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139. Manage Menopause Symptoms with Oprah-featured Expert Dr. Heather Hirsch

• Dr. Adrienne Youdim

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Cut through the Informational Noise, Learn How to Manage Menopause Symptoms with Oprah-featured Menopause Expert Dr. Heather Hirsch

Perimenopause and menopause are natural phases of a woman's life, yet they are often met with silence and confusion. It is time to break that silence and empower women to take control of their health and well-being during this transitional period. 

Women are no longer accepting the lack of information and support surrounding menopause.

Heather Hirsch, MD, MS, NCMP is a menopause guru and expert who has gained recognition for her expertise in the field. She was recently featured by Oprah and her new book, "Unlock Your Menopause Type," has been highly acclaimed as a must-read for women in or entering menopause.

She believes that hormonal changes play a significant role in how we experience life, be it from puberty to post-partum, to perimenopause, and ultimately menopause. For far too long, women have not been taught enough about the menopausal transition, and she's here to break down those barriers.

What you will learn from this episode:

  • Find out the important concerns women have that can be attributed to either perimenopause or menopause
  • Learn how to distinguish symptoms attributed to perimenopause or menopause so you get the appropriate medication
  • Who are the ideal candidates for hormone replacement therapy (HRT) and who are not, and the non-contraindications to HRT?
  • Recommended medicines, nutrients, and herbal supplements to alleviate menopause discomfort


Ways to Connect with Dr. Heather Hirsch:

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Ways that Dr. Adrienne Youdim Can Support You

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Connect with Dr. Adrienne Youdim

TRANSCRIPT


THE NUMEROUS CHANGE OCCURRING DURING PERIMENOPAUSE AND MENOPAUSE THAT MOST WOMEN ARE UNAWARE OF


Dr. Adrienne Youdim

Heather, I am so excited to have you here and to have this conversation.


Dr. Heather Hirsch

This conversation about midlife and menopause, especially right now, is such an exciting one, and there's so much we could get through in this episode.


Dr. Adrienne Youdim

Absolutely. And we may even have to consider doing this part two because there is so much to discuss. But before we started the recording, we talked about how much our worlds are aligned in terms of what we do in our medical practices, both of us. Well, I don't treat women exclusively, but certainly many women are coming to me in the midlife period saying, WTF, this is not how the script was running. And all of a sudden I hit this maybe 42, even 38, 51, and bam, everything has changed in terms of everything. What they discuss with me is their metabolic health and so little is known about it.


Dr. Heather Hirsch

I see it all the time. And what's interesting is that for particularly my patient panel, they'll say to me, now that my kids are grown and now I'm actually, and now that I've got some money, I've got a trainer and I've got a nutritionist, and I have more time and I'm working out harder. And yet I still feel as though I don't recognize myself when I look in the mirror. I'm either gaining weight or it may not be numbers on the scale. Maybe the weight shifted, maybe their bra size has gone up, which actually women don't want.


Dr. Adrienne Youdim

Right. It's like, why now?


Dr. Heather Hirsch

Yeah. Exactly. So they're like, come on, I don't want these things. Now they've served their purpose. Right. Or it's the mid belly or it's whatever. And it's so frustrating for women. I think it begs to have a discussion. You're a great person actually, to have this discussion with me, because what I see is that it's no coincidence that as we lose estrogen, maybe progesterone, maybe testosterone, progesterone, actually probably not too much involved in this, but I think that that's the same time that we start to see insulin resistance and we start to see changes in adipose tissue, where it's going, how fast we're metabolizing carbs, foods, et cetera. And I see this big shift with the onset of perimenopause into the menopause transition.


Right. And I think, what I really would love to start with is, we've talked a lot about, on my podcast about, this change in hormones and how it causes not only a change in metabolism, the propensity for weight gain, uh, a shift in where that adipose tissue gets distributed, as you mentioned, more towards the midsection, less subcutaneous or maybe all around, but certainly this mid abdominal bulge that we all have to contend with at this time of life. What I would love to start with though, Heather, is this is what I love about your work. Not only debunking the myths, but starting with what are some of the things that we don't know? What are some of the symptoms that you're hearing about all the time where in your world you're like, duh, of course this is perimenopause, but you're surprised that the general public doesn't know it could be attributed to that.


