The Misunderstood Journey of Menopause and the Truth About HRT with Dr. Heather Hirsch and Dr. Jenn

Foreign.

Hi there, it's Dr. Jen. Welcome back to another episode of the Keeping Abreast podcast. I have something really. I know I say this all the time, so, like, my credibility is probably shot, but I have someone so, so, so special to you today. Let me just say that I think I bring you a lot of special people and it's always a goal of mine. So maybe my credibility is in shot, but this woman is especially special. She has a fascinating journey and how she got to where she is today. And she is really changing the face of care in an area that has been so long neglected and needs attention and the tender, loving care of this brilliant woman. So I am going to introduce to you Dr. Heather Hirsch. Dr. Heather Hirsch is at a physician who was trained in internal medicine but did a fellowship in. In midlife and menopause. And that is where your focus is. You wrote your first book, which was released in 2023, unlock your menopause type. And we want to hear all about how that's going. But first, Heather, welcome.

Thank you for that extremely kind introduction. Like, that really hypes me up.

So thank you. I am, I am admittedly starstruck. I've been. What does Nasha Winters say about me? She says that she is quietly stalking me. So I'm going to pay it forward and telling tell you that I've been quietly stalking you. And I know how brave a move you made, right, Because I walked away from big academic center, big job, big salary, to do the right thing. And you did the same thing. So let's start with sharing your story. Like, let's hear about what you did and why you did it.

I would love to. Well, I love the silently stalking. I bet I should think about the people I silently stalk. There are definitely some, mostly probably in the, like, finance and, like, entrepreneurial space, you know, So I always wanted to take care of women. I always had this love and this passion for women's health. And I think I intuitively realize that women are so different than men. And that sounds, like, obvious, but I. I think even like being younger. I just even thought the fact that we had periods was just like, so crazy, you know? So I started my career in OB gyn. I did a year and a half of that, and that was probably the first act of bravery. Although at the time, I probably thought it was not bravery. I probably thought it was some kind of, you know, early life crisis. But I left my ob GYN residency because I didn't feel like I fit in there. And I then transitioned to internal medicine. And it was actually that transition that was so crucial for me because during that transition, I sort of became the go to colleague that all my internal medicine residents would ask questions to me about, can I get this pregnant lady Colace? Or is, you know, aspirin safe during pregnancy? Or how do you treat a yeast infection? And I was just like, you guys, this is easy stuff. You should know how to do this. And so I went on to do. Interestingly, you'll find, but with that, we.

Do have major holes in our education and we have so overly compartmentalized that you can understand how that happens.

Oh, yeah.

And I don't know if you know Tabitha Barber, but she is someone who, you know, was at an academic center practicing obgyn, and she hit an impass because she realized that people think of obgyns as hormonal experts, but the truth is that they are surgeons. That during your four years of ob GYN training, you get very little in the way of hormonal management. And I'm sure you know that more than anything right now.

Oh, yes. I. I always kind of jokingly will say, and. And for any of you listening who are OBGYNs, I say this so respectfully, but, you know, like five medications, you know, one for blood pressure and one for anxiety and birth control pill. And. And that's really. That's really the extent of, you know, the internal med. Right. And so there's not a lot that you get because, you know, obgyn have to train so much in obstetrics and surgery, so there's only so much one human can do.

Yeah.

But I was going to say, interestingly, I then thought I was going to go and do an oncology fellowship because I thought, oh, I'm going to become a breast cancer doc. That is my calling. Like, I love taking care of women. I left OBGYN and I was doing rotations with someone named Dr. Silverman in Cleveland at Case Western. And I thought she was lovely and brilliant. And I would go into the room as the resident and, you know, say, how is your sex life? And they were like, I don't know, lady. And I was like, well, how are you sleeping? They were like, well, terrible. Why do you care? And I was like, you know, how is your mood? And they were like, it's awful. Why are you asking me all these days, so interested in the whole person? And it was actually my mom that said, I think you're really interested in, like, the whole person. Maybe not just breast cancer. So I ended up doing fellowship at Cleveland Clinic and, you know, spent the two years really looking at the ins and outs of hormone therapy and the evidence based information that is, is, is hidden in plain sight. And I was just so amazed at how little I learned about this very, very vital transition. So, long story short, I worked at academic centers for over six years and I decided to leave because I was gaining this entrepreneurial spirit. I had started creating courses in 2019, 2020. I had a podcast in 2018. I had so many ideas because just like you were referring to, I saw a lot of gaps in care and I had ideas of my own on how I could improve these gaps, how I could make care more efficient, more accessible. And so leaving academics was really hard because there's kind of this idea that you're only a credible physician if you work at an academic hospital. And not only did I want to not be the quacky doctor down the road, but I didn't want to be the quacky hormone doctor. You put those two things together and, you know, there's just a high likelihood of, you know, you just don't know what's on the other side of the door. But, you know, since actually ripping off the band aid and starting my own private practice, mostly via telemedicine, and now expanding that and doing courses for clinics and all of these things that I've really wanted to do, it has been so amazing. And I love inspiring other physicians, other healthcare professionals to do the same.

