Episode 47
Menopause Myth Busting with Dr. Heather Hirsch: What You Need to Know
Did you know that many menopause myths could be impacting your health choices? Dr. Heather Hirsch joins us to clear the confusion and empower women with the facts.
Menopause is often clouded by myths and misinformation, leaving many women confused about their health options. In this episode, Dr. Sameena Rahman invites Dr. Heather Hirsch, a dedicated expert in women's health, to share her journey into menopause care and the profound insights she's gained over the past decade.
From the misconceptions surrounding HRT (Hormone Replacement Therapy) to the nuanced challenges of treating perimenopause, Dr. Hirsch discusses her unique "hormone stacking" approach and how it aids in managing side effects effectively.
This conversation goes beyond surface-level explanations, diving into the realities of balancing treatment, understanding progesterone sensitivities, and how personalized care makes a difference in women's experiences. Listen in for a blend of clinical expertise and relatable advice that champions informed choices and women's health advocacy.
Highlights
- Dr. Hirsch’s Journey: From OBGYN to menopause specialist—how her path shaped her passion for women’s health.
- Hormone Stacking Insight: Why introducing hormones one at a time can be transformative for treatment.
- Perimenopause Realities: Breaking down misconceptions and exploring why tailored care is essential.
- Progesterone Sensitivities: Understanding the third-rule approach to help patients navigate side effects.
- Brain Health & HRT: The untold story of how hormone therapy impacts cognitive function and mental health.
Enjoyed this discussion? Don't forget to subscribe, like, and leave a comment. Your engagement helps us bring you more expert conversations. What other guest would you like to see on the podcast. Send me a DM on Instagram and let me know!
Dr. Hirsch’s Bio :
HEATHER HIRSCH, M.D., MS, NCMP, is the founder of the Menopause & Midlife Clinic at Brigham and Women’s Hospital and a former Harvard Medical School faculty member. Board certified in Internal Medicine, she completed advanced fellowship training in Women’s Health at the Cleveland Clinic. Her practice specializes in menopausal hormone therapy, perimenopause, breast cancer survivorship, sexual dysfunction, and bone health. Dr. Hirsch is an active member of the North American Menopause Society and the International Society for the Study of Women’s Sexual Health and serves on the medical advisory board of Midi Health. She now sees patients via her private telemedicine practice.
Get in Touch with Dr. Hirsch
Get in Touch with Dr. Rahman:
Transcript
Hey, y'all, welcome back to another episode of Gyno Girl Presents, Sex, Drugs and Hormones. I am super duper excited. One of my good friends and colleagues is here today to give you the scoop. You all know her from every platform and every media opportunity that you've probably seen her on. So many things. The amazing Dr. Heather Hirsch is here today and we're gonna talk
Heather Hirsch MD (:Okay.
Heather Hirsch MD (:coming up.
Dr Sameena Rahman (:All about menopause myths and controversies. It's gonna be great and I don't even want to waste time I want to just dive right into it, but Heather, please reintroduce yourself to my audience. Dr. Hirsh and let them know I mean I've obviously made your intro already but you know just Tell them a little bit about everything that you're doing and what brought you into the menopause space That's one question. I ask everybody what brought them into the menopause or sex med space
Heather Hirsch MD (:Yeah.
Heather Hirsch MD (:Okay.
I got you. I will add something to the intro that you're gonna, you know, record and they've already heard about me, but I actually started my career in OBGYN and I did about a year and a half and I was like, I cannot stay for the middle of the night. I do not like doing surgery. I just want to talk, talk, talk. I love talking. And so that's one of the reasons I transitioned to internal medicine. And then I always wanted to take care of women. And I really wasn't sure what my footing was going to be. Actually, I considered
Dr Sameena Rahman (:I have some leverage.
Mm-hmm.
Dr Sameena Rahman (:Mm-hmm.
Heather Hirsch MD (:going into oncology and I did a rotation with a breast oncologist and I was like, this is my calling. I didn't want to deliver babies, but I'm gonna do breast cancer. And when I would rotate, I'd go into the rooms and I'd be like, well, how is your sleep and how is your sex life and how is your mood? And they were like, girl, they're terrible, but like, why are you even asking me this? Like, I'm dealing with breast cancer, you know?
Dr Sameena Rahman (:Yeah.
Heather Hirsch MD (:I just was really so interested in sort of the holistic picture of going through perimenopause to menopause. And I had no idea that there was a fellowship in basically menopause, which is an unaccredited ACGME fellowship. So it's not an accredited ACGME. Sorry, I kind of said that funky. Which just means that unlike like cardiology or gastroenterology for anyone who's listening, you don't have a specific board. And you can kind of make your two-year fellowship whatever you are really interested in. So one night when I was on call,
I found this fellowship at Cleveland Clinic, which is right next to Case Western. And I came in very, very interested in contraception and IUD placements, all the things that I learned how to do because I was a guy in resident for a year and peripartum complications. I thought I was going to be like an expert in like peripartum cardiomyopathy. Okay. I had like all these ideas and I, my mentor, Dr. Holly Thacker, she trained me and I really, a credit so much of what I've learned too.
Dr Sameena Rahman (:I'm see.
Heather Hirsch MD (:my experience in training with her, just on menopause. I had like maybe an hour or two, you know, of education on menopause, which is not unlike most of my colleagues and friends. And I was like, what is this? Women were coming from all over the country to get care for menopause. HRT was like absolute kryptonite. This is 2014. And I started doing all the research and looked at the WHI very deeply. And I was like,
Dr Sameena Rahman (:Yeah. Yeah.
