and is therefore thought to be safer. “Too much equipment,” I told Rachel Rubin, the sexual-health expert, when she suggested it. “This is why I don’t ski.” I found myself thinking often about an insight that Santoro says she offers her patients (especially those under 60 and in good health): If you’re having any symptoms, how can you weigh the risks and benefits if you haven’t experienced the extent of the benefits?

In November, I started on a low-dose birth-control pill. I am convinced — and those close to me are convinced — that my brain is more glitch-free. I have no hot flashes. Most surprising to me (and perhaps the main reason for that improvement in cognition): My sleep improved. I had not even mentioned my poor quality of sleep to my gynecologist, given the length of our discussion, but I had also assumed that it was a result of stress, age and a sweet but snoring husband. Only once I took the hormones did I appreciate that my regular 2 a.m. wakings, too, were most likely a symptom of perimenopause. The pill was an easy-enough experiment, but it carried a potentially higher risk of clots than the IUD and patch; now convinced that the effort of an IUD is worth it, I resolved to make that switch as soon as I could get an appointment.

How many women are doing some version of what I did, unsure of or explaining away menopausal symptoms, apologizing for complaining about discomforts they’re not sure are “significant,” quietly allowing the conversation to move on when they meet with their gynecologists or internists or family-care doctors? And yet … my more smoothly functioning brain goes round and round, wondering, worrying, waiting for more high-quality research. Maybe in the next decade, when my personal risks start escalating, we’ll know more; all I can hope is that it confirms the current trend toward research that reassures. The science is continuing. We wait for progress, and hope it is as inevitable as aging itself.

Marta Blue is a visual artist based in Milan. She is the recipient of a LensCulture Emerging Talent Award and has exhibited her work at Art Basel and Photofairs Shanghai.

Susan Dominus is a staff writer for The New York Times Magazine. In 2018, she was part of a team that reported on workplace sexual harassment issues and won a Pulitzer Prize for public service.