Dr. Heather Hirsch

Yeah. These are great questions because when these are not well understood, women end up seeing on average, I think it's like five to seven doctors, right? Or clinicians, until they're diagnosed with either perimenopause or menopause. Some common things that I see that are common in my world, but uncommonly thought of as menopause related. Let's go head to toe. Hair loss. I wouldn't say everyone doesn't correlate that, but certainly estrogen is really good for hair, skin and nails. So hair loss, brittle nails, nails that crack, those can be signs of low estrogen. Vertigo. That's that, dizziness. A lot of people get misdiagnosed with positional vertigo, where let's say, you have dizziness when you move your head. Now there is certainly, there are certainly different etiologies at these. So I don't want to say all of this is estrogen.


Sure. But vertigo, interestingly, patients will come to me after seeking out lots of different care, vestibular rehab and will try estrogen. And that will work. Or even tinnitus, which is ringing in the ear that can be related to menopause. And again, you know, to clarify, not always, but sometimes if you've already ruled out other things, palpitations. Now, this one, I think is getting a little bit more well known. Oprah talked about this on the Oprah Daily panel about how she had heart palpitations. But most women end up going to their internist and then they get a holter monitor and then a cardiologist, and they do all this workup only to be told they have benign palpitations. Interestingly, and also, estrogen plays a huge role in that. So bloating, constipation, slow transit, slow gut. These are not necessarily just related to estrogen, but at the same time as we lose estrogen, we have other indirect changes in our life.


We may not be sleeping well. We may be gaining weight because of emotional eating or binge eating,because it's also the sandwich time when you're dealing with kids and spouses and pets and houses and all of those things. Uh, uh, some other one, joint aches and pains. Now this is really common as well as we age because of osteoarthritis or bone on bone, but there are estrogen receptors in your joints and joint aches and pains is even known to be menopause-related. It's on a pre-validated score that we use called the MRS, the Menopause Rating Scale. And for many women, but not all, again, when we replace estrogen, that can help with the joint aches and pain. So those are some very obvious ones to me. That's crazy. But may some mean takeaway.


Dr. Adrienne Youdim

Can I just interrupt you to say that I never knew there were estrogen receptors in our joints? This is, and then you followed that with, this is very obvious to me, and yet i am a practicing physician for almost 20 years. Never. Yeah.


Dr. Heather Hirsch

Yeah. So, you know, that's great because I also need to be reminded that the world that I'm so deep in, or the world that you're so deep in, we start to almost assume that like, well, everyone knows that, right? Everyone knows hormones don't cause cancer. But it's always great to be reminded that even though I may have said these 10 or a hundred times or even thousands of times to my patients, still, that's why we are podcasting and meeting and educating women around the globe with these connections, with these shows, et cetera.


Dr. Adrienne Youdim

Yeah. No, I love that. And I just do want to point out that, and you mentioned this, but I want to reiterate it, that some of these symptoms have a lot of potential causes and can be serious. So the point here is not to shrug our shoulders and attribute heart palpitations necessarily to menopause, but to know that after we've done our due diligence and you're kind of scratching your head saying, what the heck is wrong with me? That is certainly, once you've ruled out the scary things, as we say, it certainly can be related to something that is natural and benign.


Dr. Heather Hirsch

You Got it.


PROPERLY DIAGNOSING SYMPTOMS OF MENOPAUSE OR IDENTIFYING OTHER CAUSES


Dr. Adrienne Youdim

A question that comes to me frequently by my patients is like, how do I know that this is menopause? And so it's related to what we were talking about or perimenopause. Oftentimes people want blood tests, but then it's like, what do you do with that? Can you talk about maybe even this, the validated screening score that you mentioned, lab tests, why they're helpful and why they may not be?


Dr. Heather Hirsch

Absolutely. So one of the things that's really helpful as a listener to the show is, if you could start tracking symptoms, periods, that is gold. You have no idea how gold that is, that is your labs right there. We want to know as a clinician, and, and I'll explain why labs aren't so helpful, because women often feel very dismissed if their doctor says, oh, I don't need your labs. It's just, it's all good. And you're, the patients are left like, well,no one is helping me. So like, there's gotta be something. I will figure this out myself, right? So I offer labs to my patients because I can interpret them. But perimenopausal, if as a woman you're still having periods, and if you're not having periods because you have an IUD or an ablation or hysterectomy, listen up too, because this is still really helpful.