Heather Hirsch MD (:this is crazy and once you see it, you can't unsee it. And I was, this is the biggest gap in women's healthcare. And, you know, I had fellowship colleagues that went on to do chronic pelvic pain and women's health and sleep and women's health and obesity. And some people do osteoporosis like Dr. Christy Tuff, a good friend of ours. But I was obsessed with the menopause transition. And so I've really been doing perimenopause and menopause since 2014.
Dr Sameena Rahman (:Yeah.
Dr Sameena Rahman (:wonderful. You and I both, but we came at it differently. Like you at least had someone teach it to you. had to go and find, you know, this trending on social media right now is like why I was such a bad menopause doctor before. I guess you can't really say that because you came in, was it blazing trail, trail blaze, whatever. Fire. Yeah.
Heather Hirsch MD (:Bedmenopause doctor. Yeah. Yeah.
Heather Hirsch MD (:trailblazing right out of, well, I was thinking about it too and I was like, I'm happy to kind of, I definitely was, I will say I was so lucky that I did that fellowship training. It's really not as though there was something better or special that I just woke up and knew. I had two years dedicated to learning this, so.
Dr Sameena Rahman (:Yes.
Heather Hirsch MD (:I, and again, I didn't go in thinking I wanted to be, I never went to med school and I was like, I'm gonna be a menopause doctor. It really just kind of happened that way. One thing that I used to do when I first started that I don't do now is I used to start estrogen, progesterone, testosterone, vaginal estrogen. I would start them all at the same time. And I have learned sort of what I call hormone stacking, which I don't think is anything like I specifically coined.
Dr Sameena Rahman (:Yeah.
Dr Sameena Rahman (:yeah.
Dr Sameena Rahman (:That's what we do.
Heather Hirsch MD (:But now I have this incredible class and I teach my students, start with one and then stack and then do another, whether it's even two weeks or four weeks. And this is something great if you're a patient, not a clinician, is to stack a little bit your HRT because I very soon realized, actually by soon, a few years in, because now it's been a decade, that if there was a side effect or if someone felt like HRT wasn't
Dr Sameena Rahman (:necessarily take place.
Heather Hirsch MD (:quite right for them. It was usually one hormone, not all of them. And so I've kind of learned to do this hormone stacking and kind of try to pinpoint what, by using my best gestometer, is it more of a progesterone or estrogen or testosterone problem, and then kind of starting with that and then stacking from there. So that's one thing I've definitely learned over the last decade that I did not do right out of the gate.
Dr Sameena Rahman (:Yeah, that's true.
Dr Sameena Rahman (:Yeah, I think that's something I came to learn too over the years. And it's mainly because, well, one, like when you talk to patients about all the things that you want them to try, it gets very overwhelming for them to try everything at once too. So sometimes they're like, whoa. So I learned too that some patients just couldn't synthesize everything so quickly. And then the other thing is like, yeah, the side effects, you don't know which one. And sometimes when you fix somebody's sleep and you could cure their hot flashes,
Heather Hirsch MD (:Well, Ming. Yeah, yeah.
Dr Sameena Rahman (:know, their libido comes back. So maybe they don't even need the testosterone, you know, like in those little things. Or sometimes when you cure their vaginal pain from sex with the, you know, intra-rosa or vaginal estrogen, they don't need the testosterone either. So, you you have to kind of go stepwise and see what you do. I totally agree with you.
Heather Hirsch MD (:Yeah. Right.
Heather Hirsch MD (:Yeah. Yeah, exactly. And it's really, really, I think the experience of doing it for so long and sort of the confidence that I know that there will be a big impact from even just one of the things and really being able to find the words to explain why, you know, instead of the old, fast way is like kind of called the cowgirl way. So we're just going to cowgirl it. And that's what we kind of sometimes do in crisis mode. If like everything's falling apart and everything feels like it's a mess,
Dr Sameena Rahman (:Mm-hmm. Yes.
Dr Sameena Rahman (:Yeah.
Dr Sameena Rahman (:Bye.
Heather Hirsch MD (:I still do it, but very rarely now. I really have learned sort of the waiting and being patient sort of sucks, but I've been able to sort of learn some of the words I can use to help my patients. then, so that all kind of came with experience.
Dr Sameena Rahman (:Yeah, I agree totally. Sometimes I'll, you know, because like you, I opened my practice in 2014 and fell into menopause because my first few patients were like perimenopausal or menopausal. And then I had to go do the menopause society stuff and work with Dr. Goldstein and all that. But sometimes like now I have like colleagues that are kind of like trying to get into menopause. And then they like text me like aggressively, like how to go to Heather Horses, Hershey's course. OK, because I can't answer all your questions.
Heather Hirsch MD (:Yup. Yeah.
Dr Sameena Rahman (:So I've sent people to you that way because I'm like, from what I've seen and like I didn't have the pleasure of taking, I did take the breast cancer one with Dr. Men recently, so which was really great. But I think that just what you've done has been so remarkable. Can you tell me how you came up with the Heather Hirsch Academy? Because we all know that there's a big gap in medical education. And like I said, when I have colleagues texting me like crazy, I'm like, hey, let's just go do Dr. Heather Hirsch's course, okay?
Heather Hirsch MD (:Yeah
Heather Hirsch MD (:Yes. Yeah. Yeah.
Dr Sameena Rahman (:Because like, I can't manage your patients for you.
Heather Hirsch MD (:I know, exactly. because also to a lot of it is like just stult of like, and you're missing a lot of context, you know? And so you're like, I'd love to tell you this story. You know, so I spent the majority of my career in academic medicine. It wasn't really until the end of 22 that I left the Brigham and Women's Hospital. And I've been in academics for many years.
Dr Sameena Rahman (:Yeah, I'll... I'll...
