Your Gynecologist Can't Fix This: The Cardiometabolic Side of Menopause with Dr. Heather Hirsch

Summary

Podcast Summary

Podcast: BETTER! Muscle, Metabolism, Meals, & Mindset in (Peri) Menopause with Dr. Stephanie Estima
Episode: Your Gynecologist Can't Fix This: The Cardiometabolic Side of Menopause with Dr. Heather Hirsch
Date: May 11, 2026
Host: Dr. Stephanie Estima
Guest: Dr. Heather Hirsch

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Episode Overview

This episode dives deep into the often-overlooked cardiometabolic changes of perimenopause and menopause. Dr. Stephanie Estima is joined by Dr. Heather Hirsch, a renowned menopause expert and founder of the Collaborative telemedicine practice, to challenge conventional "bikini medicine" thinking and reframe menopause as a physiological, whole-body transition—with a special focus on heart health, metabolism, muscle, bone, and brain health. The conversation offers actionable strategies for women navigating this life stage and insight into how hormone therapy can serve both diagnostic and therapeutic purposes.

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Key Discussion Points & Insights

1. The Biggest Lie About Perimenopause: It's Not Only a Gynecologic Issue

• Perimenopause is a cardiometabolic, not just gynecologic, transition
  • Dr. Hirsch challenges the tendency to view menopause only as a reproductive hormone issue (04:32–05:30).
  • Shift the focus: It's about long-term health, including cardiovascular risk, metabolic changes, and more.
  • Quote (Dr. Hirsch, 04:32):
    “Perimenopause and into that menopause transition is a cardio metabolic transition... That's just a downstream effect of one of the many things that happens to the body.”

2. Subtle and Early Signs of Perimenopause

• Symptoms Before Period Changes

  • Sleep disturbances, brain fog, uptick in anxiety, and subtle hormonal changes emerge even before periods change (06:01–07:39).
  • Poor sleep is an early, often overlooked signal.

• Quality of Life: Brain Fog vs. Hot Flashes

  • Brain fog is more damaging than hot flashes; it impacts confidence, economic outcomes, and is a source of fear and anxiety about cognitive decline (07:49–08:54).
  • Quote (Dr. Hirsch, 07:49):
    “The brain fog makes me feel inferior. It makes me lose my confidence. It makes me want to retire earlier, not go out for that promotion... it scares the death out of women.”

3. Distinguishing Sleep Hygiene from Hormonal Causes

• Journaling & Tracking: Identifying triggers and cyclical patterns (10:27–11:57).
• Hormone therapy as a diagnostic tool
  • Applying hormone therapy can help determine if symptoms are hormonally mediated (12:23–14:02).
  • Quote (Dr. Hirsch, 12:23):
    “Hormone therapy can be just as diagnostic as it is therapeutic. It’s funny to think, oh, we’re going to use hormone therapy as a diagnostic tool. But I have done this many, many times.”
  • This reframing is highlighted as a key “aha” from the episode.

4. Menopause as a Cardiometabolic Risk Factor

• Estrogen’s Role in Vascular Health & Disease Prevention

  • Estrogen is beneficial for blood vessel health; its decline increases cardiovascular and metabolic risk (17:04–19:18).
  • Nitric oxide release from estrogen maintains vessel flexibility, which is critical for heart and brain health.
  • Women’s Health Initiative (WHI) explained:
    • Estrogen use within 10 years of menopause lowers heart disease risk and reduces diabetes diagnoses (18:22–20:44).
    • Menopause was labeled an independent risk factor for heart disease by the American Heart Association in 2020.

• Medical Training Gaps

  • Most physicians, even OB/GYNs, lack training in the full ramifications of menopause beyond hot flashes and gynecologic symptoms (21:50–22:40).

5. Reframing & Understanding the WHI Study

• WHI Misinterpretations
  • The initial negative reaction to the Women’s Health Initiative led to widespread fear of hormone therapy, but the study’s nuanced results actually support careful use of HRT (22:53–26:01).
  • Dr. Hirsch: “Do not knock the Women’s Health Initiative unless you actually read it.”
  • Formulations used at the time (Premarin, Prempro) are less common now; current best practices favor other forms like micronized progesterone and transdermal estrogen.

6. Why So Much Confusion? Disagreement Among Doctors & Social Media Debates

• Bias and Research Interpretation
  • Clinical nuance and experience are essential; data are often interpreted like artwork, with inherent bias (30:47–35:26).
  • Legal culture in gynecology can foster an overly cautious approach and reluctance to prescribe hormone therapy (35:56–37:34).
  • “It is easy to brush patients off because doing menopause care...does not make a clinic money, does not make a doctor money.” — Dr. Hirsch (37:34)

7. Is It Ever Too Late for HRT?

• Age and Hormone Therapy Initiation
  • Benefits for heart and bone are clearest within 10 years of menopause, but transdermal estrogen can be considered within 20 years of the last period, pending individual risk assessment (38:47–40:36, 65:00).
  • Non-estrogen options (progesterone, testosterone gel, vaginal estrogen) are available for older women.

8. Silent Changes: Bone & Musculoskeletal Health

• Invisible Risks
  • Bone loss is rapid in the two years before menopause; fractures are a major concern (41:38–43:34).
  • Estrogen is key for bone health — all studies agree.
  • Lifting weights and protein intake are crucial for maintaining bone and muscle.
  • Routine DEXA scans should begin at menopause, not age 65, especially for at-risk groups (45:39–46:27).
  • Dr. Hirsch: “It’s flabbergasting...that we would wait routinely till 65 for a woman with no risk factors. Menopause should be a risk factor.”

9. Muscle Mass & Lifestyle Approaches

• The Under-Muscling of Midlife Women
  • Many women enter perimenopause “under-muscled” and under-fueled due to decades of cardio, dieting, and poor protein intake (54:14–55:59).
  • Estrogen loss amplifies the consequences of prior lifestyle patterns—metabolic adaptation, decreased bone/muscle, increased fat gain.
  • Practical advice:
    • Take inventory and invest in your health now, with professional support if needed (56:38–59:37).
    • “A little bit of money into yourself will take you and your family so far.” — Dr. Hirsch (59:37)

10. Menopause Types: Personalizing Treatment

• Menopause and Perimenopause "Types"
  • Dr. Hirsch describes her approach to categorizing patients by “type” to offer quick wins and personalized treatment—by primary symptom, age, cause (natural/surgical), etc. (63:44–66:31).

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Notable Quotes & Moments

• "Menopause is an independent risk factor for heart disease." — Dr. Hirsch (18:22)
• "Brain fog makes me feel inferior. It makes me lose my confidence. It has economic downstreams. It scares the death out of women." — Dr. Hirsch (07:49)
• "Research is really nothing more than artwork, and it's the artist who's going to put their impression into the artwork." — Dr. Hirsch (30:47)
• "Do not knock the Women’s Health Initiative unless you actually read it." — Dr. Hirsch (22:53)
• "This is a great time to reinvest in your health. A little bit of money into yourself will take you and your family so far." — Dr. Hirsch (59:37)
• "Hormones talk to each other... They're in a WhatsApp group." — Dr. Hirsch (51:57)
• “You cannot just do this alone. Willpower is just not going to be enough.” — Dr. Hirsch (59:38)
• "Why is nobody talking about... [that] the American Heart Association called menopause an independent risk factor?" — Dr. Hirsch (67:14)
• "This is the first time in your life that you're gonna feel stable day after day after day." — Dr. Hirsch (70:15)

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Actionable Takeaways

• Rethink perimenopause/menopause: It’s a cardio-metabolic, musculoskeletal, and neurological transition—not just a gynecologic event.
• Consider HRT not only for symptom relief but also as a diagnostic tool after tracking and journaling patterns.
• Go beyond the scale: Monitor metabolic markers, bone density, and muscle mass as primary health measures.
• Lift weights, increase protein, and prioritize recovery as foundational midlife health strategies.
• Personalize your approach: Identify your key symptoms and work with trained professionals to tailor interventions.
• Demand education and discussion: Advocate for yourself with clinicians and seek out trustworthy, evidence-based resources.

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Timestamps for Important Segments

• Cardiometabolic reframing: 04:32–05:30
• Early signs and brain fog: 06:01–08:54
• Sleep vs. hormones & journaling: 10:27–12:12
• Hormone therapy as diagnostic tool: 12:23–14:02
• Estrogen, cardiovascular and brain health: 17:04–20:44
• WHI study breakdown: 22:53–26:01
• Why doctors disagree: 30:47–35:26
• Age, timing, and HRT safety: 38:47–40:36
• Bone health and DEXA scans: 41:38–46:27
• Muscle, metabolism, and practical tips: 54:14–59:37
• Menopause archetypes/personalization: 63:44–66:31
• Reframing menopause as a positive life phase: 69:50–72:16

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Episode's Tone & Closing Thoughts

The tone is candid, empowering, and practical, balancing science with actionable wisdom. Both Drs. Estima and Hirsch openly discuss gaps in medical education, cultural stigma, social media misinformation, and the need for women to advocate for themselves. The episode closes on a positive note: Menopause, when addressed holistically, can be a liberating and stable period of life—one to look forward to, not dread.