If you're still having periods that's perimenopause and at any given time your labs could be up to the sky or down to the floor. And so they're not helpful in diagnosing. What's helpful in diagnosing this is this history of, I get hot flashes two weeks before my periods, or I get insomnia right when I'm ovulating or, my periods are starting to skip. And so they're every 36 days and 72 days, then 15 days. So that journaling is going to give you the diagnosis of perimenopause. Perimenopause is what we call clinical diagnosis. I'm the clinician, decide. And so that's really why lab work isn't very helpful. Now, if you don't have periods at all IUD or hysterectomy or ablation, the one and only lab that could be really helpful is to follow the follicle stimulating hormone or FSH levels that start to go up and up and up and up and up and up past 35.


That might mean menopause. And then the next question you asked, which is really important, is, how can I tell if this ringing in my ear is menopausal or if it's a virus, right? Or viral? Both of those are completely different etiologies, you can go about this a couple of different ways, but let me tell you an example of a patient I had. She had tinnitus, she'd seen her doctor and she'd done vestibular rehab and nothing was helping her. She said, I'm meeting with you and I'm also going to Mayo Clinic. I'm flying out to Mayo Clinic to figure out what this is. And I'm meeting with an ENT doctor. I said, okay, do you feel comfortable trying hormone therapy for six weeks just to see? And she said, yeah, I don't mind that at all. I will do anything to get this to stop ringing.


And that's why I'm seeing you, Heather, is because in my own little investigative research, because my internist, didn't couldn't help me pass that. I thought I saw it was hormonal. I said, well, why don't we do this before you book that flight to Mayo Clinic, why don't we try an estrogen, postmenopausal estrogen patch and see. And she came back to see me in six weeks and she's like, it's gone. And I said, this is great. This doesn't always happen. This is wonderful, but now you can cancel that clinic. But I said to her, that trip, right? I said, if it doesn't help at all, then take that trip because you know it's not hormonal, you've crossed it off the list. So truth be told, the way to know if it's hormonal or not is in my opinion, I mean, but I'm not the hormone doctor, trial HRT, because that is giving you back your hormones, right?


Giving you back your estrogen. Similar to a thyroid disease, everyone either knows someone with hypothyroidism or has hypothyroidism. So common, imagine if for all those people who are hypothyroid, we said, well, we have thyroid medication, but we're not going to use it. We don't want to give it to you. It could cause problems, it could get too high and there's risks, so we don't want to give it to you. That's silly, right? So the same thing of menopause for some women it is just like any other endocrinopathy and when we replace it, it really does help. You could also argue you could come at this the other way that she could go to Mayo Clinic first and then come back if that didn't work. But the argument about trying HRT first is that it is so simple. It is so easy and it's so fast and I guess that actually may not be true. As I say that out loud, I'm sure some of your listeners are like, whoa, Dr. Hirsch, I don't know that you think it's that easy to get an estrogen patch for tinnitus, but at least listen to my logic, that's how you would know.


Dr. Adrienne Youdim

Okay. So let's get into that. I recognize that we kind of jumped over a lot of things that we could have talked about because you are so the nuts and bolts person that I was like, I want nuggets for my listeners.


Dr. Heather Hirsch

You Got it. So


Dr. Adrienne Youdim

Let's talk about treatment because we've certainly seen the pendulum swing and now starting to swing back. I believe I'm a little bit older than you. I remember when in medical school I was being taught that everybody, like the instant they smell menopause should be on TRT. I remember, I mean, it's funny, I think this is a total aside, and maybe it's going to prove my point that I think I've always had ADD or ADHD. I was growing up in this timeframe I'd be diagnosed. So the point being that I don't remember anything I was told in college or medical school. I don't remember learning anything in class. But I remember the moment that they were like, all women need to be on HRT and that neuron is still firing in my brain.


Dr. Heather Hirsch

It was like on that day, right?


DISPELLING MYTHS ABOUT HORMONE REPLACEMENT THERAPY[HRT], WARNING ABOUT COMPOUNDING MEDICINES AND PELLETS, AND WHO IS AN IDEAL CANDIDATE FOR [HRT]


Dr. Adrienne Youdim

Yeah. Then fast forward, I'm in residency and the studies of the WHI came out the Women's Health Initiative where there were like, oh my God, nobody should be on hormone replacement therapy because everyone's going to have heart attacks and get breast cancer. And then all of a sudden overnight it all dried up. Nobody was getting prescriptions, and now we're entering that realm of recognition of menopause. But people, practitioners included, are afraid of prescribing. So can you talk a little bit about that journey that HRT has taken your current position on it and a little bit more about how it can be prescribed or how it should be used?