Dr Sameena Rahman (:Yes.
Dr Sameena Rahman (:Remember we're at Ishwesh together and you're like, I'm thinking of leaving. Do you remember that? I was like, you should. well, you need to.
Heather Hirsch MD (:Yes, I was so afraid. Yes, I remember we sat at, we were like on the rooftop and you had private practice and I knew that because actually I was like stalking you on Instagram and it's so funny now how we're all just like best friends. And I was really trying to pick your brain about like, what's it like, know, not having like a, you know, healthcare, retirement. But anyways, so.
Dr Sameena Rahman (:Yes.
Dr Sameena Rahman (:Okay, we're always talking. Yeah, I know.
Heather Hirsch MD (:I was always sort of in the academic track when it came to things like promotion and things. And there's really kind of like, for those of you interested, although it's not that interesting, there's like a research track, academic and clinical excellence. Yeah.
Dr Sameena Rahman (:It's not a show. Both of us have been in academic. You know what? It's not a gig. Right when you come out, it's not a bad gig to give you a little confidence. You know?
Heather Hirsch MD (:It's not, yeah, it's kind of like your junior residency again, you know? And so I was kind of always in this teaching pathway and I always loved teaching. And the more and more I learn about myself, the more I find that teaching and mentoring and building communities brings me the most joy. Whether it's like the community of my patients altogether or it's teaching my patients, think teaching is actually the thing that brings me the most joy. And, thanks. I mean, I...
Dr Sameena Rahman (:Yes.
Dr Sameena Rahman (:Well, you're so good at it too.
Heather Hirsch MD (:I hope, I guess you can see it's hard for me to accept it, but for many...
Dr Sameena Rahman (:You are. on. You're done at it. People always do great things about your course. It's amazing.
Heather Hirsch MD (:know, well, Samina, for many years, always I like wanted to be a researcher. I really, really tried. I tried to can twist and contort myself into being a researcher. And particularly when I was at Harvard, that's very much academic currency. But the truth of it was is that I am naturally a teacher. And I learned that, you know, I actually learned that and finally accepted it was like TikTok. Like, I finally accepted that.
teaching really is where I shine and I just naturally fall as opposed to being a researcher, even though that was always kind of this, I wanted to be this big researcher. But I've really, you know, settled into this is really my genius zone is teaching. And so I was actually kind of creating a CME outline for a course when I was at Harvard. And then because I left, I sort of took that outline, essentially, that was my intellectual property, and I took it with me. And, you know, what really kicked this whole thing off was I had been
Dr Sameena Rahman (:Yeah.
Heather Hirsch MD (:collecting an email list of people who wanted to take this Harvard course at the time, this is like 2022, and I emailed all of them and I was like, hey, so I'm not there anymore, but who still wants to learn from me? And like 50 people signed up in like two days and it was just an immense success. And since then I've gone on to do a couple of different iterations, rerecorded it a bunch of times, taken my students' feedback, incorporate that into some of the rerecordings and built this incredible community
Dr Sameena Rahman (:Yeah.
Dr Sameena Rahman (:Yeah.
Heather Hirsch MD (:of the students in the class. This sounds like now an infomercial, it's really just because I'm so excited about it.
Dr Sameena Rahman (:Yeah, it's true though. mean, all the people I've spoken to that have taken your class are always like, you know, this is has been transformative for me. Like this is something that, you know, really like change how I practice medicine.
Heather Hirsch MD (:I mean, and I think that...
I love that so much because I think a couple of things that we've all missed. You we missed when we were in training, basically like learning from your attendings or learning from your mentors. And so my class, especially the way I teach it, I've thrown a lot of nuances and cases kind of like on the fly and then we do these monthly lives. So it's almost like you're getting that experiential learning that you would if you were like a resident and you were kind of following around.
Dr Sameena Rahman (:Yeah.
Heather Hirsch MD (:and then you can build your confidence because you'll be like, I saw this lady with a protein C deficiency. Everyone just vote, can I do transtermal estrogen? Then 20 people are like, yes, girl. And then that patient gets a win and then the patient comes back and then the patient's fine and then the clinician grows their confidence just a hundredfold. And so it's just been beautiful. And I really credit all the students, I credit all the women who have said we demand better.
Dr Sameena Rahman (:Yes.
Dr Sameena Rahman (:Yes.
Heather Hirsch MD (:I credit so many things besides for just my teaching, really do. The group really runs on the energy of the current students and it's just been the most exciting and transformative thing of my life. They teach me so much, like what are the gaps? What else can I do better? It's been amazing. And then I've had the privilege of having some of my other amazing colleagues come in and teach and hopefully you too in 2025.
Dr Sameena Rahman (:Yeah.
Dr Sameena Rahman (:Yeah.
Dr Sameena Rahman (:I need this, I can't wait! What's going on everyone? I'm gonna sleep freak.
Heather Hirsch MD (:I have this all-star lineup of like, yeah, these are incredible clinicians who all have, you know, sort of like pockets of these deep expertise. And, you know, I don't have the deep expertise that everyone else does. And they're kind of area that they've also like along this journey found themselves in, right? You kind of found yourself in sort of sexual health, but also
cultural perspectives and that's just where, you know, everyone looks to you for that and it's just like a beautiful thing. It's, yeah.
Dr Sameena Rahman (:Yes.
Dr Sameena Rahman (:Yeah, no, it really is. It's wonderful. And it's almost like it was chosen for us, right? Because it came to us and then, yeah. Well, that's awesome. I love that story. And I love everything that you're doing. But let's get to some nitty gritty about what people might want to know about. I love when you do your myths and controversies. There's been social media is exploding with menopause information. Everybody's an expert. I actually just heard someone, some person who is a
Heather Hirsch MD (:Yeah. Yeah.