So I want to go back to that quacky hormone doctor comment that you made, because we really have set the stage for that, right? Because with the Women's Health Initiative, everyone kind of came away from that with hormones are bad, right? There's no benefit to hormones in anyone. And that if you did that, you were not only a quack, you were dangerous. Right. And then when the data actually came out and when the study was retracted, it like fell on deaf ears.

Deaf ears. It's like, yeah, we're like the New.

York Times retractions, right? Like, everyone only hears the false information when the truth, when the truth comes out, it's like a bell that you can't unring.

Yeah, right, exactly.

And so how, how do you think we should tackle that problem? Because decades of women have suffered.

So I think that we have started to do this. Me personally, there's two big ways that I know of. One is activating the army of women. And actually I get asked this question quite frequently, which is, you know, other. Why do you think all of a sudden there's this menopause movement. And I think that it's not so much coming from the medical establishment, it's coming from women being on their phones, being on social media, starting to open up the discussion about midlife and menopause, especially during the pandemic. Then you sprinkle in some social media doctors and you had a recipe for success. So one is really advocating on social media, which I have, you know, started to do and have been doing for the last couple of years. And then the second is really educating and re educating our clinicians, which you know, I'm so excited that I get to do this in kind of my own way. So now I have a course for providers called how to prescribe and manage hormone replacement therapy with confidence and ease. And I have to tell you that as much as I appreciate and I really, you know, I'm a part of the national and professional societies here in the United States where we practice, but there just still is not enough focus on the nuts and bolts of exactly how to clinically do hormone replacement therapy. Know steps aside from the big research and the big ideas about hormone therapy being safer and effective. We need people on the ground, we need clinicians on the ground who can safely prescribe FDA approved hormone replacement therapy because the quacks grew out of the failure of the medical community to adequately Counsel women on FDA approved hormone therapy since the WHI came out 100%.

I mean I finished my fellowship in 2003 and you know, that's just when those, those findings were released. And so you know, the person who trained me, which for all intents and purposes, I mean he was one of the first guys in the country doing breast only surgery. He kind of coined what that whole field would, would look like and what, what it looks like today. You know, he was a Harvard guy, general surgery trained, but decided that its own discipline and made it that way and did, you know, developed a fellowship and I was the first fellow to come through his program and you know, he taught me that hormone replacement was for women that absolutely, positively couldn't live any other way. And if you were to give it to them, it was the lowest dose for the shortest amount of time. Right. And that, and that prevailing theory still exists today all over the US all over there's there are doctors. I mean, of course I know my space is a little more controversial because I talk about doing it in the breast cancer population. I mean people think that I am crazy to talk about hormone replacement in the breast cancer population, but the truth is that like they're people too. And why should they suffer?

Mm.

Because they're suffering.

They're. They're suffering. And I feel like, you know, that population feels as though the menopause movement has, you know, come and left them sort of in the dust, like they have no options here. And we could definitely talk about that. I prescribe hormone therapy to breast cancer survivors all the time.

Yeah.

They come to me saying that they're thinking about ending their lives. They're, you know, having such difficult mental health. Stressors, haven't been sexually active, you know, are now riddled with lots of chronic conditions and diseases and all because, you know, we've had to, you know, protect the boobs, and yet we forgot about the body behind it. Which is exactly why I think when I was doing my fellowship, my. My thinking about fellowship. Right. And I was rotating with the Breast cancer clinician, Dr. Silverman, I was like, wait a second, there's like a human behind those boobs, you know, and it's silly to say, but it's true. And actually, there's not even been a lot of data that's shown that hormone therapy is particularly dangerous after breast cancer diagnosis. It's just a knee jerk emotional response that we have. You put estrogen, which is already emotional, and breasts, which is already emotional together, and you probably have the most emotionally charged conversation and logic just goes by the wayside.