Dr. Heather Hirsch

This leads right into where we are today, which is a lot of unregulated, compounded injections or pellets that are really, really harmful. But the onus is on the medical community. I always say patients will come to me and they're like, Heather, I did those pellets. And I know. And I'm like, it's okay. I post a lot about the dangers of them because I have to scream really loud because they're all so really loud. But, I was, in 2005 or six was my first year of medical school, and that's when I learned that HRT will kill you. But that neuron of like, everyone gets HRT as soon you can smell it. I wish I don't know what life would be like if I had experienced both sides, because I'm sure that was very traumatic to go through.


Since then, because of how far and deep and widespread the biases about HRT were, since then, that's where we had the leeway, the door open for all these unregulated things because women were like, I feel like, there has to be something better here. And then the Vitality Clinic was like, well, we will restore that. But the problem is, is that FDA approved hormone replacement therapy is extraordinarily effective and extraordinarily safe, and I don't have too much time to get into that. So we could talk about why I think it's safe next time. And not only that, but it really stand in stark contrast to this unregulated, and these injections like pellets are actually really dangerous, but there's information overload. So women now in 2023 can go on TikTok, can go on Instagram and they can get easily influenced and swayed.


They can also easily get influenced on a Facebook group where someone's taking a pellet and like, I'm having sex every day and I feel like I'm 27 who's like, yeah, I'll sign up for that. And it's not the same thing in that study that tried to kill people, right? Yeah. And so if doctors also are relaying the message, which many of them still do, which I still can't believe, like I still live in this world where I found it hard to believe, but my patients remind me where they say I won't prescribe HRT, like literally I won't, they don't even know what they're talking about or that it's going to give you breast cancer or give you heart disease. We are harming women, which is one of the reasons I love being a menopause doctor, and I'm happy to really dispel the myths about compounding and pellets. And that's my story and I'm sticking to it.


Dr. Adrienne Youdim

I mean, this really needs to be reiterated because there is this sense that compounding products and formulations are safer than FDA approved drugs because we hate pharma or whatever the narrative is. Yeah. And nothing could be further from the truth that FDA regulation means that there's certain rules and regulations and checks and balances. That what we say it is, it really is. And that all these other things like compounding pellets, we don't really know what is in there because it's not regulated. And we don't even know that the people who are making it have access to the tools or the screenings to determine what is in that compound. And so the pivot should not be from western medicine or from FDA approved drugs to compounding pharmacies. The pivot should be from physicians who don't understand HRT to finding a physician who does.


Dr. Heather Hirsch

Beautifully said. And I want to make clear, this is a good time to say this, is that yes, I'm a big proponent of FDA-approved hormone replacement therapy, but I don't want women to feel as though all is lost. If they can't or they choose not to, we can, that will be part three. There are certainly other options, but the reason I talk about this so much and want to really answer those questions is exactly what you said. We don't want people to turn to the other side of the coin, which is actually in truth, much more dangerous, much more costly. It is unregulated. And it's scary because the pandemic really, I think, add fuel to the fire of medical mistrust. And then of course, like this study on hormone therapy, which came out 20 years ago, it is still leaving its footprint in the sand of mistrust. And so I have created a course for providers like an online course, and I've had like, just a year 45 or so people go through. But , when I'm not seeing patients, I really do try as hard as I can to educate our clinicians. And even if it's, because they saw me on Instagram or TikTok, like the new, the younger doctors hopefully might also start to realize like, I can't just ignore this and I'm interested in this. And that's a great, great shift to see.


Dr. Adrienne Youdim

I know we can't get into all of this and as you're talking, I'm trying to pace myself with all the questions popping up in my head. Breath, Adrienne, pace yourself. But can you tell us maybe who is the ideal and there's variations, right? So I don't want to make you tell me a one-size-fits-all prescription, but you do this enough that you can see the patterns. So can you start with who's the ideal candidate for HRT? Who is the slam dunk? And then can you also specify the people who should be wary or ask more questions before they dive in headfirst?