Heather Hirsch MD (:yeah.
Heather Hirsch MD (:Yeah.
Dr Sameena Rahman (:like a health coach talk about how perimenopausal women don't need estrogen, they need progesterone and testosterone only. They don't need estrogen because you're still making it. So you know, you hear all these people saying stuff and probably with good intention because that's what they're using, right? But that's like not, or maybe they're trying to push a supplement or whatever they want. But like the reality is there's a lot of information and misinformation.
Heather Hirsch MD (:Mm-hmm. Mm-hmm. Mm-hmm. Myths abound.
Dr Sameena Rahman (:And we as experts need to make sure that we know we can disseminate the right information. So let's talk about some of those. What about that one that I just said? Because I just literally saw that today. Like, do perimenopausal women need estrogen? They're still making it.
Heather Hirsch MD (:Yeah. Yes. my goodness. I...
I love, you know, it's funny, I teach the way I kind of teach in my class, not to go back to that, but I teach based on complexity. Like we start with menopausal women who've had a hysterectomy. And whether you're a clinician or not, that's actually kind of one of the more easiest cases, because you can imagine they don't have bleeding and side effects. And then the very last, the most complicated is HRT and perimenopause.
Dr Sameena Rahman (:Mm-hmm.
Yeah.
Dr Sameena Rahman (:is just right.
Heather Hirsch MD (:And HRT and perimenopause is quite complicated because it is so based on symptoms. And your hormones are still fluctuating, your estrogen is volatile, it's spiking, it's bottoming out, your progesterone's piecing out, your testosterone's like maybe sticking around, maybe it's increasing because of stress. And so it is so dependent on the woman and her symptoms. But absolutely, I mean, you could use all three of the trifecta, estrogen, progesterone, testosterone.
Dr Sameena Rahman (:All
Dr Sameena Rahman (:the roller coaster.
Heather Hirsch MD (:and what really is gonna drive it is symptoms. so, you know, this kind of, first of all, talk about this myth of you can't use hormone therapy unless you've been a year of no period. That makes absolutely no sense. There's no textbook, there is no rule, there's no guideline, there's nothing that says that. And in my decade of experience, the majority of women in perimenopause do so well on postmenopausal HRT. Some do okay on birth control pills, although birth control pills,
Dr Sameena Rahman (:Night.
Heather Hirsch MD (:can have side effects as well. And some women psychologically do not want to take them. And so postmenopausal HRT has many benefits. Number one, it's lower dose. Number two, it's transdermal, particularly the estrogen. Number three, you can stack, you can separate, right? Birth control pills, you just get one oral combination of synthetic estrogen, ethanol, estrogel, is the formulation and norethindrone typically, or drosperinone in your progesterone. And then...
Dr Sameena Rahman (:Thank
Dr Sameena Rahman (:Yeah.
Heather Hirsch MD (:If you're using postmenopausal, you can also use our quote, bioidentical, which is a fancy word for it's just more plant-based. And so there's just so many benefits. sometimes we use sort of like common threads, so hot and dry, that typically means you need estrogen, anxious and insomnia, that typically means progesterone, low energy, low muscle mass, low libido, especially athletes, testosterone, any type of vaginal dryness, pain with intercourse vaginal estrogen.
And it just so much depends. And then you also have to juggle, will that make periods worse? Do you still get periods? Do you have an IUD? Et cetera, et cetera. And so there is no one answer for perimenopause. And I think a lot of these telemedicine practices do list progesterone and testosterone because they're just so afraid of the irregular bleeding if they give estrogen and the confusion. And so they just don't. But my gosh, I have many, many perimenopausal women
Dr Sameena Rahman (:Right. Right.
Dr Sameena Rahman (:Absolutely.
Dr Sameena Rahman (:Yeah.
Heather Hirsch MD (:who use estrogen and it's so helpful.
Dr Sameena Rahman (:Yes, yeah, yeah, it's very helpful. And you know, it is complex because there's one month you might have your own estrogen levels are sky high and then you're giving them the normal level and then maybe you're like, you need to cut back that month. But that's why the consistency and the precision care is so important because of those fluctuations.
Heather Hirsch MD (:Right, a lot of patient education. So, you know, I always say my patients are kind of heatherified when they're like, I stopped it. I stop it usually for this week when I, you know, when I'm ovulating and my breasts are super tender and I'm like, you got
Dr Sameena Rahman (:Yeah.
Dr Sameena Rahman (:Yeah, yeah. You just have to give them a heads up and educate them, right? Like these are signs of high estrogen. This is when you need to cut back, right? The heavy bleeding, painful, the headaches, the painful breasts, you know, like that's when your estrogen might be a little high for that month. But, well, let's talk a little bit about the progesterone aspect then, because that's the one that confuses, I think, a lot of people in terms of, you know, so many people have progesterone sensitivities.
Heather Hirsch MD (:Yeah.
Yeah.
Heather Hirsch MD (:Yeah. Yeah.
Dr Sameena Rahman (:What does that look like? Well, how do you see that clinically when you talk about patients that have forgesterone sensitivities?
Heather Hirsch MD (:Mm-hmm.
Heather Hirsch MD (:Yeah, I kind of have this third, third rule. So third, third rule. So when it comes to progesterone in general, especially we're talking the bioidentical oral prometrium, about a third of women love it. They're like, it feels like a warm blanket, just just encasing me with love and sleep. About a third of women have like a null effect. It doesn't bother them. It doesn't feel like a warm, cozy blanket. A warm, blanket.
Dr Sameena Rahman (:Mm-hmm.
