TODAY'S AJENDA #83

“Most protein powders and shakes have more lead in one serving than our experts say is safe to have in one day.” 

Last week, Consumer Reports’ findings on heavy metals made headlines. If I were still at Good Morning America, this is exactly the kind of story I’d have covered. 

While I’m no longer on GMA, I can tell you here that the presence of heavy metals in our supplement supply isn’t new. But America’s obsession with protein is. Ready for my dose of honesty? 

The Real Story on Heavy Metals 

There’s this idea that heavy metals are a surprise intruder in our pristine food supply. The reality is they’re everywhere: in our soil, water, food, and yes, supplements. 

Just like microplastics (a story for another day), they’re nearly impossible to avoid. 

And while the word “toxic” gets used a lot, it's nuanced. A 2021 study testing 370 fruit and vegetable samples found that beetroot, celery, and frozen raspberries had high lead levels. 

Does this mean you should cut them from your diet forever? 

No. It means aiming for smarter exposure, not zero exposure (since that isn’t realistic). And what’s safe depends on the person, dose, and type of metal. Let’s go over the big three: 

1) Lead 

After menopause, bone turnover accelerates. Lead stored in your bones from past exposure can be released back into your bloodstream. This explains why postmenopausal women show higher blood lead levels. Plus? Lead interferes with vitamin D activation and calcium absorption, which is the opposite of what we want for bone health. 

2) Cadmium  

No, you don’t need to live near a factory to be exposed. Low-level cadmium from food (including protein powders) and tobacco smoke (even secondhand) has been associated with lower bone density and a higher risk of osteoporosis. 

3) Arsenic  

Arsenic shows up often in rice, particularly in its inorganic form. While arsenic isn’t as directly tied to bone health as lead and cadmium (and is technically a metalloid and not a heavy metal), chronic low-level exposure has been linked to cardiovascular disease, especially for stroke and heart disease. 

How to Aim For Lower and Smarter Exposure

Don’t panic (and definitely don’t feel helpless). Here’s what you can do: 

1. Don’t Fear Fish. Fish Smart. 

Fish is one of the best sources of omega-3s and protein, and you can get its benefits with low mercury species such as salmon, trout, sardines, pollock, and cod. 

2. Protein Powders Are Helpers, Not a Food Group. 

Consumer Reports’ findings shouldn’t send you into a panic-tossing frenzy. They should make you more selective and remind you that supplements aren’t a primary protein source. 

3. Cook Rice With More Water. 

Rinse your rice before cooking to remove some surface arsenic. Then, cook it in 6-10 parts water to 1 part rice and drain it like pasta. This method can reduce inorganic arsenic by 40-60%. 

And rice doesn’t have to be your default carb. Mix in lower-arsenic grains like quinoa or farro during the week. 

4. Use Caution With Imported Botanicals. 

Use caution with imported remedies (e.g., Ayurvedic formulas for digestion or Chinese herbal blends for energy). It’s not that all imported products are contaminated. The issue is they come from countries with different manufacturing regulations, and without third-party testing, you can’t verify purity. 

When in doubt, ask your clinician, or if your budget allows it, send it to a commercial lab for testing. 

5. Protect Your Bones to Lower Metal Risk. 

Adequate calcium and vitamin D, resistance training, and not smoking help reduce bone turnover and, by extension, the release of legacy lead from bone. 

Remember: the goal isn’t zero exposure; it’s lower, smarter exposure.  

Menopausal hormone therapy (HRT) is the single most effective treatment for hot flashes, night sweats, and dry and painful sex. It can also help preserve bone mineral density, help preserve cognitive function and promote cardiovascular health.

And yet, less than 5% of American women aged 50-59 use it. Sadly, they (and their doctors) are still confused or not up-to-date with its nuances. 

• The Why: A 2002 study led people to believe that HRT could lead to breast cancer and heart disease. While the findings have been retracted conclusively, the fear and misinformation stuck. 

That’s like suffering with a splitting headache and never touching the Advil in your cabinet because someone told you once it might be dangerous. 

So,  let’s get clear on what we actually know. 

1) There’s a “window of opportunity.” 

Timing matters with HRT. Starting within six years of your final period, or before age 60, is associated with a lower risk of heart disease compared to starting later. 

• Science Says: A study with 643 women found that those who started estradiol within 6 years of menopause had slower artery wall thickening (a marker of heart disease). But those who started estradiol 10 years after menopause saw no difference. 

Doctor’s Note: This doesn’t mean you can’t start after this window. It just means it’s a more individualized discussion with your doctor about risks and benefits.

2) Estrogen alone can lower breast cancer mortality. 

Remember that study that scared everyone from hormone therapy? 

Well, 20 years later, researchers revisited those same women. They found that women who’d had a hysterectomy and used estrogen-only HRT had FEWER breast cancers and LOWER  breast cancer deaths than those on placebo. 

