I pit the New York Times, specifically their science reporting

The BBQ Pit
1

So, the big medical/science news yesterday was that the FDA plans to remove the “black box warning” on estrogen products designed for hormone replacement therapy in menopausal women. This is a topic i happen to know a lot about, because i spent an enormous amount of time researching it when i entered menopause and was debating taking estrogen. (Spoiler alert: i decided to do it, and I’m still wearing an estrogen patch.)

Some details about the issues and the research

The back story is that doctors have long observed that women have lower cardio-pulmonary rush than men until they enter menopause, when the risks become about the same. So they speculated that estrogen was protective, and ran a big study where they gave estrogen to older women with heart disease to see if it helped. (Actually, it was a huge study and probably didn’t just include women with pre-existing heart disease, i forget, i did this research five years ago.) Anyway, not only did it not help, it actually increased the risks of blood clots and strokes, as well as the risk of breast cancer. The study was halted early, and the black box label was created.

But here’s the thing: Hormone replacement therapy isn’t usually prescribed to women in their sixties and seventies (the average age of women in the study was 63), it’s usually prescribed around the time a woman enters menopause, which is typically around 50.

There were several good observational studies that had previously shown that women who took estrogen starting around menopause did well, and the estrogen was protective of overall health. And after the dust settled, it turned out that the data from that very study, a large, randomized, prospective study, found that when you stratified by age and years since onset of menopause younger women closer to menopause had a net health gain from HRT and older women had significant risks. It’s complicated, and estrogen increases the risk of breast cancer at all ages, but for younger women the total mortality of women taking estrogen was lower than for those not taking estrogen.

And there have been a lot of advances since that study was conducted. Women in that study took a funky version of estrogen purified from the urine of pregnant mares, and took it orally. Today most estrogen medications are estradiol, the version most prevalent in the blood stream, and it can be delivered via a patch or other routes that don’t get processed by the liver. This appears to mostly eliminate the risk of blood clots, as compared to oral premarin. And some estrogen products, like vaginal creams, are basically just topical, and have very little systemic impact. But they, too, carry a big scary warning.

And i left out some important stuff about progesterone and uterine cancer that you ought to understand if you are considering hormone replacement therapy, but it’s not really relevant to this announcement.

Anyway, based on modern understanding of the risks and benefits of hormone replacement therapy, women at high risk of breast cancer, and with certain other conditions, shouldn’t take it. And women who are over 60 and more than ten years past menopause shouldn’t start taking it systemically. Younger women with menopausal symptoms who aren’t at high risk of breast cancer generally can take it safely. And even older women suffering from vaginal dryness or urinary incontinence can probably use a topical estrogen product. Whether the overall risk is enough to justify a black box warning is a judgement call. But here are four articles about the FDA announcement:

https://www.wsj.com/health/healthcare/fda-calls-for-removal-of-hormone-replacement-therapy-warnings-1a2552b2?st=AD8BXw&reflink=desktopwebshare_permalink

FDA to lift warnings on menopause hormone therapy, potentially boosting access

https://www.washingtonpost.com/health/2025/11/10/hormone-replacement-therapy-menopause-warning-lift/

6 questions to ask about hormone therapy for menopause 6 questions to ask about hormone therapy for menopause : NPR

The NYT article opens by citing the big study that found estrogen use to be risky. Then it cited a single doctor, with the language “Dr. Makary, long a champion of the treatment, asserted”. All the arguments in favor of dropping the warning are attributed to him, and it also warns “Critics opposed to removing the warning, the strongest kind the F.D.A. issues, had urged Dr. Makary to convene a scientific advisory panel to carry out a careful assessment of the evidence before making any changes to the label.” It sounds like he’s some maverick ignoring medical evidence.

The other three are much more balanced. The WSJ one is shortest, also citing Dr. Makary, but adding "Makary cited several studies that showed some health benefits associated with the drugs, including reducing the risk of heart disease and slowing cognitive decline. "

The WaPo article is long and detailed, giving a lot of background, citing multiple doctors and referencing various studies, and also explains the politics of the decision and why it is controversial. They may have lost a large fraction of their their journalists, but they still have some excellent science journalists on staff.