Dr. Heather Hirsch

So NAMS, the North American Menopause Society, and I agree with this completely that truth be told, most women are candidates for hormone replacement therapy, especially if it started within 10 years of your last period. And especially if you have no known contraindications to estrogen. Now, this is the part that gets people tripped up because doctors have told them they have contraindications when they actually don't. It's actually much easier to tell you who should stay away from hormone therapy. The list is actually really short. So if you have active breast cancer, if you have a recent history of estrogen receptor positive breast cancer, in caveat, I have some breast cancer survivors who do come to see me to discuss HRT. So even that in and of itself, it's not necessarily that the door is completely slammed shut because we let women who have breast cancer get pregnant if that's what they so desire, right?


Okay. Next, is if you've had a blood clot, specifically an unprovoked blood clot, a clot in your lungs, a life-threatening clot, those are usually like red flags and candidate, not good candidate, active liver disease. And when we say active liver disease, we mean like cirrhosis, not fatty liver or a little bit of a S T A L T. That's a little like medical jargon, but we're talking serious liver disease, recent history of a heart attack, and we mean an NSTEMI, Non-ST-Elevation MI was caused by a clot, not vasoconstriction or vasomotor disease or other kinds of heart conditions that are actually more inflicted by stress. Those are actually, and then unexplained vaginal bleeding. If you're having unexplained vaginal bleeding, that needs to be worked out. But those are like, that's the short list. Those are the hard facts. Everything else, yes.


Dr. Adrienne Youdim

Or contraindicated.


Dr. Heather Hirsch

Everything else. Here's some big myths. Family has a history of breast cancer, not a contraindication to HRT, that's silly. We don't take your ovaries out unless you have a genetic mutation. And even then, if you don't have cancer, we actually talked to you about H R T, but a family history alone in a woman who has no cancer is not a contraindication to hormone therapy, metabolic syndromes or the, the makeup of metabolic syndrome, which is high blood pressure, high cholesterol, obesity, high blood pressure. Did I say that one twice? Diabetes. I said them a bunch of times. Your listers probably know those, those are not contraindications to hormone replacement therapy. Now, ideally, we want to get those under control, if they're really out of control. But actually, and you might think I sound like a crazy person, but sometimes when they're controlled and we say start HRT, it can really solidify that control. There is nothing helpful about hot flashes and blood pressure, let me tell you.


Dr. Adrienne Youdim

And poor sleep and sleep disruption.


Dr. Heather Hirsch

And there's nothing helpful about sleep disruption. And that's one of the things when we opened, even talking about how estrogen can change insulin resistance, how you're not sleeping. These can change weight, right? The first thing, I mean, it's always on people's list is weight. And, these things, metabolic arrangements all play a role in that. And these are not contraindications to hormone therapy. Does hormone therapy cause weight loss? Not necessarily. However, I do find that my patients when they do start H R T, they feel like the work they're finally doing is starting like their metabolism's like alive a little bit, right? You're not going to miraculously lose weight like you would with a semi glide, but you will start to feel like your body is just kind of jiving a little bit better. And there's data to show that women who take H R T gain less weight compared to women that don't, who cares about that?


There's data to show that women who take H R T have less diabetes. And that's what we care about. Because that's, to me, proof in the pudding that diabetes is when your insulin resistance goes up. And there's proof to me that estrogen and insulin have this sort of relationship and when one sort of retires the other is a little sad, I guess to explain it. A family history of blood clot, that's not a contraindication. People ask me about that all the time. That didn't happen to you. And certainly, of course, these are conversations that we have and sometimes we do lab work, but at face value, high blood pressure, diabetes, a mother with breast cancer, none of these are contraindications to hormone therapy. You probably were told they were, but they're not.


THE FOUR THINGS HRT IS FDA APPROVED FOR AND THE MANY MORE BENEFITS IT HAS AND HOW LONG IT SHOULD BE TAKEN


Dr. Adrienne Youdim

Yeah. I just want to say, I feel like I have to just put in this plug that although Heather and I are doctors, we are not your doctor. And so this is for education for professional purposes only, but yes, use it as a point of reference to find someone who knows this information well and who can counsel you properly. So, those are the people who are potentially slam dunk knows, and not slam dunk knows who are the ideal candidate or what are some of the symptoms that you aren't finding that you can manage in alternative ways or rather not because HRT is so effective. What are those circumstances?