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For Further Engagement

Host’s call to action:
"What's the single biggest lie you've been told about perimenopause or menopause? Leave your answer in the comments!"

Recommended for:
Women approaching or in midlife, healthcare providers, and anyone seeking a modern, whole-picture perspective on menopause that combines physiology, lifestyle, and individualized care.

Transcript

[A]

It is easy to brush patients off because doing menopause care in an RV UB system does not make a clinic money, does not make a doctor money. In fact, usually they're losing money. I say a lot that hormone therapy can be just as diagnostic as it is therapeutic. And it's funny to think, oh, we're going to use hormone therapy as a diagnostic tool. But I have done this many, many times. Let's be clear. Research is really nothing more than artwork. And it's the artist who's going to put their impression into the artwork. I'm sorry. It is impossible for us to be biased about anything.

[B]

I think that a lot of women arrive in perimenopause under muscled. They especially like the cardio bunnies, right?

[A]

Speak it, girl, speak it.

[B]

And we, we spent hours, I spent hours, years on the elliptical machine.

[A]

This is a great time to reinvest in your health. So maybe you need that trainer and you have put off your own health or put off your needs because you're paying for your kids, travel, soccer and the big graduation party. And you're putting your money into all these people, but a little bit of money into yourself will, will take you and your family so far.

[B]

Hello, my friends. Welcome back to another episode of better with Dr. Stephanie tis me, as always, your host, Dr. Stephanie Seema. You want to be listening to this show today because we are taking perimenopause beyond bikini medicine and that is to say, beyond what is just underneath the bikin. And we are talking about the suite of options that can be available to you so that you have the privilege of aging like a man. My guest today is Dr. Heather Hirsch. She is a board certified internist and entrepreneur and founder and CEO of the Collaborative, which is a concierge telemedicine practice for women navigating perimenopause and menopause and as well as the Heather Hirsch Academy. After completing Advanced Women's Health Fellowship training at Cleveland Clinic, Dr. Hirsch founded the Menopause and Midlife Clinic at Brigham and Women's Hospital and served at the faculty at Harvard Medical School. Now, my biggest takeaway for you, I'm going to give you a little Easter egg so that you listen for it is when Dr. Hirsch talks about HRT or menopause hormone therapy as the diagnostic tool. Now that is a really cool concept that I have not heard before. And in the conversation you'll hear me say, oh, that makes a lot of sense because when I was doing orthopedic testing, the ortho test then became the program if the patient failed. So now can we look at HRT or MHT as the diagnostic tool? Listen out for that. Let me know what you think. Without further delay, here's my conversation with Dr. Heather Hirsch. Here's something nobody told me when I was grinding through every training session on willpower alone, that your brain runs on ketones. It already knows how to use them, and it makes them. The problem is they can only access ketones after days and days and weeks and weeks of strict keto, and most of us aren't doing that. And I also don't recommend that you do that either. And this is where kinetic comes in. It's drinkable ketones. It's not a diet. You don't have to be following a ketogenic diet to take it. It's not a protocol. It's just the fuel that your brain and your body already prefer, delivered directly without the restriction. I drink it before training almost every day, and I also take it before long recording sessions or just generally before anything that requires me to be sharp and requires me to be present. So there's no crash, there's no jittery energy from coffee that makes you feel like you're running from something. Just clean, sustained mental output. If you have been white knuckling your focus, it's definitely not a discipline problem. It might just be a fuel problem. Try it out for yourself by going to drinkkinetic.com forward/,/better and use code better for 15 off your purchase. That's D R I N K K E N e t I k.com better. All right, Dr. Heather Hirsch, welcome to the show. Happy to have you here.

[A]

I know. I'm so excited to. To, like, get to sit down and talk. So much on our minds, right?

[B]

So much on our minds. So let me just start with the big question. In terms of perimenopause, what do you think that the single biggest lie women have been told about perimenopause is?

[A]

Well, you know, I. I think one of the biggest lies or one of the biggest misconceptions is that perimenopause is a gynecologic issue. To me, perimenopause and into that menopause transition is a cardio metabolic transition. It doesn't mean that one doctor is the right doctor to treat you and one doctor is not. You know, I think when we think about going into, you know, our training and medical school, you know, menopause became sort of a gynecologic issue. It was, like, filed away under gynecology why? Because maybe our periods changed or then our periods stopped. That's just a downstream effect of one of the many things that happens to the body as we go through perimenopause and menopause. And so I think it's so crucial that we think about this transition, you know, not just as how do I alleviate these symptoms? Which is very important, of course, because I'm right in the throes of it. But what does this mean for my long term health for the next decades to come?

[B]

So what are some of the cardio metabolic changes that a woman in perimenopause might experience? What are some of the more subtle signs and symptoms that might indicate? Because we know perimenopause is not a. You can't do a test and be like, oh, yep, there you go, it's perimenopause.

[A]

Yeah, that was going to be the other one. I was going to say. There's a test for perimenopause.

[B]

Yeah, there's also a method. No test, but sometimes it's one or two. But there are clusters of clinical presentations or symptoms that someone might experience. So what are some of the sort of early signs of that? And then I want to come back to your comment around cardio metabolic changes as well.

[A]

Yeah, so it's a little different for everyone, as you mentioned, but some of the more, you know, more well documented or sort of, you know, common things just, you know, people say is first, women will notice, especially in early perimenopause, which is your periods may not even be changing yet, but your hormones are sort of declining, maybe your periods are a little bit heavier, maybe they're a little bit closer together. This can be the signs of early perimenopause and your progesterone declining. And so women tend to have issues with sleep. And this of course will tie this into, you know, once you start poor sleep, breaking those poor sleep habits, the longer that poor sleep goes is so detrimental to your health. So sleep starts to change, the brain starts to change, and women experience significant brain fog. And I know because this happens to me all the time, hopefully I don't get it on your show today, but you guys will probably be pretty patient with me if I do. And so there's so many changes in the brain and this neuroplasticity, this time in our lives is full of these changes. As these changes are occurring, you know, then we also start to see some uptick in anxiety. So it's insomnia, it's anxiety, it's a Little bit of brain fog. These can be some of the earliest signs. And so, you know, the other thing that starts to happen to women is we do a couple of different things. We brush it off. We say, oh, I'm not sleeping because I'm stressed at work. Everyone told me that's a reason I'm doom scrolling, that's why I'm not sleeping. We have so many reasons we can think about as to why we can push these off. But then the longer that goes on, the worse that is for our health long term.

[B]

Right, right, right, right. So if you could. So if you could abolish one thing, brain fog, or let's say the classic hot flash, which one would you choose and why?

[A]

Brain fog. Easy. I'll tell you why I've done this. I've done two studies on this one. When I was at Brigham and Women's Hospital, that was my last academic position. And I did a study on my patients there in Boston. What symptom affected your quality of life the most? And it was brain fog. And a lot of my patients say, I did this again in my, in my private, now telemedicine practice. Same thing affected your quality of life the most. Women you know, we're tough. Hot flashes definitely suck. But, you know, a lot of women say, you know, gosh, I've had like, pregnancies, periods, endometriosis, like a hot flash sucks, but I can get through it. The brain fog makes me feel inferior. It makes me lose my confidence. It makes me want to retire earlier, not go out for that promotion. It has economic downstreams. It scares the death out of women. They think that they may be having, you know, Alzheimer's or et cetera. And it's very, very scary when it happened. So if I could abolish one brain fog for sure.

[B]

And so when we talk about sleep, like, one of the things that I find is that there are. I mean, absolutely, we have some of these hormonal changes as you described. We have progesterone, and then obviously the erratic changes of estrogen over the course of perimenopause and the eventual decline of it. But I do find that there are a lot of confounding variables in there. Like, I can speak to my own experience right now. Like, right now I'm in my soccer mom era. So I have whoever thought it was a great idea for a 15 year to start his practice at 9:15 in the evening.

[A]

Oh, in the evening.

[B]

So it ends. Okay, so, okay, let me just air out my dirty laundry here. 9:15 to 10:30 he get. And then we get home at like 10:45 ish, let's say 11. And then he has to eat, he has to wind down. So the child is not in bed until like 11:30 at night because he's just been running around like crazy. And I'm, you know, the chaperone, right? So I find that my sleep, even though I would much rather prefer to go to bed, if I go to bed at, at nine in the evening, like I feel like I'm winning at life, but that's not always the case for me. And then so the next he has two of those nights. It's like Wednesdays and Thursdays. So like Thursdays and Fridays I'm bagged. Like I'm really, really tired. So I know that that's a contributing factor. I know that I'm not the only one with like teenagers in there, you know, with their extracurricular activities. So how do we tease out whether it's sleep hygiene? So in my case, I sleep very well, save for those two nights when they're very, very late. How, how do we. Bad sleep hygiene versus a hormonal change.

[A]

Love this question. I get asked it all the time. How do I know if it's perimenopause or is it my son's soccer practice? I'm in my theater mom era, which is even scarier because I don't know what I'm doing there. But anyways. Well, I really don't. Now I do all this fun stuff, but at one point I went to medical school and I was just a little science nerd.