Dr Sameena Rahman (:Right.
Heather Hirsch MD (:I was gonna say a mug of hot chocolate. It just is kind of neither. They just take it because they know I told them to and it's best for them. And then about a third of women have progesterone intolerant. Okay, of that third, you break that into a third. A third is mild, a third is moderate, and a third is severe. All right, let's work backwards. Severe, I have heard suicidal ideations. I have heard like extreme bloating.
Dr Sameena Rahman (:Yeah. Yeah.
Heather Hirsch MD (:And patients tell me like, how do I know if I'm gonna have a severe side effect? I'm like, in three nights, you will never wanna touch it again. That is usually a telltale that you have severe progesterone intolerance. If it's moderate, it's sort of like, I really don't love this. It kind of, after a couple of nights, I feel just sedated and gunky and bloated and that's kind of more of like your mild, moderate, yep.
Dr Sameena Rahman (:Yeah, absolutely. Yeah.
Dr Sameena Rahman (:I can't get my stuff full. Yeah.
Heather Hirsch MD (:And then mild intonation is like, really don't love it, I can tolerate it for the lowest dose if we can get away with that based on what the estrogen dose is. And so those are kind of what I see doing this for a decade. So if it is moderate and severe, obviously severe, we have to just try and find other ways of uterine protection. So that could be due of A.
Dr Sameena Rahman (:Thank you.
Heather Hirsch MD (:which is basadoxyphene and I know you know this and estrogen. And interestingly about DuAve, if your patients or if you're listening and your patient this happens to you, you know, it is oral and we have convinced everyone that transdermal is the one and only holy grail. And that is not true. In fact, here's a fun fact. Guess who takes oral estradiol? Guess who is the craziest of all crazies? Me. I actually take oral estradiol. I know.
Dr Sameena Rahman (:love them.
I love it.
Heather Hirsch MD (:And I love it, you know, I take oral estero. What?
Dr Sameena Rahman (:love my juva action. said I love my juva. I take my juva too sometimes when I, cause I have so many samples in my office. I'm just like.
Heather Hirsch MD (:Yup, exactly. And we could get into that myth, but the risk of blood clot is actually very, very, very, very small. I had three children and birth control pills and surgeries, and so I know that I'm kind of at no risk. Anyways, so basidoxapine or the duovase is a good option with severe or moderate progesterone intolerance. You could try NIUD. That does scare people because it still has a form of progesterone, but...
I have all of the patients, I have had severe side effects to progesterone. The IUD has been great for them. It does not travel systemically. Once it can get over the fear, you could do an IUD or you can switch to different forms of progesterone like norethin drone or provera and there's some other ones in there. And then we just kind of figure out what we're gonna do.
Dr Sameena Rahman (:Thank you.
Dr Sameena Rahman (:Right. What did you say? Like one of my big telltale signs is if someone like has a known diagnosis of PMDD or something where you know they have a progesterone sensitivity, I'm always like, you you have PMDD. Let's, we'll trial it. You can try it for a couple of days and let's see. But you know, you might be someone that goes straight to duet or an IUD or something like that, you know?
Heather Hirsch MD (:Mm-hmm.
Heather Hirsch MD (:You're welcome.
Heather Hirsch MD (:Yep, exactly. I do the same thing. They're almost always kind of excited to try it because not actually, that's not true, not always. Some of them are like, I, know, a lot of women have had to do progesterone or prometrium for infertility or for recurrent miscarriages and they're like, I do never wanna touch it again. But again, it's different, different doses, different routes. So it's always different. But if you're gonna kind of have a severe reaction,
Dr Sameena Rahman (:Yeah, got it. Yeah. Yeah.
Heather Hirsch MD (:You will probably know within a couple of nights, it's gonna go away just as soon as it came on, and then we can kind of work backwards from there.
Dr Sameena Rahman (:Yeah, awesome. And I think, so one of the other controversies that's been around, I guess, for the last month or two is around, you know, are menopause specialists like us touting menopausal hormonal therapy too much? I mean, you and I both know there's no magic bullet to getting through menopause, right? It's a part of our toolkit. But this is what obviously some people have picked up on. Even the Menopause Society came out with a statement like, let's be, you know.
Heather Hirsch MD (:Right? Right?
Dr Sameena Rahman (:cautious about why we're saying menopausal hormone therapy should be used. And so let's talk about what's the difference between like a guideline and data that exists, clinical practice. exactly. Because, you know, we all know it takes a long time for guidelines to pick up on clinical data. But we know that there's data that exists that, you know, will confer a lot of what we say.
Heather Hirsch MD (:clinical practice.
Heather Hirsch MD (:Yeah
Heather Hirsch MD (:You know, this is a great question and I'm glad you asked me and I'm really glad to tackle it. The first thing off the gate is I do think it would be potentially more, well, actually I'm gonna leave that for the end. So, know, yes, the guidelines are FDA approval of hormone therapies for four things. Hot flashes, night sweats, GSM, and osteopenia.
And it's not FDA approved for joint aches and pains, for mood, for hair, skin, and nails, for the vertigo, which again, if there's 38 or 56 symptoms, there's four that it's FDA approved for. Now, in clinical practice, we certainly do see that hormone therapy improves mood and joint aches and pains a big majority of the time. And what I always explain, for example, to my students is,
look, you can probably find one of four indications, osteopenia or even GSM. Like basically all women have GSM because the pH of the vagina is going to change. And most women are gonna have a hot flash or a knife sweats. You can almost always find an FDA approved indication. And as long as you're telling the patient, this is an FDA approved for joint aches and pains. This isn't FDA approved for long-term prevention of heart disease although the data shows that. As long as the patient knows, but you're like, we're using this one to treat this other thing.
