Podcast Summary

That Can't Be True with Chelsea Clinton

Episode: The Truth about Perimenopause, HRT and Breast Cancer Risk
Guests: Dr. Heather Hirsch & Tamsen Fadal
Date: November 20, 2025
Production: Lemonada Media & The Clinton Foundation

Episode Overview

Chelsea Clinton leads a myth-busting conversation with Dr. Heather Hirsch (internist and menopause specialist) and Tamsen Fadal (journalist and menopause advocate) about perimenopause, menopause, hormone replacement therapy (HRT), and breast cancer risk. Together, they break down persistent stigma, clarify current scientific understanding, and offer actionable advice for women seeking to navigate midlife health.

Key Discussion Points & Insights

1. Menopause and Perimenopause: Definitions and Stages

• Menopause is defined as one full year without periods. After that, a person is postmenopausal.

• Perimenopause is the transitional phase leading up to menopause, marked by fluctuating hormones and evolving symptoms.

• Perimenopause sub-stages:

  • Early: Periods may become heavier/closer together; symptoms like insomnia, anxiety.
  • Late: Periods space out; symptoms expand to hot flashes, night sweats, mood changes, etc.

• Dr. Hirsch:

  “Once you're postmenopausal, you're always postmenopausal.” (03:17)
  “Everyone will go through perimenopause... hormones are actually starting to slowly decline.” (03:49)

• Not all experiences are the same:

  • Onset age and severity vary greatly, sometimes due to surgeries or genetics.
  • “I had a patient once who was 17 actually, who was in menopause, 22 who was in menopause. And I have a 58-year-old who is still in perimenopause.” – Dr. Hirsch (08:50)

2. Symptoms and the Importance of Awareness

• Many women lack language and awareness around symptoms:

  • Brain fog, lack of libido, insomnia, irritability, social withdrawal.
  • “You don't feel like yourself. Right. You might have brain fog, which is really what happened to me. And that was kind of debilitating.” – Tamsen Fadal (05:01)
  • Open conversations are now more common but were largely missing for previous generations.

• Symptom distinction can be challenging:

  “How do I know if it's just not this colleague that is driving me crazy? Or is it perimenopause?” – Dr. Hirsch (06:52)

3. Diagnosis and Tracking

• Track symptoms and cycles to identify patterns and assess progression.
  • Hormonal treatment can be diagnostic as well as therapeutic: if symptoms resolve with HRT, it’s likely related to menopause.

4. Hormone Replacement Therapy (HRT): Shifting Scientific Consensus

• FDA recently removed black box warnings from many menopause hormone therapies (HRT), a reversal after two decades.

  • Past warnings were based on the 2002 Women's Health Initiative, which scared many women and doctors.
  • New data indicate HRT can be safe and highly beneficial for many.
  • “The morning after the announcement ... the word menopause was in every headline across every newspaper.” – Tamsen Fadal (11:19)
  • This change empowers conversations and options, especially for younger women.

• HRT should always be personalized; not everyone is a candidate, and non-hormonal options exist.

5. Options for Symptom Management

A. Hormonal Therapies

• Systemic HRT:
  • Estrogen (oral, patch, gel, spray, ring).
  • Progesterone (esp. important for those with an intact uterus).
  • Transdermal options (patch/gel) avoid liver metabolism and reduce clot risk.
• Local Vaginal Estrogen:
  • Targets genitourinary symptoms (e.g., UTIs, dryness, pain).
  • “Vaginal estrogen should be the first line treatment for any woman with recurrent urinary tract infections.” – Dr. Hirsch (18:16)
  • Shown to be very safe, including for breast cancer survivors.

B. Non-Hormonal Options

• SSRIs (e.g., Brizdell) for hot flashes.
• New drugs targeting core body temperature.
• Addyi (Flibanserin) for low libido.
• Sleep/mood medications as needed.
• Lifestyle and supplements play a role but are not “one size fits all.”