[B]

I mean, it's our first time at life too, right? Like we are, you know, I'm 48. It's my first time lifing at 48. Like I have no, you know, just like anyone. I don't know what I'm doing.

[A]

Great. I appreciate that. Thank you. Thank you for that reminder. So this is a great question because it's so relevant. Women ask it all the time. How do you know? So there's, there's two, two ways we can tackle this. The first is just tried and true journaling and tracking, easy peasy. But like it is because we're lifing at the right now and, and things are crazy. Just taking the time to journal is really difficult. I love journaling. I have so many journals. I have journals with prompts. I have journals for gratit. I have journals for my goals. I have journals, free flowing journals. And I'll do one for a week or two. I'll get really good at it, and then I'll leave it. And I'm someone who loves journaling, but as a mom of three and business owner and clinician. So hard. But if you can journal on track for you, for example, you could probably start to see some patterns. Ah, like a night or two after I'm up super, super late. I can see that. Then my sleep's really, really bad. So you can start to see some patterns. Another common pattern. Ah, before my period. If you're a woman that gets periods. My sleep is really disrupted.

[B]

Yeah.

[A]

Then you can maybe start to see if something is cyclic as opposed to if there's a specific trigger. Oh, you know, I have to see this certain colleague at work, like on Wednesdays. So I notice Wednesdays and Thursdays I don't sleep well. Okay. Maybe there's a specific trigger. So true. Lane tracking is tried and true.

[B]

Or if you're a doctor, there's a certain patient that comes in every Friday that's very difficult for you.

[A]

No, I know. Patients, patients.

[B]

We all have our favorites. We're not allowed to say that, but we do. Okay.

[A]

Oh, yeah. And the other way is a little bit of a different spectrum, and we're just going to go right into something. You didn't think I was going to say, but try hormone therapy. So why, you know, really, the best way we can tell if something is hormonally mediated is you. You put the hormone therapy on and you see if it gets better or if it doesn't.

[B]

Right.

[A]

Now, this is not necessarily for everybody, but I say a lot that hormone therapy can be just as diagnostic as it is therapeutic. And it's funny to think, oh, we're gonna use hormone therapy as a diagnostic tool. But I have done this many, many times. I had a patient, it's not so much sleep, but she had severe joint aches and pains. She had all these X rays. She didn't see any osteoarthritis. She was gonna go off to some fancy schmancy hospital and go see one of the world's experts, but a friend told her this could be hormonal. So she comes in to see me, and so I say, you know, she's like, how do I know there is no test. We gotta kind of just try you on estrogen in this case. And we did, and she was so much better, and she canceled that appointment. And then she knew the opposite could also have been true for her. It could have not helped. And then she's gonna say, okay, well, now I Know, it's not that. So we can do this sometimes for sleep as well or any of these different ailments. And we can talk about, you know. Well, that's not technically on label for what MHT is for. It's not supposed to be a diagnostic tool, but I'm gonna tell you that it is a great diagnostic tool after the tracking and the journaling and then, you know, we know that labs aren't. Unfortunately, I wish labs were more helpful because it would be nice to have some objective data. And that's a topic for. Why don't we do enough research on this? But we don't have a lot of objective measures, so we kind of use HRT as a diagnostic tool.

[B]

I actually love that when I was in practice, we would do a lot of orthopedic testing. So obviously chiropractor by background and, you know, you get to the diagnosis through the orthopedic test. And sometimes the rehab program is the ortho test, right? It's like if you can't do a Trendelenburg, if you can't do it, stand, let's say, with your knee elevated, when you're standing on one leg and the hip isn't dropping, well, that now becomes your program, right? So that you are training that motor skill. So in the same way, I actually really love that reframe as, yeah, maybe you need to try hormone therapy. Because sometimes the decline in your quality of life, let's say, or your sleep or your mood or your affect is so subtle that it's. It's virtually impossible for you to. Even if you have stacks and stacks of journals, for you to go back and mine that data and say, yeah, I felt really. I feel really different now than I did three and a half years ago. So I actually really like that because for most patients, I mean, for me, I would find as soon as a patient was out of pain, like, they couldn't remember what it felt like, you know? So, like, when you are doing, you know, when you're doing evaluations, like, how are you feeling? I'm feeling great. You know, how are you feeling relative to you were. Were a month ago? It's like, I don't remember how I felt a month. I don't remember how I felt yesterday, you know, So I really, really like that as a. As a reframe. It's like, maybe you need to try it. Maybe now becomes the therapy. Yeah, that's a really cool. Really cool way of looking at it.

[A]

Speaking back to brain fog, I will say this because we we opened with that, and we talked about that, and we were talking about how, you know, this, this, my, my thought here for this current, you know, month is that this is not a gynecologic transition. Women will come to me so worried about brain fog. And how else do you, you know, if you've ever experienced perimenopausal brain fog, it's hard to almost verbalize what it feels like. You kind of feel like it's. You're glitching a little bit, or like you've. Or like you just. You're processing so slowly. And this is one of the best ways to tell if it's hormonal and it makes patients feel so much better. And because it affects their quality of life so much. So, no, menopausal hormone therapy is not FDA approved to treat brain fog. And brain fog isn't even really a medical term. It's really just kind of what we all say to each other.

[B]

Yeah.

[A]

But it can be so, so, so imperatively helpful for women.

[B]

So let's get back to the cardio metabolic changes that you were talking about before. So we. You mentioned that perimenopause has often just been sort of categorized as this, like, gynecological event, but certainly we know that hormones don't just affect the breasts and the vagina and the vulva. They certainly affect the entire body. So talk to us about some of the cardio metabolic changes that happen for a woman in those transition years. And then, because it's probably still at large viewed as a gynecological problem, what do we need to mandate or what do we need to be teaching the OB GYNs who are seeing these patients who are probably, you know, in a patient's minds, like, oh, this is a reproductive hormone thing. I should go to the OB gyn. What do we need to teach them before seeing a perimenopausal patient as well?

[A]

Oh, you're speaking my language. So. So many things happen cardiometabolically. If you are, you know, listening to this and you're thinking, hmm, my cholesterol is creeped up, my blood pressure's creep up, my sugars have started to creep up, or my A1C is starting to go up, or my glucose levels are starting to go up. And I know you talk a lot about, like, I'm getting a little bit of weight gain, or maybe you're not gaining weight on the scale, but the distribution of, you know, your adipose tissue is changing, your physique is changing. Yeah, don't even Add the you're not sleeping part onto that. Right. Because that's going to contribute to cardiometabolic regimen. So what happens is actually as estrogen is declining. Estrogen is really, really good for the vessels, the vessels in our body and particularly the vessels around our heart, the coronary vessels. Estrogen releases nitric oxide. Nitric oxide is a vasodilator. So it keeps those vessels nice and open. And you want those vessels open so you can get this beautiful blood flow, get all the inflammation out of there, keep everything healthy. If your listeners know anything about genitourinary syndrome of menopause, this is the exact same freaking process. It's just happening in the vagina. You're not getting good blood flow anymore to the vagina. So what happens to the vaginal tissue? The ph changes. The ph goes from acidic to basic that it doesn't like.

[B]

Why?

[A]

Primarily because of lack of nitric oxide and vasodilation and just good blood flow. So while we're waiting for data on estrogen and brain health, particularly for Alzheimer's, this is different than just brain fog. Think about this too. In the brain, why does this make sense that estrogen would be brain protective? It is doing what to those vessels? Opening them up, which is going to give you so much better cerebral and brain function and health. Okay, so back to the heart, back to the heart, back to the heart. So estrogen is, is, has been shown therefore, when it's used within 10 years of menopause to decrease the risk of heart disease, death from all causes and non fatal heart attacks. This is not emotional, this is not. I sort of have looked at the data and I have decided this, this is very, very factual. And we see this in the biggest study that gets the most slack, the Women's Health Initiative, the women who were in the estrogen only and the estrogen plus progesterone arm who within age 50 to 59 had reductions in cardiometabolic diseases which included those non fatal mis. And get this diabetes, get this diabetes. I love when I teach to endocrinologists I say, did you know there's like a medicine that helps to decrease the diagnosis of diabetes? We can't say prevent and that's a whole nother story. And it's estrogen. And I just think we weren't taught this stuff about estrogen. We were taught that, you know, estrogen increases breast cancer, estrogen declines, then we don't get periods like we were taught about it in a gynecologic way. That's so Wrong. It misses the mark entirely. In 2020, something really exciting happened in the world of menopause. The American Heart association, or the aha, came out with a super important paper and it said menopause is an independent risk factor for heart disease. This is so, so crucial because cardiologists for a long time have teetered this line of like, is estrogen good or is estrogen bad? Now what else happened in 2020 shall not be named. But this then therefore got no news. This didn't get any coverage. Good things for women don't typically get any coverage anyways. But even the American Heart association is now recognizing the loss of estrogen as a risk factor for heart disease and diabetes. Metabolic syndrome is then when you have any combination of, you know, a couple of these clusters, high blood pressure, prediabetes, diabetes, central obesity, elevated lipids, and so all these things, therefore this, this, this change in your sleep and the, and in your physiology. We don't even talking about bone health because remember how we talked about this as. Yeah, we'll get to not a gynecologic issue. So we'll just put bones on like the, the table up there. Because that's just not even, I mean, that's just so crazy. Right? And so this is really, really important that we have to reteach how we think about menopause. Not even just the fact that we need to make sure this training is in, you know, not just medical schools, nursing schools and PA schools, but as you said, for any specialty in healthcare that takes care of women in this age. We have to understand how important this is and we need to re. Reframe this training. This is. Yes, it's not to say, you know, I kind of want to say this is not about hot flashes. It's about more than hot flashes, but so much more than hot flashes. Hot flashes to me also, how good would your vessel. How was a hot flash vasomotor syndrome? When your vessels squeeze and then release and squeeze and then release. Like, how good would that be for you? Probably not very good. So if you're a cardiologist, wouldn't you be thinking, hmm. And we have data, clear data, that women with persistent and untreated vasomotor symptoms have higher risks of cardiovascular disease. So we need to retrain for generalists that this is a topic for primary care, family medicine and longitudinal health. And then for those special specialists, sorry, cardiologists and oncologists, endocrinologists, sleep doctors, mental health. We need to also reframe how it is touching their specialty because this is a team effort.