Dr. Heather Hirsch

Well, you know, H R T is FDA approved for four things, hot flashes, night sweats, osteopenia and vaginal dryness or genitourinary syndrome of menopause. And in a woman whose relatively healthy, hormone replacement therapy should be the first line option.


Dr. Adrienne Youdim

Say those again.


Dr. Heather Hirsch

Hot flashes. Yes. Night sweats, genitourinary syndrome of menopause or a.K.a pain with intercourse, vaginal dryness, urinary tract infections and osteopenia. Or the beginning stages of bone loss. It should be the first line , for far too long. And you recall when hormone therapy dropped off and no one prescribed it anymore? Right. And there was this fear for far too long, antidepressants have been the first line, and that is first of all, besides for Brisdelle 7.5 milligrams, which is Paxil and SSRI, there are no SSRIs or SNRIs that are FDA approved to treat hot flashes, night sweats, vaginal dryness, and osteopenia and estrogen hormone therapy should be the first line. If your doctor pulls out though, well, we could try Effexor or Venlafaxine or an SSRI. That is not the first line. There's a new medication called Veoza which is coming out on the market very soon.


It's been FDA approved to treat hot flashes. And this is not an SSRI or S N R I, and I'm excited about this because it's nice to have a non-hormonal option, but is it going to help with bones? No. Is it going to help with vaginal dryness? No, absolutely not. Is it going to help with hot flashes, maybe sleep, because it's helping the, basically the night sweats. So, if I leave you with anything, it's really that hormone replacement therapy, FDA approved hormone replacement therapy. Many women are good candidates. They've been dragged along for far too long to be told that, no, you're not a candidate because of X, Y, or Z. Or they've been told by their Facebook friend, you should get this pellet injected. It's not really hormone therapy, it's just a massive amount of testosterone. That's not what we want.


Dr. Adrienne Youdim

In your tush.


Dr. Adrienne Youdim

Jammed in your tush. And I even have a whole course too where I actually help women write out their health goals and learn about their history and their family history, and actually spit out what their H R T regimen would be and, and how to go to your doctor to get that regimen. And it's helped a lot of people. But again, there is this new medication Veoza. There are vaginal estrogens that are not systemic HRT that can help with dryness. There are many medications for bones. If that's the problem. So there are other ways to put this together. I just want to continue to spread the message that many women are candidates and it doesn't cause weight gain. In fact, it can actually really help decrease, well, it can help decrease the risk of cardiovascular disease, if started within 10 years of menopause. So there's many, many, many benefits not just to the waistline.


Dr. Adrienne Youdim

Yeah. And how long would you recommend treatment? So when is the discussion about when to stop or taper down?


Dr. Heather Hirsch

In 2015, the Menopause Society came out with a position or a statement that said, there is no longer any specific stopping point to H R T and that it really should be shared decision making, especially when it started within the 10 years. So I tell all my patients that it's a shared decision making journey. I'm never going to pull it away from you. So long as you're up to date on your screening and you're still a good candidate and meeting your health goals and et cetera, et cetera. No side effects. And I have patients across all spectrums. I have patients that after one, two years they would like to wean down. And I have patients that say, never take this from my cold dead hands. And I work with my patients to use shared decision making, making sure they're staying healthy and they're safe. But it's really individualized.


Dr. Adrienne Youdim

But I think, the take home message is that medically, we don't necessarily need to yank it after X many years in order to keep people safe.


Dr. Heather Hirsch

There's some data even to show, and I believe this, that the year when you come off, there's actually some endothelial or vessel cell instability because it's kind of had this estrogen. So I used to, when I would do these grand rounds, I would always this doctor and say, you know, Dr I have this 83 year old and she's still on her hormone therapy and she will not stop. And I'm like, leave her alone. Like, you're going to do more harm taking it off at this point. Like she's outlived at this point, breast cancer's from age, at this point the highest risk of a blood clot in the first six months. Leave her alone .


Dr. Adrienne Youdim

Maybe she's having great sex at age 80.


Dr. Heather Hirsch

I hope so.