Yeah, yeah, that's exactly what's happening. And I also think that it is somewhat tethered to the pharmaceutical industry in that. And I understand that even bioidentical, like, we're still talking about synthetic hormones and that is the pharmaceutical industry, but the much louder noise is the pharmaceutical industry in the cancer space. And they, because they have anti estrogen drugs, they're beating that anti estrogen drum to the complete detriment of the breast cancer population. And the longer they beat that drum, the more. The longer these women are on these medications, the more they're suffering. So I really want to get into what is happening on a physiologic basis when women are going through menopause. And because there are so many symptoms that people are having that they don't even connect to estrogen depletion.

I always say the fact that we call estrogen progesterone and testosterone our sex hormones is the greatest disservice that we've ever experienced because they do more than sex. They do more than make milk for babies and make your uterus work so you can get pregnant and then have you bleed. And, you know, there's Estrogen receptors from head to toe. In every cell of the body there's estrogen receptors, which is what's always driven me crazy about ERP or positive breast cancer. No, you know, you could say ERP or about, you know, the cell years. Guys like, yeah, this is, this is like basic level. This is calling like a, a house. A house. Even though there's multiple different types of houses. Right. So anyways, we have estrogen receptors from head to toe. And the place where I think we have the most, actually we do the highest concentration in the external genitalia and the, and the, you know, genital track. So we're talking the clitoris, the labia, the vagina, the bladder, etc, that's why sometimes women on systemic hormone therapy also need vaginal therapy. This apparently is also controversial. I. But the brain, the brain, the brain, the brain. We have estrogen receptors in our prefrontal cortex that's going to determine our decision making capacity, our mental load, our recall, our, you know, even if you want to use words like motivation or energy, a lot of those are thought patterns. And so there's your prefrontal cortex and in the hippocampus where we have like memory and emotions, like there's estrogen receptors there and the hypothalamus where we control core body temperature. Right. And that's where vasomotor symptoms come from. All in your brain. So so many of the mental health changes, which we say mental health, but we mean everything from like fatigue to motivation to energy levels, things that are kind of vague to describe. But then again also this idea of like brain fog or depression or anxiety.

Or etc, every crazy stuff I can tell you. I thought I was losing my mind when I went through menopause and I, I was always really, really, really good with numbers. Like I was a cashier in high school. I worked as a year through high school. And so like I can make change on a dime, you know, I, in, in a second I knew exactly how much change to give someone. And I got into my mid-50s and it was like I couldn't do math anymore. I'm like, what the hell is going on? Yeah, it is crazy. And people would never associate that, you know.

And you know, there are clinicians who I see also on social media saying you can't blame everything on menopause. And like, sure, okay, you know, but.

I know you can blame a lot.

You can.

And you know, I didn't get dumb overnight.

Right, Exactly. I think that women are allowed to, to sort of say like, gosh, this is the one thing that has changed. And then we go from the brain to, of course, the heart and to the bones. We know that estrogen is really good in reducing the risk of cardiovascular disease, reducing the risk of bone loss, reducing the risk of colon cancer, decreasing the risk of diabetes and even weight gain, which. There you go. You've got your gut connections all the way down to, you know, your. Your genital urinary syndromes of menopause, which is just like, not just, you know, pelvic floor, vaginal dryness, or lack of. Or lack of secretions or decrease in moisture, but also your bladder health, your bladder function. So decreasing urinary tract infections with estrogen, you know, I mean, head to toe.

And frequency and continents and. Yeah, things that really, really matter to people, really matter.

The three things that land a healthy woman in a nursing home. Dementia. There's your brain connection, right? A hip or spine fracture. There's your bone connection. And urosepsis. There's your urinary tract association. Right? And so estrogen, really. And I'm always careful because I also, you know, in my book, I. For each type, I talk about how to use hormone therapy and how not to use hormone therapy. I really am careful. I don't want to say, like, look, you have to do this or this is the only way, or you're doomed. No, no, no, no. But I feel like for centuries, women were never given the full, you know, book on what does estrogen actually do? What does this deprivation actually mean? How safe is estrogen to actually then make a full decision? Right? And even still, even while they have all this information, they're collecting it. They're all getting mini PhDs listening to your podcast. This podcast, this book, that book. But the truth of the matter here is that estrogen is extraordinarily safe, extremely effective, and really does increase lifespan and reduce the risk of chronic diseases.