Dr Sameena Rahman (:Yeah. Yeah.
Heather Hirsch MD (:And we're gonna use it as a diagnostic tool to see if it helps this and if it's therapeutic thing great and those of us who are in clinical practice day in and day out seeing patients we know that hormone therapy helps many many things now the other part of this is Will we ever get an FDA approval for joint angst and pains? No, no why it's gonna take millions if not a billion dollars to do a huge randomized double-blind controlled trial and I do think
we'd be hard pressed to randomize women to HRT versus placebo because of the inherent biases that we have. So we'll never have big trials. They're going to expand the FDA approval repertoire. Next point is that for many, many years, it was absolutely okay to use off-label SSRIs or antidepressants to treat menopausal symptoms. But now there's kind of this, well, the reverse isn't true. You can't use hormone therapy off-label. Well, again,
We've used as a rise off label for about two decades to treat menopausal symptoms. And why was that okay? That causes low libido. That causes, you know, other side effects too. And of being an internist of all of the medications that I've prescribed in my lifetime, I have never seen a safer medication on the planet. Like there is kind of this, you know, yes, we should still be cautious and we should still be smart, but hormone therapy is overall.
Dr Sameena Rahman (:Yeah. Yeah.
Heather Hirsch MD (:Extraordinarily safe, things that land people in the ER is insulin, aspirin, right? Even overdosing on your SSRIs. That lands people in an emergency room, which I've also seen. And so, you know, that's kind of the yin and the yang to this argument. And I think we got to make sure that we know our facts. We're not saying, it's FDA approved for hair loss. We should not be saying things like that. I agree. But again, if someone is saying I'm having a
Dr Sameena Rahman (:Yeah. Well, it's right. Yeah.
Right. Yeah.
Heather Hirsch MD (:my hair's the thing that's bothering me. I've heard about estrogen, I've tried all these things. Yeah, I've got a nice, yeah, I'm a little bit of vaginal dryness. Okay, let's try the HRT and also see if it improves your hair. I don't think this is playing with fire. I do think what we should be going after is clinicians, if we're gonna spend time kind of rounding up math versus fact.
Dr Sameena Rahman (:Mm-hmm. Yeah.
Heather Hirsch MD (:those clinicians who are doing pellet injections or compounded HRT. Let's go more in working on getting people off unapproved medications, which are actually unsafe, versus a big to do about prescribing HRT for joint aches and pains. And so that is my perspective on it. I really very much kind of, think by the time that perspective is out, you can see how it's like very balanced. Like I'm not saying they're wrong, but I'm also not saying it's not the whole story.
Dr Sameena Rahman (:Yeah.
Dr Sameena Rahman (:No.
Heather Hirsch MD (:and it is a little bit of like the kettle calling the cat black or the black calling the cat, I don't know, right? Because we use so many things off-label to treat menopause for so many years that actually probably did harm. So we do harm in the name of do no harm for so long. And again, because I've had this amazing opportunity and responsibility of being a clinician doing menopause for the last decade, I have seen...
Dr Sameena Rahman (:Yeah, whatever. Whatever it is. The cat. Yeah. Yeah.
Heather Hirsch MD (:so many women benefit from HRT. And I know that we're never going to be able to have the studies that show it because it's going to cost way too much and no IRB is going to approve it. So we have to, you know, find a way to be logical that's beyond just what's actually in the textbook right now, because that's just not the whole story, but that's all we got.
Dr Sameena Rahman (:Yeah. And the reality is we're still seeing that the number of prescriptions for FDA approved menopausal hormonal therapy is still very low. It's like less than 2 % or something. And so there are people getting hormones through these hormone clinics that are not FDA approved versions. And that can be dangerous. That can give them really high levels of testosterone, give them deep voice, clitoral megal... All the things.
that are dangerous for them. there's no gatekeeping with that really, but there is a lot when it comes to this. And we're trying to dispel 20 years of myths, right? Or of misinterpreted data, I guess I should say. Misinterpreted data.
Heather Hirsch MD (:Right, right, exactly. So I think that a little bit of discussion is great, but I don't wanna harm patients and have this idea that if transromoestrogen is going to improve someone's mood, physicians should have the clinical authority because medications are prescribed off label all the time. Trazadone, gabapentin, clonidine,
Dr Sameena Rahman (:Right. Yes.
Heather Hirsch MD (:Propanolol. I mean, don't even give me a list of medications that are approved off-label. As an internist, like, don't come at me with this. Yeah.
Dr Sameena Rahman (:Yeah, yeah, absolutely, absolutely. What, and so, I forgot my train of thought. I was gonna ask you about something else. Well, okay, let's talk about the myth around the timing, because like, people are like, you have to, you know, with the cardiovascular risk and the 10 years and can someone over the 10 year from menopause, so around whether or not you can get hormone therapy if your 10 years past your menstrual period or, you know, the...
Heather Hirsch MD (:Yeah.
Dr Sameena Rahman (:the data around that because that's pretty much where people have consistently heard about, but we know that there's some data to suggest different.
Heather Hirsch MD (:Absolutely, this is another great myth especially. I love myth busting, so this is perfect for me. You know, this idea of the 10-year window is a little bit, it's a little misleading. There's a couple things that we do know. And the main premise of this 10-year window predominantly comes from the use of oral estrogen and oral conjugated equine estrogen and MPA. They really saw that there was.
Dr Sameena Rahman (:Why not?