This is the opposite of what most women have been told for decades. 

3) Not all progestogen is created equal. 

If you have a uterus, you need progesterone alongside estrogen to protect your uterine lining. But the type of progesterone changes your risk profile. 

• Medroxyprogesterone Acetate (MPA): A synthetic progestin. It’s been linked to a slightly higher risk of blood clots. 

• Micronized Progesterone: This bioidentical form is chemically similar to what your body makes. A 2015 study found there was no increased risk of blood clotting.  

4) How estrogen gets into your body matters. 

When it comes to deciding between pills, patches, or creams, your delivery method matters more than you realize. 

Oral estrogen (pills) has a higher risk of thrombosis since it goes through your liver first. Meanwhile, transdermal estrogen (patches and gels) absorbs directly into your skin and bypasses the liver, reducing your chance of blood clots. 

• Doctor’s Note: If you’re at higher risk for blood clots, transdermal is often the safer route. 

5) Progesterone is not optional. 

As I mentioned earlier, if you have a uterus, and you take systemic estrogen, you need progesterone because estrogen stimulates the uterine lining. Without progesterone, that unchecked growth could lead to endometrial cancer. 

In other words, progesterone is a safety requirement. 

6) Breast cancer survivors can use vaginal estrogen. 

Many women assume breast cancer means all estrogen is off-limits. Not true! Low-dose vaginal estrogen can be used safely because it stays local and very little gets absorbed into your bloodstream. 

So if you’ve been treated for breast cancer, there’s NO reason you need to suffer with vaginal dryness, frequent UTI’s or painful sex. Ask your doctor about vaginal estrogen! 

7) “Bioidentical” is both a chemistry and marketing term. 

FDA-approved estradiol and micronized progesterone are bioidentical. They’re well-studied and regulated. 

But the term “bioidentical” has also been hijacked by marketing. When you see it advertised, it usually refers to compounded custom-mixed hormones from specialty pharmacies. That said, there are pharmaceutical-grade bioidentical HRT options that are safe, effective and regulated. 

• Zoom In: Compounded hormones should only be used in rare situations when no approved option fits, because dose consistency and safety data are limited. ACOG is explicit on this and I agree.

Looking to Get On HRT? 

If you’re thinking, “Maybe I should get on HRT,” great! Here’s how you can move forward: 

1. Get Specific. Bring up to your doctor your age, time since menopause, uterus status, personal and family history, migraine pattern, blood pressure, and venous thromboembolism (VTE) risk. These factors will tailor your plan. 

2. Ask About Formulation. Match the molecule and the route to your goal. For most, it’ll be transdermal estradiol plus oral micronized progesterone. But if you don’t have a uterus, estradiol alone could be a good option. 

3. Set Expectations. HRT treats symptoms and preserves function, especially bone. But it is not a forever cardiology prescription for everyone, and it’s not a beauty serum. 

Lastly? Zoom out. Remember that the biggest things you can control to lower midlife breast cancer risk are alcohol, maintaining a healthy weight, and staying active. HRT decisions should live within that larger conversation about sleep, strength training, nutrition, and community.

I know what you’re thinking: a vaginal cream on my face? 

These creams contain estriol, a form of estrogen known to rejuvenate tissue. And what estriol does for vaginal mucosa, it can do for your facial skin too! 

• Mini-Med School: As estrogen levels drop during menopause, your skin loses collagen, moisture, and elasticity. Topical estriol may help restore some of that benefit by boosting collagen production, hydration, and firmness. 

This isn’t new. Dermatologists and gynecologists have known about these effects for decades. 

What is new? The popularity. The awareness. And crucially, the access and formulations. Today, you can find topical estriol products designed specifically for your face, and they’re packed with complementary ingredients: 

• Hyaluronic Acid for hydration 

• Peptides to signal collagen production 

• Tretinoin and Niacinamide for fine lines and pigment control

But before you order a tube, let’s go through the pros and cons. 

The Pros of Topical Estriol 

1) It’s designed specifically for midlife skin. 

Menopausal skin responds to a drop in estrogen with thinning, dryness, and fine lines. A formula built around estrogen replacement specifically targets the root cause (and not just surface symptoms). 

It’s refreshing to find a skincare line aimed explicitly for menopausal or post-50 skin. It helps you feel seen. I like the messaging of a brand that doesn’t try to be “jack of all trades and master of none.” 

2) Topical delivery keeps it local. 

While systemic estrogen circulates through your entire body, topical estrogen works directly where you apply it. It “speaks” to estrogen receptors in your facial skin to potentially improve elasticity and hydration. 

3) It's a well-formulated facial product. 

Beyond the estriol, these products are thoughtfully “stacked” with proven actives. A serum might combine estriol with hyaluronic acid and peptides. A cream may add deeper moisturizers with estriol. 