Dr. Adrienne Youdim

No doubt. And so I , please, please leave her alone. But on the flip side, I had this patient, she lived in northern California. She came to see me in Boston. She's like, my doctor won't let me come off of it . And I'm like, that's silly. She's like, they just kept shaming me if I came off of it. So I was like, let's wean you down, let's see what happens when we go to the next lowest dose. So she goes to the next lowest dose and she's like, I feel the same. I said, okay, what do you want to do now? She's like, I still want to keep, I want to try and get off it. Okay. So we went to the next lowest dose and she's like, oh no, I do not feel good.


She's like, so let's go back to that middle dose. So interestingly, like in this scenario, I think it can go both ways. Most of the time doctors are trying to rip it from people because they're afraid. I don't know what they're afraid of. We have an emotional fear, not a logical scientific fear. Yeah. But also I also want to present the other side of the coin where if my patients say I would like an opportunity to see how my body is off of this, then, women should be allowed to do so. And I've actually had plenty of patients come off after three, four years and feel pretty good. Maybe they take some ashwagandha in their sleep or add more plants to their diet, have a more plant-based diet to have those phytoestrogens to reduce hot flashes.


And they're great and they feel like they got over the hump and they are still going toget a lot of metabolic benefits from the 2, 3, 4 years they were on it. So to each their own, we cannot shame women for X, Y, or Z And also, I don't want women to feel ashamed for doing pellets or doing compounded hormone therapy. I completely understand the route of arriving there, but also I still want to be the one or I would apply to put myself out there because trust me on TikTok, I get all the mean comments to really remind you thought that this actually could be dangerous and that there are other options. And that's a whole story in and of itself.


WHEN TO STOP TAKING BIRTH CONTROL


Dr. Adrienne Youdim

Right? Yeah. And I love this conversation because I think it is debunking a lot of myths in terms of absolutes of how we can or cannot treat something that is so very common. And the bottom line is here's some information to broaden your view, either for or against or for short-term use, whatever the case may be. But broaden your view in terms of treatment and again, finding a practitioner or a clinician or let's just say a physician because that's really what it comes down to. Who knows their prescribing and who knows this topic. I have a question for you. This comes up a lot. What about people who are in that age range of perimenopause slash menopause? They have been on birth control forever or they have an IUD and it's just kind of hanging out and the question always is, well maybe I'm in perimenopause or menopause, or maybe I'm past it and when should I stop the birth control or should I just take the I U D out and see what do you advise in that scenario?


Dr. Heather Hirsch

Well, the IUDs are a little bit easier because if you have an I U D, you can check an F S H level, that molecule stimulating hormone level I talked about a while ago. And if that's over 35 on several occasions, you know, you're in menopause and then you could take the IUD out if you're no longer needing contraception or if it's still releasing progesterone, if, and you want to do H R T, all you need is to add a little bit of maybe an estrogen patch or an estrogen gel because you have the progesterone protecting your uterus. So if you're on birth control pills, it's actually a different story. You can't check in FSH because an FSH will always be falsely low. You could be 105 on birth control and your FSH will be too. It will, say this, this woman's not postmenopausal in that scenario. A woman could take birth control pills if she's otherwise healthy up to age 55.


And I always tell my patients when they come to see me that they've got a couple of options they can stay on it, which I would only recommend if they're symptom free and they're doing great and they're just like, don't take it from me. I have those patients that are like, can I have for one more year? And again, shared decision making. And that's when you want a skilled physician. If they're having symptoms or if they want to know they're in menopause, the only way to really know is to stop it. And you can check in F S H after about two or three months. Now your doctor should know this. You shouldn't have to memorize this, but case be told the fact of the matter is you may be telling your doctor, but, and then you can check an F S H after those birth control pills have almost left the system for about two months.


And the third scenario that I do with my women is , this is because women are often seeing me specifically from symptoms, right? So this is now a little bit more just what I see clinically as that bias. But they'll just come right off their birth control pills and go right on post-menopausal hormone therapy. And I'll say, we may never know the exact day, the exact time menopause struck, but you'll be able to tell your daughter and your kids that, you know, at 52 you went from birth control pills to menopausal hormone therapy and you felt better. So it was somewhere in that average age of menopause. So we might not get to know, but there's no trophy really. And that's really what I say. I know I could talk forever. So I hope I haven't lost you guys.


Dr. Adrienne Youdim

No, there's so much important nuggets here. We talked a little bit about pellets and compounding. And I want to be mindful of the time because we've been chatting for a bit, but can you speak a little bit about herbal preparations, supplements, things that have maybe some evidence or those that really people should stay away from because of potential harm?