Heather Hirsch MD (:you know, in the Women's Health Initiative, which was using this oral combination of synthetic estrogen progesterone, that there were major benefits if you started within 10 years of your last menstrual period. But I have so many patients at the collaborative, as do so many of other doctors at my practice, who were like, man, this is so unfair. I missed the window. No one is writing New York Times articles. Oprah wasn't talking about it in 2016. am I?
know, SOL. And actually, what we really do, again, is because we know that there absolutely can be benefits, especially if women are still having symptoms, which the majority of the time they do. And we talk about, you know, using low dose transdermal, bioidentical, estradiol, and prometrium, and looking at their medical history and looking if they have any what we call yellow lights, or that's kind how I teach, which is kind of those slow down when making your decision.
about it, but it's never like the door is slammed shut because it has been 10 years. I actually think there is no good data to suggest that. And in fact, even in the WHI, it was pretty arbitrary. For women who are between 10 and 20 years, there's kind of a null impact on cardiovascular disease. And it was really if you were two decades or if you were, let's say on average, 70 and up, that there was maybe some slight.
Dr Sameena Rahman (:It was arbitrary to the metric.
Heather Hirsch MD (:risks over benefits. But again, this was oral, right? So we don't really have good data on what if you're 13 years out and you're pretty healthy, you've got some seasonal allergies and you've got a frozen shoulder and a little bit of hypertension that's well controlled and lysine-approved. Can you use a transtermal estrogen patch? We don't have any really good data, but at the collaborative, we do this on an individualized basis. And you're never too young, you're never too old.
Dr Sameena Rahman (:Yep, and that's why I think it's really just so important to really remember is that those of us that probably do this well are very nuanced and precision-based. Like we're really looking at each factor. I'm sure you do what I do, get calcium scores on them, maybe a CIMT if they're passed, like when you start 60 plus year olds and you find some of them like cardiovascularly are better than some of the 40 year olds. Like dang, you're a good one.
Heather Hirsch MD (:Yeah. Yep.
Heather Hirsch MD (:Yes, yes. I know, I'm like, the more I think about it, the more I'm like, there is something in our food. You know, I don't want to admit it, but like, I think I am like, you know, you know, and I guess I'll throw in another myth of my own while we're on the topic. Or I don't know if it's a myth, but certainly I hear all the time. Do you think perimenopause is starting earlier? Do you think symptoms are lasting longer? And the truth to that is I don't know because we don't have
Dr Sameena Rahman (:I
Right, yeah.
Dr Sameena Rahman (:Hmm.
Heather Hirsch MD (:records of perimenopause from the 60s and the 70s. Like we really don't, especially because it is a clinical diagnosis. Like clinicians were not writing theses on perimenopause like I'd like to do. And so we don't have a great baseline. So part of me thinks maybe, maybe it is starting earlier, or do we just know about the symptoms now so we're more aware? You know, we don't know, but I certainly get asked that question all.
Dr Sameena Rahman (:Yeah.
Heather Hirsch MD (:the time, know, is menopause worse or are symptoms worse or do symptoms last longer? And I wouldn't be surprised if we had data that did show, we actually have data to show that the average age of menopause is actually very slightly increasing and went from like 50 to like 51 and a half. Now it's like pushing 52. But the question of, do symptoms start earlier when you're menstruating? Do they last longer? Like, I don't know, but I wouldn't be surprised.
Dr Sameena Rahman (:Yeah, exactly. And let's talk about the brain too while we're at it because that's another thing that, and even at the Menopause Society, was really like, we don't have any good data for dementia, like quit touting that it's gonna help your brain, all the things, which I think that is a confounding factor, but we know that, I guess, well, let's just talk about that because,
Heather Hirsch MD (:Yeah.
Dr Sameena Rahman (:What kind of brain benefits do we see either cognitively or mental health wise? We know women in the mid-life have such mental health issues that come up.
Heather Hirsch MD (:Yeah, you know, I can say without a shadow of a doubt that women who report brain fog, which is kind of this just kind of general word of like, it could mean either I just like I can't remember things the way I used to have to write everything down. I can't sit and write a book when they complain of that, which is actually in both of my studies at Harvard and then at the collaborative, the number one symptom that affected quality of life. wasn't hot flashes, although that's what we have the most data on. Women actually are like.
Dr Sameena Rahman (:Mm-hmm.
Heather Hirsch MD (:I gave birth and you know, had periods, I can handle a hot flash, but brain fog, absolutely not. You, without a shadow of a doubt, see major improvements in brain fog in women when they start on hormone therapy. If you're a clinician, you can raise your hand, or if you have patient that's experienced this, you know. And why it works, we're not really sure. It could be indirect, you're just like sleeping better. It could be direct, we know that estrogen...
increases serotonin in the brain. We know that estrogen increases blood flow. It increases blood flow to the clitoris. It probably increases blood flow to the heart, increases blood flow around the coronary arteries. It's not far off to think that it's going to keep the brain healthier. Now, is it FDA approved for that? No. Is it FDA, you know, do we have long-term data on this? We don't, of course we don't. You know, we have the WIMS study. That's the Women's Health Initiative memory study. They looked at women 65 and older.
Dr Sameena Rahman (:All right.
Heather Hirsch MD (:and put them on conjugated equine estrogen, and medoxyprogesterone acetate. And so a sort of worsening brain outcomes. Well, that makes sense. But what about starting women within 12 months, or 16 months, or 24 months of their last period, and following them for two, three decades? Now, all of that is going to take time. We'll hopefully be retired by then. We'll still be probably on Instagram. And our kids will be like, mom, that's... Yeah, our grandkids will be like, my god, grandma's on Instagram again.
but you know, be like, stay, we told you guys.
Dr Sameena Rahman (:Look how sharp I am.