[B]

Let's talk a little bit about the whi I think that a lot of people love to hate on this study. So tell us a little bit about what your, what the primary findings are from a clinical perspective and how you use that in your everyday practice.

[A]

Yes. So what I actually pretty famously, but probably within my circle of friends, was sitting on the FDA Menopause Expert Panel back in July of 2025. We did this with Commissioner Marty McCary before the Black box was removed. I famously said I love the wit whi I love the Women's Health Initiative. It is at it is. Let's I'm going to make something very clear. Demonizing this study is not the goal. There's a difference between what logically was in this study and then the emotional feelings that people have towards the way this study impacted women's health for the next two decades. So we need to separate those. So when the Women's Health study was publicized in 2002, it immediately put menopausal hormone therapy in a negative light. And since then, we've really had mass destruction to women's health because hormone therapy was considered dangerous and harmful. That is not let me repeat what the study shows. So me and my colleagues will famously say, do not knock the Women's Health Initiative unless you actually read it. A lot of the data on the safety of menopausal hormone therapy, the timing hypothesis, the reductions in heart disease, the reductions in bone disease. The largest and the best study on this, which was a randomized, double blinded, placebo controlled study, was the Women's Health Initiative. Now, the only difference is in hindsight, you know, what's that called? Being like a backseat driver. If we did this study on prometrium and transdermal estrogen, it would be a different world. But this study was started kicked off in the early to mid-90s. So they used the formulation of medication that was most available then, which was conjugated equine estrogen and meoxy progesterone acetate, which is either premarin estrogen only if you didn't have a uterus, or Prempro if you did have a uterus. The safety data even on Prempro is pretty wild. But we don't use Prempro all that much because we do find that prometrium micron progesterone and maybe estradiols. Although I, I, I was just talking today about how I, if I, if a patient would is okay with me using prem and I will use it because the, the most safety data we have on these medications comes from the Women's Health Initiative. So we should never demonize this study. It doesn't do anything but polarize us. And it actually, I'm gonna go so far as to say, makes you not well studied on the nuances of menopausal hormone therapy. So if a doctor is saying that debunk study, let me make it clear. The study was a great study. There was nothing to debunk. There was things to clarify like the risk of breast cancer, like the, you know, and et cetera, which we could talk about. It just had to deal with the formulation of progesterone. What we needed to change was the way history changed when they publicized the study. That was the problem, never the study itself.

[B]

If you're navigating perimenopause or midlife, you've probably noticed shifts in your energy, your recovery, and even that underlying fatigue that can be hard to explain. One compound I've really been focused on lately is spermidine. As we age, our natural production of spermidine declines. And that matters because spermidine activates something called autophagy, which is your body's cellular renewal process. And also mitophagy, which also helps clear out damaged, old, slow mitochondria and it helps to support healthy energy production. And since your mitochondria are responsible for powering every single cell in your body, this is going to directly impact how you feel. So your energy, your resilience and your vitality. I love and use Primadine from Oxford healthspan because it delivers a food derived polyamine matrix, meaning that you're getting spermidine in its natural form alongside other polyamines that work synergistically with it. It's simple and it's a foundational way for you to support your cognitive function, your cellular health and sustained energy as you age. If you want to try it, head over to oxfordhealthman.com Dr. Stephanie, that's my name. And use code doct stephanie to get 20% off your order. That's oxford healthspan.com Dr.Sefani and use Dr. Stephanie at checkout. Let me tell you something that the fitness industry never bothered to tell you. Creatine isn't a bodybuilder supplement. It's not just for the bros. It's not going to make you bulky. It's not just for men, right? It is one of the most researched, most, most evidence backed compounds on the planet. And ladies, especially ladies in midlife, we are chronically under using it. And we actually produce less creatine than our male counterparts. So here's what creatine actually does. It replenishes something called phosphocreatine in your muscles, which means more energy available during your lifts, faster recovery between sets, better sprints, better muscle protein synthesis over time. And the more muscle you have, the better body composition you will have. Right? And the research on women, specifically creatine, also crosses the blood brain barrier. This is going to lead to better cognitive function, better mood, better memory. These are not small things, right? And the dosing is super simple. Just three to five grams per day, every day. You don't need to load, you don't need to do any of this loading phase stuff. You can take it anytime before your workout, after your workout, literally. Consistency is the only thing that matters here. Qualia creatine is what I use. It is creatine monohydrate, which is the form with the most research behind it. And it makes this clean. I also love that they add some magnesium and some electrolytes in there. So you're sort of getting like a three for one, right? Head over to qualia life.com better and use code better to save up to, to 50% 5, 0% plus an additional 15% off. That's qualia creatine at quality of life.com forward/better. Okay, riddle me this doc, because one of the things I see online, one of the things I value most is nuance. I really love when there are two sides of an argument. Let's say the science is always evolving and we have people on one, you know, on one side advocating for a certain outcome. People on what I see on social media, particularly with the rise of social media and the ability for anybody and, and everyone to be able to render their opinion is there are, I mean, OB GYNs who are like, there is absolutely, you know, the menopause society or whatever does not advocate for estrogen for dementia. There is absolutely weak or limited evidence that it's going to help with, you know, know, preventing bone loss. And I think that that can, I mean, I think the discord, I think the discourse is great. I think that we need that. I think that anybody who shies away from discourse usually means that they're hiding something. So I do think that there needs to be discussion. But I, I find that some of the opposition to what you're just, to what you've been describing, I mean, maybe it's the way in which the, the, the discussion is handled that I find salty and I don't like. But what, you know, and we like names. Doesn't matter the names. But it. Why. Why are. Are obgyns who, let's say, have maybe a prominent, you know, social media following. Very contrarian to what you've just said. And it's not just you saying it, by the way. There's lots of people saying, you know, estrogen for dem. Estrogen for brain health, estrogen for dementia, estrogen for bone loss. Loss.

[A]

Huh. I have a lot of. I have. I have several theories as to why this is. First, I think just to try to say safely, I think it just as you said, I want to echo the fact that, you know, when we look at a painting, you know, if we were at the Met, we both, we, you and I may have different interpretation of what this means. I mean, like, oh, this. This is a happy, joyous thing. You're like, that's all black and bad. Like, I love the night. And you're like, I love the day. So I think it's totally also like, like what. This is the first time I've ever said this, so just, just bear with me. But like data and data, research papers, I'm going to tell you this. They're nothing more than just an artist's work. We want to say, like, these are facts. And the. The more women involved in the study and the less bias involved in the study, the less confounding factors in the study and the more blinding in the outcome of the study, the more on the spectrum of quantitative than it is in qualitative. But look, let's be clear. Research is really nothing more than artwork, and it's the artist who's going to put their impression into the artwork. I'm sorry, it is impossible for us to be biased about anything when we come to the. Even like the Women's Health Initiative. I'll tell you what sort of. Other people who look at this say. They'll say this study wasn't designed specifically to look at only women 50 to 60. So therefore, that was not the primary objective of this study. You are extrapolating that, Dr. Hirsch. And that will be the reason as to sort of having a different viewpoint or perspective on the data. However, the reason my perspective on the data is also because we have to use what we have. All data is imperfect. Everyone says that. And the bigger the study, though, the better I can lean into it. And then there are multiple and multiple and multiple studies that do look at women closer to menopause, that do all point to this. This being very Very true. Now, the other thing about this is that there isn't, let's say, an FDA indication. Hormone therapy, you'll notice I said, is not a primary prevention for diabetes. Does the data support that? Probably. But would we say to a patient in our year of 2026, we're going to use hormone therapy to prevent diabetes? No, we can't technically say that, and that's because that's not what the studies were powered to do. So there's some nuance in, like, why people say one thing or the other. Secondly, I still think there is fear about hormone therapy in the people who say, for example, when the black box was removed, the black box warning was removed from hormone therapy in November. For anyone who's deep into this topic, they love this topic. They're interested in the public discourse. You know, even among clinicians, there was discourse along the side of like, is this really safe? And, and I will tell you because I've been prescribing hormone therapy for 14 years and doing nothing else. Not delivering babies, not doing pap smears, not doing breast exams. I mean, day in, day out, menopausal hormone therapy, it is one of the safest medications you can absolutely prescribe. So here we are fighting about the nuance, like, oh, wow, there's no data that it prevents Alzheimer's. Come on, think about, think about the things we just talked about. How estrogen works, what we know estrogen's good for. Yes, I agree. We should not necessarily make claims that aren't true. So notice I'll never say hormone therapy prevents Alzheimer's disease. That's, that's not true. But I will say it is. It is interesting to see the research and I would not be surprised if it's likely to decrease the diagnosis of Alzheimer's in women who take HRT within 10 years from their last period.