So, you know, just being that.

Increasing the risk of breast cancer, in my opinion.

Yeah, I. And I 100% agree with you. But so being the devil's advocate, why do you think people are so willing to accept that estrogen isn't safe? Why do you think people are so willing to. You know, because the other drugs that was part of the Women's Health Initiative is that, what kind of. Why do we need estrogen? I. I forget the name of the cardiologist who was one of the primary investigators, but his whole premise was that it's time to stop this runaway estrogen train. Right. And. And that we have perfectly good medications that can control those secondary side effects of menopause. Like we have antidepressants and anxiolytics. Like we have beta blockers. Like we have the bisphosphonates for bone health. Like we have sleeping meds for people who can't sleep, you know, and, and the list kind of goes on and on and on. And so, you know, they wanted to portray this situation. You know, we have a fexor for hot pot flashes and they wanted to portray this situation, that these other medicines were adequate in managing the symptoms instead of just giving women absolute replacement.

This is such bullshit. Even just listening to you as your listeners can think, like, wait, I'm missing one thing. Shouldn't I just replace that versus why would I take take five drugs to control all the things that Esther can do while estrogen can improve my longevity? And these other medications are not shown to do that? I honestly, I mean, you have to get a little, I don't even want to say conspiracy theory esque, but there's some politics involved here. I think that some people want to make their stamp on the world that, oh, estrogen, it turns out in the 80s and 90s, we thought it was so beneficial. Oh my gosh. I am the one to find out.

It's not.

I am the one to find out. We did this huge study and wow, look at me. Look what I found. I found that estrogen increased the risk of breast cancer. You guys didn't know that?

I think that's why they had those findings. I think that that's what they were looking for.

Yeah, you could go deeper. Do we just want to keep women small? Do we want to keep women unhealthy? Do we want to. I don't, I don't know. And again, not necessarily the hugest, like, I, I going that deep kind of makes me like a little nauseous, but like, there is no clear explanation for why estrogen has become so demonized like 20 years ago. Of course I can understand now. This is because clearly we have two decades, two decades of, you know, doctors who have never seen hormone therapy be prescribed. So they have no clue. So what we're, you and I are discussing is like, what happened 20, 22 years ago where they kind of were just like, oh, I mean, I'm sure it was something to do with ego and money and, and status. I'm sure it had something to do with that.

Yeah. And, and quite frankly, I mean, the far from, from the pharmaceutical industry standpoint, why give one drug when you can give five or six?

Exactly. That there, there you go. There. You're right. There's that pharmaceutical push that you were talking about. Right.

And so, but, but decades of women have suffered. And what was always amazing to me is they were so quick to believe that that hormone replacement was bad and these other drugs were good, despite the fact that the drugs work in seldom few. And even when they relieved one symptom, they created three more.

Right.

You know, and so, you know, the dangers of bisphosphonates are not insignificant. Right. There's like all those warnings on the box. Don't lie down, don't do this, don't do. You know, like, esophageal perforation is no joke.

Well, Jenna, I joke all the time. As an internist. I've never had someone land in the emergency room because of estrogen. Never, never, never. Aspirin lands people in the emergency room. Bisphosphonates can land people in the emergency room for terrible gerd. Insulin can kill people. We prescribe. We prescribe crazy medications all the time. And estrogen is the most, like, benign of all of them. Yes, it can cause a little bit of bleed. The last decade that I been prescribing hormone replacement therapy, I've really never had anyone have any of these, you know, scary side effects that they talk about. They have a lot of, you know, more normal adverse effects like, you know, adjusting to it and bleeding, which can all be worked through. And not everyone has that, but we have just instilled this fear in women. We love doing that. The media loves doing that. They've instilled this fear that is just so hard to undo. And then, you know, not only do we have two decades of doctors that have never prescribed hormone therapy, but then you've got the medical system in general, which is a complete, you know, complete mess. So women necessarily aren't given the time to adequately be counseled. They go in for their annual exam and it's refills and it's weight and it's immunizations and it's change your diet and it's your out the door. And so that was another reason I wanted to leave academics. It was just failing. It's just feeling people in general, but mostly women, because women are 10 times more complicated than men. Men can get away kind of with this, like in and out, these, you know, 15 minute appointments a couple times a year, but women truthfully cannot. It is a huge disservice. And the whole system's a complete mess.

Yeah, I, I couldn't agree more. So let's Talk about how you approach the woman who is maybe in her 40s, late 40s, early 50s. What kinds of things are you asking them and then how are you taking them through this process?