Heather Hirsch MD (:Yeah, exactly. And so, you know, it makes a lot of clinical sense. We still need those studies and early studies are really promising. And so I think it's kind of this, this, this extreme like coming after each other is only, it's only hurting the women who are trying to make sense of all this and saying, well, this doctor says absolutely not. There's no proof of that. This doctor is saying like, definitely it does. Where the truth is actually somewhere in the middle. Like we're not exactly sure yet we're doing the studies, but it's
It's clinically, you know, seems likely and early studies suggest that. Like, I don't know why there has to be this big fight because all it's doing is making the women who are making these decisions frustrated and confused. Yeah.
Dr Sameena Rahman (:Absolutely. And when it comes to like, you know, mental health concerns, anxiety, depression, we know that increases in the midlife. When do you like, what's your thought around like, okay, we'll see if the hormones help. At what point would you say like, no, it's time for an SSRI? Because most people are getting SSRIs first. But I think most of us that are doing menopausal medicine and have they have other symptoms, we're trying to see if the hormones help.
Heather Hirsch MD (:Yes, yes, you know, agree. I do a lot of shared decision making, which means that, you know, I'm never like, this is the one path, you know. It definitely is individualized. Some patients are like, was on Lexapro before, I probably need it again. know, there are some times where you're like, okay, maybe that's, you know, not a bad idea, but I am more likely to be more prone to start hormone therapy, and that's also probably...
Dr Sameena Rahman (:Thanks a lot.
Heather Hirsch MD (:patient bias, that's what they come to me specifically for. So I'm likely doing HRT first. I usually give it, once I feel like they're on the right dose and it's therapeutic, if there's no improvement within like 10 to 12 weeks, then it might be time to do something else. Whether that's CBT or therapy or an SSRI or SNRI or whatever it might be. Usually again, I wanna first make sure they're on the right cocktail, the right dose.
It fits into their lifestyle and once we get there, if after 10 to 12 weeks, no improvement, it might be time for something else.
Dr Sameena Rahman (:I want to be cognizant of your time Heather because I know that you have other things going on. So tell us what's coming up because I and then we'll have to you come back again for some more controversies because I want to talk about testosterone controversies with you but I don't know if you have time because I know you have to get going but let's tell us what's coming up for you and what's what's happening and where people can find you and I'll put it in the show notes of course.
Heather Hirsch MD (:yes!
Heather Hirsch MD (:Yes, well, I'm so excited to spend any time I get with you because we're all so in demand, you know, and we're all, you know, kind of flying all over and giving lectures and giving talks and then raising kids and, you know, taking care of our patients and trying to take care of ourselves in the middle of all that. And I'd love to talk about, you know, and for the Cliff Notes, I probably think the same thing about testosterone as I do about some of the other things, right?
Dr Sameena Rahman (:Yeah.
Heather Hirsch MD (:Basically a lot that we know clinically and not enough that we know scientifically, but let's just, you know, use our logical brains here. But there's so much happening. So, you know, I started the class and grew the Heather Hirsch Academy and I'm having just this amazing crew of guest faculty. And so I'm excited to see more courses there of which hopefully you're teaching one. We've been talking about that for 2025 and growing that, you know, it is my dream to get thousands of clinicians trained because
Dr Sameena Rahman (:Yeah, that's a call. I mean, that's pretty impressive.
Heather Hirsch MD (:If we can train one clinician, we can help thousands of women, right? And so I just absolutely love it. I've been working on building my telemedicine platform and I've got a new book that I'm writing. I'm writing a book on perimenopause, yes! Tentatively called the Perimenopausal Survival Guide and we talk, it should be coming out next year, we talk all about like...
Dr Sameena Rahman (:wonderful.
Dr Sameena Rahman (:Please.
Heather Hirsch MD (:these different ways people use HRT and perimenopause, why that myth exists, what do you do if bleeding is the rate limiting factor, you know, all the things because honestly, perimenopause is really so different than menopause, you could write a whole book on them. And going through perimenopause right along everyone else, I am like right there with you. So, yes, right?
Dr Sameena Rahman (:me to have a fairy system.
Heather Hirsch MD (:And, you know, actually, interestingly, as of this day of recording, we're in November, I don't have any big events for the end of the year, which I'm actually kind of happy about. It's time for me to like take a breather. I really, really like to do. I'm a very big journalers. I'm kind of already in my like how did 2024, 2024 review? What's up for 2025? I also have an AI based app coming out in 2025.
Dr Sameena Rahman (:Happy.
Dr Sameena Rahman (:I don't remember you doing that, like...
Heather Hirsch MD (:Yeah, then I can chat more with when it's here. But I want to work on, truthfully, I'm just like many of you, anyone who's listening, I'm trying to work on bettering myself along this journey. I've hired a trainer and I'm squatting and I'm eating the protein and I'm doing all the things too. We're just humans. And as I'm settling in for the winter,
Dr Sameena Rahman (:Yeah.
Dr Sameena Rahman (:Yeah.
Heather Hirsch MD (:I'm actually looking forward to just, you know, work it out myself a little bit too. So we all need to do that.
Dr Sameena Rahman (:working on yourself, right? Yeah, yeah, yeah. Yeah, that's very important because we're no good to anyone else if we can't get up in the morning ourselves. So, well, that's awesome. Heather, I'm so excited that you came here and I'm going to have you come back. And I can't wait to work with you this project that we have for the spring. So hopefully we'll bring that to fruition. But thank you again. I'm Dr. Smeena Raman. Thank you for joining me for Gyno Girl Presents Sex, Drugs, and Hormones.
Heather Hirsch MD (:No, it's true.
Heather Hirsch MD (:Yes.
Dr Sameena Rahman (:Remember, I'm here to educate so you could advocate for yourself. Please stay tuned for my next episode next week.