[B]

Or potentially the severity of it. Right.

[A]

Or potentially the severity. Right.

[B]

Not maybe not even qualifying for the maybe. It doesn't have to do with the qualifying for the diagnosis. If you do have cognitive impairment to some degree, it can attenuate. It can actually make your symptoms better potentially. And I think what you're drawing on is your clinical expertise. So I like to think of evidence based care, whether that's medicine or otherwise, as sort of like 3 interest, as like a Venn diagram. Right. So we have what's available in the literature, typically 10 to 20 years lagging, but still what is available in RCTs and the best quality meta analysis, Mendelian Random, et cetera, and in the other circle we have a clinician's experience. So what she can draw from her pattern recognition, her years of treating and caring for patients. So that's another arm, let's say, or vertical of evidence based care. And then the third is like what the patient wants. That's sort of the third layer.

[A]

Shared decision making.

[B]

Right, right, shared decision making. Like what does that woman or patient want? And then you triangulate those things and where those three circles inter or intersect or overlap is the decision making tree that you have. But what I think often happens with these sort of like evidence based Internet trolls is that you tend. It's like, well, there's no RCT for that. There's no RCT for that. It's like, that's nice. But I have 25 years of clinical experience that tells me otherwise.

[A]

Right, exactly. And I think you add on top of that, and I feel for my gynecology colleagues because I did a year of obgyn and I know a lot of obgyns. And you grow up in your residency. This very medical legal culture, you know, it is a very it. And to my gynecologists, your work is so difficult. Late night decisions, surgeries. You know, this is, is, is intense stuff. But there may be a bias, I think, to the idea that like it's so easy to harm your patients. And I, I think what I'm trying to say is, you know, I think that's where this fear comes in. Not so much just risk, fear of the unknown or fear of the data, but like this unnecessary fear that these medications are gonna put your patients at risk. At risk for what? Breast cancer, uterine cancer? These things are actually very, very, very, very rare, particularly for patients who are on the right HRT regimens. And so I also think to add to this because this is a topic that I think, you know, no one's brave enough to talk about, but here we are, is, I think also this is a topic that requires a lot of talking to patients. And so it's, it is easy to brush patients off because doing menopause care in an RV UB system does not make a clinic money, does not make a doctor money. In fact, usually they're losing money. And so because there is so much talking about what does it mean to maybe have a dense. You know, my patient came to me, I just saw her this morning. She's been in HRT for two years. So she's like, heather, what does it mean that I have dense breast tissue now? And so that's just a 15, 20 minute conversation.

[B]

Right.

[A]

And you know, to help her understand what that means in context, because you can look up online and see 18 different things about that. What does it mean to have a little bit of bleeding after you started hrt? You know, and so I think there's also sort of this, this, this fear of the, of the, Can I say this out loud? The fear of the hard work that goes into taking care of women who are in menopause and want to start hrt. So if you don't want to do that, that wouldn't you stand up on your hill and say don't. No, no, no. Mh. No, no, no, no, no. Women do not need this. Women do not need it is a lot of work on the side of a clinician. Serious hard work. Lots and lots and lots and lots of minutes of time.

[B]

I have to include the 60 and 70 year old. We call our audience our Betty's. So our 16, 70 year old Betty's, or potentially someone who's listening, who has a mom who is 60, 70 or 80 years old, who maybe opportunity, let's say, to have the conversation around mht. Is there evidence, clinical or in the literature or otherwise, that a woman who is 65 or 70 can start hormone therapy and derive and profit from some of the benefits that it may offer in terms of what we've been talking about today?

[A]

Yes, absolutely. In fact, I did an entire episode of this on my own podcast because I think the rise of questions of this type of women in this age group who feel like they missed the boat happened in the last couple of months with the black box removal. So what I'll say is this, when we look at the data, when we look at the Women's Health Initiative, which was on oral, women in the 50 to 60 age range had reductions in cardiovascular disease. We just talked about that ad nauseam. But the women who are between 60 and 70 had a null impact on their cardiovascular health. They didn't get the same benefit benefits, but actually they didn't really have any downsides. It was at 70 or on average. I don't like ages, I like year since menopause that if you were 20 years out of your last period and you hadn't seen estrogen, maybe that's where the risks slight ever so slightly like, you know, kind of increased compared to the benefits. So here's what I say. If you're within 20 years from your last period, I think it is absolutely within your, within your wheelhouse house to consider mht. But I would use Transdermal, because even that study that showed a null impact on cardiovascular disease. And this is typically the risks where typically clots, clots in your heart, clots in your brain. These were the things that happened to, in the study in women who took oral after, after 20 years of menopause. I think it is safe as, as it could be to use transdermal estrogen up until 20 years from your last period. If you're after 20 years, then it's where shared decision making comes into play. How is your cardio metabolic health right now? Are you still having symptoms? Because we have to. Then the second thing I say to patients is menopausal hormone therapy does not have to mean estrogen. It could be progesterone, a little bit of testosterone gel, vaginal estrogen. And so no matter what age you are, there are tools in this MHD toolbox that you can use.

[B]

We've been talking a little bit about some of the silent changes. Primarily. I do want to get to some of the more obvious ones. So the brain fog is maybe a more obvious one. But the cardio metabolic changes, for example, like you don't really feel your cholesterol level rising. You don't notice that you're insulin, insulin level is now 15 or that you're, you know, fasting glucose is 115. The other silent change is bone health. So in the two years leading up to menopause, this is where we actually see the biggest change. If you are not being strategic, I mean, my, my wheelhouse is the lifestyle, right? So I can get your bone density and I can get your muscle mass up. But if you have no idea when you're going to go through menopause, because it's a retroactive diagnosis anyway, you only know about it after you've gone a year without periods. How can we think about, again, prophylactically thinking about our bone health and maybe to a greater, you know, painting a greater picture to the, to the musculoskeletal system. How can we think about preserving that system as we are leading up to menopause?

[A]

I love this question because again, it goes back to the fact that this is, this has nothing to do with gynecology, right? This is our bones. And one in two women will suffer an osteoporotic fracture. And this data is atrocious. Atrocious. And we know that the risk of having an osteoporotic fracture increased drastically after 2002, when women were routinely not offered HRT anymore. So then of course, we have to go Back to, you know, estrogen. Oh, darn. Okay, we'll talk about the other things, you know, next. But, you know, it's no secret. It's just no secret that potentially one of the best things for your bone health is estrogen. Because that study, I really don't think any. Any clinician, any doctor, be it whatever your specialty is gonna say that, you know, the data doesn't show that estrogen is good for bone health. Hogwash, everyone. Every study shows that. And it's a crucial piece of bone health. Doesn't mean you have to do it. No, but again, it's thinking about so differently. Women are not small men. And, you know, every year, the United States Preventative Task Force Services comes out with grades for medications, for their standing in preventing primary disease. So taking a medication to stop something from ever happening. And so estrogen should get an A when it comes to bone health. Let's just say just for bone health, for sake of this argument, every year it gets an F. You know, it always fails. And everyone texts me and is like, can you believe this? Like, of course I can believe it. Because nobody wants to really, really sit with the fact that this could save trillions of dollars in healthcare. This could save women so much morbidity and mortality. So it's so significant that when we lose estrogen, our bones absolutely change.

[B]

You are probably drinking enough water. You are probably not replacing what your body is actually losing. Here is what nobody told you. As estrogen drops in perimenopause, your kidneys become less efficient at holding onto sodium. I mean, it's so cruel. Which means that your electrolyte needs go up right at the exact moment that most women are still operating on that strategy. Like, drink more water, Stay hydrated, Stay hydrated. Low sodium is pretty sneaky, and it's hard to kind of put your finger on it. Can look like fatigue, brain fog, headaches after workouts, that afternoon crash that you've been blaming on poor sleep. Sleep. It feels like your body's failing you, but it isn't. It's your body asking for something very specific, which is salt. This is why I drink element every single day. I usually do it before training. So I'll put half of a sachet in my water before training, or I'll do it when I'm really sweating. So after a really big sprint session, one packet in my water is going to give me a thousand milligrams of sodium, 200 milligrams of potassium, and 60 milligrams of magnesium. And I usually Half that. So there's no sugar, there's no junk, just the minerals that actually move the needle. You are building something special here, your body. So you have to fuel it properly. My friend. Head over to DrinkElement.com better and receive a free sample pack with any order. That's drinklmnt.com better.