The NPR article (there was a slightly different version over the air, but it’s in the middle of a longer news hour, and this seemed more accessible to a message board) mentions the FDA change, and then launches into a pretty good discussion of the risks and benefits of hormone replacement therapy, and the alternatives.

So, IMHO, the NYT article stands alone as being misleading and fear-mongering. And this isn’t a unique occurrence. I can’t imagine i can find it now, but during the covid pandemic, they published a graph showing a huge spike in risk for people aged ~30. But… The risk they were showing was something like the % increase in mortality. And people that age have a very low overall mortality, so the fact that their risk of death had increased (on as percentage basis) more than for people of other ages was basically meaningless. Someone took all the data (and i believe that the data was accurate) and massaged it every which way until they were able to produce a graph that looked like it said something scary about young adults. Damn it, there were plenty of real things to be scared of about covid, we didn’t need fake stuff muddying the waters.

And they frequently start graphs above zero so as to exaggerate the visual impact of a small change. (At least, when i objected to doing that at work, my boss described it as “the NYT style”, as he advocate for doing it.)

And they rarely actually link to studies, making it harder to track down the original. And I’ve seen them conflate correlation with causation too often.

Anyway, i distrust New York Times science reporting, and recommend that you do so, too.

2

This is extremely common. I’d estimate 80% or more of graphs in media do this as opposed to doing it correctly.

3

Disclaimer: hormone replacement therapy is outside my area of expertise and familiarity.

That said, the NYT article seems straightforward and sober in tone to me, including links to a menopause working group’s advisories that support the FDA’s decision..

The article could have said more about Marty Makary’s previously established record as a medical gadfly, including his embrace of “a more fluid concept of evidence” and earlier pronouncements that Covid-19 would be mostly gone in the U.S. by April 2021, that the Omicron variant was “Nature’s vaccine” and making misleading claims about medical error being a top cause of death.

For a non-cheerleading article that quotes critics of the idea that HRT needs to be used lots more (including to prevent divorce!), try this one.

These days I would be skeptical about anything promoted by RFK Jr. and Makary as “gold standard science” and suggest that one’s physician’s advice and checking the research, especially systematic literature reviews/meta-analyses (the PubMed database offers free searches) is a much better way to go than relying on popular mass media.

4

The Mother Jones article is very good, thanks for the link. I knew Makary was squirrelly, but didn’t realize the extent of it.

I’m going to say that the FDA ought to be revisiting the warning using the usual procedure, not a directive from on high, and also, that the current black box warning is almost certainly excessive. And that despite the poor FDA methodology, the NYT article remains weirdly biased. Moreso than the Mother Jones article, despite that often being a biased news source, and despite it taking a much harder take on Makary.

We have so much to legitimately be alarmed at. This isn’t one of the things we should panic about.

5

My wife and I recently canceled our subscription after decades because of the NYT’s rapid descent into clickbaiting. My wife was particularly incensed by David French’s Oct. 23 editorial, “How Women Destroyed the West.” (Sorry, it’s paywalled and I can no longer provide a gift link.)

Oh, and a few days ago, Ross Douthat wrote an opinion piece called “Did Liberal Feminism Ruin the Workplace?”

6

I’ve never read the NYT on a regular basis, nor subscribed, so I have no background. Therefore I have this question, the answer to which is emotionally neutral to me:

Do folks think this NYT behavior is a shift driven by considerations of profit, or a shift driven by considerations of politics, or some of both, or not a shift at all, or a shift driven by something else? (Maybe I should make a poll, but I’ll be surprised if there are enough answers to make it worthwhile.)

7

I’ve never regularly read the paper. I observed this shortly after i first subscribed, which was the first time finals Trump was elected. I decided one of the few things i could do was to support journalism, so i subscribed to a while bunch of papers, both free and paid. I was really disappointed by the NYT, which felt like it often had a political bias in the news reporting. I mean, everyone does, but it felt stronger than in other news sources i followed.