6. Navigating Risks: HRT and Breast Cancer

• Not all HRT formulations have the same risk profile; newer regimes (e.g., bioidentical estradiol, micronized progesterone) are safer.
  • “We don't see an increased risk of diagnosis above a woman's baseline.” – Dr. Hirsch (25:13)
  • Estrogen alone may even lower breast cancer risk in some (from large studies).
  • Importance of separating emotional reactions and fear from actual data.
  • “I guess my whole life growing up, I was like, estrogen bad. That was all I knew... and I don't even know if I knew …” – Tamsen Fadal (28:09)
  • Individual risk must always be assessed, especially with strong family histories.

7. Research Gaps and Advocacy

• More head-to-head trials needed (e.g., patch vs gel, hormone levels for optimal health).
• Major research barriers persist: funding, IRB approvals, and historical stigma.
• Recent FDA changes may stimulate interest and investment.
  • “A lot of the questions I get asked, I don't have clear answers to.” – Dr. Hirsch (31:31)

8. Social Media: Sorting Fact from Fiction

• Misinformation and “menopause influencers” abound.
• No single fix or magic supplement; skepticism is warranted for “one-size-fits-all” advice.

  “If somebody is promising you this one size fits all, this is a solution. Save your money. Because there is, as you can hear, ... a lot of different options.” – Tamsen Fadal (36:27)

  • Seek science-based sources and show self-compassion in the face of overwhelming advice.
  • Start with manageable lifestyle changes; avoid guilt over not doing everything at once.
  • “Is what you're … consuming mainly motivating you to be afraid or motivating you to feel empowered?” – Chelsea Clinton (37:38)

9. Rapid-Fire "Fact or Fiction" Segment (37:53–42:46)

Quick Takes:

• Hypnosis can reduce hot flashes: Fact
• Food can change your hormones: “We don’t know yet” for menopause, possibly for other hormonal disorders.
• The Hot Girl Menopause Smoothie: Fact. (See Tamsen's recipe at 38:58)
• Women over 40 need 90–120g protein/day: Fact
  • “It's going to keep you feeling fuller, longer and … nice and stable during the day.” – Dr. Hirsch (39:49)
• HRT can’t be used with GLP-1 inhibitors: Fiction; in fact, they can be used together and may be synergistic.
• Most doctors aren't comfortable treating menopause: Fact—especially internal/family medicine residents; education is a pressing need.

Notable Quotes & Moments

• “Women don't have the whole story. And we really want women to have the whole story to make the decision for them.” – Dr. Hirsch (25:13)
• “There is not one blood test in perimenopause that's going to say like, this is it, here you go, here's your answer.” – Tamsen Fadal (36:57)
• “Suffering through menopausal symptoms really can derail your health. There’s no kind of gold medal at the end.” – Dr. Hirsch (24:10)
• “The more that we talk about it and ... put women’s health at the top, top where it should be, that we’ll have more solutions for women.” – Tamsen Fadal (30:54)

Timestamps for Key Segments

• Defining menopause & stages: 02:50–04:49
• Symptom awareness and challenges: 05:01–06:52
• How to distinguish symptoms: 06:52–08:34
• HRT and FDA news, shifting risks: 10:11–13:39
• Vaginal vs systemic estrogen, detailed treatment options: 17:36–22:03
• Non-hormonal therapies: 22:31–24:36
• Breast cancer risk and HRT: 25:13–29:23
• Research gaps: 31:31–34:07
• Social media advice: 34:50–37:38
• Fact or Fiction rapid fire: 37:53–42:46

Conclusion

Chelsea Clinton, Dr. Heather Hirsch, and Tamsen Fadal emphasize education, individualized care, and empowerment for women entering perimenopause and menopause. Misconceptions still reign—especially around HRT and cancer—but the climate is finally changing. The consensus: Women deserve both information and choices, not shame or fear.

Resources:

• Dr. Heather Hirsch: [Instagram/TikTok @heatherhirschmd], Book: The Perimenopause Survival Guide
• Tamsen Fadal: [Instagram/TikTok @tamsenfadal], Book: How to Menopause

“We’re quite clearly in a better place today than we were 5, 10, or 15 years ago, in large part because of people like the two of you and also particularly the two of you.” – Chelsea Clinton (42:46)