[A]

So, of course, there's other things that we can do. Women have to be, you know, retrained to think about lifting weights. And you're so good at doing this. And nowadays, I do think that the message is getting out there, but like anything, it's gonna be slow to change, because if, you know, for my age, we grew up in, like, the cardio era, where, you know, I ran many marathons, and I loved that. So lifting weights is a new skill for a lot of us in our, you know, 30s, 40s, or 50s. And we're learning how to do it It. And if we don't do it right, we actually could. Like, you could break something.

[B]

Yeah, totally.

[A]

I. You know, you could have bad form. You know. You know, we want to make sure that we're eating protein and then we're rebuilding the muscle. We just broke down to make ourselves stronger. We need to make sure we're looking at DEXA scans and not ordering them at can you. 65 every. You know, it's. It's flabbergasting to even say out loud that we would wait routinely till 65 for a woman with no risk factors. Menopause should be a risk factor. Just like the American Heart association said that menopause was an independent risk factor for heart disease. Menopause should be a risk factor for a bone density scan, period. In women who have menopause early or for surgery or surgical or they have premature ovarian insufficiency or their periods stop because chemo, et cetera. These women all need bone density scans, and they're not. Stephanie, they're not getting them. They're not getting them.

[B]

Yeah, it's a tragedy. Like, I've seen fractures. Certainly I've seen hip fractures. Help rehab them. It is. Is, like, very transparently. It's gross. Like, it's gross.

[A]

It's malpractice.

[B]

It's. It's so awful. I mean, just looping back to the brain fog piece. Like, the cognitive decline that these women experience post pelvic fracture, learning how to walk again. I mean, it's heartbreaking. And, yeah, I would say it's. It's malpractice for sure. And I think that, yeah, I don't wish that on anyone. And I think that as a woman in her, you know, I'm in my 40s, I'm 48. I don't think a lot of women in their 40s or even 50s really think about falling and breaking a hip. Like, we've all seen the commercial. Like, I've helped, I've fallen and I, you know, I can't get up. Right. But it's like that becomes a real problem when you're 75 or 85 if you're not doing the things. Now, the whole idea that you don't know when you're going through menopause, but the two years prior to when you do go, you are losing the majority of your bone density in and of itself, even just as a prophylactic, to see if estrogen might be something there. And then again, in tandem with. It can't just be hormone therapy, but in tandem with things like plyometrics and lifting weights and learning that motor skill, as you, as you mentioned, I think are. Are important. But, yeah, rehab, like a lot of women like that you don't come back from. That's my clinical experience anyways. Like, you just don't come back the same. After a hip fracture, it's very difficult to walk. It's very difficult to walk. Again, most people don't even get there.

[A]

And it is, it's, it's, again, it's re. Reshaping the way that we, we teach this and reshaping the lens of importance. You know, when I think about my medical training, it was really men's health. I feel like it was really men's health. And, and one of the things that's come up so, so often recently is as women are now learning so much about this topic from social media and podcasts like yours and others, they're starting to even, like, see the very obvious gaps now and saying, why don't we have answers to some of these basic things? And maybe it's not just like, why do we not have answers? But, like, why is it that, you know, doctors don't agree? Like, why is it that, you know, care is so different based on who you see these questions are. They keep me up at night. They're bothersome because it's, it really is a failure of the medical system. And I just hope in my lifetime things can be different. We're getting there, but it's still rather slow.

[B]

Yeah. And it's back to this idea of, like, I don't want to be a man, but I would love the privilege to age like a man because they are given. And like, we love men. I love men. I'm married to one. I have two children that are both male, you know, so I love men. And there are inherent biases in the system that are. Are baked in whether people are consciously aware of them or not. Where we are designed to brush women off, like, oh, exaggerator, hysterical. My favorite word based on the word like means literally wandering womb. You know, like, she's hysterical. She's, you know, hypochondriac. All of these things are dismissed. Whereas if a. If a man were to show up, let's say and say, hey, you know, sex is kind of painful. I'm not really feeling the way I'm get. I have a lot of brain fog. I don't feel motivated anymore. I kind of feel sad. Like no one would ever say to him, you know, maybe you should try pottery.

[A]

My patients were told. They were told to garden.

[B]

Yeah, yeah. Told to guard. You need a hobby, or here's an antidepressant. You know, they would be given the option of hormone therapy and obviously discussed whether it's right for them or not. So I think that the same access. We should be given the same access. And we have people like yourself and many others who are advocating for women to help educate them, because I think that's really the only way that we're really going to change things is right now. There's going to be this time where the patient, in many cases, is more educated than the clinician than the clinician. And, you know, the clinician's like, oh, no, no, no. That causes breast cancer. Oh, no, no, no. You can only go on for five years. Oh, no, no, no, no. You're past ten. You can't. Ten years of menopause. You can't have.

[A]

We're.

[B]

We're gonna have this sort of slew of patients that are actually more educated than the clinicians until it's time for it to sort of work its way through the system. But it's no longer. You can't just delegate your health to someone else because you have no idea what that person knows. And right now, in this time in 2026, it's likely to. This podcast, you probably know more than

[A]

your clinician does a hundred percent.

[B]

Yeah. Let's talk about weight gain, something that everybody notices because it does change. Again with estrogen changing how we distribute fat. Talk to us a little bit about why weight gain, or changes in fat deposition maybe more accurately is more of a biological phenomenon rather than a Lack of willpower or something being inherently wrong with her.

[A]

You know, this topic was so interesting to me that actually when I was at Brigham, I did look at actually a very interesting looking at the metabolomics, or basically the metabolics of amino acids of women who took the hormone therapy in the WHI and women who didn't. And we clearly see, and I talked about this back in the beginning of the show, that women who do take hormone therapy or have estrogen have reductions in the progression to diabetes, which means they have better insulin sensitivity. So who cares about that? It just actually means that hormones talk to each other. Other. They talk to each other. They're like friends. They have friend groups. You know, they're in a WhatsApp.

[B]

They're in a WhatsApp group.

[A]

They're all in a WhatsApp group. And so we know that estrogen talks to insulin. And so when we think about to obesity medicine, we're starting to learn that there is hundreds of little hormone signals and metabolites that are going on throughout our body. Like, I think what is happening in our body in terms of the hormonal mil milieu is like, we have no clue. We do not know what we don't know. And so to me, this is.

[B]

So.

[A]

This is entirely a hormonal. Hormonally driven. But the. We'll come back to that. So. So there's two things happening. There's a direct response, which is the hormonally driven changes, but then there is indirect changes as well. So if we know that insulin talks to estrogen and estrogen declines, and then at that same point, then there tends to be an increase in insulin resistance that can lead to diabetes. And then I'm gonna guess that insulin talks to granin and leptin and all these other hormones that influence your fat distribution. How much adipose and how much, you know, you're absorbing in your food, how much maybe you're excreting in your food, how much water you're holding onto, how much you're not, how much salt you're holding onto, how much you're not. It is a very, very, very, very, very complex signaling pathway. And to me, the main driver is the. The hormonal changes. Because if you ask most women, when did your weight gain, when did your cholesterol change, when did your sleep change? When did your sugars change? Around the same time as their hormones change? No coincidence to me, because it happens to, like, pretty much every woman that I see. These are directly correlated. Now, indirectly, then you add the not Sleeping and maybe your mood is bad, so you're craving Ben and Jerry's and you know, maybe you're not sleeping, so you're up in the middle of the night eating peanut butter. You add sort of the stress of also being in midlife with the hormonal changes and you can get, you know, again, changes in your physique. So I think the kind of old model of like your metabolism slows down. I don't know, maybe, maybe it does, maybe it doesn't. I don't think that that is mature enough. I think there is a ton of hormonal changes, a ton of hormones talking to each other, neur neurotransmitters talking to each other, signaling pathways, proteins changing. And then your lifestyle's changing at the same time. And this can absolutely lead to weight gain for women.

[B]

Women. Yeah. I think that this may be a hard truth for some women to hear, but you don't listen to me. Just for, just for unicorns and circles.

[A]

No BS approach. That's what I always say.

[B]

No BS approach. I think that a lot of women arrive in perimenopause under muscled. They especially like the cardio bunnies, right?

[A]

Speak it, girls, speak it.

[B]

We, we spent hours, I spent hours, years on the elliptical machine. And I think that we also have this, you know, we're under muscled, we're under fueled, like we're not eating enough. How many women have I counseled that are like, Yeah, I have 1100 calories a day and I just can't seem to. It's like, well that's why that's the problem. Your metabolic adaptation, like you need to eat so your bone density goes down again. You can make the argument that estrogen also can. Estrogen also influences the osteoclastic versus osteoblastic activity like your, your bone resorption rate. So with estrogen typically inhibits bone resorption. So when you lose it, you get more of it. So that's why your bone density goes down. Same thing with your muscle mass mass. So I think that when you get to your 40s, let's say, and now you have this erratic presence of estrogen because it's, the overall trend is down, but for a while it's kind of like all over the place. It's just reveal. It's also just revealing or amplifying some of the lifestyle that lifestyle patterns and behaviors that you've been adopting for the last 20 years, not lifting enough, don't have sufficient strength or muscle mass, don't have sufficient bone density. The Elicity, the elasticity and recoil in your ligaments, tendons and joints are not there. And then now you lose estrogen on top of that along with, you know, testosterone slowly and progesterone and you have this like cacophony and then you, you feel terrible, you can't sleep, you have brain fog. It's like estrogen decline reveals the lifestyle also that your body may have been able to deal with when you were 25, but is sick of it and not dealing with it anymore when she's 45.