Yeah, well, you know, nowadays most women seek me out for a second opinion. So now that I do telemedicine, kind of unlike the days where they just like one wound up as me as their primary care doctor or someone sent them to me maybe before they knew me, nowadays they come to me and this is just the reality of 2024 and being on social media and they already have so much that they've kind of already thought about and they want to tell me. But truthfully, I think that's really quite interesting. So a lot of times I start with my patients and I usually just say, tell me your story, girl. Like, get it all off your chest. Like it's just, tell me all the things, tell me what you've been feeling, when it started, what you've tried. And they kind of go through that. And one of the other interesting things that I will have to say is when I have a patient, I also ask them, I'll say, hey, you know, Jen, and what do you think is going on? What do you think you need? And then I always preface this with like, don't worry, you don't need to have a plan or a thesis. Like, I'm the clinician, but I bet you've been watching me or some of the other clinicians and you've been on YouTube and you've been Googling and like, what do you think? I like to meet my patients where they are. And sometimes I'll say things like, I think I need progesterone, I think I need vaginal estrogen, I think I need an estrogen patch. Okay, what's fascinating about this is that 10 years ago, nobody would have had any clue. They would be like, I don't know, do I need a psych ward? Am I going crazy? Do I have dementia?

It just wasn't talked about.

It wasn't talked about. And so now I, I really like this approach. I use a lot of shared decision making and I always tell women, and especially my patients who come to see me, and if we're talking about a perimenopausal woman, even menopause, of course, like I always say, there is is so many different ways to treat this. There is not one way, there is not one size, there's not one dose, there's not one route. But I like to give them this freedom to one, tell me Their story because very rarely do women get to be listened to. We've had so much trauma, and I know that we overuse the word trauma, but like, my God, bleeding out of your vagina every month for starters is like pretty traumatic. We just glaze over. This right?

Yeah, no biggie.

Having a miscarriage, having an abortion, having a baby, breastfeeding. Just like, like milking somebody. Milk. I milked, I been fed, breastfed. Three babies, you know, like, and then you don't want someone to touch you, and then your nipples look strange and then you hit your body and then there's vaginal dryness and then your partner still wants. I mean, we go through so much. It's just nice to just talk about your experience and then meet them where they are. And you know what I try to do and then, you know, often as I'm trying to think through is this seem like more low estrogen? Does it seem more like low progesterone? Does it seem more like low testosterone? Does it seem like two out of the three? All the three. And then sort thinking through how could we go about replacing our hormones? And I used to spend so much time working through women's fears of hormone therapy, but I don't find that I'm doing that as much anymore. They actually now, again, this is different because remember, women are finding me on social media and they're coming to me for second opinion. So that could be selection bias. They're coming to me because they're already frustrated. They want hrt. They can't. Their doctors are the ones sort of saying, no, no, no there, it's going to cause cancer. That might be a little bit different. But the other thing is that I give all my patients a course on menopause that they get when they become my patient. And you know, what I have always wanted to do, even years ago, and I was really starting to get again, the entrepreneurial itch was like, how can I asynchronously work with patients? How can they listen to me and learn from me and talk to me when I'm doing other things? Because I cannot. I tell you, Jen, I have an hour with each patient. Now, the way that I've set up my clinic, and that also means they've got the resources to do that. But even sometimes, you know, oh, I hear you.

And so I know what you go through. And I have all of those issues plus a breast cancer diagnosis on top of it. So it's like, you know, more to.

Unpack, more trauma, say, like, what do you mean?

You can't get through your, your meeting in 90 minutes. I was like, like, you try it.

You try it. I hear you.

I know women want to tell their story. That that's exactly what you were talking about. Like it is cathartic for them to tell their story. And I don't want to cut off their story because that's their truth. And so many story is where you.

Figure out where this coming from is the nuanced. Yeah, yeah, exactly. Exactly. And so it's a beautiful thing. It's so beautiful. And you know, I love what I get to do. I love getting to spend such quality time with patients and really help them navigate through this.

But you're limited. You're limited in how many people you can do that with because there's only so many hours in a day and only so many days in a week.

There is.

And you are spending quality time.