The Cons (& Important Caveats) of Topical Estriol 

1. Access and prescription could be a hassle. 

Some estriol products are labeled “Rx” and may require a consultation. If it’s a compounded formula, your dermatologist or clinician may need to approve, though many Direct to Consumer (Patient) sites now offer a bypass to this process. 

2. Topical estriol is not a systemic hormone replacement. 

The marketing can oversell the results. Topical estriol may improve your facial skin, but it’s not systemic HRT. It won’t replicate HRT’s benefits, like bone and cardiovascular protection. 

3. There are safety and regulatory questions. 

When you’re putting estriol on your face, it’s fair to want to know: 

How much gets absorbed? Are there systemic levels? What’s the long‐term safety in your situation (e.g., history of hormone-sensitive cancer)?  

The good news is that most peer-reviewed data suggest there is minimal absorption with facial estriol, which is why needing to take progesterone to protect the endometrial lining is not needed when using facial estriol. That said, slathering it all over your body is NOT recommended.

4. Not all promises are backed by proof. 

The marketing of these products can be aggressive. Before buying in, look at the actual data behind the claims (e.g., 12-week trial shows visible firming, etc, per site). 

Then tailor whether the benefits are worth the risk and benefit for you. 

My Rx For You 

If you were my patient (post-menopausal like me, dealing with thinning skin and wrinkles), and curious about topical estriol, here’s what we’d do. 

First: do no harm/safety. I’d ask you about your hormone-sensitive history: breast cancer, prior HRT use, history of blood clots, etc. 

Then: instructions: 

• Apply the serum in the morning and cream at night (or follow the brand’s routine). 

• Pair it with a broad-spectrum SPF 30+ every single day. 

• Monitor every 3-4 months. If you’re not seeing results, evaluate whether your lifestyle could be undermining things.

Finally: set realistic expectations. Topical estriol may improve texture, fine lines, and elasticity, but it takes time. And it won’t fix sagging, jowls, or volume loss (that’s procedural territory). 

Remember: hormonal skin changes are just one piece of the midlife puzzle. Nutrition, sleep, resistance training, and stress management all matter. 

If you want a visual guide that organizes all the essential elements of thriving in midlife, Alloy’s Periodic Table of Menopause just launched last week for Menopause Awareness Month. I love the visual here and think it’s very informative!

It’s information like this that’ll help us approach menopause with curiosity and intention, not fear or devaluation. Menopause is a privilege, because not every woman gets to this stage of life. 

The Topical Estriol I’d Recommend 

As you can tell from their periodic table, Alloy* has a deep understanding of midlife women. Their topical estriol is no exception. This smart, woman-owned company was actually the first company to offer skincare with estriol! 

And the best part? Alloy makes it easy. Their prescription process includes access to a menopause-trained doctor at no additional cost, so you can get expert guidance and peace of mind without the hassle of separate appointments or fees.

Alloy’s M4 Face Cream Rx is a bestseller. In a clinical study over 12 weeks, women using M4 creams saw: 

• 68% in overall skin health 

• 86% boost in skin elasticity and bounce

• 25% reduction in wrinkles around the eyes 

And from a safety standpoint, the data is reassuring. It found no significant change in blood estriol levels, meaning the cream delivers results on your facial skin without systemic absorption.

They've since expanded their skincare with the M4 Lift & Renew Eye Cream and M4 Face Serum. Together, these three M4 products may boost collagen production, restore hydration, improve elasticity, and support hormonal skin to keep it glowing and resilient. 

I’m a fan of Alloy because they’re formulated specifically for midlife skin and as a company has ‘seen’ the issue that so many women have with accessing these management approaches and are trying to offer options and solutions in this space. I am also a fan of the state of the art skin ingredients they have formulated together- putting hyaluronic acid, with estriol, with peptides is a winning combo! I wish I had thought of it! If you’ve been searching for skincare that restores your skin post-50s (and beyond), this could be for you. 

Use the code AJENDA20 for 20% off to try it out yourself! 

P.S. Curious to learn my exact daily skincare routine? Subscribe to my new newsletter, Off Duty with Dr. Jen, to get the breakdown of which products I use, how I use them, the results I’ve seen, the high/low cost tiers for these products  and so much more. 

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ABOUT DR. JEN

In her former roles as chief medical correspondent for ABC News and on-air cohost of “GMA3: What You Need to Know,” Dr. Jennifer Ashton—”Dr. Jen”—has shared the latest health news and information with millions of viewers nationwide. As an OB-GYN, nutritionist, and board-certified obesity medicine specialist, she is passionate about promoting optimal health for “the whole woman.” She has authored several books, including the national best-seller, The Self-Care Solution: A Year of Becoming Happier, Healthier & Fitter—One Month at a Time. And she has gone through menopause…

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