[A]

I couldn't agree more. This is a great addition to all of that.

[B]

And the other, the other piece of that is that people are like, we're more sedentary. Like let's just be honest. You know, when we were 20 we were part of the, you know, you're part of the gymnastics team or the track team or whatever at university and that sort of, you know, life gets lifey. You have kids, you open a clinic, you run a business, you know, or whatever it is, you have a career. And we're more sedentary than maybe we would like. So, so let me ask you as a doctor, but also as a human being, what are some things that you do in terms of your lifestyle that help you in addition to the hormone therapy that I would assume is, has been very helpful for you, what are some of the things that you do to help mitigate some of those changes that happen as we age?

[A]

Yeah. So you know, really honestly I'm going to, you know, tell you. I kind of took an inventory of my life at around like 41 and I realized that actually I was, I, I one I think starts with some self reflection for me. I was actually getting a little skinny fat or like, you know, I was actually just, I was, I was under muscled and that would exactly be. Had I waited a little bit longer, you know, right. In sort of that like then I would really start to gain that weight pretty fast because I'm not building any muscle. So I started just by taking inventory in my life and I think around perimenopause. I think this is why this is a great time to do this. We're starting to think about our long term health, our generational health, transitioning from being, you know, oh, I could just crash diet over the weekend and I'll fit into that dress for the gala. Like no, no. This is the time right. Where all these things change.

[B]

Yeah.

[A]

So I, I did some inventory. I wasn't working out. I was not eating enough pro. I wasn't eating well, and I wasn't sleeping well, so I, I just get boring. I just got some support, you know, I found someone who could help me with my weightlifting. So, you know, I feel blessed. I have actually one of my best friends, she works with me and she has been a personal trainer and trainer for many years, hours. So I enlisted her help and she will literally. And again, I, I know that this is like airing out all my life, but she will literally sometimes come get me out of bed because she loves me so much now. I know, I, I know, I'm very grateful for that, but it was like, find the thing that'll work for you. Do you need an online program? Do you need an app? There's so many great, you know, people who are really trying to make fitness easy and accessible, especially when it comes to lifting them weight weights. And so I just, you know, started with some inventory and really started with building muscle. Building muscle I think actually encouraged me to eat better because I noticed I was always hungry, Stephanie. Right. So then I was always hungry. So I realized that like my kids, Trader Joe's animal Crackers, which are addicting, we're not ever cutting it.

[B]

So, you know, they're not driving the, they're not driving the muscle adaptations that you want at all.

[A]

And then I was like, you know, as I started to build this muscle, I was like, I, I feel like if I eat better I could look really, really, really good. And she's like, well then, yeah girl, it's time for that too. So then I kind of, you know, rethought like what I would eat. It's so funny to my or I'm always taint, you know, and everyone sees the, the memes everywhere, like, eat more protein, eat more protein. So I was like, I need protein today. I need protein now. I'm hungry, I need protein. I know that without protein I'm never going to be full and satisfied. So then it was about kind of like changing my diet and then, you know, it kind of all dominoed. Then I really wanted to get my sleep on par because Lindsay would come in the morning and because you're a busy mom so you work out in the morning and then you got to get to sleep and then you got to stop the doom scrolling. Honestly, I would even say I don't know the right answer for everybody. It's so different. But one, this is a great time to reinvest in your health. So this is also, you know, maybe you need that trainer, you know, and you have put off your own health or Put off your needs because you're paying for your kids, travel, soccer, and, you know, the big, you know, graduation party. And you're putting your money into all these people, but a little bit of money into yourself will. Will take you and your family so far.

[B]

Are.

[A]

So get the personal trainer or hire the nutritionist or. Or upgrade the app so that you can get support. You cannot just do this alone. Willpower is just not going to be enough. You've got to fill your fill up so that you have support and so that it's fun and so that you're accountable, but accountable in, like, a fun and positive way where you start to feel the positive benefits from this. That would be my advice.

[B]

I love that. I love that. You know what nobody told me when I started lifting that the workout isn't actually the hardest part. The recovery is your joints are doing the invisible work between sessions. Your tendons, ligaments, and connective tissue holding the whole system together. That's your infrastructure. And most of us have spent years ignoring it entirely. This is where incrediwear comes in. I wear their elbow sleeve when I'm playing tennis, their knee sleeves when I'm squatting, and when I recover. They're not just compression sleeves. The technology here is different. The fabric woven into them increases the circulation to the tissue, which means that your body is actively repairing between sessions, not just waiting to feel better. That means that you are going to feel less stiffness, you're going to have faster recovery, your joints are going to actually keep up with the work that you're asking them to do. Now, of course, muscle is the engine, but your joints are the road. Okay? Take care of the road. Whether you're an athlete dealing with chronic joint pain or. Or just somebody who wants to feel better in your body today, this is worth trying. Head over to drstephaniestima.com incrediware and use code DrSteff20 for 20% off your order. That's drstephaniestima.com incorpiware and use code DrSteff 20. That's dash, R, S, T, E, P, H2, Z0 and muscle. You know, again, to your point, I feel it's a fundamental skill for everyone. A lot of women were not taught it. So it is a skill. It is a motor skill. In the same way that when you first were learning English, right? It's a. It's a skill of you learn a couple of words, and then you learn verbs, and then you learn adverbs and adjectives, and then you can String together paragraphs and pages and essays. It. But it takes years. And I think that one of the things I'm constantly reminding my audience who are like, oh, here she goes again. Just, just take your time. You know, it's like, don't worry, it doesn't have to be done in six weeks. Just take the next three years. And how much easier is it when you take inventory the way that you did, to say, okay, the next three years is how I'm going to map this out. So there's. I'm not putting another piece of pressure or another, you know, weight on the scale that's already, you know, very heavy. Another thing on the to do list, I can take some time to learn, can, you know, go on Instagram and find a creator that I really like or download an app, as you mentioned, that I really like, or buy a program or hire a trainer. So now you have time to give yourself to, like, if you were to. If I said to you, okay, we are going to learn how to speak Mandarin, and I said, but we're going to. You got to learn it in six weeks, you'd be like, you're crazy. I'm not even going to get through the first couple of letters in the Alphabet. Right. But if you give yourself two years, then all of a sudden this is a much more reasonable approach to learning. And I think that this is all, I will get off my box now. But I think that. I think that we put so much pressure on ourselves as women to do things right away, and then when we fail because it's impossible, you are never going to learn. Like, even now, I have been in the gym for 20 plus years. I can, I'm. There's always a better way that I can find it to squat. You know, like, it's a very. There's technicalities to it. So just be gentle with yourself. Give yourself a long Runway. And because you deserve it, that's. That's what I would say.

[A]

Hungary.

[B]

Okay, so in the book, you talk a little bit about these menopause or these menopausal types. I wonder if you could maybe expand on that a little bit for us.

[A]

Yeah, you know, I, I really think that when I sort of write both my books, the Menopause Type and Perimenopause Survival Guide, I kind of have this, this sort of way of practicing where I like when my patients come to see me, and we can get what I kind of call a quick win. That sounds cheap. Not a cheap quick win, but. And the way to kind of do that to help patients and women really kind of get this over this first hump is to figure out what bothers you the most and maybe also like where you are in your journey. So even just defining, are you perimenopause or menopause? Was it surgical? Was it early? Was it. It actually, you know, do you just have every symptom under the sun? And so in both of those books I kind of talk about different types. So in unlock your menopause type it was like early menopause and then really surgical menopause, often due to an abrupt reason like cancer chemotherapy, the mind type of menopause where really mood disruptions and the brain fog, like we said, that's your main symptom. Maybe your main symptoms are from head to toe. Maybe it's you're in your 70s, which is kind of like the seemingly never ending or maybe you don't have any symptoms. And so you're wondering why this topic's even important to you. So it's important to me. I like to write my books that way so that, you know, in my, in my view, I love to personalize women's journeys and their plans for them in the office. I can't do that in a book very well because there's millions of people who could be reading this book. Well, this is my way of doing that in a way that I can write it. So these types really, I think, think where my way of helping women sort of start where their biggest pain point is and better identify them. Meaning, you know, not just what's my biggest pain point, but how am I different than somebody else? So I have a patient who's 22, I had a patient who was 17. They're so much different than a woman who's 56. Right, right, right. So I really wanted an inclusive book. And then when it came to the perimenopause survival guide, same idea. Idea, but now it's different. Is bleeding your main issue in perimenopause? Cuz we gotta treat that actually differently than we would treat low libido or brain fog or the weight gain. And so I, I like to sort of write my books in that way so that people can start with where they're the most frustrated and then keep learning from there. Like peeling back the layers of the onion.