I know. Well, you know, I, I've got a couple more ideas in, in my head, as I almost always do. I' just expanded my practice so I just hired, working with, oh my gosh, 10 or 12 clinicians who are going to be seeing patients alongside me in different states and so expanding that way and yes, can't, can't always be me. But you know, again, that's, that's. We have clinicians just as good, if not better than me and just as excited and just as interested and just as, you know, in love with helping women and women's health. And all my patients get, all the patients that come and get that same course that I teach. And now we've got a community where I speak and I talk and I give little, you know, lessons and things to even the p. Patients of the practice that see maybe another doctor. Because there has to be ways to be able to, to, to provide this knowledge and these resources to so many people. Like, I don't want to gatekeep. I don't want it all in my head. I don't want to work just by myself.

Yeah, yeah. And there is so much joy in the camaraderie on both sides of it. Right. Like you, you, you have a shared decision making model. But it's also nice to have a colleague, like to not hold it all by yourself.

Honestly, I feel like I've been working by myself for a long time. Even when I was at an academic center, I was, you know, building these cute little menopause clinics is kind of how I felt. They, they would consider them, they'd probably say differently, but, you know, I was pretty siloed because I was really the only one at the menopause clinic. Patients would come to me in Boston and say like, oh, like, wow, this clinic is amazing. Like, who else is here? And I'm like, oh no, it's just me. And you know, so this is really the first time in a long time actually that I feel like I'm getting to work with colleagues and like minded colleagues. And so these colleagues also came from the course that I teach. So they'd been, you know, trained by me and doing lives and complex cases with me for over a year, seeing patients in their own right. Like they're, they're clinicians that have been, you know, clinicianing for 10, 20 years. And it's just so fun. It's just a really wonderful time to be doing midlife and women's health.

Yeah. So I'm going to ask you the question that I'm sure you've come up against and people really want to know. So who are hormones safe for?

Well, you know, Jen, I just did a. I'll give you two answers. I just did a. I did my own podcast, I don't know, maybe a few weeks ago I said there isn't a woman on the planet I wouldn't prescribe HRT for. Okay, There isn't. There isn't a woman I would not prescribe HRT for. And that is because it is just one of the safest and medications that I've ever used being an internist and is nothing that improves quality of life quite like hormone therapy. And you know, all these menopause experts and menopause clinicians and menopause doctors are all on hormone therapy and so are all of their spouses and, and it seems at some level like we're kind of gatekeeping. Right. So there is not a person I would not prescribe hormone therapy for for. Now the textbook says you should not prescribe hormone therapy for patients with an unprovoked blood clot, meaning a blood clot that just kind of you had while you were sitting watching tv, a blood clot in your lungs that's called the pulmonary embolus. End stage liver disease. That's called cirrhosis. That's not called fatty liver. That's not end stage liver disease. A history of or I think it.

Is going to be the number one cause of end stage liver disease disease.

Fatty soup.

Probably going to eclipse everything, eclipse the.

Alcohol intake or, and, or in combination of. But so the textbook says history of or active breast cancer. Now we're going to put an Asterisk by that because, you know, we've both talked about how we kind of, you know, disagree with that and that women with a history of breast cancer usually don't. Nowadays don't necessarily die from breast cancer when it's caught early. But I feel like, feel like their quality of life dies because of that diagnosis and the treatments they must.

And you know, it's, it's a compounded issue because it is the inflammation that led to the breast cancer that when not would not acknowledged and removed and remediated, that inflammation goes on to manifest as cardiovascular disease. And all of the treatments, not all of the treatments, most of the treatments for breast cancer which involve chemotherapy or hormonal blockade, when you take estrogen out of the picture, you are really sacrificing a bunch of the very important systems, not the least of which is the cardiovascular system and the heart. And so what happens is women who get breast cancer, who are treated for breast cancer are two to three times more likely to die of heart disease disease. And this is a huge problem when we are treating women for a disease that mo probably would not have changed the duration of their life.

I know.

And now we are changing the quality and the duration of their life, of their life.

Negatively, negatively, negatively. Yeah, I know, I know. Like the, the, the way we think about breast cancer has got to be changed. But I think. I don't know. You're an oncologist, right?

I'm on it. That's my mission. That's why I'm here.

You know, I just. We have done so much harm in the name of do no harm really.

You know, start starting with mammograms. Starting with mammograms, right. I mean, you know, this conversation could go in that, in that whole direction, but I don't want it to. I want to, I want to stay on the hormone path. But, but we, we need to acknowledge that the way that we are approaching breast cancer is just wrong. It's wrong and it's. And it's primarily based around what we're doing to women's hormones.