RECOMMENDED HERBAL MEDICINES AND SUPPLEMENTS TO COMBAT DISCOMFORT DURING MENOPAUSE


Dr. Heather Hirsch

So when it comes to supplements that I recommend especially for menopausal symptoms, I really like ashwagandha root. It's a really, valerian root or lavender. Lavender is not necessarily an herb that you're going to ingest, but as a soothing scent. So there are some properties in those herbals that are really quite calming. They're really good at bedtime. There's some great sleepy time, even menopause teas that will have some of those in their ashwagandha, magnesium. Those are really nice for resting and relaxing at bedtime. When it comes to a supplement specifically for something like hot flashes, I think black cohosh has got the best evidence. And black cohosh is often, sometimes the main ingredient, like maybe Ambrin or Estrogen. These are brands that you can buy but what you're really looking for is black cohosh.


I'm not a huge fan of anything. This is proprietary blend on it because that just means I don't know what else is in there. Right? But I'm definitely not an integrative medicine specialist. But I do know a couple, if your listeners are really interested, but I really like black cohosh. In terms of supplements and vitamins, I'm really a big fan of the basics Vitamin D for bone health and getting calcium in your diet, if possible as opposed to supplements, magnesium, B12, B vitamins. Those are great supplements that I really, really like to stick with. And I think some of the herbals can be very, very soothing. I don't necessarily think that they're going to help if you have full throttle menopause, like if you are in the thick of it.


One of the things I just want to kind of as we're summarizing and looping back, like if a patient is having severe hot flashes that is affecting our quality of life, it's actually unlikely that black cohosh is going to take them away for a long time. And over the time that the woman is suffering or sticking it out because society tells us that, that's what we should do. Your health can be really derailed. So my sort of thought on supplements and herbals is there are some great things, and if they help, they help. But if it's at the point where this is a physiologic process that is really derailing your health, seek care, seek treatment. Women do not have to suffer. This has to stop.


Dr. Adrienne Youdim

Yeah, good advice. What are some last pearls or the takeaways that you think people really should know?


Dr. Heather Hirsch

I really want people to know that the myths about hormone replacement therapy are just that. And there's been so much new data since the study that came out in the early two thousands and actually a lot of information from that study really showing how safe estrogen and progesterone replacement can be. And there is bioidentical, I know that's a word, people like FDA-approved hormone therapy, that's just estradiol. And I really am working hard on the mission of continuing to educate healthcare providers because I can't do this in a funnel and I always call on my army of women. I say, because I do think that this generation of women are pushing clinicians to say, I could use some CME on that, or I think maybe we should have a grand round on this because my patients are asking about it. So women being proactive, even if it's painful at times, is helping. So, menopause is a big physiologic shift and it can cause we've talked about a plethora of symptoms in this show alone. Some that are obvious, some that are less well-known, some that you now might see why weight gain or a sluggish metabolism makes sense because of the loss of estrogen. And this is a head to toe universal process. We should be talking about this more and women should be better prepared to handle this transition.


Dr. Adrienne Youdim

Yeah, I love that too. And thankfully, your medical services are available in many states. You do telehealth. If people are interested in hearing more about you learning, more connecting, and also your book just came out, which I'm so excited to dive into, where can they find you?


Dr. Heather Hirsch

The best place is over on my website, heatherhirschmd.com and all of my socials are @heatherhirschmd. I know I made it really easy and I have so many resources all the way from my YouTubes and my reels and TikToks all the way up to courses and seeing me as a patient. And I am trying to get more and more and more states. And it's just so exciting because the days where I see my patients,I see my patients Tuesdays, Thursdays right now and it feels my heart with so much joy. I love what I do. I love helping women. I say I don't deliver babies anymore. I'm actually an internist, but I started as an ob gyne but I help women be reborn and it's just a wonderful thing. And I'm sure you feel the exact same way.


Dr. Adrienne Youdim

It is joyful to connect with patients and to help with common processes and problems that we all invariably are dealing with as women. So agreed. We will put tags to all of that in the show notes. I definitely want to have you back again. Thank you so much for spending this time with us.


Dr. Heather Hirsch

My pleasure.




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Adrienne Youdim MD

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