[B]

Yeah. And then they can find themselves in those archetypes. Right. It's like, oh, I'm the, I'm the one who bleeds. Okay. So this is the thing I need. Oh, okay. I'm experiencing the. Yeah. I really love that because I think that I love the idea of a quick win too, because it's not like a cheap, like dopamine that you're gonna get from scrolling kind of win. Like, you're talking about, like, hey, let's actually create some momentum here for you. Like, let's give you like a low hanging fruit, you know, let's, let's start the momentum, let's start the race off right.

[A]

Yeah. Well, how many times a week do

[B]

you hear something in your clinic that makes you think, like, why is nobody talking about this?

[A]

Oh, every, Every patient. Yeah, every. Every single patient. Do you mean just like, like fill in the blank? Like, why is nobody talking about just anything or.

[B]

Yeah, if someone comes in and they're like, one of the things I, I think that we should be screaming from the rooftops is the association of alcohol and breast cancer risk. I mean, we always hear about estrogen and breast cancer risk. Let's say, like, you know, to our, you know, nod to our previous earlier in the conversation. Alcohol. Like, no one talks about that, but I do hear, oh, it's wine o' clock somewhere.

[A]

Yes.

[B]

You know, I, I hear that all the time. This wine culture, some things.

[A]

You got it. Oh, my goodness. I could make a list of all the things, you know, for example, why is nobody talking about, just from this whole show that the American Heart association called menopause and independent risk factor, or that estrogen alone in the Women's Health Initiative decreased the risk of breast cancer to compare it to the placebo. There is so many things like that. And I think that's why, I think that is the crux of why I'm on social media in the first place is when I learned these things, I was like, everybody has to learn these. I didn't realize how hard it is to disseminate information in a world where you're just bombarded with information and then people think you're kind of crazy to say something like, you know, I don't believe that prometrium or transdermal estrogen increase the risk of breast cancer whatsoever. People will look at you and say you're crazy when you first talk about these things. So almost so many things I could say where I think it's crazy that we still think about perian menopause as a gynecologic issue. All of these things. I'm like, why is nobody talking about this in a way that is like, we need to reshape medicine. We need to reshape, you know, the way we culturally Talk about menopause and midlife. Everything. Absolutely everything.

[B]

I actually want to double click on what you just said. I love what you just said about reshaping the conversation culture that we have about menopause. We have a little segment on the show that we do called the After Party. And so this is just like my take on the whole, like what I loved about, you know, the, the guest or the conversation, what I thought, you know, we could have expanded on, et cetera. And I kind of think of menopause that way. It's sort of like an after party, right? It's like you, everybody wants to get invited to the after party. Like, how great is it not to have? I mean, I know that there's some people that love to bleed and it's like you, you totally fine. But I am looking forward to the time where I don't have to, I don't have to worry about, do I have enough tampons or am I going to bleed through my tampon and my pad in the next couple of hours? You know what? I'm, I love the idea of looking forward to menopause. And I know that there are a lot of women who are there already who are friends and, and they act as mentors for me that are like, I'm having the best sex of my life.

[A]

Oh, yes, I feel so.

[B]

I give zero.

[A]

Not everything. It's the best.

[B]

I, you know. So tell us how we can maybe think about reframing perimenopause and menopause. I think that this, there's this like perseverating idea that Perryman. Oh, you're old now. Oh, you're over the hill. Oh, you're a hag. Right? So how do we, how can we start to culturally shift this narrative without like disseminating the patriarchy? But how can we talk about.

[A]

We can do that too. I, I would, I'd love to like leave off on this and end with this in this positive note. And I say this to my patients all the time, that, that truly, if you, the, the most difficult part is probably, probably, you know, the years leading up to menopause and then, you know, the, the years after menopause. Now that, that doesn't sound, that's a long time, but there is a light at the end of the tunnel. Especially particularly if you do go through the transition and you take inventory and you take stock and you think about your long term health and you do invest in your health in this time, you will come out better. Because think about this, ladies. Every single day of your life from the time you menstruated up until. Until a few years after menopause. So give it a little bit of time. I wouldn't say the day after. Your hormones have been changing every single day. And we have never appreciated how intense that is on our physical bodies and our mental health. The way we show up all the time, you know, culturally, you know, PMS is something people still make fun of on sitcoms, like, oh, is that that time of the month again? Like, this is a physiologic process, whether it's going up or whether the hormones are going down. And for the first time in your life that you can probably remember, unless you remember being six, pretty crystal clear, this is the first time in your life that you're gonna feel stable day after day after day. And actually it's the first time where things will actually stay the same. Like, this is what happens to men. They don't have hormonal swings like we do. So you get to get there, you know, a little bit after menopause. And I promise you ladies that particularly if you treat perimenopause and menopause with somewhat seriousness. You're doing that. You're listening to the show. You're watching the Grams. You're trying to find a clinician. I got you, you know, more than your clinician. We're working on it. We're working on training clinicians, we're working on getting good information out there on socials. You just hang in there. If you do this work now, which you are, because you're listening to the show. So absolutely, you are going to find yourself in a couple of years feeling the best you've ever felt. And I know, know, because my patients. I know. I was just talking to one yesterday. They. And they're like, gosh, well, is there another shoe gonna drop? And I'm like, no, girl, like, you did.

[B]

You.

[A]

You like, you did it. You graduated. You're here. So I wanna leave them with that, that. That there is a. A. A wonderful life to be experienced postmenopausally.

[B]

I love that. So I'm gonna keep them strong, lifting weights and sprinting, and you are gonna make sure that they are getting the right kind of hrt, the right kind of MHT for them. And yeah, together that, like, I love that blend or that marriage of, like, pharmacology and medicine and lifestyle medicine. So, yes, yes. Thank you so much for your time today. It's been such a delight talking with you. I know we were rescheduling it but we got it done. We got you on here.

[A]

That's. That's how it goes. We do it for the love of sharing, like, our. Our deep knowledge how much we care. But then, like, coming together on a show like this, we get to, like, bounce off each other and share things. And so. Thank you so much for having me. Me on.

[B]

Thank you so much. It's been a delight. Fantastic.

[A]

Yay.

[B]

It's afterparty time. Welcome, welcome. Where I tell you what I really thought about this episode. So I think the most impressive thing here is hormone replacement therapy as the diagnostic tool that really is super cool. So for me, the orthopedic test in practice often became the program. So if somebody couldn't do something, then. Then that's what they ended up practicing. They ended up practicing that motor skill so that they could develop the neural pathway and the motor learning and the motor memory and the proprioception and the balance and all the things. I love this idea as, hey, it is probably going to be beyond your capacity to remember what it felt like when you were 25, when you had abundant energy, abundant reserves. So why don't we just put you on hormone therapy and if you feel like a million bucks, then it was probably a hormonal deficiency problem in addition to the lifestyle stuff that we talked about. So that. That was kind of like the big aha for me. And I loved the. We kind of got into it more at the end. But this idea that we have to stop talking about menopause as this, like, pro and perimenopause as this problem, like, there's something wrong with us now. It's like, hey, you know what? You get to be free from periods for the. The rest of your life. You're going to have amazing sex and you are going to feel so good because you have spent probably decades giving to other people, and now you get to give a little bit back to yourself and you have more money probably now than you did when you were 25. You have more wisdom than you did when you were at 25. You have more life experience than you did now than you than at 25. So it's a freaking great time to be alive. So that was, like, my big takeaways. I really appreciated. There was a point when I said, hey, riddle me this, doc. Why are some doctors online talking about, you know, if you mention estrogen and dementia, they jump all over you like you are an absolute idiot. I thought she handled that answer with a lot of grace and a lot of compassion, which is often something I actually don't see coming from the other side, people who are criticizing. And that's not to say that I don't like discussion and discourse. I love it. I just love it when it's done in a way that's intellectual and respectful. Unfortunately, the algorithm, it is what it is. You know, like you people either love you or they hate you. And the way that you make people pay attention to you is usually by rage baiting. And there's a couple of doctors online that really do a great job of that and which is why they have huge, huge numbers. But loved her conversation on estrogen and dementia. If you're a woman who's past menopause, you know, 10 years, 15 years past menopause, and now you see that that black box label has been removed, what are your options? I thought she did a really, really, really great job with that. So that's what I got for you. I want to know from you what is the single biggest lie that you think, think that you have been told as a woman going through perimenopause and menopause? Put it in the comments. If you think that this is a episode worth sharing, worth discussing with your girlfriend group, your WhatsApp group, the way that the hormones that you in your body are having that WhatsApp chat, let us know in the comments on YouTube, let us know on Apple podcasts, on Spotify. We are watching. We are listening to you. So until next time, my friends. Friends, we'll see you then. I hope you enjoyed today's episode. And now I must give you the obligatory legal and medical disclaimer. This podcast, Better with Dr. Stephanie, is for general information only. The advice and recommendations we discuss do not replace medical, chiropractic or any other primary healthcare provider's advice, treatment or care in the consumption of this podcast. There is no doctor patient relationship and the use and implementation of the information discussed are at the sole discretion of the listener. Please, please take this information to your primary healthcare provider to make the best choice for you. Remember, I am a doctor, but I am not your doctor, and these episodes are meant for educational purposes only.