So, as best as i can tell, it’s not a recent change.

My mother complained that it used to be “the paper of record”, where, for instance, you could find the full text of a political address. I get why they don’t do that anymore – who looks at a paper newspaper for that when they can watch the complete speech on YouTube? But she felt like they’d lost their North Star, and had declined in quality.

8

The announcement was carried live on CNN, and rerun at least once.

From my own vantage point, nobody really reads those black box warnings. Even pharmacists don’t do that. We know which drugs are REALLY dangerous (thalidomide, isotretinoin, that kind of thing) and no, your local pharmacy isn’t going to have the black-box drug list posted anywhere, that I’m aware of.

9

Well, the reaction here on the dope seems to have been, “shit, we can’t use these”

HRT plunged when that study first ended and the warning was created. Even though the dangers for women who start taking it around the onset of menopause are generally modest. (And generally offset by benefits.)

10

Yeah, I saw reposts of those articles, amoung others. I am glad I let my subscription lapse a couple years ago.

11

Anecdote: I sure do, as does everyone in my family, precisely because they are sometimes skipped or overlooked by prescribers.

12

My first job after graduating in 1994 was in a mail-order facility, after working there as a technician during my last year of college. I could identify Premarin 0.625 #90 just by the way the vial felt, and the 1.25mg #90 as well, because we dispensed so many of them.

Then word got out what Premarin really was, and a lot of women stopped taking it.

13

I don’t think it was because it came from horse piss, i think it was because of that study.

Also, i don’t think anyone takes premarin any more, because estradiol is now cheap and widely available. (Some preparations are expensive, but the underlying drug is cheap, as are oral tablets of it.)

14

A couple of years ago I did a presentation for my kid’s middle school class about ways people lie with charts and statistics (including that old classic that you point out, @puzzlegal, of starting plots at non-zero places to exaggerate the effect), thinking about bias, that kind of thing. As part of my prep for the presentation I followed various big news stories in the WSJ and the NYT for a couple of weeks. I definitely noticed that the WSJ was more cautious (the NYT would be like “BIG STORY!” and the WSJ would be like, “There is an alleged BIG STORY but we haven’t confirmed yet,” and not really go all “BIG STORY” until they’d confirmed it) and the NYT also tended to have more sensational clickbait takes on things. So yeah.

I have Makary’s book but haven’t read it yet – I know there’s a chapter in there on HRT and I’ll have to see what it says. I bought it before he became the FDA commissioner – I got it based on reading the first chapter on peanuts, which I did think had some very good points, given that I had two kids whose early years spanned the whole “peanuts are bad” → “peanuts are good” evolution. I’m sorry to hear he might have tipped over into the crank category, though I think the message of “one should read the studies to figure out what’s actually going on” is a good one.

15

The more cautious approach of the WSJ noted, overall, compared to other major venues, are they much worse?

Science reporting is often … breathless, ISTM. I’ve read some reasonable science article in the NYT too. But maybe I just didn’t know enough about the subject to realize that it wasn’t?

16

Huh, i didn’t know he wrote about peanuts. I feel a little smug about that one. I was pretty certain the whole “must avoid feeding new foods to children” thing was misguided, and gave my kids tastes of everything we ate pretty much as soon as they were weaned. (Except sweets. We held off on chocolate and candy and soda until they were a little older.) But we just took bits of our meals and mashed it with the back of a fork or cut it up fine to make it edible without teeth. So our kids had peanut butter from a very young age. And i watched the peanut research as it evolved, because i suspected it was better to start eating allergens early and was excited to see my intuition proven by careful research.

Now I’m curious about this guy.

17

Makary has an odd view of “nuanced discussions” and “robust review” of the evidence.

For an actual nuanced view (which praises the FDA decision but emphasizes the need to discuss risks and benefits with individual patients, there’s reaction from the American College of Obstetricians and Gynecologists (ACOG).