You know, I remember asking like, why. This may be different now. You can tell me. But I remember thinking, why can't we treat it? Why can't we do, for example, prostate cancer where they have watch and wait trials for early stage and. Etc. Why can't we do, you know, DCIS and stage one, watch and wait. Oh my gosh. I remember years ago, people are like, that is. Would be literally considered unethical. And I'm like, why Is that considered unethical? Do they do any watch and wait trials for dcis?

None. None. And that. And that is the question, why is it unethical? Why is it unethical? Why are women so quick to believe the hype that. Why are they still so instilled with fear? DCIS. 40,000 cases a year of DCIS where women are opting for mastectomy for a disease that literally has never killed them.

Well, I think I know the answer. Cancer. In every movie and every rom com with a single dad, what did the mom die of?

Breast cancer.

Of course we have. It's almost like compulsive heterosexuality, which I. I don't want to comment on, but, like, there's just this compulsive idea that breast cancer is the most dangerous thing.

Yeah, I mean, it's a really good. It's a really good marketing campaign.

Yeah.

For industry. I mean, a really good marketing campaign.

And you say makes a lot of money.

Yeah, it does. And they. They are bought in, hook, line and sinker. And so much so that, you know, we don't even talk about or examine the real statistics, which are women die exponentially more often of cardiac disease in every single decade of their life past 30. Exponentially more. And yet people are so much more afraid of breast cancer than they are of heart disease. I know every single year, the same number of women die of a fracture, a complication of a fracture, as do of breast cancer. Why aren't we talking about bone health with the same. Same frequency and emotion that we're talking about breast cancer?

I know, because.

But it's like emotional, the show.

Yeah, it is. It's emotional. It's an emotional knee jerk. I'll tell you this, because I know we're getting close to the end here, but, you know, people will always ask me, like, what would you do? Or what would you do? And, you know, I'm happy to close this podcast by saying I will take hormone therapy whether I have a symptom or hot flash or not. I probably. I already get them. So actually, I do. I take dividel. I have an IUD right now, so I take estrogen mostly around when I get my period, because I'm in early perimenopause and I'm going to take hormone therapy again whether I had symptoms or not, which I already do. Probably. Probably long term. And even if I got breast cancer, which of course, I've thought of, because one in eight women will. I would still take hormone therapy. It would not persuade me, and I don't even know that I would necessarily take any treatments or any anti. Any anti. Estrogen for my, for my cancer. I'd probably just do a lumpectomy and move on and call it a day. If you really want my straight shooter thoughts here.

And, and let's be clear. Women who go on hormone replacement are going to get breast cancer. Women who don't go on hormone replacement are going to get breast cancer. And we have demonstrated in these last two decades, if anything, and if anything positive came out of these last two decades, it's that the rate rate of hormone replacement use dropped precipitously and the rate of breast cancer increased.

Rose. Exactly.

Okay. Exactly. So it's not the hormones, ladies. It's not the hormones.

In the majority of women who get breast cancer aren't on hormone therapy. Only 10% of women or so are on hormone therapy. I think.

Yeah, of course. And if you do get breast cancer and we're talking about afterwards and you've recovered, you're beyond, you know, you have no evidence of disease, you've had a lumpectomy or, or, you know, you've had some kind of intervention where you no longer have breast cancer, those women, you know, the people that are going to recur, they're going to recur whether they go on hormone replacement or not. And we've seen that that demonstrated played out completely right. Because no one was on hormone replacement after breast cancer for the last two decades. And there's still few and far between and too few and far between, quite frankly. Like, we need to do so much better. And I can't tell you how delighted I am to hear that you both embrace that, that you prescribe it, because there are women out there that are suffering. They are suffering so much. My lady, my ladies have me. But just like you, my bandwidth is. Is minimal. And while I am intent on building a network like you built your network and having practitioners, you know, having more of me like the clones. Right.

Yeah.

We also need troops on the ground like you.

Yeah.

So that women can go to their doctor and you know that breast cancer diagnosis is history and what they need is help right now.

Yeah. Yep. It has been such a refreshing. I know the two of us, we're. So how are we gonna go back to our daily lives? This has been so cathartic. I mean, I. I hope you feel you got enough questions to ask me, but I feel like it's just mostly vibing on this idea that, you know, there's just so many myths and misconceptions surrounding menopause. And hormone therapy. And certainly the biggest is the breast health and just deconstructing that. And you know, anytime you're, or women or our patients or your listeners are thinking about this, like, step away from the emotion, think to yourself, am I acting emotionally? And go to the logic. Because the logic and the data and the research, you know, there's, there's so much, sorry, there's not a ton, but there is actually a lot of evidence all pointing to, you know, the actually hormone therapy not increasing the risk of breast cancer or recurrence for breast cancer survey. Yes.

Yeah. And I, I do think that though the numbers are not big. There's, you know, between 20 and 30 studies and they all have the same conclusion. So it can't be an accident. It just can't be an accident. And when they try to prove otherwise, they have to try, really. And then we look back and we're like, wait a minute. These findings are incorrect. The statistics were manipulated. And you can't data mine to find the, the things that you want because when you do that. I remember in Avram Blooming's book, he gave a list of things that increase breast cancer when you, when you data mine. And one of them was like using an electric blanket.

I know. I thought one was like being a coal miner or something.

Rand so many ridiculous things that clear like if you, if you work the night shift on Tuesdays or, you know, like it was, well, the night shift really does increase your risk of breast cancer because you're supposed to sleep at night and not work at night. But there is enough data there that supports the safety of hormone replacement and certainly there's enough data there to support the efficacy of hormone replacement. I would love it if you would just run through the benefits. And then I want to end on, if nothing else, I want to know if you agree with the statement that everyone should be on vaginal estrogen.

Oh, I can't even leave that to the end. Of course I think vaginal estrogen should be over the counter. I think it should get mailed to your house. House when you turn 45. Yeah, yeah, yeah.

Okay.

The benefits, right? There's two buckets. The benefits that you can feel and the benefits that you can't feel. And we've spent a lot of time talking about both. But let's just run down the list. So hormone therapy is FDA approved to reduce the risk of hot flashes, night sweats, vaginal dryness, or genit syndrome of menopause. And the ones that you can't, the One that you can't feel in that group is osteopenia and prevent osteoporosis. So a little bit of both. However, it can also help with mood. I've seen this happen. I mean I've been treating women for over a decade, traded thousands of women. So mood disruptions, joint aches and pains, brain fog. I've seen it help. Bloating, nausea, constipation. I've seen it help so many things and it tinnitus, ringing in your ear, heart palpitations, so many symptoms it really, really can support and then what you can't feel. Hormone therapy is shown to increase your lifespan. It is by average 3 to 4 years. Decreases the risk of diabetes, decreases the risk of cardiovascular disease, improves bone health, improves quality of life, improves sexual health. It can. Women who take hormone therapy tend to gain less weight than women who don't. And so there's just so many, so many benefits from both buckets. I'm probably missing some but you know.

I think you did pretty well. I think they got the gist. We're gonna have to have you come back because we need a longer conversation. But in the meantime, because I know so many people need your help, where can they find you and where can they get access to your amazing, amazing network?

I would love, love, love, love to have anyone as a patreon patients. So you can go to heather hmd.com and you can book a visit right there under, you know, book a visit. You can learn all about the collaborative, you can learn all about the doctors and what states we're in. We're currently in 25 states and we'll probably be in all 50 very very soon. It is a cash pay practice but we do really, really well with getting super bills for patients or using HSAs or FSAs. And you get my eight hour course which is worth the whole price, the Facebook group and hourong visits and just so much, much good stuff on the inside. I also have, I sell the course separately. If you just want to take the course that's called the Reclaiming Menopause masterclass. Also on my website how the HershMD.com and you know also my book is a great place to start. I think you can get it at 18 bucks or so on Amazon and if, if that's a great place to start for you, that's a great place to start. Plus I also do tons of free social media on Instagram, on tik tok, on YouTube, everywhere and I'm at Heather H M and I've actually had so many people. Jen messaged me to say, I watched hours of your stuff, and it really helped me have a good conversation with my doctor. So there's so many different ways to work with me, whether we know it or not.

So I am so grateful for the change that you made from that brave walk away from the security and the prestige of academic medicine, because I know that that is. That's not an easy walk to take.

Take.

Right. Especially when there's so much uncertainty. Right. But you. You clearly made the right decision. You're making a huge difference to a group of people that need you so badly, and you are fulfilling a huge need. So I'm so grateful for you, for the work that you do. And we will make sure that we get all your links attached to this so that people can come to you and get the help that. That they need. I thank you so much for your time today, and we're going to have you back real soon.

Thank you. Thank you so much for having me. And all the same, right back at you.

It's Dr. Jen. Bye for now.